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This study explored whether virtual reality (VR) exposure therapy was effective in the treatment of spider phobia. We compared a treatment condition vs. a waiting list condition in a between group design with 23 participants. Participants in the VR treatment group received an average of four one-hour exposure therapy sessions. VR exposure was effective in treating spider phobia compared to a control condition as measured with a Fear of Spiders questionnaire, a Behavioural Avoidance Test (BAT), and severity ratings made by the clinician and an independent assessor. Eighty-three percent of patients in the VR treatment group showed clinically significant improvement compared with 0% in the waiting list group, and no patients dropped out. This study shows that VR exposure can be effective in the treatment of phobias.
Behaviour Research and Therapy 40 (2002) 983–993
Virtual reality in the treatment of spider phobia: a controlled
A. Garcia-Palacios
, H. Hoffman
b, c
, A. Carlin
, T.A. Furness III
C. Botella
Departamento Psicologia Basica Clinica y Psicobiologia, Universidad Jaume I, Campus Borriol, Ctra Borriol s/n,
12080 Castellon, Spain
Human Interface Technology Laboratory, Box 352142, 215 Fluke Hall, University of Washington, Seattle, WA
98195-2142, USA
Department of Psychology, University of Washington, Seattle, WA 98195-2142, USA
Accepted 1 July 2001
This study explored whether virtual reality (VR) exposure therapy was effective in the treatment of
spider phobia. We compared a treatment condition vs. a waiting list condition in a between group design
with 23 participants. Participants in the VR treatment group received an average of four one-hour exposure
therapy sessions. VR exposure was effective in treating spider phobia compared to a control condition as
measured with a Fear of Spiders questionnaire, a Behavioural Avoidance Test (BAT), and severity ratings
made by the clinician and an independent assessor. Eighty-three percent of patients in the VR treatment
group showed clinically significant improvement compared with 0% in the waiting list group, and no
patients dropped out. This study shows that VR exposure can be effective in the treatment of phobias.
2002 Elsevier Science Ltd. All rights reserved.
Keywords: Virtual reality; Exposure therapy; Spider phobia
1. Introduction
An estimated 10–11% of the US population experiences a specific phobia at some point in
their lives, (American Psychiatric Association, 1994; Magee, Eaton, Wittchen, McGonagle &
Kessler, 1996). Approximately 40% of specific phobias belong to the category of “bugs (including
* Corresponding author. Tel.: +34-964-729353; fax: +34-964-729350.
E-mail address: (A. Garcia-Palacios).
0005-7967/02/$ - see front matter 2002 Elsevier Science Ltd. All rights reserved.
PII: S0005-7967(01)00068-7
984 A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983–993
spiders), mice, snakes or bats(Chapman, 1997). Spider phobics characteristically display a per-
sistent fear of spiders, an immediate anxiety response upon exposure to a spider, and avoidance of
spiders. Phobics often recognize that their fear is excessive or unreasonable (American Psychiatric
Association, 1994). In fact, for some, fear of the irrational reaction they will have when encoun-
tering a spider (losing control, panic attack) is a major source of their anxiety. Consistent with
Rachmans theory (1976, 1977) about the acquisition of phobias, Ost and Hugdahl (1981) found
that the majority of phobics reported acquiring their fear via conditioning (58%). Others reported
instruction (e.g. by their parents) as the source of their phobia (10%), acquired their fear vicari-
ously (15%), or couldnt remember (10%).
In vivoexposure therapy has been used successfully with a wide range of phobias including
fear of spiders (Craske & Rowe, 1997; Marks, 1987; Ost, 1997) and is considered to be the
treatment of choice for specic phobias (Antony & Swinson, 2000; Marks, 1987; Mathews, 1978).
With in vivo therapy for spider phobia, patients gradually and systematically approach closer to
a live spider over a period of several one-hour sessions. Some researchers have had great success
treating spider phobics in an accelerated single massed three-hour in vivo exposure session, both
with individuals and group sessions (see Ost, 1997 for a review). However, the experience is
likely more distressing for the patients than multiple sessions distributed over a period of days,
weeks or months. In general, for patients motivated enough to seek therapy for their phobia,
single session in vivo exposure therapy has a high success rate (Ost, 1996), and fear reduction
tends to be long term, with low relapse rates. Imagery exposure therapy, having the patient
imagine situations involving spiders, can also be effective (Hecker, 1990), but is limited by the
fact that some patients have trouble imagining spiders, and/or the imagined spiders do not elicit
sufcient anxiety to be valuable.
Unfortunately, around 6085% of those aficted with specic phobias never seek treatment for
their problem (Agras, Sylvester, & Oliveau, 1969; Boyd et al., 1990; Magee et al., 1996). Many
phobics are probably too afraid of confronting the feared object or situation to seek therapy
(Marks, 1992). Now that researchers and therapists have succeeded in developing and testing
effective ways of treating phobias, new efforts are needed to increase the number of phobia
sufferers who seek treatment.
In a recent study, Garcia-Palacios, Hoffman, Kwong See, Tsai, & Botella (2001) surveyed a
total of 777 undergraduate students. Participants read a brief general description of how exposure
therapy works, and were asked about their willingness to get involved in two different ways of
applying the therapy to spider phobia, in vivo exposure or virtual reality (VR) exposure. Garcia
et al. found that people high in fear of spiders (over one SD above the sample mean on a fear
of spiders questionnaire) strongly preferred VR exposure treatment (81% in study 1 and 89% in
study 2) compared to in vivo exposure therapy. Furthermore, in study 2, only 8% of fearful
students said they would absolutely notbe willing to come in for three, one-hour VR exposure
therapy sessions, whereas 34% of fearful students said absolutely notto one massed three-hour
in vivo therapy session.
