Cue Exposure Therapy Research Articles

Virtual reality cue-exposure therapy in reducing cocaine craving: the Promoting Innovative COgnitive behavioral therapy for Cocaine use disorder (PICOC) study protocol for a randomized controlled trial

BackgroundCocaine craving is a central symptom of cocaine use disorders (CUD). Virtual reality cue-exposure therapy for craving (VRCET) allows more immersive, realistic, and controllable exposure than traditional non-VR cue-exposure therapy (CET), whose efficacy is limited in treating substance use disorders. The purpose of this study is to evaluate the efficacy and acceptability of VRCET, as a stand-alone and add-on intervention (i.e., combined with cognitive therapy), compared to a picture-based CET (PCET), in reducing self-reported cocaine craving in inpatients hospitalized for CUD.MethodsFifty-four inpatients hospitalized for CUD will be randomized in one of two intensive 3-week treatment arms: 10 meetings/2-week treatment of VRCET plus 5 meetings/1-week treatment of memory-focused cognitive therapy (MFCT; experimental arm), or 15 meetings/3-week treatment of PCET (active control arm). The Craving Experience Questionnaire (CEQ – F & S) will be used to assess the primary outcome, i.e., the post-treatment decrease of self-reported cocaine craving frequency (within the past 2 weeks) and intensity scores (in VR exposure to cocaine cues). Secondary endpoints include urinary, physiological, and self-reported cocaine use-related measures. Assessments are scheduled at pretreatment, after 2 weeks of treatment (i.e., VRCET vs. PCET), post-treatment (3 weeks, i.e., VRCET + MFCT vs. PCET), and at 1-month follow-up. Acceptability will be evaluated via (i) the Spatial Presence for Immersive Environments – Cybersickness along VRCET and (ii) the Client Satisfaction Questionnaires after 2 weeks of treatment and post-treatment.DiscussionThis study will be the first to evaluate the acceptability and efficacy of VRCET for CUD, as a psychotherapeutic add-on, to reduce both cocaine craving frequency and intensity. Additionally, this study will provide evidence about the specific interest of VRCET, compared to a non-VR-based CET, as a cue reactivity and exposure paradigm for treating substance use disorders.Trial registrationNCT05833529 [clinicaltrials.gov]. Prospectively registered on April 17, 2023.

Study on the efficiency of virtual reality in the treatment of alcohol use disorder: study protocol for a randomized controlled trial

ContextAccording to the World Health Organization, alcohol is a major global public health problem, leading to a significant increase in illness and death. To treat alcohol use disorders, new therapeutic tools are being promoted, among which virtual reality (VR) shows promise. Previous research has demonstrated the efficacy of VR in reducing alcohol cravings in patients, but there is a lack of data on its effectiveness in maintaining abstinence or reducing consumption in recently abstinent individuals.The E-Reva study aims to compare the efficacy of a treatment strategy combining virtual reality cue exposure therapy (VR-CET) and cognitive behavioral therapy (CBT) with conventional CBT in reducing alcohol consumption and craving in patients with alcohol use disorder (AUD). In addition to this primary objective, the study will compare the effects of VR-CET combined with CBT on anxiety, depression, rumination, and feelings of self-efficacy versus conventional CBT.MethodsThis prospective randomized controlled trial will be conducted over 8 months in four addiction departments in France. It includes two parallel groups: i) the VR-CET + CBT group, and ii) the CBT-only group, which serves as a control group.Participants will be recruited by the investigating doctor in the addiction centers. The sample will consist of 156 patients diagnosed with AUD and abstinent for at least 15 days.Both treatment groups will participate in four group CBT sessions followed by four individual sessions: i) the VR-CET group will be exposed to virtual environments associated with alcohol-related stimuli, ii) the CBT-only group will receive traditional CBT sessions. After completion of the 8 sessions, patients will be followed up for 6 months. The primary outcome is the cumulative number of standard drinks consumed at 8 months, assessed using the TLFB method.DiscussionDespite the promise of VR-CET to reduce the desire to drink, the effect on alcohol consumption remains uncertain in the existing literature. Our protocol aims to address the limitations of previous research by increasing sample size, targeting consumption reduction, and incorporating neutral environments. E-Reva aims to enrich the literature on the use of VR in the treatment of AUD and open new perspectives for future interventions.Trial registrationClinicalTrials.gov ID NCT06104176, Registered 2023/11/13 (https://clinicaltrials.gov/study/NCT06104176?id=NCT06104176&rank=1).N° IDRCB: 2022-A02797-36.Protocol version 1.0, 12/05/2023.

