COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A MULTIPLE-CASE REPORT USING VIRTUAL REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING

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1 COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A MULTIPLE-CASE REPORT USING VIRTUAL REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING CYBERTHERAPY 12 CONFERENCE ALEXANDIRA, VIRGINIA Dennis Patrick Wood, Ph.D., ABPP (CAPT, MSC, USN-ret) The Virtual Reality Medical Center, San Diego dpwcapt@aol.com VRMC/ONR Graded Exposure, Physiologically Monitored Treatment Programs 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 (#N C- 0136) to Virtual Reality Medical Center, San Diego, CA.

2 VRMC VRGET PROJECT AT NAVAL MEDICAL CENTER SAN DIEGO NAVAL MEDICAL CENTER SAND DIEGO: 1.Largest Military Hospital in the world 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 NH,MCBCP: 1.60 miles North of San Diego 2.MCBCP = 250 square miles bed facility 4.MCBPC home to: FIRST MARINE CORPS DIVISION & THE FIRST MARINE EXPEITIONARY FORCE (MEF)

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4 Virtual Reality Medical Center Clinical Services (San Diego, West LA, Palo Alto) Specific Phobias Flying Driving Public Speaking Claustrophobia Heights Spiders Medical Procedures School Panic Disorder Agoraphobia Generalized Social Phobia due to motor vehicle accidents VRMC/IMI Funders

5 Virtual Reality Measurements Physiological Respiration HR, HRV Skin temperature Skin conductance Psychological Mini Neuropsychiatric Interview BAI PCL-M PHQ-9 Combat Exposure Scale Blast Assessment Virtual Reality Hardware Hardware Set-Up Head Mount Display: i-glasses

6 Cluster 1. Life threatening event to self or others resulting is markedly distressing 2. Event persistently re- experienced: intrusive distressing recollections, recurrent distressing dreams/nightmares, flashbacks

7 Cluster 3. Persistence avoidance: avoid thoughts, activities &/or reminders of event; detached feelings; foreshortened future 4. Persistent arousal: sleep problems, irritability, hyper- arousal or startle, concentration difficulties Psychiatric Diagnoses Related to Combat in Iraq and Afghanistan Following OIF, Depression, Anxiety & rates were: 15% 17% for Iraqi combat veterans 11.2% for Afghanistan combat veterans (Hoge et al., 2004)

8 and the War on Terrorism It is anticipated that the rate of will be higher among troops who have been to Iraq more than once.. (COL Elspeth Ritchie, July 19, 2006) rates, among soldiers hospitalized following serious combat injury, was 12% at 7 months following hospitalization (Grieger et al, 2006) and the War on Terrorism Soldiers who deployed longer (i.e., greater than six months) or 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).

9 VRMC/ONR Graded Exposure, Physiologically Monitored Treatment Programs Naval Medical Center San Diego Navy Hospital, Marine Corps Base Camp Pendleton Funded by Office of Naval Research (ONR) Funded by TATRC

10 VRMC/ONR Virtually Reality Assisted, Physiologically Combat Support Personnel (i.e., Naval Corpsmen, Seabees, non-infantry personnel) All warriors have a pre-treatment assessment, including two interviews; self-report questionnaires, objective measures & pyschophysiological measures Wood et al., Combat Related Post Traumatic Stress Disorder: A Case Report Using Virtual Reality Exposure Therapy with Physiological Monitoring. CyberTherapy & Behavior, 10 (2), 2007 VRMC/ONR Virtually Reality Assisted, Physiologically ASSESSMENT: Pre-RX assessment Mid-RX assessment following 5 th RX session Post-RX assessment following 10 th RX session Assessment at 3 & 6 months F/U

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13 WARRIORS WHO HAVE COMPLETED 10 SESSIONS OF VRGET (N = 6) RANK AGE COMBAT TOURS PURPLE HEART TBI SURGERY ONSET MED BRD RES HM2 (E5) 32 1 Yes Yes Yes 19 months Yes No CM1 (E6) 47 1 (12 Months) No No Yes 2 months Yes No EO1 (E6) 40 1 No No No 2 months Yes Yes HM2 (E5) 31 1 No Yes No 31 months Yes No LCDR (04) 49 Multiple No No No 13 months No Yes HMC (E7) 44 1 No No No 15 months No No VRMC/ONR Virtually Reality Assisted, Physiologically VRGET system: two Dell computers, VR HMD goggles with headphones, & joy stick; 3 rd computer to run the physiological monitoring All combat environments were graded immersive & patient only experienced computer generated audio & visual stimuli Patient walked through the combat zones Weekly treatment sessions 90 minutes long

