Ebook: Annual Review of Cybertherapy and Telemedicine 2013

ARCTT is a peer-reviewed all-purpose journal covering a wide variety of topics of interest to the mental health, neuroscience, and rehabilitation communities. The mission of ARCTT is to provide systematic, periodic examinations of scholarly advances in the field of CyberTherapy and Telemedicine through original investigations in the telemedicine and cybertherapy areas, novel experimental clinical studies, and critical authoritative reviews.

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 seven main sections:

1. Editorial: This introductory text expresses the position of the Editors – Brenda K. Wiederhold and Giuseppe Riva – about the focus of this year's issue;

2. White Paper: This introductory chapter states the position of the International Association of CyberPsychology, Training, and Rehabilitation (iACToR – http://iactor.ning.com/) about critical issues for the future of the field;

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

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

5. Original Research: These chapters include research studies which address new cybertherapy methods or approaches;

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

7. Work in Progress: These chapters include papers describing 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.

We are grateful to Chelsie Boyd from the Virtual Reality Medical Institute for her 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 make an improvement to healthcare systems.

Brenda K. Wiederhold, Secretary General, iACToR

Giuseppe Riva, President, iACToR

The European Commission identified active and healthy ageing as a societal challenge common to all European countries, and an area which presents considerable potential for Europe to lead the world in providing innovative responses to this challenge (http://ec.europa.eu/active-healthy-ageing). To tackle the challenge of an ageing population, the European Commission launched the European Innovation Partnership (EIP) on Active and Healthy Ageing. What can cyberpsychology offer to this process? After presenting the main features of cyberpsychology, this paper identifies in patient engagement and positive technologies the key assets that will allow the technological innovations constantly being developed to provide greater help and care in enabling elderly people to live more normal, happier, fulfilling lives.

Despite the fact that older adults are healthier than in the past, the current trend of an ageing population implies an increased risk and severity of chronic diseases. Low-resource healthcare systems face increased organizational healthcare costs, which is likely to result in an allocation of limited health resources. Healthcare organizations themselves must deal with patients' increasing need for a more active role in all the steps of the care & cure process. Technological advances may play a crucial role in sustaining people's health management in daily life, but only if it is “ecologically” designed and well-attuned to people's health needs and expectations. Healthcare is more and more called to orient innovative research approaches that recognize the crucial role of a person's engagement in health and well-being. This will enable patients to reach a higher quality of life and achieve a general psychophysical well-being. Thus, positive technological innovation can sustain people's engagement in health and invoke community empowerment, as we shall discuss in this document.

Several approaches to the treatment of bulimia nervosa have proved effective, including cognitive–behavioral therapy; however, not all patients improve. It is therefore necessary to explore the possibilities of increasing the efficacy of such treatments. One way to attempt this is to incorporate new technologies. This review explores the possibility of developing a new, empirically validated procedure for the treatment of bulimia nervosa patients that involves cue exposure via virtual reality.

The presence of interactive technologies both in field and laboratory research settings makes new instruments and new methodological perspectives to have a complete view of the processes taking place in the setting. This contribution suggests that recording data and taking the researcher position in the setting into consideration may enrich the data production process.

Virtual training applications with high levels of immersion or fidelity (for example for social phobia treatment) produce high levels of presence and therefore belong to the most successful Virtual Reality developments. Whereas display and interaction fidelity (as sub-dimensions of immersion) and their influence on presence are well researched, realism of the displayed simulation depends on the specific application and is therefore difficult to measure. We propose to measure simulation realism by using a self-report questionnaire. The German VR Simulation Realism Scale for VR training applications was developed based on a translation of scene realism items from the Witmer-Singer-Presence Questionnaire. Items for realism of virtual humans (for example for social phobia training applications) were supplemented. A sample of N = 151 students rated simulation realism of a Fear of Public Speaking application. Four factors were derived by item- and principle component analysis (Varimax rotation), representing Scene Realism, Audience Behavior, Audience Appearance and Sound Realism. The scale developed can be used as a starting point for future research and measurement of simulation realism for applications including virtual humans.

Recently, many studies demonstrated the efficacy of using Virtual Reality (VR) in clinical setting, and in particular for neuropsychological assessment. However reliability and usability of the test developed within virtual reality paradigm are often neglect. In this study we test both reliability and usability using well-known psychometrics methods for the Virtual Multiple Errands Test (VMET). In a first experiment, for the reliability, two independent researchers scored the test through several videos. For the usability assessment we analyzed 21 healthy participants and 3 patients with Parkinson's disease.

