Tuesday, December 11, 2012

Virtual Reality in the Fight against Post-Traumatic Stress Disorder

I have been interested in psychology since I was young, but really had never given virtual reality a second thought. Well, except for when it came to video games or theme park rides. I always thought it would be amazing to be able to interact with a virtual world. I was a child when the movie, Honey I Shrunk the Kids, was released. I always wanted to experience that world. After reading about virtual reality and how it can help those suffering with PTSD, I am amazed at what this technology can do. The field of communication and media overlaps quite often with the field of psychology. Virtual reality combining with exposure therapy to treat Post-Traumatic Stress Disorder is a dynamic example of such an overlap. The U.S. government has embraced this new therapy and technology, and it has been shown to be effective.

Post-traumatic stress disorder (PTSD) is an anxiety disorder that could potentially develop in anyone. PTSD can occur after a person witnesses or experiences a traumatic event. The event would need to involve death or the threat of death. This disorder can occur in adults, teenagers, and children. It is commonly seen after crimes such as assault or rape, natural disasters, terrorism, war, and more. While the exact cause of PTSD is unknown, it has been linked to stress. Stress hormones carrying information to neurotransmitters are affected, thus changing the body’s response to stress (“Post-traumatic”).

People suffering from PTSD can find it very difficult to lead normal and productive lives. Disruptive symptoms can fall into three major categories: reliving the event, avoidance, and arousal. When a person relives the event, he or she may “flashback” to the event. A flashback can happen again and again and causes the person to feel like the event is reoccurring. Repeated memories of the event may occur as well. These memories are not as intense as a flashback but are just as disruptive and disturbing. This group of symptoms also includes nightmares, and feeling uncomfortable in situations that remind the person of the even that occurred (“Post-traumatic”).

Avoidance includes symptoms of depression, like not wanting to do things that one used to be interested in, and not feeling like one has a future. It also includes the inability to feel emotion, feeling detached, and not remembering parts of the traumatic event. Like the name avoidance suggests, people may also avoid other people, places and things that may remind them of the event (“Post-traumatic”).

Lastly, arousal refers to be startled easily, and over-reacting when startled. Having trouble concentrating, being irritable, angry outbursts, and insomnia are all further examples of arousal symptoms. Guilt of having survived the event also falls into this category. This is called survivor guilt and can manifest in dizziness, fainting, headaches, and other symptoms (“Post-traumatic”).

As you can imagine, these symptoms of PTSD can be very disruptive. People become depressed, can’t sleep, and start avoiding things that they may have enjoyed or are vital to normal living. For example, take a soldier who was in a military vehicle when she witnessed an explosion that killed a young child. She may have trouble sleeping, because whenever she closes her eyes she sees that child. When she does sleep she has nightmares. She can no longer play with her children, or hold them, or read them bedtime stories. It isn't that she doesn't love them anymore; she just doesn't enjoy playing or reading anymore. Every time she looks at them she remembers that horrific event. When she went with her family to see the 4th of July fireworks, the noise of the fireworks startled her and threw her into a flashback. That was when this soldier knew she needed help.

One effective treatment of PTSD is exposure-therapy. This is a behavioral therapy that targets the learned avoidant behavior. When a person experiences a traumatic event he or she may develop avoidant behavior. The person may start to try to avoid situations, people, events, that are perceived to be a danger. For example, the soldier mentioned before may avoid going to firework displays, or concerts that may have pyrotechnics. While this avoidant behavior is normal, and in some cases a healthy response as the person is trying to protect one's self, it can also become unhealthy as it negatively impacts normal living. A person with PTSD may even avoid thinking about the event that occurred. Our soldier from before may stop talking about what happened. She won’t talk about it with her husband or her friends and family. This means the person can never confront and process what happened (Tull, “Exposure Therapy”).

