vret - User contributions [en-gb]

Projects

2010-06-05T23:19:12Z

Matthew: /* Research / Literature Assignment */

== Phobias ==
*[[Projects_Fear_of_Flying|Fear of Flying]]
*[[Projects_Fear_of_Heights|Fear of Heights]]
*[[Projects_Social_Phobia|Social Phobia]]
*[[Projects_ClaustroPhobia|ClaustroPhobia]]
*[[Projects_PTSD|PTSD]]

== User Interfaces ==
*[[User_Interface_Therapist|Therapist]]
*[[User_Interface_Patient|Patient]]
*[[User_Interface_MultiplePatients|MultiplePatients]]

== Research / Literature Assignment ==
*[[Literature_Assignment|Literature Assignment]]
*[[Data_Gathering|Data Gathering]]
*[[Data_Analysis|Data Analysis]]
*[[AddPapers|Add Papers]]
*[[Bibliography|Bibliography]]
*[http://mmi.tudelft.nl/vret_oud/index.php/Image:Vretlogo_big.png Logo]

== Master thesis and graduating ==
*[[Graduating_101|Graduating guide]]

== VRET Technology ==
*[[Repository|Software Repository (SVN) ]]
*[[BugTracking|Bug Tracker (TRAC)]]
*[https://mmi.tudelft.nl/cgi-bin/vret_oud.cgi/ setup PyQt4, Eclipse]
*[[VRET_Archi|System Architecture]]
*[[VRET_Vizard|Vizard]]
*[[VRET_WTK|WTK (World tool kit)]]
*[[VRET_Unreal|Unreal]]
*[[VRET_Maya|Maya]]
*[[VRET_Speech_Recognition|Speech Recognition]]
*[[VRET_Hardware|Hardware]]
*[http://mmi.tudelft.nl/reserveringen/readonly/ Medialab reservation]
*[[VRET_Demos|Demo's]]
*[[VRET_physiological| Physiological measurement]]
*[[Video_Hardware|Video hardware]]
*[[VRET_Avatars|Vizard Complete Characters]]
*[[3Ds_MAX_Character_Modeling|Create your own 3D character in 3Ds MAX]]
*[[3Ds_MAX_Unwrap_UVW_Tutorial|3Ds MAX Unwrap UVW Tutorial]]
*[[Cal3D_Avatars|Export Cal3D avatars from 3Ds MAX]]

== Software ==
*[[Python|Python]]
*[[VRET_pyQt|pyQt]]

== Wiki Help ==
*[[Wiki_About|About this wiki]]
*[[Wiki_Help|Help]]
*[http://www.mediawiki.org/wiki/Help:Contents Official Wiki Help]

Graduating 101

2010-06-05T23:16:53Z

Matthew:

Dutch only, sorry!

== Welkom ==

Omdat het vinden van informatie omtrent het afstuderen soms erg moeilijk te vinden is op de TUDelft campus site, heb ik besloten om een kleine guide te maken met daarin links naar belangrijke formulieren en deadlines. Deze guide helpt je een beetje op weg met het administratieve aspect van het afstuderen. Het onderzoek, de evaluatie en het schrijven van de thesis zijn zeer grote onderdelen wat betreft het afstuderen, echter moet je het plannen van je presentatie en het op orde stellen van bijvoorbeeld het afstudeercomité niet onderschatten. Zeker aan het eind van het afstudeertraject moet er een hoop geregeld worden.

== Na je literatuurverslag ==

SOON!

Geschreven door:
Matthew van den Steen
vragen? mmvdsteen@gmail.com

User:Matthew

2010-05-23T21:55:14Z

Matthew:

[[Image:MatthewVanDenSteen.jpg|thumb]]

== Info ==

:Human-Computer Interaction (graduated)
:E-mail: mmvdsteen [AT] gmail.com

== Master thesis project ==

*[[Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD]]

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-05-23T21:50:20Z

Matthew: /* About */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

[http://www.booksonline.iospress.nl/Content/View.aspx?piid=16768 Link to paper (iospress)]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==Abstract thesis==

As soldiers can be exposed to various different traumatic stressors, such as fire fights and
terrorist attacks, during their deployments, chances increase that these people develop a combatrelated
Post-Traumatic Stress Disorder.

Various methods exist to treat veterans suffering from this type of disorder, each having both
several advantages and disadvantages. One persisting problem is the high drop-out rate of patients.
This and several other problems have 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 faceto-
face therapy. This thesis discusses a new and unexplored concept which uses computer assisted
technology to support trauma-focused psychotherapy, focusing on restructuring and relearning of
past events. The proposed application allows patients and therapist to visualize the patient’s past
experience using maps, personal photos, stories and self created 3D virtual worlds. The tool aims to
allow patients to restructure, reappraise and relearn about their past experience involving the
problematic stressors.

The design of the system followed a situated cognitive engineering approach. The first step of this
approach was to do a domain analysis. This was done in close cooperation with a psychiatrist
experienced in treating veterans suffering from a combat-related PTSD, which eventually lead to the
establishment of an inventory of human factor knowledge, operational demands and envisioned
technology. The knowledge was used to create several scenarios and prototypes. Experts with a
psychology background were asked to review these scenarios and discuss various possibilities and
limitations, while prototypes were evaluated and tested by experts with a background in Human-
Computer Interaction. The acquired feedback made it possible to constantly refine the requirements
baseline.

The experiment which followed suggested that all three main interface components were easy to
use. Also, differences were found in a way a story was told with the application compared to a story
told without the use of the system. The results hinted at a more structured and precise way of
storytelling. A case study with a veteran showed that the patient enjoyed working with the
application. He felt encouraged to work with it as he saw the purpose of talking about past events by
managing a media archive.

==Demo features 3MR system (final)==

<anyweb>http://www.youtube.com/v/MrfwISJlOEA&hl=nl_NL&fs=1&</anyweb>

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Scenario movie clips ==

The following movie clips were used during the scenario phase of the study. Movie clips were presented showing a low-fidelity prototype being used in a possible therapeutic setting.
Do note that the people recorded in these clip are students from the TUDelft. They played either the role of a patient or the role of the therapist.

===Initial idea: 3D world editor===

<anyweb>http://www.youtube.com/v/_AHRGSLvgGk&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - 3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-05-23T21:49:53Z

Matthew: /* About */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

[http://www.booksonline.iospress.nl/Content/View.aspx?piid=16768 Link to paper]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==Abstract thesis==

As soldiers can be exposed to various different traumatic stressors, such as fire fights and
terrorist attacks, during their deployments, chances increase that these people develop a combatrelated
Post-Traumatic Stress Disorder.

Various methods exist to treat veterans suffering from this type of disorder, each having both
several advantages and disadvantages. One persisting problem is the high drop-out rate of patients.
This and several other problems have 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 faceto-
face therapy. This thesis discusses a new and unexplored concept which uses computer assisted
technology to support trauma-focused psychotherapy, focusing on restructuring and relearning of
past events. The proposed application allows patients and therapist to visualize the patient’s past
experience using maps, personal photos, stories and self created 3D virtual worlds. The tool aims to
allow patients to restructure, reappraise and relearn about their past experience involving the
problematic stressors.

The design of the system followed a situated cognitive engineering approach. The first step of this
approach was to do a domain analysis. This was done in close cooperation with a psychiatrist
experienced in treating veterans suffering from a combat-related PTSD, which eventually lead to the
establishment of an inventory of human factor knowledge, operational demands and envisioned
technology. The knowledge was used to create several scenarios and prototypes. Experts with a
psychology background were asked to review these scenarios and discuss various possibilities and
limitations, while prototypes were evaluated and tested by experts with a background in Human-
Computer Interaction. The acquired feedback made it possible to constantly refine the requirements
baseline.

The experiment which followed suggested that all three main interface components were easy to
use. Also, differences were found in a way a story was told with the application compared to a story
told without the use of the system. The results hinted at a more structured and precise way of
storytelling. A case study with a veteran showed that the patient enjoyed working with the
application. He felt encouraged to work with it as he saw the purpose of talking about past events by
managing a media archive.

==Demo features 3MR system (final)==

<anyweb>http://www.youtube.com/v/MrfwISJlOEA&hl=nl_NL&fs=1&</anyweb>

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Scenario movie clips ==

The following movie clips were used during the scenario phase of the study. Movie clips were presented showing a low-fidelity prototype being used in a possible therapeutic setting.
Do note that the people recorded in these clip are students from the TUDelft. They played either the role of a patient or the role of the therapist.

===Initial idea: 3D world editor===

<anyweb>http://www.youtube.com/v/_AHRGSLvgGk&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - 3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-05-18T12:53:18Z

Matthew: /* Research methodology */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==Abstract thesis==

As soldiers can be exposed to various different traumatic stressors, such as fire fights and
terrorist attacks, during their deployments, chances increase that these people develop a combatrelated
Post-Traumatic Stress Disorder.

Various methods exist to treat veterans suffering from this type of disorder, each having both
several advantages and disadvantages. One persisting problem is the high drop-out rate of patients.
This and several other problems have 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 faceto-
face therapy. This thesis discusses a new and unexplored concept which uses computer assisted
technology to support trauma-focused psychotherapy, focusing on restructuring and relearning of
past events. The proposed application allows patients and therapist to visualize the patient’s past
experience using maps, personal photos, stories and self created 3D virtual worlds. The tool aims to
allow patients to restructure, reappraise and relearn about their past experience involving the
problematic stressors.

The design of the system followed a situated cognitive engineering approach. The first step of this
approach was to do a domain analysis. This was done in close cooperation with a psychiatrist
experienced in treating veterans suffering from a combat-related PTSD, which eventually lead to the
establishment of an inventory of human factor knowledge, operational demands and envisioned
technology. The knowledge was used to create several scenarios and prototypes. Experts with a
psychology background were asked to review these scenarios and discuss various possibilities and
limitations, while prototypes were evaluated and tested by experts with a background in Human-
Computer Interaction. The acquired feedback made it possible to constantly refine the requirements
baseline.

The experiment which followed suggested that all three main interface components were easy to
use. Also, differences were found in a way a story was told with the application compared to a story
told without the use of the system. The results hinted at a more structured and precise way of
storytelling. A case study with a veteran showed that the patient enjoyed working with the
application. He felt encouraged to work with it as he saw the purpose of talking about past events by
managing a media archive.

==Demo features 3MR system (final)==

<anyweb>http://www.youtube.com/v/MrfwISJlOEA&hl=nl_NL&fs=1&</anyweb>

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Scenario movie clips ==

The following movie clips were used during the scenario phase of the study. Movie clips were presented showing a low-fidelity prototype being used in a possible therapeutic setting.
Do note that the people recorded in these clip are students from the TUDelft. They played either the role of a patient or the role of the therapist.

===Initial idea: 3D world editor===

<anyweb>http://www.youtube.com/v/_AHRGSLvgGk&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - 3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:46:01Z

Matthew: /* Scenario movie clips */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==Abstract thesis==

As soldiers can be exposed to various different traumatic stressors, such as fire fights and
terrorist attacks, during their deployments, chances increase that these people develop a combatrelated
Post-Traumatic Stress Disorder.

Various methods exist to treat veterans suffering from this type of disorder, each having both
several advantages and disadvantages. One persisting problem is the high drop-out rate of patients.
This and several other problems have 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 faceto-
face therapy. This thesis discusses a new and unexplored concept which uses computer assisted
technology to support trauma-focused psychotherapy, focusing on restructuring and relearning of
past events. The proposed application allows patients and therapist to visualize the patient’s past
experience using maps, personal photos, stories and self created 3D virtual worlds. The tool aims to
allow patients to restructure, reappraise and relearn about their past experience involving the
problematic stressors.

The design of the system followed a situated cognitive engineering approach. The first step of this
approach was to do a domain analysis. This was done in close cooperation with a psychiatrist
experienced in treating veterans suffering from a combat-related PTSD, which eventually lead to the
establishment of an inventory of human factor knowledge, operational demands and envisioned
technology. The knowledge was used to create several scenarios and prototypes. Experts with a
psychology background were asked to review these scenarios and discuss various possibilities and
limitations, while prototypes were evaluated and tested by experts with a background in Human-
Computer Interaction. The acquired feedback made it possible to constantly refine the requirements
baseline.

The experiment which followed suggested that all three main interface components were easy to
use. Also, differences were found in a way a story was told with the application compared to a story
told without the use of the system. The results hinted at a more structured and precise way of
storytelling. A case study with a veteran showed that the patient enjoyed working with the
application. He felt encouraged to work with it as he saw the purpose of talking about past events by
managing a media archive.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Scenario movie clips ==

The following movie clips were used during the scenario phase of the study. Movie clips were presented showing a low-fidelity prototype being used in a possible therapeutic setting.
Do note that the people recorded in these clip are students from the TUDelft. They played either the role of a patient or the role of the therapist.

===Initial idea: 3D world editor===

<anyweb>http://www.youtube.com/v/_AHRGSLvgGk&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - 3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Scenario cycle 2: Early version of 3MR - Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:45:13Z

Matthew: /* Revised scenarios (PTSD among soldiers) */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==Abstract thesis==

As soldiers can be exposed to various different traumatic stressors, such as fire fights and
terrorist attacks, during their deployments, chances increase that these people develop a combatrelated
Post-Traumatic Stress Disorder.

Various methods exist to treat veterans suffering from this type of disorder, each having both
several advantages and disadvantages. One persisting problem is the high drop-out rate of patients.
This and several other problems have 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 faceto-
face therapy. This thesis discusses a new and unexplored concept which uses computer assisted
technology to support trauma-focused psychotherapy, focusing on restructuring and relearning of
past events. The proposed application allows patients and therapist to visualize the patient’s past
experience using maps, personal photos, stories and self created 3D virtual worlds. The tool aims to
allow patients to restructure, reappraise and relearn about their past experience involving the
problematic stressors.

