Difference between revisions of "Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD"
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Status: writing final thesis report | Status: writing final thesis report | ||
| − | == Introduction == | + | ==Introduction== |
| − | Whether people go to work, study, or plan their holidays, there is most likely something out there that puts them in an inevitable stressful situation. Despite the fact that most people want to avoid such situations, | + | Whether people go to work, study, or plan their holidays, there is most likely something out there that puts them in an inevitable stressful situation. Despite the fact that most people want to avoid such situations, the involved stress is still manageable. However, this is not the case when someone is exposed to a traumatic event, an occurrence beyond the bounds of common, everyday human experiences. This results in a ‘Post-Traumatic Stress Disorder’ (PTSD) (Emmelkamp, Bouman, & Scholing, 1995). According to the ‘Diagnostic and Statistical Manual of Mental Disorders IV’ (1995) this disorder is characterized by re-experiencing the traumatic event accompanied by symptoms of increased arousal and avoidance of stimuli associated with the trauma. Such traumatic events vary widely, causing a variety of PTSD forms. Traumatic events can be related to war, assault, child abuse, accidents or natural disasters. This study focuses on combat-related PTSD, one of the health problems many soldiers face upon their return from deployment. In this case traumatic events include: getting injured, being threatened by death or witnessing another person’s death. These events are often referred to as stressors. |
| − | |||
| − | + | ==Problem definition== | |
| − | A study | + | War is known for its high rates of potential traumatic events. Fire fights, terrorist attacks, losing comrades and taking care of dead bodies are only some of the events a soldier is exposed to during war. A study (Hoge, et al., 2004) among ‘Operation Iraqi Freedom’ veterans concluded that up to 18% of the returning soldiers were affected by traumatic experiences and exhibited PTSD symptoms. Another study (Milliken, Auchterlonie, & Hoge, 2007), also concerned with returning soldiers from Iraq, has shown that over 66% of the soldiers were exposed to potential stressors. The same study reported that almost 17% of active duty soldiers and over 24% of reserve soldiers screened positive for PTSD. When soldiers or other military personnel get deployed multiple times, the chances of developing a PTSD multiplies by a factor of 1.5 ( Mental Health Advisory Team, 2006). Other reports (Garcia-Palacios, Hoffman, Carlin, Furness, & Botella, 2002) have shown that a large number of people do not seek treatment, unless the disorder causes drastic changes in their lifestyle. People tend to rather avoid various stimuli then seek appropriate treatment (Emmelkamp, et al., 1995). A reason mentioned by Hoge (2004) is the stigmatization attached to the treatment, causing soldiers to experience anxiousness towards possibly losing their jobs or facing others who know about their treatment. |
| + | Another issue is requiring data needed for treating patients with combat-related PTSD. The therapist needs information about the deployment and the problematic stressors in order to address them. Some patients are not willing to go into detail as some events may be too painful to remember. It is also possible that the patient does not recall what happened accurately or does not feel required to share aspects related to a particular time period. Of course therapists have acquired general data about a deployment through an intake session and reports, but this is often not sufficient. The therapist needs to let the patient re-experience, relearn and reappraise past events in order to process the traumatic ordeal. | ||
| + | Two effective methods to treat combat-related PTSD are ‘Cognitive Behavior Therapy’ (CBT) and ‘Eye Movement Desensitization and Reprocessing’ (EMDR) (Bisson et al., 2007; Seidler and Wagner, 2006). However, a recent review (Schottenbauer et al., 2008) reports high drop-out rates for both CBT and EMDR. The risk of a patient not receiving sufficient treatment adds up because of patients who are not willing to finish their treatment. This has lead to the exploration of new emerging treatment methods to help patients with a combat-related PTSD as well as to increase appeal relative to traditional face-to-face therapy (Cukor, Spitalnick, et al., 2009). One such treatment is Virtual Reality Exposure Therapy (VRET). It allows therapists to gradually expose patients to distressing stimuli in virtual scenarios using computer assisted technology. An unexplored field is the use of computer assisted technology to support trauma-focused psychotherapy. The emphasis is on restructuring and reappraising memory elements. The exploration and design of a system that allows the patient to re-experience, restructure and reappraise particular moments of a past deployment is the main focus of this thesis. | ||
| − | + | ==Research methodology== | |
