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The present study compared the efficacy of virtual reality (VR) in virtuo exposure and in vivo exposure in the treatment of spider phobia. Two treatment conditions were compared to a waiting-list condition. A 3-month follow-up evaluation was conducted in order to assess the durability of the treatment effects. Participants were randomly assigned to the treatment groups. A total of 16 participants received the in virtuo treatment, and 16 received the in vivo treatment. The waiting-list condition included 11 participants. Participants received eight 1.5-hour treatment sessions. Efficacy was measured with the Fear of Spiders Questionnaire, the Spider Beliefs Questionnaire (SBQ-F), and a Behavioral Avoidance Test (BAT). In addition, a clinician administered the Structured Interview for DSM-IV to assess DSM-IV's criteria for specific phobia and severity. Clinical and statistically significant improvements were found for both groups. Differences in treatment groups were found on one of five measures of fear: greater improvement on the SBQ-F beliefs subscale was associated with in vivo exposure.
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A Randomized, Controlled Clinical Trial
of In Virtuo and In Vivo Exposure for Spider Phobia
David Michaliszyn, M.Ps.,
Andre´ Marchand, Ph.D.,
Ste´ phane Bouchard, Ph.D.,
Marc-Olivier Martel, B.Sc.,
and Joannie Poirier-Bisson, B.Sc.
The present study compared the efficacy of virtual reality (VR) in virtuo exposure and in vivo exposure in the
treatment of spider phobia. Two treatment conditions were compared to a waiting-list condition. A 3-month
follow-up evaluation was conducted in order to assess the durability of the treatment effects. Participants were
randomly assigned to the treatment groups. A total of 16 participants received the in virtuo treatment, and 16
received the in vivo treatment. The waiting-list condition included 11 participants. Participants received eight 1.5-
hour treatment sessions. Efficacy was measured with the Fear of Spiders Questionnaire, the Spider Beliefs
Questionnaire (SBQ-F), and a Behavioral Avoidance Test (BAT). In addition, a clinician administered the
Structured Interview for DSM-IV to assess DSM-IV’s criteria for specific phobia and severity. Clinical and
statistically significant improvements were found for both groups. Differences in treatment groups were found
on one of five measures of fear: greater improvement on the SBQ-F beliefs subscale was associated with in vivo
The efficacy of in vivo exposure in the treatment of
specific phobia has been empirically demonstrated, and
is currently considered the treatment of choice for this prob-
Research in this area has investigated the effectiveness
of different methods of exposure, and found that in vivo ex-
posure is generally more effective than imaginal exposure
treating specific phobias. Results from some studies that have
explored the optimal duration of treatment suggest that one
3-hour treatment session is as effective as shorter, multiple-
session treatment.
However, Rowe and Craske
better results after 1 month with multiple exposure sessions or
four sessions a week than with a 1-day 4-hour session. These
results suggest that gains can be maximized by spacing out
exposure over several days. It is additionally recommended
that the client be exposed to varied stimuli, such as different
types of spiders. The use of varied stimuli maximizes the
maintenance of gains and reduces the possibility that fears
will reemerge. Exposure in multiple contexts also protects
against relapse.
Virtual reality (VR) is a new tool of interest
for exposure, offering the possibility of optimal exposure
parameters in the treatment of spider phobia. However, it still
requires more empirical validation.
The effectiveness of VR exposure therapy (VRET), or
in virtuo exposure, has gained empirical support. The litera-
ture in this area indicates a 25% refusal and drop-out rate
(combined) for individuals offered conventional exposure
In the same direction, a survey has found that 76%
of respondents would prefer in virtuo exposure over tradi-
tional exposure therapy, and the refusal rate for in vivo expo-
sure (27%) was higher than the refusal rate for in virtuo
Further development of in virtuo exposure could be
an effective treatment for people who consult for phobias.
Moreover, this type of treatment could reduce the stigma
associated with traditional therapy and the reluctance often
associated with exposure.
In virtuo exposure has a number of advantages over con-
ventional therapy, such as: (a) greater control over phobo-
genic stimuli and thus greater accuracy in inducing anxiety,
Department of Psychology, Universite
´du Que
´bec a
´al, Montreal, Quebec, Canada.
Department of Psychology, Universite
´du Que
´bec a
´al, Centre de recherche Fernand-Se
´guin, Montreal, Quebec, Canada.
Department of Psychology, Universite
´du Que
´bec en Outaouais, Gatineau, Canada.
Department of Psychology, McGill University, Montreal, Quebec, Canada.
Volume 13, Number 6, 2010
ªMary Ann Liebert, Inc.
DOI: 10.1089=cyber.2009.0277
and the ability for the therapist to repeat exposure at will; (b)
limited unexpected events during exposure; (c) exposure to
fears that can be difficult to reproduce in vivo (e.g., fear of
flying, fear of storms) and reduction of costs (e.g., taking the
plane); (d) remaining in the clinician’s office during exposure
facilitates confidentiality; and (e) decreased maintenance and
associated costs required for animals (hygiene, food, etc.)
used for exposure.
In addition, research in this area suggests that in virtuo ex-
posure can be effective in the treatment of arachnophobia.
Garcia-Palacios et al.
found significant improvement in 23
patients treated with in virtuo exposure, in comparison to a
waiting-list condition. Using a Stroop task and heart-rate
measures, Co
´and Bouchard
demonstrated therapeutic
gains with 28 participants on a cognitive and physiological
level using in virtuo exposure. Further evidence of the effec-
tiveness of this type of treatment comes from Carlin et al.
Hoffman et al.
