Terry Schell, Ph.D., received a Ph.D. in social psychology from the University of California, Santa Barbara and completed a postdoctoral fellowship at the University of Illinois, Urbana-Champaign in psychological measurement and modeling. Currently, his primary area of research is the study of trauma and mental health problems. This has included work within military, veteran, refugee, natural disaster and crime victim populations. He also maintains programs of research on substance use, racial bias in policing, evaluation of criminal justice programs, barriers to mental health services, and psychosocial measurement. Dr. Schell is the Lead Investigator of the longitudinal survey of individuals previously deployed to Operations Iraqi Freedom/Operation Enduring Freedom (e.g., Schell & Marshall, 2008). Dr. Schell is currently the PI of an NIMH R01 award examining the health of war veterans over time, and a recently completed NIMH R01 award investigating the natural course of PTSD symptoms.

The Invisible Wounds of War

Since October 2001, approximately 2 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom in Afghanistan and Iraq. Early evidence suggests that many returning service members may be suffering from post-traumatic stress disorder and depression. In a large study funded by California Community Foundation, and subsequently by NIMH, RAND has investigated the post-deployment health-related needs associated with post-traumatic stress disorder and major depression; examined the treatment capacity of the current health care system, and estimated the costs of providing quality health care to all military members who need it. This current presentation will present data on the prevalence of these conditions among returning service members, the risk factors for these problems, and the economic costs and benefits of expanded access to evidence-based treatment. The presentation will also include information that goes beyond the data available in RAND’s Invisible Wounds of War book, including data on the longitudinal course of mental health symptoms in this population and the mental health treatment preferences of service members.

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Barbara Olasov Rothbaum, Ph.D. is a professor in psychiatry and Associate Vice Chair of Clinical Research at the Emory School of Medicine in the Department of Psychiatry and Behavioral Sciences and director of the Trauma and Anxiety Recovery Program at Emory. Dr. Rothbaum specializes in research on the treatment of individuals with anxiety disorders, particularly focusing on Posttraumatic Stress Disorder (PTSD). She has authored over 200 scientific papers and chapters, has published 4 books on the treatment of PTSD and edited 2 others on anxiety, and received the Diplomate in Behavioral Psychology from the American Board of Professional Psychology. She is a past president of the International Society of Traumatic Stress Studies (ISTSS), is currently on the Scientific Advisory Boards for the Anxiety Disorders Association of America (ADAA) and the Obsessive Compulsive Foundation (OCF), and the Board of Directors for ADAA, and is a pioneer in the application of virtual reality to the treatment of psychological disorders. She is a fellow of the American Psychological Association’s Division 56 (Division of Trauma Psychology) and was awarded with her collaborating team the 2010 “Award for Outstanding Contributions to the Practice of Trauma Psychology” for APA Division 56 and the Robert S. Laufer Award for Outstanding Scientific Achievement from the International Society for Traumatic Stress Studies (ISTSS). She is a member of the Institute of Medicine’s (IOM) Study on Assessment of Ongoing Efforts in the Treatment of PTSD. Her current NIMH grants focus on treating chronic PTSD in Iraq veterans using virtual reality exposure therapy combined with medication (d-cycloserine, alprazolam, or placebo), trying to prevent the development of PTSD in emergency room patients, and testing a CRF1 antagonist for the treatment of PTSD in females.

History of Virtual Reality as an Adjunct to the Treatment of Anxiety Disorders and Virtual Vietnam

Cognitive behavioral therapy (CBT) includes a variety of treatment programs that have been found useful for treating anxiety. One form of CBT particularly useful with individuals with anxiety disorders is exposure therapy, which assists patients in confronting their feared memories and situations in a therapeutic manner. A relatively new medium for delivering exposure therapy uses Virtual reality (VR). VR offers a human–computer interaction system in which users are no longer simply external observers of images on a screen but are active participants within a computer-generated three-dimensional virtual world. Virtual environments exist for the fear of heights, flying, public speaking, and for posttraumatic stress disorder (PTSD), among others. The first virtual reality environment used to treat a psychiatric disorder was for the fear of heights. The history of VR leading to the first VR used to treat PTSD in Vietnam combat Veterans will be presented, as will preliminary results of ongoing trials with Virtual Iraq.

