Virtual Reality and PTSD

Jeff Pyne, MD, CAVHS

Outline

• Relevant PTSD background

• Exposure therapy for PTSD

• VR assisted exposure therapy

• Psychophysiologic predictors of PTSD

• Future directions

PTSD Prevalence

• OIF/OEF veterans – 11 to 20% met PTSD criteria 3-4 months after returning from combat

• Persian Gulf War veterans – 9% met PTSD criteria• Vietnam veterans – 31% of men and 27 % of women

met criteria PTSD at some point after their return from the war – recently revised to 18.7%

• Other veterans – 8 to 12% met criteria PTSD

OIF/OEF Veterans• The violent guerrilla tactics used by insurgents in

Iraq will take a considerable toll on the mental health of troops, resulting in a lifetime of disability payments for many of those who return from war. Anthony Principi, U.S. Secretary of Veterans

Affairs, September 23, 2004

OIF/OEF PTSD vs. Gulf War PTSD

• Expectations are for greater numbers with IOF/OEF because:– Longer deployments– Repeated deployments– Non-conventional warfare– Increased use of reservists (~50%)

PTSD Treatment Consensus Panel (2000)

• SSRIs – most appropriate first-line medication treatment for PTSD

• Exposure therapy – most appropriate psychotherapy for PTSD

Emotional Processing Theory – Basis for Exposure Therapy

• Fear memories are stored as a fear structure– Fear structure = stimuli + meaning + responses– Accessing the fear memory allows for fear structure

change

• Access– Imaginal– In-vivo– Virtual

• Change – Cognitive re-frame– Habituation, re-appraisal, and mastery

• Many patients are unwilling or unable to effectively visualize the traumatic event– Avoidance of reminders of the trauma is inherent in

PTSD– Inability to emotionally engage (in imagination) is a

predictor for negative treatment outcomes (Jaycox, Foa, & Morral, 1998).

• “…some patients refuse to engage in the treatment, and others, though they express willingness, are unable to engage their emotions or senses.” (Difede & Hoffman, 2002).

• Risk of flooding and flashbacks

Potential Problems with Imaginal Exposure

VR PTSD R&D

• Virtual Vietnam – Emory University• World Trade Center – Weill Cornell Medical Center/U of Wash• Terrorist Bus Bombing - U. of Haifa/U of Wash• Motor Vehicle Accidents – Univ. of Buffalo

• Virtual Angola – U. of Lusófona de Humanidades e Tecnologias, Lisbon

• Virtual Iraq – USC Institute for Creative Technologies• Virtual Baghdad – Virtual Reality Medical Centers

Virtual Vietnam

Published VR PTSD studiesPublished VR PTSD studiesPublished VR PTSD studiesPublished VR PTSD studies

AuthorAuthor YearYear SubjectsSubjects ResultsResults

Rothbaum Rothbaum et alet al

20012001 10 of 16 Vietnam 10 of 16 Vietnam veterans recruitedveterans recruited

Open trial, 8 – 16 biweekly sessions, Open trial, 8 – 16 biweekly sessions, 15 – 67% decrease in CAPS scores at 15 – 67% decrease in CAPS scores at 6 months6 months

Difede et alDifede et al 20062006 17 WTC 17 WTC survivors who survivors who failed previous failed previous ETET

Wait list control, 14 sessions, large Wait list control, 14 sessions, large effect sizeeffect size

Basoglu et Basoglu et alal

20072007 31 earthquake 31 earthquake survivorssurvivors

Assessment only control versus single Assessment only control versus single session, significant symptom session, significant symptom differences at 8 weeksdifferences at 8 weeks

Beck et alBeck et al 20072007 6 MVA survivors6 MVA survivors 10 sessions, significant decrease in 10 sessions, significant decrease in PTSD symptom severityPTSD symptom severity

Ongoing VR Combat PTSD Studies

• “Virtual Reality (VR) as an Adjunct Therapy for Acute PTSD in Non-Combatants.” Office of Navy Research. February 2005-January 2008

• “Use of Virtual Reality with Returning OIF and OEF Combatants with Acute Stress Response and PTSD.” Office of Navy Research. February 2005-January 2008

• “Psychophysiological Reactivity to Identify and Treat Veterans at Risk for PTSD.” VA Clinical Research Service. April 2007-March 2010

Combat PTSD VR Elements

• Multiple scenario settings• Selectable user perspective options• Create library of “trigger” stimuli• Create a highly usable “Wizard of OZ” clinician interface• Options:

– Integrate scent and vibration– Integrate physiological recording into clinician interface

• Major Goal: customize VR exposure based on client experienceustomize VR exposure based on client experience

Multiple Scenario Settings

• City Scenes

• Small Rural Villages

• Building Interiors

• Convoys & Checkpoints

• Desert Base

• Desert Highway

City Scenario - 1

City Scenario - 2

Selectable User Perspective Options

• Walking Alone

• Walking with One Person

• Flocking Patrol

• HUMVEE Interior View

• HUMVEE Convoy

• Helicopter Interior View

HUMVEE Convoy

Helicopter Interior View

“Wizard of Oz” type clinical interface

• Tool for placing patient in a virtual environment similar to that in which traumatic events occurred

• Customize the therapy experience to the patient’s experience

• Therapist retains control of environment intensity

• Systematic delivery of “trigger” stimuli

• Scenario and settings– Location, Time of Day,

Weather, etc.

