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© Mary Ann Liebert Inc. Publishers, 2000 1




F. Vincelli1-2, M.S.; Y.H. Choi3, M.D.; E. Molinari2, Ph.D.; B.

Wiederhold4, Ph.D.;G. Riva1-2, Ph.D.


ATN-P Lab, Istituto Auxologico Italiano, Verbania, Italy 2 Department of Psychology, Università Cattolica, Milan, Italy 3 Seoul Paik Hospital, Inje University, Seoul, South Korea 4 Center for Advanced Multimedia Psychotherapy, CSPP Research and Service Foundation, San Diego, California This is a unrevised version of the paper published by the journal ”CyberPsychology and Behavior”, 3 (3), 375-386, 2000 Journal web site: http://www.liebertpub.com/cpb/default.htm Copyright Notice This paper is included as a means to ensure timely dissemination of scholarly and technical work on a non-commercial basis. Copyright and all rights therein are maintained by the authors or by other copyright holders, notwithstanding that they have offered their works here electronically. It is understood that all persons copying this information will adhere to the terms and constraints invoked by each author's copyright. These works may not be reposted without the explicit permission of the copyright holder. Please contact the authors if you are willing to republish this work in a book, journal, on the Web or elsewhere. Thank you in advance.


Applied Technology for Neuro-Psychology Lab. - Istituto Auxologico Italiano P.O. Box 1, 28044 Verbania, Italy Tel: +39-323-514246 - Fax: +39-323-587694 E-mail: fvincelli@hotmail.com © Mary Ann Liebert Inc. Publishers, 2000 2




1. Introduction Through the development of epidemiologic studies we are able to say that 3.5% of the general population suffer from panic disorder1, with serious personal and social repercussions, such as depression, substance abuse and suicidal tendencies2.

According to DSM-IV3, the essential feature of panic disorder (PD) is the occurrence of panic attacks. A panic attack is a sudden onset period of intense fear or discomfort associated with at least four symptoms that include: palpitations, breathlessness, dizziness, trembling, a feeling of choking, nausea, de-realization, chest pain, and paraesthesias. The panic is characterized by a cluster of physical and cognitive symptoms, which occurs unexpectedly and recurrently, such as pervasive apprehension about panic attacks, persistent worry about future attacks, worry about the perceived physical, social or mental consequences of attacks, or major changes in behavior in response to attacks.

Panic disorder is often associated with circumscribed phobic disorders such as specific phobias, social phobias, and especially with agoraphobia4-5. Agoraphobia is described separately from panic disorder in the DSM-IV to highlight the occurrence of agoraphobic avoidance in individuals with or without a history of panic disorder3.

Agoraphobia consists of a group of fears of public places such as going outside, using public transportation and being in public places, i.e.

supermarkets, theaters, churches, football stadia, etc, which cause serious interference in daily life. Other fears may spring from this core phobia, such as going through tunnels, using lifts, crossing bridges, etc., as well as other internal fears, such as excessive worry about physical sensations (palpitations, vertigo, dizziness, etc.) or an intense fear of panic attacks, including fear of social interaction. The results of these psychopatological symptoms are that the patient tends to avoid the feared situation and, from then on, this avoidance carries over into other situations. Indeed, avoidance of public places in order to reduce fear or panic becomes the main cause of incapacity in patients, who, in more serious cases, are confined to their homes6-7.

The recognition of panic disorder as specific syndrome was introduced by Klein8-9. He disclosed that patients with recurrent panic attacks responded to imipramine but not benzodiazapines, and vice versa for anxious patients without recurrent panic attacks. His studies were © Mary Ann Liebert Inc. Publishers, 2000 3 particularly influential in establishing panic disorder as a separate diagnostic entity.

In the aetiopathology of PD, Barlow10 describes the initial panic attack as a misfiring of the "fear system," under stressful life circumstances, in physiologically vulnerable individuals. But an isolated panic attack does not necessarily lead to the development of panic disorder, as evidenced by the scientific literature1,11. The individuals who developed a panic disorder had a physiological vulnerability, a sort of anxious apprehension conceptualized by Barlow as a set of danger-laden beliefs about the symptoms of panic and about the meaning of panic attacks. After the initial panic attack the unrealistic interpretations persist because patients engage in cognitive and behavioural strategies that are intended to prevent the feared events from occurring. As the fears are unrealistic, the main effect of these strategies is to prevent patients from disconfirming their negative beliefs. Then, such as in many anxiety disorders, the symptoms of anxiety are additional sources of perceived danger, and produce a series of vicious circles which further contribute to the maintenance of the disorders10,12.

The words of Clark13 clarify the aetiopathogenetic model of PD:

“Individuals who experience recurrent panic attacks do so because they have a relatively enduring tendency to interpret certain bodily sensations in a catastrophic fashion. The sensations that are misinterpreted are mainly those involved in normal anxiety responses (e.g., palpitations, breathlessness, dizziness, paresthesias) but also include some other sensations. The catastrophic misinterpretation involves perceiving these sensations as much more dangerous than they really are and, in particular, interpreting the sensations as indicative of immediately impending physical or mental disaster-for example, perceiving a slight feeling of breathlessness as evidence of impending cessation of breathing and consequent death, perceiving palpitations as evidence of an impending heart attack, perceiving a pulsing sensation in the forehead as evidence of a brain haemorrhage, or perceiving a shaky feeling as evidence of impending loss of control and insanity”. (Clark 1988, p. 149).

2. The treatment of Panic Disorder and Agoraphobia

–  –  –

disorder with agoraphobia14-17.

Clark, Salkovskis, Barlow, and other colleagues6,7,10,13-15 have outlined the treatment for PD with agoraphobia. The traditional protocol involves a mixture of cognitive and behavioral techniques which are intended to help patients identify and modify their dysfunctional anxiety-related thoughts, beliefs and behavior. Emphasis is placed on reversing the maintaining factors identified in the cognitive and behavioral patterns.

