Viktoriia Tsokota

Viktoriia Tsokota

3/04/2017

VIRTUAL REALITY EXPOSURE THERAPY DURING RECOVERY FOR PARTICIPANTS OF LOCAL MILITARY CONFLICTS: INTERNATIONAL EXPERIENCE

The article is devoted to the analysis of a international experience of using Virtual Reality Exposure Therapy (hereinafter – VRET) during the recovery for participants of local military conflicts (hereinafter – LMC). The change of Cyberpsychology interests is determined. It is moving from the concentration on the Internet social networks (CIS countries) to a human–computer system and related technologies. Four main areas of Telemental health development are considered and supplemented. There are computerized and Internet–mediated cognitive–behavioral therapy (hereinafter – CBT), Exposure Therapy with virtual and augmented reality, and mobile therapy.

The components of the VRET are analyzed. There are a type of virtual environment; a type of spatial interaction; an intensity of impact; a level of immersion and a quality of virtual experience. Generalized results of studies and components of a VRET protocols for participants of LMC are presented. The results reported significant improvement on the symptoms of PTSD in the groups treated with VRET. But there are no differences between groups of traditional psychotherapy methods and groups of VRET. VRET is no less effective methods of psychotherapy of PTSD for participants of LMC. It can be used for increasing of level for consent to treatment. VRET is more useful, if we take into account the features of veterans of LMC and especially resistant groups to traditional methods.

Key words: Cyberpsychology, Virtual Reality Exposure Therapy (VRET), Augmented Reality Exposure Therapy (ARET), Post traumatic stress disorder (PTSD), local military conflict (LMC).

Formulation of the problem. The active development of computer technology makes it possible to use the latest technical means within the framework of therapeutic and diagnostic processes, to study the influence of technical innovations on the human psyche, its daily life and behavior. Exposure therapy in the Virtual Reality (Virtual Reality Exposure Therapy (VRET) [1], Virtual reality exposure-based therapy (VR-EBT), Virtual reality therapy (VRT), Virtual reality immersion therapy (VRIT) , Simulation for therapy (SFT)) [2] refers to cyberpsychology. At the same time, the question arises of the absence of a single terminological base and the absence and inconsistency of definitions between the English-speaking, and Ukrainian and Russian-language literature. And also the divergence of the fields of cyber psychology and the methods of psychotherapy that are actively used in the US, Australia and Europe in the last decade. A narrow range of publications on this subject is due to the high cost of computerized complexes and their development, which, under conditions of underfinancing of post-Soviet science, does not allow testing them and introducing their advantages for the treatment of mental disorders. The problem of post-traumatic stress disorder (PTSD) after the traumatic events of a military nature, due to the aggravation of the geopolitical situation in the world and a large number of local military conflicts (the Post Traumatic Stress Disorder (PTSD)), is of particular importance for Ukraine and the world community Further – ЛВК) and terrorist acts. Immersive virtual reality technologies can come to the rescue in this case, and the reconstruction of traumatic events and their re-experience to react to negative emotions will move from the category of “excruciating treatment” to the category of “fascinating game.”

Analysis of recent research and publications.

Publications on the territory of the CIS interpret the concept of Cyberpsychology in the narrow sense, referring to it only the branch of psychology, which unites the methodology, theory and practice of researching the types, methods and principles of people’s use of social Internet services [3]. At the same time, the World Psychological Community and English-language literature understand the term Cyber ​​Psychology much broader and include within its boundaries the study of human reason and behavior in the context of human interaction and communication in the human-machine system, further expanding its boundaries with the culture of computers and the virtual environment that takes place in The Internet [4]. Taking this approach into account, the research towards technical computerized tools for psychological health (English Telemental health) [5] also belongs to the field of Cyberpsychology.

Diagnosis and treatment of PTSD using computerized facilities within Telemental health is one of the most common areas. According to the World Health Organization, 3.6% of the total world population suffers from PTSD [6]. The concept of PTSD was transformed from “military fatigue”, “combat exhaustion”, “military neurosis”, “posttraumatic neurosis” [7] to the DSM-V system [8] introduced in 2013 by the American Psychiatric Association, which provides a refined system of its components Signs. PTSD is seen as a system of symptoms that are expressed in the repetition of a trauma (flashback), evasion of memories of it, and can be accompanied by emotional numbness or hyperexcitation [9]. The consequences of PTSD are the decline in the quality of life in all its spheres: social, labor and family.

