Virtual Reality Biofeedback in Health: A Scoping Review.

Over the past decades, virtual reality (VR) has found its way into biofeedback (BF) therapy programs. Using VR promises to overcome challenges encountered in traditional BF such as low treatment motivation, low attentional focus and the difficulty of transferring learnt abilities to everyday life. Yet, a comprehensive research synthesis is still missing. Hence, this scoping review aims to provide an overview over empirical studies on VR based BF regarding key outcomes, included samples, used soft- and hardware, BF parameters, mode of application and potential limitations. We systematically searched Medline, PsycINFO, Scopus, CINAHL, Google Scholar and Open Grey for empirical research. Eighteen articles met the inclusion criteria. Samples mostly consisted of healthy (44.4%) and/or adult (77.7%) participants. Outcomes were mainly anxiety (44.4%), stress (44.4%) or pain reduction (11.1%), which were reduced by the VR-BF interventions at least as much as by classical BF. Participants in VR-BF interventions showed higher motivation and involvement as well as a better user experience. Heart rate or heart rate variability were the most frequently used BF parameters (50.0%), and most VR-BF interventions (72.2%) employed a natural environment (e.g., island). Currently, there is no clear evidence that VR-BF is more effective than traditional BF. Yet, results indicate that VR-BF may have advantages regarding motivation, user experience, involvement and attentional focus. Further research is needed to assess the specific impact of VR and gamification. Also, testing a broader range of clinical and younger samples would allow more far-reaching conclusions.

The impact of problematic smartphone use on children's and adolescents' quality of life: A systematic review.

AIM: To provide a systematic review on studies examining problematic smartphone (PSU) use in children and adolescents, and its impact on quality of life, life satisfaction, and well-being. METHODS: An extensive literature search was conducted in Google Scholar, Scopus and Pubmed. RESULTS: The search yielded k = 9 articles for which inclusion criteria were met. Five studies examined health-related or overall quality of life, two assessed life satisfaction, and two evaluated well-being in relation to PSU. Negative associations between PSU and the outcome variables were reported almost consistently, with one study yielding only a trend for a negative correlation of PSU with life satisfaction, and one study finding no significant correlation regarding quality of life. Comparability between studies was impeded by the scarcity of studies which met inclusion criteria and by the use of different measures. CONCLUSION: More research is needed regarding PSU and the outcome variables in children and adolescents. Also, a distinct and consistent theoretical conceptualisation of PSU is required to replicate findings, and to enhance comparability between studies. Based on the trend reported here, the development of customised, early on interventions for children and adolescents at risk of PSU is warranted.

Mothers' and Fathers' Perspectives on the Causes of Their Child's Disorder.

BACKGROUND: Parental beliefs about the cause of their child's illness are thought to affect parents' help-seeking behaviors, treatment decisions, and the child's health outcomes. Yet, research on parental beliefs about disease causation is still scarce. While a small number of studies assesses parental cause attributions for singular disorders (e.g., neurodevelopmental disorders), no study has compared disorders with differing physical versus mental conditions or with mixed comorbidities in children and adolescents or their caregivers. Furthermore, most pediatric research suffers from a lack of data on fathers. OBJECTIVE: Hence, the objective of the current study was to test for possible differences in mothers' and fathers' perceptions about the etiology of their child's illness. METHODS: Forty-two parent couples (overall N = 84) whose child had been diagnosed either with Attention Deficit Hyperactivity-Disorder (ADHD) or Autism Spectrum Disorder (ASD) (category "neurodevelopmental disorder") or with a primary physical illness and a comorbid mental disorder, e.g. depression (category "psychosomatic disorder") were asked to rate possible causes of their child's illness using a modified version of the revised Illness Perception Questionnaire (IPQ) Cause scale. RESULTS: A two-way ANOVA showed that psychosomatic disorders were significantly more strongly attributed to be caused by medical and environmental stressors than neurodevelopmental disorders. A significant parent × illness category interaction revealed that this effect was more pronounced in fathers. CONCLUSIONS: By providing first insights into parental beliefs about the etiology of their children's neurodevelopmental versus psychosomatic disorders, this study paves ground for future research and tailored counseling of affected families.

[Multilingual children and language impairment]. / Mehrsprachiges Aufwachsen und Sprachentwicklungsstörungen. Eine Übersichtsarbeit.

