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Influence of perceptual cues and conceptual information on the activation and reduction of claustrophobic fear
Abstract
Background:
Fear reactions in phobic patients can be activated by specific perceptual cues (C) or by conceptual fear-related information (I). An earlier study with spider phobic participants documented that perceptual stimuli are particularly potent to trigger fear responses. Because fear of spiders is activated by very circumscribed stimuli, we set out to investigate whether another phobia with more contextual fear-elicitation (i.e., a situational phobia) would yield similar patterns. Thus, we investigate the two paths of fear activation (cues vs. information) and fear reduction during exposure in claustrophobic patients.
Method:
Forty-eight claustrophobic patients and 48 healthy control participants were randomly assigned to one of three virtual reality exposure conditions: C, I, or a combination of both (CI). Exposure lasted 5 min and was repeated 4 times. Self-report and physiological reactions were assessed.
Results:
Claustrophobic patients experienced more initial self-reported fear when confronted with fear-relevant perceptual cues than conceptual information, when the perceptual cues were combined with conceptual information there was no significant enhancement. Furthermore, fear habituated more in the perceptual condition. For the physiological parameters, groups differed and in claustrophobic patients heart rate decreased differently in the conditions.
Limitations:
Longer exposure duration and long-term effects of the manipulation were not investigated.
Conclusion:
We found similar patterns in a situational phobia as compared to a specific-cue related phobia (animal type). Thus, once more this highlights the central role of visual cues in phobic fear and the potential of virtual reality for conducting exposure therapy.
... In anxiety disorders, all studies used CBT, but otherwise, the literature was also highly heterogeneous, which prevented the authors from undertaking a meta-analysis [36]. Interestingly, the included studies were consistent in showing declines in cortisol over the course of CBT for generalised anxiety disorder [43][44][45][46][47][48][49][50]. The only Biomedicines 2022, 10, 1361 5 of 15 study published since the systematic review [31] investigated social anxiety disorder and confirmed an earlier null-finding regarding changes of cortisol during CBT [45]. ...
... Few studies have attempted to determine whether cortisol varies as a consequence of therapeutic interventions. Interestingly, confronting patients with phobic stimuli has generally not been found to elicit a significant cortisol response [27,44,45,48]. A notable exception is a recent study in social anxiety disorder, which observed significant increases in cortisol within exposure sessions; however, these increases appeared to be driven by less than a third of the patients [31]. ...
... Hormone Cortisol Phobias: Low levels during exposure predict worse outcomes [27,[31][32][33][34][35] Social anxiety disorder: Low levels predict greater fear during exposure [33] Generalised anxiety disorder: Levels decrease over treatment [43][44][45][46][47][48][49][50] Social anxiety disorder: No change [31,45] Phobias: No change with exposure [27,31,44,45,48] Oxytocin Phobias: High levels predict worse outcomes [67] Social anxiety disorder: No effects on outcomes, but high levels predict better evaluation of appearance and speech performance [66] --- ...
The questions of for whom and why psychotherapy is effective have been the focus of five decades of research. Most of this knowledge is based on self-report measures. Following the biopsychosocial model of mental disorders, this article explores the potential of hormones in answering these questions. The literature on cortisol, oxytocin, and oestradiol in psychotherapy was systematically searched, focusing on (a) baseline hormonal predictors of who may benefit from psychotherapy and (b) hormonal changes as indicators of therapeutic change. The search was limited to depression and anxiety disorders. In sum, the findings show that, of all three hormones, the role of cortisol is most established and that both cortisol and oxytocin are implicated in psychotherapy, although a causal role is still waiting to be demonstrated. Moreover, there is a differential role of hormones in the psychotherapy of depression versus anxiety. The directions of research mapped in this article may elucidate how psychotherapy can be selected to match patients’ endocrine states and how hormonal levels can be manipulated to improve outcomes.
... Gerçekleştirilen uygulamaların amacı hastalığın getirdiği semptomları azaltmak ve kişilerin hastalık durumlarını ortadan kaldırmaya yardımcı olarak yaşam kalitesini arttırmaktır. Literatürde yer alan çalışmalar gösteriyor ki sanal gerçeklik ve artırılmış gerçeklik uygulamalarının otizmli kişilerde sosyal beceriler, biliş ve işleyiş durumunu geliştirdiği ve uygulanabilir olduğu [7,10,11,12,13], dikkat eksikliği ve hiperaktivite bozukluğu olan kişilerde dikkat eksikliği durumunda iyileşme gözlendiği [8], fobi durumunda sıklıkla sanal gerçeklik gözlüklerinin tercih edildiği görülmekte olup uygulamalara bağlı olarak kişilerin korku ve anksiyete durumlarında azalma olduğu [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] görülmektedir. Diğer mental bozukluk durumlarında ise kişilerin günlük aktivitelerini daha kolay yapabilmelerine, yaşam kalitesini artırdığı yapılan çalışmalar ile ortaya koyulmuştur [35,38,48]. ...
... EKG verileri ve solunum parametreleri değerlendirildiğinde gerçekleştirilen sanal ortamın kişilerin EKG ve solunum düzeyleri ortam deneyimi esnasında normal düzeyde kalmıştır. Sonuçta; gerçekleştirilen sistemin kapalı alan korkusu üzerindeki etkisini Anova yöntemi ile ortaya koymuşlardır[20].Schweizer vd. (2017) anksiyete durumu olan 269 kişi çalışmalarına dahil etmişlerdir. ...
In this study, studies conducted in the last 10 years in psychiatric disorders with virtual reality and augmented reality application were examined. Studies done so far; The psychiatric disorder studied, the equipment used, the number of people participating in the study, the database in which the study was scanned, and the results of the studies were evaluated according to the criteria. Studies using disease-specific questionnaires include 30% of all studies. In some studies, it is seen that physiological parameters are also used. Studies using physiological parameters correspond to only 10% of all studies. The practices carried out are to reduce the symptoms brought by the disease and to increase the quality of life by helping to eliminate the disease conditions of the people. Approximately 77% of the studies were carried out in the field of virtual reality and 23% in the field of augmented reality. Based on the articles examined within the scope of the study, some deficiencies in virtual reality and/or augmented reality applications in psychiatric diseases were identified. For example, whether the applications made have a disturbing effect on the users should be determined by using the SSQ questionnaire. In addition, the auditory parameters as well as the visual parameters that make up the virtual environment should be used effectively in this process. It has been observed that among the studies in the literature, the positive or negative effects of auditory parameters on users are not mentioned. It is considered that it will be beneficial for studies to examine the effect of auditory elements in the use of virtual reality environment.
... Lastly, it is essential to underscore that while this study is primarily centered around the exploration of ludic and narrative features, we acknowledge the indispensable role of perceptual cues, or perceptual immersion, in the context of exposure therapy. Research has shown that perceptual cues are fundamental in inducing higher fear activation and facilitating greater fear habituation when compared to conceptual cues [90]. Therefore, the utilization of non-perceptual cues should not be regarded as a replacement for their perceptual counterparts. ...
In the context of therapeutic exposure to phobias, virtual reality (VR) offers innovative ways to motivate patients to confront their fears, an opportunity not feasible in traditional non-digital settings. This systematic literature review explores the utilization of narratives and digital games in this context, focusing on identifying the most common ludic and narrative immersion features employed in studies dedicated to animal phobias. Via a search on the Scopus and Web of Science scientific databases, twenty-nine studies were selected for in-depth analysis. The primary objective was to evaluate the presence of ludic and narrative elements in each study to understand their immersive potential across both dimensions. Findings suggest that ludic elements are more commonly used than narrative elements, which are notably scarce, and the exploration of the emotional dimension of narrative immersion is limited. An essential takeaway is that features fostering narrative immersion are invariably linked to the ludic dimension, often functioning as secondary components. This study provides a guiding framework for developing therapeutic interventions in VR, emphasizing the incorporation of ludic and narrative aspects. Additionally, it identifies untapped research opportunities, particularly the integration of autonomous narratives that are less reliant on ludic elements.