Both of these studies used ‘‘tactile augmen-
tation,’’ which consists of holding an artificial spider (taran-
tula) while visually perceiving a virtual spider. These studies
demonstrated efficacy of tactile augmentation. Hoffman et al.
demonstrated that participants in the tactile augmentation
condition showed the greatest progress on behavioral mea-
sures. This finding is limited by the fact that only 8 of the 36
participants were phobic at a clinical level.
The most important issue in considering the use of in virtuo
exposure is comparing the efficacy of this form of therapy
with that of conventional therapy. This has been addressed
and most studies converge toward the finding that in virtuo
exposure is as effective as in vivo exposure for acrophobia
(fear of heights) and fear of flying.
This same conclusion
cannot be made yet for arachnophobia, because the existing
studies of in virtuo exposure for this problem report com-
parisons of pre–post measures and=or comparisons to a
waiting list but do not directly compare a in virtuo exposure
group to a traditional exposure group. In addition, few
studies have included follow-up evaluations to verify treat-
ment durability for arachnophobia.
The first goal of this study is to evaluate the efficacy of
in virtuo exposure therapy and simultaneously compare it to
conventional in vivo exposure therapy. The second goal is to
measure the maintenance of gains in a 3-month follow-up
Participants were French speakers recruited in the Mon-
treal area by several methods, including: (a) oral presenta-
tions and flyers in university courses, (b) advertisements in
local newspapers, and (c) individuals who requested treat-
ment for fear of spiders through referrals and acquaintances.
The eligibility criteria for participation in the study were:
(a) Fulfillment of DSM-IV
diagnostic criteria for Specific
Phobia Animal Type (spiders), as evaluated by trained
doctoral students. Criteria E and D varied between
clinical and subclinical levels, given that people could
avoid places where they might come in contact with
spiders without necessarily affecting everyday func-
tioning, but still react with irrational fear in the pres-
ence of spiders.
(b) A minimum of 1-year duration of the phobia.
(c) An inability to touch a vivarium with a tarantula in it
prior to treatment, as evaluated during the Behavioral
Avoidance Test (BAT).
(d) A score in the clinical range on both the Fear of
Spiders Questionnaire
and Spider Beliefs Ques-
(e) No other psychiatric problem in need of immediate
treatment (participants were screened for anxiety dis-
orders and depression; participants with comorbid
spider phobia and primary anxiety disorder were ex-
(f) No current alcohol or drug dependence or medication.
(g) No severe physical illness.
Participants were on average 29.1 years old (SD ¼7.99; range
18–51), with 16.53 years of education (SD ¼2.37; range 12–
22). A total of 64% of the sample were in a romantic rela-
tionship and 36% had a child. Further, 64% of participants
were currently employed, and only one participant was male.
Of the 32 participants included (16 in virtuo,16in vivo), 28 met
the full DSM-IV criteria for specific phobia (15 in virtuo,13
in vivo). Four participants had a partial diagnosis of specific
phobia but scored within the phobic range on the question-
naire measures and on the BAT.
The virtual environments (VEs) were generated using a
personal computer with a Pentium
4 3.0 GHz 1.00 GB of
RAM cpu, 256MB of graphics memory, and a wide 256-bit
memory interface ATI Radeon 9800 XT video card. The en-
vironments were displayed on monoscopic I-glasses
PC=SVGA A502085
(i-O Display Systems) head-mounted
display (HMD) with a resolution of 800600 pixels. The
HMD was draped with a 30 cm40 cm black cloth to block
out ambient light. The HMD was also equipped with an IS-
300 Pro
tracker (3 dof) that sensed the movement of the
participants’ heads. Together, the HMD and tracker provided
a view that followed the participants’ head movements as
they tilted, panned, and swiveled their heads to scan the VE.
The participants used a handheld wireless Gyration mouse to
control their forward and backward movements in the VE.
Ambient sounds were played on the PC’s stereo speakers and
through the HMD. The arachnophobia environments were
modified computer-game environments based on the Max
Payne video game and downloaded from the Universite
´bec en Outaouais (UQO) Cyberpsychology laboratory
Web site ( The computer-graphic
artists used the Max Payne platform to customize the envi-
ronments and populate them with animated spiders of dif-
ferent shapes and sizes.
Participant evaluation. A battery of questionnaires and a
structured clinical interview were systematically adminis-
tered to participants in order to obtain and document the
following information: age, gender, marital status, general
health, level of education, presence intensity, duration of
arachnophobia, and presence of comorbid disorders. Mea-
sures were taken pretreatment, during treatment, posttreat-
ment, and at a 3-month follow-up.
Measures of fear. The Structured Clinical Interview for
was used to confirm the diagnoses of
spider phobia (principal diagnosis) and comorbid anxiety
disorders (secondary diagnosis), as defined by DSM-IV.
SCID-I has good concurrent validity with clinician judgment
(k¼0.69) and inter-rater reliability has been reported at 0.77
and 0.92.
The Questionnaire sur la Peur des Araigne
´es (FSQ-F;
French translation of the Fear of Spiders Questionnaire)
chosen for a subjective measure of the efficacy of in virtuo
treatment. This questionnaire is reported to have excellent
split-half reliability and internal consistency, and good test–
retest consistency. In addition, the FSQ-F’s good convergent
validity is demonstrated by highly significant correlations
with the BAT (r¼0.65). Good construct validity is demon-
strated by the test’s ability to discriminate phobics from non-
phobics, as measured by a BAT.
The FSQ-F is composed
of 18 items about fear and avoidance of spiders to be rated on
a scale from 1 to 7 (1 ¼does not apply to me;7¼very much
applies to me).
