Order of Exposure
Develop basic physiological control strategies first to control stress/reduce attention allocated to emotions
Teach physiological control first
Absolute fidelity is not necessary or desirable
Virtual reality simulations better than real video
(pg 213): "an effective method for reducing anxiety and enhancing performance in stressful environments. The results of this analysis should clearly encourage further application and research."
Take-home message: CBT
reduces anxiety, results in higher levels of functioning, and increases quality of life.
TADMUS vs. VRMC: a 1-to-1 correlation
TADMUS vs. VRMC: a 1-to-1 correlation
TADMUS highlights several very important facts about training and the lack of appropriate training, which can have very serious consequences. In general, training tasks must be performed under an equal or higher level of stress in order for effective training to take place. Second, the training environment does not necessarily need to replicate the reallife scenario in true fidelity. Third, before training skills can be learned, basic coping mechanisms must be mastered in order to build confidence and self-efficacy in trainees. This preparation allows the trainee to completely focus attention on the tasks at hand and avoids a major problem of training, which is distraction.
Although not generally used in training, the measurement of real-time physiology during the training program can provide invaluable information as to the level of engagement, anxiety, or boredom during training. We have found that by measuring self-reported anxiety in combination with EEG brainwaves, skin conductance, and heart rate variability from the EKG, we can not only assess performance during training (or therapy), but also predict who will perform well and who may need additional training or remediation.
As the photos below illustrate, our teaming strategy is to combine the flexibility afforded by simulation and virtual training with the realism enabled by the Strategic Operations Tactical Training Laboratory.
Uses of virtual environments and simulations for training, although pioneered by the military, are finding increased applications in clinical psychology and executive training in the private sector. Studies have shown that training of skills in a non-stress condition does not transfer to improved task performance when those same skills are then performed in a stressful situation. Therefore, it would be advantageous to employ more real-world stress simulations to allow for more generalizability of skill sets. In 1988, a National Research Council study on enhancing military performance found that when a person is given knowledge of future events, stress surrounding those events is then reduced . In general, this occurs because stress is viewed as a new, novel task. Stress training therefore renders the task less novel and improves the trainee's self-efficacy, which in turn improves performance.
At the Virtual Reality Medical Center (VRMC), we have used a combination of cognitive-behavioral therapy and physiological monitoring for the treatment of a variety of psychological disorders. We have evaluated over 5,000 sessions in virtual environments and have noted that successful treatment of stress and anxiety-related disorders requires gradual exposure to more and more stressful situations, which allows the patient to over-learn coping skills and renders the task less novel, which allows for a sense of mastery and an increase in self-efficacy.
The DSM-IV classifies Posttraumatic Stress Disorder as a heterogeneous disorder that develops following exposure to traumatic events such as a serious injury or threat of injury or death to the self or others. Symptoms of PTSD, which must persist for at least 1 month, include increased anxiety or arousal, dissociation, avoidance of stimuli associated with the trauma and numbing of general responsiveness, as well as flashbacks to the traumatic experience . Both anxiety-reducing medication as well as CBT can help in recovery. In recent years, VR has been shown to improve treatment efficacy for PTSD in survivors of motor vehicle accidents (MVA), war veterans, and those involved in the 9/11 World Trade Center attacks, as well as in other areas [9-15].
4.1. VR Training/Therapy for Pre-Deployment/Post-Deployment in U.S. Military Personnel
The Virtual Reality Medical Center has been funded by the Office of Naval Research (ONR) to develop virtual reality worlds and test them, using our established clinical protocols in combination with physiological monitoring and feedback, to treat non-combatants (including SeaBees and medical personnel) returning from Iraq who are diagnosed with PTSD. The systems will be tested at Balboa Naval Hospital and Camp Pendleton. In addition, we are investigating treatment protocols at both facilities with combatants returning from Iraq utilizing software developed by USC's Institute for Creative Technologies. Initial results indicate that the worlds do elicit arousal, physiologically and subjectively, in those reporting PTSD symptoms. After treatment, individuals tested thus far no longer meet criteria for PTSD.
