1. HANDLING PHOBIAS WITH VIRTUAL REALITY
Sylvia Rosado
(ANXIETY UNIT, HOSPITAL DEL MAR, BARCELONA) 1

2. ANXIETY DISORDERS
Anxiety Disorders (AD) are the most common psychiatric disorders in the general population (14.6%).
AD consume many healthcare resources (emergency services and other medical services).
AD have a high comorbidity with other psychiatric disorders (affective disorders, substance abuse and personality disorders), as well as physical problems (such as migraines, muscular tension, irritable bowel syndrome, etc), and this worsens the prognosis.
AD affect very significantly the quality of life with a high functional limitation.
Phobias are the most common anxiety disorder in the general population
We all are afraid of something!

3. PHOBIAS
Disproportionate or irrational fear, triggered by the presence or anticipation of a specific object or situation (flying, heights, enclosed spaces, injections, animals...)
Exposure to the phobic stimulus provokes an immediate anxiety.
The person recognizes that that fear is irrational or disproportionate, but usually avoid the situation or face it with a high anticipatory anxiety and at the moment.
This can interfere with the routine of the person.

4. Cognitive response Somatic response
PHOBIA AND PANIC ATTAC
Intense fear can cause a Panic Attac in such situation:
Cognitive
response
Estimulus
Behaviour
Response
(Fight or flight)
Somatic
response

5. PHOBIAS TREATMENT
Facing the fear has been proved to be the most effective intervention to overcome a phobia:
1. Psychoeducation
- Anxiety and Panic concepts
- Learn to identify symptoms/thoughts/behaviour
2. Exposure to symtoms and situations
3. Withdraw security and avoidance behaviors
4. Cognitive techniques

6. PHOBIA AND EXPOSURE
A main aspect of anxiety disorders is avoidance.
One of the most effective techniques to deal with fear is to confront a feared situation repeatedly, gradualy and systematicly.
- by imagination
- in vivo
- by virtual reality

7. EXPOSURE Hight anxiety
In the feared situation anxiety increases, and after avoiding or scaping, anxiety dicreases quickly (but only untill the next time)
When remaining in the situation, anxiety dicreases
Low anxiety

8. Difficulties of exposure treatment for fears
By imagination:
Sometimes it's difficult to recreate the situation or it does not provoke anxiety
It's demonstrated to be less effective than in vivo exposure
In vivo:
Facing the feared situation can be very difficult sometimes
Sometimes it is complicated to practice the exposure to some situations frequently or it is difficult to happen
Planning gradual objectives to repeat sometimes is not realistic (lack of time, money...), and requires a lot of visits and time
In vivo exposure can increase general anxiety during the whole treatment
Intensive treatment ofen requires a cotherapist (nurse, family, friend, a user that overcame the fear to that situation)

9. Tecnology and health WHO:
E-health is a relatively recent term for healthcare practice supported by electronic processes and communication, dating back to at least 1999.
“Using information and communication technologies to improve health control. For example, for treating certain people, promoting research, creating training tools for students, assessing several diseases, and monitoring public health”.
There are some mental health app for smartphones and computers.

10. VITUAL REALlTY: What is this?
Jaron Lanier is the pioneer in the field of VR (1986)
It is an innovative technological tool that has been used in the educational, social and experimental context, and currently is also being used in health around the world
Recreates realistic environments with visual and sound effects that provide a realistic experience
Virtual Reality for education have been shown to increase students attention levels by 92%, while at the same time creating a new level of engagement for students and staff.
It's been used to treat some mental health problems, mostly for Anxiety disorders (from 1990, there is some research from 1995). Now, it's also being used for eating disorders, addictions and sexual dysfunction

11. VIRTUAL REALITY and Anxiety Disorders
The application offers an itinerary of exposure situations from lowest to highest degree, using immersive virtual environments of augmented reality and virtual reality.
Before treatment, diagnosis tests and biofeedback measures are performed to plan the best therapy.
The biofeedback measures the relative variation in the level of sweating when the person is facing the audiovisual stimulus.
There is scientific evidence showing that VR is more effective than imagination to treat specific phobias, social phobia, agoraphobia and PTSD, and as effective as in vivo exposure.

