Annual Review of CyberTherapy and Telemedicine, Volume 15 Annual Review of CyberTherapy and Telemedicine Copyright © 2017 Interactive Media Institute 6540 Lusk Boulevard, Suite C115 San Diego, CA 92121 ISBN: 1554-8716 All rights reserved. Printed in the United States of America Journal Web site: http://www.arctt.info Interactive media Institute Website: http://www.interactivemediainstitute.com LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information vii Contents Preface v Brenda K. Wiederhold Giuseppe Riva Mark D.Wiederhold Chris Fullwood Alison Attrill-Smith Gráinne Kirwan Section I. Editorial 1. A Healthy Mind in a Healthy Virtual Body: The Future of Virtual Health Care 3 Giuseppe Riva, Brenda K. Wiederhold, Andrea Gaggioli Section II. Critical Reviews 1. The small-world of cybertherapy 10 Brice Gouvernet and Lise Haddouk 2. Neural Basis of Virtual Exposure Treatment 16 Aleksandra Landowska,, David Roberts, and Peter Eachus 3. The Internet as a possibility of empowerment for the lower classes in Brazil 19 Paula Melgaço, Bruna Madureira and Junia De Vilhena Section III. Evaluation Studies 4. An e-health protocol to help elderly breast cancer patients to cope with chemotherapy: preliminary results 27 Daniela Villani, Chiara Cognetta, Davide Toniolo, Francesco Scanzi , and Giuseppe Riva 5. A Robot Game to Enhance Wayfinding and Recycling in Children 33 Elvis Mazzoni, Gioele Piobbico, and Martina Benvenuti 6. To what extent does Internet use affect academic performance? Using Evidence 39 from the large-scale PISA study Dmitri Rozgonjuk and Karin Täht 7. Enhancing psychological wellbeing of women approaching the childbirth: a 45 controlled study with a mobile application Claudia Carissoli, Daniela Villani, Deborah Gasparri and Giuseppe Riva 8. Constructions of blame and responsibility in online interactions 51 Navpreet Johal and Bryn Alexander Coles 9. Modes of Cyberstalking and Cyberharassment: Measuring the negative effects in 57 the lives of victims in the UK Antony Brown, Marcia Gibson And Emma Short Section IV. Original Research 10. The Sensorimotor Dimension of the Networked Flow: An Exploratory Study Using an Interactive Collaborative Platform 65 Alice Chirico, Alessandro D’Ausilio, Serena Graziosi, Francesco Ferrise, Alberto Gallace, Cedric Mosconi, Marie Jasmine Cazzaniga, Valentino Zurloni, Massimiliano Elia, Francesco Cerritelli Fabrizia Mantovani, Pietro Cipresso, Giuseppe Riva, and Andrea Gaggioli 11. Educational Robotics to Improve Mathematical and Metacognitive Skills 70 Filippo La Paglia, Caterina La Cascia, Maria Margherita Francomano, and Daniele La Barbera 12. Measuring Prejudice and Ethnic Tensions in User-Generated Content 76 Olessia Koltsova , Svetlana Alexeeva, Sergey Nikolenko, and Maxim Koltsov 13. Attention and Social Cognition in Virtual Reality: The effect of engagement mode and character eye-gaze 82 Brendan Rooney, Katalin Balin,, Thomas D. Parsons, Colin Burke, Tess O’Leary, Sharon Chi Tak Lee , and Caroline Mantei 14. Self-disclosure online and offline: the Effect of Age 88 Yadviga Sinyavskaya and Olessia Koltsova 15. A frame effect in Avatar Customization: how users’ attitudes towards their avatars 92 may change depending on virtual context Stefano Triberti, Ilaria Durosini, Filippo Aschieri, Daniela Villani , and Giuseppe Riva 16. How virtual embodiment affects episodic memory functioning: a proof-of-concept 98 study Cosimo Tuena, Silvia Serino, Alexandre Gaston-Bellegarde, Eric Orriols, Dominique Makowski, Giuseppe Riva, Pascale Piolino Section V. Clinical Observations 17. Virtual reality-based software for the treatment of fibromyalgia: a case study 105 Ferran Vilalta-Abella, Marta Ferrer-Garcia, and José Gutiérrez-Maldonado 18. Two-phases innovative treatment for anorexia nervosa: The potential of virtual reality 111 body-swap Silvia Serino, Alice Chirico, Elisa Pedroli, Nicoletta Polli, Chiara Cacciatore, and Giuseppe Riva 19. VR-based cue-exposure therapy (VR-CET) versus VR-CET plus pharmacotherapy in 116 the treatment of bulimic-type eating disorders Joana Pla-Sanjuanelo, Marta Ferrer-Garcia, Ferran Vilalta-Abella, Giuseppe Riva, Antonios Dakanalis, Joan Ribas-Sabaté, Alexis Andreu-Gracia, Fernando Fernandez-Aranda, Isabel Sánchez, Neli Escandón-Nagel, Osane Gomez-Tricio, Virgínia Tena, and