Engaging in Awkward Social Interactions in a Virtual Environment Designed for Exposure-Based Psychotherapy for People with Generalized Social Anxiety Disorder: An International Multisite Study

The effectiveness of in virtuo exposure-based treatment of performance-only social anxiety disorder (SAD) has been demonstrated in several studies. However, few studies have validated virtual environments with participants suffering from generalized SAD. The goal of this study is to confirm the potential of a virtual environment in inducing anxiety in adults suffering from generalized SAD, compared to adults without SAD, when engaged in awkward social interactions. Differences between participants from two different countries were also explored. The sample consisted of 15 participants with SAD from Canada, 17 participants without SAD from Canada, 16 participants with SAD from Spain, and 21 participants without SAD from Spain. All participants were immersed in a control virtual environment and in an experimental virtual environment considered potentially anxiety-inducing for individuals with generalized SAD. As hypothesized, results showed that the experimental virtual environment induced a higher level of anxiety than the control environment among participants with SAD compared to those without SAD. The impact on anxiety of each socially threatening task performed during the experimental immersion was statistically significant. In terms of anxiety responses, no significant differences were found between participants from Canada and Spain. However, spatial presence and ecological validity were higher in Canadians than in Spaniards. Unwanted negative side effects induced by immersions in virtual reality were higher in the SAD group. This study highlights the importance for therapists to engage people with SAD in clinically relevant tasks while immersed in VR psychotherapeutic applications.

The moderating and mediating role of telepresence and cognitive change in cognitive behaviour therapy delivered via videoconference

In this study, we combined the results of two controlled trials and examined the relationships between working alliance, telepresence, cognitive change and treatment outcome. Sixty-five participants with a primary diagnosis of generalized anxiety disorder (GAD) or panic disorder with agoraphobia (PDA) received cognitive behaviour therapy delivered via videoconference. Participants completed measures of working alliance and telepresence after three psychotherapy sessions. They also completed measures of treatment outcome and dysfunctional beliefs (cognitive change) specific to PDA and GAD at pretreatment and posttreatment. Results revealed that telepresence at the fifth session moderated the relationship between the working alliance at the first and fifth sessions. As telepresence increased, its impact on the working alliance diminished. Cognitive change mediated the relationship between the working alliance at the fifth session and treatment outcome.

Arguing in Favor of Revising the Simulator Sickness Questionnaire Factor Structure When Assessing Side Effects Induced by Immersions in Virtual Reality

Two issues are increasingly of interest in the scientific literature regarding unwanted virtual reality (VR) induced side effects: (1) whether the latent structure of the Simulator Sickness Questionnaire (SSQ) is comprised of two or three factors, and (2) if the SSQ measures symptoms of anxiety that can be misattributed to unwanted negative side effects induced by immersions in VR. Study 1 was conducted with a sample of 876 participants. A confirmatory factor analysis clearly supported a two-factor model composed of nausea and oculomotor symptoms instead of the 3-factor structure observed in simulators. To tease-out symptoms of anxiety from unwanted negative side effects induced by immersions in VR, Study 2 was conducted with 88 participants who were administered the Trier Stress Social Test in groups without being immersed in VR. A Spearman correlation showed that 11 out of 16 side effects correlated significantly with anxiety. A factor analysis revealed that items measuring general discomfort, difficulty concentrating, sweating, nausea, and vertigo loaded significantly on the anxiety factor comprised of items from the State-Trait Anxiety Inventory. Finally, a multiple regression indicated that the items measuring general discomfort and difficulty concentrating significantly predicted increases in anxiety. The overall results support the notion that side effects associated with immersions in VR consist mostly of a nausea and an oculomotor latent structure and that a few items are confounding anxiety and cybersickness. The data support the suggestion to revise the scoring procedures of the Simulator Sickness Questionnaire when using this instrument with immersions in VR.

Videoconferencing Psychotherapy for Panic Disorder and Agoraphobia: Outcome and Treatment Processes From a Non-randomized Non-inferiority Trial

BACKGROUND

In the context of the COVID-19 pandemic, legislations are being modified around the world to allow patients to receive mental health services through telehealth. Unfortunately, there are no large clinical trial available to reliably document the efficacy of delivering videoconferencing psychotherapy (VCP) for people with panic disorder and agoraphobia (PDA) and whether basic psychotherapeutic processes are altered.

