Combat related post traumatic stress disorder: a multiple case report using virtual reality graded exposure therapy with physiological monitoring

The current report summarizes case studies from an Office of Naval Research (ONR) funded project to compare the effects of Virtual Reality Graded Exposure Therapy (VRGET) with a treatment as usual control condition in active-duty Navy Corpsmen, Navy SeaBees and Navy and Marine Corps Support Personnel. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Pain modulation during drives through cold and hot virtual environments

Evidence exists that virtual worlds reduce pain perception by providing distraction. However, there is no experimental study to show that the type of world used in virtual reality (VR) distraction influences pain perception. Therefore, we investigated whether pain triggered by heat or cold stimuli is modulated by "warm "or "cold " virtual environments and whether virtual worlds reduce pain perception more than does static picture presentation. We expected that cold worlds would reduce pain perception from heat stimuli, while warm environments would reduce pain perception from cold stimuli. Additionally, both virtual worlds should reduce pain perception in general. Heat and cold pain stimuli thresholds were assessed outside VR in 48 volunteers in a balanced crossover design. Participants completed three 4-minute assessment periods: virtual "walks " through (1) a winter and (2) an autumn landscape and static exposure to (3) a neutral landscape. During each period, five heat stimuli or three cold stimuli were delivered via a thermode on the participant's arm, and affective and sensory pain perceptions were rated. Then the thermode was changed to the other arm, and the procedure was repeated with the opposite pain stimuli (heat or cold). We found that both warm and cold virtual environments reduced pain intensity and unpleasantness for heat and cold pain stimuli when compared to the control condition. Since participants wore a head-mounted display (HMD) in both the control condition and VR, we concluded that the distracting value of virtual environments is not explained solely by excluding perception of the real world. Although VR reduced pain unpleasantness, we found no difference in efficacy between the types of virtual world used for each pain stimulus.

Stress, mental health, and cognition: a brief review of relationships and countermeasures

Today's network-centric battlefield environment is highly stressful and cognitively demanding. Many warfighters are feeling overwhelmed and end up being medically evacuated from theater due to mental health problems [i.e., post traumatic stress disorder (PTSD) and depression]. Of a sample of troops evacuated for psychiatric reasons, 21% (106 out of 509) had psychiatric histories prior to deploying to the theater of operations. Most cases were either related to stress (i.e., PTSD, n - 33, 310%) or to depression (n = 72, 66%). Stress disorders and depression predominate among the psychiatric causes for medical evacuation. This review paper discusses stress theories as they pertain to warfighting, the types of stress and stress disorders most prevalent on modern battlefields, the relationships among stress, psychiatric disease, and cognitive performance, and potential methods to decrease some types of stress-related acute and chronic disorders (i.e., virtual-reality stress inoculation training).

Combat-Related Post-Traumatic Stress Disorder: A Case Report Using Virtual Reality Exposure Therapy with Physiological Monitoring

The current report summarizes a case study from an Office of Naval Research (ONR) funded project to compare the effects of virtual reality graded exposure therapy (VRGET) with cognitive behavioral group therapy in active-duty corpsmen. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Neurophysiological age differences during task-performance in a stereoscopic virtual environment

In today's society, there is an increasing number of workplaces in virtual environments (VE). But, there are only a few reports dealing with occupational health issues or age effects. The question arises how VR generally interferes with cognitive processes. This interference might have relevant implications for workability and work-efficiency in virtual environments. Event-related potentials are known to reflect different stages of stimulus reception, evaluation, and response. We have established an electroencephalographic (EEG) monitoring, focussing on event-related potentials (N100; mismatch negativity, i.e., MMN) to obtain access to attention dependent and pre-attentive processing of sensory stimuli applied in VE. The MMN is known to be correlated with the ability of subjects to react to an unexpected event. The aim of the present study was to investigate cognitive responses to distracting auditory stimuli in two different age groups in a virtual environment (VE) and in a real environment ("real reality"), and to compare characteristic neurophysiological response patterns. Data show that stimulus detection as given by the N100 amplitude and latency does not differ in both age groups and task conditions. In contrast, the pre-attentive processing as given by the MMN is altered in the VR such as the non-VR condition in an age-related manner. A relevant finding of the present study was that the age related differences seen in the non-VR condition were not strengthened in VR.

