>> GOOD AFTERNOON. THANK YOU FOR COMING. MY NAME IS MIKE SPITLE IN THE OFFICE OF BEHAVIORAL AND SOCIAL SCIENCE RESEARCH AND IT'S A PLEASURE TO INTRODUCE DR. BARBARA ROTHBAUM. DR. ROTHBAUM IS PROFESSOR IN PSYCHIATRY AT THE EMORY SCHOOL OF MEDICINE, DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES AND DIRECTOR OF THE TRAUMA AND ANXIETY RECOVERY PROGRAM AT EMORY. DR. ROTHBAUM SPECIALIZES IN RESEARCH AND TREATMENT OF INDIVIDUALS WITH ANXIETY DISORDERS PARTICULARLY FOCUSING ON POST TRAUMATIC STRESS DISORDER. SHE'S AUTHORED OVER 200 SCIENTIFIC PAPERS AND CHAPT ERGS, PUBLISHED FOUR BOOKSES ON THE TREATMENT OF PTSD AND TWO OTHERS ON ANXIETY AND RECEIVED THE DIPLOMATE FROM THE AMERICAN BOARD OF BEHAVIORAL PSYCHOLOGY. PAST PRESIDENT OF THE INTERNATIONAL SOCIETY OF TRAUMATIC STRESS STUDY, ON THE SCIENTIFIC ADVISORY BOARD FOR DISORDERS ASSOCIATION OF AMERICA AND THE OBSESSIVE COMPULSIVE FOUNDATION AND BOARD OF DIRECTORS FOR ADAA AND IS PIONEER IN THE APPLICATION OF O VIRTUAL REALITY TO TREATMENT OF PSYCHOLOGICAL DISORDERS. WILL YOU PLEASE HELP ME WELCOME DR. ROTHBAUM. [APPLAUSE] >> THANK YOU. CAN EVERYBODY HEAR ME OKAY? I HAD BEEN TOLD I'M TOO SHORT TO STAND BEHIND A PODIUM SO I WILL STAND NEXT TO IT. I WANT TO THANK YOU FOR INVITING ME AND AS MANY ACADEMICS WHO OWE A DEBT OF GRATITUDE TO NIH, NIH -- ASK ANYTHING AND IF I CAN DO IT I WILL. I ALSO WANT TO THANK YOU, ONE OF MY PATIENTS WE'RE SCHEDULING SOME THINGS AND YOU KNOW I WAS GOING TO GO -- SHE KNEW I WAS GOING TO GO AWAY AND SPEAK AND SHE SAID DON'T -- O SHE'S IN FOR FEAR OF PUBLIC SPEAKING. SHE SAYS AREN'T YOU SCARED TO SPEAK PUBLICLY? MY FEAR IS THE OPPOSITE, NO ONE SHOWING UP. SO THANK YOU FOR SHOWING UP AND ALLAYING THAT FEAR. SO WE'RE GOING TO TALK SO FIRST DISCLOSURE, I'M GOING THE TALK ABOUT VIRTUAL REALITY, EMORY AND GEORGIA TECH TOOK US AND START AD START UP COMPANY, I'M FULL TIME AT EMORY BUT THERE'S A COMPANY VIRTUALLY BETTER. THE VIRTUAL IRA WAS NOT CREATED BY VIRTUALLY BETTER BUT I DISCLOSE AND DISCLOSE. SO MOST OF US THINK OF PTSD AND THE WAR VETERANS DISEASE. IT IS CERTAINLY A HUGE PROBLEM BUT ESTIMATES 7 ARE 70% WILL UNS GO A TRAUMATIC NEFNT OUR LIFETIME CAPABLE OF PRODUCING PTSD. IT DOESN'T MEAN 70% OF US END UP WITH PTSD, BUT IT DOES MEAN THAT TRAUMA IS UBIQUITOUS AND THE ESTIMATES ARE ABOUT 10% OF THE POPULATION IN THE UNITED STATES AT ANY POINT IS SUFFERING FROM PTSD. SO FIRST LET'S TALK A LITTLE BIT ABOUT WHAT PTSD IS. IN THE DSM III AN 3,R, PTSD IS THE ONLY ANXIETY DISORDER THAT EXTERNAL EVENT IS PART OF THE DIAGNOSTIC CRITERIA. SO IT INCLUDES THE DEFINITION OF THE TRAUMA. THE DSM III AN 3,R, THE DEFINITION OF TRAUMA WITH OUTSIDE WITH RANGE OF USUAL HUMAN EXPERIENCE SO IT'S A VARIED AUDIENCE, ANY LAWYERS IN THE AUDIENCE? SO WE'RE OKAY TO RASH THE LAWYERS? SO FOR EXAMPLE, IF SOMEONE WENT TO COURT AFTER A MOTOR VEHICLE ACCIDENT AND ALSO CLAIMING PTSD, THE LAWYERS ARE SAYING MOTOR VEHICLE ACCIDENTS AREN'T OUTSIDE THE RANGE OF USUAL HUMAN EXPERIENCE, THEREFORE THEY CAN'T HAVE PTSD. THEN DEPENDING ON WHAT STATISTICS YOU LOOK AT, 1 IN 4 OR 1 IN 5 WOMEN CAN BE THE VICTIM OF SEXUAL ASSAULT IN THEIR LIFETIME AND LAWYERS SAY THAT'S NOT OUTSIDE THE RANGE OF HUMAN EXPERIENCE SO WE NEED TO GET RID OF THAT DEFINITION AND WE REPLACED IT WITH WHAT I THINK OF AS THE EXLAX DEFINITION. GRU EAR AS OLD AS I AM YOU MIGHT REMEMBER THE OLD EXLAX COMMERCIALS, REGULAR IS WHAT'S REGULAR FOR YOU. SO WE TRIED TO CHANGE IT TO TRAUMATIC IS WHAT'S TRAUMATIC FOR YOU. AND ACTUALLY THAT IS THE BEST PREDICTOR WHO GETS PTSD SO WE COULD BE WALKING DOWN THE STREET TOGETHER AND GET HELD UP, YOU'RE SURE HE WANTS OUR MONEY, WILL LEAVE US ALONE, I'M SURE HE'S CRAZY ON CRACK AND WILL KILL US. PEOPLE WILL SAY WE HAVE BEEN THROUGH THE SAME EVENT BUT WE HAVEN'T. BECAUSE IN YOURS YOUR LIFE WASN'T IN DANGER AND MINE IT WAS. SO IT'S IMPORTANT TO ASSESS WHAT WERE YOU SCARED OF? WHAT DID YOU THINK COULD HAPPEN TO YOU? IN GENERAL THE WAY I SEE PTSD IS THE PEOPLE ARE HAUNTED BY SOMETHING THAT HAPPENED TO THEM IN THEIR PAST. AND THE HAUNTING NATURE COMES OUT IN THE REEXPERIENCING SYMPTOMS. PEOPLE WILL THINK ABOUT IT WHEN THEY DONE WANT TO THINK ABOUT IT AND IT KNOCKS THEM OFF KILTER. NIGHTMARES I HAD ONE YOUNG WOMAN WHO HATED HER NIGHTMARE SO MUCH SHE WOULD DO EVERYTHING SHE COULD TO STAY AWAKE ALL NIGHT LONG, FINALLY FALL ASLEEP EXHAUSTED AT 6 A.M., NOT A WAY TO BE FUNCTIONAL IN THE REST OF HER LIFE. FLASH BACK. PEOPLE HEARD VIETNAM VETERANS HEARING A CAR BACKFIRE AND HITTING THE GROUND. I WORK WITH SEXUAL ASSAULT SURVIVORS AND A LOT OF THEIR FLASH BACKS ARE SEXUALLY INDUCED. IT COULD BE MOVING O WHISPERING A CERTAIN WAY AND IT CAN SEND THEM BACK THERE. IN GENERAL, PEOPLE WITH PTSD ARE VERY AVOIDANT. THEY DON'T WANT TO THINK OR TALK ABOUT IT. NOTHING TO REMIND THEM OF IT. SOMETIMES I CAN COME ACROSS SOMEBODY AND ESPECIALLY ACTUALLY IN OUR CURRENT VETERAN POPULATION WHO CAN TALK ABOUT IT SEEMINGLY EASILY AND I REALIZE THEY HAVE CUT THEMSELVES FROM THEIR EMOTIONS AND IT'S LIKE THEY'RE GIVING A POLICE BLOT OR REPORT OR SOMEONE ELSE'S SAD STORY AND THEY'RE SHUT DOWN FROM EMOTIONS. PSYCHOGENIC AMNESIA IN EXTREME, PEOPLE DON'T KNOW WHAT HAPPENED. ONE OF THE EXAMPLES I SAW WHEN I WAS WORKING IN PHILADELPHIA, A RAPE VICTIM REMEMBERED ENCOUNTERING THE ASSAILANT ON THE STAIRWELL, NEXT THING IT WAS 45 MINUTES LATER SHE WAS BACK IN HER APARTMENT, NO RECOLLECTION, ANYTHING BAD HAD HAPPENED. HER FIRST CLUE WAS WHEN SHE WHEN TO THE BATHROOM AND HAD CUTS ON HER THIGHS. IT WAS A MONTH AND A HALF LATER SHE WAS ABLE TO REMEMBER WHAT HAPPENED. AND I SHOULD ADD AN ASTERISK BECAUSE IT TURNS OUT SHE WAS ALSO THE VICTIM OF CHILDHOOD SEXUAL ABUSE AND MORE PRONE TO DISSOCIATE. BUT I SEE IT ALONG A CONTINUE WUM. PEOPLE WILL SAY I COULDN'T GET AWAY SO I LEFT MY BODY. I WAS LOOKING DOWN ON MY BODY OR OUTSIDE THE VEHICLE LOOKENING AND I SEE THIS ALONG THE SAME CONTINUUM. THESE ARE THE NUMBERING SYMPTOMS OF PTSD AND A BIG OVERLAP WITH DEPRESSION. I DON'T THINK THAT NUMBERING IS JUST THE ABSENCE OF A RESPONSE. I THINK NUMBERING CAN BE A RESPONSE IN AND OF ITSELF. IN A FEW MINUTES I'LL TELL YOU ABOUT TREATMENT THAT WE USE A LOT, EXPOSURE THERAPY AND SOMETIMES IN THAT OUR GUYS WILL TELLS I'M NUMBERING OUT NOW. AND I THEY TELL THEM STAY WITH IT AND IT WILL PASS. AND SOMETIMES THEY CAN TELL YOU WHERE IN THEIR BODIES THEY'RE FEELING NUMB. A LOT OF SLEEP PROBLEMS WITH PTSD AND A LOT OF REASONS FOR SLEEP PROBLEMS. WE MENTION NIGHTMARES. ALSO PTSD IS AN ANXIETY DISORDER. IF YOU'RE SCARED, NIGHTTIME IS A REALLY SCARY TIME. THE HOUSE IS QUIET, EVERYBODY IS ASLEEP. VERY EASY TO MISINTERPRET THOSE NOISES AN THINK MY GOSH, IS SOMEBODY TRYING TO GET IN, DO I CALL 911 AND THEY PLAY OUT THE MANEUVERS IN THEIR