Virtual Reality: An Emerging Form of PTSD Treatment for War Veterans
Chelsea Nguyen
Professor Townsend
Writing 340
May 7, 2013
Nguyen 2
Abstract
A large percentage of veterans, from past and present wars, who return home from active
combat duty suffer from posttraumatic stress disorder (PTSD). However, the social stigma that is
oftentimes associated with this disorder as well as with the treatment methods prevent these
veterans from seeking the help that they so greatly need. The commonly known forms of PTSD
treatment, such as psychotherapy, eye movement desensitization and reprocessing (EMDR), and
prescription medications, are not fully effective in treating PTSD since they more often than not
deter veterans from seeking help rather than encourage them. Virtual reality is an alternative
form of treating PTSD. It is an emerging trend in health care that, while not yet widespread, has
been proven to be more effective in treating PTSD than the more traditional methods.
Introduction
The fact that the percentage of war veterans who are being diagnosed with PTSD after
they return home is at an all-time high should incite the health care and veteran communities to
develop effective treatment methods. It is said that one in five veterans returning home from Iraq
and Afghanistan are diagnosed with posttraumatic stress disorder, accounting for nearly 300,000
veterans [1]. Despite this alarmingly high statistic, the majority of war veterans who are
diagnosed with PTSD do not seek help and instead suffer alone in their homes. Refusal to seek
treatment is detrimental to the individual, as the symptoms only increase in severity. Although
there are several PTSD treatments currently available, like psychotherapy, EMDR, and
prescription medications, many of them are ineffective in fully treating PTSD since they do not
target the root of PTSD but rather work to only suppress its symptoms. The focus must turn to
more effective treatment methods, which is what a team of researchers at University of Southern
California has done by creating a virtual reality system, where the patients re-experience their
trauma through a virtual environment. This new technology, although novel, has been proven to
Nguyen 3
be effective in treating PTSD in war veterans and is oftentimes used as a first line of treatment
before any others.
Prevalence of PTSD in War Veterans
Today’s U.S. war veterans who return home from combat have a thirty percent chance of
being diagnosed with posttraumatic stress disorder (PTSD) [2]. Figure 1 below from The SFGate
Newspaper shows the percentage of war veterans who were diagnosed with PTSD from the
different wars, spanning all the way back to the Vietnam War to the current wars in Iraq and
Afghanistan. As it can clearly be seen, the percentage of war veterans being diagnosed with
PTSD has not abated at all with time. In fact, it has remained disturbingly steady, with twentyfour percent being diagnosed after the Vietnam War, twenty- three percent being diagnosed after
the Gulf War, and twenty percent being diagnosed after the wars in Iraq and Afghanistan. To
prevent these percentages from staying the same or increasing as time goes on, it is imperative
that our society make every effort to not only understand PTSD, but to also develop effective
treatment method that targets the true, underlying cause of PTSD rather than just address the
surface symptoms.
Figure 1: Percentage of War Veterans
Diagnosed With PTSD
20%
20%
24%
Vietnam War
Gulf War
23%
Afghanistan
Iraq
Figure 1: Percentage of U.S. War Veterans with PTSD (from different wars)
Data Source: http://www.sfgate.com/health/article/U-S-wars-and-post-traumaticstress-disorder-2627010.php
Nguyen 4
PTSD: Symptoms and Barriers to Treatment
In order to develop an effective method to treat PTSD, it is important to first understand
what it is and what the symptoms are. PTSD is an anxiety disorder that develops after a person
experiences or witnesses a traumatic event [3]. For war veterans, this traumatic event takes the
form of a life-threatening situation where they may have experienced a roadside bombing or
have just been in combat [4]. The four common symptoms of PTSD are re-experiencing the
trauma (through flashbacks or nightmares), avoidance (for example, avoiding situations that
reminds the person of the actual event), feeling numbness (such as depression, difficulty
expressing feelings or talking about the trauma), and hyperarousal (being easily startled, irritable,
or angered) [3]. Contrary to many veterans’ beliefs, this is a disorder that does not simply go
away on its own and must be treated in order to have improved physical, emotional and mental
well-being. Despite the clear evidence that veterans should receive treatment in order to regain
stable and productive lives, studies have shown that only thirty to forty percent of veterans
diagnosed with PTSD actually seek treatment [5].
