Abstract
High prevalence rates of post-traumatic stress disorder (PTSD) exist among veterans, as noted by the Department of Veterans Affairs. We have established the integration of a psychological skills training program with simulated racing called Race Camp to improve clinical and practical outcomes in veterans with PTSD. The primary goal was to examine a three-day variant of our program that excluded pre- and post-assessments. Veterans are often viewed as ‘tactical athletes’; therefore, our intervention combined human performance-based models with a psychological skills training program to enhance engagement and improve overall clinical outcomes. The objective of this three-day experience was to ensure veteran participants experienced the engaging aspects of a racecar-simulation psychoeducational intervention and produce meaningful clinical effects. We employed a single-case experimental design with a range-bound changing criterion, collecting multiple data points across phases to highlight each participant’s individualised trajectory. Findings demonstrated marked reductions in core PTSD symptoms as demonstrated by the PCL-5 and the TSI-2. We also discovered improvements in quality of life, wellbeing and self-efficacy. Follow-up structured interviews with each participant confirmed these gains persisted.
Introduction
Numerous interventions and strategies are available for managing and treating post-traumatic stress disorder (PTSD) in veterans. The present study sought to integrate multiple approaches and theoretical frameworks into one structured experimental protocol to reduce PTSD symptoms in three veterans. Specifically, the study combined psychological skills training (PST) with the Individual Zones of Optimal Functioning (IZOF) model and biofeedback (BFB), incorporating a stress inoculation training (SIT) framework delivered in a competitive simulated race setting, all structured within a periodisation framework. Multimodal treatment strategies in both clinical practice and research are well supported and have shown efficacy.1 The main objective was to create a novel intervention platform called Race Camp, which was designed to improve treatment retention, boost participant engagement and produce favourable clinical outcomes.
Overview and prevalence of PTSD in veterans
Around 10% of male veterans and 19% of female veterans receiving care through the Veterans Affairs system have a PTSD diagnosis. Data from the Department of Veterans Affairs indicate that PTSD occurs more frequently in veterans than in the general civilian population, affecting at least 7% of veterans.2 Variations in PTSD prevalence and symptom expression among veterans can be influenced by factors such as gender, age, era of service and deployment history.3 The authors also noted that deployed veterans are approximately three times more likely to develop PTSD than those who were not deployed, although the condition remains highly idiosyncratic.
The individualised nature of PTSD in veterans
PTSD manifests in a highly personalised manner, with considerable differences across individuals in symptom type, intensity and timing of onset. These differences arise from complex interactions among factors including personal characteristics; the nature, duration and proximity of traumatic exposure (e.g., direct participation versus observation); peritraumatic emotional or physiological responses; perceived life threat; and post-event social support.
Co-occurring life stressors or pre-existing psychiatric conditions may further exacerbate or alter symptom profiles, rendering PTSD a deeply individual reaction rather than a standardised condition.4 Given this heterogeneity, interventions should be customised for each veteran via individualised assessment that identifies specific needs, triggers and treatment objectives. Accordingly, early-phase intervention development is best conducted using single-subject methodologies. Large-group trials may mask important individual variations essential for therapeutic change. Consistent with recommended treatment-development guidelines, we employed an exploratory, single-case, small-n design to examine the clinical and practical effects of our intervention.5
Relevant models
High-ranking military personnel experiencing chronic PTSD symptoms often continue to fulfil operational duties, yet frequently manage symptoms privately without seeking help.6 An established intervention for veterans and active-duty service members aimed directly at treating symptoms of PTSD is stress inoculation training (SIT).7 SIT is a preventative strategy intended to equip individuals with skills to withstand stress, while proceeding through three phases: conceptualisation, skill acquisition and application. Its core aims are to develop effective coping skills, build confidence in applying them, and increase awareness of how context shapes coping choices. These elements overlap with components of conventional PST, encompassing goal setting, self-talk, mental imagery, and arousal control (psychophysiological regulation).
