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Virtual Reality Exposure Therapy for Spider Phobia

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Virtual Reality Exposure Therapy for Spider Phobia Alexander Miloff The overall aim of this thesis has been the study of an automated virtual reality exposure therapy treatment for spider phobia. Using Virtual reality exposure therapy inexpensive hardware and not requiring a human therapist to deliver, such treatments may help ensure that the benefits of exposure therapy for spider phobia can be disseminated widely. A rigorous methodology was designed to evaluate the efficacy and safety of the novel virtual reality treatment as compared to gold-standard in-vivo exposure therapy. Effort was made for spider phobia therapy reality exposure Virtual Alexander Miloff to provide sufficient justification necessary to allow for future effectiveness trials to be conducted in community settings outside the laboratory, such as in local clinics or a home environment. A process evaluation focusing on the virtual therapist component of the treatment and requiring the development of a new questionnaire was undertaken to better understand how the treatment imparted its therapeutic effects. Finally, quantitative and qualitative baseline data concerning what participants fear about spiders was analyzed to explore how future generations of exposure therapy treatment could be improved. ISBN 978-91-7911-114-4 Department of Psychology Doctoral Thesis in Psychology at Stockholm University, Sweden 2020 Virtual reality exposure therapy for spider phobia Alexander Miloff Academic dissertation for the Degree of Doctor of Philosophy in Psychology at Stockholm University to be publicly defended on Friday 29 May 2020 at 10.00 in David Magnussonsalen (U31), Frescati Hagväg 8. Abstract Exposure therapy for specific phobia involving systematic and repeated presentation of an aversive stimuli or situation is a highly effective treatment for reducing fear and anxiety. Dissemination of this evidence-based treatment has proved challenging, however, and for over 20 years an alternative method of delivery using virtual reality technology has been explored with positive results. This thesis consists of three empirical studies examining a new generation of virtual reality exposure therapy (VRET) that by using automation, inexpensive hardware, and downloadable software aims to ensure that a highly efficacious exposure therapy can be made available to almost anyone. Study I evaluated the efficacy of this novel automated VRET for spider phobia as compared to gold-standard in-vivo one-session treatment (OST) using a randomized non-inferiority design. Results indicated that large effect size reductions in self-reported fear were evident at post-assessment in both treatments and the automated VRET was not inferior to OST at 3- and 12-months follow-up according to behavioral approach test, but was significantly worse until 12-month follow-up. No significant difference was noted on a questionnaire measuring negative effects of treatment. Study II conducted a process measure evaluation of patient alliance towards the virtual therapist used in the VRET treatment with a purpose-built questionnaire entitled the Virtual Therapist Alliance Scale (VTAS). Exploratory factor analysis indicated a sound two-factor solution composed of a primary task, goal and co-presence factor and a secondary bond and empathy factor. Psychometric evaluation of the VTAS suggested good internal consistency, and a moderate correlation between the VTAS and change in self-reported fear over follow-up. Study III assessed what individuals with a fear of spiders found most frightening about spiders. Both quantitative ratings and qualitative descriptions indicated that movement characteristics were reported as most fear provoking and to a lesser extent appearance characteristics, however factor analysis of scores in these categories did not find a correlation with participant baseline self-reported fear. Overall, the above findings suggest that VRET is a potential alternative to OST for the treatment of spider phobia also with respect to therapist alliance, and spider movement characteristics should be emphasized in future VRET treatments. Keywords: Specific phobia, spider phobia, spider, fear, anxiety, virtual reality, exposure therapy, automated, alliance, psychometric, factor analysis, virtual therapist, RCT, randomized, non-inferiority, clinical trial, dissemination, 12-month follow-up. Stockholm 2020 http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-180746 ISBN 978-91-7911-114-4 ISBN 978-91-7911-115-1 Department of Psychology Stockholm University, 106 91 Stockholm VIRTUAL REALITY EXPOSURE THERAPY FOR SPIDER PHOBIA Alexander Miloff Virtual reality exposure therapy for spider phobia Alexander Miloff ©Alexander Miloff, Stockholm University 2020 ISBN print 