The American Psychological Association recognizes a wide range of psychotherapeutic approaches for the treatment of PTSD (prolonged exposure therapy, currently centered psychotherapy, cognitive-behavioral therapy (CPT) and its abbreviated options, reproduction of a sense of security (with concomitant use of psychoactive substances), desensitization and Recycling of traumatic experience with the help of eye movement) [10].

Long-term exposure therapy is recognized as effective in the treatment of PTSD [11]. It is based on active processing of traumatic experience, involving mechanisms for mastering control over the situation and fear in the safe circumstances of the psychotherapeutic cabinet. The patient under the control of the therapist receives access to traumatic memory, and studies the emotions, thoughts and behavior associated with it. In the process of cognitive processing of traumatic experience, the patient, at the conclusion of psychotherapy, can change his life for the better by abandoning non-adaptive posttraumatic behavioral strategies.

However, despite the high effectiveness of prolonged exposure therapy with which more than 50% of psychotherapists are familiar, only 17% used it for the treatment of PTSD [12], due to a lack of professional training and work experience, and fears of possible worsening of symptoms in the patient and premature Discontinuation of treatment. What is very important is objective and subjective Th barrier from the side of psychotherapists and doctors for the distribution of prolonged exposure therapy. In turn, the development of new technologies and the creation of universal therapeutic protocols can contribute to its universal dissemination because of the increase in the motivational component to treatment by psychotherapists and patients. Based on the literature analysis, to systematize the experience of using the ETWR method in the conditions of the recovery period of participants in local military conflicts. The analysis of the main material. Studies of the recovery period indicate significant differences in its course among the participants of the LVK and groups not associated with military service. American studies of individuals during the recovery from drug addiction found that the phase of drug addiction among veterans was 4 years longer than in the group of non-veterans, and they felt much more financial and legal problems [13]. Differences in the course of the recovery period in the participants of the LVK determine the need for the search and standardization of methods and strategies for the introduction of psychological care, taking into account the characteristics of the sample. Differential differences among the participants of the LVK are determined: – low level of motivation for psychological help, because of the maintenance of the idea “soldiers do not cry” Presence of “combat reflexes”, which can be directed at others, including specialists who are carrying out therapy, – maintaining the “militaristic style”, transferring to civilian life Forms, clothes and behavior learned during the military service. Taking into account the features of the participants of the LVK, it is promising to use the opportunities of Telemental health. This includes expanding the access to psychological care through interest in new “gadgets,” increasing efficiency, reducing the stigma associated with visiting a psychologist at or outside the clinic, and the ability to circumvent specific barriers to treatment, for example, when PTSD prevents a patient from leaving From the home. Taking into account the current state of Telemental health, four main areas are identified: computerized CBT (cCBT), internet mediated CBT (Internet-mediated CBT (iCBT)), ETWR and exposure therapy Complementary (ARET), mobile therapy (mtherapy) .Computerized and Internet-mediated CPT have the most proven efficacy, followed by ETVR and ETDR. Is one of the youngest areas, but the massive development of applications for psychological health for smartphones (6% of the market for all applications to mobile phones [14]) is gaining increasing popularity. The advantage of mobile therapy is the absence of technological barriers In comparison with ETWR and ETDR. In turn, ETWR and ETDR make it possible to use deeper emotional involvement by creating an individualized environment for experiencing trauma. For a schematic separation of ETWR and ETDR, one can use the Paul Milgram and Fumio Kishino model “Simplified representation of the virtual continuum” (Fig. 1). [15]. 1. Continuum Reality-Virtuality Milgram The main difference in this case is that the technology of augmented reality introduces a virtual object into the real world to the subject, “supplementing” the world with a new component, in turn, the virtual The real reality involves moving the subject to the virtual world, completely replacing the environment. In this case, a virtual environment can be defined as the creation of a 3D digital space using computer technology. It consists of visual stimuli that are projected onto the surface (for example, a wall, computer screen, glasses display) and, as a rule, acoustic stimuli obtained by electronic devices (for example, speakers, headphones) and can be supplemented with tactile (contact), olfactory , Or even taste stimuli. The main goal of the virtual environment is to “pull” the user from the “physical” world and “immerse” him in the synthetic world, is achieved by providing