Psychologists funded by the Dept. of Defense have created computer simulation called 'Virtual Iraq' that is being used "to treat Iraq war veterans suffering from post-traumatic stress disorder," the New York Times reported Tuesday.[1]  --  "By repeatedly encountering sights, sounds, smells, and rumblings that evoke painful memories, experts say, veterans with the disorder can begin to reprocess traumatic events and become desensitized to them, perhaps suffering fewer side effects like insomnia, nightmares, and flashbacks," Amanda Schaffer wrote.  --  "The simulation is available to a small number of patients at sites including the Veterans Administration Medical Center in Manhattan, the Naval Medical Center in San Diego, the Emory University School of Medicine in Atlanta, and Walter Reed Army Medical Center in Washington."  --  The simulation was first created in 2003 by Dr. Albert Rizzo, director of the Virtual Environments Lab at the University of Southern California by modifying the Xbox game "Full Spectrum Warrior."  --  In 2004, he and an entrepreneur "received financing from the Office of Naval Research to develop the current simulation, with extensive feedback from veterans and active-duty members of the military."  --  It is unsurprising and predictible that a visit to the USC web site reveals that one of the military's goals in pursuing this research is also to "Develop and test pre-combat Stress Inoculation Virtual Reality scenarios with VRMC,"[2] but this use goes unmentioned by the New York Times.  --  Defense Update says that "The treatment objective is to help veterans come to terms with what they've experienced in places like Iraq and Afghanistan by immersing vets in the sights and sounds of those theaters of battle, including visual and sound effects of gunshots," another detail omitted by the Times.[3]  --  "Visual effects of gunshots" is presumably an antiseptic expression for "wounds."  --  And the antiseptic Times piece does not make clear, as a Newsweek piece published two months ago did, how the realistic effects are produced.  --  The virtual experiences are "experienced from inside a virtual-reality helmet, complete with goggles and powerful headphones.   Don the helmet, and you are instantly immersed in a disturbingly realistic videogame version of an urban Iraqi battleground.  The platform underfoot houses a motor that shakes the ground whenever simulated rockets hit or bombs blast," Brian Braiker reported.[4]  --  One woman with PTSD who went through the program "'is actually going back' into combat, says Rizzo" — a fact that is sure to interest military researchers....

1.

Health

NOT A GAME: SIMULATION TO LESSEN WAR TRAUMA
By Amanda Schaffer

New York Times
August 28, 2007
Page D5

http://www.nytimes.com/2007/08/28/health/28game.html

[PHOTO CAPTION: Dr. Michael Kramer, left, and a colleague in Manhattan demonstrating Virtual Iraq.]

[INSET]

The sun shines on an empty Iraqi street. A Blackhawk helicopter circles overhead. The aromas of spices from a market fill the air.

Suddenly, insurgents hiding on a roof launch a rocket-propelled grenade. The ground shakes violently and plumes of black smoke cloud your vision.

Those images, produced when a person puts on a headset, are at the heart of Virtual Iraq, a simulation created to treat Iraq war veterans suffering from post-traumatic stress disorder.

By repeatedly encountering sights, sounds, smells and rumblings that evoke painful memories, experts say, veterans with the disorder can begin to reprocess traumatic events and become desensitized to them, perhaps suffering fewer side effects like insomnia, nightmares and flashbacks.

The simulation is available to a small number of patients at sites including the Veterans Administration Medical Center in Manhattan, the Naval Medical Center in San Diego, the Emory University School of Medicine in Atlanta, and Walter Reed Army Medical Center in Washington.

So-called exposure therapy, in which patients are asked to confront memories of a trauma by imagining and recounting it in painstaking detail, has long been a first-line psychological treatment for post-traumatic stress disorder. But the bells and whistles of virtual reality may make exposure therapy more effective, said Michael Kramer, a clinical psychologist at the Veterans Administration hospital in Manhattan who is overseeing the introduction of Virtual Iraq there.