... Following the above-mentioned review of Böhnlein et al [10], important behavioral factors might have been missing, such as sufficient variation of context, which is a necessary success factor of ET. Other studies make use of rather simple settings to induce claustrophobic fears (eg, a closed box [41] or a room with a sudden fire), which might trigger confounding fears, in addition to claustrophobia [42]. The experience of narrow space in reality is not only influenced by the size of a room but also by the presence of other people, such as in crowded places or supermarkets. ...
... Following the above-mentioned review of Böhnlein et al [10], important behavioral factors might have been missing, such as sufficient variation of context, which is a necessary success factor of ET. Other studies make use of rather simple settings to induce claustrophobic fears (eg, a closed box [41] or a room with a sudden fire), which might trigger confounding fears, in addition to claustrophobia [42]. The experience of narrow space in reality is not only influenced by the size of a room but also by the presence of other people, such as in crowded places or supermarkets. ...
Background
The effectiveness of virtual reality exposure (VRE) in the treatment of anxiety disorders is well established. Several psychological mechanisms of VRE have been identified, whereby both emotional processing and the sense of presence play a key role. However, there are only few studies that contribute to our knowledge of examples of implementation in the case of VRE for claustrophobia based on patients' experiences and the perspective of therapists.
Objective
This study asks for key elements of a VRE app that are necessary for effective exposure for people with claustrophobic symptoms.
Methods
A mixed methods design was applied in which patients (n=15) and therapeutic experts (n=15) tested a VRE intervention of an elevator ride at 5 intensity levels. Intensity was varied by elevator size, duration of the elevator ride, and presence of virtual humans. Quantitative measures examined self-reported presence with the Igroup Presence Questionnaire (IPQ) ranging from 0 to 6 and 15 Likert-scaled evaluation items that had been developed for the purpose of this study, ranging from 1 to 5. In both measures, higher scores indicate higher levels of presence or agreement. Think-aloud protocols of the patients and semistructured interviews posttreatment of all participants were conducted to gain in-depth perspectives on emotional processes.
Results
The intervention induced a feeling of presence in patients and experts, posttreatment scores showed a high IPQ presence score (mean 3.84, SD 0.88), with its subscores IPQ spatial presence (mean 4.53, SD 1.06), IPQ involvement (mean 3.83, SD 1.22), and IPQ experienced realism (mean 2.75, SD 1.02). Patients preferred a setting in the presence of a therapist (mean 4.13, SD 0.83) more than the experts did (mean 3.33, SD 1.54). Think-aloud protocols of the patients revealed that presence and anxiety both were achieved. Qualitative interviews of patients and experts uncovered 8 topics: feelings and emotions, personal story, telepresence, potential therapeutic effects, barriers, conditions and requirements, future prospects, and realization. The intensity levels were felt to appropriately increase in challenge, with ambivalent results regarding the final level. Virtual humans contributed to feelings of fear.
Conclusions
Key elements of a VRE app for claustrophobic symptoms should include variation of intensity by adding challenging cues in order to evoke presence and anxiety. Virtual humans are a suitable possibility to make the intervention realistic and to provide a sense of closeness; however, some of the fears might then be related to symptoms of social phobia or agoraphobia. Patients may need the physical presence of a therapist, though not all of them share this view. A higher degree of sophistication in the intensity levels is needed to deliver targeted help for specific symptoms of anxiety.
... As previous work introduced, social anxiety is thought to be more cognitive in nature [70,130,131,145] compared to other specific anxiety disorders, which are based in the interaction with either certain animals [24,149] or physical aspects of the world, such as height or space [47,126,128]: Cognitive models of social anxiety [37,70,71,145] depict this anxiety as a reaction to a mismatch between the individual's cognitive self-image, and the perceived expectations of the surrounding social context [70]. Socially-anxious individuals tend to overestimate the expectations of social observers and fear that they will not satisfy these high standards [72,73]; biased by previous 'failures', they are quick to judge that a social interaction or performance in front of others will go poorly [29]. ...
The treatment of social anxiety through digital exposure therapy is challenging due to the cognitive properties of social anxiety-individuals need to be fully engaged in the task and feel themselves represented in the social situation; however, avatar customization has been shown to increase both engagement and social presence. In this paper, we harness techniques used in commercial games, and investigate how customizing self-representation in a novel digital exposure task for social anxiety influences the experience of social threat. In an online experiment with 200 participants, participants either customized their avatar or were assigned a predefined avatar. Participants then controlled the avatar through a virtual shop, where they had to solve a math problem, while a simulated audience within the virtual world observed them and negatively judged their performance. Our findings show that we can stimulate the fear of evaluation by others in our task, that fear is driven primarily by trait social anxiety, and that this relationship is strengthened for people higher in trait social anxiety. We provide new insights into the effects of customization in a novel therapeutic context, and embed the discussion of avatar customization into related work in social anxiety and human-computer interaction. ?
... VR is useful for exposure therapy because it allows delivering realistic experiences while providing control over the stimuli. Previous research suggests that exposure therapy in VR might be effective for the treatment of a least three types of phobias: social phobia (Shiban et al., 2015), claustrophobia (Shiban et al., 2016), and spider-phobia (Peperkorn et al., 2014). ...
A cluster of research in Affective Computing suggests that it is possible to infer some characteristics of users’ affective states by analyzing their electrophysiological activity in real-time. However, it is not clear how to use the information extracted from electrophysiological signals to create visual representations of the affective states of Virtual Reality (VR) users. Visualization of users’ affective states in VR can lead to biofeedback therapies for mental health care. Understanding how to visualize affective states in VR requires an interdisciplinary approach that integrates psychology, electrophysiology, and audio-visual design. Therefore, this review aims to integrate previous studies from these fields to understand how to develop virtual environments that can automatically create visual representations of users’ affective states. The manuscript addresses this challenge in four sections: First, theories related to emotion and affect are summarized. Second, evidence suggesting that visual and sound cues tend to be associated with affective states are discussed. Third, some of the available methods for assessing affect are described. The fourth and final section contains five practical considerations for the development of virtual reality environments for affect visualization.
... Heart rate, skin conductivity, or the respiration rate are often used to quantify anxiety reactions to stimuli that can be related to a phobia. Common examples for this are public speaking situations (Kothgassner et al., 2016;Kahlon et al., 2019), standing on elevated places (Gonzalez et al., 2016;Ramdhani et al., 2019), confrontations with spiders (Hildebrandt et al., 2016;Mertens et al., 2019), being locked up in a confined space (Shiban et al., 2016b;Tsai et al., 2018), or reliving a warscenario Maples-Keller et al., 2019). ...
Measurements of physiological parameters provide an objective, often non-intrusive, and (at least semi-)automatic evaluation and utilization of user behavior. In addition, specific hardware devices of Virtual Reality (VR) often ship with built-in sensors, i.e. eye-tracking and movements sensors. Hence, the combination of physiological measurements and VR applications seems promising. Several approaches have investigated the applicability and benefits of this combination for various fields of applications. However, the range of possible application fields, coupled with potentially useful and beneficial physiological parameters, types of sensor, target variables and factors, and analysis approaches and techniques is manifold. This article provides a systematic overview and an extensive state-of-the-art review of the usage of physiological measurements in VR. We identified 1,119 works that make use of physiological measurements in VR. Within these, we identified 32 approaches that focus on the classification of characteristics of experience, common in VR applications. The first part of this review categorizes the 1,119 works by field of application, i.e. therapy, training, entertainment, and communication and interaction, as well as by the specific target factors and variables measured by the physiological parameters. An additional category summarizes general VR approaches applicable to all specific fields of application since they target typical VR qualities. In the second part of this review, we analyze the target factors and variables regarding the respective methods used for an automatic analysis and, potentially, classification. For example, we highlight which measurement setups have been proven to be sensitive enough to distinguish different levels of arousal, valence, anxiety, stress, or cognitive workload in the virtual realm. This work may prove useful for all researchers wanting to use physiological data in VR and who want to have a good overview of prior approaches taken, their benefits and potential drawbacks.
