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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.
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
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
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
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
VRMC Research & Development
Research Studies VR for Training Student Internship/Fellowship Programs Clinical Trials Evaluation of New Software Software Development Collaborations
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
VRMC Technologies
Virtual Reality/Simulation Videogames Non-Invasive Physiological Monitoring Shared Internet Worlds Biometrics Human-Robot Interactions
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.
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
UQO TechnologiesUQO Technologies
The VRMC Protocol Non-invasive Physiological monitoring
Heart rate & HRVRespiration rateSkin conductancePeripheral skin temperature
Patient Kevin
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.
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
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
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
Possible Interrelationships
AbsorptionAbsorption
Presence
Hypnotizability
Immersion Involvement
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)
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
Anxiety Disorders
The Anxiety Equation
Alarm =Danger /
threat=
Consequences X probabilities X imminence
Perceived self-efficacy
Avoidance (safety seeking behavior)
maintains
the perceived consequences;the overestimation of probabilities;the low perceived self-efficacy to cope.
The Trap of Avoidance
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)
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)
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).
Amygdala /Lymbic system
Pre-frontal
One hypothesis…
Perceived self-efficayPerceived self-efficay
Automatic processing Automatic processing of threat-related cuesof threat-related cues
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.
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
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
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
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
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.
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
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)
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)
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%
Results
% completers: 95.5%Dropout rate of 4.5% (much lower than in vivo or
imaginal therapy rates)Responders: 94%
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.
Cognitive-Behavior Therapy
Self-monitoringTransmission of informationCognitive restructuringExposureProblem solvingRelapse prevention
ModelingRelaxation
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.
Session 2 : Information
What are anxiety and phobias… ? How did you acquire your phobia ? Avoidance. Exposure. Habituation curve.
Anxi
ety
Time (minutes)
The Process of Exposure
Functional exposure
Avoidance (safety seeking behavior, neutralization)
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..
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).