Effectiveness evaluation for short-term group pre-deployment VR computer-assisted stress inoculation training provided to Polish ISAF soldiers

The goal of this study was to assess effectiveness of a short collective stress inoculation training (SIT) conducted according to the methodology of the Virtual Reality Medical Center of San Diego (Training of Physiological Control Exposure to Virtual Stressor while Maintaining Physiological Control). The results obtained indicate a short-term effectiveness of the training as a method of tension reduction. However, in the long-term perspective these results are ambiguous and they suggest a need of further research. In order to extend the analysis effects of temperamental factors on training effectiveness was presented.

Ubiquitous health in practice: the interreality paradigm

In this paper we introduce a new ubiquitous computing paradigm for behavioral health care: "Interreality". Interreality integrates assessment and treatment within a hybrid environment, that creates a bridge between the physical and virtual worlds. Our claim is that bridging virtual experiences (fully controlled by the therapist, used to learn coping skills and emotional regulation) with real experiences (allowing both the identification of any critical stressors and the assessment of what has been learned) using advanced technologies (virtual worlds, advanced sensors and PDA/mobile phones) may improve existing psychological treatment. To illustrate the proposed concept, a clinical scenario is also presented and discussed: Daniela, a 40 years old teacher, with a mother affected by Alzheimer's disease.

Personal health systems for mental health: the European projects

Since the European funded project VREPAR--Virtual Reality in Neuro-Psycho-Physiology (1995)--different European research activities have been using virtual reality and advanced information and communication technologies to improve the quality of care in the treatment of many different mental health disorders including anxiety disorders, eating disorders and obesity. Now the European Commission funding is shifting from the traditional hospital-centred and reactive healthcare delivery model toward a person-centred and preventive one. The main outcome of this shift is the "Personal Health Systems" (PHS) paradigm that aims at offering continuous, quality controlled, and personalized health services to empowered individuals regardless of location. The paper introduces four recently funded projects--Interstress, Monarca, Optimi and Psyche--that aim at using PHS based on virtual reality, biosensors and/or mobile technologies to improve the treatment of bipolar disorders, depression and psychological stress.

Reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder: a pilot study

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

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.

CyberStudies: lessons from the trenches

Many individuals suffer from anxiety, stress, and depression and those serving in the U.S. military are no exception. Warfighters keep returning from theater with combat stress. Several of these military service members are also technology oriented and tend to prefer performing their daily life activities with and/or near computerized systems. Fortunately, some researchers specialize in helping warfighters via gaming or virtual reality technologies. Nevertheless, a dearth of literature is published about challenges researchers face when conducting these types of studies. This article shares the experiences of a research team, under a uniformed Army Research Psychologist (Stetz), who runs research studies (a) with warfighters, (b) with technological equipment, and (c) in nonstandard laboratory settings.

Interreality in the management of psychological stress: a clinical scenario

The term "psychological stress" describes a situation in which a subject perceives that environmental demands tax or exceed his or her adaptive capacity. According to the Cochrane Database of Systematic Reviews, the best validated approach covering both stress management and stress treatment is the Cognitive Behavioral (CBT) approach. We aim to design, develop and test an advanced ICT based solution for the assessment and treatment of psychological stress that is able to improve the actual CBT approach. To reach this goal we will use the "interreality" paradigm integrating assessment and treatment within a hybrid environment, that creates a bridge between the physical and virtual worlds. Our claim is that bridging virtual experiences (fully controlled by the therapist, used to learn coping skills and emotional regulation) with real experiences (allowing both the identification of any critical stressors and the assessment of what has been learned) using advanced technologies (virtual worlds, advanced sensors and PDA/mobile phones) is the best way to address the above limitations. To illustrate the proposed concept, a clinical scenario is also presented and discussed: Paola, a 45 years old nurse, with a mother affected by progressive senile dementia.

Clinical observations during virtual reality therapy for specific phobias

Virtual environments offer a new method of providing exposure therapy to patients with specific phobias. Although the stimuli (three-dimensional computer simulations) is new, the method of systematically desensitizing the patient to phobic stimuli until habituation occurs is a concept that was formally introduced by Joseph Wolpe over 40 years ago. Our article discusses some of the clinical observations that have been made during nearly 500 virtual reality exposure therapy sessions with patients and research participants who have come to our center in the past 15 months with a fear of flying or driving.

