inter reality in the treatment of psychological stress in soldiers- rationale and protocol of the...

8/7/2019 Inter Reality in the Treatment of Psychological Stress in Soldiers- Rationale and Protocol of the Inter Stress Project-1

1/13

Coping with Posttraumatic Stress Disorders in Returning Troops,

Wiederhold, B.K.

NATO Science for Peace and Security Series - E:

Human and Societal Dynamics.

Volume 68, 2010

DOI: 10.3233

221

Interreality for the treatment of psychological

stress in soldiers:

rationale and protocol of the INTERSTRESS

project

Andrea GAGGIOLIa,b1

, Alessandra GORINIa, Brenda WIEDERHOLD

c, Federica PALLAVICINI

a,d, Simona

RASPELLIa, Davide ALGERI

aand Giuseppe RIVA

a,b

aIstituto Auxologico Italiano IRCSS, Applied Technology for Neuro-Psychology Laboratory, Milan, Italy

bDepartment of Psychology, Catholic University of Milan, Italy

cVirtual Reality Medical Center, San Diego, CA, USA

dUniversity of Milano Bicocca, Italy

Abstract. The use of virtual reality is not new in the treatment of psychological stress and anxiety disorders:

virtual worlds are used to facilitate the activation of the stressful events during the exposure therapy.

However, during the therapy, the virtual worlds are new and distinct realms, separate from the real-life

emotions and behaviors. In fact, the patients behavior in the virtual world has no direct effects on his/her

real-life experience, and emotions and problems experienced by the patient in the real world are not directly

addressed in the virtual exposure. In this paper we present the INTERSTRESS project, a new technological

paradigm for the treatment of psychological stress in soldiers, based on interreality. The main feature ofinterreality is a twofold link between the virtual and the real worlds: (a) behavior in the physical world

influences the experience in the virtual one; (b) behavior in the virtual world influences the experience in the

real one. This is achieved through 3D shared virtual worlds; biosensors and activity sensors (from the real to

the virtual world); and personal digital assistants and/or mobile phones (from the virtual world to the real one).

We will describe the different technologies involved in the interreality approach and the clinical rationale of

the protocol. To illustrate the concept of interreality in practice, a clinical scenario regarding a soldier affected

by acute psychological stress will be also presented and discussed.

Keywords. Psychological stress, virtual worlds, interreality, battlefield stress.

Introduction

The INTERSTRESS project intends to design, develop and test an advanced ICT (Information andCommunication Technology) based solution for the assessment and treatment of psychological stress

occurring in soldiers. According to JAMA [1] psychological stress occurs when an individual perceives that

environmentaldemands tax or exceed his or her adaptive capacity. Stressful experiences are conceptualized

as person-environment transactions, whose result is dependent on the impact of the external stimulus on the

individual. This process is mediated by:

- the persons appraisal of the stimulus: when faced with a stimulus, the subject evaluates its potential

threat (primary appraisal) establishing if it is stressful, positive, controllable, challenging or irrelevant.

1Corresponding Author: Istituto Auxologico Italiano IRCSS, Applied Technology for Neuro-Psychology Laboratory. Via Pellizza

da Volpedo, 41, 20149 Milan, Italy; E-mail: [email protected].


2/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

222

- the personal, social and cultural resources available: facing a significant stimulus, the second appraisal

follows, which is an assessment of the individuals coping resources and options. Secondary appraisals

address what one can do about a specific situation.

- the efficacy of the coping efforts: if required by the appraisal process the individual starts a problem

management phase aimed at regulation of the external stimulus.

