Combat Duty in Iraq and Afghanistan, Mental Health Problems of Care

HONOLULU " The scene from the front of the Veterans Affairs Medical Center (VAMC) offers a postcard view of palm trees swaying in the breeze, rain-greened hills and, in the distance, the Pacific Ocean, marked by the wake of a Navy cruiser leaving Pearl Harbor.

In a nondescript VAMC conference room on the fifth floor at the Pacific Telehealth and Technology Hui, the visions of paradise fade to the reality of combat. After donning a head-mounted virtual reality display, you're bouncing behind the steering wheel of a Humvee making its way down what looks like a street in Iraq.

At first, the drive seems routine. A woman clad in black crosses the road while a civilian SUV turns in front of the Humvee. The only sounds are engine noises. Dr. Sarah Miyahira, co-director of the Virtual Reality Behavioral Health Program and Laboratory at the center, then asks a technician to turn up the intensity.

The SUV suddenly swerves in front of the Humvee, and the vehicle's occupants start firing machine guns. A rocket-propelled grenade comes within inches of the Humvee's windshield. The rat-a-tat-tat of combat fills the room. Then the technician turns off the action, and the room returns to silence.

Miyahira, a VA psychologist, wants to use this immersive experience to help treat Iraq war veterans suffering from post-traumatic stress disorder.

Using virtual reality to treat PTSD has its roots in the traditional treatment for the disorder: imaginal exposure therapy. In that therapy, a patient repeatedly describes traumatic events to a therapist and, in the process, tries to overcome memories. Iraq veterans have memories similar to those that have afflicted more than 800,000 Vietnam War veterans.

The virtual reality experience benefits those who cannot or will not conjure the images that cause them stress, Miyahira said. Virtual reality therapy helps break down those barriers by gradually reintroducing patients to the scenes of their trauma. Patients usually attend 10 therapist sessions during a five-week period, Miyahira said.

Iraq World
Hunter Hoffman, a cognitive psychologist at the University of Washington and Miyahira's research partner on what he calls the Iraq World virtual reality project, said gradual exposure to traumatic events helps patients slowly gain access to the memories that are at the root of their PTSD.

The avoidance of such memories is a natural and even healthy response to combat trauma, Hoffman said. Within six months, most people get over the experience. But roughly 15 percent avoid dealing with those memories, which can lead to depression, a high rate of alcohol and substance abuse, flashbacks, and damaged personal relationships.

Hoffman said virtual reality is a trigger for bringing back those memories in a safe environment with a therapist who can then talk a patient through a traumatic event. Virtual reality therapy is also an attraction for the most recent generation of veterans who grew up with video games. They feel less stigmatized seeking virtual reality treatment than they might with more traditional forms of therapy, Hoffman said.

The Office of Naval Research (ONR) is funding the Honolulu VAMC virtual reality project and two others. Cmdr. Russell Shilling, ONR virtual reality program manager, said that unlike the treatment of PTSD in Vietnam War veterans, one of the objectives of the project is early intervention and treatment, a lesson learned from the Vietnam era.

Sounds of choppers
The Navy's virtual reality research project draws on the efforts of Dr. Barbara Rothbaum of the Emory University School of Medicine. In 1997, Rothbaum's Virtual Vietnam project pioneered the use of virtual reality for treating Vietnam veterans suffering from PTSD. Rothbaum said imaginal exposure therapy requires a patient to focus the mind's eye, but virtual reality allows them to take a trip back to buried memories "with their eyes open."

According to a paper she wrote for the Journal of Clinical Psychiatry, Rothbaum based Virtual Vietnam on two scenarios involving helicopters. Research had shown, she said, that "one of the most common complaints of Vietnam veterans with PTSD is a strong emotional response to the sound of helicopters." To stimulate memory recall, sounds in Virtual Vietnam included chopper sounds, explosions and troops calling for help, Rothbaum said.

One scenario in Virtual Vietnam involved a helicopter ride from the viewpoint of a passenger in a cargo compartment. In this exercise, patients sat in a chair that had a bass woofer speaker mounted underneath the seat to replicate helicopter vibrations. Patients took a virtual flight that mimicked Vietnam scenes, with the helicopter banking and twisting as it followed a jungle river and then flew over rice paddies.

The other scenario was a landing zone in a clearing filled with sounds of helicopters, explosions and troops calling for help, Rothbaum said. Virtual Vietnam worked so well in stimulating memory that patients recalled details that did not exist in the virtual reality program as their memories added a richness and depth of personal experience to the virtual reality.

Virtual Iraq, Afghanistan
Although no therapeutic approach has proven to consistently treat combat-related PTSD, virtual reality-based exposure therapy has led to significant reductions in PTSD in the eight patients Rothbaum followed throughout the Virtual Vietnam study, she wrote. Those patients reported a decrease in PTSD symptoms ranging from 15 percent to 67 percent.

Rothbaum is now applying the lessons learned from Virtual Vietnam to virtual reality treatment of PTSD for warfighters who have served in Iraq and Afghanistan. A grant from ONR supports the work, which is part of a partnership with Dr. Albert "Skip" Rizzo of the University of Southern California's Institute of Creative Technologies and Ken Graap of Virtually Better, a company that develops environments to treat PTSD in addition to phobias such as the fear of public speaking and fear of flying.

Rizzo said the team developed its Iraq/Afghanistan virtual reality with a nifty bit of recycling " it used some of the graphics originally developed for the Army-funded combat tactical simulation environment "Full Spectrum Command," which later evolved into a highly successful X-Box video game.

Scenarios developed for the Iraq virtual reality include a city setting with mosques, buildings and warehouses; a traffic checkpoint; building interiors; rural village scenes; a U.S. military base
in the desert; and a desert road convoy scene complete with battle wreckage and human figures standing by the side of the road.

Warfighters drive through those scenes in realistic Humvees that include turret gunners, or they walk as members of patrols through the city and rural village scenes. Sounds include helicopter flyovers, explosions, wind and gunfire. The Iraq virtual reality experience also provides tactile stimuli much like the Honolulu VAMC virtual reality does. It uses bass woofers to provide the sense of driving over tough terrain.

Scent memory
Rizzo has added another key memory trigger to his Iraq virtual reality not found in Virtual Vietnam or other ONR-backed projects: smells. A smell machine from Envirodine Studios connects to a USB port on the PC running the virtual reality. On cue, it emits eight smells associated with Iraq and war, Rizzo said.

Scents generated by the Envirodine machine include Iraqi spices, burning rubber, cordite, garbage, body odor, smoke, diesel fuel and gunpowder, which it transmits to participants through a series