Psychophysiology Lab and Biofeedback Clinic Carmen Russoniello, Ph.D., LRT, LPC, BCB, BCN Matthew Fish, M.S., LRT, BCB
"There aint much fun in medicine, but theres a heck of a lot of medicine in fun" Josh Billings-‐Humorist and Lecturer (1808-‐1885)
Casual Video Games Demonstrate Ability to Relieve Stress, ImproveMood: Potential Clinical Significance Highlighted “This Is Your Brain on a Videogame” “Medicinal use of video games growing” “Just Click the Mouse. Follow the Cursor. You Are Calm. You Feel Good.” “Medicinal use of video games growing After decades of research, medical communitys acceptance of video games for therapy growing” Game Industry: “Casual Games fight depression” Games for Health: “Casual Gaming’s Effects on Mood, Stress” WebMD Believe It or Not “Computer“How I Played Games for Science” Games Can Be Healthy”
"There ain’t much fun in medicine, but there’s a heck of a lot of medicine in fun” Josh Billings-‐Humorist and Lecturer (1818-‐1885)
Previous Game Research Therapies such as board games, card games, biofeedback, meditation and massage have been useful in helping people change brain and autonomic nervous system activity from areas associated with depression and stress to areas associated with relaxation and alertness (Russoniello, 1991, 2008).
The Ini(al Scien(ﬁc Inves(ga(on was Designed to Determine Whether Casual Video Games Could Improve Mood and/or Decrease Stress in a “Normal” Popula(on Results from surveys indicated that people played PopCap casual video games because the games reduced their stress and improved their mood.
Method Data from 134 participants (Average Age=26). Participants were monitored EEG and HRV equipment Subjects played/surfed the web for 20 minutes.
Psychological Measurement The Proﬁle of Mood States or POMS is a factor analytically derived inventory that measures six subscales: tension, depression, anger, vigor, fatigue, and confusion. In addition it calculates a “Total Mood Disturbance” and has established reliability on “Right Now” administration.
Total Mood Disorder Changes Overall POMS Changes md se df p Control Group(n=31) 2.6 2.4 30 .284 Bookworm (n=29) 7.9 2.5 28 .002 Bejeweled II (n=38) -‐11.3 2.2 37 .000† Peggle (n= 36) -‐14.9 2.3 35 .000†† †† Signiﬁcantly diﬀers from control p=.000. †Signiﬁcantly diﬀers from control p=.009.
Physiological Measure of Mood Using Brain Wave Measurement It is has been shown that leC hemisphere frontal alpha brain waves can be correlated with mood and associated behaviors. • Increases in alpha power in the leC hemisphere is associated with negaDve aﬀect, depression and avoidance/withdrawal behaviors. Conversely, decreases in leC alpha power improves mood and decreases avoidance/withdrawal behaviors.
Brain Waves and Mood (cont.) • Decreases in right hemisphere alpha power has been also been associated with negative mood. Conversely increases in right alpha power improves mood and increases Approach/Engage behaviors • The ratio between right and left brain alpha has been used to measure emotional stability/mental relaxation (Davidson,1988 and Marshall & Fox, 2000).
Bejeweled 2 Changes Pre-‐post Left Alpha Changes md se df p Control Group (n=22) .99 1.5 21 .50 Bejeweled 2 (n=28) -‐3.3 1.3 27 .014† †Signiﬁcantly diﬀers from control p=.032
Peggle Changes in R-‐Alpha Pre-‐post Right Alpha Changes md se df p Control Group (n=22) .427 10 21 .996 Peggle Group (n=29) 17.9 9 28 .048
Depression Depression is a serious medical illness; it’s not something that you have made up in your head. It’s more than just feeling "down in the dumps" or "blue" for a few days. It’s feeling "down" and "low" and "hopeless" for weeks at a time. (National Institute of Mental Health, 2010)
Par(cipants Participants were Adults (=>18) that signed an Institutional Review Board approved informed consent agreeing to participate and met the criteria score for inclusion (PHQ9 score=>5).
Par(cipants Qualifying participants then completed the POMS, State/Trait Anxiety Inventory, psychological assessments, demographic proﬁle sheet, and the remaining components of the Patient Health Questionnaire (PHQ). The participants also gave a small saliva sample for biochemical testing. At this point participants opened an envelope containing a random assignment to the control or experimental groups.
Experimental Group If the participant was assigned to the experimental group they were given a choice of three popular casual video games to play. Research has demonstrated that freedom to choose is an important precursor to experiencing the full beneﬁts of recreation participation. The participant then played the games of their choice for 30 minutes while being recorded.