“One of the hallmarks of P.T.S.D. is avoidance,” Dr. Kramer said. “Patients spend an awful lot of time and energy trying not to think about it or talk about it. But behaviorally, avoidance is what keeps the trauma alive.

“With virtual reality, we can put them back in the moment. And we can do it in a gradual, controlled way.”

Virtual Iraq features two scenarios. In one, patients navigate the streets of a generic Iraqi city, walking past buildings, cars, civilians, and markets. With the touch of a therapist’s keypad, a little boy might appear on a street corner and wave, apparently in friendship, or a man might stumble down the middle of the street calling for help, a sight that provokes anxiety in some veterans who have come to fear ruses.

In the other scene, veterans ride in a Humvee. Other vehicles might slow down in front of them, and strangers might open fire. Enemy combatants might appear under bridges. Objects dotting the roadside might explode as the Humvee passes.

The patient cannot shoot back at the insurgents and also cannot die or be wounded in the simulation.

In choosing which stimuli to introduce, the therapist’s goal is to evoke the conditions present when specific traumatic events occurred, as accurately as the simulation will allow. Smells like spices, burning garbage, or body odor can be emitted in four-second puffs. And the scene can be set to day or night, sun or fog, or even a sandstorm.

Given the power of traumatic memories, Dr. Kramer said, it is important “to go at a pace that the veteran can tolerate, so that he isn’t overwhelmed,” and he starts to realize that the memories cannot harm him.

One risk of introducing potent material too fast is that a veteran could become retraumatized and perhaps unwilling to continue other kinds of therapy, as well.

Not all patients with the stress disorder are likely to benefit from this therapy. Veterans who lack basic coping mechanisms, are actively having flashbacks or who have unaddressed problems with substance abuse should probably not enter the simulator, Dr. Kramer said.

Dr. Albert Rizzo, the director of the Virtual Environments Lab at the University of Southern California who helped develop the simulator, said, “It’s a hard treatment for a very hard problem.”

Dr. Rizzo first created a simulation for Iraq veterans with the disorder in 2003, by modifying the Xbox game Full Spectrum Warrior. In 2004, he and Ken Graap, president and chief executive of Virtually Better in Decatur, Ga., received financing from the Office of Naval Research to develop the current simulation, with extensive feedback from veterans and active-duty members of the military.

Virtually Better also offers a Virtual Vietnam, as well as programs to address fear of heights and flying, social phobias, and addictive behaviors.

Exposure therapy may not be enough for veterans with complicated symptoms resulting from chronic stress and multiple traumatic episodes, said Dr. Rachel Yehuda, director of the post-traumatic stress disorder program at the James J. Peters Department of Veterans Affairs Medical Center in the Bronx.

“I don’t believe,” she said, “that any study of exposure therapy for combat-related P.T.S.D. has shown a clinically significant improvement” in more than half the patients.

“While I would offer it to a veteran in a heartbeat, I would be prepared for the fact that it might have to be supplemented with other forms of assistance” like medication and social services, she said.

“If we’re too enthusiastic,” Dr. Yehuda added, “then people may expect veterans to be cured after 12 weeks, and it just doesn’t work that way.”

Hunter Hoffman, a cognitive psychologist at the University of Washington in Seattle, said: “With the growing ranks of Iraq war veterans who have developed P.T.S.D., now is the time for them to receive effective treatment, not 20 years from now.

“We know from Vietnam that for most patients diagnosed with P.T.S.D., these problems don’t just go away over time.”

2.

POST-TRAUMATIC STRESS DISORDER ASSESSMENT AND TREATMENT

Institute for Creative Technologies
University of Southern California

http://www.ict.usc.edu/content/view/31/84/

The Virtual Reality (VR) Assessment and Treatment of Combat-Related Post-Traumatic Stress Disorder (PTSD) project develops immersive virtual environment applications for the treatment of Iraq War veterans diagnosed with PTSD. This project is funded as part of a larger multi-year effort by the U.S. Office of Naval Research (ONR). The project uses a VR environment as the basis of treatment, whereby a veteran with PTSD can experience a combat-relevant scenario in a low-threat context to therapeutically process emotions and decondition the effects of the disorder.