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Albert “Skip” Rizzo received his Ph.D. in Clinical Psychology from the State University of New York at Binghamton. He is an Associate Director at the University of Southern California Institute for Creative Technologies (Medical Virtual Reality) and has Research Professor appointments with the USC Dept. of Psychiatry and Behavioral Sciences, and at the USC Davis School of Gerontology. Dr. Rizzo conducts research on the design, development and evaluation of Virtual Reality (VR) systems targeting the areas of clinical assessment, treatment and rehabilitation. This work spans the domains of psychological, cognitive and motor functioning in both healthy and clinical populations. In the psychological domain, the Virtual Iraq/Afghanistan project has focused on the creation of a VR exposure therapy application for combat-related PTSD with OIF/OEF service members and veterans. This system, available at 55 clinics, is now being retooled for a resilience training application for use at prior to a combat deployment. He is also involved with ICT collaborators in the creation of artificially intelligent virtual human patients that clinicians can use to practice skills required for challenging clinical interviews and diagnostic assessments (sexual assault, resistant patients, etc.) and for creating online virtual human healthcare guides for breaking down barriers to care in psychological health and TBI. His cognitive work has addressed the use of VR applications to test and train attention, memory, visuospatial abilities and executive function. In the motor domain, he has developed VR Game systems to address physical rehabilitation post stroke and Traumatic Brain Injury and for those aging with a disability. He has also investigated the use of VR for pain distraction at LA Children’s Hospital and has conducted research on VR applications that use 360 Degree Panoramic video for role-playing applications (anger management, etc.), journalism studies and digital media art creation. In spite of the diversity of these areas of research and development, the common thread that drives all of these applications involves the study of how VR simulation technology can be usefully applied to serve the needs of the user/client/patient in a manner that goes beyond what is available with traditional 20th Century tools and methods. He was awarded the Laval Virtual Reality International Conference “Best Medical Application” in 2008 for “Virtual Iraq”, “Best Medical Application” and ‘Best of Show” in 2003 for the “Virtual Classroom for Attention Process Assessment” project. He recently received the “American Psychological Association 2010 Award for Outstanding Contribution to the Practice of Trauma Psychology” and the MMVR Satava Award for excellence in the use of VR for therapeutic applications. In his spare time, he plays rugby, listens to music, rides his motorcycle and thinks about new ways that VR can have a positive impact on clinical care by dragging the field of psychology, kickin’ and screamin’, into the 21st Century. To view some videos on his work, please visit this YouTube channel.

The Virtual Iraq/Afghanistan Exposure Therapy System for PTSD

Numerous reports indicate that the growing incidence of posttraumatic stress disorder (PTSD) in returning OEF/OIF Service Members and Veterans is creating a significant healthcare and economic challenge. These findings have served to motivate research on how to enhance the development and dissemination of evidence-based treatments for PTSD. Virtual Reality delivered exposure therapy (VRET) for PTSD has been previously used with reports of positive outcomes. This presentation will detail the development and initial results from use of the Virtual Iraq/Afghanistan exposure therapy system with active duty Service Members and Veterans. The system consists of a series of customizable immersive virtual scenarios designed to represent relevant Middle Eastern contexts, including city, desert and mountainous environments and has been disseminated to 55 sites for use as a tool for delivering prolonged exposure. The initial process for gathering user-centered feedback from returning OEF/OIF military personnel to inform the evolution of the system will be discussed. This will be followed by a summary of initial treatment results and an overview of how the system is being re-purposed for PTSD assessment and resilience training. The presentation will conclude with the unveiling of the “next-generation” Virtual Iraq/Afghanistan system. The system rebuild was commenced in 2011 using state of the art software to expand the diversity and detail of the exposure content based on feedback from clinicians and patients who had used and experienced the original VRET system. This feedback informed the development and evolution of the system such that it may have more clinical relevance for a wider range of combat experiences.

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Dr. Risbrough received her B.A. degree in Psychology and her Ph.D. in Neuroscience from the University of California, San Diego. She joined the Psychiatry Department at UCSD in 2007. Dr. Risbrough focuses on translational studies of post-traumatic stress disorder as well as other neuropsychiatric illnesses. She is the Principal Investigator on awards from the National Institute of Health, NARSAD and the U.S. Department of Defense and was a recent Guest Editor for the 2012 Neuropharmacology PTSD Special Issue. She is Chief of the Psychophysiology Unit of the Center of Excellence for Stress and Mental Health at the San Diego Veterans Healthcare System and is currently directing a prospective study of emotional and cognitive markers of PTSD risk in >1000 Active Duty Marines (Marine Resiliency Study-II).

Dr. Risbrough’s research is centered on translational mechanisms and treatments of anxiety disorders using preclinical and clinical approaches. Her primary focus is understanding mechanisms of risk and resilience to develop anxiety disorders, particularly post-traumatic stress disorder. For example, she examines the contribution of corticotropin releasing factor and the catecholamine system to stress and anxiety responses using pharmacological and genetic techniques in mice. Her program also identifies developmental, genetic, epigenetic and environmental contributions to stress behavior, fear learning and fear extinction across humans and mouse models. By measuring physiological responses to stress (including heart rate and startle reactivity) in animal models and in the clinic, her research provides a bridge between putative causal mechanisms of stress responding in animals with biomarkers and treatment targets in PTSD patients.