Stressful events can vary in a number of ways: duration, severity, predictability, degree of loss of

control, self-confidence of the person experiencing the stress, and suddenness of onset. Accidents, natural

disasters, and military combat can cause high levels of stress and may result in a stress disorder. Stress may

also be the result of a personal crisis, such as being raped or bereaved. Stress disorders that require clinical

attention - adjustment disorders, acute stress disorder, and post traumatic stress disorder (PTSD) - are

pathological because they go beyond expected, normal emotional and cognitive reactions to severe personal

challenges. In the adjustment disorder, a recent increase in life stress precedes what is usually a temporary

maladaptive reaction. In the acute stress disorder and PTSD, changes in behavior, thought, and emotion arelinked to an extremely traumatic stressor. Stressful events can influence the pathogenesis of physical diseases

by causing negative affective states (e.g., feelings of anxiety and depression), which in turn exert direct

effects on biological processes or behavioral patterns that influence disease risk. The way in which people

cope with stress depends on their vulnerability and resilience. Vulnerability increases the likelihood of a

maladaptive response to stress; resilience decreases it. Having a positive self-concept, enjoying new

experiences, and having good interpersonal relationships contribute to resilience.

Today, most clinicians recognize the need for more research on treatments of the stress-related

disorders. They also acknowledge the need to treat stress-related disorders with a combination of the

following components:

acceptance of what the individual is going through;

education and training regarding useful coping responses to stressors;

overcoming fear of trauma-related memories;

cognitive restructuring (e.g., questioning and revising trauma-related schemas).

According to the Cochrane Database of Systematic Reviews [2; 3; 4], the best validated approachcovering both stress management and stress treatment is the Cognitive Behavioral Therapy (CBT) approach.

This approach may include both individual and structured group interventions (10 to 15 sessions) interwoven

with didactics. It also includes in-session didactic materials and experiential exercises (learning to cope with

daily stressors (psychological stress) or traumatic events (PTSD), and optimizing one's use of personal and

social resources) and out-of-session assignments (practicing relaxation exercises and monitoring stress

responses). The CBT approaches also:

- use group members and group leaders as role models (for positive social comparisons and social

support);

- encourage emotional expression;

- replace doubt appraisals with a sense of confidence by means of cognitive restructuring;

- hone skills in anxiety reduction (by progressive muscle relaxation or diaphragmatic breathing and

relaxing imagery), interpersonal conflict resolution, and emotional expression (by means of assertion

training).

The CBT package thus includes both problem-focused (e.g., resource optimization and better planning)

and emotion-focused (e.g., relaxation training, use of emotional support) coping strategies. Even if CBT is

the best validated approach for the treatment of stress, further clinical research is needed to tune existing

protocols and fully exploit its clinical potential. As suggested by Cohen and colleague in their JAMA review

[1]: The development of interventions that can reduce the behavioral and biological sequelae of

psychological stress and the demonstrated efficacy of such interventions in randomized clinical trials would

provide critical data on the clinical importance of this work.

Another critical point is that, because stress-related problems stem from a wide variety of stressors, the

selection of an appropriate treatment depends on a number of factors associated with the way in which


3/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

223

individuals experiencing their own difficulties. The main challenge in treating stress is that it is a very

personal experience. For these reasons the focus for assessment, prediction and treatment has to be the

situated experience of the patient.

1.1.The Project ObjectivesThe main aim of the INTERSTRESS project is to develop a completely new concept for the treatment of

psychological stress defined interreality. This innovative approach combines CBT with a hybrid, closed-loop

empowering experience bridging real and virtual worlds.

From the technological point of view interreality is based on the below devices/platforms:

3D individual and/or shared virtual worlds (3DWs) aimed to provide objective assessments and

provision of motivating feedback. They will be immersive (in the health care centre) or non-immersive (at

home) role-playingexperiences in which one or more users mutually interact through their avatars. 3DWs

provide an advanced social networkservice combined with the general aspects of fully immersive 3D virtual

spaces. Residents can explore the worlds, meetother users, socialize, and participate in individual and group

activities;

personal biomonitoring system (PBS) that connects the real world to the virtual one allowing objective

and quantitative assessment and decision support for treatment. Typically 3DWs are closed worlds that do

not reflect the real activities and the status of their users. In interreality, instead, the PBS is used to track the

emotional/health status of the user and to influence his/her experience in the virtual world (aspect, activity

and access). Data coming from the PBS will be integrated by a data fusion module and analyzed by a

