Dr. Greg Reger reviews the rationale for virtual reality exposure in the treatment of PTSD and presents summaries of some of the published literature. The presentation includes a description of T2's on going clinical trial study.
Activation of Combat Trauma Memories Using Virtual Reality
Activation of Combat Trauma MemoriesUsing Virtual Reality Greg M. Reger, PhD
Acknowledgements• RCT VR vs. PE is sponsored by the Department of the Army, W81XWH-08-2-0015. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014 is the awarding and administering acquisition office.• Greg Gahm, Kevin Holloway, Patie Woods, Kimberlee Zetocha, Amber Shaw, Emily Fantelli, Skip Rizzo, Barbara Rothbaum, Joann Difede, Frank Andrasik, Andy Leon
DisclaimerThe opinions or assertions containedherein are the private views of the authorsand are not to be construed as official oras reflecting the views of the Departmentof the Army or the Department of Defense.
Prolonged Exposure Foa & Kozak’s Emotional Processing Theory • Activation of the fear structure (Emotional Engagement) • Incorporation of new, corrective disconfirming information4
Activation of the Fear Structure Physiological Meaning of the Stimulus and Behavioral stimulus and Responses responsesRepresentations Increased “Garbage on theof IEDs sweating, road is dangerous” increased heart rate “Increased heart rate means there is threat”
Scientific Literature on Exposure Therapy “...the evidence from many well-controlled studies across a wide range of trauma survivors is very compelling…no other specific CBT program has such strong evidence for its efficacy…” – Practice Guidelines from the International Society for Traumatic Stress Studies (2009) “…strongly recommended…” – VA/DoD Clinical Practice Guidelines for PTSD “…the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD…” – Institute of Medicine, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2007)6
Treatment Response by Trauma Type Trauma Type Effect Size (d) • Sexual or Physical Assault 1.82 • Mixed Trauma 1.24 • Combat Trauma .81 Bradley et al. (2005) American Journal of Psychiatry7
OIF PTSD and VR Exposure: Case Report Case Background77 1. OIF Gunner in HMWVV 2. Traumatic Death of an enemy combatant57 3. 90-minute sessions 4. 6 Sessions provided across four weeks. 5. Utilized ICT VR Iraq37 Convoy environment17 PreTreatment PostTreatment ** P < .001Reger & Gahm (2008). Journal of Clinical Psychology 10
Treatment Completers Mean Pre/PostScores: PTSD Checklist-Military (PCL-M)5752 Treatment Completers n=184742 p < .001 (n=18)37 p < .001 Pre-Treatment (n=13) Post-32 Treatment27 14 of 18 No Longer meet DSM criteria for PTSD at Post-TX2217 PRE TX POST TX POST TX
VR Exposure in Clinical Practice Active Duty Soldiers Study Method 77 1. Treatment non-responders or those specifically seeking VR treatment. 2. 90-minute sessions 57 3. Sessions were approx ** weekly 4. Range number of sessions 37 was 5-11 depending on progress. 5. 24 patients received VR Exposure 17 PreTreatment PostTreatment** P < .0005 VRET Reger et al. (2011), Journal of Traumatic Stress 12
Comparing Virtual Reality Exposure Therapy to Prolonged Exposure in the Treatment of Soldiers with PTSD Referred for study 12 pending assessment completion•Enrollment planned at 2 sites: assessment (n = 362) 127 Others not appropriate for JBLM (enrolling since 2009) screen/not interested/no contact Ft. Bragg (planned enrollment spring 2012) Assessed for eligibility (n = 223) Excluded : 96•Original single-site enrollment planned for 162 randomized, increased Randomized (n = 127) with multisite addition Assigned VRET: 42 Assigned PE: 42 Assigned WL: 43 Baseline Study Design Outcome Referral and Follow-up PE, VRET, or WL Assignment Consent Period Clinical Screening SUDs, Psycho- Treatment Interview physiology Satisfaction Treatment Session: 1 5 10 Time in Study (weeks) : -1 0 2.5 5 31 1713
VR Exposure Therapy Greg M. Reger, Ph.D. Innovative Technology Applications National Center for Telehealth & Technology 9933C West Hayes Street Joint Base Lewis-McChord Tacoma, WA 98431 AskUs@T2Health.org