Unraveling the Neurobiology of Fear Extinction

Fear extinction (FE) occurs when an organism learns through repeated exposure that a cue previously associated with an aversive event (e.g. trauma) no longer predicts the aversive event and conditioned fear responses dissipate. This phenomenon is critical for trauma recovery and is the basis for arguably one of the most effective treatments for PTSD, exposure therapy. However much is left to be understood of the mechanisms of fear extinction in order to enhance treatment efficacy and identify potential at risk populations (e.g. poor extinguishers). Here we will briefly review the evidence for extinction abnormalities in PTSD patients and the putative circuit and pathway mechanisms that may play a role in these abnormalities. We will describe our approach to identify mechanisms of individual differences in fear extinction and fear circuit abnormalities using a mouse model of fear recovery. We found that epigenetic mechanisms affect fear extinction potentially through alterations in frontal cortex spine density and morphology. We will also describe a recent study examining oxytocin treatment effects on fear extinction learning and recall in humans, showing that oxytocin may facilitate extinction recall. Finally, we will describe ongoing prospective studies in Active Duty Marines in which fear conditioning and extinction tasks are being tested for validity to predict PTSD risk and resilience, and to identify novel biomarkers associated with these fear processes that contribute to emotion regulation and recovery.

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Dr. Difede is a Professor of Psychology in Psychiatry at Weill Cornell Medical College, an Attending Psychologist at the New York-Presbyterian Hospital/Weill Cornell Medical Center, and Director of the Program for Anxiety and Traumatic Stress Studies in the Department of Psychiatry. She is internationally recognized for her pioneering work using virtual reality technology in the treatment of PTSD consequent to the WTC attack of September 11, 2001, and more recently in treatment of combat-related PTSD. Dr. Difede has served as the PI of several NIH-funded treatment studies concerning the development of innovative treatments for PTSD. She is also the recipient of many grants and corporate medical contracts for projects concerning the delivery of optimal care for trauma survivors and their families, both from private foundations and publicly held Fortune 500 corporations. Her treatment research spans survivors of burn injuries, terrorism, and occupations at-risk for PTSD, including U.S. soldiers deployed to OIF/OEF, firefighters, police officers, and disaster rescue and recovery workers. Previously, she established a program at Weill Cornell to screen and treat civilians, disaster workers and their families affected by the WTC attacks; a program that continues to serve the community today.

Dr. Difede is currently the PI of a multi-site, randomized controlled clinical trial funded by the Department of Defense entitled, “Enhancing Exposure Therapy for PTSD: Virtual Reality and Imaginal Exposure with a Cognitive Enhancer,” for the treatment of combat-related PTSD. The study will examine the effects of virtual reality enhanced exposure therapy versus prolonged exposure therapy, and will determine if this therapy can be enhanced by adding DCS versus placebo. She is also the co- PI of an NIH and Weill Cornell Clinical and Translational Science Center feasibility study providing a mental health education and wellness curriculum to active duty service members and veterans via simultaneous videoconferencing technology.

Dr. Difede is currently serving on the NYC Mayor’s Advisory WTC Working Medical Group, the editorial board of the Journal of Traumatic Stress (JTS), the Scientific Advisory Board for the American Anxiety Disorders Association, and the advisory board of the Jericho Project, a non-profit foundation serving homeless veterans. She has advised many corporations, non-profit organizations, and governmental agencies in the U.S. and internationally regarding the implementation of best practices for the screening, evaluation and treatment of trauma and PTSD. Additionally, Dr. Difede has served on NIH special emphasis review panels on occupations at-risk for trauma and PTSD and CDMRP review panels, among others.

Dr. Difede received the 2010 Award for Outstanding Contributions to the Practice of Trauma Psychology from the American Psychological Association’s Division of Trauma. In addition to her scholarly endeavors, her work has been featured in many popular media venues including the New Yorker, the NY Times, Newsweek, the Washington Post, Scientific American as well as on many television programs including CNN, NBC and ABC’s World News Tonight with Peter Jennings. Notably, she was featured in New York magazine’s Best Doctors issue in 2005 for her work developing a virtual reality-based treatment for WTC-related PTSD, and was profiled in September 2011 for the tenth anniversary of the WTC attacks in a leading international medical journal, The Lancet, for her work developing innovative treatments for PTSD.