12. VIRTUAL REALITY: What about?
Free Android smartphone
3D glasses of Virtual Reality
Biofeedback sensor to mesure skin conductance
Laptop with wifi connection

13. VIRTUAL REALITY: How does it work?
Web platform
User
Therapist

14. VIRTUAL REALITY: advantages
Offers a better immersion degree in users with difficulties to use imagination
Allows multi-sensory stimulation
It requires fewer resources than in vivo exposure
The user often prefers VR to in vivo exposure (25% can't deal with in vivo exposure)
Allows the therapist to monitor and control the simulation while interacting with the user, as well as structuring a more personalized treatment
Easier access to situations where the gradual and repeated practice is complicated, or the facts are not expected to happen
Offers a secure environment, this can reduce the number of abandonments
Permits to observe user's reactions using the biofeedback
The users can practice at home if they have the app
It does not require technical knowledge to use it
Generates reports automatically
Privacy and confidentiality

15. VIRTUAL REALITY: disadvantages
Some users experience dizziness, head ache, disorientation, nausea. However, it's rare in current systems.
There are no standarized protocols yet.
Not all the hospitals/users have the resources to use it, and an adapted app can be expensive.
Tecnologies are increasingly present in our daily life, but it cannot replace face to face
There's no proof of effectiveness treating Severe Mental Disorders.

16. VIRTUAL REALITY: environements
Fear of flying
Fear of needles
Acrophobia
Claustrophobia
Agoraphobia
Social phobia
Relaxation
Fear of driving
Fear of insects

17. VIRTUAL REALITY and AUGMENTED REALITY
( virtual elements in a real environement)
Virtual Reality

18. PREVIOUS RESEARCH: review
The beginnings of the use of VR as a therapeutic tool for anxiety disorders:
In 1995, VR is proved to be effective treating acrophobia (Routhbaum et al.)
In 2003, VR exposure is such effective as in vivo exposure, and that it is maintained over time. Users prefer VR for exposure (Fabregat, 2004).
Research review:
Study cases of acrophobia, claustrophobia, flight phobia, insects phobia. Highlighted pub: Vincelli et al, Botella et al (2004, 2003, 2000, 1998), Bouchard et al (2003), Hoffman et al (2003), Jang et al (2002), García-Palacions et al (2002), Choi et al (2001), Baños et al (2001), Klein (1999), Wiederhold et al (1998), North et al (1997), Carlin et al (1997).
Used with good results for agoraphobia; driving phobia: Wald i Tailor (2003, 2000), Walshe et al (2003); and also social phobia: Anderson et al (2003). And later for PTSD: Rothbaum et al (2004, 2001), Difede & Hoffman (2002), Botella et al (2005), Baños et al (2005).
There are also some research with no positive results: Emmelcamp et al (2002) for phobias, Yaicox et al (1998) for PTSD.

19. PREVIOUS RESEARCH: revision
Other disorders:
Eating desorders: some results demonstrate an improvement in body image, to display certain foods "forbidden", to walk certain places or carrying certain types of clothing: Perpiñá, Palacios & Baños (2003); Riba et al (1999, 2002, 2003).
Autism: Stricklard (1997)
ADHD: Rizzo et al (2000)
Addictions and gambling: Botella (2004), Kuntze et al (2001), Lee et al (2003), Nemire et al (1999).
Acute Pain: Hoffman et al (2000, 2001); Chemotherapy: Gershon et al (2004, 2003), Schneider i Workman (1999).

20. A CASE STUDY
James is 34 years old, and he has much fear of flying since he was a kid.
This was not a problem until now. He had a promotion in his job, and despite he's excited with that he said 'no' because he would have to fly twice a month.
He has never been treated for that and he has never taken any medication. He does not refer other fears, nor mood disorders. We decide to start exposure using virtual reality before taking a plane.

21. A CASE STUDY
PLAN
1. Psychoeducation (1 session): what is a phobia, phisical sensations, thoughts/fears, exposure vs avoidance, how does the virtual reality work.
2. Exposure using virtual reality (6 sessions + 1 session 3 days before flying)
Environments: at the airport, in the plane (taking off, flight and landing)
The therapist controls meteorology, people around, noises, turbulences, time of the day, seat...
3. Going to the airport and watching the planes tanking off and landing.
4. In vivo exposure a month after virtual reality exposure.

22. A CASE STUDY
At home
In a taxi to the airport
Boarding gate
Plane

23. A CASE STUDY GRADUAL EXPOSURE:
1. Take off, fly, landing: in a sunny day, no incidences, sitting in the aisle at the beginning of the plane.
2. Take off, fly, landing: in a sunny day with some rain, no incidences, sitting in the aisle in the middle of the plane.
3. Take off, fly, landing: in a rainy day, no incidences, sitting at the window at the end of the plane.
4. Take off, fly, landing: in a stormy day, with soft turbulences, sitting at the window at the end of the plane.
5. Take off, fly, landing: in a stormy day, with medium turbulences, sitting at the window at the end of the plane.
6. Take off, fly, landing: in a stormy night, with heavy turbulences, sitting at the window at the end of the plane.
7. Before the flight we repeated the last session.

