History of Virtual Reality as an Adjunct to the Treatment of

Anxiety Disorders and Virtual Vietnam

Barbara Olasov Rothbaum, Ph.D., ABPPDirector, Trauma and Anxiety Recovery Program

Professor of Psychiatry

Associate Vice Chair of Clinical Research

Emory University School of Medicine

Disclosure

• Virtually Better, Inc (VBI), part owner – managed under Emory University's Conflict of Interest Policy

• Virtual Iraq created by Dr. Skip Rizzo at USC, not VBI, but VBI is selling virtual reality products

Virtual Reality

• Interactive computer environment

• More than simply multimedia

• Sense of PRESENCE

• IMMERSIVE

Virtual Reality Hardware

• Head-mounted display

• Position tracker

• Sensor

• Hand tracker

• Computer

• Monitor

• Headphones

• Thunder Chair

• Microphone

Head-Mounted Display

Emotional Processing Theory

• Foa & Kozak, 1986

• Fear memories contain information about stimuli, responses, meaning

• Must 1) Activate memory and 2) Provide Corrective Information to modify

First Study of VRE for Psychiatric Disorder: VRE for Acrophobia

• 3 Foot Bridges

• 4 Outdoor Balconies

• Glass Elevator

Rothbaum, Hodges, Kooper, Opdyke, & Williford (1995). Effectiveness of Virtual Reality Graded Exposure in the Treatment of Acrophobia. American Journal of Psychiatry, 152, 626-628.

Virtual Reality Exposure Therapy

• Individualized hierarchy

• 1st session familiarized with VR

• Allowed to progress at own pace

• Remained at each height until anxiety attenuated

• SUDs gathered every 5 minutes

• Therapist viewed on monitor

• Comparable to in vivo exposure

Results on Acrophobia Questionnaire

PRE POST PRE POST0

10

20

30

40

50

60

PRE POST PRE POST

VRE

Control

ANXIETYANXIETY AVOIDANCEAVOIDANCE

Physical Symptoms During VRE

• Sweating

• Butterflies

• Light-headed

• Heart Palpitations

• Tense

• Motion Sensations

• Restlessness

• Shakiness

• Nervous/scared

• Weak in Knees

• Tightness in Chest

• Motion Sickness

Conclusions

• Physical symptoms of anxiety experienced in virtual environment

• Perceptions and behavior in the physical world can be modified based on experiences within a virtual world

• May be able to replace some physical or imagined environments with virtual environments

Scientific American clip

A Controlled Study of Virtual Reality vs. Standard Exposure Therapy for the Fear of Flying

Rothbaum, Hodges, Smith, Lee, & Price (2000). A Controlled Study of Virtual Reality Exposure Therapy

for the Fear of Flying. Journal of Consulting and Clinical Psychology, 68, 1020-1026.

Virtual Airplane

• Patient wears Head-mounted Display– Position Tracker

– Covers Entire Field of View

– Hears only audio from earphones (including therapist).

• Sits in Thunderseat

• Simulates– Sitting in plane on

runway, engine on/off

– Taxi

– Takeoff

– Flight in good weather

– Flight in bad weather

– Landing

Fear of Flying Inventory Study 1: n = 45)

0

20

40

60

80

100

120

140

VRE SE Waitlist

PREPOSTSix Months

Limitations & Strengths of Study

• Small Sample Size (n = 45)

• One Therapist

• Random Assignment

• Controlled Design

• DSM Inclusion Criterion

• Blind Independent Assessment

• Compared 2 active treatments and a control group

• Post-treatment Flight

Virtual Reality and Standard Exposure in the Treatment of the

Fear of Flying

Barbara Rothbaum, Ph.D.

Page Anderson, Ph.D.

Larry Hodges, Ph.D.

Elana Zimand, Ph.D.

Jeff Wilson, M.S.

Rothbaum, et al (2006). Behavior Therapy, 37, 80-90.

Fear of Flying Inventory Study 2: N = 75

Actual Flight Data

0

10

20

30

40

50

60

70

80

%Flew SUDs Out SUDs Back

VRE

SE

WAIT

Virtual Airplane Clip

Posttraumatic Stress Disorder

(PTSD)

Virtual Reality Exposure Therapy for

PTSD Vietnam Veterans

Rothbaum, Hodges, Ready, Graap, & Alarcon (2001). Virtual Reality Exposure Therapy for Vietnam Veterans with Posttraumatic Stress

Disorder. Journal of Clinical Psychiatry.

