Ebook: Annual Review of Cybertherapy and Telemedicine 2012

Healthcare delivery systems have been evolving to rely more heavily on technology. There has been a shift in care diagnosis and treatment which has decreased the importance of traditional methods of care delivery. Technology provides new ways to monitor and treat heart disease, inflammation, infection, cancer, diabetic condition, and chronic conditions. Monitoring technologies and blood work are being used in combination with imaging and telemetrics to provide a real time, continuous evaluation of patients' conditions. In addition, technology has not only helped to extend our lifespan but it has improved the quality of life for all citizens.

We have put a great deal of effort into the definition of the structure of the volume and in the sequence of the contributions, so that those in search of a specific reading path will be rewarded. To this end we have divided the different chapters into five main sections:

1. Critical Reviews: These chapters summarize and evaluate emerging cybertherapy topics, including technology-enhanced rehabilitation, Interreality, and Intersubjectivity;

2. Evaluation Studies: These chapters are generally undertaken to solve some specific practical problems and yield decisions about the value of cybertherapy interventions;

3. Original Research: These chapters research studies addressing new cybertherapy methods or approaches;

4. Clinical Observations: These chapters include case studies or research protocols with long-term potential;

5. Work in Progress: These chapters include papers describing a future research work.

For both health professionals and patients, the selected contents will play an important role in ensuring that the necessary skills and familiarity with the tools are available, as well as a fair understanding of the context of interaction in which they operate.

In conclusion, this volume underlines how cybertherapy has started to make progress in treating a variety of disorders. However, there is more work to be done in a number of areas, including the development of easy-to-use and more affordable hardware and software, the development of objective measurement tools, the need to address potential side effects, and the implementation of more controlled studies to evaluate the strength of cybertherapy in comparison to traditional therapies.

We are also grateful to Chelsie Boyd, Tanisha Croad and Laura Masterton from the Interactive Media Institute for their work in collecting and coordinating chapters for this volume.

We sincerely hope that you will find this year's volume to be a fascinating and intellectually stimulating read. We continue to believe that together we can change the face of healthcare.

Brenda K. Wiederhold

Giuseppe Riva

Introduction: Guided Internet-delivered treatments were developed in the late 1990s and have since been tested in numerous controlled trials. While promising, there are yet few direct comparisons between Internet treatments and traditional face-to-face treatments. The aim of the present study is to present an overview of the evidence in the field of anxiety disorders.

Method: Studies were located, including unpublished trials from our research group in Sweden.

Results: Results of direct comparative trials on panic disorder (n=3) and social anxiety disorder (n=3) show equivalent outcomes. One study on specific phobia did not show equivalent outcomes with an advantage for face-to-face treatment. However, a systematic review by Cuijpers et al. (2010) found equivalent outcomes across several self-help formats, suggesting that guided self-help overall can be as affective as face-to-face treatments.

Conclusion: Overall, there are still few large-scale trials and statistical power is often limited. A preliminary conclusion is that guided Internet treatment can be as effective as face-to-face treatments, but there is a need to investigate moderators and mediators of the outcome.

“Psychological stress” occurs when an individual perceives that environmental demands tax or exceed his or her adaptive capacity. According to the Cochrane Database of Systematic Reviews, the best validated approach covering both stress management and stress treatment is the Cognitive Behavioral (CBT) approach. CBT has undergone a very large number of trials in research contexts. However, it has been less efficacious in clinical contexts and it has become obvious that CBT has some failings when applied in general practice. INTERSTRESS is a EU-funded project that aims to design, develop and test an advanced ICT-based solution for the assessment and treatment of psychological stress that is able to address three critical limitations of CBT: a) the therapist is less relevant than the specific protocol used. b) the protocol is not customized to the specific characteristics of the patient; c) the focus of the therapy is more on the top-down model of change (from cognitions to emotions) than on the bottom-up (from emotions to cognitions). To reach this goal the INTERSTRESS project applies an innovative paradigm for e-health – Interreality – that integrates assessment and treatment within a hybrid environment, bridging physical and virtual worlds. On one side, the patient is continuously assessed in the virtual and real worlds by tracking the behavioral and emotional status in the context of challenging tasks (customization of the therapy according to the characteristics of the patient). On the other side, feedback is continuously provided to improve both the appraisal and the coping skills of the patient through a conditioned association between effective performance state and task execution behaviors (improvement of self efficacy). Within this conceptual framework, it is possible to set up and test psychological treatments that could be extended also beyond the traditional research and clinical setting by using more and more emerging mobile technology to deliver real-time interventions during daily activities and ecological contexts.