Augmentation of Virtual Reality Exposure Therapy for WTC-related PTSD with a Novel Pharmaceutical Agent for the Treatment of Chronic PTSD

The development of virtual reality software for the treatment of PTSD and the facilitation of exposure therapy with a cognitive enhancer will be discussed. Our current research builds upon our previously published work, which showed that virtual reality exposure (VRE) therapy was a promising new treatment for WTC-related PTSD. In the current study, we extended the earlier work by enhancing VRE therapy with a novel pharmacological agent. The principal aim of the study was to conduct an evaluation of the pharmacologic agent d-cycloserine (DCS) as an enhancer of exposure therapy for the treatment of WTC-related chronic PTSD. DCS, a broad spectrum antibiotic, has been shown to facilitate extinction learning, the mechanism hypothesized to underlie exposure therapy, in animal models of conditioned fear. In this randomized double-blind controlled clinical trial, twenty-four participants with chronic PTSD were assigned to one of two treatment groups: 1) VR-DCS or 2) VR-placebo. Twelve weekly, ninety-minute treatment sessions were given. Standardized assessments, completed by an assessor blind to treatment condition, were conducted pre- and post-treatment, and at six-months. Patients in the VR-DCS (n=13) group showed earlier, greater and longer lasting improvement compared to the VR-placebo (n=12) group. The difference between the VR-DCS and VR-placebo groups increases linearly over time (the between group effect sizes (Hodges d) at post-treatment and six-months were medium and large, (d=.44 and d=.85 respectively)). A similar pattern of results was observed for depression (BDI) and anger (Staxi-II) scores. These results hold promise for reducing the distress and disability associated with PTSD.

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Tanja Jovanovic received her Ph.D. in Neuroscience and Animal Behavior from Emory University in 2002, and is currently an Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Emory University School of Medicine. Dr. Jovanovic has significant expertise in psychophysiological research with PTSD patients, as the focus of her NIMH postdoctoral fellowship (NRSA) was fear potentiated startle in combat-related PTSD. For the last decade she has been investigating mechanisms of fear inhibition using fear-potentiated startle in combat veterans and civilians with PTSD. She also set up an international collaboration with a team of clinicians are researchers from the University Hospital Zagreb in Croatia, in order to use the fear inhibition paradigms with Croatian war veterans with PTSD. Dr. Jovanovic directs a research program focusing on the interaction of neurophysiology, neuroendocrinology, and genetics in mental disorders. She heads the Neurophysiology laboratory of the Grady Trauma Project in Atlanta, and is the PI on two NIMH R21 grants to examine the effects of cortisol suppression on fear-potentiated startle in PTSD and neuroimaging correlates of fear inhibition in PTSD. In addition, she was awarded a NARSAD Young Investigator Award for her research examining early precursors of fear dysregulation in children of mothers with PTSD. Her research has resulted in over 50 peer-reviewed publications, and national and international recognition in the field of PTSD neurobiology.

Psychophysiological Approach to Assessing Startle Response Conditioning and Extinction

The symptoms of posttraumatic stress disorder (PTSD) can be described, at least in part, as dysregulated fear responses. We have used fear conditioning paradigms in both combat and civilian trauma populations, and have shown that PTSD is associated with increased fear responses to conditioned danger cues and impaired fear inhibition to conditioned safety cues. In addition, PTSD subjects have deficient extinction of conditioned danger cues. In the present study, fear-potentiated startle was examined in individuals exposed to civilian trauma with and without PTSD. We measured electromyography of the eyeblink muscle contraction during startle, as well as skin conductance responses, as psychophysiological indices of conditioned responses. We used a differential fear conditioning protocol in which one colored shape (reinforced conditioned stimulus, CS+) was paired with an aversive airblast to the larynx and a different colored shape was not paired to the airblast (nonreinforced condition stimulus, CS-). Fear was extinguished 10 minutes later through repeated presentations of the CSs without reinforcement. Both groups demonstrated successful fear conditioning, however, participants with PTSD displayed greater fear-potentiated startle responses to the CS+ and CS- compared to the trauma group without PTSD. During fear extinction, the PTSD group showed elevated fear-potentiated startle responses to the previously reinforced CS+ during extinction compared to controls. These results suggest that PTSD is associated with enhanced fear expression of fear to the danger signal (CS+), impaired inhibition of fear during presentation of the safety signal (CS-) and deficits in extinction of fear to the CS+.