The Questionnaire des Croyances a
`propos des Araigne
(SBQ-F) is a French translation of the Spider Beliefs Ques-
This instrument is composed of 78 items divided
into two subscales (SBQ-F beliefs, SBQ-F behaviors) that re-
spectively address beliefs about spiders and beliefs about
own behavior in the presence of spiders. Arntz et al.
ported internal consistency of 0.94 for this measure. Test–
retest reliability values between 0.59 and 0.84 have been
The BAT is a popular objective measure of clinical progress
in overcoming phobias. A large spider (female rosy-haired
tarantula, approximately 10 centimeters long including front
legs and cephalothorax) was placed in a vivarium without a
lid. The cage was placed on a table at the far end of a room
and a chair was placed 3 meters from the vivarium. The pa-
tient was instructed to enter the room, sit down in the chair,
and then get up and walk as close to the cage as possible.
Participants were advised that the BAT was an objective
measure of their fear of spiders and not part of the therapy.
During the test, the experimenter stayed behind the client, in
an effort to minimize any potential impact of his presence.
When the participants were as near as possible to the spider,
the distance in meters between participant and spider was
measured. The measure of distance was converted to a be-
havioral score that ranged from 0 to 11, where 0 ¼anything
less than sitting down on the chair; 1 ¼50 centimeters; 2 ¼100
centimeters; 3 ¼150 centimeters; 4 ¼200 centimeters; 5 ¼250
centimeters; 6 ¼300 centimeters; 7 ¼staring into the open
vivarium for 5 seconds; 8 ¼touching the vivarium on side
farthest from the spider for at least 5 seconds; 9 ¼touching the
vivarium on side closest to the spider for at least 5 seconds;
10 ¼inserting one hand into the vivarium and putting one
finger on the ground on the side farthest from the spider for at
least 5 seconds; 11 ¼placing one hand on the branch in the
middle of the vivarium for at least 5 seconds.
An end-state functioning index was developed to assess
clinically significant improvement using five measures and
their respective cut-off points to rate clinical success. The in-
dex included:
(a) BAT (10), SBQ-F beliefs (23.15), SBQ-F behaviors (21.5),
FSQ-F (65.3), and SCID-I evaluation of specific phobia.
The cut-off score for treatment success on the BAT
(scores 0–11) was determined by the sample distribu-
tion and set at 10 or higher (inserting one hand in the
vivarium and putting one finger on the ground on the
side farthest from the spider for at least 5 seconds)
(b) For the SBQ-F beliefs, SBQ-F behaviors, and FSQ-F
scales, the established cut-off point for clinically sig-
nificant change was entry into the non-phobic range.
This stricter cut-off point was chosen for its relevance
within our data (stricter than 2 SD from the phobic
(c) An absence of specific phobia diagnosis on the SCID-I
was required to meet the criteria of clinical success.
Clinical success was awarded 1 point and failure was
awarded 0 point.
The scores on these five measures were added together to
produce a score out of five.
Control measures. The Inventaire de la De
´pression de
Beck (IDB),
the French translation of the Beck Depression
Inventory (BDI),
measured the presence and intensity of 21
symptoms of depression. The French version of this ques-
tionnaire was validated by Bourque and Baudette,
and it
was used in this to match the treated participant’s language
and population. Temporal stability over 4 months was 0.62
and internal coherence varied between 0.90 and 0.92.
The E
´chelle d’E
´valuation du The
´rapeute (EET)
is a
French translation of the Therapist Evaluation Scale.
questionnaire includes 25 items that measure the participant’s
perception of his or her therapist.
The Questionnaire sur la Perception du Traitement pour
Phobies Spe
´cifiques (QPTPS) is a French adaptation for spe-
cific phobia of the Questionnaire on Treatment Perception
and Credibility.
It consists of five questions that measure
the participant’s perception of treatment credibility. The test–
retest reliability is 0.90 ( p<0.05).
Virtual-reality questionnaires. The Questionnaire sur
´tat de Pre
´sence (PQ-F) (French translation of the Pre-
sence Questionnaire
) was administered following the
exposure session. Each of the PQ-F’s 19 items are rated on
total score and five subscale scores. The five subscales are:
Realism (similarity between the VE and the equivalent
natural environment), Affordance to Act (ability to actively
explore and manipulate the VE), Interface Quality (delays
or awkwardness related to the software or apparatus),
Affordance to Examine (ability to approach virtual objects
and to examine them from different angles), and Self-
Evaluation of Performance (feeling of competence for per-
forming tasks in the VE). The Presence Questionnaire has
good reliability (Cronbach’s a¼0.81).
The Questionnaire sur les Cybermalaises (SSQ-F; French
translation of the Simulator Sickness Questionnaire
) was
also administered after the exposure session. The SSQ-F has a
4-point scale to rate 16 symptoms of simulator sickness, such
as nausea, eye fatigue, and vertigo. The SSQ-F produces a
total score and three subscale scores: Nausea,Ocular-Motor
Problems, and Disorientation. Although the SSQ-F is presently
in the validation process, it is already commonly used in VR
therapy research.
A total of 32 participants with a diagnosis of specific
phobia took part in this randomized controlled clinical trial.
Participants were randomly assigned to one of three condi-
tions: waiting list, in virtuo exposure, or in vivo exposure.
Participants in the waiting-list group waited for 8 weeks be-
fore being reevaluated and randomly assigned to one of the
two treatment groups.