Immersive VR works as follows. The subject dons a VR Helmetthat positions two goggle
sized TV screens close to the users eyes. Each eye gets a slightly different image of the virtual
world. The image shown to the left eye is offset slightly from that seen by the right eye. The
brain fuses these two images into a single 3-D image, helping to give users the illusion that the
virtual environment has depth. Position tracking devices keep the computer informed of changes
985A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
in the users head and hand locations. The scenery in VR changes as the user moves his/her head
orientation (e.g. virtual objects in front of the user in VR get closer as the user, wearing his/her
VR helmet, leans forward in the real world). Any one of these techniques alone might be uncon-
vincing, but combined, they give users a uniquely compelling experience of being therein the
virtual world. The essence of immersive VR is the illusion it gives users that they are inside the
computer-generated environment, as if they are therein the virtual world. In the present study,
the place our patients visited was a virtual kitchen, and the virtual object they picked up was the
plump furry body of a virtual Guyana bird-eating tarantula.
To make VR more convincing, tactile augmentation can enhance the quality of the virtual
world. With this technique, real objects are used as props in the interaction with 3-D VR graphics
(Hoffman, 1998; Hoffman et al., 1996; Hoffman, Holander, Schroder, Rousseau, & Furness,
1998). Pilot studies and case reports suggest that VR exposure therapy can be an effective medium
for the reduction of specic phobias such as fear of heights (Rothbaum et al., 1995), fear of ying
(Hodges, Rothbaum, Watson, Kessler, & Opdyke, 1996), claustrophobia (Botella et al., 1998;
Botella, Ban
˜os, Villa, Perpin
`, & Garcia-Palacios, 2000) and spider phobia (Carlin, Hoffman, &
Weghorst, 1997). Recent controlled studies have shown that VR exposure therapy was as effective
as in vivo exposure to treat ying phobia (Rothbaum, Hodges, Smith, Lee, & Price, 2000) and
fear of heights (Emmelkamp et al., in press).
The present study is the rst controlled study to test whether immersive VR exposure therapy
is effective for treating spider phobia. We compared the effectiveness of VR exposure vs. a
waiting list condition. Practical implications of our ndings are discussed.
2. Method
2.1. Participants
Participants were recruited from different sources: (a) mass testing in an introductory Psy-
chology class; (b) through advertisements in the University newspaper and (c) from people who
contacted us requesting treatment for their fear of spiders. Participants from mass testing com-
pleted a fear of spiders questionnaire (Szymanski & ODonohue, 1995). Students scoring over
two standard deviation above the class mean in fear of spiders (i.e. a score greater than 97) were
invited to undergo exposure therapy for fear of spiders. These students received extra credit in
their class for participating. Thirty participants were invited. To participate in the study, subjects
had to meet the following criteria: (1) meet DSM-IV (American Psychiatric Association, 1994)
criteria of Specic Phobia, Animal Type (spiders) according to the judgement of two clinical
Psychologists, one of them, blind to the conditions of the study; (2) a minimum of one-year
duration of the phobia; (3) patient must not be able to remove the lid of a cage with a tarantula
prior to treatment, during the Behavioural Avoidance Test (BAT); (4) have no other psychiatric
problem in immediate need of treatment; (5) no current alcohol or drug dependence; (6) no severe
physical illness.
Twenty-three participants met the inclusion criteria and took part in the study. Of the thirty
persons invited to participate, four were excluded from the experiment because they did not meet
the DSM-IV criteria for Specic Phobia according to the judgement of the interviewer or of a
986 A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
blind clinician who made a diagnostic judgement after listening to the interviews. Three more
participants were excluded because they were able to remove the lid during the BAT.
The average age was 29.25 years (SD=10.79; range 1858). Most participants were female
(90.9%) and only 9.1% were male. The mean reported duration of their fear was 21 years
(SD=11.76; range 650 years). One participant had received previous psychological treatment for
fear of spiders without success.
2.2. Equipment
A Silicon Graphics
Octane MXE with Octane Channel Option (allowing stereo vision) coupled
with a relatively wide eld-of-view (60°diagonal) head mounted visual display
( V8 helmet was used to create an immersive, 3-D, interactive, com-
puter-simulated environment. A PolhemusFastrak position tracking system was used to measure
the position of the users head and hand position, and the location of the virtual spider. The
patients experienced SpiderWorld, a modied version of KitchenWorld
2.3. Measures
2.3.1. Anxiety Diagnostic Interview Schedule IV (ADIS-IV)
During this ADIS-IV (Di Nardo, Brown, & Barlow, 1994), the patient was asked about each
criteria of DSM-IV specic phobia, animal type (American Psychiatric Association, 1994). We
also obtained information on demographic and clinical variables: the duration of the problem,
severity of the phobia as perceived by the patient, former treatments, and presence of other
psychological or physical problems.
2.3.2. Fear of spiders questionnaire
This questionnaire (Szymanski & ODonohue, 1995) was chosen as a subjective measure of
the efcacy of VR treatment. Previous researchers have found this questionnaire to have excellent
split half reliability and internal consistency, good testretest consistency, convergent validity due
to its highly signicant correlations with a BAT (r=0.65, p0.001), and construct validity in its
ability to discriminate phobics from non-phobics as measured by a BAT (ODonohue & Szyman-
ski, 1993; Szymanski & ODonohue, 1995; see also Muris & Merckelbach, 1996). The question-
naire has 18 items rated on a 17 scale (1=does not apply to me, 7=very much applies to me)
about fear and avoidance regarding spiders.
