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Int J Disabil Hum Dev 2011;10(4):379–3 83 © 2011 by Walter d e Gruy ter • Berlin • Boston. DOI 10.1515/IJDHD.2011.061
Case report
Post-traumatic stress disorder treatment with virtual reality
exposure for criminal violence: a case study in assault with
violence
Georgina C á rdenas-L ó pez * and Anabel De la
Rosa-G ó mez
Virtual Teaching and Cyberpsychology Laboratory ,
National Autonomous University of Mexico, Mexico City,
Mexico
Abstract
Exposure to criminal violence is associated with mental
health problems, such as depression, substance use and abuse.
However, one of the most important psychological problems
linked with victims of violence is post-traumatic stress disor-
der (PSTD). In Mexico, according to the ENSI-5 in 2009, 11 %
of the population over 18 years of age experienced a crime.
One in four of those who were victims of violence develop
PSTD symptoms. Due to this socially relevant problem and
based on the effi cacy of previous virtual reality (VR) clini-
cal applications for combat-related PSTD, our group devel-
oped four VR scenarios to treat victims of criminal violence.
Data obtained from a case study of a person who experienced
assault with violence showed signifi cant changes through
reduced levels of anxiety and PTSD symptoms, illustrating
the effectiveness of such treatment.
Keywords: criminal violence; post-traumatic stress disorder
treatment; prolonged exposure; virtual reality.
Introduction
Violence is an issue of great importance for the general popu-
lation, because of health and economic implications. Assaults
in the public streets create an atmosphere of danger and
vulnerability. According to the World Health Organization
(1) , violence has important implications, both psychologi-
cally and physically. Among the consequences of violence
are depression, alcohol use and substance abuse. The most
important psychological diffi culties experienced by victims
are posttraumatic stress disorder (PTSD).
In Mexico, according to data reported by the National
Survey on Insecurity (2) , almost 11 % (11,980/per 100,000
inhabitants) of the population over 18 years old were victims
of a crime. Of these cases, one in four had developed PTSD
symptoms. In contrast, the epidemiologic psychiatric sur-
vey (3) , informed that 5.6 % of urban populations experience
PTSD after suffering kidnapping, and 1.8 % following robber-
ies or assaults with weapons. Contemplating this background,
it is important to note the great impact of violence on mental
health. The prevalence of PTSD requires attention because
those who suffer from this disorder have elevated degrees of
anxiety, fear and avoidance, thereby interfering in personal
development and everyday life.
PTSD appears when a person experiences or witnesses a
physiological injury or incident that threatens their own life
or the life of another person. Those who suffer with PTSD
often feel an intense fear and horror and defenseless. There
are three important aspects for the clinical diagnosis of PTSD:
a) intrusive thoughts and constant involuntary fl ashbacks of
the traumatic event, b) cognitive and behavior avoidance
of places and situations related with traumatic incident and
c) hyper activation responses, such as concentration prob-
lems, irritability and sleeping disturbance (4) .
Psychological consequences after being in a threatening
incident not only depend on the intensity and characteristics
of the situation, but also on the differences between individu-
als, such as: age, background, violent experiences, emotional
stability, psychological resources, self-esteem, social and
familial support among others. For this reason, risk and pro-
tection factors are important issues in order to understand the
psychological consequences of traumatic events (5) .
Nowadays, there are effective cognitive-behavior therapy
(CBT) treatments for PTSD. These treatments employ expo-
sure techniques that help patients to overcome the presence
of feared objects or situations related to the traumatic event.
Prolonged exposure (PE) is the preferred exposure technique
for treating PTSD (6) . However, this technique is poorly used
in clinic treatments (7) . The least used of these treatments
is due to cognitive avoidance of patients to recall traumatic
memories and the diffi culty for some patients to engage in
imaginal exposure (8) .
Virtual reality exposure technique (VRET) can help to
overcome some restrictions of traditional exposure therapy
*Corresponding author: Georgina Cárdenas-López, PhD, Virtual
Teaching and Cyberpsychology Laboratory, National Autonomous
University of Mexico, Av. Universidad 3004, Col. Ciudad
Universitaria, Mexico City, Mexico
Phone: +55-56222292, Fax: +55-56160778,
E-mail: mgcl@servidor.unam.mx
Received November 1, 2010; accepted May 1, 2011
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380 C á rdenas-L ó pez and De la Rosa- G ó mez: Post-traumatic stress disorder
(in-vivo or imagined). VRET can simulate the traumatic sit-
uation with a high sense of reality; therefore, this can help
patients irrespective of their ability for imaginal engagement.
