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Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
ViRTICo: Virtual Reality Therapy and Imaging in Combat Veterans
COL Michael J. Roy, M.D., M.P.H.Director, Division of Military Medicine
Professor of MedicineUniformed Services University
Bethesda, MD
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Collaborators
WRAMC/USU• Greg Lande• Patricia Taylor• Jennifer Francis• Josh Friedlander• Lisa Banks-Williams• Vanita Tarpley • Wendy Law
• NIMH• Meena Vythilingam• James Blair• Husseini Manji• Jennifer McLellan• Allan Mallinger• Stephen Sinclair
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Other Key Consultants
• Barbara Rothbaum, Emory University
• Skip Rizzo, Inst for Creative Technologies, USC
• JoAnn Difede, Weill Medical School, Cornell
• Ivy Patt (therapist supervision and fidelity assessments)
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Funding
• Office of Naval Research, $900,000– Russ Shilling, Project Manager
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Aims of ViRTICo I
• Establish utility of functional MRI to distinguish OIF/OEF veterans with PTSD and mild TBI (“blast exposure”) from combat-exposed controls
• Identify efficacy of Virtual Reality Exposure Therapy (VRET) for combat-related PTSD, compared to current first-line therapy, Foa’s Prolonged Imaginal Exposure (PE)
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Mild TBI
• No penetrating trauma or shrapnel
• < 1-2 mins’ loss of consciousness
• Lower end of range ill-defined:– Symptoms attributed to blast include headaches,
dizziness, tinnitus, irritability, sleep problems, memory or balance problems
– Medical literature: 2/3 don’t meet criteria for concussion, but 15-29% have persistent cognitive impairment (attention span, memory, executive function)
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Hypotheses
• fMRI can reproducibly distinguish between veterans with PTSD, mild TBI, both, and neither– Digital photos may be more effective at this
than current validated tests such as the Stroop
• VRET is non-inferior to PE in treatment of PTSD– VRET might accelerate response rate
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Study Questionnaires
• CAPS to confirm diagnosis (score of 40), and at end of treatment and follow up– PCL-M and PC-PTSD more frequently
• BDI and BAI for depression, anxiety
• CAGE, AUDIT for alcohol
• SCID-I,II for other psych disorders
• DVBIC questionnaire for TBI
• SF-36 and WHO-DAS II: functional status
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Functional MRI
• Blood oxygen level dependent (BOLD) – Stimulation causes feedback loop to increase
oxygenation within specific brain areas, increases intensity on T2 images
• Prior studies show greater amygdala and decreased prefrontal activation for PTSD than trauma-exposed controls
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
fMRI phase of study
• Compare 4 groups of 22 each– PTSD and TBI– PTSD only– TBI only– Deployed, no PTSD or TBI
• Two stimuli used in scanner– Affective Stroop: previously validated– Digital photos from Iraq & Afghanistan
• Repeat fMRI after treatment for PTSD
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Digital photos taken by soldiers• Emotionally charged scenes
• Emotionally neutral scenes
• Judged by veterans, providers
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Treatment phase subjects
• 44 subjects randomized to VRET or PE– 22 subjects each with PTSD alone and PTSD
plus TBI from fMRI phase– Individuals with shrapnel preventing fMRI may
enter treatment phase directly, so additional subjects will be recruited to fill fMRI phase slots
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
VR Exposure Therapy• 12 90-minute sessions, average 2 per week• Manualized treatment adapted from Difede, in
turn based on Virtual Vietnam– Begin with CBT approach– Homework, relaxation techniques– VR introduced @ 4th session, ½ of session
• 1st person, present tense• Therapist choreographed, following SUDS, physiologic
monitoring to guide progression
• Includes characteristic audio, video, and olfactory features of Middle East
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Prolonged Exposure
• Manualized treatment, based on work by Edna Foa, UPenn
• Same length (90 mins) and number of sessions (12) and overall approach as for VRET arm
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Vibration platform
• Explosions
• Vehicle movement
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Olfactory stimulation
• Theoretic basis: olfactory bulb proximity to hippocampus, and long phylogenetic history– Iraqi spices– Chordite– Body Odor– Burning Rubber– Burning Trash
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Physiologic Monitoring
• Heart rate
• Blood pressure
• Respiratory rate
• Skin conductance
• HRV
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Outcome measures
• CAPS at end of treatment and q 4 weeks for 12 weeks of follow up
• PCL-M and PC-PTSD
• BDI, BAI for depression, anxiety
• CAGE, AUDIT for alcohol abuse/dep
• SF-36 and WHODAS-II for functional status
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Initial participants (n=17)
• 2 withdrew during baseline eval, 2 ineligible due to subthreshold PTSD
• 8 completed baseline including fMRI, 2 had shrapnel, 1 aborted fMRI, 2 pending
• Four completed treatment; one withdrew during treatment; 3 in active treatment
• Demographics: 1 female; 1 Hispanic, 3 African-Americans; age range: 24-49
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Challenges encountered
• Recruitment: high rate of alcohol abuse– Amended protocol to relax entry criteria
• Distinguishing mild TBI problematic– Relies on self-report
• Mild TBI rarely unaccompanied by PTSD symptoms
• Secondary gain issues sometimes interfere with reported response
Michael J. Roy, COL, MC, USADivision of Military Internal Medicine
Summary
• Numbers small, but only 1 of 3 in VR arm had a 30% decrease in CAPS; 0/2 in PE arm– But, significant behavioral changes noted– Hard for subjects to acknowledge
improvement for fear of losing benefits
• fMRI and physiologic measures not yet analyzed