Isradipine augmentation of virtual reality cue exposure therapy for tobacco craving: a triple-blind randomized controlled trial.

Preclinical research with rodents suggests that the L-type calcium channel blocker isradipine can enhance long-term extinction of conditioned place preference for addictive substances when it is administered in conjunction with extinction training. Although isradipine alone, which is FDA-approved for hypertension, has not shown a direct effect on craving in human drug users, its potential to augment behavioral treatments designed to reduce craving remains unknown. We conducted a triple-blind, randomized placebo-controlled pilot clinical trial of isradipine combined with a novel virtual reality cue exposure therapy (VR-CET) approach with multimodal cues that targeted craving. After 24 hours of abstinence, 78 adults with an ongoing history of daily cigarette use received isradipine (n = 40) or placebo (n = 38) and reported craving levels after each of 10 trials of VR-CET. Consistent with pre-registered hypotheses, the isradipine group had significantly lower mean craving across cue exposure trials at the medication-free 24-hour follow-up (d = -0.42, p = 0.046). There were no serious adverse events; however, side effects such as headache and dizziness occurred more frequently in the isradipine group. The findings of the current study support follow-up clinical trials that specifically test the efficacy of isradipine-augmented VR-CET for reducing smoking relapse rates after an initial quit attempt. clinicaltrials.gov: NCT03083353.

The Role of Personalization in Virtual Reality Exposure Therapy During the Treatment of Alcohol Use Disorder

IntroductionIn Cue-Exposure-Therapy (CET), clients are exposed to triggers through objects, people and environments that arouse craving (Sinha et al. Neuropsychopharmacol. 2009;34 1198–1208). Virtual Reality Exposure therapy (VRET) is used to experience these triggers in a realistic, safe, and personalized way. VR has been used successfully in the treatment of psychiatric disorders. It has not yet been developed and sufficiently tested as an adjuvant in the clinical post-detoxification phase of treatment of alcohol use disorders (AUD) (e.g. Bordnick et al. Addict.Behav 2008;33 743-756; Hone-Blanchet et al. Front.Hum.Neurosci. 2014; 8(844) 1-15). Additionally, these treatment methods have been tested for effect, but not for effectiveness around different VR technologies (Ghita & Gutierrez-Maldonado. Addict.Behav 2018; 81 1-11; ). This study focuses on VRET-Recovry to examine to what extent VR worlds could be personalized in an effective manner to help treat AUD as well as clarifying on the ways in which the VR worlds could be optimized to achieve its goal.ObjectivesThe primary objectives of this study are to assess the necessity of personalization in VR environments for AUD treatment, identify the critical elements for personalization, and examine their impact on craving in AUD patients.MethodsThe study included 10 AUD patients diagnosed according to DSM-V criteria, aged between 18 and 65, who were in the final week of clinical detoxification at a large addiction clinic in The Netherlands. A controlled experiment was conducted using the Recovry 1.0 VR system on Samsung Gear VR and Samsung Galaxy S9. The experiment involved exposure to various VR scenes (CG and 360o), including a neutral setting, a bar scene, and a home situation, with the duration and sequence controlled by a therapist. Data collection consisted of pre- and post-exposure questionnaires, heart rate and blood pressure measurements, and interviews.ResultsCraving was remarkably low in the VR bar scene, primarily due to its unsociable context, limited alcohol visibility, and absence of peer pressure. Technical limitations, such as suboptimal resolution, also affected the feeling of presence. Positive results were shown that craving was predominantly stimulated in the apartment scene, driven by the presence of alcohol-related visual cues and social elements, resembling relaxed drinking with others.ConclusionsThis study underscores that some degree of personalization is needed on all craving dimensions with clear preference was given to CG or 360°. The environments were dependent on the personal history and associations they represent to different levels of alcohol visibility (messy or clean), and types of drink (based on past drinking behavior), and different emotional contexts are needed (positive and negative).Disclosure of InterestNone Declared