Experimental Group In addition to the two lab sessions scheduled one month apart, the experimental group was instructed to play the casual video game of their choice at home for at least 30 minutes 3x per week (At least 24 hours between sessions) for one month. Participants were asked to keep a log of the amount of time spent playing the game during the month. The average game playing time for the experimental group was minimum 30 max 68 minutes and the mean 40.7 minutes.
Control Group If the person was assigned to the control group biosensors were placed by the researcher and baseline psychophysiological data was recorded for 6 minutes. The control participant was then instructed to surf the National Institutes of Mental Health consumer web site on depression for 30 minutes while psychophysiology data was being recorded. http://www.nimh.nih.gov/health/topics/ depressionindex.shtml
Methods All sessions were conducted in a room with minimal distractions (blank walls, no outside view, minimal noise). The researcher administered psychological assessments and connected the participants to physiological monitoring equipment following the same procedure for both groups. All participants sat in the same chair in front of the same computer.
RESULTS PHQ9 Diﬀerences between Experimental and Control Groups Time Mean Diﬀ Std. Err Sig 1 -‐.345 1.33 .797 2 3.13 1.36 .024 3 2.85 1.23 .024 4 3.13 1.08 .005 PHQ 9 scores did not diﬀer at time 1 (the initial baseline) but did so after time 2 or post session one; time 3 or baseline for session two obtained 1 month after initial data collection and time 4 or post second session.
Changes in Clinical Depression Pre-‐Post Study (PHQ-‐9) Score Minimal Minor Moderate Severe Total Pre Study Control Count 12 9 6 2 29 Percent 41.4% 31.0% 20.7% 6.9% 100.0% Post Study Control Count 18 9 1 1 29 Percent 62.1% 31.0% 3.4% 3.4% 100.0% Minimal Minor Moderate Severe Total Pre Study Experimental Count 14 9 3 4 30 Percent 46.7% 30.0% 10.0% 13.3% 100.0% Post Study Experimental Count 26 4 0 0 30 Percent 86.7% 13.3% 0% 0% 100.0%
Changes in Clinical Depression within CVG Group 100 80 PERCENT 60 40 20 0 PHQ post Minimal PHQ pre Mild Moderate Severe Minimal Mild Moderate Severe PHQ pre 42.9 50 7.1 0 PHQ post 100 0 0 0
Proﬁle of Mood States (POMS) Overall mood during game play was also measured. The POMS measures Psychological Tension, Anger, Depression, Vigor, Fatigue and Confusion. Cumulatively, these six aspects of mood are combined to form “Total Mood Disturbance,” (TMD) Time Mean Diﬀ Std. Err Sig 1 .252 11.2 .982 2 24.4 7.4 .002 3 24.0 10 .020 4 29.6 7.7 .000 A decrease in TMD indicates a positive change in mood. In terms of TMD during game play the experimental group experienced a 65% reduction in TMD and this was signiﬁcant from control after each measure except for the initial baseline
Changes in POMS Categories The following slides depict the diﬀerences between the video game group and the six categories of the POMS. In general there were Decreases in: Tension: 49.6% Anger: 55% Depression: 50% Fatigue: 58% Confusion: 50% and a 33% Increase in Vigor
Anxiety Anxiety and fear are two diﬀerent emotions but are commonly regarded as the same. Fear is deﬁned by an obvious source of danger. However, with anxiety, danger is not typically speciﬁed clearly, as it can occur in situations where danger is not observable (Butcher, et al., 2007).
Anxiety Cont’d Anxiety disorders develop when anxiety becomes excessive or uncontrollable Common symptoms Negative mood Unnecessary worry Chronic stress Avoidance of speciﬁc situation
Types of Anxiety State anxiety refers to a transitory emotional state or condition that can be characterized by subjective, consciously apparent feelings of tension and apprehension, and an ampliﬁed autonomic nervous system. Trait anxiety refers to an individual’s proneness for anxiety and a common tendency to respond with anxiety when confronted with a perceived threat.
STAI To determine if there is any change in participants anxiety level the STAI will be used to measure changes in both state (S-‐Anxiety) and trait (T-‐ Anxiety) anxiety. The STAI is a brief, self-‐report inventory that consists of 20 S-‐Anxiety questions and 20 T-‐ Anxiety questions, for a total of 40 anxiety questions.
RESULTS STAI-‐S Diﬀerences between Experimental and Control Groups Time Mean Diﬀ Std. Err Sig 1 3.28 2.98 .275 2 8.48 2.72 .003 3 8.34 3.06 .009 4 11.64 2.72 .000 STAI-‐S scores did not diﬀer at Time 1 (the initial baseline). However, at Time 2, pre session 1, and Time 3, baseline for session two, which was obtained 1 month after the initial baseline, was statically signiﬁcant as well as Time 4.
