Course:COGS200/2017W1/RESEARCH PROPOSAL GROUP 4

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Introduction

The principle goal of this research project is to complete the development and clinical trialing of an end user development (EUD) tool that enables the creation of customized virtual reality simulations to aid in Prolonged Exposure therapy for Post-Traumatic Stress Disorder in refugees displaced by the Syrian civil war and resettled in Canada, as well as identifying best practices for structures in EUD tools.

A psychiatrist would first confer with the patient in order to ascertain details of the trauma. The psychiatrist would then use the EUD tool to create a customized virtual reality simulation incorporating these details. The psychiatrist would select a background (from a preprogrammed repository) as similar as possible to the locale in which the trauma occurred, and populate it with objects (animate and inanimate as required) and auditory stimulus intended to elicit traumatic memories. The psychiatrist would do this iteratively to create a series of simulations, each more similar to the trauma than the previous simulation. After initial sessions consisting of traditional psychoeducation coupled with training in relaxation techniques and preparing the participant (explaining to them what the VR simulation will entail), treatment using the simulations created by our tool would commence with the mildest iteration. Once the simulation no longer elicits strong traumatic memories, the next simulation, slightly closer in some elements to the trauma, would take its place; this process would be repeated until all the simulations had been used.

There would be four major steps in creating and testing our tool. First, we would build a beta version with the pre-programmed set of stimuli and design tools set forward in this proposal. Next, we would pilot the program with a small group of psychiatrists and Syrian refugees and/or other experts on the Syrian civil war. The design tools for generating simulations would be culled and refined based on the preferences and results from the psychiatrists, and elements and backgrounds would be added in and adapted based on the feedback of the Syrian refugees and experts on the Syrian civil war. Furthermore, a two week training would be developed for training non-technical users of the program. After the first round of piloting and testing is over, a clinical trialing phase would begin. Performance of the tool would be assessed by comparing changes in scores on clinical measures of PTSD before and after therapy for participants using our tool with scores from participants receiving typical treatment.

We hypothesize that Prolonged Exposure PTSD therapy utilizing our tool will be more effective than traditional Prolonged Exposure therapy and that our EUD tool could be used by the vast majority of non-technically skilled psychiatrists with a two week training to create effective virtual reality simulations.

Importance

Post-Traumatic Stress Disorder is a serious mental illness that makes normal basic functions difficult. PTSD has negative consequences for those close to the patient, as well as society as a whole. While there are current treatments that are often effective in treating PTSD, they are not perfect. Treatments also have a high rate of dropout and are not usually effective in twenty to thirty percent of the patients. As such, further research into improving treatment of PTSD is warranted.

Our work is especially timely given that, in the last year alone, more than 25,000 refugees from the Syrian Civil war have been resettled into Canada. Past studies of refugee populations have demonstrated that as many as twenty percent of refugees from a violent crisis will eventually develop PTSD. In a 2014 Eastern Mediterranean Public Health Network (EMPHNET) report, between 50 and 57 percent of Syrian refugees suffer from PTSD. Those who have been resettled in Canada represent a tiny part of the overall population of those displaced by the crisis. Clearly, there is a large and growing population of PTSD sufferers who could make use of a tool like the one whose development we propose. This research, and its implementation as a form of therapy, has potential applications for governments, both local and international, responding to the Syrian refugee crisis, and also for mental health organizations who aim to alleviate the symptoms of and treat PTSD and other war trauma-induced mental health illnesses (Ibrahim, & Hassan, 2017).

Furthermore, the results of the clinical trial suggest to us that our tool would be a meaningful contribution to existing knowledge about using virtual reality in order to treat PTSD-related disorders. It has been established that virtual reality can be a tool that is similarly effective to traditional methods of therapy in treating veterans with PTSD; however, it is unknown if these findings will transfer to refugee populations. Whether or not they do will provide insight into the nature of each kind of trauma and help us better understand their differences.The first major study comparing traditional treatments of Post Traumatic Stress Disorder with treatments augmented with virtual reality produced results which suggested that virtual reality may not in fact be superior to traditional forms of therapy. Whether or not our results are similar will have important implications for future research.

