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Soldier’s Heart

The Medical College pioneers treatments for post-traumatic stress disorder

vr scene

Painful memories: the view from inside Weill Cornell’s virtual-reality simulator for combat veterans

Photo: provided by JoAnn Difede, PhD

Retired Army Lieutenant Colonel John O’Brien can pinpoint the moment when he hit bottom. It was when he found himself handcuffed in the back of an NYPD cruiser, having been pulled off the hood of a taxi. He’d been clinging to the car, shouting and banging, as the cabbie drove around trying to dislodge him. “It was just crazy behavior,” O’Brien recalls, years later. “I wasn’t so much violent as very, very short-tempered. I’d be in my apartment yelling out the window, screaming at the top of my lungs. There was constant tension from the noise, the sirens, the garbage trucks—when they hit a bump it was like boom, boom, boom! They’d practically send me through the ceiling. I became more and more withdrawn. I didn’t want to socialize. I drank to excess. I was lucky I didn’t get put in jail.”

Instead, an FDNY captain at the scene of the taxi incident, intuiting the source of O’Brien’s distress, brokered his release in exchange for an apology to the arresting officers. The NYPD and FDNY are, after all, paramilitary organizations whose members know the emotional costs of stress and trauma. Their ranks include many combat veterans of Iraq and Afghanistan, and the memory of 9/11 remains raw more than a decade later.

Although O’Brien has worked as a journalist—so he’s well aware that details matter—he isn’t keen to delve into his four tours of duty in the Middle East. He’ll say that a rocket attack caused a mild traumatic brain injury. He’ll admit he was a hundred or so yards away from a checkpoint where a deadly suicide bomb went off. He’ll refer obliquely to “beheaded people and the son of a bitch who was responsible for it, and the videos we got afterwards showing how it was done.” He mentions surviving an ambush. “I’ve seen a lot of dead people, and one blurs into another,” he says. “As each tour came along, each mission, what was happening just got more and more blurry.”

Handcuffed in that patrol car, O’Brien had had a full-blown flashback. He was convinced he’d been abducted by insurgents and was about to be killed—maybe even beheaded. To this day, he’s deeply grateful to the fire captain who, rather than watching him get hauled off to jail, took him aside and said: “Buddy, you’d better get some help.”

The idea that O’Brien had post-traumatic stress disorder (PTSD) wasn’t new. He’d been diagnosed in 2008, after a heart attack led to his retirement from the service, but he’d never gotten proper treatment. “I was embarrassed,” admits O’Brien, a former Special Operations officer. “I wanted to hide it. I went to a couple of different psychotherapists and a psychiatrist for medication. I was taking Lexipro, Ambien, Klonopin, plus like six drugs for my heart—and of course I was drinking more and more. I’d calm down, then I’d go back and act like an idiot and jump on taxi cabs.”

JoAnn Difede

Weill Cornell psychologist and PTSD researcher JoAnn Difede

Photo: John Abbott

After that fire captain’s act of kindness, though, O’Brien eventually found his way to NewYork-Presbyterian Hospital/Weill Cornell Medical Center. He underwent intensive treatment for PTSD with Judith Cukor, an assistant professor of psychology in psychiatry. It was slow, painstaking work. The current standard of care for PTSD is what’s known as imaginal exposure therapy, in which patients are guided in reliving their trauma in a safe environment, with the goal of facilitating “extinction learning”—consolidating the experiences as memories rather than as volatile, emotionally fraught episodes that can re-emerge as flashbacks. Weill Cornell PTSD expert JoAnn Difede cites that classic Psych 101 example of operant conditioning, Pavlov’s dog—but instead of hearing a pre-dinner bell, the animal receives an electric shock each time a light goes on.