The design of the system followed a situated cognitive engineering approach. The first step of this
approach was to do a domain analysis. This was done in close cooperation with a psychiatrist
experienced in treating veterans suffering from a combat-related PTSD, which eventually lead to the
establishment of an inventory of human factor knowledge, operational demands and envisioned
technology. The knowledge was used to create several scenarios and prototypes. Experts with a
psychology background were asked to review these scenarios and discuss various possibilities and
limitations, while prototypes were evaluated and tested by experts with a background in Human-
Computer Interaction. The acquired feedback made it possible to constantly refine the requirements
baseline.

The experiment which followed suggested that all three main interface components were easy to
use. Also, differences were found in a way a story was told with the application compared to a story
told without the use of the system. The results hinted at a more structured and precise way of
storytelling. A case study with a veteran showed that the patient enjoyed working with the
application. He felt encouraged to work with it as he saw the purpose of talking about past events by
managing a media archive.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Scenario movie clips ==

The following movie clips were used during the scenario phase of the study. Movie clips were presented showing a low-fidelity prototype being used in a possible therapeutic setting.
Do note that the people recorded in these clip are students from the TUDelft. They played either the role of a patient or the role of the therapist.

===Initial idea: 3D world editor===

<anyweb>http://www.youtube.com/v/_AHRGSLvgGk&hl=nl_NL&fs=1&</anyweb>

===General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:40:52Z

Matthew: /* Research methodology */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==Abstract thesis==

As soldiers can be exposed to various different traumatic stressors, such as fire fights and
terrorist attacks, during their deployments, chances increase that these people develop a combatrelated
Post-Traumatic Stress Disorder.

Various methods exist to treat veterans suffering from this type of disorder, each having both
several advantages and disadvantages. One persisting problem is the high drop-out rate of patients.
This and several other problems have 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 faceto-
face therapy. This thesis discusses a new and unexplored concept which uses computer assisted
technology to support trauma-focused psychotherapy, focusing on restructuring and relearning of
past events. The proposed application allows patients and therapist to visualize the patient’s past
experience using maps, personal photos, stories and self created 3D virtual worlds. The tool aims to
allow patients to restructure, reappraise and relearn about their past experience involving the
problematic stressors.

The design of the system followed a situated cognitive engineering approach. The first step of this
approach was to do a domain analysis. This was done in close cooperation with a psychiatrist
experienced in treating veterans suffering from a combat-related PTSD, which eventually lead to the
establishment of an inventory of human factor knowledge, operational demands and envisioned
technology. The knowledge was used to create several scenarios and prototypes. Experts with a
psychology background were asked to review these scenarios and discuss various possibilities and
limitations, while prototypes were evaluated and tested by experts with a background in Human-
Computer Interaction. The acquired feedback made it possible to constantly refine the requirements
baseline.

The experiment which followed suggested that all three main interface components were easy to
use. Also, differences were found in a way a story was told with the application compared to a story
told without the use of the system. The results hinted at a more structured and precise way of
storytelling. A case study with a veteran showed that the patient enjoyed working with the
application. He felt encouraged to work with it as he saw the purpose of talking about past events by
managing a media archive.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Revised scenarios (PTSD among soldiers) ==
===General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:39:01Z

Matthew: /* Photos Case Study with real patient */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

== Revised scenarios (PTSD among soldiers) ==
===General use===
<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

===3D editor===
<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

===Returning to a previously edited day===
<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:38:05Z

Matthew: /* Revised scenarios (PTSD among soldiers) */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:37:50Z

Matthew: /* Photos Case Study with real patient */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==
<gallery widths="300px">
Image:Foto0210.jpg

Image:Foto0211.jpg

Image:Foto0215.jpg

</gallery>

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:37:10Z

Matthew: /* Version 0.2 3D editor feature */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==
<gallery widths="300px">
Image:Editor4.jpg

Image:Editor5.jpg
</gallery>

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:36:17Z

Matthew: /* Improved prototype after more feedback (formative) */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

<gallery widths="300px">
Image:V7-1.jpg
</gallery>

=== Edit a day (text files shown) ===

<gallery widths="300px">
Image:V7-2.jpg
</gallery>

=== More features shown, such as hiding images and webcam shots ===

<gallery widths="300px">
Image:V7-3.jpg
</gallery>

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:35:16Z

Matthew: /* Improved concept screens */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===
<gallery widths="300px">
Image:1heuristic.jpg
</gallery>

=== Adding media view ===
<gallery widths="300px">
Image:2heuristic.jpg
</gallery>

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:34:27Z

Matthew: /* New concept to explain features */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==
<gallery widths="300px">
Image:Oldconcept.jpg
</gallery>

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:34:05Z

Matthew: /* Early concept screens (therapist side) */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

<gallery widths="300px">
Image:Concepttherapist.jpg

Image:Concepttherapist2.jpg
</gallery>

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:33:38Z

Matthew: /* Early concept screens */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

<gallery widths="300px">
Image:0000.jpg

Image:2 3.jpg
</gallery>

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:29:25Z

Matthew: /* About */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

E-mail: mmvdsteen [AT] gmail.com

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-29T13:28:31Z

Matthew: /* About */

[[Image:Multi.jpg]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

File:Multi.jpg

2010-04-29T13:27:45Z

Matthew:

Project Team

2010-04-29T13:20:46Z

Matthew: /* Master Students */

== Project Leaders ==
{|
|-
|[[Image:CvdMast05.jpg|frameless|80px]]
|
:Dr.ir. Charles A.P.G. van der Mast (contact person)
:Human-Computer Interaction
:[mailto:c.a.p.g.vandermast@tudelft.nl c.a.p.g.vandermast@tudelft.nl]
:[http://mmi.tudelft.nl/~charles homepage]
|-
|[[Image:Paul.jpg|frameless|80px]]
|
:Prof.dr. Paul M.G. Emmelkamp
:Clinical Psychology
:P.M.G.Emmelkamp (at) uva.nl
:[http://home.medewerker.uva.nl/p.m.g.emmelkamp/ homepage]
|-
|[[Image:Erik.jpg|frameless|80px]]
|
:Prof.dr. Ir. Erik W. Jansen
:Computer Graphics
|-
|[[Image:Willem-PaulBrinkman.jpg|frameless|80px]]
|
:Dr.ir. Willem-Paul Brinkman (contact person)
:Human-Computer Interaction
:W.P.Brinkman (at) tudelft.nl
:[http://mmi.tudelft.nl/index.php?option=com_contact&task=view&id=130 homepage]
|-
|[[Image:Mark-Neerincx.jpg|frameless|80px]]
|
:Prof. Dr. Mark Neerincx
:Human-Computer Interaction
:M.A.Neerincx (at) tudelft.nl
:[http://mmi.tudelft.nl/index.php?option=com_contact&task=view&id=82 homepage]
|-
|[[Image:N_Morina_6_09.jpg|frameless|80px]]
|
:Dr. Nexhmedin Morina
:Clinical Psychology
:n.morina (at) uva.nl
:[http://home.medewerker.uva.nl/n.morina/ homepage]

|}

== Partners ==
{|
|-
|[[Image:Lucas.gif|frameless|80px]]
|
:Dr. Lucas van Gerwen (PhD thesis: June 2004)
:Psychology
:[mailto:info@valk.org info@valk.org]
:[http://www.valk.org/ VALK foundation homepage]
|-
|[[Image:Spinhoven.gif|frameless|80px]]
|
:Prof. Dr. Philip Spinhoven
:Psychology
:spinhoven(at)fsw.leidenuniv.nl
|}

== PhD Students ==
{|
|-
|[[Image:Martijn.jpg|frameless|80px]]
|
:Dr. Martijn J. Schuemie (PhD thesis: March 2003)
:Human-Computer Interaction
|-
|[[Image:Merel.jpg|frameless|80px]]
|
:Dr. Merel Krijn (PhD thesis: Jan 2006)
:Clinical Psychology
|-
|[[Image:Katharina_web.jpg|frameless|80px]]
|
:Katharina Meyerbröker
:Clinical Psychology
:K.Meyerbroker(at)uva.nl
:Look at: [http://www2.fmg.uva.nl/virtualreality/ http://www2.fmg.uva.nl/virtualreality/]
|-
|[[Image:BertBusscher.jpg|frameless|80px]]
|
:Bert Busscher
:Clinical Psychology
:b.h.busscher(at)umail.leidenuniv.nl
:VALK Foundation
|}

== Master Students ==
{|
|-
|[[Image:Sietske.jpg|frameless|80px]]
|
:Drs. Sietske de Vries
:Clinical Psychology
|-
|[[Image:Alex.jpg|frameless|80px]]
|
:Alexander M.Hulsbosch
:Clinical Psychology
|-
|[[Image:Peter.jpg|frameless|80px]]
|
:Peter van der Straaten
:Human-Computer Interaction
|-
|[[Image:Roeline.jpg|frameless|80px]]
|
:Roeline Biemond
:Clinical Psychology
|-
|[[Image:Claudius.jpg|frameless|80px]]
|
:Claudius de Wilde de Ligny
:Clinical Psychology
|-
|[[Image:Lucy.jpg|frameless|80px]]
|
:Lucy Trianawaty Gunawan
:Human-Computer Interaction
|-
|[[Image:Fitri.jpg|frameless|80px]]
|
:Fitri Nurdini Rahayu
:Human-Computer Interaction
|-
|[[Image:Bas_van_Abel.jpg|frameless|80px]]
|
:Bas van Abel
:Human-Computer Interaction
|-
|[[Image:jenn.jpg|frameless|80px]]
|
:Jenneke Wiersma
:Clinical Psychology
|-
|[[Image:Rio.gif|frameless|80px]]
|
:Rio A Sopacua
:Human-Computer Interaction
|-
|[[Image:Pietoo8.jpg|frameless|80px]]
|
:Piet van der Ploeg
:Clinical Psychology
|-
|[[Image:Frans.gif|frameless|80px]]
|
:Frans S. Hooplot
:Human-Computer Interaction
|-
|[[Image:Iulia.gif|frameless|80px]]
|
:Iulia Dobai
:Human-Computer Interaction
|-
|[[Image:Siemen.gif|frameless|80px]]
|
:Siemen Roorda
:Human-Computer Interaction
|-
|[[Image:BurakAslan.jpg|frameless|80px]]
|
:Burak Aslan
:Human-Computer Interaction
|-
|[[Image:PhongBui.jpg|frameless|80px]]
|
:Phong Bui
:Human-Computer Interaction
|-
|[[Image:PhotoArtan.jpg|frameless|80px]]
|
:Artan Sulji
:Human-Computer Interaction
|-
|[[Image:Anouk_web.jpg|frameless|80px]]
|
:Anouk Taytelbaum
:Clinical Psychology
|-
|[[Image:Anthony.jpg|frameless|80px]]
|
:Anthony Adler Claude
:Human-Computer Interaction
|-
|[[Image:Donovan2.jpg|frameless|80px]]
|
:Donovan Tjien-Fooh
:Human-Computer Interaction
|-
|[[Image:Kenan2.jpg|frameless|80px]]
|
:Kenan Saracevic
:Human-Computer Interaction
|-
|[[Image:Ifa.jpg|frameless|80px]]
|
:Ifa Chaeron
:Project:[[Measuring fear from voice|Measuring fear from voice]]
:Human-Computer Interaction
|-
|[[Image:Nophoto.jpg|frameless|80px]]
|
:Ervin Sabadi
:Human-Computer Interaction
|-
|[[Image:Nophoto.jpg|frameless|80px]]
|
:Fatma Inan
:Project:[[Recreating a social situation in Virtual Reality|Recreating a social situation in Virtual Reality]]
:Human-Computer Interaction
|-
|[[Image:Abigail.jpg|frameless|80px]]
|
:Abigail Struik
:Clinical Psychology
|-
|[[Image:Guntur_HMD_3.jpg|frameless|80px]]
|
:Guntur Sandino
:Project:[[Generic therapist user interface |Generic therapist user interface ]]
:Human-Computer Interaction
|-
|[[Image:DanieldeVliegher.jpg|frameless|80px]]
|
:Daniel de Vliegher
:Project:
:Human-Computer Interaction
|-
|[[Image:IngmarGoudt.jpg|frameless|80px]]
|
:Ingmar Goudt
:Project:[[Non-verbal communication in virtual environments|Non-verbal communication in virtual environments]]
:Human-Computer Interaction
|-
|[[Image:ChristianPaping.jpg|frameless|80px]]
|
:Christian Paping
:Project:[[Designing a Multiple patient VRET system|Designing a Multiple patient VRET system]]
:Human-Computer Interaction
:[http://home.tiscali.nl/~cjpaping/ homepage]
|-
|[[Image:NielsterHeijden.jpg|frameless|80px]]
|
:Niels ter Heijden
:Project:[[Virtual conversation|Virtual conversation]]
:Human-Computer Interaction
|-
|[[Image:MatthewVanDenSteen.jpg|frameless|80px]]
|
:Matthew van den Steen
:Project:[[Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD|Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD]]
:Human-Computer Interaction
|-
|[[Image:Panics.jpg|frameless|80px]]
|
:Sacha Panic
:Project:[[Assessment and rehabilitation of cognitive skills using virtual reality |Assessment and rehabilitation of cognitive skills using virtual reality]]
:Human-Computer Interaction
|}

== Bachelor Students ==

News

2010-04-28T18:22:11Z

Matthew:

__TOC__
== Matthew van den Steen graduated ==
<div style="text-align: right;"><small>April 28, 2010</small></div>
On April 28, 2010 [[Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD|Matthew van den Steen]] successfully defended his master thesis [http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf The Design and Evaluation of a Multi-Modal Memory Restructuring System for patients suffering from a combat-related PTSD].

