Critical Care nurse and assistant professor at the University of Central Florida, Brian Peach, and clinician with UCF Restores, Quentin Smith talk about virtual reality therapy for hospital PTSD.
Interview conducted by Ivanhoe Broadcast News in 2023.
Do you call this PICS and can you explain that?
Peach: There are some patients that months and years after their hospital admission, they have these prolonged symptoms of anxiety, depression, PTSD. They oftentimes have physical and cognitive issues that last long after their admission. Impacts their ability to work, there’s at least a third of them are unable to return to work within the first year.
Now, I’d have to think that it’s probably not diagnosed often, if you’re in the ICU you might not be the healthiest. Are you blaming it on whatever got you to the ICU?
Peach: Yes. There are large number of primary care physicians and psychologists, that are just now learning about this condition. This is something that we’ve talked about for quite awhile in critical care conferences, and in critical care literature. But there’s a lot of primary care physicians that are learning about this condition right now, even though it’s not a new condition. But the idea that people develop these long-term cognitive and mental health issues, is something that’s really a newer finding within the last few years.
I thought it was fascinating when I was reading about it, that how many people suffer from it.
Peach: Yes. There are certainly groups that are more predisposed, survivors of sepsis and something called acute respiratory distress syndrome. Some people that have massive inflammation on their lungs, trauma patients, and in particular people that were on ventilators for a long period of time. If you think about it, when somebody is on a ventilator they’re oftentimes on sedatives. They may be on analgesics, and they can be on a ventilator for quite a long period of time, and they can be very confused when they’re on the ventilator. One of the things that we know, is that patients that develop delirium in the hospital, are more likely to develop this post intensive care syndrome afterwards.
When you say ventilator, everybody goes to COVID and you’re getting so many more long COVID patients and the symptoms seem a lot alike.
Peach: Absolutely. In fact there is some similarity there, and there are some researchers out there that were quite surprised, when they started to hear about long COVID and about some of the same symptoms. There are some differences in terms of cognition, in terms of some of the mental health issues. In particular the focus my work, PTSD. You don’t tend to see the PTSD in the long COVID group. You may see some anxiety and depression, but not that PTSD component.
Is there a time you are usually in the ICU for longer than three days, or can it be for a day or 15 days?
Peach: It’s much more common in patients that were in the ICU for a longer period of time. As I said, particularly patients that were on a ventilator, doesn’t have to be on a ventilator. For our study, we want people that were on a ventilator, because we know that they oftentimes develop these long-term issues. Sure.
Do you see it in longer-term ICU people or just short?
Peach: We tend to see it more in people that were in the ICU for a very long period of time. That could be multiple days, that could be sometimes weeks to months. There’s some ICU patients that are in the hospital for a very long period of time, depending on their condition. We know from another one of our research studies that some of the more traumatic events are when someone has a breathing tube being placed. Or when they are coming off the ventilator and if you imagine they’re coming off sedation, and analgesics and they can be very confused. What we find is that people oftentimes live with these very vivid memories from their time in the hospital.
You never think that you can get some post stress from the hospital, it makes sense?
Peach: Yes. People have these very long period afterward where they’re hyper-vigilant. Where they’re waiting for potentially getting sick again and they don’t want to miss getting seconds. They’re in this just as you see with soldiers and this hyper-vigilant mode.
Tell me a bit about how your study worked?
Peach: This is what we’re calling compressed exposure therapy. It is a therapy that’s completed over two weeks. It’s a combination of some cognitive behavioral therapy, introduction of sensory triggers. Things that we know that have the triggers for someone in their daily life. It also involves virtual reality, where a person wears a virtual reality visor and they are in a hospital setting. If they look to one side they may see it nurse, they may see or they may actually hear the sound of beeping alarms monitor.
When you do this for two weeks, is it every day for an hour, how’s that?
Peach: Yeah, so it’s typically every day for between one to two hours particularly early on in therapy, it may be a little bit longer. Patients would come into the UCF restores clinic. They’ll meet with one of the therapists here, and they’ll walk them through the therapy and what that looks like early on. Then every day they’ll come in and the idea is that, you are desensitizing someone so they’re not having a strong emotional response, every time they encounter let’s say bleach wipes. For some people the smell of bleach wipes trigger these very vivid memories. Or if they encounter some other sound, or some other visual thing that triggers their PTSD.
Is there a breakthrough time? Is it usually in session number four or six?
Peach: It can vary depending on the patient. Sometimes it comes a little bit later in therapy, can be a little bit harder early on because someone is encountering their triggers. But gradually as they go along, we see a positive response.
This a fairly large study too?
Peach: Yes. This is.a trial right now, this is not a new therapy. This is a therapy that’s been used successfully for years by UCF restores. It’s been used with military members, it’s been used with first responders. What’s new about this study though is we’re using it with critical illness survivors.
Anything I’m missing as far as this goes, he’s going to walk us through?
Peach: Well, I guess one thing I would say is, for me the big motivation for this is I’m a practicing ICU nurse. I hate the idea that we save people’s lives only for them to have a terrible quality of life afterward. That’s a big motivator for me. I’d like to be able to address this PTSD so that people can have a normal quality of life, after they survived critical illness.
Is it your job to walk patients through the virtual reality therapy?
Smith: Yes. I’m a clinician and particularly what I would do is I would do the exposure therapy in any adjunct therapy we were doing with that particular patient.
