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4.11 The display system The Sony Glasstron PLM-A55 head mounted provided the visual display. The HMD displays 800 lines of 255 pixels to each eye and uses LCD technology (two active matrix 7" color LCDs). An InterSense InterTrax 30 tracker provided head tracking. The tracker can sense azimuth, elevation and roll with a sensitivity of 360 degrees per second.

The response latency is 38ms+/-2ms.

In this research we did not use a stereoscopic display. Previous researches regard stereoscopy as important because it provides the © Mary Ann Liebert Inc. Publishers, 2000 7 user with good cues of depth29. However, the refresh rate of graphics decrease by 50% for the need of two different images for each eye.

Consequently, we decided against implementing a stereoscopic display. To compensate for the lack of binocular cues, we included perspective cues (light and shade, relative size, textural gradient, interposition and motion parallax) in the virtual environment30.

4.12 Motion input system The data glove-type motion input device is very common in virtual environments for its capability of sensing many degrees of freedom simultaneously. However the operator is also frequently confused by the difficulty in correctly using it, expecially when there is a time delay contained in the feed-back loop).

To provide a easy way of moving in VEPD we used an infrared twobutton joystick-type input device: pressing the upper button the operator moves forward, pressing the lower button the operator moves backwards. The direction of the movement is given by the rotation of operator's head.

4.13 The virtual environment VEPD is a 4-zone (see Figure 1) virtual environment developed using the Superscape VRT 5.6 toolkit. The four zones reproduce different potentally fearful situations - an elevator, a supermarket, a subway ride, and large square. In each zone the characteristics of the anxietyrelated experience are defined by the therapist through a setup menu.

In particular the therapist can define the lenght of the virtual experience, its end and the number of virtual subjects (from none to a crowd) to be included in the zone.

Zone 1: In this zone, an elevator in which the subject has to enter, the subject becomes acquainted with the appropriate control device, the head mounted display and the recognition of collisions.

Zone 2: this zone show a supermarket in which the patient can go for shopping. The subject can pick up objects and pay for them at the cash-register.

Zone 3: this zone reproduces a subway ride. The subject is located in the train which moves between different stations.

–  –  –

Subjects Subjects will be consecutive patients seeking treatment in one of the institutions involved in the study who met will DSM IV criteria for panic disorders and agoraphobia for a minimum of 6 months as determined by an independent clinician on clinical interview.

Individuals will be excluded if they were acutely suicidal, medically ill or pregnant, had abused alcohol or drugs within the last year or had evidence of cardiac conduction disease. Before starting the trial, the nature of the treatment will be explained to the patients and their written informed consent will obtained.

The selected subjects will be randomly divided in three groups: ECT group, that will experience the ECT treatment; CBT group, that will experience the traditional Cognitive Behavioral approach and a no-med group. A wait-list control group matched to the other three will be also used.

Assessment Subjects will be assessed by independent assessment clinicians who will not involved in the direct clinical care of any subject. They will be MA-level chartered psychologists or PhD-level chartered psychotherapist. For the clinical interview they will use a semistructured interview with the aim of identifying relevant DSM IV diagnostic criteria in the subjects. All the subject will be assessed at pre treatment, upon completion of the clinical trial and after a 1-month, 3-month, 6-month, 12-month and 24-month follow-up period.

The following psychometric tests will be administered at eachassessment point:

1. BDI - Beck Depression Inventory (Beck, Ward, Mendelson, Mock & Erbaugh, 1961)31;contains 21 items which address behavioral, physical, cognitive, and affective components of depression. Each item has four choices that are scored from 0 to 3 in terms of severity.

2. STAI - State-Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg & Jacobs, 1983)32. ; measures a person’s situational (or state) anxiety, as well as the amount of anxiety a person generally feels most of the time (trait). The two scales contain 20 items each, which © Mary Ann Liebert Inc. Publishers, 2000 9 may be scored 1 (not at all) to 4 (very much so). Trait anxiety has a reliability of.81 and state of.40, with internal consistency of between.83 and.92.

