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Overview Overview Introduction of the workshop leaders. Essentials in the treatment of anxiety disorders. General issues about VR and anxiety. Interactive technology for therapeutic interventions All anxiety disorders except OCD and GAD. Summary of some of the studies detailed in the handout. Visit at the UQO Lab (anxiety disorders clinic) for a hands-on experience.

Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

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Page 1: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

OverviewOverview

Introduction of the workshop leaders.Essentials in the treatment of anxiety disorders.General issues about VR and anxiety.Interactive technology for therapeutic

interventionsAll anxiety disorders except OCD and GAD.Summary of some of the studies detailed in the handout.

Visit at the UQO Lab (anxiety disorders clinic) for a hands-on experience.

Page 2: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

The VRMC TeamThe VRMC Team

William H. Rickles, M.D. Kathrine Gapinski, Ph.D. Shani Robins, Ph.D. Kathy Vandenburgh, Ph.D. Elizabeth Durso, M.S. Lingjun Kong, M.S. Michael Yun, M.S. Michael Albani Sarah Atilano Tina Chen Jamie Choi Eric Christopherson Lei (Laycee) Fan Gina Hou ThienDi (Kari) Lam John Law

Esteban (Steve) Leon Michelle Mathieu Megan Mendoza Scott Tanner Mitten Tadashi Nakatani Makoto Ogawa Annie Phan Lilas Ros Natalie Sanchez Kira Schabram MeiLi Tippakorn Triet Ton Jocelyn Tong Mike Tran Frances Tsang Thuy Vu

Brenda K. Wiederhold, Ph.D., MBA, BCIABrenda K. Wiederhold, Ph.D., MBA, BCIAMark D. Wiederhold, M.D., Ph.D., FACPMark D. Wiederhold, M.D., Ph.D., FACP

Page 3: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

VRMC Research CollaborationsVRMC Research Collaborations Balboa Naval Hospital

Pain Distraction, PTSD Camp Pendleton

PTSD Region’s Hospital, Minnesota

Pain Distraction Scripps Clinic

Pain Distraction Stanford University

Anxiety, Physiology UCSD

Pain Distraction University of Washington

Pain Distraction USC

ADHD, PTSD, Pain Distraction, Rehabilitation

Walter Reed Army Hospital, D.C. Rehabilitation

Hanyang University, Korea Smoking Cessation/Prevention,

Schizophrenia, ADHD, Rehabilitation, Pain Distraction

Inje University Paik Hospital, Korea Anxiety

Istituto Auxologico, Italy Eating Disorders, Obesity, Anxiety,

Pain Distraction University of Basel

Anxiety, Physiology, Addictions, Pain Distraction

University of Quebec Anxiety Disorders, Pain Distraction

Page 4: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Virtual Reality Clinical Services(San Diego, West LA, Palo Alto)

Specific Phobias Flying Driving Public Speaking Claustrophobia Heights Spiders Medical Procedures School

Panic Disorder Agoraphobia Generalized Social Phobia PTSD due to motor vehicle accidents

Page 5: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Research Studies

Eating Disorders & Obesity

Distraction during Painful Medical & Dental Procedures

Cue Exposure Health Promotion Anger Management Autism

Attention Deficit Attention Deficit Hyperactivity Disorder Hyperactivity Disorder (ADHD) (ADHD)

Driving Deficits after Driving Deficits after Brain Injury Brain Injury

Functional DisordersFunctional Disorders PTSD in Gulf War PTSD in Gulf War

VeteransVeterans Quality of Life in Chronic Quality of Life in Chronic

DiseaseDisease

Page 6: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

VRMC Research & Development

Research Studies VR for Training Student Internship/Fellowship Programs Clinical Trials Evaluation of New Software Software Development Collaborations

Page 7: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Interactive Media Institute (IMI)a 501 c3 non-profit organization

Non-profit affiliate of VRMC International Advisory Board Scientific and public education

Publications Conferences Continuing Education Courses

Our mission: To further the application of advanced technologies for behavioral

healthcare To serve as a unifying organization for basic and clinical research To create a set of standards and guidelines for simulations

Page 8: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

VRMC Technologies

Virtual Reality/Simulation Videogames Non-Invasive Physiological Monitoring Shared Internet Worlds Biometrics Human-Robot Interactions

Page 9: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Stéphane Bouchard, Ph.D. CRC Clinical CyberPsychologyPatrice Renaud, Ph.D.

