Behavior Design AMS - Willem-Paul Brinkman

Talkingwithvirtualhumans

Willem-PaulBrinkmanInterac(veIntelligenceGroupDel3UniversityofTechnology

Mission:Developingandunderstandingempiricallygroundedcomputermodelsthatgenerateeffec(veandacceptablecomputer

behaviourforbehaviourchange

Computersupportforanxietydisordertreatmentathome(CATCH)

1.

Humancontrolledversusautoma0cdialogue

Social phobia – speech recognition

PublicSpeaking

terHeijden,N.,andBrinkman,W.-P.(2011).Designandevalua(onofavirtualrealityexposuretherapysystemwithautoma(cfreespeechinterac(on.JournalofCyberTherapyandRehabilita0on,4(1),41-55.

1

2

3

4

5

6

7

Speechdetector Limitedspeechrecogni(on

Speechrecogni(on

Humancontrol

Ccom

putervshum

ancon

trol

2.

Priminganddialogueswithavirtualhuman

Qu,C.,Brinkman,W.P.,Wiggers,P.,&Heynderickx,I.(2013).Theeffectofprimingpicturesandvideosonaques(on-answerdialogscenarioinavirtualenvironment.Presence:TeleoperatorsandVirtualEnvironments,22(2),91-109.

Human–HumanDialogue

0

1

2

3

4

Unrelated Related

Keyw

ords

Pictures

Unrelatedvideo Relatedvideo

Human–VirtualHumandialogue

0

1

2

3

4

Unrelated Related

Keyw

ords

Pictures

Unrelatedvideo Relatedvideo

3.

Listeningversusspeaking

Qu,C.,Brinkman,W.P.,Ling,Y.,Wiggers,P.,&Heynderickx,I.(2013).Humanpercep(onofaconversa(onalvirtualhuman:anempiricalstudyontheeffectofemo(onandculture.VirtualReality,1-15.

Speakingandlistening

QuC,BrinkmanW,LingY,WiggersP,HeynderickxI,(2014).Conversa(onswithavirtualhuman:Synthe(cemo(onsandhumanresponses,ComputersinHumanBehavior,34

4.

VirtualRealityExposuretherapy

Virtual Reality Exposure Therapy for Social Anxiety Disorder:A Randomized Controlled Trial

Page L. AndersonGeorgia State University

Matthew PriceUniversity of Vermont

Shannan M. Edwards, Mayowa A. Obasaju, Stefan K. Schmertz, Elana Zimand, and Martha R. CalamarasGeorgia State University

Objective: This is the first randomized trial comparing virtual reality exposure therapy to in vivoexposure for social anxiety disorder. Method: Participants with a principal diagnosis of social anxietydisorder who identified public speaking as their primary fear (N ! 97) were recruited from thecommunity, resulting in an ethnically diverse sample (M age ! 39 years) of mostly women (62%).Participants were randomly assigned to and completed 8 sessions of manualized virtual reality exposuretherapy, exposure group therapy, or wait list. Standardized self-report measures were collected atpretreatment, posttreatment, and 12-month follow-up, and process measures were collected duringtreatment. A standardized speech task was delivered at pre- and posttreatment, and diagnostic status wasreassessed at 3-month follow-up. Results: Analysis of covariance showed that, relative to wait list, peoplecompleting either active treatment significantly improved on all but one measure (length of speech forexposure group therapy and self-reported fear of negative evaluation for virtual reality exposure therapy).At 12-month follow-up, people showed significant improvement from pretreatment on all measures.There were no differences between the active treatments on any process or outcome measure at any time,nor differences on achieving partial or full remission. Conclusion: Virtual reality exposure therapy iseffective for treating social fears, and improvement is maintained for 1 year. Virtual reality exposuretherapy is equally effective as exposure group therapy; further research with a larger sample is needed,however, to better control and statistically test differences between the treatments.