A study was conducted to find out what prevented war veterans from seeking the help
that they so clearly need. The results ultimately showed that the reluctance stems from not just
one but rather a myriad of reasons. In the study, two hundred war veterans who were diagnosed
with PTSD but were not getting treatment were interviewed by phone for forty-five to sixty
minutes to find out why they were not seeking help [6]. Figure 2 below from Psychiatric News
illustrates the results from the study. Based on these interviews, one of the conclusions was that
participants avoided seeking help because they disliked the treatment options that were available
to them and were also concerned about the treatment process. The veterans also felt that they
would be misunderstood by clinicians and that the medications that would be prescribed to them
would not relieve their symptoms. Thirty-five percent of the interviewees responded that they
Nguyen 5
were reluctant to seek help because they were not emotionally ready to start the treatment
process. Sixteen percent of the participants admitted that they did need help but were hesitant to
reach out because of the social stigma that is associated with having the disorder, since in their
view, PTSD would make them appear weak in the eyes of society and would also jeopardize
their careers [4]. Logistical problems, such as the time that would be needed to be set aside to
travel to the clinics, did not majorly influence the participants’ decision to not seek help [6]. The
valuable information that the researchers gained from these interviews can be utilized to
determined what treatment methods, if not the traditional ones, would be most effective in
treating PTSD and ultimately allow these war veterans to be restored back to a normal, healthy
and productive life style.
Figure 2: Reasons War Vets Avoid
Seeking Help
Concerns about treatment
40%
Emotional readiness
35%
Stigma
16%
Logistical issues
8%
0
5
10
15
20
25
30
35
40
45
Frequently reported beliefs
Figure 2: Commonly reported reasons why war veterans avoid getting help
Modified from: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid
=1676239
Nguyen 6
Current Ineffective Treatments
Treatment methods like psychotherapy (counseling), prescription medication, and eye
movement desensitization and reprocessing (EMDR) have been shown to be ineffective in
treating PTSD, and thus a greater focus must be turned to alternative methods that would truly
help war veterans as they transition from violent war zones to more stable, predictable lifestyles
at home [3]. Psychotherapy, also known as counseling, involves a patient meeting with his
therapist once a week to discuss his feelings and the trauma that he has experienced while at war.
The goal of psychotherapy is for the patient to “understand [his] thoughts and feelings, and find
practical ways to cope with them” [7]. What psychotherapy does not take into account, however,
is the fact that many war veterans find it very difficult to share a traumatic event with someone
who has not experienced it and thus cannot truly know and understand what it must have been
like to be in that particular situation [4]. Because of this, psychotherapy more often than not
results in twenty to fifty percent of veterans walking away from the therapy sessions before they
were supposed to [8].
Medication treatment involves prescribing antidepressant drugs such as Zoloft or Paxil in
order to reduce depression, a common PTSD symptom, seems to only address the symptoms
rather than the underlying cause of PTSD. Studies have shown that these types of medications
result in unwanted side effects like nausea, rapid weight gain, and extreme tiredness and do not
really treat PTSD [9]. Patients who took antidepressants indicated that “they did not feel any
better,” yet their doctors continued to believe that the disorder was being treated and that
symptoms were being alleviated [7]. EMDR treatment involves the patient discussing the
traumatic event while focusing on an external stimulation (e.g. following the therapist’s moving
finger) [10]. By focusing on the moving finger, the patient’s rapid eye movements would in
theory allow him to work through the traumatic memories without any distress [3]. However,
Nguyen 7
research has found that “theorized eye movements are an unnecessary component” and the
mechanisms used in EDMR is not enough to treat PTSD alone [11]. While the three treatment
methods just described sound helpful in theory, they clearly are not in practice since they do not
aim to truly understand the cause of PTSD and only focus on PTSD’s physical manifestations. It
is crucial that an alternative treatment method be utilized that seeks to first understand how
PTSD develops in patients in the first place and then targets that cause.
