The growth in acceptability of mental illness and its treatment is putting therapist services under pressure across the world, while terrorist and other mass causality incidents are increasingly placing sudden surge in demands.
More efficient ways of working are needed to meet this growing and unpredictable demand. ExposureTherapy is the most evidenced treatment for phobia and PTSD, however, it suffers high dropout rate, typically from too low or high engagement. VirtualRealityExposureTherapy (VRET) has potential to address this, as it seems more engaging to resistant populations and stimuli can be controlled to theoretically manage engagement. VRET has demonstrated clear efficacy across the treatment of phobias but efficacy varies across studies of treatment of PTSD. It could be argued that those with PTSD are in general in more need of greater control of engagement and support from the therapist. We argue that using traditional technologies, management of engagement is hampered by immersing the client alone within the stimuli before they have had help to approach it.
Short-term virtualrealityexposure treatment of PTSD in an OIF veteran resulted in a substantial drop in the patient’s self-reported PTSD symptoms. This participant reported feeling comfortable with the technology utilized in this form of treatment and found the treatment to be logical and credible. Although the participant still met CAPS criteria for a PTSD diagnosis at posttreatment, he anecdotally reported experiencing improvement in functioning in many areas of his life as a result of treatment, including increased ability to concentrate at work, increased communication with spouse, decreased anhedonia, and decreased avoidance of friends and fellow soldiers. He also discussed feeling that he no longer needed to “keep thinking about” the identified trauma. The limitations of an uncontrolled case report are obvious; nevertheless, this outcome provides preliminary promise for the use of virtualrealityexposuretherapy with OIF veterans with PTSD.
In particular, some parts of this work should be presented in front of a group of audience. PSA, a subtype of social phobia, which can be a destructive disorder among novice software engineers. Such individuals might have excessive concerns about being embarrassed and judged by other people . Some research indi- cated that subjects exposed to the feared social situations and learnt to modify their thoughts and behaviors show decreased anxious symptoms . In virtualrealityexposuretherapy, this kind of anxiety is elicited by a predesigned vir- tual environment, and here in this study, it is used to observe a small set of novice computer engineers. Indeed, virtualreality has increasingly been used as a therapeutic tool to explore human behaviors and emotions as well as cogni- tion. It provides a well-controlled environment so that therapist can manipulate the stimuli determined beforehand. Since VRET can be adapted to individual’s needs, it opens door to creativity and flexibility for therapeutic usage . The purpose in the present study was to test the effects of VREI on public speaking anxiety of novice software engineers.
Published online: 10 June 2010
# Springer Science+Business Media, LLC 2010
Abstract Anxiety disorders, including phobias and post- traumatic stress disorder, are common and disabling disorders that often involve avoidance behavior. Cognitive-behavioral treatments, specifically imaginal and in vivo forms of exposuretherapy, have been accepted and successful forms of treatment for these disorders. Virtualrealityexposuretherapy, an alternative to more traditional exposure-based therapies, involves immersion in a computer-generated virtual environment that minimizes avoidance and facilitates emo- tional processing. In this article, we review evidence on the application of virtualrealityexposuretherapy to the treatment of specific phobias and post-traumatic stress disorder and discuss its advantages and cautions.
During the trial participants are not allowed to receive any therapy aimed at improving social participation.