José Gutierrez-Maldonado 20. An Initial Validation of Virtual Human Administered Neuropsychological Assessments 123 Thomas D. Parsons, Paul Schermerhorn, Timothy Mcmahan, Justin Asbee and Nicole Russo 21. Preventing Post-Traumatic Intrusions using Virtual Reality 129 Sarah Page and Matthew Coxon 22. Behavioral, craving, and anxiety responses among light and heavy drinking college students in alcohol-related virtual environments 135 Alexandra Ghiţă, Marta Ferrer-Garcia and José Gutiérrez-Maldonado 23. Exploring the relationship between the acceptability of a Flying phobia treatment delivered via the Internet and clinical outcomes 141 Soledad Quero, Daniel Campos, Adriana Mira, Diana Castilla, Cristina Botella and Juana Bretón-López 24. Does owning a “fatter” virtual body increase body anxiety in college students? 147 Marta Ferrer-Garcia, Bruno Porras-Garcia, Cristina González-Ibañez, Mireia Gracia-Blanes, Ferran Vilalta-Abella, Joana Pla-Sanjuanelo, Giuseppe Riva, Antonios Dakanalis, José Achotegui-Loizate, Antoni Talarn-Caparrós, Joan Ribas- Sabate, Alexis Andreu-Gracia, Marina Díaz-Marsa, Miquel Monràs-Arnau, Eduardo Serrano-Troncoso, Janet Treasure, and José Gutiérrez-Maldonado 25. Influence of Simulation Fidelity on Perceived Simulation Realism – An Exploratory Study on a Virtual Public Speaking Training Application 154 Mariia Dubiago, Sandra Poeschl, and Nicola Doering Section VI. Work In Progress 26. Revenge Porn: Findings from the Harassment and Revenge Porn (HARP) Survey – 161 Preliminary Results Emma Short, Antony Brown, Melanie Pitchford, And James Barnes 27. Towards a Mobile Application for Monitoring and Reporting Mobile Victimisation 167 among South African High School Students Shallen Lusinga and Michael Kyobe 28. Automation of Community-Based HIV and STI Testing Service 174 Richard Boyle Section VII. Brief Communication 29. Chronic pain treatment through Virtual Reality 181 Danilo Guarino, Filippo La Paglia, Marco Daino, Valerio Maiorca, Salvatore Zichichi, Filippo Guccione, Ambra Pintabona, Mark D Wiederhold, Giuseppe Riva, Brenda K Wiederhold, and Daniele La Barbera 30. Triggering and measuring social inhibitory response in humans immersed in interactions with virtual humans 185 Godson Ahamba, David Roberts and Peter Eachus 31. Video games as learning tools at school: parents’ attitude 189 Claudia Carissoli, Daniela Villani, Melissa Caputo and Stefano Triberti 32. Acceptability of positive technologies by patients with eating disorders: Results from 192 a Randomized Control Trial Ángel Enrique, Juana M. Bretón-López, Guadalupe Molinari, Soledad Quero and Cristina Botella 33. “Positive Bike” – An Immersive Biking Experience for Combined Physical and 196 Cognitive Training of Elderly Patients Andrea Gaggioli, Luca Greci, Sara Arlati, Marco Stramba-Badiale, Elisa Pedroli, Desirée Colombo, Silvia Serino, Pietro Cipresso, and Giuseppe Riva 34. Exploring the impact of hand movement delays and hand appearance on myoelectric prosthesis embodiment using Immersive Virtual Reality 200 Andrew Hodrien, Adam Galpin, David Roberts, and Laurence Kenney 35. Longer the Game, Better the Sleep: Intense Video Game Playing is Associated to Better Sleep Quality and Better Daytime Functioning 204 Sara Peracchia, Stefano Triberti, and Giuseppe Curcio 36. Web-based, self-help intervention for Adjustment Disorders: acceptance and usability 207 Iryna Rachyla, Soledad Quero, Marian Pérez-Ara, Mar Molés, Daniel Campos and Adriana Mira 37. The Effect of Immersion and Presence in a Virtual Reality Public Speaking Task 211 Luke Wilsdon and Chris Fullwood Subject Index 214 Author Index 216 116 Annual Review of Cybertherapy and Telemedicine 2017 VR-based cue-exposure therapy (VR-CET) versus VR-CET plus pharmacotherapy in the treatment of bulimic-type eating disorders Joana PLA-SANJUANELOa*, Marta FERRER-GARCIAa, Ferran VILALTA- ABELLAa, Giuseppe RIVAb,c, Antonios DAKANALISd, Joan RIBAS-SABATÉe, Alexis ANDREU-GRACIAe, Fernando FERNANDEZ-ARANDAf, Isabel SÁNCHEZf, Neli ESCANDÓN-NAGELg, Osane GOMEZ-TRICIOh, Virgínia TENAi, and José GUTIERREZ-MALDONADOa. a Department of Clinical Psychology and Psychobiology, Universitat de Barcelona, Spain b Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy c Applied Technology for Neuropsychology Laboratory, Istituto