2.3.3. Behavioural Avoidance Test (BAT)
The BAT is a popular objective measure of clinical progress in overcoming phobias. A large
spider (tarantula) was placed in a glass cage with a lid. The cage was placed on a table at the
far end of a room 5 m from the entrance. The patient was instructed to enter the room, walk up
to the cage and remove the lid. Participants were informed that the BAT was an objective measure
Silicon Graphics, Inc. 2011 N. Shoreline Blvd. Mountain View, CA 94043, USA,
Division Incorporated, 1400 Fashion Island Blvd, Suite 510, San Mateo, CA 94404,
987A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
of how afraid they were of spiders and not part of the therapy. During the test, the experimenter
remained just outside the door of the room to minimize the possible impact of his presence. When
the participants approached as close to the spider as they could, the distance in meters from the
participant to the spider was measured, and participants rated their anxiety using the subjective
units of discomfort scales (Wolpe, 1969). The distance measure was converted to a behavioural
score that ranged from 0 to 8; where 0=refuses to enter the room, 1=stops 5 m from the container,
2=stops 4 m from the container, 3=stops 3 m from the container, 4=stops 2 m from the container,
5=stops 1 m from the container, 6=stops close to the container, 7=touches the container,
8=removes the lid. After the BAT, the experimenter, who was blind to the experimental condition
to which the patient belonged, rated the severity of the patients phobia on a scale from 0 to 8;
where 0=free of symptoms and 8=extremely disabling.
2.3.4. Clinician rating
This scale was the same as that used by Ost, Stridh and Wolf (1998). The clinician rated the
severity of the patients phobia on a scale from 0 to 8 where 0=symptom free and 8=extremely
severe and disabling, all aspects of life affected.
2.3.5. Clinically significant improvement
We choose our criteria to decide when a patient had achieved a clinically signicant improve-
ment following Ost et al. (1998) criteria, based on the Jacobson, Follette, & Revenstorf (1984)
guidelines. To meet the criterion for a clinically signicant improvement in spider phobia, the
change from pre- to post-treatment must be statistically signicant and the post-test score must
be within the range of a normal sample or outside the range of the patient group, that is, M±2SD
in the direction of functionality.
BAT score (0–8): The change must be 2 points and the cut-off score 7 (touching the container).
BAT assessor rating of phobic severity (0–8): The change must be 2 points and the cut-off
score 4.
Clinician rating of phobic severity (0–8): The change must be 2 points and the cut-off score 4
Fear of spiders questionnaire: The score must be outside the range of the patient group, that
is, M±2SD in the direction of functionality. The mean was 98.65 and the standard deviation
was 15.73. The cut-off score was 67.
2.4. Procedure
During the pre-treatment assessment, participants were interviewed to determine if they met
criteria for specic phobia, animal type, spiders (DSM-IV, American Psychiatric Association,
1994) using the structured interview ADIS-IV (Di Nardo et al., 1994). These interviews were
We used two measures of severity, the assessor rating during the BAT and the clinician rating. It could be argued that those
measures are too similar. The reason for doing so was to control assessors bias. The measure during BAT was done by an independent
assessor, blind to the experimental conditions and the clinician rating was done by the clinicians who carried out the diagnostic
interviews and the treatments and who were aware of the experimental condition the participants belonged to.
988 A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
audiotaped and another clinician, blind to the study, made a diagnosis. Then patients completed
a questionnaire assessing their fear of spiders, and were given the BAT. The participants who
satised the entry criteria were randomly assigned to one of the two conditions: VR exposure
group or waiting list control group.
During the post-treatment assessment, participants were given the same measures as pre-treat-
ment except the diagnostic interview. Participants in the waiting list group went through the two
assessment sessions within one or two weeks with no treatments between assessments. Afterwards
they were offered treatment. The participants in the treatment group received several one-on-
one clinical VR exposure therapy sessions for treatment of spider phobia. Each session lasted
approximately one hour and participants completed all sessions and the post-treatment assessment
within two or three weeks of beginning treatment.
2.4.1. Treatment
Treatment consisted of a standardized exposure protocol delivered by two experienced clinical
psychologists trained in Experimental Psychology (authors A.G. and A.C.). The treatment was
composed of gradual exposure tasks. There was no xed number of sessions. We established a
criterion to dene the completion of treatment. To have completed treatment the patient must be
able to achieve a nal exposure goal, holding a big virtual spider with tactile feedback while
reporting low levels of anxiety. The average number of sessions to achieve this goal was four
and it ranged from 3 to 10. On the rst sessions, participants saw a virtual spider in a virtual
kitchen and approached as closely as they could using their 3-D wand to navigate through the
virtual world. The goal was to come within arms reach of the virtual spider. During the following
session/s, participants touched the virtual spider with their cyber hand (with no tactile feedback).
The virtual spider responded to being touched by eeing. Patients then picked up a virtual spider
vasewith their cyberhand. When they let go of the virtual vase, an animated spider with wiggly
legs drifted to the oor of the virtual kitchen accompanied by a brief sound effect from the movie
Psycho. Participants repeated this task until they reported little anxiety. During the last therapy
sessions, the participants were encouraged to touch the virtual spider image with their cyberhand.