Decision Support System. The PBS will consist of independent lycra-based wearable bands for the

examination of the physiological and behavioral signs. In this way the link between the real and the virtual

worlds will be both in real-time - allowing the development of advanced dynamic biofeedback settings - or

not, to ensure health tracking also in situations where an Internet connection is not immediately available;

personal digital assistants (PDAs) and/or mobile phones that connect the virtual world with the real one

giving an objective assessment and provision of warnings and motivating feedbacks. As explained before,

virtual worlds are closed and have not a direct impact on the real life of the user. On the contrary, in the

interreality paradigm, the social and individual user activity in the virtual world has a direct link with the

users life through a mobile phone/digital assistant. The clinical use of these technologies in the interreality

paradigm is based on a closed-loop concept that involves the use of technology for assessing, adjusting

and/or modulating the emotional regulation of the patient, his/her coping skills and appraisal of the

environment (both virtual, under the control of a clinician, and real, facing actual stimuli) based on a

comparison of the patients behavioral and his/her physiological responses with a baseline (Figure 1).


4/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

224

Figure 1. The INTERSTRESS subsystem

These devices are integrated around two subsystems: the clinical platform (used for the inpatienttreatment, and fully controlled by the therapist) and the personal mobile platform (the real world support,

available to the patient and connected to the therapist) that allow to:

a. monitor the patient behavior and his/her general and psychological status, through an early detection

of symptoms of critical evolutions and a timely activation of the appropriate feedback;

b. monitor the response of the patient to the treatment, supporting the doctors in their therapeutic

decisions.In conclusion, in the INTERSTRESS approach, behaviors in the physical world influences the

experience in the virtual world, and behaviors in the virtual world influences the experience in the real

world.

More in details, the specific objectives of the project are the following:

Objective 1: to design, develop and test an advanced ICT based solution for the diagnosis and

treatment of psychological stress.Actual CBT approach can be crudely described as imagining evokes emotions and the meaning of the

associated feelings can be changed through reflection and relaxation. The interreality-based approach

suggests the following alternative: controlled experience evokes emotions that result in meaningful new

feelings which can be reflected upon and eventually changed through reflection and relaxation (Figure 2).On one side, the assessment will be conducted continuously in the virtual and real worlds tracking the

individuals behavioral and emotional status over time in the context of realistic task challenges. On the other

side, the information will be constantly used to improve both the appraisal and the coping skills of the patient

through a conditioned association between the effective performance state and the task execution behaviors.

The clinical platform and the personal mobile platform will provide:

- an objective and quantitative assessment of symptoms obtained by biosensors and behavioral analysis:


5/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

225

monitoring the patients behavior and his/her psychological status, the system will provide an early detection

of symptoms and a timely activation of feedback in a closed loop approach;

- a decision support for treatment planning through data fusion and detection algorithms that monitor the

patients response to the treatment, supporting the doctors in their therapeutic decisions;- a provision of warnings and motivating feedback to improve the compliance and the long-term

outcome: the sense of presence provided by this approach affords the opportunity to deliver behavioral,

emotional and physiological self-regulation training in an entertaining and motivating way.

Figure 2. The interaction between real and virtual worlds

Objective 2: to obtain an objective and quantitative assessment of psychological stress symptoms.a) Using biosensors and behavioral analysis. A wireless Personal Biomonitoring System (PBS) will

collect, fuse, analyze, and visualize data originating from various sensors integrated to different service

infrastructures. Specifically, the PBS will unobtrusively perform an ecological tracking of full body motion

through a 3D wearable motion analysis platform that integrate the heart rate variability (HRV), the

electrodermal response (EDR) and the peripheral temperature, as well as the EEG. Stressful event

recognition is the most challenging goal since it involves going from raw signals to events related to the

users behavior, physical state, mental state, context, communication with others, etc. Algorithms will be

developed for the detection and recognition of specific trigger events/ external stimuli that have

discriminating potential and may be used by a decision support system for treatment planning and

contextualized guidelines and provisions.

b) Identifying new biomarkers for the evaluation of the interreality therapeutic outcome. These


6/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

226

biomarkers can be measured in blood and/or spittle using existingtechnologies.

