Dennis Patrick Wood, Ph.D., ABPP (CAPT, MSC, USN-ret) Brenda K. Wiederhold, Ph.D., MBA

1. COMBAT RELATED POST TRAUMATIC STRESS DISORDER: A REPORT EMPLOYING VIRTUAL REALITY GRADED EXPOSURE THERAPY WITH PHYSIOLOGICAL MONITORING (VRGET) CYBERTHERAPY 13 SAN DIEGO, CALIFORNIA Dennis Patrick Wood, Ph.D., ABPP (CAPT, MSC, USN-ret) Brenda K. Wiederhold, Ph.D., MBA The Virtual Reality Medical Center, San Diego www.vrphobia.com

2. CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, Treatment for PTSD (VRGET) Co-investigators: Kristy Center, M.A., VRMC Jennifer Murphy, M.A., VRMC Robert McLay (CDR-sel MC USN), NMCSD Carol Russ, Ph.D. (CDR MSC USNR-ret), VRMC Robert Koffman (CAPT MC USN), BUMED Scott Johnston (CDR MSC USN), NMCSD James Spira, Ph.D., VRMC

3. CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored Treatment for PTSD (VRGET) Disclaimer: The views in this presentation are those of the individual authors, and do not necessarily represent those of the Department of the Navy, Department of Defense, the Department of Veterans Affairs, or the U.S. Government. Research described has been approved by the Institutional Review Board at the Naval Medical Center San Diego. The information in this presentation was approved under the NMCSD Institutional Review Board. This study was sponsored by the ONR Contract (#N00014-05-C-0136) to Virtual Reality Medical Center, San Diego, CA.

4. Dad, Ivan & Megan: Fayetteville, NC Nov 2007

5. VRMC VRGET PROJECT AT NAVAL MEDICAL CENTER SAN DIEGO • NAVAL MEDICAL CENTER SAND DIEGO: • World’s Largest Military Hospital • Home of the Comprehensive Combat Casualty Care Program (C-5) • USS Mercy • 4. 4 additional West Coast Navy Hospitals

6. VRMC VRGET PROJECT AT NAVY HOSPITAL MARINE CORPS BASE CAMP PENDLETON • Navy Hospital MCBCP • 1. 60 miles North of San Diego • MCBCP = 250 square miles • 3. 123 bed facility • MCBPC home to: • 1st Marine Corps Division & 1st Marine Expeditionary Force (MEF)

8. VRMC/IMI Funders

10. PTSD Cluster • Life threatening event to self or others that is “markedly distressing” • INTRUSIVE: Event persistently re-experienced: distressing recollections, recurrent distressing dreams/nightmares, flashbacks

11. PTSD Cluster 3.AVOIDANCE: Persistence avoidance of thoughts, activities &/or reminders of event; detached feelings; foreshortened future 4.AROUSAL: Persistent arousal sleep problems, irritability, hyper-arousal or startle , concentration difficulties

12. CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, Treatment for PTSD (VRGET) • ABC Video Clip: PTSD & VRMC/ONR Funded VRGET

13. Psychiatric Diagnoses Related to Combat in Iraq and Afghanistan Following OIF and OEF, PTSD, Depression and Anxiety rates for warriors were: • 15 – 17 % for Iraqi combat veterans • 11.2% for Afghanistan combat veterans (Hoge et al., 2004)

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

15. PTSD and the War on Terrorism “Soldiers who deploy longer (i.e., greater than 6 months) or who had deployed multiple times were more likely to screen positive for a mental health issue”. (DOD, Mental Health Advisory Team (MHAT-IV) Survey: 04 May 2007)

16. PTSD and the War on Terrorism • 6 – 11% of OEF combat veterans have PTSD • 12 – 20% of OIF combat veterans have PTSD • VA should aggressively prevent and treat PTSD (Report on the President’s Commission on Care for America’s Returning Wounded Warriors, July 2007)