This study aimed at measuring objectively the experience of using social network sites (SNSs). At this aim, a model of experience has been defined, focusing on three main aspects of time-space continuum of individuals' states: physiological arousal, emotional valence, and attentional resources. At this purpose we developed a new approach to assess such an experience. The main idea is to consider arousal, valence and attention to track the users' experience collecting psychophysiological indexes at predefined period (for example each 10 seconds) to build an empirical model based on these data. Once we got the empirical curve we can fit these data using mathematical models.

A high percentage of patients with eating disorders (ED) respond to treatments such as cognitive-behavioural therapy. However, some patients do not progress significantly with these treatments, or suffer relapses. The incorporation of new technologies may help to increase the efficacy of standard treatments. Virtual reality has been successfully used to treat body image disturbances in ED patients and seems a suitable technology for cue exposure therapy in this setting. We review the published literature and discuss the results.

This review describes the state-of-the-arttechnologiesthat support mental resilience training for PTSD prevention. It characterizes four current systems across training approaches; seeks insights via interviews with the systemdevelopers; and extracts from thesea set of essential guidelines for future developers. The guidelines include four distinct project-limiting factors, which were found to constrain the reviewed developments. These were Culture, Effectiveness, Engineering, and Resource constraints.This research is novel in reviewing technologiesfor PTSD prevention as opposed to treatment, and in analyzing from the perspective ofsystem development and designissues.

We are entering a new age where people routinely visit, inhabit, play in and learn within virtual worlds (VWs). One in eight people worldwide are VW participants, according to the latest 2011 figures from KZERO [1]. VWs are also emerging as a new and advanced form of telehealth care delivery. In addition to existing telehealth care advantages; VWs feature three powerful affordances that can benefit a wide range of physical and psychological issues. First, the highly social nature of VWs encourages social networking and the formation of essential support groups. Secondly, the type of spaces that have been proven in the physical world to promote psychological health and well-being can be virtually recreated. Finally, research suggests that embodied avatar representation within VWs can affect users psychologically and physically. These three aspects of VWs can be leveraged for enhanced patient-client interactions, spaces that promote healing and positive responses, and avatar activities that transfer real benefits from the virtual to the physical world. This paper explains the mounting evidence behind these claims and provides examples of VWs as an innovative and compelling form of telehealth care destined to become commonplace in the future.

Recent developments in technology have helped to improve the process of psychotherapy. Unfortunately, many therapists lack the computer skills or financial resources needed for the newest technology. Nonetheless, even basic advances in technology may help to improve the treatment of depression.

Method: The literature is reviewed for journal articles on the treatment of depression published during the past seven years in which treatments have been guided by technology.

Results: Six novel findings are summarized that may be helpful even when the therapist lacks skill or resources for advanced technology. 1) The efficient assessment of depression can be facilitated by technology, whether using standardized measures or simple daily ratings of mood. 2) Technology tools can be used to send semi-automated daily reminders to help clients develop more adaptive habits in thoughts or actions. 3) Depressed clients can begin to confront their negative view of self, often triggered by some form of loss, failure, or rejection, whether real, imagined, or anticipated. 4) Clients can confront their problems through therapeutic dialogue, whether conducted in person, over the telephone, or via video conference. 5) Clients can use writing assignments to identify, label, explore and express their thoughts and feelings. These writing assignments can be conducted via paper, email, or internet forms. 6) Clients value rapport with a therapist, and this bond seems important to ensure participation and adherence with treatment.