Multilingual children and language impairment Abstract. For many children with a migration background, difficulties acquiring their second language skills influences their educational success. Because of the wide range of languages and their varieties, which are not described linguistically in detail, development of reliable and valid assessment procedures is hindered. This results in a diagnostic dilemma, as children who have problems learning their second language, along with many other reasons, have to be distinguished from children suffering from a specific language impairment (SLI). Children with migration background may show linguistic profiles which superficially resemble those of children with SLI. The current paper constitutes a selective review of relevant literature and offers suggestions for meeting those respective challenges. It is assumed that the prevalence for clinically relevant language disorder is the same in multilingual as in monolingual children. Also, multilingual children like monolingual children can show subtle cognitive weaknesses. The relevance of language disorder in psychiatrically ill multilingual and monolingual children is well known and has to be considered in the context of a comprehensive assessment. For those children with a migration background who face more pronounced problems acquiring their second language skills, language assessment in their mother tongue is essential.

How to Prevent Depression? Current Directions and Future Challenges in Children with Chronic Medical Conditions.

With its high rates of chronicity and concomitant economic costs to society, depression ranges among the most prevalent mental disorders. Several trials have succeeded in demonstrating the beneficial effects of early depression prevention programs for otherwise healthy children and adolescents. However, comparable programs for children and adolescents with a medical condition are still scarce. This paper discusses the situation of chronically ill children and adolescents who are at risk of developing comorbid depressive symptoms using the example of three conditions frequently encountered in pediatric psychosomatic medicine: diabetes, epilepsy and inflammatory bowel disease (IBD). Each patient group is introduced with regards to specific risk factors and correlates of depression. Also, existing customized depression prevention programs and according research trials are presented. Reviewing the body of literature, it becomes apparent that risk factor research and depression prevention are still in their infancy for these three patient groups. While new risk factor models and biomarker approaches emerge as a promising rationale for depression prevention, research is called upon to include randomized control trials as well as longitudinal designs in order to achieve more optimally tailored preventive interventions for children and adolescents with chronic medical conditions.

A Matter of Trust: Confidentiality in Therapeutic Relationships during Psychological and Medical Treatment in Children and Adolescents with Mental Disorders.

Background: Confidentiality is a crucial ethical principle in therapy, particularly for children and adolescents, yet their perception of it remains understudied. We aimed to explore minors' perspectives and attributions on confidentiality in psychological and medical treatment. Methods: We interviewed 11 pediatric patients aged 7 to 15 and used reflexive thematic analysis to analyze their responses. Results: Four main themes were extracted from the data: (1) confidentiality and uncertainty regarding what information will be shared with clinicians and parents; (2) consequences of breaching confidentiality, encompassing breaches of confidentiality in the past and their negative effects on interactions with parents and health professionals; (3) exceptions to confidentiality, including understanding the limits of confidentiality; and (4) autonomy and self-determination, reflecting the desire for involvement in medical decisions. Conclusions: Explanations about confidentiality rules and limits, especially with younger children, are crucial. This is particularly important because it is fundamental to promote children's development and self-determination through increasing autonomy, as well as to provide a sense of security and respect through transparent rules. A single educational session on confidentiality at the outset of therapy is insufficient; ongoing conversations are needed to reinforce understanding and promote autonomy.

Impact of the COVID-19 pandemic on the work of clinical psychologists in Austria: results of a mixed-methods study.

Introduction: Clinical psychologists in Austria shouldered a large part of the massive increase in demand for mental health services caused by the COVID-19 pandemic. This study aimed to find out how the pandemic affected their work and to gather information on how best to support the profession in the event of a crisis. Methods: N = 172 Austrian clinical psychologists participated in a cross-sectional online survey between 11 April 2022 and 31 May 2022, including both closed and open-ended questions about their work. Open-ended questions were analyzed using qualitative content analysis. A mixed-methods analysis was conducted to test correlations between the categories derived from the qualitative analysis and professional variables. Results: The analyses revealed that clinical psychologists, especially those with more years of experience, perceived an increased need for clinical psychological treatment, especially for children and adolescents, a lack of coverage for clinical psychological treatment by health insurance, a change to remote treatment formats, and a number of burdens associated with complying with COVID-19 measures. Discussion: Clinical psychologists reported an urgent need to increase resources in both outpatient and inpatient settings and to promote health insurance coverage. To support the clinical psychology profession in providing high-quality work in times of crisis, there is a need to facilitate more opportunities for team and peer exchange, as well as financial support in the event of loss of income.