Is the exposure therapy threefolds? Is it sight and sound?
Smith: Each patient is different than what we would do is we would identify what we call their trauma scenario. That is the specific set of circumstances and triggers that contributed to the formation of PTSD symptoms. For example for this particular study, it’s patients that were in the ICU. We identify what their particular hospital area look like, any triggers they may have, whether it be sounds, smells for this particular patient. We use the background of the breathing machine in the ICU, but we could use any smells that they’d have.
Are these all medical sounds and smells or could it be the burnt rubber if you went in because of a car accident? Would that be something that would be part of this or not?
Smith: It could be if that was part of that individual patients, what they had experienced. For example if they’d been in a serious car accident and then they’d gone to the ICU and perhaps somehow those were linked. We can certainly integrate those individual experience.
What smells would you integrate?
Smith: Anything that worked for that particular patient. We’ve used everything from ketchup to body odor to a smell or particular perfume or substance. Things like a magazine, or things that that you wouldn’t really expect if it serves as a trigger or reminder for that particular patient and we can get a hold of the smell, we’ll use it.
What kind of sounds do you find are the ones that are the biggest triggers?
Smith: Again, there is tailored towards that the individual needs of the patients. For these particular patients in this study, hospital sounds, the background noise of people talking, the sounds of the breathing machines, nurses calling, hospital calls, things like that are particularly useful.
Can you show us how you would walk someone through it?
Smith: What we do is when the patient came in was develop that trauma narrative with that individual patient. Then we use the virtual reality to try to create that situation as best we can. It often doesn’t have to be precisely perfect. Sometimes we want to address discrepancies. For example, we have a male nurse with white shirt. If you had a female nurse with a red shirt, we might try to change that dynamic if we could. Your sounds and smells would be unique to your particular experience. We tried to customize it for each one. The way it works with exposure therapy is essentially the brain has connected that state of arousal with these memories. When you hear, for example, that breathing machine or you smell those cleaning, you get a strong sense of physiological and psychological arousal, things like getting sweaty or clenching your jaw or muscle tension, chest pain, nausea, symptoms like that. What we do an exposure is we keep you in that so your body feels that distress. Over time your body will learn or your brain will learn that those two things don’t need to be paired together. That’s what we call habituation. That’s the the background or the act of working mechanism for exposure therapy.
When you’re going through exposure therapy, how can you see these patients react?
Smith: Often, especially early when they’re distressed is at its highest, we see very visible reaction. Things like body movements, we can see that they get sweaty. We can see that they clenched their jaw. They will grip the handle, the chairs. We see a lot of this leg balancing, knee balancing, these are physical indicators of that level of distress. Additionally, for this study, we used a pulse ox so we can tell what their heart rate is, for example, to give us additional bio information to support what we were seeing physically. As sessions go on both during an individual session. Over time, we expect to see that physical distress decrease. After you’ve been aroused or a distressed for 45-minute, eventually your body goes into time out. That starts to decrease significantly. In session, habituation occurs. Then, over the course of repeated sessions, it tends to get lower and lower and lower. In the first session, we tend to see a very high level of distress. Then over sessions that distress starts out lower and lower. Then we ask our patients to rate their distress on a scale of zero to eight. Zero being no distress and eight being the most distress you can experience. Often, after the first sessions pateints say seven or eight. But once we get into the sessions and as they progress through treatment, they start getting visibly more relaxed. Their speech changes, their posture changes, all those physical and key indicator that distract- they were distressed. We can see those change over the course of treatment.
At the end of 10 sessions, would you say they come in now and there are two or four or are do they come back in as an eight and you have to walk them back down?
Smith: Yes. At least in my experience, it’s very rare once they habituate, once that’s occurred, it just doesn’t come back and it continues to get lower. Since I’ve been here, the patients see continuous improvement. One of the good things about our treatment is it tends to be quicker. In this particular study, it’s two weeks and we have another program that’s three weeks. Treatment is relatively quickly and it’s extremely effective.
How it does affect your life like throughout your life if you don’t get it treated?
Smith: Remember, anxieties that aren’t treated tend to grow. All of us get a little nervous, for example, when we get on an airplane. tHE clinical difference is if something causes you so much distress, you have a panic attack. That’s when it approaches this clinical strength. What we’re really talking about is the more severe symptoms and they tend to migrate. Yes, you may not hear a breathing machine all that often, hopefully, but you might be reluctant to seek medical treatment because you’re so concerned about going back to the hospital. Another factor might be other noises might take the place of that in your mind. Those things tend to migrate and they tend to get bigger as time goes on. Unfortunately, if it’s treated successfully, symptoms clear up pretty significantly and we see a lot of positive change if it’s not treated. Often, those symptoms can get worse and patienta learn how to deal with them.
Can you walk me through a couple of the sounds that you would use?
Smith: Sirens, the sound of a rescue ambulance. That is something that is very common with trauma, especially if there’s hospitalization where they were transported and things like that.
What would the person’s see with the VR on?
Smith: So for this study, the patient would actually wear this VR. For this study, they would read where the VR headset, or put this over their head and see this in an immersive manner. With this, they can actually turn their head and it will move with them. They can look around and explore their environment a little bit. Again, this scenario would be as individualized to that particular patient as possible. This is one that we would use. Then we would try to tailor it. Often, for example seeing this machine can cause some distressing the nurse and things like that.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Chad Binette
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
