2012 12th International Conference on Computational Science and Its Applications
ARVET AND SAPTEPT: A Virtual Environment and a System supported by
Fuzzy Logic in Virtual Reality Exposure Therapy for PTSD patients
Fernando M. de Oliveira
Regina S. Lanzillotti
Rosa M. E. Moreira da Costa
Ps-Graduao em Cincias Computacionais
Universidade do Estado do Rio de Janeiro
Rio de Janeiro RJ Brasil
e-mail: fernando@ime.uerj.br
reginalanzillotti@terra.com.br rcosta@ime.uerj.br
Abstract This paper describes two systems that explore
Virtual Reality technology and Fuzzy Logic to support and to
control the assessment of people with Post-Traumatic Stress
Disorder during the Virtual Reality Exposure Therapy.
Keywords - Virtual Reality, Fuzzy Logic, PTSD, VRET.
I. INTRODUCTION
The scientific production of Virtual Reality studies is
undeniable, particularly in the areas of Medical Sciences.
The appeal of the "three-dimensional worlds" creates
environments that provide scenarios suitable for simulations
of rehabilitation processes of loss of cognitive functions due
to accidents and injuries. The fact that simulations of real
situations in psychological evaluations, a method "without
risk to the patient", makes Virtual Reality applied to health
care an area of increasing interest to computer science
researchers who study Virtual Reality Exposure Therapy
(VRET) and benefits both areas, health care and the
software industry.
In general, many people suffer trauma, but only 6% of
men and 5% of women who have undergone traumatic
events develop lifelong Post-traumatic Stress Disorder
(PTSD) [1]. PTSD is classified as an anxiety disorder, and
as such is characterized as a kind of inappropriate behavior
to stimuli that do not represent real danger [1]. In 1994, the
American Psychiatric Association presented the DSM-IV,
which describes the trauma that a person was exposed to,
highlighting two characteristics: if the person experienced,
witnessed or was confronted by an event or events that
involved death or threat of death or inflicted severe injury or
threatens the physical integrity of self or others; and, if there
was a response that led to internal fear, helplessness or
978-0-7695-4710-7/12 $26.00 2012 IEEE
DOI 10.1109/ICCSA.2012.26
Raquel Gonalves
Paula Ventura
Instituto de Psiquiatria
Universidade Federal do Rio de Janeiro
Rio de Janeiro RJ Brasil
e-mail: mgoncalves.raquel@gmail.com
paularventura@uol.com.br
Luis A. Vidal de Carvalho
COPPE
Universidade Federal do Rio de Janeiro
Rio de Janeiro RJ Brasil
e-mail: luisalfredo@ufrj.br
horror. This disorder is related to the occurrence of some
"traumatic" event of great magnitude in the past.
The purpose of this paper is to explain the method used
to stimulate the memory of the patient with PTSD to trauma
through a virtual reality environment, called ARVET -
Environment Virtual Reality Exposure to Trauma, which
performs a reprocess of the patient's memory in a more
healthy and adaptive way by VRET. The Fuzzy Logic
subsidizes the SAPTEPT - System of Evaluation of Patients
with Post-traumatic Stress Disorder, it will support the
assessment of patients submitted to the stimulus
experienced trauma. Section 2 describes the main concepts
related to the proposed systems, section 3 outlines the
support given by fuzzy logic to the evaluations, section 4
presents the expected results of a simulation of the
interaction between the systems and in the conclusion it is
described the reason to continue this study.
II. ASSOCIATED CONCEPTS
A. PTSD, Evaluation and Treatment
Delay in seeking specialized treatment can aggravate the
PTSD and increase the incidence of related disorders. The
use of drugs can control the disease progression; however, if
the person doesnt expose themselves to new situations and
consequently break the combination of stressful situations
and other related stimuli, the person may continue to respond
the same way and showing the same behavior. Behavior
Therapy is the most appropriate approach to psychological
therapies to treat PTSD; its aim is to break the cycle of
symptoms leading to a habituation of stimuli. Moreover, it
attempts to develop relaxation skills, enabling the patient
control of their emotional and physiological response in
order to decrease their reaction when faced with stressful
situations. People with PTSD, after a traumatic event, cant
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adapt back to the environment in which they live. Thus, a
rereading of the environment will be fundamental to resize
the situations experienced and current threats. The
Cognitive-Behavioral Treatment (CBT) is considered a good
choice of treatment for Post-traumatic Stress Disorder
(PTSD) and it is performed alongside techniques that include
Psychoeducation, Cognitive Restructuring Techniques,
Anxiety Management, Imaginary Exposure and Live
Exposure.

