Claustrophobia VR

8/20/2019 Claustrophobia VR

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P E R G A M O N

Behaviour Research and Therapy 36 (1998) 239-246

B E H V l O U R

R E S E R C H N D

T H E R P Y

S h o r t C o m m u n i c a t i o n

V i r t u a l r e a l i ty t r e a t m e n t o f c l a u s t r o p h o b i a a c a s e

r e p o r t

C . B o t e l l a a * , R . M . B a f i o s b , C . P e r p i f i ~ b , H . V i l la a , M . A l c a f i i z c ,

A Re y c

~Departamento de Psicologia B6sica, Clinica y Psicobiologia, Universidad Jaume I, Carretera de

Borriol, s/n, 12080-Castel16n, Spain

bDepartm ent of P ersonality, Un iversidad de Valencia, Spain

CDesign Image Developm ent, Universidad Politkcnica de V alencia, Spain

Received 22 July 1997

A b s t r a c t

The e f fi cacy o f a t r ea tmen t f o r c l aus t ropho b ia us ing on ly Vi rtua l R ea l i t y (VR ) exposure was

examined. The subject was a 43-year -old female who suf fered f rom cl in ical ly s igni f icant d is t ress and

impa i rmen t and sough t psycho log ica l t he r apy . E igh t i nd iv idua l VR g raded exposure sess ions were

conduc ted . A l l se l f - r epor t measures were r educed fo l lowing VR exposure and were ma in t a ined a t one

mo nth fo l low-up . The necess i ty o f a t heo re t ica l f r ame wo rk fo r th i s new me d ium fo r exposure the r apy i s

discussed. © 1998 Elsevier Science Ltd . Al l rights reserved.

1 I n t r o d u c t i o n

T h e t e r m V i r t u a l r e a l it y ( V R ) w a s c o i n e d i n 1 9 89 b y J a r o n L a n i e r , a l t h o u g h S u t h e r l a n d

( 1 96 5 , 1 96 8) is u s u a ll y c o n s i d e r e d t o b e t h e f a t h e r o f t h is n e w t e c h n o l o g y . T h e p o t e n t i a l o f V R

i s s u c h t h a t p r a c t i c a l l y a l l t h e c l i n i c a l d i s c i p l i n e s w i l l b e a b l e t o b e n e f i t f r o m t h i s m a n - c o m p u t e r

i n t e r f a c e ( G r e e n l e a f , 1 9 95 ).

A l t h o u g h t h e f u t u r e is p r o m i s i n g , V R a p p l i c a t i o n s t o t h e fi el d o f th e p s y c h o l o g i c a l

t r e a t m e n t s a r e s c a r c e . T h e f i r s t a p p l i c a t i o n w a s S c h n e i d e r ' s s t u d y ( 1 9 8 2 ) , i n w h i c h t h e

e f f e c t iv e n e s s o f a v e r y r u d i m e n t a r y i n it ia l t o o l w a s t e s t e d ( s p e c i a l le n s e s w h i c h a l t e r e d t h e

* Author for correspondence.

This artic le was partially spon sored by Conselleria de Cultura Educacio i Ci6ncia (Generalitat V alenciana) [GV-D -

ES-17-123-96] and Instituto de la M ediana y P eq ue fia Industria de la Generalitat V alen cian a (IMPIVA )

[971801003559].

0005-7967/98/$19.00 © 1998 Elsevier Science Ltd. All rights reserved.

P I I : S 0 0 0 5 - 7 9 6 7 ( 9 7 ) 1 0 0 0 6 - 7



24 C. Bote l la e t a l . / Behav iour Research and Therapy 36 1998 ) 239 - 246

p e r c e p t i o n o f d e p t h a n d w h i c h w e r e u s e d t o m a g n i f y th e s e n s a t i o n o f h e i g h t d u r i n g t h e p r o c e s s

o f

in vivo

e x p o s u r e ) . A d v a n c e s s i n c e t h e n i n c l u d e t h e w o r k b y t h e g r o u p o f t h e U n i v e r s i t y o f

