VR Therapy for PTSD and Anxiety – Dr. Barbara Rothbaum – HPP 89

SPEAKERS
Keith Kurlander, Dr. Will Van Derveer, Dr. Barbara Rothbaum

Dr. Barbara Rothbaum 00:00
As I mentioned, PTSD is a disorder of avoidance. And I think war veterans are particularly avoidant because they’re trained in it. You don’t want someone to have a big emotional response in a war zone. You want them to compartmentalize and just do what they’re trained to do. But then sometimes it’s hard to put the emotions back together with the memory and with the experience.

Dr. Will Van Derveer 00:28
Thank you for joining us for The Higher Practice Podcast. I’m Dr. Will Van Derveer, with Keith Kurlander. And this is the podcast where we explore what it takes to achieve optimal mental health. I’m delighted to introduce today’s guest. A true pioneer in the world of mental health who has focused the past 25 years on finding, developing, testing, virtual reality as a venue for providing effective treatments. Barbara Rothbaum is a professor of psychiatry and Associate Vice Chair of Clinical Research at the Emory University School of Medicine’s Department of Psychiatry and Behavioral Sciences. She is the executive director of the Emory healthcare Veterans Program and trauma and anxiety recovery program. She holds the Paul H. Hansen chair and neuro psychopharmacology. Dr. Rothbaum specializes in research on the treatment of individuals with anxiety disorders, particularly focusing on Post Traumatic Stress Disorder, as well as pioneering the application of virtual reality to the treatment of psychological disorders. She’s authored over 300 scientific papers and chapters, including five published books on the treatment of PTSD. And she’s edited three other books on anxiety. Dr. Rothbaum’s outreach efforts include training community clinicians and evidence based treatment for PTSD. The Emory healthcare Veterans Program is a member of the warrior care network funded by the Wounded Warrior Project, and is able to provide world class treatment to post 911 veterans from around the country at no cost to the veteran. Welcome Dr. Barbara Rothbaum, to the show.

Dr. Barbara Rothbaum 02:20
Thank you. I’m very happy to be here.

Dr. Will Van Derveer 02:23
It’s wonderful to have you. I’ve kind of been following as a psychiatrist for the emergence of virtual reality for a while now and it’s just a delight to get to speak with one of the pioneers here and we want to thank you for your work.

Dr. Barbara Rothbaum 02:38
Thank you. Yeah, it was the first published study using virtual reality to treat psychiatric or psychological disorders. We published it in 1995. We’ve been doing this for very long.

Dr. Will Van Derveer 02:53
Well, it’s a long time. Yeah. And it takes time in medicine to move things forward.

Dr. Barbara Rothbaum 02:59
Right, conventional wisdom is about 20 years. So we’re pretty much there.

Dr. Will Van Derveer 03:06
Beautiful. Well, for our audience who may not be as familiar with VR, who aren’t up to date yet on where things are at this point in its application for therapy, can you just give us an update, and let us know where we are today?

Dr. Barbara Rothbaum 03:20
Sure first one, I want to talk about what actual VR is, because a lot of people kick around and don’t do a lot of things virtual reality, or VR. VR is an interactive computer environment. And what’s special about it is that the user experiences a sense of presence in that environment. So for example, I could take a picture of the room I’m in and you could get a sense of the room, I could take a video of the room I’m in and you get a little bit better sense of the room, you wouldn’t feel present in it. And if I had it rendered in virtual reality, in 20 seconds, that would be your reality, and you would feel present. It’s a 360-degree environment, you could crawl under my desk, you could move all around in it. We outfit users in a head mounted display, which is basically like a strappy helmet with two television screens in front of each eye, earphones and a position tracker. So just as my view changes when I move my head in reality, so it does in virtual reality. We also have a couple of others I call them tricks that computer scientists don’t like when I call them tricks. For example, for most of our environments, we have people sitting on a raised platform with a woofer or bass shaker underneath. So for example, in the virtual airplane, you feel the vibration of the airplane, you feel the landing gear coming up. You can feel turbulence. For many environments, we have basically a joystick or gamepad that you can maneuver yourself or the virtual environment. For example, you could, in the early one, manipulate a virtual hand to push the elevator button. And in ones we have now you can drive the Humvee in the virtual Iraq and Afghanistan. So that’s a long answer to tell you what VR is.

