2. The Bus

3. PANIC DISORDER & AGORAPHOBIA Treatment ä 2 SESSIONS ä EDUCATIONAL COMPONENT ä COGNITIVE REESTRUCTURING ä SLOW BREATHING ä 6 VR GRADED EXPOSURE SESSIONS ä VRE: SITUATIONAL + INTEROCEPTIVE ä 1 RELAPSE PREVENTION SESSION

4. Diagnosis SCREENING INTERVIEW ADIS-IV (PANIC/AGORAPHOBIA) INDEPENDENT ASSESOR EXCLUSION CRITERIA – ALCOHOL/DRUG ABUSE – PSYCHOSIS – SEVERE PHYSICAL ILLNESS TARGET BEHAVIORS: – FEAR AND AVOIDANCE – BELIEF IN CATASTROPHIC THOUGHTS PANIC DISORDER & AGORAPHOBIA

5. EXPECTATIONS/SATISFACTION ABOUT EXPOSURE (AXIS II): – Logic – Satisfaction – Recommendation to a friend – Useful for your problem – Aversiveness – Useful for other problems PANIC DISORDER & AGORAPHOBIA Expectations/Satisfaction

6. Self-report Measures BECK DEPRESSION INVENTORY (BDI, Beck, Ward, Mendelson, Mock, & Erbaugh, 1961 ) PANIC DISORDER SEVERITY SCALE (PDSS, Shear, Sholomskas, & Cloitre, 1992 ANXIETY SENSITIVITY INDEX (ASI, Reiss, Peterson, Gursky, & McNally, 1986 ) MOBILITY INVENTORY (MI,Chambless, Caputo, Jasin, Gracely, & Williams, 1985) PANIC DISORDER & AGORAPHOBIA

7. THE HOUSE Scenarios: Situational Exposure Anticipatory anxiety Being alone at home Go out alone from home Take the elevator

8. PANIC DISORDER & AGORAPHOBIA THE SUBWAY Scenarios: Situational Exposure Using public transportation: Subway Train Being in crowded places Being far from home

9. PANIC DISORDER & AGORAPHOBIA THE BUS Scenarios: Situational Exposure Using public transportation: Bus Being in crowded places Being far from home

10. PANIC DISORDER & AGORAPHOBIA THE SHOPPING MALL Scenarios: Situational Exposure Go shopping Being in crowded places Being in line Being in narrow spaces Go to unknown places Using escalators

11. PANIC DISORDER & AGORAPHOBIA Scenarios: Situational Exposure THE TUNNEL Being in situations where finding the exit is difficult

12. PANIC DISORDER & AGORAPHOBIA Scenarios: Interoceptive Exposure Breathing and heart rate Mild Moderate Accelerated Visual effects Tunnel vision Blurred vision Double vision

13. A SINGLE CASE STUDY [Villa, Botella, García-Palacios, and Osma (Submitted)] – 3, 6,AND 9 MONTHS FOLLOW-UP A BETWEEN SUBJECT DESIGN (2 GROUPS) [Botella, Baños, Villa, Guillén, Jorquera, Fabregat, & Gallego, (2003 )] – VIRTUAL REALITY EXPOSURE (VRE) (n=5) – IN VIVO EXPOSURE (IVE) (n=5) A BETWEEN SUBJECT DESIGN (3 GROUPS) [Botella, et al. (Submitted)] – VRE (n=12) – IVE (n=12) – WAITING LIST (WL) (n=12) PANIC DISORDER & AGORAPHOBIA Works

14. BETWEEN SUBJECT DESIGN WITH REPEATED MEASURES EXPERIMENTAL CONDITIONS (RANDOMLY ASSIGNED): IN VIVO EXPOSURE (IVE) VIRTUAL REALITY EXPOSURE (VRE) WAITING LIST (WL) MEASURES: BEFORE TREATMENT (PRE-TEST) AFTER TREATMENT (POST-TEST) n METHOD n PARTICIPANTS N=36 VRE in the Treatment for PDA (Botella et al., submitted) VEPSY PROJECT