== Kunnen avatars mensen helpen? ==
<div style="text-align: right;"><small>April 21, 2010</small></div>
[http://mmi.tudelft.nl/vret_oud/images/c/ca/Avatars-VRET-21APR10%3DV5.pdf Slides]zoals vertoond voor W&T Academie in Delft op 21 april 2010. (pdf, in Dutch)

== Junior TU Delft working on VRET ==
<div style="text-align: right;"><small>March 23, 2010</small></div>
For the third time Willem-Paul and Charles are giving a 5-day course in the Junior TU Delft program for the best high school students of the Netherlands. They develop this year new interactive worlds for treatment of social phobia. Our master student Daniel de Vliegher created an empty world and interaction framework for them. The students of this program will model there own objects to fill the world and create there own interactive dialogs.

== VRET in Delta Universitity Journal ==
<div style="text-align: right;"><small>March 3, 2010</small></div>
The Delta university journal published a small article on the
success of our research. Presented is how our research is resulting in
deployment in Dutch society. [http://mmi.tudelft.nl/vret_oud/images/1/1f/DELTA.pdf See here]

== Christian Paping graduated ==
<div style="text-align: right;"><small>November 25, 2009</small></div>
On November 25, 2009 [[Designing a Multiple patient VRET system|Christian Paping]] successfully defended his master thesis [http://mmi.tudelft.nl/vret_oud/images/8/8c/Thesis_Multiple_patient_virtual_reality_exposure_therapy.pdf Multiple patient virtual reality exposure therapy]. Previously his work was presented at the 2009 NATO Wounds of War conference.

== Research on PTSD ==
<div style="text-align: right;"><small>November 23, 2009</small></div>
In 2009 we started collaboration with Col Eric Vermetten MD, PhD on PTSD. Eric is Head of research of Military Mental Health Center / Utrecht Medical Center. Our master student [[Post-Traumatic_Stress_Disorders_%26_Virtual_Reality | Matthew van den Steen]] is working on a scenario-based study to develop a prototype for treating military employees suffering PTSD with experiences in Bosnia, Iraq, Afganistan, etc. First experiment with patients are planned for December 2009.

== Appearance on Teleac TV program Helder (in Dutch) ==
<div style="text-align: right;"><small>November 12, 2009</small></div>

On November 11, 2009 Willem-Paul and Guntur presented the VRET system in Dutch [http://www.teleac.nl/helder/ Teleac TV program Helder] about fear. Host, Pernille la Lau, worn the head mounted display to see one of VR world designed to treat patients for their fear of heights. In the studio it was very nice also to see the patient view on the big screen wall. The audience could see what Pernille was experiencing while she was in the virtul world. The program will be [http://www.teleac.nl/helder/?site=site_helder&nr=2047519&item=2647857 broadcasted] on 30 Nov 2009.

== Afscheidssymposium Charles van der Mast (in Dutch) ==
<div style="text-align: right;"><small>March 2, 2009</small></div>

On March 19, 2009 an "Afscheidssymposium" will be held on the occasion of the retirement of Charles. He will still be connected to the VRET-project, but other research and education will be minimized. On this [http://mmi.tudelft.nl/afscheidssymposium/ link] you find all details of the programme.

== Virtueel van je angsten af (in Dutch) ==
<div style="text-align: right;"><small>February 9, 2009</small></div>

Katharina Meyerbröker is interviewed for the ECHO website. Her goal is to get in contact with participants for her experiments on agoraphobia. [http://www.echo.nl/ec-ce/stad/lees/826521/virtueel.van.je.angsten.af/ Here] is the link. Look and ask for an invitation.

== Report on Presence and Anxiety ==
<div style="text-align: right;"><small>December 4, 2008, 2008</small></div>
Liesbeth Kuiper (student Research Master Clinical Psychology from Leiden University) published a report on her internship at VALK foundation. The report is in Dutch (Stageverslag) but the core chapter Presence & Anxiety is in English. Look under Publications and scroll to Reports.

== Fatma Inan and Ervin Sabadi graduated ==
<div style="text-align: right;"><small>November 21, 2008</small></div>
Our master students [[User:Fatma Inan|Fatma]] and Ervin graduated in November 2008. The title of Fatma's thesis is: Virtual Reality and Social Phobia: Recreating a social situation in Virtual Reality. Ervin's thesis is entitled: Reaching a higher sense of presence in VR through 3D architectural visualization. See Own Publications>Reports.

== First scientific field study on VRET results in a Dutch clinic ==
<div style="text-align: right;"><small>October 30, 2008</small></div>
Wiersma, J, Greeven, A., Berretty, E., Krijn, M en Emmelkamp, P. (2008). De effectiviteit van Virtual Reality Exposure Therapy voor hoogtevrees in de klinische praktijk. Gedragstherapie, 41, p. 253-259. (in Dutch)-- Look under [[Publications|Publications]] on this site.

'''Summary in English'''. The effectiveness of Virtual Reality Exposure Therapy (VRET) for patients with acrophobia in clinical practice. The effectiveness of Virtual Reality Exposure Therapy (VRET) for patients with acrophobia has been shown in several academic settings. However, it is not clear if these results can be translated to the daily clinical practice. This article describes the effectiveness of VRET of acrophobia in a centre for anxiety disorders. Thirty-two patients participated in the study. At post-treatment there was a significant reduction of acrophobia and avoidance and participants gained significantly more self-efficacy and a more positive attitude towards heights. The effect sizes were high and comparable to those found in academic settings. It can be concluded that the effectiveness of VRET in academic settings can be translated to clinical practice. In short, VRET is a promising, and time-limited treatment for acrophobia. Key words: Virtual Reality Exposure Therapy, acrophobia, clinical practice

== Interesting Blog about our project ==
<div style="text-align: right;"><small>September 17, 2008</small></div>
Eliane Alhadeff published an interesting blog about our project. She made a very good op-to-date summary of current and future research on VRET in Delft. Here is the [http://elianealhadeff.blogspot.com/2008/09/vret_oud-serious-games-treat-anxiety.html link].

== New Video Tutorial available ==
<div style="text-align: right;"><small>July 8, 2008</small></div>
Two Delft students produced a new video tutorial about the use of our DVRET system for fear of flying. The focus is to explain the operational procedures of the VRET software to non-technical '''therapists'''. First, a general description is given of the DVRET system. Then, the main functionality, which is exposed by the graphic user interface of the VRET software, be discussed in a short session. This is followed by a schematic description of all the operational tasks, such as takeoff and landing of the airplane, which could be performed with a therapeutic session. Lastly, a few of these tasks will be described in more detail. Two video's are part of of the tutorial. Text on screen is in English, all voice overs are in Dutch.

== Our project in QUEST ==
<div style="text-align: right;"><small>June 16, 2008</small></div>
In the Dutch popular science journal Quest an article is published on fear of flying. The title is "Ontspannen Op Reis". Issue of Quest 07/2008 pp. 52-55. The work of our partner VALK and our Delft VRET system is presented.

== New poster about our VRET project ==
<div style="text-align: right;"><small>May 9, 2008</small></div>
A new poster of our project and system is designed by Willem-Paul Brinkman. Our new focus on social phobia is presented. You can download it [http://mmi.tudelft.nl/~vrphobia/images/Poster_VRET2008.pdf here]. (pdf)

== Junior TU Delft on VRET [continued] ==
<div style="text-align: right;"><small>April 28, 2008</small></div>
The highschool students finished the course on VRET succesfully. Four worlds were developed for treating social phobia. They are evaluated with scenarios designed by the highschool students themselves! The worlds are: Platform on a train station, Bus stop, Clothing shop and Reception desk of a restaurant. Made with Maya and run in UnReal. With talking avatars. Here are impressions of the worlds. The implementation is done by Daniel de Vliegher.

<gallery widths="300px">
Image:News_Bushalte.jpg
Image:News_Restaurant.jpg
Image:News_Treinstation.jpg
Image:News_Winkel.jpg
</gallery>

== Junior TU Delft on VRET ==
<div style="text-align: right;"><small>March 10, 2008</small></div>
Delft University of Technology presents during March and April 2008 a course on VRET for high school students in Randstad. In 5 days the students (5-6 VWO) design a virtual world for treating fear for public speaking. The real implementation is done by our master students.

== Lecture on the Delft VRET system ==
<div style="text-align: right;"><small>March 10, 2008</small></div>
For the course Highly Interactive Systems of the master programme Media and Knowledge Enineering at Delft Charles van der Mast gave a lecture about the architecture and the development of the Delft VRET system. The lecture takes 45 minutes. The recording of voice and slides is [http://yukon.twi.tudelft.nl/weblectures/IN4034_08/Lecture4A/in4034_Lecture4A.html here].

== Master thesis by Siemen Roorda ==
<div style="text-align: right;"><small>February 14, 2008</small></div>
Our master student Siemen Roorda finished his Thesis for the programme Media and Knowledge Engineering The title is: Develop[ing a general framework for the Delft VRET application. He re-implemented our system based on Vizard and the programming language Python. Look under [[Publications|Publications/Reports]] at this site.

== Research Assignment by Ervin Sabadi ==
<div style="text-align: right;"><small>November 7, 2007</small></div>
Our master student Ervin Sabadi finished his Research Assignment on VRET for agoraphobia from a home ententainment perspective. Look under [[Publications|Publications/Reports]] at this site.

== Delft VRET system in use at University of Amsterdam ==
<div style="text-align: right;"><small>October 12, 2007</small></div>
[[image:VRET-system-UvA-crop.jpg|left|thumb|300px|The Delft VRET system for research at University of Amsterdam in the group of Prof. Paul Emmelkamp.]]
Paul Emmelkamp and his group is using the Delft VRET system now for new controlled experiments. Katharina Meyerbröker started her PhD project in September 2007. Recently a new HMD was delivered by Cybermind. Here you see one of the worlds for acrophobia.

== Delft VRET system in use at VALK foundation ==
<div style="text-align: right;"><small>October 5, 2007</small></div>
VALK foundation in Leiden is using the Delft VRET system now on a large scale with several therapists. An internal workshop is given this month. Here is how the system looks while being tested in a new room. All cables are invisible now!

<gallery>
Image:VRETsystemVALK07.jpg|The Delft VRET system for treating fear of flying at VALK in Leiden
Image:DVRETsystem2.jpg|at Delft University of Technology
</gallery>

== Xbox live and Second life ==
<div style="text-align: right;"><small>October 3, 2007</small></div>
This month we started a project to investigate the possibilities of Xbox Live and Second Life (and others) to function as a technical platform for phobia treatment.

== New world for fear of flying ==
<div style="text-align: right;"><small>August 17, 2007</small></div>
Burak Aslan finished his bachelor project to build a new VR-world for treating fear of flying. He developed a complete new cabin of a KLM Boeing 737-800 with high quality graphics. This virtual environment is far more realistic than the previous one we have. Also Schiphol airport is completely redesigned by Kenan Saracevic. Google Earth is used to show the view through the window during the flight. This is still a prototype we have to improve. Modelled with Maya and run with Quest-3D. You can find his report under Publications-section Reports. More information from Charles van der Mast, see Team.

<gallery>
Image:FoF07.jpg
Image:Airport_from_air.jpg
Image:Final_gate_3.jpg
</gallery>

== AWARE Psychology ==
<div style="text-align: right;"><small>June 1, 2007</small></div>
Our system is described in the new Dutch science magazine Aware Psychology. The title is Virtuele wereld IN/UIT.

== Bacinol Expo ==
<div style="text-align: right;"><small>June 1, 2007</small></div>
From June 6 - July 8 our VRET system will be present on an exhibition Virtual Realism. Several research projects are presented for a general public.

== VRET for hiking ==
<div style="text-align: right;"><small>May 31, 2007</small></div>
On March 15 two journalists of the popular Dutch Journal '''Op Pad''' (for adventures and hiking) visited our project. They are very interested in VRET for hikers suffering acrophobia in the mountains. The article is published in May 2007, Op Pad, Vol 4, pp. 70-73.[In Dutch: Een '''lichte trilling''' gaat door je lijf, je handen worden klam, '''je hartslag''' loopt op, '''je ademhaling''' versnelt, '''je pupillen''' worden groter, '''de haren in je nek''' staan overeind... HELP, see: http://www.oppad.nl]. Our system is used by [http://www.psyq.nl/ PsyQ] for treating acrophobia (hoogtevrees, zeer effectief! You may contact PsyQ).

== Thesis on Augmented Reality ==
<div style="text-align: right;"><small>Mar 16, 2007</small></div>
Marlon Richert finished his Thesis, too. Look under [[Publications|Publications]], categrory Reports.

== Survey on treating Hemiplegia ==
<div style="text-align: right;"><small>Jan 16, 2007</small></div>
Marlon Richert finished his Research Assignment on treating hemiplegia. Look under [[Publications|Publications]], categrory Reports.

== Workshop for GGZ Nederland ==
<div style="text-align: right;"><small>Oct 6, 2006</small></div>
On Wednesday October 4, 2006 we gave two workshops for the visitors of a GGZ Nederland conference in MediaPlaza/Utrecht. Charles van der Mast, Paul Emmelkamp and Martijn Schuemie gave a presentation for very interested therapists. Martijn discussed the demands from the clinics (therapists and managers) for applying VRET. To implement VRET in clinics a commercial version of the system is needed. Martijn will start to develop this in close collaboration with the research project. The fundamental research will be continued of course.
Some pictures of the workshop are [http://mmi.tudelft.nl/~vrphobia/WorkshopsGGZ-NL.pdf here].

== DVRET at Parnassia / PsyQ ==
<div style="text-align: right;"><small>Sep 14, 2006</small></div>
At Parnassia / PsyQ about 60 patients have been treated for acrophobia. In four sessions of 90 minutes each the treatment could be finished successfully. Drop-out rate was low. See [http://www.psyq.nl/ here].

== DVD on our project ==
<div style="text-align: right;"><small>February 3, 2006</small></div>
[[Image:DVD_box.jpg|thumb|300px|]]
Students from our bachelor program Media&Knowledge Engineering have produced an interesting DVD about our vrphobia project (in English). On the DVD you find an overview of the VRET system we made, some scientific results, many publications and some interviews of team members (in Dutch&English). Interested? Ask Charles van der Mast. You will get a copy.

