Tuesday, November 21, 2006

'Virtual 9/11' Brings Ground Zero Survivors Real Healing

(HealthDay News) -- Psychologists estimate that hundreds, even thousands, of people directly affected by the events of Sept. 11, 2001, are still crippled by post-traumatic stress disorder.

Could a virtual-reality "revisiting" of that horrific day actually help them?

New York City psychiatrist Judith Cukor believes that it can.

"We are getting tons of calls for 9/11-related post-traumatic stress disorder -- it's five years out, and we are still seeing people who have never had treatment," said Cukor, an instructor in the department of psychiatry at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "A lot of people have had traditional treatment, too, but it's not helping."

Cukor is supervising a unique clinical trial that uses high-tech virtual reality to help fight the more stubborn cases of 9/11-linked post-traumatic stress disorder, or PTSD. "We're seeing very positive results here, in terms of people finally getting better," she said.

For people who suffer from the emotional numbness, terrifying flashbacks, nightmares and avoidance behaviors of PTSD, "exposure therapy" remains the gold-standard treatment. The therapy involves patients being asked to imagine in detail the past event that caused them such pain.

It sounds counterintuitive, but this type of controlled re-exposure "allows your brain to metabolize it, break it down and deal with it," Cukor explained. "At the end of the treatment, people's memories are still sad and difficult, but they are not taking over their lives."
In many cases, however, simply imagining the scene isn't enough.

"Sometimes people aren't able to engage when they close their eyes -- they are still avoiding," explained Cukor, an instructor in the department of psychiatry at Weill Cornell. "That's where virtual reality comes in."

The new project at Weill Cornell uses state-of-the-art, multi-sensory technology to create a "virtual reality 9/11" that helps PTSD patients break through that avoidance "wall" and find the path to healing. During a typical session, patients stand in place, wearing the type of video-equipped helmet usually associated with high-end video games.

Except this is no game. Instead, the programmers who designed this "virtual 9/11" listened carefully to eyewitness accounts and recreated that day onscreen in fine detail. Patients see and hear the first notes of alarm from inside the offices of the Twin Towers. They frantically search for an exit. They make the nerve-wracking descent down long, claustrophobic stairwells and finally emerge into the ensuing chaos on the ground.

The technology works so that the participant scans their virtual environment in 3-D, with the scene changing perspective as they move or tilt their head. At key moments -- such as when a plane hits one of the Towers -- the platform upon which the user is standing can be made to rumble and shake, much like the buildings' floors did on that fateful day. As patients recount their memories aloud, the clinician -- who is sitting next to them -- manipulates the program to add in sights or sounds to better match what the patient is recalling.

"We recently got a smell machine, too, so soon, odors -- such as smoke or other smells they have talked about -- will waft out," Cukor said. "We really try and engage all the senses, because we know that the more engaged you are, the better it works."

Early trials suggest the device does work, even better than standard "imagining"-based therapy. For example, in a Weill Cornell study that used an earlier version of the virtual 9/11 technology -- one that showed the World Trade Center from the outside only -- five of eight patients who had not responded to prior therapy achieved full resolution of their PTSD. That study was published earlier this year in Annals of the New York Academy of Sciences.

Hunter Hoffman is a research scientist at the University of Washington, Seattle, and one of America's leading experts on the use of virtual reality to ease mental and physical pain. He first used virtual "worlds" a few years ago to help patients overcome a variety of phobias. Hoffman explained that the treatment of phobia and PTSD -- both of which are anxiety disorders -- relies on the same principle.

"We know that getting emotionally aroused and then processing those emotions is the key to treatment," he said. "This therapy involves having them remember the traumatic experience, but in a place of safety where they do not feel they are going to die or be harmed. Gradually, this diminishes the impact."

Weill Cornell's Dr. JoAnn Difede contacted Hoffman soon after 9/11, after she had heard about his pioneering work with phobias.

"We capitalized on that work and thought, 'Wouldn't this be good for PTSD?' " said Difede, who is associate professor of psychology in psychiatry at the college. "There were thousands of people affected by the World Trade Center disaster, and not everyone was being helped by the standard of care."

She and Hoffman developed that first prototype, and the work has since graduated to the much more interactive model Cukor is using in the new trial.

Cukor stressed that therapy occurs in a gradual fashion, with patients first viewing relatively innocuous scenes before they move on to more graphic depictions. "There's that element of control -- we're only doing what the patient wants to do," she said.

The new trial also has a second component that adds another element to the mix.

"We're trying the concurrent use of low doses of an old tuberculosis drug, called D-cycloserine (DCS). It's been shown in animal studies to enhance learning," Cukor said. The hope is that taking a small amount of the harmless drug just before a virtual-reality session will "imprint" the impact of the treatment, speeding PTSD recovery.

In prior trials in which researchers used DCS to help with phobia treatment, "they were able to do in two sessions what they used to do in six," Cukor explained.

So far, the researchers have noted dramatic outcomes for PTSD patients using the "virtual 9/11" approach.

Hoffman, who is not involved in the current studies, said he vividly remembers one of the first patients who was treated using the original virtual 9/11 prototype. The patient, a 26-year-old financial executive, had run from the Towers as debris and bodies rained down around her. The woman was so traumatized by what she had gone through that she emotionally shut down for months.

"One of the signs that it's going to be a really tough patient is if they are unable to become emotional during regular therapy. This woman was so affected that she just couldn't," Hoffman noted.

"I remember, though, that during our treatment, she looked up at the Towers in virtual reality and started recounting things that had happened to her. And after a few minutes, she started crying," Hoffman said.

After just six one-hour sessions, the woman no longer met the criteria for PTSD.

More information
Learn more about PTSD at the U.S. National Institute of Mental Health.

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