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Dr. JoAnn Difede, a psychologist at New York-Presbyterian Hospital/Weill Cornell Medical Center and an expert in the treatment of trauma, is using virtual reality exposure therapy to treat post-traumatic stress disorder in victims of the WTC attacks, as well as to treat a number of phobias in the general public such as fear of heights, fear of flying, and fear of public speaking. This was the first clinical program in the Northeast to use virtual reality (VR) exposure therapy to treat post-traumatic stress disorder (PTSD). And it is one of the few VR treatment facilities in the nation.

The PTSD system, which depicts the WTC on September 11, was co-developed by Dr. Difede and Dr. Hunter Hoffman, a researcher at the University of Washington.

In order to get better, patients must confront what they fear, says Dr. Difede. They need to retell their trauma in order to become desensitized to it. This is how imaginal exposure therapy, the standard treatment for PTSD and phobias, has worked as well. A therapist encourages patients to imagine what frightens them and to talk about it. But for many patients, especially those with PTSD or phobias, this can be a problem. Inherent in the ailments is the tendency to avoid fear, and this leaves many patients unwilling or unable to open up. Here is where virtual reality has a real advantage.

By putting on a VR helmet, the patient is immediately immersed into a three-dimensional environment. When they look down or sideways, the scenery shifts. It's a sensory rich virtual world that creates an evocative therapeutic environment, says Dr. Difede. It encourages the patient to emotionally engage.

One of the project's initial PTSD patients, a young female executive who survived the WTC attacks, suffered from flashbacks, avoidance (i.e., refusal to watch news reports or stay in tall buildings), sleep problems, hypervigilance to avoid disaster, and anger and irritability. Traditional imaginal exposure therapy was ineffective, and during her initial evaluation for VR, the patient's engagement was limited. With little emotion, she described her experience on September 11.

However, upon putting on goggles and entering into the virtual world of lower Manhattan, she saw the twin towers and began to cry for the first time. After six VR sessions, an independent evaluator determined that the patient no longer met the criteria for PTSD, Major Depression, or any other psychiatric disorder. Her verbal self-report was also consistent with the evaluator's findings.

Virtual reality offers the therapist and patient total control over their environment and the ability to proceed at an individualized pace. You desensitize people to their fears in a graded fashion, says Dr. Difede. With the9/11 software, for example, a patient can experience planes flying by the WTC until they are comfortable enough to watch one hit a tower. In treating phobias such as fear of flying, a smooth flight might precede one with dark skies and turbulence.

At the moment, Dr. Difede is collaborating with Dr. Barbara Rothbaum of Emory University to introduce the use of Seromycin into their virtual reality therapy sessions. Seromycin is a medication that is currently used to treat tuberculosis, but it has also been found to aid in the transmission of a key protein to a certain brain receptor. The medication can speed a patient's unlearning of a particular fear and reduce the number of VR sessions needed to perhaps as few as two or three. Typically, most patients now require about six or seven one-hour sessions.

Compared with the expense of creating situations in the real world, virtual reality is cost effective, and it will allow therapists to treat a wider spectrum of people. (Compare a reusable flight simulation versus travel to an airport and the cost of tickets for a patient and therapist.) Decreasing costs for developing software and computer equipment will also help to make VR treatment more accessible.

Dr. JoAnn Difede and NewYork Presbyterian/Weill Cornell offer treatment for PTSD and phobias. Current environments include a downtown Manhattan/WTC site on 9/11, a simulated flight to treat fear of flying, an active lecture audience to treat fear of public speaking, a simulated job interview, a cocktail party to treat fear of social interaction, a tall building to treat fear of heights, and an environment to treat fear of storms.

Dr. Difede is an Associate Professor of Psychology in Psychiatry at Weill Cornell Medical College; an Associate Attending Psychologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center; and the Director of The Program for Anxiety and Traumatic Stress Studies at the Payne-Whitney Clinic at NewYork-Presbyterian Hospital. She has worked with survivors of trauma for the past 15 years and is currently Principal Investigator of two National Institute of Mental Health (NIMH)-funded studies for the treatment of PTSD. Following the World Trade Center attacks of September 11, 2001, the National Institutes of Health awarded Dr. Difede one of the few supplement grants to extend her treatment study to survivors of the WTC attacks.

The virtual reality work at NewYork-Presbyterian Hospital/Weill Cornell Medical Center is supported by Pfizer, Inc., Dell Computers, the National Institute on Drug Abuse (NIDA), and the Paul Allen Foundation. A company known as Virtually Better created the software to treat phobias.