Post-traumatic stress disorder (PTSD) first gained public awareness after the Vietnam War, as large numbers of returning veterans presented with depression and problems with substance abuse, which occur frequently with PTSD, and either a lack of or inappropriate emotional responses. As the Iraq War grinds into its fifth year, it's not surprising that PTSD has regained the headlines. Bringing a high-tech solution to this latest battlefield is Barbara Olasov Rothbaum, PhD, ABPP, Emory School of Medicine, Atlanta, GA.

Dr. Rothbaum first gained an understanding of the onset of PTSD. Plotting the course of PTSD after trauma exposure, Dr. Rothbaum assessed female rape victims on a weekly basis for a total of 12 weeks following their assault. Results showed that in the first week, 94% met symptomatic criteria for PTSD. “This indicates that this is the normal response to trauma,” said Dr. Rothbaum. “What we wanted to figure out is when a normal response to trauma ends and when a pathopsychological response that requires diagnosis and treatment begins.” While all subjects showed improvement after 4 weeks, a subset of patients stalled in their recovery. “We now see PTSD as a disorder of extinction. So, what you want to do is extinction training through exposure therapy—therapeutic exposure.”

Therapeutic exposure can be imaginary, wherein the patient recalls the trauma in the present tense, or in vivo, where the site of the trauma is actually revisited; thanks to advances in technology, the trauma also can be virtually recreated. This technique, called virtual reality (VR), reasonably creates all the sensory inputs of sight, sound, vibration, and even smell of an actual traumatic setting. First used to treat Vietnam veterans, VR applications have expanded to include treatment for social disorders, fear of heights, and fear related to the events of 9/11.

VR is currently used in conjunction with relaxation techniques, education, and cognitive therapy, but Dr. Rothbaum is investigating the use of pharmacotherapy to enhance the efficacy of VR therapy. The investigative drug is D-cycloserine (DCS), an older antibiotic that has been shown to be a potential cognitive enhancer, facilitating extinction of the fear response in animal studies. Dr. Rothbaum first used DCS to help patients who had a fear of heights [Arch Gen Psychiatry 2004] and was eager to try it with veterans who were returning from Iraq.

Her current study randomizes PTSD patients to one of 3 treatments, alprazolam, placebo, or 50 mg DCS, given 30 minutes prior to VR trauma exposure. “Animal data indicate that it's best to have the drug on board during the consolidation as well as during the exposure.” Though results on the first 27 patients are still blinded, all patients seem to be responding well to therapy with VR.

“But you have to ask yourself, ‘What is the treatment ideal?” Dr. Rothbaum asks. “Well, that would be to prevent PTSD before it starts.” To that end, she has proposed a study of emergency room trauma patients to be treated immediately for PTSD or observed for 12 weeks. The working hypothesis is that early disruption may change how the traumatic memory is consolidated. “It's like getting right back on the bike after you've fallen off.”

For more information on virtual reality therapy, please visit www.virtuallybetter.com.