Objective 3: to design and develop a decision support system for treatment planning through data

fusion and detection algorithms.

The decision support system will be trained:

- by the therapist, using the patients responses in the virtual environments;

- by the patient, by pressing a stress button in the real world context.

In the therapists office, the system will collect data from different sensors during the virtual reality

experience and will integrate them using a data fusion technique to facilitate the assessment process. These

data will be used by the therapist to initially train the decision support system. On the other side, in the real

world setting, the system will provide contextualized support using advice (warnings and feedback) and

exercises (homework). The patient will train the decision support system by pressing a stress button. This

involves also the development of a flexible, scalable, context-aware, secure, and resilient architecture andtechnologies to enable dynamic management policies that ensure end-to-end secure transmission of data

across heterogeneous local infrastructures and networks, including dynamic networks of tiny insecure sensor

devices.

Objective 4: to test the new interreality paradigm based on a dual-change closed-loop approach.

How is it possible to change a patient? Even if this questions has many different answers, ingeneral change

comes through an intense focus on a particular instance or experience [5]: by exploring it as much as

possible, the patient can relive all of the significant elements associated with it (i.e., conceptual, emotional,

motivational, and behavioral) and make them available for a reorganization.

Within this general model we have the insight-based approach of psychoanalysis, the schema-

reorganization goals of cognitive therapy or the enhancement of experience awareness in experiential

therapies. According to Safran and Greenberg [6], behind each specific therapeutic approach we can find two

different models of change: bottom-up and top-down (Figure 3). These two models of change are focused on

two different cognitive systems, one for information transmission (top-down) and the other for conscious

experience (bottom-up), both of which may process sensory inputs. Even if many therapeutic approaches are

based on just one of the two change models, a therapist usually requires both. Our claim is that bridging

virtual experiences fully controlled by the therapist, used to learn coping skills and emotional regulation -

with real experiences that allows both the identification of any critical stressors and the assessment of what

has been learned using advanced technologies (virtual worlds, biosensors and advanced PDA/mobile

phones) is the best way to address both these two change models.


7/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

227

Figure 3. The Top-Down and Bottom-Up approaches to clinical change

The INTERSTRESS project is interested in validating this approach in the real clinical setting related to

the battlefield stress giving: (i) an objective and quantitative assessment of symptoms using biosensors and

behavioral analysis; (ii) a decision support system for treatment planning based on data fusion and detection

algorithms and (iii) warnings and motivating feedbacks to improve compliance and long-term outcome. To

our knowledge, this is the first attempt worldwide to use this approach in healthcare.

1.2.The Battlefield Stress: When Acute Stress Afflicts SoldiersBattlefield stress is the consequence of man being exposed to the hostile environment of combat [7].

Combat stress is specifically caused by man's feat of the dangers of combat, and is fueled and tempered by

other variables such as morale, cohesion, fatigue, confidence, training and intensity of the combat. The

history shows that a stressed soldier may be a significant problem. In the battles of Faid-Kasserine, the first

major engagements of US forces in World War II, 20 to 34 percent of the casualties were caused not by

direct wounds and disease but by battlefield stress [8]. And the situation is not significantly changed. As

demonstrated recently by Morgan and colleagues [9], acute stress may impair working memory and visuo-

spatial ability even in elite soldiers. In their study, including 184 Special Operations warfighters, stress

exposure impaired visuo-spatial capacity and working memory of the sample, potentially reducing

performance of duty. For these reasons, stress management is a critical issue for the Army. The Field Manual

26-2 provides different techniques and consideration for the management of stress in the US Army operation

[10]. Specifically, it depicts three different and increasing levels of support (Stress Management Module)

based on installation resources:

- Level one: it is designed as a minimum program that includes placement of

pamphlets/brochures/posters around the military community, making sure that welcome packets are provided

to all new members and ensuring sponsorship of new arrivals;

- Level two: it includes level one plus community education classes (learning new skills and activities)

and the use of radio/TV spots;

- Level three: it includes level one and level two plus specific intervention programs conducted byqualified health care professionals. These programs include, as the traditional CBT programs, relaxation

techniques, problem solving, cognitive restructuring and clarification of life goals.