17. PTSD and the War on Terrorism Mild Traumatic Brain Injury in Soldiers Returning from Iraq: 5% of 2,500 Soldiers DX with Mild TBI; 48% of the Soldiers with Mild TBI DX with PTSD • Symptoms included: headache, dizziness, irritability, fatigue & memory problems • Analysis: with the exception of headache, PTSD & Depression accounted for all other health outcomes or symptoms (Hoge et al, 2008)

18. PTSD and the War on Terrorism Early Treatment for PTSD: - “Early recognition and treatment may be key for our newest veterans returning with combat-related PTSD” (Hooten et al, 2008) - Early treatment is imperative in order to maintain personnel on active duty and to reduce the future burden for the Veterans Administration Health Care System (Ritchie & Owens, 2004; Wain et al, 2005; Forsten & Schneider, 2005)

19. PTSD and the War on Terrorism PTSD Treatment With Virtual Reality Graded Exposure Therapy with Physiological Monitoring (VRGET): - “VR has been shown to improve treatment efficacy for PTSD in survivors of MVA, war veterans and those involved in the 9/11 World Trade Center attacks” (Wiederhold et al., 2006). - Efficacy of combined physiological and psychological VRGET for a number of phobias & PTSD documented (Wiederhold & Wiederhold, 1998).

21. CYBERTHERAPY 13: VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, Treatment for PTSD (VRGET) • Naval Medical Center San Diego • Navy Hospital, Marine Corps Base Camp Pendleton • Funded by Office of Naval Research (ONR) • Funded by TATRC

22. Cybertherapy 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for PTSD (VRGET) • Combat Support Personnel (i.e., Corpsmen, Seabees, non-infantry Marines) • Evaluation: qualifying assessment, including two interviews, completion of self-report measures and objective questionnaires, & psychophysiological measures assessment • Wood et al., Combat Related PTSD: A Case Report Using VRGET with Physiological Monitoring. CyberTherapy & Behavior, 10 (2), 2007.

23. CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for PTSD (VRGET) ASSESSMENT: • Pre-RX assessment • Post-RX assessment following 10TH RX session • Assessment at 3 months following 10th RX session

25. Physiological and Psychological Measurements: Virtual Reality Medical Center/ONR VRGET • Physiological • Respiration • HR, HRV • Skin Temperature • Skin Conductance • Psychological • Mini Neuropsychiatric Interview • BAI • PCL-M • PHQ-9 • Combat Exposure Scale • Blast Assessment

26. Virtual Reality Medical Center Hardware Hardware Set-Up Head Mount Display: i-glasses

30. CYBERTHERAPY 13: VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for Combat-related PTSD (VRGET) • VRGET Sessions 1 & 2: Meditation Training, exposure to SUDs, CBT, review of Sentinel Event • VRGET Sessions 2 – 10: Individualized VRGET focused on increasing the intensity of the combat “elements”, immersion in the combat environment, eliciting SUDs & effecting “habituation” • Reassessment following 10 VRGET Sessions

31. CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET): Pilot Study Patients

32. CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET):Controlled Study Patients

33. CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 1: Significant Reduction in PTSD Symptom Severity t=3.16, p=.009

34. CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 2. Significant Reduction in Depression Symptom Severity t=2.55, p=.027

35. CYBERTHERAPY 13 - VRMC/ONR VRGET Program Figure 3. Reduction in Anxiety Symptom Severity t=1.40, p=.188

36. CYBERTHERAPY 13 - VRMC/ONR VRGET Program: Figure 4. Skin Conductance: Significant Differences Between Pre-Tx & Post-Tx in SC Change from *Baseline to Stressor AND **Stressor to Recovery *t=2.63, p=.039 **t=2.42, p=.052

37. CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET) VRGET SUMMARY: 1.Significant reductions in the warriors’ PTSD scores 2. Significant reductions in the warriors’ Depression scores 3. Significant reductions in the warriors’ Skin Conductance

38. CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET) VRGET SUMMARY: 4. Measurable reductions in the warriors’ Anxiety scores 5. 75% of patients had a reduction in PTSD symptoms 6. 42% did not meet criteria for PTSD after VRGET treatment 7. 66% fit for full duty after VRGET treatment

39. CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET) VRGET SUMMARY 8. Two warriors currently deployed to Al-Asad, Iraq 9. One active duty warrior back in a “full duty” status in CONSUS 10. Two Reserve warriors in an “active” Reserve status

40. CYBERTHERAPY 13 - VRMC/ONR Virtual Reality Graded Exposure, Physiologically Monitored, PTSD Treatment (VRGET) VRGET SUMMARY Functional Improvement: • Reduced Psychotropic Medication Usage • Warriors reported improved Interpersonal and Occupational Functioning • 3 warriors have enrolled/re-enrolled in College since their discharge • 6 warriors have started to work or have returned to their civilian employment since their discharge

41. VRMC/ONR Virtually Reality Graded Exposure, Physiologically Monitored, Therapy for Combat-related PTSD CONCLUSIONS: 1. Pt reported presence of improved life- management skills 2. New VRGET Therapy for combat veterans DX with PTSD successfully developed 3. Currently soliciting input from Treated Warriors concerning the PROS and CONS of their VRGET

42. CYBERTHERAPY 13: VRMC/ONR Virtually Reality, Graded Exposure Physiologically Monitored, Therapy for Combat-related PTSD (VRGET) CONCLUSIONS: 4. 20 VRGET sessions, with sessions twice a week, may be more effective 5. Homework being “framed” using results from PCL-M administered between re-evaluations

43. CYBERTHERAPY 13: VRMC/ONR Virtually Reality, Graded Exposure Physiologically Monitored, Therapy for Combat-related PTSD (VRGET) CONCLUSIONS 6. Compare the treatment outcomes for the Warriors’ first 10 VRGET sessions against their treatment outcomes for their second 10 VRGET sessions.

44. Why VR ? Advantages and illustrations • Not dependent upon patients’ imagery abilities • Provides a structured environment • Visual and auditory stimuli • Can “over-learn” skills = “habituation” or develop concept of “safety” • Done in the therapist’s office • Less time consuming • Less expensive • Safer

45. VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-related PTSD Combat Town: • Battalion Base • Market Place • Village • Hospital • Combat zone

46. VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-related PTSD BATTLEGROUND CONVOY COMBAT MEDIC

47. VRMC/ONR Virtually Reality Assisted, Physiologically Monitored, Graded Exposure Therapy for Combat-related PTSD References (cont) [10] Wiederhold BK, Wiederhold MD. (2005) Virtual Reality Therapy for Anxiety Disorders. Washington, DC: American Psychological Association. [11] Wiederhold BK, Wiederhold MD. A review of virtual reality as a psychotherapeutic tool. CyberPsychology & Behavior 1998; 1(1): 45 – 52. [12] Walshe D, Lewis E, Kim SI, O’Sullivan K, Wiederhold BK. Exploring the use of computer games and virtual reality in exposure therapy for fear of driving following a motor vehicle accident. CyperPsychology & Behavior 2003; 6(3): 329 – 234. [13] Wood DP, Murphy JA, Center K, McLay R, Reeves D, Pyne J, Shilling R, Wiederhold BK. Combat-related post-traumatic stress disorder: a case report using virtual reality exposure therapy with physiological monitoring. CyberPsychology & Behavior 2007; 10 (2), 309 – 315. [14] Spira JL, Wiederhold BK, Pyne J, Wiederhold MD. (2007) Treatment Manual: virtual reality physiological monitored, graded exposure therapy in the treatment of recently developed combat-related PTSD. San Diego, CA: Virtual Reality Medical Center. [15] Wiederhold BK, Wiederhold MD. Three-year follow-up for virtual reality exposure for fear of flying. CyberPsychology & Behavior 2003; 6 (4): 441 – 328. [16] Wiederhold BK, Jang DP, Kim SI, Wiederhold, MD. Physiological monitoring as an objective tool in virtual reality therapy. CyberPsychology & Behavior 2002; 5(1): 77 – 82. [17] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994. [18] Orr SP, Roth WT. Psychophysiological assessment: clinical applications for PTSD. Journal of Affective Disorders (2000); 61: 225 – 240.

48. Semper Fi!