HEAD. NOT A WAY TO REPLAX AND -- RELAX AND GET TO SLEEP. SOME PEOPLE THAT I SEE, THAT I THINK FUNCTION WELL WITH PTSD, ONE WAY THEY DO IT IS STAY VERY BUSY ALL DAY LONG. SO AT NIGHT WHEN THEY'RE LAYING DOWN, AND ALL OF THESE DISTRACTIONS THAT HAVE BEEN HOLDING THESE THOUGHTS AT BAY ARE CLEARED AWAY, THESE THOUGHTS COME FLOODING BACK TO THEM. DIFFICULTY CONCENTRATING. I THIS THINK OF A KID, I WENT TO TEXAS A AND M UNIVERSITY AFTER THE BONFIRE COLLAPSE AND ONE OF THE STUDENTS THERE WAS ALSO EMT RESPONDER. HE SAID BEFORE THE CLAPTION HE HAD 3.0 GPA, AFTER THE BOND FIRE COLLAPSE HE HAD A .6 GPA. THE WAY HE DESCRIBED HIS DIFFICULTY CONCENTRATING. HE SAID HE WOULD TRY TO DO READING ASSIGNMENTS AND THEY WERE JUST WORDS ON A PAGE, HE COULDN'T PUT THEM TOGETHER TO MAKE ANY SENSE OUT OF THEM. HYPERVIGILANCE AND EXAGGERATED STARTLE. I THINK A LOT OF TIMES -- HELLO, MICHAEL. I USED TO WORK WITH MICHAEL IN PENNSYLVANIA BEFORE WE WENT A LITTLE BIT -- I WENT FARTHER SOUTH. I THINK A LOT OF TIMES EVEN AFTER WE SUCCESSFULLY TREAT THE PTSD, I THINK PEOPLE ARE LEFT JUDGE PIER HAHN BEFORE HAHN. THE WAY I SEE THAT, YOU JUST DON'T GO THROUGH THESE TYPES OF EVENTS THAT LEAD TO PTSD AND WALK THROUGH LIFE AS CALMLY AS YOU DID BEFORE. SO ACTUALLY THIS DATA IS FROM PENNSYLVANIA. IF YOU REMEMBER PTSD FIRST CAME ABOUT AS AN OFFICIAL DIAGNOSIS IN 1980. THE DSM III. SO IT WAS IN RESPONSE TO THE LARGE NUMBER OF VIETNAM VETERANS WITH PTSD. IT WAS RETROSPECTIVE, VERY MALE, SO WE DID A STUDY TRYING TO PERSPECTIVELY PLOT THE COURSE OF PTSD SO WE MA ET WITH FEMALE -- MET WITH FEMALE RAPE VICTIMS AN ASSESSED PTSD FOR 12 WEEKS. SO WE WERE VERY SURPRISED TO SEE IN THE FIRST WEEK FOLLOWING THE ASSAULT, 94% MET SYMPTOMATIC, NOT DURATION BUT SYMPTOMATIC CRITERIA FOR PTSD. SO WHAT THAT SAYS TO ME, THOSE SYMPTOMS, THAT'S THE NORMAL RESPONSE TO TRAUMA. SOMEBODY HOLDS A KNIFE TO YOUR THROAT AND SAYS DON'T SCREAM OR I'LL CUT YOU YOU'LL HAVE PROBLEMS SLEEPING AND PROBLEMS CONCENTRATING AND BE SCARED TO GO OUTSIDE BY YOURSELF, THAT'S NORMAL. SO WHAT WE WANTED TO FIGURE OUT IS WHEN A NORMAL RESPONSE TO TRAUMA ENDS, AND A PSYCHOPATH PATH LODGE -- PSYCHOPATHOLOGICAL RESPONSE THAT DIAGNOSIS AN TREATMENT BEGINS. SO WE FOLLOW OVER TIME AND WE WERE SURPRISED TO FIND THREE MONTHS LATER 12 WEEKS LATER ALMOST HALF MET THE FULL CRITERIA FOR PTSD. SO WHAT WE DID IS WE DIVIDED UP THE DATA FROM WEEK 12 AND WENT BACKWARDS. TOP LINE REPRESENTS PEOPLE WITH CHRONIC PTSD, BOTTOM REPRESENTS PEOPLE WHO DON'T END UP WITH PTSD. IF WE WANT THE TERM RECOVER WE CAN USE THAT LOOSELY. THEN IT TELLS A DIFFERENCE STORY. EVERYBODY STARTS HIGH, EVERYBODY COMES DOWN A LOT IN THE FIRST FOUR WEEKS. THAT HAVE, IF YOU LOOK AT THE BOTTOM LINE THE PEOPLE WHO RECOVER, THEY CONTINUE TO IMPROVE STEADILY ACROSS TIME. IF YOU LOOK AT PEOPLE WITH CHRONIC PTSD, AFTER WEEK FOUR THEY DON'T CHANGE. THEY DON'T GET WORSE BUT THEY DON'T GET BETTER. THIS IS LED SOME OF US TO THINK OF PTSD AS DISORDER OF DISTINCTION. FEAR AND ANXIETY IS A NORMAL RESPONSE TO TRAUMA. FOR MOST THAT FEAR EXTINGUISHES OVER TIME FOR SIGNIFICANT MINORITY, IT DOESN'T. THE GOOD THING ABOUT THAT, WE KNOW A LOT ABOUT EXTINCTION TRAINING. SO EXTINCTION TRAINING IN RODENTS IS ANALOGOUS TO EXPOSURE THERAPY IN HUMANS. SO NOW I SWITCH AND TALK ABOUT THAT. SO ACTUALLY THIS IS FROM EMBARRASSING MICHAEL A SECOND BECAUSE THIS IS BASED ON EMOTIONAL PROCESSING THEORY AND HAS EVERYONE IN THIS ROOM HAS NOT READ BACK TO 1986, WHEN I READ IT WAS ONE OF THESE PAPERS THAT I WAS PROUD TO KNOW YOU GUYS AND I WISH I HAD WRITTEN. I THOUGHT IT MADE SO MUCH SENSE. SO THE IDEA BEHIND THAT IN EMOTIONAL SPROASESSING THEORY OF PTSD, WHEN SOMETHING IMPORTANT HAPPENS TO US, WE NEED TO EMOTIONALLY PROCESS IT. USE A MINOR EXAMPLE. SAY ON YOUR WAY INTO WORK, YOU HAD A CLOSE CALL IN A CAR. FIRST PERSON YOU SIGH IN ENINVESTIGATOR YOU MAY TALK ABOUT IT. THEN YOU SEE THE SEC AT WORK AND YOU SAY MAN THIS JEEP CAME OUT OF NOWHERE. BY THE END OF THE DAY YOU'RE NOT TALKING ABOUT IT ANY MORE. YOU PROCESSED IT. YOU TALKED ABOUT IT ALL YOU NEED TO. BLOW THAT UP ABOUT A THOUSAND TIMES AND THAT'S WHAT WE HAVE WITH PTSD. I THINK THERE ARE VARY ROWS ROWS -- VARIOUS REASONS FOLKS WITH PTSD HAVEN'T BEEN ABLE TO PROCESS IT. SOME IS FEAR AND ANXIETY, IF IT MAKES ME FEEL BAD TO THINK ABOUT IT OR TALK AIN'T MY NAM -- TALK ABOUT IT MY NATURAL INSTINCT IS THE TO AVOID IT. BUT THAT DOESN'T MAKE IT AMENABLE TO PROCESS. ALSO SOCIAL CONVENTIONS. OUR SOCIETY IS NOT VERY GOOD ABOUT TALKING ABOUT ANYTHING NEGATIVE. I LOOK WHERE PEOPLE CAN TALK ABOUT BREAST CANCER AND WEAR PINK RIBBONS AN THINK HOW MANY DECADES IT'S GOTTING TO THAT POINT AND PEOPLE AREN'T TALKING ABOUT THAT AND CERTAINLY NOT THE TYPES OF EVENTS THAT LEAD TO PTSD. I THINK THIS IS A LARGE PART OF WHAT HAPPENED TO OUR VIETNAM VETERANS. ONE GUY TOLD US AS HIS PLANE WAS TAKING OFF YOU HAVE FROM SAIGON, THERE ARE WALKING MORTARS FOLLOWING IT SO HE BARELY ESCAPES WITH HIS LIFE. LESS THAN 24 HOURS LATER H'S BACK IN THE STATES AND HIS PARENTS LIVING ROOM WATCHES WHAT HE SAID AND I BELIEVE HIM WERE LIES ON THE EVENING NEWS ABOUT THE WAR. SO CHANCE TO TALK ABOUT IT, DEBRIEF, DECOMPRESS, NOTHING. AND IT WAS AN UNPOPULAR WAR. SO NOBODY WANTED TO HEAR ABOUT THAT. EVEN THOUGH IT'S A CLAY SHAI, I THINK FOR -- CLICHE FOR THE WORLD WAR II VETERAN IT IS LONG BOAT RIDE HOME WAS VERY THERAPEUTIC. THEY STAYED WITH THE SAME FOLKS THEY SEIVED WITH, THEY SPENT THESE WEEKS TOGETHER, THEY COULD GRIEVING TO IF THEY LOST BUDDIES THEY CAN TALK AND PROCESS IT. WHEN THEY GOT BACK TO THE STATES THEY WERE MORE READY TO REENTER SOCIETY AND THEY REENTERED SOCIETY AS HEROES. SO PEOPLE WANTED THE TO HEAR THEIR STORIES. SO ALL THESE REASONS THEY DON'T GET TO PROCESS IT AND SO IT JUST FESTERS. THAT'S HOW I SEE THAT IT HAUNTS THEM. SO WHAT WE THINK IS REQUIRED FOR GOOD PROCESSING ACTIVATE THE MEMORY, BRING IT UP BUT THEN PUT IT BACK DIFFERENTLY. YOU DON'T WANT TO ACTIVATE IT AND GET PEOPLE SCARED AND TRIGGERED AND PUT IT BACK THE SAME WAY. YOU WANT THEM TO LEARN SOMETHING DIFFERENT. SO THERE'S SEVERAL WAYS TO ACTIVATE THE MEMORY. WE HAVE FOUND EXPOSURE IS GOOD AT ACTIVATING MEM RISM WE ASK PEEP TOM GO BACK IN THEIR MIND'S EYE TO THE TIME OF THE TRAUMATIC EVENT AND WE COUNT IT OUTLOUD IN THE PRESENT TENSE OVER AND OVER AND OVER. WE TAPE RECORD IT AND GIVE THEM A TAPE TO LISTEN TO. FOR HOME WORK TO BE PRACTICING AND DOING MORE EXPOSURE EVERY DAY AT HOME. WE ALSO DO WHAT'S CALLED IN VIVO EXPOSURE IN REAL LIFE. FOR EXAMPLE, EXPOSING THEMSELVES TO SITUATIONS REALISTICALLY SAFE THOUGH I TRY NOT TO USE SAFE VERSUS DANGEROUS WITH PTSD FOLKS, FOR EXAMPLE, MOTOR VEHICLE ACCIDENT SURVIVOR NOT WANTING TO DRIVE AGAIN OR DRIVE THAT CAR OR DRIVE THROUGH THAT