The treatment followed a standardized exposure protocol
from the Cyberpsychology Laboratory at UQO. It was ad-
ministered by five doctoral students in psychology, super-
vised by a senior psychologist. Treatments were equal in both
groups (in vivo and in virtuo) in terms of number of sessions,
exposure time, and techniques in order to allow for valid
comparisons. Treatment consisted of psychoeducation about
spiders, gradual exposure, and cognitive restructuring. Eight
90-minute treatment sessions were planned. The first session
included evaluation, information about treatment, and psy-
choeducation about phobias and spiders. The next six ses-
sions consisted of gradual exposure tasks and cognitive
restructuring. Each exposure session lasted approximately 1.5
hours, with pauses every 20 to 30 minutes to prevent cyber-
sickness in VR and to rest in the in virtuo group. The final
session focused on relapse prevention. Treatment completion
criteria were as follows: for participants in the in virtuo group,
completing treatment meant going through all three levels of
the VR program and confronting a large black-widow spider.
In addition, participants had to report low levels of anxiety
throughout the program. Participants in the in vivo group
were considered to have completed treatment when they
were able to manipulate two types of live spiders (Tegenaria
domestic and Pholcus) in their hands. Three participants (two
in vivo and one in virtuo) achieved these goals prematurely
and therapy ended after seven sessions for them. All other
participants received eight sessions. Exposure proceeded ac-
cording to a list of tasks assigned by the therapist and rated
by the participants with a Subjective Units of Distress (SUDs)
rating. The tasks were designed to elicit a SUDs rating be-
tween 30 and 70 (out of 100).
Significance was set at p¼0.05 for this study. Posttreat-
ment analyses included data from the waiting-list group after
they were distributed among the in vivo and in virtuo groups.
Pretreatment tests
Independent ttests revealed no significant differences in
demographic and clinical variables between the waiting-list
condition and the treatment condition at pretreatment,
p<0.05. Further ttests revealed no significant differences in
demographic and clinical variables between the in virtuo
group and the in vivo group at pretest ( p<0.05).
Pretreatment and posttreatment tests
A one-way between-groups multivariate analysis of vari-
ance (22 MANOVA) was conducted to compare the waiting-
list condition to the combined treatment groups. The depen-
dant variables were FSQ-F, SBQ-F beliefs, and SBQ-F behav-
iors. No significant differences were found on any clinical
variables for the waiting-list group between both pretreat-
ment evaluations, F(3, 10) ¼0.233, p<0.871, indicating no
improvement prior to treatment. A statistically significant
difference was found between the waiting-list group at pretest
and the treatment group at posttest, F(3, 44) ¼3.65, p¼0.02.
Virtual-reality questionnaire
Scores on the PQ-F showed elevated total presence
(M¼84.21, SD ¼14.35). Cybersickness scores on the SSQ-F
were slightly higher than the questionnaire norms (M¼19.41,
SD ¼14.79), but lower than SSQ-F scores in a phobic sample
reported by Robillard et al.
We therefore consider our
in virtuo treatment to have been conducted according to the
control standards.
Posttreatment and follow-up tests
Of the 36 participants in this study, 32 completed the
posttest evaluation, and 26 were evaluated at a 3-month
follow-up. Incomplete evaluations at posttest were explained
by psychosocial stressors, and the participants with incom-
plete evaluations were distributed evenly between the treat-
ment groups. Three participants were switched from the
in virtuo group to the in vivo group due to a lack of reactivity
to the virtual spiders. This created an even distribution of
participants, with 16 in the in virtuo group and 16 in the in
vivo group. At follow-up, seven non-completers were counted
in the in vivo condition, and three in the in virtuo group. The
non-completion in the in virtuo condition was explained by
cybersickness related to a medical condition and three of the
absences in the in vivo condition were due to being out of the
country. The remaining four participants removed them-
selves for personal reasons. Independent ttests revealed no
significant differences between the missing cases and the
completers in age, gender, level of education, and employ-
ment status. Significant differences were found with regard to
children and civil status. None of the missing participants
were married or had children. No significant differences in
clinical variables were found between missing participants
and completers ( p<0.05).
Self-report questionnaires
A repeated-measures MANOVA was conducted on the
SBQ-F (beliefs and behaviors subscales) and FSQ-F, revealing
a significant time effect, and demonstrating treatment efficacy
over time (Table 1). Both in virtuo and in vivo exposure pro-
duced significant improvement at posttest and follow-up.
However, a significant time-by-treatment interaction was
found on the SBQ-F beliefs subscale ( p<0.05) at follow-up.
In vivo exposure scores decreased slightly over time, whereas
in virtuo exposure scores did not change significantly (Table 2).
A similar non-significant trend was observed for the SBQ-F
behaviors subscale. There were no significant differences be-
tween groups for interaction effects or treatment effects on the
Intent-to-treat analysis
To address attrition in this study, an intent-to-treat analysis
(repeated-measures MANOVA) was conducted on the SBQ-F
(beliefs and behaviors subscales) and FSQ-F. This analysis
revealed a significant time effect, demonstrating treatment
efficacy over time, F(6, 28) ¼17.12, p¼0.00. Both in virtuo
and in vivo exposure produced significant improvement at
posttest and follow-up. There was no significant time-by-
treatment interaction for the SBQ-F beliefs subscale, p<0.05.
The BAT posttreatment scores were asymmetrical and non-
transformable. This variable was therefore modified to rep-
resent participants’ improvement by (a) subtracting pretest
scores from posttest scores and (b) subtracting pretest scores
from follow-up scores. The new change variable had a normal
distribution. A ttest revealed a significant change at posttest,
M¼6.73, SD ¼2.96; t(31) ¼12.86, p¼0.00, and at follow-up,
M¼6.87, SD ¼3.18; t(25) ¼11.01, p¼0.00. A two-way
between-groups ANOVA was conducted to compare treat-
ment groups on the new change variable. There was no
significant difference between in vivo and in virtuo treatment
groups, F(1, 24) ¼2.55, p¼0.12.