The development and implementation of our tool will be the first large scale effort to test and implement an End User Development Environment for virtual reality. Feedback from the process will be valuable for determining which sets of tools are best for allowing non-technical users to create detailed virtual reality simulations. Given the expected increase in the accessibility of these virtual reality technologies and the enthusiasm for their implementation in a variety of fields that may outpace evidence-based review, it is certain that there will be mistakes in their implementation and use. Well-implemented EUD environments are a promising avenue for solving the complications which will inevitably arise from these tools, since the end users will have greater control over the content themselves.

Background Research

Post Traumatic Stress Disorder is an anxiety disorder caused by a traumatic event. The most recent edition of the Diagnostic and Diagnostic and Statistical Manual of Mental Disorders (DSM–V) outlines symptoms as a combination of intrusive and distressing re-experiencing of the event through dreams, memories, or episodes of dissociative recall, avoidance of stimulus that is related to the event, negative changes in mood or cognition, and increased arousal and reactivity that arise and persist for at least three months after the experience of the trauma (DSM-V Task Force, 2013). Combat is a major source of trauma that may lead to PTSD, and as such refugees displaced by conflict, as well as combatants, tend to suffer from very high rates of post traumatic stress (Al-ghzawi et al., 2014).

The current frontline treatment of PTSD is usually Prolonged Exposure therapy. Participants are exposed to stimulus that evokes traumatic memories, then guided to reframe the thoughts they trigger using Cognitive Behavioural Therapy with the support and supervision of the therapist until they are no longer distressing to the patient. The process is repeated with more intensive stimulus, usually for eight to ten sessions.

These treatments are not perfect. The core tenant of Prolonged Exposure therapy is exposure to stimulus related to the event combined with an element of Cognitive Behavioural Therapy to help the patient reframe the trauma. Since avoidance of stimulus related to trauma is a major symptom of PTSD, patients often do not continue the therapy resulting in a very high dropout rate (Beidel et al, 2017). Even if therapy is successfully completed, meaningful recovery does not always occur.

The integration of virtual reality is one possible route to improving therapeutic outcomes that has been explored. Therapies often involve exposure to the same settings that the trauma occurred in, commonly called in vivo exposure, which is not often realistically possible. Virtual reality provides an alternative in these cases (Mishkind et al, 2017). Theoretically, the more realistic stimulus of virtual reality could allow for more engagement with the traumatic memories, something that patients struggle with and is often an indicator of whether or not therapy will be successful. Early results from small scale research was promising. One study developed a simulation that was successfully used to treat a group of individuals who were suffering from PTSD related to the 9/11 terrorist attacks. A number of patients who had previously received traditional therapy responded to the virtual reality aided simulation and had improvement in symptoms. Overall, the group that received virtual reality aided therapy had better outcomes than the waitlist control group (Difede et al, 2007). Virtual reality was also integrated in the a treatment of veterans of the vietnam war with similar success (Ready et al, 2006).

In later years, more therapeutic virtual reality tools have been developed for use in treating PTSD with a particular focus on treating veterans of the conflicts in Iraq and Afghanistan. One such simulation, BRAVEMIND, contains over 15 different independent simulations and is currently being upgraded in order to include functionality for treating other sources of trauma like sexual assault (Rizzo et al, 2014). More recent research with larger sample sizes demonstrated the effectiveness of treatments integrating virtual reality in much larger sample sizes of veterans suffering from PTSD related to the conflicts in Iraq and Afghanistan (Beidel et al, 2017).

However, there are still serious gaps in knowledge of treating these conditions with virtual reality. The first and only study to compare treatment involving virtual reality assisted therapy to traditional therapies did not support the conclusion that virtual reality had higher rates of success than more traditional frontline therapies (Reger et al, 2016). In addition, little to no work has taken place examining whether or not virtual reality treatments might be helpful in treating the other major population that has suffered as a result of the conflict in the Middle East: refugees and displaced persons.