Exposure-therapy has the person confront his or her fears and anxieties. By confronting them the person can learn techniques to handle the anxiety, learn that it will lessen and that there really isn't anything to fear anymore. The avoidant behavior will start to decrease and the person can return to a normal, healthy lifestyle. There are a few different types of exposure therapy, such as interoceptive, imaginal, and in vivo (Tull, “Exposure Therapy”). The one that we are most interested in is virtual reality exposure therapy.
For combat veterans suffering from PTSD, virtual reality (VR) works well because in exposure therapy the person needs to confront as real a situation as one can get (Tull, “Using Virtual”). It isn't plausible to put the veteran back onto the front line to relive the event. VR can recreate a scenario as close to the original as possible without putting the person into harm’s way. Instead, a 360 degree virtual scenario that resembles the area where the veteran suffered the trauma can be created. This experience immerses the participant in an interactive environment. This relies on two key ideas, depth of information and breadth of information. According to the article written by Jonathan Strickland for HowStuffWorks.com, depth is, “...the amount and quality of data in the signals a user receives when interacting in a virtual environment”. While breadth is, ‘number of sensory dimensions simultaneously presented’. These ideas and definitions are credited to Jonathan Steuer. A participant experiences the depth of information through the graphics. What is the resolution? How complex or simple are the graphics? The images below demonstrate a difference in graphic images :
Graphics of Warcraft II released in 1995 

Graphics of World of Warcraft released in 2007 and continually updated

Breadth of information is concerned with how many senses are being utilized in the virtual scenario. Is there audio? Are there smells? Can the user feel the sun and the wind? The wider the breath, the more senses are activated, and the more “real” the virtual reality feels.

When the participant can interact with the environment it is called haptic feedback. Scientists are working on developing these systems so that participants can experience the sense of touch. Then participants could feel objects picked up, and interact more fully with the environment (Strickland).

Using virtual reality as a tool for exposure-therapy means that the scenario needs to feel as real as possible. Participants need to be able to experience the traumatic event as authentically as possible. The stress levels felt at the time of the event need to be duplicated so that they can be addressed. The participant also needs to feel that level of anxiety again in order to learn that the feeling will fade, and that the experience is not as harmful as believed. This means that the most effective VR tools will need a wide depth and breadth of information. Images that are pixilated, smaller or larger than life size, etc. could be distracting and would take away from the feeling of being in a real place. Images should be high quality and realistic, with sounds that are undistorted and at a normal volume. This will make the user feel like the virtual environment is a real environment. 

Having the imagery and the sound be authentic to the event are important to trigger the memory and experienced stress levels. I feel that the smaller details can be important as well. Often times it is a smell that triggers a memory of a flash of panic felt before. The smell of gunpowder or explosives can make the VR that much more realistic for the user. The desert will feel more real with heat lamps shining down on the participant, and perhaps a fan blowing the hot air. There are ways to engage the senses without having to create complicated haptic systems.

Many studies have been done with VRET. In 2006, a preliminary study began at Emory University. This study focused on a combination therapy of VRET and a drug called d-cycloserine (DCS). 150 confidential participants, who served in Iraq and have been diagnosed with PTSD, are taking part in the study. This study states that the drug and the VRET are used in a psychological process called extinction. By causing the participant to go into a state of fear and anxiety over and over again a protein in the brain called the NMDA receptor is manipulated. The participant feels the fear and anxiety but nothing negative happens to him or her. Having no negative effects occur will teach the participant that nothing bad will happen, thus making the fear and anxiety extinct (“Virtual Reality”).

The participants were slit up into three random groups. All three groups have five weeks of VRET therapy, and one week of therapy without the use of VR. One group takes the DSC, one group takes a generic Xanax, and the other takes a placebo. The therapists talk the participants through the VR scenarios, and also measures physiological responses, such as heart rate and the amount of stress hormone in saliva (“Virtual Reality”).

Preliminary data was presented in 2008 to the American Psychiatric Association that showed the combination therapy was effective (“Virtual Reality”).

In the September of 2009 the United States Air Force issues a press release about PTSD and VR therapy. It was being offered at a newly opening PTSD clinic in San Antonio to troops returning home from Iraq and Afghanistan (“Air Force Study”). The United States Army followed suit in the January 2010 press release. They announced the start of a four year VRET study. This study has 120 participants, also split up into three groups. The three groups will each participate in a different type of therapy: imaginal prolonged exposure therapy, virtual reality exposure therapy, and any therapy after a period of five weeks (“Combating”).

Virtual reality, or virtual environments, can be used as entertainment but it is growing increasingly popular as a therapy tool. Having different branches of U.S. military offering virtual reality exposure therapy to returning servicemen and women, and taking part in studies about the therapy, demonstrates how popular the therapy has become. Study after study has shown results, and preliminary results, that support the legitimacy of VRET. This therapy can work.
Since virtual reality (VR) is currently an accepted and even celebrated method of treating post-traumatic disorder (PTSD), perhaps it has another use as well. Skip Rizzo is leading a team at the University of Southern California. These psychologists, computer scientists, and engineers are studying the use of virtual reality to prevent PTSD from occurring in the first place (“Battle Ready?”).

