Spring 2008: Of Note

Barbara Rothbaum

Back to Iraq: Barbara Rothbaum helps veterans recover from PTSD through therapeutic exposure to scenes of war.

Jon Rou

The Emotional Fallout of War

Virtual reality therapy is advancing treatment for Post-Traumatic Stress Disorder

By Mary J. Loftus

During the early 1800s, military doctors began to diagnose “exhaustion” in soldiers, who were then removed from the front for a time before being sent back into battle. During World War I, the term “shell shock” was coined. After WWII, veterans who exhibited stress and anxiety disorders were said to be experiencing “combat fatigue.” This was followed by “Post-Vietnam syndrome,” symptoms of which included nervousness, irritability, insomnia, and survivor’s guilt.

Most likely, Post-Traumatic Stress Disorder (PTSD) has existed since the beginnings of war and conflict itself, described by many different names and diagnoses over the years.

Now, more than 52,000 veterans who fought in Iraq or Afghanistan have been treated or evaluated for PTSD by the Department of Veterans Affairs.

Researchers at Emory have created novel treatments for PTSD, some of which are considered frontline therapies at VA hospitals around the country.

One such therapy, developed by Professor of Psychiatry Barbara Rothbaum, director of the Trauma and Anxiety Recovery Program, and colleagues, involves virtual reality exposure (VR) therapy using a computerized Iraq scenario.

Symptoms of PTSD

Recurrent thoughts of the original trauma.

Hyper-alertness in public.

Anxiety, panic, insomnia.

Irritability, anger.

Extreme reactions to noises and other stimuli.

Virtual scene in Iraq

One of the scenes of war.

Courtesy Virtually Better

“In exposure therapy, they go back in their mind’s eye and recount the experience in the present tense over and over,” she says. “It’s painful, but by doing this it gets easier. To get past it, they have to emotionally process that memory.”

The simulation program, which was first developed as a treatment for phobias such as a fear of heights, uses a Pentium computer system with stereo sound and a vibrating platform. Veterans wear head-mounted displays to enter a 3-D immersion scenario that evokes the sights, sounds, feel, and sometimes smell of combat.

Virtual therapy has proven successful with Vietnam veterans and is currently being studied with Operation Iraqi Freedom veterans who are experiencing anxiety.

A combination treatment, developed by Rothbaum, Assistant Professor of Psychiatry Kerry Ressler, and psychologist Mike Davis, involves using a small dose of an old tuberculosis drug, D-cycloserine, which has been shown to hasten the extinction of the fear response in rodents.

In one study, Rothbaum’s team is giving all participants Virtual Iraq therapy in combination with either D-cycloserine, a placebo, or the antianxiety drug alprazolam (Xanax). “Treatment in this study is brief—only six sessions,” Rothbaum says. “And it’s a new paradigm because they only have to take one pill before each of the five virtual reality sessions, so five pills total.” Volunteers can be treated at Emory or at the Atlanta VA Medical Center.

Exposing veterans to sights and sounds that remind them of traumatic experiences may seem counterintuitive. But the ability to experience physiological sensations that are as close as possible to the real situation actually helps if done therapeutically, says Josh Spitalnick, director of research and clinical services at Virtually Better, an Emory start-up company that specializes in the development of VR therapies for anxiety disorders. “Any time we can provide anxiety-based interventions for a patient in a safe environment with a trusted clinician,” he says, “we are likely to increase his or her sense of mastery and control over their debilitating fears.”

Skip Rizzo of the University of Southern California Institute for Creative Technologies collaborated with Rothbaum and Virtually Better in developing Virtual Iraq. The method has gained widespread support—the American Psychological Association–initiated Center for Deployment Psychology included exposure therapy in its training of psychologists and other health professionals working with returning Iraq and Afghanistan soldiers.

“Providing veterans with psychotherapies for PTSD that have the strongest evidence base is one of our highest priorities,” psychologist Antonette Zeiss, deputy chief consultant for mental health at the agency, told the media. “The VA was able to support the science so the research didn’t just sit around in a journal and get discussed. They put money toward it and asked us to help do a major rollout of the treatment.”

Emory researchers and VA doctors say PTSD is escalating. According to the military, most soldiers who have combat-related emotional and psychological problems do not seek help. Even so, some VA centers have seen more than a tenfold increase in PTSD claims since the start of the Iraq war. As troops return from deployments, the need for PTSD treatment is expected to increase.

PTSD is an anxiety disorder that can occur after a person has survived a traumatic event, such as combat. It can also be caused by other traumas, such as child abuse, car accidents, or natural disasters. Reactions, which can last for decades, include depression, constant alertness, lack of concentration, disturbing dreams or insomnia, upset stomach, trouble eating and sleeping, pounding heart, rapid breathing, severe headache, suicidal thoughts, aggressive behavior, and addictions.