him with synthetic sensory information that simulates real life stimuli. In turn, Virtual Reality is a program that, in a very near real time, allows the user to navigate through, and interact with the virtual environment. [16]. ETHRP prototypes are first-person shooter (FPS )), Which are also used for medical and training purposes for military personnel. The beginning of scientific developments on the ETWR is 1994, with the publication of Max North. In 1996 his book “Virtual Reality Therapy, an Innovative Paradigm” was published on the basis of his doctoral dissertation. Active development of ETWR began in 2005 in the United States under the project “Bravemind: Virtual Reality Exposure Therapy”, which today attracts more than 60 centers in clinics, military bases and universities, under the guidance of Professor Skip Rizzo. Based on the scientific background and previous studies (USC ICT) has developed Virtual Iraq / Afghanistan simulations that are used in various clinical trials to investigate the potential for this type of treatment (Figure 2). Figure 2. Virtual scenarios Iraq / Afghanistan. Better Inc. And the University of Southern California, the Institute of Creative Technology. [17]. ETWR represents an opportunity for the patient to navigate and travel in the digital environment, with pre-established conditions and perform the necessary tasks there, tailored to address the particular disorder. The rapid development of technology makes it possible to use not only powerful computer processors, using computer technologies and special audio-visual equipment, but also screens of smartphones connected to glasses to play virtual reality. These systems can be supplemented by various stimulators for movement and changing the position of the body to increase the authenticity of the created image and imitate various weapons and weapons for completeness of perception, to engage more receptors during the therapeutic process and create the illusion of being in another time and space. With this alternative form of psychotherapy, patients interact with a safe virtual representation of traumatic stimuli in order to reduce the fear response. To date, one of the main directions of using ETVR is the treatment of PTSD. One of the most important advantages of ETWR is the increase of motivation for treatment and the reduction of the resistance threshold, due to the reaction to novelty and the attractiveness of virtual technologies, and their perception as games and entertainment. According to polls from patients with PTSD in the US, the use of ETWR reduces psychological resistance from 27% to 3% [18]. In turn, a survey of ATU veterans in Ukraine shows a much higher level of resistance to treatment compared to their American counterparts, and according to the Union of Veterans, the ATU is estimated at about 86%, while according to various data the level of psychological trauma among combatants varies from 20% to 55% [19]. Also, the benefits of the ETVR include the possibility of repeating, stopping and restarting traumatic scenarios, as many will be deemed necessary. In addition, the whole process of exposure can be completed in safety and privacy through the additional use of a virtual therapist (AI) therapist. The prototype of this therapist is Ellie (Figure 3) of the Institute of Creative Technology of the University of Southern California, which Is part of a virtual reality program called SimSensei, using tools from defense research projects (DARPA). It helps to track the veracity of the patient’s answers, by tracking his mimic reactions (66 points on the face of the patient), voice analysis (speech speed, pause time before answering a question), body position, head and eye movements. The web camera and microphone allow you to observe the patient and give feedback in the form of an empathetic “nod”. The prototype is at the stage of clinical research. Figure 3. Virtual psychotherapist «Ellie». Better Inc. And the University of Southern California, the Institute of Creative Technology. [20] .Cristina Botella and co-authors [2] in 2015, analyzing the effectiveness of previous studies of the ETWR, notes the high level of consent in participating in EEVR sessions, which allows attracting more victims for voluntary treatment . In turn, the use of ETVR for the treatment of PTSD is noted also acceptable among physicians who perceive ETWR as a step towards progress in treatment. It is possible to single out the following components of ETWR: 1) the type of virtual environment [21] – realistic plots (modeling specific situational events in Vietnam, Iraq, Afghanistan, the terrorist act of 11 September, etc.). At the same time, there are difficulties in the individualization of the scenarios proposed by the ETWR, which relate specifically to the traumatic experience of the patient, because of the need to create individual plots for everyone. – A flexible virtual environment that uses symbols to represent any traumatic situation through the “symbolic” (Eg pictures, music, sounds, video, etc.) 2) type of spatial interaction [16]: – egocentric point of view (“first person”) , The representation of oneself in another point of space, – the allocentric point of view (allocentric) – “from the third person”, the displacement of the virtual notion of self “avatar.” 