Effects of systematic cue exposure through virtual reality on cigarette craving

A randomized controlled experiment testing the use of virtual reality to trigger cigarette craving in people who smoke

Automated delivery of therapy in virtual reality (VR) has the potential to be used for smoking cessation. Most obviously, it could be used to practise and establish alternative reactions to smoking cues. The first step in treatment development is to show that VR environments can trigger sufficient cravings in smokers. We evaluated a new VR public house outdoor scenario with 100 individuals who smoked daily. Participants were randomly assigned to the VR scenario with smoking cues or a neutral experience in VR. The VR experiences were presented in a standalone VR headset. Before and after VR, we collected self-reported craving scores for cigarettes and alcohol using the Tobacco Craving Questionnaire (TCQ) and visual analogue scales (VAS). Physiological data were also collected. Compared to the neutral condition, exposure to the smoking cues led to a large increase in craving for a cigarette (TCQ β = 11.44, p < 0.0001, Cohen's d = 1.10) and also a moderate increase in craving for alcohol ( β = 0.7 , p = 0.017 , d = 0.50 ) . There were no significant physiological differences between the two conditions. These results provide good evidence that VR experiences can elicit strong craving for cigarettes. The programming can be part of developing a new VR cognitive therapy to help people reduce smoking.

Virtual reality cue-exposure therapy in reducing cocaine craving: the Promoting Innovative COgnitive behavioral therapy for Cocaine use disorder (PICOC) study protocol for a randomized controlled trial

BACKGROUND

Cocaine craving is a central symptom of cocaine use disorders (CUD). Virtual reality cue-exposure therapy for craving (VRCET) allows more immersive, realistic, and controllable exposure than traditional non-VR cue-exposure therapy (CET), whose efficacy is limited in treating substance use disorders. The purpose of this study is to evaluate the efficacy and acceptability of VRCET, as a stand-alone and add-on intervention (i.e., combined with cognitive therapy), compared to a picture-based CET (PCET), in reducing self-reported cocaine craving in inpatients hospitalized for CUD.

METHODS

Fifty-four inpatients hospitalized for CUD will be randomized in one of two intensive 3-week treatment arms: 10 meetings/2-week treatment of VRCET plus 5 meetings/1-week treatment of memory-focused cognitive therapy (MFCT; experimental arm), or 15 meetings/3-week treatment of PCET (active control arm). The Craving Experience Questionnaire (CEQ - F & S) will be used to assess the primary outcome, i.e., the post-treatment decrease of self-reported cocaine craving frequency (within the past 2 weeks) and intensity scores (in VR exposure to cocaine cues). Secondary endpoints include urinary, physiological, and self-reported cocaine use-related measures. Assessments are scheduled at pretreatment, after 2 weeks of treatment (i.e., VRCET vs. PCET), post-treatment (3 weeks, i.e., VRCET + MFCT vs. PCET), and at 1-month follow-up. Acceptability will be evaluated via (i) the Spatial Presence for Immersive Environments - Cybersickness along VRCET and (ii) the Client Satisfaction Questionnaires after 2 weeks of treatment and post-treatment.

DISCUSSION

This study will be the first to evaluate the acceptability and efficacy of VRCET for CUD, as a psychotherapeutic add-on, to reduce both cocaine craving frequency and intensity. Additionally, this study will provide evidence about the specific interest of VRCET, compared to a non-VR-based CET, as a cue reactivity and exposure paradigm for treating substance use disorders.

TRIAL REGISTRATION

NCT05833529 [clinicaltrials.gov]. Prospectively registered on April 17, 2023.

Towards virtual reality exposure therapy for cocaine use disorder: A feasibility study of inducing cocaine craving through virtual reality

Background

Craving is a core symptom of cocaine use disorders (CUD). Inducing craving in exposure to substance cues is of relevant interest for numerous clinical applications. Virtual reality exposure (VRE) might be a promising candidate for improving cue-exposure paradigms but remains almost not studied for cocaine. This feasibility study's main aim is to assess whether VRE to cocaine cues is capable to induce cocaine craving compared with VRE to neutral cues.

Methods

We conducted a within-subjects controlled trial in which cocaine users performed 3 consecutive 10 mins-tasks: VRE to neutral and cocaine cues, and a relaxation-based resting procedure. The primary outcome was the change in Cocaine Craving Questionnaire-Brief (CCQ-Brief) scores between VRE to neutral and cocaine cues. Secondary outcomes included between-tasks changes in scores of cocaine craving, pleasant/unpleasant emotions as well as self-efficacy to cope with craving.

Results

We recruited 11 chronic cocaine users including mostly crack smokers (45 %), cocaine snorters (36 %) and injectors (18 %), with 73 % of participants meeting DSM-IV criteria for cocaine dependence and/or abuse. Non-parametrical sign tests indicated significant large increases of CCQ-Brief scores from neutral to cocaine cue-VRE (S(11) = 11, p < 0.01, Cliff's Δ = 0.65, 95 % CI: 0.17-0.88). Exploratory comparative analyses indicated significant changes after our post-cues VRE relaxation procedure, with cocaine craving and emotions restored to baseline.

Conclusions

VRE to cocaine cues was feasible and capable to induce cocaine craving in cocaine users. This second VRE-based cue-reactivity study in cocaine paves the way for unexplored research on VRE clinical applications for CUD.