INTERSECTION. THINGS THEY WANT TO BE ABLE TO DO AND SCARED TO SINCE THE TRAUMATIC EVENT. AND I'LL ALSO TALK TODAY ABOUT VIRTUAL REALITY EXPOSURE THERAPY. SO YOU WANT IT TO BE A THERAPEUTIC EXPOSURE. YOU WANT IT TO CHANGE SOMETHING. AN EXAMPLE UNRELATED TO THIS, A DOG GETS BITTEN BY A DOG AND DEVELOPS A DOG FOABIA. IF YOU PUT HIM IN A ROOM WITH A DOG HEAN RUNS OUT CRYING IT'S AN EXPOSURE BUT NOT THERAPEUTIC EXPOSURE. NOTHING CHANGED. YOU WANT TO PUT HIM IN A ROOM WITH A CUTE PUPPY, LET HIM STAY IN THAT ROOM LONG ENOUGH TO LEARN IN HERE AND IN HERE THAT THAT ANIMAL POSES NO THREAT. THEN MAYBE GRADUALLY INCREASE THE TYPE OR KIND OF DOG TO KEEP THAT LEARNING, TO LEARN THAT ANIMAL POSES NO THREAT. I WON'T GO THROUGH ALL THE EVIDENCE TBLU'S MORE EVIDENCE FOR EXPOSURE -- THERE'S MORE EVIDENCE FOR EXPOSURE THERAPY IN THE TREATMENT OF PTSD THAN ANY OTHER INTERVENTION. WE HAVE TWO FDA APPROVED MEDICATIONS FOR PTSD AND THE INSTITUTE OF MEDICINE REPORT FROM 2007 I THINK. THOUGH I HAVE ISSUES WITH THAT REPORT, THEY CONCLUDED THAT EXPOSURE THERAPY WAS THE ONLY ONE THAT HAD THE STRENGTH OF THE EVIDENCE TO SAY IT CAN BE RECOMMENDED FOR PTSD. SO NOW I'M GOING BACK, THE FIRST TIME WE TRIED TO APPLAUD VIRTUAL REALITY, EXPOSURE THERAPY TO PTSD IT WAS WITH VIETNAM VETERANS. WE FIGURED AT THAT POINT THEY WERE ALREADY KIND OF A CRUSTY GROUP, THOSE STILL IN TREATMENT OR STILL HAD PTSD. WE THOUGHT WE MIGHT NEED A POTENT STIMULUS AND TRY THAT FOR THEM. FIRST, WHAT IS VIRTUAL REALITY? IS IT A MULTI-MEDIA INTERACTIVE COMPUTER ENVIRONMENT BUT MORE THAN THAT, BECAUSE THE USER EXPERIENCES A SENSE OF PRESENCE IN THAT ENVIRONMENT. SO I COULD TAKE A PICTURE OF THIS ROOM AND YOU GET A SENSE OF THIS ROOM. I COULD TAKE A VIDEO AND YOU GET A LITTLE BETTER SENSE BUT NOT PRESENT IN THIS ROOM. IF I HAD THIS ROOM IN VIRTUAL REALITY YOU WOULD FEEL PRESENT IN THIS ROOM SO WE THINK THAT'S USEFUL FOR EXPOSURE THERAPY. IT'S EASIER TO SHOW YOU. SO PEOPLE WEAR A HEAD MOUNT DISPLAY, A STRAP HELMET WITH TWO TELEVISION SCREENS IN FRONT OF EACH EYE, EARPHONES AND A POSITION TRACKER SO JUST AS I MOVE MY HEAD AND MY VIEW CHANGES IN REALITY, SO IT DOES IN VIRTUAL REALITY, I USED TO CALL IT A CHEAP TRICK AND COMPUTER SCIENTISTS DON'T LIKE THAT. THIS RAISED PLATFORM, IT HAS A BASE SHAKER, A WOOFER, A SPEAKER UNDERNEATH IT SO IT PRODUCES VIBRATIONS. SO IT LOOK LIKE THIS GUY IS IN THE VIRTUAL AIRPLANE AND WE DON'T REALIZE BUT A LARGE PART OF THE INFORMATION WE GET IN THE AIRPLANE AND STIMULATION WE FEEL THE ENGINES, WE FEEL THE LANDING GEAR COMING UP WE FEEL THE TURBULENCE. SO YOU CAN FEEL THAT IN THE VIRTUAL HUMVEE YOU CAN FEEL THE VIBRATIONS FROM THE VEHICLE. YOU CAN FEEL THE VIBRATIONS FROM EXPLOAGS OR FROM THE HELICOPTER. THE THERAPIST IS ABLE TO SEE EVERYTHING ON THE MONITOR THE PATIENT CAN SEE IN THE HEAD MOUNT DISPLAY SO WE CAN COMMENT APPROPRIATELY. FOR SOME, THE WOMAN ON THE RIGHT IS HOLDING A HAND HELD SENSOR OR JOY STICK. SO FOR SOME ENVIRONMENTS THEY -- WE'LL USE THAT AND CAN MANEUVER IN THE VIRTUAL ENVIRONMENT. SO FOR THE FIRST TIME WE DID IT WE DID THE EXPOSURE TO THE MOST TRAUMATIC VIETNAM MEMORYINGS BUT WITH EYES OPEN AND IMMERSED IN THE VIRTUAL VIETNAM. WE HAD TWO SCENARIOS, ONE WAS A VIRTUAL CLEARING SURROUNDED BY JUNGLES THAT MOST REFER TO AS LANDING ZONE. THESE ARE EARLY SCREEN SHOTS OF IT. AND ANOTHER WAS A VIRTUAL HUEY HELICOPTER THAT COULD FLY OVER JUNGLES, OVER RICE PATTIES, COULD FOLLOW A RIVER. >> VERY FIRST PATIENT. VIRTUAL VIETNAM (INAUDIBLE). (INDISCERNIBLE) (INDISCERNIBLE) >> NOT GOING TO THE HEAR THEM SAY WHAT HE SAYS AT THE END, IT SEEMS LIKE IT ISN'T BOTHERING ME. I THINK THAT'S THE MOST WE CAN HOPE FOR. MOST PATIENTS COME TO ME, THEY WAN IT TO NEVER HAVE HAPPENED, NOT REMEMBER IT BUT THAT'S NOT REALISTIC. THE BEST WE CAN HOPE FOR SEEMS LIKE IT ISN'T BOTHERING ME. SO WE DID A SMALL OPEN CLINICAL TRIAL WITH THE VIETNAM VETERANS IN THE MID '90s AND FOUND STATISTICALLY SIGNIFICANT HOPEFULLY CLINICALLY SIGNIFICANT, OUR COLLEAGUES MET FRIEDMAN AT THE NATIONAL CENTER FOR PTSD, HAVE AN ALGORITHM THEY FIGURED OUT ARC TEN POINT DIFFERENCE ON THE CAP. THE CLINICIAN ADMINISTERED PTSD SCALE IS CLINICALLY SIGNIFICANT. SO THIS IS A SELF-REPORT MEASURE OF PTSD. SO SINCE THAT TIME, NOW A NUMBER OF PEOPLE AROUND THE WORLD ARE USING VIRTUAL REALITY TO TREAT DIFFERENT FORMS OF PTSD. MY COLLEAGUE JOANNE DEFITI HZ A VIRTUAL WORLD TRADE CENTER IN MANHATTAN THEY USE TO TREAT SURVIVORS OF THE 9/11 ATTACKS. SO NOW I'M GOING TO SHIFT AROUND AND TALK FOR THE REST OF THE TIME ABOUT TRANSLATIONAL RESEARCH THAT WE'VE DONE. AND YOU'LL SEE HOW I PUT IT ALL TOGETHER HOPEFULLY. THE DECYCLE SERENE, I HAVE THE GOOD FORTUNE OF WORKING WITH NICE AN SMART COLLEAGUES AT EMORY, AND THEY FOUND DEPSYCH CASH FLOW SERINE IS AN AGONIST, IN RODENTS FACILITATED THE EXTINCTION OF FEAR. IT'S AN OLD TUBERCULOSIS DRUG, AN ANTIBIOTIC. SO SINCE IT WAS FDA APPROVED FOR HUMANS WE COULD TRY T IN HUMANS. I'LL TELL YOU ABOUT THE OTHERS. THEY FOUND MIKE DAVIS' MAIN MEASURE THE FEAR POTENTIATED STARTLE. THE AUSTRALIA GROUP ALSO FOUND THAT IT WORKS ON FREEZING. AND WHAT WAS REALLY COOL, THE AUSTRALIA GROUP FOUND THAT IF YOU ADMINISTER THE DECYCLE SOAR REEN RIGHT AFTER THE EXTINCTION TRAINING, THAT IT ALSO FACILITATES DECREASE OF FEAR IN EXTINCTION TRAINING SO THE IMPLICATIONS FOR US CLINICALLY MAYBE HAVE A GOOD EXPOSURE THERAPY SESSION AND YOU TELL YOUR PATIENT HERE, TAKE THIS. BECAUSE THEN MAYBE -- MAYBE IT'S THE RECONSOLIDATION PHASE WHERE THEY'RE LEARNING AND WHERE THE DECYCLE SERENE IS HAVING IMPACT. SO WE USE VIRTUAL REALITY BECAUSE ONE OF THE ADVANTAGES WE SAW THE VIRTUAL REALITY, A LOT OF TIMES DOING PSYCHOTHERAPY RESEARCH, THE PSYCHOTHERAPY PART IS A LITTLE BIT SOFTER. METHODOLOGICAL. WHAT WE COULD DO WITH THE VIRTUAL REALITY IS EXACTLY CONTROL THE DOSE OF EXPOSURE THERAPY AND MAKE SURE EVERY PATIENT GOT EXACTLY THE SAME EXPOSURE AND SAME DOSE SO WE COULD CONTROL IT THAT WAY. WE DID IT FOR FEE OF HEIGHT BECAUSE IT WAS A FAIRLY CLEAN DISORDER TO START WITH THE FIRST TEST OF DECYCLE SERINE IN HUMAN. THIS DOESN'T DO MUCH FOR ME. IF YOU'RE SCARED OF HEIGHTS AND HAD IT RENDERED IN THE VIRTUAL REALITY THEY HAVE TO WALK OUT ON THE CAT WALK AND IT DOES GET PEOPLE SCARED. SO THE YELLOW ARE PEOPLE WHO RECEIVE THE DECYCLE SERENE, BLUE PEOPLE RECEIVE THE DRUG. THIS IS THE SUDS UNIT AING SITY GOING UP SO THE HIGHER THE NUMBER ON THIS ONE, THE HIGHER THE THE ANXIETY. THE VIR CHILL FLOOR. AS YOU WOULD EXPECT, ANYBODY IN A HEIGHT SITUATION SCARED OF HIEG IT IS HIGHER THE FLOOR GOES, THE HIGHER THE ANXIETY GOES. YOU CAN ALSO SEE THIS IS IN THE FIRST SESSION, THE DRUG IS NOT SEDATIVE IN ANY WAY WHICH IS WHAT WE WANT. THE DRUG SEEMS TO DO NOTHING IN AND OF ITSELF ONLY TO HAVE IT) BOARD DURING