One reason that that past research on virtual reality has not been conducted in populations of refugees is that their traumas frequently extend beyond exposure to combat. It is typical that at least one violation of international humanitarian law, war crimes, or crimes against humanity will have been inflicted upon a refugee from war-affected zones (Qouta & El Sarraj, 2004; Khamis, 2005; Fasfous et al., 2013). These traumas include imprisonment, torture, displacement, starvation, lack of medical access, sexual violence, forced participation in harming or killing others, as well as the witnessing of warfare (including artillery fire and airstrikes), violence, sexual violence and the destruction of homes and villages (Jones, 2013). In addition to this, there is the trauma of exile, and eventually, of the resettlement in a new culture and country where refugees are faced with racism and suspicion, while the typical structures they depend upon, such as cultural traditions, religious ceremonies, and extended family, are lacking or absent (Mollica, Cui, McInnes, & Massagli, 2002; Porter, & Haslam, 2001.)

However, many of the more traditional treatments that have been shown as efficacious in veterans have also been demonstrated to help refugees. Research regarding treatment of PTSD has been conducted within refugee camps and in individuals in clinical settings using various trauma screens, including the Harvard Trauma Questionnaire, and various measures of psychological distress, including the Hopkins Symptom Checklist-25 (Mollica, Cui, McInnes, & Massagli, 2002). Treatment of PTSD may include Cognitive Behavioural Therapy, exposure therapy, and medication. Typical treatments are done individually or in group sessions and normally include a three phase process: stabilization, exposure therapy, and reintegration. (Milne, Bourne, & Nolan, 2016).

One reason that virtual reality may not yet have been generalized as a treatment for PTSD in refugees is that, in the past, increased realism has come at the cost of flexibility. Since refugees are subjected to a wider degree of traumas, flexibility is a much more important factor in their treatment. Recent achievements in the field of computer science, however, have produced an approach to the development of virtual reality systems known as End User Development tools that allow non-technical users to create customized simulations. Choosing from a wide variety of entities and backgrounds, users can implement simulations while immersed in virtual reality, allowing them to see how changes affect their creations in real time (Zarraonandia T., Díaz P., Montero A., Aedo I., 2016). Such an approach could allow a psychiatrist to create a virtual reality-based stimulus specifically tailored to specific patients in much the same way that they currently create slightly stronger treatments out of more conventional media.

These recent developments in computer science combined with the existing state of affairs in the psychological research mean that it is the right time for the research we propose to take place.

Methods

Software and Hardware System Specifics

We propose implementing the VR GREP (Game Rules scEnarios Platform). This EUD tool is immersive, allowing the user to change a VR environment from within it instead of through a desktop interface, facilitating the users’ ability to see what the participants will see. Also, it uses the Unity game engine, a freely available and widely used engine that supports many VR platforms, including HTC Vive, Oculus Rift, Playstation VR, and Microsoft HoloLens (not yet commercially available), making the decision between these VR equipment options primarily a question of price (the simulation quality differences between the devices is minimal enough not to make an impact on participant outcomes). Thus, we propose using an Oculus Rift headset, connected to a desktop (as is required for the device). We also propose coupling this setup with Leap Motion controllers, mounted to the headsets; they are used to monitor and interpret hand motion data from the participant, used as input to the simulation. It should be noted, however, that, as the aforementioned recent commercial availability has reduced the barrier to entry in VR implementation, it will also increase the commercial viability of software tools for VR hardware, so, as competition increases in this space, the quality of EUD tools (both the one mentioned and its competitors) should also be expected to increase. Therefore, should our proposed study be executed, a routine reconsideration and comparison of EUD tools (and VR hardware) would be warranted to improve the quality of the simulations on an ongoing basis.


Proposed Entities, Background, and Auditory Content

BACKGROUNDS:

  • Aleppo city block
  • Aleppo bedroom
  • Refugee Camp
  • Rural Syrian Village
  • Syrian Village bedroom
  • Jail Cell
  • Dark Room
  • Boat
  • Truck
  • Destroyed Aleppo city block
  • Destroyed Rural Syrian Village
  • Destroyed Refugee Camp
  • Burning Aleppo city block
  • Buring Rural Village
  • Burning Refugee Camp

ENTITIES:

  • Dead person MALE / FEMALE / CHILD / ADULT (In typical garb of syrian civilian)
  • Live Person MALE / FEMALE / CHILD / ADULT (In typical garb of syrian civilian)
  • Amputated part of human body
  • Shell casings
  • Impact crater
  • Debris (Typical syrian household items)
  • Debris (Destroyed car)
  • Militant Soldier
  • Western Soldier
  • Crowbar
  • Whip
  • Jumper cables

SOUNDS:

  • Screaming (Loud / Soft / Adult / Child)
  • Gunfire (constant / intermittent / approaching)
  • General explosion noises (constant / intermittent / approaching)
  • Sound of soldiers (Constant / intermittent / approaching)
  • Sounds of bodies being struck during torture.
  • Typical rural syrian city noise
  • Typical aleppo / urban area city noise
Rationale

Each element, background, and auditory aspect listed above is included in order to help design more realistic simulations and to assist in making incrementally stronger simulations. The Aleppo environments of the city block and bedroom along with the rural syrian village and bedroom are included in order to help patients engage with traumatic memories linked to these areas. The destroyed aleppo city block and the destroyed rural syrian village are primarily included for use in the subsequent stronger simulations, along with the burning rural village and the burning rural village. The dead and living people, shell casings, explosion animation, as well as the soldiers are included so that further simulations can be closer to the actual trauma. The variation in noises could be utilized in a similar way; the soundscape would transition from the typical rural or urban noises into the sounds of explosions, soldiers, screaming, and gunfire as elements related to combat are added to the subsequent simulations.

The refugee camp, boat, and truck environments are primarily included for use with patients who experienced displacement related traumas, although they allow for replication of scenarios in which the patient had a traumatic combat related experience while fleeing from violence. The destroyed and burning refugee camp backgrounds are added to assist in creating subsequent stronger simulations in the same way as the destroyed and burning aleppo and rural syrian village. The soundscape would transition with the other forms of stimulus as treatment progressed in the same way as described for the the treatment of .

The jail cell and dark room scenarios are added to help in creating simulations to assist in the treatment of traumas related to torture. Scenarios of greater intensity could by introducing the torture implements and the sound of screaming.

Clinical Trialing

Methods

Fifteen to twenty psychiatric practices that were currently treating or generally treated a high volume of Syrian refugees patients with PTSD with traditional PE therapy would be recruited. All psychiatrists would receive an intensive two week training in the use of the tool that we propose developing. Through these practices, we would hope to recruit a group of 300 Syrian refugees. After obtaining informed consent, screening would take place to establish that all participants were currently suffering from PTSD using the Clinician-Assisted Post Traumatic Stress Scale and the DSM-V criteria and that participants did not meet any exclusion criteria for our study. The participants receiving treatment from each psychiatrist would be randomly assigned to either receive traditional Prolonged Exposure therapy or PE delivered with our tool. The two groups would be compared based on scores on the Clinical-Administered Post-Traumatic Stress Disorder Scale (CAPS) before treatment began, after treatment ended, and three to six months after treatment ended.

Additionally, open-ended feedback on realism and aspects that detracted and added to engagement would be obtained from the Syrian refugees in the virtual reality group and feedback on the virtual reality creation tools obtained from all of the psychiatrists. If the tool was demonstrated to be efficacious, another development period would take place integrating the feedback from the larger clinical trial to further improve the quality of the simulation itself, the tools for building it, and the training.

Expected Results

We expect to see statistically significantly lower CAPS scores on the initial post-therapy CAPS assessment as well as CAPS assessment during the three month and six month post treatment follow up sessions on average the group that utilized the tool we designed compared to the group that received treatment using solely conventional methods.

Participant Pool

Participants would be excluded from participation in the study if they suffered from heart problems and/or comorbid depression with suicidal ideation. Both populations are particularly vulnerable to iatrogenic effects from exposure therapies; being exposed to stimulus that evokes traumatic memories is often deeply upsetting. Patients with heart conditions will experience stress that may have negative consequences for their health. Patients with suicidal ideation may be at higher risk for suicide attempts after being exposed to such stimulus.