The posttreatment and follow-up results on the SCID-I
were asymmetrical and non-transformable. This variable was
therefore dichotomized, and non-parametric tests were em-
ployed for the analysis. Friedman’s test revealed a significant
difference between pretest and posttest results, as well as
between pretest and follow-up measures ( p¼0.00), thereby
demonstrating treatment efficacy. Fisher’s exact test was used
to compare the treatment outcome on the SCID-I. No signif-
icant differences were found between the in virtuo and in vivo
(p¼0.226) groups at posttest or at follow-up ( p¼0.238). It
was also observed that, at pretest, the in vivo group included
14 participants with a full diagnosis of specific phobia and
two participants with a partial diagnosis (criteria D and E
subclinical). At posttest, none of the in vivo participants still
had a diagnosis of specific phobia. The in virtuo group in-
cluded 15 participants with a diagnosis of specific phobia and
one participant with a partial diagnosis at pretest. At posttest,
only two participants had a remaining partial diagnosis and
one participant still had a full diagnosis of specific phobia.
Table 1. Treatment Outcome and Treatment Interaction for In Vivo
and In Virtuo Exposure for Spider Phobia
Time effect Treatment interaction
Measure FpZ
DF p Z
FSQ-F 70.12 0.000 0.753 1 0.814 0.445 0.034 0.177
SBQ-F beliefs 39.48 0.000 0.632 1 4.96 0.012 0.177 0.778
SBQ-F behaviors 39.92 0.000 0.634 1 0.309 0.714 0.013 0.094
FSQ-F, Fear of Spiders Questionnaire; SBQ-F beliefs, Spider Beliefs Questionnaire, beliefs subscale; SBQ-F behaviors, Spider Beliefs
Questionnaire, behaviors subscale.
Table 2. Mean and Standard Deviation for Outcome Measures at Pretreatment,
Posttreatment, and 3-Month Follow-Up
In vivo In virtuo
Variable MSDMSD
BAT score
Pretreatment 3.17 2.55 3.56 2.89
Posttreatment 10.47 1.67 9.25 2.72
Follow-up 9.86 2.15 9.73 2.43
FSQ-F score
Pretreatment 103.28 13.13 104.61 9.59
Posttreatment 47.88 14.07 54.37 22.46
Follow-up 47.81 32.25 56.67 23.99
SBQ-F beliefs
Pretreatment 47.73 14.31 41.17 15.58
Posttreatment 16.50 17.83 18.47 20.26
Follow-up 9.71 9.02 16.92 10.81
SBQ-F behaviors
Pretreatment 45.20 15.45 45.53 18.49
Posttreatment 11.32 17.38 16.39 21.40
Follow-up 9.76 8.29 13.54 15.95
SCID-I diagnosis
Pretreatment 1.83 0.38 1.94 0.24
Posttreatment 0.00 0.00 0.25 0.58
Follow-up 0.17 0.58 0.33 0.72
BAT, Behavioral Avoidance Test; FSQ-F, Fear of Spiders Questionnaire; SBQ-F beliefs, Spider Beliefs Questionnaire, beliefs subscale; SBQ-F
behaviors, Spider Beliefs Questionnaire, behaviors subscale; SCID-I, Structured Clinical Interview for DSM-IV.
End-state functioning index
The posttreatment and follow-up scores on the end-state
functioning index were asymmetrical and non-transformable.
This variable was therefore dichotomized, and non-parametric
tests were employed for the analysis. The Friedman test re-
vealed significant differences in scores over the three time
periods ( p¼0.00), indicating treatment efficacy. Differences
between the in vivo and in virtuo groups were evaluated with a
Fisher’s exact test. No significant differences were found at
posttreatment ( p¼0.76)oratfollow-up(p¼0.62).
Participants in both in virtuo and in vivo exposure therapy
for spider phobia demonstrated significant improvement on
objective and subjective measures of fear after eight 90-minute
treatment sessions. No significant differences between the
groups were found at posttest or at follow-up on the fol-
lowing measures of fear: FSQ-F, SBQ-F behaviors subscales,
and the BAT. At the posttest evaluation, several participants
in the in virtuo group indicated that they were curious to
know how they would react to a spider in their natural en-
vironment. At the follow-up period, some had finally en-
countered a spider and were appreciative of their reaction
toward it. Significant differences between groups were also
found for the SBQ-F beliefs subscale at follow-up. In vivo
scores decreased on this measure from posttest to follow-up,
whereas in virtuo scores were maintained over time. The
greater treatment gains in the in vivo group may be attribut-
able to the direct contact with spiders and learning about the
behaviors and reactions of a live spider.
This randomized controlled study found slight differences
between in vivo and in virtuo treatments for fear of spiders.
The effect size between treatment groups at follow-up on the
SBQ-F beliefs subscale was 6.9%.