The Cyberpsychology Lab

Supported by grants from : UQO, CHPJ Canada Research Chair CFI, CIHR, FCAR MDERR, DEC

StudentsStudents Micheline Allard, Micheline Allard, Ph.D. Cand.Ph.D. Cand. Julie St-Jacques, Julie St-Jacques, Ph.D. Cand.Ph.D. Cand. Stéphanie Dumoulin, Stéphanie Dumoulin, Ph.D. Cand.Ph.D. Cand. Tanya Guitard, Tanya Guitard, Ph.D. Cand.Ph.D. Cand. Geneviève Chartrand-Labonté, Geneviève Chartrand-Labonté,

Ph.D. CandPh.D. Cand Manon Bertrand,Manon Bertrand, Ph.D. Cand. Ph.D. Cand. Cidalia Sylva, Cidalia Sylva, Ph.D. Cand.Ph.D. Cand. Francine Doré,Francine Doré, Ph.D. Cand. Ph.D. Cand. Louis Dallaire,Louis Dallaire, Ph.D. Cand. Ph.D. Cand. Philippe Gauvreau, Philippe Gauvreau, Ph.D. Cand.Ph.D. Cand.

Sylvain Chartier, Ph.D.Sylvain Chartier, Ph.D. Guilhaume Albert, Guilhaume Albert, Ph.D. Cand.Ph.D. Cand. Sylvain Benoît, Sylvain Benoît, Ph.D. Cand.Ph.D. Cand.

Researchers and professionals

Judith Lapierre, Ph.D. Geneviève Forest, Ph.D. Bruno Émond, Ph.D.

Genevieve Robillard, M.Sc.

Christian villemaire, B.A.

Dominic Boulanger. Serge Larouche.

Page 10: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Virtual Reality Clinical Services(Gatineau, Qc, Canada)

Specific Phobias Spiders, heights,

enclosed spaces, airplane, thunderstorms.

Panic Disorder w. Ago Social Phobia and public

speaking. Body image Gambling Clinical training Research

Page 11: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

UQO TechnologiesUQO Technologies

Page 12: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical
Page 13: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

The VRMC Protocol Non-invasive Physiological monitoring

Heart rate & HRVRespiration rateSkin conductancePeripheral skin temperature

Page 14: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Patient Kevin

Page 15: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Why VR ?Advantages and Illustrations

Not dependent upon patients’ imagery abilities.

Provides a structured environment.

Visual and auditory stimuli. Can “overlearn” skills. Done in the therapist’s office. Less time consuming. Less expensive. Safer.

Page 16: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Three Systems of Emotion

Emotional assessment requires 3 domains of measurement because correlations between domains are only in the order of 0.3.

Heart racing

Physiology

„Afraid!“

Self-report

Running

Behavior

Not good!

0.3 0.3

0.3

Lang, P. J. (1978). Anxiety: toward a psychophysiological definition. In H. S. Akiskal & W. L. Webb (Eds.), Psychiatric diagnosis: exploration of biological criteria (pp. 265-389). New York: Spectrum. From F. WilhelmFrom F. Wilhelm

Page 17: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Evaluative Evaluative MeasuresMeasuresEvaluative Evaluative MeasuresMeasures

Subjective

Objective

3 Systems Theory: Experience, behavior, and physiology are loosely coupled, rather independent data sources that should be assessed concurrentlyin anxiety disorders to provide a comprehensive picture of change in anxiety.

- P. Lang

Subjective Units of Distress

Self-Report Scales (P & P)

Overt Behavioral Observation

Personality Inventory

Physiology

Page 18: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Skin conductance change & SUDS change are positively

correlated (N = 482, r = 0.13, p = 0.005).