Cigarette craving in virtual reality cue exposure in abstainers and relapsed smokers

Cue exposure therapy (CET) in substance-use disorders aims to reduce craving and ultimately relapse rates. Applying CET in virtual reality (VR) was proposed to increase its efficacy, as VR enables the presentation of social and environmental cues along with substance-related stimuli. However, limited success has been reported so far when applying VR-CET for smoking cessation. Understanding if effects of VR-CET differ between future abstainers and relapsing smokers may help to improve VR-CET. Data from 102 participants allocated to the intervention arm (VR-CET) of a recent RCT comparing VR-CET to relaxation in the context of smoking cessation was analyzed with respect to tolerability, presence, and craving during VR-CET. Cue exposure was conducted in four VR contexts (Loneliness/Rumination, Party, Stress, Café), each presented twice. Relapsed smokers compared to abstainers experienced higher craving during VR-CET and stronger craving responses especially during the Stress scenario. Furthermore, lower mean craving during VR-CET positively predicted abstinence at 6-month follow-up. Attempts to improve smoking cessation outcomes of VR-CET should aim to identify smokers who are more at risk of relapse based on high craving levels during VR-CET. Specifically measuring craving responses during social stress seems to be well suited to mark relapse. We propose to investigate individualized treatment approaches accordingly.

Cue-reactivity targeted smoking cessation intervention in individuals with tobacco use disorder: a scoping review

Objectives

Cue-reactivity is a critical step leading to the emergence of addictive psychology and the triggering of addictive behaviors within the framework of addiction theory and is considered a significant risk factor for addiction-related behaviors. However, the effect of cue-reactivity targeted smoking cessation intervention and the cue-reactivity paradigms used in the randomized controlled trials varies, which introduces more heterogeneity and makes a side-by-side comparison of cessation responses difficult. Therefore, the scoping review aims to integrate existing research and identify evidence gaps.

Methods

We searched databases in English (PubMed and Embase) and Chinese (CNKI and Wanfang) using terms synonymous with 'cue' and 'tobacco use disorder (TUD)' to April 2023, and via hand-searching and reference screening of included studies. Studies were included if they were randomized controlled trials taking cue-reactivity as an indicator for tobacco use disorder (TUD) defined by different kinds of criteria.

Results

Data were extracted on each study's country, population, methods, timeframes, outcomes, cue-reactivity paradigms, and so on. Of the 2,944 literature were retrieved, 201 studies met the criteria and were selected for full-text screening. Finally, 67 pieces of literature were selected for inclusion and data extraction. The results mainly revealed that non-invasive brain stimulation and exercise therapy showed a trend of greater possibility in reducing subjective craving compared to the remaining therapies, despite variations in the number of research studies conducted in each category. And cue-reactivity paradigms vary in materials and mainly fall into two main categories: behaviorally induced craving paradigm or visually induced craving paradigm.

Conclusion

The current studies are still inadequate in terms of comparability due to their heterogeneity, cue-reactivity can be conducted in the future by constructing a standard library of smoking cue materials. Causal analysis is suggested in order to adequately screen for causes of addiction persistence, and further explore the specific objective cue-reactivity-related indicators of TUD.

Virtual reality cue exposure therapy for tobacco relapse prevention: a comparative study with standard intervention

BACKGROUND

Successful interventions have been developed for smoking cessation although the success of smoking relapse prevention protocols has been limited. Cognitive behavioural therapy (CBT) in particular has been hampered by a high relapse rate. Because relapse can be due to conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality cue exposure therapy (VRCE) can be a potential tool to generate 3D interactive environments that simulate risk situations for relapse prevention procedures.

METHODS

To assess the effectiveness of VRCE with CBT, a comparative trial involving 100 smoking abstinent participants was designed with all required virtual environments (VE) created with an inexpensive graphic engine/game level editor.

RESULTS

Outcome measures confirmed the immersive and craving eliciting effect of these VEs. Results demonstrated that more participants in the VRCE group did not experience smoking relapse and that VRCE is at least as efficacious as traditional CBT in terms of craving reduction and decrease in nicotine dependence. Dropout and relapse rate in the VRCE group was noticeably lower than the CBT group. Aside from mood scores, no significant differences were found regarding the other scales.

CONCLUSION

The present clinical trial provides evidence that VRCE was effective in preventing smoking relapse. Improvement in technology and methodology for future research and applications is delineated.

VR for Studying the Neuroscience of Emotional Responses

Emotions are frequently considered as the driving force of behavior, and psychopathology is often characterized by aberrant emotional responding. Emotional states are reflected on a cognitive-verbal, physiological-humoral, and motor-behavioral level but to date, human research lacks an experimental protocol for a comprehensive and ecologically valid characterization of such emotional states. Virtual reality (VR) might help to overcome this situation by allowing researchers to study mental processes and behavior in highly controlled but reality-like laboratory settings. In this chapter, we first elucidate the role of presence and immersion as requirements for eliciting emotional states in a virtual environment and discuss different VR methods for emotion induction. We then consider the organization of emotional states on a valence continuum (i.e., from negative to positive) and on this basis discuss the use of VR to study threat processing and avoidance as well as reward processing and approach behavior. Although the potential of VR has not been fully realized in laboratory and clinical settings yet, this technological tool can open up new avenues to better understand the neurobiological mechanisms of emotional responding in healthy and pathological conditions.

The Treatment of Substance Use Disorders: Recent Developments and New Perspectives

Substance-related disorders are complex psychiatric disorders that are characterized by continued consumption in spite of harmful consequences. Addiction affects various brain networks critically involved in learning, reward, and motivation, as well as inhibitory control. Currently applied therapeutic approaches aim at modification of behavior that ultimately leads to decrease of consumption or abstinence in individuals with substance use disorders. However, traditional treatment methods might benefit from recent neurobiological and cognitive neuroscientific research findings. Novel cognitive-behavioral approaches in the treatment of addictive behavior aim at enhancement of strategies to cope with stressful conditions as well as craving-inducing cues and target erroneous learning mechanisms, including cognitive bias modification, reconsolidation-based interventions, mindfulness-based interventions, virtual-reality-based cue exposure therapy as well as pharmacological augmentation strategies. This review discusses therapeutic strategies that target dysregulated neurocognitive processes associated with the development and maintenance of disordered substance use and may hold promise as effective treatments for substance-related disorders.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Assessing the attentional bias of smokers in a virtual reality anti-saccade task using eye tracking

INTRODUCTION

Cognitive biases (among them attentional bias, AB) are considered an important factor in the development, maintenance, and recurrence of addiction. However, traditional paradigms to measure AB have been criticized regarding external validity and methodical issues. Therefore, and because the neurophysiological correlates of anti-saccade tasks are known, we implemented a novel smoking anti-saccade task in virtual reality (VR) to measure AB and inhibitory control in different contexts and with higher ecological validity.