EXPOSURE THERAPY SESSION. SO WHAT WE DID IS WE PURPOSEFULLY UNDERDOSED EXPOSURE THERAPY. WE KNOW EXPOSURE THERAPY IS EFFECTIVE SO WE GAVE TWO DOSE, TWO SESSIONS OF EXPOSURE THERAPY AND THAT MEANT THEY ONLY GOT TWO DOSES OF THE MEDICATION, TWO PILLS, ONE RIGHT BEFORE EACH SESSION. SO THAT WAS IN THE FIRST SESSION, THIS WAS IMMEDIATELY POST TREATMENT. THE BLUE ARE FOLKS GOT PLACEBO. NOW WE'RE TALKING ABOUT CHANGE IN ANXIETY T. PLACEBO FOLKS DIDN'T CHANGE MUCH POST TREATMENT AND WE KNEW WE WERE UNDERDOSING EXPOSURE THERAPY, ONLY GAVE THEM TWO SESSIONS BUT THE FOLKS THAT RECEIVED THE DECYCLE SERENE DECREASED ANXIETY MORE. THIS IS AFTER TWO PILLS, TWO SESSION, THIS IS A WEEK LATER SO NOT ON DRUG. IF YOU LOOK AT -- WE BROUGHT THEM BACK IN THREE MONTHS LATER, THE FOLKS WHO GOT THE PLACEBO ARE ABOUT THE SAME, PRETTY MUCH WHERE THEY CAME IN AND THE FOLKS WITH DECYCLE SERINE MAINTAINED SIGNIFICANT IMPROVEMENT. WE SAW THIS ON PRETTY MUCH EVERY MEASURE THAT WE LOOKED AT. SO THIS IS -- WE DIDN'T ASK THEM TO EXPOSE THEMSELVES IN REAL LIFE TO HEIGHT SITUATION BUT AT THE THREE MONTHS FOLLOW-UP WE ASKED IF THEY HAD, HOW MUCH THEY EXPOSED THEMSELVES, THE FOLKS WITH DECYCLE SERE REN REPORTED, EXPOSING THEMSELVES TO HEIGHT SIGNIFICANTLY MORE. THEIR GAL VONNIC SKIN RESPONSE FLUCTUATION, HOW MUCH THEY'RE SWEATING, A PSYCHOPHYSIOLOGICAL RESPONSE. IT DIDN'T CHANGE IN THE FOLKS WITH PLACEBO AN DECREASED SIGNIFICANTLY IN THE FOLKS WITH DECYCLE SERINE AND WHAT'S COOL IS THE CHANGE IN THIS SWEATING PSYCHOPHYSIOLOGICAL RESPONSE WAS RELATED TO HOW MUCH THEY EXPOSED THEMSELVES IN HEIGHT. AT THAT THREE MONTH POINT. THIS WAS JUST THE THREE MONTH FOLLOW-UP DATA I SHOWED YOU AND A NUMBER OF GROUPS AROUND THE WORLD HAVE TESTED DECYCLE SERE REN WITH DIFFERENT GROUPS AND DIFFERENT EXPOSURE THERAPY. I THINK THE LINES LOOK ABOUT THE SAME. THIS IS WITH THE BOSTON GROUP WITH SOCIAL ANXIETY DISORDERCH THIS IS WITH THE AUSTRALIAN GROUP WITH SOCIAL ANXIETY DISORDER. THIS IS WITH OBSESSIVE COMPULSIVE DISORD OAR AND ANOTHER GROUP ABSCESSSIVE -- OBSESSIVE COMPULSIVE. IT DOESN'T MAKE THERAPY BETTER BUT A LOT OF TIMES IT MAKES THERAPY FASTER. THAT WE THINK IS AN ADVANTAGE. SO THE CURRENT TRIAL WE'RE DOING, NIMH FUNDEDDED, TAWCH. IT'S -- THANK YOU VERY MUCH. IT'S ONGOING NOW VETERANS WITH PTSD VETERANS FROM IRAQ AND AFGHANISTAN. AGAIN, WE'RE PURPOSEFULLY UNDERDOSING THE EXPOSURE THERAPY, USING THE VIRTUAL REALITY EXPOSURE THERAPY, THEY'RE GETTING SIX SESSIONS TOTAL. SO FIVE OF VIRTUAL REALITY AND THAT MEANS ONLY FIVE PILLS. SO EITHER GETTING THE DECYCLE SERINE OR PILL PLACEBO OR A DRUG WITH A DIFFERENT MECHANISM OF ACTION THAT LOTS OF PATIENTS ARE ON OR IN SOME WAYS ARE ASKING FOR WITH THEIR SYMPTOMS, ALPRAZOLAM, XANAX. A LOT OF PATIENTS ARE ON BEZOs OR WANT THEM BECAUSE THEY EXPRESS ANXIETY PROBLEMS SLEEPING. A LOT OF PROBLEMS, DON'T LIKE THE PATIENTS ON BENZO BECAUSE WE WANT TO SEE THE ANXIETY LEVEL COME DOWN AND NOT ATTRIBUTE TO A PILL. SO PEOPLE THAT DON'T WORK WITH VETERANS WONDER IF THIS IS WHAT THEY SAW IN IRAQ OR AFGHANISTAN. HOW IS IT THEY GET SO TRIGGERED HERE? WE'RE COLLIELY -- MOST OF WHERE WE WORK NOT (INAUDIBLE) A COMBAT ZONE. BUT YOU FIGURE THIS IS WHAT THEY SEE HERE. AND I THINK IT'S FAIRLY SIMILAR UP HERE IN ATLANTA YOU GOT TO DRIVE. WE DON'T HAVE A VERY GOOD PUBLIC TRANSPORTATION SYSTEM AND OUR GUYS ARE GETTING TRIGGERED ALL THE TIME DRIVING, ON THE INTERSTATES AN TRAFFIC JAMS AN UNDERPASSES AND OVER PASSES AN TRASH ON THE SIDE OF THE ROAD. SO THEY ARE REALLY GETTING TRIGGERED ALL THE TIME. SO WHAT WE DO IS SIMILAR TO THE VIRTUAL VIETNAM. SO BACK IN THEIR MINDS'S EYE TO THE WORST EVENTS FROM IRAQ, DESCRIBE IT OUTLOUD, WITH THEIR EYES OPEN AND THE THERAPIST IS MATCHING WHAT THEY'RE DESCRIBING WE HAVE A VIRTUAL HUMVEE AND CITY. WE CAN PUT THEM IN WHATEVER POSITION IN THE HUM IF DRIVER, OR PASSENGER WE CAN PUT THEM IN THE TURRIC. WE CAN CHANGE TIME OF DAY, CREATE SMOKE, PUT THEM IN’N‡NIGHT VISION GOGGLES. THIS I'M GOING TO WARN YOU THIS IS TAKEN OFF THE INTERNET, A CLIP OF AN ACTUAL I.E.D SO IF ANYONE SERVED IT COULD BE UPSETTING AND THERE'S SOME BAD LANGUAGE IN IT. (INDISCERNIBLE)¨ >> THIS IS JUST A CLIP THAT I GOT FROM SKIP RUSSO, HIS GROUP AT USC DEVELOPED THE VIRTUAL IRAQ. IT'S NOT MEANT TO MATCH THAT, WE USE THESE CLIPS FOR THE PSYCHOPHYSIOLOGICAL MONITORING, AND ASSESSMENT WE DO AT DIFFERENT POINTS. THIS IS A CLIP THAT INCREASES IN SEVERITY ANTHROS EVERYTHING AT SOMEBODY. WHEN WE'RE USING IT THERAPEUTICALLY, IF THEY'RE DRIVING DOWN THE ROAD, IED ON THE RIGHT, (INAUDIBLE). THAT'S WHAT WE DO. WE'RE NOT GOING TO PRODUCE ALL OF THIS. ALSO SHOWS BLOOD. I THINK WE CAN TALK ABOUT THAT AFTERWARDS. NOT CREATING -- I DON'T WANT TO EXPOSE PEOPLE TO ANYTHING. (INDISCERNIBLE) >> THIS IS DR. GREG REAGER, HE HAS A BETA VERSION OF THE VIRTUAL IRAQ IN IRAQ GIVING US FEEDBACK. SO I LIKE IT WHEN OUR GUYS PUT IT ON AND THEY SAY THIS IS JUST WHAT IT LOOKED LIKE. THIS WAS JUST OUR VERY FIRST GUY, THIS WAS NOT ON MEDICATION OR FIRST PATIENT WE WERE PILOTING THROUGH THE PROGRAM, THE VIRTUAL IRAQ, HE ONLY HAD FOUR SESSIONS AND WE SAW 56% DECREASE IN HIS CAP SCORE. CLINICIAN ADMINISTERED PTSD SCALE. AND A SIMILAR DECREASE IN HIS SELF-REPORT. IT'S INTERESTING HE GOT REDEPLOYED AFTER WE TREATED HIM, WHICH IS WHAT PEOPLE WANT -- HE WAS A NATIONAL GUARDSMAN. SO THIS IS FROM ABOUT TWO OR THREE WEEKS AGO SO WE ENTERED A FEW MORE FOLKS THAN THIS. THIS IS AN ON GOING TRIAL. WE HAVEN'T BROKEN THE BLIND YET, SO THIS SMAINLY A MAIN EFFECT OF THE VIRTUAL REALITY EXPOSURE THERAPY. AND WE MIGHT EXPECT AT THE END OF THE DAY WE'LL SEE TO MAYBE HAVE THREE DIFFERENT LINES MAYBE WITH WITH THE DECYCLE SERENE PLACEBO AND ALPRAZOLAM. BUT IN THE SIX SEXES FIVE OF THE VIRTUAL -- SIX SESSIONS FIVE VIRTUAL REALITY ARE DECREASING THEIR PTSD SYMPTOMS. THIS IS THE PTSD SYMPTOM SCORE A SELF-REPORT MEASURE THEY FILL OUT AT EVERY SESSION SO GOING THE SAME WAY. JUST TO SHOW YOU'RE DATA WE'RE WORKING WITH COLONEL MIKE ROY WHO USED TO BE AT WALTER REED BUT NOW THERE'S NO MORE WALTER REED SO AT BETHESDA NAVAL MEDICAL CENTER. HE DID A STUDY USING VIRTUAL REALITY WITH ACTIVE DUTY GUYS WITH T BIRKS AND PTSD AND LOOKING AT IMAGING. AND SAW CHANGES, NORMALIZATION IN EVERY REGION OF INTEREST AFTER THE TREATMENT. WHICH I THINK IS INTERESTING. SO LOOKING AT ANOTHER MEASURE, STARTLE L REACTIVITY THAT ACTUALLY MICHAEL KOZAK USED TO DO A LOT, ASK HIM ABOUT STARTLE OF WARDS, NOT ME. AND -- AFTERWARDS, NOT ME. THIS IS A TRANSLATIONAL MEASURE BECAUSE MIKE DAVIS MEASURES FEAR POTENTIATED STARTLE IN THE RATS AND HEP BUILT THIS CAING, -- AND HE BUILT THIS CAGE. I HAVE NOT WANTED TO PUT A PERSON IN A SIMILAR CON CONTRAPTION SO THIS IS HOW WE MEASURE WITH HUMAN, THE EYE BLINK RESPONSE AND WE CAN