Dr. Zimand is director of children’s services and Dr. Anderson is director of clinical services at Virtually Better, Inc., in Atlanta.
Dr. Gershon is a psychology intern at the Boston Consortium in Boston.
Mr. Graap is president and CEO of Virtually Better, Inc., in Atlanta.
Dr. Hodges is professor and chair of computer science in the Department of Computer Science at the University of North Carolina in Charlotte.
Dr. Rothbaum is associate professor of psychiatry in the Department of Psychiatry at the Emory University School of Medicine in Atlanta.
Acknowledgments: Drs. Rothbaum and Hodges receive research funding and are entitled to sales royalty from Virtually Better, Inc., which is developing products related to the research described in this article. In addition, they serve as consultants to, and own equity in, Virtually Better, Inc. The terms of this arrangement have been reviewed and approved by Emory University and Georgia Institute of Technology in accordance with their conflict of interest policies.
How is virtual reality being used in the treatment of anxiety disorders? Virtual reality is a relatively new technology that combines visual, auditory, and kinesthetic experience in a computer-generated world. Current research indicates its efficacy as a powerful tool in the treatment of a number of anxiety disorders. Specifically, controlled studies of exposure therapy using virtual reality have demonstrated efficacy for specific phobias, including fear of flying, heights, and spiders. Virtual reality has also been used with other anxiety disorders such as panic disorder with agoraphobia, social phobia, and posttraumatic stress disorder in Vietnam veterans. Additionally, virtual reality has been used as a form of distraction among the pediatric population undergoing painful medical procedures. As the technology improves and the cost of equipment decreases, virtual reality will become more available to mental health practitioners. The benefits of virtual reality therapy include ease of use, increased confidentiality, public appeal, and greater control of the therapy. This article describes virtual reality technology, offers rationale for its use in mental health, reviews virtual reality treatment outcome studies, and examines future directions for the field.
To bridge clinical research and practice, professionals must evaluate the effectiveness of different treatment approaches and techniques. The fast pace of technological innovation underscores the need for systematic evaluation to identify promising treatments. Whereas many of the applications of technology in mental health remain largely untested and unvalidated, virtual reality is an example of cutting-edge technology applied to mental health issues that has been examined within traditional research paradigms. Although this technology is still emerging, a number of studies indicate that virtual reality exposure therapy can be efficacious in helping patients overcome and manage certain anxiety disorders.
What Is Virtual Reality?
Virtual reality is a medium of human-computer interaction whereby an individual becomes an active participant within a three-dimensional virtual world. The user experiences multisensory stimuli (eg, visual, auditory, kinesthetic) that serve to immerse the individual into a computer-generated environment by wearing a helmetlike, head-mounted display consisting of display screens for each eye, earphones, and a head-tracking device. The head tracking provides orientation information to a computer, such that the images in the virtual world change in correspondence with the user’s movements. The environment changes in real time with the users’ movements, making the user feel like an active participant within the virtual world.
Theoretical Basis for Virtual Reality Use in Mental Health
The application of virtual reality to the treatment of anxiety disorders is based on cognitive/behavioral techniques and associated theories (eg, emotional-processing theory).1 In general, therapy for anxiety disorders is aimed at modifying a fear memory by first activating it through exposure and then pairing it with a new response or meaning (ie, relaxation, cognitive restructuring). With continued exposure to the feared stimuli in the absence of feared consequences, the process of habituation and extinction occur such that the previously feared stimuli no longer elicit the same anxiety response. Therefore, if virtual reality can activate the fear memory just as traditional exposure does, and if the exposure conducted in virtual reality generalizes to real-life situations, then this form of treatment should allow the individual to confront the feared situation in real life and manage the symptoms of anxiety.
Whereas the use of virtual reality exposure therapy for anxiety disorders capitalizes on immersing patients in a virtual world meant to recreate the real world, virtual reality for pain management benefits patients by distracting them from their real world. The basic theory behind distraction is that a patient’s attention is diverted away from a stimulus that produces anxiety or pain, and instead allows one to focus on a neutral or more pleasant stimulus.2 However, painful and noxious stimuli can be so overwhelming that passive forms of distraction (eg, watching videotapes, listening to audiotapes, or fantasy imagery) may not provide sufficient attentional demands to divert the patient’s attention away from the procedure. Virtual reality, on the other hand, engages multiple senses such that fewer attentional resources are available to focus on the less pleasant stimuli and should allow the patient to endure painful medical procedures with less distress.
Treatment of Specific Phobias
Initially, case studies were used to test the efficacy of virtual realitly in the treatment of specific phobias including claustrophobia, and fear of spiders, heights, and flying.3-7 In each of these reports, brief and focused treatment was deemed successful based on decreased self-report of anxiety and greater ease of confronting a previously fearful object or situation. These positive results led researchers to further test virtual reality using larger-scale clinical trials.
