Virtual Reality: An Emerging Form of PTSD Treatment for War Veterans

Chelsea Nguyen

Professor Townsend

Writing 340

May 7, 2013

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Abstract

A large percentage of veterans, from past and present wars, who return home from active

combat duty suffer from posttraumatic stress disorder (PTSD). However, the social stigma that is

oftentimes associated with this disorder as well as with the treatment methods prevent these

veterans from seeking the help that they so greatly need. The commonly known forms of PTSD

treatment, such as psychotherapy, eye movement desensitization and reprocessing (EMDR), and

prescription medications, are not fully effective in treating PTSD since they more often than not

deter veterans from seeking help rather than encourage them. Virtual reality is an alternative

form of treating PTSD. It is an emerging trend in health care that, while not yet widespread, has

been proven to be more effective in treating PTSD than the more traditional methods.

Introduction

The fact that the percentage of war veterans who are being diagnosed with PTSD after

they return home is at an all-time high should incite the health care and veteran communities to

develop effective treatment methods. It is said that one in five veterans returning home from Iraq

and Afghanistan are diagnosed with posttraumatic stress disorder, accounting for nearly 300,000

veterans [1]. Despite this alarmingly high statistic, the majority of war veterans who are

diagnosed with PTSD do not seek help and instead suffer alone in their homes. Refusal to seek

treatment is detrimental to the individual, as the symptoms only increase in severity. Although

there are several PTSD treatments currently available, like psychotherapy, EMDR, and

prescription medications, many of them are ineffective in fully treating PTSD since they do not

target the root of PTSD but rather work to only suppress its symptoms. The focus must turn to

more effective treatment methods, which is what a team of researchers at University of Southern

California has done by creating a virtual reality system, where the patients re-experience their

trauma through a virtual environment. This new technology, although novel, has been proven to

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be effective in treating PTSD in war veterans and is oftentimes used as a first line of treatment

before any others.

Prevalence of PTSD in War Veterans

Today’s U.S. war veterans who return home from combat have a thirty percent chance of

being diagnosed with posttraumatic stress disorder (PTSD) [2]. Figure 1 below from The SFGate

Newspaper shows the percentage of war veterans who were diagnosed with PTSD from the

different wars, spanning all the way back to the Vietnam War to the current wars in Iraq and

Afghanistan. As it can clearly be seen, the percentage of war veterans being diagnosed with

PTSD has not abated at all with time. In fact, it has remained disturbingly steady, with twenty-

four percent being diagnosed after the Vietnam War, twenty- three percent being diagnosed after

the Gulf War, and twenty percent being diagnosed after the wars in Iraq and Afghanistan. To

prevent these percentages from staying the same or increasing as time goes on, it is imperative

that our society make every effort to not only understand PTSD, but to also develop effective

treatment method that targets the true, underlying cause of PTSD rather than just address the

surface symptoms.

24%

23%20%

20%

Figure 1: Percentage of War Veterans Di-agnosed With PTSD

Vietnam WarGulf WarAfghanistanIraq

Figure 1: Percentage of U.S. War Veterans with PTSD (from different wars)Data Source: http://www.sfgate.com/health/article/U-S-wars-and-post-traumatic-stress-disorder-2627010.php

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PTSD: Symptoms and Barriers to Treatment

In order to develop an effective method to treat PTSD, it is important to first understand

what it is and what the symptoms are. PTSD is an anxiety disorder that develops after a person

experiences or witnesses a traumatic event [3]. For war veterans, this traumatic event takes the

form of a life-threatening situation where they may have experienced a roadside bombing or

have just been in combat [4]. The four common symptoms of PTSD are re-experiencing the

trauma (through flashbacks or nightmares), avoidance (for example, avoiding situations that

reminds the person of the actual event), feeling numbness (such as depression, difficulty

expressing feelings or talking about the trauma), and hyperarousal (being easily startled, irritable,

or angered) [3]. Contrary to many veterans’ beliefs, this is a disorder that does not simply go

away on its own and must be treated in order to have improved physical, emotional and mental

well-being. Despite the clear evidence that veterans should receive treatment in order to regain

stable and productive lives, studies have shown that only thirty to forty percent of veterans

diagnosed with PTSD actually seek treatment [5].