Burdens and resources of Austrian clinical psychologists: results of a qualitative study two years into the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic increased the mental health burden in the general population, enhancing the demands placed on mental healthcare professionals. METHODS: This study aimed to assess the burdens and resources of clinical psychologists that emerged since the beginning of the pandemic. N = 172 Austrian clinical psychologists participated in a cross-sectional online survey between April and May 2022. The burdens and the sources of support that emerged during the pandemic were analyzed using qualitative content analysis. RESULTS: Mental health-related issues were identified as the greatest burden, followed by work-related themes and restrictions imposed by the government to combat the spreading of the virus. The most important resources mentioned by the clinical psychologists were social contacts and recreational activities. Practising mindfulness and focusing on inner processes and work-related aspects were further important resources mentioned. CONCLUSION: Overall, it seems that clinical psychologists have a high awareness of mental health-related problems related to the pandemic and use adaptive coping strategies to deal with them.

Comparison of mental health indicators in clinical psychologists with the general population during the COVID-19 pandemic.

Mental healthcare professionals face diverse challenges during the COVID-19 pandemic, which may augment their risk of experiencing adverse mental health outcomes themselves. We aimed to compare depressive, anxiety, insomnia, and stress symptoms in Austrian clinical psychologists during the COVID-19 pandemic with the Austrian general population. A total of N = 172 Austrian clinical psychologists (91.9% women; mean age: 44.90 ± 7.97 years) participated in an online survey in spring 2022. A representative sample (N = 1011) of the Austrian general population was surveyed simultaneously. Symptoms of depression (PHQ-2), anxiety (GAD-2), insomnia (ISI-2), and stress (PSS-10) were assessed. Differences in the prevalence of clinically relevant symptoms were analyzed using univariate (Chi-squared tests) and multivariable (binary logistic regression including covariates age and gender) analyses. Clinical psychologists showed lower adjusted odds for exceeding the cut-offs for clinically relevant depression (aOR 0.37), anxiety (aOR 0.50), and moderate to high stress levels (aOR 0.31) compared to the general population (p < 0.01). No difference was observed for insomnia (aOR 0.92; p = 0.79). In conclusion, clinical psychologists experience better mental health than the general population during the COVID-19 pandemic. Future studies are needed to analyze the underlying reasons.

Personality traits and stress coping among obstetricians diagnosing and communicating fetal death: A cross-sectional study.

OBJECTIVE: To assess obstetricians' personality traits (empathy, locus of control [LoC], situational affect) and relate these to stress coping when making the diagnosis and delivering the news of late fetal death to parents. METHODS: Cross-sectional questionnaire study. RESULTS: 341 Austrian obstetricians (72.7% females) participated in this online survey. Participants' mean age was 46.4 ± 10.8 years. The majority of participants (n = 158, 46.3%) had been previously involved in the diagnosis of fetal death and subsequent breaking news up to five times. We observed no gender-specific differences in physicians' stress coping, including situational affect, perceived stress, challenge, self-concept, or perceived control, nor in internal or external LoC, and perspective taking. Female obstetricians showed significantly higher trait empathy and reported higher levels of distress regarding fetal death than males. Obstetricians with greater experience in dealing with fetal death (>11 times) reported a higher ability to cope with stress as reflected by lower situational affect, less perceived stress, less challenge, and higher situational control. CONCLUSION: While obstetricians' stress coping in diagnosing and communicating fetal death is independent of physicians' gender, greater ability to empathize with the parents diminishes overall sense of control and affect over the situation, whereas increased level of clinical experience with fetal death supports all domains of control and stress coping.

Virtual reality biofeedback interventions for treating anxiety : A systematic review, meta-analysis and future perspective.