The first published controlled study of virtual reality exposure therapy and phobia involved the treatment of acrophobia.8 Twenty individuals who met Diagnostic and Statistical Manual of Mental Disorders,9 Fourth Edition (DSM-IV) criteria for acrophobia were randomly assigned to virtual reality exposure or a wait-list control. The treatment group received seven weekly individual treatment sessions consisting of exposure to virtual footbridges, virtual balconies, and a virtual elevator presented according to each participant’s self-rated fear hierarchy. Participants were allowed to progress at their own pace, but were encouraged to spend as much time in each situation as needed for their anxiety to decrease. Results indicated significant decreases in anxiety, avoidance, and distress from pre- to posttreatment assessment for the virtual reality exposure group, but not for the control group. Furthermore, the virtual reality exposure group reported more positive attitudes toward heights than the control group. Without being instructed to do so, 7 of the 10 virtual reality exposure treatment completers faced real-life height situations by the end of treatment. This controlled study provided the first evidence that, not only could virtual reality exposure lead to decreased reported fear and avoidance, but it could also lead to changed behavior in the real world.
An independent replication compared virtual reality exposure with in vivo exposure therapy.10 Ten participants who met DSM-IV criteria for acrophobia received two sessions of virtual reality therapy followed by two sessions of in vivo exposure. Virtual reality exposure was found to be as effective as in vivo exposure in reducing anxiety and avoidance. In fact, following only two sessions of virtual reality exposure, participants were found to have approached a ceiling effect, having successfully overcome their fear and diminishing the potential effect of the in vivo exposure. These positive results support the previous research and suggest that brief exposure using virtual reality can be effective in overcoming a phobia.
In summary, virtual reality exposure for fear of heights was effective in reducing self-reported anxiety and avoidance of heights, improving attitudes toward heights, and reducing the need for in vivo exposure. These studies show that fear could be experienced and overcome in the virtual world, and that this improvement generalizes to the real world.
Fear of flying is a significant problem, affecting approximately 10% to 25% of the population,11 and standard in vivo exposure therapy for fear of flying is inconvenient and cumbersome for therapists as well as extremely expensive for patients. Researchers thus developed and tested a virtual airplane to treat aerophobia. Forty-five fearful flyers were randomly assigned to one of three conditions: wait list, standard exposure therapy, and virtual reality exposure therapy.12 Treatment consisted of eight individual therapy sessions conducted over a 6-week study period. The first four sessions of both virtual reality exposure and standard exposure consisted of training in anxiety management using breathing retraining, cognitive restructuring for irrational beliefs, thought-stopping, and hyperventilation exposure. These were followed by four exposure sessions, either in virtual reality or to an actual airplane at the airport (standard exposure). Virtual reality exposure sessions were conducted twice weekly in the therapist’s office, using such stimuli as sitting in the virtual airplane, taxiing, taking off, landing, and flying in both calm and turbulent weather. For standard exposure sessions, patients were exposed to preflight stimuli (eg, ticketing, waiting area) and to a stationary airplane. Immediately following the treatment or wait-list period, all patients were asked to participate in a behavioral-avoidance test consisting of an actual commercial round-trip flight. The therapist accompanied participants in a group on a flight that lasted about 1.5 hours each way.
Results indicated that both types of treatment were equally superior to the wait-list condition. Participants receiving virtual reality exposure or standard exposure showed substantial improvement, as measured by self-report questionnaires, willingness to participate in the graduation flight, self-report levels of anxiety on the flight, and self-ratings of improvement. There were no differences between the virtual reality exposure and standard exposure treatments on any measures of improvement. Wait list participants demonstrated no significant differences between pre- and posttreatment self-report measures of anxiety and avoidance, and only one of the 15 wait-list participants agreed to fly.
Follow-up data gathered 6 months posttreatment indicated that treated participants maintained their treatment gains and 93% had flown since completing treatment.12 Follow-up data collected 1 year following treatment indicated that patients maintained their gains.13 These data represent the first controlled study to compare the use of virtual reality in the treatment of a specific phobia to the current standard of care—standard exposure therapy. The findings suggest that virtual reality exposure is as efficacious as standard exposure.
