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Fast development of computer and information technology enables realization and application of new methods and systems that were not feasible in the past century. One example of such development is the area of virtual reality (VR), virtual surgery (VS), virtual endoscopy (VE), computer assisted surgery (CAS), 3D-CAS, robotic/telerobotic surgery, and Tele-3D-CAS. The real visual, auditory, and tactile cues are replaced by computer-generated sensory cues, therefore giving the user a sense of presence in a virtual world. CAS and VR have found many applications in the field of medicine. Advances in high performance computing, graphics, and networking, together with new human-machine interfaces form a technological basis for VR/3D-CAS/Tele-3D-CAS applications. Related fields and terminology such as augmented reality, full and partial immersion, wearable computers, telepresence, and telemedicine will be introduced in the paper. The aims of the paper are to present VR, 3D-CAS, and Tele-3D-CAS technology, to provide an overview of some mentioned research activities, information and research resources. An overview of the current research activities in the field of medicine of the 21st century includes: education, surgical planning and simulation, visualization, telemedicine/telesurgery, computer-aided surgery, human-machine interfaces, and rehabilitation and therapy. [ABSTRACT FROM AUTHOR]

Several studies using VR exposure therapy for PTSD have been conducted to date, with promising results. The need for better accuracy of the patient's arousal assessment requires aggregation of various measures of arousal, including physiological ones, which may increase the mental burden on the therapist. Assessment of the patient's arousal, automated by the computer, may therefore be useful. As the therapist also needs to manipulate user interface to introduce appropriate trigger stimuli in the virtual environment, automated adaptation of VR scenarios in response to the patient's level of arousal may alleviate this task. This paper describes the architecture of the software that performs appropriate automation according to the rules of graded exposure therapy, and discusses issues for successful implementation of such software. [ABSTRACT FROM AUTHOR]

Controlled studies by groups throughout the world have proven the efficacy of virtual reality (VR) exposure for “mental rehabilitation,” including treatment of Specific Phobias (SP), Social Phobia (SoP), and Panic Disorder with Agoraphobia (PDA). In addition, many are now showing the power of adding VR to protocols to treat individuals with Posttraumatic Stress Disorder (PTSD) as well as to prevent PTSD by “inoculating” individuals against stressful situations they may encounter (Stress Inoculation Training). Others have shown how VR can be added to protocols for those needing “physical rehabilitation” to improve patient compliance and outcomes. In addition, studies have shown the addition of physiological monitoring and feedback to the VR protocol can have added benefit, both in terms of short term effectiveness and in terms of lowering recidivism in the long term. VR allows stimuli to be presented in a systematic, controlled fashion, and physiology provides objective evidence of when the stimuli are eliciting appropriate responses in the patient or trainee. This enables treatment and training to be individualized, focusing in on those specific parts of the experience which cause the individual the most difficulty. By combining such measures as subjective ratings, physiological data, personality type, and self-report questionnaire scores, with expert clinical observations; it is possible to further refine and improve clinical and research-based protocols. Decades after the first simulators were used to train fighter pilots, advanced technologies and simulations are now impacting military medicine. This paper highlights illustrative studies to introduce the reader to this area. [ABSTRACT FROM AUTHOR]

Post Traumatic Stress Disorder is reported to be caused by traumatic events that are outside the range of usual human experiences including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) exposure treatment has been used in previous treatments of PTSD patients with reports of positive outcomes. The aim of the current paper is to specify the rationale, design and development of a Virtual Iraq PTSD VR application that has been created from the virtual assets that were initially developed for a combat tactical training simulation, which then served as the inspiration for the X-Box game entitled Full Spectrum Warrior. [ABSTRACT FROM AUTHOR]

