The virtues of virtual reality in exposure therapy.

Virtual reality can be more effective and less burdensome than real-life exposure. Optimal virtual reality delivery should incorporate in situ direct dialogues with a therapist, discourage safety behaviours, allow for a mismatch between virtual and real exposure tasks, and encourage self-directed real-life practice between and beyond virtual reality sessions.

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.

The Impact of User Engagement With Exposure Components on Posttraumatic Stress Symptoms in an mHealth Mobile App: Secondary Analysis of a Randomized Controlled Trial.

Background: Mobile mental health apps are a cost-effective option for managing mental health problems, such as posttraumatic stress disorder (PTSD). The efficacy of mobile health (mHealth) apps depends on engagement with the app, but few studies have examined how users engage with different features of mHealth apps for PTSD. Objective: This study aims to examine the relationship between app engagement indices and PTSD symptom reduction using data from an unblinded pilot randomized controlled trial of "Renew" (Vertical Design), an exposure-based app for PTSD with and without coaching support. Because exposure is an effective approach for treating PTSD, we expected that engagement with exposure activities would be positively related to symptom reduction, over and above overall app usage. Methods: Participants were veterans (N=69) with clinically significant PTSD symptoms who were recruited online using Facebook advertisements and invited to use the Renew app as often as they wanted over a 6-week period. Participants completed screening and assessments online but provided informed consent, toured the app, and completed feedback interviews via telephone. We assessed users' self-reported PTSD symptoms before and after a 6-week intervention period and collected app usage data using a research-instrumented dashboard. To examine overall app engagement, we used data on the total time spent in the app, the number of log-in days, and the number of points that the user gained in the app. To examine engagement with exposure components, we used data on total time spent completing exposure activities (both in vivo and imaginal), the number of in vivo exposure activities completed, and the number of characters written in response to imaginal exposure prompts. We used hierarchical regression analyses to test the effect of engagement indices on change in PTSD symptoms. Results: Usage varied widely. Participants spent an average of 166.09 (SD 156.52) minutes using Renew, over an average of 14.7 (SD 10.71) mean log-in days. Engagement with the exposure components of the app was positively associated with PTSD symptom reduction (F6,62=2.31; P=.04). Moreover, this relationship remained significant when controlling for overall engagement with the app (ΔF3,62=4.42; P=.007). The number of characters written during imaginal exposure (ß=.37; P=.009) and the amount of time spent completing exposure activities (ß=.36; P=.03) were significant contributors to the model. Conclusions: To our knowledge, this is the first study to show a relationship between symptom improvement and engagement with the active therapeutic components of an mHealth app (ie, exposure) for PTSD. This relationship held when controlling for overall app use, which suggests that it was engagement with exposure, specifically, that was associated with symptom change. Future work to identify ways of promoting greater engagement with self-guided exposure may help improve the effectiveness of mHealth apps for PTSD.

Heart rate variability profiles and exposure therapy treatment outcome in flight phobia.

The goal of this study was to explore why certain patients in a previous study on exposure therapy for flight phobia did not experience an improvement in their conditions. Participants from a treatment study (N = 45) were selected according to post-treatment results and divided into two groups: the unsatisfactory treatment outcome group (UTO, N = 10) and the satisfactory treatment outcome group (STO, N = 10). The differences between these two groups prior to receiving exposure therapy were analyzed at the behavioral, physiological, and cognitive levels. The UTO participants had been avoiding flying longer than the STO phobics. Following Thayer and Lane's neurovisceral model of emotion regulation, heart rate variability was analyzed at two levels: tonic and phasic. Low frequency and high frequency (HF) power were calculated in the frequency domain and Sample Entropy was computed in the time domain. The tonic HF power of the UTO group was higher than the STO group's tonic HF power. In the phasic level, while the STO group's HF power decreased under exposure and subsequently returned to baseline level, the UTO group demonstrated a more rigid pattern. Finally, the STO group reported higher emotional involvement than the UTO group when they were shown a sample of the therapy. Based on these results, the challenge of matching exposure therapy to each patient's profile is discussed.

The use of online resources in the treatment of three cases of simple phobia.

