The Bus PANIC DISORDER & AGORAPHOBIA Treatment ä 2 SESSIONS ä EDUCATIONAL COMPONENT ä COGNITIVE REESTRUCTURING ä SLOW BREATHING ä 6 VR GRADED EXPOSURE.

“The Bus”

VR Research

STRESS-RELATED DISORDERSPOSTTRAUMATIC STRESS DISORDER

EMMA PROJECT

Controlled Studies: PTSDControlled Studies: PTSDAuthorAuthor YearYear # of Pts# of Pts EquipmentEquipment ResultsResults

RothbaumRothbaum 20012001 1616 V6 Head-Mounted DisplayV6 Head-Mounted Display CAPS scores at 6 month CAPS scores at 6 month follow-up showed reduction follow-up showed reduction in PTSD symptomsin PTSD symptoms

TarnanasTarnanas 20012001 5050 VPL Eye Phone 1, MR VPL Eye Phone 1, MR toolkit, vibrations platetoolkit, vibrations plate

Less negative thoughts Less negative thoughts toward earthquake scenariostoward earthquake scenarios

DifedeDifede 20022002 11 Head Mounted DisplayHead Mounted Display 90% reduction in PTSD 90% reduction in PTSD symptoms after VR symptoms after VR exposure therapy exposure therapy

Univ. Of Univ. Of BuffaloBuffalo

20032003 44 UB SimulatorUB Simulator Preliminary results are Preliminary results are promisingpromising

WiederholdWiederhold 20032003 88 EEG, PC computerEEG, PC computer VR environment increased VR environment increased performance on taskperformance on task

LivanouLivanou 20032003 1010 Earthquake simulator, shake Earthquake simulator, shake table (9 levels of intensity)table (9 levels of intensity)

Significant improvement (8 Significant improvement (8 patients improved, 2 patients improved, 2 slightly improved) slightly improved)

WalsheWalshe 20032003 1414 3D Head Mounted Display3D Head Mounted Display Significant post-treatment Significant post-treatment reductions on all measuresreductions on all measures

EMMA’s room include several elements to treat stress related disorders: EMMA’s room include several elements to treat stress related disorders:

A A database screendatabase screen, where a listing of icons shows all the elements that a , where a listing of icons shows all the elements that a user can manipulate, including three-dimensional objects, sound, images, user can manipulate, including three-dimensional objects, sound, images, colored lights, movies and texts; colored lights, movies and texts;

The The book of lifebook of life, where the user can move and modify any element from the , where the user can move and modify any element from the database. This book has an index and several chapters defined by the user, database. This book has an index and several chapters defined by the user, and in each chapter he/she can describe any idea or story. It is represented and in each chapter he/she can describe any idea or story. It is represented by a virtual book; the object holders spread all around the environment give by a virtual book; the object holders spread all around the environment give life to any element by showing its representation (a three-dimensional life to any element by showing its representation (a three-dimensional object, a sound, or a light illuminating the environment); object, a sound, or a light illuminating the environment);

A A virtual keyboardvirtual keyboard that allows the user to label elements or chapters in the that allows the user to label elements or chapters in the book of lifebook of life

The The processorprocessor,, element of the environment where the user can “physically” transform the experiences

STRESS-RELATED DISORDERS

STRESS-RELATED DISORDERS

EMMA’s room also has available different scenarios or EMMA’s room also has available different scenarios or ‘landscapes’. The aim is to reflect and enhance the emotion ‘landscapes’. The aim is to reflect and enhance the emotion that the user is experiencing or to induce certain emotions. that the user is experiencing or to induce certain emotions. It is possible to include modifications in the scenario and to It is possible to include modifications in the scenario and to graduate the intensity of these modifications in order to graduate the intensity of these modifications in order to reflect the changes in the participants’ mood states. reflect the changes in the participants’ mood states.

Besides the specific variations for each emotional scenario Besides the specific variations for each emotional scenario it is possible to modify the environment according to the it is possible to modify the environment according to the time. That means that we can establish day or night in each time. That means that we can establish day or night in each scenario with the aim of reflecting or enhancing the scenario with the aim of reflecting or enhancing the participant’s mood state.participant’s mood state.

STRESS-RELATED DISORDERS

In summary, the different three-dimensional objects, the sounds, the colors, the In summary, the different three-dimensional objects, the sounds, the colors, the lights, the images, the symbols... all of them are designed to help the person to lights, the images, the symbols... all of them are designed to help the person to confront, accept and manage the emotions and experiences that he/she has gone confront, accept and manage the emotions and experiences that he/she has gone through previously in his/her life and is going to experience in the therapy through previously in his/her life and is going to experience in the therapy environment. environment.