METHODS

Smokers (n = 20) and non-smokers (n = 20) were tested on a classic pro- and anti-saccade task, a VR anti-saccade task and a VR attention fixation task (all containing smoking-related and neutral stimuli) while eye-tracking data was collected. Two VR contexts (park and office room) were applied.

RESULTS

Saccade latencies were significantly higher for the smoking group in the VR anti-saccade task. However, this effect did not differ between smoking-related and neutral stimuli, thus overall no AB was observed. Instead, AB was only present in the park context. Additionally, saccade latencies and error rates were significantly higher in the park context.

CONCLUSIONS

Results indicate impaired inhibitory control in smokers relative to non-smokers. The lack of evidence for a general AB might be due to the lower severity of smoking dependence in the smoking sample. Instead, results suggest context specificity of AB. Implications for smoking cessation interventions in the field of inhibitory control training and attention bias modification are discussed.

Virtual Reality Technology Use in Cigarette Craving and Smoking Interventions (I "Virtually" Quit): Systematic Review

BACKGROUND

Over the last 2 decades, virtual reality technologies (VRTs) have been proposed as a way to enhance and improve smoking cessation therapy.

OBJECTIVE

This systematic review aims to evaluate and summarize the current knowledge on the application of VRT in various smoking cessation therapies, as well as to explore potential directions for future research and intervention development.

METHODS

A literature review of smoking interventions using VRT was conducted.

RESULTS

Not all intervention studies included an alternative therapy or a placebo condition against which the effectiveness of the intervention could be benchmarked, or a follow-up measure to ensure that the effects were lasting. Virtual reality (VR) cue exposure therapy was the most extensively studied intervention, but its effect on long-term smoking behavior was inconsistent. Behavioral therapies such as a VR approach-avoidance task or gamified interventions were less common but reported positive results. Notably, only 1 study combined Electronic Nicotine Delivery Devices with VRT.

CONCLUSIONS

The inclusion of a behavioral component, as is done in the VR approach-avoidance task and gamified interventions, may be an interesting avenue for future research on smoking interventions. As Electronic Nicotine Delivery Devices are still the subject of much controversy, their potential to support smoking cessation remains unclear. For future research, behavioral or multicomponent interventions are promising avenues of exploration. Future studies should improve their validity by comparing their intervention group with at least 1 alternative or placebo control group, as well as incorporating follow-up measures.

Clinical Relevance of Immersive Virtual Reality in the Assessment and Treatment of Addictive Disorders: A Systematic Review and Future Perspective

(1) Background: Virtual reality (VR) has been investigated in a variety of psychiatric disorders, including addictive disorders (ADs); (2) Objective: This systematic review evaluates the current evidence of immersive VR (using head-mounted displays) in the clinical assessment and treatment of ADs; (3) Method: PubMed and PsycINFO were queried for publications up to November 2020; (4) Results: We screened 4519 titles, 114 abstracts and 85 full-texts, and analyzed 36 articles regarding the clinical assessment (i.e., diagnostic and prognostic value; n = 19) and treatment (i.e., interventions; n = 17) of ADs. Though most VR assessment studies (n = 15/19) showed associations between VR-induced cue-reactivity and clinical parameters, only two studies specified diagnostic value. VR treatment studies based on exposure therapy showed no or negative effects. However, other VR interventions like embodied and aversive learning paradigms demonstrated positive findings. The overall study quality was rather poor; (5) Conclusion: Though VR in ADs provides ecologically valid environments to induce cue-reactivity and provide new treatment paradigms, the added clinical value in assessment and therapy remains to be elucidated before VR can be applied in clinical care. Therefore, future work should investigate VR efficacy in randomized clinical trials using well-defined clinical endpoints.

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose

Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches.

Findings

There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances.

Summary

This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required.

Is Virtual Reality Cue Exposure a Promising Adjunctive Treatment for Alcohol Use Disorder?

This narrative review presents recent developments in virtual reality (VR)-based interventions for alcohol use disorders (AUDs). The latest advances in mental healthcare hail an imminent cyber revolution, ushering in novel treatment options, with immersive virtual technology at the very forefront of expected change. With an aim to (a) provide a background on VR use in mental healthcare of AUD patients, (b) summarize existing evidence on conventional approaches to the treatment of AUDs and a trending paradigm shift towards VR applications in their management, and (c) describe key issues and future directions in research on craving assessment and VR cue-induced therapy in AUDs, a search for experimental and meta-analytic evidence was performed in six databases: PubMed and EBSCO (Medline, ERIC, PsychINFO, Academic Search Ultimate, and Health Source: Nursing/Academic Edition). Pooled results were screened for eligibility, and relevant papers were selected for inclusion. The analysis revealed VR’s promising effects in the treatment of AUDs. Its remarkable potential to simulate cues underlying subsequent addictive behaviors makes its application in the assessment and treatment of AUDs an attractive alternative to researchers and clinicians alike. Nevertheless, more evidence is needed before virtual reality cue exposure therapy (VR-CET) can become a clinical standard of care.