Dysregulation of the autonomic nervous system in PTSD has been associated with alterations in physiological markers such as heart rate and muscle tension.8,9 Interventions incorporating heart rate variability biofeedback (HRV-BFB) have demonstrated symptom reduction and enhanced wellbeing.10-12 Although standalone modalities show promise, low engagement often limits patient adherence.13 Combining these approaches with motivating and competitive elements may therefore enhance participation and compliance.
Psychophysiological research has documented links between emotional states and physiological responses, particularly how these interactions affect performance in competitive contexts.14,15 Self-report studies further show how emotions and physiology contribute to performance efficacy within the IZOF.16,17 The IZOF model lets practitioners integrate multiple concurrent or recalled internal and external states (e.g., cardiac and respiratory rhythms) to delineate personalised zones from optimal to dysfunctional performance.
For veterans and military personnel, limited insight into personal optimal and suboptimal psychophysiological profiles may hinder emotional regulation in diverse situations. PST can address this by educating individuals to recognise and chart their zones, consistent with contemporary evidence.18 This aligns with the concept of the ‘tactical athlete’, by emphasising tailored strategies for occupational optimisation in military-based service members.19 Complementing this, SIT provides a systematic resilience-building method involving progressive stressor exposure, cognitive restructuring and coping rehearsal to facilitate active arousal management and has been applied in pre-deployment preparation.20
To seamlessly incorporate emotional-physiological connections, IZOF profiling, PST and SIT, a periodisation structure is recommended. Periodisation sequences training across preparation, adaptation and peaking phases to support scenario-specific goal setting. The Learning-Modification-Application (LMA) model exemplifies this iterative process of skill refinement.21 Such phased progression ensures controlled progression with adequate recovery, minimising burnout risk while fostering sustained mastery and appropriate stress inoculation levels.
Experimental objectives
- Examine the effects of a simulated racecar psychoeducational intervention on clinical PTSD sequelae.
- Examine the effects of a simulated racecar psychoeducational intervention on quality of life and subjective wellbeing.
- Identify optimal zones of functioning by examining the relationship between track performance and physiological measures of breathing and heart rhythms.
- Explore how the veterans perceived their experience with Race Camp.
Methods
Participants
Eligibility for the intervention, termed Race Camp, was restricted to US Military Veterans who had received a formal PTSD diagnosis at any time following separation from service. The Veterans Trust organisation in Fort Lauderdale, Florida, recruited participants. Inclusion required a PCL-5 score in the range of 32–80 (Clinical range), indicating probable PTSD diagnosis. Key exclusion criteria encompassed asthma, emphysema, chronic obstructive pulmonary disease or any prior cardiac conditions.
This study recruited three male veterans. Cases 2 and 3 were Marines, and Case 1 was a US Army soldier. Their ages ranged from 30 to 50, and they were discharged from service more than 10 years ago. All three exhibited clinically significant symptoms of PTSD, as indicated by their PCL-5 scores (ranging from 51 to 60). Their combat exposure levels vary: Case 1 showed moderate exposure (score of 21), Case 2 moderate-to-heavy (score of 25), and Case 3 lighter-to-moderate (score of 12) per the Combat Exposure Scale. All three cases received a PTSD diagnosis from Veterans Affairs and preliminary health screening confirmed the absence of exclusionary medical issues (see Table 1).
Table 1. Demographic and key characteristics
| Characteristic | Case 1 | Case 2 | Case 3 |
| Branch | Army | Marine | Marine |
| Age | 30–40 | 40-50 | 30-40 |
| Gender | M | M | M |
| PCL-5 | 51 (clinical) | 60 (clinical) | 59 (clinical) |
| Combat Exposure Scale | 21 – Moderate | 25 – Moderate-Heavy | 12 – Light-Moderate |
| Time since discharge | 10+ years | 10+ years | 10+ years |
Equipment
TVT Racing Simulator. Full Send Sims (FSS) custom-built the simulator. FSS is a racing simulation company that builds custom simulators and provides live coaching by certified race instructors. The Veterans Trust Racing Simulator is a semiprofessional platform comprising a GT-style seat, high-torque direct-drive force-feedback wheel, load-cell brake and accelerator pedals and multiple high-resolution monitors.
