New Virtual Tools for Treating PTSD

Written by Ted McKenna

MMT 2009 Volume: 13 Issue: 6 (September)

Virtual reality software is not a magic solution for post-traumatic stress disorder (PTSD), but advocates argue that it does provide an increasingly useful tool for clinicians in part because of improvements in the availability, interactivity and variety of the software.

Dr. Walter Greenleaf, CEO of Palo Alto, Calif.-based InWorld Solutions and Decatur, Ga.-based Virtually Better, both of which provide software and services for treating PTSD and other mental health problems with virtual reality, said the advances in virtual reality software reflect continued improvement in computer processing power and cost.

That means, for one thing, that graphics and scenarios within virtual reality applications are becoming much more sophisticated and varied, just as computer games in the commercial realm are becoming more sophisticated yet cheaper.

If the value in the software lies in its ability to help patients better visualize or remember traumatic events that bother them either consciously or subconsciously and then essentially “reprocess” their memories to better understand and cope with the associated feelings of guilt, fear or other emotions, then a wider range of scenarios, and more complex social interactions within specific scenarios, provide that many more opportunities to confront traumatic events.

“Instead of just having a Virtual Iraq, it has a virtual everything,” Greenleaf said. “[Newer software have] train stations, football stadiums, jazz studios, bedrooms, kitchens [and] F-16 fighters. Because people can participate, the clinician is there with you as another avatar; you can do a variety of things that aren’t scripted. The clinician can say, ‘OK, we’ll be dealing with your trauma from the time you were in the barracks and there was a fight and somebody got knifed.’”

The ability for the clinician not only to be within the scenario, participating and commenting, but also controlling the events as they come, is a key aspect of virtual reality software used for treating PTSD, alcohol addiction or other focuses of cognitive-behavior therapy, noted Dr. Patrick Bordnick, director of the Virtual Reality Clinical Research Lab at the University of Houston’s Graduate College of Social Work.

“Virtual reality allows us to bring that context in, so that I am showing or presenting the triggers for a certain behavior,” Bordnick said. “Say it’s a virtual bar or party. The therapist is watching in realtime and can see when you walk up to a bar or someone offers you a drink and can say, ‘OK, Bob, let’s practice a refusal skill.’ Or, ‘Do you have a craving right now? Let’s find a way to manage those cravings.’

Dr. Skip Rizzo, a research scientist at the University of Southern California’s Institute for Creative Technologies and a research professor at the school’s department of psychiatry, noted that with Virtual Iraq, the main virtual reality software being used within the Department of Defense, expansion of the various scenarios is more broad than deep. That is, the emphasis by software developers is on creating greater variety as opposed to greater detail within each scenario.

“We want diversity over detail,” said Rizzo, who helped leads development of the software, including the original version as well as updates such as Virtual Afghanistan. “We’re finding that it doesn’t have to be an extremely detailed one. People tend to think that the imagination is turned off in a virtual environment; it’s not. Users fill in the details themselves. We’ve got to have it credible, but to have a range of environment is more important.”

BROADER APPLICATIONS

For companies like Virtually Better or the San Diego-based Virtual Reality Medical Center (VRMC), the broader range of virtual scenarios becoming available also provides the potential to treat a broader range of conditions, including drug and alcohol addictions; fear of flying, closed space and driving; and anxiety disorders. Not only does the broader range offer opportunities for clinics to treat a wider variety of phobias and other mental health problems, but they also offer the potential to treat PTSD in virtual situations totally outside the war zone.

“You can do role-playing,” Greenleaf noted. “Maybe it’s a reintegration issue [following deployment], where you’re dealing with some anger management or you’re trying to deal with getting reintroduced to your teenage kid and your wife after being deployed for a year and a half. The therapist can say, ‘All right, I’m going to pretend to be your son, who’s been giving you some lip.’”

Developers and users of virtual reality software also note that another helpful attribute of the new class of applications is that increasingly, as is the case with software applications in general, the software is server- as opposed to client-based. That means the applications need not reside on the computer on which they are running, permitting patients to use the applications remotely. VRMC, for instance, implemented a system based in Warsaw, Poland, in 2007 that allowed soldiers in the Polish military formerly deployed in Iraq to participate, using the software while in other cities throughout the country.

Also in development at VRMC are applications that let patients and clinicians do treatments on iPhones or other types of handheld computer devices. Greenleaf said a key benefit of telemedicine, whatever the computing device being used, is follow-on treatment for servicemembers in areas where clinicians are not physically present.

“So if you want to follow up after someone’s discharge,” Greenleaf said, “if you want to check in with them, all they need to do is go to their computer and meet you in the virtual world and say, ‘OK, how’s it going?’ ‘I got into a fight with my wife the other day.’ ‘Well, what happened?’ And you can practice how to handle that.”

Dr. Brenda Wiederhold, VRMC’s executive director, noted that in the Polish trial and other uses of her company’s software, measurement of physiological response is also an aspect seeing steady refinements in accuracy and sophistication. Patients are not always honest with clinicians or themselves about situations or environments that frighten them, yet identifying and understanding the physiological response can be key to cognitive-behavioral therapy.

“You don’t always know. You don’t always know how stressed out you’re getting if your children are sitting there playing the same game over and over, with the same music,” Wiederhold said. “But showing the patient what’s happening with different triggers helps to educate them, and then they become a better judge and can start doing some stress management before their system gets overloaded and the situation is intolerable.”

Virtual reality software was first used for treatment of PTSD in 1997, when Georgia Tech and Emory University researchers tested a prototype software with Vietnam veterans. Among the most recent developments in the study of the technology for veterans, USC’s Rizzo said his group recently won funding for a three-site trial—at a Los Angeles Veterans Affairs clinic, a civilian Manhattan health care clinic, and at the Walter Reed Army Research Center in Washington, D.C.—that will examine how use of Virtual Iraq may be aided by patients taking a drug called cycloserine, helping speed what clinicians in the field of cognitive-behavior therapy sometimes call “fear extinction.” ♦

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