Virtual reality exposure therapy for active duty soldiers

The deep past in the virtual present: developing an interdisciplinary approach towards understanding the psychological foundations of palaeolithic cave art

Virtual Reality (VR) has vast potential for developing systematic, interdisciplinary studies to understand ephemeral behaviours in the archaeological record, such as the emergence and development of visual culture. Upper Palaeolithic cave art forms the most robust record for investigating this and the methods of its production, themes, and temporal and spatial changes have been researched extensively, but without consensus over its functions or meanings. More compelling arguments draw from visual psychology and posit that the immersive, dark conditions of caves elicited particular psychological responses, resulting in the perception-and depiction-of animals on suggestive features of cave walls. Our research developed and piloted a novel VR experiment that allowed participants to perceive 3D models of cave walls, with the Palaeolithic art digitally removed, from El Castillo cave (Cantabria, Spain). Results indicate that modern participants' visual attention corresponded to the same topographic features of cave walls utilised by Palaeolithic artists, and that they perceived such features as resembling animals. Although preliminary, our results support the hypothesis that pareidolia-a product of our cognitive evolution-was a key mechanism in Palaeolithic art making, and demonstrates the potential of interdisciplinary VR research for understanding the evolution of art, and demonstrate the potential efficacy of the methodology.

VR for Cognition and Memory

This chapter will provide a review of research into human cognition through the lens of VR-based paradigms for studying memory. Emphasis is placed on why VR increases the ecological validity of memory research and the implications of such enhancements.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

Posttraumatic Stress Disorder Symptom Cluster Structure in Prolonged Exposure Therapy and Virtual Reality Exposure

The emotional processing theory of posttraumatic stress disorder (PTSD) posits that avoidance is central to PTSD development and maintenance. Prolonged exposure (PE) therapy, which clinically focuses on avoidance reduction, has strong empirical support as a PTSD treatment. Virtual reality exposure (VRE) has been utilized to accelerate avoidance reduction by increasing multisensory engagement. Although some exposure therapy studies have found associations between avoidance and PTSD symptoms, others have indicated that reexperiencing or hyperarousal symptoms drive symptom trajectories. Using a cross-lagged panel design, the present secondary data analysis examined temporal associations between clinician-assessed PTSD symptom clusters during treatment with PE, VRE, or a waitlist control condition. There were no significant differences between PE and VRE regarding symptom clusters at any assessment. Compared to the waitlist condition, individuals who received VRE or PE exhibited earlier reductions in avoidance/numbing symptoms, β = -.19, 95% CI [-.33, -.05], followed by reductions in hyperarousal symptoms, β = -.21, 95% CI [-.33, -.09]. Hyperarousal symptoms predicted changes in later avoidance/numbing and reexperiencing outcomes across treatment: pretreatment to midtreatment, β = .29, 95% CI [.17, .42]; midtreatment to posttreatment, β = .23, 95% CI [.07, .39]. Reexperiencing symptoms predicted changes in hyperarousal outcomes earlier in treatment, β = .22, 95% CI [.02, .37], whereas avoidance/numbing symptoms predicted changes in hyperarousal outcomes later in treatment, β = .18, 95% CI [.04, .32]. These findings support the efficacy of exposure therapy in addressing avoidance/numbing symptoms and highlight the potential importance of hyperarousal symptoms in relation to other symptom clusters.

Controlling the Sense of Embodiment for Virtual Avatar Applications: Methods and Empirical Study

BACKGROUND

The sense of embodiment (SoE) is the feeling of one's own body, and research on the SoE extends from the rubber hand illusion to the full-body ownership illusion with a virtual avatar.

OBJECTIVE

The key to utilizing a virtual avatar is understanding and controlling the SoE, and it can be extended to several medical applications. In this study, we aimed to clarify these aspects by considering the following three subcomponents of SoE: sense of agency, ownership, and self-location.

