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COMBAT RELATED POST TRAUMATIC STRESS DISORDER A
REPORT EMPLOYING VIRTUAL REALITY GRADED EXPOSURE
THERAPY WITH PHYSIOLOGICAL MONITORING
(VRGET) CYBERTHERAPY 13 SAN DIEGO, CALIFORNIA
Dennis Patrick Wood, Ph.D., ABPP (CAPT, MSC,
USN-ret) Brenda K. Wiederhold, Ph.D., MBA The
Virtual Reality Medical Center, San
Diego www.vrphobia.com
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• CYBERTHERAPY 13 VRMC/ONR Virtual Reality
• Graded Exposure, Physiologically Monitored,
  Treatment for PTSD
• (VRGET)

Co-investigators Kristy Center, M.A.,
VRMC Jennifer Murphy, M.A., VRMC Robert McLay
(CDR-sel MC USN), NMCSD Carol Russ, Ph.D. (CDR
MSC USNR-ret), VRMC Robert Koffman (CAPT MC
USN), BUMED Scott Johnston (CDR MSC USN),
NMCSD James Spira, Ph.D., VRMC
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CYBERTHERAPY 13 VRMC/ONR Virtual Reality Graded
Exposure, Physiologically Monitored Treatment
for PTSD (VRGET)
Disclaimer The views in this presentation are
those of the individual authors, and do not
necessarily represent those of the Department of
the Navy, Department of Defense, the Department
of Veterans Affairs, or the U.S. Government.
Research described has been approved by the
Institutional Review Board at the Naval Medical
Center San Diego. The information in this
presentation was approved under the NMCSD
Institutional Review Board. This study was
sponsored by the ONR Contract (N00014-05-C-0136)
to Virtual Reality Medical Center, San Diego, CA.
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• Dad, Ivan Megan Fayetteville, NC
• Nov 2007

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VRMC VRGET PROJECT AT NAVAL MEDICAL CENTER SAN
DIEGO

• NAVAL MEDICAL CENTER SAND DIEGO
• Worlds Largest Military Hospital
• Home of the Comprehensive Combat Casualty
  Care Program (C-5)
• USS Mercy
• 4. 4 additional West Coast Navy Hospitals

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VRMC VRGET PROJECT AT NAVY HOSPITAL MARINE CORPS
BASE CAMP PENDLETON

• Navy Hospital MCBCP
• 1. 60 miles North of San Diego
• MCBCP 250 square miles
• 3. 123 bed facility
• MCBPC home to
• 1st Marine Corps Division 1st Marine
  Expeditionary Force (MEF)

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VRMC/IMI Funders
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PTSD Cluster

1. Life threatening event to self or others that is
   markedly distressing
2. INTRUSIVE Event persistently re-experienced
   distressing recollections, recurrent distressing
   dreams/nightmares, flashbacks

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PTSD Cluster

• 3. AVOIDANCE Persistence avoidance of
  thoughts, activities /or reminders of event
  detached feelings foreshortened future
• 4. AROUSAL Persistent arousal sleep problems,
  irritability, hyper-arousal or startle ,
  concentration difficulties

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

• ABC Video Clip PTSD VRMC/ONR Funded VRGET

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Psychiatric Diagnoses Related to Combat in Iraq
and Afghanistan

• Following OIF and OEF, PTSD, Depression and
  Anxiety rates for warriors were
• 15 17 for Iraqi combat veterans
• 11.2 for Afghanistan combat veterans
• (Hoge et al.,
  2004)

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PTSD and the War on Terrorism

• It is anticipated that the rate of PTSD will be
  higher among troops who have been to Iraq more
  than once. (COL Elspeth Ritchie, July 19, 2006)
• PTSD rates, among soldiers hospitalized following
  serious combat injury, was 12 at 7 months
  following hospitalization (Grieger et al, 2006)

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PTSD and the War on Terrorism

• Soldiers who deploy longer (i.e., greater than 6
  months) or who had deployed multiple times were
  more likely to screen positive for a mental
  health issue.
• (DOD, Mental Health Advisory Team (MHAT-IV)
  Survey 04 May 2007)

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PTSD and the War on Terrorism

• 6 11 of OEF combat veterans have PTSD
• 12 20 of OIF combat veterans have PTSD
• VA should aggressively prevent and treat PTSD
• (Report on the Presidents Commission on Care
  for Americas Returning Wounded Warriors, July
  2007)

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PTSD and the War on Terrorism

• 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)

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PTSD and the War on Terrorism

• 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)

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PTSD and the War on Terrorism

• 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).

