By Stephen Spotswood
BETHESDA, MD — Research rooted in treating trauma in the civilian sector is examining how a combination of pharmaceuticals and virtual reality can help combat veterans recover more swiftly from chronic PTSD.
Barbara Rothbaum, PhD, director of the Trauma and Anxiety Recovery Program at Emory University School of Medicineis an expert on PTSD and anxiety and a pioneer in virtual reality for the treatment of psychological disorders. Lecturing on the campuses of NIH recently, she described how her work treating civilian-trauma survivors has put her and her research in the perfect position to treat returning Iraq veterans.
Barbara Rothbaum, PhD, director of the Trauma and Anxiety Recovery Program and a professor at Emory University School of Medicine, demonstrates virtual reality therapy for PTSD.
PTSD Is Universal“Most of us think of PTSD as the war veteran’s disease, and it’s certainly a huge problem in veteran populations, but estimates are that 70% of us will undergo a traumatic event in our lifetime capable of producing PTSD,” Rothbaum explained. “Trauma is ubiquitous. About 10% of the population in the U.S. at any point is suffering from PTSD.”
Looking at victims of rape, Rothbaum found that half met the full criteria for PTSD following the event, while a slightly more than 20% developed chronic PTSD. “This tells me that the symptoms of PTSD are a normal response to trauma,” she said.
The goal of PTSD research is to focus on where the normal response ends and a psychopathological response, such as chronic PTSD, begins.
“This has led some of us to think of PTSD as a disorder of extinction,” Rothbaum said. “Fear and anxiety is a normal response and, for most people, it extinguishes over time. For a significant minority, it doesn’t.”
There are many reasons people with PTSD have not been able to process the event: One is fear and anxiety of reliving the event, while another is society’s unwillingness to embrace and talk publicly about traumatic events.
“I think this is what happened to our Vietnam veterans,” Rothbaum said. “One of our [patients] told us as his plane was taking off from Saigon, there were walking mortars following it. He barely escaped with his life, and, 24 hours later, he was sitting in his parent’s living room watching what he said were lies on the evening news about the war. No chance to talk about it, debrief, decompress — nothing. And it was an unpopular war, so nobody wanted to talk about it.”
The slower withdrawal from theater for veterans of World War II may be one of the reasons there is a lower level of PTSD seen in that population, she said. “ I think that long boat ride home was actually very therapeutic. They stayed with the people they served with. They could talk together, grieve together if they had lost buddies, and they could talk about it and process it.”Can Virtual Reality Help Veterans Avoid As Well As Recover from PTSD Cont
Virtual Reality Treatment
Virtual reality exposure (VRE) therapy gives veterans another opportunity to process the event — this time with a therapist present.
VRE first was used to treat PTSD when Rothbaum and her colleagues recruited Vietnam veterans who had lived for decades with chronic PTSD. With a VRE helmet strapped to their heads, patients were run through two scenarios: a landing zone and the inside of an in-flight helicopter skirting over rice paddies and jungle. Therapists were able to follow the veterans’ progress on a monitor and comment appropriately.
Since the treatment’s demonstrated success, VRE scenarios have been developed to help veterans and civilians.
Now, Rothbaum is studying the use of a chemical enhancer to the therapy. D-Cycloserine (DCS) — an NMDA partial agonist which has been used in the extinction of fear in rodents; preclinical trials indicated it could work similarly in humans.
An initial trial using it in patients with fear of heights showed that combining DCS with VRE resulted in a significantly greater decrease in anxiety. Three months after treatment, patients who used both maintained significant improvement.
With that success, Rothbaum has moved on to a trial involving veterans of the Iraq conflict. Veterans receive five sessions of VRE therapy where they are virtually placed in a Humvee. The session is augmented to match the veteran’s actual experience. For example, they can be placed in the driver or passenger seat, or in the turret if they were the gunner. What happens to the Humvee in the virtual scenario matches as much as possible what happened to them in combat.
The study participants are placed in one of three groups: DCS, placebo and alprozolam, which is used to treat anxiety and panic disorder and which some patients already are taking.
So far, the patients are showing overall improvement, which is expected because VRE alone has been proven to work. Rothbaum and her colleagues have yet to break the study’s blinds, but, when they do, they expect to see three lines of improvement, with DCS enhancement showing the greatest.
Early Treatment Prevents PTSD
The next step for Rothbaum is to find a way to prevent chronic PTSD from developing.
“I’ve spent my entire career treating chronic PTSD. Where I would love to go is into preventing it,” she said. “The primary way to prevent it is to prevent exposure to traumatic events, but that’s not going to happen. Life is dangerous.”
In animal studies, researchers have found that using extinction training (the equivalent of exposure therapy) within 10 minutes of a traumatic event can prevent consolidation of fear memory. Essentially, if given quickly enough, therapy can prevent PTSD from becoming chronic.
As part of that research, Rothbaum and her colleagues stationed investigators in the emergency department at Grady Memorial Hospital in Atlanta from 7 a.m. to 7 p.m. By the time they were finished, they had assessed 9,000 patients. Of those, only 3,000 were trauma victims. Of those, only 137 met the criteria and agreed to participate.
Half of those patients were not only assessed but were given a modified exposure therapy. Patients were asked to describe the event. Their description was taped and given to them to listen to. They talked about unhelpful thoughts, and therapists walked them through things they might want to avoid.
Those getting the treatment also were seen one week and two weeks later for follow-up treatment. In one-month and four-month follow-ups, researchers found that those who received the intervention had significantly lower PTSD severity, as well as less depression.
The next step, Rothbaum said, is to figure out how to transfer this to combat theater and to mass-casualty events.
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