The limitations of this approach is twofold. First, given the limited number of qualified professionals on


8/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

228

the battlefield, treatment is often as simple as giving soldiers time to rest for a few hours or days, to get a

shower and some sleep, and to talk about the feelings they have in the presence of a counselor. Second, in the

civilian population there is a broad spectrum of techniques available; however, the available techniques are

much less when applied to the battlefield. Because the duration of stress and the intensity of the battle

usually also reduce imagination and relaxation abilities, the stress coping strategies requested in the military

context are even more challenging.

In the next paragraph we will suggest the application of the interreality paradigm for the provision of

advanced coping techniques for the treatment of an acute stress disorder occurred in a soldier involved in the

last conflict in Afghanistan.

1.3.The INTERSTRESS Project in PracticeThe clinical scenarioPaolo is a 30-year-old Italian soldier. Four months ago he went to Afghanistan for a Peace Mission,

immediately after his girlfriend decided to interrupt their 5-year relationship. Ten days later his command

was involved in a terrible explosion and 5 of his comrade-in-arms died in front of his eyes. One of them was

also one of his best friend. He was immediately sent back home, but everybody closed to him noticed that he

was completely changed. In particular, Paolo had difficulty accepting the true reality that his girlfriend left

him and his best friend died. Furthermore, he was convinced he lost his job because he felt himself unable to

combat again. These events caused him to think he has lost two of the most important things of his life,

making him feel totally alone. Moreover, Paolo felt like no one can help him: their parents live far away

from him and his friends cannot understand. He though that those who have not directly experienced such a

situation can never really understand it.

What makes the situation even more difficult is the fact that Paolo believes his coping efforts were

ineffective: he believes he had no control over the situation and insufficient resources to cope with such it.

Paolo was exposed to a situation of chronic stress and was manifesting many of the difficulties associated

with psychological stress: indeed he appeared to have effectively dealt with previous stressors but not the

current one (Figure 4).


9/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

229

Figure 4. A schematic view of the INTERSTRESS rationale

1.3.1 The applied protocol

Paolo will first need to accept what he is going through. This will require a cognitive restructuring

activity to allow for re-appraisal of the event followed by education and training regarding useful coping

responses to the type of stressors he is dealing with.

Considering the severity of the situation, the medical military staff decides to send Paolo a therapist.

When he arrives, the therapist welcomes him giving him an immediate sense of being less alone and makes

him begin to feel better.After a short interview and some paper-and-pencil self-report questionnaires, the therapist decides to

apply the INTERSTRESS protocol. He helps Paolo to wear biosensors to monitor his physiological

parameters, explaining him how they work and beginning the education process. Then the therapist

introduces Paolo to the first virtual world, called the Experience Island (Figure 5) where he was

progressively exposed to a virtual traumatic situation similar to the one that he had experienced in

Afghanistan. Within this virtual environment Paolo had to walk in the city streets and to drive a military jeep

in different conditions (from a very safe condition to a very dangerous one). In the meantime the data fusion

system allows the therapist to directly index how the various stressors are impacting Paolos

neurophysiological reactions, thus providing an objective understanding of the different stressors and their

importance and impact on his well-being.


10/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

230

At the end of the clinical session, the therapist prescribes Paolo some homework. This, the therapist

explains, will allow Paolo to be an active participant in his own well-being and to practice the skills he has

started to learn, thus making them become more readily available to him during real-life stressful situations.

The homework: First Paolo is asked to expose himself to the critical situation recorded in the virtual

world and displayed on her PDA. Then he must expose himself to the real world situation. In real world

situations, the biosensors will track his response, and the Decisions Support System, according to the

difference from his baseline profile, will provide positive feedback and /or warnings.

Finally the therapist explains Paolo that he can press a stress button in the PDA if he feels excessively

stressed: this will record the most critical experiences that will be discussed with the therapist in the next

face-to-face session. In this way the therapist will teach the patient how to effectively handle the future

situational stressors.

