From Medscape Medical News Virtual Environment May Help Veterans With PTSD/TBI Better Adjust to Civilian Life

 BY Deborah Brauser 

     September 8, 2009 — A virtual world environment (VWE) currently in development may help veterans with posttraumatic stress disorder (PTSD) and/or mild traumatic brain injury (TBI) better adjust to and cope with the challenges of civilian life, according to a presentation given at the Military Health Research Forum 2009.


In this phase 1 proof-of-concept report, investigators introduced a VWE set in a seemingly mundane supermarket scenario to assist veterans in acclimating to daily tasks such as decision-making, money management, and even conflict resolution.

The veteran and therapist can log on from different locations, and avatars representing the 2 individuals allow them to interact within the virtual setting.

"The VWE will simulate everyday life encounters that are challenging to those with mild TBI/PTSD and allow the veteran and therapist to confront and overcome barriers that block successful social reintegration," said lead investigator Charles E. Levy, MD, chief of physical medicine and rehabilitation service at the North Florida Foundation for Research and Education, Inc, and the North Florida/South Georgia Veterans Health System at Gainesville.

"This is the beginning of a whole new way of delivering patient-centered care," he added.

Rare Use

The prevalence of mild TBI and PTSD in returning combat veterans is estimated at almost 20% for each condition, reported Dr. Levy. Some of the symptoms of TBI/PTSD include deficits in attention and memory, impaired cognitive processing, anxiety, impulsiveness, emotional outbursts, and intolerance of crowds.

The mainstays of treatment for these conditions are pharmacology and psychotherapy. However, traditional psychotherapy, which demands repeated travel to a clinic, is often impractical for many returning veterans.

Although there is emerging evidence that use of VWEs may contribute greatly to mild TBI/PTSD rehabilitation, its use in combat veterans is rare and is usually limited to portraying battle as a part of exposure therapy.

For this program, an expert team of physicians, nurses, therapists, university-based digital artists, and arts-in-medicine and computer engineering specialists were tasked with creating a proof-of-concept prototype of a therapeutic VWE that was both intuitive and accessible.

"Our goal was to develop a working VWE prototype that could augment traditional psychotherapy for combat veterans with mild TBI/PTSD," explained Dr. Levy.

Common Environment, Multiple Challenges

After considering several different scenarios, the development team chose a supermarket setting for veterans to receive both cognitive and emotional challenges such as creating a shopping list, choosing between items from the shelves, and making payments from a virtual wallet at the checkout counter. Conflict resolution challenges include shopping cart collisions with other shoppers and disputes at checkout.

The therapist will also be able to customize the program to reflect specific issues that the veteran may have, such as the appearance and number of other shoppers in the store, lighting, and noise levels.

"The grocery store was ultimately chosen [because] it was felt to be a common environment which could easily present multiple challenges that are often vexing to those with mild TBI/PTSD," said Dr. Levy.

"If you have problems with memory and concentration, then getting grocery items can be pretty difficult. And if you have a list of items that are distributed all over the store, what do you do when the item you wanted isn’t available or isn’t where you thought it would be? Those are all cognitive issues, but they also present stimuli that will likely provoke a response of anger or frustration when those responses might not be called for."

Great Promise

Dr. Levy ended his report by explaining that although the program is still under development, his team’s goals of demonstrating the initial feasibility of concept have been achieved.

"We conclude that therapeutic VWEs for mild TBI/PTSD are possible and show great promise to fill treatment gaps in current care delivery regardless of distance, thus enhancing the lives of our returning veterans."

In addition, Dr. Levy said that this technology could also be used in treating civilians. "The tools that we’re building could be helpful for people with a variety of difficulties, whether or not they’ve been in a combat zone. If people are phobic or have other kinds of problems, virtual environments are one way to help overcome them."

He added that his team’s immediate plans include upgrading the store and developing additional VWEs, with pilot studies and then randomized controlled studies needed in the future.

"Exciting Stuff"

"This is exciting stuff," said Captain E. Melissa Kaime, MD, director of the Congressionally Directed Medical Research Programs, a part of the US Army Medical Research and Materiel Command, to Medscape Psychiatry. "It takes an approach that I think is very innovative and yet very practical, using a tool that our younger generation is comfortable with." Captain Kaime was not involved with this study.

She added, "It’s important to have something like this for those coming back from war, especially for reservists or guardsmen who often don’t have their unit nearby and can feel pretty isolated. Also, their local communities may not have a VA hospital or mental health facility close by. So a computer-based technology could be helpful, as it takes away that barrier to care.

"When you’ve been living in wartime and in a hypervigilant state, it’s very hard to turn that off when you come back home," continued Captain Kaime. "What we’re finding in PTSD is that these people are always still on constant alert and feeling like they’re still in a threatening environment."

She said that the grocery store design is "very smart," as it helps veterans decompress and deconstruct that feeling of having to be hyperalert and always on guard.

"However, I can report from my own experience that going from the front lines, where you really have no choices, and then going to the store with 5 different brands of pasta sauce to choose from — that is almost mind boggling and a little challenging because it’s just too much input," added Captain Kaime. "I think we all have to relearn when we come back from a very intense environment to reset the stimulus thermostat.

"I’m excited that we’ve come to the point where we have the technology to be able to build a scenario like this that is so meaningful. And I’m happy that [the investigators] are exploring other modalities for ways to get care to the war fighter."

This study was supported by the Congressionally Directed Medical Research Programs/Department of Defense Concept Award: Design of Effective Therapeutic Interventions for Mild TBI/PTSD Using Interactive Virtual World Environments.

Dr. Levy and Captain Kaime have disclosed no relevant financial relationships.

Military Health Research Forum (MHRF) 2009: Abstract P4-4. Presented September 2, 2009.

Authors and DisclosuresJournalistDeborah Brauser

is a freelance writer for Medscape.

Deborah Brauser has disclosed no relevant financial relationships.


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Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master's of Nursing Science Degree as an Educator. She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen - one daughter-in-law; Katie - two granddaughters; Isabella Marianna and Zoe Olivia - and one grandson, Alexander Paul. She also shares her life with her husband Gordon Duff, many cats, and two rescues.