System and software. Physiological data were acquired and managed using a desktop computer with dual monitors running BioTrace+ Advanced Physiological Monitoring and Feedback software (Version 2025; Mind Media B.V., Roermond-Herten, The Netherlands), interfaced with a wireless NeXus-10 MK3 Bluetooth biofeedback device.
Heart rhythms. Electrocardiography (ECG) in a standard lead II configuration recorded heart rate and heart rate variability (HRV) in beats per minute (bpm).
Breathing. Respiratory rate and relative depth were monitored via an abdominal strain-gauge sensor, expressed as breaths per minute (BPM).
Pre-, post- and in-trial-assessments
Post-traumatic stress disorder checklist for DSM-5 (PCL-5).22 The PCL-5 is employed for provisional diagnosis, screening and tracking symptom change. Internal consistency typically ranges from 0.85 to 0.96, and test-retest reliability shows good temporal stability across time intervals (often r ≥0.82).
Quality of Life Scale (QOLS).23 A measure of overall life satisfaction applicable to both clinical and general populations. Internal consistency is good (Cronbach’s α typically 0.82–0.92 across samples) and test-retest reliability is high (r ≈ 0.78–0.84).
General Self-Efficacy Scale (GSE).24 A 23-item scale grounded in Bandura’s social cognitive theory, evaluating general and social self-efficacy. Internal consistency typically ranges from 0.75 to 0.94 across diverse samples and test-retest reliability coefficients generally span from 0.69 to 0.80 over extended intervals.
Emotional Self-Efficacy Scale (ESE).25 Evaluates perceived competence in recognising and responding to emotional cues. Internal consistency is typically strong (α ≈ 0.96 for the overall scale) and test-retest reliability is also strong (r ≈ 0.85).
Psychological Well-Being Scale (PWB-18).26 An 18-item tool examining wellbeing across six theoretical dimensions. The authors noted that internal consistency values for individual subscales usually range from 0.70 to 0.83. Test-retest coefficients over short intervals typically demonstrate adequate stability for most subscales
Trauma Symptom Inventory-2 (TSI-2).27 A 136-item questionnaire is designed to assess a broad range of trauma-related sequelae in adults. The TSI-2 includes four major clinical subscales, which are (a) SELF (self-disturbance), (b) TRAUMA (post-traumatic stress), (c) EXT (externalisation) and (d) SOMA (somatisation). Internal consistency values for clinical scales typically range from 0.74 to 0.94 and test-retest coefficients across time intervals generally range from 0.76 to 0.94.
Combat Exposure Scale (CES).28 This 7-item self-report instrument quantifies the extent of wartime stressors experienced.
Procedure
After obtaining Institutional Review Board approval, the participants provided informed consent and completed baseline/pre-assessments. Each participant completed an ‘onboarding’ process that included meeting all relevant project parties, including an assigned mentor. Next, each participant was scheduled to start the initial Learning phase (see Table 2 for a complete outline of phases).
Table 2. Overview of Race Camp
| Component | Phase | Session | Session type/Description |
| 1 | Pre-assessment | 1 | Baseline assessments administered |
| 2 | Learning phase | 2 3 4 5 6 | Preparatory training with FSS* Race trials Psychological skills training Race trials Psychological skills training |
| 3 | Modification phase | 7 8 9 10 11 | Preparatory training with FSS Race trials w/PST Psychological skills training Preparatory training with FSS Race trials w/PST |
| 4 | Application phase | 12 13 | Preparatory training with FSS Race-day experience |
| 5 | Post-assessment | 14 | Post-assessments administered |
| 6 | Debrief | 15 | FSS League Race/Driver School options Mentor certification |
| 7 | 3-month follow-up | 16 | Follow-up assessments administered |
Note. * = Full Send Sims (FSS). FSS provided the training via live coaching. Components 2-4 were conducted face-to-face. All other components were completed virtually.
Design. The study implemented a single-case range-bound changing criterion (RBCC) design, allowing incorporation of the LMA framework, which called for progressive performance demands (see Table 3 for the legend and configuration and Table 4 for the design structure). At the start of Session 3, participants received live, race-specific training from a certified FSS race coach, covering course layout, vehicle handling and racing lines. Then, predefined performance criteria were set for each LMA phase to operationalise the stress-inoculation process. Criterion mastery was evidenced by consistently meeting or exceeding the target within a phase, with continued improvement as demands escalated across phases.
