Part 1 - The Virtual Reality Medical Center

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14 Νοε 2013 (πριν από 3 χρόνια και 7 μήνες)

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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.


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




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











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
Hyperactivity Disorder
(ADHD)


Driving Deficits after
Brain Injury


Functional Disorders


PTSD in Gulf War
Veterans


Quality of Life in Chronic
Disease

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 CyberPsychology

Patrice Renaud, Ph.D.

The Cyberpsychology Lab

Supported by grants from

:



UQO, CHPJ



Canada Research Chair



CFI, CIHR, FCAR



MDERR, DEC



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.

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 Technologies

The VRMC Protocol


Non
-
invasive Physiological monitoring


Heart rate & HRV


Respiration rate


Skin conductance


Peripheral 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. Wilhelm

Evaluative Measures

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

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 conductance change
-40
-20
0
20
40
60
80
100
SUDS change
Possible Interrelationships

Absorption

Absorption

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
Percentage of
Respondents
Treatment Responders
(n=103)
Treatment Non-
Responders (n=18)
SUDS

High

Low

High Subjective,

High Objective

Arousal

Low Subjective,

Low Objective

Arousal

High Subjective,

Low Objective

Arousal


Low Subjective,

High Objective

Arousal

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 Anxiety

Amygdala

Thalamus

Peripheral receptor

cells of exteroceptive

auditory,visual

somesthetic

sensory systems


Single or

Multisynaptic


pathways

Orbitofrontal

cortex

Periaqueductal

gray

Locus

ceruleus


Parabrachial

nucleus


Dorsal motor

nucleus of the

Vagus



Lateral

hypothalamus



Paraventricular

nucleus of the

hypothalamus

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

Fight or

flight

response











Increase

urination

defecation

ulcers

bradycardia


Tachycardia

increase BP

sweating

piloerction

pupil dilat


Hormonal

stress

response

Visceral

afferent

pathways

Nucleus

Paragigantocellularis

Olfactory

sensory

stimuli

Cingulate gyrus

Afferent system

Stimulus processing

Efferent system

Fear and Anxiety

Response Patterns

Striatum

Trigeminal


nucleus

Facial motor

nucleus

Primary sensory and Association Cortices

( Charney & Deutsch 1996)

Phillips et al., 2003.

Dorsolateral prefrontal cortex

Dorsomedial prefrontal cortex

Dorsal anterior cingulate gyrus

Hippocampus

Amygdala

Insula

Ventrolateral prefrontal cortex

Orbitofrontal cortex

Ventral anterior cingulate gyrus

Thalamus

Ventral striatum

Brainstem nuclei


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)
.

Amygdala /

Lymbic system

Pre
-
frontal

One hypothesis…

Perceived self
-
efficay

Automatic processing
of 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


1

Anxiety 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
Presence
First
Immersion
(CTRL)
Second
Immersion
Third
Immersion
Measured at post immersion
CTRL - ANX - NOANX
CTRL - NOANX - ANX
0
2
4
6
8
10
Anxiety
First
Immersion
(CTRL)
Second
Immersion
Third
Immersion
Measured at post immersion
CTRL - ANX - NOANX
CTRL - NOANX - ANX
Exposure and Presence


2

Is it related to efficacy?


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










N = 24


Time,
p

< .001


Interaction ns.

0
10
20
30
40
50
60
70
Total score (IPQ)
Session 1
Session 2
Session 3
ITC-SOPI. Krijn et al., 2004
CAVE
HMD
0
10
20
30
40
50
60
Acro. Q.- Anxiety
Pre
Post
Treatment effectiveness. Krijn et al., 2004
CAVE
HMD
0
5
10
15
20
Acro. Q.- Avoid.
Pre
Post
Treatment effectiveness. Krijn et al., 2004
CAVE
HMD
0
10
20
30
40
50
60
BAT
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
Fear of Flying Scale
VR (+cogn.)
Cogn. Therapy
Waiting list
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

N = 47

Assignement to WL not random

VR > 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 Flying Scale
VR + Motion
VR - No Motion
One session Rx
0
2
4
6
8
10
Pre
Post
6-mo Fup
Avoidance rating
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
T4
All 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 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

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
(with startle
probe)
Anticipation
with
audience
noise
Anticipation
with 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 with
audience)
Startle reactivity
Skin conductance
Anxiety
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


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


% 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
-
monitoring


Transmission of information


Cognitive restructuring


Exposure


Problem solving


Relapse prevention



Modeling


Relaxation

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.

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 to

patient’s needs (if not

in an outcome study).