14 VRMC/ONR Virtually Reality Assisted, Physiologically First two treatments: focused on meditation training and familiarity with the combat town Sessions 3 10: individualized & focused on progressively increasing the combat threat or elements & the patient s s immersion in the combat zones, eliciting SUDs levels, and effecting habituation Re-assessment following Sessions #5 & #10 VRMC/ONR Virtually Reality Assisted, Physiologically PRE-RX MID-RX POST-RX PCL-M PHQ-9 BAI Figure 1. Results of PCL- M, PHQ- 9 & BAI at Pre, Mid- & Post- treatment Assessments Scoring guidelines: PCL- M: < 50 = no ; > 50 = ; PHQ- 9: = Severe depression; = Moderately Severe; = Moderate; 5 9 = Mild; 0 4 = Minimal; BAI: = Severe Anxiety; = Moderate; 8 15 = Mild; 0 7 = Minimal. (N = 6)

15 VRMC/ONR Virtually Reality Assisted, Physiologically BASE STRESSOR RECOVERY Figure 2. Physiological Assessment of Skin Conductance (MicroMhos per second) at Pre- Treatment, Mid- Treatment, and Post-Treatment (N = 6) VRMC/ONR Virtually Reality Assisted, Physiologically BASE STRESSOR RECOVERY Figure 3. Physiological Assessment of Peripheral Temperature (Degrees Fahrenheit) at Pre-,, Mid-,, & Post-Treatment (N = 6)

16 VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-Related BASE STRESSOR RECOVERY Figure 4. Physiological Assessment of Heart Rate (Beats per Minute) at Pre-, Mid-, and Post- Treatment (N = 6) VRMC/ONR Virtually Reality Assisted, Physiologically SUMMARY: Post-treatment treatment PCL-M scores decreased; with two Warriors in remission Post-treatment treatment Depression scores decreased (i.e., Moderate Severe to Moderate) Post-treatment treatment Anxiety scores decreased from Severe to Moderate

17 VRMC/ONR Virtually Reality Assisted, Physiologically SUMMARY: Skin Condutance is a modifiable physiological response 1. Pre-Treatment SC was not reduced between Recall and Recovery (i.e., 7.14 to 7.34) 2. Mid-Treatment SC was reduced between Recall and Recovery (i.e., 6.07 to 2.8) 3. Post-Treatment SC Recall was lower (i.e., 4.64) VRMC/ONR Virtually Reality Assisted, Physiologically SUMMARY: Much variability to Peripheral Temperature (PT) 1. 3 Warriors PT increased and 3 Warriors PT decreased between Pre- Treatment Base and Post-Treatment Recovery (Pre-RX Base = 91.84) 2. May take more than 10 VRGET sessions to demonstrate a positive change in PT

18 VRMC/ONR Virtually Reality Assisted, Physiologically SUMMARY: Much Heart Rate (HR) variability between Pre-,, Mid-,, and Post- Treatment assessments (i.e., 74.02; 83.04; 77.79); Analysis of individual HR needed 1. Warriors differences in Initial HR (i.e., low = 66.5 vs. 86.3) 2. Warriors differences in Post-RX Recovery HR (i.e., 68.8 vs. 90.6) VRMC/ONR Virtually Reality Assisted, Physiologically CONCLUSIONS: 1. Pt reported presence of improved life- management skills 2. New VRGET Therapy for combat veterans DX with successfully developed 3. Currently soliciting input from Treated Warriors concerning the PROS and CONS of their VRGET

19 VRMC/ONR Virtually Reality Assisted, Physiologically CONCLUSIONS: VRGET sessions, with sessions twice a week, may be more effective 5. VRGET DVD developed for warriors homework with meditation CD 6. Homework being framed using results from PCL-M M administered between re-evaluations evaluations VRMC/ONR Virtually Reality Assisted, Physiologically CONCLUSIONS: 7. Review the bio-feedback data documenting the acquisition curve for Warriors converting increased Heart Rate VLF to LF the VLF-LF ratio represents the true Philosopher's Stone (Dr. James Spria) 8. Compare VRGET outcomes for 10 Wafrriors first 10 sessions against their second 10 VRGET sessions outcomes

20 VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-related WARRIORS VRGET SESSIONS COMPLETED Enrolled for Eval 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 s office Less time consuming Less expensive Safer

21 VRMC/ONR Virtually Reality Assisted, Physiologically Combat Town: Battalion Base Market Place Village Hospital Combat zone

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27 Semper Fi!