A study was conducted to find out what prevented war veterans from seeking the help

that they so clearly need. The results ultimately showed that the reluctance stems from not just

one but rather a myriad of reasons. In the study, two hundred war veterans who were diagnosed

with PTSD but were not getting treatment were interviewed by phone for forty-five to sixty

minutes to find out why they were not seeking help [6]. Figure 2 below from Psychiatric News

illustrates the results from the study. Based on these interviews, one of the conclusions was that

participants avoided seeking help because they disliked the treatment options that were available

to them and were also concerned about the treatment process. The veterans also felt that they

would be misunderstood by clinicians and that the medications that would be prescribed to them

would not relieve their symptoms. Thirty-five percent of the interviewees responded that they

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were reluctant to seek help because they were not emotionally ready to start the treatment

process. Sixteen percent of the participants admitted that they did need help but were hesitant to

reach out because of the social stigma that is associated with having the disorder, since in their

view, PTSD would make them appear weak in the eyes of society and would also jeopardize

their careers [4]. Logistical problems, such as the time that would be needed to be set aside to

travel to the clinics, did not majorly influence the participants’ decision to not seek help [6]. The

valuable information that the researchers gained from these interviews can be utilized to

determined what treatment methods, if not the traditional ones, would be most effective in

treating PTSD and ultimately allow these war veterans to be restored back to a normal, healthy

and productive life style.

Logistical issues

Stigma

Emotional readiness

Concerns about treatment

0 5 10 15 20 25 30 35 40 45

8%

16%

35%

40%

Figure 2: Commonly reported reasons why war veterans avoid getting helpModified from: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1676239

Frequently reported beliefs

Figure 2: Reasons War Vets Avoid Seeking Help

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Current Ineffective Treatments

Treatment methods like psychotherapy (counseling), prescription medication, and eye

movement desensitization and reprocessing (EMDR) have been shown to be ineffective in

treating PTSD, and thus a greater focus must be turned to alternative methods that would truly

help war veterans as they transition from violent war zones to more stable, predictable lifestyles

at home [3]. Psychotherapy, also known as counseling, involves a patient meeting with his

therapist once a week to discuss his feelings and the trauma that he has experienced while at war.

The goal of psychotherapy is for the patient to “understand [his] thoughts and feelings, and find

practical ways to cope with them” [7]. What psychotherapy does not take into account, however,

is the fact that many war veterans find it very difficult to share a traumatic event with someone

who has not experienced it and thus cannot truly know and understand what it must have been

like to be in that particular situation [4]. Because of this, psychotherapy more often than not

results in twenty to fifty percent of veterans walking away from the therapy sessions before they

were supposed to [8].

Medication treatment involves prescribing antidepressant drugs such as Zoloft or Paxil in

order to reduce depression, a common PTSD symptom, seems to only address the symptoms

rather than the underlying cause of PTSD. Studies have shown that these types of medications

result in unwanted side effects like nausea, rapid weight gain, and extreme tiredness and do not

really treat PTSD [9]. Patients who took antidepressants indicated that “they did not feel any

better,” yet their doctors continued to believe that the disorder was being treated and that

symptoms were being alleviated [7]. EMDR treatment involves the patient discussing the

traumatic event while focusing on an external stimulation (e.g. following the therapist’s moving

finger) [10]. By focusing on the moving finger, the patient’s rapid eye movements would in

theory allow him to work through the traumatic memories without any distress [3]. However,

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research has found that “theorized eye movements are an unnecessary component” and the

mechanisms used in EDMR is not enough to treat PTSD alone [11]. While the three treatment

methods just described sound helpful in theory, they clearly are not in practice since they do not

aim to truly understand the cause of PTSD and only focus on PTSD’s physical manifestations. It

is crucial that an alternative treatment method be utilized that seeks to first understand how

PTSD develops in patients in the first place and then targets that cause.

