Dennis Patrick Wood, Ph.D., ABPP (CAPT, MSC, USN-ret) Brenda K. Wiederhold, Ph.D., MBA The Virtual Reality Medical Center, San Diego COMBAT

Dennis Patrick Wood, Ph.D., ABPP(CAPT, MSC, USN-ret)

Brenda K. Wiederhold, Ph.D., MBAThe Virtual Reality Medical Center, San Diego

www.vrphobia.com

COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A REPORT EMPLOYING VIRTUAL

REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING (VRGET)

CYBERTHERAPY 13SAN DIEGO, CALIFORNIA

COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A REPORT EMPLOYING VIRTUAL

REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING (VRGET)

CYBERTHERAPY 13SAN DIEGO, CALIFORNIA

CYBERTHERAPY 13: CYBERTHERAPY 13: VRMC/ONR Virtual Reality VRMC/ONR Virtual Reality

Graded Exposure, Physiologically Monitored, Treatment for PTSD Graded Exposure, Physiologically Monitored, Treatment for PTSD

(VRGET) (VRGET)

Co-investigators:Kristy Center, M.A., VRMCJennifer Murphy, M.A., VRMCRobert McLay (CDR-sel MC USN), NMCSDCarol Russ, Ph.D. (CDR MSC USNR-ret), VRMCRobert Koffman (CAPT MC USN), BUMEDScott Johnston (CDR MSC USN), NMCSDJames Spira, Ph.D., VRMC

Disclaimer:Disclaimer: The views in this presentation are those of The views in this presentation are those of the individual authors, and do not necessarily the individual authors, and do not necessarily represent those of the Department of the Navy, represent those of the Department of the Navy, Department of Defense, the Department of Veterans Department of Defense, the Department of Veterans Affairs, or the U.S. Government. Research described Affairs, or the U.S. Government. Research described has been approved by the Institutional Review Board has been approved by the Institutional Review Board at the Naval Medical Center San Diego. The at the Naval Medical Center San Diego. The information in this presentation was approved under information in this presentation was approved under the NMCSD Institutional Review Board. This study the NMCSD Institutional Review Board. This study was sponsored by the ONR Contract (#N00014-05-C-was sponsored by the ONR Contract (#N00014-05-C-0136) to Virtual Reality Medical Center, San Diego, 0136) to Virtual Reality Medical Center, San Diego, CA.CA.

CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored Treatment for PTSD

(VRGET)

Dad, Ivan & Megan: Fayetteville, NCDad, Ivan & Megan: Fayetteville, NC

Nov 2007Nov 2007

VRMC VRGET PROJECT AT NAVAL

MEDICAL CENTER SAN DIEGO

NAVAL MEDICAL CENTER SAND DIEGO:

1. World’s Largest Military Hospital

2. Home of the Comprehensive Combat Casualty Care Program (C-5)3. USS Mercy4. 4 additional West Coast

Navy Hospitals

VRMC VRGET PROJECT AT NAVY HOSPITAL MARINE CORPS BASE CAMP

PENDLETON

Navy Hospital MCBCP

1. 60 miles North of San Diego

2. MCBCP = 250 square miles 3. 123 bed facility4. MCBPC home to:

1st Marine Corps Division & 1st Marine

Expeditionary Force (MEF)

VRMC/IMI FundersVRMC/IMI Funders

PTSD ClusterPTSD Cluster

1.1. Life threatening event to self or Life threatening event to self or others that is “markedly others that is “markedly distressing”distressing”

2.2. INTRUSIVE:INTRUSIVE: Event persistently Event persistently re-experienced: distressing re-experienced: distressing recollections, recurrent distressing recollections, recurrent distressing dreams/nightmares, flashbacksdreams/nightmares, flashbacks

PTSD ClusterPTSD Cluster

3.3. AVOIDANCE:AVOIDANCE: Persistence Persistence avoidance of thoughts, activities avoidance of thoughts, activities &/or reminders of event; detached &/or reminders of event; detached feelings; foreshortened futurefeelings; foreshortened future