VRETp treatment has a maximum of 16 treatment ses- sions of 60 minutes each. This number of sessions is somewhat larger than is usual for CBT in anxiety disor- ders. Our rationale for this is our expectation that treat- ing paranoia requires more time compared with treating regular anxiety. People suffering from a psychotic dis- order often show severity and durance in their social avoidance. Negative symptoms make it difficult to mo- tivate people for therapy and this is a continuing process during treatment. The treatment protocol states that the therapists receive 16 hours of training; all therapy ses- sions are recorded. A selection of the sessions is rated for treatment fidelity using the Cognitive Therapy Rating Scale (CTRS). The CTRS is a reliable  and valid 
Environment 2. The classroom. The classroom consists of four rows and four columns (16 school desks). Both levels of difficulty in this environment are determined by the type of responses avatars simulating classmates and the teacher offer to the behaviour displayed by the student. The “easy” level allows the user to seat immediately anyplace close to the door without having to move much and be exposed to the look of their classmates. The avatar of an indul- gent teacher asks the students to introduce themselves from their place in the classroom giving their name, surname, and age and to talk about any hobby. The professor acts as a model introducing himself to the class. The audience consisting of virtual students behaves in a neutral way all the time, making no critiques or comments. Later on, the teacher asks the students to go in front of the class and resolve a mathematical calculus on the blackboard. If the stu- dents solve the problem correctly the teacher offers a positive verbal rein- forcement whereas if the students make a mistake the professor gives them another opportunity to try again. If the solution is mistaken again the teacher asks the students to return to their school desk and to keep trying, using a neu- tral tone. The activity is finished when the teacher makes a comment to the whole classroom reinforcing their participation in class and their positive attitude towards trying to solve problems. In the “difficult” level the subject must be seated in a chair in the centre of the classroom surrounded by the other students and near a group of intimidating characters. An avatar simulating the demanding teacher requests the students to go in front of the class to introduce themselves giving their name, surname, and age and also talking about any hobby. The self introduction is not previously modelled by the teacher and the audience responds with expressions of discontentment and pejorative comments. Next, the subject must solve a complex arithmetic problem on the blackboard. The teacher makes no commentary if the solution is correct. If the solution is mis- taken, the pupil is verbally punished and is not allowed to have another oppor- tunity to try again. Disregarding the result, the rest of the class adopts a critical position, responding with expressions of discontentment and pejorative com- ments. As it occurs with the “easy level”, the activity is finished when the teacher makes a comment reinforcing the participation in class and the posi- tive attitude towards trying to solve problems.
Advantages and Disadvantages of VRE
VR is employed at the point in therapy when exposuretherapy would normally be introduced, and has several advantages over other exposure approaches. First, VR offers a type of shared experience between the therapist and participant that is not possible elsewhere. For example, it is impossible to bring clinicians on the battlefield with combat PTSD patients, though it is currently impossible to share all PTSD patients’ imagined scenes. Second, VR extends the range of options available to a clinician by allowing the opportunity for exposures to situations that are difficult or costly or time-consuming in real life. For instance, using a virtual airplane, the therapist can expose the patient to the airport and spend time taking off, flying in smooth and turbulent weather, and landing, repeatedly, without leaving the office, and all within the typical therapy hour. Third, in VR, the therapist can adjust the situation to create the perfect exposure for the patient; for example, he or she can guarantee that there will be no turbulence until the patient is ready to confront turbulence therapeutically. Fourth, VRE augments the patient’s imaginative capacities with visual, auditory, olfactory, and even haptic computer-generated experiences. In this way, VR provides a sensory-rich and evocative therapeutic environment that may be particularly helpful for patients who are reluctant to recall feared memories, have difficulty emotionally engaging in the traumatic memory, or are not very good at imagining situations. Fifth, VRE may have special appeal for members of the digital generation who may not otherwise participate in therapy. Wilson, Onorati, Mishkind, Reger, and Gahm (2008) recently found that one in five military personnel who reported not being interested in therapy would consider VRE. This suggests that VRE may provide a means of reaching 20% of this particular population who may not otherwise seek or participate in treatment. The ability to repeat needed exposures, opportunities to monitor patients’ responses in multiple domains, and less exposure of the patient to possible harm or embarrassment are other clinical benefits of using VR for exposuretherapy (Wilson, Onorati, Mishkind, Reger, & Gahm, 2008).
Oskam (2005) evaluated the use and effectiveness of VRET as a treatment of anxiety disorders. Oskam noted that for VRET to be effective, there are four factors that must be present, namely that virtual environments must have a strong cognitive presence, cognition, elicit strong emotions, and the effects of VRET must be able to be generalized to the real world. Furthermore, Oskam went on to argue that the general effectiveness of VRET is tied to the realism of the environment and that realism of the environment directly affects each of these factors. Oskam concluded by stating that the effectiveness of VRET could potentially be improved if the realism of the virtual environment is improved and that it is likely that improving realism within the virtual environments will also allow the effects to be more generalizable to the real world. However, the author noted that more research will have to be done in this area to determine exactly how this can be accomplished. Therefore, by conducting this research study, I aspired to fill this gap.
There are obstacles and disadvantages to VR as well. Some patients may not be able to overcome the fact that the exposure is not to the "real" stimulus, and we do not yet have information on what type of person constitutes a good candidate for VR versus in vivo exposure. The obvious goal of therapy is to increase patients' comfort in the real feared environments, so in vivo exposure is always recommended as the end goal. Although the VR does allow the therapist to control some aspects such as take-off, landing, and turbulence, many aspects are not under therapist control. If particular exposures are required that are not already included in the virtual environments, it would be very difficult for the therapist to add these components. The seat does not move, and several users have commented that they miss the G-force and seat positions of a real airplane. Although hydraulic seats exist that would more closely match this experience, they are expensive and temperamental, and it was decided not to include them in this VR setup to keep costs relatively low. Of course, with any computer application, there are occasional computer glitches or difficulties that may interfere with a smooth exposure. The therapist may find treatment difficult or frustrating if a computer glitch occurs, although these have been rare.