Discussion

Our reasoning behind conducting research related to virtual reality is centered around the idea that it is a promising but understudied avenue for improving treatments for PTSD. Virtual reality exposes subjects to a more realistic and all-encompassing replication of experiences, which creates an environment where they are obligated to face past traumas and can more easily recollect memories which may have been suppressed. It also allows for the creation of elaborate, customized environments that are not readily available to recreate in the real world. There is a need for replication of recent studies and generalization to other groups before greater propagation of the use across psychiatric practices, which the clinical trialing of our tool will generate (Miskin, 2017).

Virtual reality has suffered from limits related to flexibility in the past, a concern that is especially significant for refugees who tend to have more diverse traumas. The bluntest solution is to hire programmers for this purpose, but that would likely significantly increase costs as higher-level simulations require significant work and acumen to produce. Recent research in computer science offers a potential answer to these concerns; End User Development (EUD) tools. These tools allow users to create and adjust VR environments much more easily, automating many of the more complicated elements. This allows the users to focus on the specifics of the VR environment (deciding on the appropriate virtual elements, as outlined in the “Proposed Entities, Background, and Auditory Content” section above), instead of the technical requirements of their development (Zarraonandia T., Díaz P., Montero A., Aedo I., 2016).

The development of our tool would be the largest scale implementation of End User Development models of virtual reality simulation generation to date. We intend to make available to the development community the knowledge we gain in our design process about the preferences non-technical users have for tools over others and the efficiency of tool use will inform subsequent design tools. Our project will also involve the creation of the first training program developed for using these tools. Knowledge of these two aspects is only going to be increasingly important as virtual reality technology use increases as better and cheaper technology becomes available. Developing best practices for End User Development tools of virtual reality will provide an avenue for knowledgeable but non-technical experts to contribute to the developing virtual reality for its multitude of suggested applications.

We acknowledge that there are challenges in the treatment of PTSD in refugees regardless of what the treatment is. Language barriers exist, and this necessitates the need for an interpreter throughout the treatment process (Weine, 2001). In addition, each person has a varying expression of psychological distress (Terheggen, Stroebe, & Kleber, 2001), so it can be difficult to know how to engage with or respond to the subject. Because stressors and traumatic events vary for each individual subject, the virtual reality will be specifically tailored for each subject, which may complicate the treatment process.

Designing the tool that we suggest and completing the clinical trial we plan on carrying out will be financially costly. However, given the importance of the work and the potential for application, we believe that the expense will be warranted.

Ultimately, the success of our tool will be assessed based on its performance in the clinical trial that we propose.

Conclusion

The first major insight that we drew from this project is that there is a significant dearth in the knowledge of treating combat related PTSD with virtual reality. However, with the studies that are available, it is plausible to say that the use of Virtual Reality Exposure Therapy (VRET) can be more effective than traditional forms of PET. This is due to the constant creation and recreation cycle that involves both the clinician, but most importantly, the patient. Being actively involved in the therapeutic process allows patients to feel more in control and secure, and thus respond more rapidly to treatment. More so, VRET picks up where traditional therapies leave off. One symptom of PTSD is the inability to recollect memories of trauma as coping mechanisms and thus are unable to contribute to the imaginative process required in PET. VRET does this imaginative work for the patient and recounts those memories for them more effectively. Regardless, more research is still required before drawing to a drastic conclusion (although there is strong theoretical basis for the assumption that VRET exceeds the efficacy of traditional exposure therapies).

In addition, the length of the publication process seemed to be a barrier for research to remain current with developments in hardware and design best practices. When studies are published applying the newest technology to problems, it is often no longer the most recent technology. As the trend of acceleration in technical progress continues this problem will only get worse.

It was also interesting to see how much research was focused on testing groundbreaking treatments on some groups above others. The authors do not mean to disparage the sacrifice of the men and women in the United States and Canadian Armed Forces, but the exclusive focus on veterans hurts generalizability of results and our overall knowledge of trauma. There is a clear need for therapies to be researched and implemented that are focused on and tailored for refugees. A therapy designed for combatants would come from the perspective of a combatant, which would at best be unhelpful but at worst detrimental to a refugee whose experiences are from a very different perspective - a refugee's intent is to escape combat while the combatant's is to engage in it.

The authors will definitely be watching how the development of virtual reality as a tool for therapy unfolds in the coming years; it will certainly be interesting to see how this field evolves.

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