Virtual Reality Therapy Gains Ground for PTSD, Other Disorders

Nancy A. Melville

April 10, 2018

UPDATED April 16, 2018 // WASHINGTON — As virtual reality (VR) exposure therapy rapidly gains ground as an effective and increasingly affordable approach for posttraumatic stress disorder (PTSD), new research suggests unique benefits regarding public speaking anxiety, sexual trauma, and comorbid depression.

Several studies of such approaches were presented in a VR-dedicated session here at the Anxiety and Depression Association of America (ADAA) Conference 2018.

One study by Swedish investigators showed improvements in anxiety related to public speaking through a novel approach involving just one VR exposure therapy session followed by 4 weeks of participation in an Internet-based program.

A second study, the first to evaluate VR exposure in the treatment of military sexual trauma–related PTSD (MST-PSD), assessed 15 veterans, including four men. For those who completed the study, there were significant improvements in PTSD symptoms between baseline and the end of treatment. These improvements were maintained through the 3-month follow-up period.

A third study assessed the effect of VR treatment augmented with D-cycloserine (DSC) on comorbid depression in a group of survivors from the September 11, 2001, terrorist attacks.

The DSC-augmented group showed improvements in PTSD that extended to improvements in depression and vice versa, albeit to a lesser extent. The effects were also significantly stronger than for the placebo-augmented group.

These findings were published online recently in the Journal of Anxiety Disorders.

"The research is showing that virtual reality has arrived. It's no longer a matter of 'can we do it?' " session moderator Barbara O. Rothbaum, PhD, professor and director of Emory Healthcare Veterans Program and the Trauma and Anxiety Recovery Program at the Emory University School of Medicine, Atlanta, Georgia, told meeting attendees.

"It clearly is feasible, and I think at this point it is an accepted alternative for treatment," she said.

Public Speaking Phobia

VR may be uniquely suited to address the phobia of public speaking, which is very common, the investigators noted.

In a randomized trial of the approach, 50 patients with scores of 60 or greater on the Personal Report of Public Speaking Anxiety questionnaire were assigned to receive either one 3-hour session of VR treatment followed by a 4-week online booster intervention or to a wait-list control group.

Of the participants (72% women; mean age, 31 years), 78% also met DSM-5 criteria for social anxiety disorder.

During the therapist-guided VR session, patients were asked to stand up and close their eyes while wearing the VR headset. After some questioning and instructions from the therapist, the patients opened their eyes and saw a virtual audience before them.

They were then given speech tasks, such as presenting themselves for 120 seconds and taking unexpected questions from the audience. The tasks become progressively more challenging, such as having 1 minute to prepare to discuss a topic and then 2 minutes to speak on the topic before the audience.

The therapist recorded the speech. Afterwards, patients rated the experience according to subjective units of distress and were asked about their catastrophic thoughts.

The patients then closed their eyes again and listened to a recording of themselves, this time from the point of view a member of the audience. Afterward, they were again asked to discuss problems such as catastrophic thoughts.

Fear Conquered

Changes after the initial 3-hour session alone, assessed with the Public Speaking Anxiety Scale, showed improvement in the treatment group compared with the wait-list group (Cohen's d = 0.84).

Further assessment after the follow-up 4-week online maintenance program showed increased improvement in public speaking anxiety (between-group effect size, d = 1.56).

Presenting author Per Carlbring, PhD, Stockholm University, Sweden, said that during the initial 3-hour session, participants could take many breaks.

"Three hours is the total time, but patients don't use the headset for 3 hours. Usually the virtual reality headset was used only for up to 10 minutes prior to a break," he told Medscape Medical News.

In general, patients responded remarkably well to the interventions, he noted. "Most, if not all" participants reported having conquered their fear of public speaking in their regular checkups via questionnaires, Carlbring reported.

Although numerous self-administered public speaking programs are available online, he noted that the participation with a therapist is recommended.

"This is not replacing a human, just boosting their effectiveness, [which is] a great combination," said Carlbring.

Confronting Trauma

Past research has shown that VR used in conjunction with standard PTSD therapy with prolonged exposure is helpful in overcoming avoidance and in confronting the traumatic memory, especially for combat-related PTSD.

In another study presented during the session, Laura Loucks, PhD, Emory University School of Medicine, Atlanta, Georgia, and colleagues evaluated the feasibility and efficacy of VR exposure therapy in the treatment of MST, which can have detrimental effects on one's mental and physical health and can increase the risk for PTSD.

