Update and Expansion of the Virtual Iraq/Afghanistan PTSD Exposure Therapy System

Fig. 16.1

PCL-M scores across treatment

Fig. 16.2

BAI and PHQ-9 depression scores

Another open clinical trial with active duty soldiers (n = 24) produced significant pre-/post-reductions in PCL-M scores and a large treatment effect size (Cohen’s d = 1.17) (Reger et al., 2011a). After an average of 7 sessions, 45 % of those treated no longer screened positive for PTSD and 62 % had reliably improved. In a small preliminary quasi-randomized controlled trial (McLay et al., 2011), 7 of 10 participants with PTSD showed a 30 % or greater improvement with VR, while only 1 of 9 participants in a “treatment as usual” group showed similar improvement. While the results of this study are limited by its small sample size, lack of blinding, a single therapist, and treatment comparison with a relatively uncontrolled care as usual condition, these results do add to the incremental evidence suggesting VR to be a safe and effective approach for delivering PE for combat-related PTSD. Finally, at the 2012 American Psychiatric Association Convention, McLay (2012) presented data from an ongoing comparison of VRET with the traditional, evidence-based PE approach in active duty SMs. The results showed significantly better maintenance of positive treatment outcomes at 3-month follow-up for VRET compared to traditional PE (McLay 2012). The overall trend of these positive findings (in the absence of any reports of negative findings) is encouraging for the view that VRET is safe and may be an effective approach for delivering an evidence-based treatment (PE) for PTSD.

Currently, five randomized controlled trials (RCTs) are ongoing using the Virtual Iraq/Afghanistan system with active duty SM and Veteran populations. Two RCTs are focusing on comparisons of treatment efficacy between VRET and prolonged imaginal exposure (PE) (Reger & Gahm, 2010, 2011b) and another is testing VRET compared with VRET + a supplemental care approach (Beidel, Frueh, & Uhde, 2010). Two more RCTs (Difede, Rothbaum, & Rizzo, 2010; Rothbaum et al., 2008) are investigating the additive value of supplementing VRET and imaginal PE with a cognitive enhancer called D-Cycloserine (DCS). DCS, an N-methyl-d-aspartate partial agonist, has been shown to facilitate extinction learning in laboratory animals when infused bilaterally within the amygdala prior to extinction training (Walker, Ressler, Lu, & Davis, 2002). The first clinical test in humans combined orally administered DCS with VRET (Ressler et al., 2004) with participants diagnosed with acrophobia (n = 28). Participants who received DCS + VRET experienced significant decreases in fear within the virtual environment 1 week and 3 months posttreatment, and reported significantly more improvement than the placebo group in their overall acrophobic symptoms at 3-month follow-up. The DCS group achieved lower scores on a psychophysiological measure of anxiety than the placebo group. Further evidence of both VRET and DCS effectiveness has recently been reported by Difede et al. (2013) in a clinical trial with World Trade Center PTSD patients. In a double-blinded controlled comparison between VRET + DCS and VRET + Placebo, both groups had clinically meaningful and statistically significant positive outcomes with the DCS group achieving equivalent gains with fewer sessions. Finally, a current multisite PTSD RCT (NICoE, Weill-Cornell, and the Long Beach VAMC) (Difede et al., 2010) is testing the effect of DCS vs. placebo when added to VRET and PE with active duty and veteran samples (n = 300). Further details on DCS and PTSD can be found in the Burton, Youngner, McCarthy, Rothbaum, and Rothbaum (2014).

Significant funding support for these RCTs underscore the interest that the DOD/VA has in exploring this innovative approach for delivering PE using VR. However, while RCTs are the gold standard for gaining acceptance by the scientific and clinical communities for the use of emerging treatment approaches, it should be noted that at its core, the therapeutic model/principle that underlies VRET (CBT with exposure) is in fact evidence-based (IOM, 2007, 2012). VRET is simply the delivery of this evidence-based treatment in a format that may serve to engage a wider range of patients in the necessary confrontation and processing of traumatic memories or “fear-structures” (cf. Foa, Davidson, & Frances, 1999) needed for positive clinical outcomes. Thus, even equivalent “non-inferior” positive results with PE in these RCTs would validate the use of VRET as another safe and evidence-based treatment option. Moreover, the VRET approach could serve to draw SMs and Veterans into treatment, many of whom have grown up “digital” and may be more likely to seek care in this format compared to what they perceive as traditional talk therapy.

