War Games: Using Virtual Reality to Treat PTSD
Video games seem to be everywhere these days, so it was only a matter of time before medicine harnessed them for serious work. Soldiers are returning from battle with unseen scars in the form of Post-Traumatic Stress Disorder (PTSD). Technology in war is often about weaponry, but in the case of Virtual Reality Exposure Treatment (VRE), psychiatrists are using technology to help soldiers deal with the traumatic events of war. Typical treatment usually includes accessing the traumatic memory repeatedly to minimize its effects on the psyche. Right now, psychiatrists in the civilian world and in the military itself are performing studies to see if virtual reality can be an effective tool in helping combat veterans overcome these troubles. The current culture of gaming that today’s soldiers have grown up in could make VRE an excellent choice for treating Iraq and Afghanistan veterans who have PTSD.
Soldiers returning from combat may have any number of injuries, but one of the least understood is the one that does not leave a physical wound: Post-Traumatic Stress Disorder (PTSD). Even Traumatic Brain Injury is easier for the injured person and his unit to deal with since it leaves trauma on the brain, visible with an MRI (McLay, 2012). With PTSD, there is no visible wound, even with an MRI, and even the list of symptoms is debatable (McLay, 2012). It is a mental health issue that is not specific to soldiers, as it is also common in rape victims, anyone who was witness to traumatic events, and even some children who watched the Twin Towers fall on September 11, 2001(McLay, 2012). With the rise in terrorist attacks on the general populace, the search is on for a method to minimize the psychological consequences of terror (Freedman, Hoffman, Garcia-Palacios, (Tamar)Weiss, Avitzour, & Josman, 2010). The National Institute of Mental Health lists three categories of symptoms for PTSD: Re-experiencing, Hyperarousal, and Avoidance (NIMH, n.d.). Re-experiencing includes flashbacks and nightmares (NIMH, n.d.). Flashbacks may be the biggest symptom according to pop culture, since many Vietnam veterans in movies see themselves in the jungle searching for Charlie instead of in the grocery store, but nightmares and insomnia are the most common reasons soldiers seek psychiatric help in the first place, and are great predictors of PTSD itself (McLay, Klam & Volkert, 2010a; McLay, 2012). They may simply be asking for a sleep aid, such as a pill, but when currently in a warzone, being unable to jump into action from a dead sleep is a great risk. Instead, the psychiatrists in the field will try to use therapy to address the nightmares which could lead to a diagnosis of PTSD. Hyperarousal is another symptom common in portrayals of PTSD, which includes being easily startled, feeling “on edge,” and having an unusually short temper (NIMH, n.d.). Again, this includes the veteran who hears a car backfire, but thinks it is gunfire. The final group of symptoms is what makes PTSD so difficult to diagnose or treat. With Avoidance, the veteran may simply avoid places, actions, or thoughts that may remind them of the event, may feel extreme guilt or depression, may lose interest in enjoyable activities, and may even push the traumatic event so far away that they cannot remember it (NIMH, n.d.). They may also Avoid treatment since they typically believe there is nothing wrong, or have an issue with appearing to be weak in front of friends, family, or their unit (McLay, 2012). There are a variety of treatments that practitioners use, but the most successful, by far, is Exposure Therapy. Essentially a psychiatrist will help the patient remember the traumatic event repeatedly, reminding him that he is in a safe place, then try to build healthier responses to the memories, eventually diminishing the effect the memory has on the patient (Garske, 2011). This process is called habituation, and is similar to a construction worker becoming accustomed to the sound of heavy machinery, eventually he just does not hear it anymore (Ready, Gerardi, Backscheider, Mascaro, & Rothbaum, 2010).
