1
The Bus
2
Treatment
PANIC DISORDER AGORAPHOBIA

• 2 SESSIONS
• EDUCATIONAL COMPONENT
• COGNITIVE REESTRUCTURING
• SLOW BREATHING
• 6 VR GRADED EXPOSURE SESSIONS
• VRE SITUATIONAL INTEROCEPTIVE
• 1 RELAPSE PREVENTION SESSION

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Diagnosis
PANIC DISORDER AGORAPHOBIA

• SCREENING INTERVIEW
• ADIS-IV (PANIC/AGORAPHOBIA)
• INDEPENDENT ASSESOR
• EXCLUSION CRITERIA
• ALCOHOL/DRUG ABUSE
• PSYCHOSIS
• SEVERE PHYSICAL ILLNESS
• TARGET BEHAVIORS
• FEAR AND AVOIDANCE
• BELIEF IN CATASTROPHIC THOUGHTS

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Expectations/Satisfaction
PANIC DISORDER AGORAPHOBIA

• EXPECTATIONS/SATISFACTION ABOUT EXPOSURE (AXIS
  II)
• Logic
• Satisfaction
• Recommendation to a friend
• Useful for your problem
• Aversiveness
• Useful for other problems

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Self-report Measures
PANIC DISORDER AGORAPHOBIA

• BECK DEPRESSION INVENTORY (BDI, Beck, Ward,
  Mendelson, Mock, Erbaugh, 1961 )
• PANIC DISORDER SEVERITY SCALE (PDSS, Shear,
  Sholomskas, Cloitre, 1992
• ANXIETY SENSITIVITY INDEX (ASI, Reiss, Peterson,
  Gursky, McNally, 1986 )
• MOBILITY INVENTORY (MI,Chambless, Caputo, Jasin,
  Gracely, Williams, 1985)

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Scenarios Situational Exposure
PANIC DISORDER AGORAPHOBIA
THE HOUSE
Anticipatory anxiety Being alone at home Go out
alone from home Take the elevator
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Scenarios Situational Exposure
PANIC DISORDER AGORAPHOBIA
Using public transportation Subway Train Being
in crowded places Being far from home
THE SUBWAY
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Scenarios Situational Exposure
PANIC DISORDER AGORAPHOBIA
THE BUS
Using public transportation Bus Being in
crowded places Being far from home
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Scenarios Situational Exposure
PANIC DISORDER AGORAPHOBIA
Go shopping Being in crowded places Being in
line Being in narrow spaces Go to unknown
places Using escalators
THE SHOPPING MALL
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Scenarios Situational Exposure
PANIC DISORDER AGORAPHOBIA
THE TUNNEL
Being in situations where finding the exit is
difficult
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Scenarios Interoceptive Exposure
PANIC DISORDER AGORAPHOBIA
Breathing and heart rate Mild Moderate Accelera
ted Visual effects Tunnel vision Blurred
vision Double vision
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Works
PANIC DISORDER AGORAPHOBIA

• A SINGLE CASE STUDY
• Villa, Botella, García-Palacios, and Osma
  (Submitted)
• 3, 6,AND 9 MONTHS FOLLOW-UP
• A BETWEEN SUBJECT DESIGN (2 GROUPS)
• Botella, Baños, Villa, Guillén, Jorquera,
  Fabregat, Gallego, (2003)
• VIRTUAL REALITY EXPOSURE (VRE) (n5)
• IN VIVO EXPOSURE (IVE) (n5)
• A BETWEEN SUBJECT DESIGN (3 GROUPS)
• Botella, et al. (Submitted)
• VRE (n12)
• IVE (n12)
• WAITING LIST (WL) (n12)

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VRE in the Treatment for PDA (Botella et al.,
submitted) VEPSY PROJECT

• PARTICIPANTS
• N36

• METHOD

• BETWEEN SUBJECT DESIGN WITH REPEATED MEASURES
• EXPERIMENTAL CONDITIONS (RANDOMLY ASSIGNED)
• IN VIVO EXPOSURE (IVE)
• VIRTUAL REALITY EXPOSURE (VRE)
• WAITING LIST (WL)
• MEASURES
• BEFORE TREATMENT (PRE-TEST)
• AFTER TREATMENT (POST-TEST)

14
VRE PDA A BETWEEN SUBJECTS DESIGN
Participants
IV (N12)
VR (N12)
WL (N12)
AGE
31.92 (8.83)
31.50 (11.04)
39.25 (14.74)
WOMEN
58.30
83.30
75
MEN
41.70
16.70
25

PD PDA
25 75
25 75
100
15
FEAR
VRE PDA A BETWEEN SUBJECTS DESIGN
AVOIDANCE
BELIEF
F (3,31) 39.665, plt0.001
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PDSS
VRE PDA A BETWEEN SUBJECTS DESIGN
ASI
F (2,31) 29.206, plt0.001
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FQ-AG
VRE PDA A BETWEEN SUBJECTS DESIGN
MI-Alone
F (2,29) 12.152, plt0.001
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VRE PDA A BETWEEN SUBJECTS DESIGN
Treatment Opinion
Expectations
Any difference was significative
19
Conclusions
VRE PDA