Three participants in the in virtuo group displayed no re-
action to the virtual spiders and were reassigned to the other
group. This possible limitation of VR should be considered in
treatment planning. The primary limitations of in virtuo ex-
posure published to date have been associated with lack of a
sense of presence and cybersickness. Further studies should
be required to evaluate levels of presence and cybersickness
in participants who react unfavorably to VEs. In addition,
future research could explore other variables that may predict
treatment success. In the meantime, in vivo exposure is re-
commended when possible. The rate of attrition in the present
study was higher in the in vivo group than in the in virtuo
group at follow up. Specifically, at post-test, 2 non completers
were counted in both groups, while 7 and 3 non completers
were counted at follow up for the in vivo group and the
in virtuo group, respectively. The majority of drop-outs
occurred after treatment was completed. Therefore this does
not support Garcia-Palacios et al.’s
suggestion that in virtuo
exposure may be less threatening than in vivo exposure. The
drop-out rate in this study (27%) is therefore attributed to
normal attrition.
The strength of this study is the use of randomized dis-
tribution and a control group to directly compare in vivo and
in virtuo exposure. Authors of future research on spider
phobia may wish to consider the following suggestions for
improving study design. First, spider phobia in Quebec is
likely to differ from spider phobia in other areas. Spiders in
Quebec may bite and cause a local reaction, but they are not
deadly or cause for medical concern. To assess functionality
in participants in Quebec properly, a BAT task of touching or
manipulating a local spider should be considered as an ad-
junct to the traditional BAT task with a tarantula in both
exposure methods. Second, in their study of the use of VR in
spider phobia, Garcia Palacios et al.
included anxiety mea-
sures such as the State–Trait Anxiety Inventory (STAI) in the
pre, post, and follow-up evaluations, and included the SUDs
during the BAT. This more rigorous evaluation could have
been used in the present study to provide more accurate
measures of treatment outcome on the BAT. Third, the
posttest results on the BAT in the present study demonstrated
a ceiling effect. The inclusion of a more complex BAT task,
such as manipulating a local spider or touching the live ta-
rantula with a pencil or straw, could prevent the ceiling effect
and provide a more accurate measure of participants’ im-
provement. Fourth, although this idea was not explored in
this study, in vivo exposure following in virtuo exposure could
consolidate treatment gains Finally, another option would be
to include tactile augmentation to the in virtuo exposure as
did Hoffman et al.,
allowing greater presence and improved
treatment outcome.
This study did not include physiological measures such as
heart rate and skin conductance although they have been
demonstrated empirically to be modified by in virtuo expo-
sure. Wiederhold and Wiederhold
found that arousal in the
VR environments varied between individuals on measures of
skin resistance and cardiac response, which could affect
treatment efficiency. Also, Co
´and Bouchard
found that
in virtuo exposure modified cardiac response. In another
study, Co
´and Bouchard
found that changes in perceived
self-efficacy and dysfunctional beliefs were the best pre-
dictors of change in general outcome and cardiac response.
These measures should be included in future researches to
measure therapeutic gains.
In conclusion, both in vivo and in virtuo exposure are
efficient methods of treating spider phobia. A slight ad-
vantage of in vivo exposure over in virtuo exposure was
found, as revealed by significant and continued gains on
the SBQ-F beliefs subscale after posttest in the in vivo
group. The effectiveness of VR therapy could likely be en-
hanced considerably by using tactile augmentation
complementary in vivo exposure. If equivalent efficiency is
achieved, in virtuo exposure has compelling advantages
over in vivo exposure and could make it the treatment of
This study is the doctoral thesis of David Michaliszyn,
Ph.D. (candidate). Andre
´Marchand, Ph.D., acted as his thesis
advisor. The study was conducted at the Laboratoire de
Cyberpsychologie of l’Universite
´du Que
´bec a
(UQAM) where the first author is completing his Ph.D. Spe-
cial thanks go to Ste
´phane Bouchard from the Laboratoire de
Cyberpsychologie of l’Universite
´du Que
´bec en Outaouais
(UQO) ( for his invaluable help dur-
ing all the stages of this study. Also, we wish to give special
thanks to Me
´lissa Martin and Joannie Poirier-Bisson for their
contributions. This study was funded by the Canada Foun-
dation for Innovation.
Disclosure Statement
No competing financial interests exist.
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Case Postale 8888
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... The majority of VRIs outperformed waitlist controls on various self-report measures of social anxiety (Anderson et al., 2013;Bouchard et al., 2017;Kampmann et al., 2016;Kim et al., 2017;Lindner, Miloff, Fagernas, et al., 2019;Robillard et al., 2010), panic disorder with/without agoraphobia (Meyerbröker et Shiban, Brutting, et al., 2015). Many VRIs were either equally effective or not statistically different from other active treatment conditions, such as for social anxiety disorder (Anderson et al., 2013;Robillard et al., 2010), panic disorder and agoraphobia (Malbos et al., 2013;Pelissolo et al., 2012;Quero et al., 2013), PTSD (Beidel et al., 2019;Norr et al., 2019;Reger et al., 2019), and various specific phobias (Lindner, Miloff, Fagernas, et al., 2019;Michaliszyn et al., 2010;Raeder et al., 2019;Rus-Calafell et al., 2013;Tortella-Feliu et al., 2011). Some VRIs were more effective than active treatments for social anxiety (Bouchard et al., 2017), PTSD (McLay et al., 2011), and specific phobia (Gujjar et al., 2019). ...