We believe that this Advanced Research Workshop has given participants an opportunity to foster essential international collaborative research on the diagnosis and treatment of posttraumatic stress disorder, a common and disabling consequence of war, terrorism, and natural disasters. As a result, it represents an important piece in efforts to help soldiers and civilians of NATO and partner nations in the face of future international conflicts. This publication contains the full papers corresponding to the relevant presentations provided at the workshop. This text is organized so as to provide a coherent picture of the work and thoughts of participants in the ARW, rather than necessarily following the exact order of the presentations as they were provided in Cavtat, although this summary conveys to the reader the manner in which presentations and working groups were conducted. Appropriate financial support was vital for the successful organization and implementation of the workshop. Grateful acknowledgments for generosity go to the primary sponsor, the NATO Security through Science Programme, as well as to a number of Croatian donors, who recognized the importance of this event. As a token of our appreciation, the logos of all sponsors are included here. The workshop was organized and this accompanying publication was assembled by joint dedication and efforts from the members of Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD, and University of Zagreb, Faculty of Electrical Engineering and Computing (FEEC), Croatia. Professor Michael Roy of USUHS, the NATO-country program co-director and organizing co-director, conceived the overall design of the workshop, and with the assistance of his research assistant Patricia Kraus, wrote and submitted an application to NATO. Dr. Roy selected and invited the majority of the speakers and participants, and he and Ms. Kraus edited each of the chapters incorporated in this publication. Professor Kresimir Cosic, the organizing co-director and a member of FEEC, coordinated financial aspects of the ARW, solicited additional funding from Croatian donors, invited representatives of the Government of Croatia, and promoted the workshop within international politico-military circles. He coordinated coverage of the workshop with Croatian Radiotelevision, and organized meals as well as a boat trip to Dubrovnik for participants. Professor Dragica Kozaric Kovacic, the partner-country program co-director and a member of University Hospital Dubrava in Zagreb, Croatia, extended invitations to several international speakers, further improving the quality of the workshop. Assistant Professor Miroslav Slamic, a member of FEEC, handled accreditations, the purchase of consumable supplies, and designed such items as the workshop poster, program cover, and the appearance of compact disks (CDs) of presentations and pictures for participants. He was also the workshop photographer. Sinisa Popovic, a member of FEEC, was the “glue” that held together the planning and smooth running of the workshop, coordinating travel, lodging and meal arrangements, precise estimation of expenses, assembling of workshop materials, and other arrangements with the conference site. Marko Cosic designed the gala dinner menu and coupons, and assisted Mr. Popovic with local arrangements and assembling of workshop materials, handled some on-site financial matters, etc. Workshop CDs were made possible through the joint efforts of Miroslav Slamic, Sinisa Popovic, Marko Cosic, and Patricia Kraus. Dr. Roy also gratefully acknowledges the many hours of assistance Ms. Kraus provided in reviewing the manuscripts for this text. [ABSTRACT FROM AUTHOR]

This paper describes the result of a discussion in a working group and a plenary discussion at the NATO Advanced Research Workshop on Novel approaches to the diagnosis and treatment of posttraumatic stress disorder. Several technological challenges are presented with regard to the basic functions of a VRET system. Most challenges are demand-driven and are focused on better ways to support the therapist, for better and more efficient treatment. Tele-care is one of the most promising but difficult challenges. The results give directions for both fundamental and practical research. [ABSTRACT FROM AUTHOR]

Virtual reality is a new technology that has been applied to the treatment of several mental disorders. The first case study using this new tool was published in 1995. After ten years, several studies have been conducted in the field of Clinical Psychology, mainly in the application of VR for the treatment of anxiety disorders. The present work is a review of the use of Virtual Reality in the treatment of mental disorders. The advantages and limitations of virtual reality are discussed and the findings to date are reviewed. [ABSTRACT FROM AUTHOR]

Soldiers returning from combat military operations are at risk for developing a range of psychological problems. One way to facilitate the identification of these atrisk soldiers is to have them complete a psychological screening survey. Such a survey can be used to link soldiers reporting psychological problems with appropriate mental health services. The challenge of developing such a screen is to ensure that it is valid, short, and easy to administer. The US Army Medical Research Unit-Europe has been at the forefront of developing a valid psychological screen for use with soldiers at post-deployment. Research conducted prior to 2004 showed that screening needed to include five domains: post-traumatic stress disorder, depression, alcohol problems, anger, and relationship problems. Blind validation studies conducted in 2004 led to the selection of scale items and cut-offs for each domain resulting in an effective short screen with good sensitivity and specificity values. Finally, the question of when to conduct psychological screening at post-deployment has also been addressed through a comparison of prevalence estimates at immediate reintegration and three months post-deployment. Future research will examine scale refinement and the use of sleep problem questions in subsequent screening efforts. [ABSTRACT FROM AUTHOR]