• AXIS I
• VR USEFUL FOR THE TREATMENT OF PANIC DISORDER AND
  AGORAPHOBIA
• VRE WAS EQUALLY EFFECTIVE THAN IVE
• VR INTEROCEPTIVE EXPOSURE COMBINED WITH VR
  SITUATIONAL EXPOSURE USEFUL FOR DECREASING FEAR
  TO BODILY SENSATIONS
• AXIS II
• POSITIVE ACCEPTANCE OF VR
• VR DID NOT PRODUCE NEGATIVE SIDE EFFECTS
• NO DIFFERENCES BETWEEN IVE AND VRE RELATED WITH
  TREATMENT SATISFACTION

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VR Research
STRESS-RELATED DISORDERS POSTTRAUMATIC STRESS
DISORDER
EMMA PROJECT
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Controlled Studies PTSD
Author Year of Pts Equipment Results
Rothbaum 2001 16 V6 Head-Mounted Display CAPS scores at 6 month follow-up showed reduction in PTSD symptoms
Tarnanas 2001 50 VPL Eye Phone 1, MR toolkit, vibrations plate Less negative thoughts toward earthquake scenarios
Difede 2002 1 Head Mounted Display 90 reduction in PTSD symptoms after VR exposure therapy
Univ. Of Buffalo 2003 4 UB Simulator Preliminary results are promising
Wiederhold 2003 8 EEG, PC computer VR environment increased performance on task
Livanou 2003 10 Earthquake simulator, shake table (9 levels of intensity) Significant improvement (8 patients improved, 2 slightly improved)
Walshe 2003 14 3D Head Mounted Display Significant post-treatment reductions on all measures
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STRESS-RELATED DISORDERS

• EMMAs room include several elements to treat
  stress related disorders
• A database screen, where a listing of icons shows
  all the elements that a user can manipulate,
  including three-dimensional objects, sound,
  images, colored lights, movies and texts
• The book of life, where the user can move and
  modify any element from the 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 by a virtual
  book the object holders spread all around the
  environment give life to any element by showing
  its representation (a three-dimensional object, a
  sound, or a light illuminating the environment)
• A virtual keyboard that allows the user to label
  elements or chapters in the book of life
• The processor, element of the environment where
  the user can physically transform the
  experiences

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STRESS-RELATED DISORDERS

• EMMAs room also has available different
  scenarios or landscapes. The aim is to reflect
  and enhance the emotion that the user is
  experiencing or to induce certain emotions. It is
  possible to include modifications in the scenario
  and to graduate the intensity of these
  modifications in order to reflect the changes in
  the participants mood states.
• Besides the specific variations for each
  emotional scenario it is possible to modify the
  environment according to the time. That means
  that we can establish day or night in each
  scenario with the aim of reflecting or enhancing
  the participants mood state.

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STRESS-RELATED DISORDERS

• 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 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 environment.
• 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 cognitive reappraisal
  tasks, but also, and essentially, with the
  experiential reorganization aspects.

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Other Applications
EMMAS ROOM

• EMMAS 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.

32
Study
STRESS-RELATED DISORDERS

• To test the efficacy of EMMAs room in the
  treatment of stress-related disorders (PTSD,
  adjustment disorder).
• Between-subject design
• Traditional CBT treatment.
• CBT treatment delivered with EMMAs room.

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Participants
STRESS-RELATED DISORDERS
Clinical condition Sex Age
Total sample 11 clinical 7 subclinical N 18 7 male 11 female Range 18 to 46 Mean 31.61 SD 9.02
Traditional condition 5 clinical 4 subclinical 4 male 5 female Range 18 to 40 Mean 28.22 SD 8.45
EMMA condition 6 clinical 3 subclinical 3 male 6 female Range 21 to 46 Mean 35 SD 9.58
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Measures
STRESS-RELATED DISORDERS

• 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).

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Treatments
STRESS-RELATED DISORDERS

• PTSD Adaptation of Foa Rothbaum (1998)
  Prolonged Exposure program.
• Adjustment disorder (pathological bereavement)
  Adaptation of Neimeyer (2002) program for
  pathological bereavement.

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Results
TRADITIONAL TRADITIONAL EMMA 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)
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Results
TRADITIONAL TRADITIONAL EMMA 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)
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Results
Openess to New Experiences
39
Results
Satisfaction with Treatment
Traditional Traditional EMMA 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)
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Results
Treatment Aversiveness
41
Results
Presence
42
Discussion
STRESS-RELATED DISORDERS

• EMMAS 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 EMMAs room condition rated the
  treatment as less aversive than the group in the
  traditional condition.

43
Discussion
STRESS-RELATED DISORDERS

• 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 EMMAs room condition showed a
  higher openness to new life experiences.

44
Discussion
STRESS-RELATED DISORDERS

• 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 EMMAs 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.

45
Conclusions
STRESS-RELATED DISORDERS

• EMMAs 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.

46
Conclusions
STRESS-RELATED DISORDERS

• 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.

47
Conclusions
STRESS-RELATED DISORDERS

• 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.

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Other Applications
EMMAS ROOM

• EMMAS 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.