Virtual Reality Exposure Therapy Effective for Patients With Specific Phobias

Virtual Reality Exposure Therapy Effective for Patients With Specific Phobias

by Arline Kaplan Patients afraid of flying are responding favorably to virtual reality exposure therapy (VRET) in clinical trial findings, treatment experts reported at a symposium on virtual reality and mental health, which was part of the 8th Annual Medicine Meets Virtual Reality Conference in Newport Beach, Calif.

Barbara O. Rothbaum, Ph.D., from Emory Clinic in Atlanta, and colleagues described virtual reality (VR) as integrating “real-time computer graphics, body tracking devices, virtual displays and other sensory input devices to immerse participants in a computer-generated virtual environment.”

At the symposium’s opening presentation, Brenda K. Wiederhold, Ph.D., director of the Center for Advanced Multimedia Psychotherapy and California School of Professional Psychology Research and Service Foundation, explained that VR applications are primarily being explored for four areas: anxiety disorders, eating disorders, distraction techniques (e.g., during chemotherapy or bandage changes), and neuropsychological assessment and testing.

Optimistic about the future of this nascent therapy, Wiederhold said both the private and public sectors are now funding research grants. Additionally, the knowledge transfer is broadening with the publication of several books (Lamson, 1997; North et al., 1997; Riva et al., 1998). Presentations have moved from conceptual data to published studies and controlled trials on acrophobia (Rothbaum et al., 1995), agoraphobia (North et al., 1996), posttraumatic stress disorders with Vietnam veterans (Rothbaum et al., 1999) and eating disorders (Riva et al., 1999).

Several of the studies described at the symposium focused on fear of flying. Estimates are that 25 million people in the United States are afraid of flying, said Larry Hodges, Ph.D., of the College of Computing at Georgia Institute of Technology.

Hodges is co-founder of Virtually Better Inc., which builds, tests and markets virtual reality systems for therapy. He explained that VR exposure therapy has proven efficacious for patients with specific phobias, such as flying.

“The legitimate question then becomes how well does it work compared to standard exposure (SE) therapy,” he said. If VRET is close to imaginal exposure, then it may mean “we are spending a lot of money on something that is not very worthwhile.” If it is close to in vivo exposure, however, then “it is very worthwhile, because of advantages in terms of therapists’ time, control of the situation and repeatability.”

Hodges presented the unpublished results of a fear-of-flying study funded by the National Institutes of Health. The study compared VR exposure (n=15) to SE therapy (n=15) and a control group receiving no therapy (n=15). Pre- and post-assessments were conducted by a blind, independent assessor. Forty-two of the patients had simple phobias of flying, three had panic disorder with agoraphobia where fear of flying was the trigger and eight had fear of heights. Some patients had multiple diagnoses.

SE therapy for fear of flying requires the therapist and patient to travel to the nearest airport, spend time on planes and often fly together. In contrast, the VR therapy is conducted in the therapist’s office. VRET puts the patient into the passenger cabin of a virtual airplane to experience the various aspects of flying. The patient wears a head-mounted display that provides visual and audio sensory cues consistent with being on a plane.

The VRET patient is gradually exposed to a hierarchy of situations: sitting on the airplane with the engines off, then on; taxiing; takeoff; flying in good and then bad weather; and landing. With the head-mounted display, the patient can look left out the plane’s window at the gate, look right and see an empty aisle, and look up and see the ceiling of the plane’s cabin.

The patient sits in a seat similar to an airplane seat. When the sound of engines is heard in the VR program, the “thunderseat” will vibrate. When the virtual plane takes off, the vibration becomes more intense.

VRET is individualized, Hodges said. All therapy is conducted by licensed clinical psychologists.

In VR therapy, patients rated their anxiety every five minutes according to the Subjective Units of Discomfort Scale (SUDS). The scale ranges from 0 to 100, with 0 being no anxiety and 100 being the most anxiety they have ever felt.

During the VRET, a computer monitor shows the therapist what the patient sees in the head-mounted display. The therapist seeks to make the experience comparable to flying on a real airplane, Hodges said. “So if we do a takeoff, we would do flying and a landing. We would not just have the plane take off and magically be back at the runway. We try to make it a complete experience as much as possible.”

In the NIH-funded study, free treatment was provided for eight sessions conducted over a six-week period. For both VR and SE groups, the first session was devoted to information-gathering and patient histories. The next three sessions focused on anxiety management techniques, such as relaxed breathing and cognitive restructuring, for both groups. For the next four sessions, the VR-exposure patients came twice weekly to the therapist’s office. For the patients in SE therapy, there were two double sessions arranged at the airport.

During the first airport session, the SE patients stood in the ticket line and walked to the gate. During the second session, they got on a stationary, empty plane and imagined taking a flight.

“We tried to make the time actually with the therapist equal for the VR therapy and the non-VR therapy,” Hodges said.