METHODS

This 2-arm intent-to-treat non-inferiority study reports on a clinical trial on VCP and documents how therapeutic working alliance and motivation toward psychotherapy are associated to treatment outcome. We hypothesized that VCP would not be inferior to standard face-to-face (FF) cognitive behavior therapy for PDA. No specific hypothesis was stated to address working alliance and treatment mechanisms. VCP was compared to a gold-standard psychotherapy treatment for PDA, which was delivered either in person or in videoconference, with a strict tolerance criterion of about 2 points on the primary outcome measure. Seventy one adult patients were recruited. Measures of working alliance were collected after the first, fifth, and last session. Motivation toward therapy at pre-treatment and working alliance after the fifth therapy session were used as predictors of treatment outcome and compared with change in dysfunctional beliefs toward bodily sensations.

RESULTS

Panic disorder, agoraphobia, fear of sensations and depressed mood all showed significant improvements and large effect-sizes from pre to post-treatment. Gains were maintained at follow-up. No significant differences were found between VCP and FF, and effect sizes were trivial for three of the four outcome measures. Non-inferiority tests confirmed that VCP was no less effective than FF therapy on the primary outcome measure and two of the three secondary outcome measures. Working alliance was very strong in VCP and did not statistically differ from FF. Working alliance and motivation did not predict treatment outcome, which was significantly predicted by the reduction in dysfunctional beliefs. The strength of the therapeutic bond was correlated with change in dysfunctional beliefs.

CONCLUSION

Mental health professionals can use VCP to provide services to patients with PDA. Building and maintaining a sound working alliance should not be a source concern. Practical recommendations are formulated.

ISRCTN TRIAL REGISTRATION NUMBER

ISRCTN76456442.

Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: a three-arm randomised controlled trial

BackgroundPeople with social anxiety disorder (SAD) fear social interactions and may be reluctant to seek treatments involving exposure to social situations. Social exposure conducted in virtual reality (VR), embedded in individual cognitive-behavioural therapy (CBT), could be an answer.AimsTo show that conducting VR exposure in CBT for SAD is effective and is more practical for therapists than conducting exposure in vivoMethodParticipants were randomly assigned to either VR exposure (n = 17), in vivo exposure (n = 22) or waiting list (n = 20). Participants in the active arms received individual CBT for 14 weekly sessions and outcome was assessed with questionnaires and a behaviour avoidance test. (Trial registration number ISRCTN99747069)ResultsImprovements were found on the primary (Liebowitz Social Anxiety Scale) and all five secondary outcome measures in both CBT groups compared with the waiting list. Conducting exposure in VR was more effective at post-treatment than in vivo on the primary outcome measure and on one secondary measure. Improvements were maintained at the 6-month follow-up. VR was significantly more practical for therapists than in vivo exposure.ConclusionsUsing VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.

Using Virtual Reality in the Treatment of Gambling Disorder: The Development of a New Tool for Cognitive Behavior Therapy

Virtual reality (VR) can be used in the treatment of gambling disorder to provide emotionally charged contexts (e.g., induce cravings) where patients can practice cognitive behavior therapy (CBT) techniques in the safety of the therapist's office. This raises practical questions, such as whether the cravings are sufficient to be clinically useful but also manageable enough to remain clinically safe. Pilot data are also needed to test the development of a treatment manual and prepare large randomized control trials. This paper reports on three studies describing (a) cravings induced in VR compared to real gambling and a control game of skill with no money involved (N = 28 frequent gamblers and 36 infrequent gamblers); (b) the usefulness of a treatment protocol with only two CBT sessions using VR (N = 34 pathological gamblers); and (c) the safety of a four-session treatment program of CBT in VR (N = 25 pathological gamblers). Study 1 reveals that immersions in VR can elicit desire and a positive anticipation to gamble in frequent gamblers that are (a) significantly stronger than for infrequent gamblers and for playing a control game of skill and (b) as strong as for gambling on a real video lottery terminal. Study 2 documents the feasibility of integrating VR in CBT, its usefulness in identifying more high-risk situations and dysfunctional thoughts, how inducing cravings during relapse prevention exercises significantly relates to treatment outcome, and the safety of the procedure in terms of cybersickness. Results from Study 3 confirm that, compared to inducing urges to gamble in imagination, using VR does not lead to urges that are stronger, last longer, or feel more out of control. Outcome data and effect sizes are reported for both randomized control pilot trials conducted in inpatient settings. Suggestions for future research are provided, including on increasing the number of VR sessions in the treatment program.

Empathy toward virtual humans depicting a known or unknown person expressing pain

This study is about pain expressed by virtual humans and empathy in users immersed in virtual reality. It focuses on whether people feel more empathy toward the pain of a virtual human when the virtual human is a realistic representation of a known individual, as opposed to an unknown person, and if social presence is related to users' empathy toward a virtual human's pain. The 42 participants were immersed in virtual reality using a large immersive cube with images retro projected on all six faces (CAVE-Like system) where they can interact in real time with virtual characters. The first immersion (baseline/control) was with a virtual animal, followed by immersions involving discussions with a known virtual human (i.e., the avatar of a person they were familiar with) or an unknown virtual human. During the verbal exchanges in virtual reality, the virtual humans expressed acute and very strong pain. The pain reactions were identical in terms of facial expressions, and verbal and nonverbal behaviors. The Conditions by Time interactions in the repeated measures analyses of variance revealed that participants were empathic toward both virtual humans, yet more empathic toward the known virtual human. Multivariate regression analyses revealed that participants' feeling of social presence--impression that the known virtual character is really there, with them--was a significant predictor of empathy.

