1994 VR Conference Proceedings

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The Effects of Virtual Reality Immersion In The Treatment Of Anxiety, Panic, & Phobia Of Heights

By: Ralph J. Lamson, Ph.D. and Mark Meisner, M.D.
Department of Psychiatry
Kaiser-Permanente Medical Group, Inc.

Abstract

Kaiser-Permanente Health Plan members responded to advertisements placed in newspapers, to participate in an experimental study of "Fear of Heights". The on-going study takes place in the Department of Psychiatry, Kaiser-Permanente, San Rafael, California. It is designed to determine the effects of immersing individuals into a computer generated virtual environment where they encounter the perception of depth and height. The treatment of psychiatric conditions with immersion in simulated environments is termed "Virtual Therapy" (Lamson, 1993). DIVISION, INC. provided PROVISION 100 VTX, monitors, hand-held grip, and head-mounted-display, engineers, and virtual world software for periods of research. Immersion is accomplished by placing a Head-Mounted-Display over the eyes. Tests measuring anxiety, depression, and internal-external locus of control were administered before Virtual Therapy Immersion, as were self-reports of anxiety, panic, and phobia of heights. During Virtual Therapy Immersion, heart rate and blood pressure were monitored. Eighty-nine (89) Kaiser-Permanente Health Plan members volunteered for the study. After a group screening process, participants were pretested and randomly assigned to one of four conditions. The treatment condition was Virtual Therapy and control conditions included medication, cognitive therapy, and waiting lists.

This study differs from previous research in the experiential application of virtual reality technology. The integration of cognitive-behavioral principles with virtual reality technology is herein termed "Virtual Therapy" (Lamson, 1993). The power of Virtual Therapy is its ability to focus patient perceptual powers on a specific problem or experience and by association, reduce and eliminate disabling fears.

Virtual Therapy research is based upon a review of the literature concerning treatment of anxiety disorders, clinical application of cognitive-behavioral therapy to anxiety disorders, and review of virtual reality research and experiential applications. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) was used to describe anxiety disorders. In this research, interventions for generalized anxiety disorder (300.02), simple phobia, most common of anxiety disorders in the general population (300.29), and panic disorder without agoraphobia, most common among people seeking treatment (300.01), was conducted. Three hypotheses guiding the research are stated.


Hypotheses

Hypothesis #1. The variables of anxiety, depression, internal/external control and biologic markers such as heart rate and blood pressure are expected to show significant correlations with acrophobia. Hypothesis #2. Participants in an intervention program combining cognitive therapy principles with virtual reality technology are expected to show greater reduction of anxiety, depression, heart rate, and blood pressure with increase in internal-external locus of control than control group participants. Hypothesis #3. Treatment group participants are expected to spend less time in therapy for treatment of anxiety disorders than those in control groups.

Virtual Therapy participants were expected to habituate to emotional arousal when faced with heights. Habituation has been described as "a progressive decrease in the vigor of elicited behavior that may occur with repeated presentations of the eliciting stimulus" (Domjan & Burkhard, 1982). Habituation persists for varying amounts of time and is strongly influenced by procedures used to establish it. When a person fearful of heights encounters heights in a virtual environment, the response is often fear. After exposure, fear provoking aspects of the virtual environment cease to elicit strong emotional reactions. The mechanisms of opponent-process theory help to explain habituation.


Significance

Cognitive-Behavioral Principles and Virtual Therapy

Cognitive-behavioral principles are integrated with virtual reality technology for the purpose of treating anxiety disorders. In a study of "Virtual Therapy" for acrophobia, individuals seeking treatment complained of anxiety, panic, and phobia.

Selected theories describing cognitive, cognitive-behavioral, social-cognitive, and information processing principles have been researched. The efficacy of therapeutic approaches derived from these theories in treating anxiety (Bandura, 1977; Beck & Emery, 1985; Brown, Hertz, & Barlow, 1992; Freeman, Pretzer, Fleming, & Simon, 1990) is reported in the psychotherapeutic literature.

