USU Study Expands Virtual Reality as a Treatment Method for PTSD

The CARE4PTSD trial at the Uniformed Services University’s (USU) Center for Neuroscience and  Regenerative Medicine brings virtual reality into treatments for Posttraumatic Stress Disorder. 

An artist's rendering of therapy sessions conducted using the CAREN. The therapist stands beside the participant, guiding them through the photos and memories which trigger symptoms of their PTSD. (Rendering courtesy of Dr. Michael Roy, USU)
An artist's rendering of therapy sessions conducted using the CAREN. The therapist stands beside the participant,
guiding them through the photos and memories which trigger symptoms of their PTSD. (Courtesy of Dr. Michael 
Roy, USU)

June 6 2023 by Hadiyah Brendel

A clinical trial at the Uniformed Services University (USU) brings virtual reality into treatments for Posttraumatic Stress Disorder. The trial, CARE4PTSD, places participants within a Motion Assisted, Multi-Modular Memory Desensitization Reconsolidation (3MDR) environment. The immersive virtual environment pairs a treadmill-like device with participant-selected images and music. The photos and music are representative of the participants’ trauma. Based on studies by Dutch and British researchers, USU’s trial enrolls participants with comorbid PTSD and mild traumatic brain injury (mTBI). The trial also includes an eye-movement (EM) task. Additionally, USU’s trial is the first to include female service members.  

Dr. Michael Roy (USU photo)
Dr. Michael Roy (USU photo)
Led by principal investigator retired Army Col. (Dr.) Michael Roy, the research team is conducting their second randomized clinical trial. Roy is a professor of Medicine at USU’s School of Medicine (SOM), and deputy director for the Center for Neuroscience and Regenerative Medicine (CNRM) and  Traumatic Brain Injury Research Center at USU. Additional USU staff collaborating on the trial include Paula Bellini, study coordinator and lead therapist; Annabel Lee Raboy, therapist; Kerri Dunbar, therapist; and Melvin Jones, engineer.

PTSD is a behavioral health condition characterized by psychological reactions following a highly stressful or traumatic event, such as combat, physical violence, or a natural disaster. The reactions include depression, anxiety, flashbacks, recurrent nightmares, and avoidance of activities that trigger memories of the event.

Current treatment options for PTSD include psychotherapy, such as Prolonged Exposure (PE) therapy, or medication. For mTBI, treatment includes rest, surgery, or medication. While both psychotherapies and medications show effective results in treating PTSD, many service members are hesitant to begin these treatment options. 

PE therapy is an intense exposure-based and trauma-focused therapy. Participants revisit and describe the trauma in extreme detail with a psychiatrist. The goal is for participants to respond to the trauma in a safe and supportive environment while also learning how to reframe and de-escalate their responses to triggers of the event. For those able to complete PE therapy, results are positive. However, 35-62% of participants who begin PE therapy drop out before completion.

The process of reliving the event repeatedly is too stressful for many PTSD sufferers. And according to Roy, PE therapy doesn’t work particularly well for service members. One potential reason for this difference is that more than one acute stressor often leads to their PTSD. The nature of combat, prolonged exposure to stressors, and preexisting life stressors such as sexual trauma are additional factors for onset of PTSD among service members. These additional factors make treating PTSD “like peeling an onion,” Roy says.

Yet, those looking for treatment outside of PE and other therapies often hesitate. Existing stigmas around medication together with awareness that medications prescribed for PTSD treat the symptoms, but don’t cure it, fuel reluctance to start.  

Why Virtual Environments?

The complexity of factors leading to PTSD in service members drives the need for diverse treatment options. Roy’s colleague, Dr. Eric Vermetten, was the first to conduct a study using the CAREN. 

CAREN stands for Computer Assisted Rehabilitation Environment (CAREN). It is a million-dollar machine developed by the Dutch company MOTEK. Only a few exist in the world, and two of them are located on the same base as USU.

The CAREN allows for the combination of 3MDR with walk-and-talk therapy. Vermetten, a retired colonel who holds both MD and PhD degrees, is strategic advisor of Research at the Military Mental Health Service with the Dutch Ministry of Defense. While observing the CAREN in its implication for rehabilitation of physical injuries, Vermetten wondered if it could also aid in PTSD therapies. Vermetten also served as trainer/consultant on both USU’s pilot and current study.

The CAREN consists of a treadmill placed within a deep well, with curved screens that fill half the room. The screens also fill the field-of-vision of the participant. The platform can move in all directions, and depending on the task performed, can rock and roll to simulate movement. Additionally, about 64 speakers fill the environment, creating an immersive experience.

The Pilot Study

The pilot study sought to confirm that 3MDR helped female as well as male veterans, all of whom had comorbid PTSD and mTBI. Composed of 10 overall sessions, six in the CAREN, the study utilized pre-selected photos and songs to personalize the experience to the participant. Participants select 14 pictures and two songs, each representative of the trauma, with the help of the therapist. When played, the first song signals the start of the study; the second song brings the participant back to the present day. Before participants begin the study, three preparatory sessions familiarize participants with the 3MDR environment and how to utilize the CAREN.

Once accustomed, participants begin the therapy sessions. The first song plays in entirety as participants traverse through a series of virtual hallways. Then, as they continue to walk, their first photo fills the screens of the CAREN.

