2014 - Virtual Reality for War Veterans

VIRTUAL REALITY FOR WAR VETERANS

Dr EDUARDO C. GERDING

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The Merriam-Webster dictionary defines Post-traumatic stress disorder (PTSD) as a psychological reaction that occurs after experiencing a highly stressing event (as wartime combat, physical violence, or a natural disaster) outside the range of normal human experience and that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of reminders of the event. It can no longer be considered as an anxiety disorder and that is reflected in the new Diagnostic and Statistical Manual of Mental Disorders commonly known as DSM 5 chapter. 26

PTSD may be associated with changes in endogenous opioid peptide function.A pilot data suggest a differential alteration in plasma beta-endorphin response to exercise in PTSD.14

Frueh et al published a provokative article in 2009 claiming that retrospective reports of veterans reveal that delayed-onset PTSD (current, subthreshold or lifetime) is extremely rare 1 year post-trauma, and there was no evidence of PTSD symptom onset 6 or more years after trauma exposure .9

Holbrook and colleagues1 report that the use of morphine among injured US Navy and Marine Corps personnel during early (usually <1 hour) resuscitation and trauma care was significantly and protectively associated with a lower risk of PTSD. 17

However, this requires a rigorous follow-up. 10,11

Although medications and talk therapy can help calm the symptoms of PTSD, the most effective therapies often require confronting the trauma, as with virtual reality immersion therapy (VRIT) based treatments. 22


PTSD and the 1982 South Atlantic Conflict

In 1984 Capt HH Price published a article underlining that the rate of evacuated British psychiatric casualties was 2 percent of all wounded with 16 declared cases evacuated from the British hospital ship Uganda. 25 Three years later Gareth H. Jones and Jonathan Lovett published another article on the delayed psychiatric sequelae among British Falklands war veterans. 19

Morgan O'Connell FRC was the Psychiatrist to the Task Force in 1982, sailing on Canberra with 3 Cdo. Bde. His colleague was on the Hospital Ship SS Uganda. Between them they identified some 25 Psychiatric Casualties during the conflict- about 4.5 percent of all casualties. Both physicians set up the first PTSD programme in UK at the then Royal Naval Hospital Haslar Portsmouth in 1987. By the time O´Connell left the RN in 1996, the number of Psychiatric Casualties amongst those who had served in 1982 was closer to 1,000- the majority of whom were not suffering PTSD. 13

Patterns observed by British were similar to that shown by Vietnam war veterans and they underlined the fact that general practitioners were in a unique position to recognize and treat these problems. 19

British suicides

255 British soldiers died in the 1982 Conflict. The claim (first made in 2002 of 262 suicides) 8 , often repeated in the media and by British veterans' groups 1,4 that more Falklands vets had killed themselves than died fighting in the actual conflict, has been roundly rejected by a study specially commissioned by the Ministry of Defence. 18

The MoD investigated the circumstances of 21,432 Falklands veterans. It found that as of 31 December 2012, some 1,335 had died. That figure compares with an estimated 2,079 deaths that would have been expected among veterans if they had experienced the same mortality rate as the UK population as a whole. Of the Malvinas British veterans, 7% ( 95 deaths) were due to "intentional self-harm and events of undetermined intent (suicides and open verdict deaths)", says the MoD study.23

Argentine suicides

649 Argentines dies during the conflict: 323 belonged to the cruiser ARA General Belgrano and 326 died in the islands.12

According to a lecture given by the Argentine President on February 7th, 2012 there have been 439 Argentine war veterans deaths since 1982. There are no official figures of how many of them might have been as a result of suicides.

According to a research 4 of every 10 Argentine war veterans tried to commit suicide. 65,2 percent of them some time of their lives thought they would be better dead. 21

According to the Argentine Health Minister during the last 12 years 26,940 persons committed suicide; 21.331 were male. Most cases correspond to people between 15 and 24 years old. 6

A model of suicidal behavior

Sher proposed a model of suicidal behavior in war veterans with "posttraumatic mood disorder PTMD. The model consists of the following components: (1) genetic factors; (2) prenatal development; (3) biological and psychosocial influences from birth to mobilization/deployment; (4) mobilization/pre-deployment stress; (5) combat stress, traumatic brain injury, and physical injury; (6) post-deployment stress; (7) biological and psychosocial influences after the deployment; (8) trigger (precipitant) of a suicidal act; and (9) suicidal act.

