Anxiety and presence during VR immersion: a comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games

A controlled study of agoraphobia and the independent effect of virtual reality exposure therapy

OBJECTIVES

Past controlled clinical trials centred on virtual reality exposure therapy (VRET) for agoraphobia mostly used multicomponent therapy with success. However, the present paper aimed to evaluate the independent effect of VRET for agoraphobia.

METHODS

A controlled study involving 18 agoraphobic participants assigned to two groups: VRET only and VRET with cognitive therapy. Nine specific virtual environments were developed using an affordable game level editor.

RESULTS

Questionnaires, behavioural tests and physiological measures indicated a positive effect of VRET. Correlations supported the predictive value of presence towards treatment outcome. The addition of cognitive therapy did not provide significant additional benefit.

CONCLUSIONS

Overall, the isolated effects of VRET did not seem to be significantly less than the effects of VRET combined with cognitive therapy. Future research should explore the use of other components in addition to cognitive therapy and VRET for agoraphobia as well as its possible use in patients' homes.

Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia

Virtual reality exposure (VRE) has been shown to be effective for treating a variety of anxiety disorders, including social phobia. Presence, or the level of connection an individual feels with the virtual environment, is widely discussed as a critical construct both for the experience of anxiety within a virtual environment and for a successful response to VRE. Two published studies show that whereas generalized presence relates to fear ratings during VRE, it does not relate to treatment response. However, presence has been conceptualized as multidimensional, with three primary factors (spatial presence, involvement, and realness). These factors can be linked to other research on the facilitation of fear during exposure, inhibitors of treatment response (e.g., distraction), and more recent theoretical discussions of the mechanisms of exposure therapy, such as Bouton's description of expectancy violation. As such, one or more of these components of presence may be more strongly associated with the experience of fear during VRE and treatment response than the overarching construct. The current study (N=41) evaluated relations between three theorized components of presence, fear ratings during VRE, and treatment response for VRE for social phobia. Results suggest that total presence and realness subscale scores were related to in-session peak fear ratings. However, only scores on the involvement subscale significantly predicted treatment response. Implications of these findings are discussed.

Virtual reality treatment of posttraumatic stress disorder due to motor vehicle accident

Posttraumatic stress disorder (PTSD) is a complex, multifaceted disorder encompassing behavioral, emotional, cognitive, and physiological factors. Although PTSD was only codified in 1980, there has been an increasing interest in this area of research. Unfortunately, relatively little attention has been given to the psychological treatment of motor vehicle accident survivors, which is remarkable because vehicular collisions are deemed the number one cause of PTSD. As the emotional consequences of vehicular collisions prevail, so does the need for more effective treatments. Randomized controlled clinical trials have identified exposure-based therapies as being the most efficacious for extinguishing fears. One type of exposure-based treatment, called virtual reality exposure therapy (VRET), provides a safe, controlled, and effective therapeutic alternative that is not dependent on real-life props, situations, or even a person's imagination capabilities. This modality, while relatively new, has been implemented successfully in the treatment of a variety of anxiety disorders and may offer a particularly beneficial and intermediary step for the treatment of collision-related PTSD. In particular, VRET combined with physiological monitoring and feedback provides a unique opportunity for individuals to objectively recognize both anxiety and relaxation; learn how to manage their anxiety during difficult, albeit simulated, driving conditions; and then transfer these skills onto real-life roadways.

A randomized, controlled clinical trial of in virtuo and in vivo exposure for spider phobia

The present study compared the efficacy of virtual reality (VR) in virtuo exposure and in vivo exposure in the treatment of spider phobia. Two treatment conditions were compared to a waiting-list condition. A 3-month follow-up evaluation was conducted in order to assess the durability of the treatment effects. Participants were randomly assigned to the treatment groups. A total of 16 participants received the in virtuo treatment, and 16 received the in vivo treatment. The waiting-list condition included 11 participants. Participants received eight 1.5-hour treatment sessions. Efficacy was measured with the Fear of Spiders Questionnaire, the Spider Beliefs Questionnaire (SBQ-F), and a Behavioral Avoidance Test (BAT). In addition, a clinician administered the Structured Interview for DSM-IV to assess DSM-IV's criteria for specific phobia and severity. Clinical and statistically significant improvements were found for both groups. Differences in treatment groups were found on one of five measures of fear: greater improvement on the SBQ-F beliefs subscale was associated with in vivo exposure.