Auxologico Italiano, Milan, Italy d Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy e Department of Psychiatry and Mental Health, Igualada General Hospital, Spain f Department of Psychiatry, University Hospital of Bellvitge-IDIBELL and CIBEROBN, Spain g Department of Psychology, Temuco Catholic University, Chile h Department of Psychiatry, University Hospital Joan XXIII, Spain i Centro ABB Tarragona, Spain Abstract. Treatment guidelines recommend antidepressant medication for bulimic- type eating disorders either as an alternative to or in combination with cognitive behavioural therapy (CBT). This study compared the efficacy of two second-line treatments of patients with bulimic-type eating disorders resistant to CBT: virtual reality- based cue-exposure therapy (VR-CET) alone or VR-CET in combination with pharmacotherapy. Results showed that bingeing episodes, bulimic symptomatology (the bulimia EDI-3 score) and food cravings (FCQ-T/S) were significantly reduced after both interventions. However, no significant differences were found between the combined intervention and VR-CET alone. Improvements from the treatments continued at the 6- month follow-up. Our results support the use of VR-CET as an effective treatment of bulimic-type eating disorders, reducing bulimic symptoms and food cravings. The addition of antidepressants to VR-CET does not provide any additional benefit. *Corresponding author:joanapla@ub.edu. J. Pla-sanjuanelo et al. / VR-based cue-exposure therapy (VR-CET) versus VR-CET plus 117 pharmacotherapy in the treatment of bulimic-type eating disorders Keywords: virtual reality, cue-exposure therapy, clinical sample, food cravings, bulimic-type disorders, binge eating 1. Introduction Bulimic-type eating disorders represent a public health problem according to World Mental Health (WMH) surveys, affecting a broad section of the population [1, 2]. These disorders include both bulimia nervosa (BN) and variants of BN, of which binge eating disorder (BED) is the most common [1]. Cognitive behavioural therapy (CBT) is the first-choice treatment for BN and BED [3, 4]. Although several studies support the efficacy of CBT in treating BE and the psychopathology associated with BN and BED [5], a significant percentage of patients do not improve after undergoing CBT [6]. Treatment guidelines recommend antidepressant medication for bulimic-type eating disorders either as an alternative to or in combination with CBT [7]. Based on studies showing serotonin system dysfunctions in BN and BED, selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine) are the most commonly prescribed antidepressants, reducing binge eating in patients with bulimic-type eating disorders [8]. In general, randomised controlled trials (RCTs) suggest that combination therapies with certain antidepressants yield better results than pharmacotherapy alone, but are not more effective than psychotherapy alone [3, 8, 9]. Cue-exposure therapy (CET), an exposure-based extinction technique [10], has also been proposed as an effective second-line treatment for patients who show poor or no response to previous CBT and pharmacological therapy, reducing binge eating and other psychopathological symptoms in clinical patients [11, 12]. Several constraints of CET have led to its adaptation to virtual reality technology (virtual reality-based cue-exposure therapy (VR-CET)) [13]. VR-CET has been reported to reduce food cravings and anxiety [14], as well as eliminating episodes of binge eating in a BN patient [15] after systematic exposure to virtual food-related contexts and cues. In view of these findings, the present study aimed to compare the efficacy of two second- line treatments of patients with BN and BED resistant to CBT: VR-CET alone or in combination with pharmacotherapy. 