Cigarette craving in virtual reality cue exposure in abstainers and relapsed smokers

Cue exposure therapy (CET) in substance-use disorders aims to reduce craving and ultimately relapse rates. Applying CET in virtual reality (VR) was proposed to increase its efficacy, as VR enables the presentation of social and environmental cues along with substance-related stimuli. However, limited success has been reported so far when applying VR-CET for smoking cessation. Understanding if effects of VR-CET differ between future abstainers and relapsing smokers may help to improve VR-CET. Data from 102 participants allocated to the intervention arm (VR-CET) of a recent RCT comparing VR-CET to relaxation in the context of smoking cessation was analyzed with respect to tolerability, presence, and craving during VR-CET. Cue exposure was conducted in four VR contexts (Loneliness/Rumination, Party, Stress, Café), each presented twice. Relapsed smokers compared to abstainers experienced higher craving during VR-CET and stronger craving responses especially during the Stress scenario. Furthermore, lower mean craving during VR-CET positively predicted abstinence at 6-month follow-up. Attempts to improve smoking cessation outcomes of VR-CET should aim to identify smokers who are more at risk of relapse based on high craving levels during VR-CET. Specifically measuring craving responses during social stress seems to be well suited to mark relapse. We propose to investigate individualized treatment approaches accordingly.

Cue-exposure treatment influences resting-state functional connectivity—a randomized controlled fMRI study in alcohol use disorder

RationaleCue-exposure therapy (CET) consists of exposing patients to the cause of their affliction in a controlled environment and after psychological preparation. Ever since it was conceived, it has been suggested as a treatment for different types of behavioural impairments, from anxiety disorders to substance abuse. In the field of addictive behaviour, many different findings have been shown regarding the effectiveness of this therapy.ObjectivesThis study aims to examine the underlying neurobiological mechanisms of the effects of CET in patients with alcohol use disorder using resting-state functional magnetic resonance imaging (rs-fMRI).MethodsIn a randomized, controlled study, we examined patients after inpatient detoxification as well as healthy controls. Patients underwent nine sessions of CET spaced over 3 weeks. Rs-fMRI was conducted before treatment and 3 weeks after treatment onset in patients, healthy controls received only one rs-fMRI measurement. The final participant sample with complete data included 35 patients in the CET group, 17 patients in the treatment-as-usual group, and 43 HCs.ResultsOur results show differences in the Salience Network when comparing the CET group to the treatment-as-usual group (TAU). Functional connectivity between the anterior cingulate Cortex (ACC) and the insula was increased after CET, whereas it was decreased from ACC to the putamen and globus pallidus. Further, increased connectivity with the precuneus was found in the dorsal attention network after cue exposure treatment.ConclusionsThese findings suggest that cue exposure therapy changes the resting-state brain connectivity with additional effects to the standard psychotherapy treatment. Hence, our study results suggest why including CET in standard therapies might improve the preparation of patients in front of daily situations.

Molecular mechanisms underlying sex and treatment-dependent differences in an animal model of cue-exposure therapy for cocaine relapse prevention.