In a second study funded by ONR, Stress Inoculation Training (SIT) protocols are being tested to determine if providing stress hardening skills prior to deployment can decrease incidence of PTSD.
And a third project, funded by the Telemedicine and Technology Research Center, is allowing us the opportunity to ship a VR system to Iraq in August 2005. This will allow us to receive crucial feedback from troops in theater on how the software might need to be adjusted to better meet their needs. Having the end user in the development loop has been an important attribute we have encouraged over the past decade and provides for quicker iterations in the development cycle and a more useful end product.
Hyperarousal to presentation of combat-related stimuli has been shown in several physiological measurements, including heart rate  and electrodermal activity [17-18]. Veterans with PTSD clearly show an increased physiological response as compared to veterans without PTSD. To build on this research, a 1996 article measured visual event-related potentials (ERPs) in both a control group and PTSD patients . Event-related potentials reflect neural activity associated with information processing. The P3 component of the ERP reflects stimulus relevance, and its amplitude and latency are thought to be determined by the subjective value of a stimulus . The N1 component of the ERP reflects early-stage selection and its amplitude is dependent on the physical attributes of a stimulus . PTSD patients showed increased P3 and N1 amplitudes in response to combat-related pictures, and also earlier P3 and N1 components for combat-related pictures. They did not show these increases when presented with neutral pictures. The control group of combat veterans who did not have PTSD did not show these patterns. It is important to further explore these measures as virtual reality graded exposure therapy (VRGET) begins to be used to treat this population. It has been hypothesized that the ERP paradigm could possibly be used as a diagnostic tool for PTSD. The 3-dimensional nature of the VR stimuli could allow for more accurate representation of stimuli and would allow for systematic presentation of the relevant stimuli . Dr. Alex Bullinger from the University of Basel has been engaged to provide consulting on these measures. He has been an industry leader in this area of research over the past decade, having published results of several studies indicating the usefulness of 3-dimensional stimuli and its direct effect on physiology.
VR has proven an effective method of exposure for those suffering from PTSD, whether it is due to a MVA, natural disaster, terrorism, or war-related trauma. Often in PTSD treatment it is not practical or advisable to re-expose the patient to the trauma in a real-world setting. VR, however, can effectively place the patient back into that scenario so that the necessary processing of memories can occur, allowing the individual to move through the trauma and on to recovery.
In order to provide a more time-sensitive solution to those who have been exposed to recent combat situations, several groups are now developing VR worlds and have begun initial testing to treat those returning from Iraq who are suffering from PTSD and Acute Stress Disorder. It is hoped that by providing treatment earlier, many of the co-morbid conditions which often occur, such as substance abuse, can be avoided. Treatment response is also hoped to be greater since the PTSD is not as long-standing.
VRMC is developing advanced computer-assisted rehabilitation systems specifically designed to improve the treatment of the physical and cognitive injuries resulting from battle-related trauma. By employing recent advances in simulation and measurement technology, as well as improved rehabilitation paradigms that leverage the brain's ability to relearn after an injury (neuro-plasticity), it is possible to bring next-generation rehabilitation technology to bear upon the immediate needs of injured military personal.
A funded project by DARPA to test inexpensive off-the-shelf videogame environments, such as the EyeToy, as an adjunct to traditional physical therapy protocols will begin pilot testing in September 2005 at the Walter Reed Hospital in Bethesda, Maryland. It is hypothesized that the adjunctive treatment will increase compliance, while decreasing depression and anxiety rates. It is also anticipated that many of the amputees may be experiencing PTSD symptoms due to their physical trauma. These amputees will also be potential participants for an additional arm of our PTSD study.
The long-term benefit of this project will be the development and deployment of advanced rehabilitation technologies and strategies. While these technologies will have immediate benefit for injured military personal, their development will also serve to catalyze improvement and change within clinical rehabilitation at large.
