Cavtat June 1316 2005

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In June, 2005, in the town of Cavtat on the Adriatic coast of Croatia, we brought together many of the leading researchers in the use of VR therapy in psychological disorders. The purpose of this NATO-sponsored Advanced Research Workshop (ARW) was to give these groundbreaking researchers an opportunity to share their experiences and expertise, to achieve consensus on the best methods for incorporating VR in the treatment of veterans of war and terrorism, and to foster multinational collaborative studies in this regard. To achieve this, invited experts shared the most salient findings of recent research with which they have been involved. We then divided all workshop participants into working groups to focus on four key elements of the challenges faced in utilizing VR and other new technologies in the treatment of PTSD:

• Diagnostic and epidemiologic concerns with PTSD

• Technological challenges in the use of VR

• Integration of cognitive behavioral therapy and virtual reality approaches

• Outcomes measurement and issues in follow up

Each working group drafted a consensus document, which the group leader then presented to all ARW attendees. Feedback was solicited to ensure a general consensus and the working group leaders incorporated this into the documents that comprise the final four chapters of this book.

The workshop opened with a welcome from several Croatian hosts, including Dr. Dragica Kozaric-Kovacic, Professor Kresimir Cosic, and Deputy Prime Minister Jad-ranka Kosor. Among other things, they emphasized the magnitude of the problem that PTSD poses for Croatia. The best estimates are that there are 10,000 Croatian Homeland War veterans with PTSD, another 1500 veterans have committed suicide, and since the war was fought on their own soil, countless civilians also have been traumatized by the war. It is estimated that 15-40% of Croatian Homeland War veterans have PTSD, and that 50-90% of them have comorbid psychiatric conditions such as depression. Deputy Prime Minister Kosor emphasized that it is also well-recognized that many veterans have delayed manifestations of disability, which is why the Croatian Parliament agreed to render compensation available to those veterans displaying effects within 10 years after the end of the war.

Dr. John Gruzelier of Imperial College, London, reviewed the significance of theta waves on electro-encephalograms (EEGs), emphasizing their association with survival behavior, memory, and anatomical areas of the brain that are thought to be of particular importance in PTSD, such as the hippocampus. He also noted the significance of theta waves in autobiographical positive memories as well as flashbacks. Later in the first day of the conference, Dr. Kostovic, Director of the Croatian Institute for Brain Research, expanded upon this to detail the central role of the amygdala and limbic system in pathways that are central in PTSD. In addition, Dr. Nela Pivac from the Rudjer Boskovic Insitute in Croatia reviewed work on the neurobiologic basis for PTSD, particularly associated changes in various neurotransmitter levels.

Dr. Dragica Kozaric-Kovacic, Professor of Psychiatry, Director of the Referral Center for Stress-Related Disorders at the University of Zagreb School of Medicine, Croatia, documented that up to 40% of Croatian Homeland War veterans with PTSD had psychotic symptoms. These symptoms were quite well-circumscribed, representing hallucinations specifically related to their combat exposure, rather than the more bizarre hallucinations characteristic of schizophrenia. She also noted that Croatian veterans completing the Minnesota Multiphasic Personality Inventory, Version 2 (MMPI-2) had their highest average scores on scale 8, unofficially known as the "schizophrenia" scale. She believes that those with psychotic symptoms represent a more severe form of PTSD, and it is her experience that treatment with antipsychotic medication is beneficial to these individuals. Finally, Dr. Kozaric also emphasized the high rate of comorbid psychiatric conditions, upwards of 60%, in those with PTSD; alcohol abuse was the single most common comorbid condition.

Dr. Tim Brennen, professor of psychology at the University of Norway, and Elke Geraerts, a doctoral candidate at the University of Maastricht in the Netherlands, reviewed their work on the cognitive processes underlying PTSD, as well as their efforts to model what occurs cognitively after traumatization. They described some fascinating work on the effects of PTSD on memory, utilizing lists of words that included both trauma-related and unrelated terms, then asking PTSD and control patients what they were able to remember. Dr. Brennen documented that those with PTSD have greater difficulty forgetting words associated with their trauma, even when asked to try to do so. He also reported that combat veterans with PTSD are more likely than controls to think they heard trauma-related words that were not on the list, but there was no difference for unrelated words. Ms. Geraerts reported similar findings with women victims of sexual assault.

