Virtual Reality Therapy for Phobias and Anxiety Disorders Creating Immersive Exposure Experiences

HealthHow virtual reality exposure therapy is helping to treat phobias and paranoia

As part of her work, Corrie Ackland collects some pretty strange objects.

She has toy spiders, snakes and lizards. Her office is stocked with picture books full of images of blood and needles.

But the most important things she stockpiles are a series of immersive 360-degree videos with scenes of dogs on the beach, or pigeons in St Mark's Square in Venice.

That's because Ms Ackland is a psychologist who treats phobias a type of fear that causes someone distress or impairment.

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And she uses virtual reality a futuristic headset displaying all-encompassing videos of crawling spiders or dizzying heights to help people manage their anxiety and learn to live with a phobia.

In fact, virtual reality (VR) technology is increasingly being used or trialled in treating a number of conditions from post-traumatic stress disorder (PTSD) to the depressive symptoms of dementia.

Why virtual reality?

Ms Ackland's VR phobia practice builds on exposure therapy, which has been around for decades and is the leading evidence-based treatment for anxiety disorders and phobias.

As the name suggests, it exposes someone gradually to the thing they're afraid of. If it's needles, they might first be exposed to imagesof needles, then practice syringing oranges, working up to getting an injection themselves.

But the limitation of traditional exposure therapy is you can't always do it in a gradual and repeated way, Ms Ackland says.

"There's a lot of [people with] needle phobia coming into the clinic at the moment with COVID," she says.

"Even if someone was able to go and get a needle, an injection takes a matter of seconds;that's not usually enough time to apply strategies and note success in that task, and it's also something that we can't repeat 20 times to see it improve."

Ms Acklandsays VR allows people to access those otherwise tricky environments.

"It allows us to do it over and over and over again, so I can get a client here getting an injection 20 times in a session, and for them to actually see that it did get better over time."

She says the VR experience helps expose people to their phobia in a safe and controlled way, allowing them to ramp the intensity up or down, depending on how anxious they are.

Evidence supporting VR as a therapy began to emerge in the '90s, starting with an experiment that found it could successfully reduce someone's fear of heights.

But it's only been in the past decade or so with the development of more powerful tools that the use of VR therapy has really taken off.

A systematic review published two years ago looked at the comparative efficacy of VR exposure therapy to real-life exposure across nine studies.

It found both therapies worked well, and there was no major difference between them when treating most phobias.

Can you 'cure' a phobia?

Ms Ackland says phobias may develop from a "critical event" like being attacked by a dog but can also develop naturally over time.

That's especially the case when it comes to things most people don't like at the best of times like going to the dentist or getting a needle.

Steering clear of these experiences feeds into a cycle of avoidance and fear that can build into a phobia.

And while the level of anxiety when presented with the feared thing a cockroach, for example can reduce, it can't be eliminatedentirely.

"We wouldn't expect that you would love cockroaches, or that you would even want a pet cockroach," Ms Ackland says.

"What we would want you to be able to do is feel ready in your everyday life to potentially see one and feel confident that you could manage that if you did, secure in the knowledge that they are not dangerous and you can cope and you can manage anxiety well."

VR may help to increase therapy access

At the University of Oxford, researcher Poppy Brown is using VR therapy to help people with paranoia and delusions re-enter social situations.

"For people with psychosis, just walking down a street or going into a supermarket or a caf can be extremely frightening," she says.

"In VR, we can provide a safe space where we can simulate that street or that supermarket, help those people to go into that virtual world and practice overcoming their fears in a safe and controlled setting."

Therapy can be far cheaper to deliver per person than your standard face-to-face psychological therapy,and this means far more people could have access to the therapy,Ms Brown says."So it's not at all to replace psychological therapists, that time with a highly trained psychological therapist will often be essential for a lot of people. But there might be some people who actually only need quite minimal contact."

Ms Browncautions that some people will still need a specialist guiding them through therapy but for less severe issues, treatment delivered straight to someone's VR headset at home could be an option.

"I think a safe space where you are with someone who has some sort of experience in working with these problems can be really helpful and will be important, but there are definitely certain problems or difficulties or people who will be able to just actually do these things themselves at home and find a real benefit in it," she says.