After more than a decade of using VR to treat anxiety disorders, a database of thousands of sessions with patients in virtual worlds has been accumulated. What began with the controlled studies and protocols for the treatment of specific phobias (flying, driving, public speaking, claustrophobia, heights, and spiders) has now expanded to include, amongst others, PDA, PTSD, and SoP. Perhaps the lesson that has been learned above anything else is that there is no "one-size-fits-all" treatment. Responses to virtual worlds vary not only between phobic and non-phobic groups, but also from individual to individual. There is a great deal of variance in the pace at which each patient progresses, as well as their personal feeling of presence in the world. As study results indicate that such variables as personality characteristics and previous VR experience can affect one's level of immersion (measured through subjective, emotional, and physiological responses), researchers and clinicians, working together in multidisciplinary teams, must continue to create more complex virtual worlds, providing richer and more realistic experiences that can be customized to suit the needs of individual users. Further, as we have learned that this sense of immersion may need to vary among the different phobias being treated, we must continuously refine our protocols. While a person with a specific fear may need to become deeply immersed in the world and ignore his/her surroundings, a patient with PTSD or SoP may feel the need to verbalize feelings during exposure. Finally, we are learning there is a wide range of new technology available, which can be utilized for our common goal of improving the behavioral healthcare field.
All studies presented in this paper, whether they were conducted in a million-dollar immersive chamber, HMD, the Internet, or a modified videogame, have shown positive results that point to a promising future for the healthcare application of VR.
In developing new virtual reality tools, it is important to keep several concepts in mind. Existing therapeutic concepts should form the basis for the construction of virtual worlds. Virtual reality technology must be understood in light of existing science and established paradigms. The application of virtual reality in relation to existing therapeutic approaches and a consideration of the costs of using this technology need to be central in assessing the clinical applications of virtual reality. Multi-disciplinary teams of experts can be very helpful in the development and delivery of virtual reality systems.
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Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder 161
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Indications provided by the Eating Disorder Module of the VEPSY Updated Project: towards a new generation of virtual environments for clinical applications
Gianluca CASTELNUOVO, Ph.D.1abc, Gianluca CESA, M.S. ac, Andrea GAGGIOLI, Ph.D. ad, Fabrizia MANTOVANI, Ph.D. ae, Mauro MANZONI, M.S. ac, Enrico MOLINARI, Ph.D. bc, Giuseppe RIVA, Ph.D. abc a Applied Technology for Neuro-Psychology Istituto Auxologico Italiano, Milan, Italy b Clinical Psychology Lab, Catholic University, Milan, Italy c Clinical Psychology Lab, Istituto Auxologico Italiano, Verbania, Italy d Laboratory of Psychology, Department ofPreclinical Sciences LITA Vialba, University of Milan, Milan, Italy e Centre for Studies in Communication Sciences (CESCOM), University of Milan Bicocca, Milan, Italy
Abstract. This chapter stresses in particular some clinical observations obtained in the eating disorder module of the VEPSY Updated Project and it also proposes some clinical considerations to take into account during the development of new virtual environments for mental health care purposes. For further information, please contact Gianluca Castelnuovo: [email protected]
In recent years, clinical applications of virtual reality (VR) and telemedicine have been rapidly developing both in medicine and in clinical and rehabilitation psychology . Many
Corresponding author: Gianluca Castelnuovo. San Giuseppe Hospital, Istituto Auxologico Italiano, Casello Postale 1-2892, Intra (Verbania) Italy Telephone: +39 0323514339-4278 Fax: +39-0323514338 Email: [email protected]
terms have been coined to denote this newly developed match between technology and care: cybertherapy and e-health, the integration of telehealth technologies with the Internet and shared virtual reality, are only two examples. This chapter stresses in particular some clinical observations of the eating disorder module of the European funded project VEPSY Updated Project also proposing some clinical considerations to take into account in the development of new virtual environments for mental health care purposes.