Project BRAVEMIND: Updating and Expanding the Virtual Iraq/Afghanistan VRET System

Based on the initial encouraging outcomes to date using VRET to treat combat-related PTSD and the urgency of the need for diverse evidence-based treatment options for the growing numbers of those reporting PTSD symptoms, the U.S. Army has funded the development of an updated and expanded version of Virtual Iraq/Afghanistan system, now referred to as BRAVEMIND. One of the primary goals for this project was to update and expand the diversity of the VR scenario content and functionality to improve the customizability of stimulus delivery to meet the needs of users having had a diverse range of trauma experiences. These aims were supported by drawing on patient and clinician feedback that has now come from a large number of SM and Veterans who were treated with the previous version of the VRET system. The system has been updated using the Unity Game Engine, an advanced state-of-the art VR development software platform that supports full 3D graphic rendering, physics, and a wide variety of interaction device options.

The current BRAVEMIND system now consists of 14 diverse scenarios. The original system contained four: a foot patrol navigable 18-block middle eastern city and 3 Humvee driving scenarios within Iraq, Afghanistan, and USA-themed settings (cf. Reger et al., 2014). The four original 2007 environments have been completely rebuilt (Video 5–2013 Bravemind Humvee Turret Attack Mix Scenes: https://www.youtube.com/watch?v=8ZQjrfTqvDs&feature=youtu.be) and 10 additional scenarios have been added for a total of 14 (Videos 6 and 7–2013 Bravemind Collected Scenes: https://www.youtube.com/watch?v=iMeEuSdJ7EU&list=UUQrbzaW3x9wWoZPl4-l4GSA&index=1 and https://www.youtube.com/watch?v=_XO4nq4XUcA), including: separate Iraq and Afghanistan cities, a rural Afghan village, an industrial zone, a roadway checkpoint, slum and high-end residential areas, a mountainous forward operating base, and a Bagram Air Force Base setting (see Fig. 16.1). New features include selectable Humvee/MRAP/Helicopter vehicles, vehicle-to-foot patrol transitioning, expanded weather and time of day controls, customizable sound trigger profiles, and an updated clinical interface designed with clinician feedback to enhance usability. The Unity Game Engine and higher fidelity graphic art/animation have been used to enhance the realism and credibility of the stimulus content while presenting an experience that is uniquely designed to differentiate it from a commercial video game. The system was also designed to use off the shelf components (e.g., standard laptop, head mounted display, tracking/interface technology, etc.) that require only one computer with the aim to reduce equipment costs to well under $5,000. The BRAVEMIND VRET system is currently undergoing beta testing and has been designed to provide a flexible software architecture that will support the efficient addition of new content for the expansion and diversification of the system as new clinical needs are specified. More information on the BRAVEMIND system components is available in a detailed equipment/software manual available from the first author and an 18-min media story with new BRAVEMIND content and a former patient can be seen here (Video 8): https://www.youtube.com/watch?v=glIxXwT0cK4&list=UUQrbzaW3x9wWoZPl4-l4GSA. More videos of various PTSD system content, media pieces, and patient interviews can be accessed here: https://www.youtube.com/playlist?feature=edit_ok&list=PLMuMO5eoYy_BDmAfZrFSLBLlniAtvAdad.

The rebuilding of this VRET system has now provided the architecture to support the flexible and efficient expansion of the system’s content and functionality to support new customizable and relevant options for conducting VRET with a wider range of relevant trauma experiences. The BRAVEMIND VRET system is now being further evolved to address the unique therapeutic needs of combat medics/corpsmen and in persons who have experienced military sexual trauma (MST) with PTSD. As well, the software has now been reconfigured to provide a VR tool that is being tested for its use for providing psychological resilience training prior to a combat deployment (Buckwalter & Rizzo, 2011; Rizzo et al., 2013) (Figs. 16.3, 16.4, 16.5, 16.6, 16.7, and 16.8).

Fig. 16.3

Afghanistan city market

Fig. 16.4

Afghanistan FOB

Fig. 16.5

Afghanistan rural village

Fig. 16.6

Iraq Alley patrol

Fig. 16.7

Checkpoint zone

Fig. 16.8

Clinician control panel

Combat Medics/Corpsman VRET Project

Observations from our existing clinical work and from reports by medics (Cannady, 2012) indicate that there is a growing need to address PTSD in combat medics & corpsman. This will require specialized VR content that is more relevant to their experiences with emotionally challenging situations that are fundamentally different from what has been effective with other SMs. The primary role of the combat medic (Army and Air Force) and corpsmen (Navy and Marines) is to provide medical treatment to the wounded in a combat environment. Often they are assigned one to platoon or equivalent unit and this is mandatory due to their importance to the success of the unit’s mission (Cabrera, Figley, & Yarvis, 2012). Combat medics/corpsmen are a unique population within the ranks of deployed SMs. They serve double duty, both professionally and psychologically. In addition to bearing all the responsibilities of soldiering, medics must calmly treat the devastating wounds of modern warfare: legs and arms mangled by roadside bombs, bodies peppered with shrapnel, arteries severed by high-velocity bullets. They are more exposed than other soldiers to seriously wounded or dead fellow SMs. Unlike hospital doctors or nurses, who rarely know their patients, medics have the added pressure of being close to the soldiers they are trying to keep alive. And when one dies, medics often face self-doubt—an emotion they must hide or risk losing the platoon’s confidence.