Virtual Reality for the Treatment of Anxiety Disorders: A Scoping Review

Posttraumatic Stress DisorderCrdenas-Lpez & Rosa-Gmez (2011)Level 4N = 1 veteran with PTSDTherapist (unspecified)Vuzix iWear VR920 (Vuzix, Rochester, NY)Repetitions of the traumatic memory on the streets of Mexico City, on a pedestrian bridge, and in a vehicle10 weekly, 90-min sessionsUp to 9 hrMcLay etal. (2011)Level 2N = 20 veterans with PTSDn = 10 control participantsn = 10 participants receiving VRETLicensed psychologistUnspecified VR goggles with built-in headphones used with joystick controllerSimulation of Iraq or Afghanistan approximating most salient traumatic experiences12 sessions/wk, up to 10 wk, 50 min eachBetween 160 and 320 minRothbaum etal. (2001)Level 4N = 10 veterans with PTSDClinical psychologistVirtual Research V6 (Virtual Research Systems, Aptos, CA) used with electro magnetic tracking (Polhemus, Colchester, VT)2 VEs: virtual jungle clearing and virtual helicopterImaginal exposure with therapist controlling VE to mirror patients description816 biweekly, 90-min sessionsApproximately 6 hrSpecific Phobias: AcrophobiaAbdullah & Shaikh (2018)Level 3N = 20 participants with acrophobian = 10 participants receiving invivo exposuren = 10 participants receiving VRETUnspecifiedGear VR with Samsung Galaxy S7 Edge (Samsung Electronics, Seoul, South Korea) used with Microsoft Kinect (Microsoft, Redmond, WA)2 height exposure scenarios: atop a mountain and a city building8 weekly, 25-min sessionsApproximately 200 minChoi etal. (2001)Level 4N = 1 participant with acrophobiaUnspecifiedProView XL50 (Kaiser Electro-Optics, Ann Arbor, MI) used with motion tracking (Polhemus, Colchester, VT) and Nascar Force Pro driving simulator (Thrustmaster, Carentoir, France)Riding a 4-sided open elevator starting from the 1st floor through the 25th floor while looking down6 sessions, 30 min eachBetween 80 and 100 minDonker etal. (2019)Level 2N = 193 participants with acrophobian = 96 participants receiving VRETn = 97 waitlist control participantsSelf-guidedGoogle Cardboard (Google, Mountain View, CA) used with unspecified smartphoneCompleting tasks in a 3D theater environment: standing on a tall ladder, standing on balconies, walking on a high bridge, and bungee jumping6 modules (540 min each) over 3 wk; only 1 module completed in HMD-VRBetween 5 and 40 minGromer etal. (2019)Level 2N = 49 participants who were fearful of heightsUnspecifiedHTC Vive (HTC, New Taipei City, Taiwan)Height scenario (edge of a deep canyon) and a control forest scenario1 session, 3 exposuresApproximately 3 minHong etal. (2017)Level 3N = 48 participants with acrophobian = 24 participants with low fearn = 24 participants with high fearUnspecifiedGear VR with Galaxy S6 (Samsung Electronics, Seoul, South Korea)4 missions: elevator taking, cliff driving, heli-skiing, and rooftop walking4 sessions over 2 wk (20 min each)Approximately 40 minJuan & Prez (2009)Level 2N = 25 healthy participantsUnspecified5DT (Virtual Realities, League City, TX) used with WingMan Cordless Rumblepad (Logitech, Lausanne, Switzerland)Acrophobia scene: floor falling away1 immersion lasting 7 min7 minKrijn etal. (2004)Level 2N = 30 participants with acrophobian = 10 participants receiving HMD VRETn = 14 participants receiving CAVE VRETn = 11 waitlist control participants (some progressed to the experimental group)UnspecifiedVisette Pro (Cybermind, Leicestershire, United Kingdom)4-floor shopping mall, a 6-floor fire escape, a roof garden on a building, and an 8-floor virtual building site3 sessions (1.5 hr each; 1 hr of exposure)3 hrSchfer etal. (2015)Level 3N = 42 healthy participants with acrophobia tendenciesn = 21 participants with body trackingn = 21 participants without body trackingTherapist (unspecified)Oculus Rift DK1 (Oculus VR, Menlo Park, CA) used with Microsoft Kinect (Microsoft, Redmond, WA) and SixAxis Controller (Sony Corporation, Tokyo, Japan)Acclimatization at street level, balcony with railings, and protrusion without railings1 sessionAverage = 295 sSpecific Phobias: AgoraphobiaMalbos etal. (2008)Level 4N = 6 participants with claustrophobiaUnspecifiedGlasstron LDI-100B (Sony Corporation, Tokyo, Japan) used with a head tracker (Intersense Intertrax, Bedford, MA)9 VEs containing a combination of 7 elements: houses, corridors, hallways, caverns, concrete channels, underground access, and elevators5055 min per VE over 8 sessions (5 sessions in HMD-VR)Between 7.50 and 8.25 hrMalbos etal. (2013)Level 4N = 18 participants with panic disorder and agoraphobiaUnspecified42 Pro HMD (Virtual Realities, League City, TX) used with a wireless controller and Logitech Momo steering wheel with vibration and force feedback (Logitech, Lausanne, Switzerland)9 VEs: a valley, the outback, lifts, supermarket, subway stations, car parks, a cinema, flying on an airplane, and driving on a highway30- to 35-min sessions, unspecified number of sessionsBetween 180 and 225 minPrez-Ara etal. (2010)Level 2N = 29 participants with agoraphobia, with and without panic disordern = 14 participants receiving VRETn = 15 participants receiving traditional therapyPsychologistV6 HMD (Virtual Research Systems, Aptos, CA)Agoraphobic scenarios and audio