3. ACQ - Agoraphobic Cognitions Questionnaire (Chambless, Caputo, Bright & Gallagher, 1984)33; the questionnaire consist of 15 items and evaluate cognitive changes such as the so-called fear of fear.

The patients have to indicate with what frequency they have negative thoughts when they are anxious, such as "I'm going to die," "I'm going to go crazy etc.

4. FQ - Fear Questionnaire (Marks & Mathews, 1979)34; the questionnaire consists of a subscale of agoraphobia, which has five items and is limited to the evaluation of motor behavior.

During the assessment will be also used:

- Subjective measurements (self reports, diaries)

- Subjective Units of Distress (SUDs) during exposure to virtual environments. In particular SUDs will be taken at baseline, after 10 minutes and after 20 minutes. (scale is from 0 = no anxiety to 100 = maximum anxiety) Session 1 n Description of the etiologic model according cognitivebehavioral approach n Programmation of Cognitive-Experiential Treatment n Introduction to Virtual Environments.

n Graded exposure to virtual environments The first goal of session 1 is to discuss with our patient the etiologic model of Panic Disorder and Agoraphobia and to describe the programme of Experiential-Cognitive Therapy. The description is necessary to obtain an active role of the patient in the therapy.

Then we introduce our patient to Virtual Reality through the use of head mounted display and joystick.

The innovative principle of ECT is to integrate cognitive and behavioral techniques with the experiential possibilities offered by Virtual Reality.

Then the next step of the first session is to structure the Gradued Exposure procedure to virtual environments.

In imagination and in vivo exposure to the feared stimuli are the most effective psychological treatments available to confront avoidance © Mary Ann Liebert Inc. Publishers, 2000 10 behaviours in phobic disorders35. The objectives of the therapy are things which the patient fears or avoids and which create difficulty in their daily life. The tasks are the concrete steps needed to reach each one of these objectives. We have developed a virtual reality software with virtual environments, reproducing a square, a supermarket, an underground subway station and an elevator, which allow the patient to face feared stimuli, allowing gradued exposure therapy.

The second step is to show the patient the role of avoidance as the main source of agoraphobic and panic behaviors. The therapist underlines the importance of regular exposure to feared situation and structures with his patient a self-exposure schedule. In vivo gradued self-exposure as homeworks, initially with the co-therapist (when it is possible), is very important to empower the efficacy of the therapy36.

This step can be more easily approached by gradued exposure to

virtual reality and produce important advantages for the patient:

reducing the number of sessions, reducing dependency on the therapist and helping to mantain therapeutic achievements.

According Barlow37 and Clark13 exposure mainly affects avoidance, but also have a significant effect on panic symptoms and cognitive distortions. In Panic Disorder the graded exposure treatment has much wider effects and leads to improvements in: fear during exposure, avoidance, physiological arousal and catastrophic thoughts.

The long term follow-up studies show that the improvements tend to increase with the introduction of self-exposure36. This technique stimulates the patients adopting a main role and attributing the success to their own efforts.

Session 2 n Breathing retraining and Relaxation n Graded exposure to virtual environments n Introduction and scheduling of in vivo Self-Ex posure n Homework: in vivo Self-Exposure with co-therapist Before to pursue graded exposure work we teach Breathing Retraining and Relaxation. A consistent percentage of panickers describe hyperventilatory symptoms as being very similar to their panic attack symptoms38. This observation had stimulated the idea that hyperventilation may play an important causal role in panic attacks. In this conception panic attacks are viewed as stress-induced respiratory changes that provoke fear because they are perceived as frightful and augment fear elicited by other panic stimuli. Many researchers have © Mary Ann Liebert Inc. Publishers, 2000 11 examined the efficacy of breathing retraining that consist of training in slow and diaphragmatic breathing39.