Dr. Will Van Derveer 05:26
Great, I’ve got so many questions from what you just said, but I’m gonna try to stay on track here with my thinking. Can you tell us about the applications in therapy and how it’s being used today?

Dr. Barbara Rothbaum 05:39
Right. And there are a number of applications out there, and it’s really almost just limited by people’s imagination and computer programmers to create it. We have a virtual Iraq and Afghanistan, and I’ve run the Emory healthcare Veterans Program. And so we will use it for exposure therapy with veterans, and we’ve done a number of studies with that as well. Probably my favorite environment is the virtual airplane, because I live in Atlanta. I’m assuming most people if you have flown through the Atlanta airport, I actually love it, I can get almost anywhere in the world in one flight. Not lately, not during COVID. But it was a real pain. Before VR, if I had a patient who was scared of flying, if I really had to go to the airport to get through Atlanta traffic, you’ve got a range of stationary airplanes, you have a range of security to be able to get through. And with the virtual airplane, we can take off and land as many times as we need to all within the 45-50 minute therapy session and without leaving my office. That’s my favorite thing about him for fear of public speaking with them, for fear of storms, for Swype spiders, small animals. And I also want to disclose I’m full time at Emory. I’m a professor in psychiatry. But years ago, when we published the study, Emory and Georgia Tech thought there might be a marketable product. And they literally took us by the hand to a lawyer to incorporate and that’s virtually better. So I’m a part owner, and Virtually Better. Like I said, although I’m full time at Emory, I always like to disclose that.

Dr. Will Van Derveer 07:26
Great. Well, and I’m curious with regard to I mean, that’s such a great example of how much easier it is for patients to access treatment for fear of flying, rather than having to do all the things that you just listed off and getting there.

Dr. Barbara Rothbaum 07:42
I can add, I mean, the other advantage is, the therapist has complete control over what you’re presenting to the patient. So when my patient is ready for turbulence, I can guarantee there’ll be turbulence. If my patient’s not ready for turbulence, I can guarantee there won’t be turbulence. So you really do have complete control.

Dr. Will Van Derveer 08:03
That’s one of the really important things about I think, in my experience with trauma therapy, to expose people in a titrated way and to be able to have control over the titration, I think is what you’re talking about.

Dr. Barbara Rothbaum 08:15
Right.

Dr. Will Van Derveer 08:15
Yeah, beautiful

Dr. Barbara Rothbaum 08:17
And PTSD, in war veterans, for example, you control the intensity with the volume. Or if they say we heard gunfire far away, the easy way to do that in virtual reality is turn the volume down. It is a way to titrate it.

Dr. Will Van Derveer 08:35
And so at this point outside of specific phobias, and PTSD, and I’m just curious, are there people applying VR and other conditions like mood disorders or other situations people deal with?

Dr. Barbara Rothbaum 08:49
Absolutely, people have been using it for depression, I think Chris Bruin in England has been using it for depression. People are using it for substance use disorders, and it’s really cool for that because for example, you can expose your patient to the cues, but in a safe environment, you want to teach them, for example drug refusal tools without being on the corner when someone’s actually holding drugs in their hand and consequences are greater if they don’t get the refusal skills quite right. So that’s a good one, use it for relaxation, people use it for distraction especially during painful techniques. Some people have been using it for a number of different disorders.

Dr. Will Van Derveer 09:34
And is there, would you say that the problem of COVID, telemedicine and teletherapy, does it seem to you like that’s accelerated the adoption of VR or the use of VR, any sense of that?

Dr. Barbara Rothbaum 09:49
Well for us it’s actually interfered so I love telemedicine and when COVID hit we pivoted our Veterans Program to be able, because right now we fly veterans in from all around the United States and put them up for two weeks and treat them every day. we pivoted to telemedicine and it’s working just as well. But if you remember going back to my original definition of VR, for it to be real VR,it needs to be immersive. So for us, that means being present in the room with us and wearing the virtual reality head mounted display. So people are talking about doing VR over telemedicine.,Aad my impression is that it’s not real VR, and doing research, I try to be precise in my language, and not call it virtual reality. If it’s not, it might be in a multimedia display, there are plenty of other things that it could be that are cool and effective. But in my mind, it’s probably not immersive VR.

