Virtual Reality App Helps Calm Fear of Heights

A self-guided virtual reality cognitive-behavioral therapy (VR-CBT) app can help alleviate symptoms of acrophobia, new research suggests.

Investigators randomly assigned almost 200 adults with acrophobia to either a wait-list control group or to a group that underwent an intervention with a self-guided VR-CBT app called ZeroPhobia that uses low-cost cardboard goggles, together with CBT techniques.

Participants in the VR-CBT group experienced significantly greater reduction in self-reported acrophobia symptoms compared to those in the control group.

"Acrophobia can be treated through an app on your smartphone using rudimentary VR viewers, even without clinician guidance," lead author Tara Donker, PhD, assistant professor, licensed psychologist, and registered CBT therapist, Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands, told Medscape Medical News.

"The app has been tested without the intervention of a clinician, but of course it can be used for practicing clinicians as well," she said.

The study was published online March 20 in JAMA Psychiatry.

"Tricking" the Mind

"Access to evidence-based psychological treatment for mental health disorders is a global challenge because of high treatment costs and the limited availability of mental health professionals," the authors write.

"Since 2014, healthcare insurance does not cover treatment for specific phobias, but specific phobias are highly prevalent, of which acrophobia is the most prevalent," Donker said.

Therefore, "we felt the need to develop a treatment for specific phobias, starting with acrophobia, which is accessible for everyone at lost costs," she added.

Virtual reality exposure therapy (VRET) offers an "immersive virtual environment" that can replace a real-life exposure setting. Previous research has suggested that it can be as effective as conventional exposure therapy.

However, to date, VRET has required the involvement of a therapist and expensive VR equipment.

"Phobias are normally treated with CBT, with exposure as the most important element, wherein people learn to expose themselves to the object or situations of their fear — in this case, height situations," Donker explained.

"Nowadays, people can also expose themselves in computer-generated environments, and when you put on your VR goggle, your brain tricks your mind, and it will feel as if you are really immersed in this VR environment," she said,

The reason is that the visual cortex "is the largest in your brain, and therefore you rely mostly on what you see, even though you know the environment is not real," she noted.

The researchers set out to study the effectiveness and user-friendliness of ZeroPhobia, a fullly self-guided VR-CBT for acrophobia symptoms that is delivered through a smartphone.

To "ensure scalability," the VR-CBT app relies on participants' own smartphones and basic ($10) cardboard VR goggles.

Anxiety Lowering

In the app, "people find themselves in a VR theater and need to conduct all kinds of chores — like replacing a light bulb while standing on a kitchen ladder — and with each level, people need to conduct these chores at higher altitude, until they need to fix the roof of the theater," she explained.

"Playfully, they are forced to look down, and when they feel anxious, they need to look down until they feel their anxiety drops," she said.

"When this happens, the next time they will practice in VR, the anxiety level will most likely be lower and also will drop quicker, and the process needs to be repeated until the anxiety is very low," she added.

The researchers recruited participants (n = 193; 66.84% women; mean [SD] age, 41.33 [13.64] years) from the Dutch general population.

Participants were required to score ≥45.45 on the Acrophobia Questionnaire (AQ)–Anxiety and to have access to an Android smartphone.

People with severe depression or suicidality or those who were receiving current phobia treatment or psychotropic medications were excluded.

Participants were given six animated CBT-based modules that utilized two-dimensional animations and a voice-over provided by a virtual therapist.

Each module took between 5 and 40 minutes to complete. Participants were asked to complete the entire intervention within 3 weeks.

The VR-CBT app also included a "gamified immersive VR environment" and four videos that covered the entire exposure spectrum, which were to be used from module 3 onward.

Baseline, posttest, and 3-month follow-up measures were completed online.

The primary outcome was a reduction in AQ score. Secondary outcomes included scores on the Attitudes Towards Heights Questionnaire (AHQ), the Beck Anxiety Inventory, the System Usability Scale, the Igroup Presence Questionnaire, and the Patient Health Questionnaire–9.

Innovative Technologies

A total of 193 participants qualified for the trial and were randomly assigned to either the VR-CBT app group or the wait-list control group (n = 96 and n = 97, respectively).

The pretreatment attrition rate in the VR-CBT group was 23%; these patients failed to participate either because of illness or because of incompatible smartphones.

In the intervention group, 59% of participants completed the posttest assessment, and 49% completed the follow-up. In the wait-list group, 91% completed the posttest assessment.

Demographics were similar between the two groups. Dropout rates were not related to background characteristics, prescores, or other covariates.

