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As such, someone who would constantly feel the urge to gamble throughout the day may report just one episode or at most a few distinct episodes if attention was distracted away from a constant craving. A few minimal exclusion criteria were applied during the recruitment of participants: suffering from GD but not associated with VLT or casino slot machines, being a minor, suffering from health issues that could be exacerbated by treatment using VR major cardiac disorder, severe and frequent motion sickness when traveling by car, vestibular or inner ear disorders, recurring migraines, epilepsy, balance or ocular disease and suffering from a potentially contraindicated mental health issue schizophrenia, mental retardation, etc. Audio recordings of the therapy sessions were played back to confirm that the instructions in the treatment manual were followed. It constitutes an empirically validated form of treatment recommended by experts and is considered to be among best practices 2 β€” 5. The intervention that took place during the two gambling exposure sessions imagination and VR conditions was recorded in an audio file, and a random selection of 20 of the 59 recordings available 9 sessions were not recorded due to technical problems were reviewed to confirm that the interventions were conducted as planned. Study 1 reveals that immersions in VR can elicit desire and a positive anticipation to gamble in frequent gamblers that are a significantly stronger than for infrequent gamblers and for playing a control game of skill and b as strong as for gambling on a real video lottery terminal. The conditions and interactions effects are not significant. Occasional recreational gamblers were recruited as a control group with enough minimal experience with VLTs to know what they are and how to use them. Frequent players were excluded if they scored 9 or more for ethical reasons due to concern about inducing cravings in people suffering from GD [9 is a score clearly within the range of potential GD but below the severity of the majority of those diagnosed with GD 23 , 24 , p. Following immersions in VR, the magnitude of the increase on two subscales out of three on the measure assessing the urges to gamble corresponds to large effect sizes that are essentially in the same range as playing on a real VLT. Experimental setup for Study 1 on the potential to induce cravings with a real video lottery terminal and virtual reality. The focus group confirmed that therapists were satisfied with the use of VR. People who suffer from gambling disorder GD are characterized by the inability to resist the urge to gamble, adversely affecting all aspects of their lives including their home, social, professional, and personal life 1. Study 3 primarily aims to document the safety, in terms of intensity of gambling cravings post-session, of applying VR to CBT, and to provide pilot data on increasing the use of VR to four sessions. Unwanted negative side effects induced by the immersion in virtual reality VR i. To test whether the virtual environments developed for GD can induce an urge to gamble, adults between the ages of 18 and 65 familiar with VLTs were recruited. For the Anticipation subscale, all three interaction contrasts were statistically significant [control vs. The few studies on this topic suggest that imaginal exposure helps reduce cravings in pathological gamblers 12 , 14 , But, this technique is still limited because a not everyone is skilled at bringing the stimuli to life in their mind; b therapists have no way of knowing what, exactly, their clients are thinking about during the exercises; c the therapeutic exercises performed by clients increase their cognitive load, causing a corresponding decline in their ability to fully imagine themselves in that situation; and d therapists sometimes have trouble getting gamblers to put their dysfunctional thoughts into words. The data were analyzed with two conditions frequent gamblers experimental condition vs. Suggestions for future research are provided, including on increasing the number of VR sessions in the treatment program. A similar pattern was observed for the Desire subscale [control vs. The therapists also made several suggestions that contributed to improving the treatment program and the development of two additional modules where VR could be used for cognitive restructuring Getting around denial by stating contradictions between what is expressed by the patients and how they behave during the immersion. A sample of 25 adults with a primary diagnosis of GD according to the DSM-5 criteria 1 was recruited following a semi-structured telephone interview conducted by mental health and GD care professionals. There are many factors that contribute to high-risk situations for gamblers 16 , such as images and logos associated with gambling, being in the presence of video lottery terminals VLTs in public places, feeling strong physiological and affective responses, seeing others gamble and win or give up their spot because they lost, being in the relaxed atmosphere of a bar, or the glamorous surroundings of a casino, etc. The