1. Virtual Reality Exposure: Efficacious Treatment for Combat PTSD? Sarah D. Miyahira, Ph.D. Pacific Telehealth & Technology Hui Department of Veterans Affairs Pacific Islands Health Care System Honolulu, Hawaii Hunter G. Hoffman, Ph.D University of Washington, Seattle, Washington Raymond A. Folen, Ph.D. Tripler Army Medical Center, Honolulu, Hawaii Azucena Garcia-Palacios, Ph.D. Universitat Jaume 1, Castellon,Spain Cybertherapy 2008 Conference San Diego, CA, USA June 24, 2008

2. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture U.S. Warfighters Deployed to Iraq & Afghanistan-RAND Report, 2008  Approximately 1.64 million U.S. warfighters deployed to Iraq and Afghanistan since October 2001  Many experience prolonged exposure to stressful and traumatic combat events  18.5% returning troops have PTSD or depression  ≈50% who need treatment, seek treatment  ≈50% who are treated receive minimally adequate care  Recommendation: improve access to High Quality care (supported by scientific evidence)

3. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Prevalence of Mental Health or Cognitive Impairment

4. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture What We Know About Exposure to Combat  Intensity and frequency of violence and threat of death in combat increases risk for PTSD  Most warfighters do not develop PTSD  Most with PTSD will recover naturally over time  Others develop chronic PTSD if not treated  High co-morbidity: alcohol & drug abuse, medical problems, depression, other psychiatric disorders

5. “To this day I can still hear our screams and recall the feeling of the truck being lifted and shaken with every explosion.” Spc. J. Norrel Convoy attack and IED explosion survivor

6. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Virtual Reality Treatment for PTSD  Potentially powerful treatment approach  Early studies show promising results Rothbaum et al (2001) Difede and Hoffman (2002; 2006)  Few published controlled studies  More empirical evidence required

7. VR Exposure Treatment of Combat PTSD Randomized controlled study Compare VR exposure treatment to delayed treatment of PTSD in returning warfighters from Iraq and Afghanistan Treatment: CBT augmented with VR exposure 10 treatment sessions (2x/week) Graded VR exposure (auditory, visual, kinesthetic stimuli) Physiologic monitoring: heart rate, temperature, skin conductance, respiration

8. VR Environment: Middle East World (MEW)  Humvee convoy in Middle East town  Critical events: IED explosions, gunfire attack, swerving car, RPG attack  VR elements: 3D visual animation, stereophonic audio, chair vibrations  Therapist interface: keyboard to activate and deactivate images, sounds, and animation  Individual customization of stressful events  Increase or decrease level of stress arousal

9. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture VR Environment: Middle East World

12. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture

13. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Sample Characteristics CharacteristicMean Value or Status Age 24.2 Number of Months in Military59.3 Length of Deployment14 months RankE 4-5 FunctionInfantry, MP, Medic EducationHS Diploma/Some College Martial StatusSeparated or Divorced EthnicityWhite (71%)/Hispanic (29%)

14. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Pre-Treatment Status MeasureMeanLevel CES30.2Moderate Heavy CAPS81.5Severe PDS35.5Moderate Severe BDI24.7Moderate TRGI51.7Mild QOLI35.5Low

15. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Sessions 2-6 - Temp

16. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Sessions 2-6 - Resp

17. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Sessions 2-6 - HR

18. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Sessions 2-6 - EDR

19. Surveys of OIF warfighters report significant levels of mental health impairment Sample data indicates moderately heavy combat exposure and high PTSD severity Preliminary physiologic data indicates VR arousal & habituation with repeated exposure Anecdotal & subjective ratings indicate high presence Controlled studies needed to demonstrate efficacy of VR Summary

20. Pacific Telehealth and Technology Hui A DoD/DVA Joint Venture Acknowledgements Funding for this research study is provided by the Office of Naval Research, Science and Technology This material is the result of work supported with resources and the use of facilities at the, Department of Veterans Affairs, Pacific Islands Health Care System, Honolulu, HI

21. Contact Information: Sarah D. Miyahira, Ph.D. Pacific Telehealth & Technology Hui 459 Patterson Road Ste. 4E-B100 Honolulu, Hawaii, USA 96819-1522 Sarah.Miyahira@pacifichui.org