**5.2.2 Virtual reality exposure therapy**

*Virtual reality exposure therapy* has been used to treat soldiers that served in Vietnam, Operation Enduring Freedom, and Operation Iraqi Freedom. Computer programs were developed for both populations containing scenes that look similar to the surroundings veterans would have experienced during combat. The Vietnam virtual reality environment contains a scene with a virtual jungle and includes sounds of the jungle, gunfire, and nearby helicopters and has a separate scene within a helicopter (Gerardi et. al., 2010). *Virtual Iraq* was developed for veterans of current war. (A. A. Rizzo, et al., 2008). Virtual Iraq contains scenes of a Middle Eastern themed city, where the person is able to travel through the city by foot or in a truck. This environment can be adapted based on the client's therapeutic needs. In addition to the virtual reality scene, the individual is also presented with auditory, tactile, and olfactory stimulation. The client sits on a platform equipped with subwoofers, and the therapist controls which sounds the client hears. Furthermore, the platform vibrates in coordination with the virtual reality environment. The

Combat Related Posttraumatic Stress Disorder –

into something resulting in trauma to the head.

disorder more challenging (Chard et. al., 2011).

**7. Conclusion** 

problems, dizziness, and headaches (Kennedy & Moore, 2010).

History, Prevalence, Etiology, Treatment, and Comorbidity 45

soldier is said to have a *primary blast injury* when they were close enough to an explosion to experience the extreme changes in atmospheric pressure, otherwise known as a "blast wave." A blast wave can easily permeate a combat helmet and can ultimately cause trauma to the brain. A *secondary blast injury* can be obtained when a fragment from the explosion hits the soldier on the head hard enough to cause brain injury symptoms. This type of injury can be external but may also permeate the skull. Lastly, a soldier is said to have obtained a *tertiary blast injury* when an explosion causes the soldier to either be knocked to the floor or

Despite the high comorbidity, researchers continue to struggle to detangle the overlap of symptoms between posttraumatic stress disorder and traumatic brain injury. The residual symptoms that one experiences as a result of a traumatic brain injury are called *postconcussive symptoms*. Many of the symptoms associated with posttraumatic stress disorder overlap with postconcussive symptomology, which include irritability, memory deficits, sleep problems, and difficulty focusing attention (Kennedy & Moore, 2010). Some of the symptoms that can often be unique to a traumatic brain injury diagnosis include balance

Brenner and colleagues (2010) examined the unique contribution of posttraumatic stress disorder and traumatic brain injury to a sample of injured Army personnels' endorsement of postconcussive symptoms (headache, dizziness, memory problems, balance problems, irritability). They concluded that soldiers with either posttraumatic stress disorder or a traumatic brain injury endorsed more postconcussive symptoms than those without a diagnosis. Those with both posttraumatic stress disorder and a traumatic brain injury endorsed more symptom prevalence than those with a single diagnosis. Although it is noteworthy that a comorbid posttraumatic stress disorder and traumatic brain injury diagnosis can increase postconcussive symptomology, it is also important to recognize that

the co-occurrence of either disorder can reciprocally exacerbate the other (King 2008).

Researchers have speculated that standard treatments for posttraumatic stress disorder could be less effective when a comorbid traumatic brain injury diagnosis exists (Bryant, 2001; Carlson et. al., 2011). This is solely speculation because there has been limited research to explore the efficacy of current treatments for those with this comorbidity. King (2008) suggests that early education about postconcussive symptomology and an explanation of the reciprocal relationship of the co-occurrence of posttraumatic stress disorder and traumatic brain injury can aid in proper detection and treatment. It is important for further research to explore the effectiveness of treatment for those with a comorbid diagnosis due to the high prevalence of soldiers who suffer from the co-occurring disorders. In addition, it is important for clinicians to be aware that the presence of a mild traumatic brain injury in a patient with posttraumatic stress disorder may make recovery from the posttraumatic stress

Throughout the years we have gained a far better understanding of posttraumatic stress disorder. We have refined our diagnostic criteria for the disorder and developed more complex theories for understanding its' etiology. With the high prevalence of soldiers who are affected by posttraumatic stress disorder, it is important that we continue to refine our

clinician also controls the smells that are emitted from the "olfaction box" which includes various scents such as: burning rubber, body odor, and gasoline. Since all of these stimuli are presented simultaneously, it increases the reality of the virtual environment (A. A. Rizzo, et al., 2010).

Individuals undergoing treatment with the Virtual Iraq technology typically come in twice a week for 90 minutes over the course of five weeks (A. A. Rizzo, et al., 2008). The initial sessions are dedicated to identifying the details of the traumatic event and teaching the client stress management techniques such as deep breathing. They are also taught how to use the technology and to rate their distress so that it can be used as a reference throughout treatment. In a study on the efficacy of this treatment modality, Reger and Gahm (2008) found that patient's PTSD Checklist score decreased by approximately 50% post-treatment and they also showed a significant functional improvement. A major criticism of this type of therapy is the cost of the technology. Although this complaint is justified, virtual reality may prove to be a very valuable tool for clinicians that can afford to use it.