Keywords: virtual reality exposure therapy, social anxiety disorder, social phobia, cognitive behavioraltherapy

Virtual reality exposure therapy (VRE) for the treatment ofanxiety disorders has received considerable attention (Parsons &Rizzo, 2008). During VRE, a person encounters a feared stimulusin a computer-generated environment, often through the use of ahead-mounted display and motion tracker that allows for multi-sensory input and natural movement. Several advantages of VREhave been noted—both clinical, such as treatment acceptability(Emmelkamp, 2005), and methodological, such as the ability toconduct exposure in a tightly controlled environment (Shiban,Pauli, & Mühlberger, 2013). Two recent meta-analyses concludethat VRE is better than a waiting list control and equally effectiveas in vivo exposure therapy, both as a stand-alone treatment(Powers & Emmelkamp, 2008) and as part of cognitive behavioraltherapy (Opris et al., 2012). A systematic review of studies,

however, highlights that empirical support for VRE varies acrossanxiety disorders (Meyerbröker & Emmelkamp, 2010). Specifi-cally, randomized controlled trials support the efficacy of VREwith fear of flying (e.g., Rothbaum, Hodges, Smith, Lee, & Price,2000) and acrophobia (e.g., Emmelkamp et al., 2002) and showthat it is equally effective as in vivo exposure. These phobias lendthemselves well to VRE; the feared stimulus is circumscribed andcontains powerful physical cues that can be produced within avirtual environment. There is less controlled research on the use ofVRE for other anxiety disorders. The current study examines VREfor social anxiety disorder, which is characterized by fear ofnegative evaluation and thus may be more difficult to evoke andtreat using a virtual environment.

VRE is effective for reducing symptoms of social anxiety dis-order and public speaking fears as shown in case studies (Ander-son, Rothbaum, & Hodges, 2003), an open clinical trial (Anderson,Zimand, Hodges, & Rothbaum, 2005), and a study using amatched design (Klinger et al., 2005). Two randomized trials havebeen conducted. Wallach, Safir, and Bar-Zvi (2009) found thatindividually administered cognitive behavioral therapy—with andwithout VRE—was more effective than wait list on most self-report measures and on self-ratings of anxiety during a behavioraltask; these gains were generally maintained at 1-year follow-up(Safir, Wallach, & Bar-Zvi, 2012). This study, however, did notutilize participants with a clinical diagnosis of social anxiety

Page L. Anderson, Department of Psychology, Georgia State University;Matthew Price, Department of Psychology, University of Vermont; Shan-nan M. Edwards, Mayowa A. Obasaju, Stefan K. Schmertz, Elana Zimand,and Martha R. Calamaras, Department of Psychology, Georgia State Uni-versity.

Correspondence concerning this article should be addressed to Page L.Anderson, Department of Psychology, Georgia State University, P.O. Box5010, Atlanta, GA 30302-5010. E-mail: [email protected]

Thi

sdo

cum

ent

isco

pyri

ghte

dby

the

Am

eric

anPs

ycho

logi

cal

Ass

ocia

tion

oron

eof

itsal

lied

publ

ishe

rs.

Thi

sar

ticle

isin

tend

edso

lely

for

the

pers

onal

use

ofth

ein

divi

dual

user

and

isno

tto

bedi

ssem

inat

edbr

oadl

y.

Journal of Consulting and Clinical Psychology © 2013 American Psychological Association2013, Vol. 81, No. 5, 000 0022-006X/13/$12.00 DOI: 10.1037/a0033559

1

Exposure to virtual social interactions in the treatment of socialanxiety disorder: A randomized controlled trial

Isabel L. Kampmann a, *, Paul M.G. Emmelkamp c, d, Dwi Hartanto b,Willem-Paul Brinkman b, Bonne J.H. Zijlstra e, Nexhmedin Morina a

a Department of Clinical Psychology, University of Amsterdam, Weesperplein 4, 1018 XA, Amsterdam, The Netherlandsb Interactive Intelligence Group, Delft University of Technology, Mekelweg 4, 2628 CD, Delft, The Netherlandsc Netherlands Institute for Advanced Study, Meijboomlaan 1, 2242 PR, Wassenaar, The Netherlandsd King Abdulaziz University, Abdullah Sulayman, 22254, Jeddah, Saudi Arabiae Department of Educational Sciences, University of Amsterdam, Nieuwe Achtergracht 127, 1018 WS, Amsterdam, The Netherlands

a r t i c l e i n f o

Article history:Received 4 September 2015Received in revised form19 December 2015Accepted 23 December 2015Available online 29 December 2015

