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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.

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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.


  • The 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

    The VRMC Team

    Brenda K. Wiederhold, Ph.D., MBA, BCIA

    Mark D. Wiederhold, M.D., Ph.D., FACP


    Vrmc 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

    VRMC Research Collaborations


    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

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


    Research studies
    Research Studies

    • Attention Deficit Hyperactivity Disorder (ADHD)

    • Driving Deficits after Brain Injury

    • Functional Disorders

    • PTSD in Gulf War Veterans

    • Quality of Life in Chronic Disease

    • Eating Disorders & Obesity

    • Distraction during Painful Medical & Dental Procedures

    • Cue Exposure

    • Health Promotion

    • Anger Management

    • Autism


    Vrmc research development
    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

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


    Vrmc technologies
    VRMC Technologies

    • Virtual Reality/Simulation

    • Videogames

    • Non-Invasive

    • Physiological Monitoring

    • Shared Internet Worlds

    • Biometrics

    • Human-Robot Interactions


    The cyberpsychology lab

    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.

    The Cyberpsychology Lab

    Stéphane Bouchard, Ph.D. CRC Clinical CyberPsychology

    Patrice Renaud, Ph.D.

    • Students

    • Micheline Allard, Ph.D. Cand.

    • Julie St-Jacques, Ph.D. Cand.

    • Stéphanie Dumoulin, Ph.D. Cand.

    • Tanya Guitard, Ph.D. Cand.

    • Geneviève Chartrand-Labonté, Ph.D. Cand

    • Manon Bertrand, Ph.D. Cand.

    • Cidalia Sylva, Ph.D. Cand.

    • Francine Doré, Ph.D. Cand.

    • Louis Dallaire, Ph.D. Cand.

    • Philippe Gauvreau, Ph.D. Cand.

    • Sylvain Chartier, Ph.D.

    • Guilhaume Albert, Ph.D. Cand.

    • Sylvain Benoît, Ph.D. Cand.

    • Supported by grants from :

    • UQO, CHPJ

    • Canada Research Chair

    • CFI, CIHR, FCAR

    • MDERR, DEC


    Virtual reality clinical services gatineau qc canada
    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



    The vrmc protocol
    The VRMC Protocol

    • Non-invasive Physiological monitoring

      • Heart rate & HRV

      • Respiration rate

      • Skin conductance

      • Peripheral skin temperature



    Why vr advantages and illustrations
    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

    Physiology

    Self-report

    Behavior

    0.3

    0.3

    0.3

    Heart racing

    Running

    „Afraid!“

    Three Systems of Emotion

    • Emotional assessment requires 3 domains of measurementbecause

      correlations between domains are only in the order of 0.3.

    Not good!

    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. Wilhelm


    Evaluative Measures

    Subjective Units of Distress

    Self-Report Scales (P & P)

    Overt Behavioral Observation

    Personality Inventory

    Physiology

    Subjective

    Objective

    3 Systems Theory:

    Experience, behavior, and physiology are loosely coupled,

    rather independent data sources that should be assessed concurrently

    in anxiety disorders to provide a comprehensive picture of change in anxiety.

    - P. Lang


    Skin conductance change suds change are positively correlated n 482 r 0 13 p 0 005
    Skin conductance change & SUDS change are positively correlated (N = 482, r = 0.13, p = 0.005).


    Possible interrelationships
    Possible Interrelationships correlated

    Hypnotizability

    Absorption

    Absorption

    Presence

    Immersion

    Involvement


    Framework correlated

    SUDS

    Low

    High

    High Subjective,

    High Objective

    Arousal

    Low Subjective,

    High Objective

    Arousal

    1

    2

    Aroused

    Physiology

    High Subjective,

    Low Objective

    Arousal

    Low Subjective,

    Low Objective

    Arousal

    3

    4

    Normal


    Anxiety disorders
    Anxiety correlated Disorders


    The anxiety equation
    The Anxiety Equation correlated

    Alarm =

    Danger /

    threat

    Consequences X probabilities X imminence

    =

    Perceived self-efficacy


    The trap of avoidance
    The Trap of Avoidance correlated

    • Avoidance

    • (safety seeking behavior)

    • maintains

    • the perceived consequences;

    • the overestimation of probabilities;

    • the low perceived self-efficacy to cope.


    Functional Neuroanatomy of correlated Fear and Anxiety

    Fear and Anxiety

    Response Patterns

    ( Charney & Deutsch 1996)

