1. Advanced workshop: Applications of VR for Anxiety Disorders Brenda K. Wiederhold, Ph.D., MBA, BCIA Interactive Media Institute Virtual Reality Medical Center Stéphane Bouchard, Ph.D. Dept of Psychoeducation and Psychology Université du Québec en Outaouais Changing the Face of Healthcare CYBERTHERAPY 2008

2. 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.

3. 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

4. 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

5. 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

6. 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

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

8. 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

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

10. Stéphane Bouchard, Ph.D. CRC Clinical CyberPsychology Patrice Renaud, Ph.D. The Cyberpsychology Lab Supported by grants from : n UQO, CHPJ n Canada Research Chair n CFI, CIHR, FCAR n 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.

11. 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

12. UQO Technologies

14. VR Research FEAR OF FLYING PANIC DISORDER & AGORAPHOBIA POSTTRAUMATIC STRESS DISORDER CLAUSTROPHOBIA SMALL ANIMAL PHOBIA WITH AUGMENTED REALITY SOCIAL PHOBIA ACROPHOBIA: FEAR OF HEIGHTS ARACHNOPHOBIA: FEAR OF SPIDERS

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

16. Patient Kevin

17. 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.

18. 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 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

19. 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

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

21. Possible Interrelationships Absorption Presence Hypnotizability Immersion Involvement

23. 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

24. Anxiety Disorders

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

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

27. Functional Neuroanatomy of Fear and Anxiety Amygdala Thalamus Peripheral receptor cells of exteroceptive auditory,visual somesthetic sensory systems Peripheral receptor cells of exteroceptive auditory,visual somesthetic sensory systems Single or Multisynaptic pathways Multisynaptic pathways Hippocampus Orbitofrontal cortex Orbitofrontal cortex Periaqueductal gray Periaqueductal gray Locus ceruleus Locus ceruleus Parabrachial nucleus Dorsal motor nucleus of the Vagus Lateral hypothalamus Paraventricular nucleus of the hypothalamus 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 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 Fight or flight response Increase urination defecation ulcers bradycardia Tachycardia increase BP sweating piloerction pupil dilat Hormonal stress response Visceral afferent pathways Visceral afferent pathways Nucleus Paragigantocellularis Nucleus Paragigantocellularis Olfactory sensory stimuli Olfactory sensory stimuli Entirhinal coertex Entirhinal coertex Cingulate gyrus Afferent system Stimulus processing Efferent system Fear and Anxiety Response Patterns Fear and Anxiety Response Patterns Striatum Trigeminal nucleus Trigeminal nucleus Facial motor nucleus Facial motor nucleus Primary sensory and Association Cortices ( Charney & Deutsch 1996)

28. 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 Identification Production Regulation autonomic resp. (of affective states) Integration Executives functions Regulation - effortful (of affective states)

29. 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).

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

31. 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. n Renaud et al., 2002. n Head tracking of fearful and non-fearful subjects. n Significant differences in behavior when looking at a spider.

32. 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).

33. 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.

34. Is more hardware necessary? Mühlberger et al., 2003. 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

35. 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.

36. Delay and Anxiety / Presence (Meehan et al., 2003, VR’03) n They measured heart rate when 164 adults threw balls in the training room and the Pit. n Random assignment to two delays, 50 ms or 90 ms. (120 ms was considered unacceptable in previous immersions). n Anxiety: difference in HR pre to PIT of +3.1 ( p =.05). N = 61. n Anxiety: measured with one item 0-7. Ns. n Presence: SUS calculated with 5, 6, 7 = 1. NS. n Cybersickness: ns.

37. Anxiety and Image Quality (Zimmons, 2004, Ph.D. dissertation, in preparation) n 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

38. Heart rate ANOVA N = 42 : n Time: p <.001 n Group: p <.05 n Gr X T : ns Contrasts : n Pre vs PIT : p <.001 n PIT vs post : p <.001 Condition 3 vs others : n All p <.001 Grid vs the others: n All ns. Presence n « SUS » at post: ns n Effect size =.05 Grid Text - / Light + Anxiety and Image Quality (Zimmons, 2004, Ph.D. dissertation, in preparation)

39. 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)

40. 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%

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

42. 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.

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

44. 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.

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

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

47. 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..

48. 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).