Environmental enrichment combined with the glycine transporter-1 inhibitor Org24598 (EE+ORG) during cocaine-cue extinction (EXT) inhibited reacquisition of 1.0 mg/kg cocaine self-administration in male but not female rats in a previous investigation. In this investigation, we determined if this treatment benefit in males required EXT training and ascertained the molecular basis for the observed sex difference in treatment efficacy. Nine groups of male rats trained to self-administer 1.0 mg/kg cocaine or receiving yoked-saline underwent EXT or NoEXT with or without EE and/or ORG. Next, they underwent reacquisition of cocaine self-administration or were sacrificed for molecular analysis of 9 protein targets indicative of neuroplasticity in four brain regions. Two groups of female rats trained to self-administer 1.0 mg/kg cocaine also underwent EXT with or without EE + ORG and were sacrificed for molecular analysis, as above. EE + ORG facilitated the rate of EXT learning in both sexes, and importantly, the therapeutic benefit of EE + ORG for inhibiting cocaine relapse required EXT training. Males were more sensitive than females to neuroplasticity-inducing effects of EE + ORG, which prevented reductions in total GluA1 and PSD95 proteins selectively in basolateral amygdala of male rats trained to self-administer cocaine and receiving EXT. Females were deficient in expression of multiple protein targets, especially after EE + ORG. These included total GluA1 and PSD95 proteins in basolateral amygdala, and total TrkB protein in basolateral amygdala, dorsal hippocampus, and ventromedial prefrontal cortex. Together, these results support the clinical view that sex-specific pharmacological and behavioral treatment approaches may be needed during cue exposure therapy to inhibit cocaine relapse.

Effects of virtual reality-based cue exposure therapy on craving and physiological responses in alcohol-dependent patients-a randomised controlled trial

BackgroundCue exposure therapy is used to treat alcohol dependence. However, its effectiveness is controversial due to the limitations of the clinical treatment setting. Virtual reality technology may improve the therapeutic effect. The aim of this study is to explore whether virtual reality-based cue exposure therapy can reduce the psychological craving and physiological responses of patients with alcohol dependence.MethodsForty-four male alcohol-dependent patients were recruited and divided into the study group (n = 23) and the control group (n = 21) according to a random number table. The control group received only conventional clinical treatment for alcohol dependence. The study group received conventional clinical treatment with the addition of VR cue exposure (treatment). The primary outcome was to assess psychological craving and physiological responses to cues of patients before and after treatment.ResultsAfter virtual reality-based cue exposure therapy, the changes in VAS and heart rate before and after cue exposure in the study group were significantly lower than those in the control group (P < 0.05), while the changes in skin conductance and respiration between the study group and the control group were not significantly different (P > 0.05). The changes in VAS and heart rate before and after cue exposure in the study group were significantly lower than those before treatment (P < 0.05), while the changes in skin conductance and respiration were not significantly different from those before treatment (P > 0.05). The changes in VAS, heart rate, skin conductance and respiration before and after cue exposure in the control group were not significantly different from those before treatment (P > 0.05).ConclusionVirtual reality-based cue exposure therapy can reduce the psychological craving and part of the physiological responses of alcohol-dependent patients during cue exposure in the short term and may be helpful in the treatment of alcohol dependence.Trial registrationThe study protocol was registered at the China Clinical Trial Registry on 26/02/2021 (www.chictr.org.cn; ChiCTR ID: ChiCTR2100043680).

An explorative single-arm clinical study to assess craving in patients with alcohol use disorder using Virtual Reality exposure (CRAVE)—study protocol

BackgroundAlcohol use disorder (AUD) belongs to the most burdensome clinical disorders worldwide. Current treatment approaches yield unsatisfactory long-term effects with relapse rates up to 85%. Craving for alcohol is a major predictor for relapse and can be intentionally induced via cue exposure in real life as well as in Virtual Reality (VR). The induction and habituation of craving via conditioned cues as well as extinction learning is used in Cue Exposure Therapy (CET), a long-known but rarely used strategy in Cognitive Behavioral Therapy (CBT) of AUD. VR scenarios with alcohol related cues offer several advantages over real life scenarios and are within the focus of current efforts to develop new treatment options. As a first step, we aim to analyze if the VR scenarios elicit a transient change in craving levels and if this is measurable via subjective and psychophysiological parameters.MethodsA single-arm clinical study will be conducted including n = 60 patients with AUD. Data on severity of AUD and craving, comorbidities, demographics, side effects and the feeling of presence in VR will be assessed. Patients will use a head-mounted display (HMD) to immerse themselves into three different scenarios (neutral vs. two target situations: a living room and a bar) while heart rate, heart rate variability, pupillometry and electrodermal activity will be measured continuously. Subjective craving levels will be assessed before, during and after the VR session.DiscussionResults of this study will yield insight into the induction of alcohol craving in VR cue exposure paradigms and its measurement via subjective and psychophysiological parameters. This might be an important step in the development of innovative therapeutic approaches in the treatment of patients with AUD.Trial registrationThis study was approved by the Charité—Universitätsmedizin Berlin Institutional Review Board (EA1/190/22, 23.05.2023). It was registered on ClinicalTrials.gov (NCT05861843).