Look [http://mmi.tudelft.nl/~vrphobia/DVD_shots.pdf here] for screenshots (8MB pdf) of the DVD.

== VRET and Serious Games! ==
<div style="text-align: right;"><small>November 23, 2005</small></div>
On November 21, Charles van der Mast presented our project and system at a seminar of Media Plaza (Utrecht). This seminar was organized to bring together professional computer game producers under the label "Serious Games". VRET was presented as a great example of a serious game in which emotions are controlled more carefully and accurately than in commercial games. Interesting collaborations may emerge!

== New World for agoraphobia ==
<div style="text-align: right;"><small>October 6, 2005</small></div>
Frans Hooplot implemented the Markt in Delft as a new world for treatment of agoraphobia. A lot of parameters can be changed by the therapist. Three photo's are here.

<gallery>
Image:MarktDelft_SMALL.jpg
Image:Markt1_SMALL.jpg
Image:Markt2_SMALL.jpg
</gallery>

== Visit to Valencia ==
<div style="text-align: right;"><small>August 6, 2005</small></div>
On July 21, Charles van der Mast visited the Universidad Politecnica de Valencia where he met our collegues Mariano Alcaniz, Carmen Juan, Jose Lozano and Sole Quero. And our Delft master student Dennis Joele.
Here are two photo's with Mariano (left) and Charles (right).

<gallery>
Image:Mariano2_Edited.jpg
Image:Charles2Edited.jpg
</gallery>

== VRET transfered to PsyQ in the Hague ==
<div style="text-align: right;"><small>July 6, 2005</small></div>
Today, July 6, we transfered a dedicated VRET system to the headquarters of PsyQ (part of Parnassia) in the Hague. From this week on, PsyQ will treat patients with fear of heights and claustrophobia within virtual worlds. The transfer was without problems and we are expecting great results. PsyQ will remain an important partner in the future, too. For more information about PsyQ and the phobia treatments, take a look at PsyQ's [http://psyq.nl/programma/angststoornissen website] (in Dutch).
This is the first time the VRET system is actually used in a clinic, rather than the research lab which was the case until now. If you are interested in a complete system in your clinic, please contact [http://graphics.tudelft.nl/~vrphobia/vrteam.html Charles van der Mast].

<gallery>
Image:Vret_psyq_1.jpg
Image:Vret_psyq_2.jpg
</gallery>

== Technological challenges for VRET ==
<div style="text-align: right;"><small>June 23, 2005</small></div>
The participation to the NATO Advanced Research Workshop generated a lot of value and interest for our project. We chaired a workgroup 2 and the slides we discussed with the participants plenarily are included [http://mmi.tudelft.nl/~vrphobia/NATO_ARW_PTSD_GROUP2.pdf here]. The draft of our paper is [http://mmi.tudelft.nl/~vrphobia/VANDERMAST_NATO050.pdf here].
[Mast, C. van der, Popovic, S., Lam, D., Castelnuovo, G., Kral, P. & Mihajlovic, Z. (2005). Technological challenges in the use of Virtual Reality Exposure Therapy, Proceedings of the NATO Advanced Research Workshop on Novel approaches to the diagnosis and treatment of posttraumatic stress disorder, Amsterdam IOS Press. (in press)] A book will be published later.

== Phobia treatment over the Internet! ==
<div style="text-align: right;"><small>June 1, 2005</small></div>
Today, June 1, we proved that our VRET-system can work over the internet. Our VRET-system is composed of two separate computers. The therapist computer can control the patient computer containing the virtual worlds completely. In this way the therapist can treat patients in other clinics or home. An intercom connection is needed for normal human communication between therapist and patient. The principle works. Now we have to prepare usability studies.

== Collaboration with Universidad Politecnica de Valencia ==
<div style="text-align: right;"><small>May 26, 2005</small></div>
Dennis Joele is a student from the master programme Media & Knowledge Engineering of Delft. He is doing his master thesis project at the Medical Image Computing Laboratory of the Universidad Politecnica de Valencia. His local supervisor is Dr. Maria Carmen Juan-Lizandra. From Delft he is supervised by Charles van der Mast. Dennis just finished his research assignment "Augmented Reality using ARToolkit with user invisable markers". He will continue his project at Valencia. This is the start of a collaboration on VRET.

== NATO Advanced Research Workshop ==
<div style="text-align: right;"><small>May 19, 2005</small></div>
Paul Emmelkamp and Charles van der Mast will participate in the NATO Advanced Research Workshop on Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. June 13-15, 2005, Dubrovnik, Croatia. They will moderate workshops on Outcomes Measurement and Issues in Follow-up, and Technological Challenges in the Use of VR. We will report on the outcome.

== New Partners ==
<div style="text-align: right;"><small>March 10, 2005</small></div>
Two official partners are added to the list. Mentrum and CyberMind sent us a Letter of Intent to support a new research project on VRET we are preparing now. [http://www.mentrum.nl/ Mentrum] is an organisation of about 1000 employees treating mental disorders in Amsterdam. They treat about 15,000 clients a year for mental disorders and a part of them for phobias. [http://www.cybermind.nl/ CyberMind] is a leading provider of VR equipment in the EU. They deliver the hardware components of our VRET system to implement the virtual worlds. They develop head mounted devices and they resell products of other developers. They will contribute in developing a special version of a HMD suited for phobia treatment in the future.

== New Partner Parnassia/PsyQ ==
<div style="text-align: right;"><small>February 11, 2005</small></div>
Recently [http://www.parnassia.nl/ Parnassia] sent us a Letter of Intent to participate in a new research project we are preparing right now. We will collaborate in developing new worlds and new treatment procedures. Parnassia will be involved in field studies. They will buy a copy of our VRET-system to train the therapists and to start VRET treatment with patients in their own clinics. Parnassia is a large organisation of about 3000 employees who provide instruction, treatment, coaching and nursing of people with psycho-medical problems or disorders. Parnassia is operating in about 30 clinics in the province of Zuid-Holland. About 40 phobia therapists are working for Parnassia.

== Our project at NGC in the Netherlands ==
<div style="text-align: right;"><small>January 10, 2005</small></div>
On Wednesday January 12, 2005 our project will be presented in the program Hot Sciences from Holland. Time 9 p.m. This video was produced almost two years agoo but the content is still very up-to-date in 2005! Click [http://mmi.tudelft.nl/~vrphobia/VR-1.wmv Phobia VR treatment movie] for the movie in dutch (copyright NGC). This program is being broadcasted all over the world by NGC.

== Parnassia/PsyQ visiting our project ==
<div style="text-align: right;"><small>November 2rd</small></div>
On October 28, 2004 about 35 (!!!) phobia therapists from the health institute Parnassia in the Hague visited our project. Charles van der Mast and Paul Emmelkamp gave an overview of the project and the impressive results. Click [http://mmi.tudelft.nl/~vrphobia/Parnassia/Foto.htm here] for some pictures.

== Our project at IST 2004 ==
<div style="text-align: right;"><small>September 23th</small></div>
Our project will be present at the European IST 2004 Event - Participate in your future. Participants will be there from all European countries. This year's edition of the most important European Information Society Technologies (IST) event is organised under the EU’s Dutch Presidency by the European Commission in partnership with the Dutch Ministry of Economic Affairs. The event will include a conference, an exhibition of research results and networking facilities for the about 4000 participants. The overall themes are "People" and "Economy". At the exhibition our system for fear of flying treatment is demonstrated. Look at [http://europa.eu.int/information_society/istevent/2004/index_en.htm This link] for the website. [http://mmi.tudelft.nl/~vrphobia/ist_2004_100kbps.wmv Click here] to view the movie. And [http://mmi.tudelft.nl/~vrphobia/ist2004_fotos/display.htm Click here] to view the pictures.

== SuperAssist ==
<div style="text-align: right;"><small>June 15th</small></div>
The group MMI at Delft University got funds from IOP-MMI (in cooperation with other patners) for a research project SuperAssist on Personal assistants for distributed supervision of complex task environments, see [http://mmi.tudelft.nl/~charles/SuperAssistAbstract.pdf abstract]. The application domain is medical. Later VRET may be supported by results from SuperAssist.

== Our project at TV Quiz Hoe?Zo! ==
<div style="text-align: right;"><small>Dec 15th</small></div>
Our project contributed to the interesting sience quiz Hoe?Zo! at Dutch TV on December 11, 2003. Rio and Charles were present. This is a [http://graphics.tudelft.nl/~vrphobia/hoezo.gif screen] of the explanation for our question: Does treatment of acrophobia help 20 % or 50 % or almost 100% of the patients? The last possibility is the right one.

== KLM pilots visiting our project ==
<div style="text-align: right;"><small>July 5</small></div>
On June 24, 2003 some pilots from KLM, therapists and the board of Stichting VALK visited our project at Delft. They are all involved in regular therapies for fear of flying. They experienced our vrphobia system personally in the role of patient as well as therapist. As experts they were impressed by the experiences using the newest version with more realistic features developed by Lucy Gunawan, including an enhanced user interface for the therapist. Click [http://mmi.tudelft.nl/~vrphobia/valk.jpg here] to see some pictures.

== Our Project on National Geographic ==
<div style="text-align: right;"><small>February 5</small></div>
On January 31, 2003 a team of film makers visited our project in Amsterdam. They filmed the treatment of acrophobia with a real patient, including the intake interview and the interview after the treatment. They also recorded the virtual world for fear of flying treatment. The film will be broadcasted worldwide in the Autumn 2003. Click [http://graphics.tudelft.nl/~vrphobia/natgeopics.jpg here] to see the pictures.

== Our therapy and system again on Dutch TV ==
<div style="text-align: right;"><small>December 30</small></div>
The well known Dutch AVRO TV show "Vinger aan de pols" covered phobia treatment in November 2002. The presenter Pia Dijkstra discussed phobia treatment extensively with Prof. Paul Emmelkamp. Merel Krijn is shown treating (in the background of the discussion) an acrophobia patient using our system. You can see the entire show or scenes of the show (in Dutch) below in [http://real.com/ RealMedia]. The codec used is RealVideo 9.

{|
|-
|'''Scene''' || '''Duration''' || '''56K dial-up modem'''|| '''128K Dual ISDN''' || '''256K DSL or Cable'''
|-
|Annemieke on her fear of heights || 31 sec. || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene1_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene1_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene1_RV9_256k.ram 256 kbit/s]
|-
|Prof. Emmelkamp on phobias, part 1 || 3 min. 29 || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene2_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene2_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene2_RV9_256k.ram 256 kbit/s]
|-
|Prof. Emmelkamp on phobias, part 2 || 16 sec. || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene3_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene3_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene3_RV9_256k.ram 256 kbit/s]
|-
|Prof. Emmelkamp on phobias, part 3 || 57 sec. || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene4_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene4_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene4_RV9_256k.ram 256 kbit/s]
|-
|VR-world for fear of heights, part 1 || 1 min. 57 || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene5_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene5_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene5_RV9_256k.ram 256 kbit/s]
|-
|Prof. Emmelkamp on VR-treatments || 3 min. 3 || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene6_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene6_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene6_RV9_256k.ram 256 kbit/s]
|-
|VR-world for fear of heights, part 2 || 2 min. 25 || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene7_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene7_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene7_RV9_256k.ram 256 kbit/s]
|-
|Prof. Emmelkamp on phobias, part 4 || 27 sec. || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Scene8_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Scene8_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Scene8_RV9_256k.ram 256 kbit/s]
|-
|Entire show || 34 min. 54 sec. || [http://graphics.tudelft.nl/~vrphobia/RV9/056k/VadP_Entirely_RV9_056k.ram 56 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/128k/VadP_Entirely_RV9_128k.ram 128 kbit/s] || [http://graphics.tudelft.nl/~vrphobia/RV9/256k/VadP_Entirely_RV9_256k.ram 256 kbit/s]
|}

== Cooperation with the VALK Foundation ==
<div style="text-align: right;"><small>June 29th</small></div>
We are very pleased to announce that we have a new partner: [http://www.valk.org/ the VALK Foundation]. This organisation is specialised in treatment of fear of flying and is connected to [http://www.leidenuniv.nl/ the University of Leiden]. More news on our cooperation will follow.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T18:15:48Z

Matthew: /* About */

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/images/8/83/ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:44:46Z

Matthew: /* About */

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008

Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:44:30Z

Matthew: /* About */

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:44:17Z

Matthew:

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:43:06Z

Matthew: /* Research methodology */

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

All necessary information needed for the domain analysis was acquired in close cooperation with a military psychiatrist from UMC Utrecht. Additional meetings throughout the study were planned to discuss various scenarios and prototypes.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:39:39Z

Matthew: /* Revised scenarios (PTSD among soldiers) */

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:39:29Z

Matthew: /* Proposed system */

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

[[Image:Ptsd3MRsetting.jpg|640px]]

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:39:08Z

Matthew: /* Photos Case Study with real patient */

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:38:31Z

Matthew:

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

== Revised scenarios (PTSD among soldiers) ==

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0216.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

[[Image:Foto0214.jpg|640px]]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

File:Ptsd3MRsetting.jpg

2010-04-28T07:37:03Z

Matthew:

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:35:23Z

Matthew:

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Link to thesis]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:34:17Z

Matthew:

Literature study and thesis by:
[[User:Matthew|Matthew van den Steen]]

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

Started: November 2008
Ended: April 2010

==Introduction==

War is known for its high rates of potential stressors. 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 chance of developing a PTSD multiplies by a factor of 1.5. 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). 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 question ==

The initial idea was to let the patient recreate a particular setting from the past by adding and rearranging 3D models in a virtual world. This allows patients to better explain what they experienced and to rethink of what they thought that happened is really true. At that time VRET was the only treatment that used computer assisted technology to treat patients with a combat-related PTSD. VRET also showed similarities with the concept as it puts the patient in a virtual representation of the real world. With VRET, however, the focus is not on restructuring and relearning. Patients can talk about what they experienced, but the patient is not given any tools to flexibly facilitate memory. Although analyzing VRET was found to be useful when designing the new system, it did not provide sufficient information to see if treatment would really benefit from the new envisioned approach. The envisioned system is a new concept and therefore needs a thorough domain analysis to obtain the knowledge required to establish a first requirements baseline. The research question of this thesis is as follows:

Is it possible, and what is required, to enhance the treatment of combat-related PTSD, focusing on the restructuring and relearning of a past event, using computer assisted technology?