While very preliminary findings have suggested that medics might be more resilient and less likely than other soldiers to have symptoms of PTSD, a small survey study looked at medics only 3 and 12 months after their deployments and reported PTSD symptoms that were seen to develop over time (Chapman, 2011). Cabrera et al. (2012) are currently studying this issue longitudinally in more detail. However, regardless of the limitations of the extant data on relative comparative rates of PTSD, there is no doubt that there is a clinical need for optimal treatment for this group and it has been the aim of this project to create the content required to meet that need.

This effort has required the tailoring of the existing scenarios to include more wounded virtual humans that can display a range of wounds/burns and manifest realistic injury behaviors. Helicopter insertion and extraction scenarios and a Bagram Air Force Base hospital setting for medic “first receivers” have been developed (see Figs. 16.9, 16.10, and 16.11). This effort has required the creation of significant new graphic art, motion capture animation, airborne vehicle integration, and a library of virtual human content that emulates the wounds and injuries common to the combat environment in order to offer relevant VRET for combat medics/corpsmen with PTSD. This system is currently nearing completion and will be available for use in early 2014.

Fig. 16.9

Combat injury site

Fig. 16.10

Helicopter evacuation

Fig. 16.11

Bagram first receiver area

Military Sexual Trauma

PTSD can result from exposure to actual or threatened death, serious injury, or sexual violation (APA, 2013). New to the APA DSM-5 is the explicit reference to a sexual violation as a possible source of trauma. This is of particular relevance for SMs who may face trauma from both the threat that is naturally inherent in the combat theater, as well as from the possible additive occurrence of sexual violations from within the ranks. Thus, military sexual trauma (MST) that is experienced as a result of an occurrence (or threat of an occurrence) of a sexual violation or assault within a military context can produce additional risk for the development of PTSD in a population that is already at high risk due to the existing occupational hazards present in the combat environment.

In a recent report issued by the Joint Chiefs and Commandant of the Coast Guard, together with the DoD Sexual Assault Prevention and Response Program (SAPR) (DoD, 2012a), sexual assault has been defined “as intentional sexual contact, characterized by the use of force, threats, intimidation, abuse of authority, or when the victim does not or cannot consent. Sexual assault includes rape, forcible sodomy, and other unwanted sexual contact that is aggravated, abusive, or wrongful (to include unwanted and inappropriate sexual contact), or attempts to commit these acts.” (p. 5). The report further specifies the need for improvements in, “…advocacy coordination, medical services, legal support and [behavioral health] counseling for the victim” (p. 13). This has become an issue of grave concern within the military, as reports of sexual violations and assaults have not only been on the rise over the last 10 years (see Fig. 16.12), but have also garnered significant popular media attention (Kime, 2013; Valencia, 2013). Overall, 6.1 % of women and 1.2 % of men (active duty SMs) indicated they experienced unwanted sexual contact in 2012. For women, this rate is statistically significantly higher in 2012 than in 2010 (6.1 vs. 4.4 %) (DoD, 2012b).

Fig. 16.12

Service member victims in DoD sexual assault reports, CY04–FY12 (from DoD2012c)