Using biofeedback while immersed in a stressful videogame increases the effectiveness of stress management skills in soldiers

This study assessed the efficacy of using visual and auditory biofeedback while immersed in a tridimensional videogame to practice a stress management skill (tactical breathing). All 41 participants were soldiers who had previously received basic stress management training and first aid training in combat. On the first day, they received a 15-minute refresher briefing and were randomly assigned to either: (a) no additional stress management training (SMT) for three days, or (b) 30-minute sessions (one per day for three days) of biofeedback-assisted SMT while immersed in a horror/first-person shooter game. The training was performed in a dark and enclosed environment using a 50-inch television with active stereoscopic display and loudspeakers. On the last day, all participants underwent a live simulated ambush with an improvised explosive device, where they had to provide first aid to a wounded soldier. Stress levels were measured with salivary cortisol collected when waking-up, before and after the live simulation. Stress was also measured with heart rate at baseline, during an apprehension phase, and during the live simulation. Repeated-measure ANOVAs and ANCOVAs confirmed that practicing SMT was effective in reducing stress. Results are discussed in terms of the advantages of the proposed program for military personnel and the need to practice SMT.

The development of the SWEAT questionnaire: a scale measuring costs and efforts inherent to conducting exposure sessions

For decades, empirical studies have shown the effectiveness of exposure techniques when used in cognitive-behavioral therapy (CBT) treatment for anxiety disorders. A few studies are now suggesting that using Virtual Reality (VR) may be an effective way to conduct exposure and overcome some of the limitations of in vivo exposure. The aim of this study is to validate the Specific Work for Exposure Applied in Therapy (SWEAT) questionnaire that measures costs and efforts required to conduct in vivo and in virtuo exposure. A total of 265 exposure sessions (in vivo = 140; in virtuo = 125) were rated by experienced psychologists. Reliability analysis revealed three main factors in the construct of the SWEAT questionnaire. Results also showed that conducting exposure in VR is less of a burden and more readily adapted to the patients' needs than in vivo.

Presence is just an illusion: using fMRI to locate the brain area responsible to the meaning given to places

Researchers have suggested different models to describe the feeling of presence. Most of them imply that presence is some kind of alternate state. Research conducted in our research team lead us to consider presence simply like a very powerful perceptual illusion, with the addition of challenging the meaning given to the place where the user actually is (i.e., being "there"). The aim of this study is to investigate the neural correlates of the illusion of presence in VR. Five right-handed adults were scanned in the fMRI and were immersed in two conditions: high and low presence, where the exact same stimulus was presented to participants during each condition but the context (narrative) provided differed significantly. Results show a clear, specific and statistically significant involvement of the parahippocampal area, the brain responsible for giving contextual meaning of places.

Effectiveness of virtual reality exposure in the treatment of arachnophobia using 3D games

Buying or creating a virtual reality (VR) software is very costly. A less expensive alternative could be to modify already existing 3D computer games. The goal of this study is to assess the effectiveness of in virtuo exposure in the treatment of arachnophobia using modified 3D games. Participants were 10 women and 1 man. Virtual worlds were created using the game editor of a 3D computer game (Half-Life), modified to offer graduals hierarchies of fearful stimuli (spiders). Analyses revealed significant improvement between pre and post results on the behavioral avoidance test, the Spider Beliefs Questionnaire, and perceived self-efficacy. These promising results suggest that therapy using virtual reality exposure via a modified computer game is useful in the treatment of arachnophobia.

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

Virtual reality can be used to provide phobic clients with therapeutic exposure to phobogenic stimuli. However, purpose-built therapeutic VR hardware and software can be expensive and difficult to adapt to individual client needs. In this study, inexpensive and readily adaptable PC computer games were used to provide exposure therapy to 13 phobic participants and 13 non-phobic control participants. It was found that anxiety could be induced in phobic participants by exposing them to phobogenic stimuli in therapeutic virtual environments derived from computer games (TVEDG). Assessments were made of the impact of simulator sickness and of sense of presence on the phobogenic effectiveness of TVEDGs. Participants reported low levels of simulator sickness, and the results indicate that simulator sickness had no significant impact on either anxiety or sense of presence. Group differences, correlations, and regression analyses indicate a synergistic relationship between presence and anxiety. These results do not support Slater's contention that presence and emotion are orthogonal.