B. Virtual Reality
PTSD involves a constant sense of fear generated by the Fig. 1. Top view image of the environment where the patient will
improper consolidation of autobiographical memory of the navigate in first person.
trauma [2]. Foa and Kozak [3] suggest that to have the
proper processing of the traumatic memory and the
consequent extinction of fear, it needs to be activated and
safe components inserted. In spite of exposure therapy,
employed to stimulate the emotional engagement during
imaginal exposure, some patients find it difficult to immerse
themselves in the scene due to avoidance symptoms, leading
some of them to abandon treatment. In some studies,
dropouts and non-response rates can reach 50% of cases [4].
Therefore, the use of new technologies could smooth the
progress of exposure to avoidant patients. In this sense,
virtual reality has been used as a tool for exposure and it has
achieved positive results for treatment of several anxiety
disorders, including Specific Phobias, Social Phobia, Panic Fig. 2. Image of a street where the patient will navigate.
Disorder and PTSD [5]. The Virtual Reality Exposure
Therapy (VRET) facilitates the emotional engagement of
patients with PTSD during expositions, overcoming the
avoidance symptoms, and consequently eases the control to
the therapist [6]. According to Rothbaum and Mellman [7],
the sense of presence induced by the virtual environment,
which is rich in sensory stimuli, helps processing the
emotional memories related to trauma. This technological
device allows the exposure to the feared environment to be
done gradually, according to the needs of each patient. The
study conducted by McLay et al. [8] evaluates the
effectiveness of the VRET in the treating PTSD patients
serving in Iraq. Overall, three-dimensional virtual
Fig. 3.Image of as sidewalk with characters.
environments with characteristics of "Serious Game" can be
used to simulate situations aimed at training and therapy [9]. The exposure to virtual environments can generate
Thus, we are developing ARVET - Environment Virtual reactions difficult to be assessed jointly with a therapist.
Reality Exposure to Trauma. The ARVET is a virtual reality Aiming to integrate these data and classify the patient in real
environment that is being built with the possibility of time during the VRET process, we developed an application
stereoscopic viewing through a large screen and the use of that explores the techniques of fuzzy logic - the SAPTEPT -
appropriated glasses, which interacts with the patient and System of the Evaluation of the Patients with Posttraumatic
stimulates them. The tools being used to create this Stress Disorder.
environment are: Blender 2.5 to model objects in the scene The SAPTEPT was developed in Python and shows the
and Unity3D 3.4.2 for the animations and interactions. This classification of the patient every five minutes from the start
first built prototype simulates some situations involving of the evaluation, monitored by a psychologist, to the end,
urban violence. Fig. 1, 2 and 3 show images of ARVET. along with their degree of relevance obtained by Fuzzy Sets.
This system classifies the patients degree of anxiety while
theyre subjected to VRET in real time, then it indicates the
change to be done in the virtual scenario ARVET.

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C. Fuzzy Logic It is worth noting that, it is interesting to do a
Fuzzy Logic is concerned with the formal principles of reassessment of therapeutic gain one month after completion
approximate reasoning and searching to model imprecise of the treatment, as shown in Fig. 4.
modes of reasoning, involved in the human skill of making
decisions. It has been a powerful tool able to capture
inaccurate information described in natural language and 1st evaluation follow up
translate them to a qualitative and quantitative form, (rest) (rest)

2nd 3rd 4th 5th

allowing taking the position of super categories. evaluation evaluation evaluation evaluation

Traditionally, a logical position has two extremes: "true" or (rest)

