· 2015. 10. 19. · dennis patrick wood, ph.d., abpp (capt, msc, usn-ret) the virtual reality...

Dennis Patrick Wood, Ph.D., ABPP(CAPT, MSC, USN-ret)

The Virtual Reality Medical Center, San Diegodpwcapt@aol.com

www.vrphobia.com

COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A MULTIPLE-CASE REPORT USING

VIRTUAL REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING

CYBERTHERAPY 12 CONFERENCEALEXANDIRA, VIRGINIA

COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A MULTIPLE-CASE REPORT USING

VIRTUAL REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING

CYBERTHERAPY 12 CONFERENCEALEXANDIRA, VIRGINIA

Disclaimer:Disclaimer: The views in this presentation are those of The views in this presentation are those of the individual authors, and do not necessarily the individual authors, and do not necessarily represent those of the Department of the Navy, represent those of the Department of the Navy, Department of Defense, the Department of Veterans Department of Defense, the Department of Veterans Affairs, or the U.S. Government. Research described Affairs, or the U.S. Government. Research described has been approved by the Institutional Review Board has been approved by the Institutional Review Board at the Naval Medical Center San Diego. The at the Naval Medical Center San Diego. The information in this presentation was approved under information in this presentation was approved under the NMCSD Institutional Review Board. This study the NMCSD Institutional Review Board. This study was sponsored by the ONR Contract (#N00014was sponsored by the ONR Contract (#N00014--0505--CC--0136) to Virtual Reality Medical Center, San Diego, 0136) to Virtual Reality Medical Center, San Diego, CA.CA.

VRMC/ONR Graded Exposure, Physiologically Monitored PTSD Treatment Programs

VRMC VRGET PROJECT AT NAVAL

MEDICAL CENTER SAN DIEGO

NAVAL MEDICAL CENTER SAND DIEGO:

1.Largest Military Hospital in the world2.Home of the Comprehensive Combat Casualty Care Program (C-5)3.USS Mercy4. 4 additional West Coast Navy Hospitals

VRMC VRGET PROJECT AT NAVY HOSPITAL MARINE CORPS BASE CAMP PENDLETON

NH,MCBCP:1.60 miles North of San Diego2.MCBCP = 250 square miles 3.123 bed facility4.MCBPC home to:

FIRST MARINE CORPS DIVISION & THE FIRST MARINE EXPEITIONARY FORCE (MEF)

Virtual Reality Medical Center Clinical Services(San Diego, West LA, Palo Alto)

Specific PhobiasSpecific PhobiasFlyingFlyingDrivingDrivingPublic SpeakingPublic SpeakingClaustrophobiaClaustrophobiaHeightsHeightsSpidersSpidersMedical Procedures Medical Procedures School School

Panic DisorderPanic DisorderAgoraphobiaAgoraphobiaGeneralized Social PhobiaGeneralized Social PhobiaPTSD due to motor vehicle accidentsPTSD due to motor vehicle accidents

VRMC/IMI FundersVRMC/IMI Funders

Virtual Reality MeasurementsVirtual Reality MeasurementsVirtual Reality Measurements

PhysiologicalPhysiologicalRespirationRespirationHR, HRVHR, HRVSkin temperatureSkin temperatureSkin conductanceSkin conductance

PsychologicalPsychologicalMini Neuropsychiatric Mini Neuropsychiatric

InterviewInterviewBAIBAIPCLPCL--MMPHQPHQ--99Combat ExposureCombat Exposure

ScaleScaleBlast AssessmentBlast Assessment

Virtual Reality HardwareVirtual Reality Hardware

Head Mount Display: Head Mount Display: ii--glassesglasses

Hardware SetHardware Set--Up Up

PTSD ClusterPTSD Cluster

1.1. Life threatening event to self or Life threatening event to self or others resulting is others resulting is ““markedly markedly distressingdistressing””

2.2. Event persistently reEvent persistently re--experienced: intrusive experienced: intrusive distressing recollections, distressing recollections, recurrent distressing recurrent distressing dreams/nightmares, flashbacksdreams/nightmares, flashbacks