4.4. AROUSAL:AROUSAL: Persistent arousal Persistent arousal sleep problems, irritability, hyper-sleep problems, irritability, hyper-arousal or startle , concentration arousal or startle , concentration difficultiesdifficulties

CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, Treatment for PTSD

(VRGET)


(VRGET)

ABC Video Clip: PTSD & VRMC/ONR ABC Video Clip: PTSD & VRMC/ONR Funded VRGETFunded VRGET

Psychiatric Diagnoses Related to Psychiatric Diagnoses Related to Combat in Iraq and AfghanistanCombat in Iraq and AfghanistanPsychiatric Diagnoses Related to Psychiatric Diagnoses Related to Combat in Iraq and AfghanistanCombat in Iraq and Afghanistan

Following OIF and OEF, PTSD, Following OIF and OEF, PTSD, Depression and Anxiety rates for Depression and Anxiety rates for warriors were:warriors were:

15 – 17 % for Iraqi combat veterans15 – 17 % for Iraqi combat veterans11.2% for Afghanistan combat 11.2% for Afghanistan combat

veteransveterans (Hoge et al., 2004)(Hoge et al., 2004)

PTSD and the War on TerrorismPTSD and the War on Terrorism

““It is anticipated that the rate of PTSD It is anticipated that the rate of PTSD will be higher among troops who have will be higher among troops who have been to Iraq more than once”. (COL been to Iraq more than once”. (COL Elspeth Ritchie, July 19, 2006)Elspeth Ritchie, July 19, 2006)

PTSD rates, among soldiers PTSD rates, among soldiers hospitalized following serious combat hospitalized following serious combat injury, was 12% at 7 months following injury, was 12% at 7 months following hospitalization (Grieger et al, 2006) hospitalization (Grieger et al, 2006)


““Soldiers who deploy longer (i.e., greater Soldiers who deploy longer (i.e., greater than 6 months) or who had deployed than 6 months) or who had deployed multiple times were more likely to multiple times were more likely to screen positive for a mental health screen positive for a mental health issue”.issue”.

(DOD, Mental Health Advisory Team (DOD, Mental Health Advisory Team (MHAT-IV) Survey: 04 May 2007)(MHAT-IV) Survey: 04 May 2007)


6 – 11% of OEF combat veterans have 6 – 11% of OEF combat veterans have PTSDPTSD

12 – 20% of OIF combat veterans have 12 – 20% of OIF combat veterans have PTSDPTSD

VA should VA should aggressivelyaggressively prevent and treat prevent and treat PTSDPTSD(Report on the President’s Commission on Care for (Report on the President’s Commission on Care for America’s Returning Wounded Warriors, July 2007)America’s Returning Wounded Warriors, July 2007)


Mild Traumatic Brain Injury in Soldiers Returning from Iraq: 5% of 2,500 Soldiers DX with Mild TBI; 48% of the Soldiers with Mild TBI DX with PTSD

- Symptoms included: headache, dizziness, irritability, fatigue & memory problems

- Analysis: with the exception of headache, PTSD & Depression accounted for all other health outcomes or symptoms

(Hoge et al, 2008)


Early Treatment for PTSD:- “Early recognition and treatment may be key for

our newest veterans returning with combat-related PTSD” (Hooten et al, 2008)

- Early treatment is imperative in order to maintain personnel on active duty and to reduce the future burden for the Veterans Administration Health Care System (Ritchie & Owens, 2004; Wain et al, 2005; Forsten & Schneider, 2005)


PTSD Treatment With Virtual Reality Graded Exposure Therapy with Physiological Monitoring (VRGET):

- “VR has been shown to improve treatment efficacy for PTSD in survivors of MVA, war veterans and those involved in the 9/11 World Trade Center attacks” (Wiederhold et al., 2006).

- Efficacy of combined physiological and psychological VRGET for a number of phobias & PTSD documented (Wiederhold & Wiederhold, 1998).

