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Playing Through the Pain

Lara Crigger | 7 Nov 2006 11:00
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Rothbaum points out another benefit of virtual reality: "If you think about who the Iraq war veterans are, it's a very video-savvy, electronic generation," she says. "For people who don't want traditional therapy, the idea of virtual reality might be attractive. They might get curious and try it."

Virtual imaginal exposure therapy works much like the real-world version does, but instead of recreating a patient's memories in his mind, his experiences are replicated in a digital environment. Wearing a binocular headset, the patient traverses the virtual world using a game controller. The therapist guides her through that artificial environment, tweaking stimuli and environmental details according to the patient's specific memories. To keep track of anxiety levels, the patient gives a Subjective Units of Discomfort reading every five minutes, rating her emotional distress from 0-100. As the patient grows comfortable, the therapist includes more stress-inducing stimuli into the virtual world.

In 1997, Rothbaum's company, Virtually Better, worked with Rizzo and designer Jarrell Pair to develop the first virtual reality treatment specifically designed for veterans with PTSD. That application, Virtual Vietnam, was a simple program that allowed patients to enter a virtual Huey helicopter and fly over two locations: a rice patty and a clearing surrounded by jungles. What they found was that although the graphics were primitive, patients didn't seem to care. "People would come out of the simulation, and they'd tell you these elaborate stories about how they ran to the helicopter when the Vietcong came out of the jungle," says Rizzo. "That wasn't in the environment. People filled in the gaps themselves."

Rothbaum explains that it's the PTSD that inspires patients to make up the missing details. "As long as you tap into some of their fears and get people anxious, they will fill in the rest," she says. The approach proved to be a surprising success. A 2006 paper in the Journal of Clinical Psychiatry reported that after six months, 78 percent of the Vietnam veterans who used Virtual Vietnam for therapy had improved mental functioning, opposed to 50 percent who'd used other methods.

Virtual Iraq is the spiritual successor to Virtual Vietnam, although the application is generations ahead of its predecessor in both capability and design. For example, Virtual Iraq features several environments, including a small village, a large city, checkpoints and a Humvee convoy. The therapist also has far more control over environmental stimuli, everything from weather patterns and time of day to the volume and variety of ambient sounds. The graphics, too, are much improved: Virtual Iraq is based off Full Spectrum Warrior, a commercially released console game originally intended to train Army officers.

Virtual Iraq goes beyond the audio-visual experience, tapping into other sensory organs. Into the simulation, Rizzo has introduced a vibration mechanism that rumbles the platform upon which a patient sits or stands so as to match explosions in the virtual world. Also, Rizzo's team has built a smell box that pumps up to eight distinct scents into patients' noses, including body odor, burning rubber, gunpowder and rotting garbage. "Smell is a key ingredient here, because sense of smell is directly connected to the limbic system, which is responsible for memory," says Rizzo.

Imprint Interactive, a virtual reality technology company based out of Seattle, has also developed a number of applications for soldiers with PTSD, collaborating with the Army, Veterans Administration and the Office of Naval Research. But the company has also worked extensively to bring virtual therapies to civilians grappling with PTSD. Imprint helped modify a simulation of the 9-11 World Trade Center attacks built by the University of Washington and, more recently, worked with Israel's University of Haifa to develop a bus bomb simulator.

Like Virtual Iraq, Imprint's bus bombing simulation scales in intensity. Clinicians can control several different factors: noise levels, AI reactions, siren sounds, intensity of the bus explosions, etc. It is entirely customizable. "There's a fine line between getting patients to clear the air around their memories and re-traumatizing them," says Ari Hollander, technical director at Imprint Interactive. "You want to gradually reintroduce people to their memories."

Virtual reality exposure therapy is still a new technique, and no paradigms or precedents exist for therapists who want to use it for treatment. From technical design to graphical realism, everything about these applications is mostly trial and error. "All of these things are not well understood," says Hollander. "One of the main goals of our research is to find what does and doesn't work."

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