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

• Naval Medical Center San Diego
• Navy Hospital, Marine Corps Base Camp Pendleton
• Funded by Office of Naval Research (ONR)
• Funded by TATRC

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Cybertherapy 13 VRMC/ONR Virtually Reality
Graded Exposure, Physiologically Monitored,
Therapy for PTSD (VRGET)

• Combat Support Personnel (i.e., Corpsmen,
  Seabees, non-infantry Marines)
• Evaluation qualifying assessment, including two
  interviews, completion of self-report measures
  and objective questionnaires,
  psychophysiological measures assessment
• Wood et al., Combat Related PTSD A Case Report
  Using VRGET with Physiological Monitoring.
  CyberTherapy Behavior, 10 (2), 2007.

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CYBERTHERAPY 13 VRMC/ONR Virtually Reality
Graded Exposure, Physiologically Monitored,
Therapy for PTSD (VRGET)

• ASSESSMENT
• Pre-RX assessment
• Post-RX assessment following 10TH RX session
• Assessment at 3 months following 10th RX session

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Physiological and Psychological Measurements
Virtual Reality Medical Center/ONR VRGET

• Physiological
• Respiration
• HR, HRV
• Skin Temperature
• Skin Conductance

• Psychological
• Mini Neuropsychiatric Interview
• BAI
• PCL-M
• PHQ-9
• Combat Exposure
• Scale
• Blast Assessment

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Virtual Reality Medical Center Hardware

Head Mount Display i-glasses
Hardware Set-Up
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CYBERTHERAPY 13 VRMC/ONR Virtually Reality
Graded Exposure, Physiologically Monitored,
Therapy for Combat-related PTSD (VRGET)

• VRGET Sessions 1 2 Meditation Training,
  exposure to SUDs, CBT, review of Sentinel Event
• VRGET Sessions 2 10 Individualized VRGET
  focused on increasing the intensity of the combat
  elements, immersion in the combat environment,
  eliciting SUDs effecting habituation
• Reassessment following 10 VRGET Sessions

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CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded
Exposure, Physiologically Monitored, PTSD
Treatment (VRGET) Pilot Study Patients
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
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CYBERTHERAPY 13 - VRMC/ONR Virtual Reality
Graded Exposure, Physiologically Monitored, PTSD
Treatment (VRGET)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
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CYBERTHERAPY 13 - VRMC/ONR VRGET
Program Figure 1 Significant
Reduction in PTSD Symptom Severity
t3.16, p.009
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CYBERTHERAPY 13 - VRMC/ONR VRGET Program
Figure 2. Significant Reduction in
Depression Symptom Severity
t2.55, p.027
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CYBERTHERAPY 13 - VRMC/ONR VRGET Program
Figure 3. Reduction in Anxiety Symptom
Severity
t1.40, p.188
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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
t2.63, p.039 t2.42, p.052
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CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded
Exposure, Physiologically Monitored, PTSD
Treatment (VRGET)

• VRGET SUMMARY
• 1. Significant reductions in the warriors PTSD
  scores
• 2. Significant reductions in the warriors
  Depression scores
• 3. Significant reductions in the warriors Skin
  Conductance

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

• VRGET SUMMARY
• 4. Measurable reductions in the warriors
• Anxiety scores
• 5. 75 of patients had a reduction in PTSD
  symptoms
• 6. 42 did not meet criteria for PTSD after
• VRGET treatment
• 7. 66 fit for full duty after VRGET treatment

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

• VRGET SUMMARY
• 8. Two warriors currently deployed to
• Al-Asad, Iraq
• 9. One active duty warrior back in a full duty
  status in CONSUS
• 10. Two Reserve warriors in an active Reserve
  status

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

• VRGET SUMMARY
• Functional Improvement
• Reduced Psychotropic Medication Usage
• Warriors reported improved Interpersonal and
  Occupational Functioning
• 3 warriors have enrolled/re-enrolled in College
  since their discharge
• 6 warriors have started to work or have returned
  to their civilian employment since their
  discharge

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

• CONCLUSIONS
• 1. Pt reported presence of improved
  life- management skills
• 2. New VRGET Therapy for combat veterans DX
  with PTSD successfully developed
• 3. Currently soliciting input from Treated
  Warriors concerning the PROS and CONS of their
  VRGET

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

• CONCLUSIONS
• 4. 20 VRGET sessions, with sessions
• twice a week, may be more effective
• 5. Homework being framed using
• results from PCL-M administered
• between re-evaluations

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

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

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Why VR ? Advantages and illustrations

• Not dependent upon patients imagery abilities
• Provides a structured environment
• Visual and auditory stimuli
• Can over-learn skills habituation or
  develop concept of safety
• Done in the therapists office
• Less time consuming
• Less expensive
• Safer

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

• Combat Town
• Battalion Base
• Market Place
• Village
• Hospital
• Combat zone

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

• BATTLEGROUND
• CONVOY
• COMBAT MEDIC

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

• 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, OSullivan 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.

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Semper Fi!