PTSD ClusterPTSD Cluster

3.3. Persistence avoidance: avoid Persistence avoidance: avoid thoughts, activities &/or thoughts, activities &/or reminders of event; detached reminders of event; detached feelings; foreshortened futurefeelings; foreshortened future

4.4. Persistent arousal: sleep Persistent arousal: sleep problems, irritability, hyperproblems, irritability, hyper--arousal or startle , arousal or startle , concentration difficultiesconcentration difficulties

Psychiatric Diagnoses Related to Combat in Iraq and AfghanistanPsychiatric Diagnoses Related to Psychiatric Diagnoses Related to Combat in Iraq and AfghanistanCombat in Iraq and Afghanistan

Following OIF, Depression, Anxiety Following OIF, Depression, Anxiety & PTSD rates were:& PTSD rates were:

15% 15% –– 17% for Iraqi combat 17% for Iraqi combat veteransveterans11.2% for Afghanistan combat 11.2% for Afghanistan combat

veterans veterans (Hoge et al., 2004)(Hoge et al., 2004)

PTSD and the War on TerrorismPTSD and the War on Terrorism

““It is anticipated that the rate of PTSD It is anticipated that the rate of PTSD will be higher among troops who have will be higher among troops who have been to Iraq more than oncebeen to Iraq more than once””. (COL . (COL Elspeth Ritchie, July 19, 2006)Elspeth Ritchie, July 19, 2006)PTSD rates, among soldiers PTSD rates, among soldiers hospitalized following serious combat hospitalized following serious combat injury, was 12% at 7 months following injury, was 12% at 7 months following hospitalization (Grieger et al, 2006) hospitalization (Grieger et al, 2006)

PTSD and the War on TerrorismPTSD and the War on Terrorism

““Soldiers who deployed longer Soldiers who deployed longer (i.e., greater than six months) or (i.e., greater than six months) or had deployed multiple times had deployed multiple times were more likely to screen were more likely to screen positive for a mental health positive for a mental health issueissue”” (DOD, Mental Health (DOD, Mental Health Advisory Team (MHATAdvisory Team (MHAT--IV) IV) Survey: 04 May 2007).Survey: 04 May 2007).

VRMC/ONR Graded Exposure, Physiologically Monitored PTSD Treatment Programs

Naval Medical Center San Diego Naval Medical Center San Diego Navy Hospital, Marine Corps Navy Hospital, Marine Corps Base Camp PendletonBase Camp PendletonFunded by Office of Naval Funded by Office of Naval Research (ONR)Research (ONR)Funded by TATRCFunded by TATRC

VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat- related

•• Combat Support Personnel (i.e., Naval Corpsmen, Combat Support Personnel (i.e., Naval Corpsmen, Seabees, nonSeabees, non--infantry personnel)infantry personnel)

•• All warriors have a preAll warriors have a pre--treatment assessment, treatment assessment, including two interviews; selfincluding two interviews; self--report questionnaires, report questionnaires, objective measures & pyschophysiological measuresobjective measures & pyschophysiological measures

•• Wood et al., Combat Related Post Traumatic Stress Wood et al., Combat Related Post Traumatic Stress Disorder: A Case Report Using Virtual Reality Disorder: A Case Report Using Virtual Reality Exposure Therapy with Physiological Monitoring. Exposure Therapy with Physiological Monitoring. CyberTherapy & Behavior, 10 (2), 2007 CyberTherapy & Behavior, 10 (2), 2007

ASSESSMENT:ASSESSMENT:PrePre--RX assessmentRX assessmentMidMid--RX assessment following 5RX assessment following 5thth

RX sessionRX sessionPostPost--RX assessment following 10RX assessment following 10thth

RX sessionRX sessionAssessment at 3 & 6 months F/UAssessment at 3 & 6 months F/U

RANK AGE COMBATTOURS

PURPLE HEART

TBI SURGERY PTSD ONSET

MED BRD

PTSD RES

HM2 (E5)

32 1 Yes Yes Yes 19 months

Yes No

CM1(E6)

47 1 (12 Months)

No No Yes 2 months

Yes No

EO1(E6)

40 1 No No No 2 months

Yes Yes

HM2 (E5)

31 1 No Yes No 31 months

Yes No

LCDR(04)

49 Multiple No No No 13 months

No Yes

HMC (E7)