By recycling virtual graphic assets built for the combat tactical simulation training game Full Spectrum Warrior and other ICT assets, the project is able to build prototypes quickly and cost-effectively. With the help of ONR, this project brings together the technical, clinical, and creative forces of ICT, Virtually Better, Inc., and the Virtual Reality Medical Center (VRMC) to help veterans overcome the effects of PTSD and restore quality of life to them and their families.

GOALS

The goals of the PTSD project are as follows:

* Build the Virtual Iraq PTSD application, with design input from returning Iraq War military personnel

* Establish agreements with multiple clinical test sites (e.g., Wiell Cornell Medical Center in New York City, the West Los Angeles VA Medical Center, the Providence Rhode Island VA Medical Center, and others) and begin clinical testing with the application.

* Conduct empirical research on the diagnostic validity and clinical efficacy of the system

* Conduct research on psychophysiological monitoring as an aid to diagnosis and treatment

* Develop and test pre-combat Stress Inoculation Virtual Reality scenarios with VRMC

Differences Between This Project and Others in the Field

This project differs from others in the following ways:

* It delivers a comprehensive range of objective VR exposure scenarios that can be tailored to the individual experiences of a person with PTSD (Other research uses “imaginal” therapy.)

< * It contains a “Wizard of Oz” clinician’s interface that enables the clinician to control the virtual environment in real time to modulate patient anxiety level as is required for therapeutic gain.

Related Projects
VrPsych
FlatWorld

Team Members
Jarrell Pair, Co-Project Investigator
Thomas Parons, Co-Project Investigator
Albert “Skip” Rizzo, Co-Project Investigator

External Collaborators
Ken Graap, Virtually Better, Inc. This email address is being protected from spambots. You need JavaScript enabled to view it.
Barbara Rothbaum, Emory University This email address is being protected from spambots. You need JavaScript enabled to view it.
Brenda Wiederhold, VRMC, This email address is being protected from spambots. You need JavaScript enabled to view it.
Mark Wiederhold, VRMC, This email address is being protected from spambots. You need JavaScript enabled to view it.
Jim Spira, San Diego Naval Medical Center, This email address is being protected from spambots. You need JavaScript enabled to view it.
Jeff Pyne, San Diego Naval Medical Center, This email address is being protected from spambots. You need JavaScript enabled to view it.
Col. Greg Gahm, Fort Lewis, This email address is being protected from spambots. You need JavaScript enabled to view it.
Cpt. Greg Reger, Fort Lewis/Baghdad, Iraq, This email address is being protected from spambots. You need JavaScript enabled to view it.

Contact Name
Albert “Skip” Rizzo (This email address is being protected from spambots. You need JavaScript enabled to view it.)

3.

VIRTUAL IRAQ -- VR BASED THERAPY FOR POST-TRAUMATIC STRESS DISORDER

** Virtually Better **

Defense Update
Year 2005
Issue 3

http://www.defense-update.com/products/v/VR-PTSD.htm

Developed by Virtually Better, with funding from the Naval Research Office, “Virtual Iraq” VR environment suitable for therapy of anxiety disorders resulting from the high-stress environment. The treatment involves exposing the patient to a virtual environment containing the feared situation rather than taking the patient into the actual environment or having the patient imagine the stimulus. The virtual environment is controlled by the therapist through a computer keyboard ensuring full control of the exposure to the programmed situations.

The system [is] designed to treat military veterans suffering from Post-Traumatic Stress Disorder (PTSD). Using components from the popular game "Full Spectrum Warrior," psychologist Skip Rizzo and his colleagues introduce the patient to a virtual world simulating the sources of combat stress. The treatment objective is to help veterans come to terms with what they've experienced in places like Iraq and Afghanistan by immersing vets in the sights and sounds of those theaters of battle, including visual and sound effects of of [sic] gunshots. Virtual reality exposure treatment allows the therapist to manipulate situations to best suit the individual patient during a standard therapy hour (usually 45-50 minutes) and within the confines of the therapist's office. By gradually re-introducing the patients to the experiences that triggered the trauma, the memory becomes tolerable. Early results from trials suggest virtual reality therapy is uniquely suited to a generation raised on video games.