N o t t i n g h a m , w h e r e a V R s y s te m h a s b e e n d e v e l o p e d f o r th e s p i d e r p h o b i a t r e a t m e n t , a n d t h e

w o r k s o f t h e K a i s e r - P e r m a n e n t M e d i c a l G r o u p o f C a l if o r n ia , w h e r e a s et o f t e st s h a s b e e n

d e v e l o p e d to a ss es s t h e u t il it y o f V R i n t h e a c r o p h o b i a t r e a t m e n t ( V in c e , 1 9 9 5 ) . T h e g r o u p o f

R o t h b a u m i n C l a r k A t l a n t a U n i v e r s it y h a s p u b l i s h e d t h e fi rs t re p o r t s a b o u t t h e u t il it y o f

s o f tw a r e s d e s i g n e d f o r a c r o p h o b i a t r e a t m e n t ( N o r t h a n d N o r t h , 1 99 4 a n d 1 9 9 6 ; R o t h b a u m

e t a l. , 1995a,b ) and f o r t he f ea r o f fl y ing ( R o t h ba um e t a l. , 1996). The f i rs t book o f t r e a t m en t

b y m e a n s o f V R h a s b e e n r e c en t ly p u b l is h e d :

Virtual Reality Therapy An Innovative Paradigm

(Nor th e t a l . , 1997) .

I n s ho r t , t he r e i s ev i dence f o r t he u t il i ty o f V R f o r t he t r e a t m en t o f s pec if ic phob i a s . T he

pr e s en t wo r k s eeks t o adv ance t h i s f ie l d and f ocus e s on t he t r e a t m en t o f c l aus t r op hob i a by

m e a n s o f V R .

The cho i ce o f c l aus t r o pho b i a is j u s t if i ed by t he s pec ia l cha r ac te r i s ti c s o f t h is ph ob i a . I t i s

s i m il a r t o a g o r a p h o b i a w i th a m o r e c o n s t r i c te d r a n g e o f a v o i d a n c e (B a r lo w , 1 9 8 8 ; B o o t h a n d

R a c h m a n , 1 9 9 2 ; O s t , 1 9 8 7 ) ; m o r e o v e r , c l a u s t r o p h o b i a c a n b e i n c a p a c i ta t i n g a n d d i s tu r b i n g ,

s i nce c l o s ed p l ace s a r e com m on i n da i l y l i f e ( e l eva t o r s , a e r op l anes , t unne l s , boo t hs , e t c . ) . I n

s om e c i rcum s t ances , t h i s pho b i a c an be e s pec i a ll y i m pa i r i ng , f o r exam pl e , whe n ce r t a i n t e s ts

f o r m e d i c a l d i a g n o s i s / t h e r a p y a r e n e c e s s a r y ( C o m p u t e d T o m o g r a p h y S c a n - C T S - , M a g n e t i c

R e s o n a n c e I m a g i n g - M R I - , H y p e r b a r i c O x y g e n T r e a t m e n t , e tc . ) ( K a t z e t a l. , 1 9 9 4 ; K i l b o r n

an d La bbe , 1990; Hi l l a rd , 1990) .

Exp os u r e t h e r apy is an e f f ec ti ve way t o t r e a t s pec if ic pho b i a s ( Ma r ks , 1987 ; Os t , 1989 ;

W a r w i c k a n d M a r k s , 1 98 8) in c l u d i n g c l a u s t r o p h o b i a ( F r a n k e l , 1 9 7 0 ; G a t c h e l , 1 9 7 7 ; K o u l a k

e t a l ., 1976 ; Le i t enb erg e t a l ., 196 8, 197 0, 1971 ; t ) s t e t a l ., 198 2; Spe l t z and Bern s te in , 1979) .

Howeve r , expos u r e t he r apy has l i m i t a t i ons . F i r s t l y , i t does no t bene f i t a l l peop l e who s u f f e r

f r o m p h o b i a s , s i n ce m a n y p a t ie n t s ( a r o u n d 2 5 % ) a r e a f ra i d o f fa c in g t h e t h r e a t e n i n g o b je c t

o r c o n t e x t a n d , t h e r e f o r e , t h e y r e f u s e t o p a r t i c i p a t e i n a n e x p o s u r e p r o g r a m o r t h e y d r o p - o u t