Effectiveness of Reducing Craving in Alcohol Use Disorder Using a Serious Game (SALIENCE): Randomized Controlled Trial.

Alcohol use disorder (AUD) has become a major global health problem. Therapy for this condition is still a great challenge. Recently, it has become increasingly evident that computer-based training is a valuable addition to the treatment of addictive disorders. This study aims to evaluate the web-based serious game SALIENCE (Stop Alcohol in Everyday Life-New Choices and Evaluations) as an add-on therapy for AUD. It combines the cue-exposure therapy approach with elements of decision-making training, enhanced by interactive panoramic images. The effects of SALIENCE training on levels of craving, attention, and cognitive bias are investigated. In a randomized controlled trial, 62 participants with AUD undergoing 3 weeks of an extended alcohol detoxification program were randomly allocated to an intervention and a control group. A total of 49 individuals (mean age 44.04 y; 17/49, 35% female) completed all sessions and were included in the analysis. Only pretreatment data were available from the other 13 patients. Participants answered questionnaires related to alcohol consumption and craving and completed neuropsychological tasks at the beginning of the study and 2 weeks later to evaluate levels of attention and cognitive biases. During the 2-week period, 27 of the participants additionally performed the SALIENCE training for 30 minutes 3 times a week, for a total of 6 sessions. We observed a significant decrease in craving in both groups: the control group (mean 15.59, SD 8.02 on the first examination day vs mean 13.18, SD 8.38 on the second examination day) and the intervention group (mean 15.19, SD 6.71 on the first examination day vs mean 13.30, SD 8.47 on the second examination day; F1,47=4.31; P=.04), whereas the interaction effect was not statistically significant (F1,47=0.06; P=.80). Results of the multiple linear regression controlling for individual differences between participants indicated a significantly greater decrease in craving (β=4.12; t36=2.34; P=.03) with the SALIENCE intervention. Participants with lower drinking in negative situations reduced their craving (β=.38; t36=3.01; P=.005) more than people with higher drinking in negative situations. The general effectiveness of SALIENCE training as an add-on therapy in reducing alcohol craving was not confirmed. Nevertheless, taking into account individual differences (gender, duration of dependence, stress, anxiety, and drinking behavior in different situations), it was shown that SALIENCE training resulted in a larger reduction in craving than without. Notably, individuals who rarely consume alcohol due to negative affect profited the most from SALIENCE training. In addition to the beneficial effect of SALIENCE training, these findings highlight the relevance of individualized therapy for AUD, adapted to personal circumstances such as drinking motivation. ClinicalTrials.gov NCT03765476; https://clinicaltrials.gov/show/NCT03765476.

Cue exposure for alcohol use disorders: A commentary on Kiyak et al. (2023)

While cue exposure therapy (CET) gives similar effects to cognitive-behavior therapies (CBTs) for Alcohol Use Disorder, it does not consistently add to effects of CBT alone. If the non-random trial of Nattala, Murthy, Leung, Rentala and Ramakrishna (2018) is omitted from the systematic review and meta-analysis of Kiyak, Simonetti, Norton and Deluca (2023), even average effects against less stringent controls are not substantial. Some trials have used sub-optimal versions of CET, but effects of CET are also constrained by the fact that many alcohol dependent patients do not exhibit strong craving. In vivo coping skills practice in the presence of powerful alcohol cues remains a viable treatment, especially if a key focus is on skills with wide situational application rather than solely on habituation. Multisensory motivational imagery for alcohol control represents one such strategy.

A new circuit underlying the renewal of appetitive Pavlovian responses: Commentary on Brown and Chaudhri (2022).

A new circuit underlying the renewal of appetitive Pavlovian responses: Commentary on Brown and Chaudhri (2022).

