Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose: Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches. Findings: There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances. Summary: This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required

The Use of Virtual Reality in Craving Assessment and Cue-Exposure Therapy in Substance Use Disorders

Craving is recognized as an important diagnosis criterion for substance use disorders (SUDs) and a predictive factor of relapse. Various methods to study craving exist; however, suppressing craving to successfully promote abstinence remains an unmet clinical need in SUDs. One reason is that social and environmental contexts recalling drug and alcohol consumption in the everyday life of patients suffering from SUDs often initiate craving and provoke relapse. Current behavioral therapies for SUDs use the cue-exposure approach to suppress salience of social and environmental contexts that may induce craving. They facilitate learning and cognitive reinforcement of new behavior and entrain craving suppression in the presence of cues related to drug and alcohol consumption. Unfortunately, craving often overweighs behavioral training especially in real social and environmental contexts with peer pressure encouraging the use of substance, such as parties and bars. In this perspective, virtual reality (VR) is gaining interest in the development of cue-reactivity paradigms and practices new skills in treatment. VR enhances ecological validity of traditional craving-induction measurement. In this review, we discuss results from (1) studies using VR and alternative virtual agents in the induction of craving and (2) studies combining cue-exposure therapy with VR in the promotion of abstinence from drugs and alcohol use. They used virtual environments, displaying alcohol and drugs to SUD patients. Moreover, some environments included avatars. Hence, some studies have focused on the social interactions that are associated with drug-seeking behaviors and peer pressure. Findings indicate that VR can successfully increase craving. Studies combining cue–exposure therapy with virtual environment, however, reported mitigated success so far

Predictors of Changes in alcohol craving levels during a virtual reality cue exposure treatment among patients with alcohol use disorder

Background/Objective: Determining the predictive variables associated with levels of alcohol craving can ease the identification of patients who can benefit from treatments. This study aimed to describe changes (improvement or no change/deterioration) in alcohol craving levels and explore the predictors of these changes from admission to discharge in outpatients with alcohol use disorder (AUD) undergoing treatment-as-usual (TAU), or treatment-as-usual supplemented with virtual reality cue-exposure therapy (TAU + VR-CET). Method: A prospective cohort study was conducted amongst 42 outpatients with AUD (n = 15 TAU + VR-CET and n = 27 TAU) from a clinical setting. Changes in the levels of alcohol craving between admission and discharge were assessed with the Multidimensional Alcohol Craving Scale. Sociodemographic characteristics (age, gender, education, and socioeconomic and civil status), cognitive-a ective behavioral patterns (AUD severity, abstinence duration, psychiatric comorbidity, state anxiety, attentional bias, and substance use), and type of treatment (TAU + VR-CET and only TAU) were also evaluated. Results: The TAU + VR-CET group showed greater changes of improvement in the levels of alcohol craving than the TAU group ( 2 = 10.996; p = 0.001). Intragroup changes in alcohol craving from pre to post-treatment were significant in the TAU + VR-CET group ( 2 = 13.818; p = 0.003) but not within the TAU group ( 2 = 2.349; p = 0.503). The odds of an improvement in any of the craving levels between pre- and post-test was 18.18 (1/0.055) times higher in the TAU + VR-CET group with respect to the TAU group. The use of illicit drugs in the month prior to the test increased the odds of having a positive change by 18.18 (1/0.055) with respect to not having consumed. Conclusions: Including VR-CET in TAU programs may provide benefits in the treatment of AUDs mainly among patients with intense alcohol craving and individuals having used illicit substances prior to treatment

Cue-exposure software for the treatment of bulimia nervosa and binge eating disorder