Introducing Virtual Reality: A New Kind of Treatment
The development of a virtual reality system is the answer to an effective treatment for
war veterans with posttraumatic stress disorder. This innovative technology was developed by
Albert “Skip” Rizzo, a researcher at the University of Southern California, and his team of
engineers, psychologists, computer scientists, and U.S. military officials [12]. The idea behind
the virtual reality system is to immerse the war veterans into a realistic environment that is
representative of what they have experienced and add different types of stimulations that will
mentally trigger the traumatic event. This allows veterans to confront the traumatic event head
on and force them to work through it rather than repress it [13]. During the virtual reality
simulation, the patient wears a head-mounted display that consists of a set of goggles with
“separate display screens for each eye” and a head-tracking device. The patient is then immersed
into a computer-generated virtual “reality” that is similar to a video game. The patient is free to
move about in their environment by using a controller (similar to ones used for video games) as
seen in Image 1 below [14]. This aspect makes the PTSD treatment more appealing to the
younger technological generations of war veterans because they grew up playing video games,
and thus are comfortable using the virtual reality form of treatment [15].
Nguyen 8
Image 1: Patient interacting with their virtual environment through the controller
Source: http://news.cnet.com/8301-13576_3-57464637-315/virtual-reality-vs-ptsd-helpingcombat-vets-heal/
During the treatment, a trained clinician will sit nearby and controls the patient’s virtual
world on a computer. To help trigger the traumatic experience, a clinician engages the patient to
situations that are similar to combat (such as a roadside bombing) and adds various forms of
sensory stimuli (such as the smell of burning gasoline, loud sound of gunfire, or replicating the
weather of the war region) [13]. The clinician will then monitor the patient’s physiological
responses (such as their heart rate or breathing patterns) while the patient is re-living the
traumatic event, and will discuss what they experienced after, as depicted in Image 2 below [16].
Based on the patient’s response to certain stimuli, the clinician is able to choose the appropriate
ones related to their trauma and repeatedly apply them to the patient’s virtual world [17]. The
ability to recreate and bring the war veterans back to their traumatic event in a realistic virtual
Nguyen 9
environment, makes the virtual reality system an innovative and effective tool in treating the
underlying cause of PTSD rather than simply addressing the physical symptoms.
Image 2: A trained clinician is monitoring the patient’s response to their virtual world
Source: http://www.northwestmilitary.com/news/articles/2010/05/northwest-military-ranger
newspaper-northwest-airlifter-cassandra-fortin-virtual-reality-program-hel/
Why Virtual Reality Works
The virtual reality technology is an effective way to treat war veterans with
posttraumatic stress disorder because it incorporates exposure therapy, the most successful form
of treatment for PTSD. Research has shown that 90 percent of the patients who received eight,
ninety-minute sessions of exposure therapy no longer met the criteria for having posttraumatic
stress disorder [10]. Exposure therapy is a behavioral therapy method that targets avoidant
behaviors, a common symptom of PTSD [18]. War veterans tend to avoid talking or thinking
about the traumatic event and go so far as to avoid situations that serve as reminders of the
experience [15] [18]. Exposure therapy allows patients to “confront their fears and anxieties”
through a technique called imaginal exposure [18]. In imaginal exposure, the patients are forced
to confront their fears and anxieties by imagining the traumatic event again, discussing how they
Nguyen 10
felt during the experience, explaining what he saw, smelled, heard, and tasted, and being
repeatedly exposed to a situation that reminds them of the traumatic experience. The patients
who received the exposure therapy all showed significant improvements from when they first
started, experiencing a 74 percent decrease in the severity of PTSD symptoms [10] [18]. Due to
the success rate of exposure therapy in treating PTSD, virtual reality technology serves as a
valuable tool in enhancing the effectiveness of this type of treatment.