3) the intensity of the impact [22]: – flooding – an intensive approach when incentives , Which cause the greatest anxiety are exposed first. For example, first of all demonstration of scenes of shooting or wounding fellow soldiers for soldiers with PTSD, and then follow less stressful Incentives, such as war sounds. Graded-exposure, during which the least traumatic stimuli are shown to gradually become accustomed to exposure. 4) immersion level [23]: – without immersion – the virtual reality system uses a conventional graphical workstation With a monitor, keyboard and mouse – Semi-immersive – A computer system of sufficiently high graphic performance is used in combination with a large surface for displaying a visual scene – Full immersion – with The system demonstrates virtual reality with the help of some kind of hardware (helmet), a large projection surface is installed in which the user is “enclosed”. 5) The quality of virtual experience [16]: – the sense of presence – consists of three levels: personal (sense of transfer to another space ), Environmental (sensation of interaction with surrounding objects) and social (sense of presence of other people in virtual reality) – realism – degree of convergence between user expectations and actual experience in Virtual environment. – Reality – evaluation of sensations in virtual reality, as real ones. The main condition is the complete filling of the user’s visual field. The advantages of the ETWR are the high level of motivation to use in the medical process, both from patients and from the side of psychotherapists, a high level of control of the exposure due to the parallel measurement of psychophysiological markers of PTSD (HR, HRV , SC, ASR) and control of their level to prevent retraumatization. In this case, ETB can be used in patients who are resistant to classical methods of psychotherapy and demonstrate limited Imagination. According to the study, the phenomena of the aphytasia from 2.1 to 2.7% of the sample, as a rule, can not imagine a visual image in consciousness [24]. The main disadvantage of ETWR is the presence of a technological barrier – the need for special equipment (glasses, simulators, sensors) and Its high cost. What is especially important for countries with low financial support for rehabilitation programs for patients with PTSD. Also there is no standardized approach to the process itself and technical equipment for conducting ETWR, the number and duration of sessions, which makes it difficult to assess the effectiveness of the protocol. One of the most well-known scenarios for the treatment of PTSD is Virtual Iraq. The military / veteran patients with the joystick control the military Hamer, watching the changes on the screen in the conditions of virtually reproduced Iraq, Afghanistan in the US. In this case, developers claim the ETBR has a low cost and, perhaps higher success rates, and a reduction in symptoms of PTSD observed on average 50%, and the reduction of PTSD symptoms in 75% of patients after treatment with ETWR. “Raquel Gonçalves et al. [25] summarized in 2011-2012 preliminary studies on the effectiveness of ETWR based on an analysis of all previous pu Glitches. The authors considered studies of patients diagnosed with PTSD in accordance with DSM-IV, which used CPT and virtual reality for treatment. To analyze the risks of biased results in the studies, the Cochrane Collaboration Tool for Assessing the Risk of Bias was used with the addition of 6 additional items. As a result, the analysis rose to 10 studies that met the previous criteria. The authors point out the potential efficacy of ETVR in the treatment of PTSD. Among the six studies that included the control group, a statistically significant reduction in the evaluation of symptoms of PTSD was observed in four, with the results in the groups for which ETB was used were significantly higher. However, there were no differences between classical exposure therapy, classical CBT and ETWR [26]. At the same time, the authors determine the inadequate sample size for high accuracy of results (the maximum number of participants is 40, most of which are veterans of the war). In three out of four studies without control samples, the ETBR showed its effectiveness based on measurements of PTSD symptoms before and after treatment. In general, Raquel Gonçalves and co-authors note the potential effectiveness of ETWR, but insist on the need for large-scale research “[21]. The main techniques used during the ETRR protocol are: 1. Psychological information; 2. Breathing training; 3. Biofeedback systems; 4. Medicines; 5. Prevention of relapses. The sessions of the ETVR are included in the complex of the general protocol using some of the techniques presented. Cristina Botella with co-authors on the basis of her literature review offers her recommendations for an adequate protocol [2]: – Treatment with ETWR voluntarily, Exposure therapy has already proved its effectiveness – The number of sessions from 8 to 12 – The duration of the session ETRV – 90 minutes – Frequency – one – twice a week. At this point The list of equipment and additional incentives recommended for the ETWR does not determine, it can be arranged depending on the research objectives and the needs of the patient. The effectiveness of the ETWR was investigated specifically by participants in local military conflicts (Vietnam, Iraq, Afghanistan). As the comparison groups, the participants of the LVK who did not undergo any psychotherapy (control group) or were treated with traditional psychotherapeutic methods (prolonged exposure