The sun shines on an empty Iraqi street. A Black Hawk helicopter circles overhead. The aromas of spices from a market fill the air.
Suddenly, insurgents hiding on a roof launch a rocket-propelled grenade. The ground shakes violently and plumes of black smoke cloud your vision.
Those images, produced when a person puts on a headset, are at the heart of Virtual Iraq, a simulation created to treat Iraq War veterans suffering from post-traumatic stress disorder.
By repeatedly encountering sights, sounds, smells and rumblings that evoke painful memories, experts say, veterans with the disorder can begin to reprocess traumatic events and become desensitized to them, perhaps suffering fewer side effects like insomnia, nightmares and flashbacks.
The simulation is available to a small number of patients.
So-called exposure therapy, in which patients are asked to confront memories of a trauma by imagining and recounting it in painstaking detail, has long been a first-line psychological treatment for post-traumatic stress disorder (PTSD). But the bells and whistles of virtual reality may make exposure therapy more effective, said Michael Kramer, a clinical psychologist at the Veterans Administration hospital in Manhattan who is overseeing the introduction of Virtual Iraq there.
"One of the hallmarks of PTSD is avoidance," Kramer said. "Patients spend an awful lot of time and energy trying not to think about it or talk about it. But behaviorally, avoidance is what keeps the trauma alive.
"With virtual reality, we can put them back in the moment. And we can do it in a gradual, controlled way."
Virtual Iraq features two scenarios. In one, patients navigate the streets of a generic Iraqi city, walking past buildings, cars, civilians and markets. With the touch of a therapist's keypad, a little boy might appear on a street corner and wave, apparently in friendship, or a man might stumble down the middle of the street calling for help, a sight that provokes anxiety in some veterans who have come to fear ruses.
In the other scene, veterans ride in a Humvee. Other vehicles might slow down in front of them and strangers might open fire. Enemy combatants might appear under bridges. Objects dotting the roadside might explode as the Humvee passes.
The patient cannot shoot back at the insurgents and also cannot die or be wounded in the simulation.
In choosing which stimuli to introduce, the therapist's goal is to evoke the conditions present when specific traumatic events occurred, as accurately as the simulation will allow. Smells like spices, burning garbage or body odor can be emitted in four-second puffs. And the scene can be set to day or night, sun or fog or even a sandstorm.
Given the power of traumatic memories, Kramer said, it is important "to go at a pace that the veteran can tolerate, so that he isn't overwhelmed," and he starts to realize that the memories cannot harm him.
One risk of introducing potent material too fast is that a veteran could become re-traumatized and perhaps unwilling to continue other kinds of therapy, as well.
Not all patients with the stress disorder are likely to benefit from this therapy. Veterans who lack basic coping mechanisms, are actively having flashbacks or who have unaddressed problems with substance abuse should probably not enter the simulator, Kramer said.
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