Mechanisms of virtual reality exposure therapy: the role of the behavioral activation and behavioral inhibition systems

J. A. Gray's (1975) theory distinguishes between two motivational systems, which he refers to as the behavioral activation system (BAS) and the behavioral inhibition system (BIS). D. C. Fowles (1980) has shown that heart rate responses reflect activity of the BAS, and electrodermal responses reflect activity of the BIS. Both BAS and BIS are reliably activated during in-vivo exposure to fearful situations (F. H. Wilhelm & W. T. Roth, 1998). However, due to the constraints imposed by virtual reality (VR), we hypothesized that VR exposure to fearful situations would activate the BIS alone. To test this hypothesis, a VR free-standing elevator simulation was presented to participants selected for high and low fear of heights. As predicted, the high-anxious group strongly responded electrodermally (effect size d = 1.53), but showed only minimal HR elevations during exposure (d = 0.12), and little other cardiovascular or respiratory changes. The low-anxious control group showed little electrodermal and HR reactivity (d = 0.28 and 0.12). A comparison with data from a previous study demonstrated that this pattern was in stark contrast to the large electrodermal and cardiovascular response observed during situational in-vivo exposure outside the laboratory. We conclude that the BIS, but not BAS, is selectively activated during VR exposure, causing discordance between self-report and commonly used physiological measures of anxiety. Results are discussed within the framework of E. B. Foa & M. J. Kozak's (1986) emotional processing theory of fear modification, suggesting different mechanisms underlying VR and in-vivo exposure treatments.

Cognitive ergonomics in virtual environments: development of an intuitive and appropriate input device for navigating in a virtual maze

For patients suffering from mild cognitive impairments, the navigation through a virtual maze should be as intuitive and efficient as possible in order to minimize cognitive and physical strain. This paper discusses the appropriateness of interaction devices for being used for easy navigation tasks. Information gained from human centered evaluation was used to develop an intuitive and ergonomic interaction device. Two experiments examined the usability of tracked interaction devices. Usability problems with the devices are discussed. The findings from the experiments were translated into general design guidance, in addition to specific recommendations. A new device was designed on the basis of these recommendations and its usability was evaluated in a second experiment. The results were used to develop a lightweight interaction device for navigation in the virtual maze.

A Functional Magnetic Resonance Imaging (fMRI) Study of Cue-Induced Smoking Craving in Virtual Environments

Smokers who are exposed to smoking-related cues show cardiovascular reactivity and smoking craving compared with their responses to neutral cues, and increased cue reactivity predicts decreased likelihood of successful cessation. Several brain imaging studies suggested four candidate brain regions that might differ in gray matter volumes and densities between smokers and nonsmokers. However, in these studies, smokers were only exposed to smoking-related objects. In our pilot study utilizing a virtual reality (VR) technique, virtual environments (VEs) were more immersive and evoked smoking craving more effectively than traditionally used methods. In this study, we sought to test whether smokers could experience cue-induced smoking craving inside the MRI scanner by using the VR system. The smoking cue reactivity scenario was based in part on our preliminary task and consisted of 2D and 3D (or VE) conditions. The group mean of participants had increased activity in the prefrontal cortex (PFC), left anterior cingulate gyrus (ACC), left supplementary motor area, left uncus, right inferior temporal gyrus, right lingual gyrus, and right precuneus in the 2D condition. Areas of differential activation in the 3D condition were as follows: left superior temporal gyrus, right superior frontal gyrus, and left inferior occipital gyrus in the 3D condition. This finding is consistent with those of previous studies of nicotine craving showing PFC and ACC activation. However, in the 3D condition, the PFC including the superior frontal gyrus as well as the superior temporal gyrus, inferior occipital gyrus, and cerebellum were activated. Therefore, in the 3D condition, participants seemed to have more attention, visual balance, and coordinating movement than in the 2D condition.