Background: Cue-exposure therapy (CET) has proven its effi cacy in treating patients with bulimia nervosa and binge eating disorder who are resistant to standard treatment. Furthermore, incorporating virtual reality (VR) technology is increasingly considered a valid exposure method that may help to increase the effi cacy of standard treatments in a variety of eating disorders. Although immersive displays improve the benefi cial effects, expensive technology is not always necessary. Method: We aimed to assess whether exposure to food related virtual environments could decrease food craving in a non-clinical sample. In addition, we specifi cally compared the effects of two VR systems (one non-immersive and one immersive) during CET. We therefore applied a one-session CET to 113 undergraduate students. Results: Decreased food craving was found during exposure to both VR environments compared with pre-treatment levels, supporting the effi cacy of VR-CET in reducing food craving. We found no signifi cant differences in craving between immersive and non-immersive systems. Conclusions: Low-cost non-immersive systems applied through 3D laptops can improve the accessibility of this technique. By reducing the costs and improving the usability, VR-CET on 3D laptops may become a viable option that can be readily applied in a greater range of clinical contexts

Identifying Triggers of Alcohol Craving to Develop Effective Virtual Environments for Cue Exposure Therapy

Background: Many studies have indicated that alcohol craving is a core mechanism in the acquisition, maintenance, and precipitation of relapse in alcohol use disorder (AUD). A common treatment approach in AUD is cue exposure therapy (CET). New technologies like virtual reality (VR) have the potential to enhance the effectiveness of CET by creating realistic scenarios in naturalistic environments. In this study, we aimed to determine relevant triggers of alcohol craving in patients with AUD. Methods: We enrolled 75 outpatients diagnosed with AUD according to the DSM-5 criteria Participants completed the Alcohol Use Disorder Identification Test and a self-administered questionnaire to assess alcohol craving. The variables included in the craving questionnaire were as follows: presence of others, situations, time of the day, day of the week, mood, and type of alcoholic beverage. Results: Greater levels of alcohol craving were seen in many situations, including being at a party, in a restaurant, in a bar or pub, and at home. Drinking alone and drinking with two or more friends were equally associated with higher levels of craving. Drinking at night and drinking at weekends also emerged as triggers for alcohol craving. Emotional states like anxiety or tension, sadness, stress, frustration, or irritability were highly associated with urges to drink alcohol. The alcoholic drinks most highly associated with increased levels of craving were beer, wine, and whisky. Gender and age implications were discussed. Conclusion: This study is part of a larger project aiming to develop and validate CET based on VR technology for patients with AUD who are resistant to classical treatment. The identified triggers have been used to develop relevant VR environments for CET, and further research is ongoing to implement our findings

Social Pressure-Induced Craving in Patients with Alcohol Dependence: Application of Virtual Reality to Coping Skill Training

OBJECTIVE: This study was conducted to assess the interaction between alcohol cues and social pressure in the induction of alcohol craving. METHODS: Fourteen male patients with alcohol dependence and 14 age-matched social drinkers completed a virtual reality coping skill training program composed of four blocks according to the presence of alcohol cues (x2) and social pressure (x2). Before and after each block, the craving levels were measured using a visual analogue scale. RESULTS: Patients with alcohol dependence reported extremely high levels of craving immediately upon exposure to a virtual environment with alcohol cues, regardless of social pressure. In contrast, the craving levels of social drinkers were influenced by social pressure from virtual avatars. CONCLUSION: Our findings imply that an alcohol cue-laden environment should interfere with the ability to use coping skills against social pressure in real-life situations.ope

Enhancement of psychosocial treatment with D-cycloserine: models, moderators, and future directions

Advances in the understanding of the neurobiology of fear extinction have resulted in the development of d-cycloserine (DCS), a partial glutamatergic N-methyl-D-aspartate agonist, as an augmentation strategy for exposure treatment. We review a decade of research that has focused on the efficacy of DCS for augmenting the mechanisms (e.g., fear extinction) and outcome of exposure treatment across the anxiety disorders. Following a series of small-scale studies offering strong support for this clinical application, more recent larger-scale studies have yielded mixed results, with some showing weak or no effects. We discuss possible explanations for the mixed findings, pointing to both patient and session (i.e., learning experiences) characteristics as possible moderators of efficacy, and offer directions for future research in this area. We also review recent studies that have aimed to extend the work on DCS augmentation of exposure therapy for the anxiety disorders to DCS enhancement of learning-based interventions for addiction, anorexia nervosa, schizophrenia, and depression. Here, we attend to both DCS effects on facilitating therapeutic outcomes and additional therapeutic mechanisms beyond fear extinction (e.g., appetitive extinction, hippocampal-dependent learning).F31 MH103969 - NIMH NIH HHS; K24 DA030443 - NIDA NIH HHS; R34 MH099309 - NIMH NIH HHS; R34 MH086668 - NIMH NIH HHS; R21 MH102646 - NIMH NIH HHS; R34 MH099318 - NIMH NIH HH