| + | The design of the system followed the situated cognitive engineering approach as described by Neerincx and Lindenberg (2008). It is an iterative approach where the requirements baseline continuously changes as new insights are acquired through prototype evaluations and reviews with experts in the field during the entire design process. The first step that has to be taken is a Work Domain and Support (WDS) analysis to establish an inventory of all relevant human factors, operational demands and envisioned technology. Knowledge can be gained by analyzing the current situation, resulting in a better understanding of all involved actors, used theories, activities and the clinical environment. Using the data acquired from this analysis, core functions and claims can be defined and scenarios can be created. This results in a preliminary requirements baseline. Afterwards this baseline needs to be refined and verified which is done in the last phase. Figure 1-1 shows an overview of all the separate phases of the approach. | ||
== Discussion points == | == Discussion points == | ||
Revision as of 15:23, 8 March 2010
Human-Computer Interaction
Contents
About
Research on: Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD
Started: November 2008
Status: writing final thesis report
Introduction
Whether people go to work, study, or plan their holidays, there is most likely something out there that puts them in an inevitable stressful situation. Despite the fact that most people want to avoid such situations, the involved stress is still manageable. However, this is not the case when someone is exposed to a traumatic event, an occurrence beyond the bounds of common, everyday human experiences. This results in a ‘Post-Traumatic Stress Disorder’ (PTSD) (Emmelkamp, Bouman, & Scholing, 1995). According to the ‘Diagnostic and Statistical Manual of Mental Disorders IV’ (1995) this disorder is characterized by re-experiencing the traumatic event accompanied by symptoms of increased arousal and avoidance of stimuli associated with the trauma. Such traumatic events vary widely, causing a variety of PTSD forms. Traumatic events can be related to war, assault, child abuse, accidents or natural disasters. This study focuses on combat-related PTSD, one of the health problems many soldiers face upon their return from deployment. In this case traumatic events include: getting injured, being threatened by death or witnessing another person’s death. These events are often referred to as stressors.
Problem definition
War is known for its high rates of potential traumatic events. Fire fights, terrorist attacks, losing comrades and taking care of dead bodies are only some of the events a soldier is exposed to during war. A study (Hoge, et al., 2004) among ‘Operation Iraqi Freedom’ veterans concluded that up to 18% of the returning soldiers were affected by traumatic experiences and exhibited PTSD symptoms. Another study (Milliken, Auchterlonie, & Hoge, 2007), also concerned with returning soldiers from Iraq, has shown that over 66% of the soldiers were exposed to potential stressors. The same study reported that almost 17% of active duty soldiers and over 24% of reserve soldiers screened positive for PTSD. When soldiers or other military personnel get deployed multiple times, the chances of developing a PTSD multiplies by a factor of 1.5 ( Mental Health Advisory Team, 2006). Other reports (Garcia-Palacios, Hoffman, Carlin, Furness, & Botella, 2002) have shown that a large number of people do not seek treatment, unless the disorder causes drastic changes in their lifestyle. People tend to rather avoid various stimuli then seek appropriate treatment (Emmelkamp, et al., 1995). A reason mentioned by Hoge (2004) is the stigmatization attached to the treatment, causing soldiers to experience anxiousness towards possibly losing their jobs or facing others who know about their treatment. Another issue is requiring data needed for treating patients with combat-related PTSD. The therapist needs information about the deployment and the problematic stressors in order to address them. Some patients are not willing to go into detail as some events may be too painful to remember. It is also possible that the patient does not recall what happened accurately or does not feel required to share aspects related to a particular time period. Of course therapists have acquired general data about a deployment through an intake session and reports, but this is often not sufficient. The therapist needs to let the patient re-experience, relearn and reappraise past events in order to process the traumatic ordeal. Two effective methods to treat combat-related PTSD are ‘Cognitive Behavior Therapy’ (CBT) and ‘Eye Movement Desensitization and Reprocessing’ (EMDR) (Bisson et al., 2007; Seidler and Wagner, 2006). However, a recent review (Schottenbauer et al., 2008) reports high drop-out rates for both CBT and EMDR. The risk of a patient not receiving sufficient treatment adds up because of patients who are not willing to finish their treatment. This has lead to the exploration of new emerging treatment methods to help patients with a combat-related PTSD as well as to increase appeal relative to traditional face-to-face therapy (Cukor, Spitalnick, et al., 2009). One such treatment is Virtual Reality Exposure Therapy (VRET). It allows therapists to gradually expose patients to distressing stimuli in virtual scenarios using computer assisted technology. An unexplored field is the use of computer assisted technology to support trauma-focused psychotherapy. The emphasis is on restructuring and reappraising memory elements. The exploration and design of a system that allows the patient to re-experience, restructure and reappraise particular moments of a past deployment is the main focus of this thesis.