Introducing Virtual Reality: A New Kind of Treatment

The development of a virtual reality system is the answer to an effective treatment for

war veterans with posttraumatic stress disorder. This innovative technology was developed by

Albert “Skip” Rizzo, a researcher at the University of Southern California, and his team of

engineers, psychologists, computer scientists, and U.S. military officials [12]. The idea behind

the virtual reality system is to immerse the war veterans into a realistic environment that is

representative of what they have experienced and add different types of stimulations that will

mentally trigger the traumatic event. This allows veterans to confront the traumatic event head

on and force them to work through it rather than repress it [13]. During the virtual reality

simulation, the patient wears a head-mounted display that consists of a set of goggles with

“separate display screens for each eye” and a head-tracking device. The patient is then immersed

into a computer-generated virtual “reality” that is similar to a video game. The patient is free to

move about in their environment by using a controller (similar to ones used for video games) as

seen in Image 1 below [14]. This aspect makes the PTSD treatment more appealing to the

younger technological generations of war veterans because they grew up playing video games,

and thus are comfortable using the virtual reality form of treatment [15].

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Image 1: Patient interacting with their virtual environment through the controllerSource: http://news.cnet.com/8301-13576_3-57464637-315/virtual-reality-vs-ptsd-helping-combat-vets-heal/

During the treatment, a trained clinician will sit nearby and controls the patient’s virtual

world on a computer. To help trigger the traumatic experience, a clinician engages the patient to

situations that are similar to combat (such as a roadside bombing) and adds various forms of

sensory stimuli (such as the smell of burning gasoline, loud sound of gunfire, or replicating the

weather of the war region) [13]. The clinician will then monitor the patient’s physiological

responses (such as their heart rate or breathing patterns) while the patient is re-living the

traumatic event, and will discuss what they experienced after, as depicted in Image 2 below [16].

Based on the patient’s response to certain stimuli, the clinician is able to choose the appropriate

ones related to their trauma and repeatedly apply them to the patient’s virtual world [17]. The

ability to recreate and bring the war veterans back to their traumatic event in a realistic virtual

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environment, makes the virtual reality system an innovative and effective tool in treating the

underlying cause of PTSD rather than simply addressing the physical symptoms.

Image 2: A trained clinician is monitoring the patient’s response to their virtual world Source: http://www.northwestmilitary.com/news/articles/2010/05/northwest-military-ranger newspaper-northwest-airlifter-cassandra-fortin-virtual-reality-program-hel/

Why Virtual Reality Works

The virtual reality technology is an effective way to treat war veterans with

posttraumatic stress disorder because it incorporates exposure therapy, the most successful form

of treatment for PTSD. Research has shown that 90 percent of the patients who received eight,

ninety-minute sessions of exposure therapy no longer met the criteria for having posttraumatic

stress disorder [10]. Exposure therapy is a behavioral therapy method that targets avoidant

behaviors, a common symptom of PTSD [18]. War veterans tend to avoid talking or thinking

about the traumatic event and go so far as to avoid situations that serve as reminders of the

experience [15] [18]. Exposure therapy allows patients to “confront their fears and anxieties”

through a technique called imaginal exposure [18]. In imaginal exposure, the patients are forced

to confront their fears and anxieties by imagining the traumatic event again, discussing how they

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felt during the experience, explaining what he saw, smelled, heard, and tasted, and being

repeatedly exposed to a situation that reminds them of the traumatic experience. The patients

who received the exposure therapy all showed significant improvements from when they first

started, experiencing a 74 percent decrease in the severity of PTSD symptoms [10] [18]. Due to

the success rate of exposure therapy in treating PTSD, virtual reality technology serves as a

valuable tool in enhancing the effectiveness of this type of treatment.