New electroencephalography (EEG) devices, more portable and cheaper, are appearing on the market. Studying the reliability of these EEG devices for emotional studies would be interesting, as these devices could be more economical and compatible with Virtual Reality (VR) settings. Therefore, the aim in this work was to validate a low-cost EEG device (Emotiv Epoc) to monitor brain activity during a positive emotional induction procedure. Emotional pictures (IAPS) were used to induce a positive mood in sixteen participants. Changes in the brain activity of subjects were compared between positive induction and neutral conditions. Obtained results were in accordance with previous scientific literature regarding frontal EEG asymmetry, which supports the possibility of using this low-cost EEG device in future mood induction studies combined with VR.

In the last decade, Virtual Reality has encountered a continuous development concerning medical purposes and there are a lot of devices based on the classic “cyberglove” concept that are used as new therapeutic method for upper limb pathology, especially neurologic problems [1;2;3]. One of the VR devices is Pablo (Tyromotion), with very sensitive sensors that can measure the hand grip strenght and the pinch force, also the ROM (range of motion) for all the joints of the upper limb (shoulder, elbow, wrist) and offering the possibility of interactive games based on Virtual Reality concept with application in occupational therapy programs. We used Pablo in our study on patients with hand surgery as an objective tool for assessment and as additional therapeutic method to the classic Rehabilitation program [4;5]. The results of the study proved that Pablo represents a modern option for evaluation of hand deficits and dysfunctions, with objective measurement replacement of classic goniometry and dynamometry, with computerized data base of patients with monitoring of parameters during the recovery program and with better muscular and neuro-cognitive feedback during the interactive therapeutic modules.

Of the available training methods for emergency responders, including other methods based on computer technology, virtual reality video game training with haptics (tactile) features will be shown to provide the most effective transfer of skills to real-world emergency situations, providing a model for the development of new training products for combat medics and civilian first responders. This paper aims to provide a methodological case study of haptics use in medical training programs and highlight achievements in terms of performance. Review of these cases show that the addition of haptics to an existing simulation-based training program increases user performance in terms of completion time, error rates, and learning rate. With this case study, haptics can be further incorporated into training programs designed for military combat medics.

Smoking has increasingly become a burden on America's health and economic status. The fact that four out of every five adult smokers begins tobacco use before the age of eighteen indicates a need for teenage smoking cessation programs. The Virtual Reality Medical Center created an internet-based program that addresses the issue by utilizing cue exposure therapy in home and school environments to teach teens which cues trigger nicotine cravings and how to combat those cravings. The effectiveness of the program was measured through questionnaires administered before and after its use. Results indicated that the participants were engaged in the virtual environment, and that, in every aspect of the program, at least 8% more participants were knowledgeable about the subject than prior to the use of the program. Success of such a program could reduce teen smoking rates, ultimately leading to reduced smoking mortalities, complications, and costs overall.

Flow is an optimal experience characterized by the perception of high challenges and high skills, positive affect, complete absorption in the activity carried out and intrinsic motivation. Although much research has examined the psychological features of flow, little is known about its biological underpinnings. The present study aimed at contributing to this gap by investigating the psychophysiological correlates of flow experience during daily routines. To this end, 15 university students took part in an experience sampling study, in which they provided real-time information on daily activities and associated experience while cardiac activity was monitored. After seven days of observation, 32 flow events were identified among 10 participants. A multilevel regression analysis revealed a significant correlation between optimal experience and specific cardiovascular indexes. In particular, the experience of flow was associated with increased heart rate and increased LF/HF ratio, suggesting relative sympathetic enhancement. These findings are in line with those obtained by previous related studies and indicate the feasibility of investigating physiological correlates of subjective experience in ecological contexts.

Nightlife well-being interventions, although much needed, face several challenges related to the specificity of the context addressed. We argue that a game-facilitated intervention helps with facing these challenges. The characteristics of a game developed to this goal and the results of user tests conducted in situ are presented.

The impact of perceptual visual cues on spider phobic reactions has been thoroughly investigated over the last years. Although the fear of being touched by a spider is part of the clinical picture of spider phobia, findings on the impact of tactile fear cues are rare. This study uses virtual reality to selectively apply visual and tactile fear cues. Self-reported fear and the experience of presence in VR were measured in 20 phobic and 20 non-phobic participants. All participants were repeatedly exposed to visual cues, tactile cues, the combination of both and no fear relevant perceptual cues. Participants were exposed in each condition for five times in random order. Results show that tactile fear cues have the power to trigger fear independent of visual cues. Participants experienced highest levels of presence in the combined and the control condition. Presence may not only be seen in association with the emotional impact of specific cues in VR but also appears to depend on the comparability of a virtual environment to a real life situation.

We report the results of a preliminary study testing the effect of participants' mood rating on visual motor performance using a haptic device to manipulate a cartoonish human body. Our results suggest that moods involving high arousal (e.g. happiness) produce larger movements whereas mood involving low arousal (e.g. sadness) produce slower speed of performance. Our results are used for the development of a new haptic virtual reality application that we briefly present here. This application is intended to create a more interactive and motivational environment to treat body image issues and for emotional communication.

