Scott L. Johnston

Development and Testing of Virtual Reality Exposure Therapy for Post-Traumatic Stress Disorder in Active Duty Service Members Who Served in Iraq and Afghanistan

This study was an open-label, single-group, treatment-development project aimed at developing and testing a method for applying virtual reality exposure therapy (VRET) to active duty service members diagnosed with combat post-traumatic stress disorder (PTSD). Forty-two service members with PTSD were enrolled, and 20 participants completed treatment. The PTSD Checklist-Military version, Patient Health Questionnaire-9 for depression, and the Beck Anxiety Inventory were used as outcome measures. Of those who completed post-treatment assessment, 75% had experienced at least a 50% reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD at post treatment. Average PSTD scores decreased by 50.4%, depression scores by 46.6%, and anxiety scores by 36%. Intention-to-treat analyses showed that statistically significant improvements in PTSD, depression, and anxiety occurred over the course of treatment and were maintained at follow up. There were no adverse events associated with VRET treatment. This study provides preliminary support for the use of VRET in combat-related PTSD. Further study will be needed to determine the wider utility of the method and to determine if it offers advantages over other established PTSD treatment modalities.

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.

Combat-Related Post-Traumatic Stress Disorder: A Case Report Using Virtual Reality Graded Exposure Therapy With Physiological Monitoring With a Female Seabee

In this report we describe virtual reality graded exposure therapy (VRGET) for the treatment of combat-related post-traumatic stress disorder (PTSD). In addition, we summarize the outcomes of a case study, from an Office Of Naval Research (ONR)-funded project of VRGET with an active duty female Seabee who completed three combat tours to Iraq. Details of the collaborative program involving this ONR-funded project at Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) are also discussed.

Virtual reality posttraumatic stress disorder (PTSD) exposure therapy results with active duty OIF/OEF service members

Abstract Posttraumatic stress disorder (PTSD) is reported to be caused by exposure to traumatic events including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggest 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/Afghanistan PTSD VR therapy application and present initial findings from its use with PTSD patients. Thus far, 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 at San Diego Naval Medical Center of the first 20 treatment completers indicate that 16 no longer met PTSD screening criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

Support of Marines and Sailors Returning From Combat: A Comparison of Two Different Mental Health Models

As Navy medicine continues to support the Global War on Terrorism, various approaches are used to attenuate combat stress casualties. This article examines two different mental health models, one employed at sea and one in the combat zone, used for active duty forces immediately after cessation of combat operations. Both models focus on screening, early prevention, and treatment implemented during the transition from the combat theater to garrison. Returning by sea provided the opportunity for greater education and decompression of combat stress as the service members transitioned back to garrison when compared to those who returned by air. It was also found that the Post Deployment Health Assessment (PDHA) did not capture as many individuals with mental health issues leaving combat theater, which identified 6% on both missions, compared to the capture rate with the Post Deployment Psychological Screener (PDPS), which identified 16-20%. Limitations, opportunities, and recommendations for future interventions are discussed.

Interactive effects of stress and individual differences on alcohol use and posttraumatic stress disorder among personnel deployed to Guantanamo Bay.

This study examines the role of factors such as perceived stress, neuroticism, beliefs in psychotherapy stigma, resilience, and demographics in understanding posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) among deployed military personnel. Results show that personnel who screened positive for PTSD were more likely to screen positive for AUD (versus those who did not screen positive for PTSD). Perceived stress, neuroticism, and psychotherapy stigma all have direct multivariate relationships with PTSD symptoms. Moderated regression analyses show that the positive relationship between perceived stress and PTSD symptoms is significantly stronger among those scoring high on neuroticism and psychotherapy stigma. The positive relationship between perceived stress and AUD symptoms is only significant among those scoring high on psychotherapy stigma. Given the moderating role of psychotherapy stigma in the relationship between perceived stress and PTSD symptoms and the relationship between perceived stress and AUD symptoms efforts to reduce the stigma associated with mental health care in the military should be expanded. Also, the current research adds to the literature highlighting the role of neuroticism as a key variable in understanding PTSD.

