Virtual Reality Exposure: Efficacious Treatment for Combat PTSD?

Virtual Reality Exposure: Efficacious Treatment for Combat PTSD?

Sarah D. Miyahira, Ph.D.Pacific Telehealth & Technology Hui

Department of Veterans Affairs Pacific Islands Health Care System Honolulu, Hawaii

Hunter G. Hoffman, Ph.DUniversity of Washington, Seattle, Washington

Raymond A. Folen, Ph.D.Tripler Army Medical Center, Honolulu, Hawaii

Azucena Garcia-Palacios, Ph.D.Universitat Jaume 1, Castellon,Spain

Cybertherapy 2008 ConferenceSan Diego, CA, USA

June 24, 2008

Pacific Telehealth and Technology Hui

A DoD/DVA Joint Venture

U.S. Warfighters Deployed to Iraq & Afghanistan-RAND Report, 2008

Approximately 1.64 million U.S. warfighters deployed to Iraq and Afghanistan since October 2001

Many experience prolonged exposure to stressful and traumatic combat events

18.5% returning troops have PTSD or depression

≈50% who need treatment, seek treatment

≈50% who are treated receive minimally adequate care

Recommendation: improve access to High Quality care (supported by scientific evidence)



Prevalence of Mental Health or Cognitive Impairment



What We Know About Exposure to Combat

Intensity and frequency of violence and threat of death in combat increases risk for PTSD

Most warfighters do not develop PTSD

Most with PTSD will recover naturally over time

Others develop chronic PTSD if not treated

High co-morbidity: alcohol & drug abuse, medical problems, depression, other psychiatric disorders

“To this day I can still hear our screams and recall the feeling of the truck being lifted and shaken with every explosion.” Spc. J. Norrel

Convoy attack and IED explosion survivor



Virtual Reality Treatment for PTSD

Potentially powerful treatment approach Early studies show promising results

Rothbaum et al (2001)

Difede and Hoffman (2002; 2006) Few published controlled studies More empirical evidence required

VR Exposure Treatment of Combat PTSD

Randomized controlled study

Compare VR exposure treatment to delayed treatment of PTSD in returning warfighters from Iraq and Afghanistan

Treatment: CBT augmented with VR exposure

10 treatment sessions (2x/week)

Graded VR exposure (auditory, visual, kinesthetic stimuli)

Physiologic monitoring: heart rate, temperature, skin conductance, respiration

VR Environment: Middle East World (MEW)

Humvee convoy in Middle East town

Critical events: IED explosions, gunfire attack, swerving car, RPG attack

VR elements: 3D visual animation, stereophonic audio, chair vibrations

Therapist interface: keyboard to activate and deactivate images, sounds, and animation

Individual customization of stressful events

Increase or decrease level of stress arousal



VR Environment: Middle East World







Sample Characteristics

Characteristic Mean Value or Status

Age 24.2

Number of Months in Military 59.3

Length of Deployment 14 months

Rank E 4-5

Function Infantry, MP, Medic

Education HS Diploma/Some College

Martial Status Separated or Divorced

Ethnicity White (71%)/Hispanic (29%)



Pre-Treatment Status

Measure Mean Level

CES 30.2 Moderate Heavy

CAPS 81.5 Severe

PDS 35.5 Moderate Severe

BDI 24.7 Moderate

TRGI 51.7 Mild

QOLI 35.5 Low



Sessions 2-6 - Temp

8 11

04

22

00

32

96

43

92

54

88

65

84

76

80

87

76

98

72

10

96

812

06

413

16

014

25

615

35

216

44

817

54

418

64

019

73

620

83

221

92

823

02

424

12

025

21

626

31

227

40

8

Case Number

90.000

92.000

94.000

96.000

Va

lue

Temp2

Temp3

Temp4

Temp5

Temp6



Sessions 2-6 - Resp

8 11

04

22

00

32

96

43

92

54

88

65

84

76

80

87

76

98

72

10

96

81

20

64

13

16

01

42

56

15

35

21

64

48

17

54

41

86

40

19

73

62

08

32

21

92

82

30

24

24

12

02

52

16

26

31

22

74

08

Case Number

10.000

20.000

30.000

40.000

Valu

eResp2

Resp3

Resp4

Resp5

Resp6



Sessions 2-6 - HR

1 4 7 10

13

16

19

22

25

28

31

34

37

40

43

46

49

52

55

58

Case Number

65.00

70.00

75.00

80.00

85.00

Valu

eHR250to90

HR350to90

HR450to90

HR550to90

HR650to90



Sessions 2-6 - EDR

8 1088

2168

3248

4328

5408

6488

7568

8648

9728

10808

11888

12968

14048

15128

16208

17288

18368

19448

20528

21608

22688

23768

24848

25928

27008

Case Number

0.000

1.000

2.000

3.000

Va

lue

EDR2

EDR3

EDR4

EDR5

EDR6

Surveys of OIF warfighters report significant levels of mental health impairment

Sample data indicates moderately heavy combat exposure and high PTSD severity

Preliminary physiologic data indicates VR arousal & habituation with repeated exposure

Anecdotal & subjective ratings indicate high presence

Controlled studies needed to demonstrate efficacy of VR

Summary



Acknowledgements

Funding for this research study is provided by the Office of Naval Research, Science and Technology

This material is the result of work supported with resources and the use of facilities at the, Department of Veterans Affairs, Pacific Islands Health Care System, Honolulu, HI

Contact Information:

Sarah D. Miyahira, Ph.D. Pacific Telehealth & Technology Hui 459 Patterson Road Ste. 4E-B100 Honolulu, Hawaii, USA 96819-1522 [email protected]

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Virtual Reality Exposure: Efficacious Treatment for Combat PTSD?