Robert J. Ursano, MD

The Ebola outbreak has given reason for concern across the globe and most recently in the US. Recent media attention and ongoing coverage of the Ebola outbreaks in West Africa, as well as recent cases in the US, contribute to confusion among many. All this attention has also created fear and distress for our patients and their families and for health care workers. Individuals with preexisting psychiatric conditions may be particularly vulnerable to anxiety and mood symptoms as well as to the use of maladaptive coping, including substance use.

When widespread fear and anxiety about the spread of an infectious disease stress our society, psychiatrists can play a variety of important roles in population health management (

). They can work directly with patients to encourage frank discussion of worries and distress, and they can identify symptoms such as sleep disturbances and exacerbation of underlying mental illness. Psychiatrists can also support primary care physicians and encourage them to address patients’ concerns.

In the community, psychiatrists can educate leaders about risk communication to decrease fear and anxiety. For psychiatrists who work in hospitals that may receive Ebola patients, additional consultation and work with the infectious disease teams and families of the patients (or those in quarantine) are needed. Ensuring optimal care for patients requires that psychiatrists understand the clinical aspects of Ebola and the principles of risk communication.

Ebola virus disease (EVD) is rare but potentially fatal; it is caused by infection with one of the Ebola virus strains. There are 5 identified Ebola virus species: 4 cause disease in humans; 1 causes disease only in non-human primates. Ebola was first discovered in 1976 near the Ebola River in what is now the Democratic Republic of the Congo; it has now spread to several other African countries. Since its discovery, outbreaks of Ebola have appeared sporadically in Africa. The natural reservoir host of Ebola virus remains unknown, but researchers believe the most likely reservoir is bats.

The onset of symptoms is usually abrupt, generally starting 8 to 10 days after exposure. However, the incubation period can range from 2 to 21 days. People become contagious once they begin to show symptoms. Fever, anorexia, and weakness are common, along with chills, myalgia, and malaise. The nonspecific nature of these symptoms can be confused with other, more common diseases, such as influenza and meningococcemia, so a high degree of suspicion is needed.

Additional symptoms that may present around day 5 of the disease course include an erythematous maculopapular rash that can desquamate and a range of GI problems (eg, abdominal pain, profuse diarrhea, nausea, vomiting). Patients may also experience chest pain, shortness of breath, headache, confusion, conjunctival injection, hiccups, seizures, and frank bleeding. When early symptoms are severe, mortality is increased and generally results from multiorgan failure and septic shock. Mortality rates range from 55% to 75%; patients who receive early aggressive treatment fare better.

Despite ongoing media coverage of the issue of Ebola being aerosolized, epidemiological evidence suggests this is not a mode of transmission. Ebola virus is spread by direct contact with blood and other body fluids, such as vomitus, urine, fecal matter, or breast milk, of an infected person or someone who has recently died of Ebola. Infection can also be transmitted by surfaces or objects contaminated by body fluids of an infected person. Persons who handle dirty linen, clean examination rooms, or perform other support tasks in hospitals are at increased risk and need to be educated about safety procedures.

The issues of sexual transmission can create family burdens and distress after a patient has survived an initial infection with Ebola. Ebola virus has been detected in semen up to 3 months following recovery from infection, and media reports suggest that women who have recovered from EVD may be capable of transmitting the disease through vaginal fluids. Thus, experts recommend abstaining from sex (including oral sex) for 3 months after recovery.

EVD can only be confirmed by laboratory testing. Treatment of EVD is supportive, with an emphasis on preventing dehydration through the use of intravenous fluids and oral rehydration. While there is currently no specific treatment or medication that cures EVD, case reports of patients who improved following a blood transfusion from a recovered patient are prompting additional research into mechanisms for enhancing or transferring immunity.

Although many patients will be concerned about Ebola, it is expected that very few will actually contract the disease in the US. “Very few” for medical people (eg, tens, hundreds) does not necessarily translate to usual community language; most people want or expect zero risk and no cases. Fear is a normal response to threats that we do not fully understand.