At the start of any new session, the therapist uses the compliance data and warning log to define the

structure of the clinical work. Also, the Decision Support System will analyze the stressful situationsindicated by Paolo to understand more what happened and the context in which they occurred.

By showing the patient what situations caused him the most physiological arousal, he often develop a

new awareness, that brings on added insight and allows for self-treatment to proceed more effectively.

Moreover, utilizing new skills and coping mechanisms taught by the therapist, the patient is able to employ

these skills prior to stress becoming overwhelming. This is where Virtual Worlds have an immensely

beneficial advantage.

In the following sessions, the virtual world is not only used for assessment but also for training and

education. Within the environment, Paolo has the opportunity to practice different coping mechanisms:

relaxation techniques, emotional/relational management and general decision-making and problem- solving

skills. For example, if Paolos real world outcome is poor (e.g., he can not do a task without feeling irritable

and impatient when his friends and relatives) he will experience again a similar experience in the virtual

environment and will be helped in developing specific strategies for coping with it. Later, in the relaxation

areas he will enjoy a relaxing environment and learn some relaxation procedures. As with any new skill, as

Paolo has the opportunity to practice the coping skills, they become second nature, and these new behaviors

replace the older, outdated behavior patterns which caused the initial overwhelming stress.

The therapist now prompts Paolo to visit another virtual world the Learning Island. Within it, Paolo

learns how to improve his stress management skills and receives information about the main causes of stress

and about how to recognize its symptoms, to learn stress-management skills such as better planning, to learn

stress relieving exercises such as relaxation training and to get the information needed to succeed.

After some other sessions, the therapist invites Paolo to participate in a virtual community where he will

meet other patients who suffer of the same problem. Within this virtual world called Community Island-

Paolo has the opportunity to discuss and share his experience with other users who may be facing a similar

situation.

However, sometimes Paolo experiences new critical situations that may raise his level of stress. For

example, he had to discuss with her boss in the morning and this left him feeling very upset during the rest of

the day. At the end of the work day, when he returned home he felt very excited/stressed and nervous and the

Decision Support System alerted him twice about this. Both the signals were sent also to the therapist who

appeared on his PDA display as an avatar suggesting Paolo to practice some of the acquired relaxation

techniques.


11/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

231

Figure 5. The virtual worlds used in the interreality approach

Paolo is scheduled to see the therapist the next day. The therapist asks him if the avatar was helpful and

his answer is positive: the avatar gave him an emotional boost appearing in the exact moment he needed it

and suggesting him helpful relaxation techniques he had previously learned.

Then the therapist asks Paolo about the experienced difficulties. In particular, the therapist wants to get

information about where Paolo was: what he was doing and thinking, and what his reactions were. Paolo

relates all the information to the therapist: he was in his office and was quarrelling with a colleague, causinghis stress level to become higher. The information provided by Paolo is compared by the therapist with the

information provided by the Decision Support System. Any difference is explored and interpreted.

By working as a team, Paolo is taught a new skill of interpretation, and his therapist is more able to

understand any differences in his self-perception of stress and the objective measurements shown by the

DSS. This will help to more effectively individualize and guide future training and therapy sessions.

In the following sessions, Paolo tells the therapist that he feels better thanks to being able to frequently

experience stressful situations within safe virtual environments. He also says that meeting other people in the

community has helped him to find much-needed support and to discover new strategies to manage his

emotions. With regard to this, he also says the community experience has helped him with seeing the stressor

in a new perspective. Moreover, by listening to others experiences, he was facilitated in adopting new

coping skills.

The therapist helps Paolo to cognitively restructure the critical situation, which now he is more able to

deal with through the strategies he has learned. The last session ends with advice on the prevention ofrelapse.

In general, the patient reports that this kind of highly personalized treatment is very useful because

allows to experience different stressful situations specifically related to his own traumatic experience in a

safe virtual environment. Paolo also reports that receiving correct information about the disorder and meeting

other people is useful for him to find the needed psychological support and to discover new strategies to

manage his negative emotions. Finally, having full-time support through the PDA increases his self-efficacy

and the benefit obtained from the therapy.