The trouble with traditional forms of exposure therapy is in accessing and holding onto the memories long enough for habituation to take effect, especially if the patient has avoided or suppressed the memory for a long period of time. Virtual Reality Exposure Therapy (VRE) can help maintain the connection between the patient and his memory through external cues. Like a video game, VRE uses a computer program to show a specific location, such as a marketplace in Iraq (McLay, 2012). The graphics are not the same quality one would see in a top title like Call of Duty, but this actually assists in the therapy. As the patient views the simulation, and interacts with it, his memory starts to fill in the blanks. For example, one simulation run for Vietnam vets featured rice paddies and a helicopter fly-over, but when recalling the simulation, some veterans said there were civilians working in the paddies because their own personal memories had added to the simulation (Ready, et al., 2010). McLay used a particular set-up in theater, described in his book, which included one computer laptop to run the simulation, one to provide bio-feedback and information about the patient’s heart rate, palm sweat, and breathing, and one that allowed the psychiatrist to change anything about the simulation from time of day to roadside bombs and firefights (McLay, 2012). Instead of looking at a screen, the patients wear headphones and a headset that adjusts the view when the patient’s head moves, allowing for a more immersive experience, and they sit on what is essentially a giant subwoofer which transmits the vibration from loud bass sounds from effects like bombs (McLay, 2012). Some versions even have a treadmill to pick up the patient’s movement, but McLay’s had a controller similar to gaming console controllers (2012). All of this technology can assist the patient with holding the memories long enough for habituation because the patient does not have to try to maintain the mental picture.
While VRE can be greatly beneficial to Vietnam veterans who may have suppressed their memories for a long time, there are generational issues to overcome in its use. PTSD is a medical condition, so it is hard enough to have patients choose a relatively new treatment over the established version, and it is ethically questionable to press the issue with a patient. While the first patients of VRE were Vietnam veterans, the practitioners discovered that many veterans were choosing not to pursue VRE for treatment because of unfamiliarity with computer technology or an apprehensive approach to new technology (Ready, et al., 2010). Those older veterans who do take the risk tend to see better results than those who are treated with a basic, non-exposure therapy method (Ready, et al., 2010). Essentially this means that exposure therapy, whether it is performed in a virtual setting or on a psychiatrist’s couch, it is still more effective than non-exposure therapy (McLay, McBrien, Wiederhold & Wiederhold, 2010b). A further study was done to determine whether VRE was more effective than traditional exposure therapy, but with such a small sample size, the results were not statistically significant (Ready, et al., 2010).
Video games are a staple in the lives of most 18-30 year olds, including today’s soldiers, providing them with the accessibility the Vietnam veterans did not have. Some of today’s soldiers may even choose to use the VRE treatment instead of traditional treatment because they can equate it to a video game and fun instead of therapy. In fact, video games, often demonized for the potential for “de-sensitizing” our youth to violence may be an effective protection for the nightmares often accompanying traumatizing events (Gackenbach, Ellerman & Hall, 2011). Soldiers who play video games regularly experienced less threat, had more control, and generally had less war content in their dreams in a recent study, and since nightmares are a large part of PTSD, it may even provide some sort of inoculation against PTSD itself (Gackenbach, et al., 2011). Regarding VRE in particular, a small study was performed using Iraq and Afghanistan active duty service members, comparing VRE to traditional exposure therapy. According to McLay, a Naval officer himself, seven of the ten VRE patients improved by 30% while only one of the nine returning patients had similar results (McLay, Wood, Webb-Murphy, Spira, Wiederhold, Pyne, & Wiederhold, 2011). There are issues with the study, such as small size and the use of a single psychiatrist, but the results were still clinically and statistically significant, showing that VRE is at least as good, if not better than, traditional exposure therapy, at least for this generation of gaming soldiers (McLay, et al., 2011).
