Virtual war, real healing

Times Staff Writer

NONE of this is really happening, but the experience is almost overwhelming in “virtual Iraq.”

The Humvee plows along a desert road. The engine rumbles underfoot and Blackhawk choppers whirl overhead. A sandstorm blows in, and insurgents pop up and start to shoot with sickening blasts that shatter the windshield. Is that the smell of burning rubber?

Those sensations of war are being fed into a special helmet, goggles and earphones. They are conjured by a computerized virtual reality developed in part by gaming engineers and psychologists at USC and being tested, among other places, at the Naval Medical Center in San Diego. The goal is to treat post-traumatic stress disorder.


Universities, private firms and the federal government are pouring millions of dollars into creating and testing such virtual Iraqs to help ease the psychological disorder that, according to a 2004 study by the Walter Reed Army Institute of Research, affects more than 15% of combat personnel returning from Iraq.

Sufferers may have anxiety, nightmares, flashbacks, emotional numbness, extreme jumpiness and physical pain. Unable to return to combat or civilian jobs, some receive disability payments for years or for life.

With a therapist’s supervision, the virtual Iraqs are designed to vividly, yet safely, allow those veterans to confront war experiences in ways that go beyond traditional counseling and drug therapy. The computer programs, even with the somewhat cartoonish digital depictions of combat, seek to relieve trauma by repeatedly revisiting its origins and not letting fear fester. Lt. Cmdr. Robert McLay, a Navy psychiatrist who is a research leader on virtual-reality treatment of PTSD in San Diego, explained that more customary forms of exposure therapy for trauma may require visits to actual locations, such as returning a rape victim to the scene of the assault. “You don’t want to send someone who is traumatized back to Iraq,” he said. “This allows us to bring someone back, but within the situation here.”

And, he said, some PTSD sufferers are unable or unwilling to recall things in counseling sessions without stimuli, such as the digital images of a combat hospital, a recorded Islamic prayer melody or the smell of cordite explosives misted into a psychologist’s office.

In 2005, the Office of Naval Research awarded $4 million to support tests of such virtual-reality treatments in San Diego and at Tripler Army Medical Center in Hawaii. The funds also bolster related work by USC’s Institute for Creative Technologies in Marina del Rey, the University of Washington and allied high-tech firms.

Cmdr. Russell Shilling, the Office of Naval Research’s program officer for medical science and technology, said virtual Iraqs might be especially useful to remove the stigma of psychological therapy for a younger generation who grew up playing video games.

Though it is too early to make judgments about the trial runs, early results “look very promising,” Shilling said.

The National Institute of Mental Health is funding a $2-million study at Emory University School of Medicine that uses a virtual Iraq along with a drug, D-cycloserine, that has been shown to reduce the fear of heights.

“The potential impact for men and women with stress adjustment problems is really substantial” and the possible impact on medical research “is extraordinarily important,” said Farris Tuma, chief of the national institute’s traumatic stress disorders program.

But Tuma cautioned that no treatment is a panacea. “We want to be careful not to oversell it as a simple fix for very complex conditions,” he said.

AT the sprawling Navy hospital near San Diego’s Balboa Park, researchers are testing two somewhat different systems: one for combat fighters who saw no relief from other therapies, the other for medics and support staff traumatized by war.

So far, McLay said, nine people have completed the cycle of 10 sessions. The goal by next year is have 150 treated at San Diego and Camp Pendleton, including some also suffering from concussions and crushed limbs.

Marines put on a helmet and goggles that allow them to be visually and aurally engulfed, often for 45 minutes. They stand or sit over a small platform that can vibrate. They work a joystick that allows them to walk or ride at various speeds. They can change directions on computerized streets and alleys by twisting their heads and bodies. In one biofeedback version, their respiration, heart rate and palm sweat are monitored.

Psychologists such as Karen Perlman sit at computers and help tailor the experience to the patients, conversing with them throughout.