( M a r k s , 1 99 2). O n e o f t h e a d v a n t a g e s o f V R is t h a t t h e c o n t e x t g e n e r a t e d b y t h e c o m p u t e r

c a n b e c o m p l e t e l y c o n t r o l l e d b y t h e t h e r a p is t a n d b y t h e p a t i e n t . A n o t h e r e l e m e n t t h a t

p r ov i des s a f e ty t o the pa t i en t is t he v i r t ua l i t y o f t he env i r onm en t . The r e f o r e , V R can be a

k e y i n t e r m e d i a t e st ep b e t w e e n t h e t h e r a p i s t 's c o n s u l t i n g r o o m , c o m p l e t e l y p r o t e c te d , a n d t h e

t h r ea t en i ng r ea l env i r onm en t . Howeve r , t he f r i gh t en i ng s i t ua t i on i s no t a l ways ea s i l y

access i b le ( an ae r op l an e , a c ave , a t unne l ) . I n t he s e in s t ances i m age r y exp os u r e is u s ua l ly

us ed , bu t t h is t r e a t m en t is l es s e f fec ti ve and t he r e a r e i nd i v i dua l d i f fe r ences i n i m a g i na t i ve

a b il it y. A n o t h e r p r o b l e m o f e x p o s u r e t r e a t m e n t s i s t h a t p a t i e n t s c o n t i n u e m a n i f e s ti n g

r e s i dua l f e a r s i n t he s ca r i ng s i tua t i ons . As V R can go bey on d w ha t a r ea l s i t ua t i on

wou l d a l l ow, a g r ea t con t r o l o f t he phob i c s e t t i ng i s pos s i b l e and t he r e f o r e t he r e s i dua l f e a r s

m a y d i s ap p e a r .

Bes i de s t he pos s i b l e advan t ages o f VR, t h i s s pec i a l k i nd o f expos u r e m ay a l s o con t r i bu t e t o

o t he r i m p or t an t a s pec t s o f the t he r apy . F i r s tl y , t he r ap y m ay be con s i de r ed li ke a s pec i al ,

p r o t ec t ed en v i r o nm en t i n wh i ch t he pa t i en t c an s t a r t t o exp l o r e and t o ac t ( t ha t i s, t o cope

wi t h wha t he / s he f ea r s ) . The v i r t ua l s i t ua t i on i s a s a f e ba s e a t t he pa t i en t ' s s e r v i ce whe r e

n o t h i n g o f w h a t h e /s h e f e ar s c a n a c t u a l l y h a p p e n . V R a l s o a l lo w s o n e t o g r a d e t h e si t u a ti o n

i n s uch a way t ha t t he pa t i en t c an p r og r e s s f r om t he ea s i e s t pe r f o r m ances un t i l t he m os t



C. Bote l la e t a l . / Behav iour Research and T herapy 36 1998 ) 2 39- 24 6 24

d i f f i cu l t ones a t h i s / he r own pace . Tha t i s , t he v i r t ua l t r e a tmen t c an be de s igned so t ha t i t f i t s

e a c h p a t i e n t. S o m e o f t h e p r e v i o u s t es t s o f V R u s e d V R e x p o s u r e a s t h e o n l y th e r a p e u t i c

i n t e r v e n t i o n ( N o r t h a n d N o r t h , 1 9 9 6 ; R o t h b a u m e t a l. 1 9 9 5 a, b) , b u t o t h e r s t u d ie s c o m b i n e d

V R e x p o s u r e a n d a n x i e t y m a n a g e m e n t t e c h n i q u e s ( R o t h b a u m e t a l . , 1 9 9 6 ) o r in vivo e x p o s u r e

(Car l in e t a l . , 1997) .

T h e p u r p o s e o f t h e p r e s e n t w o r k w a s t o e x a m i n e t h e e ff ic a cy o f a t r e a t m e n t f o r

c l a u s t r o p h o b i a u s i n g only V R e x p o s u r e , i n a p e r s o n w h o s u ff e re d f r o m c l in i c a ll y s i g n if i ca n t

d i s t r e s s a n d i m p a i r m e n t a n d s o u g h t p s y c h o l o g i c a l t h e r a p y .