METHODS

We defined a human avatar (HA), point light avatar (PLA), and out-of-body point light avatar (OBPLA) and compared them in three user studies. In study 1, 28 participants were recruited and the three avatar conditions (HA, PLA, and OBPLA) were compared. In study 2, 29 new participants were recruited, and there were two avatar conditions (HA ad PLA) and two motion synchrony conditions (synchrony and asynchrony). In study 3, 29 other participants were recruited, and there were two avatar conditions (PLA and OBPLA) and two motion synchrony conditions (synchrony and asynchrony). Dependent measures included sense of agency, ownership, and self-location; emotional response; presence; and simulator sickness.

RESULTS

The findings of study 1 showed that the three avatar generation methodologies can control the sense of ownership and self-location in a stepwise manner while maintaining a high sense of agency. In studies 2 and 3, we found dependencies among the three subcomponents of SoE and observed that they affected users' subjective experiences.

CONCLUSIONS

Our findings may have implications for boosting the effects of virtual avatar applications in medical areas, by understanding and controlling the SoE with a full-body illusion.

The training game SALIENCE for the therapy of alcohol use disorder

The feasibility study was aimed to develop a web-based gaming tool for the therapy of alcohol use disorder to offer patients a cue-exposure-based extinction and decision training, enhanced with virtual reality. To increase the training effect, patients playfully experience situations that resemble critical real-life situations. For implementing the game, a combination of HTML5 and JavaScript was used. The application comes with an administrator interface, to allow editing the game content. Initially, we included 21 patients (Group 1), 18 suffering from alcohol use disorder and 3 using cannabis (18/3 male/female, mean age 39 ± 13 years). Considering the iterative process of a feasibility study, we developed the game design as suggested by participants of Group 1 and additionally included 11 novel participants (Group 2) (11 suffering from an alcohol use disorder, 7/4 male/female, mean age 46 ± 14 years). Basically, the game was very well received. Usability ratings were generally high, even in patients with little computer experience. Both groups rated the application as realistic, and would generally be willing to play it on a daily basis. Given that SALIENCE is inexpensive, easily available, and engaging, it might be a reasonable add-on intervention to the standard treatment of alcohol use disorder.

Exposure and response prevention for obsessive-compulsive disorder: A review and new directions

Obsessive-compulsive disorder (OCD) is characterized by distressing thoughts and repetitive behaviors that are interfering, time-consuming, and difficult to control. Although OCD was once thought to be untreatable, the last few decades have seen great success in reducing symptoms with exposure and response prevention (ERP), which is now considered to be the first-line psychotherapy for the disorder. Despite these significant therapeutic advances, there remain a number of challenges in treating OCD. In this review, we will describe the theoretical underpinnings and elements of ERP, examine the evidence for its effectiveness, and discuss new directions for enhancing it as a therapy for OCD.

Investigating the Relationship Between Eye Movement and Brain Wave Activity Using Video Games: Pilot Study

Background

All eye movements are related in one way or another to our mental processes with lateral eye movements being associated with the different hemispheres of the brain. Eye movement techniques form the basis of eye movement desensitization and reprocessing therapy, wherein forced eye movements activate neurological pathways to treat the subject.

Objective

The objective of our study was to examine the relationship between players' eye movements and their brain wave activities using a video game.

Methods

We used similar eye movement techniques in the form of a video game called Lifeguard that could potentially stimulate different eye movement mode and create a more engaging experience for the user. By designing an experiment, we further explored the differences in electroencephalogram spectral power activity for the alpha, beta, theta, delta, and gamma frequency bands in Lifeguard and Tetris.

Results

The game based on eye movement technologies resulted in decreased delta power and increased beta power, but significant difference between 2 games was not found.

Conclusions

The applied uses of this research could mean that eye movement desensitization and reprocessing can be conducted in a more fun and engaging way through the use of gaming technology.