Numerous creative methods have been developed to incorporate computer technology into cognitive behavior therapy for anxiety disorders. In contrast, little has been written about the role that computer technology might play in therapy with hypnosis. This article is an exploration of some basic ways that clinicians can use images from computer search engines and YouTube to enhance exposure therapy for phobias. These adaptations may be particularly useful for the subgroup of patients who have difficulty re-creating and experiencing vivid and compelling aversive imagery in hypnosis, and consequently are reluctant to pursue in vivo exposure. Three cases are presented that illustrate ways in which computer images of fear inducing stimuli can be used with traditional permissive hypnosis to amplify exposure therapy.

Automatic mechanisms for measuring subjective unit of discomfort.

Current practice in Virtual Reality Exposure Therapy (VRET) is that therapists ask patients about their anxiety level by means of the Subjective Unit of Discomfort (SUD) scale. With an aim of developing a home-based VRET system, this measurement ideally should be done using speech technology. In a VRET system for social phobia with scripted avatar-patient dialogues, the timing of asking patients to give their SUD score becomes relevant. This study examined three timing mechanisms: (1) dialogue dependent (i.e. naturally in the flow of the dialogue); (2) speech dependent (i.e. when both patient and avatar are silent); and (3) context independent (i.e. randomly). Results of an experiment with non-patients (n = 24) showed a significant effect for the timing mechanisms on the perceived dialogue flow, user preference, reported presence and user dialog replies. Overall, dialogue dependent timing mechanism seems superior followed by the speech dependent and context independent timing mechanism.

Technology complementing military behavioral health efforts at tripler army medical center.

The purpose of this article is to provide a short narrative on the ways that behavioral health professionals and their patients are currently benefitting from the use of technology. Examples stem from applications of technology to patients/research participants at the Tripler Army Medical Center. The paper also discusses how current use of this technology has made it possible to serve individuals in their own cultural environment, providing a cost-effective means of providing mental health services.

A Mobile Phone App Featuring Cue Exposure Therapy As Aftercare for Alcohol Use Disorders: An Investigator-Blinded Randomized Controlled Trial.

BACKGROUND: Cue exposure therapy (CET) is a psychological approach developed to prepare individuals with alcohol use disorder (AUD) for confronting alcohol and associated stimuli in real life. CET has shown promise when treating AUD in group sessions, but it is unknown whether progressing from group sessions to using a mobile phone app is an effective delivery pathway. OBJECTIVE: The objectives of this study were to investigate (1) whether CET as aftercare would increase the effectiveness of primary treatment with cognitive behavior therapy, and (2) whether CET delivered through a mobile phone app would be similarly effective to CET via group sessions. METHODS: A total of 164 individuals with AUD were randomized to one of three groups: CET as group aftercare (CET group), CET as fully automated mobile phone app aftercare (CET app), or aftercare as usual. Study outcomes were assessed face-to-face at preaftercare, postaftercare, and again at 6 months after aftercare treatment. Generalized mixed models were used to compare the trajectories of the groups over time on drinking, cravings, and use of urge-specific coping skills (USCS). RESULTS: In all, 153 of 164 individuals (93%) completed assessments both at posttreatment and 6-month follow-up assessments. No differences in the trajectories of predicted means were found between the experimental groups (CET group and app) compared with aftercare as usual on drinking and craving outcomes over time. Both CET group (predicted mean difference 5.99, SE 2.59, z=2.31, P=.02) and the CET app (predicted mean difference 4.90, SE 2.26, z=2.31, P=.02) showed increased use of USCS compared to aftercare as usual at posttreatment, but this effect was reduced at the 6-month follow-up. No differences were detected between the two experimental CET groups on any outcomes. CONCLUSIONS: CET with USCS delivered as aftercare either via group sessions or a mobile phone app did not increase the effectiveness of primary treatment. This suggests that CET with USCS may not be an effective psychological approach for the aftercare of individuals treated for AUD. TRIAL REGISTRATION: ClinicalTrials.gov NCT02298751; https://clinicaltrials.gov/ct2/show/NCT02298751.

The Effect of Augmented Reality and Virtual Reality on Inducing Anxiety for Exposure Therapy: A Comparison Using Heart Rate Variability.