Accordingly, we have decided to have a safe cut off of
≤ 2 SUDS scores before moving to the next VR scenario.
This criterion was earlier applied in a similar study .
The exposures with scenario 1, 2, 3, 4 and 5 are repeated p,q,r,s and t times respectively until SUDS score of ≤ 2 is achieved. For instance, when participant reaches ≤ 2 SUDS with VR scenario of sitting idle on the dental chair then the next VR scenario of inspecting the oral cavity with a dental mirror is introduced. In subsequent ses- sions, the intensity of VR experiences will be progres- sively increased from a less threatening scenario to a more threatening scenario to make the simulation more realistic while focusing on areas of particular stress. For example, if a dental phobic participant report a fear of drills, the exposure is progressively increased from
is believed to be an important indicator of emotional processing during exposuretherapy (Foa & Kozak, 1986; Foa & Kozak, 1998; Foa & McNally, 1996).
Selective BIS Activation During VR Exposure
Our findings are in accordance with Fowles’ (1988) motivational theory. Whereas VR exposure apparently mainly activates what Fowles refers to as the behavioral inhibition system (BIS), in-vivo exposure activates both the BIS and the behavioral activation system (BAS). We speculate that the crucial difference between VR and in-vivo contexts may be that the real-life exposure study made use of ambulatory monitoring systems that allow participants to move freely during exposure and, thus, at least theoretically, to show active avoidance, allowing for the BAS to be activated. In contrast, participants of the current study were enclosed in a small darkened testing room, wore a VR headset, and had various sensors attached to an immobilized arm. While standing on a small platform they were connected to stationary amplifiers and thus could not move without restraint. Within the VR world, they were not in control over the movement of the elevator platform. Apparently, one or more of these contextual factors have hindered the triggering of a cardiovascular fight-flight response, which is often conceptualized as an evolutionarily evolved preparation mechanism for physical work.
prevent software crashes, a high-end laptop and a mesh backpack were purchased to prevent overheating of NIRSport recording device. The aim of this study was to measure the PFC brain activity indicative of fear inhibition and cognitive reprisal, and a psychophysiological response indicative of emotional arousal, within a single session of VRET with improved ecological validity. This was achieved by combining wireless brain imaging device – fNIRS NIRSport with a large CAVE-like VR display system – Octave. The study involved twenty-seven healthy participants walking on the virtual wooden plank while their brain activity and HR were recorded. The result showed increased activity in the DLPFC and MPFC during exposure to virtual heights consistent with fear inhibition and appraisal measured in previous neuroimaging studies that had not used VR. Although the study did not detect significant within- session neuronal changes, the trend was revealed towards involvement the bilateral DLPFC at the beginning of session consistent with emotional reappraisal. This pattern of activation extended to the bilateral MPFC during the second block (2.4 minutes) of exposure and increased in magnitude during the third block. Unfortunately due to equipment failure, the study did not find a significant effect of VRET on HR, however, the analysis demonstrated a trend towards an increased HR when participants were exposed to virtual heights, which then decreased during the course of the experiment.
However, previous studies have employed brain imaging technology which restricts people’s movement and hides their body, surroundings and therapist from view. This is at odds with the way engagement is typically controlled. We used a novel combination of neural imaging and VR technology—Functional Near-Infrared Spectroscopy (fNIRS) and Immersive Projection Technology (IPT), to avoid these limitations. Although there are a few studies that have investigated the effect of VRET on a brain function after the treatment, the present study utilized technologies which promote ecological validity to measure brain changes after VRET treatment. Furthermore, there are no studies that have measured brain activity within VRET session. In this study brain activity within the prefrontal cortex (PFC) was measured during three consecutive exposure sessions. N = 13 acrophobic volunteers were asked to walk on a virtual plank with a 6 m drop below. Changes in oxygenated (HbO) hemoglobin concentrations in the PFC were measured in three blocks using fNIRS. Consistent with previous functional magnetic resonance imaging (fMRI) studies, the analysis showed decreased activity in the DLPFC and MPFC during first exposure. The activity increased toward normal across three sessions. The study demonstrates potential efficacy of a method for measuring within-session neural response to virtual stimuli that could be replicated within clinics and research institutes, with equipment better suited to an ET session and at fraction of the cost, when compared to fMRI. This has application in widening access to, and increasing ecological validity of, immersive neuroimaging across understanding, diagnosis, assessment and treatment of, a range of mental disorders such as phobia, anxiety and PTSD or addictions.
