Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying.

This controlled clinical trial tested virtual reality exposure (VRE) therapy for the fear of flying (FOF), a relatively new and innovative way to do exposure therapy, and compared it to standard (in vivo) exposure therapy (SE) and a wait list (WL) control with a 6- and 12-month follow-up. Eighty-three participants with FOF were randomly assigned to VRE, SE, or WL. Seventy-five participants, 25 per group, completed the study. Twenty-three WL participants completed randomly assigned treatment following the waiting period. Treatment consisted of 4 sessions of anxiety management training followed either by exposure to a virtual airplane (VRE) or an actual airplane at the airport (SE) conducted over 6 weeks. Results indicate that VRE was superior to WL on all measures, including willingness to fly on the posttreatment flight (76% for VRE and SE; 20% for WL). VRE and SE were essentially equivalent on standardized questionnaires, willingness to fly, anxiety ratings during the flight, self-ratings of improvement, and patient satisfaction with treatment. Follow-up assessments at 6 and 12 months indicated that treatment gains were maintained, with more than 70% of respondents from both groups reporting continued flying at follow-up. Based on these findings, the use of VRE in the treatment of FOF was supported in this controlled study, suggesting that experiences in the virtual world can change experiences in the real world.

Cognitive behavior therapy for fear of flying: sustainability of treatment gains after September 11.

This study examines the long-term efficacy of cognitive-behavioral therapy (CBT) for fear of flying (FOF) after a catastrophic fear-relevant event, the September 11, 2001, terrorist attacks. Participants (N = 115) were randomly assigned to and completed treatment for FOF using 8 sessions of either virtual reality exposure therapy (VRE) or standard exposure therapy (SE) prior to September 11, 2001. Individuals were reassessed in June, 2002, an average of 2.3 years after treatment, with a response rate of 48% (n = 55). Analyses were run on the original data and, using multiple imputation procedures, on imputed data for the full sample. Individuals maintained or improved upon gains made in treatment as measured by standardized FOF questionnaires and by number of flights taken. There were no differences between VRE and SE. Thus, results suggest that individuals previously treated for FOF with cognitive-behavioral therapy can maintain treatment gains in the face of a catastrophic fear-relevant event, even years after treatment is completed.

Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear.

BACKGROUND: Traditional pharmacological approaches to treating psychiatric disorders focus on correcting presumed biochemical abnormalities. However, some disorders, particularly the anxiety-related disorders exemplified by specific phobia, have an emotional learning component to them that can be facilitated with psychotherapy. OBJECTIVE: To determine whether D-cycloserine (DCS), a partial agonist at the N-methyl-d-aspartate receptor that has previously been shown to improve extinction of fear in rodents, will also improve extinction of fear in human phobic patients undergoing behavioral exposure therapy. DESIGN: Randomized, double-blind, placebo-controlled trial examining DCS vs placebo treatment in combination with a precisely controlled exposure paradigm. SETTING: Participants were recruited from the general community to a research clinic. PARTICIPANTS: Twenty-eight subjects with acrophobia diagnosed by the Structured Clinical Interview for DSM-IV were enrolled. INTERVENTIONS: After we obtained pretreatment measures of fear, subjects were treated with 2 sessions of behavioral exposure therapy using virtual reality exposure to heights within a virtual glass elevator. Single doses of placebo or DCS were taken prior to each of the 2 sessions of virtual reality exposure therapy. Subjects, therapists, and assessors were blind to the treatment condition. Subjects returned at 1 week and 3 months posttreatment for measures to determine the presence and severity of acrophobia symptoms. MAIN OUTCOME MEASURES: Included were measures of acrophobia within the virtual environment, measures of acrophobia in the real world, and general measures of overall improvement. An objective measure of fear, electrodermal skin fluctuation, was also included during the virtual exposure to heights. Symptoms were assessed by self-report and by independent assessors at approximately 1 week and 3 months posttreatment. RESULTS: Exposure therapy combined with DCS resulted in significantly larger reductions of acrophobia symptoms on all main outcome measures. Subjects receiving DCS had significantly more improvement compared with subjects receiving placebo within the virtual environment (1 week after treatment, P

A pilot and feasibility study of virtual reality as a distraction for children with cancer.

