Prolonged Exposure and Virtual Reality–Enhanced Imaginal Exposure for PTSD following a Terrorist Bulldozer Attack: A Case Study

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  • Prolonged Exposure and Virtual RealityEnhancedImaginal Exposure for PTSD following a Terrorist

    Bulldozer Attack: A Case Study

    Sara A Freedman, Ph.D.,1 Hunter G. Hoffman, Ph.D.,2 Azucena Garcia-Palacios, Ph.D.,3

    Patrice L (Tamar) Weiss, Ph.D.,4 Sara Avitzour, MSW,1 and Naomi Josman, Ph.D.4


    In this case study, virtual reality was used to augment imaginal exposure in a protocol based on prolongedexposure. A 29-year-old male patient developed posttraumatic stress disorder after surviving a deadly terroristbulldozer attack on two civilian buses and several cars in Jerusalem; the traumas witnessed by the survivorincluded a decapitation. The crowded bus in which the patient was riding was pushed over onto its side by theterrorist, injuring, trapping, and terrifying the passengers and causing gasoline to leak. Guided by his therapist,the patient entered an immersive computer-generated virtual world to go back to the scene of the traumaticevent to help him gain access to his memories of the event, process and reduce the intensity of the emotions(fear=anger) associated with his pathological memories, and change unhealthy thought patterns. Traumaticmemories of childhood abuse and traumatic memories of the bulldozer terrorist attack were treated usingimaginal exposure while the patient was in the virtual environment BusWorld. The patient showed largeposttreatment reductions in PTSD symptoms, and his Clinician-Administered PTSD Scale (CAPS) scoresdropped from 79 pretreatment to zero immediately posttreatment, and CAPS was still at zero 6 months later.Although case studies are inconclusive by nature, these encouraging preliminary results suggest that furtherexploration of the use of virtual reality during modified prolonged exposure for PTSD is warranted. As terroristattacks increase in frequency and severity worldwide, research is needed on how to minimize the psychologicalconsequences of terrorism.


    Asubset of people who experience a terrifying and po-tentially deadly physical or emotional incident developchronic psychological problems such as posttraumatic stressdisorder (PTSD). The incidence of developing PTSD followingdirect exposure to a terrorist attack is as high as 37.8%.1 Peoplewith PTSD commonly have persistent thoughts, memories, ornightmares about the traumatic event; have trouble sleeping;avoid thinking about the traumatic event; feel emotionallynumb; and show social avoidance. Other common symptomsinclude recurring flashbacks, irritability, anger, rage, and hy-pervigilance. PTSD sufferers often systematically avoid mem-ories and emotions associated with the traumatic event. Foaand Kozak2 theorize that avoidance perpetuates pathologicalmemories of traumatic events and interferes with recovery.

    When used to treat PTSD, the core components of exposuretherapy include having participants repeatedly self-generate,visualize, and describe their recollection of the traumaticevent (imaginal exposure) and gradually exposing them re-peatedly to fear-evoking, real-world situations or objects thatremind them of their traumatic event (in vivo exposure).3

    According to Foa and Kozak,2 the most effective exposuretherapy involves eliciting a fear response as patients ac-cess their memory of the traumatic event. During therapy,while their memory of the traumatic event is activated andthey are showing a fear response, patients process theiremotions associated with the traumatic memory (e.g., viahabituation). While their memory of the traumatic event isaccessed, information incompatible with some of the patho-logical elements of memory is introduced. For example, in-stead of the erroneous belief that avoiding any thoughts

    1Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel.2HITLab, Mechanical Engineering, University of Washington, Seattle, Washington.3Department of Psychology, Jaume I University, Castellon, Spain.4Department of Occupational Therapy, University of Haifa, Mount Carmel, Haifa, Israel.

    CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKINGVolume 13, Number 1, 2010 Mary Ann Liebert, Inc.DOI: 10.1089=cyber.2009.0271


  • associated with the traumatic event is their best coping strat-egy, patients may realize during therapy that gradually ap-proaching and remembering the traumatic event will reducetheir suffering in the long run. During therapy, a healthiermemory is formed containing new elements. Patients developmore accurate metamemorial assumptions and retain fewerpathological beliefs. Exposure therapy is the most empiri-cally supported intervention for PTSD4 and has a high treat-ment success rate for patients who complete treatment.Unfortunately, most people who have PTSD never seektreatment, and most people with PTSD who seek treatmentnever receive cognitive behavior therapy (CBT) involvingexposure (e.g., prolonged exposure [PE]). Although large-scale efforts to increase dissemination are underway, CBTcombined with exposure is not widely used by clinicians in thecommunity who treat patients with PTSD.5 Several differentexposure therapy protocols for treating PTSD have been de-veloped and studied. In addition to the goal of improvingoutcome of completers, increasing patient and clinician ac-ceptance and reducing treatment dropouts are importantareas for future improvement.