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Dr. Raskind’s career first focused on brain noradrenergic abnormalities in aging and Alzheimer’s disease. This background served him well as his focus broadened to military PTSD after assuming directorship of the VA Puget Sound Health Care System Mental Health Service. Dr. Raskind’s search for better treatments for military PTSD began with his clinical experience as medical advisor to the VA Puget Sound African American Veterans Stress Disorders Program beginning in 1995 (a role he continues to the present). The most common and distressing symptoms reported by these Vietnam combat Veterans with chronic PTSD are terrifying combat reenactment nightmares that awakened them sweating, anxious and unable to return to their severely disrupted sleep; and daytime irritability, hypervigilance and unpredictable anger outbursts that continued to destroy careers and families decades after these Veterans had returned from war. Dr. Raskind observed that these treatment resistant PTSD symptoms appeared to arise from a persistent and now maladaptive increased brain response to the “adrenaline-like” stress chemical, norepinephrine. Dr. Raskind reasoned that a medication that normalized the brain norepinephrine response and was able to enter the brain easily would alleviate these Veterans’ previously treatment resistant PTSD symptoms. Prazosin, an inexpensive norepinephrine “blocker” drug introduced to treat hypertension in 1973, was just such a medication and it worked! First with VISN 20 MIRECC support, and then with VA R&D Merit Review and DoD funding support, Dr. Raskind and his colleagues completed three positive randomized controlled trials of prazosin for PTSD in Vietnam Veterans at VA Puget Sound and in active duty soldiers at Joint Base Lewis McChord who have returned from Iraq and Afghanistan combat deployments (study performed by VA and Army personnel on site at JBLM). This active duty soldier MIRECC study is the first ever performed for any behavioral disorder in active duty combat experienced service members, and a pioneering example of VA/DoD collaboration. Prazosin is increasingly widely prescribed across VA and DoD for PTSD. Over 50,000 Veterans with PTSD were prescribed prazosin in 2010 and the number treated with prazosin has further increased in 2011. Dr. Raskind also noted prazosin reduced or eliminated alcohol abuse as “self medication” in the Veterans whose PTSD symptoms responded beneficially to prazosin. And, coming full circle to Alzheimer’s disease, he and his colleagues have demonstrated that increased noradrenergic activity contributed to agitation in dementia. In recognition of his contributions to noradrenergic system involvement in PTSD, alcohol abuse, and dementia, Dr. Raskind was selected as the 2011 Barnwell awardee, VA’s highest honor for excellence in clinical research.

Application of Novel Pharmacotherapies for OIF/OEF Veterans with PTSD

Trauma nightmares and sleep disruption are among the most prominent and treatment-resistant symptoms for which combat Veterans (and many civilians) with PTSD seek treatment. These nighttime symptoms, as well as daytime hypervigilance and irritability/anger PTSD hyperarousal symptoms, likely reflect increased brain responsiveness to the arousing effects of norepinephrine (the “adrenaline” of the brain). Prazosin is an inexpensive, non-sedating, generic alpha-1 adrenoreceptor antagonist approved in the 1970’s for treatment of hypertension by reducing response of peripheral blood vessels to norepinephrine. Because prazosin easily enters the brain, it is a rational approach to reducing excessive brain responsiveness to norepinephrine. At the VA Puget Sound Health Care System MIRECC in Seattle, we carried out two placebo controlled prazosin studies in Vietnam combat Veterans with chronic PTSD and intractable distressing combat trauma nightmares. Both studies demonstrated substantial improvement in nightmares, sleep quality and global function. A third study in mostly women civilian trauma PTSD patients confirmed the positive results seen in Veterans and demonstrated that prazosin increased total sleep time by 93 minutes and reduced total PTSD symptoms compared to placebo. Two recent studies have found similar beneficial prazosin results in Veterans and active duty soldiers returned from Iraq and Afghanistan. At the University of Pittsburgh, investigators demonstrated that both prazosin and behavioral treatment for insomnia are superior to placebo for reducing sleep disturbance and total PTSD symptoms. Our group recently completed a 15 week placebo controlled prazosin trial in 67 active duty Soldiers at Joint Base Lewis McChord. This study added a modest daytime prazosin dose (up to 5 mg midmorning) to the usual larger nighttime dose (up to 20 mg an hour before bed). Again, prazosin was effective for nightmares, sleep quality, global function and total PTSD symptoms. In all of these studies, prazosin has been well tolerated. Supporting prazosin effectiveness and acceptance, the percentage of Veterans with a PTSD diagnosis across the VA health care system prescribed prazosin has increased steadily from 2% in 2003 to 13% in 2011. Future studies will address the role of prazosin for alcohol use disorders comorbid with PTSD, headache following blast concussion mild traumatic brain injury, and the possibly synergistic beneficial effects of prazosin and evidence-based psychotherapies.

