History of Virtual Reality as an Adjunct to the Treatment of Anxiety Disorders and Virtual Vietnam

1. History of Virtual Reality as an Adjunct to the Treatment of Anxiety Disorders and Virtual Vietnam Barbara Olasov Rothbaum, Ph.D., ABPP Director, Trauma and Anxiety Recovery Program Professor of Psychiatry Associate Vice Chair of Clinical Research Emory University School of Medicine

2. Disclosure • Virtually Better, Inc (VBI), part owner – managed under Emory University's Conflict of Interest Policy • Virtual Iraq created by Dr. Skip Rizzo at USC, not VBI, but VBI is selling virtual reality products

3. Virtual Reality • Interactive computer environment • More than simply multimedia • Sense of PRESENCE • IMMERSIVE

4. Head-mounted display Position tracker Sensor Hand tracker Computer Monitor Headphones Thunder Chair Microphone Virtual Reality Hardware

5. Head-Mounted Display

6. Emotional Processing Theory • Foa & Kozak, 1986 • Fear memories contain information about stimuli, responses, meaning • Must 1) Activate memory and 2) Provide Corrective Information to modify

7. First Study of VRE for Psychiatric Disorder: VRE for Acrophobia • 3 Foot Bridges • 4 Outdoor Balconies • Glass Elevator Rothbaum, Hodges, Kooper, Opdyke, & Williford (1995). Effectiveness of Virtual Reality Graded Exposure in the Treatment of Acrophobia. American Journal of Psychiatry, 152, 626-628.

8. Virtual Reality Exposure Therapy • Individualized hierarchy • 1st session familiarized with VR • Allowed to progress at own pace • Remained at each height until anxiety attenuated • SUDs gathered every 5 minutes • Therapist viewed on monitor • Comparable to in vivo exposure

9. Results on Acrophobia Questionnaire ANXIETY AVOIDANCE

10. Sweating Butterflies Light-headed Heart Palpitations Tense Motion Sensations Restlessness Shakiness Nervous/scared Weak in Knees Tightness in Chest Motion Sickness Physical Symptoms During VRE

11. Conclusions • Physical symptoms of anxiety experienced in virtual environment • Perceptions and behavior in the physical world can be modified based on experiences within a virtual world • May be able to replace some physical or imagined environments with virtual environments

12. Scientific American clip

13. A Controlled Study of Virtual Reality vs. Standard Exposure Therapy for the Fear of Flying Rothbaum, Hodges, Smith, Lee, & Price (2000). A Controlled Study of Virtual Reality Exposure Therapy for the Fear of Flying. Journal of Consulting and Clinical Psychology, 68, 1020-1026.

14. Patient wears Head-mounted Display Position Tracker Covers Entire Field of View Hears only audio from earphones (including therapist). Sits in Thunderseat Simulates Sitting in plane on runway, engine on/off Taxi Takeoff Flight in good weather Flight in bad weather Landing Virtual Airplane

22. Fear of Flying Inventory Study 1: n = 45)

23. Limitations & Strengths of Study • Small Sample Size (n = 45) • One Therapist • Random Assignment • Controlled Design • DSM Inclusion Criterion • Blind Independent Assessment • Compared 2 active treatments and a control group • Post-treatment Flight

24. Barbara Rothbaum, Ph.D. Page Anderson, Ph.D. Larry Hodges, Ph.D. Elana Zimand, Ph.D. Jeff Wilson, M.S. Virtual Reality and Standard Exposure in the Treatment of the Fear of Flying Rothbaum, et al (2006). Behavior Therapy, 37, 80-90.

25. Fear of Flying Inventory Study 2: N = 75

26. Actual Flight Data

27. Virtual Airplane Clip

28. Posttraumatic Stress Disorder (PTSD)

29. Virtual Reality Exposure Therapy for PTSD Vietnam Veterans Rothbaum, Hodges, Ready, Graap, & Alarcon (2001). Virtual Reality Exposure Therapy for Vietnam Veterans with Posttraumatic Stress Disorder. Journal of Clinical Psychiatry.

30. VRE for PTSD • Vietnam combat veterans • Virtual Huey helicopter • “Fly” over the jungles of Vietnam • Walk in clearing near jungle, swamp • Imaginal exposure immersed in Vietnam stimuli

31. Descriptive Information Diagnoses: PTSD Major Depressive Disorder Past Substance Abuse Age: 51.3 (3.2) range 49-56 N = 10 CES: 26.8 (2.9) range 25-31 Medications? ALL YES Rothbaum et al (submitted) Journal of Clinical Psychiatry.

35. Clinician Administered PTSD Scale Mean CAPS Score p=.0727 p=.0256 p=.0021 N=9 N=9 N=5 N=8 Rothbaum et al. Journal of Clinical Psychiatry. 2001;62:617-622.

36. Impact of Events Scale Mean IES Score p=.0327 p=.0912 N=9 N=9 N=5 N=8 Rothbaum et al. Journal of Clinical Psychiatry. 2001;62:617-622.

37. Virtual Vietnam Video Clip

38. VR for Addictions

39. Cue Exposure • Based on classical conditioning • Cues typically presented in pictures, videos, paraphernalia • With VR, can be immersive • includes olfactory cues

40. VR for Nicotine

41. VR for Nicotine and Alcohol

42. VR for Nicotine and Alcohol

43. VR for Nicotine and Alcohol

44. VR for Nicotine and Alcohol

45. VAS Scales in VR Indicate your greatest craving to smoke at this time. __________________________________________ NoneMore than ever

49. Virtual Crack House Short Clip

50. N=13 ANOVA F=15, df=4, p=.001