With Exposure

"false". However, in fuzzy logic, a premise varies in degree

5th month
3rd month

4th month
1st month

2nd month
Start of Treatment
1 week
of truth or relevance falling in the range 0-1, which leads to
concepts of partly true or partly false. The control
performed by the fuzzy logic mimics behavior-based rules,
rather than a control explicitly restricted to deterministic
Fig. 4. Evaluations during the treatment of PTSD.
models. The goal of Fuzzy Logic is to generate a logic
output from a set of non-precise inputs, noisy, incomplete or
even absent ones. According to Braga, Baker and Machado The LINPES researchers distinguish the groups of
[10], "Fuzzy Math is an attempt to bring together the Psychometric and psychophysiological variables, whose
characteristic precision of mathematics and the inherent values are collected during evaluations 1 and 2 and related
to the patient at rest, Frame 1. Psychometric scales are
imprecision of the real world, born from the deep desire to
established by filling in forms of self-report and
better understand the mental processes of reasoning". The
Fuzzy Set "A" is represented by the pair (x, A(x)), where Psychophysiological through the Biopac (Physiological
"X" is the variable of the Universe under study and "A(x)" various data acquisition system).
is a function whose image belongs to the interval [0,1], FRAME 1: VARIABLES ATTACHED TO PATIENT DURING THE ASSESSMENTS
where "1" represents the total concept of relevance and "0" AT REST.
to irrelevance.
Psychometric Scales Psychophysiological Variables
Fuzzy Logic has been successfully exploited as a tool to Anxiety Heart Rate
support the analysis of tests of three-dimensional Depression Skin Conductance
environments (3D), devoted to the teaching and training of Resilience Respiratory Rate
Social Support Pulse Transit Time
medical practices [11]. PTSD symptoms Cortisol
Positive and Negative Affect Trait DHEA Hormone
III. INTERACTION BETWEEN ARVET AND and State Variation in Heart Rate
SAPTEPT Quality of Life
Traumatic Exposure in Childhood
Usually, the treatment of a patient with PTSD, provided
by Laboratrio de Pesquisa Integrada do Estresse (LINPES-
Evaluations 3, 4 and 5 are achieved by the same
UFRJ), results in five (5) assessments. The 1st and 2nd
variables, but the Psychometric group is reduced to a
assessments are made with the patient at rest; the 1st
subjective level of anxiety assessment obtained by different
assessment is scheduled a week before starting treatment
ways, because now the patient is subjected to stimulus
and the 2nd assessment one month after. Other evaluations
during the evaluations and is not reasonable to collect
are conducted with stimulus to the trauma suffered in
Psychometric data by filling out forms of self-report. In this
consecutive months. It is noteworthy that there are two
case, the option is the SUDS scale - Subjective Units of
forms of stimulation, imaginal and live. In imaginal
Disturbance Scale to assess the degree of anxiety that the
exposure, the patient informs details of the trauma suffered
patient is in during the trauma stimulation. The SUDS is a
in sequential manner at each visit and as a result the patient
range of integer values between 0 and 10 that measures the
is exposed to the trauma reported hearing through an audio
intensity of disturbance or distress experienced by an
recorder. However, in the live exposure the intention is a
individual when subjected to trauma. For example, the
direct and graduated confrontation to the feared objects or
individual responds to the value of this scale that refers to
situations [12]. First, it is built a hierarchy of feared
the level of anxiety at the time of exposure to the trauma,
situations; in this study it is up to ARVET to simulate the
ranging from "no anxiety" to "high anxiety" the patient
trauma gradually (Figure 1, 2 and 3). A hierarchy of
experienced. At this stage, the group of variables
exposure is a list of stimuli on a theme, ordered according to
psychophysiological is reduced, since there is no scientific
the level of anxiety they elicit, in other words, it ranks from
evidence of the parameters change in all the variables in the
the stimulus that causes the least anxiety to the ones that
patient's exposure to a traumatic stimulation.
causes more anxiety and discomfort [13].
A meta-analysis conducted by Pole [14] identified the
Heart Rate as a Psychophysiological group variable that