Table 3. RBCC legend and racecar configuration
| Design Notation | Phase | Stress Level | Goal | Configuration |
| A | Baseline | – | – | – |
| B | Learning | Easy/Introductory | Achieve personal best | Spec Miata – automatic and paddle shifting |
| C | Modification | Moderate/Intermediate | Beat personal best | Spec Miata – H-pattern and Mustang – H-pattern |
| D | Application | Difficult/Advanced | Win | Spec Miata – H-pattern |
Table 4. RBCC design structure
| Treatment phase | Design structure |
| Learning | A-B-A-B-A-B-A-B-A-B-A |
| Modification | A-C-A-C-A-C-A-C-A-C-A |
| Application | A-D-A-D-A-D-A |
Note. The Learning and Modification phases consisted of five trials and six baseline segments. The Application phase included four baseline segments and three trials, designated as training, qualifying and the actual race.
Procedural steps. Before the race trials, participants had time to acclimate to the environment and verbally indicated when they were ready to begin. Following each session, they completed the PCL-5. A trauma specialist remained available throughout to monitor safety. Each new phase began with track-specific coaching from an FSS instructor. They held PST sessions between race blocks, and later embedded key elements directly into trials. The virtual circuit replicated the Sebring International Raceway Grand Prix course in Sebring, Florida, which included accurate topography and barriers (see Figure 1).
In Session 3 (Learning phase), participants drove a Spec Miata with an automatic transmission, completing three time-trial sessions of four laps each, racing against the clock (no opponents), with the instruction to ‘perform your best’. In Session 5, stress increased when participants switched to a paddle-shift manual transmission. Continuous physiological monitoring via the NeXus-10 captured heart rate and respiration during baseline and active driving (see Image 1). This phase also gathered sufficient data to establish IZOF.29
For the Modification Phase, the goal was to ‘beat your personal best’ times. In other words, criterion mastery was achieved by surpassing the previous time-trial session lap times. In Session 8, the participant was introduced to a manual H-pattern shifter with clutch in the Spec Miata. During the driving portion, the participant was presented with his IZOF profile and a real-time secondary display of key physiological parameters (HR, respiration).30 The participants completed baseline periods to practice zone entry via BFB guidance, with instructions to re-enter optimal states during trials using learned strategies. Specifically, before the trials began, to prepare and control for cognitive overload, participants were seated in the simulator and introduced to their zones. They were able to familiarise themselves with the zone and practice breathing strategies while viewing a secondary screen during a practice race trial. A chime sounded when their heart rhythm moved out of the designated zone, signalling to the driver to engage breathing strategies. Self-regulation training followed protocols incorporating mindfulness-based BFB techniques.31 Session 10 transitioned to a more demanding Mustang (heavier vehicle with more horsepower) with a manual transmission, reinforcing control under pressure and smoother technique before the driver returned to the Miata in the subsequent phase.
During the Application phase, the objective shifted to ‘winning’. The participant returned to the Spec Miata with full manual controls. The vehicle progression (Miata → Mustang → Miata) aimed to build foundational control, manage power under load and refine technique under competitive pressure. Unlike prior phases, session tasks included a 20-minute race against 19 AI opponents, followed by a qualifying and a feature race.
Psychological skills training (PST). Early PST sessions were standalone, while later components were integrated into simulation blocks. The PCL-5 was administered after every session. Training progressed sequentially through goal setting, self-talk, arousal regulation and imagery. The first session introduced foundational concepts and completed goal-setting worksheets (process, performance and outcome). Subsequent sessions assessed and modified self-talk patterns, non-BFB arousal control (diaphragmatic breathing, progressive relaxation) and multisensory imagery, along with home practice with assigned journaling. These components aimed to emphasise the applicability of PST skills to enhance driving performance, and transfer them to personal and social aspects of life.