In general, cognitive therapy considers relationships among cognition, emotion, and behavior in human functioning (Freeman, Pretzer, Fleming, & Simon, 1990). Three aspects of cognition are emphasized: automatic thoughts, underlying assumptions, cognitive distortions. Automatic thoughts are defined as those that occur spontaneously, without premeditation. Automatic thoughts are shaped by both emotions and reactions to events.

A retired 51 year old female described her reactions to heights. She reported that her first fear of heights occurred in childhood when she became "stuck" in a pine tree and needed to be rescued. After that experience, she began to avoid heights. With the passage of time her fear worsened. She described feeling overwhelmed by anxiety provoking automatic thoughts concerning heights. At age 15, patient recalled being pushed out of a tree. She now avoids hiking, elevators on outside of buildings, auto trips where there are cliffs, ferris-wheels, and latter above the second step. She described one trip to Lake Tahoe where she "freaked out" after seeing cliffs and got down on the car floor. Dropping to the floor has occurred to this patient numerous times. She justifies avoidance of experiences where cliffs may be found by saying "I'm not interested." She indicated a desire to climb a latter for the purpose of cleaning leafs from the roof of a shed. The roof is 8 feet above ground level. Patient said her lifestyle is definitely restricted by this fear.

During a half hour follow-up session one week after Virtual Therapy, the patient reported achieving success in her self-assigned goal and exceeding it. She climbed a latter 8 feet and walked around on the top of a shed. She also looked down 25 feet below to a creek below and thoroughly enjoyed the view.

Figures 1 & 2 show heart rate and blood pressure measurements of this patient before, during, and after immersion into the virtual environment. The letters along the X-axis represent approximate virtual environment user locations. The letter "P" indicates the user is on the plank and looking downward. Figure 2, the line graph, has 3 "P" locations. Each of these represent an occasion when the user was on the plank and looking downward. The first "P" shows the greatest elevation in heart rate (108) followed by decreases on the second and third trials. The decreases in heart rate correspond to decreases in systolic blood pressure. The curves representing heart rate and systolic blood pressure roughly parallel each other. The elevation in bio-measurements on the first trail followed by decreases during the second and third trials suggest the patient is less reactive to perception of depth. People with height anxiety, panic, and phobia associate risks such as falling, injury, and death with elevations and depths. The decreases in heart rate and blood pressure also suggest that patient fears are reduced during virtual environments exposures. This process may represent habituation.

A second premise of cognitive therapy is that an individual's beliefs or assumptions or schemas shape his or her perception and interpretation of events. In the literature, belief, assumption, and schema are used interchangeably. In the previous example, the 51 year old female held an expectation that she would become fearful and "couldn't" ascend to heights. "I'm incapable" she thought. During Virtual Therapy, this patient learned she could tolerate perceptions of depth and height. To her, the virtual environment seemed real and threatening at first. But within 30 minutes, she experienced success at overcoming a sense of threat when perceiving heights and depths. She tested her virtual environment success by climbing a latter in the real world. By doing so, she broke a longstanding avoidance of heights pattern. She also created "I can do" beliefs.

A third premise of cognitive therapy is based upon Beck's (1976) observation that errors in logic known as "cognitive distortions" are quite prevalent in clients. Before Virtual Therapy, the 51 year female had elaborated upon her fear of heights for years. Her initial fear provoking experience became distorted. In her mind, the fear of heights was generalized to many places. Her thinking resulted in a highly restricted lifestyle. The power of Virtual Therapy is the immersive in vivo experience. Patients are able to overcome longstanding fears and phobias in part because they have an "as if" success experience. Attempts to reduce fears through guided imagery may not be as convincing to patients as Virtual Therapy. Individuals participating in Virtual Therapy test themselves in the real world afterwards.