Health care workers directly caring for Ebola patients need adequate training and protective equipment to reduce their anxiety and decrease the likelihood of making mistakes. Community education (schools, community leaders, stores/sales people, and your hospital and medical community) can be very helpful as well.

Psychiatrists can listen without judgment to a patient’s fears and concerns about Ebola. Avoid simple reassurances that are often experienced as dismissing patient concerns, such as, “There’s nothing to worry about,” or “Everything will be fine.” When patients are presenting for psychiatric care with an underlying concern about Ebola, a thorough medical screening is helpful. Patients also need to be evaluated for exacerbation of preexisting psychiatric illness. Stress often leads to the onset or worsening of maladaptive coping responses, such as use of alcohol, tobacco, and other drugs of abuse as well as social isolation and violence. A comprehensive risk assessment should be performed and emergency issues managed appropriately.

For patients without exacerbation of significant underlying psychiatric illness, Psychological First Aid (PFA) can be used to manage stress; it can also be used for those who have contracted EVD. The principles of PFA include optimizing safety, calming, connectedness to others, self-efficacy, and hopefulness. Teaching the patient (and his or her family) ways to maintain hopefulness and optimism are evidence-based interventions for acute trauma responses.

Help patients understand that it is essential to avoid contact with persons who are infected or traveling to areas with Ebola outbreaks. Regular hand washing is vital to infection control. Because influenza and EVD share common nonspecific symptoms during the course of illness, reducing the incidence of influenza may decrease the number of patients presenting for evaluation-encourage patients to get their flu shots.

To ensure that patients have the most accurate, up-to-date information, steer them toward well-established sources of information, such as the CDC. Suggest that patients and their families limit exposure to news and social media, which may exacerbate stress and anxiety. Episodes of excessive fear and anxiety can also be reduced by simple measures, such as diaphragmatic breathing and progressive muscle relaxation, both of which can be taught quickly and easily.

EVD is not thought to produce neuropsychiatric symptoms directly; however, patients infected with the virus may experience a range of psychological responses. Those with underlying psychiatric illness may experience an exacerbation of symptoms, complicated by unique aspects of necessary treatment, such as the need for quarantine.

A particularly significant aspect of treatment for EVD is the need to quarantine, which can increase distress for both the patient and his family. Consultation-liaison psychiatrists can suggest ways to reduce isolation, such as addressing institutional barriers that limit visiting hours or using creative IT solutions (eg, webcam). Clinically significant symptoms among those who are exposed and quarantined may include depression, acute stress disorder, PTSD, sleep disturbances, and anxiety symptoms.

Helping health care providers and the family understand how the patient is affected by symptoms of Ebola and the various aspects of treatment can be beneficial in maintaining the health care provider’s working relationship with the patient and may decrease the family’s worries of separation.

The patient’s family and friends may also express concerns, including fear of the patient’s death and anxiety about contracting the illness themselves. Because family and friends are important for enhancing the patient’s social support, addressing ambivalence in family and friends can be particularly helpful. Patients with EVD also present unique challenges for physicians, nurses, technicians, and others who provide care. Working with members of the health care team to understand their particular fears and concerns can enhance their resilience and sustain them throughout the experience.

Psychiatrists may also be in a position to advise community leaders and policymakers on ways to communicate health information to larger populations or organizations. When providing this type of consultation, consider well-established principles of risk communication.

 Begin by recommending that messages be considered and planned in advance, including anticipating questions that will be asked. What an audience wants to know, as well as what the person speaking wants them to know, should be taken into consideration. Specifically, during acutely stressful situations, most people want to know if they and their loved ones are safe and what actions they can take. Accurate information about what is known as well as what is not known should be provided.

Those in leadership positions may believe that people do not want to hear “bad news” when in fact what people really want to hear is accurate and reliable information from trusted leaders. When there is a question for which an answer is not known, leaders can commit to finding out in a timely manner and reporting back. Accurate and reliable information and keeping a promise to follow up with answers builds trust and enhances rapport.

Psychiatrists have an important role to play in the evolving impact of Ebola in the US; that role is to support the well-being of individuals, enhance health, and provide a range of consultation services. An awareness of our own emotions regarding Ebola is a critical foundation for providing effective interventions.