Skin Conductance Reactivity to Standardized Virtual Reality Combat Scenes in Veterans with PTSD

Interest in virtual reality (VR) as a clinical tool to augment posttraumatic stress (PTSD) treatment has grown substantially in recent years due to advances in VR technology. Moreover, its potential assisted use in the PTSD diagnostic process has been recognized. In this study we examined physiological responding, skin conductance, to a standardized presentation of non-personalized combat-related VR events (e.g. encountering enemy fire; explosions) as compared to non-combat classroom VR events in 19 Veterans with and 24 Veterans without combat-related PTSD who had been deployed to Iraq and Afghanistan. Veterans watched a total of 12 VR scenarios-six combat-related and six non-combat-related-with each scenario gradually increasing in emotional intensity by adding more VR events in addition to repeating prior VR events. Results show that Veterans with PTSD displayed larger skin conductance reactivity across VR combat events, but not for non-combat VR events, as compared to combat Veterans without PTSD. Nevertheless, Veterans with and without PTSD showed a similar reduction of emotional arousal to repeated presentation of the same VR combat events. Within the PTSD sample, the elevated level of VR combat-related arousal correlated marginally with severity of hyperarousal symptoms. This study confirms that the use of a non-personalized and standardized VR presentation successfully distinguishes Veterans with PTSD from those without on a measure of psychophysiological arousal to combat-related VR stimuli. The assessment of physiological reactivity during the repeated presentation of standardized, trauma-related VR events highlights its use for PTSD assessment as well as treatment.

In session extinction and outcome in Virtual Reality Exposure Therapy for PTSD

Recent research emphasizes emotional engagement and between-session extinction, but no longer within-session extinction, as the primary mechanisms underlying exposure therapy for the treatment of PTSD. No previous studies have examined change in subjective units of distress (SUDS) in virtual reality exposure (VRE) for PTSD despite its potential facilitation of engagement (see McLay et al., 2012; Reger & Gahm, 2008). Using in session data from Rothbaum et al. (2014) we examined patterns of within- and between-session SUDS change in veterans receiving VRE for PTSD augmented by d-cycloserine, alprazolam, or placebo. The number of treatment sessions significantly predicted SUDS rating (t = -7.74, p < 0.001). Time in session continued to serve as a significant predictor of SUDS (t = 13.44, p < 0.001). Specifically, engagement increased within session and then reduction (extinction/habituation) was apparent across sessions. Treatment group was a predictor of SUDS rating within treatment sessions (t = 2.26, p < 0.05) but not across sessions, such that participants receiving medication experienced greater increases in SUDS within-session than those receiving placebo. Responder status was a predictor of SUDS reduction across treatment sessions (t = -4.43, p < 0.001) but did not produce an overall or within-session effect on SUDS. Thus, medications impact within-session SUDS changes but do not impact between-session reductions in SUDS- the change most consistently and closely related to magnitude of therapeutic change and responder status.

Clinical Virtual Reality: Emerging Opportunities for Psychiatry

Virtual reality (VR) technology offers new opportunities for the development of innovative clinical research, assessment, and intervention tools. VR-based testing, training, teaching, and treatment approaches that would be difficult, if not impossible, to deliver with traditional methods are now being developed that take advantage of the assets that are available with VR technology. As research evidence continues to indicate clinical efficacy, VR applications are being increasingly regarded as providing innovative options for targeting the cognitive, psychological, motor, and functional impairments that result from various clinical health conditions. VR allows for the precise presentation and control of stimuli in dynamic, multisensory, 3D computer-generated simulations as well as providing advanced methods for capturing and quantifying behavioral responses. These characteristics support the rationale for the use of VR applications in clinical assessment, intervention, and training. This article begins with a brief review of the history of and rationale for the use of VR with clinical populations. It then details one use case for the clinical application of VR-the exposure-therapy treatment of anxiety disorders and posttraumatic stress disorder. Although significant work is cited in other areas of clinical VR (e.g., pain management, cognitive and physical assessment and rehabilitation, eating disorders, social skills, and clinical training), a full overview of such a broad literature is beyond the scope of this article. Thus, the authors have opted to provide more in-depth analysis of one specific clinical area that clearly illustrates how VR has been successfully applied and is supported by an encouraging and evolving scientific literature.

Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) military personnel has created a significant behavioural healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. The current article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004. A brief discussion of the definition and rationale for the clinical use of VR is followed by a description of a VR application designed for the delivery of prolonged exposure (PE) for treating Service Members (SMs) and Veterans with combat- and sexual assault-related PTSD. The expansion of the virtual treatment simulations of Iraq and Afghanistan for PTSD assessment and prevention is then presented. This is followed by a forward-looking discussion that details early efforts to develop virtual human agent systems that serve the role of virtual patients for training the next generation of clinical providers, as healthcare guides that can be used to support anonymous access to trauma-relevant behavioural healthcare information, and as clinical interviewers capable of automated behaviour analysis of users to infer psychological state. The paper will conclude with a discussion of VR as a tool for breaking down barriers to care in addition to its direct application in assessment and intervention.

Cue-induced Behavioral and Neural Changes among Excessive Internet Gamers and Possible Application of Cue Exposure Therapy to Internet Gaming Disorder

Internet gaming disorder (IGD) may lead to many negative consequences in everyday life, yet there is currently no effective treatment for IGD. Cue-reactivity paradigm is commonly used to evaluate craving for substance, food, and gambling; cue exposure therapy (CET) is applied to treating substance use disorders (SUDs) and some other psychological disorders such as pathological gambling (PG). However, no study has explored CET's application to the treatment of IGD except two articles having implied that cues' exposure may have therapeutic effect on IGD. This paper reviews studies on cue-induced behavioral and neural changes in excessive Internet gamers, indicating that behavioral and neural mechanisms of IGD mostly overlap with those of SUD. The CET's effects in the treatment of SUDs and PG are also reviewed. We finally propose an optimized CET paradigm, which future studies should consider and investigate as a probable treatment of IGD.

Virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability

INTRODUCTION

The essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. According to evidence-based intervention guidelines and empirical evidence, one of the most extensively researched and validated treatments for PTSD is prolonged exposure to traumatic events; however, exposure therapy can present some limitations. Virtual reality (VR) can help to improve prolonged exposure because it creates fictitious, safe, and controllable situations that can enhance emotional engagement and acceptance.

OBJECTIVE

In addition to carrying out a review to evaluate the efficacy of VR exposure-based therapy (VR-EBT) for the treatment of PTSD, the aim of this study was to contribute to analyzing the use of VR-EBT by: first, evaluating the adequacy of psychological treatment protocols that use VR-EBT to treat PTSD; and second, analyzing the acceptability of VR-EBT.

METHOD

We performed a replica search with descriptors and databases used in two previous reviews and updated to April 2015. Next, we carried out an evaluation of the efficacy, adequacy, and acceptability of VR-EBT protocols.

RESULTS

Results showed that VR-EBT was effective in the treatment of PTSD. The findings related to adequacy showed that not all studies using VR-EBT reported having followed the clinical guidelines for evidence-based interventions in the treatment of PTSD. Regarding acceptability, few studies evaluated this subject. However, the findings are very promising, and patients reported high acceptability and satisfaction with the inclusion of VR in the treatment of PTSD.

CONCLUSION

The main weaknesses identified in this review focus on the need for more controlled studies, the need to standardize treatment protocols using VR-EBT, and the need to include assessments of acceptability and related variables. Finally, this paper highlights some directions and future perspectives for using VR-EBT in PTSD treatment.

PTSD and Cannabis-Related Coping Among Recent Veterans in New York City

This article presents interview and focus group data from veterans of recent conflicts in Iraq and Afghanistan about their use of cannabis as a coping tool for dealing with posttraumatic stress disorder. Veterans' comparisons of cannabis, alcohol, and psychopharmaceuticals tended to highlight advantages to cannabis use as more effective and less complicated by side effects. Some participants suggested that cannabis can be part of an approach-based coping strategy that aids with introspection and direct confrontation of the sources of personal trauma. Others, however, held that cannabis use was part of a less productive, avoidant coping strategy. Some self-reports suggested the need for more nuanced theorizations of coping behaviors, as they indicated motivations for use that were grounded in symptom alleviation rather than any direct confrontation with (or avoidance of) sources of trauma.