12/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

232

1.4.ConclusionIn the last year virtual reality and virtual worlds have been extensively used to facilitate the activation of

certain emotions and to expose patients to specific critical events during the exposure phase of a CBT

protocol. However, the actual virtual reality-based CBT protocols for the treatment of anxiety related

disorders do not address the following issues:

1. Virtual worlds are new and distinct realms, separate from the emotions and behaviors experienced by

the patients in the real world;

2. The treatment protocol is not customized to the particular characteristics of the single patient.

3. CBT focuses on patients thoughts and behaviors but does not address relationship change and self-

efficacy.

On the contrary, the interreality protocol integrates the assessment and treatment within a hybrid

environment, bridging the physical and virtual worlds. The clinical use of interreality is based on a closed-loop concept that involves the use of technology for assessing, adjusting, and/or modulating the emotional

regulation of the patient, his or her coping skills, and appraisal of the environment based on a comparison of

the patients behavioral and physiological responses with a training or performance criterion:

1. The assessment is conducted continuously throughout the virtual and real experiences.

2. The information is constantly used to improve both the emotional management and the coping skills

of the patient.

Finally, the idea to test the interreality protocol on the military members affected by anxiety disorders

caused by the excessive battlefield stress is perfectly in line with the 2006 Army Modernization Plan, an

operationally based report that describe the modernization and investment strategies for providing the best

capabilities to the US Army, supporting a sustained transformation process [11] based on the use of the

emerging technologies.

In conclusion, although CBT focuses on directly modifying the content of dysfunctional thoughts

through a rational and deliberate process, interreality focuses on modifying an individuals relationship with

his or her thinking through more contextualized experiential processes based on: an extended sense of

presence, an extended sense of community, and a real-time feedback between the physical and virtual

worlds. The proposed approach needs to be tested on a sample of patients before being considered a valid

solution for the treatment of anxiety disorder. This is what we will intend to do thanks to the recently funded

European project, INTERSTRESSinterreality in the management and treatment of stress-related disorders

(FP7-247685), that will offer the right context to test and tune the presented ideas.

Acknowledgments

This work was partially supported by the European-funded project INTERSTRESSInterreality in

the management and treatment of stress-related disorders (FP7-247685).

References

[1] S. Cohen, D. Janicki-Deverts, and G.E. Miller, Psychological Stress and Disease. JAMA 298 (2007)

1685-1687.

[2] J. Bisson, and M. Andrew, Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane

Database Syst Rev (2005) CD003388.

[3] K. Rees, P. Bennett, R. West, G. Davey Smith, and S. Ebrahim, Psychological interventions for coronary

heart disease. Cochrane Database of Systematic Reviews (2004) Art. No.: CD002902.


13/13


Wiederhold, B.K.



Volume 68, 2010

DOI: 10.3233

233

[4] A.B. Thomson, and L.A. Page, Psychotherapies for hypochondriasis. Cochrane Database of Systematic

Reviews (2007) Art. No.: CD006520.

[5] B. Wolfe, The Role of Lived Experience in Self- and Relational Observation: A Commentary on

Horowitz. Journal of Psychotherapy Integration12 (2002) 147-153.[6] J.D. Safran, and L.S. Greenberg, Emotion, psychotherapy, and change, The Guilford Press, New York,

1991.

[7] R.J. Hibler, Battlefield stress: management techniques. Military Medicine149 (1984) 5-8.

[8] W.S. Mullins, and A.J. Glass, Neuropsychiatry in World War II. Overseas theatres 2 (1973).

[9] C.A. Morgan, A. Doran, G. Steffian, G. Hazlett, and S.M. Southwick, Stress-induced deficits in working

memory and visuo-constructive abilities in special operations soldiers. Biol Psychiatry 60 (2006) 722-729.

[10] U.S. Army, Management of Stress in Army Operations - Field Manual 26-2, Department of the Army,

Washington, D.C., 1983.

[11] U.S. Army, Army Modernization Plan, Department of the Army, Washington, D.C., 2006.

[1]

inter reality in the treatment of psychological stress in soldiers- rationale and protocol of the...

Documents