A Pioneer in the Field of PTSD

You walk through a crowded marketplace in Iraq and pass a colorful fruit stand and a butcher selling meat. Cars are parked along the street. You hear a call to prayer and, suddenly, the people vanish. You look around and realize you are now alone, the street eerily quiet. A moment later, a bomb goes off.

In reality, you are in an office with a virtual reality headset over your eyes, and a trained psychologist who sits beside you has triggered the simulated explosion — which you feel vibrate — as part of virtual reality exposure therapy to help you recover from post-traumatic stress disorder (PTSD).

The office of JoAnn Difede, Ph.D., serves as a virtual reality lab where active-duty military and veterans of the wars in Iraq and Afghanistan, as well as 9/11 first responders and survivors, can put on a headset and be transported back to the desert, a marketplace in Iraq, or to the Twin Towers. Dr. Difede, director of the Program for Anxiety and Traumatic Stress Studies at NewYork-Presbyterian and Weill Cornell Medicine, has spent the last 20 years trying to ease the pain of people who have PTSD, whose traumatic memories manifest as nightmares, causing flashbacks, irritability, difficulty sleeping, hypervigilance, and more.

“They may startle easily to loud noises,” says Dr. Difede, who is also an attending psychologist at NewYork-Presbyterian/Weill Cornell Medical Center and a professor of psychology in psychiatry at Weill Cornell Medicine. “People who have been through trauma may tell you they can’t sit with their back to the door — they are just tense all the time. It interferes with relationships, school, and work.”

Dr. Difede, a pioneer in virtual reality exposure therapy, immerses people in detailed scenarios based on their experiences to help them face and move past their trauma. To date, she and her team have treated hundreds of patients at NewYork-Presbyterian and Weill Cornell Medicine.

“The idea is that by going over and over it again as it if it were happening, your brain learns that it actually happened in the past, and that you’re safe now. Your brain is learning, ‘Oh, this is in the past. I can file it away now in the memory drawer,’” says Dr. Difede. “By going over the trauma, the person can gain a sense of control over it. We’re helping them walk through a horrifically difficult situation to help them find a way out.”

While some patients with PTSD can lessen their symptoms by recounting their trauma to a trained psychologist (prolonged exposure therapy), others may be too numb to fully engage with the memory, which holds them back from healing. This is where virtual reality and all the sensory details from memories come in, says Dr. Difede.

“Humans don’t live by the word alone,” says Dr. Difede. “We’re not just verbal creatures, which is the way psychotherapy’s typically done. In the virtual environment, you can use sensory stimuli to help emotionally engage the person.”

Inside Dr. Difede’s office, patients put on the mounted headset and can see the computer-generated environment. Using toggles, like in a video game, they maneuver through the environment — walking through the marketplace or a mountain terrain, or driving a convoy through the desert, hearing and feeling the truck rumbling beneath them. While doing so, the patient describes the traumatic experience to Dr. Difede (or a trained psychologist on her team) sitting nearby. Dr. Difede, who can see the virtual images on a computer screen, manipulates details to make them more specific to the individual. For example, if the person was alone at the time of the traumatic event, Dr. Difede can remove the other characters from the environment. She can summon a sandstorm or create an explosion (the patient feels the vibration) or introduce the sound of shooting. Or in the barracks, she can set off an “incoming” alert. She might even incorporate smells, like Iraqi spices, into the treatment.

“You want someone to have a visceral reaction so they can learn that they’re in a safe environment and whatever their trauma was, it isn’t happening anymore,” she says.

Working with computer programmers and engineers, Dr. Difede and her colleagues collected feedback from veterans and therapy clinicians around the country to design scenarios that are realistic and full of rich details that apply to many people’s experiences.

“The sensory imagery is very vivid for trauma memories. Sounds, smells and sights can evoke a fear response,” she says.

For example, garbage lines the curb in the market scenario and, during treatment, Dr. Difede may use its odor. In Iraq, trip wires that triggered explosions were sometimes hidden beneath garbage.

“So that is a huge fear for most of our soldiers here who walked patrols,” Dr. Difede says of encountering garbage on the street.