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Deborah C. Beidel, Ph.D., ABPP is Professor of Psychology and Director of the Doctoral Program in Clinical Psychology at the University of Central Florida. She received her Ph.D. in Psychology (Clinical) from the University of Pittsburgh in 1986. She holds American Board of Professional Psychology and completed a post-doctoral fellowship in clinical research at Western Psychiatric Institute and Clinic. Dr. Beidel holds Diplomates in Clinical Psychology and Behavioral Psychology and is a Fellow of the American Psychological Association and the Association for Psychological Science. She is the 1990 recipient of the Association for Advancement of Behavior Therapy’s New Researcher Award, the 1995 recipient of the Distinguished Educator Award from the Association of Medical School Psychologists, and the 2007 recipient of the Samuel M. Turner Clinical Researcher Award from the American Psychological Association. She is the author of over 200 scientific publications including journal articles, book chapters and books on the treatment of anxiety disorders and post-traumatic stress disorder. Dr. Beidel is the recipient of numerous grants from the National Institute of Mental Health and the Department of Defense. Her recent work focuses on utilizing technology to translate and disseminate efficacious treatments for anxiety disorders into standard clinical practice. Most relevant to her presentation here today, Dr. Beidel is the principal investigator on a grant funded by the Department of Defense/United States Army Military Operational Medical Research Program to examine the efficacy of two newly developed interventions for the treatment of PTSD in veterans of OIF/OEF/OND. One of these new modalities will examine the use of Virtual Iraq to enhance exposure-based treatments for PTSD – in addition to audio and visual cues, this virtual reality system will include olfactory stimulation, thereby providing the most realistic intervention to date for the treatment of this disorder.

Trauma Management Therapy for Combat-Related PTSD

In addition to its core symptoms (intrusive thoughts, reexperiencing, hyperarousal, and avoidance), PTSD is associated with social maladjustment, poor quality of life, and medical comorbidity. Exposure therapy, which operates on long-established and fundamental principles of behavior therapy, offers hope for acute symptom alleviation, but some patients have difficulty imagining the traumatic events, resulting in attenuated treatment response. Virtual reality (such as Virtual Iraq) offers an opportunity to augment exposure therapy through the virtual presentation of the sights, sounds, and smells of the traumatic event and represents an important tool when exposure therapy is the treatment of choice. As noted, PTSD is associated with social avoidance, guilt, anger, and unemployment, impulsive or violent behavior, and family discord (Frueh et al., 1995), symptoms that are not specifically addressed with exposure therapy. Trauma Management Therapy (TMT; Frueh et al., 1996; Beidel, et al.2010) combines individual exposure therapy with group social and emotional rehabilitation skills training. In this presentation, we present the rationale, design and status of our ongoing U.S. Army Military Operational Medical Research Program funded, 17 week clinical research program for the treatment of combat-related PTSD. In this project, we compare exposure therapy only (using Virtual Iraq) to TMT (exposure therapy using Virtual Iraq plus anger management, social reintegration and behavior activation therapy for depression). Additionally, we are examining the efficacy of a three week intensive TMT program in comparison to our standard 17 week program. Preliminary results regarding feasibility and acceptability will be discussed.

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Dr. Buckwalter has an active career both as an academic research scientist and as an entrepreneur in the private sector. Dr. Buckwalter’s academic career, with over 100 peer reviewed publications, has focused on psychological applications for virtual reality, psychoneuroendocrinology, resilience, advanced statistical methods and personality. In the private sector Dr. Buckwalter focuses on advanced assessment methodologies, was a co-founder of eHarmony.com and is currently developing TidePool.co, a self-quantization tool. Since coming to ICT in 2009, Dr. Buckwalter has joined the Medical VR group under the direction of Dr. Skip Rizzo. Dr. Buckwalter provided clinical and design input for the SimCoach project. As part of this project, he is comparing the administration of psychometric tests given by an avatar to standardized administration. Dr. Buckwalter has also played a key role in developing the Stress Resilience in Virtual Environments (STRIVE) project. This project uniquely combines advanced analysis of biomarkers related to stress, psychophysiological measurements and the use of VR to engage warfighters in both stressful events and resilience training prior to deployment. He is also working in conjunction with psychologists at Headington Institute to develop and validate a multi-dimensional measure of resilience, the Headington Institute Resilience Inventory (HIRI).

Stress Resilience in Virtual Environments

Coming soon...

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Nancy Skopp received her undergraduate degree from the University of Texas at Austin and her Ph.D. in Clinical Psychology from the University of Houston. Dr. Skopp is a Research Psychologist and Program Manager for the National Center for Research, Outcomes, Surveillance, and Evaluation (ROSE) Division of Telehealth and Technology (T2). She is also an Affiliate Associate Professor at the University of Washington Medical School Department of Psychiatry and Behavioral Sciences.