Keith Kurlander 10:56
So Barbara, sounds like a lot of your focus with trauma is that where you’re a lot of your focus has been?

Dr. Barbara Rothbaum 11:02
Well, anxiety and trauma, and I do a lot of exposure therapy. So that’s how virtual reality came up. The computer scientists there was an Emory, Georgia Tech seed grant. So you needed a Georgia Tech investigator, every investigator, so the computer scientist called me up, and I said, you want to do what? And he makes fun of me still, because I asked him to send me his CV to make sure he was legitimate. But this was in the early 90s, and he needed an exposure therapist, and we originally talked about doing it for fear of public speaking. But at that time, people moved into art, and at that time, virtual reality didn’t do art to people really well. It worked better in straight lines. And so we switch to the fear of heights, because the height cues could be rendered really well in VR.

Keith Kurlander 11:52
I’m curious about for me, like when I hear anxiety and phobias like to me, that’s like, sort of somewhat simple in terms of like, you create the VR world that deals with the phobia, it seems like it might get a lot more delicate in the range of what traumas could be, and what the actual event was, and what actually went down if there was physical or sexual abuse. Tell me what you’ve learned here about using VR for trauma and different types of traumas and what are you doing there?

Dr. Barbara Rothbaum 12:24
Yeah, we’ll Keith that’s probably exactly why, like the fear of flying is my favorite VR app. I like it for PTSD, and I used it for the more veterans because I think it is such a potent stimulus that it’s harder to avoid, and PTSD is a disorder of avoidance. But you’re exactly right that for PTSD, so I do a lot of imaginal exposure, prolonged exposure, PE, and in that we ask people to go back in their mind’s eye, to close their eyes, and to picture it and describe the traumatic event in the present tense as if it’s happening now. So I’m driving back to base. Jones is next to me, Smith is in the turret, we hear a loud explosion, IED blast hits on the right side, everything fills with smoke, and we go through it over and over. Now, we can exactly recreate that in virtual reality. And I again, I’d like it, especially for the veterans, because if we started at the first time we use VR, for war trauma, we created a virtual Vietnam, so this was at the end of the 90s. And at that point, I know I’m pivoting a little bit, I’ll come back, at that point, the Vietnam veterans had been in the system for a long time, it was already several decades since the war. And if they were still in the system, they were pretty much treatment resistant. And so we thought, let’s try the VR and see if it can help and it did. So when we applied it to the younger veterans from Iraq and Afghanistan, we’ve done a couple of different studies. And it has been effective. As I mentioned, PTSD is a disorder of avoidance. And I think war veterans are particularly avoidant because they’re trained in it. You don’t want someone to have a big emotional response in a war zone. You want them to compartmentalize, and just do what they’re trained to do. But then sometimes it’s hard to put the emotions back together with the memory and with the experience. And that’s part of why I like VR. It’s so potent, and everybody pays so much attention to the visuals. I actually think it’s the sounds that really get people and they know it in earlier versions, we didn’t have all the right artillery or all of the aircraft. And so matching the sounds is important, and that’s coming back to your question. If it doesn’t match the memory, it can take them out of it. And that’s why Prolonged imaginal exposure (PE) works so well because it’s their own memory. And that’s what we train new therapists in, if the patient’s doing well, we’re counting it just get out of their way and let them do it, you say the wrong thing, it can take them out of it, it can interfere. So with PTSD, it’s such an individual. We’re exposing them to the memory of their trauma, that in general, I don’t feel like VR adds a lot. But when it’s something like in war, like Iraq, or Afghanistan or Vietnam, there are so many common stimuli that are triggering just because they are there. So for you and I, if you haven’t served, we could see them, and they wouldn’t be particularly emotional for us. But anyone who served and especially if you’ve got PTSD, just the stimuli are going to be evocative and help put you back there. So I like it for that reason, and when we can use common stimuli. We have done a study with military sexual trauma survivors with PTSD, and we use VR. We do not present the perpetrator. We’re just presenting these external stimuli, for example, the environments where it might have occurred, we’ve got a vehicle, we’ve got a motel room, we’ve got a barracks, we’ve got a (FOB) Forward Operating Base, we’ve got a latrine in the showers, we’ve got these situations, and the person is describing what happened to them, but immersed in this stimuli that matches where it happened. And so we think that, that’s effective.