There is strong evidence supporting cognitive behav- ioral therapy (CBT) with exposure as the treatment of choice in treating PSA and SAD [15, 16]. However, con- ducting in-session exposure exercises for PSA has his- torically been unpractical or outright infeasible since this would require access to and control over an audience. This is in contrast with treatments of other anxiety disor- ders that rely on in-session exposuretherapy, e.g. animal phobias and other specific phobias that are highly effica- cious [17–20]. Virtualreality (VR) technology can resolve this issue by creating the illusion of being present in front of a realistic virtual audience. This is achieved by wearing a headset with dual displays that cover the eyes and simu- lates depth perception, the displayed content of which is interactive to head movement to give the illusion of being able to look around the virtual world . By creating an animated virtual audience and presenting the feared stimuli to the patient, VR ExposureTherapy (VRET) for PSA is an attractive treatment method since it provides a convenient way doing in-session exposure with immedi- ate access to controllable fear stimuli. Importantly, virtual audiences are sufficient to elicit a fear response , the basis of exposuretherapy, and several randomized con- trolled trials of VRET for PSA have shown good results [23–26].
Conducting VR exposuretherapy using modern, com- mercially available VR equipment may prove even more powerful. In addition to the evaluation of modern VR hardware, our intent in this study is also to evaluate a newly developed, gamified exposure application for the treatment of specific phobias. The software includes ad- vancements such as multiple open-ended exposure sce- narios relying on gamification to improve engagement and interest; multiple stimulus intensity variables such as appearance (small to large spiders, cartoon-like to hairy), behavior (more or less predictable, static, and ag- gressive), a variable number of spiders, and changes in lighting and protective barriers (such as caged or not); a virtual therapist that guides the participant in the use of the application and provides psychoeducation and expert advice about spiders; and inclusion of a gaze direction trackpad to allow participants to interact with the stimuli.
The premise is if visuals of various exercise activities trig- ger the functional brain areas associated with pain cata- strophizing in FMS subjects; then as a treatment, it can be postulated that graded and repeated exposure to visuals of exercise activities using a VRET program could possibly decrease pain catastrophizing and subsequently decrease fear to movement, essentially improving compli- ance towards exercise therapy programs among FMS patients. Proof-of-concept for the development and test- ing of a novel VRET program for exercise-related pain catastrophizing in FMS will either be established or negated. The results of this project are envisaged to revo- lutionize FMS and pain catastrophizing research and in the future, assist health professionals and FMS patients in reducing despondency regarding FMS management.
Some limitations to this study should be taken into account. First, there are different types of aviophobia , which we did not assess. Therefore, we did not test whether our VR therapy protocol is adequate for all types of aviophobia. Second, we only investigated a limited number of participants in this pilot study (n = 29) and therefore the power of our study is low 1 . Further studies have to confirm the results of our current study. This could possibly explain non-significant results. Concerning the calculations of initial fear activation, we did not collect baseline data for HR and SCL, but instead used the last two minutes before the landing of the third flight, assuming that physiological arousal had reached its baseline level again.
The potential impact of this approach is in reducing dropout rates of exposuretherapy. This is important as dropout rates of 40% are not uncommon in resistant populations. Furthermore, as symptoms typically increase at the beginning of a course of exposuretherapy, clients can dropout with negative health impacts. We argue that by allowing clients to both use virtualrealityexposuretherapy and work with a therapist at home, reduces the risk of non-attendance to therapy sessions. This could impact not only on success rate of treatment but in reducing costs to health providers through reducing missed appointments. We further argue that allowing the therapist and client to see each other and estimate what the other is looking at, would help to manage the grounding of the client in the safety of the present. This again has potential to reduce dropout rates by reducing the risk of retraumatisation and improving the relationship between client and therapist. While remote therapy can be done with conventional video conferencing and CGI avatars, the levels of non-verbal communication used within a clinical therapy session are not supported. Our approach has the fundamental properties to support them much better. Our demonstrator shows both the issues and the principles of the solution.