Another benefi t, is that therapists can control the character-
istics of the situation presented to the patient. These aspects
could reduce cognitive avoidance in order to increase the
emotional engagement during exposure.
Currently, there are several studies supporting the effective-
ness of VR for the treatment of PTSD (9) . The fi rst study was
conducted by the team of Rothbaum et al., who published a
case study where exposure by VR in the treatment of this dis-
order was studied. The same group (10, 11) has also provided
data on the effectiveness of this technique in a study with a
group of 10 Vietnam veterans. Rizzo et al. (12) evaluated the
effectiveness with survivors of the war in Iraq, while Difede
and Hoffman (13) studied the effectiveness of “ virtual exhibi-
tion ” on a case study of a victim of the September 11 attack.
Due to socially relevant problems and based on the effi cacy
of previous studies of war violence, our group developed four
virtual reality scenarios in order to evaluate a case study of a
treatment program for PTSD in the victim of an assault with
violence.
Methods
The objective of this study was to evaluate the effi cacy of a treat-
ment program for PTSD through VR exposure in a case study of
assault with violence. The participant was a 22 - year-old man who
covered the DSM-IV criteria for post-traumatic stress disorder type
I for assault with violence, who accepted, under informed consent,
to participate in research. He reported that he had suffered an assault
with violence and death threats by an intoxicated man, 5 months pre-
viously. As a result, the patient experienced anxiety levels when talk-
ing with unfamiliar people or strangers. The participant, reliving the
event in the form of repeated and uncontrollable memories through
nightmares, presented anguish, as well as psychological distress
and feared a repetition of the incident. There was also evidence of
avoidance behavior, such as not going out alone at night, not visiting
places on his own, and avoidance of violence in television programs
or discussion concerning the traumatic memory of the incident. He
showed symptoms of anxiety (physiological arousal), sweating,
rapid heart rate and trembling at the memory of the traumatic event
or related situations.
Procedure
A preliminary screening and interview was conducted during which
the participant was informed about study. A PTSD diagnosis was
determined by a Clinician Administrated PTSD Scale (CAPS-1)
(14, 15) , the PTSD check list, the PTSD symptom Scale Self-Report
(PSS) (16, 17) , the Beck Depression Inventory (BDI) (18, 19) , the
State-Trait Anxiety Inventory (STAI) (20) , and the Quality of Life
Inventory (INCAVISA) (21) .
Treatment
Treatment was delivered in 10, 90-min individual sessions conducted
once weekly (22) . In session 1, the participant received information
about the treatment rationale, education concerning common reac-
tions about trauma, and breathing relaxation training. Session 2 was
focused on traumatic memory. This was explained in the education
context about exposure therapy as a medium to confront feared
memories and processing of memory. Session 3 consisted of the con-
struction of a hierarchy of situations or activities and places the par-
ticipant was avoiding, in order to assign specifi c in vivo exposures
for homework. Sessions 4 – 9 consisted of repetitions of the trau-
matic memory with VR exposure. During the exposure, the patient
was asked, at 5 min intervals, to report a subjective units of distress
(SUDS) rating over a scale ranging from 0 to 10. Session 10, the fi nal
session, included discussion about the continued practice of all that
the patient had learnt during the treatment.
Materials
The equipment used in the trials comprised the following:
PC Pentium III (1000 KHZ, 256 MB, CD-ROM drive with AGP •
graphic board, 64 MB, Dell XPS).
Head mounted display (HMD), Vuzix iWear• ®, VR920, Vuzix,
Rochester, NY, USA.
Mouse, keyboard, earphones, and loudspeakers, Dell accessories. •
Microsoft Windows 7 Software• ®, with Open GL graphics library.
Virtual Reality environments, general direction of computing and •
information and communication technologies (DGTIC), UNAM,
Mexico City, Mexico.
PTSD scenario settings
Three virtual scenarios for PTSD were used, each of which are three-
dimensional (3D) dynamic graphical environments, modeled using
Studio Max, that are acoustically rich and tactile, modeled through
a computer-oriented simulation of situations with real world vari-
ables. The PTSD scenario settings (23) were: streets of Mexico City
scenario, a pedestrian bridge scenario, and a vehicle (taxi/wagon)
scenario, each with the aim of exposing the patient to the memo-
ries of the trauma. In order to achieve the immersion of the partici-
pant, each scenario is navigable and interactive. Note that the virtual
Figure 1 Exposure therapy provided in the Faculty of Psychology
at UNAM. The VR system provides confi dence to the patient to learn
that the virtual environment is handled by the therapist through a
keyboard or electronic panel that ensures total control of exposure
in real time.