Treatment of Social Phobia
Early studies of virtual reality focused on environments with powerful physical cues (eg, depth perception, loud noises, and strong vibrations). Using virtual reality to treat individuals with social phobia who have prominent public-speaking fears requires a different set of stimuli. The hallmark of social phobia is a fear of negative evaluation, and it was not known whether or not virtual reality could elicit an interpersonal fear in order to be useful as an exposure environment. Two case studies are the only known research conducted to date using virtual reality exposure in the treatment of social phobia.14 Each participant met DSM-IV criteria for social phobia, nongeneralized subtype. As in previous studies, initial sessions focused on anxiety management techniques and video-camera exposure in which the participant was videotaped giving a talk and then watched the tape. The remaining sessions used virtual reality exposure which placed the patient in front of a small audience of five individuals around a conference table where the therapist could control the reaction of the audience (eg, listening intently, clapping, bored, sleeping, hostile). Following the course of treatment, both participants reported decreased anxiety while speaking in public, with levels comparable to typical public-speaking fears in the general population. In addition, both were willing to engage in a behavioral-avoidance test in which they reported mild levels of anxiety and adequate performance. Although these results are only preliminary and are limited in their generalizability due to single-subject design, results suggest that further, large-scale investigation is warranted to further investigate the use of virtual reality exposure in the treatment of the fear of public speaking.
Treatment of Posttraumatic Stress Disorder
Approximately 830,000 veterans suffer from chronic combat-related posttraumatic stress disorder (PTSD).15 Evidence suggests that behavioral therapies with an imaginal exposure component have been more effective than most other types of treatment,16 although the effects are not robust. Obviously, in vivo exposure to combat situations is impractical. Thus, a “virtual Vietnam” environment was created to explore the efficacy of virtual reality exposure with Vietnam combat veterans with PTSD.
The first use of virtual reality exposure for a Vietnam veteran with PTSD was reported in a recent case study17 of a 50-year-old, White male veteran meeting DSM-IV criteria for PTSD. He had served as a helicopter pilot in Vietnam approximately 26 years prior to the study. Treatment consisted of 14, 90-minute individual sessions conducted over a 7-week period. Results indicated posttreatment improvement on all measures of PTSD and maintenance of these gains at 6-month follow-up.
This case study was followed by an open clinical trial of virtual reality exposure for Vietnam veterans.18 In this study, 16 male patients who met DSM-IV criteria for PTSD were enrolled, 10 of whom completed the study. These participants were exposed to two virtual environments—a virtual clearing surrounded by jungle and a virtual Huey helicopter, in which the therapist controlled various visual and auditory effects (eg, rockets, explosions, day/night, yelling). Patients were hierarchically exposed to their most traumatic Vietnam memories while immersed within the virtual environments. After an average of 13, 90-minute exposure therapy sessions delivered over 5–7 weeks, there was a significant reduction in PTSD and related symptoms. This preliminary evidence suggests that virtual reality exposure may be a promising component of a comprehensive treatment approach for veterans with combat-related PTSD. The relatively high drop-out rate suggests that more investigation is needed to understand which veterans are most likely to benefit from this type of treatment.
Distraction for Pediatric Pain Management
Virtual reality distraction for children undergoing painful medical procedures is another innovation in the field. Several case studies have demonstrated the benefit of virtual reality as a distracter. One research group found that virtual reality was somewhat successful in relieving children’s anxiety associated with chemotherapy.19 A second case study compared virtual reality distraction with a video game in three adolescent burn patients during wound-care procedures.20 All three patients reported that they experienced less pain using virtual reality distraction and that less pain medication was needed. The third case study involved a pediatric oncology patient followed over four consecutive appointments for medical procedures (J. Gershon, unpublished data, 2001). He reported less pain and lower anxiety ratings during virtual reality distraction, compared to no distraction or nonimmersive distraction, in which he could interact with the virtual environment displayed on a computer screen using a joystick.
Although these case studies have limited generalizability, the positive results for virtual reality distraction led to a clinical trial in which children were randomly assigned to either no distraction (control group), nonvirtual reality distraction (on a computer screen) or virtual reality distraction.21 Overall, results suggested a benefit from distraction compared to the control group, with virtual reality distraction demonstrating more potency as indicated by reduced physiological arousal, fewer behavioral indices of distress, lower pain ratings by nurses, and lower anxiety ratings by parents and patients.
Outcome research conducted to date using virtual reality in behavioral treatment of anxiety disorders supports its effectiveness as a powerful research and clinical tool. In the area of specific phobias, data clearly indicate that specially designed virtual environments are effective tools for exposure therapy. Early indications of virtual reality exposure efficacy in social phobia and PTSD deserve further research in controlled clinical studies. Pain distraction applications may improve the quality of patients’ experiences during some medical procedures. Additional advantages for the use of virtual reality in treatment for anxiety disorders include greater control of situations, increased safety, less travel, and improved patient confidentiality.
Finally, there is some indication that patients prefer the virtual world when given the choice.13 People appear more willing to try things in virtual reality that they might avoid completely in the real world. As costs of equipment and programming are reduced, more specially designed environments can be created, which will allow for broader virtual reality usage in treatment and research. PP
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