Virtual reality for the enhancement of emotion regulation

In recent decades, a growing body of literature has focused on emotion regulation (ER), which refers to the ability to implement strategies in order to modulate emotional responses and reach desirable goals. To date, impaired ER (i.e., emotion dysregulation) has been identified as a transdiagnostic factor across a wide range of psychopathological conditions, which shows the importance of improving patients' ability to regulate negative and positive emotions in clinical practice. In addition to the increasing evidence showing its efficacy in the treatment of several clinical conditions, virtual reality (VR) has recently emerged as a potentially powerful tool for enhancing ER, thus breaking new ground in the development of cutting-edge transdiagnostic interventions. In the present narrative review, we will provide an overview of the existing evidence about VR-based interventions in the field of ER, emphasizing the promising findings and the barriers that still have to be addressed. To this aim, the available VR-based literature will be analysed in relation to four categories of ER strategies: situational strategies, attentional strategies, cognitive strategies, and response modulation strategies. Furthermore, new emerging fields of research targeting innovative aspects of ER will be highlighted, including the use of VR to promote positive emotions and interpersonal ER skills. Besides, its cost-effectiveness will be discussed, taking into account the costs for both developers (e.g., clinicians and researchers) and end-users. Finally, future directions in this promising field of research will be outlined.

Cue-based treatment for light smokers: A proof of concept pilot

INTRODUCTION

Light smoking (smoking ≤ 10 cigarettes per day or on some days) has become increasingly prevalent in the US and increases morbidity and mortality. Many light smokers do not experience significant nicotine withdrawal but instead smoke in response to cues. Minimal evidence exists supporting interventions to help light smokers quit smoking.

METHODS

We present results from a proof-of-concept pilot study designed to evaluate the feasibility and acceptability of a cue-based smoking cessation intervention targeted to light daily and intermittent smokers. Participants were randomized to one of two arms: Arm 1) standard smoking cessation treatment or Arm 2) standard smoking cessation treatment + enhanced cue-based treatment that included interactive texting to extend cue exposure treatment to real-world settings and cue management counseling.Outcomes included feasibility (number of participants who were recruited and who completed the intervention), acceptability (intervention ratings), and preliminary efficacy (7-day point prevalence abstinence).

RESULTS

We randomized 24 English and Spanish-speaking light smokers, 13 to the treatment arm and 11 to the control arm. Across both arms, 77% attended all counseling sessions, 90% rated these sessions as very useful and 100% said that they would recommend the intervention to a friend. 15% in the treatment arm had biochemically-validated smoking abstinence compared to 0% in the standard counseling arm.

CONCLUSIONS

Results from this proof-of-concept study demonstrated that a cue-based intervention is feasible and acceptable among light smokers and suggests the need for a fully powered study to assess this approach.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03416621.

A virtual reality study on postretrieval extinction of smoking memory reconsolidation in smokers

Exposure to smoking-related stimuli may induce the reconsolidation of smoking-related memories in smokers. Research has proposed that extinction applied after the retrieval of a smoking memory may inhibit reconsolidation and prevent craving. The aim of this study was to test the effect of postretrieval extinction (PRE) on the reconsolidation of smoking memory by using a virtual reality (VR) simulation in smokers. On the day 1 session, the study exposed 46 smokers to a neutral and then to a smoking VR scenario under a fixed-block protocol. On day 2, the study randomized participants into three groups (G) and exposed them to a 15-s VR immersion in smoking (G1, G3) or neutral (G2) scenario for memory retrieval. After 15 min, the study exposed G1 and G2 to a VR PRE during the temporal window of memory vulnerability, whereas the study exposed G3 to extinction immediately after retrieval. On day 3, the study exposed all groups to neutral and smoking scenarios similar to day 1. All groups significantly increased craving for cigarettes after exposure to the smoking scenario on day 1 (p < 0.01). On day 3, VR PRE after a 15-second VR smoking memory retrieval was able to inhibit reconsolidation in G1, but not in G3 exposed to PRE before the window of vulnerability, or in G2 not exposed to the smoking memory retrieval. These findings show the superiority of VR PRE after smoking memory retrieval compared to a standard extinction procedure.

Cognitive behavioural therapy in virtual reality treatments across mental health conditions: a systematic review

Background

Virtual reality (VR) has been effectively used in the treatment of many mental health disorders.However, significant gaps exist in the literature. There is no treatment framework for researchers to use when developing new VR treatments. One recommended treatment across a range of diagnoses, which may be suitable for use in VR treatments, is Cognitive Behavioural Therapy (CBT). The aim of this systematic review is to investigateCBT treatment methods that utilize VR to treat mental health disorders.

Objectives

To investigate how CBT has been used in VR to treat mental health disorders and to report onthe treatment characteristics (number of sessions, duration, and frequency) that are linked to effective and ineffective trials.

Methods

Studies were included if patients had a mental health diagnosis and their treatment included immersiveVR technology and CBT principles. Data were extracted in relation to treatment characteristics and outcomes,and analysed using narrative synthesis.

Results

Ninety-three studies were analysed. Exposure-based VR treatments were mainly used to treat anxiety related disorders. Treatments generally consisted of eight sessions, once a week for approximately one hour. VR treatments were commonly equal to or more effective than traditional face-to-face methods. No specific treatment characteristics were linked to this effectiveness.

Conclusion

The number, frequency and duration of the VR treatment sessions identified in this review, could be used as a treatment framework by researchers and clinicians. This could potentially save researchers time and money when developing new interventions.