Risk of PTSD in service members who were fired upon by the enemy is higher in those who also returned fire

An unusual characteristic of the recent wars in Iraq and Afghanistan is that, because of attacks by snipers and improvised explosive devices (IED), many U.S. service members may come under attack without having exchanged fire. It was hypothesized that this would be associated with greater severity of post-traumatic stress disorder (PTSD) symptoms. The severity of self-reported symptoms of PTSD and depression were examined among service members who reported being shot at or attacked by an IED, those who had these experiences but who also shot at the enemy, and those who reported neither experience. Results showed that those with neither exposure reported the lowest symptom severity, but, contrary to expectations, service members who had been attacked but not shot at the enemy had less severe symptoms than those who had exchanged fire. This may support findings from earlier generations of veterans that shooting at or killing the enemy may be a particularly traumatic experience.

Professional quality of life normative benchmarks.

Objective: Those responsible for the care of trauma survivors can experience both beneficial and detrimental consequences resulting from their professional demands. Research has demonstrated that among professional caregivers, compassion satisfaction (CS), burnout (BO), and compassion fatigue (CF) are important factors contributing to professional quality of life. The current research aims to provide normative information regarding the factors contributing to professional quality of life among those who interact with survivors of trauma. The Professional Quality of Life (ProQOL) Scale is a widely used measure of CS, BO, and CF. The most recent iteration of the ProQOL manual provides normative data to assist in the interpretation of scores. However, a review of the literature reporting raw scores on the ProQOL suggests that mean scores and cutoff scores for the 25th and 75th percentiles may be misleading. Method: A review of 30 studies (total sample size of 5,612) was conducted and normative values are presented. Results: The mean (standard deviation) level of CS, CF, and BO were 37.7 (6.5), 16.7 (5.7), and 22.8 (5.4), respectively. Conclusions: Values gathered from the literature review tend to align well with one another and suggest that within a given sample, CS scores tend to be higher than BO scores, and BO scores tend to be slightly higher than CF scores.

Predicting firearms performance based on psychiatric symptoms and medication usage.

Health care providers may be asked to make recommendations whether individuals with a mental health history and/or are taking psychiatric medication should have access to firearms as part of their work. For example, in the military, some instructions require a waiver from a medical provider for those individuals taking a psychiatric medication to be able to continue carrying a weapon. There is currently little data or established protocols to help objectively guide such recommendations. This study examined the reliability and validity of using a video game simulation of firearms performance and examined variables that might predict such performance. Participants were asked questions about demographics, psychiatric symptoms, and usage of psychiatric medication. They then took a computerized neuropsychological battery and were observed in a video game simulation of firearms performance. Data were examined for relationships among measures of test−retest stability over 1 month, and models were constructed to predict performance. Results showed that most aspects of firearms performance were found to be a reasonably stable construct with good relationships to established neuropsychological measures. When predicting who would perform more poorly on the firearms simulations, performance on the neuropsychological battery was a significant predictor. Being on psychiatric medication had a small but significant effect on one aspect of firearms performance. This study provides a first step in providing a more objective means of guiding medical recommendations about firearms.

Unit Acceptance and Psychological Distress among LGB Military Service Members: Preliminary Findings from a National Survey

Abstract Literature clearly elucidates the association between unit cohesion and service members’ well-being. Similarly, social support/acceptance of sexual identity is related to better mental health among lesbian, gay, and bisexual (LGB) populations. No research exists examining the relation between perceived unit acceptance of LGB service members and LGB service members’ psychological distress. Among LGB service members in this sample, the majority reported their units were accepting of LGB members. A significant minority reported serving in non-accepting units and these participants reported greater psychological distress. Findings inform researchers, policymakers, and mental health providers serving LGB service members seeking support related to unit non-acceptance.