• User perspective– Alone, Patrol, HUMVEE,

Helicopter, etc.

• Real-time physiologic display

• Trigger stimuli

“Wizard of OZ” Clinician Interface

Example of Trigger Stimuli Display

Optional Scent and Vibration Integration

• Nasal puffer

• Scent library includes regular gunpowder, “military gunpowder”, burning rubber, trash, Iraqi spices, radiator fluid, etc.

• Vibration platform

• Heat source

Optional Physiologic Monitoring

• Therapist display shows client’s field of vision

• Physiologic monitoring used to assist with anxiety modulation training and monitoring therapeutic habituation

Monitoring and Patient Controller

Examples of Ongoing VR Combat PTSD Treatment Studies

• NMCSD– Marine Corps personnel

• 10 – 15 sessions based on Foa exposure therapy protocol– Includes listening to audio-taped narrative while in VR as

homework

– Support personnel• 10 – 20 sessions based on exposure/biofeedback protocol

• Emory– Case study – 4 sessions– VR versus VR + D-cycloserine

Example of PTSD Prediction Model Study Using Psychophysiologic Measures

1. Evaluate clinical utility of psychophysiological measures versus self-report measures as screening and outcomes monitoring tools for OIF/OEF veterans in treatment and at risk for PTSD.

2. Determine acceptability of psychophysiological reactivity measures as screening and outcomes monitoring tools for PTSD from perspectives of veterans and mental health clinicians.

3. Determine acceptability of virtual reality (VR) assisted graded exposure therapy as a treatment for combat related PTSD from perspectives of veterans and mental health clinicians.

Self-Report Risk Factors for PTSD Onset and Chronicity

• Trauma– Intensity, duration– Peri-traumatic dissociation

• Individual– Genetic, family hx, childhood trauma, – Personality d/o, poor school perf, low IQ– Baseline anger, substance abuse, somatization

• Environment– Low social support, additional life stressors

Problems with Self-Report Risk Factor Model

• Most measures are self-report and subject to reporting bias

• May be a more distal outcome of trauma exposure

• More objective measures related to arousal mechanisms and informational processing may produce less-biased and more proximal models of PTSD risk

Psychophysiologic Reactivity Measures

• Arousal mechanisms– Heart rate, heart rate variability, respiratory

rate, and skin conductance responses to VR environments

– Acoustic startle

• Information processing mechanisms– Emotional Stroop– Eye-gaze tracking to visual stimuli

Specific Aim 1

• Compare psychophysiological (objective) versus self-report (subjective) models in terms of cross-sectional and longitudinal PTSD outcomes

• Baseline and 6-month assessments• 60 patients seeking treatment for PTSD• 90 National Guard members not seeking

treatment

VR Exposure Protocol (prelim)

• Low threat level combat environment • Low threat level civilian environment • 5 minute rest period – 3 minutes VR environment

(random) – 3 minutes rest – 3 minutes other VR environment – 3 minutes of rest

• Rest periods will include neutral scene and classical music

• Physio measurement pre and post each exposure

Measures

• Subjective– CAPS, MINI (comorbid anxiety disorders), PHQ-9,

Anger, Substance abuse, Combat exposure, Non-combat trauma exposure, Mental health history, SF-12, QWB-SA, sociodemographic

• Objective– VR exposure (HR, HRV, SC), Startle (HR),

Combat/facial recognition (RT, IO, EPT), Emotional Stroop (RT)

Specific Aim 2

• Determine the acceptability of psychophysiological reactivity measures as screening and outcomes monitoring tools for PTSD from the perspectives of veterans and mental health clinicians.\

• Clinicians – focus groups• Subjects – purposive sample, qualitative

interviews, immersion measure

Specific Aim 3

• Determine the acceptability of virtual reality (VR) assisted graded exposure therapy as a treatment for combat related PTSD from the perspectives of veterans and mental health clinicians.

• Methods similar to Specific Aim 2

Potential Future Military Use of PTSD VR Technology

• Integrate VR combat exposure as part of a comprehensive program to assess fitness for duty

• Stress inoculation training• Reintegration screening using VR PTSD with physiological

recording to check for physiological reactivity • Post-combat reintegration training for military members at

risk– This could provide a treatment pathway with less perceived stigma

given younger military personnel’s familiarity with digital gaming– More attractive intervention than traditional talk therapy

Potential Future General Use of VR Technology

• Stress inoculation• Resiliency training• Diagnostic tool• Cognitive rehab• Neuroimaging with highly controlled stimulus events• Identification of physiologic or genetic markers• Addiction assessment/treatment• Occupational rehab• Physiologic reactivity to any relevant stressor

Current Clinical Uses of VR (VRMC in San Diego, West LA, Palo Alto)

• Anxiety Disorders, including Anxiety Disorders, including PTSD, phobias, and panic PTSD, phobias, and panic

• Anger managementAnger management• Stress inoculation trainingStress inoculation training• Peak performance trainingPeak performance training• Leadership trainingLeadership training• Eating disorders and obesityEating disorders and obesity• PainPain• AddictionsAddictions• AutismAutism• Classroom ADHDClassroom ADHD• TBI/Stroke cognitive rehabilitationTBI/Stroke cognitive rehabilitation• Physical rehabilitationPhysical rehabilitation