-10 0 10 20 30 40 50

skin conducta nce cha nge

-40

-20

0

20

40

60

80

100

SU

DS

chan

ge

Page 19: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Possible Interrelationships

AbsorptionAbsorption

Presence

Hypnotizability

Immersion Involvement

Page 20: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Level of Immersion

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%

100% 67% 50% 33% 0%

Percentage of Immersion Reported

Per

cen

tag

e o

f R

esp

on

den

ts Treatment Responders(n=103)

Treatment Non-Responders (n=18)

Page 21: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

SUDS

High Low

High Subjective,High Subjective,High ObjectiveHigh Objective

ArousalArousal

Low Subjective,Low Subjective,Low Objective Low Objective

ArousalArousal

High Subjective,High Subjective,Low ObjectiveLow Objective

ArousalArousal

Low Subjective,Low Subjective,High Objective High Objective

ArousalArousal

Aroused

Normal

Physiology

Framework

Page 22: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Anxiety Disorders

Page 23: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

The Anxiety Equation

Alarm =Danger /

threat=

Consequences X probabilities X imminence

Perceived self-efficacy

Page 24: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Avoidance (safety seeking behavior)

maintains

the perceived consequences;the overestimation of probabilities;the low perceived self-efficacy to cope.

The Trap of Avoidance

Page 25: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Functional Neuroanatomy of Fear and AnxietyFunctional Neuroanatomy of Fear and Anxiety

AmygdalaAmygdalaThalamusThalamus

Peripheral receptorcells of exteroceptive

auditory,visualsomesthetic

sensory systems

Peripheral receptorcells of exteroceptive

auditory,visualsomesthetic

sensory systems

Single orSingle or

Multisynaptic pathways

Multisynaptic pathways

HippocampusHippocampus

Orbitofrontalcortex

Orbitofrontalcortex

Periaqueductalgray

Periaqueductalgray

Locusceruleus

Locusceruleus

Parabrachialnucleus

Dorsal motornucleus of the

Vagus

Lateralhypothalamus

Paraventricularnucleus of thehypothalamus

Parabrachialnucleus

Dorsal motornucleus of the

Vagus

Lateralhypothalamus

Paraventricularnucleus of thehypothalamus

Fear-inducedskeletal motor

activation

Facialexpression of

fear

Fear-inducedhyperventilation

Fear-inducedparasympatheti

cnervous system

activation

Fear-inducedsympathetic

nervous systemactivation

Neuroendocrineand

neuropeptiderelease

Fear-inducedskeletal motor

activation

Facialexpression of

fear

Fear-inducedhyperventilation

Fear-inducedparasympatheti

cnervous system

activation

Fear-inducedsympathetic

nervous systemactivation

Neuroendocrineand

neuropeptiderelease

Fight orflight

response

Increaseurination

defecationulcers

bradycardia

Tachycardiaincrease BP

sweatingpiloerctionpupil dilat

Hormonalstress

response

Fight orflight

response

Increaseurination

defecationulcers

bradycardia

Tachycardiaincrease BP

sweatingpiloerctionpupil dilat

Hormonalstress

response

Visceralafferent

pathways

Visceralafferent

pathwaysNucleus

ParagigantocellularisNucleus

ParagigantocellularisOlfactorysensorystimuli

Olfactorysensorystimuli

Entirhinal

coertexEntirhinal

coertex

Cingulate gyrusCingulate gyrus

Afferent systemAfferent system Stimulus processingStimulus processing Efferent systemEfferent system

Fear and AnxietyResponse PatternsFear and Anxiety

Response Patterns

StriatumStriatum

Trigeminal nucleus

Trigeminal nucleus

Facial motornucleus

Facial motornucleus

Primary sensory and Association CorticesPrimary sensory and Association Cortices

( Charney & Deutsch 1996)( Charney & Deutsch 1996)

Page 26: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Phillips et al., 2003.

Dorsolateral prefrontal cortexDorsomedial prefrontal cortexDorsal anterior cingulate gyrus

Hippocampus

AmygdalaInsula

Ventrolateral prefrontal cortexOrbitofrontal cortex

Ventral anterior cingulate gyrus

ThalamusVentral striatumBrainstem nuclei

Iden

tifica

tion

Prod

uctio

n

Regu

latio

n au

tono

mic re

sp.

(of a

ffect

ive

stat

es)

Inte

grat

ion

Exec

utiv

es fu

nctio

ns

Regu

latio

n - e

ffortfu

l

(of a

ffect

ive

stat

es)

Page 27: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

In VRIn VR Exposure for Anxiety Exposure for AnxietyDisordersDisorders

The aim of exposure is to help the patient to confront the feared stimulus in order to correct the dysfunctional associations that have been established between the stimulus and perceived threat (e.g, it is dangerous, I can’t cope).