Isradipine enhancement of virtual reality cue exposure for smoking cessation: Rationale and study protocol for a double-blind randomized controlled trial

Cigarette smoking remains a leading cause of preventable death in the United States, contributing to over 480,000 deaths each year. Although significant strides have been made in the development of effective smoking cessation treatments, most established interventions are associated with high relapse rates. One avenue for increasing the effectiveness of smoking cessation interventions is to design focused, efficient, and rigorous experiments testing engagement of well-defined mechanistic targets. Toward this aim, the current protocol will apply a pharmacologic augmentation strategy informed by basic research in animal models of addiction. Our goal is to evaluate the enhancing effect of isradipine, an FDA-approved calcium channel blocker, on the extinction of craving-a key mechanism of drug relapse after periods of abstinence. To activate craving robustly in human participants, we will use multimodal smoking cues including novel 360° video environments developed for this project and delivered through consumer virtual reality headsets. Adult smokers will take either isradipine or placebo and complete the cue exposure protocol in a double-blind randomized control trial. In order to test the hypothesis that isradipine will enhance retention of craving extinction, participants will repeat cue exposure 24 h later without the administration of isradipine or placebo. The study will be implemented in a primary care setting where adult smokers receive healthcare, and smoking behavior will be tracked throughout the trial with ecological momentary assessment.

Virtual Reality (VR) in Assessment and Treatment of Addictive Disorders: A Systematic Review

Background: Substance Use Disorder (SUD) and behavioral addictions are common and require a multidisciplinary approach. New technologies like Virtual Reality could have the potential to improve assessment and treatment of these disorders.

Objective: In the present paper, we therefore present an overview of Virtual Reality (Head Mounted Devices) in the field of addiction medicine for craving assessment and treatment.

Method: We conducted a systematic review by querying PubMed database for the titles of articles published up to March 2019 with the terms [virtual] AND [addictive] OR [addiction] OR [substance] OR [alcohol] OR [cocaine] OR [cannabis] OR [opioid] OR [tobacco] OR [nicotine] OR [methamphetamine] OR [gaming] OR [gambling].

Results: We screened 319 abstracts and analyzed 37 articles, dividing them into two categories, the first for assessment of cue reactivity (craving, psychophysiological response and attention to cue) and the second for intervention, each drug (nicotine, cocaine, alcohol, cannabis, gambling) being detailed within each category.

Conclusions: This overview suggest that VR provide benefits in the assessment and treatment of substance use disorders and behavior addictions and achieve high levels of ecological validity. While, craving provocation in VR is effective across addiction disorders, treatments based exclusively on virtual exposure to drug related cues as shown heterogenous results.

Memory Retrieval-Extinction Combined With Virtual Reality Reducing Drug Craving for Methamphetamine: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Relapse, often precipitated by drug-associated cues that evoke craving, is a key problem in the treatment of methamphetamine use disorder (MUD). Drug-associated memories play a major role in the maintenance of relapse. Extinction training is a common method for decreasing drug craving by suppressing drug-associated memories. However, the effects are often not permanent, which is evident in form of spontaneous recovery or renewal of cue-elicited responses. Based on memory reconsolidation theory, the retrieval-extinction (R-E) paradigm may be more effective in decreasing spontaneous recovery or renewal responses than extinction. After the original memory reactivated to a labile state, extinction will be introduced within the reconsolidation window, thereby updating drug-associated memories. However, there are still some controversial results, which suggest that the reactivation of drug-associated memories and the 10 min-6 h of limited time window are two main elements in the R-E protocol. Virtual reality (VR) is supposed to promote memory reactivation by providing vivid drug-related stimuli when compared with movies.

OBJECTIVE

The aim of this study is to examine the effectiveness of R-E training combined with VR on reducing spontaneous recovery or renewal of cue-elicited responses, in comparison to extinction, R-E training provided outside the time window of 6 h and R-E training retrieved using videos, in methamphetamine abusers.

METHODS

The study is a parallel matched controlled study including 95 participants with MUD. Participants will be randomly assigned to either a R-10 min-E group (methamphetamine-related cues retrieval in VR followed by extinction after 10 min) or a NR-10 min-E group (neutral cues retrieval in VR followed by extinction after 10 min) or a R-6 h-E group (methamphetamine-related cues retrieval in VR followed by extinction after 6 h) or a RV-10 min-E group (methamphetamine-related cues retrieval in videos followed by extinction after 10 min). Cue-evoked craving and reactivity will be assessed at pre-test and at 1 day, 1 week, 1 month, and 6-month post-tests.

DISCUSSION

To our knowledge, this study will probably be the first study to examine the efficacy of R-E training combined with VR to reduce cue-evoked responses in people with MUD. This innovative non-pharmacological intervention targeting drug-associated memories may provide significant clinical implications for reducing relapse, providing the study confirms its efficacy.

CLINICAL TRIAL REGISTRATION

The trial is registered with Chinese Clinical Trial Registry at 17 October 2018, number: ChiCTR1800018899, URL: http://www.chictr.org.cn/showproj.aspx?proj=30854.

Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study

BACKGROUND

This study is part of a larger project aiming to develop a virtual reality (VR) software to be implemented as a clinical tool for patients diagnosed with alcohol use disorder (AUD). The study is based on previous research in which we identified factors that elicit craving for alcohol in a sample of AUD patients, and which led to the development of a virtual reality software to be used in cue exposure treatments of alcohol use disorder (ALCO-VR). The main objective of this study was to test the effectiveness of ALCO-VR to elicit cue-induced craving and anxiety responses among social drinkers (SD) and AUD patients. Our secondary objective was to explore which responses (cue-induced craving or anxiety) can best differentiate between AUD patients and the SD group.

METHOD

Twenty-seven individuals (13 AUD patients and 14 SD) participated in this study after giving written informed consent. Their anxiety and alcohol craving levels were measured by different instruments at different stages of the procedure. The VR equipment consisted of Oculus Rift technology, and the software consisted of the ALCO-VR platform.

RESULTS

Our data indicate that the ALCO-VR software can elicit responses of anxiety and alcohol craving, especially in the group of AUD patients. The cue-induced anxiety response differentiated AUD patients and the SD group better than the cue-induced craving response.