Dr. Ronald Poropatich, Senior Advisor to the Telemedicine and Advanced Technology Research Center at the US Army Medical Research and Materiel Command, and Dr. Ivica Klapan, Professor of Otorhinolaryngology at the University of Zagreb, each discussed various applications of new technologies. Dr. Poropatich delineated the potential use of personal digital assistants, "smart dog tags" and other digital formats for storing and transmitting medical records information. He also displayed the wide range of applications for robotics to decrease the exposure of soldiers—including medical personnel—in far-forward areas of the battlefield, from detecting chemical weapons to performing surgery at distant sites. Since his talk was tangential to the subject of PTSD, Dr. Poropatich's presentation is not covered in this book. Dr. Klapan discussed the application of three-dimensional modelling to increase the level of information available pre-operatively, improving surgical approaches.

Dr. Michael Roy, Professor of Medicine at Uniformed Services University, provided vivid examples of the face of PTSD in primary care, drawing upon patients he has seen over the years at Walter Reed Army Medical Center. He outlined the challenges in faced in making the diagnosis in primary care, from competing demands to stigmatization, while emphasizing that similar issues are relevant to combat veterans. Dr. Roy noted the lack of validated diagnostic tools for PTSD in primary care, and the need to conduct studies to establish effective screening measures. In addition, he outlined plans to use the "Virtual Iraq" environment described later in the meeting by Dr. Rizzo, integrated with a cognitive behavioral therapy approach as described by Dr. Difede, to assess the added benefit of CBT/VR to pharmacotherapy in combat veterans. Provided that commensurate funding is obtained, current plans are for this study to begin in both Washington and Zagreb in late 2005, enrolling Operation Iraqi Freedom veterans in Washington, and Homeland War veterans in Zagreb.

Mr. Sinisa Popovic of the University of Zagreb provided a presentation on behalf of collaboration with Drs. Kresimir Cosic and Miroslav Slamic. He focused on efforts to integrate physiologic measures of subjects, as well as Subjective Units of Distress (SUDs) scales, into software programs to facilitate guided progression of VR exposures, easing the pressure on the therapist to do so.

Dr. Tanja Jovanovic of the University of Zagreb described psychophysiologic measures that could prove useful in supplementing or corroborating responses to questionnaires in diagnosing PTSD. These include cardiovascular (heart rate, heart rate variability, blood pressure) measures, respiratory rate, electromyography, electroe-ncephalography, and skin conductance. Each measure adds something different in terms of the rapidity, duration, or other characteristics of the response, and they can be used to distinguish those with PTSD, in addition to later value in directing the progression of therapy.

Dr. Louis Jehel reviewed the diagnostic instruments available for PTSD. He noted that the established gold standard, the Clinician Administered PTSD Scale (CAPS) is too lengthy and time-consuming to be used as a broad screening measure. An optimal cut-off score that has high sensitivity and specificity has not yet been established for the 17-item PTSD Checklist (PCL). Other available instruments still lack validation and/or have limitations.

Dr. Brenda Wiederhold, Director of the Virtual Reality Medical Center in San Diego, California reviewed the track record of success that VR has had in treating anxiety disorders. She emphasized that one particular strength of VR is that it does not depend on patients' ability to imagine scenarios, instead directly confronting the patient with the environment, which is especially valuable in conditions such as PTSD, where avoidance is a primary feature of the disorder. Dr. Wiederhold noted that the incorporation of VR into a CBT approach has been shown to result in 33% faster response rates in the treatment of agoraphobia, for example. She also discussed the use of VR to conduct stress inoculation training (SIT), drawing parallels between SIT and treatment, with the former addressing peak performers while the latter focuses on the impaired.