Psychiatrists must have an appreciation for the pathogenesis, transmission, and treatment of Ebola as well as for the unique facets of the disease and its treatment and how these can affect patients, their loved ones, and their health care providers. An understanding of effective risk communication strategies allows psychiatrists to advise leaders and policymakers in relevant Ebola health messaging.

The views expressed are those of the authors and do not necessarily reflect the views of the Department of Defense, the Uniformed Services University, the Department of Health and Human Services, or the United States Public Health Service.

Dr Morganstein is a Commander in the United States Public Health Service; Assistant Professor and Assistant Chair, department of psychiatry, and Scientist, Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine in Bethesda, Md. Dr Ursano is Professor and Chair, department of psychiatry, and Director, Center for the Study of Traumatic Stress at the Uniformed Services University School of Medicine. They report no conflicts of interest concerning the subject matter of this article.

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Articles

When widespread fear and anxiety about the spread of an infectious disease stress our society, psychiatrists can play a variety of important roles in population health management. 

What Psychiatrists Should Know About Ebola

In recent years, we have learned a great deal about posttraumatic stress disorder (PTSD) and its public health implications. From 9/11 to Katrina and the present Iraq war, PTSD has been in the forefront of health concerns and public policy. Recent advances as well as emerging needs are leading us to new and exciting opportunities to provide better care and gain a better understanding of the complex nature of human responses to traumatic events. As we look to the future, we can be both reassured and concerned that it will, on one hand, be similar to the present and, on the other, provide new opportunities and challenges for care of those exposed to traumatic events-natural and human-made, large- and small-scale.

PTSD is a disorder of forgetting perhaps even more than of remembering. It is the inability to forget the trauma that leads to the pathology and suffering in PTSD. Forgetting is a critical component of recovery. Of course, if we could not forget, our brains would rapidly be cluttered with information and observations and perhaps more limited in cognitive control functions for other activities.

PTSD is not uncommon following many traumatic events from terrorism to  motor vehicle accidents, or industrial explosions (

 In its acute form, PTSD may be like the common cold, experienced at some time in one's life by nearly all. Some colds progress to pneumonia and may create substantial illness and impairment of function. Similarly, PTSD, when it becomes chronic, may cause major distress and requires psycho-therapeutic and/or pharmacological intervention.

To understand the breadth of the emerging treatments, interventions, and comprehension of PTSD and other trauma-related responses, we must think across neurobiology, psychology, and community and from individuals to populations. In all areas, breakthroughs and opportunities as well as challenges are evident.

The power of translating across human tissues, animal models, and biomarker studies is remarkable and offers opportunities to identify treatment targets not previously recognized.

 In the past year we have seen the first studies of postmortem PTSD human brain tissue. Exciting and groundbreaking studies have shown the possibility of identifying critical gene activity in PTSD related to various brain regions.

 In the prefrontal cortex and the amygdala, for instance, studies have suggested that there are unique genes in patients with PTSD, some of which (eg, the p11 gene) have also been found in animal models of PTSD and initial biomarker studies. Recent studies of hurricane victims have shown that PTSD is 20 times more likely to develop in those with the short/short genotype of the serotonin transporter gene (5-HTTLPR) and poorer social supports.

 The science of PTSD now requires a well-developed brain bank

 like those that exist for other psychiatric and neurological disorders (eg, schizophrenia, depression/mania, amyotrophic lateral sclerosis, Alzheimer disease).

The development of animal models is also critical for the study of therapeutic and prophylactic treatments of stress-associated psychiatric disorders, such as PTSD. Our increased ability to identify endophenotypes-specific genetically linked behavioral characteristics/phenotypes

-that relate to PTSD will greatly enhance our neurobiological understanding. 

Historically, adequate animal models have been central to developing effective therapeutic treatments. Our present animal models of PTSD include models of predator stress, social defeat, shock, restraint and shock, and serial prolonged stress. None is complete, but each provides a model of different symptoms of the trauma response. Knock-out and knock-in strains offer additional sources of study. Animal models have rarely addressed the observation that even in animal species (as in humans) PTSD-like symptoms being studied in the particular model do not develop in all individual animals; this is an important area for additional future study to identify resilience and genetic targets for risk.

