Inter-reality in the Evaluation and
Treatment of Psychological Stress
Disorders: the INTERSTRESS Project
Pietro CIPRESSO a,
, Andrea GAGGIOLI a,
Silvia SERINO a , Simona RASPELLI a, Cinzia VIGNA a, Federica PALLAVICINI a
and Giuseppe RIVA a
a Applied Technology for Neuro-Psychology Lab,
Istituto Auxologico Italiano, Milan, Italy
Abstract. “Psychological stress” occurs when an individual perceives that environmental demands tax or
exceed his or her adaptive capacity. According to the Cochrane Database of Systematic Reviews, the best
validated approach covering both stress management and stress treatment is the Cognitive Behavioral (CBT)
approach. CBT has undergone a very large number of trials in research contexts. However, it has been less
efficacious in clinical contexts and it has become obvious that CBT has some failings when applied in
general practice. INTERSTRESS is a EU-funded project that aims to design, develop and test an advanced
ICT-based solution for the assessment and treatment of psychological stress that is able to address three
critical limitations of CBT: a) the therapist is less relevant than the specific protocol used. b) the protocol is
not customized to the specific characteristics of the patient; c) the focus of the therapy is more on the top-
down model of change (from cognitions to emotions) than on the bottom-up (from emotions to cognitions).
To reach this goal the INTERSTRESS project applies an innovative paradigm for e-health – Interreality –
that integrates assessment and treatment within a hybrid environment, bridging physical and virtual worlds.
On one side, the patient is continuously assessed in the virtual and real worlds by tracking the behavioral and
emotional status in the context of challenging tasks (customization of the therapy according to the
characteristics of the patient). On the other side, feedback is continuously provided to improve both the
appraisal and the coping skills of the patient through a conditioned association between effective
performance state and task execution behaviors (improvement of self efficacy). Within this conceptual
framework, it is possible to set up and test psychological treatments that could be extended also beyond the
traditional research and clinical setting by using more and more emerging mobile technology to deliver real-
time interventions during daily activities and ecological contexts.
Keywords. Psychological stress, physiological monitoring, wearable sensors, knowledge models, decision
According to Cohen and colleagues  “Psychological Stress” occurs when an
individual perceives that environmental demands tax or exceed his or her adaptive
capacity. In this view, stressful experiences are conceptualized as person-environment
transactions, whose result is dependent on the impact of the external stimulus.
The Cochrane Database of Systematic Reviews [2, 3] identified in the Cognitive
Behavioral (CBT) approach the best validated approach for stress management and
stress treatment. Even if CBT is the treatment of choice for psychological stress, there
is still room for improvement .
Specifically, there are three major issues to solve:
the therapist is less relevant than the specific protocol used;
the protocol is not customized to the specific characteristics of the patient.
the focus of the therapy is more on the top-down model of change (from
cognitions to emotions) than on the bottom-up (from emotions to cognitions).
To overcome the above limitations, Riva and coll.  recently introduced a new
paradigm for e-health – “Interreality” - that integrates assessment and treatment within
a hybrid environment, bridging physical and virtual world. By creating a bridge
between virtual and real worlds, Interreality allows a full-time closed-loop approach
actually missing in current approaches to the assessment and treatment of
psychological stress: first, the assessment is conducted continuously throughout the
virtual and real experiences: it enables tracking of the individual’s psycho-
physiological status over time in the context of a realistic task challenge; second, the
information is constantly used to improve both the appraisal and the coping skills of the
patient: it creates a conditioned association between effective performance state and
task execution behaviors. The potential advantages offered to stress treatments by this
approach are: (a) an extended sense of presence : Interreality uses advanced
simulations (virtual experiences) to transform health guidelines and provisions in
experience; (b) an extended sense of community: Interreality provides social support in
both real and virtual worlds; (c) a real-time feedback between physical and virtual
worlds: Interreality uses bio and activity sensors and devices (PDAs, smartphones)
both to track in real time the behavior and the health status of the user and to provide
suggestions and guidelines [6, 7].
Fig. 1. A Virtual Reality based stressful situation.
From a technological viewpoint Interreality is based on the following devices/platform:
3D Individual and/or shared virtual worlds: They allow controlled exposure
and objective assessment;
Personal digital assistants and/or mobile platforms (from the virtual world to
the real one): It allows an objective assessment, provision of warnings and
Personal biomonitoring system (from the real world to the virtual one): It
allows a quantitative assessment and decision support for treatment.
These devices are integrated around two subsystems: the Clinical Platform (in patient
treatment, fully controlled by the therapist) and the Personal Mobile Platform (real
world support, available to the patient and connected to the therapist) that allow a)
monitoring of the patient behavior and of his general and psychological status, early
detection of symptoms of critical evolutions and timely activation of feedbacks in a
closed loop approach; b) Monitoring of the response of the patient to the treatment,
management of the treatment and support to the therapists in their therapeutic decisions.
The clinical use of these technologies in the Interreality paradigm is based on a closed-
loop concept that involves the use of technology for assessing, adjusting and/or
modulating the emotional regulation of the patient, his/her coping skills and appraisal
of the environment (both virtual, under the control of a clinician, and real, facing actual
stimuli) based upon a comparison of that patient’s behavioural and physiological
responses with a baseline or performance criterion.
Figure 1. Inter-reality: A link between Virtual and Real world.
The release of the main INTERSTRESS technological components was successfully
completed and the integrated service platform is currently in an advanced development
stage. The formative evaluation studies have involved so far over 100 participants in
three EU countries (Italy, Spain, Germany). The full trials are expected to run for nine
months, during which the efficacy and effectiveness of the Interreality approach in
supporting stress management will be compared with conventional cognitive-
behavioral program. The assessment phase features psychological questionnaires, a
clinical interview and a self-monitoring week, where the participants will monitor their
physiological and psychological stress reactions by means of biosensors and a
smartphone (experimental group) or by a diary (control group). In the experimental
training phase, participants in the experimental condition will be exposed to typical of
stressful scenarios in a virtual reality simulator, and then the participants will learn
basic coping strategies.
Stress is an increasingly recognized phenomenon that has negative effects on growing
numbers of people. Chronic stress is responsible for premature mortality in Western
countries, and work-related stress accounts for premature cardiovascular mortality rates.
INTERSTRESS aims to improve links and interaction between patients and doctors,
facilitating more active participation of patients in the care process. Also, it envisions a
better quality of life, where personalized, immersive e-therapy allow the ability to
detect and manage stress anytime, anywhere.
This work was supported by the European funded project ‘‘Interstress-Interreality in
the management and treatment of stress-related disorders’’, FP7-247685.
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