Conclusion: Even low-tech therapists can strengthen the treatment of depression using basic technology tools to replace, extend, or supplement traditional sessions. However, it is important to protect the rapport needed for sustained participation in therapy.

The goal of this paper is to introduce and describe the “Positive Technology” approach – the scientific and applied approach to the use of technology for improving the quality of our personal experience through its structuring, augmentation and/or replacement – as a way of framing a suitable object of study in the field of cyberpsychology and human-computer interaction. Specifically, we suggest that it is possible to use technology to influence three specific features of our experience – affective quality, engagement/actualization and connectedness – that serve to promote adaptive behaviors and positive functioning. In this framework, positive technologies are classified according to their effects on a specific feature of personal experience. More, for each level we have identified critical variables that can be manipulated to guide the design and development of positive technologies.

Human computer confluence (HCC) is an ambitious research program studying how the emerging symbiotic relation between humans and computing devices can enable radically new forms of sensing, perception, interaction, and understanding. It is an interdisciplinary field, bringing together researches from horizons as various as pervasive computing, bio-signals processing, neuroscience, electronics, robotics, virtual & augmented reality, and provides an amazing potential for applications in medicine and rehabilitation.

The aim of this paper is to demonstrate the potential of positive technology to productively and positively transform the mental health of European and American citizens in the modern era. This work will describe three aspects – hedonic, eudaimonic, and social/interpersonal – of these technologies. We approach them with guarded optimism, as all of them seek to improve our lives through various techniques. After exploring the relevant technologies, this piece will then examine the future for research within this domain.

Introduction. In Psycho-oncology, VR has been utilized mainly to manage pain and distress associated to medical procedures and chemotherapy, with very few applications aimed at promotion of wellbeing in hospitalized patients. Considering this, it was implemented a psychological intervention that uses VR to induce positive emotions on adult oncology inpatients with the purpose of evaluating its utility to improve emotional wellbeing in this population.

Method. Sample was composed of 33 patients (69.7% men, aged from 41 to 85 years old; X=62.1; SD=10.77). Intervention lasted 4 sessions of 30 minutes, along one week. In these sessions, two virtual environments designed to induce joy or relaxation were used. Symptoms of depression and anxiety (Hospital Anxiety and Depression Scale, HADS) and level of happiness (Fordyce Scale) were assessed before and after the VR intervention. Also, Visual Analogue Scales (VAS) were used to assess emotional state and physical discomfort before and after each session.

Results. There were significant improvements in distress and level of happiness after the VR intervention. Also, it was detected an increment in positive emotions and a decrease in negative emotions after sessions.

Conclusions. Results emphasize the potential of VR as a positive technology that can be used to promote wellbeing during hospitalization, especially considering the shortness of the intervention and the advanced state of disease of the participants. Despite the encouraging of these results, it is necessary to confirm them in studies with larger samples and control groups.

This study explores behavioural determinants of defending behaviour in cyberbullying incidents. Three focus groups were conducted with youngsters aged 12–16y. Major themes that were found as important behavioural determinants to defend the victim were a low moral disengagement, that the victim is an in-group member and that the bystander is popular. Bystanders preferred to handle cyberbullying offline and in person, and comforting the victim was considered more feasible than facing the bully. With a high peer acceptance of passive bystanding and lack of parental support for defending behaviour, youngsters do not receive much encouragement from their environment to exhibit defending behaviour towards victims. These preliminary results suggest befriending and peer support interventions hold promise, as well as environmental interventions with parents and teachers. These first results will need to be confirmed in more in-depth analyses and in quantitative research.