therapy, desensitization and eye movement processing, CBT, cognitive restructuring, drug treatment, etc.) were used as comparison groups. Comparative research results are presented in Table 1. Table 1: Research results and components of the EEVR protocols for participants of the LVK with PTSRAvtor. Location of LVCR. Size of the viborka. Column sessions. Session length (min.). Repeatability. Additional methods. Results. Ready et al. (N = 5) Comparison group (n = 4) 1090 Not indicated Not indicated Measurement on the CAPS scale [28] at 6 months after treatment: Improvement in the ETBR group (p <0.05) Roy et al. [29] Vietnam1 ETVR group (n = 9) 2 Traditional Exposure Therapy group (n = 10) 3 Comparison group (without PTSD) (n = 18) 12-2090Not indicated Traditional Exposure Therapy for Group 21. Measurements on the CAPS scale: Improvement in Group ETBR (p <0.05). The group of traditional exposition therapy – no change2. Measurements for PTSD checklist: Improvement in the ETVR group (p <0.05) and in the group of traditional exposure therapy. MRI measurements: a significant reduction in the activation of the amygdala after treatment in the ETBR group and the group of traditional exposure therapy. McLay et al. [30] Iraq and Aghganistan1 ETBR group (n = 6) 2 Traditional Exposure Therapy group (n = 4) 3-10He is indicated One or two times a week1. Traditional Exposure Therapy for Group 22. Biological feedback All participants showed a significant reduction in symptoms of PTSD (p <0.001). McLay et al. [31] Iraq and Aghganistan1 A group of ETWR (n = 10) 2 A group of traditional psychotherapeutic methods (n = 10) 4-20Ne shown One or two times a week1. Traditional Exposure Therapy for Group 22. Cognitive Restructuring3. Meditation and attention control4. Biofeedback The results reported a significant improvement (p <0.01), but no significant differences between the groups. Miyahira et al. [32] Iraq1 ETWR group (n = 12) 2 Comparison group (n = 10) 9 No punched twice per weekPsychological trainingBreathing training Results did not show significant differences in CAPS but there was a significant reduction in the C criterion in the ETWR group. Gamito et al. [33] African colonies1 ETVR group (n = 5) 2 Traditional Exposure Therapy group (n = 2) 3 Comparison group (n = 3) 12No quoted Not indicatedPsychological training The results showed no significant changes in the PTSD level, but participants Reduction in symptoms associated with PTSD (depression and anxiety). Rizzo et al. [34] Iraq1 ETBR group (n = 20) – resistant to traditional psychotherapeutic methods1090-120 Twice a week1 Traditional exposition therapy2. Psychological training3. Breathing training4. Biological feedback Reduction of PTSD, depression and anxiety (P <0.001). Studies show a satisfaction with the procedure for the treatment of ETVR in patients (on a scale of 2 to 32 noted the figure of 30 and above) [35]. At the same time, there was no significant difference in the satisfaction of the treatment process between classical methods and ETVR, although participants noted that it was easier to agree to treatment with ETWR. The reservations in the application of ETWR include potential side effects after exposure to virtual reality: – cybersickness (type of motion sickness caused by Stay in virtual reality), – a violation of perceptive-motor perception, memories, and usually a decrease in excitement, – escapism. Professor Rizzo notes that the ITBT technology should and used only as a tool for qualified doctors, as opposed to manipulative means to attract new customers / patients [36] .Vyvody.1. On the basis of literary analysis, the differences in the scientific field Kiberpsihologii interests in the CIS countries – emphasis on the social services of the Internet, in Europe, USA, Australia – Kiberpsihologiya considered in a broader sense, the study of the human mind and behavior in the context of human interaction and communication in the man system -Computer and related tehnologiy.2. Reviewed and amended four main development direction Telemental health: computerized CBT, Internet-mediated CBT ETVR and ETDR, mobile terapiya.3. ETVR analyzed components: type of virtual environment (realistic scenes and flexible virtual environment), the type of spatial interaction (egocentric point of view and allotsentricheskaya point of view), the intensity of the exposure (and gradient flood exposure), the level of immersion (without immersion, half-and full immersion Immersion), the quality of virtual experience (sensation of presence, realism and reality). The results of studies and components of the EEVR protocols for the participants of the LVK with PTSD were summarized: there was an improvement in the symptoms of PTSD in the groups treated with ETVR, but no differences were found between the traditional methods of therapy and ETWR. ETVR can be attributed to no less effective methods of psychotherapy for PTSD in participants of exercise therapy, which makes it possible to use it to increase the level of consent to treatment, taking into account the characteristics of veterans of the LVK and especially for those resistant to traditional methods. Prospects for further research. Consider the prospects for transition to less technologically Capacious methods of Telemental health, from virtual reality systems to extended reality systems and mobile applications for smartphones within the treatment of PTSD.

 

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