... Although both conditions are phobias (one of spiders; the other of an environment), they are essentially different (Hofmann et al., 2009;Loken et al., 2014). Shiban et al. (2016) found that, as in Peperkorn et al. (2014), individuals exhibited greater fear in response to perceptual cues alone than to conceptual cues alone. However, combining conceptual and perceptual cues did not result in a significant increase in fear response. ...
Learned fear can be generalized through both perceptual and conceptual information. This study investigated how perceptual and conceptual similarities influence this generalization process. Twenty-three healthy volunteers completed a fear-generalization test as brain activity was recorded in the form of event-related potentials (ERPs). Participants were exposed to a de novo fear acquisition paradigm with four categories of conditioned stimuli (CS): two conceptual cues (animals and furniture); and two perceptual cues (blue and purple shapes). Animals (C+) and purple shapes (P+) were paired with the unconditioned stimulus (US), whereas furniture (C-) and blue shapes (P-) never were. The generalized stimuli were thus blue animals (C+P+, determined danger), blue furniture (C-P+, perceptual danger), purple animals (C+P-, conceptual danger), and purple furniture (C-P-, determined safe). We found that perceptual cues elicited larger fear responses and shorter reaction times than did conceptual cues during fear acquisition. This suggests that a perceptually related pathway might evoke greater fear than a conceptually based route. During generalization, participants were more afraid of C+ exemplars than of C- exemplars. Furthermore, C+ trials elicited greater N400 amplitudes. Thus, participants appear able to use conceptually based cues to infer the value of the current stimuli. Additionally, compared with C+ exemplars, we found an enhanced late positive potential effect in response to C- exemplars, which seems to reflect a late inhibitory process and might index safety learning. These findings may offer new insights into the pathological mechanism of anxiety disorders.
... Similarly, VR technologies can be useful for the treatment of mental disorders associated with emotions. Particularly for treating anxiety disorders (Peperkorn et al., 2014;Shiban et al., 2016). But there are some mental disorders related to emotions that cannot be treated using the VR-based therapies that are currently available. ...
A cluster of research in Human-Computer Interaction (HCI) suggests that it is possible to infer some characteristics of users' mental states by analyzing electrophysiological responses in real-time. However, it is not clear how to use the information extracted from electrophysiological signals to create visual representations of the emotional states of Virtual Reality (VR) users. Visualization of users' emotions in VR can lead to biofeedback therapies for training emotion self-regulation. Understanding how to visualize emotions in VR requires an interdisciplinary approach that integrates disciplines such as psychology, electrophysiology, and audiovisual design. Therefore, this review aims to integrate previous studies from these fields to understand how to develop virtual environments that can automatically create visual representations of users' emotional states. This manuscript addresses this challenge in three sections: First, theories related to emotion and affect are compared. Second, evidence suggesting that specific visual and sound cues tend to be associated with particular emotions are discussed. And third, some of the available methods for assessing emotions are described.
... 8 Similarly, a recent study examined claustrophobic fear using VR. 9 Participants' anxiety ratings were highest when they perceived themselves to be in a virtual small closet with a closed door and knew that the closet they were actually in had a closed door. Anxiety was next highest when the virtual door was closed, even when the actual door was open. ...
Hoarding disorder is characterized by difficulty discarding objects and excessive clutter. The relationship between hoarding and claustrophobia, reactions to severely cluttered spaces, and clutter preferences are all areas that are yet to be investigated. The present study used a novel virtual reality (VR) platform to examine these domains. Two groups (i.e., with hoarding disorder, n = 36; without hoarding disorder, n = 40) similar in age and gender were recruited from the community. There were no differences in subjective or physiological reactivity to increasing VR clutter levels. The hoarding group reported a preference for slightly more cluttered VR rooms; however, they also reported higher claustrophobic fear. Results from this research advance our understanding of the relationship between hoarding symptoms and subjective experiences of clutter and offer implications for future VR research and treatment initiatives.
... Finally, a very interesting group of studies were brought forth by Shiban and colleagues [73][74][75][76] shedding light on the contextual factors that determine the efficacy of VRET. In particular, some of these studies [75,77,78] revealed that presenting multiple contexts increments the efficacy of the VRET for spider phobia and claustrophobia. ...
The principal aim to this chapter is to present the latest ideas in virtual reality (VR), some of which have already been applied to the field of anxiety disorders, and others are still pending to be materialized. More than 20 years ago, VR emerged as an exposure tool in order to provide patients and therapists with more appealing ways of delivering a technique that was undoubtedly effective but also rejected and thus underused. Throughout these years, many improvements were achieved. The first section of the chapter describes those improvements, both considering the research progresses and the applications in the real world. In a second part, our main interest is to expand the discussion of the new applications of VR beyond its already known role as an exposure tool. In particular, VR is enabling the materialization of numerous ideas that were previously confined to a merely philosophical discussion in the field of cognitive sciences. That is, VR has the enormous potential of providing feasible ways to explore nonclassical ways of cognition, such as embodied and situated information processing. Despite the fact that many of these developments are not fully developed, and not specifically designed for anxiety disorders, we want to introduce these new ideas in a context in which VR is experiencing an enormous transformation.
... Previous studies have found that the fear reaction decreases with less resemblance to the conditioned stimulus, reporting generalization gradients ranging approximately between 20 % and 80 % of similarity ( , Ahrens et al., 2016Holt et al., 2014;Lissek et al., 2008. That not all triggers of a fear concept are created equal has been also shown in differential responding to visual or conceptual cues of phobic situations (Diemer, Alpers, Peperkorn, Shiban, & Mühlberger, 2015;Peperkorn, Alpers, & Mühlberger, 2014;Shiban, Peperkorn, Alpers, Pauli, & Mühlberger, 2016). ...
Fear generalization is thought to be an important mechanism in the acquisition and maintenance of anxiety disorders. Previous studies have investigated fear generalization within one sensory modality - mainly within the visual domain. However, a growing body of evidence shows that emotional information is processed in more than one sensory modality. Based on network theories, we expected that fear may also generalize from stimuli in one sensory modality to another. To test our hypothesis, 42 participants underwent a differential conditioning paradigm, during which pictures were either presented with (vCS+) or without (vCS-) an aversive electric stimulus. After the acquisition phase, generalization was tested in the crossmodal group (n = 21) by presenting sounds which were semantically congruent to the visual vCS+ (i.e., the aGS+) or the vCS- (i.e., the aGS-). As a control, the unimodal group (n = 21) saw the pictures again. For the crossmodal group, we could show that US expectancy ratings generalized from conditioned pictures (vCS+) to semantically related sounds (aGS+). Moreover, when the vCS+ was presented during extinction, fear of the aGS+ extinguished, whereas extinction training with the aGS+ was found to be less effective for the vCS+. The findings are relevant for crossmodal fear acquisition and exposure therapy.
... Craske et al. (1991) varied the participant's control over the length of an exposure and found no influence on the success of treatment. Shiban et al. (2016) showed that specific perceptual cues (i.e. presenting pictures of a closed door to claustrophobic participants) lead to better success of ET (measured by physiological parameters) than fear-related conceptual information (i.e. ...