The treatment protocol includes exposure to the feared situation, interoceptive exposure, cognitive restructuring, breathing retraining, and applied relaxation. On an average the duration of the protocol is twelve-fifteen sessions. Readers interested in a more detailed description of CBT for panic disorder and agoraphobia can consult Salkovskis and Clark18, Mathews, Gelder and Johnston19 and Barlow10.

3. Virtual reality in Psychotherapy

In Psychotherapy, the virtual cyberspace offers a series of powerful and valid applications for diagnosis and treatment.

The qualities that make VR software reliable and particularly useful in the practice of assessment and rehabilitation of certain psychopathological dysfunctions emerge with extreme clarity from the specialist literature20,21.

VR consists of a three-dimensional interface that puts the interacting subject in a condition of active exchange with a world re-created via the computer. The possibility of not limiting the paradigm of interaction in a

unidirectional sense represents the strong point of the new technology:

man is not simply an external observer of pictures or one who passively experiences the reality created by the computer, but on the contrary may actively modify the three-dimensional world in which he is acting, in a condition of complete sensorial immersion21. The nature of this exchange means that the subject feels actually present in this new context. The feeling of “actual presence” is perhaps the peculiar characteristic of this tool22, 23 and is made possible both by the realistic reproduction of the cybernetic environments and by the involvement of all the sensorimotor channels during interaction.

To describe in what way the development of science and technology may favour the buttressing of the therapeutic effects associated with traditional strategies of care, we introduce two elements: the costbenefits in psychotherapy and the exposure technique23.

One of the fundamental parameters in assessing the effectiveness of therapies is the ratio existing between the “cost” of administration of the therapeutic procedure and the resulting “benefits”. By cost it is meant © Mary Ann Liebert Inc. Publishers, 2000 5 the expenditure not only in terms of money and time, but also in terms of emotional involvement by the person to whom the therapy is directed. The benefits regard the effectiveness of the treatment, i.e., the achievement of the target set, in the shortest time possible.

Exposure therapy traditionally is carried out “in imagination” or “in vivo”.

In the first case, the subject is trained to produce the anxiety-provoking stimuli through mental images; in the second case, the subject actually experiences these stimuli in semi-structured situations. Both of these methods present advantages and limitations as regards the costbenefit ratio. In the first case, the prevalent difficulty is represented by teaching the subject to produce the images that regard experiences associated with anxiety: the majority of failures linked to this therapy are those subjects who present particular difficulties in visualizing scenes of real life. The cost of the application, however, is minimal, because the therapy is administered in the physician’s office, thus avoiding situations that might be embarrassing for the patient and safeguarding his privacy. In the second case, the difficulty lies in structuring, in reality, experiences regarding the hierarchically ordered anxiety-provoking stimuli, with the result that the cost in terms of time, money and emotions is high. At the same time, the advantage of contending with real contexts increases the likelihood of effectiveness of the “in vivo” procedure24.

In this context, emerges the need to favour the possibilities of intervention on psychological dysfunctions by overcoming the limits that render the cost-benefit ratio disadvantageous, and in this framework, virtual reality technology takes its place as an experience that is able to reduce the gap existing between imagination and reality24, 25.

The prevalent elements in cognitive-behavioural therapies are that of exposing the subject to the stimuli that produce the dysfunction and of generating responses that are antagonistic to the maladaptive ones26.

VR facilitates both of these processes of treatment. Using VR software, it is possible to re-create, together with the subject undergoing treatment, a hierarchy of situations corresponding to reality, which he may experience in an authentic way thanks to the involvement of all his sensorimotor channels 27. The realistic reproduction of virtual environments enables the interacting individual to immerse himself in a dimension of real presence. This makes it possible to limit the costs as compared to traditional procedures of treatment, as pointed out above, and to consolidate the effectiveness of the treatment thanks to the possibility of re-creating a “three-dimensional world” within the walls of the clinical office23, 24.

© Mary Ann Liebert Inc. Publishers, 2000 6

4. Experiential-Cognitive Therapy Protocol: A multicomponent approach The preliminary treatment protocol for Panic Disorder and Agoraphobia, named Experiential-Cognitive Therapy (ECT), was developed at the Applied Technology for Neuro-Psychology Lab of Istituto Auxologico Italiano, Verbania, Italy, in cooperation with the Psychology Department of the Catholic University of Milan, Italy28. The actual version included the efforts of researchers from the Center for Advanced Multimedia Psychotherapy, California School of Professional Psychology, San Diego (CA), USA, and from the Seoul Paik Hospital, Inje University, Seoul, Korea.

The goal of ECT is to decondition fear reactions, to modify misinterpretational cognition related to panic symptoms and to reduce anxiety symptoms. This is possible in an average of seven sessions of treatment plus an assessment phase and booster sessions, through the integration of Virtual Experience and traditional techniques of CBT.

We decided to employ the techniques included in the cognitivebehavioral approach because they showed high levels of efficacy.

Through virtual environments we can gradually expose the patient to feared situation: virtual reality consent to re-create in our clinical office a real experiential world. The patient faces the feared stimuli in a context that is nearer to reality than imagination28.

4.1 VR design and implementation

For ECT we developed the Virtual Environments for Panic Disorders - VEPD - virtual reality system.

VEPD was developed using a Thunder 600/C virtual reality system by Virtual Engineering of Milano-Italy. The Thunder 600/C is a Pentium III

based immersive VR system (600mhz, 64 mega RAM, graphic engine:

Matrox G400 Dual Head, 32Mb WRam) including an HMD subsystem and a two-button joystick-type motion input device.

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