Naval Medical Center San Diego Naval Medical Center San Diego Navy Hospital, Marine Corps Navy Hospital, Marine Corps

Base Camp PendletonBase Camp PendletonFunded by Office of Naval Funded by Office of Naval

Research (ONR)Research (ONR)Funded by TATRCFunded by TATRC


(VRGET)

Cybertherapy 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for PTSD

(VRGET)

Cybertherapy 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for PTSD

(VRGET)

Combat Support Personnel (i.e., Corpsmen, Combat Support Personnel (i.e., Corpsmen, Seabees, non-infantry Marines)Seabees, non-infantry Marines)

Evaluation: qualifying assessment, including two Evaluation: qualifying assessment, including two interviews, completion of self-report measures interviews, completion of self-report measures and objective questionnaires, & and objective questionnaires, & psychophysiological measures assessmentpsychophysiological measures assessment

Wood et al., Combat Related PTSD: A Case Wood et al., Combat Related PTSD: A Case Report Using VRGET with Physiological Report Using VRGET with Physiological Monitoring. Monitoring. CyberTherapy & Behavior, CyberTherapy & Behavior, 10 (2), 10 (2), 2007.2007.

CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for PTSD

(VRGET)

CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for PTSD

(VRGET)

ASSESSMENT:ASSESSMENT:Pre-RX assessmentPre-RX assessmentPost-RX assessment following Post-RX assessment following

1010THTH RX session RX sessionAssessment at 3 months following Assessment at 3 months following

1010thth RX session RX session

PhysiologicalPhysiological RespirationRespiration HR, HRVHR, HRV Skin TemperatureSkin Temperature Skin ConductanceSkin Conductance

PsychologicalPsychological Mini Neuropsychiatric Mini Neuropsychiatric

InterviewInterview BAIBAI PCL-MPCL-M PHQ-9PHQ-9 Combat Exposure Combat Exposure

ScaleScale Blast AssessmentBlast Assessment

Physiological and Psychological Physiological and Psychological Measurements: Virtual Reality Medical Measurements: Virtual Reality Medical

Center/ONR VRGETCenter/ONR VRGET

Virtual Reality Medical Center HardwareVirtual Reality Medical Center Hardware

Head Mount Display: Head Mount Display: i-glassesi-glasses

Hardware Set-Up Hardware Set-Up

CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for Combat-related PTSD

(VRGET)

CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for Combat-related PTSD

(VRGET)

VRGET Sessions 1 & 2: VRGET Sessions 1 & 2: Meditation Training, Meditation Training, exposure to SUDs, CBT, review of Sentinel exposure to SUDs, CBT, review of Sentinel EventEvent

VRGET Sessions 2 – 10: VRGET Sessions 2 – 10: Individualized VRGET Individualized VRGET focused on increasing the intensity of the combat focused on increasing the intensity of the combat “elements”, immersion in the combat “elements”, immersion in the combat environment, eliciting SUDs & effecting environment, eliciting SUDs & effecting “habituation”“habituation”

ReassessmentReassessment following 10 VRGET Sessions following 10 VRGET Sessions

RANK AGE TOURS TBI MED DX

PSYCH MEDS

MED BOARD

STATUS

HM2-USN 32 1 Yes 13 Yes Yes H.D./ college

HM3-USN 29 2 Yes 6 Yes No Deployed: Iraq

CE3-USN 33 1 No 17 Yes No H.D./EOS/college

E7-USNR 45 2 No 9 Yes No H.D./EOS/working

CM1-USNR 47 1 year No 25 Yes Yes H.D./working

LCDR-USN 49 multiple No 13 Yes No Deployed: Iraq

EO1-USNR 40 1 No 18 Yes Yes H.D./working

HMC-USN 44 1 No 11 Yes No H.D./EOS/working

HMC-USNR 41 1 No 9 Yes No H.D./EOS/working

HM2-USN 31 1 Yes 18 Yes No H.D./EOS/working

HM1-USN 36 1 Yes 8 Yes No Navy Hospital

CE2-USNR 37 2 No 12 Yes Yes Pending Board

CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET):