BACKGROUND: Virtual reality (VR)-based biofeedback is a relatively new intervention and is increasingly being used for the treatment of anxiety disorders. This is the first research synthesis regarding effects and efficacy of this novel mode of treatment. METHOD: We conducted a systematic review and meta-analysis of the VR biofeedback literature on treating anxiety symptoms. The MEDLINE/PubMed, Scopus and Web of Science databases were searched for eligible pre-post comparisons and randomized controlled trials (RCTs). We used self-reported anxiety, heart rate (HR), and heart rate variability (HRV) as primary outcome measures. RESULTS: A total of 7 studies with 191 participants reported VR biofeedback interventions. Of these studies 5 were RCTs, with 103 participants receiving VR biofeedback and 99 control participants (either 2D biofeedback or waiting list controls). We found that VR biofeedback significantly lowers self-reported anxiety (g = -0.28) and HR (g = -0.45), but not HRV. Furthermore, there were no significant differences in outcomes between VR biofeedback and 2D biofeedback but a significant reduction in HR in the VR biofeedback group compared with the waiting list (g = -0.52). CONCLUSION: While the first findings are optimistic, more controlled studies with a wider variety of samples are needed to bring this field forward. Particularly, children and adolescents may profit from the combination of gamification elements, VR, and biofeedback.

Nature videos for PTSD: protocol for a mixed-methods feasibility study.

Background: Given the prevalence of post-traumatic stress disorder (PTSD), particularly among military personnel, new treatment approaches are needed. One may be virtual relaxation interventions, especially 360-degree nature videos, since studies have demonstrated their relaxation effects for healthy participants. If these relaxation effects can be reproduced in patients with PTSD, they may offer a viable tool to reduce distress and hyperarousal. Objective: This research protocol describes a planned study that will examine the relaxation effects of 360-degree nature videos for patients with PTSD. It will also investigate whether these relaxation effects differ depending on the hardware immersion level (head-mounted display [HMD] vs. PC screen) in comparison to a control condition in which patients only listen to natural sounds and do not view a video. Finally, the effect of each intervention's dose duration (five vs. ten minutes) will be explored. Method: A counterbalanced, randomised, controlled, within-subject experiment will be conducted (sample size N = 36). Only soldiers aged 18 years or older with a primary diagnosis of PTSD will be included. Those with psychosis, substance dependence, a change in psychiatric medication within the last month, suicidal intent, and motion sickness will be excluded. All patients will experience the HMD, PC, and control conditions once for five or ten minutes. Self-reported relaxation measures will be collected before and after, and patients' skin conductance level, heart rate, and heart rate variability will be assessed during each condition. Semi-structured interviews will be conducted to examine the patients' experiences in detail. Conclusions: This feasibility study will provide initial evidence of whether viewing 360-degree nature videos via HMD or PC screen is relaxing for patients with PTSD and whether the effects are greater compared with the control condition. The study will also validate the dose duration and thereby informing a subsequent confirmatory interventional trial. Trial registration: DRKS00020277. HIGHLIGHTS: This randomised controlled feasibility study will examine whether 360-degree nature videos are a suitable relaxation intervention for military personnel with post-traumatic stress disorder.

Introducción: Dada la prevalencia del trastorno de estrés postraumático (TEPT), particularmente entre militares, se necesitan nuevos enfoques de tratamiento. Uno podría ser intervenciones de relajación virtual, especialmente videos de naturaleza de 360-grados, ya que los estudios han demostrado sus efectos de relajación para participantes sanos. Si estos efectos de relajación pueden reproducirse en pacientes con TEPT, podrían ofrecer una herramienta viable para reducir la angustia y la hiperalerta.Objetivo: Este protocolo de investigación describe un estudio planificado que examinará los efectos de relajación con videos de naturaleza de 360-grados, para pacientes con TEPT. También investigará de qué manera estos efectos de relajación difieren dependiendo del nivel de inmersión del hardware (pantalla montada en la cabeza [HMD] vs. pantalla de PC) en comparación con una condición de control en la que los pacientes solo escuchan los sonidos de la naturaleza y no ven un video. Finalmente, el efecto de la duración de la dosis de cada intervención (cinco vs diez minutos) será explorados.Método: Se llevará a cabo un experimento contrabalanceado, aleatorizado, controlado e intrasujeto (tamaño de muestra N = 36). Solo serán incluidos los soldados de 18 años o más con un diagnóstico primario de TEPT. Serán excluidos aquellos con psicosis, dependencia de sustancias, un cambio en la medicación psiquiátrica en el último mes y quienes presenten ideación suicida o cinetosis (mareo de movimiento). Todos los pacientes experimentarán las condiciones de HMD, PC y control una vez durante cinco o diez minutos. Las mediciones de relajación autoreportadas se recopilarán antes y después y el nivel de conductancia de la piel de los pacientes, la frecuencia cardíaca y la variabilidad de la frecuencia cardíaca se evaluarán durante cada condición. Se realizarán entrevistas semiestructuradas para examinar las experiencias de los pacientes en detalle.Conclusiones: Este estudio de factibilidad proporcionará evidencia inicial de si visualizar videos de naturaleza de 360-grados a través de HMD o la pantalla de la PC es relajante para los pacientes con TEPT, y si los efectos son mayores comparados con la condición de control. El estudio también validará la duración de la dosis y operacionalización de los puntos de termino, informando así un ensayo interventivo confirmatorio posterior.