Stimulation of Cortisol During Mental Task Performance in a Provocative Virtual Environment

Fully immersive and stereoscopic Virtual Environments (VE) represent a powerful multimedia tool for laboratory-based simulations of distinct scenarios including scenarios for evaluating stressful situations resembling reality. Thus far, cortisol secretion as a neuroendocrine parameter of stress has not been evaluated within a Virtual Reality (VR)-based paradigm. In this study 94 healthy volunteers were subjected to a provocative VR-paradigm and a cognitive stress task. Provocative in this context means the VE was designed to provoke physiological reactions (cortisol secretion) within the respective users by purpose. It was tested (a) if a fully dynamic VE as opposed to a static VE can be regarded as a stressor and (b) if such a fully dynamic VE can modify an additional response to a cognitive stressor presented within the VE additionally. Furthermore, possible gender-related impacts on cortisol responses were assessed. A significant cortisol increase was observed only after the combined application of the fully dynamic VE and the cognitive stressor, but not after application of the dynamic VE or the cognitive stressor alone. Cortisol reactivity was greater for men than for women. We conclude that a fully dynamic VE does not affect cortisol secretion per se, but increases cortisol responses to a dual task paradigm that includes performance of a stressful mental task. This provides the basis for the application of VR-based technologies in neuroscientific research, including the assessment of the human Hypothalamus-Pituitary-Adrenal (HPA) axis regulation.

Effects of Group Experiential Cognitive Therapy for the Treatment of Panic Disorder with Agoraphobia

A treatment protocol, called experiential cognitive therapy (ExCT), was developed. It integrated traditional cognitive behavior therapy (CBT) with virtual reality exposure for the treatment of panic disorder with agoraphobia (PDA). The objective of this study was to test the efficacy of short-term (four sessions) ExCT compared with a traditional 12-session panic control program (PCP) for the treatment of PDA. Forty patients diagnosed as having PDA by the diagnostic criteria of DSM-IV were randomly assigned to ExCT and PCP groups of 20 patients each. The treatment effects were measured with self-report questionnaires, including the BDI, STAI, ASI, PBQ, ACQ, and BSQ. The authors also assessed high end-state functioning (HES), including the success rate of stopping or reducing medication at post-treatment and 6-month follow-up. In all ratings, both ExCT and PCP groups showed significant improvement post-treatment compared with pre-treatment scores. There were no significant differences between the two treatment groups in HES and medication discontinuation at post-treatment, but there was a significant difference in medication discontinuation at 6-month follow-up. These results suggested that although short-term effectiveness of ExCT might be comparable to the effectiveness of PCP, long-term effectiveness of ExCT might be relatively inferior to the effectiveness of PCP.

Nicotine craving and cue exposure therapy by using virtual environments

Smokers who are exposed to cues associated with smoking show cardiovascular reactivity and an increase in smoking urges as compared to when they are presented with neutral cues. Cue exposure therapy (CET), which refers to the repeated exposure to drug-related cues in order to extinguish this learned association, has increasingly been proposed as a potential treatment of addictive behaviors, including tobacco smoking. The result of our pilot study suggests that a cue elicited using a virtual environment (VE) is more effective than other cue exposure devices. The VE was composed of craving environments (virtual bar) and objects (an alcoholic drink, a packet of cigarettes, a lighter, an ashtray, a glass of beer, and advertising posters) that are likely to trigger craving, a smoking avatar, and an audio environment that included the noisy sound and music of a restaurant. Sixteen late-adolescent males who smoked at least 10 cigarettes a day were recruited to participate in the VE-CET study. The CET virtual bar program consisted of six sessions, and the participants were exposed repeatedly to each session using different questions and procedures. Although the effects of CET did not yield significant reductions in all of the dependent variables, the craving for cigarettes was gradually decreased during the course of the sessions. This tendency was closely related to the reduction in the smoking count between the morning before the experiment and the start of the experiment. Based on these preliminary results, it appears that VE-CET maybe a useful tool to use in treatment programs to help reduce craving in those who are nicotine dependent.

A virtual reality system for the assessment and rehabilitation of the activities of daily living

Successful rehabilitation with respect to the activities of daily living (ADL) requires accurate and effective assessment and training. A number of studies have emphasized the requirement for rehabilitation methods that are both relevant to the patient's real world environment, and that can also be transferred to other daily living tasks. Virtual reality (VR) has many advantages over other ADL rehabilitation techniques, and offers the potential to develop a human performance testing and training environment. Therefore, in this study, the virtual supermarket was developed and the possibility of using a VR system to assess and train cognitive ability in ADL investigated. This study demonstrates that VR technology offers great promise in the field of ADL training.