In this paper we present data from a cross-sectional study on cyberbullying experiences and cyberbullying perpetration in the Republic of Cyprus. Data were collected from a representative sample of the adolescent student population of the first and fourth grades of high school. Total sample was 2684 students, 48.5% of them male and 51.5% female. Research material included extended demographics, a detailed questionnaire on Internet activities, the Parental Bonding Index (PBI) and the Strengths and Difficulties Questionnaire (SDQ). We compared the results on psychometry for those students who did not report being bullied or having bullied others with those who were bullied, those who bullied others and those who were both sufferers and perpetrators of cyberbullying. Those students who reported being both victims and perpetrators tended to show similar or higher dysfunction than those students who only perpetrated cyberbullying. High maternal and paternal protection in combination with low maternal and paternal care (‘affectionless control’ parenting style) was associated with perpetrating cyberbullying, either with or without any experience of oneself being bullied as well. Results support a hypothesis that the perpetration of cyberbullying is associated with inefficient parenting styles. They also point to the existence of significant emotional symptoms for the involved adolescents and also general conduct problems, hyperactivity, peer problems and antisocial tendencies. It is important to note that perpetrators of cyberbullying were in most cases victims themselves at some point in time.

In this paper we present the results of a cross-sectional survey designed to ascertain Internet and personal computer (PC) addiction in the Republic of Cyprus. This is a follow-up to a pilot study conducted one year earlier. Data were collected from a representative sample of the adolescent student population of the first and fourth grades of high school. Total sample was 2684 students, 48.5% of them male and 51.5% female. Research material included extended demographics and an Internet security questionnaire, the Young's Diagnostic questionnaire (YDQ), the Adolescent Computer Addiction Test (ACAT). Results indicated that the Cypriot population had comparable addiction statistics with other Greek-speaking populations in Greece; 15.3% of the students were classified as Internet addicted by their YDQ scores and 16.3% as PC addicted by their ACAT scores. Those results are among the highest in Europe. Our results were alarming and have led to the creation of an Internet and PC addiction prevention program which will focus on high-school professor training and the creation of appropriate prevention material for all high-schools, starting immediately after the conclusion of the pan-Cypriot survey, focusing especially on those areas where the frequency of addictive behaviors will be highest.

Freeman et al. reported that a substantial minority of the general population has paranoid thoughts while exposed in a virtual environment. This suggested that in a development phase of a virtual reality exposure system for paranoid patients initially a non-clinical sample could be used to evaluate the system's ability to induce paranoid thoughts. To increase the efficiency of such an evaluation, this paper takes the position that when appropriately primed a larger group of a non-clinical sample will display paranoid thoughts. A 2-by-2 experiment was conducted with priming for insecurity and vigilance as a within-subject factor and prior-paranoid thoughts (low or high) as a between-subjects factor. Before exposure into the virtual world, participants (n = 24) were shown a video and read a text about violence or about mountain animals. While exposed, participants were asked to comment freely on their virtual environment. The results of the experiment confirmed that exposure in a virtual environment could induce paranoid thought. In addition, priming with an aim to create a feeling of insecurity and vigilance increased paranoid comments in the non-clinical group that otherwise would less often exhibit ideas of persecution.

Poor adherence to drug therapies still represents an unsolved problem. In order to provide a useful solution to chronic patients of all ages – with particular attention to the elderly – who are subjected to complex therapeutic regimen, an innovative ICT solution, called Dr.Drin, has been designed and tested . The aim of the developed framework is to assist the patient during the therapy and to enable and support a bidirectional communication between all healthcare stakeholders (doctors, caregivers and family members) and the patient. During the screening phase, patients were interviewed to understand what are the common practices they usually adopt to remember when and how to take a drug. The solutions which they rely the most on are the list of drugs, writing on the packaging, and setting up alarms. Patients who complained about difficulties of adherence and who had a smartphone were subsequently recruited to test Dr.Drin over a three-months period. In the following, preliminary results from the first twelve patients are presented and analyzed to prove the effectiveness of Dr.Drin in supporting patients adherence to therapies.

Cue exposure therapy has been reported to be an effective intervention for reducing binge eating behavior in patients with eating disorders and obesity. However, in vivo food exposure conducted in the therapist's office presents logistical problems and lacks ecological validity. This study proposes the use of virtual reality technology as an alternative to in vivo exposure, and assesses the ability of different virtual environments to elicit anxiety and craving for food in a non-clinical sample. The results show that exposure to virtual environments provokes changes in reported craving for food. High-calorie food cues are the ones that elicit the highest increases in craving.