‘You have reminders in the context that your trauma occurred—you can see, hear, smell, feel. They’re powerful sensory cues, and we think that will make it easier for people to process their memories.‘”Over time, the dog will get frightened and have the same reaction he would have to the shock itself when he sees only the light,” explains Difede, a professor of psychology in psychiatry. “Extinction learning would be teaching that lights aren’t scary in general—just in this particular context. What you do is repeatedly show the dog the light without a shock, and he learns that lights aren’t scary after all; it was the shock. The same thing happens with people. Let’s say you worked in the World Trade Center and escaped with your life on 9/11; stairwells are suddenly frightening places. You’ve developed a conditioned response that stairwells can be scary because you escaped down the stairs that day wondering whether or not you were going to make it out, hearing mayhem outside, maybe even one of the buildings collapsing. Stairwells are no longer neutral for you.”

By recalling the traumatic memory in the therapist’s office, Difede says, the patient can eventually uncouple stairwells—or, say, the sight of a plane flying over the city on a cloudless day—from the horrors of 9/11. “Over and over again, we’re extinguishing the cues to fear in a safe environment,” she says. “In theory, that would allow the person’s autonomic nervous system—which went into fight-or-flight mode when it perceived danger—to go back to homeostasis and say, ‘Okay, every time I see a plane in a blue sky, I don’t need to think there’s going to be a terrorist attack. It’s just another plane.'”

But imaginal exposure therapy isn’t easy. It requires patients to do what they dread most: relive the traumatic memory. For the past decade, Difede has been leading an effort to use immersive technology to facilitate the process. In a treatment room on the fourth floor of Weill Cornell’s Payson House, current and former soldiers, Marines, and National Guardsmen don virtual reality (VR) goggles and earphones and are transported back to a war zone—from a military convoy in Afghanistan being struck by a roadside bomb to soldiers on patrol in Fallujah under attack by a sniper. A subwoofer installed under a platform mimics the vibrations of explosions; a scent machine can approximate such aromas as cordite, Middle Eastern spices, and burning flesh. For some veterans, the illusion is incomplete unless they carry a faux M-16 rifle—made of plastic, but believably weighty.

“Part of PTSD is being avoidant of things that remind you of your trauma—people, places, things, memories, emotions,” explains Difede, who first developed the VR system to treat phobia sufferers and burn victims before using it with 9/11 survivors. “So when you tell someone that part of the treatment is going over what happened to them—that they have to will the memory into their mind and go over it—they’re reluctant to do that. But this way, we’re putting them back in Iraq or Afghanistan in a Humvee or on patrol in town, or at the World Trade Center, and the cues are being delivered to them. You have reminders in the context that your trauma occurred—you can see, hear, smell, feel. They’re powerful sensory cues, and we think that will help emotional engagement and make it easier for people to process their memories.”

Difede and her colleagues are currently in the midst of a study, sponsored by the Department of Defense, that will comprise some 300 subjects; some will receive standard imaginal exposure therapy, others the virtual reality version. “They’ll be sitting there with a helmet on, in a virtual Humvee, and talking in present tense, as if it’s actually happening—knowing that it’s not happening, but trying to put themselves there,” says Cukor, the study’s primary clinician. “They’ll say, ‘I’m traveling, it’s eight o’clock in the morning, it’s just a regular day. We’re joking about something, I look up and I see smoke.’ At the appropriate time in the treatment—when they’re ready for it—we’ll play an IED or have smoke in the distance. We do it in a gradual way, and they’re able to engage in their memory and habituate to the emotions around it.”

The virtual Iraq and Afghanistan were designed and refined with input from veterans who served there. The scenarios have the feel of a modern video game—but are even more immersive, because when the user turns his head, the perspective shifts accordingly. The virtual worlds are highly detailed, with atmospheric elements like calls to prayer, groups of chatting civilians, and piles of refuse (which are often used to conceal IEDs). By manipulating a joystick, the user can walk around and explore, climbing stairs and entering rooms. “Video games have a lot of validity with the generation of young men and women who went to Iraq and Afghanistan,” Difede points out. “They know how to use the technology. They’re comfortable with it. This isn’t the psychotherapy of Freud that they might have learned about in college or in popular culture; it doesn’t even look like psychological treatment. And there’s evidence that if a person thinks the treatment is going to work, they’re more likely to stay with it.” Cukor adds that for many subjects, the technological learning curve is appealingly flat. “The patient is able to move around with a joystick—and let me tell you, they’re able to do it a lot better than I am,” she says with a laugh. “I have trouble getting through some doorways, and I try to explain it to them, but they don’t even need to hear it. They’ve got it in a second.”