Virtual reality as a mechanism for exposure therapy

Virtual reality (VR) is as effective in inducing emotional responses as reality and its application is extremely valuable in exposure treatment. In virtual environments, the patients experience similar physiological symptoms and fear as they do in real life situations, thereby facilitating the habituation process. Our goal is to offer an overview of the current panorama of VR and psychotherapy, underlining the (virtual) exposure technique and the studies that focus on panic disorder treatment through the use of VR. The literature was revised through consultation to the ISI and PubMed databases. Virtual exposure treatment offers good results and great patient acceptability. However, despite the importance of this data for the evaluation of treatment efficacy, only a few studies measure physiological responses during exposure. Lack of controlled studies and standardized treatment protocols were observed. Despite the great advance of VR use in psychotherapy, a great deal of its potential is still unknown, therefore requiring the creation of new virtual environments so that controlled studies regarding its clinical application can be conducted. Throughout the process of elaboration and investigation, clinical experiences in virtual environments must be related to real experiences in a flexible context that combines relevant cultural, physical and cognitive aspects.

Can virtual reality increase the realism of role plays used to teach college women sexual coercion and rape-resistance skills?

The present study evaluated whether virtual reality (VR) can enhance the realism of role plays designed to help college women resist sexual attacks. Sixty-two female undergraduate students were randomly assigned to either the Role Play (RP) or Virtual Role Play (VRP) conditions, which were differentiated only by the use of VR technology in the VRP condition. A multimethod assessment strategy was used to evaluate the effects of VR on the experienced realism of sexually threatening role plays. Realism was assessed by participant self-reports of negative affect and perceptions of realism, direct observation of participants' verbal displays of negative affect during the role plays, and measurements of participant heart rate during the role plays. Results indicated that VR can indeed heighten the realism of sexually threatening role plays. Discussion focuses on issues regarding the use of VR-enhanced role plays for helping college women resist sexual attacks.

The validity of virtual environments for eliciting emotional responses in patients with eating disorders and in controls

This article explores the efficacy of virtual environments representing situations that are emotionally significant to patients with eating disorders (ED) to modify depression and anxiety levels both in these patients and in controls. Eighty-five ED patients and 108 students were randomly exposed to five experimental virtual environments (a kitchen with low-calorie food, a kitchen with high-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool) and to one neutral environment. In the interval between the presentation of each situation, anxiety and depressed mood were assessed. Results of several repeated measures analyses demonstrated that patients show higher levels of anxiety and a more depressed mood after eating, especially high-calorie food, and after visiting the swimming pool than in the neutral room. In contrast, controls only show higher levels of anxiety in the swimming pool. In the rest of the situations they presented a similar mood state as in the neutral room. We concluded that virtual reality is a useful vehicle for eliciting similar emotional reactions to those one would expect in real life situations. Thus, this technology seems well suited for use in experimental studies as well as in evaluative and therapeutic contexts.

Online video game therapy for mental health concerns: a review

BACKGROUND

There has been research on the use of offline video games for therapeutic purposes but online video game therapy is still fairly under-researched. Online therapeutic interventions have only recently included a gaming component. Hence, this review represents a timely first step toward taking advantage of these recent technological and cultural innovations, particularly for the treatment of special-needs groups such as the young, the elderly and people with various conditions such as ADHD, anxiety and autism spectrum disorders.

MATERIAL

A review integrating research findings on two technological advances was conducted: the home computer boom of the 1980s, which triggered a flood of research on therapeutic video games for the treatment of various mental health conditions; and the rise of the internet in the 1990s, which caused computers to be seen as conduits for therapeutic interaction rather than replacements for the therapist.

DISCUSSION

We discuss how video games and the internet can now be combined in therapeutic interventions, as attested by a consideration of pioneering studies.

