2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Using Virtual Reality for Treatment and Prevention of Post-Traumatic Stress and Other Anxiety Disorders

Significant opportunities for the health and medical communities are becoming available through technological advancements in the Virtual Reality (VR) arena. The Institute for Creative Technologies (ICT), a University Affiliated Research Center, is one example of a research center enabling the Department of Defense (DoD) to capitalize on such advancements. The ICT, which is affiliated with University of Southern California, is managed by the U.S. Army Research Laboratory, Human Research and Engineering Division, Simulation and Training Technology Center. The innovations developed by this research center represent the start of a rapidly growing field. Two of the efforts pioneering this growth are Bravemind and Stress Resilience in Virtual Environments (STRIVE).

Bravemind

Bravemind is a fully immersive, interactive VR-based application being used to assess and treat military Service Members (SMs) who are diagnosed with anxiety disorders such as Post Traumatic Stress Disorder (PTSD). VR provides a promising alternative to traditional imaginal exposure therapy in which patients with anxiety disorders are led by clinicians to imagine their traumatic experiences in an incremental, stepwise fashion. Bravemind consists of a series of VR environments designed to resemble typical SM trauma settings for use in VR exposure therapy.

One of the advantages of using VR for the treatment of anxiety disorders such as PTSD is that patients can be teleported into virtual environments representative of the traumatic experiences they are seeking to overcome. The intensity of these virtual environments can be configured and adjusted by clinicians using visual, audio, olfactory, and vibrotactile stimuli and triggers so that patients can be immersed in an incremental, stepwise fashion. By exposing patients to their traumatic experiences in a gradual fashion, clinicians can assist these patients in progressing towards overcoming their anxiety disorders. In comparison, imaginal exposure therapy relies on patients being able to effectively imagine their traumatic experiences. However, many patients are unwilling or unable to visualize these traumatic experiences. In fact, avoidance of reminders of the trauma is one of the cardinal symptoms of PTSD as indicated by the Diagnostic and Statistical Manual of Mental Disorders, 4th (DSM-IV). Bravemind addresses this potential limitation by offering a means by which to overcome such natural avoidance tendencies.

Multiple open and comparison clinical trials have been performed to test the efficacy of Bravemind. In one study, Bravemind (referred to as Virtual Iraq in its early prototypical stages), produced a statistical and clinically meaningful reduction in PTSD symptoms with SMs who did not benefit from prior traditional forms of treatment. Another study indicated that Bravemind was more effective than a cognitive behavioral group treatment in a non-randomized “standard of care” comparison. Other randomized controlled trials associated with Bravemind include comparing VR Exposure Therapy (VRET) with imaginal exposure therapy and investigating the additive value of supplementing VRET and imaginal exposure therapy with a cognitive enhancer called D-Cycloserine (DCS). DCS is a broad-spectrum antibiotic that has been used in multiple clinical trials as a cognitive enhancer. DCS has an essential role in learning and memory and has been shown to enhance learning to include the extinction of conditioned fear responses such as those experienced for various anxiety disorders. In one case, it was demonstrated that DCS combined with VRET for fear of heights significantly reduced the number of sessions needed for successful treatment from six to only two sessions. In another case it was found that DCS combined with imaginal exposure was an effective treatment for social anxiety. In one of the PTSD treatment studies conducted at the Walter Reed Army Medical Center some participants have required as many as 18-20 sessions to achieve a successful treatment response and a significant percentage of SMs dropped out of the study prior to completion. If DCS is effective in accelerating, as well as improving the response to therapy, this could make therapy more appealing, and could enable larger numbers of patients to be successfully treated since fewer sessions would be required.

STRIVE

STRIVE is a natural extension of Bravemind. STRIVE essentially repurposed and enhanced the assets used for the assessment and treatment of anxiety disorders such as PTSD (via Bravemind) into a VR-based capability for preventing such anxiety disorders and improving stress resilience. STRIVE achieves this by immersing SMs in virtual environments representative of the stressful experiences they are likely to encounter and then teaching these SMs how to better deal with and cope with these situations such that healthy mental and emotional responses result. The coaching and mentoring processes for STRIVE is provided by virtual human characters employing Cognitive Behavior Techniques (CBTs). The use of virtual human characters to effectively serve as a virtual coaches, mentors, and trainers are well documented.