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C á rdenas-L ó pez and D e la Rosa -G ó mez: Post-traumatic stress disorder 381
environments are designed with consideration for the social and cul-
tural context appropriate for the target users of the system.
Streets of Mexico City scenario: as a public space, this is consid-
ered to be a scenario that is feared by patients, perceived as an unsafe
place, which puts them in a vulnerable situation of potential assault
or kidnapping. Through this scenario, the user walks freely through
the avenue, which can incorporate virtual characters (avatars) that
look suspicious and can be placed at different levels of proximity to
the user (Figure 2 ).
Pedestrian bridge: the scenario begins at the bottom of the stairs
to a footbridge. The patient can walk across the bridge by walking
up the stairs, then walking along a narrow bridge walkway to reach
the other side and cross the street. The model can be unpopulated, or
can be populated with people who obstruct clear passage across the
bridge, in order to continue exposure and confront patient fears of
going about daily activities (Figure 2 ).
Vehicle (taxi/wagon): this scenario represents one of the most
feared by people who have been victims of assault. The user is con-
fronted with elements of discomfort or anxiety triggers, such as intim-
idation by the driver and meeting with other frightening characters
Figure 2 City, bridge and taxi views.
Table 1 Pre-treatment to post-treatment assessment ratings.
Measure Pre-treatment Post-treatment
CAPS total 81 40
CAPS Re-experiencing 20 8
CAPS Avoidance 37 10
CAPS Hyperarousal 24 16
PTSD Symptom Scale 35 20
BDI 16 5
STAI 47 25
which, together with other associated stimuli, such as a blocked path
in the street or changes in lighting levels, allow the feared situation
to be recreated (Figure 2 ).
Results
The participant ’ s clinical levels of PTSD and depression were
signifi cantly reduced and his level of anxiety was measurably
reduced from his pre-treatment assessment to post-treatment
assessment, as shown in Table 1
. Specifi cally, at the end of 10
sessions of VR program treatment, the CAPS score decreased
by 51 % from a pre-treatment total score 81. The PTSD symp-
tom scale ratings decreased from 35 to 20. The participant, when
assessed at the end of the treatment, did not meet the DSM-IV
criteria for PTSD. Anxiety reduction was shown during the ses-
sions by a decreased level of re-experiencing, avoidance and
hyperarousal ratings. The SUDS rating progressively decreased
within sessions (Table 2
and Figure 3 ). The Jacobson ’ s Reliable
Change Index (24) was employed to evaluate treatment change
on these two outcome measures (Table 3 ).
Table 2 SUDS ratings (1 – 10): in vivo exposure hierarchy, sessions
3–10.
Task S3 S4 S5 S6 S7 S8 S9 S10
Taking public transportation75 554433
Talking to strangers 86545333
Watching movies that have
some violence
67644433
Being watched or touched
by someone
77655543
0
Beginning
5 min
10 min
15 min
20 min
25 min
30 min
1
2
3
4
5
6
7
8
9
10
Session 4
Session 6
Session 8
Session 10
Figure 3 Subjective units of distress (SUDS) rating (1 – 10) during
virtual reality exposure sessions.
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382 C á rdenas-L ó pez and De la Rosa- G ó mez: Post-traumatic stress disorder
Conclusions
According to the results obtained, the application of the VR
prolonged exposure (PE) technique was effective in reducing
symptoms of re-experiencing, avoidance and hyperarousal,
which confi rms the clinical preference for this technique to treat
PTSD (6) . The participant reported feeling comfortable with
technology, as well as experiencing an improvement in func-
tioning in many areas of his life as a result of the treatment.
The combination of new technologies for psychological
treatment seems to be a promising alternative for the care of
PTSD in victims of criminal violence, which have great impact
on our country, supporting the spread of empirically validated
treatments in the Mexican mental health fi eld. The adaptation
of the treatment protocol (22) addressed properly this socially
relevant problem in Mexico. These results have encouraged
our team to conduct randomized, controlled trials with a larger
sample and to test the treatment program with other types of
criminal violence, such as victims of kidnapping.
Perspectives
New forms of criminal violence are emerging in various
countries, impacting severely the local populations, as crimi-
nal violence related to drug dealers, power abuse, insecurity,
etc., generates a deterioration in the communities ’ mental
health. Our group is taking the challenge to develop VR envi-
ronments for the treatment of pathological grief, PTSD and
adjustment disorders, related to this new threat to psychologi-
cal well-being.
Confl ict of interest statement
Authors ’ confl ict of interest disclosure: The authors stated that there
are no confl icts of interest regarding the publication of this article.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
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