Transcript A COMPARISON OF IMAGINAL EXPOSURE THERAPY AND …

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
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
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-C0136) to Virtual Reality Medical Center, San Diego,
CA.
Dad, Ivan & Megan: Fayetteville, NC
Nov 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 Mercy
4. 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 facility
4. MCBPC home to:
1st Marine Corps
Division & 1st
Marine
Expeditionary
Force (MEF)
VRMC/IMI Funders
PTSD Cluster
1.
2.
Life threatening event to self or
others that is “markedly
distressing”
INTRUSIVE: Event persistently
re-experienced: distressing
recollections, recurrent distressing
dreams/nightmares, flashbacks
PTSD Cluster
3. AVOIDANCE: Persistence
avoidance of thoughts, activities
&/or reminders of event; detached
feelings; foreshortened future
4. AROUSAL: Persistent arousal
sleep problems, irritability, hyperarousal or startle , concentration
difficulties
CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded
Exposure, Physiologically Monitored, Treatment for PTSD
(VRGET)

ABC Video Clip: PTSD & VRMC/ONR
Funded VRGET
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)
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)
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)
PTSD and the War on Terrorism
– 11% of OEF combat veterans have
PTSD
 12 – 20% of OIF combat veterans have
PTSD
 VA should aggressively prevent and treat
PTSD
6
(Report on the President’s Commission on Care for
America’s Returning Wounded Warriors, July 2007)
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)
PTSD and the War on Terrorism
Early Treatment for PTSD:
- “Early recognition and treatment may be key for
our newest veterans returning with combatrelated 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 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).
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
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.

CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure,
Physiologically Monitored, Therapy for PTSD
(VRGET)
ASSESSMENT:
 Pre-RX assessment
 Post-RX assessment following
TH
10 RX session
 Assessment at 3 months following
10th RX session
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





Virtual Reality Medical Center Hardware
Hardware Set-Up
Head Mount Display:
i-glasses
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

CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure,
Physiologically Monitored, PTSD Treatment (VRGET):
Pilot Study Patients
RANK
AGE TOURS TBI
MED
DX
PSYCH MED
MEDS 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):
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
60
50
40
PTSD Severity
(PCL-M)
30
20
t=3.16, p=.009
10
PreTreatment
PostTreatment
CYBERTHERAPY 13 - VRMC/ONR VRGET Program
Figure 2. Significant Reduction in Depression
Symptom Severity
18
16
14
12
10
8
6
4
2
0
Depression
Severity (PHQ-9)
PreTreatment
PostTreatment
t=2.55, p=.027
CYBERTHERAPY 13 - VRMC/ONR VRGET Program
Figure 3. Reduction in Anxiety Symptom Severity
25
20
15
Anxiety
Severity (BAI)
10
5
0
PreTreatment
PostTreatment
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
*t=2.63, p=.039
**t=2.42, p=.052
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
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
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
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
VRMC/ONR Virtually Reality Graded Exposure, Physiologically
Monitored, Therapy for Combat-related PTSD
CONCLUSIONS:
1. Pt reported presence of improved lifemanagement 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
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
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.
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 therapist’s office
Less time consuming
Less expensive
Safer
VRMC/ONR Virtually Reality Assisted, Physiologically Monitored,
Graded Exposure Therapy for Combat-related PTSD
Combat Town:
 Battalion Base
 Market Place
 Village
 Hospital
 Combat zone
VRMC/ONR Virtually Reality Assisted, Physiologically Monitored,
Graded Exposure Therapy for Combat-related PTSD



BATTLEGROUND
CONVOY
COMBAT MEDIC
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, 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 combatrelated 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!