Advanced PST incorporated SMART goal refinement and resonance-frequency breathing using the NeXus-10, following established HRV optimisation protocols.32,33 Additional modules addressed challenging beliefs, concentration drills, enhanced imagery and collaborative goal setting. As the LMA phases advanced, brief PST elements were mandated pre-, intra- and post-trial, consistent with graduated stress-inoculation principles. After completing the protocol, a semistructured exit interview was conducted, followed by a post-intervention assessment and a three-month follow-up.
Data analysis
Pre-intervention, post-intervention and three-month follow-up scores on the QOLS, PWB-18, TSI-2, GSE/ESE, and PCL-5 were calculated and reported without transformation. In-trial subjective measures (PCL-5) and physiological data (ECG, respiration) were examined descriptively via phase-wise plotting of level, trend and response latency. Performance and synchronised physiological data from the Learning and Modification phases were used to derive IZOF across dimensions. Lap times were categorised relative to personal best, average and worst performances, with ordinal logistic regression used to identify individual zone-of-optimal-functioning curves for heart rate (bpm).29
Results
Following the intervention (see Table 5), all three cases demonstrated improvements in quality of life, with post-assessment scores increasing by 22 points in Case 1 (from 60 to 82), 9 points in Case 2 (from 50 to 59), and 6 points in Case 3 (from 72 to 78). These gains were largely maintained at the three-month follow-up assessment (78, 67 and 79, respectively). Wellbeing scores similarly rose substantially post-treatment (Case 1: from 63 to 91, Δ = +28; Case 2: from 64 to 72, Δ = +8; Case 3: from 82 to 90, Δ = +8) and remained elevated relative to baseline at follow-up. PTSD symptom severity, as measured by the PCL-5, decreased meaningfully in every case (Δ = −14, −12 and −10, respectively), with scores continuing to remain below pre-intervention levels at the 3-month assessment. In contrast, self-efficacy changes were more modest: general self-efficacy showed no change in Case 1, a 1-point increase in Case 2 and a 5-point increase in Case 3, whereas emotional self-efficacy remained stable in Case 1 but improved by 3 points in both Cases 2 and 3.
Table 5. Pre- and post-assessments and 3-month follow-up for Cases 1, 2 and 3
| Assessment Case | Pre | Post | Δ | 3-month follow-up |
| Quality of life 1 2 3 | 60 50 72 | 82 59 78 | 22 9 6 | 78 67 79 |
| General self-efficacy 1 2 3 | 29 27 30 | 29 28 55 | 0 1 5 | 30 29 34 |
| Emotional self-efficacy 1 2 3 | 31 24 31 | 31 27 34 | 0 3 3 | 29 26 35 |
| Wellbeing 1 2 3 | 63 64 82 | 91 72 90 | 28 8 8 | 84 70 91 |
| PCL-5 1 2 3 | 51 60 59 | 37 48 49 | -14 -12 -10 | 40 47 47 |
As seen in Table 6, all three cases demonstrated reductions on the TSI-2 subscales. Self-Disturbance scores decreased substantially in Case 1 (from 57 to 44, Δ = −13), with smaller improvements in Case 2 (from 66 to 65, Δ = −1) and Case 3 (from 60 to 56, Δ = −4). Post-traumatic stress scores decline most in Case 1 (from 75 to 61, Δ = −14), followed by reductions of 9 points in Case 3 (from 72 to 63) and 2 points in Case 2 (from 64 to 62). Comparable improvements were observed on the Externalisation subscale (Δ = −10, −2, and −4 for Cases 1–3, respectively) and the Somatisation subscale (Δ = −8, −6 and −5). At the three-month follow-up, most of these improvements were maintained or only slightly attenuated.