Keith Kurlander 16:44
And so you never, if we’re talking about sexual trauma for the moment, it sounds like you would never actually have mock perpetrators within the VR environment, you’re really just going to work with the stimuli without a person in the environment. Is that right?

Dr. Barbara Rothbaum 17:03
Yes, and no, that’s how I use it. So the virtual Iraq and Afghanistan that we use for military sexual trauma, Dr. Skip Rizzo and his group at USC, and the ICT Institute for Creative Technologies developed it. And so there is a perpetrator that you can use. And the therapist has a computer screen where we can include audio stimuli, put them into different environments, make things appear and disappear. But my group, so there is one in the virtual environment, my group never ever uses it. Actually I’m going to take that back, we used it once. Because the person we were treating was now working with the perpetrator, and we used it in role playing in case they came into contact with the perpetrator now in the environment, and just being able to talk or not talk or pass, so not presenting the perpetrator as an assailant. But so that’s the only time I can think that we’ve actually used the perpetrator. We don’t for a lot of reasons, one. And this is more my philosophy, other people have different philosophies. In virtual reality, I don’t want to present anyone with anything that would be naturally threatening to anyone. That’s why I said we would see driving the Humvee in Iraq, and maybe it’d be cool, but it wouldn’t necessarily be threatening to us. But they would feel threatened right away if you’ve got PTSD from that environment. So we want to present things that are threatening, basically, because they’re conditioned stimuli. So a perpetrator and assailant is going to be naturally threatening to anyone, so that’s kind of more of almost like a moral or ethical stance, I guess, that I take. The other is, as I said earlier, if it doesn’t match, then it can take the person out of the memory. And it’s very unlikely that we’re going to match the perpetrator. And it’s better they’ve got a picture in their mind, I think it’s better for them to do that. This is also the same reason, and again, in some of the environments, Skip and his developers have injuries and blood present. I don’t show it to our folks and don’t show it for the same reasons. Anyone would respond to that. And it’s not likely to match, but we do ask people in their mind’s eye to describe the injuries and in a lot of detail.

Dr. Will Van Derveer 19:43
It makes sense to me that you would really focus on eliciting the conditioned response and not eliciting a healthy fight or flight response to a threatening stimulus, it makes a lot of sense. Pardon my ignorance here, I’m just so curious about this technology. They’re formats where the therapist also has an avatar inside the VR, and you’re interacting with your patient in the virtual environment together.

Dr. Barbara Rothbaum 20:11
We don’t do that, but they’re things like Second Life, which, again, is not real VR, but they’re things like that, that the therapist does occupy an avatar and interact. What do patients say? Because they’re going through it, we’re seeing everything that they’re seeing. And we’re in the room with them, and some of our patients say things like, I feel like you’re riding shotgun with me, like you there.

Dr. Will Van Derveer 20:38
So you’re interacting outside of the VR, in your model with real VR, it’s an important distinction, I’m glad you clarified that, that you’re interacting verbally with them. And would you maybe ask them to describe what they see? Or what are they feeling or they know that you’re there, they can feel your presence, even though you’re not in VR?

Dr. Barbara Rothbaum 20:58
Right. It is essentially, if you are familiar with PE with prolonged exposure, it’s essentially prolonged exposure. But with your eyes open, and saying it out loud, and us presenting what you’re describing in the VR. So like I said, fairly common trauma that will work within Iraq and Afghanistan veterans is getting hit by an ID when they’re driving, say a Humvee. So they describe the heading back to base now, it’s September 6, sunsetting. So we can recreate all of that we can have the sun setting, I’m driving, Jones is next to me, Smith is in the chart, we can put people, we can populate the vehicle exactly as they describe not with the names, but we can put someone in the passenger seat, we can put people in the backseat, we can put someone in the turret, we can put them in a Humvee or an MRAP. If, for example, there’s an explosion and they get out of the vehicle, we can have them get out of the vehicle, and then they can walk using the joystick say to the other vehicle, we can present the explosion wherever it is, we can present fire, we can have insurgents, we can have trash on the side of the road, it can be in the city, it can go through a village, they can be on foot patrol in the middle eastern city, almost everything that they could describe from Iraq or Afghanistan, we can recreate in virtual reality.