... A high degree of variability in dosage, duration, and frequency of VRIs was evident (Table 2). Study D1 D1 D2 D2 D3 D3 D4 D4 D5 D5 D6 D6 D7 Geraets, 2019Kampmann et al., 2016Kampmann et al., 2019Kim, 2017Lindner, Milhoff, Fagernas, et al., 2019Robillard, 2010Michaliszyn, 2010Shiban, Brutting, et al. (2015 Shiban, Schelhorn, et al. (2015) Tardif, 2019 Gujjar, 2019Freeman, 2018Levy, 2016Raeder, 2019Botella, 2014Rus-Calafell, 2013 Tortella-Feliu, 2011 Moldovan, 2014Malbos et al., 2013Meyerbroeker et al., 2013Meyerbroeker, 2011Pelissolo, 2012Quero, 2013 Beidel Frequency of treatment ranged from one-session treatment to twenty sessions of VR and duration of VRIs varied from 5 minutes to 120 minutes. Some studies scheduled breaks for participants, with most studies immersing participants sequentially for shorter intervals to mitigate adverse effects such as simulator sickness. ...
... Few studies included one or more measures of user engagement, treatment satisfaction, or attitudes towards VRIs. Studies that did include secondary outcome measures relating to user engagement included client satisfaction (Anderson et al., 2013), session opinion and treatment preference (Botella et al., 2014), working alliance (Anderson et al., 2013;Moldovan & David, 2014), mental health associated stigma (Mishkind et al., 2017), access and attitudes towards psychological treatment (Freeman et al., 2018;Reger et al., 2016), and the therapeutic relationship (Michaliszyn et al., 2010;Pelissolo et al., 2012). Scores from the experience rating scale- therapist version demonstrated that prior to administering either treatments therapists held more pessimistic views towards VRET than traditional face-to-face CBT for panic disorder with agoraphobia (p = .01). ...
Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.
... This study demonstrates that the oVRcome self-guided mobile app, which incorporates VR and cognitive behavioural therapy, reduces the severity of symptoms of five specific phobias and treatment effects persist at 6-week follow-up. The app utilised 360° VR video and showed a large effect size comparable to more expensive VR devices typically only available in research or clinical settings, usually with much higher level of clinician involvement (Botella et al., 2016;Emmelkamp et al., 2002;Garcia-Palacios et al., 2007;Krijn et al., 2004;Michaliszyn et al., 2010;Muhlberger et al., 2003). The long duration of reported symptoms (mean 26 years) and female preponderance in this study is consistent with lifetime persistence and incidence rates reported internationally (Wardenaar et al., 2017). ...
Full-text available
Objective Mobile health applications for mental health are widely accessible but most have had limited research evaluation. Virtual reality exposure therapy is an emerging treatment for specific phobias. Most virtual reality studies have investigated high-end virtual reality devices, typically only available in research and limited clinical settings for a single phobia. This study evaluated the effectiveness of oVRcome, a mobile health application combining self-guided virtual reality exposure and cognitive behaviour therapy, for five specific phobias. Methods This is a 2-arm 6-week randomised controlled trial, with a waitlist control group and follow-up at week 12. Participants were required to live in New Zealand; be aged 18–64 years; have a fear of flying, heights, spiders, dogs and needles; score above 4 on the Brief Standard Self-rating scale for phobic patients; and have access to a smartphone and Internet. oVRcome consists of six modules of psychoeducation, relaxation, mindfulness, cognitive techniques, exposure through virtual reality and relapse prevention over 6 weeks. The primary outcome was the change from baseline to week 6 on the Severity Measures for Specific Phobia – Adults. All analyses were performed on intention-to-treat set. Results A total of 126 participants were randomised, and 109 completed the follow-up at week 6, for a retention rate of 86.5%. The mean change in Severity Measures for Specific Phobia – Adults score from baseline to week 6 was greater in the active group compared with the waitlist group (active group −20.53 [standard deviation = 8.24]; waitlist group: − 12.31 [standard deviation = 10.66]; p < 0.001). The effect size for this difference was 0.86. Conclusion Self-guided use of the oVRcome app was effective at reducing severity of specific phobia symptoms in a sample of people with a self-reported fear of flying, heights, spiders, dogs or needles. Trial registry NCT04909177.
... 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). ...
Full-text available
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). ...
Conference Paper
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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.
... 7 It has previously been used in various applications including pain management, multiple sclerosis [8][9][10] and treatment of psychological conditions, such as phobias and anxiety. [11][12][13] Within cancer care, VR has been used to manage pain, anxiety and symptom distress. However, current literature regarding its effectiveness is equivocal. ...
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Objectives The SafeSpace study codesigned and tested a virtual reality (VR) intervention, incorporating relaxation and compassionate mind training to determine acceptability/feasibility in an oncology setting and evaluate impact on physical/psychological well-being and quality of life. Design A two-phase study. Phase I determined key characteristics using an experienced-based codesign approach. Phase II evaluated the intervention using various measures and qualitative interviews in a mixed methods approach. Descriptive statistics were used to analyse measures data and framework analysis to analyse interviews. Setting A specialist cancer centre, UK. Participants 11 in phase I and 21 in phase II. Participants were in cancer treatment, recovery or palliative care. Primary and secondary outcome Primary outcome: acceptability of the intervention, assessed by >60% uptake of three sessions. Secondary outcomes: impact on psychological well-being using EQ-5D/QLQ-C30, Profile of Mood Scale, Warwick and Edinburgh Mental Well-being Scale, Depression and Anxiety Severity Scale 21, Self-Compassion Scale, Acceptance and Action Questionnaire and a locally developed questionnaire to capture self-compassion post use. Physiological impact was assessed by change in heart rate (HR)/HR variability and electrodermal activity (EDA). Results Twenty participants (mean age=48.7 years; SD=16.87); 65% (n=13) completed three sessions. Mental well-being improved following each use and from baseline to after session 3 (VR 1—z=2.846, p≤0.01; VR 2—z=2.501, p≤0.01; VR 3—z=2.492, p≤0.01). There was statistically significant difference in mean scores for EDA at mid-session and post session compared with pre session ( F (1.658, 4.973)=13.364, p<0.05). There was statistically significant reduction in stress levels from baseline to post session 3. Participants found the intervention acceptable and highlighted areas for development. Conclusion The intervention is acceptable and feasible and has shown positive effects on mental well-being/stress in the oncology setting. Larger studies are needed to confirm findings.