The book of life, and the different landscape variations in EMMA’ room could be The book of life, and the different landscape variations in EMMA’ room could be useful in helping the person, not only with the important self-confrontation and useful in helping the person, not only with the important self-confrontation and cognitive reappraisal tasks, but also, and essentially, with the “experiential cognitive reappraisal tasks, but also, and essentially, with the “experiential reorganization” aspects.reorganization” aspects.

Other Applications

• EMMA’S ROOM: Flexibility– We have used EMMA for the treatment of fear of

storms in a case study. – A 70-year-old woman with a severe storm

phobia.– Two intensive exposure sessions with EMMA (3

hours each)– Good results: Clinically significant reduction in

fear and avoidance, and in impairment and distress.

EMMA’S ROOM

Study• To test the efficacy of EMMA’s room in the

treatment of stress-related disorders (PTSD, adjustment disorder).

• Between-subject design– Traditional CBT treatment.– CBT treatment delivered with EMMA’s room.

STRESS-RELATED DISORDERS

Participants

STRESS-RELATED DISORDERS

Clinicalcondition

Sex Age

Total sample 11 clinical7 subclinicalN = 18

7 male11 female

Range: 18 to 46Mean: 31.61SD: 9.02

Traditionalcondition

5 clinical4 subclinical

4 male5 female

Range: 18 to 40Mean: 28.22SD: 8.45

EMMAcondition

6 clinical3 subclinical

3 male6 female

Range: 21 to 46Mean: 35SD: 9.58

Measures• CAPS (Blake et al., 1990, 1995). • Fear/emotional distress and avoidance scales (Adapted from Mark & Mathews,

1979). • Visual-Analog Scales (VAS): Catastrophic thoughts; Emotional processing

measures; Emotional intensity.• Positive and Negative Affect Scales (PANAS) (Watson, Clark & Tellegen, 1988). • Beck Depression Inventory (BDI) (Beck, Ward, Mendelson, Mock & Erbaugh, 1961). • Impairment/Severity rated by the therapist (Adapted from Di Nardo, Brown &

Barlow, 1994).• Measures regarding expectations and satisfaction about the treatment (Adapted

from Borkovec & Nau, 1972).• The ITC-Sense of Presence Inventory (ITC-SOPI) (Lessiter, Freeman, Keogh, &

Davidoff, 2001).

STRESS-RELATED DISORDERS

Treatments

• PTSD: Adaptation of Foa & Rothbaum (1998) Prolonged Exposure program.

• Adjustment disorder (pathological bereavement): Adaptation of Neimeyer (2002) program for pathological bereavement.

STRESS-RELATED DISORDERS

ResultsTRADITIONAL EMMA

Pre-treatment

Post-treatment Pre-treatment

Post-treatment

Beck Depression Inventory (BDI) 15,25 (12,418)

7,88 (8,132)

20,75 (9,825)

10,13 (7,699)

Positive and negative Affect Scale (PANAS): Positive Affect

23,14(5,367)

28,14(5,305)

19,89 (7,288)

24 (7,746)

Positive and negative Affect Scale (PANAS): Negative Affect

23,71 (9,250)

18,29 (5,469)

32,11 (9,413)

23,78 (8,258)

Degree of Interference in the daily life t

4,78 (0,972)

2,22 (2,167)

5,22 (1,641)

2,33 (1,5)

Degree of Severity of the problem 4,44 (1,333)

2,22 (2,819)

4,67 (2,121)

1,89 (1,616)

Target behaviour: degree of Avoidance 9,00 (1,658)

2,11 (3,551)

8,38 (2,774)

2,00 (2,976)

Target behaviour: degree of Fear 7,44 (2,068)

2,22 (3,073)

8 (3,082)

2,33 (2,872)

Target thought: degree of Avoidance 8,67 (1,966)

2,50 (3,209)

9,17 (2,041)

3,17 (3,251)

Target thought: degree of Fear 8,33 (2.338)

2,67 (3,077)

9,57 (0,787)

3 (2,708)

Target thought: degree of Belief 9,00 (1,773)

4,25 (2,964)

8,87 (1,727)

4,13 (3,271)

Emotional Intensity 9,33 (0,816)

2,83 (2,714)

9,50 (0,837)

3,33 (3,882)

Results

TRADITIONAL EMMA

Pre-test Post-test Pre-test Post-test

Emotionally disturbed 5,33 (1,75)