significant repeated measures ANOVAs were followed up by interaction contrasts comparing each exposure to a gambling situation i. The sequence of participation in each condition was randomly distributed. The number of negative unwanted side effects induced by the immersion in VR in the VR condition was measured before and after the second VR therapy session. A Bonferroni correction was applied to control for inflation of the error rate due to multiple comparisons i. To balance out the potential effects of being immersed in VR e. Such preliminary results accordingly point not only to the success of the VR-S program but also underscore the need to pursue more research to increase its short-term effectiveness on GD symptoms. The two centers taking part in the project applied the Evaluation and Treatment Program for Excessive Gamblers by Ladouceur et al. The results show large effect sizes partial eta-squared of. Study 2 documents the feasibility of integrating VR in CBT, its usefulness in identifying more high-risk situations and dysfunctional thoughts, how inducing cravings during relapse prevention exercises significantly relates to treatment outcome, and the safety of the procedure in terms of cybersickness. Another session, in the last week of therapy, focuses on practising relapse prevention skills. Finally, dedicating two sessions to VR instead of following the standard treatment program was not associated with a reduction in treatment effectiveness see the general discussion for more on VR vs. Results from Study 3 confirm that, compared to inducing urges to gamble in imagination, using VR does not lead to urges that are stronger, last longer, or feel more out of control. VR also helps to identify twice as many dysfunctional thoughts, but this difference is not statistically significant. Results show a large reduction in cravings in participants in the VR condition, from a mean of The effect size of the interaction, as assessed with the partial eta-squared, was 0. Once immersed in this environment, participants were invited to imagine themselves in a high-risk situation and apply the CBT techniques. An initial pilot study was conducted to document the potential clinical usefulness of two VR immersions in the treatment of GD. The VR sessions relied on the same equipment as that the one used in Study 2 and were dedicated to the identification of high-risk situations, cognitive restructuring, and relapse prevention. Overall, the low frequency of episodes of gambling cravings might be indicative of a low urge to gamble following the sessions but likely also reflects a difficulty retrospectively isolating multiple distinct episodes. Data were analyzed with the goal of documenting the safety of using VR in CBT for GD, and therefore no correction was applied to control the potential inflation of error rate associated with multiple comparisons for assessing side effects. New clinical information gathered post therapy session about high-risk situations and dysfunctional thoughts about gambling in Study 2. Mean and SD on efficacy measures pre- and post-treatment in Study 3. Illustrations screenshots of the At Fortunes virtual environment used in all three studies. Reproduced from Bouchard et al. For a detailed description of the virtual environments and the VR technology used, see Bouchard et al. However, concerns about the safety of inducing cravings in sessions can be addressed much further. Also, because the latter paradigm is not based on extinction, it raises the very important question of whether the cravings induced by VR are too strong to be used safely, especially in outpatient settings where people can go gamble after the therapy session. We can thus estimate that with 0. This series of three studies helps determine the potential and safety of VR for the treatment of GD.{/INSERTKEYS}{/PARAGRAPH} {PARAGRAPH}{INSERTKEYS}Virtual reality VR can be used in the treatment of gambling disorder to provide emotionally charged contexts e. A regression using residualized change scores was also conducted to document the relationship between the intensity of the cravings induced during the relapse prevention session and pre-to-post-treatment improvements on the total score of the GCS. Due to ethical considerations regarding the induction of cravings in patients, the first study was conducted with a subclinical sample, the latter two studies were conducted in inpatient settings, and the number of sessions using VR progressively increased from only two in Study 2 to only four in Study 3. As described in Study 2 and 3 later in this article, therapists can use VR to identify situations, thoughts, and behaviors associated with gambling; conduct cognitive restructuring with dysfunctional beliefs underlying GD; or work on relapse prevention Using VR in combination with traditional CBT has proven effective in a few studies, but these studies are all based on the therapeutic rationale of cue exposure [i. In summary, the results from Study 1 show that VR can be used to induce cravings in gamblers. Using a cut-off score of 4 or less for the DIG i. Furthermore, inciting an urge to gamble by thinking of a past situation is still