Dr. Will Van Derveer 22:32
Do you think that the improvement or the enhancement in the technology and the sort of the graphics? Do you think that the improvements in the quality of the environment over a couple of decades has improved outcomes and from VR exposure treatments? Or do you think the technology is just allowing you to have more control over presenting the stimulus to folks in a more kind of realistic way.

Dr. Barbara Rothbaum 23:00
So, I don’t think that the improved computer graphics are related to outcome. I mean, this is decades ago, why the computer scientist was interested in obviously, I was interested in another form of treatment another way and also I mean, just making treatment feasible more accessible. For example, fear flying is going to be expensive for the patient, because insurance isn’t going to cover everything it’s going to be really time consuming, but had the airport bad to fly with someone, if I can do it all in 45 minutes and insurance pays for it, it’s just more accessible, it’s feasibly easier. But the computer scientists were more interested in what are the cues that are necessary to make people or help people feel a sense of presence. And that’s part of what we think about when exposure therapy, we want people to feel, in some ways present with what they’re dealing with, because we want their arousal up. I think in terms of there’s this and it’s theoretical, an optimal level of arousal when we’re doing exposure therapy, we don’t want someone so relaxed, they’re not going to learn, they’re not going to access anything. We don’t want someone having so much anxiety that they’re not even processing, or what you’re saying or learning more. And now I forgot your original question.

Dr. Will Van Derveer 24:23
No problem. We were exploring the question of whether better computer graphics and that really, it sounds like what you’re saying is essentially, what I’m gathering from what you’re saying is that exposure therapy is highly effective. And it’s sort of like how do you deliver it? And to the extent that VR in computers can help deliver, it’s really more about the exposure therapy itself is that right?

Dr. Barbara Rothbaum 24:48
Yes. And when you know what frightens people, and you can present it in any format, in this case in VR, and you access that Then they feel present. Because the fear and the anxiety helps them feel present with it. So early on, when we were creating the first virtual airplane, the computer scientist is rubbing his hands and he says, you know, we can crash this thing, it’s like, No, you don’t get the idea. And when I was demoing, the first ones, there was too much room between the passenger seat and the window, it felt too roomy. And what I was explaining to them is, folks with the fear of flying, about half of them have the fear of crashing, and that’s when you said, we can crash this thing. And about half of them have the more claustrophobic fear. So you really, you want it to be tight, you want it to feel like a real airplane and be claustrophobic. And as long as you tap into those fear cues, then it really doesn’t have to be too realistic. Now, everybody, I mean, we’ve got zoom, we’ve got, people have computer games, so people have an expectation of a certain level of graphics. And so it’s really more for that, than that. I think it really matters to the efficacy of treatment. It’s just the attractiveness and also the bells and whistles, what therapists are able to present and control.

Keith Kurlander 26:19
How far has VR been taken in the therapy field in terms of? Like, it seems like it’s mostly been used in more of these cognitive therapies, cognitive behavioral therapies, like is it actually been taken into people exploring using it in other types of work? Like, more exploring, psycho dynamically, your childhood, or exploring, like parts work of your psyche? Or like, is it mostly at this point, like a cognitive behavioral intervention?

Dr. Barbara Rothbaum 26:50
Most that I’m aware of, is more CBT, and it really is amenable to CBT. Although people are working with the different formats that they can, for example represent, I think a little bit well, like you were talking about earlier, keep represent the therapist and then kind of make their mouth move. To me sounds a little freaky, like those old pictures that the eyes would move. But yeah, it’s mostly been CBT kinds of applications.

Keith Kurlander 27:24
So what’s the research showing? Are there head-to-head research against other CBT interventions? And what are we seeing with VR?