Crystallization of enzyme IIB of the cellobiose-specific phosphotransferase system of Escherichia coli

Crystals of enzyme IIB of the cellobiose-specific phosphotransferase system have been obtained from 15% polyethylene glycol 4000 using both streak-seeding and macroseeding techniques at 4 degrees. Crystals were grown with the hanging drop method of vapour diffusion. Addition of 2-propanol and benzamidine/HCl proved essential to obtain single crystals suitable for X-ray analysis. The crystals diffract to 1.8 A resolution and have the monoclinic space group P2(1), with cell dimensions a = 53.6 A, b = 31.7 A, c = 60.0 A and beta = 101.7 degrees. From a self-rotation function it seems likely that there are two molecules in the asymmetric unit related by a non-crystallographic 2-fold axis.

The electrochemical H+ gradient in the yeast Rhodotorula glutinis

The electrochemical gradient of protons, delta mu H+, was estimated in the obligatory aerobic yeast Rhodotorula glutinis in the pH0 range from 3 to 8.5. The membrane potential, delta psi, was measured by steady-state distribution of the hydrophobic ions, tetraphenylphosphonium (TPP+) for negative delta psi above pH0 4.5, and thiocyanate (SCN-) for positive delta psi below pH0 4.5. The chemical gradient of H+ was determined by measuring the chemical shift of intracellular Pi by 31P-NMR at given pH0 values. The values of pHi increased almost linearly from 7.3 at pH0 3 to 7.8 at pH0 8.5. In the physiological pH0 range from 3.5 to 6, delta mu H+ was fairly constant at values between 17-18 KJ mol-1, gradually decreasing at pH0 above 6. In deenergized cells, the intracellular pHi decreased to values as low as 6, regardless of whether the cell suspension was buffered at pH0 4.5 or 7.5. There was no membrane potential detectable in deenergized cells.

Tertiary hydrogen bonds in the solution structure of transfer RNA

The high resolution nuclear magnetic resonance (NMR) spectra of hydrogen-bonded protons in four tRNAs have been studied at 270 MHz. The relative intensity of the resonances between -11 ppm and -15 ppm of Escherichia coli tRNA1-Va1 indicate that there are 26 plus or minus 3 protons, while only 20 are expected from secondary structure Watson-Crick hydrogen bonds inthe cloverleaf structure. Several possible candidates for these extra resonances are suggested by tertiary interactions observed in recent crystallographic studies. Of the four tRNAs studied, three, e.g., E. coli tRNA1Va1, E. coli tRNA-Arg and E. coli tRNA-Phe have one "GU pair" in their cloverleaf structure, while the fourth, yeast tRNA-Asp,has three "GU pairs" and one "G pair". Correlating these with the NMR spectra in the -10 ppm to -11 ppm region allows us to conclude that the "GU pairs" are not hydrogen-bonded by tautomerization to the lactim form. At the very low field region, near -14.9 ppm, the three E. coli tRNAs show a single resonance which is attributed to the 4-thiouracil 8 to adenine 14 hydrogen bond of the tertiary structure, by analogy with the recent crystal structure of yeast tRNA-Phe. This assignment is confirmed by the disappearance of this resonance after treatment with cyanogen bromide.

13C high-resolution nuclear magnetic resonance studies of enzyme-substrate reactions at equilibrium. Substrate studies of chymotrypsin-N-acetyltyrosine semicarbazide complexes

N-Acetyl-L-tyrosine semicarbazide is hydrolyzed by chymotrypsin (EC 3.4.21.1) to N-acetyl-L-tyrosine and semicarbazide. If a high concentration of semicarbazide is present, the equilibrium for the reaction can be shifted from hydrolysis to synthesis. Using N-acetyl-L-[(13)C]tyrosine enriched at the carboxyl carbon and high concentrations of semicarbazide hydrochloride, we have studied the enzyme-substrate complex of N-acetyl-L-[(13)C]tyrosine semicarbazide and chymotrypsin A(delta) by (13)C nuclear magnetic resonance. We observe no shift within the experimental accuracy of +/-0.05 ppm as the fraction of substrate bound is changed from 0.17 to 0.70. Since E + S right arrow over left arrow ES is in fast exchange on the nuclear magnetic resonance time scale, it is possible to show that when the substrate is bound to the enzyme in the Michaelis complex, the (13)C resonance is shifted less than 0.1 ppm, indicating that negligible substrate strain occurs in this complex at the site of enzymatic attack. These experiments demonstrate the application of nuclear magnetic resonance to the study of particular states along the reaction pathway for enzyme-substrate reactions at equilibrium.