title: Experiential virtual scenarios with real-time monitoring (interreality) for the management of psychological stress: a block randomized controlled trial.
abstract: BACKGROUND
  The recent convergence between technology and medicine is offering innovative methods and tools for behavioral health care. Among these, an emerging approach is the use of virtual reality (VR) within exposure-based protocols for anxiety disorders, and in particular posttraumatic stress disorder. However, no systematically tested VR protocols are available for the management of psychological stress.
  
  
  OBJECTIVE
  Our goal was to evaluate the efficacy of a new technological paradigm, Interreality, for the management and prevention of psychological stress. The main feature of Interreality is a twofold link between the virtual and the real world achieved through experiential virtual scenarios (fully controlled by the therapist, used to learn coping skills and improve self-efficacy) with real-time monitoring and support (identifying critical situations and assessing clinical change) using advanced technologies (virtual worlds, wearable biosensors, and smartphones).
  
  
  METHODS
  The study was designed as a block randomized controlled trial involving 121 participants recruited from two different worker populations-teachers and nurses-that are highly exposed to psychological stress. Participants were a sample of teachers recruited in Milan (Block 1: n=61) and a sample of nurses recruited in Messina, Italy (Block 2: n=60). Participants within each block were randomly assigned to the (1) Experimental Group (EG): n=40; B1=20, B2=20, which received a 5-week treatment based on the Interreality paradigm; (2) Control Group (CG): n=42; B1=22, B2=20, which received a 5-week traditional stress management training based on cognitive behavioral therapy (CBT); and (3) the Wait-List group (WL): n=39, B1=19, B2=20, which was reassessed and compared with the two other groups 5 weeks after the initial evaluation.
  
  
  RESULTS
  Although both treatments were able to significantly reduce perceived stress better than WL, only EG participants reported a significant reduction (EG=12% vs. CG=0.5%) in chronic "trait" anxiety. A similar pattern was found for coping skills: both treatments were able to significantly increase most coping skills, but only EG participants reported a significant increase (EG=14% vs CG=0.3%) in the Emotional Support skill.
  
  
  CONCLUSIONS
  Our findings provide initial evidence that the Interreality protocol yields better outcomes than the traditionally accepted gold standard for psychological stress treatment: CBT. Consequently, these findings constitute a sound foundation and rationale for the importance of continuing future research in technology-enhanced protocols for psychological stress management.
  
  
  BACKGROUND
  ClinicalTrials.gov: NCT01683617; http://clinicaltrials.gov/show/NCT01683617 (Archived by WebCite at http://www.webcitation.org/6QnziHv3h).
authors.affiliation: Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Milan, Italy. andrea.gaggioli@auxologico.it.
authors.forename: Andrea
authors.initials: A
authors.lastname: Gaggioli
authors.forename: Federica
authors.initials: F
authors.lastname: Pallavicini
authors.forename: Luca
authors.initials: L
authors.lastname: Morganti
authors.forename: Silvia
authors.initials: S
authors.lastname: Serino
authors.forename: Chiara
authors.initials: C
authors.lastname: Scaratti
authors.forename: Marilena
authors.initials: M
authors.lastname: Briguglio
authors.forename: Giulia
authors.initials: G
authors.lastname: Crifaci
authors.forename: Noemi
authors.initials: N
authors.lastname: Vetrano
authors.forename: Annunziata
authors.initials: A
authors.lastname: Giulintano
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Bernava
authors.forename: Gennaro
authors.initials: G
authors.lastname: Tartarisco
authors.forename: Giovanni
authors.initials: G
authors.lastname: Pioggia
authors.forename: Simona
authors.initials: S
authors.lastname: Raspelli
authors.forename: Pietro
authors.initials: P
authors.lastname: Cipresso
authors.forename: Cinzia
authors.initials: C
authors.lastname: Vigna
authors.forename: Alessandra
authors.initials: A
authors.lastname: Grassi
authors.forename: Margherita
authors.initials: M
authors.lastname: Baruffi
authors.forename: Brenda
authors.initials: B
authors.lastname: Wiederhold
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Riva
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D000704:Analysis of Variance; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005178:Faculty; D005260:Female; D006801:Humans; D008297:Male; D009726:Nurses / Q000523:psychology*; D013315:Stress, Psychological / Q000517:prevention & control / Q000628:therapy*; D063367:Virtual Reality Exposure Therapy; D064232:Visual Analog Scale
keywords: Interreality; biofeedback training; biosensors; heart rate; heart rate variability; physiological monitoring; psychological stress; relaxation training; smartphones; virtual reality