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Session 5 n Homework’s Review n Interoceptive Exposure n Graded exposure to virtual environments using relaxation n Homework: in vivo Self-Exposure The key feature of session five is Interoceptive Exposure 10,37. The theoretical basis for interoceptive exposure is one of fear extinction, given the conceptualization of panic attacks as "conditioned" alarm reactions to particular bodily cues. Since according to the cognitive model panic disorder is considered as a “phobia of internal bodily cues”, the purpose is to modify associations between specific bodily sensations and panic reactions.

According cognitive-behavioral model of Clark42 and Barlow37 the most important therapeutic focus consists, in the first place, of inducing panic-like sensations by means of voluntary hyperventilation, cardiovascular exercise or spinning in a chair; in the second place, in demonstrating mistaken beliefs about the catastrophic results of such symptoms by Socratic methods and other techniques used in cognitive therapy; and in the third place, in encouraging the patient to follow through with planned behaviours to test their previous beliefs along with reinforcing more realistic thought systems related to the symptoms.

This technique can be used also during the exposure to the virtual © Mary Ann Liebert Inc. Publishers, 2000 14 environments. After the induction of panic-like sensations the patient uses Breathing retraining and Relaxation to control symptoms.

The controlled study and the follow-up of cognitive-behavioral treatments for Panic Disorder demonstrates the effectiveness of interoceptive exposure procedures in the short-term and long-term.

The essential steps of Interoceptive Exposure are:

- Ask to our patient to hyperventilate for 1 minute to induce panic-like sensations

- Demonstrating mistaken beliefs about the catastrophic results of panic sensation

- Repetition of the exercise after few minutes to obtain a desensitization of our patient respect internal bodily cues Session 6 n Homework’s Review n Cognitive Restructuring n Graded exposure to virtual environments using relaxation The session consists of cognitive restructuring and gradued exposure with breathing exercises, to strengthen the results.

Session 7 n Homework’s Review n Cognitive Restructuring n Prevention Relapse n Booster sessions schedule After cognitive restructuring prevention relapse is an important step of the last session. In this session we have to schedule the homeworks of self-exposure, the Booster sessions and to reinforce the patient for the tasks that have been carried out and for the future tasks.

Booster sessions

–  –  –

n Management and Prevention of future relapse The number of booster sessions can be scheduled according to the results of our patients. In our experience three sessions after 1, 3 and 6 months is an appriopriate number to complete efficacing therapy. The objective of booster sessions is to verify the difficulties that have emerged and to reinforce the patient for the tasks that have been carried out. During this phase it is possible to repeat some steps of the therapeutic tecniques to improve or to stabilize the results of treatment.

5. Conclusion

The possibilities offered in this framework by virtual technology are numerous and all extremely advantageous. The administration, guided by the therapist, in VR of scenes that favour the induction of relaxation response have shown extremely positive results. This is primarily due to the intrinsic effects of the VR tool. The feeling of actual presence offered by the realistic reproduction of cybernetic environments and by the involvement of all the sensorimotor channels enables the subject undergoing treatment to live the virtual experience in a more vivid and realistic manner than he could through his own imagination23.

VR constitutes a highly flexible tool which makes it possible to programme an enormous variety of procedures of intervention on psychological distress. The possibility of structuring a large amount of controlled stimuli and, at the same time, of monitoring the possible responses generated by the user of the programme offers a considerable increase in the likelihood of therapeutic effectiveness, as compared to traditional procedures.

This innovative tool produces a change with respect to the traditional relationship between client and therapist. The new configuration of this relationship is based on the awareness of being more skilled in the difficult operations of recovery of past experiences, through the memory, and of foreseeing of future experiences, through the imagination. The therapist who knows this valid tool and knows that he can use it as an advantage in his own therapeutic practice feels more powerful and capable of intervening in a more incisive manner on the course of the distress of his client. At the same time, the subject undergoing treatment perceives the advantage of being able to recreate and use a real experiential world within the walls of the clinical office of his own therapist24,28.

VR-assisted therapy therefore offers a strong impulse to the © Mary Ann Liebert Inc. Publishers, 2000 16 development of new possibilities of prevention and care of psychological health. Through VR it is possible to reduce the serious and careful experimentation will it be possible to enjoy the numerous advantages offered by immersive VR and by technological development.


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© Mary Ann Liebert Inc. Publishers, 2000 20

Figure 1: The different zones included in VEPD © Mary Ann Liebert Inc. Publishers, 2000 21

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