Overview

1. 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.

2. 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

3. 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

4. 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)

5. 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

6. VRMC Research & Development • Research Studies • VR for Training • Student Internship/Fellowship Programs • Clinical Trials • Evaluation of New Software • Software Development • Collaborations

7. 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

8. VRMC Technologies • Virtual Reality/Simulation • Videogames • Non-Invasive • Physiological Monitoring • Shared Internet Worlds • Biometrics • Human-Robot Interactions

9. 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

10. 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

11. UQO Technologies

13. The VRMC Protocol • Non-invasive Physiological monitoring • Heart rate & HRV • Respiration rate • Skin conductance • Peripheral skin temperature

14. Patient Kevin

15. 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.

16. 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

17. 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

18. Skin conductance change & SUDS change are positively correlated (N = 482, r = 0.13, p = 0.005).

19. Possible Interrelationships Hypnotizability Absorption Absorption Presence Immersion Involvement

21. Framework 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

22. AnxietyDisorders

23. The Anxiety Equation Alarm = Danger / threat Consequences X probabilities X imminence = Perceived self-efficacy

24. The Trap of Avoidance • Avoidance • (safety seeking behavior) • maintains • the perceived consequences; • the overestimation of probabilities; • the low perceived self-efficacy to cope.

25. Functional Neuroanatomy of 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

26. Dorsolateral prefrontal cortex 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.

27. In VR 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).

28. Pre-frontal Amygdala / Lymbic system One hypothesis… Perceived self-efficay Automatic processing of threat-related cues

29. 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.

30. Exposure and Presence – 1Anxiety Increases Presence • Snake phobics are led to believe that some environments are filled with hidden snakes. Bouchard et al. (submitted).

31. 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.

32. Is more hardware necessary? 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

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

34. 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.

35. 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

36. Anxiety and Image Quality(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 +

37. Physiology in a public speaking task.(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)

38. 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% • Panic Disorder: 1.4% • Agoraphobia: 0.9% • Arachnophobia: 0.5% • Needle Phobia: 0.2% • Multiple Phobias: 8.9% • Other Specific Phobias: 1.6%

39. Results • % completers: 95.5% • Dropout rate of 4.5% (much lower than in vivo or imaginal therapy rates) • Responders: 94%

40. 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.

41. Cognitive-Behavior Therapy • Self-monitoring • Transmission of information • Cognitive restructuring • Exposure • Problem solving • Relapse prevention • Modeling • Relaxation

42. 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.

43. Session 2 : Information • What are anxiety and phobias… ? • How did you acquire your phobia ? • Avoidance. • Exposure. • Habituation curve.

44. The Process of Exposure • Avoidance (safety seeking behavior, neutralization) • Functional exposure Anxiety Time (minutes)

45. 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..

46. 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 to patient’s needs (if not in an outcome study).