In 2008—with years of war still to come—the RAND Corporation published a 500-page report on PTSD and major depression among Iraq and Afghanistan war veterans. It calculated the rate of prevalence of one or both conditions at nearly 20 percent—and noted that in the two years following deployment, PTSD and depression among returning service members cost the nation as much as $6.2 billion in medical bills, lost productivity, and other factors. The condition raises the risk of a variety of social ills—including suicide, substance abuse, and domestic strife. “Emotional constriction is one of the common features of PTSD—so people are not able to feel loving or happy feelings, which makes it very difficult to function in a marriage or as a parent,” says Megan Olden, an instructor of psychology in psychiatry. “Often people feel anger and irritation, and that also causes interpersonal difficulties. Avoidance is such a strong feature of PTSD, so people work hard to not approach anything that’s going to trigger their anxiety, which can narrow your life in an extraordinary way—avoiding driving, crowded places like malls, going out with groups of friends.”

While PTSD has always been part of war’s lingering cost—whether known by its modern label or more antiquated terms like “soldier’s heart,” “shell shock,” or “battle fatigue”—it seems to be striking veterans of the most recent conflicts especially hard, researchers say. “One factor is that people have been repeatedly deployed, so they’re encountering dangerous and traumatic situations again and again,” Olden says. “Also, the nature of the wars is different from some previous conflicts. There is more of a chronic threat level. It’s not just when you’re in battle; at any time there could be IEDs or a suicide bomber, so it’s more difficult to know when you’re safe. Some of the soldiers I’ve worked with report not feeling safe even on base. They’d be mortared all the time, or were interacting with local soldiers who they thought were tipping off the enemy. So it felt like they could never relax.”

vr goggles

Total immersion: Difede’s system includes 3-D goggles, headphones, a scent machine, a vibrating subwoofer, and even a faux M-16 rifle. The therapist can see the user’s perspective on a monitor.

Photo: John Abbott

Given the financial and human costs, finding an efficient and effective treatment for PTSD is a pressing national health issue. With the aim of maximizing treatment benefits, the DOD-funded study is also looking at the efficacy of a drug called D-cycloserine (DCS), which studies have shown to enhance extinction learning. In the current trial, half the subjects will receive DCS in addition to either imaginal exposure therapy or VR. In November, Difede and her colleagues reported successful results in the journal Neuropsychopharmacology, with the VR-plus-DCS group demonstrating markedly higher rates of symptom remission. “These results,” they write, “suggest a promising new treatment for PTSD.”

While O’Brien didn’t use the virtual reality equipment, he has served as something of a spokesperson for Weill Cornell’s PTSD program. He starred in a series of public service announcements for NewYork-Presbyterian Hospital and appeared with Difede on an episode of “Charlie Rose,” aiming to encourage others to get help by putting his face, name, and rank to the diagnosis. “There’s still a huge stigma regarding mental health treatment, period, and PTSD in particular, especially for our soldiers, cops, and firefighters,” Difede says. “To have a man who was in Special Operations and intelligence in the Army be willing to come forward is a huge step.” O’Brien, for his part, is moving on with his life. He no longer lives in New York, having traded his Hell’s Kitchen apartment for a quieter existence in New England, where he’s earning a master’s in international relations. “One of the problems with PTSD is that you give up hope, and that’s one of the most dangerous things that can happen to somebody, but I got it back,” he says. “For me, treatment was a lifesaver—and I mean that literally.”