Although Exposure Therapy (ET) is the first-line treatment of Specific Phobia (SP), there is no clear consensus on which factors influence its success, and thus on how to conduct it most efficiently. This review summarizes the current state of research regarding this topic. N = 111 studies were in accordance with our eligibility criteria: participants had at least symptoms of SP, the intervention was ET and the study investigated a factor influencing its success. Best evidence for positive effects was found for low trait anxiety, high motivation and high self-efficacy before the ET, high cortisol levels and heart rate variation, evoking disgust additionally to anxiety, avoiding relaxation, focusing on cognitive changes, context variation, sleep, and memory-enhancing drugs. These factors may be conceptualized as modulating different aspects of learning as suggested in current models of ET that focus on inhibitory learning mechanisms. Limitations lie in the great heterogeneity concerning operationalization of factors and success. Based on these findings, we make suggestions for improvements in ET conduction and which factors should be researched in the future.
... [SAD]), acrophobia [43,46] (fear of heights), agoraphobia [44,45] (fear of entering open or crowded places), aviophobia [47] (fear of flying), arachnophobia [3] (fear of spiders), and claustrophobia [48] (fear of confined spaces). Many of the IVR environments or activities were personalized for the specific patient, highlighting the benefit of using technology such as IVR for exposure therapy [2,3,49,42,[44][45]46]. ...
Background
Immersive virtual reality (IVR) presents new possibilities for application in health care. Health care professionals can now immerse their patients in environments to achieve exposure to a specific scene or experience, evoke targeted emotional responses, inspire, or distract from an experience occurring in reality.
Objective
This review aimed to identify patient-focused applications for head-mounted IVR for acute treatment of health conditions and determine the technical specifications of the systems used.
Methods
A systematic review was conducted by searching medical and engineering peer-reviewed literature databases in 2018. The databases included PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Association for Computing Machinery, Institute of Electrical and Electronics Engineers, Scopus, and Web of Science. Search terms relating to health and IVR were used. To be included, studies had to investigate the effectiveness of IVR for acute treatment of a specific health condition. IVR was defined as a head-mounted platform that provides virtual and auditory immersion for the participant and includes a minimum of 3 degrees of orientation tracking. Once identified, data were extracted from articles and aggregated in a narrative review format.
Results
A total of 58 studies were conducted in 19 countries. The studies reported IVR use for 5 main clinical areas: neurological and development (n=10), pain reduction through distraction (n=20), exposure therapy for phobias (n=9), psychological applications (n=14), and others (n=5). Studies were primarily feasibility studies exploring systems and general user acceptance (n=29) and efficacy studies testing clinical effect (n=28).
Conclusions
IVR has a promising future in health care, both in research and commercial realms. As many of the studies examined are still exploring the feasibility of IVR for acute treatment of health conditions, evidence for the effectiveness of IVR is still developing.
... VRET goes well with the emotional processing theory proposed by Foa andKozak (1986a) (Foa andKozak, 1986b), which suggests that, after being confronted with feared stimuli, the fear network is activated and can be modified by incorporating new, incompatible information into the network (Parsons and Rizzo, 2008). Furthermore, VRET puts special emphasis on perceptual cues, which have been shown to play a major role in phobic fear (Shiban et al., 2016). ...
Fear is an emotion that serves as a driving factor in how organisms move through the world. In this review, we discuss the current understandings of the subjective experience of fear and the related biological processes involved in fear learning and memory. We first provide an overview of fear learning and memory in humans and animal models, encompassing the neurocircuitry and molecular mechanisms, the influence of genetic and environmental factors, and how fear learning paradigms have contributed to treatments for fear-related disorders, such as posttraumatic stress disorder. Current treatments as well as novel strategies, such as targeting the perisynaptic environment and use of virtual reality, are addressed. We review research on the subjective experience of fear and the role of autobiographical memory in fear-related disorders. We also discuss the gaps in our understanding of fear learning and memory, and the degree of consensus in the field. Lastly, the development of linguistic tools for assessments and treatment of fear learning and memory disorders is discussed.
... On the other hand, In spite of the feeling of being in a real environment, patients can easily overcome to their fear due to sense of presence in the safe and attractive environment. [9][10][11][12][13] Some of the reported studies about the treatment of Claustrophobia using VR technology are shown in Table 1. In each of them, different game environments have been designed and evaluated that the positive results of these studies can verify the success of using VR technology in the treatment process of Claustrophobia. ...
Background:
Claustrophobia or fear of closed spaces is the most common of phobias that is typically categorized as an anxiety disorder. Different methods have been proposed for treatment of phobias that one of the most recent and successful of these methods is applying virtual reality (VR) technology and simulating computer-generated environment. In this regard, the purpose of this research is design and development of a software game called "Claustrophobia Game" for treatment of claustrophobia using VR.
Methods:
In the Claustrophobia Game project, two closed spaces, including an elevator and a magnetic resonance imaging (MRI) device, were designed and implemented in the form of a VR computer game. To design this game, environments and scenario of the game were prepared in collaboration with a psychiatrist expert. Implementation of the software game was developed in the unity three-dimensional (3D) game engine and the programming of it was done by the C# language. In addition, a personal computer and the Oculus Rift VR glasses were utilized for running and testing the Claustrophobia Game.
Results:
To evaluate, we tested the game by 33 participants (14 men, 19 women, average age 24.6 years). In this regard, the Claustrophobia Game was considered from two aspects: psychology and playability using two questionnaires. Statistical analysis of the obtained data by the Excel software showed that all playability factors were "good" performance. In addition, the mean of obvious anxiety was decreased after playing the game.
Conclusion:
The promising results demonstrate that the game has an appropriate performance and can help to treat the Claustrophobia.
... Additionally, a further study [75] explored the differential role of perceptual versus conceptual cues (fear-related information) in fear activation/reduction in claustrophobia and spider phobia. Results showed that perceptual cues produced higher fear activation and greater fear habituation. ...
This review is designed to systematically examine the available evidence about virtual reality exposure therapy’s (VRET) efficacy for phobias, critically describe some of the most important challenges in the field and discuss possible directions. Evidence reveals that virtual reality (VR) is an effective treatment for phobias and useful for studying specific issues, such as pharmacological compounds and behavioral manipulations, that can enhance treatment outcomes. In addition, some variables, such as sense of presence in virtual environments, have a significant influence on outcomes, but further research is needed to better understand their role in therapeutic outcomes. We conclude that VR is a useful tool to improve exposure therapy and it can be a good option to analyze the processes and mechanisms involved in exposure therapy and the ways this strategy can be enhanced. In the coming years, there will be a significant expansion of VR in routine practice in clinical contexts.
... Another case series demonstrated efficacy of VRE for specific phobias in young people with autism spectrum disorder [53]. While not a clinical trial, a study on participants with claustrophobia demonstrated that perceptual information presented in a virtual environment (e.g., seeing a door close on you in a virtual room) effectively led to an increase in the activation of self-reported and physiological fear, suggested that VRE might be effective in this population as well [54]. While together these studies are promising, more controlled studies with larger sample sizes are needed to test VRE's effectiveness in a wider range of specific phobias. ...
Virtual reality (VR) refers to an advanced technological communication interface in which the user is actively participating in a computer-generated 3-dimensional virtual world that includes computer sensory input devices used to simulate real-world interactive experiences. VR has been used within psychiatric treatment for anxiety disorders, particularly specific phobias and post-traumatic stress disorder, given several advantages that VR provides for use within treatment for these disorders. Exposure therapy for anxiety disorder is grounded in fear-conditioning models, in which extinction learning involves the process through which conditioned fear responses decrease or are inhibited. The present review will provide an overview of extinction training and anxiety disorder treatment, advantages for using VR within extinction training, a review of the literature regarding the effectiveness of VR within exposure therapy for specific phobias and post-traumatic stress disorder, and limitations and future directions of the extant empirical literature.