TAKE OUT THE PSYCHOPHYSIOLOGICAL MEASURES. THIS IS VERY EARLY DATA, JUST THE FIRST SEVERAL PEOPLE FOR WHICH THE HUMVEE WAS THEIR PRIMARY TRAUMA OCCURRED IN THE HUMVEE AND THEIR STARTLE IS DECREASING OVER TIME. AND JUST PUTTING THAT TOGETHER WITH THESE FOLKS, CAP SCORE, YOU CAN SEE THE PTSD AND THEIR STARTLE ARE DECREASING SIMILARLY. THIS IS JUST A CASE STUDY, WE PI GUR EVERYBODY LIKES SQUIGGLY LINES SO THIS IS JUST ONE GUY, I HAVE NO IDEA WHAT CONDITION HE'S IN, WHICH MEDICATION HE GOT. HIS CAPS WHEN FROM O 103 AT PRE-TREATMENT TO 68 POST TREATMENT. YOU CAN SEE THAT. AND I KNOW– + WILn READ, SO THE TOP RED LINE IS SKIN CONDUCTTANTS, THE MIDDLE IS STARTLE, THE EYE BLINK AND THE BOTTOM IS HEART RATE THAT'S PRE-TREATMENT AND THAT'S POST TREATMENT. AND I'LL GO BACK. SO PRE-TREATMENT SKIN CONDUCTANCE, STARTLE, HEART RATE. AND POST TREATMENT. AGAIN, JUST -- WE HAVE NO IDEA OF HIS CONDITION BUT YOU CAN SEE THERE'S SOME DECREASE RESPONDING. SO NOW I'M GOING TO SWITCH AND TALK ABOUT EARLY INTERVENTIONS BECAUSE I HAVE BEEN -- I SPENT MY ENTIRE CAREER WORKING ON TREATMENTS AND TESTING TREATMENTS FOR CHRONIC PTSD WHERE I LOVE TO GO IS PREVENTING IT. OBVIOUSLY THE PRIMARY WAY TO PREVENT IT IS EXPOSURE PREVENTION TO TRAUMATIC EVENTS. THAT'S NOT GOING TO HAPPEN. LIFE IS DANGEROUS. WE'RE NOT GOING TO PREVENT WARS UNFORTUNATELY BUT IF WE CAN FIGURE AN EARLY INTERVENTION, THAT'S ALSO FUNDED BY NIMH, THANK YOU VERY MUCH. SO AGAIN REMEMBER I SHOWED YOU THIS. LOOKING AT FOLKS IMMEDIATELY AFTER A TRAUMATIC EVENT, IN THIS CASE IT WAS RAPE. WE FIGURED IT'S A DISORD OAR OF EXTINCTION. AND SO IF YOU GO BACK, THIS IS THEORETICAL, NOT DATA, YOU LOOK AT THE ACQUISITION OF FEAR AND THEN THE EXTINCTION OF FEAR. AND THEN TESTING IT, IT COMES BACK. AND FOR THE EARLY INTERVENTIONS, THE DEBRIEFING LITERATURE IS EQUIVOCAL AT BEST AND SOME STUDIES HAVE SHOWN IT CAN CAUSE HARM. OBVIOUSLY WE DON'T WANT TO CAUSE HARM. AND IT'S REALLY VERY FRUSTRATING. I WAS PRESIDENT OF IFSTSS, THE ENTERGNASH GNAT SOCIETY OF TRAUMATIC STRESS STUDIES. THE YEAR OF THE LONDON BOMBINGS, THE TSUNAMI AND HURRICANE KATRINA. MY BROTHER SAID I WAS BAD LUCK FOR THE WORLD. OKAY, I'M READY NOT TO BE PRESIDENT. BUT INTERNATIONAL TRAUMA ORGANIZATION. EVERYBODY WANTED TO HELP. THERE WERE NO EMPIRICALLY SUPPORTED TREATMENTS TO DELIVER. I HAVE MET WITHS AT THE PENTAGON AND THEY FORM AD LITTLE SUBCOMMITTEE OF US TO COME UP WITH RECOMMENDATIONS FOR WHAT TO DO IN THEATER, WE COULDN'T COME TO A CONSENSUS. THERE'S NO DATA ON AN EFFECTIVE EARLY INTERVENTION. I REALLY BELIEVE THE BOTTOM OF MY HEART THERE ARE THINGS WE CAN DO IN THE IMMEDIATE AFTER MATH OF TRAUMA THAT CAN HELP AND THAT CAN HURT. OBVIOUSLY WE WANT TO FIGURE OUT WHAT HELPS. IT MAYBE DIFFERENT FOR DIFFERENT PEOPLE. THAT MIGHT BE PART OF IT. SO AGAIN, TALKING ABOUT THE ANIMALS, SOME OF THE PROPERTIES OF EXTINCTION. WE DON'T THINK THE EXPOSURE ALONE AN EXTINCTION TRAINING ERASES THE FEAR MEMORY. IN THE ANIMAL LITERATURE THEY SEE THREE INDICES OF THIS, SPONTANEOUS RECOVERY, IT COMES BACK WITH TIME. IT RETURNS WITH THE DELIVERY OF SHOCK OR AVERSE STIMULUS, REINSTATEMENT, AND IS EXPRESSED OUTSIDE OF THE EXTINCTION CONTEXT SO YOU PUT THEM IN A DIFFERENT CONTEXT AND THEY CALL IT RENEWAL WHEN YOU SEE IT AGAIN. THE ANIMAL EVIDENCE SUGGESTS THAT SOME IMMEDIATE EXTENSION TRAINING CAN RESULT IN THE DECREASES IN THESE THREE INDICES. MY BUDDY MIKE DAVIS IN THE ANIMAL STUDIES FOUND THAT IF YOU DID EXTINCTION TRAINING TEN MINUTES AFTER FEAR CONDITIONING, IN HIS -- IN THEIR WORDS, I WOULD NEVER SAY THIS ABOUT PEOPLE. THEY SAID IT ERASED ALL THE INDICES OF FEAR YOU SEE IN REINSTATEMENT CONTEXT SPECIFICITY AND SPONTANEOUS RECOVERY. THAT IS OPPOSED TO HOW THEY TYPICALLY DO THE EXTINCTION TRAINING WHICH IS 72 HOURS LATER. I THINK THAT THIS IS TRUE. I THINK THAT WHAT'S HAPPENED IS THEY'RE MESSING WITH THE CONSOLIDATION OF THE FEAR MEMORY BEFORE IT'S CONSOLIDATED. AND WE SEE THIS IN OUR TRAUMA SURVIVORS. OUR RAPE VICTIM, WHAT HAPPENS IN THE EMERGENCY ROOM OR WITH THE POLICE IMMEDIATELY AFTER THE TACK IS PART OF THEIR NEMRY AS WELL. AND -- THEIR MEMORY AS WELL. SO WHAT WE'RE TRYING TO DO IS SEE IF WE CAN CHANGE THAT. SO REMEMBER, REEN STATEMENT IS IN THE SAME CONTEXT, IT COMES BACK, WHEN HE DID THE STUDY FOUND THAT EXTINCTION GIVEN TEN MINUTES AFTER FEAR CONDITIONING PREVENTED RELAPSE AFTER STRESS, WHEREAS EXTINCTION GIVEN 72 HOURS LATER DID NOT. ALSO FOUND IT IN THE RENEWAL. THIS IS DIFFERENT CONTEXT. FOUND THE EXTINCTION GIVEN TEN MINUTES AFTER THE FEAR CONDITIONING. PREVENTED THE RETURN OF FEAR IN A DIRVE CONTEXT, THE LATER HE CAN -- IN A DIFFERENT CONTEXT, THE LATER DISTINCTION 72 HOURS DID NOT, FOUND IT IN SPONTANEOUS RECOVERY. SO WITH THE PASSAGE OF TIME FOUND AGAIN, EXTINCTION, TRAINING GIVEN TEN MINUTES AFTER THE FEAR CONDITIONING. YOU DIDN'T SEE THE SPONTANEOUS RECOVERY, WHEREAS THEY DID WHEN IT WAS 72 HOURS LATER. SO THIS LED US TO THINK THAT EXTINCTION TRAINING CONDUCTED VERY SHORTLY AFTER FEAR CONDITIONING MAY PREVENT CONSOLIDATION OF THE ORIGINAL FEAR MEMORY. AGAIN, THEY DO IT FEAR POTENTIATED STARTLE IN RATS. WE CAN DO IT IN ADULTS. WE DID IT IN A PRE-CLINICAL STUDY IN HUMANS, AND WHERE WE ALSO FOUND THAT THE TEN MINUTES IN THE LIGHTER YELLOW, THE EXTINCTION TRAINING AFTER TEN MINUTES, WE DIDN'T SEE THE SPONTANEOUSLY COVERRY. WHEREAS THE EXTINCTION TRAINING 72 HOURS LATE WE DID. SO WE HAVE DONE IS WE CAN SEE P IF WE CAN DO THIS IN IMMEDIATE TRAUMA SURVIVORS TO TRY TO PREVENT DEVELOPMENT OF PTSD. IF WE FIGURE PHARMACOLOGICAL AGENT, LET'S PUT IT IN WATER. WE PUT FLOWER RIDE IN WATER AND PREVENT CAVITIES BUT LET'S FIGURE OUT WHAT WILL WORK AND FOR WHOM. WHAT WE DID, IF ANYBODY KNOWS ATLANTA AND GRADY HOSPITAL, IT'S A LARGE LEVEL 1 TRAUMA CENTER INNER CITY HOSPITAL, HAVE TOLL MY HUSBAND IF I GET SHOT OR STABBED TAKE ME TO GRADY, AS SOON AS I'M STABLE GET ME THE HECK OUT OF THERE, BECAUSE IT'S A SCARY PLACE BUT A WONFUL PLACE TOO. -- WONFUL PLACE TO -- WONDERFUL PLACE TOO. IF THEIR MEDICALLY STABLE IF THEY DIDN'T HAVE A CRITERION A TRAUMA WE ASSESSED EVERYBODY IN THE EMERGENCY ROOM AND ONE MONTH LATER WHEN PTSD COULD BE DIAGNOSED AND THREE MONTHS LATER WHEN PTSD IS CHRONIC. EVERYONE ASSESSED AT THAT POINT BUT THEY WERE RANDOMLY ASSIGNED TO RECEIVE THE ASSESSMENT OR RECEIVE AN EARLY INTERVENTION. WHAT WE DID FOR EARLY INTERVENTION IS MODIFICATION OF PROLONGED IMAGINABLE EXPOSURE. WE DID ONE SESSION RIGHT THERE IN THE EMERGENCY ROOM, THEN BROUGHT THEM BACK A WEEK LATER FOR A SECOND SESSION AND A WEEK LATER FOR A THIRD SESSION. I'M RUNNING SHORT ON TIME. IT'S A MODIFICATION OF EXPOSURE. WE HAVE THEM GO BACK IN MIND'S EYE, DESCRIBE OUTLOUD, WE TAPE RECORD IT, GIVE THEM THE TAPE TO LISTEN TO. WE TALK ABOUT THUGHT THOUGHTS