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The rapid pace of Virtual Reality (VR) and Interactive Computer Games advancements are producing significant opportunities for the health and medical communities. The Department of Defense (DoD) is capitalizing on these advancements through research centers such as the Institute for Creative Technologies (ICT); a University Affiliated Research Center (UARC) that is affiliated with the University of Southern California (USC) and being managed by the U.S. Army Research Laboratory's Simulation and Training Technology Center. Innovations being developed by this research center represent the start of a rapidly growing field. One of the efforts pioneering this growth: The Virtual Iraq/Afghanistan effort. Other efforts will be addressed in future posts.
Virtual Iraq/Afghanistan is an interactive VR-based application developed to aid in the assessment and treatment of soldiers returning from Iraq and Afghanistan who are diagnosed with anxiety disorders such as Post Traumatic Stress Disorder (PTSD). The Virtual Iraq/Afghanistan application uses VR as a promising alternative to traditional imaginal exposure therapy in which patients suffering from such anxiety disorders are led by clinicians to imagine their traumatic experiences in an incremental, stepwise fashion. Just as an aircraft simulator can teach a pilot how to operate efficiently under extreme weather conditions, VR simulations can be used by a clinician to help patients cope with and overcome their trauma.
Virtual Iraq/Afghanistan consists of a series of VR environments designed to resemble Middle Eastern city and desert scenes that are typical trauma settings for use in VR exposure therapy. One of the advantages of using VR in the treatment of patients with anxiety disorders is that patients can be teleported into virtual environments that are representative of the traumatic experiences they are seeking to overcome. The intensity of these virtual environments can be configured and adjusted by clinicians using visual, audio, olfactory, and vibrotactile stimuli and triggers such that patients can be immersed into environments representative of their traumatic experiences in an incremental, stepwise fashion. By exposing patients to their traumatic experiences through immersion in representative virtual environments in this gradual fashion, clinicians can assist these patients in progressing towards overcoming their anxiety disorders. In comparison, imaginal exposure therapy relies on patients being able to effectively imagine their traumatic experiences. However, many patients are unwilling or unable to visualize these traumatic experiences. In fact, avoidance of reminders of the trauma is one of the cardinal symptoms of PTSD. The Virtual Iraq/Afghanistan application addresses this potential limitation by offering a means by which to overcome the natural avoidance tendency of trauma sufferers.
The use of VR for exposure therapy has been supported by previous reports in which patients with PTSD, who were unresponsive to previous imaginal exposure treatments, went on to respond successfully to VR exposure therapy [1, 2, 3]. In one such study the Virtual Iraq/Afghanistan exposure therapy prototype system produced a statistical and clinically meaningful reduction in PTSD symptoms for active duty military personnel who did not previously benefit from traditional forms of treatment [4].
A new clinical trial is being initiated involving the use of the Virtual Iraq/Afghanistan application. D-Cycloserene (DCS) is a broad-spectrum antibiotic which has been used in clinical trials over the last decade as a cognitive enhancer. DCS has an essential role in learning and memory and has been shown to enhance learning to include the extinction of conditioned fear responses such as those experienced for various anxiety disorders. In one case it was demonstrated that DCS combined with VR exposure therapy for fear of heights significantly reduced the number of sessions needed for successful treatment from six to only two sessions [5]. In another case it was found that DCS combined with imaginal exposure was an effective treatment for social anxiety [6]. In one of the recent PTSD treatment studies being conducted at Walter Reed Army Medical Center some participants have required as many as eighteen to twenty sessions to achieve a successful treatment response and a significant percentage of service members have dropped out of the study prior to completion. If DCS is effective in accelerating, as well as improving the response to therapy, this could make therapy more appealing, and could enable larger numbers of patients to be successfully treated since fewer sessions would be required. Results obtained through the new study will allow several significant comparisons to be made: (1) a direct comparison of VR versus imaginal exposure therapy: to date a comparison of these approaches has never been conducted for the intervention of PTSD in a randomized trial; (2) a direct test to see if DCS can help exposure therapy work faster and more efficiently; and (3) determining if the effects of DCS differ across various types of exposure therapy. This clinical trial will be performed at various locations authorized by the Institutional Review Board including Cornell and Emory colleges as well as the Long Beach Veterans Administration (VA) in California.
In summary, the Virtual Iraq/Afghanistan application provides a promising means by which people suffering from anxiety disorders such as PTSD can progress towards overcoming these anxiety disorders by immersing them in virtual environments representative of their traumatic experiences in a stepwise fashion.
Conclusion
Significant technological advancements in VR and Interactive Computer Games have generated novel opportunities for the health and medical communities. Technical innovations, such as those being developed by the ICT, will continue to advance the health and medical fields and represent the start of a rapidly growing field. Additional information regarding the Virtual Iraq/Afghanistan application and other technological innovations being developed by the ICT is available at http://ict.usc.edu/. Other new innovations that are pioneering this field will be addressed in future posts.
References
1. Rizzo AS, Difede J, Rothbaum BO, Reger G, Spitalnick J, Cukor J, et al. Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD. Ann N Y Acad Sci. 2010;1208:114-25
2. Rothbaum BO, Hodes LF, Ready D, Graap K, Alarcon RD. Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. J Clin Psychiatry. 2001;62(8):617-22
3. Difede J, Cukor J, Jayasinghe N, Patt I, Jedel S, Spielman L, et al. Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. J Clin Psychiatry. 2007;68(11):1639-47.
4. 11Kenny, P., T. Parsons, et al. (2008). Evaluation of Justina: A Virtual Patient with PTSD. 8th International Conference on Intelligent Virtual Agents. Tokyo, Japan, Springer.
5. Ressler KJ, Rothbaum BO, Tannenbaum L, Anderson P, Graap K, Zimand E et al (2004). Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Arch Gen Psychiatry 61: 1136-1144.
6. Hofmann SG, Meuret AE, Smits JA, Simon NM, Pollack MH, Eisenmenger K et al (2006). Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Arch Gen Psychiatry 63: 298-304.
This article was co-written by Albert "Skip" Rizzo, Ph.D.