978-91-7911-114-4 ISBN PDF 978-91-7911-115-1 Cover illustration Rythme n°2, décoration pour le Salon des Tuileries Robert Delaunay (Victor Félix) Reprinted with permission Musée d’Art moderne de la Ville de Paris AMVP 2575 CCØ Paris Musées / Musée d'art moderne de la Ville de Paris Printed in Sweden by Universitetsservice US-AB, Stockholm 2020 To my Great Aunt Helen and Uncle Peter “VR researchers have to acknowledge the reality of inner life, for without it virtual reality would be an absurd idea… there you are, the fixed point in a system where everything else can change.” - Jaron Lanier, Father of VR Abstract Exposure therapy for specific phobia involving systematic and repeated presentation of an aversive stimuli or situation is a highly effective treatment for reducing fear and anxiety. Dissemination of this evidence-based treatment has proved challenging, however, and for over 20 years an alternative method of delivery using virtual reality technology has been explored with positive results. This thesis consists of three empirical studies examining a new gener- ation of virtual reality exposure therapy (VRET) that by using automation, inexpensive hardware, and downloadable software aims to ensure that a highly efficacious exposure therapy can be made available to almost anyone. Study I evaluated the efficacy of this novel automated VRET for spider phobia as compared to gold-standard in-vivo one-session treatment (OST) using a ran- domized non-inferiority design. Results indicated that large effect size reduc- tions in self-reported fear were evident at post-assessment in both treatments and the automated VRET was not inferior to OST at 3- and 12-months follow- up according to behavioral approach test, but was significantly worse until 12- month follow-up. No significant difference was noted on a questionnaire measuring negative effects of treatment. Study II conducted a process meas- ure evaluation of patient alliance towards the virtual therapist used in the VRET treatment with a purpose-built questionnaire entitled the Virtual Ther- apist Alliance Scale (VTAS). Exploratory factor analysis indicated a sound two-factor solution composed of a primary task, goal and co-presence factor and a secondary bond and empathy factor. Psychometric evaluation of the VTAS suggested good internal consistency, and a moderate correlation be- tween the VTAS and change in self-reported fear over follow-up. Study III assessed what individuals with a fear of spiders found most frightening about spiders. Both quantitative ratings and qualitative descriptions indicated that movement characteristics were reported as most fear provoking and to a lesser extent appearance characteristics, however factor analysis of scores in these categories did not find a correlation with participant baseline self-reported fear. Overall, the above findings suggest that VRET is a potential alternative to OST for the treatment of spider phobia also with respect to therapist alli- ance, and spider movement characteristics should be emphasized in future VRET treatments. 1 Keywords: Specific phobia, spider phobia, spider, fear, anxiety, virtual reality, exposure therapy, automated, alliance, psychometric, factor analysis, virtual therapist, RCT, randomized, non-inferiority, clinical trial, dissemination, 12- month follow-up. 2 Sammanfattning Exponeringsterapi är en effektiv behandling för att minska rädsla och ångest vid specifik fobi, och innebär att ångestväckande stimuli och situationer på ett systematiskt sätt presenteras upprepade gånger för patienten. Det har emeller- tid visat sig vara en utmaning att implementera denna evidensbaserade metod i klinisk praktik, och därför har studier de senaste 20 åren undersökt möjlig- heten att genomföra behandlingen med hjälp av virtual reality. Denna avhand- ling består av tre empiriska studier som undersöker en ny generation av virtual reality-behandlingar som är automatiserad, använder sig av billig hårdvara, och mjukvara som enkelt laddas ner då den behövs, vilket förhoppningsvis tillgängliggör exponeringsterapi för fler. Studie 1 jämförde Virtual Reality Exponerings-Terapi (VRET) vid spindelfobi med standard ensessionsbehand- ling, med hjälp av en non-inferiority-design. Resultaten visade att båda be- handlingarna hade stora effekter på självskattad rädsla vid avslutad behand- ling, och att i ett närmandetest var VRET inte signifikant sämre än standard- behandling vid 3- och 12 månader efter avslutad behandling, men var betyd- ligt sämre vid 12 månaders uppföljning. Studie 2 var en process-studie, som undersökte patientens upplevelse av allians till den virtuella terapeuten i VRET, vilket undersöktes med ett nytt mått: Virtuell Terapeut Allians Skala (VTAS). En explorativ faktoranalys fann en tvåfaktorslösning: en faktor be- stående av uppgift-, mål- och delad närvaro-skattningar, och en faktor
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