As is common when speaking about video games, there is always a voice of dissent and the call that video games are creating monsters. One particular Iraq veteran has started working with a group called “Stay Strong Nation” that is claiming that playing games like Call of Duty can trigger PTSD symptoms and cause aggression (Benedetti, n.d.). She says that playing the games made her recall undesired memories of her time in Iraq, and wants to raise awareness for other veterans that the games can have adverse effects (Benedetti, n.d.). She also claims that she is not on an anti-gaming crusade, and is simply trying to warn veterans that it may not be in their best interest to play the games, especially if they have symptoms of PTSD (Benedetti, n.d.). The article references a Marine Corporal who went missing after playing Call of Duty 4, and was found dead later (Benedetti, n.d.). He was believed to have had flashbacks and hallucinations triggered by the game, which caused him to flee (Benedetti, n.d.). The difference in this situation, however, is that VRE is not simply “playing video games.” It is a therapy option that can be used by licensed psychiatrists in the safety of their offices. Veterans who experience PTSD symptoms, whether induced by video games or not, should always seek help from a psychiatrist.
A soldier lost to PTSD is still a soldier lost, and virtual reality is becoming a valid treatment option for returning these wounded warriors to the fight and their families. Using virtual reality and a computer program similar to a video game, psychiatrists can help their patients maintain a connection to their memories by introducing sights, sounds, and even smells that may help trigger previously buried details of their trauma. While the treatment works for Vietnam veterans, many are unwilling to use the technology, possibly due to a generational gap as pertains to computer familiarity. On the other hand, current soldiers are often using video games, even in theater, to relieve stress, and may take to the technology quickly. VRE has been shown in small studies to be at least as effective as traditional treatment options for Iraq and Afghanistan veterans, even when used in theater, such as at Camp Fallujah in Iraq. It is time to declare “Game Over” for PTSD and its hidden scars.
Benedetti, W. (n.d.). Vets warn soldiers with PTSD to avoid war games. NBC News. Retrieved September 30, 2012 from http://www.nbcnews.com/technology/ingame/vets-warn-soldiers-ptsd-avoid-war-games-125242
Freedman, S., Hoffman, H., Garcia-Palacios, A., (Tamar) Weiss, P., Avitzour, S., & Josman, N. (2010, Feb.) Prolonged Exposure and Virtual Reality- Enhanced Imaginal Exposure for PTSD Following a Terrorist Bulldozer Attack: A Case Study. CyberPsychology, Behavior & Social Networking, 13(1), p. 95-101. Retrieved September 30, 2012 from EBSCOhost.
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McLay, R., Klam, W., & Volkert, S. (2010a, October). Insomnia is the Most Commonly Reported Symptom and Predicts Other Symptoms of Post-Traumatic Stress Disorder in U.S. Service Members Returning From Military Deployments. Military Medicine, 175(10), pp. 759-762. Retrieved October 12, 2012 from EBSCOhost.
McLay, R., McBrien, C., Wiederhold, M., & Wiederhold, B. (2010b, Feb.). Exposure Therapy with and without Virtual Reality to Treat PTSD while in the Combat Theater: A Parallel Case Series. CyberPsychology, Behavior & Social Networking, 13(1), p. 37-42. Retrieved September 30, 2012 from EBSCOhost.
McLay, R., Wood, D., Webb-Murphy, J., Spira, J., Wiederhold, M., Pyne, J. & Wiederhold, B. (2011, Apr). A Randomized, Controlled Trial of Virtual Reality-Graded Exposure Therapy for Post Traumatic Stress Disorder in Active Duty Service Members with Combat-Related Post-Traumatic Stress Disorder. CyberPyschology, Behavior & Social Networking, 14(4), p. 223-229. Retrieved September 30, 2012 from EBSCOhost.
McLay, R. (2012). At War with PTSD: Battling Post Traumatic Stress Disorder with Virtual Reality [Kindle edition]. Johns Hopkins University Press: Baltimore.
NIMH. (n.d.) Post-Traumatic Stress Disorder (PTSD). National Institute of Mental Health. Retrieved October 13, 2012 from http://www.nimh.nih.gov
Ready, D., Gerardi, R., Backscheider, A., Mascaro, N., & Rothbaum, B. (2010, Feb.). Comparing Virtual Reality Expowsure Therapy to Present-Centered Therapy with 11 U.S. Vietnam Veterans with PTSD. CyberPsychology, Behavior & Social Networking, 13(1), p. 49-54. Retrieved September 30, 2012 from EBSCOhost.
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