... Conducting exposure in virtual reality (VR) is among the new forms of treatment gaining popularity in the treatment of anxiety disorders, and more specifically in the treatment of specific phobias (Michaliszyn et al., 2010;Wiederhold & Bouchard, 2014). However, only three studies have been published with children (Gutiérrez-Maldonado et al., 2009;St-Jacques et al., 2010;Wong Sarver et al., 2014). ...
Background There has been a growing interest in treatments involving virtual reality (VR) exposure for a number of anxiety disorders and phobias. Contrary to expectations, this technique has proven less popular with phobic children and is less appealing to them than to adults. The hypothesis is that children may be more apprehensive about virtual aversive stimuli than adults. Methods In Study 1, the perception of virtual phobogenic stimuli was assessed in 523 participants between the ages of 7 and 60. To analyze to what extent anxiety and phobic fear predict apprehension, 38 school-aged children took part in Study 2. Results The results show that children apprehend phobic virtual stimulus more than adults and that apprehension is associated with specific phobic fear rather than a general anxiety state. Conclusion Results are discussed in terms of clinical interest, children’s cognitive development, and a priori fear of virtual reality stimuli.
Full-text available
The advancements in immersive technologies have impacted various sectors, with mental healthcare being one of them. The subsequent interaction between immersive technologies, particularly virtual reality and mental health, has created interesting effects that call for a closer look. This chapter intends to provide a comprehensive picture of mental health conditions, namely anxiety and related disorders, post-traumatic stress disorder, and major depressive disorder, as tackled by VR-based therapy. The focus is on its effectiveness and how the results compare to the traditional modes of treatment in terms of efficacy. The impact of user experience towards this approach of intervention and the importance of ethical consideration when VR intersects with the field of mental health are addressed.
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The Center for Advanced Multimedia Psychotherapy at the California School of Professional Psychology in San Diego was established to conduct research and provide clinical treatment to persons with phobias and other mental health disorders by using virtual environments as an adjunct to traditional cognitive-behavioral therapy. Observations made over the course of 600 virtual reality sessions are discussed in this article. Physiological and self-report data collected during treatment support the effectiveness of virtual reality exposure as a useful adjunct in the treatment of phobias. The use of immersive virtual environments appears to augment treatment success through the construct of "presence."
Full-text available
Beliefs held by spider phobics about a confrontation with a spider are investigated. Study 1 explores the content of thoughts and images which spider phobics (N = 44) report to have during a confrontation with a spider and investigates the frequency and strength of the subjective belief in the idea. Spider phobics appear to have an abundance of negative, irrational ideas about the spider and about their own reactions during a confrontation with a spider. A one-session therapistassisted exposure therapy strongly attenuates these beliefs. Study 2 investigates the psychometric properties of the Spider Phobia Beliefs Questionnaire (SBQ), which measures the strength of belief of a large number of ideas derived from Study 1, in a second sample of spider phobics (N = 112). Factor analysis revealed 5 spider-related factors: harm, hunter and prey, unpredictability, territory, and multiplication; and 4 self-related factors: panic, paralysis, incubation, and unrestrained behavior. These factors have good internal consistency and reasonable test-retest reliability. The SBQ discriminates strongly between spider phobics and normals (N = 33) and has good concurrent validity as indicated by positive associations with other indices of spider phobia. It appears that spider phobics have a lot of misconceptions about spiders, e.g., that spiders attack them, take revenge, or are incalculable and about their own reactions about a confrontation with a spider, e.g., they expect to have a heart attack, to die of fear, or to exacerbate their fear. Most self-related ideas resemble those held by panic patients. Both spider-related and self-related ideas can be corrected by a one-session treatment.
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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.
Validated a French version of the Beck Depression Inventory (BDI) with 498 French speaking university students. The internal-consistency reliability measure showed a coefficient of .92 for the standard 21-item form and .90 for the short 13-item form. The test–retest procedure indicated adequate stability over a 4-mo period. The norms correspond to those obtained with American college students. The factor analysis of the questionnaire items yielded 3 factors accounting for 75.8% of the variance. Results reveal that both the standard and short form of the French version of the BDI are valid instruments for use in the college population. (English abstract) (14 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Simulator sickness (SS) in high-fidelity visual simulators is a byproduct of modem simulation technology. Although it involves symptoms similar to those of motion-induced sickness (MS), SS tends to be less severe, to be of lower incidence, and to originate from elements of visual display and visuo-vestibular interaction atypical of conditions that induce MS. Most studies of SS to date index severity with some variant of the Pensacola Motion Sickness Questionnaire (MSQ). The MSQ has several deficiencies as an instrument for measuring SS. Some symptoms included in the scoring of MS are irrelevant for SS, and several are misleading. Also, the configural approach of the MSQ is not readily adaptable to computer administration and scoring. This article describes the development of a Simulator Sickness Questiomaire (SSQ), derived from the MSQ using a series of factor analyses, and illustrates its use in monitoring simulator performance with data from a computerized SSQ survey of 3,691 simulator hops. The database used for development included more than 1,100 MSQs, representing data from 10 Navy simulators. The SSQ provides straightforward computer or manual scoring, increased power to identify "problem" simulators, and improved diagnostic capability.