Keywords:Virtual realityExposure therapySocial anxiety disorderSocial phobiaSocial interaction

a b s t r a c t

This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposureintervention comprising verbal interaction with virtual humans to target heterogeneous social fears inparticipants with social anxiety disorder. Sixty participants (Mage ¼ 36.9 years; 63.3% women) diagnosedwith social anxiety disorder were randomly assigned to individual virtual reality exposure therapy(VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analysesrevealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms,speech duration, perceived stress, and avoidant personality disorder related beliefs when compared tothe waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation,speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. TheiVET condition was further superior to the VRET condition regarding decreases in social anxiety symp-toms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up.At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stresswas significant. VRET containing extensive verbal interaction without any cognitive components caneffectively reduce complaints of generalized social anxiety disorder. Future technological and psycho-logical improvements of virtual social interactions might further enhance the efficacy of VRET for socialanxiety disorder.

© 2015 Elsevier Ltd. All rights reserved.

Social anxiety disorder (SAD) is defined as the fear of one ormore social situations in which one might behave embarrassinglyand be negatively evaluated by others (DSM-V; AmericanPsychiatric Association, 2013). SAD is one of the most commonmental disorders in the US population, with an estimated lifetimeprevalence of 12.1% (Ruscio et al., 2008). Individuals who sufferfrom SAD can experience a reduced quality of life and significantimpairments in various areas of functioning, such as work andinterpersonal relationships (Wittchen, Fuetsch, Sonntag, Müller, &Liebowitz, 2000). However, only about one third of individualswith SAD seek treatment (Ruscio et al., 2008).

The most researched treatment for SAD is cognitive behavior

therapy (CBT). CBT aims at modifying maladaptive cognitions andbehavior using both cognitive (e.g., cognitive restructuring) andbehavioural (e.g., exposure) strategies (Hofmann & Smits, 2008;Mayo-Wilson et al., 2014). During exposure therapy, participantsencounter feared stimuli in situations containing social interactionuntil anxiety decreases and/or anxiety-related expectancies areviolated. Traditional exposure exercises are usually practiced dur-ing therapy and as homework assignments. Interestingly, a meta-analysis of treatment efficacy found exposure therapy alone to becomparable to cognitive therapy and that the combination of bothwas no more effective than either one delivered exclusively(Powers, Sigmarsson, & Emmelkamp, 2008).

A relatively new form of exposure therapy is Virtual RealityExposure Therapy (VRET). During VRET, participants are confrontedwith computer-generated stimuli (e.g. virtual social interaction)that can elicit elevated subjective levels of social anxiety (Morina,

* Corresponding author.E-mail address: [email protected] (I.L. Kampmann).

Contents lists available at ScienceDirect

Behaviour Research and Therapy

journal homepage: www.elsevier .com/locate/brat

http://dx.doi.org/10.1016/j.brat.2015.12.0160005-7967/© 2015 Elsevier Ltd. All rights reserved.

Behaviour Research and Therapy 77 (2016) 147e156

•  Virtualsocialscenarios

•  Dialoguetechniques

•  Phobicstressors•  Anxietyfeedback

loop

Virtualrealitysystem

•  19scenario’s

•  Eachlas(ngaround18minutes•  Freespeech

•  Automa(cresponsevirtualhuman

Kampmann,I.L.,Emmelkamp,P.M.,Hartanto,D.,Brinkman,W.P.,Zijlstra,B.J.,&Morina,N.(2016).Exposuretovirtualsocialinterac(onsinthetreatmentofsocialanxietydisorder:Arandomizedcontrolledtrial.BehaviourResearchandTherapy,77,147-156.




loop


DialogueUnit:1.  [avatar’sques(on]2.  [pa(ent’sanswer]3.  [avatar’sresponse]

•  Eachdialogueonaverage78dialogueunits

•  Speechdetec(on

•  Keyworddetec(on




loop


8generalstrategiestoresponseswithoutkeyworddetec(onExample1:genericresponsethatfitstoanyanswer[shopassistance]“Canyoualsospecifytomethepricerangethatyou’reaimingfor?”[pa(ent]blahblahblah….[shopassistance]“Well,that’sfine”.




loop


Example2:Stateanopinionbasedonyourbeliefs,emo(onorpercep(on[avatar]“Whatmakesyouagoodteamleader?”[pa(ent]blahblahblah….[avatar]“Yeah,buthonestlyIfeelthatyou’renotreadyyettobecomeagoodteamleaderbyjudgingyouranswerandyourcurrentexperience”.