In this paper we present the results of a cross-sectional study of the entire adolescent student population aged 12–18 of the island of Kos and their parents, on Internet safety-related practices and attitudes towards the Internet. Total sample was 2017 students and 1214 parent responders. Research material included extended demographics and an Internet security questionnaire, the Internet Attitudes Scale (IAS) for parents and the Adolescent Computer Addiction Test (ACAT) for children and both parents. Both parents thus provided their views on their children's computer use and an estimate for their degree of computer addiction which was tested against their child's self-report. Results indicated that fathers and mothers who had negative views of the Internet, tended to encourage less their children to engage in online activities and worried more for the possibility that their child is addicted to computer use; their worries weren't correlated with their children's results. Parental views on the Internet had no effect on the level of security precautions they employed at home. Those parents who reported a low level of security knowledge and were unsure as to what their children were doing online, tended to consider their children more likely to be addicted to computer use; those views were confirmed by their children' self-reported results.

Novel therapeutic approaches and outcome data are needed for cognitive rehabilitation for patients with a traumatic brain injury; computer-based programs may play a critical role in filling existing knowledge gaps. Brain-fitness computer programs can complement existing therapies, maximize neuroplasticity, provide treatment beyond the clinic, and deliver objective efficacy data. However, these approaches have not been extensively studied in the military and traumatic brain injury population. Walter Reed National Military Medical Center established its Brain Fitness Center (BFC) in 2008 as an adjunct to traditional cognitive therapies for wounded warriors. The BFC offers commercially available “brain-training” products for military Service Members to use in a supportive, structured environment. Over 250 Service Members have utilized this therapeutic intervention. Each patient receives subjective assessments pre and post BFC participation including the Mayo-Portland Adaptability Inventory-4 (MPAI-4), the Neurobehavioral Symptom Inventory (NBSI), and the Satisfaction with Life Scale (SWLS). A review of the first 29 BFC participants, who finished initial and repeat measures, was completed to determine the effectiveness of the BFC program. Two of the three questionnaires of self-reported symptom change completed before and after participation in the BFC revealed a statistically significant reduction in symptom severity based on MPAI and NBSI total scores (p < .05). There were no significant differences in the SWLS score. Despite the typical limitations of a retrospective chart review, such as variation in treatment procedures, preliminary results reveal a trend towards improved self-reported cognitive and functional symptoms.

Even though it is diminishing in Europe, smoking is still a serious health problem. The craving of Nicotine is one of the hardest behaviours to tackle when a smoking cessation programme is implemented. Following on previous work [1], which aimed at evaluating the possibility of inducing smoking craving in smokers using a VR platform, the present study was devised to assess the role of craving in cognitive processing through event related potentials (ERP). From an initial sample of 89 university students (smokers and non-smokers), which was randomly exposed to VR smoking cues and VR non-smoking cue scenarios, a subsample of 13 smokers and non-smokers was drawn. This subsample (M = 23.08; SD = 4.39), which had previously been immersed in the VR smoking cues environment, was presented to a rapid (1 sec) serial of smoking and neutral images. Data on brain activity was recorded through an EEG during this task to further estimate ERPs. When compared to non-smokers, smokers showed higher frontal activation when watching smoking related images.

The aims of the present study are to examine the reliability and validity of the Heart Rate signal registered using two self-made wireless ECG systems, R-Tips and TipsShirt, and to compare them with another commercial ECG device typically used in psychophysiology studies. An ECG simulator was used to artificially generate signals corresponding to different cardiac frequencies. Results of the reliability study showed that the signal acquisition, signal processing and signal transmission were reliable and valid for R-Tips and TipsShirt. Consequently, these wireless ECG prototypes could be used for studies where the freedom of movements of the participants is fundamental without any loss of quality in the registered signals.