Virtually Better is using eMagin’s Z800 3DVisor as the medium for delivering the VR exposure, delivering 3D stereovision and sound. Virtually Better applications currently include Virtual Iraq, Virtual Airplane, Virtual Audiences, Virtual Heights, Virtual Storm, and Virtual Vietnam.

4.

Web exclusive

Technology and science

A VIRTUAL IRAQ
By Brian Braiker

** Doctors are testing a new therapy aimed at helping soldiers with posttraumatic stress disorder by having them repeatedly relive the trauma of the battlefield. **

Newsweek
June 18, 2007

http://www.msnbc.msn.com/id/19289499/site/newsweek/page/0/

Earlier this week, a reporter was escorted down an Iraqi street during the morning call to prayer. There was a marketplace to the right, nondescript buildings down the road, and a few pedestrians milling about. Then a helicopter flew overhead, accompanied by the bone-rattling sound of gunfire. The ground shook as a parked car suddenly exploded, apparently blown up by an insurgent’s improvised explosive device. Sniper fire popped from the rooftops. Dazed civilians wandered into the reporter’s path -- though it was unclear whether they were friendlies, or insurgents in disguise poised for an ambush.

All of this took place over the course of a few minutes on New York’s Upper East Side, in the one-window office of a Cornell University Weill Medical College psychologist. The Iraq in question was a simulated one, experienced from inside a virtual-reality helmet, complete with goggles and powerful headphones. Don the helmet, and you are instantly immersed in a disturbingly realistic videogame version of an urban Iraqi battleground. The platform underfoot houses a motor that shakes the ground whenever simulated rockets hit or bombs blast. JoAnn Difede, director of Weill’s program for anxiety and traumatic-stress studies, plans to put the virtual-reality helmet to use as part of a counterintuitive therapy aimed at studying, and ultimately healing, soldiers who suffer from posttraumatic stress disorder (PTSD).

“If all of this works, it will change the way we treat PTSD patients,” explains Difede. “I’m enthusiastic, or I wouldn’t be doing this.” She is working under the widely (though not universally) held theory that PTSD stems from a patient’s inability to put a traumatic event behind him. “It’s as if it’s happening over and over again,” she says -- the incident manifesting itself in flashbacks and through nightmares. The patient as a result can become numb and withdrawn, refusing to discuss anything having to do with the circumstances that traumatized him. “This allows us to help a person engage,” Difede says. She hopes the technique will also shed more light on the disorder itself, its causes, and what personality types might be most susceptible to developing it.

Virtual reality is the next step along a continuum known as “exposure therapy” -- the method generally used to treat PTSD patients today. A typical exposure-therapy patient is asked to tell and retell the story of what triggered his trauma; by talking it out, the theory goes, he is able to process it, and put it behind him. "Exposure therapy is considered to be the best empirically supported treatment for PTSD," says Albert (Skip) Rizzo, the cognitive psychologist who developed the virtual-reality software at the University of Southern California’s Institute for Creative Technologies. But there are limits to its effectiveness; patients often go to great lengths to avoid reliving the trauma, or alter key aspects of it in their memory. “The problem with imagination is that one of the facets of the disorder is avoidance,” says Rizzo. With virtual reality, he says, “we can consistently expose the patient as opposed to rely on their imagination.” Rizzo is careful to point out that the technology is not a substitute for talk therapy but rather a tool to improve it.

Rizzo acknowledges that, to the layperson, it may sound like a bad idea to expose a trauma patient to the very thing that traumatized him. But according to Spencer Eth, a member of the task force that wrote the American Psychiatric Association's guidelines for the treatment of PTSD, this is, in fact, a standard practice. "These treatments have been around for a very long time -- 20 plus years -- and they work," he says. "There's no question that they work. The use of virtual imagery is a refinement of technology, but it’s the same technique." Eth, a professor at New York Medical College, stresses that exposure therapy is just one of a large number of treatment options available to PTSD patients. "The fact [that] there are so many different kinds of treatments for PTSD shows that none of the treatments are where we want them to be."