... An economical and highly standardized possibility to investigate emotional reactions is the use of virtual reality (VR), which has become a well-established research method and has proven its ability to induce ecologically valid emotions in participants with specific phobia (Mühlberger et al., 2007a;Diemer et al., 2014). Interestingly, it has been shown that perceptual cues induce more self-reported fear in phobic participants than the knowledge of the presence of a real phobic animal or situation not seen by the participants (Peperkorn et al., 2014;Shiban et al., 2016). Notable evidence for the possibility to induce not only phobic, but also psychosocial stress in VR has been found in two studies by Hemmeter et al. (2005) as well as Bullinger et al. (2005). ...
The Trier Social Stress Test (TSST) is considered a reliable paradigm for inducing psychosocial stress. Virtual reality (VR) has successfully been applied to ensure a greater degree of efficiency and standardization in the TSST. Studies using the TSST in VR (VR-TSST) have reported significant stress reactions, with subjective and peripheral physiological reactions comparable to those in response to the in vivo TSST and with lower cortisol reactions. The current study examined whether an additional virtual competitive factor triggers larger stress responses than a standard VR-TSST. Forty-five male participants were randomly assigned to either in vivo TSST, VR-TSST (VR) or VR-TSST with a virtual competitor (VR +). A significant increase of self-reported stress, electrodermal activity, and heart rate indicated a pronounced stress reaction with no differences between groups. For salivary cortisol, however, responder rates differed significantly between groups, with in vivo participants showing overall higher response rates (86%) than participants of both VR groups (VR: 33%, VR +: 47%). In contrast, participants of both VR groups judged the task significantly more challenging than did in vivo TSST participants. In sum, our results indicate successful stress induction in all experimental conditions, and a marked dissociation of salivary cortisol levels on the one hand, and the physiological and psychological stress reactions on the other hand. The competitive scenario did not significantly enhance stress reactions. VR technology may serve as a standardized tool for inducing social stress in experimental settings, but further research is needed to clarify why the stress reaction as assessed by cortisol differs from peripheral and subjective stress reactions in VR.
... Yet 3 patients in group B reported acoustic awareness who could continue with their scans. Claustrophobia, being a situational phobia, has been extensively studied by clinical psychologists who have highlighted the central role of perceptual cues from vision in triggering phobic fear [15]. Perhaps then, it is mindless to chase the end point of fear already triggered but to prevent it by altering the visual perception of Fig. 1 Demonstrating the image quality for grade 2 (a), grade 3 (b), and grade 4 (c). ...
Study objective:
To determine the efficacy of sedation with dexmedetomidine compared to propofol for claustrophobic adults undergoing magnetic resonance imaging (MRI) in our institution.
Design:
Randomized, prospective, double-blinded study.
Setting:
University-based tertiary referral center.
Patients:
Thirty claustrophobic adults with American Society of Anesthesiologists physical status I and II who were planned for MRI.
Interventions:
Patients were randomly assigned to target-controlled infusion propofol or dexmedetomidine loading followed by maintenance dose for procedural sedation.
Measurements and main results:
The primary end point was adequate reduction in patient anxiety levels to allow successful completion of the MRI sequence. Both methods of sedation adequately reduced anxiety levels in visual analog scale scores and Spielberger Strait Test Anxiety Inventory (P<.001). Dexmedetomidine required a longer time to achieve anxiolysis, 7.36minutes (SD, 2.59), and required increasing maintenance dose to induce sleep compared to 10.71minutes (SD, 4.63) for propofol. In terms of image quality, 2 patients (16.67%) in the dexmedetomidine group were satisfactory, whereas all with propofol were graded as good to excellent. Adverse effects were seen in patients sedated with dexmedetomidine with number needed to harm 8 for hypotension and 15 for bradycardia compared to none recorded in the propofol arm. There was no significant difference in patient satisfaction scores or home readiness after the MRI.
Conclusions:
Both dexmedetomidine and propofol can effectively reduce anxiety levels of claustrophobic adults undergoing MRI, but dexmedetomidine takes longer to achieve adequate anxiolysis and sleep and may have an effect on image quality. Hypotension and bradycardia are common adverse effects observed with dexmedetomidine.
... In this context, virtual reality (VR) has proven useful as a means of investigating emotional processes, and as a new medium of exposure therapy for anxiety disorders (Mühlberger and Pauli, 2011;Diemer et al., 2015). The advantage of VR technology in the investigation of emotional reactions is that perceptual and conceptual information can be easily separated (Peperkorn et al., 2014;Shiban et al., 2016). Still, studies investigating the effects of tactile fear cues in VR are rare. ...
Embodiment (i.e., the involvement of a bodily representation) is thought to be relevant in emotional experiences. Virtual reality (VR) is a capable means of activating phobic fear in patients. The representation of the patient’s body (e.g., the right hand) in VR enhances immersion and increases presence, but its effect on phobic fear is still unknown. We analyzed the influence of the presentation of the participant’s hand in VR on presence and fear responses in 32 women with spider phobia and 32 matched controls. Participants sat in front of a table with an acrylic glass container within reaching distance. During the experiment this setup was concealed by a head-mounted display (HMD). The VR scenario presented via HMD showed the same setup, i.e., a table with an acrylic glass container. Participants were randomly assigned to one of two experimental groups. In one group, fear responses were triggered by fear-relevant visual input in VR (virtual spider in the virtual acrylic glass container), while information about a real but unseen neutral control animal (living snake in the acrylic glass container) was given. The second group received fear-relevant information of the real but unseen situation (living spider in the acrylic glass container), but visual input was kept neutral VR (virtual snake in the virtual acrylic glass container). Participants were instructed to touch the acrylic glass container with their right hand in 20 consecutive trials. Visibility of the hand was varied randomly in a within-subjects design. We found for all participants that visibility of the participant’s hand increased presence independently of the fear trigger. However, in patients, the influence of the virtual hand on fear depended on the fear trigger. When fear was triggered perceptually, i.e., by a virtual spider, the virtual hand increased fear. When fear was triggered by information about a real spider, the virtual hand had no effect on fear. Our results shed light on the significance of different fear triggers (visual, conceptual) in interaction with body representations.
Background. Virtual reality (VR) has been effectively used in the treatment of many mental health disorders.However, significant gaps exist in the literature. There is no treatment framework for researchers to use whendeveloping new VR treatments. One recommended treatment across a range of diagnoses, which may be suitablefor use in VR treatments, is Cognitive Behavioural Therapy (CBT). The aim of this systematic review is to investigateCBT treatment methods that utilize VR to treat mental health disorders.
Objectives. To investigate how CBT has been used in VR to treat mental health disorders and to report onthe treatment characteristics (number of sessions, duration, and frequency) that are linked to effective andineffective trials.
Methods. Studies were included if patients had a mental health diagnosis and their treatment included immersiveVR technology and CBT principles. Data were extracted in relation to treatment characteristics and outcomes,and analysed using narrative synthesis.
Results. Ninety-three studies were analysed. Exposure-based VR treatments were mainly used to treat anxietyrelated disorders. Treatments generally consisted of eight sessions, once a week for approximately one hour.VR treatments were commonly equal to or more effective than traditional face-to-face methods. No specifictreatment characteristics were linked to this effectiveness.
Conclusion. The number, frequency and duration of the VR treatment sessions identified in this review, couldbe used as a treatment framework by researchers and clinicians. This could potentially save researchers timeand money when developing new interventions.
Background
Virtual reality (VR) has been investigated as a medium for exposure therapy of anxiety disorders for 20 years. Various meta-analyses have provided convincing evidence of the therapeutic efficacy of exposure therapy in VR.
Objective
In recent years VR technology and its applications have considerably improved. Therefore, the current state of the art of VR exposure therapy is presented.
Material and methods
This article provides a narrative review of current research on VR exposure therapy for anxiety disorders and major directions of development in this area.