2 M e t h o d

2.1. Subject

T h e p a t i e n t w a s a 4 3 - y e a r - o l d w i d o w . S h e w a s r e f e r r e d b y t h e M e n t a l H e a l t h S e r v i c e s

b e c a u s e o f h e r s t r o n g f e a r , a n x i e t y a n d i n a b i li t y t o u n d e r g o a C T S t o d e t e c t a p o s s ib l e l e s io n i n

t h e s p i n a l c o l u m n t h a t m a y h a v e b e e n c o n t r i b u t i n g t o h e r b a c k p a i n f o r t h r e e y e a r s . T h e C T S

w a s t h e l a s t n e u r o l o g i c a l t es t s h e h a d t o c o m p l e t e b u t h e r g r e a t f e a r o f t h is k i n d o f e x p l o r a t i o n

p r e v e n t e d h e r f r o m c a r r y i n g i t o u t . S h e r e p o r t e d s h e h a d b e e n a f r a i d o f c l o s e d p l a c e s s in c e s h e

w a s a c h i l d ( e . g . e l e v a t o r s , a e r o p l a n e s , p u t t i n g h e r h e a d i n t o w a t e r , h a v i n g t h e w i n d o w s c l o s e d

dur ing s l e ep ) .

3 M e a s u r e s

3.0.1. Fear and avoidance scales F A S )

A S p a n i s h a d a p t a t i o n o f t h e M a r k s a n d M a t h e w s ' s c al e s (1 97 9) . T h e t a r g e t b e h a v i o u r ( C T S )

i s e v a l u a t e d a c c o r d i n g t o t h e d e g r e e o f f e a r a n d a v o i d a n c e , f r o m 0 t o 1 0, w h e r e 0 is I N e v e r

a v o i d i t / N o f e a r a n d 10 is I A l w a y s a v o i d i t / E x t r e m e F e a r .

3.0.2. Fear o f closed spaces measure F C S M )

O ne i t em wa s i nc lude d t o a s se ss t he deg ree o f f e a r o f c l o sed spaces , f r om 0 t o 10, wh e re 0 is

N o fe a r a n d 10 is E x t r e m e F e a r .

3.0.3. Problem-related impairment questionnaire P R IQ )

(Ech ebu r f i a an d D e Cor r a l , 1987 , i n Bo rda a nd Ech ebur f i a , 1991 ) I t cons i s t s o f r a t i ng s cal e s

f r o m 0 t o 1 0 ( f r o m N o t a t a l l , t o V e r y m u c h ) , a s se s s in g t h e o v e r a l l f u n c t i o n a l i m p a i r m e n t

c a u s e d b y t h e p r o b l e m .

3.0.4. Subjective units o f discom fort scale S U D S )

( W o l p e , 1 9 6 9 )T h e s u b j e c t r a t e d h e r m a x i m u m l ev e l o f a n x i e ty o n t e n - p o i n t s c al e i n t h e

p re sen t s i t ua t i on .



4 C. Bote l la e t a l . / Behav iour Research and Therap y 36 1998 ) 2 39- 246

3.0.5. Self-efficacy towards the target behaviour measure SETBM)

On e i t em wa s i nc lude d t o a s ses s t he deg ree o f s e lf - ef f ic acy r e l a t ed t o t he t a rge t p r ob l em

(CTS) .

3.0.6. The attitude towards CTS measure TAM)

C o n s i s t s o f o n e i t e m a s s e s si n g a t ti t u d e s t o w a r d s C T S , i n c l u d i n g th e f o l l o w i n g d i m e n s i o n s

r a t ed on a 0 t o 10 s eman t i c d i f f e r en t i a l s ca l e : good /bad ; awfu l /wonde r fu l ; qu i e t / opp re s s ive ;

d a n g e r o u s / s a f e ; t h r e a t e n i n g / u n t h r e a t e n i n g ; w i d e / n a r r o w , a n d p l e a s a n t / u n p l e a s a n t .

4 A p p a r a t u s

H a r d w a r e t o c r e a t e v i r t u a l e n v i r o n m e n t s ( V E ) c o n s i s t e d o f a S i l i c o n G r a p h i c s I n d i g o H i g h

I m p a c t c o m p u t e r g r a p h i c s w o r k s t a ti o n , a h i g h q u a li t y h e a d - m o u n t e d d i s p l ay ( F S 5 f r o m V i r t ua l

R e s e a r c h ) a n d a n e l e c t r o m a g n e t i c s e n s o r t h a t w a s u s e d to t r a c k t h e h e a d a n d r i g h t h a n d

( F a s t r a k s y s te m f r o m P o l h e m u s ) . M o d e l l i n g w a s m a d e u s i n g A u t o c a d v . 13 s o f t w a r e ( A u t o d e s k ,