Page 28: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Amygdala /Lymbic system

Pre-frontal

One hypothesis…

Perceived self-efficayPerceived self-efficay

Automatic processing Automatic processing of threat-related cuesof threat-related cues

Page 29: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Anxiety and Presence are Correlated

r = .74 (p < .01) Robillard et al., 2003

r = .28 (p < .05) Renaud et al., 2002

r = .45 (p < .05) Schumie et al., 2000

r = .25 (ns) Regenbrecht et al.

Renaud et al., 2002.

Head tracking of fearful and non-fearful subjects.

Significant differences in behavior when looking at a spider.

Page 30: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Exposure and Presence – 1Anxiety Increases Presence

• Snake phobics are led to believe that some environments are filled with hidden snakes. Bouchard et al. (submitted).

0

2

4

6

8

10

Pres

ence

FirstImmersion

(CTRL)

SecondImmersion

ThirdImmersion

Measured at post immersion

CTRL - ANX - NOANX CTRL - NOANX - ANX

0

2

4

6

8

10

Anx

iety

FirstImmersion

(CTRL)

SecondImmersion

ThirdImmersion

Measured at post immersion

CTRL - ANX - NOANX CTRL - NOANX - ANX

Page 31: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Exposure and Presence – 2Is it related to efficacy?

Acrophobics treated with CAVE or HMD environments. Krijn et al., 2004.

N = 24 Time, p < .001 Interaction ns.

010

203040

506070

Tot

al s

core

(IP

Q)

Session 1 Session 2 Session 3

ITC-SOPI. Krijn et al., 2004

CAVE HMD

0

10

20

30

40

50

60

Acr

o. Q

.- A

nxie

tyPre Post

Treatment effectiveness. Krijn et al., 2004

CAVE HMD

0

5

10

15

20

Acr

o. Q

.- A

void

.

Pre Post

Treatment effectiveness. Krijn et al., 2004

CAVE HMD

0

10

20

30

40

50

60

BA

T

Pre Post

Treatment effectiveness. Krijn et al., 2004

CAVE HMD

Page 32: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Is more hardware necessary?

Mühlberger et al., 2003. One session Rx

0

1

2

3

4

Pre Post 6-mo Fup

Fea

r o

f F

lyin

g S

cale

VR (+cogn.) Cogn. Therapy Waiting list

For 13 motion was simulated / 13 without motionNo significant interaction for mot. / no-mot.Effect sizes f :

.17 for FSS, .1 for FFratings, .29 for avoidance

N = 47Assignement to WL not randomVR > CT = WL at post.Less clear at f-up on several variables

One session Rx

0

1

2

3

4

Pre Post 6-mo Fup

Fear

of F

lyin

g Sc

ale

VR + Motion VR - No Motion

One session Rx

0

2

4

6

8

10

Pre Post 6-mo Fup

Avoi

danc

e ra

ting

VR + Motion VR - No Motion

Page 33: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Realism and Social Anxiety(Heberlin, Riquier, Vexo and Talmann, 2002)

10 non-phobics (5 high / 5 low on LSAS):– T1. Were introduced to the experiment– T2. Practiced relaxation.– T3. Were immersed in the virtual assembly (just eyes).– T4. Gave a speech in front of the virtual assembly (just eyes).

0

2

4

6

8

10

SUDS

High LSAS Low LSAS

T1 T2 T3 T4All time effects p < .01 (repeated measures ANOVA)Interactions ns.

0

20

40

60

80

100

120

Bps

High LSAS Low LSAS

Hear rate

T1 T2 T3 T4

Page 34: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Delay and Anxiety / Presence(Meehan et al., 2003, VR’03)

They measured heart rate when 164 adults threw balls in the training room and the Pit.

Random assignment to two delays, 50 ms or 90 ms. (120 ms was considered unacceptable in previous immersions).

Anxiety: difference in HR pre to PIT of +3.1 (p = .05). N = 61.

Anxiety: measured with one item 0-7. Ns.

Presence: SUS calculated with 5, 6, 7 = 1. NS.

Cybersickness: ns.

Page 35: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Anxiety and Image Quality(Zimmons, 2004, Ph.D. dissertation, in preparation)

He measured heart rate when 42 non phobics threw a ball in a training room, 3 balls in the Pit and waited in the training room.