Research methodology
The design of the system followed the situated cognitive engineering approach as described by Neerincx and Lindenberg (2008). It is an iterative approach where the requirements baseline continuously changes as new insights are acquired through prototype evaluations and reviews with experts in the field during the entire design process. The first step that has to be taken is a Work Domain and Support (WDS) analysis to establish an inventory of all relevant human factors, operational demands and envisioned technology. Knowledge can be gained by analyzing the current situation, resulting in a better understanding of all involved actors, used theories, activities and the clinical environment. Using the data acquired from this analysis, core functions and claims can be defined and scenarios can be created. This results in a preliminary requirements baseline. Afterwards this baseline needs to be refined and verified which is done in the last phase. Figure 1-1 shows an overview of all the separate phases of the approach.
Discussion points
Right after the literature study, several ideas and discussion points arose.
Virtual Reality has shown to be a useful technique for helping people suffering from a wide range of anxiety disorders. As stated in the literature study, Virtual Reality can have a positive effect on PTSD treatment as well.
A huge difference between this kind of disorder and other anxiety disorders is the memory element. Creating a virtual environment for people with a spider phobia does not appear to be too complicated. One generalized world (featuring several stimuli to change the level of exposure) may already be sufficient to treat such a group of people. This is not the case with PTSD. The virtual worlds need to correspond to the stories of the patients, or at least, the virtual worlds have to engage the patient emotionally. Elements associated to the patient’s ‘fear structure’ are needed. So far nothing is known about how exact the virtual world should resemble the patient’s memory. However, even if the virtual worlds do not need to be very exact, it will still be a cumbersome task to create virtual worlds for each and every patient. Especially if only a short amount of time is given. Creating a virtual environment for a group of people who have faced the same stressor(s) or were present at the same location is more sufficient. Parts can be reused and a toolset can be developed to customize the more general virtual world according to the patient’s needs.
As seen with traditional methods, sharing and self-confrontation can also benefit patients suffering from a PTSD. This can be done by, for example, letting patients write down their emotions and feeling at the time the trauma took place. However, it can be very difficult for patients to write about their emotions or to remember specific events. Similar problems arise with other exposure variants. The use of images or 3D objects may trigger a patient’s memory or emotion.
One possible way to combine several elements discussed in this research assignment is to let the patient create its own virtual world. Creating a world from scratch may be impossible, but letting the patient, with the help of the therapist, add buildings, people and actions to a specific unfinished world sounds more within reach. In some situations the patient’s notion of time can be wrong. Together with the option of viewing the environment from different angles new learning, self-confrontation and reappraisal can take place. Objects within the environment can trigger a patient’s memory and emotion, allowing habituation of the stressor(s). Because the patient has to create the virtual world together with the therapist, the aspect of sharing is included as well.
Towards a new system
The idea of a system were the patient can manipulate a 3D environment shows potential. Currently, therapists use a sheet of paper with a drawn map on it to let the patient explain what happened during the time the stressor took place. The patient is free to draw additional objects and buildings while telling about the events that took place. An application using a (realistic) 3D environment can add more features to this approach. It might not only provoke anxiety, but may also help the patient to remember things othrwise forgotten. Before such an application can be realized, a scenario has to be written. Several ideas and theories from former meetings and brainstorm sessions with therapists of UMC (Utrecht) resulted in one main scenario with a couple of alternative routes. Multiple video clips are combined and show how the therapist and the patient are using the system in a session. This scenario does not only provide the therapists with an overview of the general concept, but it also provokes thoughts and ideas useful for the realization of the application. Each step in the scenario comes with a set of claims. Therapists can respond to these claims by giving comments or possible alternatives.
1. Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.
2. Harvey, A.G., R.A. Bryant, and N. Tarrier, Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review, 2003. 23(3): p. 501-522.
3. Bush, J., Viability of virtual reality exposure therapy as a treatment alternative. Computers in Human Behavior, 2008. 24(3): p. 1032-1040.
4. Difede, J., et al., Virtual reality exposure therapy for the treatment of Posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 2007. 68(11): p. 1639-1647.