I n c ). I n o r d e r t o o b t a i n r e a li s ti c v ir t u a l e n v i r o n m e n t s , a s p e c i a l t e c h n i q u e o f t e x t u r e - m a p p i n g

g e n e r a t i o n w a s u s e d . V E w a s r e n d e r e d w i t h r a d i o s i t y t e c h n i q u e s u s i n g L i g h t s c a p e v . 3 . 0

s o f t w a r e ( L i g h t s c a p e T e c h n o l o g i e s ) . O n c e c a l c u l a t e d r a d i o s i t y s o l u t io n s o f V E , t h e D v i s e v .3 .0

( D i v i s i o n I n c ) w a s u s e d t o c r e a t e V E f r o m t h e m o d e l s . O n t h i s m o d e l , t h e t e x t u r e g e n e r a t e d

f r o m r a d i o s i t y s o lu t i o n s w a s m a p p e d o n t h e g e o m e t r y m o d e l s t h u s o b t a i n i n g a h i g h l y r e a li s ti c

V E .

5 P r o c e d u r e

A to t a l o f e igh t VR se s s ions we re ca r r i ed ou t i n a t h r ee -we ek pe r iod . Af t e r t he s i x th s e s s ion ,

t h e p a t i e n t r e ce i v e d a c al l f r o m t h e H e a l t h S e r v i ce s t o i n f o r m h e r a b o u t t h e a p p o i n t m e n t f o r

t h e C T S . S h e d e c i d e d t o g o , a n d h a d s l i g h t d i s t r e s s w h i l e t h e C T S w a s b e i n g c a r r i e d o u t , b u t

m a n a g e d i t v e r y w e l l . W e d e c i d e d t o g o o n w i t h t w o a d d i t i o n a l V R s e s s i o n s i n o r d e r t o a c h i e v e

ove r l ea rn ing . The s ame se l f - r epo r t s ca l e s fu l f i l l ed a t t he beg inn ing o f t r e a tmen t we re app l i ed

a g a i n i m m e d i a t e l y a f t e r th e l a st V R e x p o s u r e s e ss io n ( p o s t - t r e a t m e n t a s s es s m e n t ) a n d o n e

m o n t h a f t e r s h e h a d f i n i s h e d t h e V R t r e a t m e n t ( f o l l o w - u p a s s e s s m e n t ) .

6 T r e a t m e n t

V R g r a d e d e x p o s u r e s es si on s w e r e c o n d u c t e d f o r a p p r o x i m a t e l y 3 5 - 4 5 m i n u t e s b y C B a n d

H V . T h e t h e r a p i s t s s i m u l t a n e o u s l y v i e w e d o n a v i d e o m o n i t o r a l l t h e v i r tu a l e n v i r o n m e n t s t o

w h i c h t h e p a t ie n t w a s e x p o se d a n d c o m m e n t e d a p p r o p r i a te l y . T h e t h e r a p i st s c o m m e n t s w e r e

s i m i l a r t o t h o s e u s e d i n c o n v e n t i o n a l in vivo e x p o s u r e . T h e p a t i e n t w a s e n c o u r a g e d t o i n t e r a c t

w i t h t h e e n v i r o n m e n t s l o n g e n o u g h f o r h e r a n x i e t y t o d e c r e a s e . H e r a n x i e t y l e v e l ( S U D S ) w a s

a s s es s ed e v e r y 5 m i n u t e s d u r i n g V R e x p o s u r e s e ss io n s .



C. Botella et al. / Behaviour Research and Therapy 36 1998 ) 239-246

Table 1

Sel f - repor t scale pre- , pos- t reatment and fo l low-up

243

Pre- Pos t - Fol low-up

P R IQ 2 0 0

FAS (fear of TCS) 10 2 2

FAS (avoidance of 10 0 0

TC S )

TA M 57 32 31

SETB M 4 10 9

F C S M 8 4 3

PRIQ : Pro blem-R elated Impa i rment Ques t ionnai re .

FAS: Fear and Avoidance Scale .

TAM : T he At t i tude t owards C TS M eas u re .

SETB M: Self -Eff icacy towards Targ et B ehaviour M easure.

FCSM : F ear o f Closed Spaces Measure.