Psychological Factors of Addition and Interventions for Substance Use Disorder

Substance use disorders appeared earlier in the history of human development with the discovery of alcohol and drugs. As society develops, more and more people exhibit substance abuse and substance addiction. Therefore, substance use disorders are gradually appearing in the limelight. This review begins with an analysis of the pathology and prevalence of substance use disorders, dividing those psychological factors that can lead to substance use disorders into internalizing and social factors. Five specific therapies, including cognitive behavioral therapy, mindfulness-based cognitive therapy, prize-based contingency management approach, cue-exposure therapy, and acceptance and commitment therapy, are analyzed and discussed, also categorized as internal promotion and external influence, based on how these therapies affect clients. Finally, for future research and treatment of substance use disorders, this review combines the previous literature and suggests ways to combine two or more therapies in order to achieve the best treatment results.

Modeling cue-exposure therapy for alcohol use disorder in rhesus monkeys: Effects of putative cognitive enhancers

BackgroundCue-exposure therapy (CET) is an effective approach for anxiety-related disorders, but its effectiveness for substance use disorders is less clear. One potential means of improving CET outcomes is to include a cognitive-enhancing pharmacotherapy. This study evaluated d-cycloserine (DCS) and RY-023, putative cognitive enhancers targeting glutamate and GABA systems, respectively, in a monkey model of CET for alcohol use disorder. MethodsMale rhesus monkeys (n = 4) underwent multiple cycles of the CET procedure. During baseline (Phase 1), monkeys self-administered an ethanol solution under a fixed-ratio schedule and limited access conditions such that every 5th response in a 3-h session resulted in 30-s access to a drinking spout and a change in ethanol-paired cue lights from white to red. Behavior then was extinguished (Phase 2) by omitting the ethanol solution yet retaining the ethanol-paired stimulus lights. Monkeys also received injections of vehicle, DCS (3 mg/kg), a partial agonist at the glycine modulatory site on glutamatergic NMDA receptors, or the α5GABAA receptor-selective inverse agonist RY-023 (0.03 or 0.3 mg/kg). Once responding declined, monkeys underwent a cue reactivity test (Phase 3), and then returned to self-administration the following day to assess reacquisition (Phase 4). ResultsThrough multiple cycles, self-administration remained stable. Compared to vehicle, DCS facilitated extinction of ethanol seeking (Phase 2) and delayed reacquisition of ethanol self-administration (Phase 4). In contrast, RY-023 facilitated extinction (Phase 2) and reduced cue reactivity (Phase 3). ConclusionsAdjunctive pharmacotherapy can improve CET outcomes, but the choice of pharmacotherapy should be dependent on the outcome of interest.

Augmented reality as a novel approach for addiction treatment: development of a smoking cessation app

Objective Augmented reality (AR) is a rapidly developing technology that has substantial potential as a novel approach for addiction treatment, including tobacco use. AR can facilitate the delivery of cue exposure therapy (CET) such that individuals can experience the treatment in their natural environments as viewed via a smartphone screen, addressing the limited generalizbility of extinction learning. Previously, our team developed a basic AR app for smoking cessation and demonstrated the necessary mechanisms for CET. Specifically, we showed that the AR smoking cues, compared to neutral cues, elicited substantial cue reactivity (i.e. increased urge) and that repeated exposure to the AR smoking cues reduced urge (i.e. extinction) in a laboratory setting. Here we report the next step in the systematic development of the AR app, in which we assessed the usability and acceptability of the app among daily smokers in their natural environments. Method Daily smokers (N = 23, 78.3% female, Mean Age = 43.4, Mean Cigarettes/Day = 14.9), not actively quitting, were instructed to use the AR app in locations and situations where they smoke (e.g. home, bar) at least 5 times per day over one week. The study is registered in clinicaltrials.gov (NCT04101422). Results Results indicated high usability and acceptability. Most of the participants (73.9%) used the AR app on at least 5 days. Participants found the AR cues realistic and well-integrated in their natural environments. The AR app was perceived as easy to use (Mean = 4.1/5) and learn (mean of 2 days to learn). Overall satisfaction with the app was also high. Secondary analyses found that 56.5% reported reduced smoking, with an average 26% reduction in cigarettes per day at follow-up. Conclusions These findings set the stage for a randomized controlled trial testing the AR app as an adjuvant therapy for treating tobacco dependence, with potential applicability to other substances. KEY MESSAGE This study found that the augmented reality (AR) smartphone application that utlized cue exposure treatment for smoking cessation was perceived as easy to use and learn in the natural, day-to-day environment of daily smokers. Findings set the stage for a larger clinical trial testing the AR app as an adjuvant therapy for treating tobacco dependence, with potential applicability to other addictive behaviors.