Results
After an almost exclusive focus on specific phobias in the early days, research on more complex anxiety disorders (particularly on social anxiety disorder) is increasing. In addition, VR has become established as an experimental method to probe psychopathological processes and to elucidate the mechanism of action of (VR) exposure therapy.
Conclusion
There is still a need for more research into VR exposure therapy, especially in complex anxiety disorders (e. g. panic disorder, agoraphobia and social anxiety disorder) and trauma-related disorders. Furthermore, VR has become established as a research tool. The rapid technological development gives reason to expect a continuing increase in VR research, in clinical as well as basic research.
Dysregulations of the hypothalamus-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS), two of the most prominent stress-responsive systems, have been associated with the development and maintenance of various mental disorders. It has been suggested that these alterations might normalize in the course of psychotherapeutic interventions. We conducted a comprehensive review of psychotherapeutic intervention effects on HPA axis and ANS regulation in adult samples with mental disorders. We searched four databases for psychotherapeutic intervention studies with mentally ill patient samples, assessing cortisol and/or alpha-amylase before and after treatment. Study quality and confounder consideration within biomarker assessment were examined. Twenty-five studies were included. Psychotherapeutic interventions and biomarker assessment methodology varied substantially between studies. Accordingly, meta-analytical computations were deemed unfeasible. Study characteristics especially regarding cortisol and alpha-amylase assessment and analysis procedures were comprehensively reviewed. Study quality and biomarker confounder consideration ratings were mostly moderate to strong. Based on the results, we provide recommendations regarding intervention design and biomarker assessment methodology to increase comparability of psychotherapeutic treatment effects in future studies.
JMIR Serious Games. 2018 Jul 6;6(3):e14
[Background:]
eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move.
[Objective:]
In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health.
[Methods:]
We compiled a table of 82 studies that made use of head-mounted devices in their interventions.
[Results:]
Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist.
[Conclusions:]
Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment.
When systematic research on phobias began, fears related to specific objects or situations were still called “simple phobias”
(see Marks, 1969), a term that misleadingly implied that these phobias were of low severity. In fact, specific phobias can
incur serious life impairment, in the range of other mental disorders (Becker et al., 2007). Since the introduction of DSM-IV
(American Psychiatric Association, 1994), they are listed by the preferable term specific phobias (see Hofmann, Alpers, &
Pauli, 2009).
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual's responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
The common approach to the multiplicity problem calls for controlling the familywise error rate (FWER). This approach, though, has faults, and we point out a few. A different approach to problems of multiple significance testing is presented. It calls for controlling the expected proportion of falsely rejected hypotheses – the false discovery rate. This error rate is equivalent to the FWER when all hypotheses are true but is smaller otherwise. Therefore, in problems where the control of the false discovery rate rather than that of the FWER is desired, there is potential for a gain in power. A simple sequential Bonferroni-type procedure is proved to control the false discovery rate for independent test statistics, and a simulation study shows that the gain in power is substantial. The use of the new procedure and the appropriateness of the criterion are illustrated with examples.
This study was designed to determine the effectiveness of Virtual Reality (VR) exposure in the case of a patient with a diagnosis of two specific phobias (claustrophobia and storms) and panic disorder with agoraphobia. The treatment consisted of eight, individual, VR-graded exposure sessions designed specifically to treat claustrophobia. We obtained data at pretreatment, posttreatment, and 3-month follow-up on several clinical measures. Results point out the effectiveness of the VR procedure for the treatment of claustrophobia. An important change appeared in all measures after treatment completion. We also observed a generalization of improvement from claustrophobic situations to the other specific phobic and agoraphobic situations that were not treated. We can conclude that VR exposure was effective in reducing fear in closed spaces, in increasing self-efficacy in claustrophobic situations, and in improving other problems not specifically treated. Moreover, changes were maintained at 3 months after treatment.
A comprehensive assessment of fear or anxiety requires measurement of both self-report and physiological responses. Respiratory abnormalities have been rarely examined during real-life exposure, although they are an integral part of fear. Twenty-one women with a specific driving phobia and 17 nonphobic women were psychophysiologically monitored during 2 highway-driving sessions; phobic women completed an additional session. Respiratory movements, end-tidal partial pressure of carbon dioxide, an electrocardiogram, skin conductance, and skin temperature were recorded. Phobic patients differed from control participants both physiologically and experientially before, during, and after exposure. Effect size during exposure was large for the authors' measure of hyperventilation. Discriminant analysis indicated that multiple physiological measures contributed nonredundant information and correctly classified 95% of phobic and control participants. Thus, selected respiratory and autonomic measures are valid diagnostic and therapeutic outcome criteria for this situational phobia.
An overall assessment of phobic fear requires not only a verbal self-report of fear but also an assessment of behavioral and physiological responses. Virtual reality can be used to simulate realistic (phobic) situations and therefore should be useful for inducing emotions in a controlled, standardized way. Verbal and physiological fear reactions were examined in 15 highly tunnel-fearful and 15 matched control participants in 3 virtual driving scenarios: an open environment, a partially open tunnel (gallery), and a closed tunnel. Highly tunnel-fearful participants were characterized by elevated fear responses specifically during tunnel drives as reflected in verbal fear ratings, heart rate reactions, and startle responses. Heart rate and fear ratings differentiated highly tunnel-fearful from control participants with an accuracy of 88% and 93%, respectively. Results indicate that virtual environments are valuable tools for the assessment of fear reactions and should be used in future experimental research.
Using the startle reflex methodology, researchers have shown that darkness, a phylogenetically relevant aversive context for humans, elicits fear responses. The present study replicated these findings in an ecologically valid situation, a virtual tunnel drive. Furthermore, the study focused on the question whether the darkness-enhanced startle response is modulated by an additional task involvement of the participants. Startle responses were assessed during virtual tunnel drives with darker and brighter sections. Participants once actively drove the virtual car and once passively sat in the car as a passenger. We found more negative feelings during darker parts of the virtual tunnel and during active driving. However, facilitated startle reactions in darkness were restricted to passive drives. Furthermore, correlation analyses revealed that darkness-enhanced startle modulation was more pronounced in participants with lower state anxiety. These results extend earlier findings in an experimental paradigm using ecologically valid virtual environments. Further research should use virtual reality paradigms to address context-dependent research questions.
The common approach to the multiplicity problem calls for controlling the familywise error rate (FWER). This approach, though, has faults, and we point out a few. A different approach to problems of multiple significance testing is presented. It calls for controlling the expected proportion of falsely rejected hypotheses — the false discovery rate. This error rate is equivalent to the FWER when all hypotheses are true but is smaller otherwise. Therefore, in problems where the control of the false discovery rate rather than that of the FWER is desired, there is potential for a gain in power. A simple sequential Bonferronitype procedure is proved to control the false discovery rate for independent test statistics, and a simulation study shows that the gain in power is substantial. The use of the new procedure and the appropriateness of the criterion are illustrated with examples.
Panic and phobic disorders are common and serious psychiatric conditions. The first part of this chapter presents the commonalities and unique characteristics of the diagnostic definitions, phenomenology, and associated features of panic disorder, agoraphobia, social anxiety disorder (social phobia), and specific phobia. The second part discusses some of the specific and common psychological factors that maintain the disorder, including panic attacks and dysfunctional cognitions. Biological models and psychological theories are discussed. It is concluded that the challenge of the upcoming new edition of the DSM is to address the complexities of the relationship between these diagnostic categories within the framework of a parsimonious classification system.
