Caroline Helwick

May 26, 2010

May 26, 2010 (New Orleans, Louisiana) — For the treatment of combat-related posttraumatic stress disorder (PTSD), virtual reality exposure with arousal control (VRE-AC) may be more effective than prolonged exposure therapy with simulation, according to US Navy investigators who are studying the approach in service members returning from Iraq and Afghanistan.

Robert McLay, MD, PhD, of the Naval Medical Center, San Diego, California, described the early success here at the American Psychiatric Association (APA) 2010 Annual Meeting.

Dr. Robert McLay

PTSD is a significant problem in service members returning from deployment, but few randomized controlled trials have established the best means of treatment, especially in active duty service members serving in Iraq and Afghanistan. Virtual reality–based therapy has been emerging as a potentially useful modality, but, again, randomized studies of this are lacking, Dr. McLay said.

"One of the few things that have proven effective for PTSD is exposure therapy. Added to exposure therapy, simulator and physiological monitoring may allow greater control to both the patient and the therapist. So we took the approach that seems to work best and we tried to make it better. We asked if we could use a simulator to help subjects confront their fears in a controlled way, to tolerate it gradually as the clinician pushed forward," he said.

VRE-AC is 3-dimensional computer simulation of settings that are triggers for PTSD episodes. The treatment teaches participants to tolerate anxiety and then exposes them to the feared situation in a simulator that is manipulated and monitored by a clinician. The clinician can modulate sights and sounds and the intensity of the scenario.

"The participant, wearing a headset, has the experience of being in a city in Iraq. The therapist sits nearby and controls all aspects of this world, changing the sounds, the weather, and the level of violence. With some software we can even introduce smells and vibrations," said Dr. McLay.

Meanwhile, the patient describes his or her experience to the therapist who monitors heart rate, respiration, and other physiological parameters.

The machine was developed by the Virtual Reality Medical Center in San Diego.

VRE-AC has previously been tried in Vietnam veterans, survivors of the 9/11 attacks, Iraq and Afghanistan service members, and persons with phobias, with early but impressive results, he noted.

VRE-AC Highly Effective

The study compared VRE-AC with treatment as usual for combat PTSD in 20 active duty members diagnosed as having PTSD related to their service in Iraq or Afghanistan, most of whom had not responded to standard therapies. The study was conducted at 2 military hospitals in Southern California.

Participants were randomly assigned to receive 10 weeks of treatment with VRE-AC (n = 10) or standard therapy (n = 10), which was primarily traditional approaches to exposure. Outcomes were tracked using the Clinician Administered PTSD Scale (CAPS), with treatment success defined as a 30% or greater response. Postassessment outcomes were available in all VRE-AC participants and in 9 members of the control group.

Improvements of 30% or greater on CAPS were observed in 9 subjects in the VRE-AC arm (90%), compared with just 1 in the control arm (11%) (P < .01), Dr. McLay reported.

Dr. Jeffrey Borenstein

Participants treated with VRE-AC improved an average of 35 points on CAPS (decreasing from 83.4 to 48.1), whereas those receiving standard treatment averaged only a 9-point improvement (decreasing from 82.8 to 72.3) (P < .05).

"People improved with both types of treatment, but the gains with the virtual reality treatment were more impressive," he said.

Jeffrey Borenstein, MD, chair of the APA's Council on Communications and medical director of Holliswood Hospital in Queens, New York, moderated a press briefing during which the study was described. "This is an exciting advance in the treatment of PTSD," he commented. "The issue of making use of exposure therapy is important, and this appears to be a way to enhance it. PTSD is such a complicated problem that we need to take a full approach in treatment. If this type of virtual reality can assist in the exposure component, it is of tremendous potential."

Dr. McLay and Dr. Borenstein have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2010 Annual Meeting: Abstract NR7-55. Presented May 25, 2010.


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