Cognitive Therapy Using Mixed Reality for Those Impaired by a Cerebrovascular Accident (CVA)

There is new research showing that interactive multimodal rehabilitation may enhance cognitive therapy after cerebrovascular accident. A well-designed Mixed Reality system provides a diverse, controllable and versatile therapeutic environment to help promote neural plasticity during recovery. In addition to stroke patients, there are other groups, such as those with traumatic brain injury (TBI) that could benefit from the system. Initial results, both paper-and-pencil measures and physiological measures, in a trial with fourteen participants are discussed.

The receptiveness of stress management techniques by military personnel

Many military service members suffer from stress. Sixty Soldiers participated in a study designed to test receptivity to stress management techniques. Preliminary analyses of surveys and a focus group suggested that participants not only liked practicing relaxation techniques but would also continue practicing these after completion of the present study.

Next generation stress inoculation training for life saving skills using prosthetics

By integrating medical science with cutting edge simulation and training technologies, realistic prosthetic tissue, wounds, and part task trainers have been developed for the training of trauma care clinicians. The next generation of Stress Inoculation Training (SIT) includes the use of prosthetics developed based on human anatomy and physiology, material science, and nanotechnology. Testing has revealed that these products are highly useful and reliable.

Cost effectiveness of virtual reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder

Virtual Reality Graded Exposure Therapy (VRGET) is an effective treatment for combat-related PTSD. We summarize the outcomes of a VRGET pilot study with 12 participants who completed one to multiple combat tours in support of the War on Terrorism and who were subsequently diagnosed with combat-related PTSD. Details of the collaborative program amongst the Virtual Reality Medical Center (VRMC), Office of Naval Research, the Naval Medical Center San Diego (NMCSD) and the Navy Hospital Camp Pendleton are discussed as is the VRGET outcomes of significant reductions in PTSD symptoms severity. We also described the estimated cost-effectiveness of VRGET for the treatment of combat-related PTSD, as contrasted to Treatment as Usual (TAU) for combat-related PTSD.

Combat related post traumatic stress disorder: a multiple case report using virtual reality graded exposure therapy with physiological monitoring

The current report summarizes case studies from an Office of Naval Research (ONR) funded project to compare the effects of Virtual Reality Graded Exposure Therapy (VRGET) with a treatment as usual control condition in active-duty Navy Corpsmen, Navy SeaBees and Navy and Marine Corps Support Personnel. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Pain modulation during drives through cold and hot virtual environments

Evidence exists that virtual worlds reduce pain perception by providing distraction. However, there is no experimental study to show that the type of world used in virtual reality (VR) distraction influences pain perception. Therefore, we investigated whether pain triggered by heat or cold stimuli is modulated by "warm "or "cold " virtual environments and whether virtual worlds reduce pain perception more than does static picture presentation. We expected that cold worlds would reduce pain perception from heat stimuli, while warm environments would reduce pain perception from cold stimuli. Additionally, both virtual worlds should reduce pain perception in general. Heat and cold pain stimuli thresholds were assessed outside VR in 48 volunteers in a balanced crossover design. Participants completed three 4-minute assessment periods: virtual "walks " through (1) a winter and (2) an autumn landscape and static exposure to (3) a neutral landscape. During each period, five heat stimuli or three cold stimuli were delivered via a thermode on the participant's arm, and affective and sensory pain perceptions were rated. Then the thermode was changed to the other arm, and the procedure was repeated with the opposite pain stimuli (heat or cold). We found that both warm and cold virtual environments reduced pain intensity and unpleasantness for heat and cold pain stimuli when compared to the control condition. Since participants wore a head-mounted display (HMD) in both the control condition and VR, we concluded that the distracting value of virtual environments is not explained solely by excluding perception of the real world. Although VR reduced pain unpleasantness, we found no difference in efficacy between the types of virtual world used for each pain stimulus.