CONCLUSIONS

The general interest in applying new technologies to the assessment and treatment of mental health disorders has led to the development of immersive real-life simulations based on the advantages of VR technology. Our study concluded that the ALCO-VR software can elicit anxiety and craving responses and that cue-induced anxiety responses can distinguish between AUD and SD groups better than cue-induced craving. The data on craving and anxiety were assessed consistently by different instruments. In addition, we consider that ALCO-VR is able to ecologically assess cue-induced anxiety and alcohol craving levels during exposure to VR alcohol-related environments.

The training game SALIENCE for the therapy of alcohol use disorder

The feasibility study was aimed to develop a web-based gaming tool for the therapy of alcohol use disorder to offer patients a cue-exposure-based extinction and decision training, enhanced with virtual reality. To increase the training effect, patients playfully experience situations that resemble critical real-life situations. For implementing the game, a combination of HTML5 and JavaScript was used. The application comes with an administrator interface, to allow editing the game content. Initially, we included 21 patients (Group 1), 18 suffering from alcohol use disorder and 3 using cannabis (18/3 male/female, mean age 39 ± 13 years). Considering the iterative process of a feasibility study, we developed the game design as suggested by participants of Group 1 and additionally included 11 novel participants (Group 2) (11 suffering from an alcohol use disorder, 7/4 male/female, mean age 46 ± 14 years). Basically, the game was very well received. Usability ratings were generally high, even in patients with little computer experience. Both groups rated the application as realistic, and would generally be willing to play it on a daily basis. Given that SALIENCE is inexpensive, easily available, and engaging, it might be a reasonable add-on intervention to the standard treatment of alcohol use disorder.

Identifying Triggers of Alcohol Craving to Develop Effective Virtual Environments for Cue Exposure Therapy

Background: Many studies have indicated that alcohol craving is a core mechanism in the acquisition, maintenance, and precipitation of relapse in alcohol use disorder (AUD). A common treatment approach in AUD is cue exposure therapy (CET). New technologies like virtual reality (VR) have the potential to enhance the effectiveness of CET by creating realistic scenarios in naturalistic environments. In this study, we aimed to determine relevant triggers of alcohol craving in patients with AUD.

Methods: We enrolled 75 outpatients diagnosed with AUD according to the DSM-5 criteria Participants completed the Alcohol Use Disorder Identification Test and a self-administered questionnaire to assess alcohol craving. The variables included in the craving questionnaire were as follows: presence of others, situations, time of the day, day of the week, mood, and type of alcoholic beverage.

Results: Greater levels of alcohol craving were seen in many situations, including being at a party, in a restaurant, in a bar or pub, and at home. Drinking alone and drinking with two or more friends were equally associated with higher levels of craving. Drinking at night and drinking at weekends also emerged as triggers for alcohol craving. Emotional states like anxiety or tension, sadness, stress, frustration, or irritability were highly associated with urges to drink alcohol. The alcoholic drinks most highly associated with increased levels of craving were beer, wine, and whisky. Gender and age implications were discussed.

Conclusion: This study is part of a larger project aiming to develop and validate CET based on VR technology for patients with AUD who are resistant to classical treatment. The identified triggers have been used to develop relevant VR environments for CET, and further research is ongoing to implement our findings.

Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research

BACKGROUND

eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move.

OBJECTIVE

In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health.

METHODS

We compiled a table of 82 studies that made use of head-mounted devices in their interventions.

RESULTS

Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist.

CONCLUSIONS

Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment.

Development of an effective virtual environment in eliciting craving in adolescents and young adults with internet gaming disorder

Internet gaming disorder (IGD) is a new disorder that warrants further investigation, as recently noted in the research criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Offering controlled environments that increase cue-induced craving, virtual reality cue-exposure therapy has been shown to be effective for some addiction disorders. To assess the feasibility of virtual reality for patients with IGD, this study aimed to develop virtual environments that represent risk situations for inducing craving, and assess the effect of virtual reality in cue reactivity. A total of 64 male adolescents and young adults (34 with IGD and 30 without) were recruited for participation. We developed a virtual internet café environment and the participants were exposed to four different tasks. As the primary feasibility outcome, cravings were measured with a visual analogue scale measuring current urge to play a game after exposure to each task. The virtual internet café induced significantly greater cravings in patients with IGD compared to controls. Additionally, patients exhibited a significantly higher acceptance rate of an avatar's invitation to play a game together than that of controls. In IGD, craving response to the tasks was positively associated with the symptom severity score as measured by Young's Internet Addiction Test. These findings reveal that virtual reality laden with complex game-related cues could evoke game craving in patients with IGD and could be used in the treatment of IGD as a cue-exposure therapy tool for eliciting craving.

Selective Inhibition of Amygdala Neuronal Ensembles Encoding Nicotine-Associated Memories Inhibits Nicotine Preference and Relapse

BACKGROUND

Nicotine craving and relapse often occurs after reactivation of nicotine reward memories. We recently developed a memory retrieval-reconsolidation interference procedure in which reactivating nicotine reward memories by acute exposure to nicotine (the unconditioned stimulus [UCS]) and then pharmacologically interfering with memory reconsolidation decreased relapse to nicotine seeking in rats and nicotine craving in smokers. Here, we investigated underlying mechanisms.

METHODS

In the first series of experiments, we trained rats for nicotine-induced conditioned place preference (CPP) or nicotine self-administration and ventricularly microinjected them with the protein synthesis inhibitor anisomycin immediately after UCS-induced memory retrieval. In the second series of experiments, we used tyramide-amplified immunohistochemistry-fluorescence in situ hybridization to examine neural ensembles in the basolateral amygdala (BLA) reactivated by nicotine conditioned stimulus- or UCS-induced memory retrieval. We then used the Daun02 chemogenetic inactivation procedure to selectively inhibit the nicotine UCS-reactivated BLA neuronal ensembles.