In phobic individuals, behavioral responses to phobia-related cues are facilitated and brain responses are augmented. It has rarely been investigated whether this preferential processing is accompanied by an altered conscious perception of phobia-related cues. We used binocular rivalry to investigate conscious perception of phobia-related cues in phobic individuals. 21 spider-phobic patients and 20 non-anxious control participants viewed pictures of spiders or flowers, each paired with a neutral pattern under conditions of binocular rivalry. Spider-phobic patients more often reported that they saw spider pictures as the first percept, and the total duration of seeing spider percepts was significantly longer in patients than in non-anxious participants. A second experiment was conducted to rule out that these differences were caused by different response criteria. Results support the validity of self-report in Experiment 1. In sum, predominance of phobia-related cues in binocular rivalry provides evidence that phobia-related cues gain preferential access to visual awareness in phobic individuals.
Although prior genetic studies of interview-assessed fears and phobias have shown that genetic factors predispose individuals to fears and phobias, they have been restricted to the DSM-III to DSM-IV aggregated subtypes of phobias rather than to individual fearful and phobic stimuli.
We examined the lifetime history of fears and/or phobias in response to 21 individual phobic stimuli in 4067 personally interviewed twins from same-sex pairs from the Virginia Adult Twin Study of Psychiatric and Substance Abuse Disorders (VATSPSUD). We performed multivariate statistical analyses using Mx and Mplus.
The best-fitting model for the 21 phobic stimuli included four genetic factors (agora-social-acrophobia, animal phobia, blood-injection-illness phobia and claustrophobia) and three environmental factors (agora-social-hospital phobia, animal phobia, and situational phobia).
This study provides the first view of the architecture of genetic and environmental risk factors for phobic disorders and their subtypes. The genetic factors of the phobias support the DSM-IV and DSM-5 constructs of animal and blood-injection-injury phobias but do not support the separation of agoraphobia from social phobia. The results also do not show a coherent genetic factor for the DSM-IV and DSM-5 situational phobia. Finally, the patterns of co-morbidity across individual fears and phobias produced by genetic and environmental influences differ appreciably.
Fear reactions in spider-phobic patients can be activated by specific perceptual cues or by conceptual fear-related information. Matching perceptual fear cues and fear-related information were expected to result in maximal fear responses, perceptual fear cues alone in less fear, and information alone in the weakest responses.
We used virtual reality to manipulate the available cues and information. Forty-eight phobic patients and 48 healthy participants were repeatedly exposed to either a perceptual cue, information, or a combination of both.
In conditions with a fear-relevant perceptual cue, phobic patients reported increased fear compared to the condition with information only. Across exposures trials, these reactions diminished. Skin conductance in phobic patients was significantly higher in the combined than in the cue or the information condition.
Perceptual cues are essential for phobic fear reactions in spider phobia. In combination with fear-relevant information, perceptual cues activate an intense and persistent fear reaction.
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The importance of individual response patterns in claustrophobic patients was examined in the present study. Thirty-four psychiatric outpatients with a phobia of enclosed spaces were assessed in a small test chamber. During the test their overt behavior was video-taped, heart-rate was measured continuously, and self-ratings of experienced anxiety were made at certain intervals. On the basis of their reactions in the test situation, the patients were divided into two groups showing different response patterns—behavioral and physiological reactors. Within each group the patients were randomly assigned to one behaviorally-focused method (exposure), one physiologically-focused method (applied relaxation) and a waiting-list control group. The patients were treated individually in eight sessions. The between-group comparisons showed that both exposure and applied relaxation were significantly better than the waiting-list condition. Furthermore, exposure yielded better results than applied relaxation for the behavioral reactors, while applied relaxation was better than exposure for the physiological reactors. The improvements were maintained at a follow-up assessment 14 months after the end of treatment. The results support the hypothesis that greater effects are achieved when the method used fits the patient's response pattern than when it does not.
Nineteen snake and spider phobic subjects underwent three exposure conditions and a baseline condition, each lasting six minutes. In the distracted condition, subjects listened for specific target words during audiotaped passages while continuing to observe the phobic stimulus. In the focused condition, subjects were prompted to focus on features of the phobic stimulus and their own emotional responses. Dependent measures included ongoing subjective report of fear and heart rate, retrospective fear ratings, and percent of time focused on the phobic stimulus and emotional responses. Subjective fear ratings increased over the six-minute focused exposure, in comparison to stability of fear levels during distracted and natural exposure. Heart rate did not differ between conditions. Possible treatment and theoretical implications are described, including the natural tendency for phobics to counter an initial attentional shift towards phobic stimuli with secondary cognitive avoidance strategies.
The aim of this study was to determine the effectiveness of virtual reality (VR) exposure in the treatment of claustrophobic fear. We evaluated the intervention following a controlled, multiple-baseline design across 4 participants with claustrophobic fear who sought psychological help in our anxiety disorders clinic. The treatment consisted of 8 individual VR graded exposure sessions. Data were obtained at pretreatment, posttreatment, and 3-month follow-up on several clinical measures: Behavioral Avoidance Test, Self-Efficacy Toward Closed Spaces, Problem-Related Impairment Questionnaire, Beck Depression Inventory (Beck, 1978), and Anxiety Sensitivity Index (Peterson & Reiss, 1992). Results support the effectiveness of the VR procedure for the treatment of claustrophobic fear. An important change appeared in all measures after treatment completion. It can be concluded that VR exposure was effective in reducing fear and avoidance in closed spaces and in increasing self-efficacy in claustrophobic situations. Moreover, changes were maintained at 3-month follow-up.
Stress and stress-related health impairments are major problems in human life and elucidating the biological pathways linking stress and disease is of substantial importance. However, the identification of mechanisms underlying a dysregulation of major components of the stress response system is, particularly in humans, a very challenging task. Salivary cortisol responses to diverse acute challenge paradigms show large intra- and interindividual variability. In order to uncover mechanisms mediating stress-related disorders and to potentially develop new therapeutic strategies, an extensive phenotyping of HPA axis stress responses is essential. Such a research agenda depends on substantial knowledge of moderating and intervening variables that affect cortisol responses to different stressors and stimuli. The aim of this report is, therefore, to provide a comprehensive summary of important determinants of, in particular, human salivary cortisol responses to different kinds of laboratory stimuli including acute psychosocial stress as well as pharmacological provocation procedures. This overview demonstrates the role of age and gender, endogenous and exogenous sex steroid levels, pregnancy, lactation and breast-feeding, smoking, coffee and alcohol consumption as well as dietary energy supply in salivary cortisol responses to acute stress. Furthermore, it briefly summarizes current knowledge of the role of genetic factors and methodological issues in terms of habituation to repeated psychosocial stress exposures and time of testing as well as psychological factors, that have been shown to be associated with salivary cortisol responses like early life experiences, social factors, psychological interventions, personality as well as acute subjective-psychological stress responses and finally states of chronic stress and psychopathology.
A distinction is proposed between anxiety (frequency of symptom occurrence) and anxiety sensitivity (beliefs that anxiety experiences have negative implications). In Study 1, a newly-constructed Anxiety Sensitivity Index (ASI) was shown to have sound psychometric properties for each of two samples of college students. The important finding was that people who tend to endorse one negative implication for anxiety also tend to endorse other negative implications. In Study 2, the ASI was found to be especially associated with agoraphobia and generally associated with anxiety disorders. In Study 3, the ASI explained variance on the Fear Survey Schedule—II that was not explained by either the Taylor Manifest Anxiety Scale or a reliable Anxiety Frequency Checklist. In predicting the development of fears, and possibly other anxiety disorders, it may be more important to know what the person thinks will happen as a result of becoming anxious than how often the person actually experiences anxiety. Implications are discussed for competing views of the ‘fear of fear’.
It is argued that fear and avoidance can co-vary, vary inversely or vary independently. The consequences of this statement for therapeutic theory and practice are discussed. A critical comment on two-factor theory is followed by a discussion of two alternative theories, one proposed by Gray and the other by Herrnstein. Definitions of concordance, discordance, synchrony and desynchrony are offered.