Virtual reality cue exposure therapy for tobacco relapse prevention: a comparative study with standard intervention.

Successful interventions have been developed for smoking cessation although the success of smoking relapse prevention protocols has been limited. Cognitive behavioural therapy (CBT) in particular has been hampered by a high relapse rate. Because relapse can be due to conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality cue exposure therapy (VRCE) can be a potential tool to generate 3D interactive environments that simulate risk situations for relapse prevention procedures. To assess the effectiveness of VRCE with CBT, a comparative trial involving 100 smoking abstinent participants was designed with all required virtual environments (VE) created with an inexpensive graphic engine/game level editor. Outcome measures confirmed the immersive and craving eliciting effect of these VEs. Results demonstrated that more participants in the VRCE group did not experience smoking relapse and that VRCE is at least as efficacious as traditional CBT in terms of craving reduction and decrease in nicotine dependence. Dropout and relapse rate in the VRCE group was noticeably lower than the CBT group. Aside from mood scores, no significant differences were found regarding the other scales. The present clinical trial provides evidence that VRCE was effective in preventing smoking relapse. Improvement in technology and methodology for future research and applications is delineated.

Virtual Reality-Based Immersive Rehabilitation for Cognitive- and Behavioral-Impairment-Related Eating Disorders: A VREHAB Framework Scoping Review.

Virtual reality (VR) technology is one of the promising directions for rehabilitation, especially cognitive rehabilitation. Previous studies demonstrated successful rehabilitation in motor, cognitive, and sensorial functions using VR. The objective of this review is to summarize the current designs and evidence on immersive rehabilitation interventions using VR on cognitive- or behavioral-related eating disorders, which was mapped using a VREHAB framework. Two authors independently searched electronic databases, including PubMed, Web of Science, Scopus, CINAHL, EMBASE, and Cochrane Library. Ten (n = 10) articles were eligible for review. Treatments for anorexia nervosa and binge eating disorder/bulimia nervosa were reported through enhanced/experimental cognitive behavior therapy (ECT), cue exposure therapy (CET), and body exposure therapy (BET) via the virtual environment. Some studies reported that the VR effects were superior or comparable to traditional treatments, while the effects may last longer using VR technology. In addition, VR was perceived as acceptable and feasible among patients and therapists and could be valuable for supplementing existing therapies, relieving manpower and caregiver burdens. Future studies may consider incorporating haptic, smell, and biofeedback to improve the experience, and thus the effects of the treatments for the users.

Exposure to Olfactory Alcohol Cues During Non-rapid Eye Movement Sleep Did Not Decrease Craving in Patients With Alcohol Dependence

Background and ObjectivesCue exposure therapy (CET) has been used to reduce alcohol use, but the effect of CET during sleep on alcohol dependence (AD) is unclear. The present study examined the effect of repeated exposure to an olfactory stimulus during non-rapid eye movement (NREM) sleep on cue reactivity and craving in patients with AD.MethodsThirty-five patients with AD were enrolled according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). All the subjects were randomly assigned to the experimental or control group. The experimental group was exposed to alcohol odor for 10 min during NREM sleep. The other group (controls) was exposed to water [control stimulus (CtrS)] for 10 min during NREM sleep. Demographic, alcohol-related, and clinical characteristics were collected at baseline. A cue-reactivity test was conducted before and after exposure to evaluate the effect of memory manipulation on acute response to an alcohol stimulus.ResultsThere were no significant time × group interactions according to the visual analog scale (VAS) score of craving intensity, skin conductance response (SCR), systolic blood pressure (SBP), and diastolic blood pressure (DBP; all p > 0.05). Two-way ANOVA showed significant main effects of time on SCR [F(1,33) = 4.453, p = 0.043], SBP [F(1,33) = 14.532, p = 0.001], DBP [F(1,33) = 8.327, p = 0.007], Craving-VAS [F(1,33) = 1.997, p = 0.167] in two groups.ConclusionExposure to olfactory alcohol cues during NREM sleep had no significant effect on alcohol craving in subjects with AD during hospitalization.