15. VRE & PDA: A BETWEEN SUBJECTS DESIGN Participants IV (N=12)VR (N=12) AGE 31.92 (8.83) 31.50 (11.04) WOMEN58.30%83.30% MEN41.70%16.70% PD PDA 25% 75% 25% 75% WL (N=12) 39.25 (14.74) 75% 25% 100%

16. FEAR AVOIDANCE F (3,31) = 39.665, p<0.001 BELIEF VRE & PDA: A BETWEEN SUBJECTS DESIGN

17. PDSS ASI VRE & PDA: A BETWEEN SUBJECTS DESIGN F (2,31) = 29.206, p<0.001

18. FQ-AG MI-Alone VRE & PDA: A BETWEEN SUBJECTS DESIGN F (2,29) = 12.152, p<0.001

19. Treatment OpinionExpectations VRE & PDA: A BETWEEN SUBJECTS DESIGN Any difference was significative

20. VRE & PDA Conclusions ä AXIS I ä VR USEFUL FOR THE TREATMENT OF PANIC DISORDER AND AGORAPHOBIA ä VRE WAS EQUALLY EFFECTIVE THAN IVE ä VR INTEROCEPTIVE EXPOSURE COMBINED WITH VR SITUATIONAL EXPOSURE USEFUL FOR DECREASING FEAR TO BODILY SENSATIONS ä AXIS II ä POSITIVE ACCEPTANCE OF VR ä VR DID NOT PRODUCE NEGATIVE SIDE EFFECTS ä NO DIFFERENCES BETWEEN IVE AND VRE RELATED WITH TREATMENT SATISFACTION

21. VR Research STRESS-RELATED DISORDERS POSTTRAUMATIC STRESS DISORDER EMMA PROJECT

22. Controlled Studies: PTSD AuthorYear # of Pts EquipmentResults Rothbaum200116 V6 Head-Mounted Display CAPS scores at 6 month follow-up showed reduction in PTSD symptoms Tarnanas200150 VPL Eye Phone 1, MR toolkit, vibrations plate Less negative thoughts toward earthquake scenarios Difede20021 Head Mounted Display 90% reduction in PTSD symptoms after VR exposure therapy Univ. Of Buffalo 20034 UB Simulator Preliminary results are promising Wiederhold20038 EEG, PC computer VR environment increased performance on task Livanou200310 Earthquake simulator, shake table (9 levels of intensity) Significant improvement (8 patients improved, 2 slightly improved) Walshe200314 3D Head Mounted Display Significant post-treatment reductions on all measures

23. EMMAs room include several elements to treat stress related disorders: ä A database screen, where a listing of icons shows all the elements that a user can manipulate, including three-dimensional objects, sound, images, colored lights, movies and texts; ä The book of life, where the user can move and modify any element from the database. This book has an index and several chapters defined by the user, and in each chapter he/she can describe any idea or story. It is represented by a virtual book; the object holders spread all around the environment give life to any element by showing its representation (a three-dimensional object, a sound, or a light illuminating the environment); ä A virtual keyboard that allows the user to label elements or chapters in the book of life ä The processor, ä The processor, element of the environment where the user can physically transform the experiences STRESS-RELATED DISORDERS

24. ä EMMAs room also has available different scenarios or landscapes. The aim is to reflect and enhance the emotion that the user is experiencing or to induce certain emotions. It is possible to include modifications in the scenario and to graduate the intensity of these modifications in order to reflect the changes in the participants mood states. Besides the specific variations for each emotional scenario it is possible to modify the environment according to the time. That means that we can establish day or night in each scenario with the aim of reflecting or enhancing the participants mood state. Besides the specific variations for each emotional scenario it is possible to modify the environment according to the time. That means that we can establish day or night in each scenario with the aim of reflecting or enhancing the participants mood state.

