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Virtual Reality Medical Center & VR-GET Therapy for Combat PTSD & Anxiety

Explore the benefits of Virtual Reality Graded Exposure Therapy (VR-GET) for Combat PTSD, Anxiety Disorders, and Chronic Pain at the Virtual Reality Medical Center. Discover the effectiveness of VR treatments in managing phobias, anxiety, and pain. Learn how physiological monitoring enhances therapy outcomes.

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Virtual Reality Medical Center & VR-GET Therapy for Combat PTSD & Anxiety

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  1. Virtual Reality Medical Center & VR-GET Training/CYPSY 23 June 26, 2018Dennis Patrick Wood, Ph.D. ABPPCAPT MSC USN – Retired/www.dennispatrickwoodphd.comwww.dennispatrickwoodphd.com

  2. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 Virtual Reality- Graded Exposure Therapy (VR-GET) for the Treatment of Combat Related PTSD/PTS,Anxiety Disorders (including Flying Phobia) and Chronic Pain

  3. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 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. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 Chronic Pain Fear of Flying

  5. Virtual Reality Medical Center Clinical Services • Specific Phobias • Flying • Driving • Public Speaking • Claustrophobia • Heights • Spiders • Medical Procedures • School • Panic Disorder • Agoraphobia • Generalized Social Phobia • PTSD due to motor vehicle accidents • Pain Management

  6. Additional Useful VR Devices

  7. Virtual Reality Medical Center Clinical Services for 502 Patients • Social Phobia: 2.4% • Panic Disorder: 1.4% • Agoraphobia: 0.9% • Arachnophobia: 0.5% • Needle Phobia: 0.2% • Multiple Phobias: 8.9% • Other Specific Phobias: 1.6% • Aviophobia: 48.7% • Driving: 13.4% • Public Speaking: 7.3% • Fear of Heights: 4.5% • General Anxiety Disorder: 4.0% • Claustrophobia: 3.1% • Panic w/Agora: 2.6%

  8. Virtual Reality Medical Center Clinical Services Non-Invasive Physiological Monitoring: • Heart Rate & HRV • Respiration Rate (BPM) • Skin Conductance • Peripheral Skin Temperature

  9. 1997: Initial Controlled Study: Fear of Flying

  10. Controlled Studies: n > 8 Aviophobia

  11. Wiederhold, 1999Wiederhold & Wiederhold, 2003____________________________________________ • n = 30; Mean Age = 39.80; Range = 24 – 55 yrs. • Treatment Groups: 1. Virtual Reality Graded Exposure Therapy with physiological monitoring and visual feedback (VRGETpm) (n = 10) 2. Virtual Reality Graded Exposure Therapy with no physiological monitoring (VRGETno) (n = 10) 3. Imaginal Exposure Therapy (visualization) with physiological monitoring only (IET) (n = 10)

  12. Behavioral Outcome – 3 month follow-up________________________________________

  13. Behavioral Outcome – 3 year follow-up___________________________________

  14. Wiederhold & Wiederhold, 2003____________________________________________ • Virtual Reality is an effective treatment for fear of flying • Benefit in the utilization of physiological monitoring and feedback during treatment of those suffering from phobias • Physiological measures may be important to help guide the therapist in administering treatment protocols

  15. Virtual Reality for Pain Management________________________________________ • WIEDERHOLD B.K., WIEDERHOLD M.D., GAO K.,SULEA C., Virtual reality as a distraction technique in chronic pain patients, CyberPsychology, Behavior & Social Networking Journal, (Special Issue on Virtual Reality and Pain), 2014. 17 (6): 346-352. • WIEDERHOLD B.K., WIEDERHOLD M.D., GAO K. and KONG L., Mobile Devices as Adjunctive Pain Management Tools, CyberPsychology, Behavior & Social Networking Journal, (Special Issue on Virtual Reality and Pain), 2014. 17 (6): 385-389.