Pilot Study Patients


Controlled Study Patients


Controlled Study Patients

Rank Age Tours TBI Med Dx Psych Meds

Med Board

Status

HM2-USN 25 2 No 5 Yes No Assigned to USMC

UT2-USN 26 3 Yes 8 Yes No Pregnant; Active Duty

IT1-USN 28 1 No 1 Yes No Pre-Deployment

SGT-USMC 26 2 Yes 9 Yes Yes Pending Med Board

LCPL-USMC 23 1.5 Yes 5 Yes Yes Pending Med Board

CPT-CNG 38 2 Yes 8 Yes Yes Pending Med Board

ADJ3-USN 29 1 Yes 9 Yes No Awaiting EOS

CPL-USMC 23 1 Yes 15 Yes Yes Pending Med Board

CYBERTHERAPY 13 - VRMC/ONR VRGET Program

Figure 1: Significant Reduction in PTSD Symptom Severity

CYBERTHERAPY 13 - VRMC/ONR VRGET Program

Figure 1: Significant Reduction in PTSD Symptom Severity

10

20

30

40

50

60

Pre-Treatment

Post-Treatment

PTSD Severity(PCL-M)

t=3.16, p=.009

CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 2. Significant Reduction in Depression

Symptom Severity

CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 2. Significant Reduction in Depression

Symptom Severity

02468

1012141618

Pre-Treatment

Post-Treatment

DepressionSeverity (PHQ-9)

t=2.55, p=.027

CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 3. Reduction in Anxiety Symptom Severity CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 3. Reduction in Anxiety Symptom Severity

0

5

10

15

20

25

Pre-Treatment

Post-Treatment

AnxietySeverity (BAI)

t=1.40, p=.188

CYBERTHERAPY 13 - VRMC/ONR VRGET Program: Figure 4. Skin Conductance: Significant Differences Between Pre-Tx &

Post-Tx in SC Change from *Baseline to Stressor AND **Stressor to Recovery

CYBERTHERAPY 13 - VRMC/ONR VRGET Program: Figure 4. Skin Conductance: Significant Differences Between Pre-Tx &

Post-Tx in SC Change from *Baseline to Stressor AND **Stressor to Recovery

*t=2.63, p=.039 **t=2.42, p=.052

CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment

(VRGET)


(VRGET)

VRGET SUMMARY:VRGET SUMMARY:

1.1. SignificantSignificant reductions in the warriors’ reductions in the warriors’ PTSD scoresPTSD scores

2.2. SignificantSignificant reductions in the warriors’ reductions in the warriors’ Depression scores Depression scores

3.3. SignificantSignificant reductions in the warriors’ reductions in the warriors’ Skin ConductanceSkin Conductance


(VRGET)


(VRGET)

VRGET SUMMARY:VRGET SUMMARY:

4.4. Measurable reductions in the warriors’Measurable reductions in the warriors’

Anxiety scoresAnxiety scores5.5. 75% of patients had a reduction in PTSD 75% of patients had a reduction in PTSD

symptomssymptoms6.6. 42% did not meet criteria for PTSD after42% did not meet criteria for PTSD after

VRGET treatmentVRGET treatment7.7. 66% fit for full duty after VRGET 66% fit for full duty after VRGET treatmenttreatment


(VRGET)


(VRGET)

VRGET SUMMARYVRGET SUMMARY

8.8. Two warriors currently deployed toTwo warriors currently deployed to Al-Asad, IraqAl-Asad, Iraq

9.9. One One active duty warrior back in a “full active duty warrior back in a “full duty” status in CONSUSduty” status in CONSUS

10.10. Two Reserve warriors in an “active” Two Reserve warriors in an “active” Reserve status Reserve status


(VRGET)


(VRGET)

VRGET SUMMARYVRGET SUMMARYFunctional Improvement:Functional Improvement:

Reduced Psychotropic Medication UsageReduced Psychotropic Medication UsageWarriors reported improved Interpersonal and Warriors reported improved Interpersonal and

Occupational FunctioningOccupational Functioning3 warriors have enrolled/re-enrolled in College 3 warriors have enrolled/re-enrolled in College

since their discharge since their discharge 6 warriors have started to work or have 6 warriors have started to work or have

returned to their civilian employment since returned to their civilian employment since their discharge their discharge

VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for Combat-related PTSD

VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for Combat-related PTSD

CONCLUSIONS:CONCLUSIONS:1.1. Pt reported presence of improved life-Pt reported presence of improved life-

management skillsmanagement skills2.2. New VRGET Therapy for combat New VRGET Therapy for combat veterans DX with PTSD successfully veterans DX with PTSD successfully developeddeveloped3.3. Currently soliciting input from Currently soliciting input from Treated Treated Warriors concerning the PROS Warriors concerning the PROS and and CONS of their VRGETCONS of their VRGET

CYBERTHERAPY 13: VRMC/ONR Virtually Reality, Graded Exposure Physiologically Monitored, Therapy for Combat-related PTSD

(VRGET)


(VRGET)

CONCLUSIONS:CONCLUSIONS:

4.4. 20 VRGET sessions, with sessions20 VRGET sessions, with sessions twice a week, may be more effective twice a week, may be more effective

5.5. Homework being “framed” usingHomework being “framed” using results from PCL-M administered results from PCL-M administered between re-evaluationsbetween re-evaluations


(VRGET)


(VRGET)

CONCLUSIONSCONCLUSIONS

6. Compare the treatment outcomes for 6. Compare the treatment outcomes for the Warriors’ first 10 VRGET sessions the Warriors’ first 10 VRGET sessions against their treatment outcomes for against their treatment outcomes for their second 10 VRGET sessions.their second 10 VRGET sessions.

Why VR ?Advantages and illustrations

Why VR ?Advantages and illustrations

Not dependent upon patients’ Not dependent upon patients’ imagery abilitiesimagery abilities

Provides a structured environmentProvides a structured environment Visual and auditory stimuliVisual and auditory stimuli Can “Can “over-learnover-learn” skills = ” skills =

“habituation” or develop concept of “habituation” or develop concept of “safety”“safety”

Done in the therapist’s officeDone in the therapist’s office Less time consumingLess time consuming Less expensiveLess expensive SaferSafer

VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-related PTSD


Combat Town:Combat Town: Battalion BaseBattalion Base Market PlaceMarket Place VillageVillage HospitalHospital Combat zoneCombat zone



BATTLEGROUNDBATTLEGROUND CONVOYCONVOY COMBAT MEDICCOMBAT MEDIC



References (cont)

[10]Wiederhold BK, Wiederhold MD. (2005) Virtual Reality Therapy for Anxiety Disorders. Washington, DC: American Psychological Association.

[11]Wiederhold BK, Wiederhold MD. A review of virtual reality as a psychotherapeutic tool. CyberPsychology & Behavior 1998; 1(1): 45 – 52.

[12]Walshe D, Lewis E, Kim SI, O’Sullivan K, Wiederhold BK. Exploring the use of computer games and virtual reality in exposure therapy for fear of driving following a motor vehicle accident. CyperPsychology & Behavior 2003; 6(3): 329 – 234.

[13]Wood DP, Murphy JA, Center K, McLay R, Reeves D, Pyne J, Shilling R, Wiederhold BK. Combat-related post-traumatic stress disorder: a case report using virtual reality exposure therapy with physiological monitoring. CyberPsychology & Behavior 2007; 10 (2), 309 – 315.

[14]Spira JL, Wiederhold BK, Pyne J, Wiederhold MD. (2007) Treatment Manual: virtual reality physiological monitored, graded exposure therapy in the treatment of recently developed combat-related PTSD. San Diego, CA: Virtual Reality Medical Center.

[15]Wiederhold BK, Wiederhold MD. Three-year follow-up for virtual reality exposure for fear of flying. CyberPsychology & Behavior 2003; 6 (4): 441 – 328.

[16]Wiederhold BK, Jang DP, Kim SI, Wiederhold, MD. Physiological monitoring as an objective tool in virtual reality therapy. CyberPsychology & Behavior 2002; 5(1): 77 – 82.

[17] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.

[18]Orr SP, Roth WT. Psychophysiological assessment: clinical applications for PTSD. Journal of Affective Disorders (2000); 61: 225 – 240.

Semper Fi!Semper Fi!

Documents

Dennis Patrick Wood, Ph.D., ABPP (CAPT, MSC, USN-ret) Brenda K. Wiederhold, Ph.D., MBA The Virtual Reality Medical Center, San Diego COMBAT