Virtual reality used as a type of exposure-therapy for veterans suffering from PTSD has proven to be quite successful. It was this success that made Rizzo wondered if it could be used to prevent PTSD not just treat the disorder. The theory is to get the soldiers acclimated to the scenarios that may occur in battle. The soldiers can then become familiar with them and learn how to manage the stress caused by the event, in a sense, becoming desensitized to what might occur (“Battle Ready?”).

The team has created a VR experience that includes sights, sounds, vibrations, and even smells. The participants become part of an active tour of duty and experience the loss of a computer-generated comrade and the sight and handling of human remains. They even helplessly witness the death of a child. Unlike in real battle, these scenes can be paused at any time. This allows for a third party to step forth and interact with the participant. The mentor can lead the participant in stress-reducing exercises, and discuss how the participant is feeling. Having the participant able to identify what they are feeling and understanding that it is normal can aid in reducing the stress (“Battle Ready?”).

Rizzo's colleague, Galen Buckwalter, monitors physiological responses to the VR tour. He watches things like heart rate, pupil response, and skin reaction, i.e. sweat. He believes that as the participant learns to cope with the stress there will be changes in the physiological responses. These changes can then be used as an indicator for when someone is ready for active duty, and when someone is not psychologically ready for combat (“Battle Ready?”).

If Buckwalter's findings prove to be accurate that will cause a problem for the military. Basically, what happens to the person whose physiological responses never indicate that the person is emotionally and psychologically fit for active duty? Currently, the military will find other responsibilities for people who may not be physically able to go into active duty. Perhaps, the military would then make the same type of considerations for people with who could not be cleared for duty by this study’s standards (“Battle Ready?”). While it does raise a legitimate issue, I don’t see it as being one that will slow down this study. The different branches of the military can find a way to address this issue, if the study proves effectiveness. Being able to inoculate a soldier to PTSD could be an invaluable tool. It will be interesting to see if this theory goes any further than the current study.

Currently, VRET is quite expensive and it can be hard to find a clinic that offers the treatment (Tull). One place that offers the treatment is the Virtual Reality Treatment Center in San Diego, California. This clinic does not list PTSD on the website, but does include these as treatable of the clinic: fear of closed spaces, fear of thunderstorms, fear of driving, school phobia, fear of flying, social phobia, fear of heights, Attention Deficit Hyperactivity Disorder (ADHD), fear of needles and blood, panic disorder , fear of open space, flying anticipatory anxiety, fear of public speaking, anxiety disorder, fear of spider and pain distraction (“The Virtual Reality Medical”). So, as you can see VRET is not limited to just PTSD. A wide variety of anxiety, panic, and fear disorders can be addressed. As VRET becomes validated through the U.S. military, we may see it start to be more common for the treatment of these other disorders. Like any technology, as the demand grows, the betterment of the VR technology will increase as well. Through the years as the government puts more money into technology it may become cheaper and more readily available to clinics all over the United States.

Virtual reality is an effective tool in treating fear and anxiety disorders, because it is so immersive. In this way it is like a window. The idea of media as windows and mirrors is introduced by J. David Bolter and Diane Gromala in their book titled: Windows and Mirrors: Interaction Design, Digital Art, and the Myth of Transparency.  

The two authors introduce to us the idea that new media can act like a window, a mirror, or both. Experiencing a new media as a window essentially means that you see into it and become immersed. The users lose awareness of the interface and their surroundings. A new media acts like a mirror when it reflects something back to the user. The user may have their ideas reflected back to them, or an idea, or feeling. The user doesn't lose awareness of the interface but, instead, interacts. 

VRET is interesting because it makes use of both theories. The virtual environment acts as the window. The user “steps” into a computer-generated environment that is designed to look natural. This environment exists in 360 degrees. It may include sound, and other sensory information. The more information provided to the user, the more immersive the experience. It is a window into another environment. The user focuses on the experience and loses awareness of the interface. The interface, in this situation, is the VR room or equipment, and the user's current “real life” location. The user may even lose track of the actual date and time as they are carried into a memory of a past time in another country entirely. When left with just the VR experience you only have the window theory. It’s the added element of the therapists that then brings in the mirror.