I n t h e s o f t w a r e d e s i g n , sp e c i a l a t t e n t i o n h a s b e e n p a i d t o t h e d i f f e r e n t e l e m e n t s t h a t c o u l d

f a c i l it a t e t h e i m m e r s i v e e ff e c t o f V R a n d t h e r e a l i n t e r a c t i o n o f t h e p a t i e n t w i t h th e v i r t u a l

s e tt in g . T o g r a d e t h e l ev e ls o f d if f ic u l t y o f t h e c l a u s t r o p h o b i c e n v i r o n m e n t , t h r e e e n v i r o n m e n t s

w e r e c r e a t e d w i t h i n c r e a s i n g d e g r e e s o f di f fi c u lt y : S e t t i n g 0 : A b a l c o n y o r s m a l l g a r d e n o f

2 x 5 m . ; R o o m 1: A 4 x 5 m . r o o m w h i c h c o m m u n i c a t e d w i t h t h e b a l c o n y ; t h i s r o o m h a s

d o o r s a n d a b ig w i n d o w t h a t c o u l d b e o p e n e d a n d c l o se d in th r e e t ra c t s ;

R o o m 2 : A 3 x 3 m .

r o o m w h i c h c o m m u n i c a t e d w i t h t h e p r e v io u s o n e ; t h i s r o o m d i d n o t h a v e a n y f u r n i tu r e o r

w i n d o w s a n d t h e c ei li n g a n d t h e f lo o r w e r e d a r k e r , w i t h w o o d e n t e x t u r e to g i ve a se n s a t i o n o f

g r e a t e r e n c l o s u r e . O n c e t h e d o o r w a s c l o s e d , t h e p a t i e n t c o u l d l o c k it . T h e r e w a s a l s o a w a l l

t h a t c o u l d m o v e a s th e p a t i e n t ' s w i l l m a k i n g a g r e a t n o i s e w i t h f o u r p o s s i b il i t i e s f o r a d v a n c i n g

t o w a r d t h e p a t i e n t l e a v i n g h e r l o c k e d u p i n a s p a c e o f 1 m 2 o f w i d t h .

7 Resu l t s

A s c a n b e s e e n in T a b l e 1 a ll t h e m e a s u r e s w e r e r e d u c e d f o l l o w i n g V R e x p o s u r e a n d w e r e

m a i n t a i n e d a t f o l lo w - u p . F e a r a n d a v o i d a n c e m e a s u r e s d r a m a t i c a l l y d e c r e a se d , p r o v i d i n g

e v i d e n c e f o r t h e e f f i c a cy o f t h e t h e r a p y .

Table 2

SUD S rat ing in VR sess ions

1st Ses 2nd Ses 3rd Ses 4th Ses 5th Ses 6th Ses 7th Ses 8th Ses

R1 R2 R1 R2 R1 R2 R1 R2 RI R2 R1 R2 R1 R2 R1 R2

O C C C C C C C C C C C C

6 5 7 6 9 7 10 0 6 0 1 0 0

Ses = Session; R1 = Ro om 1; R2 = Roo m 2; O = Ope n envi ronment ; C = Closed envi ronment .



44 C. Bo te l la e t al . / Behav iour Research and T herapy 36 1998 ) 2 39-246

T a b l e 2 s h o w s t h e h i g h e s t S U D S d u r i n g e a c h s e s s i o n . T h e S U D S r a t i n g s w e r e h i g h e r a s t h e

p a t i e n t w a s e x p o s e d to a m o r e t h r e a t e n i n g e n v i r o n m e n t ( R o o m 2 ; s e s si o n s 4 a n d 5 ) a n d

d e c r e a s e d in t h e f o l lo w i n g s e s si o n s . S o m e o f h e r c o m m e n t s w e r e : I d o n ' t l ik e t h e w a l l a t a ll ,

t h i s r o o m i s s o a w f u l - - t h i s w a l l i s d i s g u s t i n g ; I h a t e t h i s w a l l m o r e t h a n C T S .

T h e p a t i e n t w a s a s k e d t o r a te t h e c o n t r i b u t i o n o f V R t o h e r p r o g r e s s i n a 0 t o 10 s c al e a n d

s h e a s s e s se d i t a s 8 . B u t w h a t i s m o r e i m p o r t a n t : t h e c l e a r e s t i n d i c a t i o n o f V R e f f e c ti v e n e ss is

t h a t t h e p a t i e n t w a s a b l e t o u n d e r g o C T S .

