Panic disorder with agoraphobia. Highly prevalent disorder High impact on functioning Highly amenable to treatment

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1 A Randomized Controlled Study of Virtual Reality Exposure Therapy and Cognitive -Behaviour Therapy in Panic Disorder with Agoraphobia Pull CB *, Cottraux J **, Berthoz A ***, Jouvent R ****, Zaoui M***, Pelissolo A ****, Pull-Erpelding MC *, Wouters L *, Aguayo G *, Genouilhac V **, Duinat A**, Znaidi F****, De Mey Guillard C**, Panagiotaki P***, Fanget F**, Viaud-Delmon I****, Mollard E** and Gueyffier F ***** * Centre Hospitalier de Luxembourg ** Centre Hospitalier Universitaire, Hôpital Neurologique, Lyon *** Collège de France, Paris **** Centre Hospitalier Universitaire, Pitié Salpetrière, Paris ***** Centre Hospitalier Universitaire, Hôpital Cardiologique, Lyon. Cybertherapy, Gatinaud, June Panic disorder with agoraphobia Highly prevalent disorder High impact on functioning Highly amenable to treatment Treatment of choice is graded exposure therapy imaginal exposure in vivo exposure virtual reality exposure c1 1

2 Diapositive 2 c1 sso Bernard;

3 Virtual Reality Exposure Therapy North et al (1996) Jang et al (2000) Vincelli et al (2000, 2003) Botella et al (2004) c2 3 University Hospital Centers Lyon Paris Luxembourg J. Cottraux R.Jouvent C.Pull Collège de France A.Berthoz M. Zaoui P. Panagiotaki 2

4 Diapositive 3 c2 sso Bernard;

5 Lyon J. Cottraux C. De Mey Guillard A. Duinat F. Fanget V. Genouilhac F. Gueyffier E. Mollard Paris R. Jouvent A. Pelissolo A I. Viaud-Delmon F. Znaidi 3

6 Luxembourg C. Pull G. Aguayo MC. Pull L. Wouters Design Randomized controlled study Cognitive-Behavioural Therapy (CBT) vs Virtual Reality Exposure Therapy (VRET) vs waiting list Patients in the waiting list randomized to CBT or VRET after 3 months 3 treatment centers (Lyon, Paris, Luxembourg) 4

7 PHRV : STUDY DESIGN Panic disorder with agoraphobia : n= 90 Three centers LYON (Dr Cottraux), PARIS (Pr Jouvent), LUXEMBOURG (Pr Pull) n=30 per center Inclusion one week after initial screening PSYCHOMETRY COGNITIVE ASSESSMENT Randomization VIRTUAl REALITY THERAPY (VRT) three months 12 sessions COGNITIVE BEHAVIOR THERAPY (CBT) three months 12 session WAITING LIST Three months Post-test Post-test Post-test Randomization Follow up six months Follow up six months VRT Three months 12 sessions CBT Three months mois 12 sesssions Follow up 12 months Follow up 12 months Post test 2 Post test 2 Follow up six months Follow up six months Follow up 12 months Follow up 12 months Inclusion criteria patients meeting DSM-IV diagnostic criteria for Panic disorder with Agorapbobia aged having given written informed consent 5

8 Exclusion criteria patients taking psychotropic medication other than valeriane patients having a score of 17 or above on the Hamilton Depression Rating Scale patients with a diagnosis of comorbid psychosis substance dependence significant physical disorders patients having another ongoing psychotherapy Assessment pre/post after 26 weeks after 52 weeks 6

9 Assessment instruments Fear Questionnaire (Marks and Mathews) Panic Disorder Severity Scale (K. Shear) Agoraphobic Cognition Questionnaire (Chambless) Panic, Phobias, Generalized Anxiety (Cottraux) Trait/State Anxiety (Spielberger ) HAM-A (Hamilton) HAM-D (Hamilton) Beck Depression Inventory (Beck, BDI, 21 items) Dissociative Experiences Scale (DES) Handicap Scale (Sheehan) Quality of Life Rating Scale (Marks) Other assessments Rod and frame test : subjective perception of verticality Complex figure (Rey) : perception and memory Photo of face : in search of an asymmetry Equitest (Nashner & Berthoz) patients expectations scale (Cottraux) assessment of cybersickness and sense of presence 7

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11 Treatment 12 sessions CBT or VRET manualized: detailed guidelines for CBT and VRET 1 session per week 90 minutes duration CBT and VRET provided by the same clinicians who are experienced therapists 9

12 Treatment CBT components Psycho-education respiratory control Relaxation cognitive restructuring exposure in imagination to anxiety provoking scenes interoceptive exposure to anxiety-related physical sensations homework involving exposure to real-life situations. Treatment VRET components psychoeducation respiratory control relaxation exposure to virtual environments VRET in blocks of 10 min therapists drive the computer programme therapists take into account the verbal and non-verbal reactions of the patients therapists interact verbally with the patient to enhance the illusion of presence 10

13 Outcome criteria Main outcome criteria agoraphobia score on the Fear Questionnaire score on the PDSS Secondary outcome criteria score on the BDI score on the Shehan Handicap Scale 12 virtual environnements 1. elevator 2. cinema 3. supermarket 4. airplane 5. bus 6. underground 7. car in the countryside 8. tunnel 9. car in town 10. car in a tunnel 11. crowd 12. derealisation scenario 11

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27 VR equipment Head Mounted Display (Kaiser Pro view 60 ) Head tracker Loudspeakers 25

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29 CLAIRECOURT CLAIRECOURT 27

30 Lyon Bus ENVIRONNEMENTS ENVIRONNEMENTS 28

31 Results 92 patients have been included treatment phase completed by June 2006 pre-post data to be analyzed July-September