Theoretical Rational

Virtual Therapy utilizes a theoretical rational underlying cognitive therapy which concerns the way in which individuals structure the world (Beck, 1967, 1976, 1991). In cognitive theory, individual cognitions are based upon schema or assumptions or beliefs. When individuals make "negative cognitive shifts" (Beck, 1991), a change in cognitive organization occurs such that positive information important to the individual is cognitively blocked while negative information become predominant in the individual's field of awareness.

Research of Virtual Therapy (Lamson, 1994) suggests immersing individuals in simulated environments may influence fear producing automatic thoughts of heights and associated beliefs. The theory underlying cognitive therapy hypothesizes that beliefs are cast into a structure from early experiences. Virtual Therapy research reveals that fear of height beliefs may emerge at any time during the lifespan. When present events stimulate and activate the belief structure, the individual may experience depression or anxiety. One structure may be stimulated by heights. In this case, the individual may start a "cognitive shift" by thinking "I'm not going to be ok. I can't do this. Something awful is going to happen. I won't be ok". In this manner, the individual experiences threat and helplessness. Virtual Therapy provides individuals the opportunity to make positive shifts through simulated "as if" experiences. Beck (1991) describes people prone to anxiety disorders as experiencing threat whereas people prone to depression experience loss or defeat.


Method and Procedure

Volunteers for the study were randomly assigned to treatment and control conditions. Treatment group participants were immersed in virtual reality for a fifty minute intervention termed "Virtual Therapy" (Lamson, 1993). They also received two, half hour follow-up "talk" sessions. Those randomly assigned to cognitive therapy were given a standard 50 minute therapy session and two, 30 minute follow-up sessions. They were introduced to learning principles and given an in-vivo guided imagery experience designed to reduce fear-of-heights. Individuals randomly assigned to the medication group were prescribed medication, when appropriate, and asked to return for follow-up interviews. Participants in the treatment and control conditions are given post-treatment testing to determine if the treatment had a significant impact on dependent variables. Participants agreed to sign "Informed Consents". Research took place in an office normally used for therapeutic interventions.


Design

This study used an Experimental Randomized Blocked Control Group Pretest-Posttest Design as described by Isaac and Michael (l987). It is also known as a Pretest-Posttest Control Group design (Campbell & Stanley, 1966). Participants for treatment and control groups consisted of volunteers from an outpatient population.


Sample Selection

Procedure for assigning subjects to treatment and control groups Subjects consisted of volunteers who responded to newspaper advertisements announcing a "fear-of-height" (anxiety, panic, phobia) study. They subscribe to the Kaiser-Permanente Health Plan. Participants were randomly assigned to those to Virtual Therapy treatment and control conditions. The mean age of all participants was 54.


Sample Size

A power calculation to determine the desired number of participants for treatment and control conditions was performed. The calculation was made to maximize opportunities to obtain statistically significant differences between the treatment and control groups. Forty-four (44) participants were randomly assigned to the Virtual Therapy treatment condition and forty-five individuals were randomly assigned to the control conditions.


Instrumentation

Participants in the treatment and control conditions of this study were given pre-treatment (Time 1) and post-treatment (Time 2) measures. These will be used to assess depression on the Beck Depression Inventory (BDI), anxiety on the State-trait Anxiety Inventory (STAI), and internality versus externality on the Rotter Locus of Control Inventory. Participants in the treatment condition received "Virtual Therapy" intervention in the form of virtual reality technology immersion, instruction, and follow-up discussion. DIVISION, Inc. provided loan equipment to conduct this research. The technology provided by DIVISION, Inc. is PROVISION-100 VTX. It is a fully integrated virtual reality system designed to operate in office environments. A head-mounted display, hand-held grip, and tracking system were included. Additionally, participants in the treatment group were monitored for pre and post treatment heart rate and blood pressure.