Only an analysis is not sufficient to properly answer the main research question. Various expert reviews are necessary and several prototypes of the 3MR system have to be built to evaluate, verify and refine the initial obtained requirements baseline.

==Proposed system ==

In traditional group therapy patients talk about their past deployments and share their experiences with each other in the presence of a therapist. In these situations pen, paper and a flap-over are used to allow patients to express themselves better. Also, memory is often compromised and due to memory distortions or amnesia for details these facilities can help the patients to remember and rethink about what happened. The envisioned application, the Multi-Modal Memory Restructuring (3MR) system, takes this a few steps further. The 3MR focus does not lay on direct exposure, but on the way patients facilitate and manage their memory to restructure and relearn about their past experience involving the problematic stressors. The system allows patients to organize various deployment-related multimedia elements on a set timeline. Of course by managing these multimedia elements there is a chance that the patient will be exposed to past traumatic events from the past.

One of the advantages of this approach is that patients now have the flexibility to rearrange content themselves and add more memory elements as the overall therapy progresses. Letting patients accomplish this by using their own material, such as personal photographs and geographical maps, and linking those to a specific day could provide a more effective way of restructuring and discussing their past experience. False memories, such as the order of events and the location of a particular stressor, can be addressed and forgotten memories may be triggered. Using a timeline which keeps track of the personal progress may even encourage patients to add more details and continue with the treatment. Another possible advantage is that the use of personal data can result in a different perception of the, often seen as problematic, deployment; good memories can be triggered of events not directly related to the stressors. These memories are often forgotten as the focus is mainly on the problematic events which occurred during that time. The additional option to let patients create a virtual representation of the real world in 3D allows them to rethink about the event to see if everything they remember is (sequentially) correct. The system is designed for use in a group therapy, but can easily be adapted for a single patient-therapist setting. When the system is used in a group therapy setting, it can provide an easier and more efficient way of sharing stories with the other patients. This is because everything is projected on a wall for everyone to see. Group members can discuss the events shown on the wall and share similar experiences with each other as part of the treatment method.

==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.

== Research assignment and thesis report ==

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment]

[http://mmi.tudelft.nl/vret_oud/index.php/Image:ThesisFinal_3MR.pdf Thesis]

Emmelkamp, P.M.G., T.K. Bouman, and A. Scholing, Anxiety disorders: a practitioner's guide. 1995, Chichester: John Wiley & Sons.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the American Medical Association, 298(18), 2141-2148.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Schottenbauer, M. A.; Glass, C. R.; Arnkoff, D. B.; Tendick, V., and Gray, S. H. (2008) Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008 Summer; 71(2), pp. 134-68.

Cukor, J., J. Spitalnick, et al. (2009). Emerging treatments for PTSD. Clinical Psychology Review 29(8): 715-726.

Neerincx, M.A. & Lindenberg, J. (2008). Situated cognitive engineering for complex task environments. In: Schraagen, J.M.C., Militello, L., Ormerod, T., & Lipshitz, R. (Eds). Naturalistic Decision Making and Macrocognition (pp. 373-390). Aldershot, UK: Ashgate Publishing Limited.

File:ThesisFinal 3MR.pdf

2010-04-28T07:31:38Z

Matthew:

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-04-28T07:25:51Z

Matthew:

[[User:Matthew|Matthew van den Steen]]

Human-Computer Interaction

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

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 [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf 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.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-03-08T15:23:13Z

Matthew: /* Introduction */

[[Image:MatthewVanDenSteen.jpg|thumb]]
[[User:Matthew|Matthew van den Steen]]

Human-Computer Interaction

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

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 [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf 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.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-03-08T15:19:38Z

Matthew: /* About */

[[Image:MatthewVanDenSteen.jpg|thumb]]
[[User:Matthew|Matthew van den Steen]]

Human-Computer Interaction

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

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, they can often handle them without any problems or complications. However, it is a whole different story when someone is exposed to a traumatic event beyond the bounds of common, everyday human experiences. In such cases a person can develop a ‘Post-Traumatic Stress Disorder’ (PTSD) [1]. This type of anxiety disorder is often linked to military soldiers who have witnessed a stressful event, but it can also affect people who have, for example, been in a motor accident or people who were confronted with a personal assault.

A wide range of possible options for treatment include therapies such as ‘prolonged imaginal exposure therapy’, ‘in vivo exposure’ and ‘eye movement desensitization and reprocessing’ (EMDR). Alternatively, various medicines are available to help patients cope with their disorder.

With the emergence of better and faster technology, various new approaches have been proposed. One such approach is the use of ‘Virtual Reality’ [2]. This technique enables the patient to interact in a virtual representation of the world. ‘Virtual Reality Exposure Therapy’ (VRET) [2] is one particular way of treatment and is already being used in practice to help people suffering from several different phobias other than a PTSD, such as, but not limited to, acrophobia and agoraphobia. In these worlds a variety of anxiety-provoking stimuli can be triggered at any time. Because the level of these stimuli can be changed, it is possible to gradually expose the patient to various levels of intensity. Studies [3] have shown promising results. However, is ‘VRET’ or virtual reality in general also a good way to treat patients suffering from a PTSD? Key aspects related to ‘Virtual Reality’ (such as ‘presence’) may be of importance, but what about other elements, if any?

A study [4] has shown that when a therapy lacks to engage the patient emotionally, it will often lead to poor, undesirable results. The same study states that facts about both the patient and the whole ordeal need to be present in order to evoke emotions. Due to certain patients either avoiding specific moments of the event, or not being able to express themselves thoroughly, it is often very difficult to gather all of the facts and link them together. It is also said that in some cases the patient even has an unrealistic view of what might have happened.

Traditional treatment for patients with a PTSD poses several problems while trying to engage the patient emotionally, whereas the use of ‘Virtual Reality’ makes it possible to accomplish this gradually with the help of a set of pre-defined stimuli. It is essential to look at traditional treatment first and see if, for example, ‘VRET’ or ‘Virtual Reality’ in general can be used to enhance the effects which are currently obtained without the help of these new techniques. This research assignment will therefore not only include research on how ‘Virtual Reality’ can be used to help people with a PTSD, but also traditional treatments and their important aspects will be taken into account.

== Discussion points ==

Right after the [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf 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.

Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD

2010-03-08T15:19:06Z

Matthew:

[[Image:MatthewVanDenSteen.jpg|thumb]]
[[User:Matthew|Matthew van den Steen]]

Human-Computer Interaction

== About ==

Research on: '''Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

Started: November 2008

Status: writing final thesis report

http://img172.imageshack.us/img172/9586/ptsdintrods5.jpg

== 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, they can often handle them without any problems or complications. However, it is a whole different story when someone is exposed to a traumatic event beyond the bounds of common, everyday human experiences. In such cases a person can develop a ‘Post-Traumatic Stress Disorder’ (PTSD) [1]. This type of anxiety disorder is often linked to military soldiers who have witnessed a stressful event, but it can also affect people who have, for example, been in a motor accident or people who were confronted with a personal assault.

A wide range of possible options for treatment include therapies such as ‘prolonged imaginal exposure therapy’, ‘in vivo exposure’ and ‘eye movement desensitization and reprocessing’ (EMDR). Alternatively, various medicines are available to help patients cope with their disorder.

With the emergence of better and faster technology, various new approaches have been proposed. One such approach is the use of ‘Virtual Reality’ [2]. This technique enables the patient to interact in a virtual representation of the world. ‘Virtual Reality Exposure Therapy’ (VRET) [2] is one particular way of treatment and is already being used in practice to help people suffering from several different phobias other than a PTSD, such as, but not limited to, acrophobia and agoraphobia. In these worlds a variety of anxiety-provoking stimuli can be triggered at any time. Because the level of these stimuli can be changed, it is possible to gradually expose the patient to various levels of intensity. Studies [3] have shown promising results. However, is ‘VRET’ or virtual reality in general also a good way to treat patients suffering from a PTSD? Key aspects related to ‘Virtual Reality’ (such as ‘presence’) may be of importance, but what about other elements, if any?

A study [4] has shown that when a therapy lacks to engage the patient emotionally, it will often lead to poor, undesirable results. The same study states that facts about both the patient and the whole ordeal need to be present in order to evoke emotions. Due to certain patients either avoiding specific moments of the event, or not being able to express themselves thoroughly, it is often very difficult to gather all of the facts and link them together. It is also said that in some cases the patient even has an unrealistic view of what might have happened.

Traditional treatment for patients with a PTSD poses several problems while trying to engage the patient emotionally, whereas the use of ‘Virtual Reality’ makes it possible to accomplish this gradually with the help of a set of pre-defined stimuli. It is essential to look at traditional treatment first and see if, for example, ‘VRET’ or ‘Virtual Reality’ in general can be used to enhance the effects which are currently obtained without the help of these new techniques. This research assignment will therefore not only include research on how ‘Virtual Reality’ can be used to help people with a PTSD, but also traditional treatments and their important aspects will be taken into account.

== Discussion points ==

Right after the [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf 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.

PTSD

2010-03-08T15:18:14Z

Matthew: /* Relevant work done in this context */

== Relevant work done in this context ==

*[[Multi-Modal Memory Restructuring for patients suffering from a Combat-Related PTSD]]

== A definition ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

A ‘Post-Traumatic Stress Disorder’ is considered one of the twelve different types of anxiety disorders. Hence, before giving the definition of a PTSD, it is useful to look at the characteristics of an ‘anxiety disorder’ first.

According to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) a generalized anxiety disorder is characterized by:

• anxiety occurring persistently

• excessive and hard to control worry

• feelings of uneasiness.

Anxiety and feelings of uneasiness are normal human reactions when someone is in a stressful situation. Sometimes anxiety even results in better performance (Raudis & Yustitskis, 2008), as seen in the Yerkes-Dodson law graph in figure 1. However, when this feeling becomes excessive and influences a person’s lifestyle, it is, like most other mental disturbances, considered a disorder. A very noticeable change in one’s lifestyle is the avoidance of certain activities, people and places (Diagnostic and Statistical Manual of Mental Disorders IV, 1995).

This definition covers anxiety disorders in general. DSM-IV provides the following description for a PTSD:

''“Posttraumatic Stress disorder is characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma.” (Diagnostic and Statistical Manual of Mental Disorders IV, 1995)''

This definition already specifies certain symptoms which make a PTSD different compared to other (anxiety) disorders. Symptoms of a PTSD can be distinguished by three different symptom clusters (Paul M. G. Emmelkamp, et al., 1995). Each cluster is related to one of the following:

• Re-experiencing,

• Avoidance

• Arousal

These symptoms occur after the person has been exposed to a specific kind of stressor. However, not everyone will experience these symptoms immediately after the event. In many cases the symptoms occur days or even months after the stressor. What are the criteria for these symptoms and what is considered a traumatic event? Also, in which ways does the person re-experience these events over and over again?

== Criteria ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

The traumatic event or ‘stressor’ has to be of an extreme nature (Paul M. G. Emmelkamp, et al., 1995). Of course this statement is somewhat subjective, as one person is able to handle a specific stressor while others can not. Also, not everybody who experiences a traumatic event will react the same way (Diagnostic and Statistical Manual of Mental Disorders IV, 1995; Paul M. G. Emmelkamp, et al., 1995). The stressor is usually of human design (kidnapping, terrorist attack, personal assault, etc.), but also exposure to natural disasters (volcano eruption, tsunami) can result in a PTSD. In both cases it is clear that these kinds of events are outside the bounds of “normal”, everyday experiences. The stressors mentioned here all have one thing in common: they can pose a serious threat to one’s life or environment. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) specifies these traumatic stressors as one of the criterion of PTSD. The stressor must suit at least one of the following:

• Experience of an event which involves a serious injury or actual or threatened death.

• Witnessing an event involving death or injury of other persons.

• Learning or hearing about unexpected or violent death, harm, threat of death or injury by a family member or close relative.

This criterion is only concerned with the possible cause of a PTSD. Not everyone will develop a PTSD when confronted with one of the above mentioned stressors. Therefore more criteria are needed to cover the response and possible symptoms following a traumatic event.

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) states that a person’s response to a stressor must involve fear, helplessness or horror. Next to this response, people who have developed a PTSD also experience certain symptoms related to the trauma. One such a symptom is the persistent re-experiencing of the stressor, as mentioned in the definition of a PTSD. There are various ways this symptom can occur. DSM-IV describes these as a new criterion:

• Recurrent recollections of the event. This includes thoughts, perceptions and images. Not only when the person is awake, but also when the person is asleep.

• The person feels or thinks as if the traumatic event recurs.

• The person is distressed when exposed to various stimuli related to the traumatic event.

• Physiological reactivity on exposure to the stimuli mentioned in the previous criterion.

Strongly related to this symptom is the persistent avoidance of specific stimuli. Of course the avoidance must occur after the exposure of the stressor. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) states that avoidance is one of the criteria related to PTSD and that at least three of the following indicators should be true.

• Avoidance of feelings, thoughts or conversations associated to the trauma

• Avoidance of activities, places or people which may trigger recollections of the trauma

• The inability to recall an important part of the traumatic event

• Lost interest in certain activities

• Feelings of detachment from friends or family members

• Limited experience of feeling or emotion

• Only thinking about the near future

Another important symptom and criterion is the increase of arousal of a person. This may lead to difficulties sleeping and concentrating. The increased arousal can also lead to sudden outbursts of anger and hyper vigilance (Diagnostic and Statistical Manual of Mental Disorders IV, 1995). The duration of these symptoms, including the re-experiencing and avoidance of the stressor, must be longer than one month.