Describes the development of the Agoraphobic Cognitions Questionnaire and the Body Sensations Questionnaire, companion measures for assessing aspects of fear of fear (panic attacks) in agoraphobics. The instruments were administered to 175 agoraphobics (mean age 37.64 yrs) and 43 controls (mean age 36.13 yrs) who were similar in sex and marital status to experimental Ss. Results show that the instruments were reliable and fared well on tests of discriminant and construct validity. It is concluded that these questionnaires are useful, inexpensive, and easily scored measures for clinical and research applications and fill a need for valid assessment of this dimension of agoraphobia. (22 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Forty-six patients fulfilling the DSM-IV criteria for claustrophobia were assessed with behavioral, physiological, and self-report measures. They were randomly assigned to four conditions: (1) one-session (E1); or (2) five-sessions of exposure (E5); (3) five-sessions of cognitive therapy (C5); and (4) Wait-list for 5 weeks. The first condition consisted of a single 3 h session of massed exposure, and condition 2 and 3 of 5 h of gradual treatment, which was done individually by very experienced therapists. The results showed that treatment was significantly better than the wait-list condition, and the three treatments did equally well with no differences between them. At post-treatment 79% of treatment patients vs 18% of the wait-list controls had improved to a clinically significant extent. When the three treatments were compared 80% in the E1-group, 81% in the E5-group, and 79% in the C5-group were clinically improved. At the 1 year follow-up the corresponding figures were 100%, 81%, and 93%, respectively. The implications of these results are discussed.
The content and psychometric properties of the Claustrophobia Questionnaire (CLQ) are described. An earlier version of the CLQ was developed to test the hypothesis that claustrophobia is comprised of two distinct but related fears--the fear of suffocation and the fear of restriction [J. Anxiety Disord. 7 (1993) 281.]. The scale was used to assess patients undergoing the magnetic resonance imaging (MRI) procedure [J. Behav. Med. 21 (1998) 255.] and in participants with panic disorder [J. Abnorm. Psychol. 105 (1996) 146; Taylor, S., Rachman, S., & Radomsky, A. S. (1996). The prediction of panic: a comparison of suffocation false alarm and cognitive theories. Unpublished data.]. On the basis of these studies, we decided to revise and shorten the CLQ, collect normative data, and provide information on the scale's predictive and discriminant validity as well as its internal consistency and test-retest reliability. This was done through a set of four interconnected studies that included psychometric analyses of undergraduate and community adult questionnaire responses and behavioural testing. Results indicate that the CLQ has good predictive and discriminant validity as well as good internal consistency and test-retest reliability. The CLQ appears to be a reliable and sensitive measure of claustrophobia and its component fears. We encourage the use of the CLQ in a variety of clinical and research applications. The scale is provided in this paper for public use.
This study was designed to assess the pCO(2) accuracy of portable mainstream (Tidal Wave, Novametrix; Propaq 106, Protocol) and sidestream capnometers (Capnocheck 8200, BCI; Capnocount mini, Weinmann; NPB-75, Nellcor Puritan Bennett; SC-210, Pryon) with respect to international standards and preclinical emergency conditions. Measurements were performed under temperature conditions of +22 degrees C and -20 degrees C using dry gas mixtures with different CO(2) concentrations (STPD) and in patients ventilated with pure oxygen (BTPS). Accuracy presented to be between +1% (Capnocheck) and +12% (Propaq) (STPD) and between -0.4% (Capnocheck) and +11% (Tidal Wave) (BTPS). The measurements were affected by low ambient temperature only in the NPB-75 (+15%). Our results indicate that portable quantitative capnometers are able to fulfill accuracy requirements as requested by international standards but can be affected by changing ambient temperatures.
This article provides a selective review and integration of the behavioral literature on Pavlovian extinction. The first part reviews evidence that extinction does not destroy the original learning, but instead generates new learning that is especially context-dependent. The second part examines insights provided by research on several related behavioral phenomena (the interference paradigms, conditioned inhibition, and inhibition despite reinforcement). The final part examines four potential causes of extinction: the discrimination of a new reinforcement rate, generalization decrement, response inhibition, and violation of a reinforcer expectation. The data are consistent with behavioral models that emphasize the role of generalization decrement and expectation violation, but would be more so if those models were expanded to better accommodate the finding that extinction involves a context-modulated form of inhibitory learning.
Extensive research on the hypothalamic-pituitary-adrenal (HPA) axis response to stress has not clarified whether that axis is activated by phobic anxiety. We addressed this issue by measuring cortisol in situational phobics during exposure treatment.
Salivary cortisol was measured in 11 driving phobics before and during three exposure sessions involving driving on crowded limited-access highways and compared with levels measured in 13 healthy controls before and during two sessions of driving on the same highways. For each subject, data collected in the same time period on a comparison nondriving day served as an individual baseline from which cortisol response scores were calculated.
Cortisol levels of driving phobics and controls did not differ on the comparison day. Phobics also had normal cortisol response scores on awakening on the mornings of the exposures but these were already increased 1 hour before coming to the treatment sessions. Phobics had significantly greater cortisol response scores during driving exposure and during quiet sitting periods before and afterward. These greater responses generally paralleled increases in self-reported anxiety. At the first exposure session, effect sizes for differences in cortisol response scores between the two groups were large. Initial exposure to driving in the first session evoked the largest responses.
The data demonstrate that the HPA axis can be strongly activated by exposure to, and anticipation of, a phobic situation.
Prevailing models of exposure therapy for phobias and anxiety disorders construe level of fear throughout exposure trials as an index of corrective learning. However, the evidence, reviewed herein, indicates that neither the degree by which fear reduces nor the ending fear level predict therapeutic outcome. Developments in the theory and science of fear extinction, and learning and memory, indicate that 'performance during training' is not commensurate with learning at the process level. Inhibitory learning is recognized as being central to extinction and access to secondary inhibitory associations is subject to influences such as context and time, rather than fear during extinction training. Strategies for enhancing inhibitory learning, and its retrieval over time and context, are reviewed along with their clinical implications for exposure therapy and directions for future research.
Fear is thought to facilitate the detection of threatening stimuli. Few studies have examined the effects of task-irrelevant phobic cues in search tasks that do not involve semantic categorization. In a combined reaction time and eye-tracking experiment we investigated whether peripheral visual cues capture initial attention and distract from the execution of goal-directed eye movements. Twenty-one spider-phobic patients and 21 control participants were instructed to search for a color singleton while ignoring task-irrelevant abrupt-onset distractors which contained either a small picture of a spider (phobic), a flower (non-phobic, but similar to spiders in shape), a mushroom (non-phobic, and not similar to spiders in shape), or no picture. As expected, patients' reaction times were longer on trials with spider distractors. However, eye movements revealed that this was not due to attentional capture by spider distractors; patients more often fixated on all distractors with pictures, but their reaction times were delayed by longer fixation durations on spider distractors. These data do not support automatic capture of attention by phobic cues but suggest that phobic patients fail to disengage attention from spiders.
The study examines whether self-reported fear and physiological activation are concordant when claustrophobic patients are exposed to small spaces, whether the measures change in synchrony for individual patients and whether initial activation of measures can predict the outcome of an exposure treatment. Ten patients with claustrophobia participated in six in-vivo exposure sessions with continuous monitoring of self-reported fear and their EKG. Partial pressure of carbon dioxide (pCO(2)), a measure of hyperventilation, was available in a subsample of patients. While evidence for concordance of self-reported fear and heart rate was limited, the measures changed synchronously within subjects. Most importantly, higher heart rate at the beginning of the first exposure session predicted better treatment outcome. Because self-reported fear turned out not to be a reliable predictor of the outcome, this is interpreted as evidence for the incremental validity of physiological measures of fear.
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