3,83 (2,85)

7,50 (3,30)

4,25 (2,49)

Prepared to accept the experience 6,67 (2,71)

8,17 (2,63)

6,29 (3,04)

8,71 (1,11)

Processing the traumatic event 5,17(2,71)

7,50 (3,39)

4,86 (2,67)

8,29 (0,75)

Openness to new experiences 7,5(2,58)

8,17 (2,29)

4,86 (3,48)

8,34 (1,57)

Results

0123456789

Pre-treatment Post-treatment

TraditionalCondition

EMMACondition

Openess to New ExperiencesOpeness to New Experiences

Results

Satisfaction with TreatmentSatisfaction with Treatment

Traditional EMMA

Before After Before After

Treatment seems logical 8,33 (1,118)

8,11 (0,928) 7,89 (0,601) 8,33 (1,00)

Treatment seems satisfactory 7,44 (2,007)

8,44 (1,333) 7,44 (2,128) 8,44 (1,130)

Participant would recommend the treatment to a friend

8,22 (1,481)

8,56 (1,333) 7,89 (1,269) 9,00 (1,118)

Treatment seems to be useful for the problem 8,56 (1,014)

8,33 (1,225) 7,33 (2,550) 8,33 (1,323)

Treatment seems to be useful for other psychological problems

7,56 (2,963)

8,00 (1,323) 7,22 (2,048) 8,44 (1,333)

Treatment seems aversive 4,33 (3,428)

4,33 (2,915) 5,11 (2,667) 2,22 (2,587)

Results

Treatment AversivenessTreatment Aversiveness

0

1

2

3

4

5

6

Pre-treatment Post-treatment

TraditionalCondition

EMMA condition

Results

PresencePresence

0

0,5

1

1,5

2

2,5

3

3,5

First Session Last Session

Spatial Presence

Engagement

Ecological Validity

Negative effects

Discussion

• EMMA’S room program equally effective than standard of care for stress-related disorders.

• Satisfaction: Both treatment programs not only met the expectations of participants, but the satisfaction went beyond the expectations.

• The group in the EMMA’s room condition rated the treatment as less aversive than the group in the traditional condition.

STRESS-RELATED DISORDERS

Discussion

• In both conditions participants reported being less perturbed, they accepted better the stressful event, and they are more open to new experiences in life. We would like to highlight that there is a tendency (p = .07) in the EMMA condition for the variable openness to new experiences in life. In this variable the participants in EMMA’s room condition showed a higher openness to new life experiences.

STRESS-RELATED DISORDERS

Discussion

• PRESENCE – Participants felt present in the experience: Spatial

presence, Engagement and Ecological validity factors. of the ITC SOPI questionnaire in the first session where participants interacted with EMMA’s room.

– The power of the virtual environment did not decrease along the treatment, given that the scores in that first session were similar to the ones in the last session.

– There was a decrement in negative side effects as the treatment went on.

STRESS-RELATED DISORDERS

Conclusions

• EMMA’s room could be as efficacious and effective as the standard of care for stress related disorders.

• EMMA treatment program was rated by the participants as less aversive than the traditional procedures.

• These are promising preliminary findings that opens an important line of research in order to delimitate which aspects produced a higher acceptance of the treatment.

STRESS-RELATED DISORDERS

Conclusions• Different approach for the treatment of PTSD: Our aim is to design

clinically significant environments for each participant, but attending to the meaning of the trauma for the individual and not to the simulation of the physical characteristics of the traumatic event with high realism. The aim is not realism, but using customized symbols and aspects that provoke and evoke an emotional reaction in the participant that help to achieve the emotional processing of the trauma, and at the same time, creating a safe and protective environment.

• Advantage: Flexibility. On one hand, it permits to individualize and personalize the environments fitting the needs and preferences of the users; on the other, these can be used for different type of traumas in the PTSD field.

STRESS-RELATED DISORDERS

Conclusions

• We have tried to structure “creative engineering” of exposure such as is recommended by Black Becker and Anderson (2004) with the aim of improving the acceptance of CBT treatment programs for PTSD.

STRESS-RELATED DISORDERS

Other Applications

• EMMA’S ROOM: Flexibility– We have used EMMA for the treatment of fear of

storms in a case study. – A 70-year-old woman with a severe storm

phobia.– Two intensive exposure sessions with EMMA (3

hours each)– Good results: Clinically significant reduction in

fear and avoidance, and in impairment and distress.

EMMA’S ROOM