A bleaker picture of the problem emerges when reports from post-discharge Veteran surveys are considered. Underreporting of MST by SMs while on active duty may occur due to fear of reprisal, concern for military careers, shame, or because they didn’t want anyone to know while in the service and this additional threat may be lessened once the person transitions to Veteran status. For example, retrospective reports of sexual assault and harassment during active duty—by female Veterans following discharge—have suggested higher MST incidence than what has been reported in active duty samples. In a nationwide randomly selected sample of women seeking care through VA medical centers, approximately 1 out of 4 reported experiencing a sexual trauma while on active duty (Skinner et al., 2000). The reported prevalence rates of MST in women were 20–25 % for sexual assault and 24–60 % for sexual harassment and more recent indicators suggest that this problem is expected to grow exponentially in the future (Department of Veterans Affairs, 2007). The implication that MST can be a primary factor for the development of PTSD has also been supported by multiple studies that indicate that many women who report experiencing a MST also experience mental health problems, with the most frequently reported being PTSD (Kimerling et al., 2010; Street, Gradus, Stafford, & Kelly, 2007; Street, Stafford, Mahan, & Hendricks, 2008). For example, within a sample of women seeking PTSD-related services within the VA system, 71 % reported MST experiences (Murdoch, Polusny, Hodges, & O’Brien, 2004). Moreover, as with PTSD, MST is associated with a variety of comorbid mental and physical health disorders (Brewin, Andrews, & Valentine, 2000; Sadler, Booth, Nielson, & Doebbeling, 2000; Zinzow, Grubaugh, Monnier, Suffoletta-Maierle, & Frueh, 2007) as well as impairments in both social functioning and quality of life (Rheingold, Acierno, & Resnick, 2004; Surıs, Lind, Kaashner, & Borman, 2007). Thus, while the DoD is mobilizing to reduce the incidence of MST with novel education and prevention programs (DoD 2012a, 2012b, 2012c), a significant effort is also required to develop and disseminate effective treatment approaches to address the existing problem of PTSD due to MST.

The current project is developing content for inclusion in BRAVEMIND that will provide new customizable options for conducting VRET with persons who have experienced MST. The novel component of the current project involves the creation of new content that will be embedded within the existing BRAVEMIND scenarios such as barracks, tents, other living and work quarters, latrines, and other contexts that have been reported by MST victims as locations where their sexual assault occurred. This system will not attempt to recreate the sexual assault, but rather set up the contexts surrounding the assault, in which users can be supported in the therapeutic confrontation and processing of MST memories in accordance with the protocol that has been used previously that implements PE within the simulations (Rothbaum et al., 2008). When the new content is complete (summer 2014) a pilot waitlist RCT will commence with 34 male and female participants. This has not been attempted previously with immersive VRET and the unique challenges for creating such unique and sensitive content are significant. While both men and women can experience MST, the urgent need for this work is underscored by the growing role of women transitioning into full combat roles in the combat theater, an area that up to now has been primarily the domain of men.

Virtual Reality Resilience Training

Resilience is the dynamic process by which individuals exhibit positive adaptation when they encounter significant adversity, trauma, tragedy, threats, or other sources of stress (McEwen & Stellar, 1993). The core aim of resilience training is to promote psychological fitness through self-awareness, self-esteem, emotional regulation, and social support. This multidimensional approach to resilience training is designed to better prepare SMs for the psychological stressors that they may experience during a combat deployment and to provide them with the tools needed to resolve the inevitable reactivity they experience after trauma/stress. There is a powerful rationale for developing methods that promote SM resilience and psychological fitness prior to a combat deployment. The current urgency in efforts to address the psychological wounds of war in SMs and Veterans has also driven an emerging focus within the military on emphasizing a proactive approach for better preparing SMs for the emotional challenges they may face during a combat deployment to reduce the potential for later adverse psychological reactions such as PTSD, suicidality, and depression. This focus on resilience training prior to deployment represents no less than a quantum shift in military culture and can now be seen emanating from the highest levels of command in the military. For example, in an American Psychologist article, Army General George Casey (2011) stated that “…soldiers can “be” better before deploying to combat so they will not have to “get” better after they return.” (p. 1), and he then calls for a shift in the military “…to a culture in which psychological fitness is recognized as every bit as important as physical fitness.” (p. 2).

This level of endorsement can be seen in practice by way of the significant funding and resources applied to a variety of resilience training programs across all branches of the U.S. Military (Cornum, Matthews, & Seligman, 2011; Hovar, 2010; Luthar, Cicchetti, & Becker, 2000). Perhaps the program that is attempting to influence the largest number of SMs is the Comprehensive Soldier Fitness (CSF) program (Cornum et al., 2011). This project has created and disseminated training that aims to improve emotional coping skills and ultimate resilience across all Army SMs. One element of this program draws input from principles of cognitive-behavioral science, which generally advances the view that it is not the event that causes an emotion, but rather how a person appraises the event (based on how they think about the event) that leads to the emotion (Ortony, Clore, & Collins, 1988). From this theoretical base, it then follows that internal thinking or appraisals about combat events can be “taught” in a way that leads to more healthy and resilient reactions to stress. This approach does not imply that people with effective coping skills do not feel some level of “rational” emotional pain when confronted with a challenging event that would normally be stressful to any individual. Instead, the aim is to teach skills that may assist soldiers in an effort to cope with traumatic stressors more successfully.

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