As noted above, PTSD is a disorder of forgetting. It is the inability to forget that leads to the pathology and suffering in PTSD. In clinical practice, forgetting is often overlooked as an important part of recovery, not only pathology. Forgetting is critical to our ability to maintain attention and conserve cognitive resources. Extinction of fear is one paradigm for examining forgetting.

 Extinction-which may also be conceived of as new learning-is a potentially important mechanism for PTSD formation and also for its treatment.

 have shown that PTSD is more likely to develop following a traumatic event in firefighters who had shown impaired extinction before exposure. Similarly, those with PTSD show impaired ability to extinguish conditioned responses.

 The ventral medial prefrontal cortex appears to be central to extinction of conditioned fear. Understanding of the story of extinction, forgetting, and the prefrontal cortex holds opportunities for treatments yet to come.

Events from the war in Iraq to bombings in London to Hurricane Katrina have reminded us of the important public health issues raised by PTSD. The public health response to large-scale emergencies and catastrophes requires consideration of the disorders (eg, PTSD, depression), distress (eg, sleep disturbance, fear, changes in economic behaviors such as purchasing houses), and health-risk behaviors (eg, increased smoking, evacuation behaviors) of those who have been exposed (

 Because the National Comorbidity Replication study had surveyed the mental health of those in the Katrina disaster region before the hurricane struck, we know that the rates of mental disorder had doubled 6 months after Katrina, from about 15% to 30%.

 The mental health costs of this, the largest natural disaster to hit the United States, continue to be seen today. Such disasters, as well as those caused by terrorism and war, remind us that recovery of populations is a long and arduous process.

In another area of public health, far too common internationally, more than 29 armed conflicts are occurring now around the globe involving 25 countries.

 For those in the United Kingdom and United States, Iraq and Afghanistan are the present teachers of lessons long known and too often forgotten. Epidemiological surveys conducted during the current conflicts in Iraq and Afghanistan suggest that as many as 13% to 17% of service members screen positive for PTSD.

The Mental Health Advisory Team (MHAT), established by the office of the US Army Surgeon General, assessed the mental health of deployed US soldiers in the fall of 2006. This team noted increases in behavioral health consequences for service members involved in multiple deployments. Soldiers who had been deployed to Iraq more than once were more likely to screen positive for acute stress (PTSD), anxiety, depression, or any mental disorder than those who had been deployed only once. Soldiers deployed multiple times were 1.6 times more likely to screen positive for PTSD than those deployed once, and 1.2 and 1.7 times more likely to screen positive for anxiety and depression, respectively. Soldiers deployed for more than 6 months were 1.5 to 1.6 times more likely to screen positive for acute stress than those deployed for less than 6 months.

War, terrorism, and natural disasters create large populations in distress. Not all distress amounts to mental disorder, but fear, worry, insomnia, and changes in health-risk behaviors all contribute to the health burden of mass violence and are targets for early public health intervention. Substantial evidence supports essential principles of immediate and midterm mass trauma interventions that are now described as psychological first aid.

 But translating these principles into widely accepted (ie, destigmatized), rapidly disseminated, culturally informed intervention programs and policy remains a present and future challenge.

In order to alter or affect behavioral change in individuals exposed to disaster, it is important to consider the social context or environment. Evidence-based and evidence-informed clinical trials have shown that in efforts to modify individual behavioral risk factors such as drug, alcohol, and tobacco use, diet, and physical activity, the most successful approaches have incorporated elements of social organizational interventions and changes.

 For example, people who are socially isolated are more likely to engage in risky behaviors and are less likely to engage in behaviors that promote health.

 Successful behavioral and health interventions incorporate the social context of the individuals' communities, work sites, and families.

New models of monitoring shifting community health care needs in real time (ie, mental health surveillance) as well as innovative models for delivering care are required.

 The mental health community's response to disaster requires the collaborative efforts of the public health system, medical care system, and emergency response systems. 

