Robert Neil McLay: Treating PTSD with Virtual Reality

 "The simulator we can control. If it becomes too much, we can tone it down, make it literally a walk in the park if we need to."

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Robert Neil McLay's story.

Public opinion polls show that the war in Afghanistan and the fragile peace in Iraq have fallen far down the list of concerns for most Americans, replaced by the economy and jobs, the federal budget deficit and spending, healthcare, and even immigration.

But there remains a dedicated group of medical professionals within the military that has not forgotten the wars, and the horrific impact they can have on the bodies and minds of the people who fight; nor have they forgotten the moral obligation this nation has to help these wounded warriors.

While it's hard to feel comfortable about medical advances that owe their development to the violence of war, that should not detract from the valiant work of people like U.S. Navy Reserve Commander Robert Neil McLay, MD, PhD, a psychiatrist and the research director in the Mental Health Directorate at Naval Medical Center San Diego.

McLay's field of expertise involves post traumatic stress disorder and the effects of combat-induced stress on the brain. He is a pioneer in the use of computer-based virtual reality simulators for treating PTSD. His treatment regimens, which include traditional therapy and consultation, have enjoyed success rates of up to 75%, even for patients with a history of treatment resistance.

"We see all types. PTSD can happen to just about anyone," says McLay, who spent seven months in Iraq in 2008. "We see the full range of people who had difficulties before they went and the trauma just made them worse, to at the other end of the spectrum, some Special Forces supermen who had never had any problems in their lives, who had always been the absolute best at anything they had ever done, and are now struggling with the very idea that, 'Hey! Why did this bother me?'" 

Simulators create a variety of scenes with varying intensity. A routine patrol on a Fallujah street can be dialed up into a bloody firefight, if the patient is ready for it.

"The first time they tell that story is often the hardest part of therapy. The simulator we can control. If it becomes too much, we can tone it down, make it literally a walk in the park if we need to," McLay says. "But just coming forward and deciding to face your own demons, that can be tough for people. That is one reason why we introduced the simulator. It is to try to be able to put it slightly more in control between the doctor and the patient, and introduce people to it a little gradually."

Much of the thought behind the simulators comes from the older forms of exposure therapy that were developed decades ago, and which are based on the idea that fear naturally burns itself out.

"It is physiologically difficult to maintain an amped up state for long periods of time, which definitely happens in PTSD," McLay says. "If you actually really are under threat repeatedly, the system will stay ramped up. The brain stem?what keeps the physiology amped up?learns from the upper brain, the part that thinks. We learn to be afraid of what we avoid. Our brain stem learns that 'This really is a dangerous situation and I need to back away from it.' And when you are backing away from something that is inside your own head, we can't do that effectively."

The simulator allows patients to address their fears, to relive the source of anxiety and see that they no longer have to fear for their safety. "Your brain stem learns, 'Maybe I can be safe. If something reminds me about the trauma, I'm not going to be hurt this time around,'" McLay says.

Even with the simulator, and the new advances in therapy and medication, McLay says a big stumbling block remains the negative perceptions of mental illness, despite the military's efforts to remove the stigma. "We deal with some amazing people who have gone through some very difficult things, in some cases quite horrific things. The hardest step for most folks is coming forward and saying, 'I am going to talk about this,'" McLay says. "If you can get over that hurdle, it doesn?t mean the rest is easy but it does show the person has shown a certain amount of motivation and has overcome a huge hurdle just by coming in."

As much as he is an advocate for simulators, McLay also remains a healthy skeptic.

"It works but I'm not convinced it?s the best thing out there," he says. "I'm not absolutely convinced yet that the gizmo portion of it—the actual virtual reality—is the active component of treatment. It may be just meeting with the therapist as often as we are and providing the type of therapy that we are."

That's the question that McLay and his colleagues at NMCSD are now trying to answer. "Do you really need all these gizmos or can you do it with a still computer image without using the fancy simulators?" he says. "If you could, that might be good news. It would mean we were able to do this type of treatment in a lot more different clinics and with a lot more people."