CONCLUSION

Future research into online video game therapy for mental health concerns might focus on two broad types of game: simple society games, which are accessible and enjoyable to players of all ages, and online worlds, which offer a unique opportunity for narrative content and immersive remote interaction with therapists and fellow patients. Both genres might be used for assessment and training purposes, and provide an unlimited platform for social interaction. The mental health community can benefit from more collaborative efforts between therapists and engineers, making such innovations a reality.

Validity of virtual reality as a method of exposure in the treatment of test anxiety

This is a validation study, aiming to explore the effectiveness of a set of virtual environments forproducing emotionally significant responses in students with high levels of test anxiety in order to be able to implement them later in treatment. Twenty-one students agreed to take part, 11 with high test anxiety and 10 with low test anxiety. The virtual environments were prepared in chronological order: the student's home, then the metro, and finally the corridor and lecture hall where the examination takes place. The results showed that the high-test-anxiety group presented higher levels of anxiety and depression than the low-test-anxiety group during exposure to the virtual environments. This study shows that virtual reality is able to provoke emotional responses in students with high test anxiety. This validation study should be followed up with treatment studies to evaluate the efficacy of virtual reality therapy for treating testanxiety.

Oscillatory brain responses evoked by video game events: the case of super monkey ball 2

Electroencephalography (EEG) was recorded while the subjects played a video game where the player had to steer a monkey into a goal while collecting bananas for extra points and had to avoid falling off the edge of the game board. Each of these three studied events evoked differential EEG oscillatory changes. Picking up bananas evoked decreased theta activation on central electrodes, decreased high alpha activation on frontal electrodes, and increased beta activation on frontal electrodes. Falling off the game board evoked decreased central theta activation and increased fronto-central beta activation. Reaching the goal evoked increased theta activation on parietal electrodes, increased low alpha activation on frontal electrodes, increased high alpha activation on frontal, central, and parietal electrodes, and increased beta activation on frontal and central electrodes. It is suggested that the EEG oscillations evoked by picking up bananas reflect increased cortical activation and arousal; the oscillations evoked by falling off the edge of the game board reflect motor functions; and the oscillations evoked by reaching the goal reflect a relaxed state. Thus, EEG may turn out to be a valuable tool when examining psychological responses to video game events.

Assessment of emotional reactivity produced by exposure to virtual environments in patients with eating disorders

The aim of this study was to assess the usefulness of virtual environments representing situations that are emotionally significant to subjects with eating disorders (ED). These environments may be applied with both evaluative and therapeutic aims and in simulation procedures to carry out a range of experimental studies. This paper is part of a wider research project analyzing the influence of the situation to which subjects are exposed on their performance on body image estimation tasks. Thirty female patients with eating disorders were exposed to six virtual environments: a living-room (neutral situation), a kitchen with high-calorie food, a kitchen with low-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool. After exposure to each environment the STAI-S (a measurement of state anxiety) and the CDB (a measurement of depression) were administered to all subjects. The results show that virtual reality instruments are particularly useful for simulating everyday situations that may provoke emotional reactions such as anxiety and depression, in patients with ED. Virtual environments in which subjects are obliged to ingest high-calorie food provoke the highest levels of state anxiety and depression.

The role of presence in virtual reality exposure therapy

A growing body of literature suggests that virtual reality is a successful tool for exposure therapy in the treatment of anxiety disorders. Virtual reality (VR) researchers posit the construct of presence, defined as the interpretation of an artificial stimulus as if it were real, to be a presumed factor that enables anxiety to be felt during virtual reality exposure therapy (VRE). However, a handful of empirical studies on the relation between presence and anxiety in VRE have yielded mixed findings. The current study tested the following hypotheses about the relation between presence and anxiety in VRE with a clinical sample of fearful flyers: (1) presence is related to in-session anxiety; (2) presence mediates the extent that pre-existing (pre-treatment) anxiety is experienced during exposure with VR; (3) presence is positively related to the amount of phobic elements included within the virtual environment; (4) presence is related to treatment outcome. Results supported presence as a factor that contributes to the experience of anxiety in the virtual environment as well as a relation between presence and the phobic elements, but did not support a relation between presence and treatment outcome. The study suggests that presence may be a necessary but insufficient requirement for successful VRE.