Procedure

Treatment Group

The treatment used in this study is based upon principles of cognitive therapy (Beck, Rush, Shaw, & Emery, l979; Beck & Emery, 1986) and the technology of virtual reality. The combination of principles of cognitive therapy and technology of virtual reality is termed, "Virtual Therapy" (Lamson, 1993). Virtual Therapy is an intervention based upon clinical observations of common denominators in emotional and behavioral disorders which later resulted in identification of essential components for successful therapy of this condition.

Virtual Therapy is an educational and experiential approach to anxiety disorders, specifically, acrophobia (fear-of-heights).

Virtual Therapy achieves in vivo exposure through patient immersion into a computer generated environment. In vivo exposure has been found to be the most potent cognitivebehavioral technique for anxiety disorders (Goisman et al, 1993). Learning is achieved by associations, both unintended and intended. When these properties are used in a virtual reality immersive environment, the probability of deconditioning anxiety was hypothesized to be superior to other forms of treatment. Rather than digging for an original event or cause to the condition of anxiety disorder, this treatment helps participants achieve immediate relief from anxiety and depression while strengthening a sense of internal control.

When avoidance of environmental cues previously precipating anxiety is overcome, participants may experience increased self-mastery. With virtual reality experiences, cognitive principles will make immediate sense. After Virtual Therapy, 90% of treatment group participants completed self-assigned height tasks. For some, this was a considerable achievement. Patient self-reports indicate long standing avoidance of heights was eliminated.

The application of virtual reality technology to anxiety disorders took place in the office of Ralph J. Lamson, Ph.D., Department of Psychiatry, 820 Las Gallinas Avenue, San Rafael, California. The office is assigned to the principal investigator and normally used for psychotherapeutic sessions. The total pre-test, intervention, post-test period occurred over a period of five weeks. The clinical virtual reality intervention and research was conducted by a licensed psychologist. During this time, participants entered virtual environments with the technology of virtual reality. The treatment consisted of placing a head-mounted display (HMD) on the participant. The HMD covers the eyes and blocks out visual distractions elsewhere in the treatment room. The participant was immersed into a computer generated virtual environment. The patient was able to move under his or her own control, within the virtual environment. Movement was accomplished with a hand-held grip.

The participant had control of speed and direction in the virtual world. The virtual environment responds to the participants movements within it. The environment is constructed so that the participant makes choices. Choices resulted in the experience of entering virtual reality and perceiving heights and depths. The participant was coached during the process. The exercise was designed to safely decondition participant fears concerning heights. Associative learning is built into the virtual environment insuring the participant is protected from noxious experiences. The treatment was administered in a single session lasting 50 minutes. The participant received only one, 50 minute Virtual Therapy exposure and up to two additional, 30 minute follow-up "talk" sessions. Participants were tested at Time 1 and Time 2.


Control Groups

Forty-five (45) participants were assigned to control groups. There are three control conditions in this study. Collectively, they will be considered as one group. They are medication, cognitive therapy, and waiting list controls. Fifteen individuals were assigned to the medication condition, fifteen to cognitive therapy, and fifteen to the waiting list control condition.


Protection of Human Subjects

Participants in this research are referred to as human subjects. They were selected from a pool of Kaiser-Permanente subscribers who volunteered to participate in the research. Human subject volunteers were screened for psychiatric conditions that would contraindicate them for treatment in this study. Inclusion criteria are that patients have at least one of the following DSM-R-III current or past diagnoses: generalized anxiety disorder (300.02), simple phobia (300.29), and panic disorder without agoraphobia (300.01).

Insufficient for inclusion, but frequently seen as co-morbid conditions are posttraumatic stress distress disorder, obsessive compulsive disorder, or anxiety disorder not otherwise specified. Subjects were at least 18 years of age. They voluntarily participated in the study and signed a written consent form. All participants were advised at the onset and completion of the study that psychiatric services will be available to them, if further required. Exclusion criteria are the presence of an organic brain syndrome, a history of schizophrenia, or current psychosis.