Nearly all of the SE and VR patients flew within six months (80% of the VRET group and 90% of the SE group), Hodges said.

On measures of fear and anxiety, such as the Fear of Flying Inventory, he said, “There was no statistical difference between virtual reality therapy and standard exposure therapy, but there was a statistical difference between both therapies and the wait-list group.”

Currently, Hodges and his colleagues are conducting a two-year, NIH-funded study of VRET for flying using a much larger sample size.

Another speaker on virtual reality for phobias was Michael Kahan, M.D., of the Adult Ambulatory Care Clinic at Hillside Hospital in Glen Oaks, N.Y.

When he took delivery of the Virtually Better Fear of Flying program a year ago, Kahan said he and colleagues wondered whether “it would work well enough to justify the investment madeand whether it would work well enough in all types of patients regardless of the reason they were afraid to fly.”

Like Hodges, Kahan individualizes patient treatment. The treatment involves psychoeducation, anxiety management techniques and VRET.

“The criteria for improvement was simply: did the patients fly?” Kahan said. To date, Kahan said, 40 people entered treatment and 31 completed it.

“On average, our patients hadn’t flown in about six and one-half years, but for some it had been 30 years,” he said. Six people sought treatment because they needed to fly for business reasons; the remainder wanted to fly for pleasure. Fifteen of the patients were on medications for their anxiety. Following treatment, 21 of the 31 patients (68%) who completed treatment flew.

In an attempt to assess if the treatment had long-term effects, patients were asked several months later to respond to a questionnaire, returned by nine of the patients who had responded to the treatment. Seven of those nine patients had flown during the follow-up period, although with some moderate anxiety.

“Our data support prior studies that the fear of flying is heterogeneous,” Kahan said. He added that their data revealed virtual reality exposure works, and there doesn’t seem to be any difference between diagnostic categories in its effectiveness.

At her center, Wiederhold uses VR approaches to treat not only patients with fear of flying, but also those with fear of driving, social phobia, agoraphobia and claustrophobia. She described lessons learned from conducting 600 VR therapy sessions (Wiederhold and Wiederhold, 1999).

Although standard cognitive and behavior therapy principles and practices are followed during the course of treatment, special emphasis is placed on individual reactions to the virtual environment, she explained.

To collect data about the patient-therapist and patient-virtual environment interactions, the center relies on four methodologies: SUDS levels during exposure; self-report questionnaires depending on the phobia, such as State-Trait Anxiety Inventory and Fear of Flying Inventory; behavioral observations of the patient, such as the patient gripping the chair arms as the virtual environment unfolds; and physiological measures, such as measurement of heart rate, respiration rate, peripheral skin temperature, skin resistance (sweat gland activity) and brain wave activity.

Using physiological measures as a guide during VR therapy appears to be an important factor in treatment, Wiederhold said. She cited the example of 30 fear-of-flying patients: 10 received VRET with physiological feedback; 10 received the therapy without the physiological feedback although they were asked every two minutes about their SUDS level and 10 received imaginal rather than virtual reality therapy.

Those who received physiological feedback moved through the various scenarios of the VR program based on their physiology stabilizing.

“Physiological measurements really aid in verification of emotional processes,” Wiederhold added. “It is necessary to have some objective measurement rather than just asking a patient what is going on.”

Other applications of VR for medicine discussed at the symposium included the treatment of obesity and eating disorders, the treatment of panic disorders with agoraphobia, motor training for post-stroke and traumatic brain-injured patients, and distracting patients undergoing chemotherapy. Participants also discussed advances in the technology and characteristics of individual patients (e.g., their hypnotizability) that may affect their ability to become immersed in the virtual world.

While VR therapies and technologies are becoming more affordable and accessible, Mark Wiederhold, M.D., Ph.D., of Science Applications International Corp. did raise ethical concerns.

“Many patients describe extremely powerful, meaningful and vivid reactions to simulated environments. Although rare, negative side effects have been documented,” he said. “Because computer simulation allows for a seemingly unlimited number of creative and interactive environments, questions concerning appropriate choices and safe, effective and ethical use of these environments should be a priority.”

Specific issues cited by Wiederhold included patient privacy and confidentiality, practitioner competence, deception in research, misuse of the technology, informed consent, and human subject protection.

A major concern of internal review board committees, he explained, is the failure to provide the safeguards required for the protection of all subjects and the failure of investigators to assess risks accurately in the consent forms that are commonly seen.

“There are inconsistencies and disagreements about consent requirements in general; for example, the blurring of the line between clinical practice and medical research,” he said. “If a patient comes in who is a typical patient with agoraphobia and you put them in a virtual therapy environment, is that patient a clinic patient or a research patient? Do they need to sign a consent form?”

Wiederhold urged investigators and presenters at the symposium to form an ad hoc committee and create a set of ethical guidelines for virtual reality therapy.