Table 6. Trauma Sympton Inventory-2 subscales
| Subscale Case | Pre | Post | Δ | 3-month follow-up |
| SELF 1 2 3 | 57 66 60 | 44 65 56 | -13 -1 -4 | 52 51 54 |
| TRAUMA 1 2 3 | 75 64 72 | 61 62 63 | -14 -2 -9 | 72 59 61 |
| EXT 1 2 3 | 52 72 59 | 42 70 55 | -10 -2 -4 | 42 55 52 |
| SOMA 1 2 3 | 71 59 69 | 63 52 64 | -8 -6 -5 | 64 51 64 |
Note. SELF = Self-disturbance; TRAUMA = Post-traumatic stress; EXT = Externalisation; SOMA = Somatisation
The second objective was to identify optimal functional zones by examining the relationship between track performance and physiological measures of breathing and heart rate. We aimed to determine whether these measures related to racing performance so we could incorporate them into the PST to self-regulate physiological states (sometimes with the help of BFB) and boost performance. The IZOF analysis uses a logistic ordinal regression model to reveal intracompetition HR (bpm) levels and the likelihood (probability) of achieving a specific performance level. ‘Zones’ include (a) poor IZOFs below the optimal zone, (b) moderate IZOFs both above and below the optimal zone and (c) an optimal IZOF. Table 7 lists all functional zones for both HR (bpm) and breathing (BPM) for each case. All zones are defined as ranges. For instance, Case 1’s optimal HR range was 67–78 bpm with an associated probability of 44%. This range assumes he is most likely to perform optimally, with lower likelihoods of moderate or poor performance.29 These resulting ‘optimal’ parameter estimates for HR and breathing were compiled and used as an index in the BFB training.34
Table 7. Established performance zones during Learning phase
| Case | Heart rate (bpm) | Breaths (BPM) | Avg. probability |
| Optimal zones 1 2 3 | 67–78 65–76 70–82 | 19–25 22–30 23–31 | 48% 55% 51% |
| Moderate below optimal 1 2 3 | 60–67 59–60 64–70 | 15–19 16–22 17–23 | 32% 29% 24% |
| Moderate below optimal 1 2 3 | 78–90 76–91 82–94 | 25–30 30–38 31–39 | 31% 26% 23% |
| Poor below and above optimal 1 2 3 | <60–>84 <59–>87 <64–>90 | <15–>19 <16–>21 <17–>23 | 85% 82% 88% |
Note. The model estimates indicate overlap. A given parameter does not guarantee a specific result (i.e., all parameters equate to an average probability).
To assess the experiment’s fidelity and monitor treatment progress, we administered the PCL-5 following each major session. Figure 2 shows PCL-5 scores throughout the experiment. Scores post-baseline indicated reductions in perceived levels of trauma; however, a slight uptick from baseline was revealed in the 3-month follow-up for Case 1. Qualitatively, one of the main goals of this examination was to understand how PST positively influences clinical symptoms and related effects of PTSD. (i.e., does improving self-regulatory skills to enhance performance in a simulated environment translate to real life?). We conducted brief, structured interviews following the completion of the Race Camp and again at the three-month follow-up.
Case 1 reported meaningful mental and emotional growth following Race Camp. He noted that he had never heard of PST at the outset of the Race Camp; however, he could now translate them into actionable plans supported by practical exercises. The participant identified deep breathing, positive thinking and self-talk as the most valuable tools, described emotional ‘opening up’ as the primary challenge, and highlighted learning new skills, meeting peers and the immediate practicality of implementing the techniques as the most rewarding elements. These learnings were said to enhance driving performance through focused FSS training, relaxation and positive self-talk to prevent frustration and disorientation. He described the beneficial transfer to personal and professional contexts, particularly the ability to self-regulate during interpersonal conflicts by calming down and refocusing using breathing strategies. Our case also supported including a mentor during the process, emphasising that pairing participants with someone who shares similar experiences could mitigate trust issues and shorten the time required to open up.
Case 2 reported beginning Race Camp with high levels of anxiety about the experience but described meaningful improvements afterward, including stronger breathing techniques and a shift towards viewing situations more positively. He identified breathing techniques and improved self-talk (particularly the ability to avoid becoming stuck in negative thought patterns) as the most valuable tools gained from the program. Nothing in the Race Camp process felt particularly overwhelming, while the enhanced ability to manage stress levels was noted as the most rewarding aspect. These skills improved driving performance by promoting better anticipation, looking farther down the road, and braking more effectively before and during turns. The participant also frequently applied breathing techniques in both personal and professional life. The participant viewed having a mentor favourably but said they probably wouldn’t serve as a mentor for future participants.
