Action-Centered Exposure Therapy (ACET): A New Approach to the Use of Virtual Reality to the Care of People with Post-Traumatic Stress Disorder

Review of Psychophysiological and Psychotherapeutic Studies of Stress Using Virtual Reality Technologies

This review addresses the use of virtual reality technologies in the psychophysiology and psychotherapy of stress. Studies using virtual reality both to introduce subjects into a state of stress and to help reduce stress reactions are reviewed. Methods developed for treating patients suffering from stress-related disorders (in particular, PTSD and phobias) are described. In many cases, reductions in stress reactions with the help of virtual reality systems are achieved not only at the self-report (experiential) level, but also at the level of central and peripheral nervous system measures. This allows virtual reality to be regarded as a modern, inexpensive, and effective method, firstly, for introducing subjects into a state of stress with the aim of testing various hypotheses in psychophysiology and, secondly, to reduce stress reactions.

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.

Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review

Some post-traumatic stress disorder (PTSD) patients do not benefit from imaginal exposure therapy. One possible approach to reach such patients are virtual trauma interventions. Herein, a qualitative scoping review was conducted. Different types of virtual trauma exposure interventions were identified. For each type of virtual trauma exposure interventions it was examined in detail: (1) which in sensu trauma exposure approach serves as therapeutic framework, how it was transferred into virtual reality, and if it was manualized; (2) which hardware and software were used; (3) whether the influence of spatial and social presence on the efficacy of virtual trauma interventions have been measured, and (4) whether the efficacy of virtual trauma interventions for PTSD patients having imagination difficulties was evaluated. These research questions were analyzed qualitatively. Accordingly, an extensive literature search was conducted using the databases Web of Science, PsycINFO, LIVIVO, PTSDpubs, and PubMed for scientific articles published between January 2013 and July 2020. Only studies aimed to reduce PTSD symptoms using virtual trauma interventions were included. The literature search was not limited to a specific study design, treatment/intervention method, or a minimum sample size. Eighteen studies were identified, which reported three different virtual trauma intervention approaches, namely, virtual reality exposure therapy (VRET), multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), and action-centered exposure therapy (ACET). Seven randomized controlled trials (RCTs), two pilot studies, and one case study were focused on VRET; while two RCTs, one pilot study, and three case studies focused on 3MDR, and two case studies on ACET. Regarding the first research question (1), the results show that VRET is based on prolonged exposure, aiming for a virtual re-creation of the patient's traumatic recounting. Several treatment protocols exist for VRET. 3MDR is based on eye movement desensitization and reprocessing, aiming to reduce the patient's avoidance behavior. In 3MDR patients walk toward individualized trauma-related symbolic images in a cave automatic virtual environment (CAVE). One treatment protocol exists for 3MDR. ACET is based on the inhibitory learning theory, aiming for active interactions with a virtual trauma-associated environment to alter the anxiety structure through new secondary inhibitory learning. One treatment protocol exists for ACET. For the second research question (2), the results indicate that all VRET studies used head-mounted displays (HMDs) with a virtual version of the Iraq/Afghanistan or the World Trade Center attacks, while 3MDR studies utilized two different versions of a CAVE with personalized trauma-related images, and the ACET studies used HMDs with virtual street scenarios. For the third research question (3), the results demonstrate that the influence of spatial or social presence on the efficacy of virtual trauma interventions was not examined in any of the included studies. Similarly, for the fourth research question (4), the results show that empirical evidence for the efficacy of virtual trauma interventions on PTSD patients having imagination difficulties was lacking. Therefore, such empirical studies are needed to fill these research gaps.

Toward Emotionally Adaptive Virtual Reality for Mental Health Applications

Here, we introduce the design and preliminary validation of a general-purpose architecture for affective-driven procedural content generation in virtual reality (VR) applications in mental health and wellbeing. The architecture supports seven commercial physiological sensing technologies and can be deployed in immersive and non-immersive VR systems. To demonstrate the concept, we developed the "The Emotional Labyrinth," a non-linear scenario in which navigation in a procedurally generated three-dimensional maze is entirely decided by the user, and whose features are dynamically adapted according to a set of emotional states. During navigation, affective states are dynamically represented through pictures, music, and animated visual metaphors chosen to represent and induce affective states. The underlying hypothesis is that exposing users to multimodal representations of their affective states can create a feedback loop that supports emotional self-awareness and fosters more effective emotional regulation strategies. We carried out a first study to, first, assess the effectiveness of the selected metaphors in inducing target emotions, and second, identify relevant psycho-physiological markers of the emotional experience generated by the labyrinth. Results show that the Emotional Labyrinth is overall a pleasant experience in which the proposed procedural content generation can induce distinctive psycho-physiological patterns, generally coherent with the meaning of the metaphors used in the labyrinth design. Furthermore, collected psycho-physiological responses such as electrocardiography, respiration, electrodermal activity, and electromyography are used to generate computational models of users' reported experience. These models enable the future implementation of the closed loop mechanism to adapt the Labyrinth procedurally to the users' affective state.