8 D i s c u s s i o n

T h e e x p o s u r e b y V R t r e a t m e n t w a s e f f e c t i v e s i n c e t h e p a t i e n t ' s a n x i e t y f o r c l o s e d s p a c e s

d e c r e a s e d , a s c a n b e o b s e r v e d f r o m t h e m e a s u r e s t a k e n b e f o r e a n d a f t e r t h e t r e a t m e n t .

I n i t i a l l y , t h e v i r t u a l s o f t w a r e p r o d u c e d a n a n x i e t y r e s p o n s e i n t h e p a t i e n t , a n d t h e v i r t u a l

e x p o s u r e r e d u c e d t h i s a n x i e t y .

T h e s e r e s u lt s a re c o n s i s t e n t w i t h t h o s e o f N o r t h a n d N o r t h ( 19 96 ); R o t h b a u m e t al. ( 1 99 5 a ,

b ) , a n d C a r l i n e t a l . (1 9 9 7 ) s h o w i n g t h e e f f ec t iv e n e s s o f V R f o r t h e t r e a t m e n t o f s p e c if ic

p h o b i a s . O u r s t u d y is th e f ir st r e p o r t o f V R t o t r e a t c l a u s t r o p h o b i a i n a p a t ie n t . M o r e o v e r , i n

t h e p r e se n t s t u d y V R w a s u s e d a l o n e, w i t h o u t t h e c o m b i n a t i o n o f a n y o t h e r t r e a t m e n t

t e c h n i q u e , a n d t h e p a t i e n t 's a c h i e v e m e n t s p e rs i s te d f o r a t l ea s t o n e m o n t h a f te r t h e t r e a t m e n t .

D u r i n g t h e V R s e s si o ns , t h e p a t i e n t r e p o r t e d s e v e ra l t im e s th a t t h e w a l l p r o d u c e s e v e n

m o r e f e a r i n m e t h a n t h e C T S d o e s . T h i s s t a t e m e n t s u g g e s t s t w o r e f le c t io n s . F ir s t ly , a s

m e n t i o n e d a b o v e , V R a l lo w s o n e t o g o b e y o n d r e a li ty b e c a u s e t h is t e c h n o l o g y m a y c re a t e a

m o r e f r i g h t e n i n g a n d f le x ib l e r e a l it y , i .e ., a r e a l i t y m o r e u s e f u l i n a t h e r a p e u t i c c o n t e x t . I n

f a c t, w e w e r e a b le t o a l t e r th e e n v i r o n m e n t in s u c h a w a y t h a t t h e p e r s o n w a s f a c e d b y a

v i r tu a l s i tu a t i o n e v e n m o r e f e a r e d th a n o n e w h i c h c o u l d h a p p e n i n a c t u a l r e a l it y . T h i s V R

c h a r a c t e r i s t i c m i g h t i m p r o v e s e l f - e f f i c a c y a n d p r o m o t e g e n e r a l i z a b i l i t y o f t h e r e s u l t s , a s t h e

p a t i e n t c l a i m e d : I f I c a n d o i t h e r e , I 'l l d o i t a n y w h e r e . S e c o n d l y , t h e e x t r e m e a n x i e t y

p r o d u c e d b y t h e s l i d i n g w a l l w h i c h m o v e s c l o s e r t o t h e p a t i e n t a n d t h e n o i s e p o i n t s o u t t h e

i m p o r t a n c e o f c e r t ai n v a r ia b l e s t o m a k e j u d g e m e n t s o f r e a li ty a n d t o fe el i m m e r s e d i n t h e

v i r t u a l e n v i r o n m e n t , a c e n t r a l i s s u e i n t h i s f i e l d . A c c o r d i n g t o B r i c k m a n ( 1 9 7 8 ) a t t r i b u t i n g

r e a li ty d e p e n d s o n t w o e l e m e n t s : (a ) t h e a c h i e v e m e n t o f a h i g h intern l correspondence o f t h e

b e h a v i o u r w i t h t h e e m o t i o n ; a n d ( b) t h e a c h i e v e m e n t o f a h i g h extern l correspondence o f t h e

b e h a v i o u r w i t h t h e c o n s e q u e n c e s in t h e e n v i r o n m e n t . O u r v i r tu a l s e t ti n g c o n t a i n e d e l e m e n t s

t h a t a l l o w e d t o g r a d e t h e c l a u s t r o p h o b i c t h re a t . P a r t ic u l a r ly , i n R o o m 2 w e a c h i e v e d a h ig h

i n t e r n a l c o r r e s p o n d e n c e , s i n c e t h e p a t i e n t f e l t a n d r e p o r t e d a h i g h a n x i e t y l e v e l w h e n s h e f a c e d

t h e c l a u s t r o p h o b i c e n v i r o n m e n t .

