Albert "Skip" Rizzo, Ph.D., tells AADPRT members that
virtual-reality technology is no longer science fiction.
Credit: Rick Brandt for AADPRT
The future is a virtual reality. Technology to create artificial
environments that can be manipulated—for teaching tomorrow's physicians,
assessing patients, and treating some conditions—has moved beyond
science fiction and is well on its way to becoming a functional tool in health
care and medical education.
Virtual reality (VR) technology has already shown utility for posttraumatic
stress syndrome, attention-deficit/hyper-activity disorder (ADHD), and other
areas of psychiatry and mental health, said Albert "Skip" Rizzo,
He made his remarks in an address titled "Virtual Reality and
Psychiatry: A Brief Review of the Future" at the annual meeting of the
American Association of Directors of Psychiatric Residency Training (AADPRT)
"Virtual reality has moved out of the phase of being an expensive toy
and into the stage of being a functional technology," said Rizzo, who is
a research scientist and professor at the Institute for Creative Technologies
in the Department. of Psychiatry and School of Gerontology at the University
of Southern California (USC).
Virtual realities can be displayed on a flat-screen, as with many computer
games, or can be viewed through the viewfinder of a head-mounted device (see
photo). The scene on the screen or in the viewfinder can be populated with
simulated stimuli that can be manipulated for whatever purpose is
necessary—whether it's amusement, education, or medical and psychiatric
A soldier in Iraq tests Virtual Reality technology that can be used in
exposure therapy for patients with PTSD.
Photo courtesy of Capt. Greg Reger, Madigan Army Medical Center and Skip
One of the most promising areas in VR technology is the treatment of
patients with PTSD.
Rizzo told Psychiatric News that an early prototype of a VR system
for Iraq veterans developed at USC, called Virtual Iraq for Exposure Treatment
of PTSD, was designed to simulate traumatic battlefield conditions in Iraq.
The system was tested in Iraq by Army Capt. Greg Reger, a clinical
psychologist, to "gather user feedback from boots on the ground as to
what needed to be in the application to make it more realistic and emotionally
evocative," Rizzo said.
He added that Reger is now using Virtual Iraq for Exposure Treatment of
PTSD with patients at Madigan Army Medical Center at Fort Lewis, Wash.
"Soldiers in treatment have also provided good recommendations for
improving the application, and this process will continue throughout the
lifecycle of this system in order to continuously evolve the features needed
to make the system better," Rizzo said.
A report by JoAnn Difede and colleagues in the November 2007 Journal of
Clinical Psychiatry reported successful use of VR Exposure Therapy for
PTSD following the September 11, 2001, terrorist attacks.
Rizzo also described preliminary efforts at using VR technology in
psychiatry residency training to simulate patient interviewing. The Virtual
Patient Project is designed to allow trainees and clinicians to conduct an
interview with an "intelligent" virtual character that emulates a
person with a DSM-IV disorder.
Army Capt. Greg Reger (left) tests virtual Iraq technology with a
Photo courtesy of Capt. Greg Reger, Madigan Army Medical Center, and Skip
Rizzo told training directors at the AADPRT meeting that the Virtual
Patient Project was based on VR technology used by the Army to train soldiers
in negotiation skills needed in dangerous settings. Because the technology is
still in its early stages, the virtual "characters" tend to
respond slowly and to utter stereotypic responses—characteristics that
match in a general way those of a resistant teenager who doesn't want to be in
So the first simulated patients were resistant male teenagers, and later a
young virtual female who had experienced a sexual assault. "The ultimate
vision would be to create a virtual character for every DSM diagnosis
so you could do training and assessment of novice clinicians' diagnostic
skills and their interactions with challenging patients," Rizzo
Also advancing is a VR system for measuring attention performance in
children with and without ADHD using a virtual classroom. The virtual scenario
consists of a classroom that allows for comprehensive and integrated
diagnostic assessment of attention and motor reactivity while in the presence
of systematically delivered distractions.
A clinical trial of the system compared eight physician-referred males with
ADHD (6 to 12 years of age) with 10 boys who did not have ADHD. Participants
in the ADHD group were off medication during the testing period with all
testing occurring in the morning prior to normal medication ingestion.
Research participants were instructed to perform a "successive
discrimination task" in which they viewed a series of letters on the
blackboard in the virtual classroom and were required to hit a response button
when a letter "X" preceded by an "A" appeared on the
Two 10-minute conditions were tested—one without distractions, and
one with distractions (classroom noises, a paper airplane flying across the
visual field, a car rumbling by the window, and a person walking into the
classroom with hall sounds occurring when the door to the room was
The discrimination task using VR technology proved to have"
ecological validity" by distinguishing ADHD patients from
controls across a number of measures, and doing so more robustly than standard
neuropsychological tests: during both the distraction and nondistraction
conditions, children with ADHD showed greater variability in response time and
made more errors of omission and commission.
Rizzo said VR also has promising uses for patients with traumatic brain
injury, Alzheimer's, schizophrenia, or mental retardation.
"All technologies go through a hype cycle," Rizzo said at the
AADPRT meeting. "In the invention phase you get inflated expectations
until people actually try it and find out it's not as good as was thought.
Then it can slip into a trough of disillusionment. But if the technology has
merit, and people do the hard work and hard science to demonstrate that merit,
it may move up the slope of enlightenment toward a plateau of
Rizzo said VR was in the trough in the 1990s, but has moved up the slope
today. "There are a number of areas where this technology is showing
value," he said. "We are not talking about science fiction
Information about the Virtual Patient Project is posted at<http://vrpsych.ict.usc.edu/Virtual_Patient_Projects.html>.
Information about the Virtual Classroom is posted at<http://vrpsych.ict.usc.edu/vr_classroom.html>.
Information about all of the VR projects at USC, as well as citations for
published studies and reports on VR, can be accessed at<http://vrpsych.ict.usc.edu>.
"Virtual Reality Exposure Therapy for the Treatment of
Posttraumatic Stress Disorder Following September 11, 2001," is posted