Three-year follow-up for virtual reality exposure for fear of flying

Thirty participants who had been treated for aviophobia with virtual reality graded exposure therapy with physiological monitoring and visual feedback (VRGETpm), virtual reality graded exposure therapy with physiological monitoring only (VRGETno), or imaginal exposure therapy (visualization) with physiological monitoring only (IET) between January 1998 and January 1999 were contacted in January 2002 for a 3-year posttreatment follow-up assessment. Of the participants in the VRGETpm group who had flown successfully by the end of treatment, all had maintained their ability to fly at follow-up. Of the participants in the VRGETno group who had flown successfully by the end of treatment, two were no longer able to fly. Of the participants in the IET group who had flown successfully, all were still able to fly. It appears that the addition of teaching self-control via visual feedback of physiological signals may serve to maintain treatment gains in long-term follow-up.

The future of cybertherapy: improved options with advanced technologies

Cybertherapy is a field that is growing rapidly due to today's technology and information boom. Virtual reality and advanced technologies have been used successfully to in a variety of healthcare issues, including treatment of anxiety disorders and phobias, treatment of eating and body dysmorphic disorders, neuropsychological assessment and rehabilitation and distraction during painful or unpleasant medical procedures. The novel applications of these technologies yield many advantages over traditional treatment modalities, and the disadvantages that accompanied the first trials of virtual reality are quickly being addressed and eliminated. Virtual reality peripherals such as data gloves, physiological monitoring and Internet worlds are swiftly demonstrating their usefulness in cybertherapy applications. Future directions for research include improvements of objective measures of efficacy such as fMRI and physiological monitoring devices, and investigations are being carried out to determine if virtual reality and advanced technologies can be used to treat a broader scope of disorders, including depression, schizophrenia, drug addiction, and autism.

A Virtual Environment for Investigating Schizophrenic Patients' Characteristics: Assessment of Cognitive and Navigation Ability

Patients with schizophrenia have thinking disorders such as delusions or hallucinations because they have a deficit in the ability to systematize and integrate information. Therefore, they cannot integrate or systematize visual, auditory, and tactile stimuli. The multimodal integration model of the brain can provide a theoretical background from which one can approach multimodal stimulus integration. In this study, we suggest a virtual reality system for the multi-modal assessment of cognitive ability of schizophrenia patients. The virtual reality system can provide multimodal stimuli, such as visual and auditory stimuli, to the patient and can evaluate the patient's multimodal integration and working memory integration abilities by making the patient interpret and react to multimodal stimuli, which must be remembered for a given period of time. The clinical study showed that the virtual reality program developed is comparable to those of the Wisconsin Card Sorting Test (WCST) and the Standard Progressive Matrices (SPM), and it provides some information related to the schizophrenic patients' behavior in 3D virtual environment.

Experimental application of virtual reality for nicotine craving through cue exposure

Research has shown that many smokers experience an increase in the desire to smoke when exposed to smoking-related cues. Cue exposure treatment (CET) refers to the manualized, repeated exposure to smoking-related cues, aimed at the reducing cue reactivity by extinction. In this study, we constructed a virtual reality system for evoking a desire of nicotine, which was based on the results of a Questionnaire of Nicotine-craving. And we investigated the effectiveness of the virtual reality system as compared to classical device (pictures). As a result, we reached the conclusion that virtual reality elicits more craving symptoms than the classical devices.

Exploring the use of computer games and virtual reality in exposure therapy for fear of driving following a motor vehicle accident

Specific phobia, situational type-driving, induced by accident (accident phobia) occurs in 18-38% of those involved in a vehicular accident of sufficient severity to warrant referral to the emergency departments of a general hospital. The objective is to investigate, in an open study, the effectiveness of the combined use of computer generated environments involving driving games (game reality [GR]) and a virtual reality (VR) driving environment in exposure therapy for the treatment of driving phobia following a motor vehicle accident (MVA) program. Fourteen subjects who met DSM-IV criteria for Simple Phobia/Accident Phobia and were referred from the emergency department of a general hospital were exposed to a Virtual Driving Environment (Hanyang University Driving Phobia Environment) and computer driving games (London Racer/Midtown Madness/Rally Championship). Patients who experienced "immersion" (i.e., a sense of presence with heightened anxiety) in one of the driving simulations (defined as an increase in SUD ratings of 3 and/or an increase of heart rate > 15 BPM in a 1-h trial session of computer simulation driving) were exposed to a cognitive behavioral program of up to 12 1-h sessions involving graded driving simulation tasks with self-monitoring, physiological feedback, diaphragmatic breathing and cognitive reappraisal. Subjects were assessed at the beginning and end of therapy with measurements of: physiological responsivity (heart rate), subjective ratings of distress (SUD), rating scales for severity of fear of driving (FDI), Posttraumatic Stress Disorder (CAPS) and depression (HAM-D) and achievement of target behaviors. Of all patients 7/14 (50%) became immersed in the driving environments. This immersed group (n = 7) completed the exposure program. Pre- and post-treatment comparisons showed significant post treatment reductions on all measures SUDS (p = 0.008), FDI (p = 0.008), CAPS (p = 0.008), HR (p = 0.008), CAPS (p = 0.008), HAM-D (p = 0.031). Further analysis of the FDI showed significant reductions in all three subscales: travel distress (p = 0.008), travel avoidance (p = 0.008), and maladaptive driving strategies (p = 0.016). The findings of this study suggest that VR and GR may have a useful role in the treatment of driving phobia post-accident even when co-morbid conditions such as post-traumatic stress disorder and depression are present.