RESULTS

Ventricular injections of the anisomycin immediately after nicotine UCS memory retrieval inhibited subsequent nicotine CPP and relapse to operant nicotine seeking after short or prolonged abstinence. More important, within BLA, distinct neuronal ensembles encoded pavlovian CPP and operant self-administration reward memories and nicotine (the UCS) injections in the home cage reactivated both neuronal ensembles. Daun02 chemogenetic inactivation of the nicotine-reactivated ensembles inhibited both nicotine CPP and relapse to nicotine seeking.

CONCLUSIONS

Results demonstrate that the nicotine UCS-induced memory retrieval manipulation reactivates multiple nicotine reward memories that are encoded by distinct BLA neuronal ensembles that play a role in nicotine preference and relapse.

Virtual reality in the assessment, understanding, and treatment of mental health disorders

Mental health problems are inseparable from the environment. With virtual reality (VR), computer-generated interactive environments, individuals can repeatedly experience their problematic situations and be taught, via evidence-based psychological treatments, how to overcome difficulties. VR is moving out of specialist laboratories. Our central aim was to describe the potential of VR in mental health, including a consideration of the first 20 years of applications. A systematic review of empirical studies was conducted. In all, 285 studies were identified, with 86 concerning assessment, 45 theory development, and 154 treatment. The main disorders researched were anxiety (n = 192), schizophrenia (n = 44), substance-related disorders (n = 22) and eating disorders (n = 18). There are pioneering early studies, but the methodological quality of studies was generally low. The gaps in meaningful applications to mental health are extensive. The most established finding is that VR exposure-based treatments can reduce anxiety disorders, but there are numerous research and treatment avenues of promise. VR was found to be a much-misused term, often applied to non-interactive and non-immersive technologies. We conclude that VR has the potential to transform the assessment, understanding and treatment of mental health problems. The treatment possibilities will only be realized if - with the user experience at the heart of design - the best immersive VR technology is combined with targeted translational interventions. The capability of VR to simulate reality could greatly increase access to psychological therapies, while treatment outcomes could be enhanced by the technology's ability to create new realities. VR may merit the level of attention given to neuroimaging.

Effect of Selective Inhibition of Reactivated Nicotine-Associated Memories With Propranolol on Nicotine Craving

IMPORTANCE

A relapse into nicotine addiction during abstinence often occurs after the reactivation of nicotine reward memories, either by acute exposure to nicotine (a smoking episode) or by smoking-associated conditioned stimuli (CS). Preclinical studies suggest that drug reward memories can undergo memory reconsolidation after being reactivated, during which they can be weakened or erased by pharmacological or behavioral manipulations. However, translational clinical studies using CS-induced memory retrieval-reconsolidation procedures to decrease drug craving reported inconsistent results.

OBJECTIVE

To develop and test an unconditioned stimulus (UCS)-induced retrieval-reconsolidation procedure to decrease nicotine craving among people who smoke.

DESIGN, SETTING, AND PARTICIPANTS

A translational rat study and human study in an academic outpatient medical center among 96 male smokers (aged 18- 45 years) to determine the association of propranolol administration within the time window of memory reconsolidation (after retrieval of the nicotine-associated memories by nicotine UCS exposure) with relapse to nicotine-conditioned place preference (CPP) and operant nicotine seeking in rats, and measures of preference to nicotine-associated CS and nicotine craving among people who smoke.

INTERVENTION

The study rats were injected noncontingently with the UCS (nicotine 0.15 mg/kg, subcutaneous) in their home cage, and the human study participants administered a dose of propranolol (40 mg, per os; Zhongnuo Pharma).

MAIN OUTCOMES AND MEASURES

Nicotine CPP and operant nicotine seeking in rats, and preference and craving ratings for newly learned and preexisting real-life nicotine-associated CS among people who smoke.

RESULTS

Sixty-nine male smokers completed the experiment and were included for statistical analysis: 24 in the group that received placebo plus 1 hour plus UCS, 23 who received propranolol plus 1 hour plus UCS, and 22 who received UCS plus 6 hours plus propranolol. In rat relapse models, propranolol injections administered immediately after nicotine UCS-induced memory retrieval inhibited subsequent nicotine CPP and operant nicotine seeking after short (CPP, d = 1.72, 95% CI, 0.63-2.77; operant seeking, d = 1.61, 95% CI, 0.59-2.60) or prolonged abstinence (CPP, d = 1.46, 95% CI, 0.42-2.47; operant seeking: d = 1.69, 95% CI, 0.66-2.69), as well as nicotine priming-induced reinstatement of nicotine CPP (d = 1.28, 95% CI, 0.27-2.26) and operant nicotine seeking (d = 1.61, 95% CI, 0.59-2.60) after extinction. Among the smokers, oral propranolol administered prior to nicotine UCS-induced memory retrieval decreased subsequent nicotine preference induced by newly learned nicotine CS (CS1, Cohen d = 0.61, 95% CI, 0.02-1.19 and CS2, d = 0.69, 95% CI, 0.10-1.28, respectively), preexisting nicotine CS (d = 0.57, 95% CI, -0.02 to 1.15), and nicotine priming (CS1, d = 0.82, 95% CI, 0.22-1.41 and CS2, d = 0.78, 95% CI, 0.18-1.37, respectively; preexisting nicotine CS, d = 0.92, 95% CI, 0.31-1.52), as well as nicotine craving induced by the preexisting nicotine CS (d = 0.64, 95% CI, 0.05-1.22), and nicotine priming (d = 1.15, 95% CI, 0.52-1.76).

CONCLUSIONS AND RELEVANCE

In rat-to-human translational study, a novel UCS-induced memory retrieval-reconsolidation interference procedure inhibited nicotine craving induced by exposure to diverse nicotine-associated CS and nicotine itself. This procedure should be studied further in clinical trials.