44 1 No No No 15 months

WARRIORS WHO HAVE COMPLETED 10 SESSIONS OF VRGET (N = 6)

VRGET system: two Dell computers, VR VRGET system: two Dell computers, VR HMD goggles with headphones, & joy HMD goggles with headphones, & joy stick; 3stick; 3rdrd computer to run the physiological computer to run the physiological monitoringmonitoringAll All ““combatcombat”” environments were environments were ““gradedgraded””immersive & patient only experienced immersive & patient only experienced computer generated audio & visual stimulicomputer generated audio & visual stimuliPatient Patient ““walkedwalked”” through the combat zonesthrough the combat zonesWeekly treatment sessions 90 minutes longWeekly treatment sessions 90 minutes long

First two treatments: focused on meditation First two treatments: focused on meditation training and familiarity with the combat towntraining and familiarity with the combat townSessions 3 Sessions 3 –– 10: 10: individualizedindividualized & focused on & focused on progressively increasing the combat threat or progressively increasing the combat threat or ““elementselements”” & the patient& the patient’’s immersion in the s immersion in the combat zones, eliciting SUDs levels, and combat zones, eliciting SUDs levels, and effecting effecting ““habituationhabituation””ReRe--assessment following Sessions #5 & #10assessment following Sessions #5 & #10

Figure 1. Results of PCLFigure 1. Results of PCL-- M, M, PHQPHQ-- 9 & BAI at Pre, Mid9 & BAI at Pre, Mid--& Post& Post-- treatment treatment Assessments Scoring Assessments Scoring guidelines: guidelines: PCLPCL-- M: < 50 = no PTSD; M: < 50 = no PTSD; >>50 = PTSD; 50 = PTSD; PHQPHQ-- 9: 20 9: 20 –– 27 = Severe 27 = Severe depression; 15 depression; 15 –– 19 = 19 = Moderately Severe; 10 Moderately Severe; 10 –– 14 = 14 = Moderate; 5 Moderate; 5 –– 9 = Mild; 0 9 = Mild; 0 –– 4 4 = Minimal; = Minimal; BAI: 26 BAI: 26 –– 63 = Severe 63 = Severe Anxiety; 16 Anxiety; 16 –– 25 = Moderate; 25 = Moderate; 8 8 –– 15 = Mild; 0 15 = Mild; 0 –– 7 = 7 = Minimal . (N = 6)Minimal . (N = 6)

PRE-RX MID-RX POST-RX

PCL-MPHQ-9BAI

Figure 2. Figure 2. Physiological Physiological Assessment of Skin Assessment of Skin Conductance Conductance (MicroMhos per (MicroMhos per second) at Presecond) at Pre--Treatment, MidTreatment, Mid--Treatment, and Treatment, and PostPost--Treatment (N Treatment (N = 6) = 6)

012345678

BASESTRESSORRECOVERY

Figure 3. Figure 3. Physiological Physiological Assessment of Assessment of Peripheral Peripheral Temperature Temperature (Degrees (Degrees Fahrenheit) at Fahrenheit) at PrePre--, Mid, Mid--, & , & PostPost--Treatment Treatment (N = 6) (N = 6)

68707274767880828486

VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-Related

Figure 4. Physiological Assessment of Heart Rate (Beats per Minute) at Pre-, Mid-, and Post-Treatment (N = 6)

SUMMARYSUMMARY::PostPost--treatment treatment PCLPCL--MM scores decreased; scores decreased; with two Warriorswith two Warriors’’ PTSD in remissionPTSD in remissionPostPost--treatment treatment DepressionDepression scores scores decreased (i.e., Moderate Severe to decreased (i.e., Moderate Severe to ModerateModerate))PostPost--treatment treatment AnxietyAnxiety scores decreased scores decreased from Severe to from Severe to ModerateModerate

SUMMARY: SUMMARY: Skin CondutanceSkin Condutance is a modifiable is a modifiable physiological response physiological response ––1.1. PrePre--Treatment SC was not reduced Treatment SC was not reduced

between Recall and Recovery (i.e., 7.14 between Recall and Recovery (i.e., 7.14 to 7.34) to 7.34)

2.2. MidMid--Treatment SC was reduced Treatment SC was reduced between between Recall and Recovery (i.e., Recall and Recovery (i.e., 6.07 to 2.8)6.07 to 2.8)