1. The VEPSY Updated Project and the Eating Disorder Module
The main goal of the "Telemedicine and Portable Virtual Environment in Clinical Psychology'"--VEPSY UPDATED--a European Community-funded research project (IST-2000-25323, www.cybertherapy.info) was to study the technical and clinical viability of using portable and shared Virtual Reality systems (shared care) in clinical psychology. The selected disorders were anxiety, male sexual disorders and obesity and eating disorders [2, 3]. Particularly its specific goal was the development of different PC-based virtual reality modules to be used in clinical assessment and treatment of social phobia, panic disorders, male sexual disorders, obesity, and eating disorders.
About the Eating Disorder Module in the VEPSY Project, the ATN-P Lab - Istituto Auxologico Italiano, the leading partner in this module, has developed the Experiential Cognitive Therapy (ECT), an integrated inpatient/outpatient (4 weeks) and telemedicine approach (24 weeks) that tries to enhance the classical cognitive-behavioral method used in the treatment of eating disorders, through VR sessions and telemedicine support in the follow-up stage. Particularly, using VR and telemedicine, ECT is able to address body experience disturbances, interpersonal relationships, self efficacy and motivation to change, key issues for the development and maintenance of eating disorders that are somehow neglected by actual clinical guidelines [4-9].
Distorted body image, negative emotions, difficulty in maintaining positive outcomes in the long term and lack of faith in the therapy are typical features of obesity and eating disorders treatment. To target these issues different groups are trying to enhance traditional cognitive-behavioral therapy (CBT) with the use of a virtual environment [1, 10-12]. ECT shares with the Cognitive Behavioral Therapy (CBT) the use of a combination of cognitive and behavioral procedures to help the patient identify and change the maintaining mechanisms. However it is different for:
• Its use of Virtual Reality (VR): 10 VR sessions.
• Its focus on the negative emotions related to the body, a major reason patients want to lose weight.
• Its focus on supporting the empowerment process. VR has the right features to support the empowerment process, since it is a special, sheltered setting where patients can start to explore and act without feeling threatened.
The VR session can approximate natural settings, providing an alternative for exposure and desensitization exercises as well as a more general enhancement to therapy.
Specifically, VR is believed to increase motivation by allowing individuals to virtually witness changes in their behavior and shape and reach their own conclusions based on actual experience. During typical VR sessions, patients are asked to wear a head mounted VR display system. An approach similar to guided imagery is used to lead the subject through various zones over the course of ten sessions. Stimuli that contribute to abnormal eating behaviors are identified, and associated anxiety and body experiences are targeted for modification. Subjects are also asked to identify figures that most closely resemble their current and ideal body sizes. They are also confronted with a photograph of their actual body.
This approach was validated through different case studies  and trials. In the first one, uncontrolled, three groups of patients were used : patients with Binge Eating Disorders (BED), patients with Eating Disorders Not Otherwise Specified (EDNOS), and obese patients with a body mass index higher than 35. All patients participated in five biweekly therapy sessions. All the groups showed improvements in overall body satisfaction, disordered eating, and related social behaviors, although these changes were less noticeable in the EDNOS group.
This approach was recently tested in further controlled studies. The first one involved twenty women with BED who were seeking residential treatment . The sample was assigned randomly to ECT or to CBT based nutritional therapy. Both groups were prescribed a 1,200-calorie per day diet and minimal physical activity. Analyses revealed that although both groups were binge free at 1-month follow-up, ECT was significantly better at increasing body satisfaction. In addition, ECT participants were more likely to report increased self-efficacy and motivation to change.