OBJECTIVE: To pilot and test the feasibility of a novel technology to reduce anxiety and pain associated with an invasive medical procedure in children with cancer. METHOD: Children with cancer (ages 7-19) whose treatment protocols required access of their subcutaneous venous port device (port access) were randomly assigned to a virtual reality distraction intervention, a non-virtual reality distraction, or treatment as usual without a distraction. The researchers obtained assessments of the child's pain and anxiety from the parent, child, and unblinded nurses. Pulse rate was monitored throughout the procedure, and behavioral indices of distress were recorded, as observed by the researchers. RESULTS: Reductions in pain and anxiety were found for children who used the virtual reality distraction in comparison with the no distraction condition as evidenced by lower pulse rate and reports of pain by nurses. No significant differences were found for the non-virtual reality condition versus the no distraction condition on pulse rate. CONCLUSIONS: These findings suggest that virtual reality may be a useful tool for distraction during painful medical procedures, but further studies are needed to test potential efficacy and feasibility during other, more distressing medical procedures with larger sample sizes.

Use of virtual reality as a distractor for painful procedures in a patient with pediatric cancer: a case study.

Virtual reality (VR) has been demonstrated as an effective tool to help people overcome a variety of anxiety disorders. In this case study, the use of VR as a distractor to alleviate pain and anxiety associated with an invasive medical procedure for a pediatric cancer patient was explored. An A-B-C-A design during four consecutive medical appointments in an outpatient oncology clinic compared no distraction (A), non-VR distraction on a computer screen (B), and VR distraction with a head set (C). Behavioral observations of distress by the researcher and reports of pain and anxiety by the patient, parent, and nurse were taken before and during the procedure. The child's pulse was monitored throughout the procedure. The findings from this case study suggest benefit from using VR distraction, as indicated by lower pain and anxiety ratings, reduced pulse, and fewer observed behavioral indices of distress. The need for larger scale studies and application of VR with younger children is discussed in the context of confirming effectiveness of this technique and providing more generalizable information about efficacy.

Virtual reality exposure therapy for social anxiety disorder: a randomized controlled trial.

OBJECTIVE: This is the first randomized trial comparing virtual reality exposure therapy to in vivo exposure for social anxiety disorder. METHOD: Participants with a principal diagnosis of social anxiety disorder who identified public speaking as their primary fear (N = 97) were recruited from the community, resulting in an ethnically diverse sample (M age = 39 years) of mostly women (62%). Participants were randomly assigned to and completed 8 sessions of manualized virtual reality exposure therapy, exposure group therapy, or wait list. Standardized self-report measures were collected at pretreatment, posttreatment, and 12-month follow-up, and process measures were collected during treatment. A standardized speech task was delivered at pre- and posttreatment, and diagnostic status was reassessed at 3-month follow-up. RESULTS: Analysis of covariance showed that, relative to wait list, people completing either active treatment significantly improved on all but one measure (length of speech for exposure group therapy and self-reported fear of negative evaluation for virtual reality exposure therapy). At 12-month follow-up, people showed significant improvement from pretreatment on all measures. There were no differences between the active treatments on any process or outcome measure at any time, nor differences on achieving partial or full remission. CONCLUSION: Virtual reality exposure therapy is effective for treating social fears, and improvement is maintained for 1 year. Virtual reality exposure therapy is equally effective as exposure group therapy; further research with a larger sample is needed, however, to better control and statistically test differences between the treatments.

Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure.

This study used an open clinical trial to test a cognitive-behavioral treatment for public-speaking anxiety that utilized virtual reality as a tool for exposure therapy. Treatment was completed by participants (n = 10) meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria for social phobia, or panic disorder with agoraphobia in which public speaking was the predominantly feared stimulus. Treatment was conducted by a licensed psychologist in an outpatient clinic. Treatment consisted of eight individual therapy sessions, including four sessions of anxiety management training and four sessions of exposure therapy using a virtual audience, according to a standardized treatment manual. Participants completed standardized self-report questionnaires assessing public-speaking anxiety at pre-treatment, post-treatment, and 3-month follow-up. Participants were asked to give a speech to an actual audience at pre- and post-treatment. Results showed decreases on all self-report measures of public-speaking anxiety from pre- to post-treatment, which were maintained at follow-up (n = 8; all P = 05). Participants were no more likely to complete a speech post-treatment than at pre-treatment. This study provides preliminary evidence that a cognitive-behavioral treatment using virtual reality for exposure to public speaking may reduce public-speaking anxiety and suggests that further research with a controlled design is needed.