The virtual reality technology allows for more comprehensive treatment by recreating

combat situations that are impossible to replicate again after the war veteran is at home. The

patient is virtually immersed back to their stressful experience in a safer and more controlled

environment. The addition of sensory stimuli in the technology helps to “evoke the trauma

memory” [19]. Psychologists believe that repeatedly exposing the war veteran to their traumatic

experience will activate repressed emotions [20]. Using virtual reality as a tool enhances the

treatment because it puts together memories, sensory stimuli, feelings, and emotions associated

with the traumatic event, all of which help the war veteran confront and cope with the complete

memory [15]. The clinician, who controls the patient’s virtual world, has the ability to pause the

system, and help them understand their emotions and responses, and eventually cope with the

memory. They can then teach the patient coping methods that can be used to manage the stress

associated with trauma, some of which include thought exercise, deep breathing, and ways to

control their emotions and thoughts [20]. Repeatedly confronting the traumatic event through the

use of virtual reality has been shown to markedly decrease the anxiety that war veterans feel

because they will have already started processing and understanding the emotions connected to

the traumatic experience rather than avoiding them. Research data indicate that anxiety scores

decreased by 36 percent in war veterans receiving virtual reality treatment [20][21]. In recent

studies in which war veterans were treated for PTSD through the use of virtual reality exposure

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therapy, 80 percent no longer met the definition of having PTSD after having completed the

therapy [21]. The use of virtual reality is not yet common and is still in the refining stages.

However, the extensive research and testing that has been conducted on this method since it was

first developed in 2005 has proved it to be the most effective approach in treating PTSD in war

veterans.

Virtual Reality: A Look into the Future

Due to the success of the virtual reality system as a method of PTSD treatment, more

extensive engineering advancements are taking place so that this technology is perfected for

future use. For example, engineers are trying to pinpoint the level of detail that is needed in the

virtual world in order for patients to respond well. Because sensory stimuli are an essential

component in creating a virtual reality, engineers are also trying to devise ways to reproduce

sensory stimuli as accurately as possible. Future virtual reality systems most likely will also

incorporate the sensory stimuli of touch that would allow war veterans to be able to virtually feel

their environment through a glove [22]. Another exciting future advancement that war veterans

and clinicians should expect to see is the incorporation of a Sim Coach, an interactive virtual war

veteran avatar. The idea behind the Sim Coach is not to replace the clinicians, but rather to

provide war veterans with the ability to anonymously talk to a virtual veteran about their PTSD

symptoms and treatment experiences outside of therapy. The patients will be able to interact with

the virtual avatar by logging onto an online virtual world and chat with them through a chat box

and a webcam in the comforts of their own home [23] [24]. The Sim Coach will be able to

provide customized assistance and responses based on the information the patient provides. This

will undoubtedly be another invaluable tool in the continuing effort to address and treat PTSD.

By perfecting the details of the virtual reality system and also enhancing the features of this

technology, it is expected that this method will be a prominent, if not dominant, form of PTSD

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treatment in the near future and where war veterans are offered the opportunity to regain a

healthy and productive lifestyle.

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Works Cited

[1] “Shocking PTSD, suicide rates for vets,” Nov. 10, 2012. [Online]. Available: http://www.facethefactsusa.org/facts/the-true-price-of-war-in-human-terms. [Accessed: April 13, 2013].

[2] C. Rubush, “Persian Gulf War Veterans PTSD Rates are Similar to Vietnam and Iraq Combat Vets,” winoverptsd.com, May 20, 2010. [Online]. Available: http://winoverptsd.com/wp/persian-gulf-war-veterans-ptsd-rates-are-similar-to-vietnam-and-iraq-combat-vets/ [Accessed: April 13, 2013].