Dr. Barbara Rothbaum 27:33
Right, so we did a number of studies with the fear of flying, looking, comparing the virtual airplane, to standard exposure therapy, so teaching the skills and then go into using a real airplane. And then the behavioral avoidance test to BIT is an old cognitive behavioral thing, where you don’t just face how your patients are doing on questionnaires or self-report, you see how they actually interact with the feared object, and often you do it before and after treatment. So after our studies, we would take people on a real airplane ride, and then that was part of the measures how many people would agree to fly on the airplane, because they had to avoid flying to get a flying phobia diagnosis, prior to treatment. And in those studies, I think one of them went up to 12 month follow up, and a 12 month follow up 90% of people who have received either treatment flew, and we got them to rate their SUDs subjective units of discomfort while they were flying. And I can’t remember it was somewhere around like 30 to 40 on a zero to 100 scale, so it was manageable fear, and so I that’s in some ways, what’s most important is that it translates into real life. In that very first study we did with the fear of heights using VR, at the end of therapy, seven out of 10 of people who had gone through the VR exposure told us that they had exposed themselves to real life hate situations. And again, they had avoided hate situations, to have a diagnosis to get into study, seven out of 10 put themselves in real life fight situations without us even asking them to. So that’s what matters, it doesn’t matter if you can ride on the virtual elevator if you can’t get on a real one or ride on a virtual airplane if you can’t get on a real one. And so the getting back to the state of the literature with the VR for fear of flying has basically shown equivalence with using a real airplane. And again, and we don’t need to be regular exposure therapy because I think that works very well. In the case of fear of flying, it’s just so much easier with VR. And Greg Rieger, was the first author on a study that we were part of, for active duty, folks who had served in Iraq and Afghanistan, with PTSD, comparing virtual reality exposure therapy to prolonged exposure therapy. And they worked equally well. And they were looking for different predictors of which treatment seemed to work better for which person. And that was more of a statistical technique. So really, in the ones that there have been head to head comparisons, it seems to be pretty equivalent to standard exposure therapy.

Dr. Will Van Derveer 30:48
Well, that’s great news, I mean, that it actually translates into real life, and it’s performing as well as traditional prolonged exposure. I’m wondering about if we could look at the future, Barbara. And I know as a scientist, you might be, most scientists are reluctant to make wild claims about what could happen in the future without studying. But in our world, it seems like a lot of the providers that we talked to are either 100% virtual or nearly so in their practices now, and some of them may not ever go back to meeting with people in person. Personally, I think there’s a lot of information I get from sitting with a patient in person that I don’t get on a screen, but please just answer as comfortably as you are here, because I don’t want to put you on the spot here. But do you see the possibility that VR could be a component of what allows providers and patients to work together remotely?

Dr. Barbara Rothbaum 31:45
Absolutely. And actually, I have thought that way, for years maybe even longer than yours. So for example, if you have a pilot on a ship, in the middle of the sea, on the other side of the ocean, who is all of a sudden scared of flying, and you don’t happen to have a cognitive behavior exposure therapist on board? If they had a VR head mounted display. And there are a lot of cheap ones out there now, and people are using them for gaming. So it’s not totally unreasonable that people could have one or even one that a smartphone could be used in, then that therapist doesn’t necessarily have to be on the ship with them. And they don’t even necessarily have to be in the same hemisphere, and that you could effectively treat them. So I’ve thought that for a long time that it would just mean outfitting the user, the patient with what they need, and being able to deliver the VR reliably, to wherever they are. So I think we’re not quite there yet, but I certainly see that we could be.

Dr. Will Van Derveer 33:00
Given the fact that we’re at least I have a pilot in the family. So I know a little bit about training and maintaining your instincts, your reaction times and so forth. In the flight simulator, it seems like a no brainer to add a feature to a simulator that would help people deal with those kinds of issues.

Keith Kurlander 33:19
I have another slightly different spin on Wills question. Since you have been one of the leading researchers in VR for so long. I’m curious, what are some of the studies you would love to see happen if you had a couple 100 years to create studies? Like, what are some of the things you would want to try out in VR, just in the therapy space in general?