Emotion recognition is known to be impaired in schizophrenia patients. Although cognitive deficits and symptomatology have been associated with this impairment there are other patient characteristics, such as alexithymia, which have not been widely explored. Emotion recognition is normally assessed by means of photographs, although they do not reproduce the dynamism of human expressions. Our group has designed and validated a virtual reality (VR) task to assess and subsequently train schizophrenia patients. The present study uses this VR task to evaluate the impaired recognition of facial affect in patients with schizophrenia and to examine its association with cognitive deficit and the patients' inability to express feelings. Thirty clinically stabilized outpatients with a well-established diagnosis of schizophrenia or schizoaffective disorder were assessed in neuropsychological, symptomatic and affective domains. They then performed the facial emotion recognition task. Statistical analyses revealed no significant differences between the two presentation conditions (photographs and VR) in terms of overall errors made. However, anger and fear were easier to recognize in VR than in photographs. Moreover, strong correlations were found between psychopathology and the errors made.

Impaired postural control with muscle weakness is an important predictor of falls within the elderly population.Particular daily activities that require weight shifting in order to be able to reach a specific target (a cup on a table) require continuous adjustments to keep the body's center of mass balanced. In the present study postural control was examined in healthy elderly and young subjects during a task in which subjects had to move the body's center of mass towards a virtual target on a screen that appeared at predictable and unpredictable locations. Postural control decreased with unpredictable targets, e.g. movement time was larger, trajectories more irregular. The results indicate that even though older individuals clearly benefitted from the early release of target location information, young individuals improved even more when target information became available.This indicates thatthe young were better able to use this information prospectively for executing the target directed movement quickly and accurately.

Executive functions are often impaired in obsessive-compulsive disorder (OCD). We used a Virtual Reality version of the Multiple Errand Test (VMET) – developed dusing the free NeuroVR software (http://www.neurovr.org) – to evaluate the executive functions in daily life in 10 OCD patients and 10 controls. It is performed in a shopping setting where there are items to be bought and information to be obtained. The execution time for the whole task was higher in patients with OCD compared to controls, suggesting that patients with OCD need more time in planning than controls. The same difference was found in the partial errors during the task. Furthermore, the mean rank for and for interpretation failures is higher for controls, while the values of divided attention and the of self correction seems to be lower in controls. We think that obsessive patients tend to work with greater diligence and observance of rules than controls. In conclusion, these results provide initial support for the feasibility of VMET as assessment tool of executive functions. Specifically, the significant correlation found between the VMET and the neuropsychological battery support the ecological validity of VMET as an instrument for the evaluation of executive functions in patients with OCD.

Balance training to improve postural control in elderly can contribute to the prevention of falls. Video games that require body movements have the potential to improve balance. However, research about the effects of type of visual feedback (i.e. the exergame) on the quality of movement and experienced workout intensity is scarce. In this study twelve healthy older and younger subjects performed anterior-posterior or mediolateral oscillations on a wobble board, in three conditions: no feedback, real-time visual feedback, and real-time visual feedback with a competitive game element. The Elderly moved slower, less accurately and more irregularly than younger people. Both feedback conditions ensured a more controlled movement technique on the wobble-board and increased experienced workout intensity. The participants enjoyed the attention demanding competitive game element, but this game did not improve balance performance more than interacting with a game that incorporated visual feedback. These results show the potential of exergames with visual feedback to enhance postural control.

Stroke patients often suffer from hemiparesis, which affects their balance condition and consequently their self-dependency and quality of life. Balance rehabilitation can be a long and tedious process. Virtual rehabilitation systems have been reported to provide therapeutic benefits to the balance recovery of stroke patients while increasing their motivation. This paper presents a follow-up study involving chronic stroke patients to evaluate the clinical effectiveness of a virtual stepping exercise using skeleton tracking through a low-cost Kinect depth sensor.

The goal of this study was to assess effectiveness of a short collective stress inoculation training (SIT) conducted according to the methodology of the Virtual Reality Medical Center of San Diego (Training of Physiological Control Exposure to Virtual Stressor while Maintaining Physiological Control). The results obtained indicate a short-term effectiveness of the training as a method of tension reduction. However, in the long-term perspective these results are ambiguous and they suggest a need of further research. In order to extend the analysis effects of temperamental factors on training effectiveness was presented.