Dr. Skopp is a co-investigator on a large DoD suicide grant designed to examine suicide mortality in relation to deployment among a large military cohort comprising 4.1 million current and former service members. She also leads and manages several research initiatives related to advancing knowledge of suicidal behavior among Service members and veterans. Her other research interests are military mental health stigma and innovative technology-based psychological health interventions and tools for military personnel, veterans, and their families.

Dr. Skopp serves as a research liaison for T2’s Innovative Technology Applications (ITA) division where she is involved in a number of research projects aimed at levering innovative technology to support the psychological health and resilience of service members, veterans, and their families. She is currently conducting an evaluation of T2’s Prolonged Exposure (PE) Coach mobile application as an adjunct to PE therapy. The PE Coach eliminates the need for the paper-and-pencil method of tracking goals, completing homework and recording daily results of in vivo exposure. Other technology based projects led by Dr. Skopp include an evaluation of T2’s Virtual PTSD Experience, a virtual environment based in Second Life. The Virtual PTSD Experience is an immersive, interactive learning experience designed to educate visitors about combat-related post-traumatic stress disorder (PTSD). Dr. Skopp is also part of a T2 research team that received a DoD grant to conduct a randomized controlled trial to evaluate virtual reality-based PE for US soldiers.

Dr. Skopp initiated a series of projects to support the development and validation of a measure of military mental health stigma as well as a stigma workshop for service members and veterans. The Military Stigma Scale (MSS) was recently published. The MSS was found to be psychometrically strong and to comprise two theoretical aspects to stigma – public and self-stigma. Further validation is underway through the deployment of the measure on the National Center for Telehealth and Technology’s (T2) AfterDeployment.org. Also to be deployed on AfterDeployment.org, is a mental health stigma workshop that is in the final stages of development.

Mobile Apps and Virtual Worlds

The National Center for Teleheath & Technology (T2) designs and builds applications employing emerging technologies in support of psychological health and traumatic brain injury recovery in the military. Equally important is T2’s work toward eradicating stigma that can deter Service Members from seeking help. Dr. Skopp will present an overview of T2 and some recent and long-term initiatives, including a Virtual Reality Exposure Therapy Randomized Controlled Trial (VRET RCT). The rationale for the VRET RCT is based on growing evidence demonstrating that VRET is an efficacious treatment for PTSD and holds the potential to improve access to care for Soldiers who would otherwise avoid treatment. Dr. Skopp will also present on T2’s mobile applications, including the PE Coach, Breath to Relax, and Life Armor among others. In addition, this presentation will cover T2’s Virtual PTSD Experience. The PTSD Experience includes a simulation demonstrating how PTSD may be acquired during a combat-related traumatic event, including an explanation of the connections between danger cues and triggers, the role of avoidance in the development of PTSD, and how PTSD is a normal human response to traumatic events. This virtual environment also includes simulations of PTSD symptoms, helping the visitor learn through interactive activities how PTSD symptoms may show up in a person’s life. Finally, this virtual environment includes information to help visitors determine whether they or a loved one is in need of care, and how to access that care whether a DoD or VA beneficiary.

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Eric currently directs the research and development of the SimCoach virtual human platform at USC’s Institute for creative technologies, bringing virtual characters to the web to support a variety of applications including helping to break down barriers to behavioral healthcare. With a strong background in modeling and simulation and complex systems, his current focus is on building creational tools aims to make virtual humans commodities in the applications marketplace. His earlier ICT successes include the BiLAT negotiation and resilience training systems–the former a U.S. Army Simulation of the Year in 2008– helping to drive technical research through applied technical achievement.

He has fifteen years of experience in developing complex software systems of varying scales. As a senior systems engineer at the MITRE Corporation’s Air Force Center, work included the development of human-oriented virtual trainers, decision support systems and solutions to improve information operations across command and control battle environments for the U.S. Air Force’s Electronic System’s Center. Eric received two B.A. degrees from Bowdoin College in Computer Science and Neuroscience.