The first four components would determine vulnerability to combat stress. 27

The signature wounds

Many researchers have declared traumatic brain injury and PTSD to be the “signature wounds” of the wars in Iraq and Afghanistan. A rececent sample of 600 veterans from Iraq and Afghanistan found: 14% PTSD : 39% alcohol abuse; 3% drug abuse. 7 50% of those with PTSD did not seek treatment Out of the half that seek treatment, only half of them get "minimally adequate" treatment (RAND Corporation study). 7% of veterans had PTSD disorder and traumatic brain injury. 28
45 percent reported they saw dead or seriously injured non-combatants, and over 10 percent saying they were injured themselves and required hospitalization. Rates of PTSD and major depression were highest among Army soldiers and Marines, and among service members who were no longer on active duty (people in the reserves and those who had been discharged or retired from the military).

Women, Hispanics and enlisted personnel all were more likely to report symptoms of PTSD and major depressions, but the single best predictor of PTSD and depression was exposure to combat trauma while deployed. (RAND Corporation- One In Five Iraq and Afghanistan Veterans Suffer from PTSD or Major Depression).

According to a 2005 VA study of 168,528 Iraqi veterans, 20 percent were diagnosed with psychological disorders, including 1,641 with PTSD.

According to Hoge et al, exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care.15,16

PTSD, Suicide Rates Differ Among U.S., U.K. Troops

Professor Wessely suggested several possible explanations for differences in PTSD rates between US and UK troops. When the wars began, troops in the British forces were on average older (27) than their U.S. counterparts. They had proportionately more officers and used fewer reservists (10 percent vs. 30 percent). Many had experienced prior deployments in other parts of the world.

Many of the difficulties of warriors have result in increased social isolation and diminished interest in getting outside the home and interacting with other people. (Pellerin)

A research suggests that British veterans aged 18 to 23 are up to three times more likely to commit suicide than their civilian counterparts.(The Independent 15 July 2009)

Virtual Reality Immersion Therapy (VRIT)

Virtual reality therapy (VRT) is also known as virtual reality immersion therapy (VRIT), Simulation for Therapy(SFT), virtual reality exposure therapy (VRET), and as Computerized CBT (CCBT).

An early exploration of VRI was done by Dr. Ralph Lamson a USC graduate then at Kaiser Permanent Psychiatry Group. He created a simulation in the early 1990s[ as a means to solve his own acrophobia.. About the same time, Dr. Larry Hodges, then a computer scientist at Georgia Tech active in VR and Dr. Barbara Rothbaum, a psychologist at Emory University, began studying VRT in cooperation with Dr. Max North.

Dr. Skip Rizzo of USC's Institute for Creative Technologies created, with DOD funding, a war simulation called Full Spectrum Warrior, with funding from Office of Naval Research created an adaptation of that game for the treatment of PTSD.(Young)

Virtual Iraq was subsequently developed and proved successful in normalization of over 70% of PTSD sufferers, and that has now become a standard accepted treatment by the Anxiety and Depression Association of America.

A virtual experience on an Afghan street
(Boyle,Alan-Virtual haven set up for combat vets-NBC News, Jan 20,2011.)

The use of VRT has thus become a mainstream psychiatric treatment for anxiety disorders and is finding increasing use in the treatment of other cognitive disorders associated with various medical conditions such as addiction, depression and insomnia. http://articles.latimes.com/1995-02-28/news/ls-37034_1_virtual-reality

VRIT has great promise since it historically produces a "cure" about 90% of the time at about half the cost of traditional cognitive behavior therapy authority, and is especially promising as a treatment for PTSD.