One 45-year-old retired Army staff seargant, who spoke with NEWSWEEK under condition of anonymity, is a bit more equivocal in his assessment of the program. Despite initial jitters at the prospect of reliving the source of his anxiety, he has completed nine weeks of virtual-reality therapy at Emory University's School of Medicine. “It has helped to a point," he says. In his third and final tour of Iraq, he was on a recovery mission interrupted by an rocket-propelled grenade; one of the soldiers under his command lost a leg. He enrolled in the study because, he says, he needed something to help him "relax and get back to my life." The scenario they created for him, he says, didn't quite look like the real thing, although the sounds were certainly real enough to jog some buried memories. "I’m still not outgoing like I used to be. I'm sleeping a little better. My wife says I’m still jumping in my sleep and moaning, but I can't remember what my nightmares are. It's not as bad as it was when I first got back." Now retired, he says he would recommend the treatment to his fellow soldiers.

Here’s how it works: after repeatedly retelling a therapist about a specific traumatic experience, a patient puts on the helmet and sits in the chair. The therapist works from her own computer, using a touch-sensitive screen to shape the virtual-reality experience. (There is an impressive array of variables at the therapist’s disposal: the sound of wind, an overcast sky, night-vision goggles, aerial views for pilots, the distant crackle of gunfire.) Say a soldier was in a convoy that was hit by a rocket, killing everyone else on board -- a common PTSD-triggering combat event. Difede’s team will recreate the event in as much detail as possible using the virtual-reality software. Then, in the course of 10 sessions spanning five weeks, the soldier will relive it again and again, until he is habituated to it. The patient's heart rate and perspiration levels are closely monitored -- so even if he doesn't verbalize any distress, the clinician has other ways of determining if the experience is getting too intense. The goal is to make the trauma “become a memory, rather than a flashback or nightmare that controls them,” says Difede.

Testing of the system -- which costs just under $10,000 and includes two computers, a mock rifle that doubles as a navigational tool, the helmet, and the base-shaking platform -- is already underway. Six patients have completed 10 sessions of the therapy in a preliminary, scaled-down study. Rizzo, the cognitive psychologist who developed the software, was in Washington this week to present the findings at the Cybertherapy conference. Of the six, five showed remission of PTSD, based on the military’s standard definition; one completed the program with no gain. “One woman is actually going back” into combat, says Rizzo. “I worry about this a little because we know that repeat deployments increases the risk of PTSD. But she made the choice, and she wanted a career in the military.” Difede’s department is one of 12 sites in the country that have either received funding for the study from the Office of Naval Research or have just begun running it, Rizzo says.

This is not the first time virtual reality has been used to help patients cope with PTSD. Difede used the same technique on World Trade Center first responders who survived 9/11. Using software designed by Rizzo, Difede immersed traumatized respondents inside virtual renderings of the towers as they filled with smoke and eventually came crashing down. Stephen King, an FDNY fire chief who was in the North Tower when the South Tower collapsed, told New York magazine that he was a “shambles” before his virtual-reality sessions with Difede; he had recurring nightmares, feared bridges, high-rises and tunnels, and was generally reluctant to travel into Manhattan from his Long Island home. “Now I’ve got my life back,” he said after his 11 sessions under the helmet.

The big challenge is to convince Iraq War soldiers and veterans to overcome the stigma some feel is attached to PTSD and seek the help they need, says Rizzo. “People at risk for developing PTSD wouldn’t go to therapy, thinking it made them look weak or it could mess their career up,” he says. “In the beginning it was hard to recruit people, but VR is a really good draw.” The videogame aspect of the therapy will certainly have its appeal to a generation of soldiers raised on Nintendo and PlayStation. But the chance to chase away the ghosts of war will be the most compelling draw of all.