Data Analysis Procedures

The Statistical Package SAS will be used to assist the investigator in analyzing the results of the study. The statistical analyses in this study is based upon a Randomized Blocked Control-Group Pretest-Posttest Design (Isaac & Michael, l987) used to determine the effect of Virtual Therapy upon anxiety, panic, and phobia of heights. In this study, particular attention will be focused upon differences between the treatment and control groups across variables. The study will also be concerned with differences that may occur as a result of the treatment intervention and therefore compared pretest scores on selected variables to posttest scores in the treatment condition.


Assumptions

The study assumes that participants in the treatment and control are approximately equivalent with respect to the variables measured at Time 1. It also assumes that any changes in the treatment group with respect to the measured variables will be due to the treatment and not extraneous variables.


Limitations

The study is limited by self-selection. Given the socio-economic background and education of participants as well as their average age, 54, the results will have limited generalization to other populations and environments. Newspaper advertisements requesting fear-of-heights volunteers did not identify treatment interventions. However, an article about the study later appeared in a local newspaper. The article may have contributed to selection bias for those seeking "novel" treatment.


Results

Habituation can be observed in measurements where heart rate and blood pressures decrease over time. In this study, data show the intensity of an observed fear response is reduced during exposure to a virtual environment of heights. Previous studies of habituation document extreme physiological arousal in skydiving trainees. Facial expressions suggested trainees were terrified during jumps. Experienced jumpers are not fearful. The primary process of fear is cancelled out by the opponent process of elation. In this study, heart rate and blood pressure of participants tend to decrease with time and exposure to a virtual environment with heights. One week after the Virtual Therapy treatment, participants reported on self-assigned height goals. Over 90% of Virtual Therapy participants reported reaching their goals. Some attributed their successes to Virtual Therapy, others said they didn't know, and a few said it wasn't helpful. For many participants, avoidance of heights had been a way of life. Others said anxiety, panic, and phobia of heights had limited their lifestyles. Whether the results will endure is unknown. Follow-up studies are necessary. Still, biological measures suggesting habituation to fear-of-heights and real-world achievements at overcoming avoidance of heights, strongly suggests Virtual Therapy is an effective form of treatment for acrophobia.


Summary

The Effects of Virtual Reality Immersion In The Treatment Of Anxiety, Panic, and Phobia of Heights is significant because it offers the possibility of rapid learning through associative learning in an in-vivo computer generated environment. Preliminary show that 90% of Virtual Therapy patients completed real world self-assigned height tasks within one week after a 50 minute treatment session. In an evaluation of Virtual Therapy treatment, some patients report generalization of effects to other conditions.

In this experimental study, participants were randomly assigned to treatment and control groups. Virtual Therapy participants are being compared to others randomly assigned medication, cognitive therapy, and no treatment waiting list conditions. Participants assigned to the treatment group received one, fifty minute Virtual Therapy session followed by one half hour "talk" session a week after treatment and another half hour "talk" session three months later. One result of particular interest concerns rapid reduction of avoidance behavior. Within one week after Virtual Therapy immersion treatment, participants sought opportunities in the real world to ascend to heights previously feared. Most of the Virtual Therapy participants reported two successes. The first success was completing self-assigned goals. The second success was completing self-assigned goals with less fear than anticipated. The duration of these effects are unknown though under study.

Research of Virtual Therapy is still underway. Interim results suggest this form of intervention is promising. Clinical observation and patient self-report of cognitive, behavioral, and physiological functioning indicate that Virtual Therapy is an effective form of treatment for height anxiety, panic, and phobia. However, this optimism needs to be guided by closer examination of data at the conclusion of the study. Research results may be limited by several factors. Some participants have complained that the virtual environment was "not real enough" while others objected that it was "too real". As expected, some participants were more phobic of heights than others. Randomization to treatment and control conditions was used to control for this variance. The study may also be limited by sensitivity of omnibus testing measures.