Buddy System

A Cornellian Marine aids fellow vets

Zach Iscol ’01 joined the Marine Corps right out of college, inspired in part by lightweight football coach Terry Cullen, MBA ’66, a decorated Vietnam vet. While Iscol had been accepted into aviator training, he requested to be assigned as an infantry officer instead. “I was worried that if I spent two years in flight school I would miss the war,” Iscol says with a rueful laugh, “which is hard to believe.”

Zach Iscol

Zach Iscol ’01 in the marines

Photo provided

After two tours of duty in Iraq, among other assignments, Iscol left the service with the rank of captain. Today, he leads two start-ups devoted to helping fellow veterans. One priority, he says, is to correct misconceptions. “Less than 1 percent of the country has served since 9/11, so there’s a huge divide between those who’ve served and those who haven’t,” says the former government major. “And through that, there are false perceptions about the military and the people who serve. If you look at the way veterans are portrayed, you’d think there were a ton of people who’ve been badly wounded, that we’re a population that’s suffering as a result of these wars, that there’s massive unemployment. Statistically, none of that is true.”

Iscol is the founder and CEO of Hirepurpose, a firm based in Manhattan’s tech corridor devoted to giving veterans career guidance and matching them with potential employers. As he describes it, it’s a win-win. “There’s a real need for a better talent solution to help transitioning military answer that age-old question—‘What do you want to do with your life?’—and to enable companies to market themselves to this incredible talent pool,” Iscol says. He cites some statistics: Ninety-nine percent of veterans have a high school degree, versus 88 percent of civilians. Seventy-six percent of eighteen- to twenty-four-year-olds don’t meet recruiting standards—making military personnel the top quartile of their age cohort. “The number-one indicator of business survivability in five years is, Is the owner a veteran?” Iscol says. “They have the lowest rate of home loan defaults of any group in America. By and large, these are the most exceptional people in our country.”

Iscol’s other enterprise focuses on a more challenging reality: that significant numbers of veterans need help with post-traumatic stress or other mental health issues. Dubbed the Headstrong Project, the nonprofit works with the Medical College to provide free, confidential services to veterans in the New York metro area. “In general, military people don’t rush to psychiatrists,” says Weill Cornell psychiatry professor Ann Beeder, Headstrong’s medical director and a longtime friend of Iscol’s family, “so he wanted to build a program that is efficient bureaucratically and is cost-free, hassle-free, and stigma-free.”

Staffed by about ten Weill Cornell-affiliated clinicians, Headstrong offers a variety of treatments, from psychotherapy to cognitive behavioral therapy to virtual reality. Unlike many such programs, the number of sessions is open-ended, with no limits on frequency of care. “We’ll work with patients until they’re better,” Iscol says. “If that means we’re seeing them every day for six years, we’ll see them every day for six years. If we see them once a week for three months, and that’s what they need, that’s fine.”

Zach Iscol

Iscol today

Photo provided

Last May, more than 500 people attended “Words of War,” a fundraiser—headlined by Jake Gyllenhaal, star of the 2005 Marine Corps drama Jarhead—that garnered $300,000 for Headstrong. So far, the group has aided dozens of veterans, many referred through word of mouth or social media. Given the nationwide scope of the problem, Headstrong aims to serve as a pilot project that can be replicated at other academic medical centers. And since many veterans live in rural areas without access to top-flight psychiatric services, technologies like Skype could help fill the gap. “What’s extraordinary is the number of vets that stay in our program,” Iscol says. “It’s over 90 percent, which is astonishing. We designed it to be welcoming, open, and always available. When a veteran comes into our network, someone makes a point of being in touch within twenty minutes.”

While Iscol says he didn’t suffer from severe problems like substance abuse or thoughts of suicide as a result of his service, he admits he was “definitely very angry” when he got back from his deployments. “If you come home from war and you have not been affected—by killing people, losing friends, witnessing the horrors—there’s something wrong with you,” Iscol says. “You’re going to feel guilt, shame, grief—and traumatic levels of those emotions. A good person does not make the types of decisions you have to make in war and come home unaffected by it.”