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
Brenda K. Wiederhold, Ph.D., MBA, BCIA
Mark D. Wiederhold, M.D., Ph.D., FACP
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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
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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
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
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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
The Cyberpsychology Lab
Stéphane Bouchard, Ph.D. CRC Clinical CyberPsychology
Patrice Renaud, Ph.D.
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.
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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.
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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.
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
Behavior
Self-report
Physiology
Not good!
0.3
0.3
0.3
Running
Heart
racing
„Afraid!“
 Emotional assessment requires 3 domains of measurement because
correlations between domains are only in the order of 0.3.
From F.
Lang, P. J. (1978). Anxiety: toward a psychophysiological definition. In H. S. Akiskal &
W. L. Webb (Eds.), Psychiatric diagnosis: exploration of biological criteria (pp. 265Wilhelm 389). New York: Spectrum.
Evaluative Measures
Subjective
Subjective Units of Distress
Self-Report Scales (P & P)
Overt Behavioral Observation
Personality Inventory
Physiology
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).
100
80
60
40
20
SUDS change
0
-20
-40
-10
0
10
20
30
skin conductance change
40
50
Possible Interrelationships
Absorption
Absorption
Hypnotizability
Presence
Immersion
Involvement
Percentage of
Respondents
Level of Immersion
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Treatment Responders
(n=103)
Treatment NonResponders (n=18)
100% 67%
50%
33%
0%
Percentage of Immersion
Reported
Framework
SUDS
High
Aroused
Low
High Subjective,
High Objective
Arousal
Low Subjective,
High Objective
Arousal
High Subjective,
Low Objective
Arousal
Low Subjective,
Low Objective
Arousal
Physiology
Normal
Anxiety Disorders
The Anxiety Equation
Alarm =
Danger /
threat
Consequences X probabilities X imminence
=
Perceived self-efficacy
The Trap of Avoidance
Avoidance
 (safety seeking behavior)
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maintains
the perceived consequences;
the overestimation of probabilities;
the low perceived self-efficacy to cope.
Functional Neuroanatomy of Fear and Anxiety
Fear and Anxiety
Response Patterns
( Charney & Deutsch 1996)
Cingulate gyrus
Primary sensory and Association Cortices
Striatum
Periaqueductal
gray
Orbitofrontal
cortex
Peripheral receptor
cells of exteroceptive
auditory,visual
somesthetic
sensory systems
Facial motor
nucleus
Single or
Multisynaptic
pathways
Trigeminal
nucleus
Thalamus
Olfactory
sensory
stimuli
Afferent system
Fight or
flight
response
Facial
expression of
fear
Amygdala
Parabrachial
nucleus
Fear-induced
hyperventilation
Dorsal motor
nucleus of the
Vagus
Fear-induced
parasympathetic
nervous system
activation
Lateral
hypothalamus
Fear-induced
sympathetic
nervous system
activation
Tachycardia
increase BP
sweating
piloerction
pupil dilat
Neuroendocrine
and
neuropeptide
release
Hormonal
stress
response
Locus
ceruleus
Visceral
afferent
pathways
Fear-induced
skeletal motor
activation
Nucleus
Paragigantocellularis
Stimulus processing
Paraventricular
nucleus of the
hypothalamus
Efferent system
Increase
urination
defecation
ulcers
bradycardia
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
Phillips et al., 2003.
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).
One hypothesis…
Perceived self-efficay
Pre-frontal
Amygdala /
Lymbic system
Automatic processing
of threat-related cues
Anxiety and Presence are
Correlated
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r = .74 (p < .01)
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Renaud et al., 2002
r = .45 (p < .05)
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r = .28 (p < .05)
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Robillard et al., 2003
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Schumie et al., 2000
r = .25 (ns)
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Regenbrecht et al.
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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).
10
8
6
4
2
0
Measured at post immersion
First
Second
Third
Immersion Immersion Immersion
(CTRL)
CTRL - ANX - NOANX
CTRL - NOANX - ANX
Anxiety
Presence
Measured at post immersion
10
8
6
4
2
0
First
Immersion
(CTRL)
Second
Immersion
CTRL - ANX - NOANX
Third
Immersion
CTRL - NOANX - ANX
Exposure and Presence – 2
Is it related to efficacy?
Acrophobics treated with CAVE or HMD
environments. Krijn et al., 2004.
Treatment effectiveness. Krijn et al., 2004
ITC-SOPI. Krijn et al., 2004
60
BAT
70
60
50
40
30
20
10
0
40
30
20
10
0
Pre
Post
CAVE
Treatment effectiveness. Krijn et al., 2004
60
Session 1
Session 2
CAVE
Acro. Q.- Anxiety
Total score (IPQ)
50
Session 3
HMD
Treatment effectiveness. Krijn et al., 2004
 N = 24
 Time, p < .001
 Interaction ns.
Acro. Q.- Avoid.
20
50
40
30
20
10
0
Pre
Post
CAVE
15
10
5
0
Pre
Post
CAVE
HMD
HMD
HMD
Is more hardware necessary?
One session Rx
Mühlberger et al., 2003.
Fear of Flying Scale
N = 47
Assignement to WL not random
VR > CT = WL at post.
Less clear at f-up on several variables
4
3
2
1
0
Pre
One session Rx
4
Avoidance rating
Fear of Flying Scale
One session Rx
3
2
1
0
Pre
Post
VR + Motion
6-mo Fup
VR - No Motion
VR (+cogn.)
10
8
6
4
2
0
Pre
Post
VR + Motion
6-mo Fup
VR - No Motion
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
Post
Cogn. Therapy
6-mo Fup
Waiting list
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).
120
100
80
Bps
–
–
–
–
Hear rate
60
40
20
0
High LSAS
Low LSAS
T1 T2 T3 T4
10
SUDS
8
6
4
2
0
High LSAS
T1 T2 T3 T4
Low LSAS
All time effects p < .01 (repeated measures ANOVA)
Interactions ns.
Delay and Anxiety / Presence
(Meehan et al., 2003, VR’03)
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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
Anxiety and Image Quality
(Zimmons, 2004, Ph.D. dissertation, in preparation)
Text - / Light +
HR
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
115
110
105
100
95
90
85
80
75
70
Pre Pit
Grid
Text low / Light high
Pit
Text low / Light low
Text high / Light high
Post Pit
Text high / Light low
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)
Mean heart rate
5
90
4
85
3
80
2
75
1
70
0
65
Baseline
Startle reactivity
Backward count
(empty VR room)
Talk (VR room with
audience)
Skin conductance
Anxiety
Baseline
Anticipation Anticipation Anticipation Anticipation Performance
(no startle (w ith startle
w ith
w ith curtain
prob)
probe)
audience
open
noise
(audience)
Speech
Backward count
Recovey
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
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What are anxiety and phobias… ?
How did you acquire your phobia ?
Avoidance.
Exposure.
Habituation curve.
The Process of Exposure
 Avoidance (safety seeking behavior, neutralization)
 Functional exposure
Time (minutes)
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).