Geropsychology: the gender gap in human aging--a mini-review.

Differences between women and men in terms of gender gaps at late stages of their lives are the focus of this mini-review. We approach the matter by taking up the position of complex yet promising standpoints, the bio-psycho-social perspective on the one hand and approaches of developmental psychology on the other. Lifespan perspectives and the brain-behavior relationship are integrated and applied to geropsychological models. Research on gender differences is presented and examined, particularly regarding physiological and psychological differences between aging men and women; additionally, gender discrepancies in psychopathology are discussed. Prevailing concepts of 'active aging' are introduced and their implications for the review of divergent gender differences are considered.

[Pandora's digital box: mental disorders in cyberspace]. / Die digitale Büchse der Pandora: Psychische Störungen im Cyberspace.

The emersion of the Internet did not only change human communication and information seeking, it also contributed to manifold alterations in the manifestation, perception and treatment of mental disorders. Thus, one focus of current psychological research lies on the relationship between the new medium and psychosocial functioning. This review embraces recent results on this topic following a discussion from two different perspectives: first, it poses the question, whether the Internet - due to its very specific character - is capable of creating new mental disorders and second, it asks whether rare disorders may possibly be uncovered by the Internet or if already known disorders may be sustained and intensified by the online medium. Accordingly, the first part of this review deals with the conceptual basis of problematic Internet use, Internet addiction and problematic online-gaming as an example of specific internet use. Predisposing psychosocial factors, such as social isolation, depression and compulsive behavior are reviewed as potential triggers for these new internet- related disorders. The second part however draws upon two already existing groups of psychological disorders: eating disorders in relation to Pro-Ana and Pro-Mia on the one hand and Body Integrity Identity Disorder (BIID) on the other hand. Recent research is discussed to explore the sustaining and intensifying effect of the Internet on these disorders.

Lack of research on efficacy of virtual reality exposure therapy (VRET) for anxiety disorders in children and adolescents : A systematic review.

Anxiety disorders are one of the most prevalent mental disorders in children and adolescents which may effectively be treated by several forms of exposure therapy. An emerging approach to exposure is virtual reality exposure therapy (VRET), but a literature search synthesis focusing specifically on the use of VRET in children and adolescents is still lacking. This systematic review sets out to provide an overview concerning VRET for the treatment of anxiety disorders in this age group. Four published trials covering an overall sample of 100 participants between the ages of 8 and 16 years were found during a systematic literature search and were included in the current review. Results reveal that participants show clinical improvements regarding anxiety symptoms after VRET. Nevertheless, the high potential of virtual reality as a tool for treating children and adolescents with anxiety disorders is contrasted by a considerable lack of controlled trials. Despite the evidence of VRET in adult samples, there is a need for more research with younger cohorts in order to be able to support this promising field of application.

Knowledge about and attitudes towards medical cannabis among Austrian university students.

BACKGROUND: The relevance of medical cannabis (MC) increases; and, educating those who are at the forefront of patient care is imperative. Yet, research on medical students' expertise and opinions is still scarce. OBJECTIVE: This study set out to evaluate Austrian medical students' knowledge about and attitudes towards MC and compare them with other academic disciplines. Additionally, gender was controlled for. METHODS: An online survey was conducted with N = 404 students enrolled in (1) medical studies, (2) studies with a medical background and (3) studies without a medical background. RESULTS: In contrast to non-medical students, 64 % of medical students said they learnt about MC at the university. Although students were confident about their knowledge, they struggled to differentiate between CBD and THC. Chronic pain, oncological diseases and palliative care were the most frequently cited indications, psychiatric indications, however, were mentioned less often. Medical students were more reserved in their attitudes towards increasing medical usage and legalizing cannabis than the two other groups. Also, they were more skeptical about whether physicians should be allowed to prescribe MC and whether they should be obliged to offer it. Males showed more confidence regarding cannabis knowledge and were more favorable of legalizing and prescribing cannabis; females perceived cannabis as more physically addictive and as a gate-way drug. CONCLUSIONS: Considering that beliefs and attitudes shape behavior, it is expected that future health care professionals will struggle with recommending cannabis for medical treatment. A coordinated approach for medical training is needed to ensure high standard medical care.