Case 3 reported beginning Race Camp with considerable performance-related anxiety and mental fatigue, but noted feeling markedly calmer, focused and mentally prepared afterward. He identified visualisation techniques, combined with positive self-talk and controlled breathing, as the most valuable tools acquired, emphasising their effectiveness in interrupting negative thought cycles. While adapting these psychological skills to real-time driving situations presented the greatest challenge, he described the resulting increase in self-confidence and emotional control as the most rewarding aspect of the experience. These learnings were reported to enhance driving performance by promoting clearer decision-making under pressure, better terrain anticipation and sustained concentration during extended stages. He also described meaningful application of the breathing and self-talk strategies in personal life, particularly for managing daily stressors. He also viewed the addition of a mentor positively and expressed willingness to serve in that role for future participants. He also noted that he would like to receive more PST.
During the 3-month follow-up interview, all three cases noted that the progress made during the Race Camp continues to positively influence their daily activities. Reminders are critical, and they all expressed willingness to return and maintain their part of the Race Camp community. However, at the time of the 3-month follow-up, the US Military was actively engaged in a conflict with Iran. Considering this context, it had a particularly negative effect on our first case, revealing increased PCL-5 scores, though still below the pre-assessment levels.
Discussion
This investigation aimed to integrate a periodisation framework (LMA), stress-inoculation principles, PST and a personalised performance model (IZOF) in a virtual setting to alleviate PTSD symptoms and associated impairments. These modalities all complement each other; however, each model contributes distinct therapeutic benefits. Together, these models create an engaging, enjoyable experience while maintaining the primary objective of improving overall quality of life and bolstering self-regulation and coping capacities. We implemented variations of Race Camp over multiple days, including additional assessments; however, we encountered several issues. For instance, the Clinician-Administered PTSD Scale (CAPS) was deliberately excluded from the assessment battery due to frequent and substantial complaints from veteran participants regarding its burdensome nature, including its time-intensive administration and perceived invasiveness, which often led to discomfort and potential dropout risks. Instead, we relied on the PTSD checklist for DSM-5 (PCL-5), which demonstrates high correlation with the CAPS (r > 0.80 in prior validations), thereby maintaining diagnostic fidelity. In addition, we utilised the TSI-2, which included a subscale designed to assess post-traumatic stress (i.e., TRAUMA).
Additionally, the original iteration of our Race Camp intervention included one session per day; however, we encountered significant challenges with participant consistency and retention, including scheduling conflicts and waning engagement over extended periods. To address these issues, we consolidated the core therapeutic face-to-face components into an intensive three-day format, which yielded promising outcomes, including improved adherence rates and positive feedback from veterans who reported higher satisfaction with the condensed structure, citing its efficiency and reduced disruption to daily life. As we continue working with veterans, we will progressively refine our approach to optimise the model. Nonetheless, our current approach did reveal overall positive outcomes, both clinically and practically.
We used a single-case methodology, consistent with Robey’s five-phase clinical outcome research framework.35 Robey advocated initial exploratory work using small-scale, idiographic approaches such as single-subject and case study designs, to identify potential treatment effects and individual variability. This approach supports rigorous, incremental development, particularly for this novel multimodal protocol. It permits detailed examination of idiosyncratic physiological and behavioural responses to stressors, rather than assuming homogeneity across individuals. Our preliminary findings offer initial lines of evidence supporting the effectiveness of this combined approach in diminishing PTSD symptomatology in veterans.
In our veterans with mild PTSD, symptom severity markedly reduced post-intervention, with the PCL-5 scores showing reductions of 10–20 points, which is considered clinically meaningful, aligning with recognised benchmarks for meaningful response in PTSD interventions.36 Parallel improvements were observed across trauma-related measures, quality of life and wellbeing for all three cases. In-session PCL-5 data further corroborated these gains, which decreased steadily across phases, pointing to enduring effects. Emotional and general self-efficacy showed minimal gains in Cases 1 and 2 and more moderate improvements for Case 3. At the three-month follow-up, all three cases’ associated scores remained below the initial baseline. The TSI-2 values indicated meaningful reductions in trauma symptoms across all three cases for each scale construct. As noted, the examination of each case prioritised clinical relevance for each vet rather than relying exclusively on traditional aggregating data, emphasising the importance of qualitative insights to supplement interpretations. In the post-intervention interview, all three veterans emphasised gains in confidence and self-regulation. All three noted the value of breathing strategies for managing real-world emotional triggers (e.g., interpersonal conflicts).