3.3. PostPost--Treatment SC Recall was lower (i.e., Treatment SC Recall was lower (i.e., 4.64)4.64)

SUMMARY:SUMMARY: Much variability to Much variability to Peripheral Temperature Peripheral Temperature (PT)(PT)1.1. 3 Warriors3 Warriors’’ PT increased and 3 PT increased and 3

WarriorsWarriors’’ PT decreased between PrePT decreased between Pre--Treatment Base and PostTreatment Base and Post--TreatmentTreatmentRecovery (PreRecovery (Pre--RX Base = 91.84)RX Base = 91.84)

2.2. May take more than 10 VRGET May take more than 10 VRGET sessions to demonstrate a positive sessions to demonstrate a positive change in PTchange in PT

SUMMARY:SUMMARY: Much Much Heart Rate (HR) Heart Rate (HR) variability between Prevariability between Pre--, Mid, Mid--, and Post, and Post--Treatment assessments (i.e., 74.02; 83.04; Treatment assessments (i.e., 74.02; 83.04; 77.79); Analysis of individual HR needed77.79); Analysis of individual HR needed1.1. WarriorsWarriors’’ differences in differences in Initial HR (i.e., Initial HR (i.e.,

low = 66.5 vs. 86.3) low = 66.5 vs. 86.3) 2.2. WarriorsWarriors’’ differences in differences in PostPost--RX RX

Recovery HR (i.e., 68.8 vs. 90.6)Recovery HR (i.e., 68.8 vs. 90.6)

CONCLUSIONS:CONCLUSIONS:1.1. Pt reported presence of improved lifePt reported presence of improved life--

management skillsmanagement skills2.2. New VRGET Therapy for combat New VRGET Therapy for combat

veterans DX with PTSD successfully veterans DX with PTSD successfully developeddeveloped

3.3. Currently soliciting input from Treated Currently soliciting input from Treated Warriors concerning the PROS and Warriors concerning the PROS and CONS of their VRGETCONS of their VRGET

CONCLUSIONS:CONCLUSIONS:4.4. 20 VRGET sessions, with sessions20 VRGET sessions, with sessions

twice a week, may be more effective twice a week, may be more effective 5.5. VRGET DVD developed for warriorsVRGET DVD developed for warriors’’

homework with meditation CDhomework with meditation CD6.6. Homework being Homework being ““framedframed”” usingusing

results from PCLresults from PCL--M administered M administered between rebetween re--evaluationsevaluations

CONCLUSIONS:CONCLUSIONS:7.7. Review the bioReview the bio--feedback datafeedback data

documenting the acquisition curve for Warriorsdocumenting the acquisition curve for Warriors’’converting increased Heart Rate converting increased Heart Rate ““VLFVLF”” to to ““LFLF””–– the the ““VLFVLF--LFLF”” ratio represents the trueratio represents the true

““Philosopher's StonePhilosopher's Stone”” (Dr. James Spria)(Dr. James Spria)8.8. Compare VRGET outcomes for 10 WafrriorsCompare VRGET outcomes for 10 Wafrriors’’

first 10 sessions against their second 10 VRGETfirst 10 sessions against their second 10 VRGETsessionssessions’’ outcomesoutcomes

VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-related PTSD

WARRIORS VRGET SESSIONS COMPLETED

3 Enrolled for Eval

Why VR ?Advantages and illustrations

Not dependent upon patientsNot dependent upon patients’’imagery abilitiesimagery abilitiesProvides a structured environmentProvides a structured environmentVisual and auditory stimuliVisual and auditory stimuliCan Can ““overover--learnlearn”” skills = skills = ““habituationhabituation”” or develop concept of or develop concept of ““safetysafety””Done in the therapistDone in the therapist’’s offices officeLess time consumingLess time consumingLess expensiveLess expensiveSaferSafer

Combat Town:Combat Town:Battalion BaseBattalion BaseMarket PlaceMarket PlaceVillageVillageHospitalHospitalCombat zoneCombat zone

Semper Fi!Semper Fi!

· 2015. 10. 19. · dennis patrick wood, ph.d., abpp (capt, msc, usn-ret) the virtual reality...

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