AN UNHELPFUL THOUGHTS. WE HELP ANTICIPATE WHERE THEY MIGHT WANT TO AVOID THAT THEY REAL IESIC -- REALISTICALLY THINK IT'S OKAY TO DO AND HELP THEM TRY NOT TO DO THAT. WE HAVE NOW JUST COMPLETED THAT STUDY. WE ASSESSED -- I KNOW IT'S HARD TO SEE, ALMOST 9,000 FOLKS. SO WHAT THAT MEANS IS WE HAD OUR STAFF COVERING THE EMERGENCY ROOM SEVEN DAYS A WEEK FROM 7A TO 7:0 O 0 P. ANYBODY ADMITTED TO THE TRAUMA AREA OF THE EMERGENCY ROOM AND HAD A TRAUMA CODE, THAT'S WHO WENT INTO THAT 9,000. SO MOST WERE NOT ELIGIBLE. I KNOW IT'S HARD TO SEE. SO 6,000 DIDN'T MEET INCLUSION CRITERIA. THEY HAD TO MEET INCLUSION CRITERIA FOR A TRAW MA. IT HAD TO HAVE BEEN TRAUMATIC FOR THEM. ANOTHER 1200 REFUSED TO PARTICIPATE. THIS IS AN INNER CITY EMERGENCY ROOM, BY THE TIME WE GOT PEOPLE THEY HAD BEEN THERE FOR HOURS, THEIR THEY WERE TIRED, VERY OFTEN IF IT HAPPENED IN THE MIDDLE OF THE NIGHT THEY'RE READY TO GO HOME. SO WE ENDED UP RANDOMLY ASSIGNING 137 TO THE INTERVENTION OR ASSESSMENT ONLY. THIS IS JUST TO TELL YOU WHO THEY ARE. SO TWO-THIRDS WERE FEMALE. MOST OF THEM IN THEIR AVERAGE EARLY 30s. BETWEEN 75 AND 80% WERE AFRICAN AMERICAN. THE TRAUMAS ROUGHLY ABOUT A THIRD, RAPE ABOUT A THIRD NON-SEXUAL ASSAULT AND ABOUT A THIRD MOTOR VEHICLE AND MY INJURY CONTROL COLLEAGUES TELL ME IT'S MOTOR VEHICLE CRASH OR COLLISION, NOT ACCIDENT, THEY SAY IT'S NOT AN ACCIDENT. THE TIME THAT WE GOT THEM, THE MEDIAN IS 6.9 HOURS SO OVER -- HALF THE PEOPLE WE SAW WITHIN 6 OR 7 HOURS OF THE TRAUMATIC EVENT OCCURRING. THE MEAN IS 11 TO 12 HOURS. AND THERE ARE A COUPLE OF OUTLIERS LATER BUT MOST PEOPLE WE SAW EARLY ON. OUR FOLLOW UP RATE, 74% AT FOUR WEEKS, AN 66% AT 12 WEEKS. THIS IS THE DATA I KNOW IT'S HARD TO FOLLOW BUT I HAVE IT GRAPHICALLY AS WELL. WHAT YOU NEED TO KEEP IN MIND IS THERE'S NO BASELINE OF THE PTSD SCORE. I DO NOT THINK IT'S VALID TO ASSESS PTSD WITHIN SIX HOURS OF TRAUMATIC EVENT. WHAT WE'RE LOOKING AT FOR PTSD IS BASICALLY CROSS SECTIONAL FROM THE RANDOMIZED GROUPS AT ONE MONTH LATER AN THREE MONTHS LATER. PROBABLY EASIER JUST TO SEE T HERE. SO THIS IS THE PTSD SYMPTOM SEVERITY, THE FOLKS WITH THE INTERVENTION IN BLUE WERE SIGNIFICANTLY LOWER AT ONE MONTH AND AT THREE MONTHS THAN THE FOLK WHOSE DID NOT RECEIVE THE SER VENGS. DEPRESSION INVENTORY, THAT WE DID ASSESS AT BASELINE. WE DID ASK THEM TO COMPLETE A BECK DEPRESSION SCORE IN THE EMERGENCY ROOM AND ONLY GAVE IT ONE MONTH LATER. THE FOLK WHOSE GOT THE INTERVENTION WERE SIGNIFICANTLY LOWER ON DEPRESSION. IT'S HARD TO SEE OTHER, THE FOLK WHOSE DID NOT MEET THE DIAGNOSIS. YOU CAN SEE 74% AT WEEK 12 WITH THE INTERVENTION DID NOT MEET THE DIAGNOSIS COMPARED TO 53%. SOME LIKE NUMBERS, SOME LIKE GRAPHS SO I DID IT IN BOTH. SO AT WEEK 12 IT WAS SIGNIFICANTLY FEWER PEOPLE. WHO RECEIVED THE INTERVENTION WHO MET PTSD DIAGNOSTIC CRITERIA. THIS IS ALSO -- THIS IS AN INNER CITY POPULATION THAT'S MULTIPLY TRAUMATIZED. SO WHEN THEY CAME IN AND AGAIN, A MONTH LATER, WE ASKED THEM TO COMPLETE THE PTSD DIAGNOSTIC SCALE FOR PREVIOUS TRAUMA, NOT THE INDEX TRAUMA THAT BROUGHT THEM TO THE EMERGENCY ROOM. WE WANTED TO TRY TO PARSE OUT O PRIOR PTSD. SO BASE LINE THEY WERE SIMILARLY SYMPTOMATIC WITH PRIOR PTSD, AT WEEK FOUR, THIS IS NOT STATISTICALLY SIGNIFICANTLY DIFFERENT BUT IT'S GOING IN THE RIGHT DIRECTION. WE WANT TO MAKE SURE WE'RE NOT MAKING ANYBODY WORSE. WE ONLY HAD THREE SESSIONS OF EXPOSURE THERAPY. IN A NORMAL COURSE OF EXPOSURE THERAPY WE WOULD HAVE TIME TO ADDRESS PRIOR TRAUMAS BUT NOT IN THREE SESSIONS. OBVIOUSLY WHAT WE WANT TO BE ABLE TO DO IS FIGURE OUT WHO NEEDS IT FOR WHOM AND HOW TO TRANSPORT IT FOR EXAMPLE, IN THEATER OR IN MASS DISASTERS OR CASUALTIES TO BE ABLE TO HAVE SOMETHING THAT PEOPLE CAN -- >> BRAIN GAME, 600. VIRTUAL REALITY AND PSYCHOLOGY ARE USED TO REWIRE THE BRAIN OF WAR VET JERRY WHO SUFFERS FROM PTSD SHORT FOR THIS. WHAT IS POST TRAUMATIC STRESS DIDS ORER. >> THAT IS IT. >> THAT WAS FROM LAST OCTOBER. SO WE FIGURE WE'RE IN CONVENTIONAL WISDOM NOW, PTSD AND VIRTUAL REIAL ON JPTY -- GENERALITY. THERE ARE LOTS OF FOLKS IN OUR -- GENERALITY. -- JE I FINISHED IN TIME TO ALLOW FEW QUESTIONS OR COMMENTS OR DISAGREEMENTS. HAVE I PUT YOU ALL TO SLEEP? IT'S AFTERNOON, HUH? [APPLAUSE] YES. WE NEED THE MIC? OKAY. (OFF MIC) >> THANK YOU. I WANTED TO IN TERMS OF RESEARCH AND THE POPULATION IS CHANGING IN A LOT OF METHODS, ALL THE RESEARCH IS GREAT, AND PTSD HAS BEEN ON MALE VETERANS AND WE'RE GOING TO HAVE WOMEN IN DIFFERENCE ROLES. I WONDER HOW THAT'S INFORMING YOUR WORK OR HOW YOU SEE THAT IN TERMS OF SOME OF YOUR FUTURE WORK WE HAVE. I THINK THE AGE CHANGED AS WELL. SO A DIFFERENT DEMOGRAPHIC IF TERMS OF VETERAN POPULATION. >> IT'S AND ALL VOLUNTEER FORCE. >> IT'S VERY DIFFERENT. >> SO WHEN THEY FIRST SENT WOMEN TO IRAQ AN AFGHANISTAN THEY SAID THEY WESTERN IN COMBAT AND JUST SUPPORT ROLES. WHAT'S ONE OF THE BIGGEST ROLE? DRIVING THE TRUCKS DOWN THE DESERT HIGHWAY THAT'S WHERE THE I.E.Ds ARE HITTING. WOMEN ARE GETTING EXPOSED TO A LOT. THIS IS GOING TO BE A SLIGHTLY POLITICALLY INCORRECT THING TO SAY. AND IT'S NOT BASED ON DATA, IT'S BASED ON MY ON SR.VATION WORKING WITH FEMALE VETS WHEN WE DID A BIG STUDY. IT WAS PAULA (INDISCERNIBLE) STUDY. A LOT OF WHAT WE WERE TREATING WAS PRE-MILITARY TRAUMA. IT DOESN'T APPLY TO ANYBODY, I MET A LOT OF FEMALE VETERANS WHO THEY COME FROM MILITARY FAMILIES. THEY ARE PATRIOTIC AND WANT TO HELP TOO BUT PEOPLE IT CAN OFFER AN ALTERNATIVE WHEN THEY NEED TO GET AWAY FROM SOMETHING SO THERE'S PRE-MILITARY TRAUMA THAT PRE-DISPOSES SOMEONE TO PTSD EXPOSED TO ANOTHER TRAUMA. IN GENERAL WOMEN GET PTSD IN THE GENERAL POPULATION TWO TO ONE TO MEN, NOT TRUE IN THE COMBAT POPULATION, IT'S GETTING MORE EVENT IN THE COMBAT POPULATION BUT AGAIN, MEN GETTING EXPOSED TO MORE SEVERE TRAUMAS, PEOPLE IN THE CURRENT CONFLICT SURVIVING INJURIES THEY WOULDN'T HAVE SURVIVED PREVIOUSLY. IN GENERAL, I DON'T KNOW THAT WE KNOW GENDER DIFFERENCES IN THE RESPONSE TO TREATMENT. MAINLY BECAUSE STUDIES USE WOMEN OR PRIMARILY MEN AND WHEN THEY ARE MIXED THERE'S NOT ENOUGH DATA, ENOUGH POWER. IN THE EARLY STUDIES PEOPLE COMMENTED IT LOOKED LIKE IT DIDN'T WORK WITH MEN. BUT THEY DIDN'T HAVE AS MANY MEN. SO I GUESS I'M ALL OF THAT IS USING A LOT OF WORDS TO SAY, I DON'T THINK I CAN REALLY ANSWER YOUR QUESTION YET. WHAT WE WOULD HAVE TO DO IS USE THREEMS THAT WE KNOW WORK -- TREATMENTS THAT WE KNOW WORK AND IN GENERAL MOST WORK FOR BOTH GENDERS. >> FASCINATING TALK. THANK YOU SO MUCH. TO WHAT EXTENT DOES SUBSTANCE ABUSE COMPLICATE THESE KINDS OF EFFORTS AT EXTINGUISHING THE TRAUMATIC MEMORIES? CAN WE SEPARATE THE TWO OUT AT ALL? >> SEASON DRA BLAO AND OTHER EPIDEMIOLOGISTS AFTER 9/11 IN MAN AT THAT TIME HAHN FOLLOWED FOLKS AND FOUND PTSD AN DECREETION