The under recognition of the psychological effects of trauma in medicine requires a modification of clinical evaluation strategies, given the gravity of the consequences of such conditions if left untreated. The most significant problems are Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD), along with comorbid disorders. The most significant comorbidities are abusive alcohol consumption, depressive episodes, symptoms of generalized anxiety, phobia symptoms, of panic disorders, as well as somatic complaints. We distinguish between the measures requiring the intervention of an evaluator and self-report measures. To follow a patient and adapt a treatment it is necessary to know the severity of the peritraumatic reaction. Two major characteristics of the trauma response have been clearly identified; dissociation (measured with the Peri-traumatic Dissociative Experience Scale and distress (measured with the Peri-traumatic Distress Inventory). Some Instruments have been validated that measure the psychopathological consequences related to a traumatic event. The recognized gold standard (Clinician Administered PTSD Scale, or CAPS) is time-consuming and requires an experienced professional to administrate. The most frequently used self-report measures are the Impact of Event Scale-Revised and the Posttraumatic Check List. To measure non-specific psychological consequences of a traumatic event we propose the General Health Questionnaire-28 and The Beck Depression Inventory. Other potentially useful measures are described to aid with the evaluation of traumatized patients. [ABSTRACT FROM AUTHOR]

Given the high prevalence and considerable individual and societal costs of PTSD, there are relatively few randomized, placebo-controlled trials in PTSD. Four placebo controlled trials have been performed with MAOIs, three with TCAs. Only one randomized placebo controlled trial was performed with benzodiazepines class, showing no effect of alprazolam on core PTSD symptoms. The majority of trials were done with SSRIs and novel antidepressants, the most of them showing moderate effect sizes over placebo. In past clinical trials antidepressants appeared with the best overall efficacy for the treatment of PTSD, although their effect may not be present in all symptom clusters. Although duration of majority of trials in psychiatry is conventionally set to 12 weeks, clinical trials in PTSD may require the acute phase of treatment to go beyond initial 12 weeks of treatment, especially if the trial includes more severely ill patients. Further clinical research is warranted, using new compounds, as well as those already marketed for other indications. It remains essential to investigate if certain treatments are more effective for particular symptom sets or for some subgroup of PTSD patients. Due to high placebo response and moderate effects of drugs researched in PTSD it is difficult to avoid the use of placebo in PTSD trials. [ABSTRACT FROM AUTHOR]

Military Operations expose personnel to stresses not normally experienced in garrison or in civilian life. The consequence of such exposure is the development of Operational Stress Injuries. The Canadian Forces has developed and continues to improve upon a phased response to assist its members in better being able to respond to these stresses beginning at recruitment and extending throughout the military career. This process is summarized. As a final point, early intervention, a subject of considerable discussion in the literature is addressed through a proposed model aimed at promoting resiliency and early treatment where needed. [ABSTRACT FROM AUTHOR]

Virtual reality (VR) offers a new human-computer interaction paradigm in which users are no longer simply external observers of images on a computer screen but are active participants within a computer-generated three-dimensional virtual world. Posttraumatic stress disorder (PTSD) is a severe and often chronic and disabling anxiety disorder, which can develop following exposure to a traumatic event that involves actual or threatened injury to self or others. The term exposure therapy refers to several behavioral and cognitive behavioral treatment programs that involve confronting feared but safe thoughts, images, objects, situations, or activities in order to reduce pathological (unrealistic) fear, anxiety, and anxiety disorder symptoms. In the treatment of PTSD, exposure therapy usually involves prolonged, imaginal exposure to the patient's memory of the trauma and in vivo exposure to various reminders of the trauma. There is substantial evidence that exposure programs are highly effective in the treatment of PTSD. A Virtual Vietnam environment was created to explore the efficacy of VR Exposure therapy with Vietnam combat veterans with PTSD. Two virtual environments, a virtual Huey helicopter and a virtual clearing surrounded by jungle were created. Patients were exposed to their most traumatic Vietnam memories while immersed within the virtual environments following a standard treatment manual. Data are presented, and other applications of VR exposure therapy in the treatment of PTSD are discussed. [ABSTRACT FROM AUTHOR]

In this chapter we describe several technological requirements that must be considered in order to achieve a practical, efficient, ecological and usable integration of behavioural therapy and virtual reality (virtual therapy or VT). Some critical aspects are considered regarding the media form and media content of virtual therapy applications. Finally, future trends and promising technological tools used for VT applications are discussed like adaptive displays and augmented reality interfaces. [ABSTRACT FROM AUTHOR]

Research into posttraumatic stress disorder is discussed from the perspective of clinically relevant measures to be included in future outcome research. It is concluded that studies into the effects of treatment of posttraumatic stress disorder should include measures for co-morbidity, impairment and quality of life. Further, recommendations are made to investigate moderator and mediator variables affecting outcome of treatment in trauma victims, including social support, personality traits, and cognitive characteristics. It is recommended to use theoretically derived variables, rather than available base-line characteristics. Further, these moderators and mediators should be studied in specific groups of trauma patients, rather than in patients who have experienced a variety of traumatic events of varying severity levels [ABSTRACT FROM AUTHOR]