Stress, mental health, and cognition: a brief review of relationships and countermeasures

Today's network-centric battlefield environment is highly stressful and cognitively demanding. Many warfighters are feeling overwhelmed and end up being medically evacuated from theater due to mental health problems [i.e., post traumatic stress disorder (PTSD) and depression]. Of a sample of troops evacuated for psychiatric reasons, 21% (106 out of 509) had psychiatric histories prior to deploying to the theater of operations. Most cases were either related to stress (i.e., PTSD, n - 33, 310%) or to depression (n = 72, 66%). Stress disorders and depression predominate among the psychiatric causes for medical evacuation. This review paper discusses stress theories as they pertain to warfighting, the types of stress and stress disorders most prevalent on modern battlefields, the relationships among stress, psychiatric disease, and cognitive performance, and potential methods to decrease some types of stress-related acute and chronic disorders (i.e., virtual-reality stress inoculation training).

Combat-Related Post-Traumatic Stress Disorder: A Case Report Using Virtual Reality Exposure Therapy with Physiological Monitoring

The current report summarizes a case study from an Office of Naval Research (ONR) funded project to compare the effects of virtual reality graded exposure therapy (VRGET) with cognitive behavioral group therapy in active-duty corpsmen. Details of the collaborative program between the Virtual Reality Medical Center (VRMC) and Naval Medical Center San Diego (NMCSD) will be discussed.

Neurophysiological age differences during task-performance in a stereoscopic virtual environment

In today's society, there is an increasing number of workplaces in virtual environments (VE). But, there are only a few reports dealing with occupational health issues or age effects. The question arises how VR generally interferes with cognitive processes. This interference might have relevant implications for workability and work-efficiency in virtual environments. Event-related potentials are known to reflect different stages of stimulus reception, evaluation, and response. We have established an electroencephalographic (EEG) monitoring, focussing on event-related potentials (N100; mismatch negativity, i.e., MMN) to obtain access to attention dependent and pre-attentive processing of sensory stimuli applied in VE. The MMN is known to be correlated with the ability of subjects to react to an unexpected event. The aim of the present study was to investigate cognitive responses to distracting auditory stimuli in two different age groups in a virtual environment (VE) and in a real environment ("real reality"), and to compare characteristic neurophysiological response patterns. Data show that stimulus detection as given by the N100 amplitude and latency does not differ in both age groups and task conditions. In contrast, the pre-attentive processing as given by the MMN is altered in the VR such as the non-VR condition in an age-related manner. A relevant finding of the present study was that the age related differences seen in the non-VR condition were not strengthened in VR.

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.

Cognitive ergonomics in virtual environments: development of an intuitive and appropriate input device for navigating in a virtual maze

For patients suffering from mild cognitive impairments, the navigation through a virtual maze should be as intuitive and efficient as possible in order to minimize cognitive and physical strain. This paper discusses the appropriateness of interaction devices for being used for easy navigation tasks. Information gained from human centered evaluation was used to develop an intuitive and ergonomic interaction device. Two experiments examined the usability of tracked interaction devices. Usability problems with the devices are discussed. The findings from the experiments were translated into general design guidance, in addition to specific recommendations. A new device was designed on the basis of these recommendations and its usability was evaluated in a second experiment. The results were used to develop a lightweight interaction device for navigation in the virtual maze.

A Functional Magnetic Resonance Imaging (fMRI) Study of Cue-Induced Smoking Craving in Virtual Environments

Smokers who are exposed to smoking-related cues show cardiovascular reactivity and smoking craving compared with their responses to neutral cues, and increased cue reactivity predicts decreased likelihood of successful cessation. Several brain imaging studies suggested four candidate brain regions that might differ in gray matter volumes and densities between smokers and nonsmokers. However, in these studies, smokers were only exposed to smoking-related objects. In our pilot study utilizing a virtual reality (VR) technique, virtual environments (VEs) were more immersive and evoked smoking craving more effectively than traditionally used methods. In this study, we sought to test whether smokers could experience cue-induced smoking craving inside the MRI scanner by using the VR system. The smoking cue reactivity scenario was based in part on our preliminary task and consisted of 2D and 3D (or VE) conditions. The group mean of participants had increased activity in the prefrontal cortex (PFC), left anterior cingulate gyrus (ACC), left supplementary motor area, left uncus, right inferior temporal gyrus, right lingual gyrus, and right precuneus in the 2D condition. Areas of differential activation in the 3D condition were as follows: left superior temporal gyrus, right superior frontal gyrus, and left inferior occipital gyrus in the 3D condition. This finding is consistent with those of previous studies of nicotine craving showing PFC and ACC activation. However, in the 3D condition, the PFC including the superior frontal gyrus as well as the superior temporal gyrus, inferior occipital gyrus, and cerebellum were activated. Therefore, in the 3D condition, participants seemed to have more attention, visual balance, and coordinating movement than in the 2D condition.