and visual effects of rapid heartbeat, panting, blurred vision, double vision, and tunnel vision8 sessions with up to 6 exposures for the VRET group (50 min each) and 6 exposures for the traditional group (25 min each)Between 5.0 and 5.5 hrRahani etal. (2018)Level 3N = 33 participantsn = 14 participants with agoraphobian = 19 healthy participantsTherapist (unspecified)Oculus Rift (Oculus VR, Menlo Park, CA)A video about fear of closed environments, an elevator in a 10-story building, and a building with an MRI roomUnspecifiedUnspecifiedSpecific Phobias: ArachnophobiaMiloff etal. (2019)Level 2N = 100 participants with arachnophobian = 50 participants receiving standard treatmentn = 50 participants receiving VRETLicensed psychologist and psychotherapistGear VR (Samsung Electronics, Seoul, South Korea) with smartphoneA serious game with 8 levels of increasingly realistic spider images in puzzles and activities3-hr exposures (M = 142.82 min, SD = 21.85)Approximately 3 hrMinns etal. (2018)Level 2N = 77 participants with arachnophobian = 38 participants receiving VRETn = 39 waitlist participantsUnspecifiedOculus Rift DK1 (Oculus VR, Menlo Park, CA)Video footage: spider being held by a model, spider positioned closer to the camera, and spider positioned even closer and moving toward camera6 videos (5 min each)30 minPeperkorn etal. (2016)Level 3N = 64 participantsn = 32 participants with arachnophobian = 32 healthy participantsUnspecifiedZ800 3DVisor (eMagin, Hopewell Junction, NY)Viewing a snake or spider under a glass container in VR while reaching toward the alternate stimulus in the real world1 session with 2 blocks (21 min each)42 minSpecific Phobias: OtherBouchard etal. (2008)Level 2N = 31 participants with snake phobiaUnspecifiedI-Glass (I-O Display Systems, Sacramento, CA) used with Microsoft joystick (Microsoft, Redmond, WA)Desert with induced anxiety, desert without induced anxiety, and control environment3 immersions lasting 5 min15 minGujjar etal. (2019)Level 2N = 30 participants with dental phobian = 15 participants receiving VRETn = 15 control participantsDentistOculus DK2 (Oculus VR, Menlo Park, CA)Dental operatory for 2 min each for 5 scenarios while sitting in a real dental chair: dental instruments and virtual dentist; virtual dentist moves toward patient with mirror; virtual dentist holds a syringe and moves toward patient; virtual dentist carries a drill without sound, then with sound, toward the patient1 session, lasting at least 10 minUnspecified; each scenario repeated until low anxiety reachedMhlberger etal. (2005)Level 2N = 25 participants with fear of flyingn = 12 participants who underwent motion simulationn = 13 participants who did not undergo motion simulationUnspecifiedV6 HMD (Virtual Research Systems, Aptos, CA) used with electromagnetic tracking (Polhemus, Colchester, VT)4 flight simulations1 session of 4 flights (18 min each)Approximately 80 minWalshe etal. (2003)Level 4N = 14 participants with situational phobia of driving, with or without PTSDUnspecifiedVFX-3D HMD (Interactive Imaging Systems, Rochester, NY) used with WingMan Formula Force GP Wheel and Pedals (Logitech, Lausanne, Switzerland)Driving in rural and city environments12 weekly, 1-hr sessionsUp to 12 hrPerformance-Based Social AnxietyKahlon etal. (2019)Level 4N = 27 adolescents with fear of public speakingClinical psychologistUnspecified cardboard headset with iPhone 7 (Apple, Cupertino, CA)7 speech-related tasks (12 min each) in a classroom with 10 adolescent avatars sitting at desks with gaze toward user; empty classroom; lobby1 session lasting 90 min (60 min in exposure)Approximately 1 hrKim etal. (2017)Level 4N = 52 participantsn = 22 participants with social anxiety disordern = 30 healthy participantsUnspecifiedGear VR with Galaxy S6 (Samsung Electronics, Seoul, South Korea)Public speaking in 3 social situations (school, business, everyday life), each with 4 levels of increasing difficulty and 3 speech topics8 self-training sessions over 2 wkUnspecifiedOrman (2003)Level 4N = 8 saxophone studentsMusic instructorVFX-3D HMD (Forte Technologies, Rochester, NY)Music performance venues: practice room, classroom with a student audience, room with music faculty members, and room with the director of bands12 weekly, 15- to 20-min sessionsBetween 3 and 4 hrOrman (2004)Level 4N = 3 saxophone studentsMusic instructorVFX-3D HMD (Forte Technologies, Rochester, NY)Music performance venues: practice room, classroom with a student audience, room with music faculty members, and room with the director of bands; nature setting2 sessions, unspecified durationUnspecifiedPertaub etal. (2001)Level 3N = 16 participantsn = 8 participants with public speaking phobian = 8 confident public speakersUnspecifiedVR8 HMD (Virtual Research Systems, Aptos, CA) used with electromagnetic tracking (Polhemus, Colchester, VT)Public speaking to either an empty room or to animated avatars displaying neutral behaviors1 immersion lasting 5 min5 minStupar-Rutenfrans etal. (2017)Level 4N = 35 students with moderate to high anxiety of public speakingSelf-guidedUnspecified HMDEmpty hall, small audience, large audience3 sessions with 5-min videos (repeated 34 times each)Approximately 1 hr