The virtual reality technology allows for more comprehensive treatment by recreating
combat situations that are impossible to replicate again after the war veteran is at home. The
patient is virtually immersed back to their stressful experience in a safer and more controlled
environment. The addition of sensory stimuli in the technology helps to “evoke the trauma
memory” [19]. Psychologists believe that repeatedly exposing the war veteran to their traumatic
experience will activate repressed emotions [20]. Using virtual reality as a tool enhances the
treatment because it puts together memories, sensory stimuli, feelings, and emotions associated
with the traumatic event, all of which help the war veteran confront and cope with the complete
memory [15]. The clinician, who controls the patient’s virtual world, has the ability to pause the
system, and help them understand their emotions and responses, and eventually cope with the
memory. They can then teach the patient coping methods that can be used to manage the stress
associated with trauma, some of which include thought exercise, deep breathing, and ways to
control their emotions and thoughts [20]. Repeatedly confronting the traumatic event through the
use of virtual reality has been shown to markedly decrease the anxiety that war veterans feel
because they will have already started processing and understanding the emotions connected to
the traumatic experience rather than avoiding them. Research data indicate that anxiety scores
decreased by 36 percent in war veterans receiving virtual reality treatment [20][21]. In recent
studies in which war veterans were treated for PTSD through the use of virtual reality exposure
Nguyen 11
therapy, 80 percent no longer met the definition of having PTSD after having completed the
therapy [21]. The use of virtual reality is not yet common and is still in the refining stages.
However, the extensive research and testing that has been conducted on this method since it was
first developed in 2005 has proved it to be the most effective approach in treating PTSD in war
veterans.
Virtual Reality: A Look into the Future
Due to the success of the virtual reality system as a method of PTSD treatment, more
extensive engineering advancements are taking place so that this technology is perfected for
future use. For example, engineers are trying to pinpoint the level of detail that is needed in the
virtual world in order for patients to respond well. Because sensory stimuli are an essential
component in creating a virtual reality, engineers are also trying to devise ways to reproduce
sensory stimuli as accurately as possible. Future virtual reality systems most likely will also
incorporate the sensory stimuli of touch that would allow war veterans to be able to virtually feel
their environment through a glove [22]. Another exciting future advancement that war veterans
and clinicians should expect to see is the incorporation of a Sim Coach, an interactive virtual war
veteran avatar. The idea behind the Sim Coach is not to replace the clinicians, but rather to
provide war veterans with the ability to anonymously talk to a virtual veteran about their PTSD
symptoms and treatment experiences outside of therapy. The patients will be able to interact with
the virtual avatar by logging onto an online virtual world and chat with them through a chat box
and a webcam in the comforts of their own home [23] [24]. The Sim Coach will be able to
provide customized assistance and responses based on the information the patient provides. This
will undoubtedly be another invaluable tool in the continuing effort to address and treat PTSD.
By perfecting the details of the virtual reality system and also enhancing the features of this
technology, it is expected that this method will be a prominent, if not dominant, form of PTSD
Nguyen 12
treatment in the near future and where war veterans are offered the opportunity to regain a
healthy and productive lifestyle.
Nguyen 14
Works Cited
[1]
“Shocking PTSD, suicide rates for vets,” Nov. 10, 2012. [Online]. Available:
http://www.facethefactsusa.org/facts/the-true-price-of-war-in-human-terms. [Accessed:
April 13, 2013].
[2]
C. Rubush, “Persian Gulf War Veterans PTSD Rates are Similar to Vietnam and Iraq
Combat Vets,” winoverptsd.com, May 20, 2010. [Online]. Available:
http://winoverptsd.com/wp/persian-gulf-war-veterans-ptsd-rates-are-similar-to-vietnamand-iraq-combat-vets/ [Accessed: April 13, 2013].
[3]
United States. Department of Veterans Affairs, “Understanding PTSD Treatment”, Feb.