Stimulation of Cortisol During Mental Task Performance in a Provocative Virtual Environment

Fully immersive and stereoscopic Virtual Environments (VE) represent a powerful multimedia tool for laboratory-based simulations of distinct scenarios including scenarios for evaluating stressful situations resembling reality. Thus far, cortisol secretion as a neuroendocrine parameter of stress has not been evaluated within a Virtual Reality (VR)-based paradigm. In this study 94 healthy volunteers were subjected to a provocative VR-paradigm and a cognitive stress task. Provocative in this context means the VE was designed to provoke physiological reactions (cortisol secretion) within the respective users by purpose. It was tested (a) if a fully dynamic VE as opposed to a static VE can be regarded as a stressor and (b) if such a fully dynamic VE can modify an additional response to a cognitive stressor presented within the VE additionally. Furthermore, possible gender-related impacts on cortisol responses were assessed. A significant cortisol increase was observed only after the combined application of the fully dynamic VE and the cognitive stressor, but not after application of the dynamic VE or the cognitive stressor alone. Cortisol reactivity was greater for men than for women. We conclude that a fully dynamic VE does not affect cortisol secretion per se, but increases cortisol responses to a dual task paradigm that includes performance of a stressful mental task. This provides the basis for the application of VR-based technologies in neuroscientific research, including the assessment of the human Hypothalamus-Pituitary-Adrenal (HPA) axis regulation.

Effects of Group Experiential Cognitive Therapy for the Treatment of Panic Disorder with Agoraphobia

A treatment protocol, called experiential cognitive therapy (ExCT), was developed. It integrated traditional cognitive behavior therapy (CBT) with virtual reality exposure for the treatment of panic disorder with agoraphobia (PDA). The objective of this study was to test the efficacy of short-term (four sessions) ExCT compared with a traditional 12-session panic control program (PCP) for the treatment of PDA. Forty patients diagnosed as having PDA by the diagnostic criteria of DSM-IV were randomly assigned to ExCT and PCP groups of 20 patients each. The treatment effects were measured with self-report questionnaires, including the BDI, STAI, ASI, PBQ, ACQ, and BSQ. The authors also assessed high end-state functioning (HES), including the success rate of stopping or reducing medication at post-treatment and 6-month follow-up. In all ratings, both ExCT and PCP groups showed significant improvement post-treatment compared with pre-treatment scores. There were no significant differences between the two treatment groups in HES and medication discontinuation at post-treatment, but there was a significant difference in medication discontinuation at 6-month follow-up. These results suggested that although short-term effectiveness of ExCT might be comparable to the effectiveness of PCP, long-term effectiveness of ExCT might be relatively inferior to the effectiveness of PCP.

Nicotine craving and cue exposure therapy by using virtual environments

Smokers who are exposed to cues associated with smoking show cardiovascular reactivity and an increase in smoking urges as compared to when they are presented with neutral cues. Cue exposure therapy (CET), which refers to the repeated exposure to drug-related cues in order to extinguish this learned association, has increasingly been proposed as a potential treatment of addictive behaviors, including tobacco smoking. The result of our pilot study suggests that a cue elicited using a virtual environment (VE) is more effective than other cue exposure devices. The VE was composed of craving environments (virtual bar) and objects (an alcoholic drink, a packet of cigarettes, a lighter, an ashtray, a glass of beer, and advertising posters) that are likely to trigger craving, a smoking avatar, and an audio environment that included the noisy sound and music of a restaurant. Sixteen late-adolescent males who smoked at least 10 cigarettes a day were recruited to participate in the VE-CET study. The CET virtual bar program consisted of six sessions, and the participants were exposed repeatedly to each session using different questions and procedures. Although the effects of CET did not yield significant reductions in all of the dependent variables, the craving for cigarettes was gradually decreased during the course of the sessions. This tendency was closely related to the reduction in the smoking count between the morning before the experiment and the start of the experiment. Based on these preliminary results, it appears that VE-CET maybe a useful tool to use in treatment programs to help reduce craving in those who are nicotine dependent.