The role of primary care providers after community exposure to disasters and terrorism is substantial. Collaboration of mental health care providers with primary care providers is an important and underdeveloped model for providing services to a large number of patients. Patients with chronic somatic symptoms, often seen after trauma exposure, respond best to a single primary care provider with regular visits in which conservative medical management and education play a primary role.

 The availability of mental health consultation and psychiatric health care extenders facilitates the recovery of those exposed to traumatic events.

Often, health care planners and providers underestimate the duration of the impact of a terrorist event or disaster on a community, focusing primarily on the acute impact rather than on the recovery stage. Such overemphasis of the impact stage neglects the important elements of recovery that include the stress of relocation and new life events involving altered economics, social settings, stigma, and job loss that occur in communities hit by disaster. These postdisaster events and secondary adversities have substantial impact on the psychological distress and health of individuals and communities and are risk factors for PTSD.

 In addition, the recovery of those with PTSD, whether from war or disaster, requires making resources available for care and addressing the barriers to care and adherence with health care recommendations. Only 32% of those in whom a mental health disorder developed following Katrina had accessed care 8 months later.

So, what is on the horizon? First, PTSD will be the first mental disorder to be preventable. It already is. Studies by Bryant

 have shown that cognitive-behavioral therapy given at about 3 weeks to those with acute stress disorder can lower the rates of PTSD. Similarly, we know that using seat belts-a protective 

-prevents injury and injury is one of the strongest predictors of PTSD resulting from motor vehicle accidents.

Current research also offers promise of early pharmacological intervention to prevent PTSD, perhaps targeted to those with risk genes. In addition, studies of PTSD biomarkers suggest that we will have both biochemical (eg, blood) and brain imaging biomarkers to predict the risk of PTSD as well as for stages of the disease process.

Second, present studies on the importance of integrating PTSD detection and treatment into primary care (and as part of screening for those who are injured) suggest that collaboration with our primary care colleagues can provide the best public health approach to PTSD, particularly in disaster populations. Easily administered screenings and algorithms for primary care treatment and referral for specialty care are needed.

Third, we can hope that the current experience with PTSD may lead to the development of postdisaster, real-time mental health and risk-behavior surveillance-just as is done for other injuries and disorders that may impair communities, such as surveillance for infectious diseases. Such changes can decrease the stigma of mental illness as the public better understands psychiatric illness as being similar to other disorders. Finally, as we better recognize PTSD as a disorder of forgetting, we may well learn a great deal about when forgetting is important to assist health and when it may impair health, a fundamental issue for all psychotherapies. The

 lists some of the aspects of potential treatment and care for PTSD in the future.

Opportunities and challenges are before us for the understanding of human responses to traumatic events and for the care of trauma and disaster victims-from psychopharmacology to psychotherapy and system interventions. The knowledge base needs to be fostered and new models need to be tested. Those who are trauma victims deserve our best health care and services.

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In recent years, we have learned a great deal about posttraumatic stress disorder (PTSD) and its public health implications. From 9/11 to Katrina and the present Iraq war, PTSD has been in the forefront of health concerns and public policy.

Posttraumatic Stress Disorder: Neurobiology, Psychology, and Public Health

After commanding a transportation unit in Iraq, a National Guardsman returned home to California (Guthrie, 2005). He thought he was fine until the nightmares and night sweats started. He felt numb and detached from his family. When he drove to work, a bump in the asphalt triggered memories of improvised devices that exploded on Iraqi roadways. With the encouragement of his family, the Guardsman finally sought counseling.

Meanwhile, a 24-year-old gunner still in Iraq became withdrawn, listless and disinterested in eating (Myers, 2003). He would lie awake, remembering how four of his friends, fellow soldiers, had their bodies torn apart by a bomb packed inside a taxi. He was referred to counseling for his "combat stress reaction" and returned to duty with his unit.

The issues are challenging: How do you reduce or avert the psychological wounds of war and prevent long-term, service-connected disabilities?

