Posttraumatic Stress Disorder

Since 11-11-05

Veteran's Day 2005

From: Waspscpo@aol.com [mailto:Waspscpo@aol.com]
Sent: Thursday, November 10, 2005 8:53 AM
To: undisclosed-recipients:
Subject: PTSD

 
Posttraumatic Stress Disorder

http://www.military-medical-technology.com/article.cfm?DocID=1171

More than just a headgame, posttraumatic stress disorder is being studied, researched and treated like the medical affliction that it is.


By Cheryl Gerber
Military Medical Technology
November 9, 2005

The Department of Veterans Affairs is exploring unique ways to use the Internet and virtual reality to assist in posttraumatic stress disorder (PTSD) treatment for victims of the September 11 attack on the Pentagon and military personnel returning from Afghanistan and Iraq. A pilot program directed by Charles C. Engel at the Walter Reed Army Medical Center in Washington, DC, utilizes a Web site to facilitate the treatment of PTSD in soldiers returning from Iraq.

One of the advantages of the Internet-based treatment is its flexibility. It can provide therapeutic care during a time of disaster or mass violence in distant locations as long as there is an Internet connection. “It allows for care either in remote areas or you can be in your home in front of a PC to learn coping skills,” said Brett Litz at the Department of Veterans Affairs Healthcare System in Boston, which oversaw the development of the National Institute of Health-funded Web site.

Currently, there is a grant under review for a larger trial in the DoD and the VA, Litz said. Veterans simply log on to a private, protected PTSD de-stress (delivery of self training and education for stressful situations) Web site to access information and complete a series of homework assignments that monitor, manage and treat PTSD symptoms. Although the work done on the Web site is self-paced and self-directed, it is managed by professional therapeutic practitioners in face-to-face meetings and telephone conversations.

The entire Web-based de-stress course takes approximately eight weeks to complete. Professional therapists hope the Web site will encourage more trauma survivors to seek the necessary treatment as a way to prevent or resolve bad habits or subsequent problems that result from protracted, untreated PTSD, such as depression, substance abuse or relationship problems. A critical time for treatment is during the re-integration or re-deployment phase, when PTSD experiences emerge.

“The key is to learn a new skill set and mind set about how to manage these new experiences as they emerge during this re-deployment phase so that bad habits don’t develop,” Litz said. The Web site provides a standardized treatment method that promotes symptom reduction by teaching coping mechanisms that counteract the tendency of veterans with PTSD to withdraw or avoid dealing with the original traumatic experiences.

The therapist-assisted Web site facilitates the teaching of anxiety reduction techniques and the correcting of maladaptive thinking related to the trauma. The therapist-assisted Web site helps trauma survivors to acquire stress reduction habits by triggering traumatic memories and applying coping strategies to increasingly difficult situations. The Web site is used not only to provide information about stress management but also to collect and score symptoms daily through the use of SUDS or subjective units of discomfort scale ratings, provide instructions for homework assignments, monitor homework completion and facilitate contact with the therapist via e-mail or phone.

Using Virtual Reality Virtual reality exposure therapy uses customized virtual environments to expose patients to feared situations rather than taking them into the actual environment or asking them to imagine it. A trained therapist controls the virtual environment using a computer keyboard to manipulate situations to best suit the patient’s needs during the therapy hour within the therapist’s office. Patients wear a head-mounted display over the eyes and ears as they receive PTSD treatment.

They are in a 3-D environment where they can move around. There’s also echo location in the head. Sounds relate to location to make it real. When patients move closer, the sounds become louder.But people with PTSD startle quicker than usual and stay startled. They are afraid to remember events because they are so painful. Consequently they avoid the memories—but this creates a pattern of avoidance,” said Dr. David Ready, a clinical psychologist at the Post Traumatic Stress Disorder Clinical Team at the VA Medical Center in Atlanta, GA.

“The first two sessions we get them used to it,” explains Ready. “Then we simulate the experience that traumatized them. As we go through the process, we duplicate all the sights and sounds we can that are related to the experience. We have found with this exposure therapy that the success rate is related to the degree to which the patient is emotionally engaged in it. If they are overly engaged, then we lower the volume, turn things off and spend more time talking to them. If they are under-engaged, then we add more stimulation but not too much.

You don’t want to overwhelm them. You want to do it in a slow manner. Gradually, they start to gain mastery over how the memory affects them so they can re-engage in it in a safe environment,” he said. The traumatic memory is in bits and pieces when patients first come in for treatment. The practitioners create a string with a beginning, middle and end. For example, they ask, “What happened before your friend was killed? What happened after?”Ready gets SUDS ratings on a 1-100 scale every five minutes.