Experiential cognitive therapy in the treatment of panic disorders with agoraphobia: a controlled study

The use of a multicomponent cognitive-behavioral treatment strategy for panic disorder with agoraphobia is actually one of the preferred therapeutic approaches for this disturbance. This method involves a mixture of cognitive and behavioral techniques that are intended to help patients identify and modify their dysfunctional anxiety-related thoughts, beliefs and behavior. The paper presents a new treatment protocol for Panic Disorder and Agoraphobia, named Experiential-Cognitive Therapy (ECT) that integrates the use of virtual reality (VR) in a multicomponent cognitive-behavioral treatment strategy. The VR software used for the trial is freely downloadable: www.cyberpsychology.info/try.htm. Moreover, the paper presents the result of a controlled study involving 12 consecutive patients aged 35-53. The selected subjects were randomly divided in three groups: ECT group, that experienced the Cognitive Behavioral Therapy-Virtual Reality assisted treatment (eight sessions), a CBT group that experienced the traditional Cognitive Behavioral approach (12 sessions) and a waiting list control group. The data showed that both CBT and ECT could significantly reduce the number of panic attacks, the level of depression and both state and trait anxiety. However, ECT procured these results using 33% fewer sessions than CBT. This datum suggests that ECT could be better than CBT in relation to the "cost of administration," justifying the added use of VR equipment in the treatment of panic disorders.

The development of virtual reality therapy (VRT) system for the treatment of acrophobia and therapeutic case

Virtual reality therapy (VRT), based on this sophisticated technology, has been recently used in the treatment of subjects diagnosed with acrophobia, a disorder that is characterized by marked anxiety upon exposure to heights and avoidance of heights. Conventional VR systems for the treatment of acrophobia have limitations, over-costly devices or somewhat unrealistic graphic scenes. The goal of this study was to develop an inexpensive and more realistic virtual environment (VE) in which to perform exposure therapy for acrophobia. It is based on a personal computer, and a virtual scene of a bunge-jump tower in the middle of a large city. The virtual scenario includes an open lift surrounded by props beside a tower, which allows the patient to feel a sense of heights. The effectiveness of the VE was evaluated through the clinical treatment of a subject who was suffering from the fear of heights. As a result, it was proved that this VR environment was effective and realistic at overcoming acrophobia according not only to the comparison results of a variety of questionnaires before and after treatment but also to the subject's comments that the VE seemed to evoke more fearful feelings than the real situation.

Introduction to the special issue on virtual reality environments in behavioral sciences

Virtual reality (VR) is usually described in biology and in medicine as a collection of technologies that allow people to interact efficiently with three-dimensional (3-D) computerized databases in real time using their natural senses. This definition lacks any reference to head-mounted displays (HMDs) and instrumented clothing such as gloves or suits. In fact, less than 10% of VR healthcare applications in medicine are actually using any immersive equipment. However, if we focus our attention on behavioral sciences, where immersion is used by more than 50% of the applications, VR is described as an advanced form of human- computer interface that allows the user to interact with and become immersed in a computer-generated environment. This difference outlines a different vision of VR shared by psychologists, psychotherapists, and neuropsychologists: VR provides a new human-computer interaction paradigm in which users are no longer simply external observers of images on a computer screen but are active participants within a computer-generated 3-D virtual world. This special issue investigates this vision, presenting some of the most interesting applications actually developed in the area. Moreover, it discusses the clinical principles, human factors, and technological issues associated with the use of VR in the behavioral sciences.