R e g a r d i n g t h e e x t e r n a l c o r r e s p o n d e n c e , t h e s o f t w a r e i n c l u d e d e l e m e n t s t h a t f a c i l i t a t e d t h e

m a n i p u l a t i o n o f t h e e n v i r o n m e n t ( to o p e n a n d c l o se w i n d o w s a n d d o o r s ; t o w a l k a r o u n d t h e r o o m ,

i .e ., t h e p a t i e n t a c t e d ) . A l l th e s e e l e m e n t s a l lo w e d t h e p a t i e n t t o e x p e r i e n c e t h e c o n s e q u e n c e s t h a t

h e r a c t i o n s h a d i n t h e v i r tu a l e n v i r o n m e n t . H e r v e r b a l r e p o r t s a b o u t t h e w a l l a n d i ts n o i s e

s u g g e s t e d a h i g h d e g re e o f r e a l is m a n d i m m e r s i o n .

H o w e v e r , t h e r e a r e s o m e l i m i t a t i o n s t o V R t r e a t m e n t . F i r s t , i t i s n e c e s s a r y t o c o n t i n u e

e n l a r g i n g t h e f i e ld o f a p p l i c a t i o n s o f V R a n d t o c h e c k t h e i r e f f e c ti v e n e s s f o r o t h e r



C . B o t e l la e t a l. / B e h a v i o u r R e s e a r c h a n d T h e r a p y 3 6 ( 1 9 9 8 ) 2 3 9 - 2 4 6 2 4 5

p s y c h o l o g i c a l d i s o r d e r s . S e c o n d , c o n t r o l l e d g r o u p s t u d i e s w i t h c l i n i c a l p a t i e n t s a n d l o n g e r

f o l l o w - u p p e r i o d s a r e n e e d e d . O b v i o u s l y , d u e t o t h e n o v e l t y o f t h e t o p ic , t h e p u b l i s h e d s t u d i e s

o n l y o f f e r p r e - t r e a tm e n t v s . p o s t -t r e a t m e n t d a t a a n d t h e y d o n o t i n f o r m o n e a b o u t t h e s ta b i li ty

o f t h e i m p r o v e m e n t , p o s t - t h e r a p y p r o g r e ss e s , r e l ap s e s, e t c. T h i r d , t h e m o s t i m p o r t a n t g a p i s

t h e a b s e n c e o f c o m p a r i s o n s b e t w e e n t h e V R e f fe c t iv e n e s s a n d t h e t r a d it io n a l e x p o s u r e

t r e a t m e n t s a n d a l s o s h o r t f o l l o w - u p p e r i o d s . L a s t , b u t n o t l e a s t , i t i s n e c e s s a r y t o p r o v i d e a

p s y c h o l o g i c a l m o d e l t h a t s e r v e s a s a t h e o r e t i c a l f r a m e w o r k t o o r g a n i z e t h e r e s u l t s a n d g u i d e

f u t u r e r e s e a r c h . C a r l i n e t a l . ( 1 9 9 7 ) w e r e a l r e a d y c o n c e r n e d w i t h t h e s e t o p i c s a n d i d e n t i f i e d t h e

i m p o r t a n c e o f t h e S s ' se n s e o f p r e s e n c e, t h e i m m e r s i v e e f f ec t , t h e a b s o r p t i o n , a n d t h e

i n d i v i d u a l d i f f e r e n c e s i n v o l v e d a s i s s u e s f o r f u t u r e r e s e a r c h . W e b e l i e v e t h a t B r i c k m a n ' s m o d e l

c a n b e a u s e f u l f i r s t s t e p i n t h e f o u n d a t i o n o f a t h e o r e t i c a l f r a m e w o r k .

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