One of the helpful aspects of VRET is that the experienced can be paused at any time. This allows for the therapist to step in and interact with the user. Perhaps, the user has come to a certain part of the VR program that has caused anxiety. The user may be sweating heavily and have an accelerated heart rate. Now, the therapist might pause, and start to talk the user through the experience. They can discuss how and what the user is feeling, and how that this is a normal reaction. The therapist may also lead the user through different stress-relieving techniques, like controlled breathing. The experience now becomes a mirror because it is reflecting back onto the user. The user becomes aware that this is not a real experience; they are reminded of where they are and who is there with them. Their fears and anxieties are reflected back like a mirror and now the user can confront them and heal.

Media, communication, technology, and psychology are all fascinating fields to study. They are all advancing and evolving. There are always new ideas, new products, and new theories. It is even more amazing when all those fields come together in one subject. Virtual Reality Exposure Therapy is an example of multiple fields of study coming together to benefit the lives of many. Servicemen and woman risks their lives, health and safety for their country when they fight for peace, justice, and freedom. Not all people are equipped to handle the emotional and psychological toll of war. Many soldiers come back home suffering from post-traumatic stress disorder. Traditional exposure therapy is a popular treatment, but wasn't working for everyone, as it relied on having the participants imagine and remember the event. Virtual reality stepped up and supplied a missing piece of the puzzle. Now people suffering from PTSD can step into a virtual environment and experience a re-creation of the event. VR as a tool made exposure therapy that much more effective. The U.S. military has supported this therapy and is sponsoring more studies. Some studies are even trying combination therapies with VRET and drugs. While some most studies are looking at treating PTSD, there is an ongoing study that is addressing the prevention of PTSD. Can VR help prepare and even inoculate our soldiers to the mental traumas of war? This field of study is ongoing and very exciting. It will be interesting to see where virtual reality goes next, and how it will help humanity.

Works Cited 

"Air Force Study Uses Virtual Reality for Post Traumatic Stress Disorder."
     US Fed News Service, Including US State NewsSep 19 2009.
     ProQuest Research Library. Web. 10 Dec. 2012 .

"Battle ready? Post-traumatic stress disorder." The Economist [US] 17 Nov. 2012:
      75(US). General OneFile. Web. 8 Dec. 2012.

Bolter, J. David, and Diane Gromala. Windows and mirrors: Interaction design, digital
     art, and the myth of transparency. Cambridge, MA: MIT P, 2003.

"Combating Post Traumatic Stress Disorder with Virtual Reality Exposure Therapy."
     US Fed News Service, Including US State NewsJan 20 2010. ProQuest Research
     Library. Web. 10 Dec. 2012 .

"Post-traumatic Stress Disorder." PubMed Health. Ed. Linda J. Vorvick, MD and
     David Zieve, MD. U.S. National Library of Medicine, 13 Feb. 2012.
     Web. 08 Dec. 2012. 
Strickland, Jonathan. "How Virtual Reality Works." HowStuffWorks.
     HowStuffWorks, Inc., n.d. Web. 10 Dec. 2012.

"The Virtual Reality Medical Center." The Virtual Reality Medical Center. N.p., n.d.
     Web. 10 Dec. 2012.

Tull, Matthew, PhD. "Exposure Therapy for PTSD." Post Traumatic Stress (PTSD).
     About.com, 2012. Web. 08 Dec. 2012.

Tull, Matthew. "Using Virtual Reality Exposure Therapy for PTSD."
     Post Traumatic Stress (PTSD). 29 Jan. 2012. About.com. 08 Dec. 2012.

"Virtual Reality may Aid Recovery for Post-Traumatic Stress Disorder,
     Preliminary Data shows." US Fed News Service, Including US State News
     May 07 2008. ProQuest Research Library. Web. 10 Dec. 2012 .


  1. It definitely seems like it would be a good thing. When I read about stuff like this, I think to myself we should be using these mediums to help people versus creating games/and other craziness that we get addicted to so easily

    1. True, although in this case the developing of games led to being able to apply it to therapy. We just need leaders in different fields to be open-minded. So many things cross fields of study and thought. You got to be able to look for solutions in even the most unlikely of places.

  2. This comment has been removed by the author.