Participants reached out their cyberhand and physically touched the visual image of the wiggly
legged virtual Guyana bird-eating tarantula. As the patients reached out with their cyberhand to
explore the virtual spider, their real hand explored the toy spider attached to a stationary Polhemus
position sensor. The virtual spider now felt furry and solid (Hoffman, 1998).
2.5. Results
2.5.1. Pre-treatment tests
No differences were found between the waiting list condition and the treatment condition at
pretreatment in demographic and clinical variables: age, t(19) =0.67, p0.05, NS, duration of
the fear, t(18) =0.89, p0.05, NS, and level of perceived impairment, t(21) =1.31, p0.05, NS.
The t-tests showed no signicant differences between the two groups with respect to the measures
of the behavioural avoidance test at pretreatment: avoidance, t(21) =1.71, p0.05, NS, level of
anxiety reported during the bat, t(21) =0.78, p0.05, NS, and independent assessor rating of
phobic severity on the bat, t(21) =0.78, p0.05, NS. With regard to other measures, no differences
between the two groups were found in the subjective measure of fear of spiders (FSQ) at pretreat-
989A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
ment, t(21) =0.39, p0.05, NS, nor in the clinician rating of phobic severity, t(21) =0.21,
p0.05, NS.
2.5.2. Pre-Post tests
We conducted a 2 (group) by 2 (time=pre- vs. post-treatment) repeated measures ANOVA for
each outcome measure to test the effectiveness of VR exposure. Means and standard deviations
at the pre- and post-test assessments are shown in Table 1. Score on the BAT For the BAT, the ANOVA regarding avoidance showed a signicant
Group effect, F(1,21)=17.10, p0.001, MSe=7.37, with an effect size of 0.45, a signicant Time
effect F(1,21)=25.25, p0.001, MSe=2.08, with an effect size of 0.55, and a signicant Group
by Time interaction F(1,21)=17.40, p0.001, MSe=2.08, with an effect size of 0.45. The interac-
tion indicates that the groups differed in amount of improvement. As shown in Table 1, the VR
exposure group showed greater improvement than the waiting list group. Anxiety during the BAT The mixed-model ANOVA showed no signicant Group effect,
F(1,21)=1.29, NS, with an effect size of 0.06, a signicant Time effect F(1,21)=18.23, p0.001,
MSe=284.79, with an effect size of 0.48, and a signicant Group by Time interaction
F(1,21)=5.99, p0.05, MSe=284.79, with an effect size of 0.23. The interaction indicates that
the VR treatment group showed signicantly greater reduction in anxiety than the control group.
Table 1
Mean and standard deviations for the outcome measures at pre- and post-treatment (note: VRE=Virtual Reality
Exposure; WL=Waiting List; BAT=Behavioural Avoidance Test)
VRE (N=12) WL (N=11)
Variable MSD MSD
BAT score
Pretreatment 3.08 2.19 1.54 2.12
Postreatment 7.00 2.29 1.90 2.07
BAT anxiety
Pretreatment 82.36 14.44 76.73 14.03
Postreatment 48.18 27.59 67.45 14.01
BAT assessor rating
Pretreatment 6.79 0.89 6.50 0.89
Postreatment 1.74 2.11 6.27 0.65
Fear of spider questionnaire
Pretreatment 97.42 17.51 100.00 14.25
Postreatment 57.42 19.07 97.09 13.44
Clinician rating
Pretreatment 6.08 1.24 6.18 0.98
Postreatment 2.42 1.68 5.91 0.94
990 A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993 Independent assessor rating of phobic severity on the BAT The ANOVA showed a
signicant Group effect, F(1,21)=22.23, p0.001, MSe=2.32, with an effect size of 0.51, a sig-
nicant Time effect F(1,21)=79.89, p0.001, MSe=1.00, with an effect size of 0.79, and a sig-
nicant Group by Time interaction F(1,21)=66.72, p0.001, MSe=1.00, with an effect size of
0.76. Again, these results revealed that the VR treatment group showed signicantly greater
reduction than the waiting list group in the severity perceived by an independent assessor on
the BAT. Fear of spiders questionnaire A mixed-model ANOVA regarding this measure showed
a signicant Group effect, F(1,21)=14.09, p0.001, MSe=363.68, with an effect size of 0.40, a
signicant Time effect (pre-treatment vs. post-treatment), F(1,21)=31.07, p0.001, MSe=170.07,
with an effect size of 0.60, and a signicant Group by Time interaction F(1,21)=23.21, p0.001,
MSe=170.07, with an effect size of 0.53. The interaction reveals that the amount of fear of spiders
reduction was not the same for each group. The treatment group achieved greater improvement
than the waiting list control group. Clinician rating of phobic severity The analysis showed a signicant Group effect,
F(1,21)=14.67, p0.001, MSe=2.52, with an effect size of 0.41, a signicant Time effect,
F(1,21)=69.67, p0.001, MSe=0.64, with an effect size of 0.77, and a signicant Group by Time
interaction F(1,21)=51.71, p0.001, MSe=0.64, with an effect size of 0.71. The interaction reveals
that the reduction in severity rated by the therapist was not the same for each group. The treatment
group achieved greater improvement than the waiting list control group. Clinically signicant improvement Eighty-three percent of the participants in the VR
exposure group achieved a clinically signicant improvement using strict criteria. None of the
participants in the waiting list group showed clinically signicant improvement on the post-test. Drop-out None of the participants refused treatment, and none of them dropped out
of the study.
3. Discussion
Using both objective and subjective measures of fear, VR exposure with tactile augmentation
signicantly reduced fear and avoidance of spiders after an average of four, one-hour VR therapy
sessions. This is the rst controlled study to demonstrate the effectiveness of VR exposure therapy
for treatment of fear of spiders.
