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CDMRP 2012 Investigator Vignette

Title: Randomized Clinical Trial of Virtual Reality and Prolonged Exposure Therapy for Active Duty Soldiers with PTSD

Investigators: Gregory Gahm, Ph.D. and Greg Reger, Ph.D., National Center for Telehealth and Technology

Gahm: The CDMRP under their PH/TBI Program have funded a formal quite extensive randomized control trial providing what we consider to become the definitive answer regarding whether or not virtual reality adds value to prolonged exposure therapy.

One of the gold standard treatments for PTSD is a treatment called prolonged exposure. It can be done by talking, it can be done imaginally, it can be done by writing; the typical program involves actually an imaginal reliving of the experience, guided by a therapist to help an individual adjust to the experience they had-to readjust and normalize that.

Reger: But there's a couple of challenges with exposure therapy. One is first of all that treatment has never been studied in a well-designed, randomized clinical trial with Active Duty Service members, so we have good reason to think it's an effective treatment with our men and women in uniform but it needs to be studied.

The second question is-is there something unique about a year-long deployment that could create barriers to effective treatment using exposure. Research has shown that exposure works best for those who have a high level of emotional engagement, in other words they're anxious when they revisit these memories. Our guys come home after long deployments, exposure to multiple potentially traumatic events, and I don't wonder if it doesn't create an adaptive emotional disengagement. They can be unplugged just to get through the deployment so that they come home and they tell their story as if it's an after-action review or a police report, really emotionally unplugged. And that could create some barriers to good clinical outcomes in treatment.

Gahm: Virtual reality really adds a component of detail of-of imagery, of realism that for some individuals they just are unable to imagine and so this will particularly reach a population that has difficulty imagining the experience over and over again.

Reger: By presenting them with the sights, sounds, vibrations, even smells that are relevant to their memory, it may really help to activate that memory in a much more emotionally engaging way, help them to process it, and accordingly there's a possibility it could result in a better clinical outcome.

Gahm: Recruiting is always a challenge even for an interesting study like this. Very few people want to brag about needing mental health treatment, and yet a huge percentage of the population would benefit from mental health care. Similarly for our soldiers, the idea of any weakness is not something that they want to show off. So, one of the components of this project is something that's somewhat akin to a game console. So for a patient population that is used to playing video games, this has a certain appeal that's potentially less threatening, less scary, and maybe less perceived by others to be a sign of weakness rather than saying they're sitting down on a couch talking to somebody or sitting in a chair talking to someone for an hour which is not something that a lot of these individuals really look forward to doing.

Reger: And so they'll be wearing a head-mounted display that has a screen for each eye; it'll track their head movements in this computer-generated world and replicate many aspects of what they've been through to help them deal with it.

For example, many of the injuries that people have sustained in the current conflicts have come from improvised explosive devices. We can use the computers to put that soldier into a virtual convoy in the position in the vehicle that they were in, at the time of day that it occurred, and activate an IED in a manner that is similar to what they've been through. We can also include vibrations that occur when explosions go off. The soldier feels this vibration from a platform that we use and we hear from many soldiers that that's one of the most activating parts to help them kind of re-engage this memory.

Gahm: For us the ability to be able to collaborate with some of the key experts in the area of virtual reality is really critical to insuring that what we're doing is state-of-the-art and that we're not-missing important components of our research study. In this case, we have Barbara Rothbaum from Emory University, who is a key leader in this area; Skip Rizzo from the Institute for Creative Technologies in Southern California; and JoAnn Difede from Cornell, who are three of the key founders of virtual reality and our ability to partner with them has been important I think to our success.

Reger: So we're hopeful that this is a treatment that really matches with the interest of this population, it may well be more appealing than traditional forms of psychotherapy and as a result help us get the opportunity to care for some of the warriors who otherwise may not seek treatment.

Gahm: So our initial project here at Joint Base Lewis McChord in conjunction with Madigan Army Medical Center is in its third year of running presently. But we also received additional funding to expand this to a second site, and that site is Womack Army Medical Center at Fort Bragg. And so we'll be able to double essentially our recruitment speed as well as to power the evaluation at a level that we were previously unable to accomplish.

Reger: If these kinds of technologies prove to be effective, I can imagine a revolution in the way that we deliver care-that technology tools would allow entirely new ways of delivering care in the future, ways that would really transform the current expectations for how a patient and provider sit together in the same room and conduct therapy. There's some really promising opportunities for where this could head in the decades to come.