2. Methods 2.1 Participants and procedure The sample comprised of 32 outpatients of both sexes diagnosed with BN (n=16) or BED (n=16), according to DSM-5 criteria [16], and presenting active episodes of binge eating behaviour after an initial structured course of CBT. Participants were referred from five collaborating hospitals in Tarragona (Spain), Barcelona (Spain) and Milan (Italy). Seventeen participants were taking a constant dose of antidepressant medication (i.e., fluoxetine) at the beginning of VR-CET and were allocated to the combined second- 118 J. Pla-sanjuanelo et al. / VR-based cue-exposure therapy (VR-CET) versus VR-CET plus pharmacotherapy in the treatment of bulimic-type eating disorders line intervention (VR-CET plus pharmacotherapy), while the other 15 participants underwent VR-CET alone. Due to the non-random patient allocation, we ensured that participants assigned to each group did not differ significantly in terms of sex, age, diagnostic rates, measured body mass index (kg/m2), frequency of binge eating episodes, self-reported bulimic symptoms and food cravings assessed prior to the interventions (all p values > .05). During the first session, participants were also assessed by validated VR- based cue-exposure software [14] to construct the exposure hierarchy of 3D interactive situations (environment and food) for use in the VR-CET sessions. The software creates an exposure hierarchy as a result of combining four VR scenarios (kitchen, dining room, bedroom and cafe) and the 10 food items each participant selected as the ones producing the highest levels of craving from a list of 30 virtual food items. Both interventions consisted of six twice-weekly individual 60-minute sessions over three weeks. During each VR-CET session, participants were exposed to their corresponding virtual environments and food based on the previously established hierarchy. Participants could interact within the virtual environments in real time and move around the scenario, sit at a table, and handle the food displayed using the keyboard and the laptop's mouse. Once seated, craving and anxiety levels were assessed periodically in the participants on a visual analogue scale from 0 to 100. Exposure finished when the reported subjective anxiety decreased by 40% in relation to the level measured when the participant entered the virtual environment. Virtual environments were displayed on a 15.6-inch stereoscopic monitor. Earphones and polarised glasses were also used. 2.2 Measurements Outcome assessment for core behavioural features included frequency (i.e., number) of binge eating episodes during the two weeks prior to beginning the second-line intervention, during the two weeks after the end of the intervention, and during the two weeks after the 6-month follow-up. The 8-item bulimia subscale of the Eating Disorder Inventory™-3 (EDI-3) [17] was administered to assess the self-reported tendency to engage in episodes of uncontrollable overeating (binge eating) at baseline (intake session), at the end of the second-line intervention, and at the 6-month follow-up. To assess food cravings, the State and Trait Food Craving Questionnaire (FCQ-T/S) [18] was also administered at baseline, at the end of the intervention, and at follow-up. 2.3 Statistical analysis Given the limited sample size, the non-parametric Friedman test was used to analyse the intervention effects (baseline vs. post-treatment vs. follow-up) on the psychometric variables of each group (VR-CET plus pharmacotherapy and VR-CET alone). Post-hoc Wilcoxon signed-rank tests were also conducted with a Bonferroni correction applied (resulting in a significance level set at p < .017) to determine specific significant differences in the psychometric variables between the time points (baseline, post-treatment and follow-up) in both groups. Mann-Whitney U test was used to analyse the between-group differences both post- treatment and at follow-up J. Pla-sanjuanelo et al. / VR-based cue-exposure therapy (VR-CET) versus VR-CET plus 119 pharmacotherapy in the treatment of bulimic-type eating disorders 3 Results There was a statistically significant difference in the intervention outcomes tested at the three time points (baseline, post-treatment and follow-up) both in the combined VR- CET plus pharmacotherapy (χ2(11) = 165, p <.001) and the VR-CET alone (χ2(11) = 149, p <.001) groups. Post-hoc analyses revealed significant differences in the frequency of bingeing episodes, the bulimia EDI-3 score, the FCQ-T total score and the FCQ-S total score between the baseline and post-treatment time points, and between the baseline and follow-up time points in both treatment groups (Table 1). As displayed in Figure 1, all participants showed significant reductions in the variables