VR exposure was more effective than a waiting list control condition in reducing the main
features of a specic phobia. Fear and avoidance were measured with a fear of spiders question-
naire, a BAT, and severity ratings made by the clinicians and an independent assessor. The VR
treatment group showed improvement on all measures, whereas the control group showed no
The change was not only statistically signicant, but also clinically signicant. Eighty-three
percent of the participants in the treatment condition met strict criteria of clinically improved and
991A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
none of the patients in the waiting list condition did so. Most of the patients in the VR group
achieved a signicant change (M±2SD in the direction of functionality) in important outcome
variables such as avoidance measured in the BAT, the fear of spiders questionnaire, and severity
ratings by an independent assessor and the therapist.
None of the participants who started the VR treatment dropped out. This result supports the
idea that VR exposure is an attractive technique for phobic sufferers that may help to increase
the number of phobics who complete treatment.
In the present study, desensitization to the virtual spider generalized to real spiders. After
treatment, participants were able to approach a large live tarantula on the BAT with low to moder-
ate levels of anxiety.
Despite these ndings we would like to address some of the limitations of our study. The
sample was carefully selected, but relatively small. Studies with larger samples are needed.
Another limitation is that we did not include a follow-up assessment (e.g. 6 months later).
Our results support our prediction that VR can be used to effectively treat a specic phobia.
However, why use VR when in vivo exposure therapy is so effective? VR gives the patient and
therapist the ability to control the feared object. For example, unlike a real spider, virtual spiders
obey commands, can be placed in various positions and orientations, and can be touched without
danger. VR allows the therapist to control how frightening the spider appears and allows patients
to confront fears that are not easily accessible. For example, in vivo exposure of fear of ying
can be an expensive project. Therapists report difculty with numerous logistic problems and
expenses, such as getting to the airport and renting a commercial jet for the purpose of treating
patients and having to buy airline tickets (Hodges et al., 1996). Condentiality is another problem-
atic issue for in vivo exposure sessions such as treating fear of heights in a hotel elevator, where
the public can see the patient getting treated. Another advantage of VR is the possibility of treating
residual fears, given the fact that VR can go beyond what a real situation would allow, making
overlearning easier to perform (Botella et al., 1998). VR provides a controlled and protected
environment that allows patients who were reluctant to start an exposure program more willing
to get involved in treatment (Garcia-Palacios et al., 2001). VR treatment is presently a relatively
expensive treatment, due to the additional equipment and software required. However, the price
of VR systems is dropping quickly and dramatically, largely because conventional desktop PC
systems are becoming powerful enough to handle the computational demands of real time VR
(Botella et al., 1999). Emmelkamp has reported results of a VR exposure treatment as effective
as an in vivo treatment for acrophobia using a conventional PC (Emmelkamp et al., in press).
Results of the present study indicate that VR exposure could offer an attractive alternative for
patients unwilling or unable to complete in vivo exposure therapy. VR exposure has potential as
a new medium for an old, well-established technique (graded exposure therapy). A medium that
makes exposure less aversive and more attractive to patients is likely to increase the proportion
of phobia sufferers who seek treatment. The high success rate of VR therapy found in the present
study, and its appeal to people with fear of spiders suggest that VR is a medium worthy of further
exploration for clinical applications.
992 A. Garcia-Palacios et al. / Behaviour Research and Therapy 40 (2002) 983993
Thanks to Ian Dillon and Silicon Graphics, Inc. for their invaluable equipment support, Division
Ltd for VR software, Ari Hollander ( and Duff Hendrickson
( for virtual spider programming and modelling, and
Ross Chambers for fundraising. The research presented in this paper was funded by Pla de Promo-
cio de la Investigacio, Fundacio Caixa Castello-Bancaixa 1999, 2000, the University of Wash-
ington Royalties Research Fund, the E.K. and Lillian F. Bishop Foundation, the Paul Allen Foun-
dation for Medical Research.
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... Researchers have applied VR in various settings, and some of them are summarized in Table 3 [Bhagat et al. 2016;Bouchlaghem et al. 2005;Carl et al. 2019;Chittaro and Sioni 2015;Crocetta et al. 2018;Dechant et al. 2017;Garcia-Palacios, Hoffman, Carlin, Furness and Botella 2002;Gebara et al. 2016;Gerardi et al. 2010;Hilfert and König 2016;Kim et al. 2009;Laver et al. 2015;Levy et al. 2016;Lindner et al. 2019;Manju et al. 2017;Maskey et al. 2014;Miloff et al. 2016;Molina et al. 2014;Motraghi et al. 2014;Mujber et al. 2004;Opriş et al. 2012;Ordaz et al. 2015;Parsons and Rizzo 2008;Ticknor 2018;Ticknor 2019;Valmaggia et al. 2016]. Furthermore, there has been much research interest in using VR to explore feedback strategies to provide social support in a VR environment for public speaking [Brundage and Hancock 2015;. ...