At the recent 13th Annual Medicine Meets Virtual Reality Conference in Long Beach, Calif., researchers discussed the development of new technologies using virtual reality to treat soldiers returning from Iraq with posttraumatic stress disorder and to provide those being deployed with stress inoculation training. As defined by researchers working with veterans, "virtual reality integrates real-time computer graphics, body-tracking devices, visual displays and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion" (Rothbaum et al., 2001). Albert "Skip" Rizzo, Ph.D., research scientist and research assistant professor at the Institute for Creative Technologies (ICT) at the University of Southern California, told conference attendees that ICT is creating an immersive virtual environment system in which to treat Iraqi War veterans diagnosed with combat-related PTSD (Rizzo et al., 2004).

We put tremendous resources into training our troops for combat, now "we need to make a strong case for dealing with the aftermath," Rizzo said. "The military has an ethical responsibility to deal with PTSD."

At press time, there are some 150,000 U.S. troops in Iraq. Reports are emerging of some severe mental health problems among them. Of the nearly 12,000 soldiers being treated at the Landstuhl Regional Medical Center in Germany, between 8% and 10% had "psychiatric or behavioral health issues," according to hospital commander Col. Rhonda Cornum (United Press International, 2004). The hospital is the main transfer point and treatment center for those being medically evacuated from Iraq, Kuwait or Afghanistan.

Rizzo said a recent study focusing on mental health problems of U.S. military units involved in combat in Iraq and Afghanistan "gave his research a reason for being." He explained that the study prepared by the department of psychiatry and behavioral sciences at Walter Reed Army Institute of Research suggested that one out of six (16.7%) Iraqi War veterans is exhibiting mental health problems (Hoge et al., 2004), a number close to PTSD levels found among Vietnam War veterans (15.2%), when surveyed in the late 1980s.

According to the study, 17.1% of 882 Army soldiers and 15.6% of 813 Marines who served in Iraq met strict criteria for PTSD, major depression or generalized anxiety when they were screened three to four months after their return to the United States (Hoge et al., 2004). By comparison, 11.2% of 1,958 Army soldiers who served in Afghanistan had mental health problems.

More specifically, rates of PTSD (12.2% to 12.9%) were significantly higher after combat duty in Iraq than before deployment (5%) as assessed using the 17-item National Center for PTSD Checklist of the U.S. Department of Veterans Affairs. The rates of PTSD were significantly associated with having been wounded or injured or having engaged in one or more firefights.

Rizzo reminded attendees that PTSD is caused by traumatic events that are outside the range of usual human experiences, such as military combat, violent personal attacks and terrorist attacks. According to the DSM-IV-TR, PTSD is identified by clusters of symptoms such as cognitively re-experiencing the event (e.g., flashbacks, nightmares), persistent avoidance of things that remind the person of the trauma, numbing of general responsiveness and hyperarousal (e.g., the person is hypervigilant, has difficulty falling or staying asleep, or is always on edge).

A standard of nonpharmacological care for PTSD has been imaginal exposure therapy. Such treatment, Rizzo said, typically involves the graded and repeated imaginal reliving of the traumatic event within the therapeutic setting. This approach is believed to provide a low-threat context where the patient can begin to therapeutically process the emotions that are relevant to the traumatic event, as well as de-condition the learning cycle of the disorder via a habituation/extinction process. While the efficacy of imaginal exposure has been established in multiple studies with diverse trauma populations (Rothbaum et al., 2000), many patients have problems with it, according to Rizzo.

"The problem with imaginal therapy is that sometimes people have a hard time imagining some of these events," he said. "Also, avoidance and loss of memory of the events is part of the symptom package. So you are asking someone who has been traumatized in an extreme combat situation to start to remember it."

Virtual reality exposure treatment has been used to treat patients with PTSD with positive outcomes. In 1997, 20 years after the Vietnam War, researchers at Georgia Tech released the first version of "Virtual Vietnam VR" for use as a graduated exposure therapy treatment for PTSD with Vietnam War veterans (Rothbaum et al., 2001). In an open clinical trial, it was used to treat 10 Vietnam War combat veterans who had PTSD as diagnosed by 

 criteria. In eight to 16 sessions, the patients were exposed to two virtual environments: a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. Reductions in PTSD symptoms ranging from 15% to 67% were reported at six-month follow-up by all eight participants interviewed.