loop

VirtualrealitysystemOtherstrategies•  Usetopicsblocksinthestorylineto

avoidtherepe((onofQ&A•  (dis)agreeonwhatthepa(entsaid•  Stateandaptudeoremo(ontowards

theanswer•  Reflectonyouroriginalques(on•  State(mis)understaningofpa(ent

answerandextendresponsewithowninforma(on

•  Stateanopinion




loop

VirtualrealitysystemDialogueUnit:1.  [Posi>ve|Nega>veavatar’s

ques(on]2.  [pa(ent’sanswer]3.  [Posi>ve|Nega>veavatar’s

response]ExamplePosi>veUnit[avatar]“Iliketoknowyourtastemusic,whatkindofmusicdoyoulike?”[pa(ent]blahblahblah…..[avatar]“Cool!Nicetasteofmusic!”




loop

VirtualrealitysystemDialogueUnit:1.  [Posi>ve|Nega>veavatar’sques(on]2.  [pa(ent’sanswer]3.  [Posi>ve|Nega>veavatar’sresponse]ExampleNega>veUnit[avatar]“Idon’tthinkthatyouhaveagoodtasteofmusic,butincaseI’mwrong,canyoutellmewhattypeofmusicyoulike?”[pa(ent]blahblahblah…..[avatar]“Mmm…asIhaveexpected,youknownothingaboutgoodmusic!”

Controlling Social Stress in Virtual Reality EnvironmentsDwi Hartanto1*, Isabel L. Kampmann2, Nexhmedin Morina2, Paul G. M. Emmelkamp2,3,

Mark A. Neerincx1,4, Willem-Paul Brinkman1

1 Department of Intelligent Systems, Delft University of Technology, Delft, The Netherlands, 2 Department of Clinical Psychology, University of Amsterdam, Amsterdam,

The Netherlands, 3 Department of Psychology, King Abdulaziz University, Jeddah, Saudi Arabia, 4 TNO Human Factors, Soesterberg, The Netherlands

Abstract

Virtual reality exposure therapy has been proposed as a viable alternative in the treatment of anxiety disorders, includingsocial anxiety disorder. Therapists could benefit from extensive control of anxiety eliciting stimuli during virtual exposure.Two stimuli controls are studied in this study: the social dialogue situation, and the dialogue feedback responses (negativeor positive) between a human and a virtual character. In the first study, 16 participants were exposed in three virtual realityscenarios: a neutral virtual world, blind date scenario, and job interview scenario. Results showed a significant differencebetween the three virtual scenarios in the level of self-reported anxiety and heart rate. In the second study, 24 participantswere exposed to a job interview scenario in a virtual environment where the ratio between negative and positive dialoguefeedback responses of a virtual character was systematically varied on-the-fly. Results yielded that within a dialogue themore positive dialogue feedback resulted in less self-reported anxiety, lower heart rate, and longer answers, while morenegative dialogue feedback of the virtual character resulted in the opposite. The correlations between on the one hand thedialogue stressor ratio and on the other hand the means of SUD score, heart rate and audio length in the eight dialogueconditions showed a strong relationship: r(6) = 0.91, p = 0.002; r(6) = 0.76, p = 0.028 and r(6) = 20.94, p = 0.001 respectively.Furthermore, more anticipatory anxiety reported before exposure was found to coincide with more self-reported anxiety,and shorter answers during the virtual exposure. These results demonstrate that social dialogues in a virtual environmentcan be effectively manipulated for therapeutic purposes.

Citation: Hartanto D, Kampmann IL, Morina N, Emmelkamp PGM, Neerincx MA, et al. (2014) Controlling Social Stress in Virtual Reality Environments. PLoSONE 9(3): e92804. doi:10.1371/journal.pone.0092804

Editor: Mel Slater, ICREA-University of Barcelona, Spain

Received November 26, 2013; Accepted February 25, 2014; Published March 26, 2014

Copyright: ! 2014 Hartanto et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This research is supported by the Netherlands Organization for Scientific Research (NWO), grant number 655.010.207. The funders had no role in studydesign, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interest exist.