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Stress during public speaking is common and adversely affects performance and self-confidence. Extensive research has been carried out to develop various models to recognize emotional states. However, minimal research has been conducted to detect stress during public speaking in real time using voice analysis. In this context, the current review showed that the application of algorithms was not properly explored and helped identify the main obstacles in creating a suitable testing environment while accounting for current complexities and limitations. In this paper, we present our main idea and propose a stress detection computational algorithmic model that could be integrated into a Virtual Reality (VR) application to create an intelligent virtual audience for improving public speaking skills. The developed model, when integrated with VR, will be able to detect excessive stress in real time by analysing voice features correlated to physiological parameters indicative of stress and help users gradually control excessive stress and improve public speaking performance
... Other studies have reported similar effectiveness between VR and traditional therapies for the treatment of fear of flying, panic disorder with agoraphobia, social phobia, and arachnophobia 21 . Additionally, children with arachnophobia preferred exposure via VR over actual exposure 22 . In our study, we aimed to provide a feeling of control which may lead to the alleviation of tinnitus by allowing patients to manipulate and eliminate objects (VR avatars) which produced tinnitus sounds in a VR environment. ...
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Abstract Virtual reality (VR) has recently been used as a clinical treatment because it can efficiently simulate situations that are difficult to control in real-world settings. In our study, we assessed the potential of VR in patients with chronic subjective tinnitus. An evaluation of its clinical benefits was performed based on analyses of patient electroencephalograms (EEGs) and by questionnaire responses after 6–8 weeks of patient involvement in our VR-based alleviation program. Clinical trials were performed at a tertiary academic hospital. Nineteen patients (aged 33–64 years) who visited our hospital with chronic subjective tinnitus over 3 months were enrolled in the study. The intervention consisted of trashing the tinnitus avatar in VR. We expected that the patients would have the subjective feeling of controlling tinnitus through our intervention. The VR environment comprised four different sessions in four different settings: a bedroom, a living room, a restaurant, and a city street. We analyzed changes in the source activities of the prefrontal regions related to tinnitus in these patients using standardized low-resolution brain electromagnetic tomography. The Tinnitus Handicap Inventory (THI), the total score (from 50.11 to 44.21, P = 0.046) and the grade (from 3.16 to 2.79, P = 0.035) were significantly improved after the VR-based tinnitus treatment program (P
... Also, VRET does not require that live animals and insects are collected and stored (Reuterskiöld & Öst, 2012). VRET for spider phobia has shown good efficacy in randomizedcontrolled trials (Garcia-Palacios et al., 2002;Hoffman et al., 2003;Michaliszyn et al., 2010;Miloff et al., 2019;Minns et al., 2018;St-Jacques et al., 2010). In the most recent trial (Miloff et al., 2019), several authors of the present study randomly assigned 100 spider phobia patients to either IVET (OST type) or VRET (with low-cost hardware and an automated treatment format). ...
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Specific phobia can be treated successfully with exposure therapy. Although exposure therapy has strong effects on self-reported ratings and behavioral avoidance, effects on measures derived from electroencephalography (EEG) are scant and unclear. To fill this gap, spider-phobic individuals received either in-vivo or virtual reality exposure treatment. Patients were tested twice (one week before and after treatment), and control subjects once. In each session, EEG was recorded to spider pictures as well as other positive, negative, and neutral pictures. During EEG recording, participants performed a simple detection task while task-irrelevant pictures were shown in the background. The task was used to reduce potential confounding effects from shifts of attention. After the task, subjects were shown the pictures again and rated each in terms of their emotional reaction (arousal and pleasantness). The results showed that before treatment, patients rated spiders as more negative than did control subjects. Patients also showed elevated early posterior negativity (EPN) and late positive potential (LPP) to spiders. After treatment, the negative emotional ratings of spiders were substantially reduced. Critically, Bayesian analyses suggested that EPN and LPP were unaffected by treatment and that the treatment groups did not differ in their responses (EPN, LPP, and ratings). These findings suggest that the effects of in vivo and virtual reality exposure therapy are similar and that the initial stages of motivated attention (EPN and LPP) are unaffected by treatment.
... Furthermore, not only does it have a powerful impact on people's real life, but the benefits obtained from the treatment are maintained over time [25]. Even for specific phobias, such as acrophobia [26,27] arachnophobia [28,29] and fear of driving [30], VRE not only decreases time required for treatment but is found to be particularly effective for patients with whom in vivo treatment may not be safe or feasible. Moreover VR graded exposure therapy is a valid alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). ...
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The purpose of this review is to present some studies existing in the literature that show that patients that experience anxiety in real-life situations can obtain advantages through virtual reality, as alternative form of cognitive, emotional and behavioural exposition. After a brief introduction, we will proceed to an analysis of the scientific contributions concerning virtual reality-ba sed interventions. Google Scholar employed to search studies on this topic from 1992 through 2019. Studies were eligible if the article: (a) concerned subjects with anxiety disorders; (b) showed the effects of VR exposure therapy for anxiety treatment; (c) employed the use of immersive VR only, keeping out not-immersive VR; (d) was published in English; (e) referred to randomized controlled trials (RCTs) and case studies. Overall, eight studies met the eligibility criteria. The benefits of VR have been largely acknowledged and VRE is revealing effective resources in different fields of psychology and health-related disciplines. However, existing evidence is insufficient because of the paucity of studies and lack of high-quality research designs. In the future, studies may build upon these limitations to extend virtual reality-based interventions into clinical settings.
... For example, instead of an office desk in their real world, a player could be presented with a virtual sci-fi control deck that they could interact with physically. An increase in presence and immersion has been demonstrated in previous studies looking at passive haptics [12,15,22] and substitutional reality [9,30]. ...