Virtual reality exposure therapy: 150-degree screen to desktop PC

Virtual reality exposure therapy (VRET) developed using immersive or semi-immersive virtual environments present a usability problem for practitioners. To meet practitioner requirements for lower cost and portability VRET programs must often be ported onto desktop environments such as the personal computer (PC). However, success of VRET has been shown to be linked to presence, and the environment's ability to evoke the same reactions and emotions as a real experience. It is generally accepted that high-end virtual environments (VEs) are more immersive than desktop PCs, but level of immersion does not always predict level of presence. This paper reports on the impact on presence of porting a therapeutic VR application for schizophrenia from the initial research environment of a semi-immersive curved screen to PC. Presence in these two environments is measured both introspectively and across a number of causal factors thought to underlie the experience of presence. Results show that the VR exposure program successfully made users feel they were "present" in both platforms. While the desktop PC achieved higher scores on presence across causal factors participants reported they felt more present in the curved screen environment. While comparison of the two groups was statistically significant for the PQ but not for the IPQ, subjective reports of experiences in the environments should be considered in future research as the success of VRET relies heavily on the emotional response of patients to the therapeutic program.

Neural correlate of spatial presence in an arousing and noninteractive virtual reality: an EEG and psychophysiology study

Using electroencephalography (EEG), psychophysiology, and psychometric measures, this is the first study which investigated the neurophysiological underpinnings of spatial presence. Spatial presence is considered a sense of being physically situated within a spatial environment portrayed by a medium (e.g., television, virtual reality). Twelve healthy children and 11 healthy adolescents were watching different virtual roller coaster scenarios. During a control session, the roller coaster cab drove through a horizontal roundabout track. The following realistic roller coaster rides consisted of spectacular ups, downs, and loops. Low-resolution brain electromagnetic tomography (LORETA) and event-related desynchronization (ERD) were used to analyze the EEG data. As expected, we found that, compared to the control condition, experiencing a virtual roller coaster ride evoked in both groups strong SP experiences, increased electrodermal reactions, and activations in parietal brain areas known to be involved in spatial navigation. In addition, brain areas that receive homeostatic afferents from somatic and visceral sensations of the body were strongly activated. Most interesting, children (as compared to adolescents) reported higher spatial presence experiences and demonstrated a different frontal activation pattern. While adolescents showed increased activation in prefrontal areas known to be involved in the control of executive functions, children demonstrated a decreased activity in these brain regions. Interestingly, recent neuroanatomical and neurophysiological studies have shown that the frontal brain continues to develop to adult status well into adolescence. Thus, the result of our study implies that the increased spatial presence experience in children may result from the not fully developed control functions of the frontal cortex.

Klinische Cyberpsychologie: Die Anwendung virtueller Realitäten in der psychologischen Diagnostik und Behandlung

Zusammenfassung. Theoretischer Hintergrund und Fragestellung: Eine von Jahr zu Jahr steigende Anzahl von Publikationen signalisiert die Entstehung eines neuen Gebiets der Klinischen Psychologie, das man “Klinische Cyberpsychologie“ nennen könnte. Die vorliegende Arbeit versucht vor allem einen Überblick über die neuesten Ergebnisse der Anwendung “virtueller Realitäten“ (VR) in der psychologischen Diagnostik und Behandlung zu geben. Methode: Es wurden drei Ansätze unterschieden: a) Die E-Therapie, b) die VR-Therapie und c) die VR-Teletherapie. Diese Dreiteilung gilt im Wesentlichen auch für den Bereich der Diagnostik, Beratung und Rehabilitation. Ergebnisse und Schlussfolgerungen: Mit Hilfe computergenerierter virtueller Szenarien kann eine wirklichkeitsnahe Reizmodellierung vorgenommen werden, die nicht nur eine gut kontrollierbare Reizdarbietung ermöglicht, sondern darüber hinaus auch eine interaktive Gestaltung zulässt. Dies gibt Anlass zur Hoffnung, dass durch den gezielten Einsatz virtueller Systeme die psychologische Diagnostik und Behandlung wesentlich verbessert werden kann.

Frequency of stuttering during challenging and supportive virtual reality job interviews

This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals' time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants' subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed.

EDUCATIONAL OBJECTIVES

After reading this article, the reader will be able to-(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.