== Fear structure and emotional processing theory ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

Some of the treatments which will be described in the next chapter, such as imaginal exposure, are strongly related to the emotional processing theory by Foa and Kozak (E. B. Foa & Kozak, 1986). This theory states that patients with a PTSD have developed so-called ‘fear structures’ consisting of information about:

• Stimuli associated with a traumatic event

• (Their) behavioural responses

• Meaning representations

The stimuli were already mentioned in the previous paragraph. People exposed to a stressor will remember facts about associated stimuli. For example a vehicle that exploded after it hits another car or seeing a comrade die by a mine.

Not only information about the stimuli is remembered but also facts about the behavioural response of the person at that time. For example a racing heart beat and perspiration.

And the last aspect is information about the meaning representation of the traumatic event. The meaning representation of a certain event can, of course, differ from person to person. The representation is strongly related to the stressors and criteria mentioned in the first part of the previous paragraph. One can, for example, associate an explosion to death or death of relatives.

Some treatments are based on activation of this fear structure using repeated exposure and adding new learning elements while anxiety is reduced (E. B. Foa & Kozak, 1986; E. B. Foa, Riggs, Massie, & Yarczower, 1995). Studies (E. B. Foa, et al., 1995) have shown that there is a correlation between activation of this fear structure and improvement in treatment.

== Literature ==

Beck, J. G., Palyo, S. A., Winer, E. H., Schwagler, B. E., & Ang, E. J. (2007). Virtual Reality Exposure Therapy for PTSD symptoms after a road accident: An uncontrolled case series. [Article]. Behavior Therapy, 38(1), 39-48.

Bradley, R. (2005). A multidimensional meta-analysis of psychotherapy for PTSD (vol 162, pg 214, 2005). [Correction]. American Journal of Psychiatry, 162(4), 832-832.

Bush, J. (2008). Viability of virtual reality exposure therapy as a treatment alternative. [Article]. Computers in Human Behavior, 24(3), 1032-1040.

Cahill, S. P., Carrigan, M. H., & Frueh, B. C. (1999). Does EMDR Work? And if so, Why?: A Critical Review of Controlled Outcome and Dismantling Research. Journal of Anxiety Disorders, 13(1-2), 5-33.

Dayan, E. (2006) ARGAMAN: Rapid Deployment Virtual Reality System for PTSD Rehabilitation, International Conference on Information Technology: Research and education, 34-38

Diagnostic and Statistical Manual of Mental Disorders IV (1995). American Psychiatric Association.

Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., et al. (2007). Virtual reality exposure therapy for the treatment of Posttraumatic stress disorder following September 11, 2001. [Article].
Journal of Clinical Psychiatry, 68(11), 1639-1647.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. [Article]. Behaviour Research and Therapy, 38(4), 319-345.

Emmelkamp, P. M. G., Bouman, T. K., & Scholing, A. (1995). Anxiety disorders: a practitioner's guide. Chichester: John Wiley & Sons.

Emmelkamp, P. M. G., Krijn, M., Hulsbosch, A. M., de Vries, S., Schuemie, M. J., & van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: a comparative evaluation in acrophobia. [Article].
Behaviour Research and Therapy, 40(5), 509-516.

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences. Therpist guide. New York: Oxford University Press.

Foa, E. B., & Kozak, M. J. (1986). EMOTIONAL PROCESSING OF FEAR - EXPOSURE TO CORRECTIVE INFORMATION. [Review]. Psychological Bulletin, 99(1), 20-35.

Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). THE IMPACT OF FEAR ACTIVATION AND ANGER ON THE EFFICACY OF EXPOSURE TREATMENT FOR POSTTRAUMATIC-STRESS-DISORDER. [Article]. Behavior Therapy, 26(3), 487-499.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). BEHAVIORAL COGNITIVE CONCEPTUALIZATIONS OF POST-TRAUMATIC STRESS DISORDER. [Review]. Behavior Therapy, 20(2), 155-176.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Harvey, A. G., Bryant, R. A., & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic stress disorder. [Article]. Clinical Psychology Review, 23(3), 501-522.

Hoffman, H. G., Garcia-Palacios, A., Carlin, A., Furness, T. A., & Botella-Arbona, C. (2003). Interfaces that heal: Coupling real and virtual objects to treat spider phobia. [Article]. International Journal of
Human-Computer Interaction, 16(2), 283-300.

Hoffman, H. G., & Ieee Comp, S. O. C. (1998, Mar 14-18). Physically touching virtual objects using tactile augmentation enhances the realism of virtual environments. Paper presented at the IEEE 1998 Virtual Reality Annual International Symposium, Atlanta, Ga.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Jaycox, L. H., Foa, E. B., & Morral, A. R. (1996, Nov). Influence of emotional engagement and habituation on exposure therapy for PTSD. Paper presented at the Annual Convention of the Association-for-the-Advancement-of-Behavior-Therapy, New York, New York.

Lang, P. J. (1977). IMAGERY IN THERAPY - INFORMATION-PROCESSING ANALYSIS OF FEAR. [Article]. Behavior Therapy, 8(5), 862-886.

Lange, A., van de Ven, J. P., Schrieken, B., & Emmelkamp, P. M. G. (2001). Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial. [Article]. Journal of Behavior Therapy and Experimental Psychiatry, 32(2), 73-90.

Marks, I., Lovell, K., Noshirvani, H., & Livanou, M. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring - A controlled study. [Article]. Archives of General Psychiatry, 55(4), 317-325.

Mast, C. A. P. G. v. d. (2009, 24 April 2009). Virtual Reality and Phobias TUDelft, from http://mmi.tudelft.nl/~vrphobia/

Mental Health Advisory Team (2006). Operation Iraqi Freedom 05-07. Washington DC.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the
American Medical Association, 298(18), 2141-2148.

National Institute of Mental Health (2006). Anxiety disorders.

Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. [Article]. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250-261.

Raudis, S., & Yustitskis, V. (2008). The Yerkes-Dodson law: The link between stimulation and learning success. [Article]. Voprosy Psikhologii(3), 119-+.

Reger, G. M., & Gahm, G. A. (2008). Virtual reality exposure therapy for active duty soldiers. [Article]. Journal of Clinical Psychology, 64(8), 940-946.

Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. [Article]. Journal of Consulting and Clinical Psychology, 70(4), 867-879.

Rime, B., Mesquita, B., Philippot, P., & Boca, S. (1991). BEYOND THE EMOTIONAL EVENT - 6 STUDIES ON THE SOCIAL SHARING OF EMOTION. [Article]. Cognition & Emotion, 5(5-6), 435-465.

Riva, G., Molinari, E., & Vincelli, F. (2002). Interaction and presence in the clinical relationship: Virtual reality (VR) as communicative medium between patient and therapist. [Article]. Ieee Transactions on Information Technology in Biomedicine, 6(3), 198-205.

Rizzo, A. A., Graap, K., McLay, R. N., Perlman, K., Rothbaum, B. O., Reger, G., et al. (2007, Sep 27-29). Virtual Iraq: Initial case reports from a VR exposure therapy application for combat-related post traumatic stress disorder. Paper presented at the Virtual Rehabilitation Conference 2007, Venice, ITALY.

Rothbaum, B. O., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., et al. (1999). Virtual reality exposure therapy for PTSD Vietnam veterans: A case study. [Article]. Journal of Traumatic Stress, 12(2), 263-271.

Rothbaum, B. O., Hodges, L. F., Ready, D., Graap, K., & Alarcon, R. D. (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. [Article]. Journal of Clinical Psychiatry, 62(8), 617-622.

Scheumie, M. J., & Mast, C. A. P. G. v. d. (2000). Virtual Reality in de therapie. Delft: Nederlands Instituut voor Psychologen.

Schoutrop, M., Lange, A., Hanewald, G., Duurland, C., & Bermond, B. (1997). The effects of structured writing assignments on overcoming major stressful events: An uncontrolled study. [Article]. Clinical Psychology & Psychotherapy, 4(3), 179-185.

Vaughan, K., & Tarrier, N. (1992). THE USE OF IMAGE HABITUATION TRAINING WITH POSTTRAUMATIC STRESS DISORDERS. [Article]. British Journal of Psychiatry, 161, 658-664.

PTSD

2010-03-08T15:16:38Z

Matthew: /* Relevant work done in this context */

== Relevant work done in this context ==

*[[Post-Traumatic Stress Disorders & Virtual Reality]]

== A definition ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

A ‘Post-Traumatic Stress Disorder’ is considered one of the twelve different types of anxiety disorders. Hence, before giving the definition of a PTSD, it is useful to look at the characteristics of an ‘anxiety disorder’ first.

According to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) a generalized anxiety disorder is characterized by:

• anxiety occurring persistently

• excessive and hard to control worry

• feelings of uneasiness.

Anxiety and feelings of uneasiness are normal human reactions when someone is in a stressful situation. Sometimes anxiety even results in better performance (Raudis & Yustitskis, 2008), as seen in the Yerkes-Dodson law graph in figure 1. However, when this feeling becomes excessive and influences a person’s lifestyle, it is, like most other mental disturbances, considered a disorder. A very noticeable change in one’s lifestyle is the avoidance of certain activities, people and places (Diagnostic and Statistical Manual of Mental Disorders IV, 1995).

This definition covers anxiety disorders in general. DSM-IV provides the following description for a PTSD:

''“Posttraumatic Stress disorder is characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma.” (Diagnostic and Statistical Manual of Mental Disorders IV, 1995)''

This definition already specifies certain symptoms which make a PTSD different compared to other (anxiety) disorders. Symptoms of a PTSD can be distinguished by three different symptom clusters (Paul M. G. Emmelkamp, et al., 1995). Each cluster is related to one of the following:

• Re-experiencing,

• Avoidance

• Arousal

These symptoms occur after the person has been exposed to a specific kind of stressor. However, not everyone will experience these symptoms immediately after the event. In many cases the symptoms occur days or even months after the stressor. What are the criteria for these symptoms and what is considered a traumatic event? Also, in which ways does the person re-experience these events over and over again?

== Criteria ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

The traumatic event or ‘stressor’ has to be of an extreme nature (Paul M. G. Emmelkamp, et al., 1995). Of course this statement is somewhat subjective, as one person is able to handle a specific stressor while others can not. Also, not everybody who experiences a traumatic event will react the same way (Diagnostic and Statistical Manual of Mental Disorders IV, 1995; Paul M. G. Emmelkamp, et al., 1995). The stressor is usually of human design (kidnapping, terrorist attack, personal assault, etc.), but also exposure to natural disasters (volcano eruption, tsunami) can result in a PTSD. In both cases it is clear that these kinds of events are outside the bounds of “normal”, everyday experiences. The stressors mentioned here all have one thing in common: they can pose a serious threat to one’s life or environment. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) specifies these traumatic stressors as one of the criterion of PTSD. The stressor must suit at least one of the following:

• Experience of an event which involves a serious injury or actual or threatened death.

• Witnessing an event involving death or injury of other persons.

• Learning or hearing about unexpected or violent death, harm, threat of death or injury by a family member or close relative.

This criterion is only concerned with the possible cause of a PTSD. Not everyone will develop a PTSD when confronted with one of the above mentioned stressors. Therefore more criteria are needed to cover the response and possible symptoms following a traumatic event.

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) states that a person’s response to a stressor must involve fear, helplessness or horror. Next to this response, people who have developed a PTSD also experience certain symptoms related to the trauma. One such a symptom is the persistent re-experiencing of the stressor, as mentioned in the definition of a PTSD. There are various ways this symptom can occur. DSM-IV describes these as a new criterion:

• Recurrent recollections of the event. This includes thoughts, perceptions and images. Not only when the person is awake, but also when the person is asleep.

• The person feels or thinks as if the traumatic event recurs.

• The person is distressed when exposed to various stimuli related to the traumatic event.

• Physiological reactivity on exposure to the stimuli mentioned in the previous criterion.

Strongly related to this symptom is the persistent avoidance of specific stimuli. Of course the avoidance must occur after the exposure of the stressor. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) states that avoidance is one of the criteria related to PTSD and that at least three of the following indicators should be true.

• Avoidance of feelings, thoughts or conversations associated to the trauma

• Avoidance of activities, places or people which may trigger recollections of the trauma

• The inability to recall an important part of the traumatic event

• Lost interest in certain activities

• Feelings of detachment from friends or family members

• Limited experience of feeling or emotion

• Only thinking about the near future

Another important symptom and criterion is the increase of arousal of a person. This may lead to difficulties sleeping and concentrating. The increased arousal can also lead to sudden outbursts of anger and hyper vigilance (Diagnostic and Statistical Manual of Mental Disorders IV, 1995). The duration of these symptoms, including the re-experiencing and avoidance of the stressor, must be longer than one month.

== Fear structure and emotional processing theory ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

Some of the treatments which will be described in the next chapter, such as imaginal exposure, are strongly related to the emotional processing theory by Foa and Kozak (E. B. Foa & Kozak, 1986). This theory states that patients with a PTSD have developed so-called ‘fear structures’ consisting of information about:

• Stimuli associated with a traumatic event

• (Their) behavioural responses

• Meaning representations

The stimuli were already mentioned in the previous paragraph. People exposed to a stressor will remember facts about associated stimuli. For example a vehicle that exploded after it hits another car or seeing a comrade die by a mine.

Not only information about the stimuli is remembered but also facts about the behavioural response of the person at that time. For example a racing heart beat and perspiration.

And the last aspect is information about the meaning representation of the traumatic event. The meaning representation of a certain event can, of course, differ from person to person. The representation is strongly related to the stressors and criteria mentioned in the first part of the previous paragraph. One can, for example, associate an explosion to death or death of relatives.

Some treatments are based on activation of this fear structure using repeated exposure and adding new learning elements while anxiety is reduced (E. B. Foa & Kozak, 1986; E. B. Foa, Riggs, Massie, & Yarczower, 1995). Studies (E. B. Foa, et al., 1995) have shown that there is a correlation between activation of this fear structure and improvement in treatment.

