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Virtual Reality exposure therapy

Using Virtual Reality for treating PTSDan innovative method for treating Post-Traumatic Stress Disorder following terrorist attacks in Israel

In Israel, civilians are a frequent target of terrorist suicide bombers such as attacks on civilians riding on public buses. After experiencing terrorist attacks, the survivors may develop post traumatic stress disorder (PTSD).


Naomi Josman and her collaborators are studying how virtual reality can be an effective treatment of PTSD. In the following lines, they present an abstract from a forthcoming manuscript by Freedman, SA, Hoffman HG, Garcia-Palacios A, Weiss PL, Avitzour S, and Josman N: “Prolonged Exposure and Virtual Reality enhanced imaginal exposure for PTSD following a Terrorist Bulldozer Attack: A Case Study” (in press), CyberPsychology and Behavior.



Post Traumatic Stress Disorder or PTSD: is a sever and ongoing emotional reaction that may occur following a traumatic event such as serious injury or threat of injury or death. The symptoms of PTSD can include reexperiencing the original trauma with flashbacks or nightmares, avoiding stimuli associated with the trauma, difficulty falling asleep and anger.

Clinician-Administered PTSD Scale or CAPS: is a structured interview that is used for diagnosing and measuring the severity of PTSD. It contains separate ratings for the frequency and intensity of each symptom, which can be summed to create a severity score for each symptom.



   The abstract

This study provided first-time evidence for the efficacy of Virtual Reality Exposure (VRE) treatment in treating Post Traumatic Stress Disorders (PTSD) triggered by an Israeli terrorist attack. In the present case study virtual reality was used to augment imaginal exposure in a protocol based on Prolonged Exposure (PE) (Foa, et al., 2005).


Jerusalem bus attackA 29 year old male patient developed PTSD after surviving a deadly terrorist bulldozer attack on two civilian buses and several cars in Jerusalem (including one decapitation). The crowded bus in which the patient was riding was pushed over onto its side by the terrorist, injuring, trapping and terrifying the passengers, and leaking gasoline. Guided by his therapist, the patient entered an immersive computer-generated virtual world to go “back” to the scene of the traumatic event to help him gain access to his memories of the event, process and reduce the intensity of the emotions (fear/anger) associated with his pathological memories and to change unhealthy thought patterns.


Traumatic memories of childhood abuse and traumatic memories of the bulldozer terrorist attack were treated using imaginal exposure while the patient was in the virtual environment (BusWorld). The patient showed large post-treatment reductions in PTSD symptoms and his Clinician Administered PTSD Scale (CAPS) scores dropped from 79 pre-treatment to zero immediately post-treatment and CAPS was still at zero six months later.


Further exploration of VR for PTSD treatment is neededAlthough case studies are inconclusive by nature, these encouraging preliminary results suggest that further exploration of the use of virtual reality during modified PE for PTSD is warranted. As terrorist attacks increase in frequency and severity worldwide, research is needed on how to minimize the psychological consequences of terrorism.

Authors : Naomi Josman, Ph.D.
  Associate Professor
  Department of Occupational Therapy
  Faculty of Social Welfare & Health Sciences
  University of Haifa
Sara A. Freedman, Ph.D.
  Department of Psychiatry
  Hadassah University Hospital Israel
Azucena Garcia Palacios, Ph.D.
  Jaume I University
Patrice (Tamar) Weiss, Ph.D.
  Full Professor
  Department of Occupational Therapy
  Faculty of Social Welfare & Health Sciences
  University of Haifa
Hunter Hoffman, Ph.D.,
  University of Washington
Introduction text by : Pauline Boinot, M.Sc.



  • Difede, J. Cukor, N. Jayasinghe, I. Patt, S. Jedel, L. Spielman, C. Giosan, & Hoffman, H.G. (2007). Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. Journal of Clinical Psychiatry, 68, 1639-1647.

  • Freedman, S. A., Hoffman, H. G., Garcia-Palacios, A., Weiss, P. L., Avitzour, S., & Josman, N. PE + VR enhanced imaginal exposure for PTSD following a Terrorist Bulldozer Attack: A Case Study. (in press), CyberPsychology & Behaviour.

  • Foa, E. B., Cahill, S. P., Boscarino, J. A., Hobfoll, S. E., Lahad, M., McNally, R. J., & Solomon Z. (2005). Social, psychological, and psychiatric interventions following terrorist attacks: recommendations for practice and research. Neuropsychopharmacology, 30, 1806-1817.

  • Josman, N., Reisberg, A., Weiss, P.L., Garcia-Palacios, A., &. Hoffman, H.G. (2008). Bus World: An Analog Pilot test of a virtual environment designed to treat Post-Traumatic Stress Disorder originating from a terrorist suicide bomb attack. (Rapid communication) CyberPsychology & Behaviour, 11, 775-777.

  • Wilson, H.G., Onorati, K., Mishkind, M., Reger, M.A. & Gahm, G.A. (2008). Soldier attitudes about technology-based approaches to mental health care. CyberPsychology & Behaviour. 11, 767-769.


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