Conference Paper
Virtual reality (VR) and augmented reality (AR) have continued to increase in popularity over the past decade. However, there are still issues with how much space is required for room-scale VR and experiences are still lacking from haptic feedback. We present LevelEd SR, a substitutional reality level design workflow that combines AR and VR systems and is built for consumer devices. The system enables passive haptics through the inclusion of physical objects from within a space into a virtual world. A validation study (17 participants) has produced quantitative data that suggests players benefit from passive haptics in entertainment VR games with an improved game experience and increased levels of presence. Including objects, such as real-world furniture that is paired with a digital proxy in the virtual world, also opens up more spaces to be used for room-scale VR. We evaluated the workflow and found that participants were accepting of the system, rating it positively using the System Usability Scale questionnaire and would want to use it again to experience substitutional reality.
... Future studies could investigate the infuence of perspective on risk-taking in VR for that purpose. When using VR scenes in exposure therapy sessions, decreasing embodiment could be an efective strategy to gradually increase exposure to an anxiety related stimulus [15]. Our work suggests that exposure experiences should begin in Out-of-Character embodiment and gradually move to Within-Character embodiment. ...
Conference Paper
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Modern games make creative use of First-and Third-person perspectives (FPP and TPP) to allow the player to explore virtual worlds. Traditionally, FPP and TPP perspectives are seen as distinct concepts. Yet, Virtual Reality (VR) allows for flexibility in choosing perspectives. We introduce the notion of a perspective continuum in VR, which is technically related to the camera position and conceptually to how users perceive their environment in VR. A perspective continuum enables adapting and manipulating the sense of agency and involvement in the virtual world. This flexibility of perspectives broadens the design space of VR experiences through deliberately manipulating perception. In a study, we explore users' attitudes, experiences and perceptions while controlling a virtual character from the two known perspectives. Statistical analysis of the empirical results shows the existence of a perspective continuum in VR. Our findings can be used to design experiences based on shifts of perception.
... The usage of VR for intergroup contact also allows researchers to measure and monitor changes in the intergroup interactions in real time [23]. VR has also increasingly been used in the field of mental health [24,25] to reduce anxiety, such as interaction with a virtual spider to help treat arachnophobia (fear of spiders) [26] and interaction with virtual humans to treat social anxiety disorder [27]. In addition, VR has been used to reduce the public stigma of schizophrenia [28][29][30]. ...
Background: Public stigma against depression contributes to low employment rates among individuals with depression. Contact-based educational (CBE) interventions have been shown to reduce this public stigma. Objective: We investigated the ability of our Virtual Reality Antistigma (VRAS) app developed for CBE interventions to reduce the stigma of depression. Methods: Sixteen medical students were recruited and randomized 1:1 to the intervention group, who used the VRAS app (VRAS group), and the control group, who watched a video on depression. The depression stigma score was assessed using the Depression Stigma Scale (DSS) and Attitudinal Social Distance (ASD) questionnaire at pre- and postintervention. Feasibility was assessed in both groups and usability was assessed only in the VRAS group after the intervention. A qualitative study was performed on the acquisition of knowledge about stigma in both groups based on participants' answers to open-ended questions and interviews after the intervention. Results: The feasibility score was significantly higher in the VRAS group (mean 5.63, SD 0.74) than in the control group (mean 3.88, SD 1.73; P=.03). However, no significant differences were apparent between the VRAS and control groups for the DSS (VRAS: mean 35.13, SD 5.30; control: mean 35.38, SD 4.50; P=.92) or ASD (VRAS: mean 12.25, SD 3.33; control: mean 11.25, SD 1.91; P=.92). Stigma scores tended to decrease; however, the stigma-reducing effects of the VRAS app were not significant for the DSS (pre: mean 33.00, SD 4.44; post: mean 35.13, SD 5.30; P=.12) or ASD (pre: mean 13.25, SD 3.92; post: mean 12.25, SD 3.33; P=.12). Qualitative analysis suggested that the VRAS app facilitated perspective-taking and promoted empathy toward the patient. Conclusions: The CBE intervention using virtual reality technology (VRAS app) was as effective as the video intervention. The results of the qualitative study suggested that the virtual reality intervention was able to promote perspective-taking and empathy toward patients. Trial registration: University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000043020;
... The current study investigates the possibility of inducing and detecting fear responses in VR-HMD using fNIRS. Specifically, we are interested in inducing and detecting a fear of heights response, which is one of the most prevailing types of human fear which can be reproduced in VR, alongside (Garcia-Palacios et al., 2002; de With et al. ...
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This Research Topic is composed of 11 accepted papers: seven dedicated to original research, a perspective, a mini review and two opinion pieces, and are dedicated to various themes and perspectives. These contributions address the multi-faceted nature of non-clinical BCIs, ranging from ethical ramifications of these neurotechnologies, applications to the arts, education, communication, wellbeing, and sports to the readiness of BCI deployment for gaming.