The use of virtual reality in craving assessment and cue-exposure therapy in substance use disorders

Craving is recognized as an important diagnosis criterion for substance use disorders (SUDs) and a predictive factor of relapse. Various methods to study craving exist; however, suppressing craving to successfully promote abstinence remains an unmet clinical need in SUDs. One reason is that social and environmental contexts recalling drug and alcohol consumption in the everyday life of patients suffering from SUDs often initiate craving and provoke relapse. Current behavioral therapies for SUDs use the cue-exposure approach to suppress salience of social and environmental contexts that may induce craving. They facilitate learning and cognitive reinforcement of new behavior and entrain craving suppression in the presence of cues related to drug and alcohol consumption. Unfortunately, craving often overweighs behavioral training especially in real social and environmental contexts with peer pressure encouraging the use of substance, such as parties and bars. In this perspective, virtual reality (VR) is gaining interest in the development of cue-reactivity paradigms and practices new skills in treatment. VR enhances ecological validity of traditional craving-induction measurement. In this review, we discuss results from (1) studies using VR and alternative virtual agents in the induction of craving and (2) studies combining cue-exposure therapy with VR in the promotion of abstinence from drugs and alcohol use. They used virtual environments, displaying alcohol and drugs to SUD patients. Moreover, some environments included avatars. Hence, some studies have focused on the social interactions that are associated with drug-seeking behaviors and peer pressure. Findings indicate that VR can successfully increase craving. Studies combining cue–exposure therapy with virtual environment, however, reported mitigated success so far.

A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder in Iraq and Afghanistan War veterans

OBJECTIVE

The authors examined the effectiveness of virtual reality exposure augmented with D-cycloserine or alprazolam, compared with placebo, in reducing posttraumatic stress disorder (PTSD) due to military trauma.

METHOD

After an introductory session, five sessions of virtual reality exposure were augmented with D-cycloserine (50 mg) or alprazolam (0.25 mg) in a double-blind, placebo-controlled randomized clinical trial for 156 Iraq and Afghanistan war veterans with PTSD.

RESULTS

PTSD symptoms significantly improved from pre- to posttreatment across all conditions and were maintained at 3, 6, and 12 months. There were no overall differences in symptoms between D-cycloserine and placebo at any time. Alprazolam and placebo differed significantly on the Clinician-Administered PTSD Scale score at posttreatment and PTSD diagnosis at 3 months posttreatment; the alprazolam group showed a higher rate of PTSD (82.8%) than the placebo group (47.8%). Between-session extinction learning was a treatment-specific enhancer of outcome for the D-cycloserine group only. At posttreatment, the D-cycloserine group had the lowest cortisol reactivity and smallest startle response during virtual reality scenes.

CONCLUSIONS

A six-session virtual reality treatment was associated with reduction in PTSD diagnoses and symptoms in Iraq and Afghanistan veterans, although there was no control condition for the virtual reality exposure. There was no advantage of D-cycloserine for PTSD symptoms in primary analyses. In secondary analyses, alprazolam impaired recovery and D-cycloserine enhanced virtual reality outcome in patients who demonstrated within-session learning. D-cycloserine augmentation reduced cortisol and startle reactivity more than did alprazolam or placebo, findings that are consistent with those in the animal literature.

Technological advances in the treatment of trauma: a review of promising practices

Given the availability of empirically supported practices for addressing posttraumatic stress disorder and other forms of trauma-related distress, the development and implementation of new technology to deliver these treatments is exciting. Technological innovations in this literature aim to expand availability of empirically based intervention, increase treatment adherence and acceptability, and overcome barriers commonly encountered with conventional trauma-focused treatment. Much of the current research on these technological developments consists of brief reviews and case studies of the separate therapy modalities. Although this work serves to document the appeal and utility of these innovations, it does not provide comprehensive information about the host of options available. To that end, the three general categories of technological advances in trauma therapy (i.e., videoconferencing, e-Health, virtual reality) are reviewed here, including information regarding their empirical support and suggestions for future research and clinical practice.

Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic

Exposure therapy is an evidence-based treatment for posttraumatic stress disorder (PTSD), but research evaluating its effectiveness with active duty service members is limited. This report examines the effectiveness of virtual reality exposure therapy (VRE) for active duty soldiers (N = 24) seeking treatment following a deployment to Iraq or Afghanistan. Relative to their pretreatment self-reported symptoms on the PTSD Checklist, Military Version (M = 60.92; SD = 11.03), patients reported a significant reduction at posttreatment (M = 47.08; SD = 12.70; p < .001). Sixty-two percent of patients (n = 15) reported a reliable change of 11 points or more. This study supports the effectiveness of exposure therapy for active duty soldiers and extends previous research on VRE to this population.