2011. [Online]. Available: http://www.ptsd.va.gov/public/understanding_TX/booklet.pdf/.
[Accessed: April 12, 2013].
[4]
T. Collins, Fort Bragg Research Examines Value of Virtual Reality as PTSD Treatment,
Army Mil, Aug. 2012. [Online]. Available:
http://www.army.mil/article/86183/Fort_Bragg_research_examines_value_of_virtual_rea
lity_as_PTSD_treatment/ [Accessed: April 13, 2013].
[5]
“Veterans statistics: PTSD, Depression, TBI and Suicide,” 2002. [Online]. Available:
http://www.veteransandptsd.com/PTSD-statistics.html. [Accessed: April 13, 2013].
[6]
A. Levin, “Expectations Deter Vets From Mental Health Care,” Psychiatric News, vol. 48,
no. 7, p. 11, April 2013. [Online]. Available:
http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1676239. [Accessed:
May 6, 2013].
[7]
“Post traumatic stress disorder,” 2009. [Online]. Available:
http://bestpractice.bmj.com/best-practice/pdf/patient-summaries/ptsd-standard.pdf.
[Accessed: April 9, 2013].
[8]
S. Robson, “Soldiers fail to seek PTSD treatment or drop out of therapy early, research
finds,” Stars and Stripes, May 15, 2012. [Online]. Available:
http://www.stripes.com/news/special-reports/post-traumatic-stress-disorder-ptsd/soldiersfail-to-seek-ptsd-treatment-or-drop-out-of-therapy-early-research-finds-1.177275.
[Accessed: April 15, 2013]
[9]
T. Staton, “Study: Antipsychotic doesn’t work for vets’ PTSD,” Aug. 3, 2011. [Online].
Available: http://www.fiercepharma.com/story/study-antipsychotic-doesnt-work-vetsptsd/2011-08-03. [Accessed: April 14, 2013].
[10]
S. Taylor, D. Thordarson, I. Fedoroff, L. Maxfield, and K. Lovell, “Comparative Efficacy,
Speed, and Adverse Effects of Three Treatments: Exposure Therapy, EMDR, and
Relaxation Training, Journal of Consulting and Clinical Psychology, vol. 71, no. 2, 2003.
[Online]. Available:
http://www.canyons.edu/faculty/rafterm/Cognitive%20Psychology/Day%20Pages/Day%
Nguyen 15
207%20Information%20page_files/2003%20--%20Comparative%20efficacy%20%20speed%20and%20adverse%20effects%20of%20three%20PTSD%20treatments%20-%20Exposure%20therapy%20-%20EMDR%20and%20relaxation%20training.pdf.
[Accessed: April 14, 2013].
[11]
United States. Department of Veterans Affairs, “Overview of Psychotherapy for PTSD”,
July 27, 2010. [Online]. Available: http://www.ptsd.va.gov/professional/pages/overviewtreatment-research.asp. [Accessed: April 13, 2013].
[12]
“Post-Traumatic Stress Disorder: Battle Ready?” The Economist, Nov. 2012, [Online].
Available: http://www.economist.com/news/science-and-technology/21566612-it-maybe-possible-vaccinate-soldiers-against-trauma-war-battle-ready [Accessed: April 13,
2013].
[13]
A. Knabe, “From Disturbing Reality to Virtual Reality,” The Officer, vol. 86, no. 4, Sept.
2010. [Online]. Available:
http://search.proquest.com.libproxy.usc.edu/docview/763168355. [Accessed: April 15,
2013].
[14]
R. Howes, “Cool Intervention #2: Virtual Reality,” Psychology Today, Feb. 2010,
[Online]. Available: http://www.psychologytoday.com/blog/in-therapy/201002/coolintervention-2-virtual-reality [Accessed: April 13, 2013].
[15]
N. Voges, “Combating PTSD Through Virtual Reality,” Los Angeles Times. July 10,
2010. [Online]. Available: http://www.latimes.com/news/nationworld/nation/sns-healthbehavioral-health-ptsd-virtual-reality,1674529,460864.story [Accessed: April 13, 2013].