Attentional bias, alcohol craving, and anxiety implications of the virtual reality cue-exposure therapy in severe alcohol use disorder: a case report

Aims: Attentional bias (AB), alcohol craving, and anxiety have important implications in the development and maintenance of alcohol use disorder (AUD). The current study aims to test the effectiveness of a Virtual Reality Cue-Exposure Therapy (VR-CET) to reduce levels of alcohol craving and anxiety and prompt changes in AB toward alcohol content. Method: A 49-year-old male participated in this study, diagnosed with severe AUD, who also used tobacco and illicit substances on an occasional basis and who made several failed attempts to cease substance misuse. The protocol consisted of six VR-CET booster sessions and two assessment sessions (pre- and post-VR-CET) over the course of 5 weeks. The VR-CET program consisted of booster therapy sessions based on virtual reality (VR) exposure to preferred alcohol-related cues and contexts. The initial and final assessment sessions were focused on exploring AB, alcohol craving, and anxiety using paper-and-pencil instruments and the eye-tracking (ET) and VR technologies at different time points. Results: Pre and post assessment sessions indicated falls on the scores of all instruments assessing alcohol craving, anxiety, and AB. Conclusions: This case report, part of a larger project, demonstrates the effectiveness of the VR-CET booster sessions in AUD. In the post-treatment measurements, a variety of instruments showed a change in the AB pattern and an improvement in craving and anxiety responses. As a result of the systematic desensitization, virtual exposure gradually reduced the responses to significant alcohol-related cues and contexts. The implications for AB, anxiety and craving are discussed

Cue Exposure Therapy for Addiction Disorders: A Review of Systematic Reviews

Mål: Avhengighetsforskningen går for tiden gjennom et paradigmeskifte ved inkluderingen av adferdsavhengighet under avhengighet som paraplybegrep. Forskning har dokumentert nevrobiologiske og erfaringsmessige likheter mellom ulike avhengighetslidelser. Dersom ulike avhengighetslidelser deler etiologi, burde terapeutiske teknikker som angriper disse likhetene vise seg nyttige. Et sentralt fellestrekk blant avhengighetslidelser er at bestemte stimuli aktiverer sterke appetitive reaksjoner som igangsetter tvangspreget konsum og adferd. Cue eksponeringsterapi (CET) er en behandling som prøver å endre pasientens respons til slike stimuli gjennom eksponering og medfølgende responsprevensjon. Metode: Denne hovedoppgaven gjennomfører en systematisk litteraturgjennomgang av tidligere litteraturgjennomganger for å undersøke evidensbasen for denne behandlingen på tvers av ulike avhengighetslidelser. Resultater: Litteraturgjennomgangen identifiserte 13 systematiske litteraturgjennomganger eller Meta-analyser som tok for seg ulike versjoner av CET. CET har blitt anvendt på Alkoholavhengighet, Opiatavhengighet, Nikotinavhengighet, Overspisningslidelser og Spillavhengighet. Forskningsfeltet lider av metodologiske svakheter og konklusjoner er derfor vanskelige å trekke. Litteraturgjennomgangene finner noe støtte forbruken CET i behandlingen av Spillavhengighet og Overspisning, men det er foreløpig lite støtte anvende CET for Avhengighet sammenliknet med andre intervensjoner. Forslag til videre forskning er diskutert.Hovedoppgave psykologprogrammetPROPSY317PRPSY