In the intention-to-treat (ITT) analysis, the VR-CBT group showed significant reduction in acrophobia symptoms compared with the control group on the AQ at posttest (b = −26.73; 95% confidence interval [CI], −32.12 to −21.34; t ₁₉₁ = −9.79; P < .001; adjusted R² = 0.52; effect size d = 1.14; 95% CI, 0.84-1.44).

The number needed to treat (NNT) was 1.7.

The VR-CBT group showed "significant" reduction in acrophobia symptoms and intervention effect compared with the control group on acrophobia symptoms (AHQ, b= −12.59; t ₁₈₂ = −8.92; P < .001; d = 1.091; 95% CI, 0.787 – 1.393).

General anxiety symptoms were reduced (Beck Anxiety Inventory: b = −3.87; t ₁₈₂ = −2.62; P < .001; d = 0.370.087 – 656), and there was an increase in the sense of mastery (b = 1.01; t ₁₈₂ = −2.00; P = .047; d = −0.11; −0.389 to 0.176).

Depressive symptoms did not change significantly between the two groups.

The treatment effect on the primary outcome measure (AQ) was found to be statistically significant, even after the researchers applied other statistical analyses that imputed outcomes for the attrition sample, using wait-list control participants.

Multiple imputation techniques for the attribution and dropout sample, based on initial treatment assignment, continued to yield statistical significance of the ITT effect on AQ (d = 1.53; 95% CI, 1.15 – 1.91).

The potential benefits were higher for participants with more severe acrophobia symptoms.

A robustness analysis confirmed that the app specifically had an impact on anxiety regarding heights and that the general anxiety effects did not drive the results.

The between-group AQ effect size for participants who returned for the posttest assessment was d = 1.53 (95% CI, 1.15 – 1.91; NNT: 1.4).

For VR-CBT participants, the within-group effect size was d = 2.68 (95% CI, 2.09 – 3.22) between baseline and follow-up.

Effect sizes on secondary outcomes for the individuals who used the app were also "large."

All the participants who returned the posttest AQ showed reliable change; 79% experienced clinically significant change (≥57.97 points on the AQ).

The VR-CBT app was rated as user friendly.

The researchers found no deterioration or negative effects, except for 24 participants who reported one or more or symptoms of transient cyber sickness.

"With current innovative technologies and recent scientific advances, we saw a solution [to creating a low-cost, accessible treatment for acrophobia] with mobile apps and VR," Donker summarized.

The authors note that in the intervention group, the high attrition rate due to incompatible smartphones was a limitation. They note, however, that the results were imputed for missing participants using a regression-based imputation to retain a "balanced experimental sample" and that robustness and sensitivity analyses "confirmed that potential bias concerns and precisions concerns did not compromise the statistical significance of the results."

Important First Attempt

Commenting on the study for Medscape Medical News, Hélène S. Simke-Wallach, PhD, senior clinical psychologist, VR-CBT Lab, Innovative Cognitive Behavior Therapy and Research Group, Department of Psychology, University of Haifa, Mount Carmel, Israel, who was not involved with this research, said that "the importance of this study is that it found that patients suffering from acrophobia who completed treatment showed impressive improvement, compared to a wait-list control group, [which is] an important first attempt at guided self-therapy using evidence-based therapy practices."

However, she continued, "It is important to note that of the patients randomly allocated to the treatment group, only 59% completed [the study]."

Moreover, follow-up was "very brief, only 3 months," and it would be "important to check again a year following therapy to determine if improvement is maintained," she said. Thus, despite the encouraging findings, "caution must be used in interpreting them," she said.

"My personal preference would be that patients would use self-help practices under the guidance of a therapist, thus enabling the therapist to determine if the diagnosis is correct, if the patient uses it correctly, and to be able to monitor if there are any unforeseen ill effects.

"The current study adds to the development of innovative and scalable delivery methods of evidence-based treatments and underlines that new technologies have the potential to transform mental healthcare worldwide," she said.

This study was funded by NWO Toegepaste en Technische Wetenschappen and NWO Creative Industrie-KIEM. Donker received grants from NWO Toegepaste en Technische Wetenschappen and NWO Creative Industrie-KIEM during the conduct of the study. Donker and another coauthor developed the virtual reality application ZeroPhobia, which was used in the present study in collaboration with Vrije Universiteit. ZeroPhobia is intended for commercial release. Donker was not involved in data analysis or any decisions related to the publication of findings. The other coauthors and Wallach have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online March 20, 2019. Abstract

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