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Three-Year Follow-Up for Virtual Reality Exposure for Fear of Flying

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Three-Year Follow-Up for Virtual Reality Exposure for Fear of Flying CYBERPSYCHOLOGY & BEHAVIOR Volume 6, Number 4, 2003 © Mary Ann Liebert, Inc. Three-Year Follow-Up for Virtual Reality Exposure for Fear of Flying BRENDAK. WIEDERHOLD, Ph.D., M.B.A., B.C.I.A., and MARK D. WIEDERHOLD, M.D., Ph.D., F.A.C.P. ABSTRACT Thirty participants who had been treated for aviophobia with virtual reality graded exposure therapy with physiological monitoring and visual feedback (VRGETpm), virtual reality graded exposure therapy with physiological monitoring only (VRGETno), or imaginal expo- sure therapy (visualization) with physiological monitoring only (IET) between January 1998 and January 1999 were contacted in January 2002 for a 3-year posttreatment follow-up assess- ment. Of the participants in the VRGETpm group who had flown successfully by the end of treatment, all had maintained their ability to fly at follow-up. Of the participants in the VR- GETno group who had flown successfully by the end of treatment, two were no longer able to fly. Of the participants in the IET group who had flown successfully, all were still able to fly. It appears that the addition of teaching self-control via visual feedback of physiological signals may serve to maintain treatment gains in long-term follow-up. INTRODUCTION sistent with previous reports on the long-term effi- cacy of in vivo exposure therapy for specific phobia XPOSURE THERAPY has long been shown as an ef- treatment, and are the first 3-year follow-up for vir- Efective treatment for reducing symptomatology tual reality exposure therapy for specific phobia in those suffering from specific phobias. As has treatment. These results seem to indicate that VR- been previously reported, 1,2 long-term follow-up of GETpm may be a robust treatment, even at long- controlled clinical studies using behavioral tech- term follow-up. With respect to virtual reality niques are sparse. However, in a more recent study exposure therapy (VRET) (without physiological that included a review of the 17 studies that did in- monitoring or feedback) for fear of flying, a clude long-term follow-up, it was shown that treat- 12-month posttreament follow-up was completed ment effects may be maintained for up to 10 years by Rothbaum, et al. 6 Results indicated that at after treatment ends. 3 The current study served to 6-month follow-up those in both a VRET group and make contact with those who had participated in a an in vivo group had maintained treatment gains. controlled study between January 1998 and Janu- However, at 12-month follow-up, with 80% of par- ary 1999 on fear of flying treatment. 4–6 We were in- ticipants completing follow-up self-report ques- terested in determining whether treatment relapse tionnaires, 17% of participants reported they had had occurred differentially in any of the three treat- avoided flying, and participants in the VR group ment groups. Our findings for the VRGETpm reported they were more likely to utilize medica- (virtual reality graded exposure therapy in combi- tion or alcohol to overcome anxiety on flights (73%) nation with physiological feedback) group are con- than those in the in vivo group (30%). The Virtual Reality Medical Center, San Diego, California. 441 442 WIEDERHOLD AND WIEDERHOLD ORIGINALSTUDY ing scenarios that was decided upon with the ther- apist during session 2. Method Participants. The study, performed over a 1-year Measures period, was approved by the Internal Review Board at the California School of Professional Psy- Physiological measures. Physiology for all three chology, San Diego. The original sample consisted groups was measured and recorded during a base- of thirty participants, comprising three treatment line period and real-time during each exposure ses- groups: virtual reality graded exposure therapy sion using an I-330 C2 computerized biofeedback with physiological monitoring and visual feedback systems with PDS Physiological Programming (VRGETpm) ( n = 10), virtual reality graded expo- Software. Measurements included electroencephal- sure therapy with physiological monitoring only ogram (EEG), or brain wave measurements at two (VRGETno) ( n = 10), or imaginal exposure therapy separate locations, CZ and O1; respiration rate, (visualization) with physiological monitoring only skin resistance, heart rate, and peripheral skin tem- (IET) (n = 10). Participants who had a history of perature. The two VR groups progressed through heart disease, migraines, seizures, or concurrent several virtual reality scenarios including sitting on diagnosis of severe mental disorders such as psy- the runway with engines off, engines on, taxi to the chosis or major depressive disorder were ex- gate, takeoff, flying at altitude in good weather, fly- cluded. The mean age of the sample was 39.80 ing at altitude during turbulence and thunder- (SD = 9.69), with a range from 24 to 55 years. Sev- storms, and landing. enty-three percent were white collar/professional status workers, 10% were students, 7% were Self-report questionnaires. In addition to SUDS young retirees, 3% were blue-collar workers, and levels and physiological measures, a number of 7% were unemployed. Ninety-three percent were self-report questionnaires were used to assess par- Caucasian and 7% were Hispanic. Further details ticipant progress. Self-report questionnaires were regarding the sample may be found in the original given pre-treatment, after two sessions of breathing study report. 