assessed post-treatment and at follow-up. Table 1. Differences in the frequency of bingeing episodes (binges), bulimia symptoms (EDI-B), and trait (FCQ-T) and state (FCQ-S) food cravings between the three time points tested (baseline vs. post-treatment; baseline vs. follow-up; and post-treatment vs. follow-up). Binges EDI-B FCQ-T FCQ-S Combined intervention Z p Z p Z p Z p Baseline - Post-treatment -3.63 <.001 -3.62 <.001 -3.58 <.001 -3.52 <.001 Baseline - Follow-up -3.53 <.001 -3.47 .001 -3.52 <.001 -3.35 .001 Post-treatment - Follow- up -1.63 .102 -1.88 .059 -1.97 .049 -0.42 .674 VR-CET alone Baseline - Post-treatment -3.30 .001 -3.18 .001 -2.73 .006 -2.59 .010 Baseline - Follow-up -2.99 .003 -2.99 .003 -3.29 .001 -2.80 .005 Post-treatment - Follow- up -0.74 .461 -1.18 .238 -1.76 .078 -0.71 .480 120 J. Pla-sanjuanelo et al. / VR-based cue-exposure therapy (VR-CET) versus VR-CET plus pharmacotherapy in the treatment of bulimic-type eating disorders Figure 1. Median of the number of bingeing episodes, bulimic symptoms (EDI-3) and food craving levels (FCQ-T/S) at baseline, post-treatment and 6-month follow-up. Mann-Whitney U test indicated no significant differences between the two intervention groups (combined intervention vs. VR-CET alone) in the number of bingeing episodes (U = 96.5, p = .200, r = .23), bulimic symptoms (U = 106, p = .423, r = .14), and trait (U = 87, p = .126, r = .27) and state food cravings (U = 114, p = .619, r = .09) post-treatment. No significant differences were also found between the two groups for the number of bingeing episodes (U = 106, p = .505, r = .12), bulimic symptoms (U = 102, p = .465, r = .13), and trait (U = 101, p = .451, r = .13) and state food cravings (U = 93, p = .282, r = .19) at follow-up. 4 Conclusions The main objective of this study was to compare the efficacy of two second-line treatments of patients with BN and BED (VR-CET alone vs. VR-CET plus antidepressant medication) who had previously undergone CBT unsuccessfully. In agreement with our previous studies [14, 15], VR-CET reduced the frequency of bingeing episodes, bulimia symptoms and food cravings in CBT-resistant patients. Therefore, VR-CET can be used to improve conventional treatments (i.e., CBT and pharmacotherapy) for bulimic-type eating disorders. Adapting in vivo CET to virtual reality technology offers several advantages such as enabling the therapist to recreate real-world environments containing significant specific stimuli and providing safe contexts for patients, which are generally preferable to full exposure prior to contact with the real world [13]. Our findings support those of other studies investigating the efficacy of pharmacological interventions in both BN and BED [3, 8, 9]. Overall, combined psychotherapy and pharmacotherapy in patients with BN and BED does not provide better results than psychotherapy alone [3]. Our results did not show significant differences in the frequency of bingeing episodes, bulimia symptoms and food cravings post-treatment and at the 6-month follow-up between those receiving the combined therapy (VR-CET plus antidepressants) and those undergoing VR-CET alone. This lead us to conclude that the addition of antidepressants to VR-CET did not provide any additional benefit. Our study had some limitations such as the non-random patient allocation and the lack of a control group that could have led confounder variables to have an effect on the outcomes measured. Furthermore, the small size of the sample makes it difficult to generalise the present results. Despite these limitations, our study supports the application of VR-CET in clinical settings and provides evidence that VR-CET is a valid and useful tool for enhancing CBT in BN and BED patients either alone or in combination with medication. Acknowledgements This study was supported by the Spanish Ministry of Science and Innovation (MINECO/FEDER/UE; project PSI2011-28801, “Virtual Reality Cue-Exposure Treatment for Bulimia Nervosa”). J. Pla-sanjuanelo et al. / VR-based cue-exposure therapy (VR-CET) versus VR-CET plus 121 pharmacotherapy in the treatment of bulimic-type eating disorders References [1] R. C. Kessler, P. A. Berglund, W. T. Chiu, A. C. Deitz, J. I. Hudson, V. Shahly, …. R. 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