Claustrophobia is an anxiety disorder characterized by the fear of enclosed spaces. Although medication treatment can effectively control symptoms, the effects quickly disappear once medication is discontinued. Many studies have shown that combining psychotherapy and medication is more efficacious than solely using medication. However, the weaknesses of the traditional psychotherapy are that it is time-consuming and expensive. Alternatively, vivo exposure therapy is proposed in which anxiety is gradually triggered with stimuli. Targeting claustrophobia is diagnosed using the traditional method, and this study established virtual reality (VR) and augmented reality (AR) environments consistent with claustrophobic characteristics, comparing the two using an experimental process to examine whether VR and AR environments are equally capable of triggering anxiety in participants. This study further analysed the efficacies of VR and AR by measuring changes in participant's heart rates variability (HRV) and examining data from survey questionnaires. HRV results indicated that the proposed VR system and AR system were both able to trigger anxiety. Furthermore, the AR environment produced a stronger experience for the participants and caused physiological reactions more evident than those caused by the VR environment. Regarding the anxiety questionnaire, the participants suggested that their anxiety was significantly higher in the VR environment than in the AR environment.

Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia.

OBJECTIVE: The authors' goal was to examine the efficacy of computer-generated (virtual reality) graded exposure in the treatment of acrophobia (fear of heights). METHOD: Twenty college students with acrophobia were randomly assigned to virtual reality graded exposure treatment (N = 12) or to a waiting-list comparison group (N = 8). Seventeen students completed the study. Sessions were conducted individually over 8 weeks. Outcome was assessed by using measures of anxiety, avoidance, attitudes, and distress associated with exposure to heights before and after treatment. RESULTS: Significant differences between the students who completed the virtual reality treatment (N = 10) and those on the waiting list (N = 7) were found on all measures. The treatment group was significantly improved after 8 weeks, but the comparison group was unchanged. CONCLUSIONS: The authors conclude that treatment with virtual reality graded exposure was successful in reducing fear of heights.

A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder.

Abstract Virtual reality (VR)-based therapy has emerged as a potentially useful means to treat post-traumatic stress disorder (PTSD), but randomized studies have been lacking for Service Members from Iraq or Afghanistan. This study documents a small, randomized, controlled trial of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) for PTSD in Active Duty military personnel with combat-related PTSD. Success was gauged according to whether treatment resulted in a 30 percent or greater improvement in the PTSD symptom severity as assessed by the Clinician Administered PTSD Scale (CAPS) after 10 weeks of treatment. Seven of 10 participants improved by 30 percent or greater while in VR-GET, whereas only 1 of the 9 returning participants in TAU showed similar improvement. This is a clinically and statistically significant result (χ(2) = 6.74, p < 0.01, relative risk 3.2). Participants in VR-GET improved an average of 35 points on the CAPS, whereas those in TAU averaged a 9-point improvement (p < 0.05). The results are limited by small size, lack of blinding, a single therapist, and comparison to a relatively uncontrolled usual care condition, but did show VR-GET to be a safe and effective treatment for combat-related PTSD.

Virtual reality exposure therapy using a virtual Iraq: case report.

Posttraumatic stress disorder (PTSD) has been estimated to affect up to 18% of returning Operation Iraqi Freedom (OIF) veterans. Soldiers need to maintain constant vigilance to deal with unpredictable threats, and an unprecedented number of soldiers are surviving serious wounds. These risk factors are significant for development of PTSD; therefore, early and efficient intervention options must be identified and presented in a form acceptable to military personnel. This case report presents the results of treatment utilizing virtual reality exposure (VRE) therapy (virtual Iraq) to treat an OIF veteran with PTSD. Following brief VRE treatment, the veteran demonstrated improvement in PTSD symptoms as indicated by clinically and statistically significant changes in scores on the Clinician Administered PTSD Scale (CAPS; Blake et al., 1990) and the PTSD Symptom Scale Self-Report (PSS-SR; Foa, Riggs, Dancu, & Rothbaum, 1993). These results indicate preliminary promise for this treatment.

Transtorno de estresse pós-traumático em pacientes com sequelas de queimaduras / Post-traumatic stress disorder in burn-injured patients

Este trabalho revisa a literatura acerca do transtorno do estresse pós-traumático, acometendo pacientes vítimas de sequelas de queimaduras. São enfocadas definições, critérios para diagnóstico, epidemiologia, patofisiologia, psicopatologias pré-mórbidas em pacientes adultos queimados, aspectos psicológicos da queimadura, aspectos clínicos e tratamento.

This paper revises the literature about the posttraumatic stress disorder in the burn patients with functional, esthetics and psychological modifications. Its relates the definition, diagnostic judgements, epidemiology, pathophysiology, premorbid psychopathology in the patients with functional, esthetics and psychological modifications, psychological aspects of the burn, clinical aspects and treatment.