INCREASED OVER TIME. IF YOU FOLLOW THEM, IT DECREASED. THEY ALSO ASSESS SUBSTANCE USE AN IT INCREASED AND IT NEVER DECREASED. IT WAS ALL SUBSTANCE TO PEOPLE STARTED SMOKING CIGARETTES AGAIN. WE SEE WHEN YOU CAN LOOK AT IT TEMPORALLY, A LOT OF TIMES, KATHLEEN BRADY AT MUSC HAS SOME DATA, IT LOOKS LIKE THE TRAUMA OCCURRED BEFORE THE SUBSTANCE USE DISORD OAR SO IT LOOKS LIKE AND SOUNDS LIKE WHEN YOU TALK TO FOLKS THAT THEY ARE SELF-MEDICATING. WE WANT OUR SAMPLE AS REALISTIC AS POSSIBLE. PEOPLE CRITICIZE SAYING THAT'S THE CLEAN PTSD PATIENTS. I DON'T KNOW WHAT A CLEAN PTSD PATIENT IS. I HAVE YET TO MEET THAT PERSON. AND IN OUR VETERAN POPULATION, WE WILL ALLOW SUBSTANCE ABUSE BUT NOT DEPENDENCE. WITHIN THE ABUSE WE'LL TALK ABOUT PARAMETERS. WE DON'T WANT SOMEBODY USING THE NIGHT BEFORE SESSION BECAUSE WE DON'T WANT THEM COMING IN HUNG OVER. WE DON'T WANT THEM USING THE DAY qJ0 THE SESSION BECAUSE WE WANT THEM TO PROCESS AN FEEL WHAT THEY'RE GOING TO FEEL. AND SEE THAT IT WILL DECREASE WITHOUT THE SUBSTANCE. IF WE DIDN'T TREAT PEOPLE WHO USE SUBSTANCES EXCESSIVELY WE WOULDN'T HAVE ANY PTSD PATIENTS SO WE'RE TRYING TO BE REALISTIC. I'M ACTUALLY IN THIS TRIAL MORE WORRIED ABOUT MARIJUANA USE THAN A LOT OF OTHERS BECAUSE THE CANNABINOID AND ENDOCANNABINOID SYSTEM IS SHOWN PARTLY BY ONE OF MY COLLEAGUES KERRY WRESTER AS BEING IMPORTANT IN CAN BEING OF -- IN CONDITIONING FEAR OF EXTINCTION SO WE ARE A LITTLE BIT MORE IN TALKING TO PEOPLE MORE ABOUT NOT USING MARIJUANA DURING THE STUDY. IT'S ONLY SIX WEEKS THE TREATMENT SO KNOCK ON WOOD, WE HAVE HAD PRETTY GOOD COMPLIANCE. THERE ARE A FEW PROGRAMS WHERE THEY TREAT IT TOGETHER. KATHLEEN BRAY SI AND (INDISCERNIBLE) TREATING PTSD SIMULTANEOUSLY WITH GOOD RESULTS. ADJUVANTS SEEKING SAFETY PROGRAM. >> YOU HAD YOUR HAND UP FIRST THEN I'LL ASK MY QUESTION. >> THANK YOU FOR THE TALK. WONDERING IF YOU COULD SPEAK ABOUT WHETHER THERE'S ANYTHING TO BACK UP OR MAYBE YOU HAVE SOME THOUGHTS ON IT, ABOUT THE IMAGINABLE THERAPY OR EXPOSURE THERAPY FOR TRAUMA THAT HAPPENED LIKE CHILD ABUSE AN ADULTS YOU MIGHT SEE AS A RESULT OF THAT. IT'S A DIFFERENT ETIOLOGY. >> RIGHT. SO IN THE FIRST STUDY WE DID WITH EDNA FOA AND MICHAEL WORKED ON THAT WITH RAPE VICTIMS, STARTING IN 1986, I CAN'T REMEMBER THE EXACT NUMBER OF HOW LONG AGO THE AVERAGE ASSAULT OCCURRED BUT I SAW SOME PEOPLE THAT IT WAS OVER 20 YEARS. FOR THAT THERE HAD TO HAVE BEEN AN ADULT ASSAULT FOR A NUMBER OF OUR PATIENTS WE'RE TREATING CHILDHOOD SEXUAL ABUSE AND INCEST AND TRAUMATIC EVENTS THAT OCCURRED 20, 30, 40, 50 YEARS AGO. AND HAVE STILL SEEN THE TREATMENT IS SUCCESSFUL. SO IT DOESN'T NECESSARILY BODE BADLY FOR TREATMENT, WHAT IT DOES, WE'RE TRYING TO DO SOME RECONSOLIDATION WORK. MARIE MUNFEELD WHO DID A COOL KNEW STUDY ON A RECONSOLIDATION PARADIGM IS EXPLAINING A LOT OF HOW SOME WORKS AND THAT WHEN THERE IS INCOMPLETE EXTINCTION, ONE BECOMES MORE RESISTANT TO EXTINCTION WHEN YOU TALK RECONSOLIDATION. SO THAT'S THE COMPLICATING FACTOR IN TRAUMAS THAT OCCUR A LONG TIME AGO. A LOT OF GUYS WHEN WE TELL THEM THE EXPOSURE THERAPY, THEY SAY WHAT DO YOU MEAN ? I THINK ABOUT IT ALL THE TIME ANYWAY. I TRY TO TELL THEM I THINK YOU THINK ABOUT IT IN WAY NOT HELPFUL AND WE'RE GOING TO TRY TO DO IT DIFFERENTLY. ONE ANALOGY WE USE ALL THE TIME, THE BOOK OPENS UP, YOU READ A LINE AND YOU SLAM THE BOOK SHUT. IT OPENS AGAIN, YOU READ A LINE AND SLAM THE BOOK SHUT. THAT KEEPS HAPPENING SO YOU FEEL LIKE YOU'RE THINKING ABOUT IT ALL THE TIME BUT T NOT CHANGING ANYTHING. WE'RE GOING TO OPEN THE BOOK AND READ THE WHOLE CHAPTER OVER AND OVER AND OVER AND OVER UNTIL YOU CAN MAKE SOME OTHER KIND OF SENSE OUT OF IT. AND PUT IT AWAY DEMPLY. THE SOONER WE CAN TREAT SOMEBODY THE BETTER CHANCES BECAUSE IS THERE'S ALSO SO MUCH COMORBIDITY AND OTHER SEQUELLA OF STUFF WITH PTSD BUT I'M NOT PESSIMISTIC ABOUT TREATING PTSD FROM A LONG AGO PRIOR TRAUMA. SO AGAIN, LONG ANSWER. >> THANK YOU FOR A VERY NICE TALK. MY NAME IS PAUL GATES. MY DIRECT FIELDS ARE ON THE TERMINOLOGY -- THIS MAY HAVE -- MAYBE AN ISSUE OF WHAT YOU'RE REFERRING TO ABOUT PHENOMENON OF UNPACK AN REPACKING THE EXPERIENCE. AND A LOT OF YOUR TALK WAS ABOUT POSSIBLE OPPORTUNITIES FOR EARLY INTERVENTION, THE FACT IT MAY BE A WINDOW YOU'RE TRYING TO FIND THAT COULD BE ESSENTIALLY A THERAPEUTIC WINDOW. INTERESTINGLY FROM POLICY PERSPECTIVE, ORGANIZATIONS LIKE THE AMERICAN RED CROSS AND DISASTER MENTAL HEALTH APPROACHES HAVE AS POLICY BEING CAREFUL TO HAVE CENTRALIZED OPERATIONS WITH DISASTER VICTIMS SO THEY DONE HAVE TO RETELL THEIR STORY OVER AN OVER AGAIN TO THE SERVICE PROVIDER, TO THE SOCIAL WORKER, MENTAL HEALTH WORKER, ET CETERA, BUT TO HAVE TO TRY TO MAKE IT WHERE THIS CAN TELL THEIR STORY ONCE AND GET WHAT THEY NEED. THERAPY ESSENTIALLY WITH DISTINCTIONS, YOU HAVE REPEATED SESSIONS. WITH EARLY INTERVENTION, REPEATED SESSIONS OVER TIME, HOW DO YOU PUT THAT TOGETHER WITH WITH HOW THE AMERICAN RED CROSS AND OTHERS ARE DEALING WITH TRYING TO CUT DOWN ON REPEATED STORY TELL SOMETHING IS IT HAVING TO DO WITH UNPACKING BUT HOW DO YOU REPACK IT? >> YES. SO IT'S ACTUALLY A COMPLICATED QUESTION AND A COMPLICATED SITUATION AND I DON'T HAVE AN ANSWER BASED ON DATA. WHEN I WAS FIRST IN ATLANTA I JOINED THE LOCAL DISASTER RESPONSE TEAM, GOT TRAINED, IN CRITICAL INCIDENT STRESS DEBRIEFING MAINLY WITH THE IDEA I WANTED TO DO RESEARCH AND WITH THE AMERICAN RED CROSS. I SOON FOUND OUT IT WAS A PARAMILITARY ORGANIZATION AND THEY REALLY AREN'T ENCOURAGING RESEARCH. WHEN I WENT TO THAT TRAINING, THEY TYPICALLY DO IT -- WHAT THAT TRAINER DID WHICH IS TYPICAL AN EVERYBODY DOES IT DIFFERENTLY, IN A GROUP FORMAT AND THEY GO AROUND THE ROOM AND THEY MAKE EVERYBODY TALK ABOUT IT. AND I MADE CLEAR WHAT IF SOMEBODY DOESN'T WANT TO TALK -- AND THEY SAID NO, EVERYBODY HAS TO TALK IT IN THAT ROOM. I DON'T WANT TO THROW OUT THE BABY WITH THE BATH WATER. THERE ARE THERAPEUTIC ELEMENTS IN DEBRIEFING, CRITICAL ELEMENT STRESS DEBRIEFING. WE NEED TO FIGURE OUT WHAT'S RIGHT FOR WHOM. I TEND TO NOT LIKE TRAUMA WORK IN GROUPS. I THINK YOU MAYBE FINE WITH YOURS AND THEN YOU HEAR WHAT HAPPENED TO HIM AND YOU THINK OH MY GOD, THAT COULD HAPPEN TO ME. I DON'T THINK PEOPLE NEED TO HEAR THAT, IT'S HARD ENOUGH DEEPING WITH -- DEALING WITH YOUR OWN. SO NOT A FAN OF TRAWKING WORKING GROUP -- TRAUMA WORKING GROUP. IT MAYBE THE WRONG DOSE, TOO SOON OR A DIFFERENT CONTEXT, AND IT TYPICALLY TENDS TO BE LIKE YOU SAID, ONE TIME. THAT'S WHY WE PURPOSEFULLY DID OURS OVER AND OVER AN OVER AN OVER. SO THEY CAN EXPERIENCE HOPEFULLY EXTINCTION OF THE FEAR. YOU SAY IT OVER AN OVER AN OVER, IT CAN TAKE THE Z THEENG OUT AND THEY CAN LOOK AT IT AND PUT IT AWAY, IT WILL BE A BAD MEMORY BUT NOT A PTSD MEMORY. SO I THINK THE MULTIPLE