* E-mail: [email protected]

Introduction

Social anxiety disorder, also commonly referred as socialphobia, is one of the most prevalent mental disorders [1]. Peoplewith social phobia experience a strong fear of being judgednegatively by others and of being embarrassed in social situations(e.g., talking to other people or eating or drinking in front of otherpeople). The gold standard to treat patients with social phobia iscognitive behaviour therapy with the central component beinggradual exposure in vivo, whereby patients are gradually exposed toanxiety provoking real-life situations until they habituate to theanxiety provoking social situations. Although exposure in vivo is aneffective treatment for most patients, it is also associated with somelimitations, such as the limited therapeutic control over differentaspects of exposure and a relatively high number of drop outs assome patients are not willing to get exposed to feared situations [2–4].

Virtual Reality Exposure Therapy (VRET) has been proposedas an effective alternative to overcome these shortcomings ofexposure in vivo [5–9]. Exposure in virtual reality (VR) makes thecontrol of exposure elements more manageable since the patient isexposed in a controlled Virtual Environment (VE) where theparameters of anxiety evoking stimuli can be changed andmanipulated by the therapist. Current VRET systems used forsocial phobia patients mainly focus on recreating a social scenesetting, such as public speaking scenarios, clothing shops, public

transport, or restaurants. At the start of the treatment, an anxietyhierarchy of anxiety-arousing social situations is established. Thishierarchy is then used to order the VR situations the patient willbe gradually exposed to, starting with less anxiety-arousingsituations and eventually moving to more anxiety-arousingsituations as treatment progresses.

Even though several studies [3,4,10,11] have reported promis-ing initial efficacy findings for VRET for social phobia, the usedVR systems mainly allow the therapist to control social anxietyonly by moving between different VR situations. Hence during theactual exposure in the VR situation, the therapist has limitedability to introduce or remove anxiety-evoking stimuli in a VRworld. Based on research on other anxiety disorders, this abilitymight prove useful for the treatment of social phobia as well [12].For example, in VRET for fear of flying, a therapist is given theopportunity to make relevant changes of the virtual world in use ifappropriate, such as switching on the sign fasten your seatbelts, flyingunder different weather conditions, or letting the pilot make aspecific announcement [13]. In VRET for fear of heights, thetherapist can move patients to a higher step of a virtual staircase,or place them closer to the edge of a balcony [14]. With regard toVRET for social phobia, however, little attention has been givento this aspect of the treatment. We argue that manipulating thedialogue between the patient and a virtual character can increasethe efficacy of VRET for social phobia. For example, by having

PLOS ONE | www.plosone.org 1 March 2014 | Volume 9 | Issue 3 | e92804

80

85

90

95

0% 25% 50% 75% 100%

Heartrate

Nega1veques1ons




loop

VirtualrealitysystemEyeGazeBodyPosture

Kang,N.,Brinkman,W.P.,vanRiemsdijk,M.B.,&Neerincx,M.(2016).Thedesignofvirtualaudiences:No(ceableandrecognizablebehavioralstyles.ComputersinHumanBehavior,55,680-694.




loop


VirtualworldBehavioralstressorsDialoguestressors

AnxietyMonitoringSubjec(veHeartrate

Anxietylevelcontroller

AnxietyDevia(on

+/-

Requiredanxietylevel

Anxietymeasured

Singleanxietymeasurement

therapist

pa(ent

5 10 15 20

6070

8090

100110

Exposure number across sessions

Hea

rt r

ate

Heartrateeven4minutes•  204Heartratesamples•  Signmaineffects:sessions(betweensessions2-9),and

exposureordernumber(withinasession1-3)

Pilot Study

Hartanto,D.,Brinkman,W.P.,Kampmann,I.L.,Morina,N.,Emmelkamp,P.G.,&Neerincx,M.A.(2015).Home-BasedVirtualRealityExposureTherapywithVirtualHealthAgentSupport.InPervasiveCompu0ngParadigmsforMentalHealth(pp.85-98).SpringerInterna(onalPublishing.

Thanksforyourawen(onICTissuccessfulwhenitsupportsyourneedforchange,andfailswhenyouneedtochangeforitssupport

Behavior Design AMS - Willem-Paul Brinkman

Design

Transcript of Behavior Design AMS - Willem-Paul Brinkman