The treatment usually starts with a digital scene and no violence. But in subsequent sessions, the therapists -- after giving warning -- heighten the intensity and specifics of the re-created event. They can make the platform shake more violently. They can set off simulated explosions and gunfire and add fog, smoke and night-vision effects, along with the smells of body odor and Iraqi spices.

“Habituation occurs when they repeat their story over and over again,” Perlman said. “They start to learn they can tolerate their distress, they can work through it.”

If all of that proves to be too much, the session can be interrupted for a discussion or be made less vivid.

Researchers say they want to ensure the experience feels real enough to trigger emotions without being overly bloody. Though some patients have temporarily removed the goggles or asked for a break, no one has completely freaked out, according to McLay. “We are prepared for that experience,” he said. “The great thing about virtual reality is that you can turn it off.”

Citing privacy issues, authorities did not allow interviews with patients. But a reporter was permitted to talk to a Navy medic who recently served in Iraq and who, though not a PTSD patient, tried one system.

“It’s pretty real. The vibration and the sights and sounds and everything were pretty darn close. I was waiting for shrapnel overhead,” said Eugene Gochicoa, a Navy corpsman 1st class. “It did kind of take me back to when I was back there ... except I knew I was safe here.”

FOR a reporter, a test run at USC’s lab had a disorienting double effect: the fun of being inside an astonishingly lively video game but also the dread of being trapped in a dangerous situation that other people controlled. The scenarios were changed to give me a sampling: I drove a Humvee through a smoky field until insurgents’ bullets cracked the windshield. I had a growing sense of paranoia. I heard my own footsteps as I walked quickly down a street past suspicious characters.

Hearing prayer calls, I entered a beautifully decorated mosque, where I suddenly encountered a gunman. Again, the story line switched and I heard and felt helicopters nearby. I ran past burning cars and a wounded man holding his head. Am I the next to be shot?

Engineers want to make systems more portable. And redesigns may make the simulated urban streets messier and add smells -- such as roasting lamb.

One of the systems grew out of the computerized war training program known as Full Spectrum Command, which was designed, with Army funding, at USC’s Institute for Creative Technologies. The institute also produces Hollywood special effects and multimedia systems for healthcare and education.

The Army software later was adapted for the popular Full Spectrum Warrior video game and then morphed again, in collaboration with Virtually Better Inc. in Georgia, for the therapy. “From training to toy to treatment” is the way the sequence was described by USC professor Albert “Skip” Rizzo, one of its adapters, along with computer engineer Jarrell Pair.

Rizzo, a psychologist who works in gerontology and directs the institute’s virtual-reality psychology lab, previously used other VR programs to aid Alzheimer’s and brain-injury patients and youngsters with attention deficits. VR, as it is often called, is being tried around the country for addictions and phobias, such as fear of flying. Weill Cornell Medical College in New York is testing a version for people who witnessed or responded to the terrorist attacks on the World Trade Center in 2001.

Because there are no clear battle lines and it is difficult to identify enemies, the Iraq war is a petri dish for the constant stress that can produce PTSD, Rizzo said.

“We are sending teenagers 19 years old to fight wars, and we owe them whatever can be done, using the latest technology, to look after those people after the fact,” he said.

The federal government has a financial, as well as humanitarian, interest in trying to speed treatment and reduce long-term disability payments. But even if some otherwise healthy malingerers use the technology to bolster phony trauma claims, Rizzo said, he can live with that “as long as I know that the people who really need the treatment are getting it.”

A more primitive virtual-reality therapy -- depicting a jungle and Vietnam-era helicopters -- produced some significant improvement for Vietnam War veterans, researchers at the VA Medical Center in Atlanta reported in 2001. According to study leader Barbara Rothbaum, director of Emory University’s trauma and anxiety recovery program, the experience was so effective that some of those veterans said they saw tanks and Viet Cong, even though none were presented on-screen.

Patients, she said, “will fill in with their own memories.”