== Literature ==

Beck, J. G., Palyo, S. A., Winer, E. H., Schwagler, B. E., & Ang, E. J. (2007). Virtual Reality Exposure Therapy for PTSD symptoms after a road accident: An uncontrolled case series. [Article]. Behavior Therapy, 38(1), 39-48.

Bradley, R. (2005). A multidimensional meta-analysis of psychotherapy for PTSD (vol 162, pg 214, 2005). [Correction]. American Journal of Psychiatry, 162(4), 832-832.

Bush, J. (2008). Viability of virtual reality exposure therapy as a treatment alternative. [Article]. Computers in Human Behavior, 24(3), 1032-1040.

Cahill, S. P., Carrigan, M. H., & Frueh, B. C. (1999). Does EMDR Work? And if so, Why?: A Critical Review of Controlled Outcome and Dismantling Research. Journal of Anxiety Disorders, 13(1-2), 5-33.

Dayan, E. (2006) ARGAMAN: Rapid Deployment Virtual Reality System for PTSD Rehabilitation, International Conference on Information Technology: Research and education, 34-38

Diagnostic and Statistical Manual of Mental Disorders IV (1995). American Psychiatric Association.

Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., et al. (2007). Virtual reality exposure therapy for the treatment of Posttraumatic stress disorder following September 11, 2001. [Article].
Journal of Clinical Psychiatry, 68(11), 1639-1647.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. [Article]. Behaviour Research and Therapy, 38(4), 319-345.

Emmelkamp, P. M. G., Bouman, T. K., & Scholing, A. (1995). Anxiety disorders: a practitioner's guide. Chichester: John Wiley & Sons.

Emmelkamp, P. M. G., Krijn, M., Hulsbosch, A. M., de Vries, S., Schuemie, M. J., & van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: a comparative evaluation in acrophobia. [Article].
Behaviour Research and Therapy, 40(5), 509-516.

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences. Therpist guide. New York: Oxford University Press.

Foa, E. B., & Kozak, M. J. (1986). EMOTIONAL PROCESSING OF FEAR - EXPOSURE TO CORRECTIVE INFORMATION. [Review]. Psychological Bulletin, 99(1), 20-35.

Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). THE IMPACT OF FEAR ACTIVATION AND ANGER ON THE EFFICACY OF EXPOSURE TREATMENT FOR POSTTRAUMATIC-STRESS-DISORDER. [Article]. Behavior Therapy, 26(3), 487-499.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). BEHAVIORAL COGNITIVE CONCEPTUALIZATIONS OF POST-TRAUMATIC STRESS DISORDER. [Review]. Behavior Therapy, 20(2), 155-176.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Harvey, A. G., Bryant, R. A., & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic stress disorder. [Article]. Clinical Psychology Review, 23(3), 501-522.

Hoffman, H. G., Garcia-Palacios, A., Carlin, A., Furness, T. A., & Botella-Arbona, C. (2003). Interfaces that heal: Coupling real and virtual objects to treat spider phobia. [Article]. International Journal of
Human-Computer Interaction, 16(2), 283-300.

Hoffman, H. G., & Ieee Comp, S. O. C. (1998, Mar 14-18). Physically touching virtual objects using tactile augmentation enhances the realism of virtual environments. Paper presented at the IEEE 1998 Virtual Reality Annual International Symposium, Atlanta, Ga.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Jaycox, L. H., Foa, E. B., & Morral, A. R. (1996, Nov). Influence of emotional engagement and habituation on exposure therapy for PTSD. Paper presented at the Annual Convention of the Association-for-the-Advancement-of-Behavior-Therapy, New York, New York.

Lang, P. J. (1977). IMAGERY IN THERAPY - INFORMATION-PROCESSING ANALYSIS OF FEAR. [Article]. Behavior Therapy, 8(5), 862-886.

Lange, A., van de Ven, J. P., Schrieken, B., & Emmelkamp, P. M. G. (2001). Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial. [Article]. Journal of Behavior Therapy and Experimental Psychiatry, 32(2), 73-90.

Marks, I., Lovell, K., Noshirvani, H., & Livanou, M. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring - A controlled study. [Article]. Archives of General Psychiatry, 55(4), 317-325.

Mast, C. A. P. G. v. d. (2009, 24 April 2009). Virtual Reality and Phobias TUDelft, from http://mmi.tudelft.nl/~vrphobia/

Mental Health Advisory Team (2006). Operation Iraqi Freedom 05-07. Washington DC.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the
American Medical Association, 298(18), 2141-2148.

National Institute of Mental Health (2006). Anxiety disorders.

Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. [Article]. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250-261.

Raudis, S., & Yustitskis, V. (2008). The Yerkes-Dodson law: The link between stimulation and learning success. [Article]. Voprosy Psikhologii(3), 119-+.

Reger, G. M., & Gahm, G. A. (2008). Virtual reality exposure therapy for active duty soldiers. [Article]. Journal of Clinical Psychology, 64(8), 940-946.

Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. [Article]. Journal of Consulting and Clinical Psychology, 70(4), 867-879.

Rime, B., Mesquita, B., Philippot, P., & Boca, S. (1991). BEYOND THE EMOTIONAL EVENT - 6 STUDIES ON THE SOCIAL SHARING OF EMOTION. [Article]. Cognition & Emotion, 5(5-6), 435-465.

Riva, G., Molinari, E., & Vincelli, F. (2002). Interaction and presence in the clinical relationship: Virtual reality (VR) as communicative medium between patient and therapist. [Article]. Ieee Transactions on Information Technology in Biomedicine, 6(3), 198-205.

Rizzo, A. A., Graap, K., McLay, R. N., Perlman, K., Rothbaum, B. O., Reger, G., et al. (2007, Sep 27-29). Virtual Iraq: Initial case reports from a VR exposure therapy application for combat-related post traumatic stress disorder. Paper presented at the Virtual Rehabilitation Conference 2007, Venice, ITALY.

Rothbaum, B. O., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., et al. (1999). Virtual reality exposure therapy for PTSD Vietnam veterans: A case study. [Article]. Journal of Traumatic Stress, 12(2), 263-271.

Rothbaum, B. O., Hodges, L. F., Ready, D., Graap, K., & Alarcon, R. D. (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. [Article]. Journal of Clinical Psychiatry, 62(8), 617-622.

Scheumie, M. J., & Mast, C. A. P. G. v. d. (2000). Virtual Reality in de therapie. Delft: Nederlands Instituut voor Psychologen.

Schoutrop, M., Lange, A., Hanewald, G., Duurland, C., & Bermond, B. (1997). The effects of structured writing assignments on overcoming major stressful events: An uncontrolled study. [Article]. Clinical Psychology & Psychotherapy, 4(3), 179-185.

Vaughan, K., & Tarrier, N. (1992). THE USE OF IMAGE HABITUATION TRAINING WITH POSTTRAUMATIC STRESS DISORDERS. [Article]. British Journal of Psychiatry, 161, 658-664.

PTSD

2010-03-08T15:16:21Z

Matthew: /* Relevant work done in this context */

== Relevant work done in this context ==

*[[Post-Traumatic Stress Disorders & 4MR]]

== A definition ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

A ‘Post-Traumatic Stress Disorder’ is considered one of the twelve different types of anxiety disorders. Hence, before giving the definition of a PTSD, it is useful to look at the characteristics of an ‘anxiety disorder’ first.

According to DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) a generalized anxiety disorder is characterized by:

• anxiety occurring persistently

• excessive and hard to control worry

• feelings of uneasiness.

Anxiety and feelings of uneasiness are normal human reactions when someone is in a stressful situation. Sometimes anxiety even results in better performance (Raudis & Yustitskis, 2008), as seen in the Yerkes-Dodson law graph in figure 1. However, when this feeling becomes excessive and influences a person’s lifestyle, it is, like most other mental disturbances, considered a disorder. A very noticeable change in one’s lifestyle is the avoidance of certain activities, people and places (Diagnostic and Statistical Manual of Mental Disorders IV, 1995).

This definition covers anxiety disorders in general. DSM-IV provides the following description for a PTSD:

''“Posttraumatic Stress disorder is characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma.” (Diagnostic and Statistical Manual of Mental Disorders IV, 1995)''

This definition already specifies certain symptoms which make a PTSD different compared to other (anxiety) disorders. Symptoms of a PTSD can be distinguished by three different symptom clusters (Paul M. G. Emmelkamp, et al., 1995). Each cluster is related to one of the following:

• Re-experiencing,

• Avoidance

• Arousal

These symptoms occur after the person has been exposed to a specific kind of stressor. However, not everyone will experience these symptoms immediately after the event. In many cases the symptoms occur days or even months after the stressor. What are the criteria for these symptoms and what is considered a traumatic event? Also, in which ways does the person re-experience these events over and over again?

== Criteria ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

The traumatic event or ‘stressor’ has to be of an extreme nature (Paul M. G. Emmelkamp, et al., 1995). Of course this statement is somewhat subjective, as one person is able to handle a specific stressor while others can not. Also, not everybody who experiences a traumatic event will react the same way (Diagnostic and Statistical Manual of Mental Disorders IV, 1995; Paul M. G. Emmelkamp, et al., 1995). The stressor is usually of human design (kidnapping, terrorist attack, personal assault, etc.), but also exposure to natural disasters (volcano eruption, tsunami) can result in a PTSD. In both cases it is clear that these kinds of events are outside the bounds of “normal”, everyday experiences. The stressors mentioned here all have one thing in common: they can pose a serious threat to one’s life or environment. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) specifies these traumatic stressors as one of the criterion of PTSD. The stressor must suit at least one of the following:

• Experience of an event which involves a serious injury or actual or threatened death.

• Witnessing an event involving death or injury of other persons.

• Learning or hearing about unexpected or violent death, harm, threat of death or injury by a family member or close relative.

This criterion is only concerned with the possible cause of a PTSD. Not everyone will develop a PTSD when confronted with one of the above mentioned stressors. Therefore more criteria are needed to cover the response and possible symptoms following a traumatic event.

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) states that a person’s response to a stressor must involve fear, helplessness or horror. Next to this response, people who have developed a PTSD also experience certain symptoms related to the trauma. One such a symptom is the persistent re-experiencing of the stressor, as mentioned in the definition of a PTSD. There are various ways this symptom can occur. DSM-IV describes these as a new criterion:

• Recurrent recollections of the event. This includes thoughts, perceptions and images. Not only when the person is awake, but also when the person is asleep.

• The person feels or thinks as if the traumatic event recurs.

• The person is distressed when exposed to various stimuli related to the traumatic event.

• Physiological reactivity on exposure to the stimuli mentioned in the previous criterion.

Strongly related to this symptom is the persistent avoidance of specific stimuli. Of course the avoidance must occur after the exposure of the stressor. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV, 1995) states that avoidance is one of the criteria related to PTSD and that at least three of the following indicators should be true.

• Avoidance of feelings, thoughts or conversations associated to the trauma

• Avoidance of activities, places or people which may trigger recollections of the trauma

• The inability to recall an important part of the traumatic event

• Lost interest in certain activities

• Feelings of detachment from friends or family members

• Limited experience of feeling or emotion

• Only thinking about the near future

Another important symptom and criterion is the increase of arousal of a person. This may lead to difficulties sleeping and concentrating. The increased arousal can also lead to sudden outbursts of anger and hyper vigilance (Diagnostic and Statistical Manual of Mental Disorders IV, 1995). The duration of these symptoms, including the re-experiencing and avoidance of the stressor, must be longer than one month.

== Fear structure and emotional processing theory ==

(Taken from [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Research assignment] )

Some of the treatments which will be described in the next chapter, such as imaginal exposure, are strongly related to the emotional processing theory by Foa and Kozak (E. B. Foa & Kozak, 1986). This theory states that patients with a PTSD have developed so-called ‘fear structures’ consisting of information about:

• Stimuli associated with a traumatic event

• (Their) behavioural responses

• Meaning representations

The stimuli were already mentioned in the previous paragraph. People exposed to a stressor will remember facts about associated stimuli. For example a vehicle that exploded after it hits another car or seeing a comrade die by a mine.

Not only information about the stimuli is remembered but also facts about the behavioural response of the person at that time. For example a racing heart beat and perspiration.

And the last aspect is information about the meaning representation of the traumatic event. The meaning representation of a certain event can, of course, differ from person to person. The representation is strongly related to the stressors and criteria mentioned in the first part of the previous paragraph. One can, for example, associate an explosion to death or death of relatives.

Some treatments are based on activation of this fear structure using repeated exposure and adding new learning elements while anxiety is reduced (E. B. Foa & Kozak, 1986; E. B. Foa, Riggs, Massie, & Yarczower, 1995). Studies (E. B. Foa, et al., 1995) have shown that there is a correlation between activation of this fear structure and improvement in treatment.

== Literature ==

Beck, J. G., Palyo, S. A., Winer, E. H., Schwagler, B. E., & Ang, E. J. (2007). Virtual Reality Exposure Therapy for PTSD symptoms after a road accident: An uncontrolled case series. [Article]. Behavior Therapy, 38(1), 39-48.

Bradley, R. (2005). A multidimensional meta-analysis of psychotherapy for PTSD (vol 162, pg 214, 2005). [Correction]. American Journal of Psychiatry, 162(4), 832-832.

Bush, J. (2008). Viability of virtual reality exposure therapy as a treatment alternative. [Article]. Computers in Human Behavior, 24(3), 1032-1040.

Cahill, S. P., Carrigan, M. H., & Frueh, B. C. (1999). Does EMDR Work? And if so, Why?: A Critical Review of Controlled Outcome and Dismantling Research. Journal of Anxiety Disorders, 13(1-2), 5-33.

Dayan, E. (2006) ARGAMAN: Rapid Deployment Virtual Reality System for PTSD Rehabilitation, International Conference on Information Technology: Research and education, 34-38

Diagnostic and Statistical Manual of Mental Disorders IV (1995). American Psychiatric Association.

Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., et al. (2007). Virtual reality exposure therapy for the treatment of Posttraumatic stress disorder following September 11, 2001. [Article].
Journal of Clinical Psychiatry, 68(11), 1639-1647.

Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. [Article]. Behaviour Research and Therapy, 38(4), 319-345.

Emmelkamp, P. M. G., Bouman, T. K., & Scholing, A. (1995). Anxiety disorders: a practitioner's guide. Chichester: John Wiley & Sons.

Emmelkamp, P. M. G., Krijn, M., Hulsbosch, A. M., de Vries, S., Schuemie, M. J., & van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: a comparative evaluation in acrophobia. [Article].
Behaviour Research and Therapy, 40(5), 509-516.

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: emotional processing of traumatic experiences. Therpist guide. New York: Oxford University Press.

Foa, E. B., & Kozak, M. J. (1986). EMOTIONAL PROCESSING OF FEAR - EXPOSURE TO CORRECTIVE INFORMATION. [Review]. Psychological Bulletin, 99(1), 20-35.

Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). THE IMPACT OF FEAR ACTIVATION AND ANGER ON THE EFFICACY OF EXPOSURE TREATMENT FOR POSTTRAUMATIC-STRESS-DISORDER. [Article]. Behavior Therapy, 26(3), 487-499.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). BEHAVIORAL COGNITIVE CONCEPTUALIZATIONS OF POST-TRAUMATIC STRESS DISORDER. [Review]. Behavior Therapy, 20(2), 155-176.

Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T. A., & Botella, C. (2002). Virtual reality in the treatment of spider phobia: a controlled study. [Article]. Behaviour Research and Therapy, 40(9), 983-993.

Harvey, A. G., Bryant, R. A., & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic stress disorder. [Article]. Clinical Psychology Review, 23(3), 501-522.

Hoffman, H. G., Garcia-Palacios, A., Carlin, A., Furness, T. A., & Botella-Arbona, C. (2003). Interfaces that heal: Coupling real and virtual objects to treat spider phobia. [Article]. International Journal of
Human-Computer Interaction, 16(2), 283-300.

Hoffman, H. G., & Ieee Comp, S. O. C. (1998, Mar 14-18). Physically touching virtual objects using tactile augmentation enhances the realism of virtual environments. Paper presented at the IEEE 1998 Virtual Reality Annual International Symposium, Atlanta, Ga.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. [Article]. New England Journal of Medicine, 351(1), 13-22.

Jaycox, L. H., Foa, E. B., & Morral, A. R. (1996, Nov). Influence of emotional engagement and habituation on exposure therapy for PTSD. Paper presented at the Annual Convention of the Association-for-the-Advancement-of-Behavior-Therapy, New York, New York.

Lang, P. J. (1977). IMAGERY IN THERAPY - INFORMATION-PROCESSING ANALYSIS OF FEAR. [Article]. Behavior Therapy, 8(5), 862-886.

Lange, A., van de Ven, J. P., Schrieken, B., & Emmelkamp, P. M. G. (2001). Interapy. Treatment of posttraumatic stress through the Internet: a controlled trial. [Article]. Journal of Behavior Therapy and Experimental Psychiatry, 32(2), 73-90.

Marks, I., Lovell, K., Noshirvani, H., & Livanou, M. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring - A controlled study. [Article]. Archives of General Psychiatry, 55(4), 317-325.

Mast, C. A. P. G. v. d. (2009, 24 April 2009). Virtual Reality and Phobias TUDelft, from http://mmi.tudelft.nl/~vrphobia/

Mental Health Advisory Team (2006). Operation Iraqi Freedom 05-07. Washington DC.

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. [Article]. Jama-Journal of the
American Medical Association, 298(18), 2141-2148.

National Institute of Mental Health (2006). Anxiety disorders.

Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. [Article]. Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 250-261.

Raudis, S., & Yustitskis, V. (2008). The Yerkes-Dodson law: The link between stimulation and learning success. [Article]. Voprosy Psikhologii(3), 119-+.

Reger, G. M., & Gahm, G. A. (2008). Virtual reality exposure therapy for active duty soldiers. [Article]. Journal of Clinical Psychology, 64(8), 940-946.

Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. [Article]. Journal of Consulting and Clinical Psychology, 70(4), 867-879.

Rime, B., Mesquita, B., Philippot, P., & Boca, S. (1991). BEYOND THE EMOTIONAL EVENT - 6 STUDIES ON THE SOCIAL SHARING OF EMOTION. [Article]. Cognition & Emotion, 5(5-6), 435-465.

Riva, G., Molinari, E., & Vincelli, F. (2002). Interaction and presence in the clinical relationship: Virtual reality (VR) as communicative medium between patient and therapist. [Article]. Ieee Transactions on Information Technology in Biomedicine, 6(3), 198-205.

Rizzo, A. A., Graap, K., McLay, R. N., Perlman, K., Rothbaum, B. O., Reger, G., et al. (2007, Sep 27-29). Virtual Iraq: Initial case reports from a VR exposure therapy application for combat-related post traumatic stress disorder. Paper presented at the Virtual Rehabilitation Conference 2007, Venice, ITALY.

Rothbaum, B. O., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., et al. (1999). Virtual reality exposure therapy for PTSD Vietnam veterans: A case study. [Article]. Journal of Traumatic Stress, 12(2), 263-271.

Rothbaum, B. O., Hodges, L. F., Ready, D., Graap, K., & Alarcon, R. D. (2001). Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder. [Article]. Journal of Clinical Psychiatry, 62(8), 617-622.

Scheumie, M. J., & Mast, C. A. P. G. v. d. (2000). Virtual Reality in de therapie. Delft: Nederlands Instituut voor Psychologen.

Schoutrop, M., Lange, A., Hanewald, G., Duurland, C., & Bermond, B. (1997). The effects of structured writing assignments on overcoming major stressful events: An uncontrolled study. [Article]. Clinical Psychology & Psychotherapy, 4(3), 179-185.

Vaughan, K., & Tarrier, N. (1992). THE USE OF IMAGE HABITUATION TRAINING WITH POSTTRAUMATIC STRESS DISORDERS. [Article]. British Journal of Psychiatry, 161, 658-664.

Post-Traumatic Stress Disorders & Virtual Reality

2010-01-25T18:08:36Z

Matthew: /* About */

[[Image:MatthewVanDenSteen.jpg|thumb]]
[[User:Matthew|Matthew van den Steen]]

Human-Computer Interaction

== About ==

Research on: '''Post-Traumatic Stress Disorders & Virtual Reality'''

[http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf Link to research assignment]

Started: November 2008

Status: case study, writing final thesis report

http://img172.imageshack.us/img172/9586/ptsdintrods5.jpg

== 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, they can often handle them without any problems or complications. However, it is a whole different story when someone is exposed to a traumatic event beyond the bounds of common, everyday human experiences. In such cases a person can develop a ‘Post-Traumatic Stress Disorder’ (PTSD) [1]. This type of anxiety disorder is often linked to military soldiers who have witnessed a stressful event, but it can also affect people who have, for example, been in a motor accident or people who were confronted with a personal assault.

A wide range of possible options for treatment include therapies such as ‘prolonged imaginal exposure therapy’, ‘in vivo exposure’ and ‘eye movement desensitization and reprocessing’ (EMDR). Alternatively, various medicines are available to help patients cope with their disorder.

With the emergence of better and faster technology, various new approaches have been proposed. One such approach is the use of ‘Virtual Reality’ [2]. This technique enables the patient to interact in a virtual representation of the world. ‘Virtual Reality Exposure Therapy’ (VRET) [2] is one particular way of treatment and is already being used in practice to help people suffering from several different phobias other than a PTSD, such as, but not limited to, acrophobia and agoraphobia. In these worlds a variety of anxiety-provoking stimuli can be triggered at any time. Because the level of these stimuli can be changed, it is possible to gradually expose the patient to various levels of intensity. Studies [3] have shown promising results. However, is ‘VRET’ or virtual reality in general also a good way to treat patients suffering from a PTSD? Key aspects related to ‘Virtual Reality’ (such as ‘presence’) may be of importance, but what about other elements, if any?

A study [4] has shown that when a therapy lacks to engage the patient emotionally, it will often lead to poor, undesirable results. The same study states that facts about both the patient and the whole ordeal need to be present in order to evoke emotions. Due to certain patients either avoiding specific moments of the event, or not being able to express themselves thoroughly, it is often very difficult to gather all of the facts and link them together. It is also said that in some cases the patient even has an unrealistic view of what might have happened.

Traditional treatment for patients with a PTSD poses several problems while trying to engage the patient emotionally, whereas the use of ‘Virtual Reality’ makes it possible to accomplish this gradually with the help of a set of pre-defined stimuli. It is essential to look at traditional treatment first and see if, for example, ‘VRET’ or ‘Virtual Reality’ in general can be used to enhance the effects which are currently obtained without the help of these new techniques. This research assignment will therefore not only include research on how ‘Virtual Reality’ can be used to help people with a PTSD, but also traditional treatments and their important aspects will be taken into account.

== Discussion points ==

Right after the [http://mmi.tudelft.nl/vret_oud/images/d/d0/Matthew_RA_final_4.pdf 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.

Projects PTSD

2010-01-19T20:07:03Z

Matthew: /* (Military) Multi-Modal Reconstruction (4MR) */

= (Military) Multi-Modal Memory Reconstruction (4MR) =

== Idea sprouted from ==
*[[Post-Traumatic Stress Disorders & Virtual Reality]]

== Revised scenarios (PTSD among soldiers) ==

!!! Use the MMIGroup YouTube account to watch these !!!

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0216.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

[[Image:Foto0214.jpg|640px]]

== Involved Members ==
:[[User:Matthew|Matthew van den Steen]]

= Other PTSD-related Projects =

none

Projects PTSD

2010-01-19T20:06:51Z

Matthew: /* Interactive Reconstructive Trauma Therapy (IRTT) (concept name) */

= (Military) Multi-Modal Reconstruction (4MR) =

== Idea sprouted from ==
*[[Post-Traumatic Stress Disorders & Virtual Reality]]

== Revised scenarios (PTSD among soldiers) ==

!!! Use the MMIGroup YouTube account to watch these !!!

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0216.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

[[Image:Foto0214.jpg|640px]]

== Involved Members ==
:[[User:Matthew|Matthew van den Steen]]

= Other PTSD-related Projects =

none

Projects PTSD

2010-01-19T19:53:51Z

Matthew: /* Improved prototype after a 'heuristic evaluation' & discussing the 'first design principles' */

= Interactive Reconstructive Trauma Therapy (IRTT) (concept name) =

== Idea sprouted from ==
*[[Post-Traumatic Stress Disorders & Virtual Reality]]

== Revised scenarios (PTSD among soldiers) ==

!!! Use the MMIGroup YouTube account to watch these !!!

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after more feedback (formative) ==

=== Maps screenshot feature using 'google maps' ===

[[Image:V7-1.jpg|640px]]

=== Edit a day (text files shown) ===

[[Image:V7-2.jpg|640px]]

=== More features shown, such as hiding images and webcam shots ===

[[Image:V7-3.jpg|640px]]

== Version 0.2 3D editor feature ==

[[Image:Editor4.jpg|640px]]

[[Image:Editor5.jpg|640px]]

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0216.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

[[Image:Foto0214.jpg|640px]]

== Involved Members ==
:[[User:Matthew|Matthew van den Steen]]

= Other PTSD-related Projects =

none

Projects PTSD

2010-01-19T19:52:31Z

Matthew: /* Photos Case Study with real patient */

= Interactive Reconstructive Trauma Therapy (IRTT) (concept name) =

== Idea sprouted from ==
*[[Post-Traumatic Stress Disorders & Virtual Reality]]

== Revised scenarios (PTSD among soldiers) ==

!!! Use the MMIGroup YouTube account to watch these !!!

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after a 'heuristic evaluation' & discussing the 'first design principles' ==

=== Opening ===

Temp. removed for updates!

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0216.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

[[Image:Foto0214.jpg|640px]]

== Involved Members ==
:[[User:Matthew|Matthew van den Steen]]

= Other PTSD-related Projects =

none

File:Foto0214.jpg

2010-01-19T19:52:24Z

Matthew:

Projects PTSD

2010-01-19T19:51:32Z

Matthew: /* Opening */

= Interactive Reconstructive Trauma Therapy (IRTT) (concept name) =

== Idea sprouted from ==
*[[Post-Traumatic Stress Disorders & Virtual Reality]]

== Revised scenarios (PTSD among soldiers) ==

!!! Use the MMIGroup YouTube account to watch these !!!

<anyweb>http://www.youtube.com/v/NKQRBklDruM&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/tfzm0SQHo_U&hl=nl_NL&fs=1&</anyweb>

<anyweb>http://www.youtube.com/v/Jc0tHuq4Wow&hl=nl_NL&fs=1&</anyweb>

== Early concept screens ==

[[Image:0000.jpg|640px]]

[[Image:2 3.jpg|640px]]

== Early concept screens (therapist side)==

[[Image:Concepttherapist.jpg|640px]]

[[Image:Concepttherapist2.jpg|640px]]

== New concept to explain features ==

[[Image:Oldconcept.jpg|640px]]

== Improved concept screens ==

=== Opening view ===

[[Image:1heuristic.jpg|640px]]

=== Adding media view ===

[[Image:2heuristic.jpg|640px]]

== Improved prototype after a 'heuristic evaluation' & discussing the 'first design principles' ==

=== Opening ===

Temp. removed for updates!

== Photos Case Study with real patient ==

[[Image:Foto0210.jpg|640px]]

[[Image:Foto0216.jpg|640px]]

[[Image:Foto0211.jpg|640px]]

[[Image:Foto0215.jpg|640px]]

[[Image:Foto0213.jpg|640px]]

== Involved Members ==
:[[User:Matthew|Matthew van den Steen]]

= Other PTSD-related Projects =

none