  16. Virtual Reality for Pain Management________________________________ • 16 patients • DX: Fibromyalgia, LowerBack Pain, Migraine Headaches, TMJ, & Reflex Sympathetic Dystrophy (RSD)

  17. Virtual Reality for Pain Management________________________________ Two Treatment Conditions: • Pain Focus: patients had to describe and rate their pain at three separate intervals • VR: patients rated their pain after experiencing the «Icy Cool World» environment

  18. Virtual Reality for Pain Management_______________________________ The «Icy Cool World» places the individual in a cold, icy setting, with hills covered in snow and penguins imprisoned in ice cubes, which they can melt to free the penguins.

  19. https://www.youtube.com/watch?v=hvU_M8VEdFw

  20. Virtual Reality for Pain Management • Patients were physiologically monitored before &during both sessions • Pain was perceived as lower in the VR sessions than in the pain focus • Higher levels of relaxation were reported during VR as patients’ skin temperatures were notably increased

  21. Virtual Reality for Pain Management CONCLUSION: • two studies support the use of VR as an adjunct to other pain management methods

  22. https://www.youtube.com/watch?v=jNIqyyypojg

  23. NAVAL HOSPITAL CAMP PENDLETON 1. 60 miles North of San Diego • MCBCP = 250 square miles 3. 123 bed facility • MCBPC home to: • 1st Marine Corps Div. • 1st Marine Expeditionary Force (MEF) • 3rd Marine Corps Air Wing

  24. PTSD/PTS CLUSTER • Life threatening event to self or others that is “markedly distressing” including Operational Stress • INTRUSIVE: Event persistently re-experienced: distressing recollections, recurrent distressing dreams/nightmares, flashbacks

  25. PTSD Cluster • 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

  26. Initial PTSD Rates for OIF & OEF Warriors Following OIF and OEF, PTSD, Depression & Anxiety rates were: • 15 – 17 % for Iraqi • combat veterans • 11.2% for Afghanistan • combat veterans (Hoge et al., 2004)

  27. PTSD and Multiple Combat Deployments “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)

  28. PTSD in OEF and OIF Warriors • 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)

  29. The Virtual Reality Medical Center San Diego Repeat Iraq Tours Raise Risk of PTSD, Army Finds By Ann Scott Tyson washingtonpost.comWednesday, December 20, 2006; Page A19 • U.S. soldiers serving repeated Iraq deployments are 50 % more likely than those with one tour to suffer from acute combat stress, raising their risk of post-traumatic stress disorder, according to the Army’s recent survey.

  30. The Virtual Reality Medical Center San Diego • More than 2 million Soldiers, Sailors, Marines and Guardsmen have deployed to Iraq or Afghanistan since 2001. • Earlier Army studies have shown that up to 30% of troops deployed to Iraq suffer from depression, anxiety or post-traumatic stress disorder (PTSD), with the latter accounting for about 10 percent.

  31. The Virtual Reality Medical Center San Diego • The proportion of soldiers who reported that they suffered a combination of anxiety, depression and acute stress rose to 17%, compared with 13% in the 2004 survey. • 14% of soldiers have taken medications, such as anti-depressants, for mental health problems. • Combat stress is higher among soldiers with at least one previous tour -- 18.4 percent, compared with 12.5 percent of those on their first deployment.

  32. VRMC Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Recovery • Edited by Terri Tanielian & Lisa H. Jaycox

  33. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • 14% of returning servicemen meet PTSD criteria • 19.5% report experiencing probable TBI during their deployment • 7% meet criteria for mental health problem & possible TBI • Total 300,000 currently suffer from PTSD or Depression • 320,000 report having experienced TBI

  34. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • Unless successfully treated, PTSD, Depression & TBI can have far reaching & damaging consequences: • Suicide • Increased unhealthy behaviors: smoking, overeating, unsafe sex, alcohol abuse/addiction • Quality of Life effects: impair relationships, disrupt marriages, domestic violence, aggravate the difficulties with parenting, tend to miss more work, less productive at work, school problems

