virtico : vi rtual r eality t herapy and i maging in co mbat veterans

Michael J. Roy, COL, MC, USADivision of Military Internal Medicine

ViRTICo: Virtual Reality Therapy and Imaging in Combat Veterans

COL Michael J. Roy, M.D., M.P.H.Director, Division of Military Medicine

Professor of MedicineUniformed Services University

Bethesda, MD


Collaborators

WRAMC/USU• Greg Lande• Patricia Taylor• Jennifer Francis• Josh Friedlander• Lisa Banks-Williams• Vanita Tarpley • Wendy Law

• NIMH• Meena Vythilingam• James Blair• Husseini Manji• Jennifer McLellan• Allan Mallinger• Stephen Sinclair


Other Key Consultants

• Barbara Rothbaum, Emory University

• Skip Rizzo, Inst for Creative Technologies, USC

• JoAnn Difede, Weill Medical School, Cornell

• Ivy Patt (therapist supervision and fidelity assessments)


Funding

• Office of Naval Research, $900,000– Russ Shilling, Project Manager


Aims of ViRTICo I

• Establish utility of functional MRI to distinguish OIF/OEF veterans with PTSD and mild TBI (“blast exposure”) from combat-exposed controls

• Identify efficacy of Virtual Reality Exposure Therapy (VRET) for combat-related PTSD, compared to current first-line therapy, Foa’s Prolonged Imaginal Exposure (PE)


Mild TBI

• No penetrating trauma or shrapnel

• < 1-2 mins’ loss of consciousness

• Lower end of range ill-defined:– Symptoms attributed to blast include headaches,

dizziness, tinnitus, irritability, sleep problems, memory or balance problems

– Medical literature: 2/3 don’t meet criteria for concussion, but 15-29% have persistent cognitive impairment (attention span, memory, executive function)


Hypotheses

• fMRI can reproducibly distinguish between veterans with PTSD, mild TBI, both, and neither– Digital photos may be more effective at this

than current validated tests such as the Stroop

• VRET is non-inferior to PE in treatment of PTSD– VRET might accelerate response rate


Study Questionnaires

• CAPS to confirm diagnosis (score of 40), and at end of treatment and follow up– PCL-M and PC-PTSD more frequently

• BDI and BAI for depression, anxiety

• CAGE, AUDIT for alcohol

• SCID-I,II for other psych disorders

• DVBIC questionnaire for TBI

• SF-36 and WHO-DAS II: functional status


Functional MRI

• Blood oxygen level dependent (BOLD) – Stimulation causes feedback loop to increase

oxygenation within specific brain areas, increases intensity on T2 images

• Prior studies show greater amygdala and decreased prefrontal activation for PTSD than trauma-exposed controls


fMRI phase of study

• Compare 4 groups of 22 each– PTSD and TBI– PTSD only– TBI only– Deployed, no PTSD or TBI

• Two stimuli used in scanner– Affective Stroop: previously validated– Digital photos from Iraq & Afghanistan

• Repeat fMRI after treatment for PTSD


Digital photos taken by soldiers• Emotionally charged scenes

• Emotionally neutral scenes

• Judged by veterans, providers


Treatment phase subjects

• 44 subjects randomized to VRET or PE– 22 subjects each with PTSD alone and PTSD

plus TBI from fMRI phase– Individuals with shrapnel preventing fMRI may

enter treatment phase directly, so additional subjects will be recruited to fill fMRI phase slots


VR Exposure Therapy• 12 90-minute sessions, average 2 per week• Manualized treatment adapted from Difede, in

turn based on Virtual Vietnam– Begin with CBT approach– Homework, relaxation techniques– VR introduced @ 4th session, ½ of session

• 1st person, present tense• Therapist choreographed, following SUDS, physiologic

monitoring to guide progression

• Includes characteristic audio, video, and olfactory features of Middle East


Prolonged Exposure

• Manualized treatment, based on work by Edna Foa, UPenn

• Same length (90 mins) and number of sessions (12) and overall approach as for VRET arm


Visual, Auditory, and Controls


Vibration platform

• Explosions

• Vehicle movement


Olfactory stimulation

• Theoretic basis: olfactory bulb proximity to hippocampus, and long phylogenetic history– Iraqi spices– Chordite– Body Odor– Burning Rubber– Burning Trash


Physiologic Monitoring

• Heart rate

• Blood pressure

• Respiratory rate

• Skin conductance

• HRV


3 computer set-up


Outcome measures

• CAPS at end of treatment and q 4 weeks for 12 weeks of follow up

• PCL-M and PC-PTSD

• BDI, BAI for depression, anxiety

• CAGE, AUDIT for alcohol abuse/dep

• SF-36 and WHODAS-II for functional status


Initial participants (n=17)

• 2 withdrew during baseline eval, 2 ineligible due to subthreshold PTSD

• 8 completed baseline including fMRI, 2 had shrapnel, 1 aborted fMRI, 2 pending

• Four completed treatment; one withdrew during treatment; 3 in active treatment

• Demographics: 1 female; 1 Hispanic, 3 African-Americans; age range: 24-49


PCL Scores: VR arm


CAPS: VR arm


PCL Scores: PE arm


Challenges encountered

• Recruitment: high rate of alcohol abuse– Amended protocol to relax entry criteria

• Distinguishing mild TBI problematic– Relies on self-report

• Mild TBI rarely unaccompanied by PTSD symptoms

• Secondary gain issues sometimes interfere with reported response


Summary

• Numbers small, but only 1 of 3 in VR arm had a 30% decrease in CAPS; 0/2 in PE arm– But, significant behavioral changes noted– Hard for subjects to acknowledge

improvement for fear of losing benefits

• fMRI and physiologic measures not yet analyzed


Questions?

virtico : vi rtual r eality t herapy and i maging in co mbat veterans

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