Post-Traumatic Stress Disorders & Virtual Reality

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Matthew van den Steen

Human-Computer Interaction


Research on: Post-Traumatic Stress Disorders & Virtual Reality

Link to research assignment

Started: November 2008

Status: case study, writing final thesis report


Whether people go to work, study, or plan their holidays, there is most likely something out there that puts them in an inevitable stressful situation. Despite the fact that most people want to avoid such situations, they can often handle them without any problems or complications. However, it is a whole different story when someone is exposed to a traumatic event beyond the bounds of common, everyday human experiences. In such cases a person can develop a ‘Post-Traumatic Stress Disorder’ (PTSD) [1]. This type of anxiety disorder is often linked to military soldiers who have witnessed a stressful event, but it can also affect people who have, for example, been in a motor accident or people who were confronted with a personal assault.

A wide range of possible options for treatment include therapies such as ‘prolonged imaginal exposure therapy’, ‘in vivo exposure’ and ‘eye movement desensitization and reprocessing’ (EMDR). Alternatively, various medicines are available to help patients cope with their disorder.

With the emergence of better and faster technology, various new approaches have been proposed. One such approach is the use of ‘Virtual Reality’ [2]. This technique enables the patient to interact in a virtual representation of the world. ‘Virtual Reality Exposure Therapy’ (VRET) [2] is one particular way of treatment and is already being used in practice to help people suffering from several different phobias other than a PTSD, such as, but not limited to, acrophobia and agoraphobia. In these worlds a variety of anxiety-provoking stimuli can be triggered at any time. Because the level of these stimuli can be changed, it is possible to gradually expose the patient to various levels of intensity. Studies [3] have shown promising results. However, is ‘VRET’ or virtual reality in general also a good way to treat patients suffering from a PTSD? Key aspects related to ‘Virtual Reality’ (such as ‘presence’) may be of importance, but what about other elements, if any?

A study [4] has shown that when a therapy lacks to engage the patient emotionally, it will often lead to poor, undesirable results. The same study states that facts about both the patient and the whole ordeal need to be present in order to evoke emotions. Due to certain patients either avoiding specific moments of the event, or not being able to express themselves thoroughly, it is often very difficult to gather all of the facts and link them together. It is also said that in some cases the patient even has an unrealistic view of what might have happened.

Traditional treatment for patients with a PTSD poses several problems while trying to engage the patient emotionally, whereas the use of ‘Virtual Reality’ makes it possible to accomplish this gradually with the help of a set of pre-defined stimuli. It is essential to look at traditional treatment first and see if, for example, ‘VRET’ or ‘Virtual Reality’ in general can be used to enhance the effects which are currently obtained without the help of these new techniques. This research assignment will therefore not only include research on how ‘Virtual Reality’ can be used to help people with a PTSD, but also traditional treatments and their important aspects will be taken into account.

Discussion points

Right after the literature study, several ideas and discussion points arose.

Virtual Reality has shown to be a useful technique for helping people suffering from a wide range of anxiety disorders. As stated in the literature study, Virtual Reality can have a positive effect on PTSD treatment as well.

A huge difference between this kind of disorder and other anxiety disorders is the memory element. Creating a virtual environment for people with a spider phobia does not appear to be too complicated. One generalized world (featuring several stimuli to change the level of exposure) may already be sufficient to treat such a group of people. This is not the case with PTSD. The virtual worlds need to correspond to the stories of the patients, or at least, the virtual worlds have to engage the patient emotionally. Elements associated to the patient’s ‘fear structure’ are needed. So far nothing is known about how exact the virtual world should resemble the patient’s memory. However, even if the virtual worlds do not need to be very exact, it will still be a cumbersome task to create virtual worlds for each and every patient. Especially if only a short amount of time is given. Creating a virtual environment for a group of people who have faced the same stressor(s) or were present at the same location is more sufficient. Parts can be reused and a toolset can be developed to customize the more general virtual world according to the patient’s needs.

As seen with traditional methods, sharing and self-confrontation can also benefit patients suffering from a PTSD. This can be done by, for example, letting patients write down their emotions and feeling at the time the trauma took place. However, it can be very difficult for patients to write about their emotions or to remember specific events. Similar problems arise with other exposure variants. The use of images or 3D objects may trigger a patient’s memory or emotion.

One possible way to combine several elements discussed in this research assignment is to let the patient create its own virtual world. Creating a world from scratch may be impossible, but letting the patient, with the help of the therapist, add buildings, people and actions to a specific unfinished world sounds more within reach. In some situations the patient’s notion of time can be wrong. Together with the option of viewing the environment from different angles new learning, self-confrontation and reappraisal can take place. Objects within the environment can trigger a patient’s memory and emotion, allowing habituation of the stressor(s). Because the patient has to create the virtual world together with the therapist, the aspect of sharing is included as well.

Towards a new system

The idea of a system were the patient can manipulate a 3D environment shows potential. Currently, therapists use a sheet of paper with a drawn map on it to let the patient explain what happened during the time the stressor took place. The patient is free to draw additional objects and buildings while telling about the events that took place. An application using a (realistic) 3D environment can add more features to this approach. It might not only provoke anxiety, but may also help the patient to remember things othrwise forgotten. Before such an application can be realized, a scenario has to be written. Several ideas and theories from former meetings and brainstorm sessions with therapists of UMC (Utrecht) resulted in one main scenario with a couple of alternative routes. Multiple video clips are combined and show how the therapist and the patient are using the system in a session. This scenario does not only provide the therapists with an overview of the general concept, but it also provokes thoughts and ideas useful for the realization of the application. Each step in the scenario comes with a set of claims. Therapists can respond to these claims by giving comments or possible alternatives.

1. Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

2. Harvey, A.G., R.A. Bryant, and N. Tarrier, Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review, 2003. 23(3): p. 501-522.

3. Bush, J., Viability of virtual reality exposure therapy as a treatment alternative. Computers in Human Behavior, 2008. 24(3): p. 1032-1040.

4. Difede, J., et al., Virtual reality exposure therapy for the treatment of Posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 2007. 68(11): p. 1639-1647.