Rizzo said his project involves the use of virtual assets that were initially built for a combat tactical simulation scenario and later licensed to create a commercially available video game. Rizzo had seen a trailer for the game and was able to obtain access to the graphic assets of the game. With the help of programmer friends, he cobbled together a variety of graphic assets to create the prototype for the virtual reality exposure application for Iraqi War veterans. The software is being designed so clinical users can be teleported to highly realistic and emotionally evocative settings (e.g., city and rural village scenes, traffic checkpoints, building interiors, and desert roads) that most closely match the patient's combat-related experiences.

Once the scenario is selected, different user perspectives can be taken, such as a soldier walking alone, being with a patrol, or riding in a HMMWV (or Humvee) or helicopter. According to Rizzo, the clinician can also control time of day and trigger stimuli, such as weapons fire, explosions, being shot at, seeing dead bodies or human remains, or being wounded or injured.

-type clinical interface, Rizzo said. The interface enables the clinician to see what the patient is seeing and control "trigger" stimuli. It also allows for the monitoring of the patient's physiological status. All of this is with the "goal of customizing the graduated exposure based on the client's needs," Rizzo added.

The virtual reality exposure PTSD project, now in design testing, will not only help in the treatment of PTSD but also in its assessment, Rizzo said.

One of the findings of the 2004 Hoge et al. combat duty study was that those who most needed mental health care were not receiving it out of fear of being stigmatized, prompting the study authors to call for PTSD screening. Instead of having returning soldiers and Marines just complete a symptom checklist, Rizzo suggested that they could participate in an initial debriefing procedure that integrates the virtual reality exposure PTSD application with physiological recording. Past research has suggested differential physiological responses in people with PTSD, so the virtual reality exposure PTSD could be used to spot people who do not self-report that they are having problems. Additionally, if indicators of substantive physiological reactivity are present during an initial virtual reality exposure, the soldier could be referred for continued "debriefing care."

Stress inoculation training is another area being explored for helping troops before they are deployed to Iraq. Brenda Wiederhold, Ph.D., and her husband, Mark Wiederhold, M.D., Ph.D., of the Virtual Reality Medical Center in California are conducting stress inoculation training research under a contract with the Pentagon's Defense Advanced Research Projects Agency. They are developing a hybrid approach combining virtual reality simulations with live training, while monitoring the physiology of warriors in tactical situations. By analyzing tactical decision making under stress, the Wiederholds hope to develop techniques to help trainees control fear and anxiety; in effect, to inoculate them against stress.

Mark Wiederhold told attendees at the Medicine Meets Virtual Reality sessions that they have trained several Marine Corps battalions with stress inoculation techniques involving virtual reality games and live experiences, and those troops are now in Iraq and Afghanistan.

"We will be able to compare rates of PTSD among troops that received stress training versus groups that have not," he said.

The whole idea of using virtual reality for therapy translates very effectively for using virtual reality for training the military, said Mark Wiederhold. He continued by saying that they're looking at training combat medics using a video game.

"Despite using a single video game, we were able to get physiological arousal with significant increases in both respiration and heart rate when [the medics] were playing it. The game essentially requires them to take care of these wounded individuals in the field. It then provides divided attention tasks where they have to break away from caring for the wounded and shoot at enemies that are shooting at them," he said.

The trainees are then tested in the real world to determine if the skills learned in simulated environments do indeed generalize to the real world.

(For more on virtual reality, see accompanying sidebar on p9 of the print edition--Ed.)

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United Press International (2004), 10% at hospital had mental problems. Feb. 19.

Traumatic events affect individuals as well as entire communities. In this Special Report on trauma and violence, a number of often forgotten traumatic experiences are described. The individuals exposed to these events are at increased risk of several psychiatric disorders, as well as behavioral changes such as increased alcohol use or cigarette smoking.

Robert J. Ursano, MD

Articles

What Psychiatrists Should Know About Ebola

Posttraumatic Stress Disorder: Neurobiology, Psychology, and Public Health

On Healing and Prevention