Facilitators and Strategies for Breaking the News of an Intrauterine Death-A Mixed Methods Study among Obstetricians.

(1) Background: The death of a baby in utero is a very sad event for both the affected parents and the caring doctors. By this study, we aimed to assess the tools, which may help obstetricians to overcome this challenge in their profession. (2) Methods: We conducted a cross-sectional online survey in 1526 obstetricians registered with the Austrian Society of Obstetrics and Gynecology between September and October 2020. (3) Results: With a response rate of 24.2% (n = 439), our study shows that diagnosing fetal death was associated with a moderate to high degree of stress, regardless of position (p = 0.949), age (p = 0.110), gender (p = 0.155), and experience (p = 0.150) of physicians. Coping strategies for delivering the news of intrauterine death to affected parents were relying on clinical knowledge and high levels of self-confidence (55.0%; 203/369), support from colleagues (53.9%; 199/369), and debriefing (52.8%; 195/369). In general, facilitators for breaking bad news were more commonly cultivated by female obstetricians [OR 1.267 (95% CI 1.149-1.396); p < 0.001], residents [χ2(3;369) = 9.937; p = 0.019], and obstetricians of younger age [41 (34-50) years vs. 45 (36-55) years; p = 0.018]. External facilitators were most frequently mentioned, including professional support, training, professional guidance, time, parents' leaflets, follow-up consultations, a supporting consultation atmosphere, and preparation before delivering the bad news. Internal facilitators included knowledge, empathy, seeking silence, reflection, privacy, and relief of guilt. (4) Conclusions: Communicating the diagnosis of fetal death evokes moderate to high levels of stress among obstetricians. Resources from both the professional and private environment are required to deal with this professional challenge on a personal level.

Cannabidiol treatment in an adolescent with multiple substance abuse, social anxiety and depression.

In this report, we present a case of a 16,9-year-old patient with multiple substance use disorder (cannabis, MDMA, cocaine, ecstacy), severe depression, social phobia and narcissistic personality disorder.We administered Cannabidiol (CBD) capsules in different dosages (starting dosage 100 mg up to 600 mg over 8 weeks) after unsuccessful treatment with antidepressants.CBD was a safe and well tolerated medication for this patient. Upon treatment with CBD and cessation of the antidepressant medication, the patient improved regarding depressive as well as anxiety symptoms including simple phobias and symptoms of paranoia and dissociation. Furthermore, the patient quit abusing illegal drugs including THC without showing withdrawal symptoms. This is the first report of CBD medication in a patient with multiple substance use disorder with a positive outcome.Until today it is not clear if CBD holds promise as a therapeutic option in substance use disorder as RCTs are lacking, but in this single case the substance seems to work in various domains.

Virtual and real-life ostracism and its impact on a subsequent acute stressor.

While ostracism constitutes a social stressor with negative effects on physical and mental health, social inclusion seems to increase resilience. This may be true not only for face-to-face settings, but also for computer-mediated interactions. Hence, this study examined the differences between ostracism and social inclusion in real-life or Virtual Reality (VR) regarding self-reported stress, neuroendocrine and cardiovascular reactivity in a subsequent real-life socio-evaluative task. 84 females were randomly assigned to a 3 (agency: face-to-face/human controlled VR-avatar/computer VR-agent) x 2 (inclusion status: inclusion/exclusion) between-subject design using a Cyberball paradigm. Subsequently, they were exposed to a real-life Trier Social Stress Test (TSST). Results indicate that the experience of ostracism constitutes a threat to fundamental social needs independent of agency. Excluded participants showed cardiovascular reactivity during TSST; also face-to-face and avatar excluded individuals had elevated salivary cortisol levels. Included participants reported more perceived social support during Cyberball and showed a blunted cortisol response to the TSST. These results suggest that face-to-face and avatar-related ostracism provokes responses in the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). Furthermore, they reveal that social inclusion may act as a stress-protector as it alters HPA- and SNS-related stress responsiveness to subsequent stressors.