Virtual Reality Exposure: Efficacious Treatment for Combat PTSD?

1. Virtual Reality Exposure: Efficacious Treatment for Combat PTSD? Sarah D. Miyahira, Ph.D. Pacific Telehealth & Technology Hui Department of Veterans Affairs Pacific Islands Health Care System Honolulu, Hawaii Hunter G. Hoffman, Ph.D University of Washington, Seattle, Washington Raymond A. Folen, Ph.D. Tripler Army Medical Center, Honolulu, Hawaii Azucena Garcia-Palacios, Ph.D. Universitat Jaume 1, Castellon,Spain Cybertherapy 2008 Conference San Diego, CA, USA June 24, 2008

2. Approximately 1.64 million U.S. warfighters deployed to Iraq and Afghanistan since October 2001 Many experience prolonged exposure to stressful and traumatic combat events 18.5% returning troops have PTSD or depression ≈50% who need treatment, seek treatment ≈50% who are treated receive minimally adequate care Recommendation: improve access to High Quality care (supported by scientific evidence) U.S. Warfighters Deployed to Iraq & Afghanistan-RAND Report, 2008

3. Prevalence of Mental Health or Cognitive Impairment

4. What We Know About Exposure to Combat • Intensity and frequency of violence and threat of death in combat increases risk for PTSD • Most warfighters do not develop PTSD • Most with PTSD will recover naturally over time • Others develop chronic PTSD if not treated • High co-morbidity: alcohol & drug abuse, medical problems, depression, other psychiatric disorders

5. “To this day I can still hear our screams and recall the feeling of the truck being lifted and shaken with every explosion.” Spc. J. Norrel Convoy attack and IED explosion survivor

6. Potentially powerful treatment approach Early studies show promising results Rothbaum et al (2001) Difede and Hoffman (2002; 2006) Few published controlled studies More empirical evidence required Virtual Reality Treatment for PTSD

7. Randomized controlled study Compare VR exposure treatment to delayed treatment of PTSD in returning warfighters from Iraq and Afghanistan Treatment: CBT augmented with VR exposure 10 treatment sessions (2x/week) Graded VR exposure (auditory, visual, kinesthetic stimuli) Physiologic monitoring: heart rate, temperature, skin conductance, respiration VR Exposure Treatment of Combat PTSD

8. Humvee convoy in Middle East town Critical events: IED explosions, gunfire attack, swerving car, RPG attack VR elements: 3D visual animation, stereophonic audio, chair vibrations Therapist interface: keyboard to activate and deactivate images, sounds, and animation Individual customization of stressful events Increase or decrease level of stress arousal VR Environment: Middle East World (MEW)

9. VR Environment: Middle East World

10. VR Environment: Middle East World

11. VR Environment: Middle East World

13. Sample Characteristics

14. Pre-Treatment Status

15. Sessions 2-6 - Temp

16. Sessions 2-6 - Resp

17. Sessions 2-6 - HR

18. Sessions 2-6 - EDR

19. Surveys of OIF warfighters report significant levels of mental health impairment Sample data indicates moderately heavy combat exposure and high PTSD severity Preliminary physiologic data indicates VR arousal & habituation with repeated exposure Anecdotal & subjective ratings indicate high presence Controlled studies needed to demonstrate efficacy of VR Summary

20. Acknowledgements Funding for this research study is provided by the Office of Naval Research, Science and Technology This material is the result of work supported with resources and the use of facilities at the, Department of Veterans Affairs, Pacific Islands Health Care System, Honolulu, HI

21. Contact Information: Sarah D. Miyahira, Ph.D. Pacific Telehealth & Technology Hui 459 Patterson Road Ste. 4E-B100 Honolulu, Hawaii, USA 96819-1522 Sarah.Miyahira@pacifichui.org