24. A CASE STUDY
RESULTS
James answered the FFQ-R at the beginning and at the end of the treatment. He showed a significant decrease in anxiety levels as he advanced treatment (scored 251 pretreatment, 59 post VR, 43 post flight).
In the first session his level of subjective anxiety was 8 (1-10 score), in the last session he scored 2 and the biofeedback showed less sweating. The time of the session decreased too from the first session to the last.
Although his anticipatory anxiety just before the first flight was 8 (in a 1-10 score), during and after the flight his anxiety has decreased.
After that, he flew 3 times more with lower anxiety.
Despite James doubted at first about the effectiveness of the method, he demonstrated a high activation during the sessions, and he “found it so real”.

25. A CASE STUDY
BIOFEEDBACK REGISTER:

26. How is it going with your fear to face therapy?
MUCH BETTER, DOCTOR!

27. VIRTUAL WORLD TO LIVE A BETTER REAL WORLD
Looking to the future
VIRTUAL WORLD TO LIVE A BETTER REAL WORLD
Potential therapeutic applications of VR are very large and, of course, more research is needed in this field.
Innovative projects may be created depending on populations' needs.
For example, we have found that many people are scared of MRI (claustrophobia already diagnosed or not). Many people leave before the test or do it in half. So PSIOUS created an environment for that (simulating the Hospital del Mar).
They also created some real environments for the fear of driving (one can drive in Barcelona city for example), etc.

28. VIRTUAL REALITY References:
Applications of Virtual Reality in Clinical Psychology: Illustrations With the Treatment of Anxiety Disorders. StCphane Bouchard, Patrice Renaud, Genevikve Robillard & Julie St- Jacques Cyberpsychology Lab, University of Quebec in Outaouais
Treating psychological and physical disorders with VR. Larry F. Hodges Georgia Institute of Technology Page Anderson Virtually Better Grigore C. Burdea Rutgers University Hunter G. Hoffman University of Washington Barbara O. Rothbaum Emory University School of Medicine
The treatment of fear of flying: a controlled study of imaginal and virtual reality graded exposure therapy Brenda K. Wiederhold, Dong P. Jang, Richard G. Gevirtz, Sun I. Kim, In Y. Kim, and Mark D. Wiederhold
A Clinical Virtual Reality Rehabilitation System for Phobia Treatment Barnabás Takács1,2,Lajos Simon SZTAKI Budapest, Hungary, 2 Digital Elite Inc., Los Angeles, USA, 3 Semmelweis University School of Psychiatry
Virtual reality treatment of flying phobia Rosa M. Baños, Cristina Botella, Concepción Perpiñá, Mariano Alcañiz, Jose Antonio Lozano, Jorge Osma, and Myriam Gallardo
Computer-Assisted Therapy in the Treatment of Flight Phobia: a case report. Bornas X, Fullana MA, Tortella-Feliu M, Llabrés J, Garcia de la Banda G. Universitat de les Illes Balears.
El tratamiento de la claustrofobia por medio de la realidad virtual. Análisis y modificación de conducta. Botella C, Baños R, Perpiña C, Quero C, Villa H, Garcia-Palacions A.
Internet based telehealth system for the treatment of agorafobia. Alcañiz M, Botella C, Baños r, Perpiña C, Rey B, Lozano J.

29. VIRTUAL REALITY
Krijn, M., Emmelkamp, P.M.G., Olafsson, R.P, Biemon, R. (2004). Virtual reality exposure therapy of anxiety disorders: A review. Clinical Psychology Review, 24,
Meyerbröker, K. y Emmelkamp P. (2010). Virtual reality exposure therapy in anxiety disorders: a systematic review of process-and-outcome studies. Depression and Anxiety, 27,
Rothbaum, B. O., Hodges, L.F., Kooper, R., Opdyke, D., & Williford, J. (1995). Effectiveness of Virtual Reality Graded
Opris, D., Pintea, S., García-Palacios, A., Botella, C., Szamosköki, S. (2012). Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis. Depression and Anxiety, 29,
Parsons, T., Rizzo A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39,
Powers, M., Emmelkamp, P. (2008). Virtual reality exposure therapy for anxiety disorders: a meta-analysis. Journal of Anxiety Disorders, 22 (3),
García-Palacios, A., Hoffman, H.G., See, S.K., Tsai, A., Botella, C. (2001). Redefining therapeutic success with virtual reality exposure therapy. Cyberpsychology & Behavior, 4(3),
García-Palacios, A., Botella, C., Hoffman, H., Fabregat, S. (2007). Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. Cyberpsychology & Behavior, 10(5),
Opris, D., Pintea, S., García-Palacios, A., Botella, C., Szamosköki, S. (2012). . Depression and Anxiety, 29,
Peñate-Castro, W., Roca Sánchez, M.J., Pitti-González, C.T., Bethencourt, J.M., de la Fuente-Portero, J.A., Garcia-Marco (2014). Cognitive-behavioral treatment and antidepressants combined with virtual reality exposure for patients with chronic agoraphobia. International Journal of Clinical and Health Psychology, 14, 9-17.

30. Thanks!