Ken Graap

Virtual Reality Exposure Therapy for PTSD Vietnam Veterans: A Case Study

Virtual reality (VR) integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). This report presents the results of the first Vietnam combat veteran with PTSD to have been treated with VRE. The patient was exposed to two virtual environments, a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. The patient experienced a 34% decrease on clinician-rated PTSD and a 45% decrease on self-rated PTSD. Treatment gains were maintained at 6-month follow-up.

Assessing reactivity to virtual reality alcohol based cues

The use of virtual reality (VR) programs in behavioral science research has been gaining prominence over the past several years. In the field of substance abuse, VR cue reactivity programs have been successfully tested for feasibility in nicotine and cocaine dependent samples. Seeking to expand VR applications in alcohol cue research, a novel VR alcohol cue reactivity assessment system incorporating visual, auditory, and olfactory stimuli was developed and tested. In a controlled trial, 40 non-treatment-seeking drinkers with alcohol use disorders were exposed to VR alcohol cue environments. Subjective craving, attention to alcohol cues, and level of presence (realism of experience) in VR were assessed across the environments. Overall, subjective craving for alcohol increased across the VR alcohol-related cue environments versus VR neutral cue environments. Participants reported high levels of presence in VR, indicating that the environments were perceived as realistic and compelling. These initial findings support the use of VR based cue reactivity environments for use in alcohol cue-based treatment and research.

Virtual Reality Cue Reactivity Assessment in Cigarette Smokers

Drug craving has purportedly been linked to relapse and to substance use. For over two decades, cue reactivity has been a viable method to assess craving and physiological reactions to drug stimuli. However, traditional cue reactivity has faced the following limitations: austere situations or stimuli, lack of complex cues, lack of standardization, and limited generalization outside of the lab setting. In order to improve cue methodologies, a virtual reality (VR) nicotine cue reactivity assessment system (VR-NCRAS) was developed and tested in a controlled experimental trial. Ten nicotine dependent smokers were exposed to VR smoking cues and VR neutral cues in a standardized, timed, computer controlled experiment. Subjective craving and physiological responses were recorded and compared across VR-NCRAS stimuli. Subjective cigarette craving increased significantly and corresponding physiological reactivity was observed in response to VR smoking cues. VR neutral cues did not result in subjective or physiological changes consistent with craving. Implications of these findings on substance abuse research and treatment are discussed.

Reactivity to cannabis cues in virtual reality environments.

Abstract Virtual reality (VR) cue environments have been developed and successfully tested in nicotine, cocaine, and alcohol abusers. Aims in the current article include the development and testing of a novel VR cannabis cue reactivity assessment system. It was hypothesized that subjective craving levels and attention to cannabis cues would be higher in VR environments with cannabis cues compared to VR neutral environments. Twenty nontreatment-seeking current cannabis smokers participated in the VR cue trial. During the VR cue trial, participants were exposed to four virtual environments that contained audio, visual, olfactory, and vibrotactile sensory stimuli. Two VR environments contained cannabis cues that consisted of a party room in which people were smoking cannabis and a room containing cannabis paraphernalia without people. Two VR neutral rooms without cannabis cues consisted of a digital art gallery with nature videos. Subjective craving and attention to cues were significantly higher in the VR cannabis environments compared to the VR neutral environments. These findings indicate that VR cannabis cue reactivity may offer a new technology-based method to advance addiction research and treatment.

A Virtual Reality Exposure Therapy Application for Iraq War Post Traumatic Stress Disorder

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experiences including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) exposure treatment has been used in previous treatments of PTSD patients with reports of positive outcomes. The aim of the current paper is to present the rationale, technical specifications, application features and user-centered design process for the development of a Virtual Iraq PTSD VR therapy application. The VR treatment environment is being created via the recycling of virtual graphic assets that were initially built for the U.S. Army-funded combat tactical simulation scenario and commercially successful X-Box game, Full Spectrum Warrior, in addition to other available and newly created assets. Thus far we have created a series of customizable virtual scenarios designed to represent relevant contexts for exposure therapy to be conducted in VR, including a city and desert road convoy environment. User-Centered tests with the application are currently underway at the Naval Medical Center-San Diego and within an Army Combat Stress Control Team in Iraq with clinical trials scheduled to commence in February 2006.

Development and Clinical Results from the Virtual Iraq Exposure Therapy Application for PTSD

Post Traumatic Stress Disorder (PTSD) is reported to be caused by exposure to an extreme traumatic stressor involving direct personal experience of (or witnessing/learning about) an event that involves actual or threatened death or serious injury, or other threat to ones physical integrity including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Such incidents would be distressing to almost anyone, and are usually experienced with intense fear, horror, and helplessness. Initial data suggests that at least 1 out of 5 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will present the rationale and description of a VR PTSD therapy application (Virtual Iraq/Afghanistan) and present initial findings from a number of early studies of its use with active duty service members. Virtual Iraq/Afghanistan consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial using Virtual Iraq with 20 treatment completers indicated that 16 no longer met PTSD diagnostic criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

Regarding the database for the Peniston alpha-theta EEG biofeedback protocol.

Five papers by Peniston and colleagues, which constitute the basic literature for alpha-theta EEG biofeedback treatment for alcoholism and posttraumatic stress disorder, are reviewed. As a result, we raise three questions: (a) Are the samples studied independent? (b) What was the clinical status of the participants prior to treatment? (c) What treatment did the participants actually receive? In seeking answers to these questions we aim to strengthen the database for neurofeedback with specific procedural information so that claims of efficacy can be tested and accepted or rejected on an objective basis.

Virtual Iraq: Initial Case Reports from a VR Exposure Therapy Application for Combat-Related Post Traumatic Stress Disorder

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper is to present the rationale and brief description of a Virtual Iraq PTSD VR therapy application and present initial findings from two successfully treated patients. The VR treatment environment was created via the recycling of virtual graphic assets that were initially built for the U.S. Army-funded combat tactical simulation scenario and commercially successful X-Box game, Full Spectrum Warrior, in addition to other available and newly created assets. Thus far, Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team.

A virtual environment for the treatment of chronic combat-related post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is one of the most disabling psychopathological conditions affecting the veteran population. An estimated 830,000 U.S. veterans currently have symptoms of chronic combat-related PTSD. No therapeutic approach has proven to be consistently effective in the management of combat-related PTSD. Behavior therapies with an exposure element have proven more effective than most other types of treatment, but a significant number of patients do not seem to benefit from them, possibly because of difficulties imagining, visualizing, or describing their traumatic experiences. In this article, we describe Virtual Vietnam, a set of two virtual environments we have developed for the treatment of combat-related PTSD, and its use as one component of a comprehensive treatment program.

A Feasibility Study of Virtual Reality-Based Coping Skills Training for Nicotine Dependence

Objective: Virtual reality (VR)-based cue reactivity has been successfully used for the assessment of drug craving. Going beyond assessment of cue reactivity, a novel VR-based treatment approach for smoking cessation was developed and tested for feasibility. Method: In a randomized experiment, 10-week treatment feasibility trial, 46 nicotine-dependent adults, completed the10-week program. Virtual reality skills training (VRST) combined with nicotine replacement therapy (NRT) was compared to NRT alone. Participants were assessed for smoking behavior and coping skills during, at end of treatment, and at posttreatment follow-up. Results: Smoking rates and craving for nicotine were significantly lower for the VRST group compared to NRT-only group at the end of treatment. Self-confidence and coping skills were also significantly higher for the VRST group, and number of cigarettes smoked was significantly lower, compared to the control group at follow-up. Conclusions: Feasibility of VRST was supported in the current study.