[3] United States. Department of Veterans Affairs, “Understanding PTSD Treatment”, Feb. 2011. [Online]. Available: http://www.ptsd.va.gov/public/understanding_TX/booklet.pdf/. [Accessed: April 12, 2013].

[4] T. Collins, Fort Bragg Research Examines Value of Virtual Reality as PTSD Treatment, Army Mil, Aug. 2012. [Online]. Available: http://www.army.mil/article/86183/Fort_Bragg_research_examines_value_of_virtual_reality_as_PTSD_treatment/ [Accessed: April 13, 2013].

[5] “Veterans statistics: PTSD, Depression, TBI and Suicide,” 2002. [Online]. Available: http://www.veteransandptsd.com/PTSD-statistics.html. [Accessed: April 13, 2013].

[6] A. Levin, “Expectations Deter Vets From Mental Health Care,” Psychiatric News, vol. 48, no. 7, p. 11, April 2013. [Online]. Available: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1676239. [Accessed: May 6, 2013].

[7] “Post traumatic stress disorder,” 2009. [Online]. Available: http://bestpractice.bmj.com/best-practice/pdf/patient-summaries/ptsd-standard.pdf. [Accessed: April 9, 2013].

[8] S. Robson, “Soldiers fail to seek PTSD treatment or drop out of therapy early, research finds,” Stars and Stripes, May 15, 2012. [Online]. Available: http://www.stripes.com/news/special-reports/post-traumatic-stress-disorder-ptsd/soldiers-fail-to-seek-ptsd-treatment-or-drop-out-of-therapy-early-research-finds-1.177275. [Accessed: April 15, 2013]

[9] T. Staton, “Study: Antipsychotic doesn’t work for vets’ PTSD,” Aug. 3, 2011. [Online]. Available: http://www.fiercepharma.com/story/study-antipsychotic-doesnt-work-vets-ptsd/2011-08-03. [Accessed: April 14, 2013].

[10] S. Taylor, D. Thordarson, I. Fedoroff, L. Maxfield, and K. Lovell, “Comparative Efficacy, Speed, and Adverse Effects of Three Treatments: Exposure Therapy, EMDR, and Relaxation Training, Journal of Consulting and Clinical Psychology, vol. 71, no. 2,

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207%20Information%20page_files/2003%20--%20Comparative%20efficacy%20-%20speed%20and%20adverse%20effects%20of%20three%20PTSD%20treatments%20--%20Exposure%20therapy%20-%20EMDR%20and%20relaxation%20training.pdf. [Accessed: April 14, 2013].

[11] United States. Department of Veterans Affairs, “Overview of Psychotherapy for PTSD”, July 27, 2010. [Online]. Available: http://www.ptsd.va.gov/professional/pages/overview-treatment-research.asp. [Accessed: April 13, 2013].

[12] “Post-Traumatic Stress Disorder: Battle Ready?” The Economist, Nov. 2012, [Online]. Available: http://www.economist.com/news/science-and-technology/21566612-it-may-be-possible-vaccinate-soldiers-against-trauma-war-battle-ready [Accessed: April 13, 2013].

[13] A. Knabe, “From Disturbing Reality to Virtual Reality,” The Officer, vol. 86, no. 4, Sept. 2010. [Online]. Available: http://search.proquest.com.libproxy.usc.edu/docview/763168355. [Accessed: April 15, 2013].

[14] R. Howes, “Cool Intervention #2: Virtual Reality,” Psychology Today, Feb. 2010, [Online]. Available: http://www.psychologytoday.com/blog/in-therapy/201002/cool-intervention-2-virtual-reality [Accessed: April 13, 2013].

[15] N. Voges, “Combating PTSD Through Virtual Reality,” Los Angeles Times. July 10, 2010. [Online]. Available: http://www.latimes.com/news/nationworld/nation/sns-health-behavioral-health-ptsd-virtual-reality,1674529,460864.story [Accessed: April 13, 2013].