very limited when comparing an imaginary situation to the omnipresence and abundance of indicators capable of triggering a craving in the everyday lives of people who suffer from GD. There have been various attempts in CBT to help gamblers practice therapeutic strategies in situations of emotional arousal and cravings to gamble 3. Note, however, that the effect size is medium, and that a sample of about 80 participants would provide a 0. Following a random assignment, 14 participants received a traditional day cognitive behavioral treatment program with 2 imaginal exposure exercises imagination condition , and 20 received the same treatment program but with the 2 exposure exercises conducted using VR immersion VR condition. Pilot data are also needed to test the development of a treatment manual and prepare large randomized control trials. Using a cut-off score of 7 or less for the CPGI post-treatment i. The two treatment centers taking part in the project have been applying the assessment and treatment program for excessive gamblers developed by Ladouceur et al. It is of interest to note that the urge to gamble in the hours and days following the sessions levels off without ever dropping down to zero, most likely pointing to the everyday degree of desire in the gamblers being treated. T tests were performed to compare the two conditions based on all of the variables measured immediately following the four therapy sessions. Hypersensitivity to cybersickness, defined as a self-reported history of severe motion sickness when calling potential study participants, was also an exclusion criterion. The lack of correlation between the place where CBT takes placeβ€”i. The integrity scores regarding compliance with the treatment manual The compliance scores for respecting the clinical objectives of each session were even higher VR-S, experimental condition where the urge is induced by stimuli recreated in virtual reality; Imag-S, control condition where the urge is induced by stimuli evoked in imagination. These differences are not statistically significant. The control condition comprised 11 participants; 14 participants were in the experimental condition. Cognitive behavior therapy CBT has repeatedly proven effective for this disorder. As in Study 2, the participants received inpatient treatment from the therapists, but this time four CBT sessions were dedicated to VR immersion [for a detailed treatment manual, see Ref. Outcome data and effect sizes are reported for both randomized control pilot trials conducted in inpatient settings. Two additional exclusion criteria were set a priori and tested in the lab once the consent form was filled out, having poor stereoscopic vision or being intoxicated during the experiment, but no participant was excluded based on these criteria. Effect sizes are reported, Bonferroni corrections applied i. Instead of using the At Fortunes bar or The 3Dice casino, participants in the control Imag-S condition were immersed in an environment representing an empty room, with no cues associated with gambling or money. This raises practical questions, such as whether the cravings are sufficient to be clinically useful but also manageable enough to remain clinically safe. The next step is to test a preliminary treatment protocol with minimal involvement of VR and documents its safety with people suffering from GD. A percentage assessment of the entire day is probably more accurate than the frequency method. This shows that VR does not induce an urge to gamble that persists post-session longer or more strongly than after imaginal therapy; that the urge remains low; and that the impression of being able to control the urge remains high. No adverse event was reported on the evenings following the therapy sessions where VR was used. The strong correlations between urges to gamble and the SOGS suggest that results might be generalizable to more severe gamblers, although this remains to be tested empirically. The second session where VR was used revealed that it was not associated with significant cybersickness and that the induction of cravings during the relapse prevention exercise was related to the treatment outcome. Before and after the second gambling exposure session, participants evaluated the intensity of their desire to gamble on a scale of 0 to 10 and filled out the Simulator Sickness Questionnaire SSQ 29 , Before and after the treatment program, the participants completed the GCS The goal of the interview was to get their impressions on the VR immersion and the clinical issues they observed. For example, research has been done on the effectiveness of imaginal exposure 12 , 13 , where gamblers picture a high-risk situation in their minds so that they can then imagine themselves using psychotherapeutic strategies to deal with it. Before and after the first gambling exposure, the participants were asked to list all of their personal high-risk thoughts and situations. Illustrations screenshots of The 3Dice virtual environment used in all three studies. The therapist can then conduct various classic CBT interventions [see, for example, Ref. Clinically, all of the founding literature on CBT [e.