In a second one, the same randomized approach was used with a sample of 36 women with BED . The results showed that 77% of the ECT group quit binging after 6 months versus 56% for the CBT sample and 22% for the nutritional group sample. Moreover, the ECT sample reported better scores in most psychometric tests including EDI-2 and body image scores. In the final one ECT was compared with nutritional and cognitive-behavioral treatments, using a randomized controlled trial, in a sample of 211 female obese patients. Both ECT and CBT produced a better weight loss than NT after a 6-month follow-up. However, ECT, as compared with CBT and NT, was able to significantly improve both body image satisfaction and self-efficacy. This in turn resulted in a reduction in the number of avoidance behaviors as well as an improvement in adaptive behaviors.
In the VEPSY Updated Project the Spanish research group, led by Cristina Botella, worked also as second centre of investigation in the eating disorder module. This group has compared the effectiveness of VR to traditional CBT for body image improvement (based on Cash  in a controlled study with a clinical population . In particular, they developed six different virtual environments including a 3D figure whose body parts (arms, thighs, legs, breasts, stomach, buttocks, etc.) could be enlarged or diminished. The proposed approach addressed several of the body image dimensions: the body can be evaluated wholly or in parts; the body can be placed in different contexts (for instance, in the kitchen, before eating, after eating, facing attractive persons, etc.); behavioural tests can be performed in these contexts, and several discrepancy indices related to weight and figure can be combined (actual weight, subjective weight, desired weight, healthy weight, how the person thinks others see her/him, etc.).
In the published trial eighteen outpatients, who had been diagnosed as suffering from eating disorders (anorexia nervosa or bulimia nervosa) according to the DSM-IV criteria, were randomly assigned to one of the two treatment conditions: the VR condition (cognitive-behavioural treatment plus VR) and the standard body image treatment condition (cognitive-behavioural treatment plus relaxation). Thirteen of the initial 18 participants completed the treatment. Results showed that following treatment, all patients had improved significantly. However, those who had been treated with the VR component showed a significantly greater improvement in general psychopathology, eating disorders psychopathology, and specific body image variables. Since then, the group has also developed a VR simulator of food and eating  actually under evaluation with patients. In summary, the data from both Italian and Spanish trials suggest that VR can help in addressing two key features of eating disorders and obesity not always adequately addressed by existing approaches: body experience disturbances and self-efficacy.
2. Why to use VR in clinical psychology: added value and limits
The advantages that VR has over traditional approaches have been repeatedly underlined by different studies, overall all in comparison with standard exposure therapies [20-25]. This is understandable given that the majority of the studies about VR-based psychological treatments have used this tool as a new procedure of applying the exposure technique. From this perspective, the following advantages have been pointed out:
2.1.1. VR exposure allows an almost total control of everything occurring in the situation experienced by the person in the virtual world
If a patient fears being trapped in a lift, or the turbulences and bad weather during a flight, we can assure him/her that these threats are not going to occur until he/she feels prepared to cope with them and, in fact, he/she accepts them to happen in the virtual world. The same can be said for numerous elements that are present in the situation and can make it more or less threatening. For instance, number of feared persons, animals or objects, size and degree of closing/opening of virtual spaces, the height of the spaces, if there is or not protecting elements, the time a determined situation last, etc. This makes it possible a personalized construction of the exposure hierarchy enabling the user to cope with the feared situation or context at his/her own pace. A VR system can generate as many audiences and social situations as the person requires and such situations can be at his/her disposal when is needed and as many times as the person desires. The only mission of the avatars and the whole virtual world is to be there in order to help. Therefore, VR provides valuable opportunities regarding training and self-training. A person with fear of driving following a motor vehicle accident can practice as many times as needed different feared elements
(overtaking a track, driving with rain, entering a tunnel, or passing over a bridge) in the virtual world. This possibility of continuous practice in many diverse contexts may help to generalize the therapy achievements to the real world.
2.1.2. VR helps the person to feel present and judge the situation as real
In fact, a central element of VR is that it provides the person a place where he/she can be placed and live the experience. Furthermore, the therapist is able to know what is always happening in the situation, what elements are being faced by the patient and what is disturbing to him/her. Obviously, this also contributes to the control of the situation and the protection of the patient.