Clark and Salkovskis14 reported a larger scale study in which the panickers received two weekly sessions of breathing retraining and cognitive restructuring training. After the treatment panic attacks were reduced markedly in that brief period of time and especially in subjects who were not significantly agoraphobic.

The goal of this step is to teach the patient a technique to control panic symptoms during exposure therapy in Virtual Reality and during selfexposure. The breathing exercises can be administered through the

following schedule40:

1. Stop what you are doing and sit down, or, at least, concentrate on the following instructions

2. Hold your breath without taking any deep breaths and count to 10

3. When you get to 10, exhale and keep saying the word "calm down" in a soothing way

4. Breathe in and out in cycles of 6 s (3 for inhalation and 3 for exhalation), saying the word "calm down" each time you exhale. As such, there will be 10 breathing cycles a minute

5. At the end of each minute (after 10 breathing cycles), hold your breath again for 10 s. As you continue, resume the six-second breathing cycles

6. Continue breathing in this way until all symptoms of involuntary hyperventilation have disappeared Session 3 n Homework’s Review n Graded exposure to virtual environments n Cognitive Restructuring n Homework: in vivo Self-Exposure with co-therapist Each session starts with the review of the homeworks, to verify the difficulties that have emerged during self-exposure and to reinforce the patient for the tasks that have been carried out.

After the graded exposure procedure, session three is based on Cognitive Restructuring41. In panic disorder cognitive treatment focuses upon correcting misappralsals of bodily sensations as threatening. The cognitive strategies reduce attentional vigilance for symptoms of arousal, level of chronic arousal, and anticipation of the recurrence of © Mary Ann Liebert Inc. Publishers, 2000 12 panic.

Cognitive treatment starts by reviewing with the patient a recent panic attack and identifying the main negative thoughts associated with the panic sensations. Once patient and therapist agree that the panic attacks involve an interaction between bodily sensations and negative thoughts about the sensations, a variety of procedures are used to help patients challenge their misinterpretations of the symptoms.

A lot of patients interpret the unexpected nature of their panic attacks as an indication that they are suffering from some physical abnormality.

In these cases informations and psycho-education about the nature of anxiety can be helpful, especially if it is tailored to patients' idiosyncratic concerns.

Among cognitive procedures one of the most useful involves helping patients to understand the significance of past events which are inconsistent with their negative beliefs.

The techniques are introduced by explaining that errors in thinking occur naturally during heightened anxiety, thus preparing the client to gain an objective self awareness and expectation that their thinking is distorted.

One of prevalent types of errors in cognitions is overestimation. The panickers are inclined to jumping to negative conclusions and treating negative events as probable when in fact they are unlikely to occur.

The procedure for countering overestimation errors is to question the evidence for probability judgements. The general format is to treat thoughts as hypotheses or guesses rather than facts and examine the evidence for predictions, while considering alternative, more realistic predictions.

Another type of cognitive error is misinterpreting events as catastrophic. Decatastrophizing means to realize that the occurrences are not as "catastrophic" as stated, which is achieved by considering how negative events are managed versus how "bad" they are.

This is best done in a socratic style so that clients examine the content of their statements and reach alternatives.

The cognitive strategies are conducted in conjunction with behavioral technique of graded exposure in virtual reality.

The steps of Cognitive Restructuring are41:

1. Introducing cognitive model of Panic Disorder and Agoraphobia

2. Individuation of NATs - negative automatic thoughts, by means of interview and DTR - dysfunctional thought record

3. Classification and role attribution of dysfunctional thought individuated

4. Verbal Reattribution Procedures (according Clark or Wells’s © Mary Ann Liebert Inc. Publishers, 2000 13 model)

5. Behavioral Reattribution Procedures Session 4 n Homework’s Review n Graded exposure to virtual environments using relaxation n Cognitive Restructuring n Homework: in vivo Self-Exposure with co-therapist The schedule of session four is the same of session three. The first part is dedicated to graded exposure. The second part is dedicated to the careful inquiry of cognitive distorsios and their modification.

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