Mechanisms of virtual reality exposure therapy: the role of the behavioral activation and behavioral inhibition systems

J. A. Gray's (1975) theory distinguishes between two motivational systems, which he refers to as the behavioral activation system (BAS) and the behavioral inhibition system (BIS). D. C. Fowles (1980) has shown that heart rate responses reflect activity of the BAS, and electrodermal responses reflect activity of the BIS. Both BAS and BIS are reliably activated during in-vivo exposure to fearful situations (F. H. Wilhelm & W. T. Roth, 1998). However, due to the constraints imposed by virtual reality (VR), we hypothesized that VR exposure to fearful situations would activate the BIS alone. To test this hypothesis, a VR free-standing elevator simulation was presented to participants selected for high and low fear of heights. As predicted, the high-anxious group strongly responded electrodermally (effect size d = 1.53), but showed only minimal HR elevations during exposure (d = 0.12), and little other cardiovascular or respiratory changes. The low-anxious control group showed little electrodermal and HR reactivity (d = 0.28 and 0.12). A comparison with data from a previous study demonstrated that this pattern was in stark contrast to the large electrodermal and cardiovascular response observed during situational in-vivo exposure outside the laboratory. We conclude that the BIS, but not BAS, is selectively activated during VR exposure, causing discordance between self-report and commonly used physiological measures of anxiety. Results are discussed within the framework of E. B. Foa & M. J. Kozak's (1986) emotional processing theory of fear modification, suggesting different mechanisms underlying VR and in-vivo exposure treatments.

Scene Perception, Gaze Behavior, and Perceptual Learning in Virtual Environments

More and more immersive environments are developed to provide support for learning or training purposes. Ecological validity of such environments is usually based on learning performance comparisons between virtual environments and their genuine counterparts. Little is known about learning processes occurring in immersive environments. A new technique is proposed for testing perceptual learning during virtual immersion. This methodology relies upon eye-tracking technologies to analyze gaze behavior recorded in relation to virtual objects' features and tasks' requirements. It is proposed that perceptual learning mechanisms engaged could be detected through eye movements. In this study, nine subjects performed perceptual learning tasks in virtual immersion. Results obtained indicated that perceptual learning influences gaze behavior dynamics. More precisely, analysis revealed that fixation number and variability in fixation duration varied with perceptual learning level. Such findings could contribute in shedding light on learning mechanisms as well as providing additional support for validating virtual learning environments.

Virtual Reality Therapy Versus Cognitive Behavior Therapy for Social Phobia: A Preliminary Controlled Study

Social phobia is one of the most frequent mental disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive behavior therapies (CBT). In this last case, graded exposure to feared social situations is one of the fundamental therapeutic ingredients. Virtual reality technologies are an interesting alternative to the standard exposure in social phobia, especially since studies have shown its usefulness for the fear of public speaking. This paper reports a preliminary study in which a virtual reality therapy (VRT), based on exposure to virtual environments, was used to treat social phobia. The sample consisted of 36 participants diagnosed with social phobia assigned to either VRT or a group-CBT (control condition). The virtual environments used in the treatment recreate four situations dealing with social anxiety: performance, intimacy, scrutiny, and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors in order to reduce anxiety in the corresponding real situations. Both treatments lasted 12 weeks, and sessions were delivered according to a treatment manual. Results showed statistically and clinically significant improvement in both conditions. The effect-sizes comparing the efficacy of VRT to the control traditional group-CBT revealed that the differences between the two treatments are trivial.

A Dual-Process Model of Reactions to Perceived Stigma

The authors propose a theoretical model of individual psychological reactions to perceived stigma. This model suggests that 2 psychological systems may be involved in reactions to stigma across a variety of social contexts. One system is primarily reflexive, or associative, whereas the other is rule based, or reflective. This model assumes a temporal pattern of reactions to the stigmatized, such that initial reactions are governed by the reflexive system, whereas subsequent reactions or "adjustments" are governed by the rule-based system. Support for this model was found in 2 studies. Both studies examined participants' moment-by-moment approach-avoidance reactions to the stigmatized. The 1st involved participants' reactions to persons with HIV/AIDS, and the 2nd, participants' reactions to 15 different stigmatizing conditions.