25. STRESS-RELATED DISORDERS ä In summary, the different three-dimensional objects, the sounds, the colors, the lights, the images, the symbols... all of them are designed to help the person to confront, accept and manage the emotions and experiences that he/she has gone through previously in his/her life and is going to experience in the therapy environment. The book of life, and the different landscape variations in EMMA room could be useful in helping the person, not only with the important self-confrontation and cognitive reappraisal tasks, but also, and essentially, with the experiential reorganization aspects. The book of life, and the different landscape variations in EMMA room could be useful in helping the person, not only with the important self-confrontation and cognitive reappraisal tasks, but also, and essentially, with the experiential reorganization aspects.

32. Other Applications EMMAS ROOM: Flexibility – We have used EMMA for the treatment of fear of storms in a case study. – A 70-year-old woman with a severe storm phobia. – Two intensive exposure sessions with EMMA (3 hours each) – Good results: Clinically significant reduction in fear and avoidance, and in impairment and distress. EMMAS ROOM

33. Study To test the efficacy of EMMAs room in the treatment of stress-related disorders (PTSD, adjustment disorder). Between-subject design – Traditional CBT treatment. – CBT treatment delivered with EMMAs room. STRESS-RELATED DISORDERS

34. Participants STRESS-RELATED DISORDERS Clinical condition SexAge Total sample11 clinical 7 subclinical N = 18 7 male 11 female Range: 18 to 46 Mean: 31.61 SD: 9.02 Traditional condition 5 clinical 4 subclinical 4 male 5 female Range: 18 to 40 Mean: 28.22 SD: 8.45 EMMA condition 6 clinical 3 subclinical 3 male 6 female Range: 21 to 46 Mean: 35 SD: 9.58

35. Measures CAPS (Blake et al., 1990, 1995). Fear/emotional distress and avoidance scales (Adapted from Mark & Mathews, 1979). Visual-Analog Scales (VAS): Catastrophic thoughts; Emotional processing measures; Emotional intensity. Positive and Negative Affect Scales (PANAS) (Watson, Clark & Tellegen, 1988). Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock & Erbaugh, 1961). Impairment/Severity rated by the therapist (Adapted from Di Nardo, Brown & Barlow, 1994). Measures regarding expectations and satisfaction about the treatment (Adapted from Borkovec & Nau, 1972). The ITC-Sense of Presence Inventory (ITC-SOPI) (Lessiter, Freeman, Keogh, & Davidoff, 2001). STRESS-RELATED DISORDERS

36. Treatments PTSD: Adaptation of Foa & Rothbaum (1998) Prolonged Exposure program. Adjustment disorder (pathological bereavement): Adaptation of Neimeyer (2002) program for pathological bereavement. STRESS-RELATED DISORDERS

37. Results TRADITIONALEMMA Pre- treatment Post-treatmentPre- treatment Post- treatment Beck Depression Inventory (BDI)15,25 (12,418) 7,88 (8,132) 20,75 (9,825) 10,13 (7,699) Positive and negative Affect Scale (PANAS): Positive Affect 23,14 (5,367) 28,14 (5,305) 19,89 (7,288) 24 (7,746) Positive and negative Affect Scale (PANAS): Negative Affect 23,71 (9,250) 18,29 (5,469) 32,11 (9,413) 23,78 (8,258) Degree of Interference in the daily life t 4,78 (0,972) 2,22 (2,167) 5,22 (1,641) 2,33 (1,5) Degree of Severity of the problem4,44 (1,333) 2,22 (2,819) 4,67 (2,121) 1,89 (1,616) Target behaviour: degree of Avoidance9,00 (1,658) 2,11 (3,551) 8,38 (2,774) 2,00 (2,976) Target behaviour: degree of Fear7,44 (2,068) 2,22 (3,073) 8 (3,082) 2,33 (2,872) Target thought: degree of Avoidance8,67 (1,966) 2,50 (3,209) 9,17 (2,041) 3,17 (3,251) Target thought: degree of Fear8,33 (2.338) 2,67 (3,077) 9,57 (0,787) 3 (2,708) Target thought: degree of Belief9,00 (1,773) 4,25 (2,964) 8,87 (1,727) 4,13 (3,271) Emotional Intensity9,33 (0,816) 2,83 (2,714) 9,50 (0,837) 3,33 (3,882)