SimCoach: Building Virtual Humans for Healthcare

In response to the clinical health care challenges that the OEF/OIF conflicts have placed on the burgeoning population of Service Members, Veterans and their families, USC’s Institute for Creative Technologies started the SimCoach project in late 2009 to develop supportive online virtual human guides for providing basic advice and promoting access to psychological healthcare information. Rather than being a traditional web portal, SimCoach allows users to initiate and engage in an anonymous confidential dialogue about their healthcare concerns with a virtual human. Traditionally, virtual humans have been applied to various training purposes including virtual patients and often are limited to standalone simulations with limited installations and throughput. However, online virtual humans provide an opportunity to engage directly with a large user population to help deal with very real issues, including PTSD and depression. Building autonomous agents that are capable of navigating sensitive interactions is not without risk and carries considerable technical challenges. Additionally, building for an online audience has other challenges in that users will expect accurate and timely information. We fully expect, however, that exposure and use will allow for continuous iterative refinements and gains over time, building a shared technical foundation to serve new virtual guides for related endeavors in the future. Furthermore, we continue to build out an integrated authoring platform, enabling more types of authors than ever the opportunity to directly contribute towards virtual human development. Our web-based application toolkit enables the ability to rapidly generate character content and immediately test the dialogue behavior, natural language understanding and animation quality, and will be critical to enabling a data-driven refinement process for delivering online virtual human systems that stand the test of time. The current version of SimCoach is presently undergoing early testing with a limited group of users. Results from this user centered testing will serve to advance the development of a SimCoach system that is expected to undergo a wider release in 2013. Although this project represents an early effort in this area, it is our view that the clinical aims selected can still be usefully addressed within the limits of current technology. However, we expect that the original aim of SimCoach will continue to evolve over time based on data collected from ongoing user interactions with the system and advances in technology.

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Michael Hollifield received his M.D. with thesis honors from the University of Washington in Seattle, and completed a dual residency training program in Family Medicine and Psychiatry at the University of New Mexico (UNM) in 1994. He is Director of the Program for Traumatic Stress at the VA Long Beach Healthcare System, Associate Professor of Psychiatry at the University of California at Irvine, and a Scientist at the Behavioral Health Research Center of the Southwest.

Dr. Hollifield’s research is about the effects of severe trauma and adverse life events on health outcomes and the development of novel interventions for trauma disorders. His National Institutes of Health funding includes projects for improving measurement of trauma and health in refugees, and for developing novel interventions for posttraumatic stress disorder (PTSD) with acupuncture, imagery rehearsal therapy (IRT), and integrated cognitive behavioral therapy. Regarding his novel intervention work, Dr. Hollifield is primary or co-author on publications that were the first to demonstrate the utility of acupuncture (2007) and imagery rehearsal therapy (2001) for PTSD. Due to these studies, the current Department of Defense/Veterans Affairs guidelines for PTSD (2010) include recommendations for the use of both acupuncture and IRT. Regarding his measurement work, Dr. Hollifield and colleagues have developed The Comprehensive Trauma Inventory-104 to assess the full range of traumatic events experienced by refugees, and the New Mexico Refugee Symptom Checklist-121 to assess persistent and distressing symptoms refugees have as a result of traumatic experiences. As evaluation director for the project Pathways to Wellness, Dr. Hollifield led the development of the Refugee Health Screener-15 (RHS-15), a 15-item instrument that is highly sensitive and specific for detecting PTSD, anxiety, and depression in multiple refugee populations. The RHS-15 is translated into seven languages and used at over 35 public health sites across the country. Other research includes the effects of trauma, PTSD, and depression on immunological, inflammatory, and nervous system functioning and gene expression. His clinical interests parallel his research.

Looking Forward: Novel Interventions and Psychobiology of PTSD

Major summative findings to date indicate that severe chronic PTSD is a complex pathological state that includes HPA axis dysfunction. ANS dysfunction, alterations in CNS processes that influence cognition, emotion, and somatic functioning, and a low level pro-inflammatory state, all of which may mediate the relationship between chronic PTSD and higher risk of medical illness. These biological systems interact in PTSD. For example, the involved CNS limbic areas are central regulators of the HPA axis and the ANS, and this coordinated dysfunction seen in PTSD is compatible with inflammatory disinhibition. Genes that regulate these systems and processes have been identified as likely important regulators of PTSD phenotype(s). You have heard about emerging therapies for PTSD in this symposium. In our NIH/NCCAM supported preliminary trial, we empirically developed then tested a manualized acupuncture intervention based on Traditional Chinese Medicine (TCM) principles. The summary is that acupuncture provided large treatment effects for PTSD symptom scores from pre- to post-treatment, similar in magnitude to group CBT. Acupuncture is now recommended as a treatment option for PTSD in the VA/DOD treatment guidelines for PTSD. Our colleagues have developed Imagery Rehearsal Therapy (IRT) which also has shown to be effective for PTSD, while a few new studies are conflicting. Other novel therapies are emerging. The presenter will review the psychobiology of PTSD and proven or theoretical mechanisms of action that some of the novel and emerging therapies have in common.