We have seen many times in therapy (and also in the real world) the importance of certain situations considered extreme in order to definitely overcome a problem. There would be different thresholds of difficulty/threat; once a very high threshold is overcome, to cope with the remaining ones is much easier. Virtual worlds allow the creation of situations or elements so "difficult or threatening" that they are not expected to happen in the real world. For instance, in our claustrophobia application one of the walls can be displaced (producing a loud noise) reducing the room to a very small space. The first patient who was treated with this application indicated precisely this: "If I am able to cope with that wall I can confront everything" . The same can be made in other virtual worlds; a person with spider phobia unexpectedly has to cope with thousands of spiders, or spiders whose size increases so much that they turn into monsters.
2.1.4.VR is an important source of personal efficacy [21, 26, 27]
According to Bandura , from all possible sources of personal efficacy, performance achievements are especially useful. We think that VR is an excellent source of information concerning personal efficacy. VR allows the construction of "virtual adventures" in which the person experiences him/herself as competent and efficacious. VR is flexible enough to permit the design of different scenarios in which the patient can develop personal efficacy expectations of highest magnitude (including from easy performances to very difficult ones) generalization (referred to very different domains) and, strength (difficult to extinguish, to achieve the patient perseveres regardless of difficulties). The goal is that the person finds out that the obstacles and feared situations can be overcome through the confrontation and effort.
The possibility offered by VR of confronting many fears inside the consulting room, without the necessity of in-vivo exposure, represents a significant advantage.
Besides these advantages that VR has over the traditional exposure technique, from a more braoder treatment perspective, VR also has limitations that should be mentioned. The first barrier is the lack of standardization in VR devices and software. The PC-based systems, while inexpensive and easy-to-use, still suffer from a lack of flexibility and capabilities necessary to individualize environments for each patient . To date, very few of the various VR systems available are interoperable. This makes difficult their use in contexts other than those in which they were developed.
The second one is the lack of standardized protocols that can be shared by the community of researchers. In reviewing two clinical databases - Medline and Psyclnfo - we found only five published clinical protocols: for the treatment of eating disorders , fear of flying [31, 32], fear of public speaking  and panic disorders . A third limitation is the expense required for to set up trials. As we have just seen, the lack of interoperable systems added to the lack of clinical protocols force most researchers to spend a lot of time and money in designing and developing their own VR application: many of them can be considered "one-off"' creations tied to proprietary hardware and software, which have been tuned by a process of trial and error. According to the VEPSY Updated studies  the cost required for designing a clinical VR application from scratch and testing it on clinical patients using controlled trials may range between 150000 and 200000 €.
Finally, the introduction of patients and clinicians to VEs raises particular safety and ethical issues . In fact, despite developments in VR technology, some users still experience health and safety problems associated with VR use. It is however true that for a large proportion of VR users these effects are mild and subside quickly .
To close this chapter it is important to point out some questions that each VR developer has to take into consideration in designing virtual environments for clinical applications (see Table 1).
Key questions ^
Possible answers ^
Applications and indications for VR designers
1) Are VEs useful, effective and efficient in clinical applications?
Evaluation of possible advantages and limits. Cost/benefit analysis.
Development of VEs that have to ensure only the factors of presence requested by each application.
2) Do VEs reproduce the physical and perceptual characteristics of real environments?
Attention on graphics and technical characteristics. Focus on realism and graphical issues.
Development of VEs that have to ensure realism and a level of presence as non-mediation and immersion.
3) Do VEs allow users to function in an ecologically valid way?
Attention on cultural and social aspects. Focus on interaction, interactivity.
Importance of relationships and context.
Development of VEs that have to ensure ecological situations of interaction, interactivity.
4) Do VEs allow users to experience optimal experiences (flow) during virtual sessions?
Evaluation of qualitative aspects in virtual experiences. Attention on users' psychological state.
Development of VEs in order to allow optimal experiences, good compliance and high motivation
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