Dr. Barbara Rothbaum 33:40
Well, it’s not necessarily time I need, but it’s money. You give me money, and I can do those studies. Any listeners want to contribute, I got some studies we can do. So there are a lot of them in combination with medication. And there are a number of reasons I like VR. For that reason, we did a study, I guess it was published a long time ago. 2004 using the cyclus searing, it’s an old antibiotic, it’s an MDA partial agonist. And my colleagues had found that it facilitated the extinction of fear in a rodent model. Like I said, it was an old antibiotic that had been FDA approved for 50 years, so we could test it in humans. And we decided to test it using VR, because usually when you test medication with a psychotherapy component, the psychotherapy components are a little softer. But with VR, we could exactly control the stimulus that every patient got, and we could make sure that every patient got exactly the same stimulus as another patient. And at that point, we could make sure that it was only under the experimental drug conditions. They weren’t likely to be exposed to it outside of the experimental drug conditions. And we use the fear of heights and we regulate it, so everybody got exactly the same. I love it, for the methodological control of testing new medications. And we’ve talked to a number of drug studies about that. I also like it, as we mentioned earlier, there are applications for substance use disorders. So for example, if you have a drug that’s supposed to reduce craving, we can test that in a virtual environment, rather than the real environment that has more danger involved in it. I also think that virtual reality has great potential as self-help, and I could have got those studies in my head that all we need is money, money and a little bit of time, more money than time maybe.

Dr. Will Van Derveer 35:51
So if we were to take that a little further with the idea of self-help and optimization, which is something that a lot of our community members are really interested in, and Keith and I like to fiddle around with ourselves, if you could design a study to look at all the different parameters or physiologic tracking, what would you be most excited about looking at in terms of the setup? Would it be a galvanic skin response? Would it be heart rate variability? Would it be brainwaves, I’m just so curious.

Dr. Barbara Rothbaum 36:23
We’re looking at all of those. And generally, we’re looking at them pre- and post-treatment, we’ve done that in a number of our VR studies. And we’ve done it in our Emory healthcare Veterans Program, we do psychophysiological studies pre- and post-treatment. And actually, for one of our paradigms, we use the VR, we have created three, two minute standard clips of being in Iraq, Afghanistan, one’s in a Humvee, one’s In alone, one’s in a convoy, one lone foot patrol in the middle eastern city, and it increases in intensity. So we have a standard activation paradigm, and we’re gathering especially startle. So startle is one of the Hallmark symptoms and exaggerated startle response, and PTSD, and it’s a translational measure. So we can do studies in animals and measure their startle response, and we can do studies in humans. I mean, it’s really just the three-neuron pathway. In humans, you probably don’t realize that but when we startle, we blink our eyes, so it’s very easy to measure the startle response with an electrode under the eye. And we have been able to show that, for example, after when we use the virtual reality exposure therapy with Iraq and Afghanistan veterans, that their psychophysiological reactivity to these cues decreased after treatment, and it stayed lower. And we also look at biomarkers in this case, in that study, we looked at salivary cortisol. And we could see that, that decreased as well, so that we’re seeing that as well in the Emory healthcare Veterans Program. So that makes me really happy. The virtual reality treatment or the two weeks of treatment, we give people in the intensive outpatient program with that treatment, their bodies are learning to become less reactive to cues. And I think that’s part of what makes people with PTSD feel crazy. They can No, they’re not in a war zone, yet their bodies are responding as if there’s the same level of threat. So when their bodies are learning to become less reactive, I think that’s wonderful. In some of our environments and treatment, we are gathering psychophysiological measures within the treatment session. We did that in I don’t want to go through all the details but we had a reconsolidation paradigm that again, was really nice to use virtual reality for the idea behind that is if you give someone a fear, cue 10 minutes prior to the exposure therapy, in the animal studies and in the preclinical human studies, in their words that prevented relapse a year later. So we could try that. And we did that with the fear of flying and we could present the cue and the virtual reality 10 minutes before the session either the airplane or just a neutral cue. We had a virtual living room and we had psychophysiological measures all through that looking particularly as you said that galvanic skin response so much for sweating, and heart rate response. We can also and so we can use the whole big polygraph for that, but there is also a free program that you can use on your iPad or your iPhone. All you have to do is buy the electrode it’s called essence. And what we found is with a dab of electro gel or ointment, it is as accurate as the big polygraphs. And we’re able we use that with a lot of our patients. And you can see the administrator’s GSR galvanic skin response. And you can see it come down, you can see it within a session, you can see it across sessions, and we’ll show it to the patients and see, look at your body, you’re feeling different, and your body’s showing that it’s feeling different too. And it’s really very cool for patients to see that.

Dr. Will Van Derveer 40:27
Kind of brings to mind an image of the firehouse or police station, or, as you said, the pilot on the carrier on the other side of the world who just has a training booth inside of their workplace that they can go and check and see if they’re startles exaggerated, if it is maybe do a little training, I think about hospital workers, medical staff, paramedics, the list goes on of people who need ongoing training, just to keep your nervous system fit.