STAI-‐S Experimental and Control Comparison 45 40 35 Axis Title 30 25 20 Control Group Time 1 Time 2 Experimental Group Time 3 Time 4 Time 1 Time 2 Time 3 Time 4 Experimental Group 38.04 31.59 30.37 28.15 Control Group 41.32 40.07 38.71 39.79
RESULTS STAI-‐T Diﬀerences between Experimental and Control Groups Time Mean Diﬀ Std. Err Sig 1 3.14 3.22 .333 2 7.86 3.24 .019 STAI-‐T scores did not diﬀer at time 1 (the initial baseline) but did so at time 2 or baseline for session two obtained 1 month after data collection.
STAI-‐T Experimental and Control Comparison 50 45 Axis Title 40 35 30 25 Control Group 20 Experimental Group Time 1 Time 2 Time 1 Time 2 Experimental Group 45.07 38.18 Control Group 48.21 46.04
Changes in Anxiety The experimental group saw signiﬁcant reductions in both state and trait anxiety. Subjects in the experimental group experienced a signiﬁcant decrease in their state anxiety score between Time 1 (session 1 baseline) and Time 3 (session 2 baseline). Likewise, subjects also experienced a signiﬁcant decrease in their trait anxiety score from Time 1 and Time 3. Subjects within the control group did not experience any signiﬁcant change in their anxiety levels.
The Eﬀectiveness of Casual Video Games in Improving Cognitive Performance in People Over 50: A Randomized Controlled Study
Why is it important? Most adults experience a decline in cognitive functioning When this loss begins and its intensity varies considerably Cognitive decline can also impact: Episodic memory (recall info in linked format) Perceptual reasoning (identifying objects) Inductive reasoning (using logic for decisions)
Speed of CogniDve Processing Area of cognition receiving most of attention due to its broad inﬂuence over various factors Important to speciﬁc operations: Episodic memory Working memory Reasoning abilities Verbal ﬂuency Also linked to: New learning Everyday task performance
Trail Making Test The TMT is a standardized set of ﬁve visual search and sequencing tasks that are heavily inﬂuenced by attention, concentration, resistance to distraction, and cognitive ﬂexibility (or set-‐shifting). It is highly useful in the evaluation and diagnosis of brain injury; frontal lobe deﬁcits; problems with psychomotor speed, visual search and sequencing, and attention; and impairments in set-‐shifting.
Improvement in CogniDve FuncDoning Trail Making Test A Control Experimental -‐3.3 Preliminary Results indicate that playing casual video games decreases response time to cognitive tests by 12 % indicating improvement in cognitive abilities -‐12
Improvement in CogniDve FuncDoning Trail Making Test B 9 Experimental Control Playing casual video games increases executive cognitive functioning as indicated by an 18% decrease in response time. Whereas the control group increased their response time by 9%. -‐18
CogniDve Improvement Both cogniDve response Dme (the speed with which a subject completes a task) and execuDve funcDon (the frequency of correctly compleDng parts of the task) were tracked. Those parDcipants that played Bejeweled or Peggle for short (30 minute) periods showed an 87% improvement in cogniDve response Dme and a 2.15 Dmes increase in execuDve funcDoning when compared to a control group.
Improvement in CogniDon These improvements in overall cognitive acuity are comparable to changes recorded after other types of cognitive interventions such as mindfulness based cognitive therapy and cognitive remediation therapy.
The Eﬃcacy of a Biofeedback Controlled Video Game in Preven(ng and Reducing Symptoms of PTSD
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References Russoniello, C. V., Obrien, K., & Parks, J. M. (2009). EEG, HRV and Psychological Correlates While Playing Bejeweled II. Annual Review of CyberTherapy and Telemedicine. Wiederhold, B.K. 7 Riva, G. (Eds.) The Interactive Media Institute and IOS Press. Doi:10.3233/978-‐1-‐60750-‐017-‐9-‐189 Russoniello, C. V. O’ Brien, K. & Parks, J. M. (2009). The eﬀectiveness of casual video games in improving mood and decreasing stress. Journal of CyberTherapy and Rehabilitation, 2 (1), 53-‐66. Russoniello, C. V. (2008). The eﬀectiveness of prescribed recreation in reducing biochemical stress and improving mood in alcoholic patients. American Journal of Recreation Therapy, 7(3), 1-‐11.
CONTACT Carmen V. Russoniello, Ph.D., Director Psychophysiology Lab and Biofeedback Clinic East Carolina University Belk Building Suite 2501 Greenville, NC 27858 firstname.lastname@example.org 252-‐328-‐0024 www.ecu.edu/biofeedback