  35. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • Homelessness • Only 53% of returning troops, with PTSD or Major Depression, south help for a provider for these conditions • 57% of returning troops had not been evaluated by a physician for TBI

  36. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • Rand Corporation’s mathematical model: 35% of soldiers and Marines who deploy to Iraq will ultimately suffer from PTSD, with 20,000 new sufferers for each additional year the War on Terrorism lasts

  37. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 Addressing Post-Deployment Needs By Laurie Slone & Matthew J. Friedman, July 14, 2011 • A service member returning home may be where the harder battles begin. • Effective evidence-based psychotherapeutic treatments are available (DOD & VA documents): CBT, CPT, SSRIs, prazosin, atypical antipsychotics, etc. • Co-morbidities (TBI, chronic pain, depression, substance use disorder, etc.). Psychiatric Times

  38. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • 13.2% of OIF/OEF combat veterans assigned to operational infantry units met PTSD criteria • Up to 25% - 30% of personnel in infantry units with the highest level of direct combat met PTSD criteria (Hoge, 2013)

  39. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • Prevalence of PTSD/PTS among U.S. Service Members serving in Afghanistan and Iraq has been reported as 13.8% (Rice, Liu & Schroeder, 2018) • Upsurge in diagnosis & treatment, of soldiers returning from Iraq & Afghanistan, totaled $4 Billion between FY 2007 & FY 2012, with 89% of the cost attributed to active duty service members (Shrestha, Cornum, Vie, et al., 2018)

  40. Virtual Reality Medical Center & VR-GETTraining/CYPSY 23 June 26, 2018 • Traditional PTSD RX with OIF/OEF combat veterans ranges between 37% and 54% effective (Milliken et al., 2007; Bradley et al, 2005) • Recovery from PTSD can be 70% to 80%, but averages only 40% (Hoge, 2013) • VR-GET, developed by VRMC, was 70 – 75% effective in reducing PTSD symptoms with warriors treated at NHCP & NMCSD (McLay et al., 2011)

  41. VRMC & VR-GET Training/ & VR-GETTraining/CYPSY 23 June 26, 2018WHY VR-GET? • Not dependent upon patient’s imagery abilities • Provides a structured environment (you know status of patient real time) • Visual and auditory stimuli facilitates “immersion” & “presence” • Can “over-learn” skills = “habituation” • Done in therapist’s office (American Lake VA Hospital) • Safe & Less expensive

  42. VR-GET for PTSD: Office of Naval Research Funded Study Participants at NMCSD & NHCP: • Combat Support Personnel (i.e., Corpsmen, Seabees, initially non-infantry Marines; now all Marines) • Evaluation: phone assessment, two face-to-face interviews, completion of self-report measures & objective questionnaires, & psychophysiological measures assessment

  43. VR-GET for PTSD Treatment ASSESSMENT: • Pre-RX assessment • Post-RX assessment following 10TH & 20th RX session • Assessment at 3 months following Final RX session

  44. VR-GET for PTSD Treatment PHYSIOLOGICAL • Skin Conductance (SC) • Heart Rate (VLF & LF) • Breaths per Minute (BPM) • Peripheral Temperature

  45. VR-GET for PTSD Treatment PSYCHOLOGICAL • Mini Neuropsychological Interview • PCL-M • BAI & PHQ-9 • Combat Exposure Scale • Blast Assessment Scale

  46. VR-GET for PTSD Treatment TREATMENT ARCHITECTURE: • VRGET Sessions 1 & 2: Meditation Training, Biofeedback 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, Sentinel Event utilization & effecting “habituation” • Reassessment following 10 VRGET Sessions

  47. VR-GET for PTSD Treatment Treatment Architecture with Breaths Per Minute(BPM)

  48. VR-GET for PTSD Treatment Treatment Architecture and Heart Rate (HR) ---- Simulation Intensity

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