- BACK ON THE STREETS: PTSD therapy.
From a room at the VA's Towbin Healthcare Center in North Little Rock, it is possible to go on foot patrol in Baghdad. To see a child pick up an I.E.D. hidden in a Coca-Cola can and the ensuing explosion. To see a soldier on the ground covered in blood. To smell him.
It's hard to imagine why anyone might want to do that. But doctors and veterans both hope that a new treatment for post-traumatic stress disorder — a virtual trip back to the scene of the triggering event — will help veterans and active duty personnel as well overcome the common, but difficult to treat, mental war wound.
The success rate for PTSD therapies hasn't been what doctors would like to see. A recent study found that cognitive, or talk therapy, helped 30 percent of PTSD patients. But 10 sessions of exposure therapy — which requires the patient to imagine the triggering event and train himself to tamp down the physical and emotional responses the memory brings on — got good results in more than half the cases. As difficult as it sounds, exposure therapy is a better way to go — for patients willing to take part in it.
Now, virtual reality technology is ratcheting exposure therapy up a notch, and the Central Arkansas Veterans Healthcare System will start this month recruiting veterans who want to try it out.
Dr. Jeffrey Pyne, one of several Veterans Affairs psychiatrists on the Best Doctors Inc. list, got first-hand experience with the technology when he was reactivated to Navy duty in San Diego in 2004.
Virtual reality, which simulates places and events with animation and sound by means of a computerized headset, was first used with Vietnam veterans, a significant percentage of whom returned from the war with what would be named in the 1980s as post-traumatic stress disorder.
With virtual reality systems much advanced since then thanks to the development of computer game platforms, Pyne and others began creating a virtual program that simulated scenes in Iraq and worked on protocols for when and how virtual reality therapy should be used with a small group of patients. Pyne and a collaborator were awarded a grant from the Office of Naval Research in 2005 to study the effects of virtual reality therapy. Now, he and clinicians at the VA are ready to try it out, in an advanced experimental stage.
In a room in the Towbin center, volunteers for the study will put on a headset that blocks out sound and sensory input from that room and enter Virtual Baghdad. The headset allows the patient to turn his head to look to the left or right or all around. He can work a joystick to move forward or backward in the scene, or fire a gun. Many scenes include children, the sounds of gunfire and explosions, helicopters all on the streets of the town. In one scene, after the child is killed by the I.E.D., an Iraqi woman dressed in black rushes up to the soldier/patient, waving her arms. The platform the volunteer is seated on will vibrate and rumble when explosions go off, and a scent machine will exude the smells of the propellant cordite, or diesel fuel, or spices from the Middle East ... even body odor. A therapist will be able to modify the scene, introducing elements to make it more closely resemble the patient's actual experience.
As the patient is immersed in Virtual Baghdad (or Virtual Iraq, another program), the therapist will ask him to tell the story of the traumatic event that has left him unable to trust the people around him, sometimes unable to control his anger and unable to fully re-enter civilian life.
As the patient repeats the sessions, Dr. Pyne said, he or she will remember more about what happened, and stories will become more complex and informative. The therapist will be able, it's hoped, to help the veteran re-experience the trauma and feel safe at the same time, training him to remember without reacting in a pathologically emotional way.
“Your mind is doing a good job of not letting you have access” to troubling memories, said Dr. Kevin Reeder, a psychologist who will work with virtual reality patients. He will be able to ramp up or make milder the particular “reality” the patient is experiencing and will ask the patients what they're feeling during the session.
The project will help clinicians refine the therapy.
Once the success of VR is better known, Pyne will study how subjects are reacting physiologically to the virtual reality experience. He'll look at data on arousal: Skin reactivity — sweat, a stress response, increases the conduction of electricity — and heart rate will be measured. “We don't know which is most reflective of stress,” Pyne said. Heart rate, for example, can be affected by the walk over to the hospital or a chronic condition. The goal is to find an objective method of diagnosing PTSD. “We would love to have a blood test,” Pyne said, “but we don't have that.”
The physiological assessment should help make the picture clearer, since patients may be motivated to underplay or exaggerate their condition. “Right now mental health therapy is tied to self-reporting,” Pyne said.
Symptoms of PTSD include nightmares and flashbacks and jitteriness when reminded of the event, avoidance of other people, hypervigilance and reacting to loud noises with a start. “They'll walk guard on their house,” Reeder said.
Reeder and Pyne are hoping that those who won't admit they need help — and that number is too high — might be attracted to the therapy by the technology. However, the candidates should be patients who haven't done well with cognitive therapy. Some patients have a hard time with “imaginal” or exposure therapy that doesn't use virtual reality, and Reeder said those patients would be good candidates for the VR project.
All the computer equipment and other components of the VR project, Reeder said, are “worth every penny, even if it helps just one guy.”