Intraprotocol performance-based data demonstrated associations between psychophysiological profiles and performance outcomes, thereby identifying optimal heart rate and respiration zones during the Learning phase. These ranges, established via probabilistic modelling,37 informed BFB-supported PST, enabling active self-regulation amid the escalating demands in the Modification and Application phases. All veteran participants noted that identifying optimal zones and the self-regulatory strategies to find and maintain them were critical for learning physiological control. Individual response stereotypy can often explain these observations, in which participants displayed characteristic, repeatable physiological stress signatures (e.g., heightened heart rate or breathing).38 The cases clearly distinguished between breathing patterns for relaxation (typically around 6 BPM) and those for performance (20+ BPM). This underscores the value of tailoring interventions to individuals.
These outcomes contribute to the growing literature on veteran PTSD management, where rates remain elevated (7–19% among those in VA care)39 and conventional unimodal treatments frequently encounter barriers such as stigma and attrition.40 By fusing stress inoculation training (SIT)41 with BFB, PST and IZOF principles,42 the protocol addresses inherent heterogeneity of PTSD symptomology.43 The staged structure of SIT conceptualisation, skill building, and application complements the LMA periodisation framework,44 facilitating controlled stressor exposure in a non-trauma-related simulated racing context. This may foster resilience without necessitating direct traumatic recall, distinguishing it from exposure-based therapies like prolonged exposure or cognitive processing therapy.45 The integration of BFB is bolstered by evidence linking HRV training to amelioration of autonomic imbalances in PTSD,46 mirrored here by enhanced parasympathetic indicators during recovery relative to active racing.
The racing simulator provided a motivating medium akin to virtual reality exposure therapy (VRET), which has yielded moderate-to-large reductions in veteran PTSD symptoms.47 In contrast to combat-themed VRET,48 the current performance-oriented, neutral scenario emphasised mastery and efficacy, potentially mitigating stigma by positioning the program as skill enhancement rather than formal treatment. This parallels reports of heightened engagement and transfer in immersive VR applications.49 From a clinical viewpoint, the approach introduces a distinctive interdisciplinary framework that could enrich VA service offerings, especially given the threefold increase in PTSD risk associated with deployment.50 Embedding psychological skills components such as arousal regulation, self-talk, goal setting and imagery targets core self-regulatory deficits in PTSD.51 The gamified format may enhance adherence, countering common disengagement that we’ve seen in standard care. Community collaborations, such as with Veterans Trust, facilitate outreach and align with advocacy for individualised, veteran-centred models. Incorporating peer-mentoring opportunities, as the participant proposed, could amplify benefits via vicarious learning and support networks.
Future directions
As an early-phase single-case investigation within Robey’s framework (Phases I–II), broader applicability is constrained; participant-specific attributes (moderate combat exposure, mild severity) may limit relevance to more severe presentations or underrepresented groups (e.g., female veterans). The absence of a comparison condition precludes a definitive causal inference, although the range-bound, changing criterion design confers reasonable internal control through demonstrated progressive gains.52
Subsequent research should replicate these findings using multiple-baseline or randomised designs to advance through later validation phases, including head-to-head comparisons with standalone SIT or VRET. Expanding samples to include greater severity, comorbidities and diversity, alongside supplementary metrics (e.g., cognitive estimation tasks), would likely strengthen generalisability. However, we do not recommend that individuals who suffer from extreme levels of PTSD participate in stress-inoculation treatment. Ongoing development involves abbreviated Race Camp variants (1- and 3-day formats) to accommodate varying accessibility needs and pre-treatment options for those who do suffer elevated levels of PTSD. Overall, findings suggest that a unified simulation-driven protocol holds promise for alleviating symptoms and improving quality of life in veterans. By bridging therapeutic and performance psychology paradigms, Race Camp represents a creative advance towards accessible, low-stigma interventions that deserve and require additional rigorous evaluation.