[16] C. Helwick, “Virtual Reality Exposure Enhances Treatment of PTSD,” Medscape Medical News, May 26, 2010. [Online]. Available: http://www.medscape.com/viewarticle/722512. [Accessed: April 15, 2013].

[17] A. Rizzo, J. Pair, K. Graap, “A Virtual Reality Exposure Therapy Application for Iraq War Military Personnel with PTSD: From Training Toy to Treatment,” NATO, [Online]. Available: http://ict.usc.edu/pubs/A%20Virtual%20Reality%20Exposure%20Therapy%20Application%20for%20Iraq%20War%20Military%20Personnel%20with%20Post%20Traumatic%20Stress%20Disorder-%20From%20Training%20to%20Toy%20to%20Treatment.pdf. [Accessed: April 15, 2013].

[18] “Virtual Reality in the fight against PTSD,” Dec. 11, 2013. [Online]. Available: http://unmfdu12.blogspot.com/2012/12/virtual-reality-in-fight-against-post.html. [Accessed: April 12, 2013].

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[19] J. Cukor, A. Rizzo, J. Difede, “Emerging treatments for PTSD,” Clinical Psychology Review, vol. 29, no. 8, Dec. 2009. [Online]. Available: http://www.sciencedirect.com.libproxy.usc.edu/science/article/pii/S0272735809001184. [Accessed: April 15, 2013].

[20] Z. Whittaker, “Virtual reality treatment used for PTSD treatment,” The Denver Post, June 30, 2012. [Online]. Available: http://www.americanhomecomings.com/culture/2012/06/30/virtual-reality-treatment-used-for-ptsd-treatment/ [Accessed: April 15, 2013].

[21] D. Terdiman, Virtual Reality vs. PTSD Helping Combat Vets Heal, CNET, Jul. 2012. [Online], Available: http://news.cnet.com/8301-13576_3-57464637-315/virtual-reality-vs-ptsd-helping-combat-vets-heal/ [Accessed: April 13, 2013].

[22] H. Rodriguez, NAE Grand Challenges for Engineering, National Academy of Engineering, 2012, [Online]. Available: http://www.engineeringchallenges.org/cms/8996.aspx [Accessed: April 13, 2013].

[23] L. Biron, “Virtual Reality Helps Service Members Deal with PTSD,” DefenseNews. June 11, 2012. [Online]. Available: http://www.defensenews.com/article/20120611/TSJ01/306110003/Virtual-Reality-Helps-Service-Members-Deal-PTSD. [Accessed: May 4, 2013].

[24] A. Piore, “Big Idea: Help Stressed Vets With Sim Coaches,” Discover Magazine. October, 2012. [Online]. Available: http://discovermagazine.com/2012/dec/25-help-stressed-vets-with-sim-coaches#.UYXiyr-nCfQ. [Accessed: May 4, 2013].

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Biography of the Author

I am currently a third-year transfer student in the USC School of Occupational Science and

Occupational Therapy. I am planning on working with kids with disabilities and special needs

and my dad, a Vietnam War veteran, was the source of inspiration behind this article.

Contact Information

Chelsea Nguyen

Phone Number: (818) 274-8202

Email: chelsean@usc.edu

Suggestions of Multi-media Applications

I think that this article would be enhanced if we were able to include videos of the virtual reality

system. I think that one video that should be included is one that shows what a patient would see

if they were to put on the goggles just so that we are able to see just how realistic the technology

is. Another type of video that should be included in this article is one that shows a treatment

session with both the patient and the clinician. There are several out there that demonstrate how

the clinician controls the patient’s environment and how they are monitoring the patient’s

response. The most important one to include would be one that demonstrates what the system

looks like and how it is used for better understanding of what this type of treatment is about. The

last suggestion would be a mock up of what the Sim Coach application would look like how it

would be used.