Text / lightening high

Text -/ light +

Text +/ light -

Text -/ light -

Grid

Page 36: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

70

75

80

85

90

95

100

105

110

115

HR

Pre Pit Pit Post Pit

Grid Text low / Light low Text high / Light low

Text low / Light high Text high / Light high

Heart rateANOVA N = 42 : Time: p < .001 Group: p < .05 Gr X T : nsContrasts : Pre vs PIT : p

< .001 PIT vs post : p

< .001Condition 3 vs others

: All p < .001Grid vs the others: All ns.

Presence « SUS » at post: ns Effect size = .05

Grid

Text - / Light +

Anxiety and Image Quality(Zimmons, 2004, Ph.D. dissertation, in preparation)

Page 37: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Physiology in a public speaking task. (Cornwell, Johnson, Berardi & Grillon, 2006)

65

70

75

80

85

90

Baseline Anticipation(no startle

prob)

Anticipation(w ith startle

probe)

Anticipationw ith

audiencenoise

Anticipationw ith curtain

open(audience)

Performance Recovey

Mean heart rate

Speech Backward count

0

1

2

3

4

5

Baseline Backward count(empty VR room)

Talk (VR room withaudience)

Startle reactivity Skin conductance Anxiety

45 non-phobics, 5 min. baseline+ 2 counterbalance tasksPaired t-tests (in the paper):

Startle: baseline < count < speechHR*: baseline = count < speechSkin c: baseline = count < speechAnxiety: count < speech

*Note. HR data from the paper not shown.HR data presented here are for all the datapoints collected (Cornwell, personnal communication, 2006)

Page 38: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

425 Patients in Clinical Database: Anxiety Disorders, Phobias, and

Panic Disorders

Aviophobia: 48.7%Driving: 13.4%Public Speaking: 7.3%Fear of Heights: 4.5%Generalized Anxiety

Disorder: 4.0%Claustrophobia: 3.1% Panic w/Agora: 2.6%

Social Phobia: 2.4%Social Phobia: 2.4%Panic Disorder: 1.4% Panic Disorder: 1.4% Agoraphobia: 0.9%Agoraphobia: 0.9%Arachnophobia: 0.5%Arachnophobia: 0.5%Needle Phobia: 0.2%Needle Phobia: 0.2%Multiple Phobias: 8.9%Multiple Phobias: 8.9%Other Specific Phobias: Other Specific Phobias: 1.6%1.6%

Page 39: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Results

% completers: 95.5%Dropout rate of 4.5% (much lower than in vivo or

imaginal therapy rates)Responders: 94%

Page 40: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

The Cybertherapy Lab Treatment Protocol for Specific Phobias

A typical exposure-based scenario using VR (between 5 and 8 sessions).

General overview : “Session” 1: Assessment (SCID-IV, etc.), overview. Session 2: Information on phobias, VR,

cybersickness. First VR immersion in a neutral environment.

Session 3 to 5: In VR exposure. Session 6: In VR exposure, relapse prevention.

Page 41: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Cognitive-Behavior Therapy

Self-monitoringTransmission of informationCognitive restructuringExposureProblem solvingRelapse prevention

ModelingRelaxation

Page 42: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Session 1 : Assessment

You should assess : depression, anxiety, psychotic disorders, substance abuse, medical problems, other addictions ; attitudes and expectations toward treatment and VR ;exclusion criteria (migraine, etc.) due to potential cybersickness problems.

Page 43: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Session 2 : Information

What are anxiety and phobias… ? How did you acquire your phobia ? Avoidance. Exposure. Habituation curve.

Page 44: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Anxi

ety

Time (minutes)

The Process of Exposure

Functional exposure

Avoidance (safety seeking behavior, neutralization)

Page 45: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Session 2 : Information

How to use the equipment. Cybersickness :

What is it ? How to reduce it ?

How to move in the environments ? take a minute to look around ; don’t go too fast ; how to advance, to turn, appraise distances, etc..

Page 46: Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical

Sessions 3 to 5¾ In VR exposure :

includes guided-mastery techniques (e.g. Öst) select the appropriate environments (hierarchy) asses anxiety (habituation curve) and presence.

Should be tailored topatient’s needs (if notin an outcome study).