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
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