Virtual reality exposure therapy for combat-related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a chronic, debilitating, psychological condition that occurs in a subset of individuals who experience or witness life-threatening traumatic events. PTSD is highly prevalent in those who served in the military. In this paper, we present the underlying theoretical foundations and existing research on virtual reality exposure therapy, a recently emerging treatment for PTSD. Three virtual reality scenarios used to treat PTSD in active duty military and combat veterans and survivors of terrorism are presented: Virtual Vietnam, Virtual Iraq, and Virtual World Trade Center. Preliminary results of ongoing trials are presented.

Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD

Numerous reports indicate that the growing incidence of posttraumatic stress disorder (PTSD) in returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) military personnel is creating a significant health care and economic challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual reality-delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will detail the development and early results from use of the Virtual Iraq/Afghanistan exposure therapy system. The system consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern contexts for exposure therapy, including a city and desert road convoy environment. The process for gathering user-centered design feedback from returning OEF/OIF military personnel and from a system deployed in Iraq (as was needed to iteratively evolve the system) will be discussed, along with a brief summary of results from an open clinical trial using Virtual Iraq with 20 treatment completers, which indicated that 16 no longer met PTSD checklist-military criteria for PTSD after treatment.

Virtual reality exposure therapy for post-traumatic stress disorder and other anxiety disorders

Anxiety disorders, including phobias and post-traumatic stress disorder, are common and disabling disorders that often involve avoidance behavior. Cognitive-behavioral treatments, specifically imaginal and in vivo forms of exposure therapy, have been accepted and successful forms of treatment for these disorders. Virtual reality exposure therapy, an alternative to more traditional exposure-based therapies, involves immersion in a computer-generated virtual environment that minimizes avoidance and facilitates emotional processing. In this article, we review evidence on the application of virtual reality exposure therapy to the treatment of specific phobias and post-traumatic stress disorder and discuss its advantages and cautions.

Psychotrauma and effective treatment of post-traumatic stress disorder in soldiers and peacekeepers

Psychotrauma occurs as a result to a traumatic event, which may involve witnessing someone's actual death or personally experiencing serious physical injury, assault, rape and sexual abuse, being held as a hostage, or a threat to physical or psychological integrity. Post-traumatic stress disorder (PTSD) is an anxiety disorder and was defined in the past as railway spine, traumatic war neurosis, stress syndrome, shell shock, battle fatigue, combat fatigue, or post-traumatic stress syndrome (PTSS). If untreated, post-traumatic stress disorder can impair relationships of those affected and strain their families and society. Deployed soldiers are especially at a high risk to be affected by PTSD but often receive inadequate treatment. Reviews to date have focused only on a single type of treatment or groups of soldiers from only one country. The aim of the current review was to evaluate characteristics of therapeutic methods used internationally to treat male soldiers' PTSD after peacekeeping operations in South Eastern Europe and the Gulf wars.

This systematic literature review returned results pertaining to the symptoms, diagnosis, timing and effectiveness of treatment. Sample groups and controls were relatively small and, therefore, the results lack generalizability. Further research is needed to understand the influence and unique psychological requirements of each specific military operation on the internationally deployed soldiers.

Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war-zone experiences

The provision of effective and timely behavioral health care for veterans returning from the conflicts in Iraq and Afghanistan has become the focus of national attention. In this special issue, attempts to provide psychological care for service members and their families are examined in light of three key constructs. First, it is contended that at no other time in history has more attention been paid to the psychological consequences of engaging in combat. Second, for the first time in recorded warfare, psychological morbidity is likely to far outstrip physical injury associated with combat. Finally, although posttraumatic stress disorder and traumatic brain injury are serious concerns, most service members return without significant physical or psychological injury and will be able to return to functioning without notable problems. Accurate diagnosis, a focus on resilience, and the expectation of readjustment are essential precepts that should guide clinical efforts and resource allocation.