3 retraining, and posttreatment. In addition, all 30 par- ticipants were contacted posttreament, three months following the end of their 8-week treatment pro- Procedure. Detailed procedures for the initial gram and asked if they had been able to fly without study may be found elsewhere. 3–5 All groups were medication or alcohol, with medication or alcohol given eight sessions of treatment: two sessions of to alleviate anxiety, or if they were unable to fly. Re- breathing retraining and six sessions of exposure sults from this post-treatment follow-up indicated tophobic stimuli, either imaginally or via virtual 100% of those in the VRGETpm group able to fly reality. Exposure sessions were each 20 min in du- with no medication or alcohol, 80% of those in the ration. The VR, or three-dimensional computer VRGETno group, and 10% of those in the IET stimuli, was administered via a Liquid Image head- group. mounted display (HMD) with a Polhemus INSIDE- TRAK position tracker. The VRGETpm group was Results allowed to view visual feedback of physiology while learning diaphragmatic breathing as a cop- The significance of this study was that it com- ing mechanism to use during exposure in VR. The bined VR with physiological feedback for the first VRGETno and IET groups were taught diaphrag- time in a controlled study for fear of flying. Al- matic breathing with a therapist modeling appro- though results for all three groups showed a lessen- priate behavior, but with no visual feedback of ing on self-report fear scores, all members of the physiological signals given during any of the ses- VRGETpm group were able to translate the reduc- sions. The VRGETpm group was progressed tions into behavioral change, that is, an ability to through the various parts of the simulated flight fly without medication or alcohol. This did not based on physiological stabilization as evidenced occur in the other two groups. When questioned by the ability to stabilize skin resistance levels. The about their belief in their ability to fly posttreat- VRGETno group was progressed based on SUDS ment, the VRGETpm group also seemed to have in- (subjective units of distress) on a 0 = no anxiety to creased self-efficacy compared to individuals in the 100 = maximum anxiety scale. The IET group mem- other two groups. Eighty percent reported they felt bers were each progressed based on SUDS levels they could fly effectively without medication or al- through an individualized hierarchy of phobic fly- cohol, and in actuality 100% flew. In the VRGETno THREE-YEAR FOLLOW-UP FOR VR FOR FEAR OF FLYING 443 group, 80% said they could fly without medication attitudes toward flying, ability to generalize treat- or alcohol, and at initial 3-month follow-up, 80% ment gains to other areas of anxiety, and any other had flown without meds or alcohol. In the IET comments the participants felt were important to group, only 10% said they could fly without alco- convey to the therapist. hol or medication, and in fact only 10% did. Al- though the VRGETno group was more successful Results than the IET group, there seemed to be an added advantage in providing the coping mechanism of Many participants related that the treatment pro- visual feedback of physiological stimuli during gram had changed not only their anxiety and stress breathing retraining, not only in short-term effec- related to flying, but that skills learned during tiveness but also in long-term maintenance of treat- treatment had generalized into stress management ment gains. during everyday life as well as in application to help conquer other phobias not targeted in treat- ment as well. In particular, one participant reported THREE-YEAR FOLLOW-UP PROCEDURE he used the techniques learned to help overcome his fear of heights in vivo without a therapist’s as- We attempted to reach all of the thirty partici- sistance. Others have reported this carryover effect pants from the original sample for a semi structured as well.1,8,9 telephone interview, based on the procedure used Of those in the VRGETpm group, all were still 1 for a 3 2-year follow-up on automated treatment for able to fly successfully without the use of medica- fear of flying done by Denholtz, et al. 1 We were able tion or alcohol to control anxiety (100%). Of those to contact all individuals in the two VR groups in the VRGETno group, two were no longer able to (100%), and 7 individuals (of 10) (70%) in the IET fly, a 20% recidivism rate.
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