The hum of a low-flying plane may not frighten most of us, but the same may not be true for victims of the Sept. 11 World Trade Center attacks--many who are now afflicted with post-traumatic stress syndrome [PTSD].

When the imaginal Prolonged Exposure Therapy proven effective for PTSD victims was not producing results in Sept. 11 survivors suffering from PTSD, doctors were forced to uncover other methods of treatment. They turned to Virtual Reality [VR] Enhanced Exposure Therapy, an innovative therapy already being used to treat phobia victims, which has become an effective solution to help disaster workers and civilians combat PTSD. 

Constantly on Red Alert

“PTSD patients have an exaggerated probability of nature,” says Dr. Barbara O. Rothbaum, professor in psychiatry and director, trauma and anxiety recovery program at the Emory University School of Medicine.

While most people live with an acceptable level of risk, PTSD sufferers experience extremes of safety and danger. Typically they “think their survival is a fluke,” says Rothbaum. “They are always waiting for the other shoe to drop."

An early-life trauma could compound the situation and affect the development of the nervous system and following Sept. 11, “a person with a genetic predictor for fear might always be on red alert.”

Understanding VR

Around the time of the attacks in 2001, Dr. JoAnn Difede, professor of psychology in psychiatry and director of Program for Anxiety and Traumatic Stress Studies at Weill Cornell Medical College, was working with Dr. Hunter Hoffman, director of the Virtual Reality Research Center at the University of Washington, in using VR to help manage pain in burn victims.

Hoffman, along with colleague Dr. Dave Patterson, a professor in rehabilitative medicine at the university, developed a VR therapy called “Snow World,” a computer-generated world much like those seen in movies like “Avatar” or “The Matrix” that simulates an icy 3-D canyon of blues, greens and whites with snowmen, mammoths, penguins and snowballs. The visions are “a total antithesis of fire,” says Hoffman, and act as a non-pharmacologic analgesic typically used along with pain medications.

Little Palm Island Resort & Spa offers guests the chance to dine
reductions in pain during VR, and their brains show large
reductions in pain related brain activity when they play SnowWorld.
(Image by Todd Richards and Aric Bills, UW, copyright
Hunter Hoffman, UW Seattle, www.vrpain.com)

Difede saw benefits in VR that could be used to help Sept. 11 victims suffering with PTSD. The imaginal Prolonged Exposure Therapy, a form of Cognitive Behavioral Therapy that is based on learning, requires that patients repeatedly recount their trauma in the present tense to their therapist to extinguish cues to fear.

However, this methodology was falling short for some Sept. 11 survivors because of their tendency for avoidance and not wanting to talk about the traumatic event. This reticence caused some victims to experience difficulty engaging with the therapy.

In imaginal exposure therapy, the eyes are closed and trauma is processed in the mind’s eye, but VR offers an additional dimension: sensory cues to trauma. Patients can hear and see and in some cases smell; much like returning to the scene of a crime or one’s childhood home, this visual perception triggers a response.

For example, a WTC victim may have been forced to go down the debris-covered stairs; VR treatment creates a picture of stairs and repeatedly presents the cue, which in the present, occurs in a safe situation.

The therapy is systematic and imagery is not used until the fourth session. During the first three sessions, the physician educates patients on treatment, discusses anxiety management and establishes a relationship. Immersive intervention starts in session four and from that point on, the patient will have to confront the fear in 3D over and over until it is extinguished.

With the WTC victims, therapy also includes simulation of the buildings with gradually increasing enhancement, based on how much the patient can tolerate. Beginning with a vision of the Trade Center towers without simulation of the attack, the therapy builds to explosions without sound, a burning and smoking building with a hole where the jet crashed, first without screaming, then with screaming, then with screaming and people jumping. A second jet crashes into Tower II with an explosion and sound effects. The second tower collapses with a dust cloud; the first tower collapses with a dust cloud—finally, the patient is exposed to the full sequence of images.

“We help them to experience this and feel control,” says Difede. “We’re laying down a new memory. Through the repeated presentation, the therapy actually helps the patient extinguish his fear as the brain processes cues to the event. We’re teaching a person that the event took place some time ago and the cues are no longer cues to danger.”

Photo and Copyright by Hunter Hoffman,
UW Seattle

Traditional VR therapy includes about 10 to 12 sessions, with no more than 14. However, researchers at Emory discovered that the use of D-cycloserine (DCS), a medication typically used for pneumonia, works as a cognitive enhancer which hastens the extinction model, according to Difede. Six out of 10 patients do better with only half the number of sessions by using the medication.

The images are not totally banished. “They won’t be nor should they be,” says Difede. “They are an integral part of who the patient is.”

The idea is to eliminate an aspect of memory, the part that causes sweaty palms, and introduce instead one that will not stimulate the automatic nervous system to fear, fight and flight, she says.

Much like with a child who is afraid to open the closet door for fear of the boogey man, or a soldier home from war who nightly hears noises and repeatedly gets up to investigate, the repeated imagery and the therapist’s Socratic questioning helps the patient decipher the exaggerated possibilities, says Rothbaum. The images combined with emotional reasoning pinpoint the difference between feeling scared and the presence of something to actually be scared of.

Says Difede, “On a beautiful day in lower Manhattan, we want patients to see an airplane without feeling fear.”