VRE for PTSD

• Vietnam combat veterans

• Virtual Huey helicopter

• “Fly” over the jungles of Vietnam

• Walk in clearing near jungle, swamp

• Imaginal exposure immersed in Vietnam stimuli

Descriptive Information

• Diagnoses: – PTSD– Major Depressive Disorder– Past Substance Abuse

• Age: 51.3 (3.2) range 49-56

• N = 10

• CES: 26.8 (2.9) range 25-31

• Medications? ALL YES

Rothbaum et al (submitted) Journal of Clinical Psychiatry.

Clinician Administered PTSD Scale

0

10

20

30

40

50

60

70

PRE POST 3 mo FU 6 mo FU

Rothbaum et al. Journal of Clinical Psychiatry. 2001;62:617-622.

Mean

CAPS

Score

N=9 N=9 N=5 N=8

p=.0727 p=.0256 p=.0021

Impact of Events Scale

0

5

10

15

20

25

30

35

40

45

PRE POST 3 mo FU 6 mo.FU

Rothbaum et al. Journal of Clinical Psychiatry. 2001;62:617-622.

Mean

IES

Score

N=9 N=9 N=5 N=8

p=.0327 p=.0912

Virtual Vietnam Video Clip

VR for Addictions

Cue Exposure

• Based on classical conditioning

• Cues typically presented in pictures, videos, paraphernalia

• With VR, can be immersive

• includes olfactory cues

VR for Nicotine

VR for Nicotine and Alcohol

VR for Nicotine and Alcohol

VR for Nicotine and Alcohol

VR for Nicotine and Alcohol

VAS Scales in VR

Indicate your greatest craving to smoke at this time.

__________________________________________

None More than ever

Virtual Crack House Short Clip

ANOVA F=15, df=4, p=.001

VAS Craving Score by VR Cue Type

19 19.2

33.34241.4

0

25

50

75

100

Baseline Neutral 1 SmokingMaterials

Smoking SocialInteraction

Neutral 2

VAS

Scor

e

**

N=13

51

VR as a Distraction During Painful Medical Procedures

52

Virtual Gorilla

53

Results: Pulse Rate

CalmCraft

Social Anxiety Disorder

A Pilot Study of Virtual Reality Exposure Therapy

for the Fear of Public Speaking

Anderson, Zimand, Hodges, & Rothbaum, B. (2005). Cognitive Behavioral Therapy for Public

Speaking Anxiety Using Virtual Reality for Exposure. Depression and Anxiety.

Personal Report of Confidence as a Speaker (PRCS) and Personal Report of Communication Apprehension (PRCA)

0

5

10

15

20

25

30

35

40

PRCS PRCA

PREPOSTmo FU 3

Self-Statements During Public Speaking (SSPS)

0

2

4

6

8

10

12

14

16

Positive Negative

PREPOSTmo FU 3

Old Audience Video Clip

New Public Speaking: Auditorium

New Public Speaking: Classroom

New Public Speaking: Conference Room

D-Cycloserine Augmentation of Exposure Therapy:

Virtual Reality Exposure for Treatment of Fear of Heights

A Double Blind, Placebo-Controlled Study

Rothbaum, Ressler, Davis Emory University Dept of Psychiatry

Anderson, Zimand,Tannenbaum, Graap, Hodges Virtually Better, Inc.

(2004). Facilitation of Psychotherapy with D-Cycloserine, a Putative Cognitive Enhancer. Archives of General Psychiatry, 61, 1136-1144.

Potential Advantages of VRE

• Attractive to video game generation

• Can control all stimuli 100%

• More potent/evocative stimulus for underengagers

• Potential for standardization for assessment, treatment, and research

• Methodological control

Potential Disadvantages of VRE

• Not as attractive as video games

• Bad VRE is just bad therapy

• Standard virtual environments may not match for everyone

• Expensive

• Technology/glitches

Journal of Anxiety

Disorders

Journal of Behavior

Therapy and Experimental

Psychiatry

VR Anxiety Disorders Meta-Analysis

2008

In: Parsons & Rizzo (2008) Journal of Behavior Therapy & Experimental

Psychiatry

VR Anxiety Disorders Meta-Analysis