Dr. Barbara Rothbaum 40:57
Yeah, I agree, for assessment. I mean, so when people come or more veterans come home from war, all they want is to get back to their families to maybe forget about what happened. And they don’t want to report that they’re having any problems, and they think it’s going to be fine, they just needed to get out of there. And then sometimes people do have problems reintegrating. And what I’m thinking is that we could use, for example, that virtual reality activation paradigm with the psychophysiological measures, when people come back to maybe predict who’s going to not have any problems, reintegrating or who might have problems and then just we can do a little bit of work to make it easier for them without all of the sequential love maybe too much drinking or for marital problems or other stuff down the road.

Dr. Will Van Derveer 41:48
I love that.

Keith Kurlander 41:49
Oh, yeah. I was just wondering, as we start to wrap up, for providers who want to start getting involved with VR, what’s the process? Is it like, basically, they’re going to get a certain specific VR headset and they’re buying software online somewhere that they just are basically using on their computer without headset or like, how does this all work for people just like, yeah, I can’t wait to get involved with VR.

Dr. Barbara Rothbaum 42:14
I’m glad you brought that up. So for most of your listeners, I mean, maybe they’re interested in VR, and that’s why they’re listening. But even if I had people tell me after we talked about it, yeah, I’m not going to do it. But at least it’s good to know about it, If you patients ask about it, and stuff going on. Some people do want to do it. And I would say you got to be trained in CBT, and exposure therapy first. It scares me if people aren’t trained in exposure therapy, and they get the VR and they think now they’re an exposure therapist. It’s kind of like a story years ago, I was working with a patient on the unit on an inpatient unit, she had panic disorder and agoraphobia, we’ve been working really well, I had to go into town, I asked the nurse to just do what we had done the day before. They got in the tunnel, patient panic, nurse panicked, and they both ran back to the unit. So you don’t want to do bad VR therapy, it’s just bad therapy. So you only want to do it if you really know about exposure therapy, and how to be therapeutic with it. So I’m glad I disclosed my relationship with virtually better earlier because they have been in the business now since 1996, creating virtual environments and training therapists in using the virtual environment. And they’ve got a website and a number of the different suites, the phobia suites and all the different things. There are a number of folks out there, but my main and with virtually better, we’ve written treatment manuals that go with each of the applications. But my main caution is don’t try this at home if you’re not an exposure therapist or get training and exposure therapy first.

Keith Kurlander 43:55
So assuming it is an exposure therapist that’s already trained in that, then the next step is so Virtually Better. Sounds like a software company and they also need to get the hardware Right?

Dr. Barbara Rothbaum 44:06
Right, But you can buy everything through Virtually Better. The whole system, the turnkey system and training too. Yeah.

Dr. Will Van Derveer 44:14
Great, cool. Wow. This is wildly educational.

Keith Kurlander 44:19
Very educational.

Dr. Will Van Derveer 44:20
Thank you for being with us. We have a question that we ask all of our guests toward the end that we’d like to pose to you now is that if you had a billboard, and could put a paragraph on it that every person in the world would see once in their lifetime. What would you like them to know?

Dr. Barbara Rothbaum 44:37
Oh, boy, I didn’t really prepare too much for this. My first reaction I don’t, I might just go ahead and stick with it. And it’s short and sweet. Listen to your mother.

Dr. Will Van Derveer 44:51
Good advice.

Keith Kurlander 44:52
Thanks, Barbara. Thanks so much for being on the show.

Dr. Barbara Rothbaum 44:55
Thank you, it’s fun.

Dr. Will Van Derveer 44:59
Well I want to first of all, thank Dr. Barbare Rothbaum, for joining us and for the steadfast and long standing commitment to advancing the treatment of PTSD specifically in anxiety disorders in general, through looking at virtual reality, I think this is something that we all are going to see a lot more of in the future. And one of the fun things about VR is that I feel like it really begins to bridge the gap between clinical treatment for psychiatric disorders and optimization for the biohacker. community, people who want to experience optimal mental health. We look forward to connecting with you again on the next episode of the higher practice podcast where we explore what it takes to achieve optimal mental health.