Dr. Difede says she stumbled into this work. She originally came to NewYork-Presbyterian and Weill Cornell Medicine as a graduate student to do research in psychoneuroimmunology, studying the effect of stress on health and the immune system.

“Twenty-five years ago, people still thought of the immune system as a closed system that couldn’t be affected by environmental stimuli,” says Dr. Difede.

While working with burn patients, she saw how people were experiencing panic attacks and an inability to sleep, and she realized she had no real intervention to offer them at the time.

“The diagnosis of post-traumatic stress disorder had changed in the decade prior to the World Trade Center,” she says, citing the current definition of PTSD, which says that a person has to have experienced directly or witnessed a life-threatening event, in which the person perceived they were either going to be killed, die, or experience a threat of harm. She adds that it is the only diagnosis in psychiatry that requires the experience of an external event, which was controversial in the field. The idea of a diagnosis of PTSD began to gain traction among experts following the Vietnam War, and was only solidifying in the years leading up to 9/11. “So imagine, if you can’t agree on what the phenomenon is, how can you study it and how can you develop treatments for it?”

Dr. Difede’s mentor, the late Dr. Samuel W. Perry, who focused on PTSD, encouraged her to write a grant to address this void. She and her colleague, Dr. Hunter Hoffman at the University of Washington, began planning a virtual reality simulation of a fire to help treat PTSD in burn survivors. Then came 9/11.

“Thousands of people were exposed to the World Trade Center attack,” says Dr. Difede. “We knew then that we certainly didn’t have a cure and barely had a treatment for PTSD. We saw it as a public health problem. People’s lives can be ruined by trauma.”

Dr. Difede and her colleagues pivoted their work to create a virtual reality simulation based on the terrorist attack, and conducted a study to see if virtual reality exposure therapy could be an effective treatment for PTSD.

“It was an experiment. We didn’t know if it would work,” she says.

The 9/11 simulation features the bright blue sky so many recall and an experience of events that occurred that morning at varying levels of intensity.

“Right after the World Trade Center, people were afraid of tall buildings, airplanes, blue skies, and stairwells because they [associated it with that day],” she says.

The results of the study and participants’ reactions suggested virtual reality could be especially useful for patients for whom imaginal exposure (recounting based on their imagination) therapy was not enough.

“I’ll never forget the first patient we treated in the study with the 9/11 simulation; she was numb and irritable and telling her story in a flat way,” recalls Dr. Difede. “She put on the head-mounted display and was immersed in the virtual world and started to cry. She said, ‘Oh my God, I never thought I’d see the World Trade Center again.’”

The patient went on to improve dramatically, says Dr. Difede.

From there, Dr. Difede began developing treatments and collaborating on studies for combat-related PTSD, and secured a $15 million grant from the Department of Defense.

At the same time, Dr. Difede also treats service members of any service era and military background, and of any duty status (active, veteran, or discharged) and their loved ones, through the NewYork-Presbyterian Military Family Wellness Center, where she serves as co-director, and previously through funding from the Welcome Back Veterans Initiative, which supports organizations that provide services to address the mental health needs of returning veterans and their families.

Her hope is that people with PTSD will seek treatment the same way someone with a cough or physical ailment goes to see a doctor.

“Don’t discriminate against your brain,” says Dr. Difede. “There are treatments that work for some people and other treatments that work for others, but the idea is to give yourself a chance to try. It’s a chronic condition, and without treatment it’s debilitating. If you’re suffering, not sleeping well, and you’re scared and irritable, what do you have to lose?”

Dr. Difede is proud of her pioneering work and says it inspires her to keep trying to advance knowledge and help people.

“It’s immensely rewarding to see someone get better,” she says.

She recalls a patient she treated during the 9/11 study who texted her one day to say, “I want you to know I got my life back.”

“That,” she says, “is why we get into medicine.”

Learn more about trauma treatment at the Program for Anxiety and Traumatic Stress Studies and find mental health services offered at NewYork-Presbyterian Military Family Wellness Center.