The participants met the diagnostic criteria for MST-PTSD; 60% of the patients also had comorbid major depressive disorder.

All were treated with exposure sessions using Bravemind VR software, which was developed at the Institute for Creative Technologies, University of Southern California, Los Angeles.

The program followed the format of traditional prolonged exposure therapy for PTSD, with six to 12 sessions. However, this exposure therapy also included VR tailored to the context of the trauma.

As a patient talks through an experience in detail, the prolonged exposure VR software allows the clinician to introduce cues, such as the setting of the scene, the time of day, and sounds that may have been part of the experience.

Feasible, Effective

The initial feasibility study included 15 participants, nine of whom completed treatment. The dropout rate for the study was consistent with rates found in prolonged exposure studies.

There were notable reductions in both PTSD and depression symptoms from pretreatment to posttreatment.

MST-PTSD affects about 14% of military service members and veterans and is related to numerous negative mental health outcomes. It tends to be associated with lower therapy completion rates compared with combat-related PTSD, underscoring the need for more diverse treatment options, said Loucks.

"We found that virtual reality exposure is likely a feasible treatment for MST-related PTSD, and the initial evidence suggests that [it] might be an effective treatment," she said.

Loucks noted that the sample size was small and that the results need to be replicated in a larger sample. "But despite that, we are very excited about the findings. This does seem to be working for people," she said.

VR + Antituberculosis Drug

The study of survivors of the 9/11 terrorist attacks provided "key insights" into how comorbid depression, which is highly common in PTSD, is affected by VR exposure treatment, the investigators reported.

"While there is extensive research on virtual reality for PTSD, there is less research of the technology in primary depression," said presenting author Melissa Peskin, PhD, of the Program for Anxiety and Traumatic Stress Studies at Weill Cornell Medical College, New York City.

Fifty-two percent of individuals with current PTSD also meet criteria for major depressive disorder. Comorbidity is associated with lower remission rates for both disorders, Peskin noted.

In the original pilot study, which was published in 2014 in Neuropsychopharmacology, patients were randomly assigned to receive DCS-augmented VR exposure therapy or placebo.

DCS, which has long been used as an antituberculosis drug, is recognized as a partial agonist of N-methyl-D-aspartate and has been shown to facilitate extinction of fear.

In the new analysis, patients received either DCS 100 mg (n = 13) or placebo (n = 12) 90 min before undergoing each of 12 weekly VR exposure sessions. Among all patients, the mean CAPS score was 98.3; 16 patients (64%) had major depression (nine in the DCS group, seven in the placebo group).

In the VR sessions, participants initially saw a depiction of jet planes flying over the World Trade Center towers. As the session progressed, the jets were seen crashing, and eventually, the towers were seen collapsing.

During the sessions, patients recounted the trauma in first-person terms with as many sensory details as possible. The target length of each session was 45 minutes. There were three dropouts, all in the placebo group.

"We found that reductions in posttraumatic symptoms influence subsequent reductions in depressive symptoms to a greater extent than the opposite," reported Peskin.

"The findings provide potentially meaningful information for clinicians deciding the best course of treatment" for these individuals. The goal is improvement in both PTSD and depression, she added.

Important Role in Psychotherapy?

After the session, moderator Rothbaum noted that there were initial concerns about use of VR, particularly regarding virtual exposure to traumatic experiences.

"When we first used virtual reality for treatment of PTSD in veterans, it was with Vietnam veterans, and we were very concerned it could be too intense," she told Medscape Medical News.

"Even though we were treating outpatients, we started it on the inpatient unit just in case. As it turns out, it was very safe and manageable and helpful, and those precautions were unnecessary," she said.

She added that VR exposure likely will continue to have an important role in psychotherapy.

"We always knew it had great potential. I think it will be a useful tool in the therapeutic toolbox," Rothbaum said. "For some applications — for example, using a virtual airplane for the fear of flying — I think it can be invaluable as an effective, efficient solution."

Dr Peskin's study received partial funding from the DeWitt-Wallace Fund of the New York Community Trust. Dr Louck's study received funding through a grant from the US Department of Defense. Dr Carlbring has disclosed no relevant financial relationships. Dr Rothbaum owns equity in Virtually Better, Inc, which creates virtual reality products.

Anxiety and Depression Association of America (ADAA) Conference 2018. Session 33R, presented April 7, 2018.

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