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Abstract Virtual reality has been used in psychotherapy efficiently to treat several psychological disorders, especially fobias in recent years. Therapists help their clients confront their fears systematically in a controlled environment created by computer. It is important for health professionals to define it in depth since it is considered to be a part of the future of clinical psychology. In this study virtual reality technologies and their uses are described, current virtual reality applications available for psychotherapy are reviewed, and lastly limitations and future of these applications are discussed. Öz Sanal Gerçeklik Terapileri psikoterapide özellikle fobiler olmak üzere pek çok rahatsızlığın tedavisi için son yıllarda etkili bir yöntem olarak kullanılmaya başlanmıştır. Bu yöntemle danışanların duyarsızlaşması gerçekleşene kadar bilgisayar tarafından oluşturulan kontrollü bir ortamda korkuları ile terapist eşliğinde sistematik bir şekilde yüzleştirilmeleri sağlanır. Klinik psikolojinin geleceğinin bir parçası olarak görüldüğü için sağlık profesyonelleri tarafından geniş bir şekilde tanımlanması önem arz etmektedir. Bu araştırmada sanal gerçeklik teknolojileri ve kullanım alanları tanımlandıktan sonra psikoterapi kapsamındaki mevcut sanal gerçeklik uygulamaları gözden geçirilmiş, son olarak sanal gerçeklik uygulamalarının sınırlılıkları ve geleceği tartışılmıştır
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Two groups of moderately snake phobic college students were given either imaginal or in vivo exposure treatment. The groups were compared on self-report and physiological measures of fear activation during exposure trials, as well as on within- and across-session habituation of fear responses. On these measures, as well as on treatment outcome, the two groups were found to be very similar. The results lend further support to the importance of the concept of emotional processing in understanding fear reduction processes. Differences in treatment procedure may be important only when one procedure facilitates emotional processing more than another.
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Experiment 1 explored the impact of physically touching a virtual object on how realistic the virtual environment (VE) seemed to the user. Subjects in a no touch group picked up a 3D virtual image of a kitchen plate in a VE, using a traditional 3D wand. See and touch subjects physically picked up a virtual plate possessing solidity and weight, using a technique called tactile augmentation. Afterwards, subjects made predictions about the properties of other virtual objects they saw but did not interact with in the VE. See and touch subjects predicted these objects would be more solid, heavier, and more likely to obey gravity than the no touch group. In Experiment 2 (a pilot study), subjects physically bit a chocolate bar in one condition, and imagined biting a chocolate bar in another condition. Subjects rated the event more fun and realistic when allowed to physically bite the chocolate bar. Results of the two experiments converge with a growing literature showing the value of adding physical qualities to virtual objects. This study is the first to empirically demonstrate the effectiveness of tactile augmentation as a simple, safe, inexpensive technique with large freedom of motion for adding physical texture, force feedback cues, smell and taste to virtual objects. Examples of practical applications are discussed.
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Fear of flying (FOF) affects an estimated 10-25% of the population. Patients with FOF (N = 49) were randomly assigned to virtual reality exposure (VRE) therapy, standard exposure (SE) therapy, or a wait-list (WL) control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane (VRE) or exposure to an actual airplane at the airport (SE). A posttreatment flight on a commercial airline measured participants' willingness to fly and anxiety during flight immediately after treatment. The results indicated that VRE and SE were both superior to WL, with no differences between VRE and SE. The gains observed in treatment were maintained at a 6-month follow up. By 6 months posttreatment, 93% of VRE participants and 93% of SE participants had flown. VRE therapy and SE therapy for treatment of FOF were unequivocally supported in this controlled study.
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The conditioning theory of fear-acquisition is outlined and the supporting evidence and arguments presented. It is argued that the theory lacks comprehensiveness and is also inadequate in other respects.Six arguments against acceptance of the theory are advanced. People fail to acquire fears in what are theoretically fear-evoking situations (e.g. air raids). It is difficult to produce conditioned fear reactions in human subjects in the laboratory. The theory rests on the untenable equipotentiality premise. The distribution of human fears is not consistent with the theory. Many phobic patients recount histories inconsistent with the theory. Lastly, fears can be acquired indirectly, contrary to the demands of the conditioning theory. It is suggested that fears can be acquired by three pathways: conditioning, vicarious exposures and by the transmission of information and instruction. Vicarious and informational transmission of fears can take place in the absence of direct contact with the fear stimuli.
This is the first case report to test the efficacy of computer-generated virtual reality (VR) for the treatment of acrophobia (fear of heights). The subject was a 19-year-old undergraduate student with a fear of heights, particularly of elevators. Twice weekly, sessions were conducted for 3 weeks, for a total of 5 sessions. Outcome was assessed on measures of anxiety, avoidance, attitude, distress, and included a behavioral avoidance test. VR graded exposure was successful in reducing fears of heights. VR graded exposure is proposed as a new medium for exposure therapy.
This comprehensive volume provides up-to-date information on the 3 main types of phobic disorder: panic disorder and agoraphobia, social phobia, and specific phobia. The book integrates current research findings with practical recommendations for diagnosis and treatment. For each disorder, clinicians will find guidelines for assessment, including diagnostic interviews, behavioral assessments, symptom diaries, and standardized self-report measures that are highly useful for differential diagnosis and treatment planning. The authors present flexible and detailed treatment protocols for each disorder that include session frequency and duration, sequencing of cognitive and behavioral strategies, bibliotherapy, homework, and monitoring forms for tracking patient progress. Basic principles of exposure-based treatment and social skills training and the most effective cognitive techniques are described, illuminated by sample therapist–patient dialogue and troubleshooting tips. A chapter on the most commonly used medications, side effects, issues related to dosage, and strategies for discontinuing medication is included. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The effectiveness of two hypothesized change mechanisms in cognitive therapy was investigated: logical analysis and empirical hypothesis testing. Thirty-eight spider phobics, as determined by performance on a behavioral avoidance test, were randomly assigned to either one of these two conditions or to a no-treatment control condition. Subjects participated in three group sessions. Outcome phobia questionnaire data suggested that both mechanisms produced desirable changes in a short period of time, with stronger evidence that logical analysis was superior to the control. Outcome from the behavior avoidance test and self-efficacy ratings failed to reach statistical significance but the trends were in the direction of positive change. Results are discussed in terms of the tripartite response dessynchrony hypothesis. Suggestions for future process research in cognitive therapy are provided.