The Use of Behavior Change Techniques and Theory in Technologies for Cardiovascular Disease Prevention and Treatment in Adults: A Comprehensive Review

This review examined the use of health behavior change techniques and theory in technology-enabled interventions targeting risk factors and indicators for cardiovascular disease (CVD) prevention and treatment. Articles targeting physical activity, weight loss, smoking cessation and management of hypertension, lipids and blood glucose were sourced from PubMed (November 2010-2015) and coded for use of 1) technology, 2) health behavior change techniques (using the CALO-RE taxonomy), and 3) health behavior theories. Of the 984 articles reviewed, 304 were relevant (240=intervention, 64=review). Twenty-two different technologies were used (M=1.45, SD=+/-0.719). The most frequently used behavior change techniques were self-monitoring and feedback on performance (M=5.4, SD=+/-2.9). Half (52%) of the intervention studies named a theory/model - most frequently Social Cognitive Theory, the Trans-theoretical Model, and the Theory of Planned Behavior/Reasoned Action. To optimize technology-enabled interventions targeting CVD risk factors, integrated behavior change theories that incorporate a variety of evidence-based health behavior change techniques are needed.

The Use of Virtual Reality in the Production of Cue-Specific Craving for Cigarettes: A Meta-Analysis

INTRODUCTION

The cue-reactivity procedure has demonstrated that smokers respond with increases in subjective craving in the presence of smoking-related cues. Virtual reality is an emerging mode of cue presentation for cue-reactivity research. Despite the successful implementation of virtual reality during the last decade, no systematic review has investigated the magnitude of effects across studies.

METHODS

This research systematically reviewed findings from studies using virtual reality in cigarette craving assessment. Eligible studies assessed subjective craving for cigarettes in smokers exposed to smoking-related and neutral environments. Cohen's d was used to assess differences in craving between smoking-related and nonsmoking-related virtual environments. A random effects approach was used to combine effect sizes.

RESULTS

A total of 18 studies involving 541 smokers was included in the final analyses. Environments with smoking-related cues produced significant increases in craving relative to environments without smoking-related cues. The mean overall effect size (Cohen's d) was 1.041 (SE = 0.12, 95% CI = 0.81 to 1.28, Z = 8.68, P < .001).

CONCLUSIONS

The meta-analysis suggested that presentations of smoking cues through virtual reality can produce strong increases in craving among cigarette smokers. This strong cue-reactivity effect, which was comparable in magnitude to the craving effect sizes found with more conventional modes of cue presentation, supports the use of virtual reality for the generation of robust cue-specific craving in cue-reactivity research.

Individual variables related to craving reduction in cue exposure treatment

INTRODUCTION

Although extensive research has demonstrated that cigarette craving can be effectively attenuated, very few studies have explored associations between individual variables and craving reduction. This study explored whether individual characteristics predict craving decreases during virtual reality cue exposure treatment (VR-CET).

METHOD

Participants were 41 treatment-seeking smokers (73% women) with a mean age of 39.4 (SD=13.2), who had been smoking 15.0 (SD=7.1) cigarettes per day for 20.0 (SD=10.7) years. Their mean score on the Fagerström Test of Nicotine Dependence (FTND) was 4.8 (SD=2.3). Participants completed five cue exposure sessions using virtual reality for smoking cessation over a five-week period. The percentage of reduction in craving was calculated by comparing self-reported craving after the first and last exposure sessions. Sociodemographic characteristics (gender, age, years of education and marital status), tobacco-related [duration of daily smoking, cigarettes per day, FTND and Nicotine Dependence Syndrome Scale (NDSS)] and psychological characteristics [depressive symptoms (Beck's Depression Inventory-Second Edition, BDI-II), impulsiveness (delay discounting) and anxiety (State-Trait Anxiety Inventory, STAI)] were examined as possible predictors for craving reductions.

RESULTS

Multiple regression revealed that greater decreases in craving were associated with younger age (β=-.30, p=.043), cigarettes smoked per day (β=.30, p=.042), higher values on delay discounting (β=.34, p=.020) and higher BDI-II scores (β=.30, p=.035).

CONCLUSION

These findings suggest that smokers with certain individual characteristics may benefit most from interventions aimed at reducing craving through VR-CET.

Withdrawal Symptoms and Nicotine Dependence Severity Predict Virtual Reality Craving in Cigarette-Deprived Smokers

INTRODUCTION

Virtual reality (VR) has been shown to be effective in eliciting responses to nicotine cues in cigarette smokers. The primary aim of this study was to investigate whether cigarette-deprived smokers would exhibit increased craving and changes in heart rate when viewing cigarette related cues as compared to non-smoking cues in a VR environment, and the secondary aim was to assess the extent to which self-assessed measures of withdrawal and dependence correlated with VR craving.

METHODS

Nicotine-dependent cigarette smokers were recruited for a 2 day study. On Day 1, participants smoked as usual and on Day 2 were deprived from smoking overnight. On both days, participants completed self-assessment questionnaires on withdrawal, craving, and nicotine-dependence. Participants completed a VR session during the cigarette deprivation condition only (Day 2). During this session, they were exposed to active smoking and placebo (non-smoking) cues.

RESULTS

The data show that self-reported levels of "craving" (p < .01) and "thinking about cigarettes" (p < .0001) were significantly greater after exposure to the active cues versus non-smoking cues. Significant increases in heart rate were found for 3 of 4 active cues when compared to non-smoking cues (p < .05). Finally, significant positive correlations were found between self-reported craving prior to the VR session and craving induced by active VR cues (p < .01).

CONCLUSIONS

In this report, active VR cues elicited craving during cigarette deprivation. This is the first study to demonstrate that self-reported craving, withdrawal symptoms, and nicotine dependence severity predict cue-induced craving in the VR setting.