Initial results of Virtual Therapy research suggest it is an effective form of treatment. It opens the door for replication studies and other innovative applications of simulation technology to psychiatric conditions. "Virtual Therapy" (Lamson, 1994) will be published by JOSSEY-BASS, Publishers, Inc., San Francisco in January, 1995. The book is intended for mental health practitioners, clinical researchers interested in collaborating with computer science and engineering departments, leaders of computer technology and software development interested in the production of virtual reality environments for mental and community health. The local and central research committees of Kaiser-Permanente and Kaiser Institutional Review Board initially approved this research which was originally submitted under the title "The Effects of Virtual Reality Immersion on Anxiety Disorders." The study is supported by Kaiser Foundation Research Institute and The Permanente Medical Group.


Method and Procedure

Volunteers for the study were randomly assigned to treatment and control conditions. Treatment group participants were immersed in virtual reality for a fifty minute intervention termed "Virtual Therapy" (Lamson, 1993). They also received two, half hour follow-up "talk" sessions. Those randomly assigned to cognitive therapy were given a standard 50 minute therapy session and two, 30 minute follow-up sessions. They were introduced to learning principles and given an in-vivo guided imagery experience designed to reduce fear-of-heights. Individuals randomly assigned to the medication group were prescribed medication, when appropriate, and asked to return for follow-up interviews. Participants in the treatment and control conditions are given post-treatment testing to determine if the treatment had a significant impact on dependent variables. Participants agreed to sign "Informed Consents". Research took place in an office normally used for therapeutic interventions.


Design

This study used an Experimental Randomized Blocked Control Group Pretest-Posttest Design as described by Isaac and Michael (l987). It is also known as a Pretest-Posttest Control Group design (Campbell & Stanley, 1966). Participants for treatment and control groups consisted of volunteers from an outpatient population.


Sample Selection

Procedure for assigning subjects to treatment and control groups Subjects consisted of volunteers who responded to newspaper advertisements announcing a "fear-of-height" (anxiety, panic, phobia) study. They subscribe to the Kaiser-Permanente Health Plan. Participants were randomly assigned to those to Virtual Therapy treatment and control conditions. The mean age of all participants was 54.


Sample Size

A power calculation to determine the desired number of participants for treatment and control conditions was performed. The calculation was made to maximize opportunities to obtain statistically significant differences between the treatment and control groups. Forty-four (44) participants were randomly assigned to the Virtual Therapy treatment condition and forty-five individuals were randomly assigned to the control conditions.


Instrumentation

Participants in the treatment and control conditions of this study were given pre-treatment (Time 1) and post-treatment (Time 2) measures. These will be used to assess depression on the Beck Depression Inventory (BDI), anxiety on the State-trait Anxiety Inventory (STAI), and internality versus externality on the Rotter Locus of Control Inventory. Participants in the treatment condition received "Virtual Therapy" intervention in the form of virtual reality technology immersion, instruction, and follow-up discussion. DIVISION, Inc. provided loan equipment to conduct this research. The technology provided by DIVISION, Inc. is PROVISION-100 VTX. It is a fully integrated virtual reality system designed to operate in office environments. A head-mounted display, hand-held grip, and tracking system were included. Additionally, participants in the treatment group were monitored for pre and post treatment heart rate and blood pressure.


Procedure

Treatment Group

The treatment used in this study is based upon principles of cognitive therapy (Beck, Rush, Shaw, & Emery, l979; Beck & Emery, 1986) and the technology of virtual reality. The combination of principles of cognitive therapy and technology of virtual reality is termed, "Virtual Therapy" (Lamson, 1993). Virtual Therapy is an intervention based upon clinical observations of common denominators in emotional and behavioral disorders which later resulted in identification of essential components for successful therapy of this condition.