105
changes when PTSD patients are exposed to a traumatic intersection of moderate and severe classifications, it is
stimulus. Thus, the heart rate level confirms the patient's called fuzzy area. If in the evaluation of the patient occurs
anxiety when using the suds level, Frame 2. results positioned in the fuzzy area of Trapezoidal and
Triangular Fuzzy Sets, each variable ranks according to the
FRAME 2: VARIABLES ATTACHED TO PATIENT DURING THE ASSESSMENTS minimum value among the pertinence of these sets.
AT STIMULUS.
The association of these variables allowed building the
Psychometric Scales Psychophysiological Variables Fuzzy Inference Machine, contingency table of the nine
Anxiety Heart Rate
rules of antecedents and consequences drawn with the
intersection of categories Mild, Moderate and Severe
According to the variables suggested by LINPES relating to anxiety and heart rate, Table 1. Pay attention to
researchers, it was necessary to model the control exposure table if the patients anxiety is MILD and the heart rate is
of ARVET. To that end, we created an algorithm built from SEVERE probably the patient had a wrong perception at the
the perspective of fuzzy logic, which is implemented in time to respond to their anxiety. We have based the
SAPTEPT. classification of heart rate that is SEVERE as maximum
The SAPTEPT is able to categorize patients in a pertinence. The same way, if the patients anxiety is
gradually scale, the measurements are made from the scales SEVERE and the heart rate is MILD probably the patient
of the variables of Psychometric and psychophysiological had a wrong perception at the time to respond to their
groups. The psychophysiological stimulus is captured by a anxiety. We have based the classification of heart rate that is
data acquisition system (Biopac) that when added the MILD as maximum pertinence.
response generated by the patient on their momentarily
degree of anxiety (SUDS) the outcome allows to determine TABLE 1: FUZZY INFERENCE TABLE.
the degree which the virtual stimulus that the patient should
be prepared to be expose. During exposure to trauma there
is the hypothesis that the psychophysiological stimuli
undergo a clinical standardization demonstrating the
effectiveness of therapy in reducing physiological reactivity
during exposure to the traumatic stimulus. The method,
from the viewpoint of fuzzy logic, allows us to recognize
patterns of anxiety (MILD, MODERATE, and SEVERE)
gradual scale, real-time measurements, when the
psychometric scales (anxiety) and psychophysiological IV. EXPECTED RESULTS
(heart rate) are performed. Pattern recognition is one of the
oldest and most obvious applications in the areas of Fuzzy The associated action between the systems SAPTEPT
Theory. and ARVET can be seen in Fig. 6, the flowchart shows the
The term "recognize pattern" is included in research on evaluation of patients undergoing therapy with Virtual
artificial intelligence, interactive computer graphics, Reality Exposure.
computer-aided project, pattern recognition in biology,
psychology and language structures. The fuzzy sets theory
when used is a promising feature and has seen successes in
medical diagnostics [15].
MILD and SEVERE standards were translated by
Trapezoidal Fuzzy Sets as MODERATE, Triangular Fuzzy
Sets for both variables, Fig. 5.
DEGREE OF ANXIETY

HEART RATE
Moderate

Moderate
Severe

Severe
Mild

Mild

Fig. 5. Fuzzy Sets.

Fig. 6: Flowchart of evaluation that the patient is subjected.
The green area means that there is an intersection of
mild and moderate ratings and the purple area shows the As an example, a patient who has undergone the ARVET
generates values of anxiety (SUDS) and heart rate (Biopac).

106
These measures represent the input variables of the
SAPTEPT, values that were fuzzificated by fuzzy sets and
translated into degrees of membership in the interval scale
between 0 and 1, with the respective categories (MILD,
MODERATE, and SEVERE). The association between the
categories obtained for anxiety and heart rate was applied in
the Fuzzy Inference Table and it allowed inferring that the
classification of the evaluation of patients with PTSD
submitted to ARVET, with maximum values obtained for the
pertinence of the input variables.
If the patient verbalizes the value 3 as anxiety level, the
graph will show two values of relevance, 0.2 in moderate
class and 0.8 in mild class. We take the smallest value, 0.2
and its classification is moderate. In heart rate, if the signal
Biopac is 132bpm, and it is in a fuzzy area, with the
pertinence values 0.4 in severe class and 0.6 in moderate
class, again we take the minimum value of relevance and its
classification, in this case, is severe.
These results fuel the Fuzzy Inference Machine, the
resulting classification of the patient is SEVERE, with
pertinence value 0.4, Table 02. The standard of patient
anxiety with exposure to ARVET associated to SAPTEPT is
recognized for 5 minutes in a qualitative and quantitative
form.
TABLE 2: PATTERN RECOGNITION OF THE PATIENT.
V. CONCLUSION
This study presents a new technique for behavioral
pattern recognize by VRET and the prototype will be
complete in august. We intend to include the use of the
ARVET and SAPTEPT during sections of the VRET of the
LINPES like test. After this SAPTEPT will control in real
time ARVET.
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