    People with PTSD fastidiously avoid thinking about theirtraumatic event. Getting them to imagine=self-generateimages of their traumatic experience during therapy can bedifficult.2 Patients often have exaggerated worries about whatis going to happen if they allow themselves to access theirtraumatic memory (e.g., they will go crazy or have a heartattack). For some patients, pathological memories may beunusually difficult to access using imaginal exposure, limit-ing emotional processing.2 According to Foa and Kozak,2

    situations that enhance fear evocation and habitation duringtherapy are expected to improve treatment outcome.

    Virtual reality (VR) computer-generated simulations oftraumatic events have been proposed as a means of facili-tating a patients ability to visualize and remember a fear-provoking traumatic event in a gradual, controlled fashion.6,8

    Instead of patients having to use great effort to self-generateimages that help them gain access to their memories oftraumatic events, the computer generates the images forthem. Guided by their therapist, patients enter an immersivecomputer-generated virtual world that helps take them backto the scene of the traumatic event. With VR, patients expe-rience gradually more realistic depictions of the terrorist at-tack they witnessed=experienced, to help them gain access totheir memories of the event, process and reduce the intensityof the emotions (fear=anger=guilt) associated with their path-ological memories (e.g., via habituation), and change un-healthy thought patterns. Graded exposure helps patientsbecome more comfortable thinking about what happenedwith much less anxiety and less avoidant of remembering thetraumatic events.

    VR therapy for PTSD was first used in a case series byRothbaum et al.7 to treat combat veterans. In the first studyusing VR to treat civilian PTSD, Difede and Hoffman6 de-veloped a virtual environment that involves a graded im-mersive simulation the September 11, 2001, attack at theWorld Trade Center in Manhattan. In the first controlledstudy on VR exposure therapy for PTSD,8 nine out of the 10VR exposure therapy patients showed a reduction in PTSDsymptoms, seven patients no longer had PTSD after VR ex-posure therapy, and five who had previously failed to im-prove with traditional therapy showed 25% to 50% or more

    reductions in PTSD symptoms after completing therapy.8

    These gains were maintained at 6-month follow-up. In con-trast, all waiting-list control patients still had clinical PTSD atthe end of the study. Further research on VR exposure ther-apy for PTSD is warranted by these encouraging preliminaryresults, and there are a growing number of patients needingtreatment for PTSD. For example, tens of thousands of U.S.soldiers are returning from Iraq and Afghanistan with PTSD.9

    As terrorist attacks increase in frequency and severity world-wide, research is needed on how to minimize the psycho-logical consequences of terrorism.4

    Palestinians and Israelis have both been victims of trau-matic events stemming from their violent conflict. Israelicivilians have been targeted in a number of Palestinian ter-rorist attacks. For example, in 2008, in downtown Jerusalem,a Palestinian construction worker driving a bulldozer at-tacked a woman and infant in a car, ramming the plow of hisbulldozer into the womans windshield, decapitating thefemale driver with his plow.10 He subsequently used hisbulldozer to lift two public transit buses loaded with civilianpassengers onto their sides, trapping the passengers inside(see Fig. 1), and went on to crush several more cars. Severalcivilians were killed, and their mutilated bodies had to beextricated from cars crushed by the bulldozer. In addition tothe fatalities, several people were injured in the attack. Anumber of survivors of that attack subsequently developedPTSD. The patient in the present case study was a passengeron one of the buses turned over in the attack. He was in gravepersonal danger and helped other passengers off the busbefore escaping himself.

    This case report presents the first results of a treatmentbased on Foas PE protocol11 but using VR to augment theimaginal exposure components during treatment of PTSD ina civilian survivor of the 2008 bulldozer attack.



    At pretreatment assessment, the patient was a 29-year-oldmiddle-class married male Israeli citizen. He had recentlysurvived the July 2008 terrorist bulldozer attack in Jerusalemand entered treatment approximately 1 month after the at-tack. He is college