Virtual Therapy is an educational and experiential approach to anxiety disorders, specifically, acrophobia (fear-of-heights). Virtual Therapy achieves in vivo exposure through patient immersion into a computer generated environment. In vivo exposure has been found to be the most potent cognitive-behavioral technique for anxiety disorders (Goisman et al, 1993). Learning is achieved by associations, both unintended and intended. When these properties are used in a virtual reality immersive environment, the probability of deconditioning anxiety was hypothesized to be superior to other forms of treatment. Rather than digging for an original event or cause to the condition of anxiety disorder, this treatment helps participants achieve immediate relief from anxiety and depression while strengthening a sense of internal control.

When avoidance of environmental cues previously precipating anxiety is overcome, participants may experience increased self-mastery. With virtual reality experiences, cognitive principles will make immediate sense. After Virtual Therapy, 90% of treatment group participants completed self-assigned height tasks. For some, this was a considerable achievement. Patient self-reports indicate long standing avoidance of heights was eliminated.

The application of virtual reality technology to anxiety disorders took place in the office of Ralph J. Lamson, Ph.D., Department of Psychiatry, 820 Las Gallinas Avenue, San Rafael, California. The office is assigned to the principal investigator and normally used for psychotherapeutic sessions. The total pre-test, intervention, post-test period occurred over a period of five weeks. The clinical virtual reality intervention and research was conducted by a licensed psychologist. During this time, participants entered virtual environments with the technology of virtual reality. The treatment consisted of placing a head-mounted display (HMD) on the participant. The HMD covers the eyes and blocks out visual distractions elsewhere in the treatment room. The participant was immersed into a computer generated virtual environment. The patient was able to move under his or her own control, within the virtual environment. Movement was accomplished with a hand-held grip.

The participant had control of speed and direction in the virtual world. The virtual environment responds to the participants movements within it. The environment is constructed so that the participant makes choices. Choices resulted in the experience of entering virtual reality and perceiving heights and depths. The participant was coached during the process. The exercise was designed to safely decondition participant fears concerning heights. Associative learning is built into the virtual environment insuring the participant is protected from noxious experiences. The treatment was administered in a single session lasting 50 minutes. The participant received only one, 50 minute Virtual Therapy exposure and up to two additional, 30 minute follow-up "talk" sessions. Participants were tested at Time 1 and Time 2.


Control Groups

Forty-five (45) participants were assigned to control groups. There are three control conditions in this study. Collectively, they will be considered as one group. They are medication, cognitive therapy, and waiting list controls. Fifteen individuals were assigned to the medication condition, fifteen to cognitive therapy, and fifteen to the waiting list control condition.


Protection of Human Subjects

Participants in this research are referred to as human subjects. They were selected from a pool of Kaiser-Permanente subscribers who volunteered to participate in the research. Human subject volunteers were screened for psychiatric conditions that would contraindicate them for treatment in this study. Inclusion criteria are that patients have at least one of the following DSM-R-III current or past diagnoses: generalized anxiety disorder (300.02), simple phobia (300.29), and panic disorder without agoraphobia (300.01).

Insufficient for inclusion, but frequently seen as comorbid conditions are posttraumatic stress distress disorder, obsessive compulsive disorder, or anxiety disorder not otherwise specified. Subjects were at least 18 years of age. They voluntarily participated in the study and signed a written consent form. All participants were advised at the onset and completion of the study that psychiatric services will be available to them, if further required. Exclusion criteria are the presence of an organic brain syndrome, a history of schizophrenia, or current psychosis.


Data Analysis Procedures

The Statistical Package SAS will be used to assist the investigator in analyzing the results of the study. The statistical analyses in this study is based upon a Randomized Blocked Control-Group Pretest-Posttest Design (Isaac & Michael, l987) used to determine the effect of Virtual Therapy upon anxiety, panic, and phobia of heights. In this study, particular attention will be focused upon differences between the treatment and control groups across variables. The study will also be concerned with differences that may occur as a result of the treatment intervention and therefore compared pretest scores on selected variables to posttest scores in the treatment condition.


Assumptions

The study assumes that participants in the treatment and control are approximately equivalent with respect to the variables measured at Time 1. It also assumes that any changes in the treatment group with respect to the measured variables will be due to the treatment and not extraneous variables.


