Advanced Wireless Augmented Reality-Enhanced Exposure Therapy for Posttraumatic Stress Disorder

Post-traumatic stress disorder (PTSD) affects 12-14% of military personnel exposed to combat or military sexual trauma. Exposure therapy (ET) is the core of effective treatments for PTSD. During ET, patients are gradually exposed to avoided situations until fear/avoidance diminish. Despite its centrality in treatment, dropout from ET is high. Furthermore, while ET allocates significant therapist time to imaginal exposure to trauma memories, it relies on patients to independently engage in in vivo exposure to real-life situations they avoid (e.g., a crowded room or a grocery store). This limits patients' success in key exposure assignments, and importantly, their ability to return to civilian life functioning and work. Often, patients' symptoms improve, but social and occupational disability persists.

Augmented reality (AR) represents the newest wave of interactive human-computer technology, wherein virtual objects are mixed with physical reality. Instead of a completely synthetic environment (as with virtual reality; VR), AR simply adds to a patient's real physical context. As such, AR is less costly and easier to develop, and most importantly, is far more representative of the environment than VR, because AR IS the patient's environment, albeit with the addition of virtual feared stimuli.

To overcome ET limitations, researchers at the Stress, Trauma and Anxiety Research Clinic (STARC), in the Department of Psychiatry and Behavioral Neurosciences at Wayne State University, have created an AR technology that for the first time, allows the use of advanced AR technology for ET. This technology, called ExpandXR, is being used for treatment of first responders with PTSD. ExpandXR connects the clinician's computer to the AR headset via local area network (LAN) or Wi-Fi and provides a real-time 3D visual of the patient's surroundings on the therapist's computer. The clinician can see the position of the patient and the AR objects in a schematic of the room (not the real room), as well as the characters in patient's field of view. Simple clicks allow the clinician to control which virtual objects are present in the environment, as well as their behavior and movement. Stereo sound is delivered to the patient via speakers inside the headset. The software allows for recording of the number of augmented avatars in patient's field of view at any moment. Patients' subjective units of distress score (SUDS) can be directly entered into the software during the session.

ExpandXR includes 'scenarios' involving exposure to crowds in diverse social contexts. These scenarios have been designed by obtaining feedback from first responders, as well as the clinicians who work with them, while the technology has been developed in collaboration with experts with decades of experience in the gaming industry to ensure the realism needed for this application, and the highest possible overall quality of the product. The scenarios are scalable from very low on the fear hierarchy (e.g., two people talking to each other in a far corner of the room) to higher levels (e.g., a loud gathering with multiple groups of people, both in the patient's field of vision and behind them, with the sound of fireworks in the background). Current fixed scenarios include a gradually crowding party (which with some props could be transformed to a restaurant or bar), a gradually crowding grocery store, a bar/restaurant, a sports event, and office space. Some characters will have military fatigue on. Importantly, these scenarios include the normal life situations that are avoided by people with PTSD due to their trauma and are NOT recreations of the trauma memories. While engaged in a scenario, the patient, wearing the AR headset, can walk around, join groups, and listen to conversations. Some characters are interactive, walking towards the patient and addressing them directly. The clinician's desktop view livestreams the patient's position in space and their point of view (clinician can toggle between views). The exposure hierarchy intensity is easily increased or decreased by clicking arrows. The scenario can be paused and restarted. Sounds effect can be selected and adjusted for each patient. Patients' SUDS can be entered in real-time, and a data file with SUDS, timestamp and the level of exposure is exported at the end of the session. The software also has a library of near 100 diverse characters from which the clinician can choose and apply customized behaviors or interactions with a patient. The clinician can choose a character with specific physical characteristics, define their behavior, and type the content of their speech live. Of note, all these behaviors are normal life behaviors like walking, shaking head, nodding, tapping foot, smiling, looking surprised, etc. This aspect of the technology can be used for customized needs of each patient and their specific avoidances. The technology also allows automated conversations with AI driven characters, for practicing having a normal safe conversation with as stranger.

The technology has been well-received by first responders (a group with experiences relevant to military personnel) and pilot data suggest great success when used in treatment. Patients' initial resistance to ET seems to be an important limiting factor in acceptance of in vivo exposure. For the past several years, some findings from using ARET are that patients are more open to initiating treatment as they cognitively "know" the objects are not real. However, when engaged in the treatment, psychophysiological (SCR), behavioral, and subjective measures indicate that ARET elicits similar level of fear and arousal in response to virtual objects as to real feared objects.