Virtual reality (VR)-facilitated exposure therapy for posttraumatic stress disorder (PTSD), recently evaluated under combat conditions in Iraq, appears to be safe and effective, according to LCDR Robert McLay, research director for mental health with the US Naval Medical Center San Diego (NMCSD). Speaking at the 17th Annual Medicine Meets Virtual Reality (MMVR-17) Conference in Long Beach, Calif, McLay said that military providers need to make PTSD treatments available in such military theaters as Iraq and Afghanistan, as well as stateside. (McLay was speaking as an individual, not as a US Navy or Department of Defense representative.)
Last year, a RAND Corporation research brief, “Invisible Wounds: Mental Health and Cognitive Care Needs of America’s Returning Veterans,” disclosed that 14% of US service members who have returned from Afghanistan and Iraq report current symptoms of PTSD, but only about half seek treatment.
Estimates are that PTSD develops in 11% to 17% of service members who have been deployed to combat zones and that the likelihood of symptoms increases for those with repeated deployments. While the “military is aggressive about providing mental health care at the front, how various treatments developed in civilian settings apply to care in a combat zone” is sometimes unclear, according to McLay and colleagues.1 VR is a “subset of exposure therapy.” It immerses patients in simulations of trauma-related environments in which the emotional intensity of the scenes can be precisely controlled by the clinician.
In 2005, the Office of Naval Research awarded $4 million to support tests of VR-based treatments at the NMCSD, the US Marine Corps Base and Naval Hospital at Camp Pendleton (Oceanside, Calif), and the Tripler Army Medical Center in Honolulu. McLay served as a principal investigator on the VR research protocols conducted at the NMCSD and the Naval Hospital at Camp Pendleton.
The VR system involves 3 computers. One displays the visual and auditory simulations developed by the Virtual Reality Medical Center (VRMC) in San Diego and is referred to as “Virtual Baghdad” or “Convoy.” The virtual simulations are viewed via a head-mounted display, and users can navigate the terrain and interact with virtual people. The second computer has a control panel and menu that the therapist uses to add arousing elements to the VR environment, visual or auditory, as well as specific weather conditions and time of day. The third computer is used to track and record biofeedback data, such as the participant’s heart rate, respirations, and skin conductance.
From February to September 2008, McLay served as a psychiatrist at Camp Fallujah, Iraq. “The base no longer exists, we handed it back to the Iraqis, but at the time, there were several thousand service members stationed there, and it was a center for medical treatment in al-Anbar Province.” At Camp Fallujah, McLay treated 175 patients, 11 of whom had combat-related PTSD, and 2 who had sexual assault–related PTSD. Treatment was conducted as part of routine clinical practice. Two modes of therapy were used: VR Exposure Therapy (VRET) and VR Graded Exposure Therapy (VRGET).
Six patients underwent VR treatment for PTSD; 5 of the patients had PTSD from previous deployments. One previously had been through an extensive course of therapy in the United States.
Patients received training in relaxation and biofeedback, recited their trauma narrative, were familiarized with the VR system, and then recited their trauma narrative while experiencing VR. Symptom changes were tracked by clinical interview and with the use of the PTSD Checklist–Military Version (PCL-M), the Patient Health Questionnaire, and the Beck Anxiety Inventory.
All patients showed some improvement with treatment, with a mean decrease in PTSD symptoms of 73% on the PCL-M. Five of the 6 patients showed effective remission of PTSD symptoms; the sixth was discharged before completing treatment.
Although the clinical experience involved relatively few patients, “it did show that VR can be successfully applied to treat PTSD in theater,” McLay noted. He cited examples of 2 patients.
1. McLay RN, Johnston SL, Wiederhold M, Wiederhold BK. Use of virtual reality in Iraq to treat posttraumatic stress disorder. Presented at: 17th Annual Medicine Meets Virtual Reality Conference (Mental Health and Simulation Session); January 19, 2009; Long Beach, CA.
2. Rizzo AA, Reger G, Gahm G, et al. Virtual reality exposure; therapy for combat related PTSD. In: Shiromani P, Keane, TM, LeDoux JE, eds. Post-Traumatic Stress Disorder: Basic Science and Clinical Practice. New York: Springer-Verlag; 2009.
3. Rizzo AA, Difede J, Rothbaum BO, et al. VR PTSD exposure therapy results with active duty OIF/OEF combatants. In: Westwood JD, Westwood SW, Haluck RS, et al, eds. Medicine Meets Virtual Reality 17, Studies in Health Technology and Informatics. Amsterdam: IOS Press; 2009:277-282.
4. Wood DP, Murphy JA, Center KB, et al. Effectiveness of virtual reality graded exposure therapy with physiological monitoring for combat-related post traumatic stress disorder. Presented at: 17th Annual Medicine Meets Virtual Reality Conference (Mental Health and Simulation Session); January 19, 2009; Long Beach, CA.