Limitations

The study is limited by self-selection. Given the socio-economic background and education of participants as well as their average age, 54, the results will have limited generalization to other populations and environments. Newspaper advertisements requesting fear-of-heights volunteers did not identify treatment interventions. However, an article about the study later appeared in a local newspaper. The article may have contributed to selection bias for those seeking "novel" treatment.


Results

Habituation can be observed in measurements where heart rate and blood pressures decrease over time. In this study, data show the intensity of an observed fear response is reduced during exposure to a virtual environment of heights. Previous studies of habituation document extreme physiological arousal in skydiving trainees. Facial expressions suggested trainees were terrified during jumps. Experienced jumpers are not fearful. The primary process of fear is cancelled out by the opponent process of elation. In this study, heart rate and blood pressure of participants tend to decrease with time and exposure to a virtual environment with heights. One week after the Virtual Therapy treatment, participants reported on self-assigned height goals. Over 90% of Virtual Therapy participants reported reaching their goals. Some attributed their successes to Virtual Therapy, others said they didn't know, and a few said it wasn't helpful. For many participants, avoidance of heights had been a way of life. Others said anxiety, panic, and phobia of heights had limited their lifestyles. Whether the results will endure is unknown. Follow-up studies are necessary. Still, biological measures suggesting habituation to fear-of-heights and real-world achievements at overcoming avoidance of heights, strongly suggests Virtual Therapy is an effective form of treatment for acrophobia.


Summary

The Effects of Virtual Reality Immersion In The Treatment Of Anxiety, Panic, and Phobia of Heights is significant because it offers the possibility of rapid learning through associative learning in an in-vivo computer generated environment. Preliminary show that 90% of Virtual Therapy patients completed real world self-assigned height tasks within one week after a 50 minute treatment session. In an evaluation of Virtual Therapy treatment, some patients report generalization of effects to other conditions.

In this experimental study, participants were randomly assigned to treatment and control groups. Virtual Therapy participants are being compared to others randomly assigned medication, cognitive therapy, and no treatment waiting list conditions. Participants assigned to the treatment group received one, fifty minute Virtual Therapy session followed by one half hour "talk" session a week after treatment and another half hour "talk" session three months later. One result of particular interest concerns rapid reduction of avoidance behavior. Within one week after Virtual Therapy immersion treatment, participants sought opportunities in the real world to ascend to heights previously feared. Most of the Virtual Therapy participants reported two successes. The first success was completing self-assigned goals. The second success was completing self-assigned goals with less fear than anticipated. The duration of these effects are unknown though under study.

Research of Virtual Therapy is still underway. Interim results suggest this form of intervention is promising. Clinical observation and patient self-report of cognitive, behavioral, and physiological functioning indicate that Virtual Therapy is an effective form of treatment for height anxiety, panic, and phobia. However, this optimism needs to be guided by closer examination of data at the conclusion of the study. Research results may be limited by several factors. Some participants have complained that the virtual environment was "not real enough" while others objected that it was "too real". As expected, some participants were more phobic of heights than others. Randomization to treatment and control conditions was used to control for this variance. The study may also be limited by sensitivity of omnibus testing measures.

Initial results of Virtual Therapy research suggest it is an effective form of treatment. It opens the door for replication studies and other innovative applications of simulation technology to psychiatric conditions. "Virtual Therapy" (Lamson, 1994) will be published by JOSSEY-BASS, Publishers, Inc., San Francisco in January, 1995. The book is intended for mental health practitioners, clinical researchers interested in collaborating with computer science and engineering departments, leaders of computer technology and software development interested in the production of virtual reality environments for mental and community health. The local and central research committees of Kaiser-Permanente and Kaiser Institutional Review Board initially approved this research which was originally submitted under the title "The Effects of Virtual Reality Immersion on Anxiety Disorders." The study is supported by Kaiser Foundation Research Institute and The Permanente Medical Group.

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