[16]
C. Helwick, “Virtual Reality Exposure Enhances Treatment of PTSD,” Medscape
Medical News, May 26, 2010. [Online]. Available:
http://www.medscape.com/viewarticle/722512. [Accessed: April 15, 2013].
[17]
A. Rizzo, J. Pair, K. Graap, “A Virtual Reality Exposure Therapy Application for Iraq
War Military Personnel with PTSD: From Training Toy to Treatment,” NATO, [Online].
Available:
http://ict.usc.edu/pubs/A%20Virtual%20Reality%20Exposure%20Therapy%20Applicati
on%20for%20Iraq%20War%20Military%20Personnel%20with%20Post%20Traumatic%
20Stress%20Disorder-%20From%20Training%20to%20Toy%20to%20Treatment.pdf.
[Accessed: April 15, 2013].
[18]
“Virtual Reality in the fight against PTSD,” Dec. 11, 2013. [Online]. Available:
http://unmfdu12.blogspot.com/2012/12/virtual-reality-in-fight-against-post.html.
[Accessed: April 12, 2013].
Nguyen 16
[19]
J. Cukor, A. Rizzo, J. Difede, “Emerging treatments for PTSD,” Clinical Psychology
Review, vol. 29, no. 8, Dec. 2009. [Online]. Available:
http://www.sciencedirect.com.libproxy.usc.edu/science/article/pii/S0272735809001184.
[Accessed: April 15, 2013].
[20]
Z. Whittaker, “Virtual reality treatment used for PTSD treatment,” The Denver Post, June
30, 2012. [Online]. Available:
http://www.americanhomecomings.com/culture/2012/06/30/virtual-reality-treatmentused-for-ptsd-treatment/ [Accessed: April 15, 2013].
[21]
D. Terdiman, Virtual Reality vs. PTSD Helping Combat Vets Heal, CNET, Jul. 2012.
[Online], Available: http://news.cnet.com/8301-13576_3-57464637-315/virtual-realityvs-ptsd-helping-combat-vets-heal/ [Accessed: April 13, 2013].
[22]
H. Rodriguez, NAE Grand Challenges for Engineering, National Academy of
Engineering, 2012, [Online]. Available:
http://www.engineeringchallenges.org/cms/8996.aspx [Accessed: April 13, 2013].
[23]
L. Biron, “Virtual Reality Helps Service Members Deal with PTSD,” DefenseNews. June
11, 2012. [Online]. Available:
http://www.defensenews.com/article/20120611/TSJ01/306110003/Virtual-Reality-HelpsService-Members-Deal-PTSD. [Accessed: May 4, 2013].
[24]
A. Piore, “Big Idea: Help Stressed Vets With Sim Coaches,” Discover Magazine.
October, 2012. [Online]. Available: http://discovermagazine.com/2012/dec/25-helpstressed-vets-with-sim-coaches#.UYXiyr-nCfQ. [Accessed: May 4, 2013].
Nguyen 13
Biography of the Author
I am currently a third-year transfer student in the USC School of Occupational Science and
Occupational Therapy. I am planning on working with kids with disabilities and special needs
and my dad, a Vietnam War veteran, was the source of inspiration behind this article.
Contact Information
Chelsea Nguyen
Phone Number: (818) 274-8202
Email: chelsean@usc.edu
Suggestions of Multi-media Applications
I think that this article would be enhanced if we were able to include videos of the virtual reality
system. I think that one video that should be included is one that shows what a patient would see
if they were to put on the goggles just so that we are able to see just how realistic the technology
is. Another type of video that should be included in this article is one that shows a treatment
session with both the patient and the clinician. There are several out there that demonstrate how
the clinician controls the patient’s environment and how they are monitoring the patient’s
response. The most important one to include would be one that demonstrates what the system
looks like and how it is used for better understanding of what this type of treatment is about. The
last suggestion would be a mock up of what the Sim Coach application would look like how it
would be used.