38. Results TRADITIONALEMMA Pre-testPost-testPre-testPost-test Emotionally disturbed5,33 (1,75) 3,83 (2,85) 7,50 (3,30) 4,25 (2,49) Prepared to accept the experience6,67 (2,71) 8,17 (2,63) 6,29 (3,04) 8,71 (1,11) Processing the traumatic event5,17 (2,71) 7,50 (3,39) 4,86 (2,67) 8,29 (0,75) Openness to new experiences7,5 (2,58) 8,17 (2,29) 4,86 (3,48) 8,34 (1,57)

39. Results Openess to New Experiences

40. Results Satisfaction with Treatment TraditionalEMMA BeforeAfterBeforeAfter Treatment seems logical8,33 (1,118) 8,11 (0,928)7,89 (0,601)8,33 (1,00) Treatment seems satisfactory7,44 (2,007) 8,44 (1,333)7,44 (2,128)8,44 (1,130) Participant would recommend the treatment to a friend 8,22 (1,481) 8,56 (1,333)7,89 (1,269)9,00 (1,118) Treatment seems to be useful for the problem8,56 (1,014) 8,33 (1,225)7,33 (2,550)8,33 (1,323) Treatment seems to be useful for other psychological problems 7,56 (2,963) 8,00 (1,323)7,22 (2,048)8,44 (1,333) Treatment seems aversive4,33 (3,428) 4,33 (2,915)5,11 (2,667)2,22 (2,587)

41. Results Treatment Aversiveness

42. ResultsPresence

43. Discussion EMMAS room program equally effective than standard of care for stress-related disorders. Satisfaction: Both treatment programs not only met the expectations of participants, but the satisfaction went beyond the expectations. The group in the EMMAs room condition rated the treatment as less aversive than the group in the traditional condition. STRESS-RELATED DISORDERS

44. Discussion In both conditions participants reported being less perturbed, they accepted better the stressful event, and they are more open to new experiences in life. We would like to highlight that there is a tendency (p =.07) in the EMMA condition for the variable openness to new experiences in life. In this variable the participants in EMMAs room condition showed a higher openness to new life experiences. STRESS-RELATED DISORDERS

45. Discussion PRESENCE – Participants felt present in the experience: Spatial presence, Engagement and Ecological validity factors. of the ITC SOPI questionnaire in the first session where participants interacted with EMMAs room. – The power of the virtual environment did not decrease along the treatment, given that the scores in that first session were similar to the ones in the last session. – There was a decrement in negative side effects as the treatment went on. STRESS-RELATED DISORDERS

46. Conclusions EMMAs room could be as efficacious and effective as the standard of care for stress related disorders. EMMA treatment program was rated by the participants as less aversive than the traditional procedures. These are promising preliminary findings that opens an important line of research in order to delimitate which aspects produced a higher acceptance of the treatment. STRESS-RELATED DISORDERS

47. Conclusions Different approach for the treatment of PTSD: Our aim is to design clinically significant environments for each participant, but attending to the meaning of the trauma for the individual and not to the simulation of the physical characteristics of the traumatic event with high realism. The aim is not realism, but using customized symbols and aspects that provoke and evoke an emotional reaction in the participant that help to achieve the emotional processing of the trauma, and at the same time, creating a safe and protective environment. Advantage: Flexibility. On one hand, it permits to individualize and personalize the environments fitting the needs and preferences of the users; on the other, these can be used for different type of traumas in the PTSD field. STRESS-RELATED DISORDERS

48. Conclusions We have tried to structure creative engineering of exposure such as is recommended by Black Becker and Anderson (2004) with the aim of improving the acceptance of CBT treatment programs for PTSD. STRESS-RELATED DISORDERS

49. Other Applications EMMAS ROOM: Flexibility – We have used EMMA for the treatment of fear of storms in a case study. – A 70-year-old woman with a severe storm phobia. – Two intensive exposure sessions with EMMA (3 hours each) – Good results: Clinically significant reduction in fear and avoidance, and in impairment and distress. EMMAS ROOM