As participants viewed a photo, the therapist asked them questions about their response to the image. For instance, “Why did you choose this picture?”, “What kind of memories are triggered for you?” and other questions to assess the participant’s response. Each picture presented for about ten to fifteen minutes. As the therapist identified key words or phrases expressed by the participant, the therapist relayed these phrases to the engineer who then superimposed the phrases over the images. The patient then read their words out loud.

The 3MDR staff (Photo courtesy of Dr. Michael Roy)
The 3MDR staff (Photo courtesy of Dr. Michael Roy)

For half of the participants, an EM task followed their encounters with each photo. In the task, a red ball with white numbers appeared on the screen. As the red ball “bounced” back and forth across the screen, superimposed over the picture, a two-digit number on the ball changed each time the ball reached one edge of the screen. The patient kept their head straight while tracking the ball with their eyes. Then, they read the numbers out loud. This task lasted for about 30 seconds, and then the picture disappeared. As the participant continued to walk, their second picture appeared. This process repeated for four to seven pictures each session. For patients in the control group, each photo only displayed for another 30 seconds without the EM task.

Each session takes about 60 to 90 minutes to complete. One final session, the Reconsolidation Session, allows the patient and therapist to reflect on the sessions. The patient writes up a page about their experience, detailing what gains they feel they’ve made. The therapist, in turn, provides feedback. The therapist will discuss what they observed, such as what key words emerged the first time a picture appeared compared to the last. This shows the evolution of the therapy sessions. Charts which scale the patient’s uncomfortableness from the beginning of the study vs the completion are also reviewed.

The result of the pilot study, published in the journal Frontiers in Virtual Reality in October 2022,  showed that about two-thirds of participants achieved resolution of their PTSD. On average, symptom severity dropped more than 20 points on the PTSD Checklist. The checklist is a 20-item measure which rates the degree of bothersome symptoms. This improvement is both statistically and clinically significant. For those who did not improve, they noted opening up a lot during the sessions, and thought their symptoms might improve with more sessions.

Furthermore, those who received the EM tasks performed better than those who did not receive them. While the mechanism of why the EM task improved results is unknown, Roy theorizes the task stimulates other key parts of the brain, or it provides a distraction that helps participants cope better with memories of their trauma.

The uniqueness of the study is also reflected in the low drop-out rate. Participants leaving the study cited COVID and scheduling conflicts as the cause. The study paused for seven months due to COVID restrictions. Upon resuming, some participants changed duty-stations or experienced other scheduling conflicts. Consequently, more women, nine out of ten, completed the study than men, seven out of ten. Significantly, no one dropped out after beginning sessions on the CAREN. Roy credits the low drop-out rate of the study to its unique approach. Although similar elements of PE therapy exist, patients perceive more control over how these sessions unfold.

“They choose the pictures, they choose the music. So, they’re really personally invested,” Roy says. Additionally, Roy says the uncomfortable sensations experienced when reliving trauma during PE therapy are potentially mitigated by the CAREN. For instance, an increase in heart rate while describing personal trauma is an expected physical response from walking on the treadmill. Therefore, participants may feel less uncomfortable and less inclined to leave the session.


CARE4PTSD, which stands for CAREN vs Augmented Reality: Expanding 3MDR Therapy for PTSD, is the randomized controlled trial which is currently enrolling volunteers. Half of the participants will experience their therapy sessions in the CAREN, like in the pilot study. The other half will experience them via a standard treadmill paired with the Microsoft HoloLens 2. The HoloLens is an augmented reality, meaning participants still maintain line of sight of things around them. Images present on the eye-pieces of the goggles, and the study proceeds in the same format. This trial also includes the EM task.

The setup for the HoloLens 2 is far less expensive than the CAREN at a few thousand dollars. However, the technology each of the participants experiences is the same. Thanks to the innovation of Roy’s collaborators, who spent two years integrating the software from the CAREN into Unity Open Software, a comparable presentation between the CAREN and the HoloLens 2 exists. Creating the same presentation between the two environments is paramount to the study. 

If the trial achieves comparable results with the less expensive set-up, the technology could expand into VA and military treatment facilities across the country. Thus servicing communities without the money or space to create a CAREN.     

As the participant responds to questions from the therapist, the engineer superimposes key words and phrases over the images. The participant then reads the superimposed words out loud. (Photo courtesy of Dr. Michael Roy)
As the participant responds to questions from the therapist, the engineer superimposes key words and phrases
over the images. The participant then reads the superimposed words out loud. (Photo courtesy of Dr. Michael 

Next Steps

The trial continues to enroll volunteers. With the first enrollment occurring a few weeks ago, the goal is to enroll 60 people with at least 25% either male or female.

To address varying levels of severity in PTSD symptoms, the team will assess if participants require more sessions after the initial six. If needed, the trial can include up to fourteen sessions for those individuals not seeing significant improvement after the standard ten sessions.

This novel PTSD treatment incorporating virtual environments stands to broaden available therapy options. If the CARE4PTSD study proves the efficacy of the new delivery mechanism, a more cost-efficient and readily available treatment for PTSD will be within reach.

“Now that we've done it, now that we've created it in this open source software environment, we can share that with people. So, we can just make it available to everybody. That would be a big plus for the field,” Roy says.