Alter Game: A Study Protocol on a Virtual "Serious Game" for Relapse Prevention in Patients With Gambling Disorder.

Cognitive behavioral therapy (CBT) is the most successful protocol in gambling disorder (GD) treatment. However, it presents some weaknesses, especially concerning relapse prevention (RP). RP is one of the most important therapeutic steps, aiming at managing cravings and to avoid future relapse increasing perceived self-efficacy. Encouraging results come from the blending of psychotherapy and virtual reality (VR), containing gambling cues. The goal of Alter Game (approved by the Ethical Commission, Prot. No. 69346) is verifying the efficacy of an innovative psychological treatment for GD based on the integration of traditional CBT therapy and an immersive VR cue exposure therapy using a serious virtual game, which is a game designed for purposes other than entertainment. RP in virtual cue-exposure therapy allows pathological gamblers to manage the urge to gamble and to avoid relapse by becoming aware of which internal and external triggers are related to craving. We hypothesize that the integrated intervention will be more effective than simple CBT with regard to self-efficacy, craving, and gambling-related distortions. Four virtual ecological environments were developed, and a virtual app, Exludo, interfaced with a computerized multiparametric acquisition system for biofeedback, was created. A sample of about 60 patients aged between 18 and 65 with GD referring to the Addiction Medicine Unit of Verona (Rossi Hospital) will be recruited. Patients will be randomly assigned to the CBT group (16 CBT sessions) or the CBT + VR group (8 CBT sessions + 8 VR cue-exposure therapy sessions). The MCMI-III, the BIS-11, and the SOGS will be used to evaluate inclusion and exclusion criteria, while the Gambling Related Cognitions Scale and the Multidimensional Gambling Self-Efficacy Scale will be used to verify changes as a function of the treatment. Craving will be evaluated through VAS, and psychophysiological variables will be assessed through biofeedback. A pre-test/post-test experimental design with a 1-month follow-up will be conducted. This study will examine an innovative psychotherapeutic protocol for GD treatment, and it will help in identifying new virtual tools to increase the efficacy of traditional therapeutic approaches that could also be applied to treat other addictions.

Effectiveness of Cue-Exposure Therapy on Alcohol Craving in Virtual Environment: Based on habit loop.

In the treatment and abstinence of alcoholism, especially in abstinence after treatment, "Craving" has an essential role. Thus, our aim was to examine the effect of cue-exposure therapy on alcohol craving in virtual environment based on the habit loop. The present investigation was a case-control experimental study with a pretest-posttest-5 weeks follow-up design. Research population were alcohol-addicted people hospitalized in a psychiatric hospital. We had 62 subjects who had abstained from alcohol consumption. The sampling method was convenience sampling and the sample allocation was randomized and matched. The intervention was VR-CET that was implemented in eight sessions. Penn Alcohol Craving Scale, Alcohol Urge Questionnaire, and Obsessive-Compulsive Drinking Scale were used to collect the data. In order to analyze the data, analysis of covariance (ANCOVA) in SPSS V.23 was performed. Our results showed that after implementation of VR-CET program the rate of PACS reduced significantly in posttest stage (p = 0.01) and follow up stage (p= 0.05). Also, the rate of AUQ and OCDS after exposure to VR-CET program declined significantly. The significant level of AUQ and OCDS in posttest and follow up stages were set at p- value < 0.01 and p-value <0.05 respectively. VR-CET program can reduce alcohol craving by paying attention to various cues and contexts. In fact, it would be more beneficial if the treatment environment resembles a conditioned context and contains as many related cues as possible.