According to Rizzo et. Al (2003), virtual reality technology should only be used as a tool for qualified clinicians instead of being used to further one’s practice or garner an attraction for new clients/patients. Another ethical issue is the issue of who is developing the virtual reality and thus benefiting from its sale?

The T2 Virtual PTSD Experience

The United Status Defense Department unveiled in 2011 the T2 Virtual PTSD Experience, a Project that lets users explore the causes and symptoms of combat stress in the latest video games. It enables soldiers and their loved ones to use an anonymous setting on Second line, a popular virtual reality platform that can be downloaded for free.2 

The National Center for Telehealth and Technology (T2) is a component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. Is a three-year-old Pentagon program housed at Joint Base Lewis-McChord.2 The Center released as well s mobile phone application that helps soldiers track their mods. Its biggest project was a web site: afterdeployment.org, that provides information about how to readjust to civilian life after serving in combat.2 

Dr. Greg Reger talks about PE Coach, the first mobile app for PTSD treatment, in an interview for the Pentagon Channel. PE Coach was released on July 31, 2012 and is available for Android and Apple devices. (http://www.t2.health.mil/news/pe-coach-pentagon-channel).Dr. Greg Reger is a licensed clinical psychologist who completed his Ph.D. at Fuller Theological Seminary. He is currently leading T2’s testing of Virtual Reality and Prolonged Exposure therapies for PTSD. Prior to joining T2, Dr. Reger worked for the Center for Deployment Psychology (CDP), served at Walter Reed Army Medical Center, and deployed to Iraq in 2005-2006.

The T2 experience isn't just about stress, however. The virtual environment also offers relaxation zones, guided meditations and forums where real-life vets can talk about their experiences using the computer-generated interface. 5

U.S. Army Sgt. Chad Parrott and Capt. Greg Reger demonstrate a simulator used to help in the treatment of post traumatic stress disorder at Madigan Army Medical Center, Fort Lewis, Wash. U.S. Army photo by Jason Kaye. http://www.defense.gov/transformation/articles/2007-03/ta032907b.html.

In February 2006 the UK's National Institute of Health and Clinical Excellence (NICE) recommended that VRIT be made available for use within the NHS across England and Wales, for patients presenting with mild/moderate depression, rather than immediately opting for antidepressant medication.

(Pellerin,Cheryl-Virtual World´Helps with 

Post-Traumatic Stress-American Forces Press Service)

The program guides users through a scenario in an Afghan marketplace that could trigger post-traumatic stress. It explains different emotional connections that might develop over time. Throughout the scenario, users can monitor their stress and click away to a “relaxation room” where they can look at calming images and practice breathing.Throughout the scenario, users can monitor their stress and click away to a “relaxation room” where they can look at calming images and practice breathing.

The graphics-dense immersive simulation requires a broadband Internet connection, he said. Users must download a copy of the Second Life world and then can access the world from any computer with a broadband connection.

The environment uses a range of activities to simulate symptoms and help visitors determine if they or a loved one need care, and offers information about where to go for more direct assistance.

Several studies have demonstrated that symptoms improve after virtual-reality exposure, and at least one study, which used functional MRI, indicated that the therapy tends to restore patients' brain activity to more normal patterns. No treatment works for everyone, however. Even in the most successful tests of virtual reality, about a quarter of patients continue to meet criteria for PTSD after treatment. Virtual reality may be a useful weapon in the battle against PTSD, but it is by no means the end of the war.

Acknowledgments:

• Harry Cooper-President of Sharkhunters, (USA) 
• Jeffrey Hyman, PhD, Tricare Management Activity, Falls Church,VA (USA) 
• Shaun Kennedy, Deputy Librarian,Royal College of Psychiatrists (UK) 
• Kevin Reilly-Communication Specialist II-2-Public & Member Communications, American Psychological Association.(USA)

Bibliography 

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3. Ashton,Adam-Virtual world developed at JBLM helps soldiers explore PTSD causes, symptoms-The News Tribune-June 19,2011. 
4. BBC News-Falklands veterans claim suicide toll-13 January 2002 
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