RETELLING I THINK IS IMPORTANT BUT IN A THERAPEUTIC CONTEXT. (OFF MIC) >> THE LINE, I DON'T KNOW. IT WASN'T MORE THAN TEN YEARS AGO BUT MAYBE HITTING CLOSE TO TEN YEARS. I KNOW PEOPLE DO IT DIFFERENTLY AND I KNOW PEOPLE TOLD ME THAT'S NOT HOW I DO IT. SO I THINK THE MULTIPLE -- I TEND TO THINK THE TELLING WAS IMPORTANT. >> THANK YOU VERY MUCH FOR THE TALK. WONDERING WHAT KIND OF STUDIES WERE DONE TO DEVELOP THESE TREATMENT METHODS? LIKE THE VIRTUAL REALITY AND ALL THAT? THE KIND OF PROFESSIONALS THAT WHEN INTO IT, WAS IT PSYCHOLOGIST, PSYCHIATRIST, BIOTECHNOLOGIST, THE TYPES OF PEOPLE THAT CAME TOGETHER TO MAKE THAT, WONDERING WHAT THE BACK GROWN IS AND ALSO WHETHER THERE'S RESEARCH BEING DONE TODAY AND WHAT TYPES THERE ARE. >> YES, YES, YES AND YES. WHAT WAS FUN ABOUT THE VIRTUAL REALITY RESEARCH IS THAT WE HAD PSYCHOLOGISTS AND PROGRAMMERS GETTING TOGETHER BRAINSTORMING AND TALKING. THE COMPUTER SCIENTIST FROM GEORGIA TECH BROUGHT HIS BRILLIANT COMPUTER SCIENCE GRADUATE STUDENTS TO MY OFFICE AND I EXPLAINED EXPOSURE THERAPY, FOR FEAR OF HEIGHTS FIRST TIME WE DID IT AND I EXPLAINED WHERE I TAKE SOMEBODY IN ATLANTA IF THEY HAD A FEAR OF HEIGHTS AND THEN THEY WENT BACK AN CREATED THOSE IN VIRTUAL REALITY. FOR THE ONE USING DI CYCLE SERINE, THAT ALSO INVOLVED KERRY WRESTLER, AN M.D. Ph.D. PSYCHIATRIST AND OTHER FOLKS. WE'RE STILL DOING LOTS OF RESEARCH WITH ALL ASPECTS OF EVERYTHING THAT YOU SAW. AND A LOT OF TIMES COMPUTER PROGRAMMERS WORKING WITH PSYCHOLOGISTS AND PSYCHIATRISTS TO COME UP WITH -- EXAMPLE, COMPUTER SCIENTISTS WHEN WE FIRST START DODDING SOMETHING, WHEN WE DID THE VIRTUAL AIRPLANE, I DIDN'T SHOW YOU THE COMPUTER SCIENCE THING, WE CAN CRASH THIS THING, LIKE NO, LARRY, YOU DON'T UNDERSTAND. WE WANT TO USE THIS THERAPEUTICALLY. SO I THINK THE TEAM APPROACH IS IMPORTANT. >> MY NAME IS (INAUDIBLE) A DRPH STUDENT AT JOHNS HOPKINS. MY QUESTION IS, WHAT'S NEXT WITH THE VIRTUAL REALITY? AFTER YOU'VE DONE STUDIES ON -- IN FAVOR OF EFFICACY OF VIRTUAL REALITY, WHAT ARE SOME OF THE POLICY NEXT THINGS TO DO FOR YOUR STUDY? >> ONE OF THE NEXT STEPS IS A STUDY WE'RE DOING NOW THAT I'M EXCITED ABOUT. AND IT'S A THREE SITE STUDY, IT'S LOOKING AT -- SO IT'S TWO BY TWO FOR THOSE WHO THINK THAT WAY. IT'S LOOKING COMPARING VIRTUAL REALITY EXPOSURE THERAPY TO PROLONGED IMAGINABLE EXPOSURE THERAPY WITH OR WITHOUT DECYCLE SERINE AND WITHOUT LOOKING AT GENETIC PREDICTORS. WE'RE LOOKING AT BDNF WHICH HAS SOME OF THE ALLELES HAVE SHOWN TO BE INVOLVED IN PEOPLE WHO AND ANIMAL WHOSE EXTINGUISH TO FEAR WELL OR NOT, RESISTANT TO EXTINCTION. SO THINKING IF YOU HAVE THE ALLELE WHERE YOU MIGHT BE MORE RESISTANT TO EXTINCTION, MAYBE THE VIRTUAL REALITY, A MORE POTENT STIMULUS, THAIB MA THAT WILL RESCUE YOU, MAYBE THE DECYCLE SERINE FACILITATING THAT WILL RESCUE YOU. BECAUSE IT'S EXPENSIVE F. YOU DON'T NEED THE COMPUTER STUFF DONE USE IT. TRYING TO FIGURE OUT WHO NEEDS WHAT KIND OF THERAPY, AND TO INDIVIDUALIZE AND PERSONALIZE WHAT PEOPLE GED GET. I ALSO WANT TO GET AWAY FROM THE HEADLINE DISPLAY F WE CAN USE A FLAT SCREEN OR DVD, IF WE DELIVER IT OVER THE INTERNET, MAKE IT EASIER AN CHEAPER, I WOULD LOVE TO GO THAT WAY AND FIGURE OUT WHO NEEDS WHAT. >> IN THE TRIALS HOW LONG DOES THE TREATMENT AFFECT LAST? HAVE YOU CURED THEM? OR ARE THEY COMING BACK? >> IN PSYCHOLOGY I DON'T INTEND TO USE THE CURE WORD THAT'S A FOUR LETTER WORD FOR ME. IN GENERAL IN PTSD AND WITH EXPOSURE THERAPY, WE SEE MORE GAINS AT FOLLOW-UP THAN AT POST TREATMENT. THAT MAYBE A MEASUREMENT ARTIFACT BECAUSE THE POST TREATMENT IF YOU'RE DOING -- SO WE'RE USING THE REGULAR DSM DEFINITION WHICH IS FOUR WEEKS. ONE MONTH THAT. INCLUDES A LOT OF TIME THEY WERE IN TREATMENT AND WITH EXPOSURE THERAPY YOU'RE STIRRING EVERYTHING UP. (OFF MIC) >> GENERALLY STILL DOING WELL. WE THINK THAT WE'RE CREATING PERMANENT CHANGES IN THE FEAR STRUCTURE. AS WE TELL PATIENTS YOU CAN'T UNDO WHAT YOU HAVE DONE HERE AND HOW YOU CAN THINK ABOUT IT DIFFERENTLY AND HOW YOU CAN GO THERE NOW. THAT'S NOT TO SAY IF THEY EXPERIENCE A NEW TRAUMATIC EVENT THAT THEY WON'T GET PTSD AGAIN BUT FOR EXAMPLE, WE DID TWO FEAR OF FLYING STUDIES WITH VIRTUAL AIRPLANE PRIOR TO 9/11 BECAUSE YOU CAN'T GET PAST SECURITY NOW WITHOUT A TICK. WE FOLLOWED UP THOSE FOLKS AFTER 9/11 TO SEE IF THEIR FEAR OF FLYING INCREASED AND WE DID A MATCH CONTROL FOR FRIENDS LIKE THEM WITHOUT THE FEAR OF FLYING. THEIR FEAR DIDN'T INCREASE. THEY CONTINUED TO USE THE COPING MECHANISMSCH OTHER FOLKS WHO DID HAVE A FEAR OF FLYING BEFORE 9/11, FEAR OF FLYING INCREASED BUT NOT THE PATIENTS TREATED. SO IN GENERAL WE'RE TEACHING PEOPLE NEW SKILLS AN NEW WAYS TO DEAL WITH IT. WE'LL SEE. YES, SIRCH LAST QUESTION. (OFF MIC) >> SO I THINK THE LEARNING FOLKS TELL YOU THERE IS A LOT OF DATA THAT MEMORIES ARE CONSOLIDATED AND THERE'S ANIMAL DATA AND HUMAN DATA FOR EARLY INTERVENTION STUDY. CONVENTIONAL WISDOM IS GET THEM BEFORE THEY SLEEP. WE TRIED TO DO THE STUDY IN FOLKS WHO HADN'T LEFT YET AND REVIEWER CAME BACK SAYING WE DONE HAVE THE DATA ABOUT THAT SO WE'LL LOOK TO SEE IF THAT INFLUENCE -- BUT IT IS CONSOLIDATED. IN SLEEP SO WE WANT TO TRY TO GET TO THEM EARLIER. I ALSO DIDN'T SHOW YOU MIKE DAVIS HAS A LITTLE BIT OF DATA, NOT PUBLISHED YET WITH THE DECYCLE SERINE GIVE -- DOING THE EXTINCTION TRAINING DURING THE DAY AND THIS IS I THINK IN ANIMALS AND GIVING THEM THE DECYCLE SERINE BEFORE THEY SLEEP AN IT WORKS. SO I THINK THAT WE DEFINITELY HAVE EVIDENCE THAT STUFF IS CONSOLIDATED IN SLEEP. DREAMS ARE A WHOLE DIFFERENCE STORY, I GUESS I SHOULD STOP. YES. (OFF MIC) >> SO FOLKS THAT DO AND DON'T GET PTSD, I THINK IT'S PRETTY COMPLICATED. AGAIN, SOME OF MY COLLEAGUES KERRY WRESTLER AND HIS GROUP FOUND A GENE BY ENVIRONMENT INTERACTION. YOU FIND ON A COUPLE OF GENES THIS WAS SKBP-5 I THINK. AND WITH A CERTAIN ALLELE AND EXPOSURE TO ADVERSITY IN CHILDHOOD, AND THEN EXPOSURE TO A TRAUMA AS AN ADULT. FOLKS GOT PTSD OR NOT SO IT WAS THE GENE BY THE ENVIRONMENT, BY THE EXPOSURE IN CHILDHOOD THAT PREDICTED WITH EXPOSURE IN ADULTHOOD IF THEY GET PTSD OR NOT. SO I THINK IT'S ACTUALLY COMPLICATED. IT IS A NATURE, NURTURE THING. I ALSO DON'T THINK IF YOU JUST LOOK AT THE FLIP SIDE OF THAT DATA, AND IF YOU -- YOU CAN CALL IT RESILIENCE BUT RESILIENCE IS ALSO MORE THAN THAT. I THINK RESILIENCE IS NOT JUST ABSENCE OF PTSD, DENNIS CHARNEY HAS DONE WORK ON RESILIENCE IN THE POWs FROM THE HANOI HILL TON AND IN NAVY SEALS. AND HE'S ENUMERATED AND OTHER FOLKS HAVE THINGS THAT THEY THINK ARE IMPORTANT FOR RESILIENCE AND I THINK RESILIENCE, YOU HAVE TO BE EXPOSED TO ADVERSITY TO DEVELOP RESILIENCE. BUT SOME OF THE THINGS HE IDENTIFIED OF VALUE SYSTEM, HUMOR, SUPPORT. SO I THINK IT GETS COMPLICATED. SO WITH THAT, I SHOULD STOP. THANK YOU.