    Fight or

    flight

    response

    Increase

    urination

    defecation

    ulcers

    bradycardia

    Tachycardia

    increase BP

    sweating

    piloerction

    pupil dilat

    Hormonal

    stress

    response

    Fear-induced

    skeletal motor

    activation

    Facial

    expression of

    fear

    Fear-induced

    hyperventilation

    Fear-induced

    parasympathetic

    nervous system

    activation

    Fear-induced

    sympathetic

    nervous system

    activation

    Neuroendocrine

    and neuropeptide

    release

    Cingulate gyrus

    Primary sensory and Association Cortices

    Striatum

    Periaqueductal

    gray

    Orbitofrontal

    cortex

    Threat

    Trigeminal

    nucleus

    Peripheral receptor

    cells of exteroceptive

    auditory,visual

    somesthetic

    sensory systems

    Facial motor

    nucleus

    Single or

    Thalamus

    Amygdala

    Parabrachial

    nucleus

    Dorsal motor

    nucleus of the

    Vagus

    Lateral

    hypothalamus

    Paraventricular

    nucleus of the

    hypothalamus

    Multisynaptic

    pathways

    Danger

    Hippocampus

    Locus

    ceruleus

    Entirhinal

    coertex

    Visceral

    afferent

    pathways

    Nucleus

    Paragigantocellularis

    Olfactory

    sensory

    stimuli

    Afferent system

    Stimulus processing

    Efferent system


    Dorsolateral prefrontal cortex correlated

    Dorsomedial prefrontal cortex

    Dorsal anterior cingulate gyrus

    Hippocampus

    Ventrolateral prefrontal cortex

    Orbitofrontal cortex

    Ventral anterior cingulate gyrus

    Amygdala

    Insula

    Thalamus

    Ventral striatum

    Brainstem nuclei

    Integration

    Executives functions

    Regulation - effortful

    (of affective states)

    Dorsal system

    Identification

    Production

    Regulation autonomic resp.

    (of affective states)

    Ventral system

    Phillips et al., 2003.


    In vr exposure for anxiety disorders
    In VR correlated Exposure for Anxiety Disorders

    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).


    One hypothesis

    Pre-frontal correlated

    Amygdala /

    Lymbic system

    One hypothesis…

    Perceived self-efficay

    Automatic processing of threat-related cues


    Anxiety and presence are correlated
    Anxiety and Presence are Correlated 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 1 anxiety increases presence
    Exposure and Presence – 1 correlated Anxiety Increases Presence

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


    Exposure and presence 2 is it related to efficacy
    Exposure and Presence – 2 correlated Is it related to efficacy?

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

    • N = 24

    • Time, p < .001

    • Interaction ns.


    Is more hardware necessary
    Is more hardware necessary? correlated

    Mühlberger et al., 2003.

    N = 47

    Assignement to WL not random

    VR > CT = WL at post.

    Less clear at f-up on several variables

    For 13 motion was simulated / 13 without motion

    No significant interaction for mot. / no-mot.

    Effect sizes f :

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


    Realism and social anxiety heberlin riquier vexo and talmann 2002
    Realism and Social Anxiety correlated (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).

    All time effects p < .01 (repeated measures ANOVA)

    Interactions ns.


    Delay and anxiety presence meehan et al 2003 vr 03
    Delay and Anxiety / Presence correlated (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
    Anxiety and Image Quality correlated (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


    Anxiety and image quality zimmons 2004 ph d dissertation in preparation1
    Anxiety and Image Quality correlated (Zimmons, 2004, Ph.D. dissertation, in preparation)

    Grid

    Heart rate

    ANOVA N = 42 :

    • Time: p < .001

    • Group: p < .05

    • Gr X T : ns

      Contrasts :

    • Pre vs PIT : p < .001

    • PIT vs post : p < .001

      Condition 3 vs others :

    • All p < .001

      Grid vs the others:

    • All ns.

      Presence

    • « SUS » at post: ns

    • Effect size = .05

    Text - / Light +


    Physiology in a public speaking task cornwell johnson berardi grillon 2006
    Physiology in a public speaking task. correlated (Cornwell, Johnson, Berardi & Grillon, 2006)

    45 non-phobics, 5 min. baseline

    + 2 counterbalance tasks

    Paired t-tests (in the paper):

    Startle: baseline < count < speech

    HR*: baseline = count < speech

    Skin c: baseline = count < speech

    Anxiety: count < speech

    *Note. HR data from the paper not shown.

    HR data presented here are for all the data

    points collected (Cornwell, personnal communication, 2006)


    425 patients in clinical database anxiety disorders phobias and panic disorders
    425 Patients in correlated 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%

    • Panic Disorder: 1.4%

    • Agoraphobia: 0.9%

    • Arachnophobia: 0.5%

    • Needle Phobia: 0.2%

    • Multiple Phobias: 8.9%

    • Other Specific Phobias: 1.6%


    Results
    Results correlated

    • % 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
    The Cybertherapy Lab Treatment Protocol for Specific correlated 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
    Cognitive-Behavior Therapy correlated

    • Self-monitoring

    • Transmission of information

    • Cognitive restructuring

    • Exposure

    • Problem solving

    • Relapse prevention

    • Modeling

    • Relaxation


    Session 1 assessment
    Session 1 : Assessment correlated

    • 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
    Session 2 : Information correlated

    • What are anxiety and phobias… ?

    • How did you acquire your phobia ?

    • Avoidance.

    • Exposure.

    • Habituation curve.


    The process of exposure
    The Process of Exposure correlated

    • Avoidance (safety seeking behavior, neutralization)

    • Functional exposure

    Anxiety

    Time (minutes)


    Session 2 information1
    Session 2 : Information correlated

    • 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 5
    Sessions 3 to 5¾ correlated

    • In VR exposure :

      • includes guided-mastery techniques (e.g. Öst)

      • select the appropriate environments (hierarchy)

      • asses anxiety (habituation curve) and presence.

      • Should be tailored to

        patient’s needs (if not

        in an outcome study).


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