Dr. Azucena Garcia-Palacios of Valencia, Spain, expanded upon the data favoring the use of VR in phobias and related disorders. She emphasized the advantage of being able to provide exposures under controlled circumstances without the risks inherent in actual in vivo exposures. In fact, she reported data demonstrating that 81% of patients preferred VR over in vivo exposures. For social phobia and panic with agoraphobia, the medical literature documents superiority for VR over waiting list controls, and comparability with in vivo exposures. Dr. Garcia-Palacios also described more recent applications of VR in eating disorders, addictions, pathological grief, autism, and ADHD. She was followed by her colleague, Dr. Cristina Botella, who reviewed the experience of VR in the treatment of PTSD. Dr. Botella noted that therapists have historically underutilized the exposure component in the conduct of CBT, with one study indicating that only 17% of therapists were using it. She reviewed the historical precedents for VR, based upon PIE—proximity, immediacy, and expectancy, developed during and subsequent to the two world wars; this policy was based upon the belief that soldiers would have better outcomes with prompt return to combat, the exposure that was responsible for their symptoms. Dr. Botella also described the EMMA project, a computer-based interactive therapy modality that enables the patient to incorporate their own elements into the virtual environment, with both visual and auditory elements.

Dr. Giancarlo Castelnuovo of Milan reviewed the experience of the VEPSY Updated project in the treatment of anxiety disorders, obesity and other eating disorders, and male sexual disorders. He reported that more than 50,000 individuals have accessed the open, free virtual environment they made available on the internet, and over 500 patients have been enrolled in certified controlled clinical trials. The VEPSY Updated project has made considerable gains in identifying the most effective treatment model for a variety of psychiatric disorders.

Dr. Barbara Rothbaum from Emory University in Atlanta, Georgia emphasized that the problem with PTSD is one of extinction—trauma has an effect on everyone initially, but it wears off over the ensuing weeks for most, while it becomes disabling for those with PTSD. VR for the latter individuals provides the opportunity to relive the trauma under therapeutic circumstances until it is no longer traumatic. Dr. Rothbaum also reported some promising initial results with d-cycloserine in the augmentation of VR.

Dr. Joann Difede of Weill Medical College at Cornell University in New York City described her use of CBT/VR with firefighters responding to the World Trade Center site on September 11, 2001. Dr. Difede reported that nearly 10% of firefighters met full criteria for PTSD, with almost 25% having subsyndromal PTSD. She then outlined the novel therapeutic approach that was initially used in those firemen who had difficulty complying with imaginal exposure in the course of CBT. A virtual environment was developed that incorporated computer-generated images of planes hitting the World Trade Centers with actual audio from newscasts from 9/11. After four sessions in which therapists used a CBT approach including psychoeducational efforts and the introduction of ujayi breathing techniques, VR was introduced and used over the course of another half-dozen or more 75-minute sessions. The use of VR in this manner had an impressively large effect size in comparison to waitlist controls.

Dr. Naomi Josman of the University of Haifa, Israel, reviewed the added value of occupational therapy with virtual reality exposure therapy, with an examination of occupational performance before and after therapy. She also discussed the significance of "presence" as a measure of the investment of the patient in VR.

Dr. Skip Rizzo of the Institute for Creative Technology at the University of Southern California reinforced Dr. Wiederhold's comments regarding the ability of VR to ensure that those with PTSD are confronted with their virtual environment, so that they can not avoid it, as those with this disorder are often inclined to do. He emphasized the need for inter-institutional collaboration, and highlighted a series of additional investigators using VR in the treatment of PTSD, including Beck at the University of Buffalo for survivors of motor vehicle accidents, and researchers in Portugal treating combat veterans of wars in former Portuguese colonies in Africa in the 1970's. In addition, Dr. Rizzo described the importance of sensory input other than vision in VR, noting the well-delineated importance of auditory input, as well as the added value of vibration through the use of a platform, and more recent work incorporating smells. He also introduced the concept of using exposure to a virtual environment as a screening tool after military deployment, identifying those with strong physiologic responses as individuals who might benefit from intervention.

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