“A 100 is when you are ready to run out of the room panicked. A 0 rating is when you are comfortable. If I am getting a SUDS rating of 90, then I’m not going to add more stimuli,” he explained. In pre-treatment, post treatment and six-month follow-up, Ready found that symptoms have decreased significantly and stayed down after treatment.Starting in 1996, a company named Virtually Better began creating virtual reality environments to treat phobias such as fear of flying, fear of heights and fear of public speaking as well as posttraumatic stress disorder.

The company expanded its growth in recent years to include speech pathology, addiction and pain distraction. Cornell University in New York has used virtual reality software to help treat September 11 survivors in New York City, noted Ready.Virtually Better grew out of the collaborative research of Barbara Rothbaum, Ph.D, Director of Trauma and Anxiety Recovery Program at Emory University School of Medicine in Atlanta, GA, and Larry Hodges, professor and chair of the Department of Computer Science, University of North Carolina, Charlotte.

“We use virtual reality as a tool to expose veterans with PTSD to their most traumatic memories in a therapeutic way. There are a lot of analogies to the grieving process,” said Rothbaum. “If they get treatment, in six months it won’t be painful.” Virtually Better produced a virtual reality program entitled Virtual Vietnam which treated Vietnam veterans with PTSD and is now being used as one of the source materials in building a new program code-named Virtual Iraq, which is funded by the Office of Naval Research.

In order to be effective, virtual reality must match the original trauma. “We can’t put a soldier who was in the Iraqi desert in a Vietnam jungle environment,” noted Ready. Researchers developing Virtual Iraq at the University of Southern California (USC) are taking that into consideration. Skip Rizzo, a research scientist and professor at USC, is working with Jarrell Pair, a USC research scientist and one of the lead programmers who created Virtual Vietnam, to build Virtual Iraq.

The team is using a video game engine called Gamebryo and 3-D Studio Max and Maya graphics programs to create virtual structures.“With Gamebryo, we have a good licensing agreement so we don’t have to worry when we distribute the final software to VA hospitals and military sites. We won’t have to pay a licensing fee for each site we set up,” Rizzo said. “And we’re doing this all on a PC using low-cost, head-mounted display and tracking technology,” he said.

Taking today’s computer and video-savvy soldiers into consideration, the USC team has also adapted assets from virtual scenarios that were developed for the game “Full Spectrum Warrior,” a soldier training program based on Microsoft Xbox. Commercially available, “Full Spectrum Warrior” is a combat simulator developed with personnel from the Army’s Infantry School at Fort Benning, GA. The game places the player in an urban fighting environment.

The Virtual Iraq program transforms those environments into combat areas in the Middle East. “The level of graphics you need in order for them to see PTSD treatment not as a game makes it more challenging. You have to up the ante,” noted Ready. As a result, the USC and Virtually Better team is using a combination of resources as they build Virtual Iraq. The San Diego Naval Medical Center and Camp Pendleton will use Virtual Iraq to treat acute PTSD in Iraq veterans.

The project is part of a clinical trial for which USC is partnered with Virtually Better. In the process of developing Virtual Iraq, the researchers will solicit feedback to check the accuracy of the scenarios from actual soldiers in Iraq via a partnership with Fort Lewis Army psychologists, Colonel Greg Gahm and Captain Greg Reger. Rizzo and Pair are building a giant map of possible environments the soldiers in Iraq would have experienced during their traumatic experiences. “We put them in a safe environment in, say, a virtual Baghdad.

Then, when they can deal with that, we add trigger stimuli like a bomb going off, a sandstorm or a helicopter flying overhead. We raise the anxiety at manageable levels to recondition and extinguish fear and anxiety as they are gradually exposed to stimuli cues or triggers,” Rizzo said.

The reality is that there is trauma in life, and war by nature is a trauma factory. But returning military personnel with clear-cut PTSD still don’t always want the stigma of a PTSD diagnosis. “We are hoping that the technology will be an entre into talking about the treatment,” Rothbaum said. Rizzo also noted that the word “therapy” still has negative connotations and stigma attached to it that soldiers avoid.

As a result, many with combat stress resulting in PTSD don’t get the care they need. “Call it post-combat re-integration training, not therapy or they won’t go,” he said. Rizzo, Rothbaum and other experts are hoping that the use of Internet and virtual reality technology will encourage more veterans to sign up for treatment.

Virtual reality has improved in recent years with the faster computer equipment available on the market today. Ten years ago, a side effect of virtual reality was nausea as a result of slow screen updates but this does not occur anymore because the screen is updated now in milliseconds.