STRIVE allows SMs to develop the resiliency and mental toughness needed to perform well and rapidly recover from high-stress conditions. Through repeated systemic stress exposure and training in coping techniques SM resilience levels can be significantly increased and maintained such that these individuals are less prone to suffering from psychological health issues such as anxiety, depression, and PTSD.

Stress Inoculation Training is associated with the notion that repeated exposure to stressful tasks allows for decreased levels of stress when subsequently exposed to these tasks. This approach has been successfully used for a wide variety of applications. Modern cognitive theory and psychotherapy indicate that emotional reactions result from appraisals of events and not the actual events themselves. As such, there is significant potential for teaching and reorienting the thought processes involved via the appraisal process such that healthier and more resilient emotional reactions result. Via STRIVE virtual human characters are being used to provide this training and reorientation process both throughout scenario execution and afterwards during the resilience training phase. Part of the training and reorientation process involves a demonstration and explanation of what happens to the brain and the body whenever stress is experienced, what the major components of resilience are, and what can be done to rapidly recover from stress such as performing various physical and cognitive exercises.

STRIVE also includes the use of stress measures to allow baselines for each SM to be established so that any changes from baseline levels can be readily determined and assessed. Acute psycho-physiological measures of stress are recorded while SMs are engaged both during the stress induction and the resilience training stages. The use of these kinds of measures indicate when a given module should be concluded (e.g., when the stress indicators are high) and when the next module should begin (e.g., when the stress indicators have significantly decreased after resilience training has been performed).

STRIVE also features the use of a range of biomarkers indicating an individual’s long-term methods of reacting to stress. One such measure is defined as Allostatic Load (AL). AL is a single index representing the combination of key biomarkers indicative of poor stress response. AL is associated with allostasis; the process by which the body adapts to acute stress in its attempt to maintain stability. AL essentially represents how individuals are affected by stress over the long term; it is not dependent on short term stressors. Higher levels of AL indicate poorer stress responses while lower levels of AL indicate healthier stress responses.

A new index being defined as Allostatic Reserve (AR) is being created to reflect key biomarkers indicative of stress resilience and stress-induced growth. It is anticipated that higher levels of AR will be associated with individuals who tend to handle stress well and rapidly recover from stressful situations and that lower levels of AR will be associated with those who tend not to handle stress well or who tend to recover more slowly from stressful situations.

By establishing a set of indices for stress and stress-resilience, the AL and AR profile of an individual could indicate how well the person might perform in stressful situations, how resilient the individual might be in recovering from these situations, and the resilience training which might be most beneficial to the person to ensure resiliency is maximized.

Conclusion

Technical innovations, such as those being developed by the ICT, will continue to provide novel opportunities for the health and medical communities. Two efforts pioneering these innovations are Bravemind and STRIVE. Bravemind assists individuals suffering from anxiety disorders such as PTSD by gradually immersing them in virtual environments representative of their traumatic experiences. STRIVE extends the Bravemind technology for use in improving stress resilience and preventing anxiety disorders such as PTSD into what can be thought of as a psychological and emotional obstacle course as a means by which to improve the performance of SMs and allow them to rapidly recover from high-stress situations. Additional information regarding Bravemind, STRIVE, and other technological innovations being developed by the ICT is available at http://ict.usc.edu/.

Joseph M. Brennan, Jr. works for the U.S. Army Research Laboratory, Human Research and Engineering Division, Simulation and Training Technology Center in Orlando, Florida where he is the Chief Engineer for the Institute for Creative Technologies (ICT) Contract. ICT is a Department of Defense University Affiliated Research Center (UARC) associated with the University of Southern California (USC) which advances the state-of-the-art in immersive virtual reality systems. References used in the development of this article are available by emailing Mr. Brennan at: joe.brennan@us.army.mil.

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