Sep 21 2021

Virtual Phobia Treatment

Are you afraid of spiders? I mean, really afraid, to the point that you will alter your plans and your behavior in order to specifically reduce the chance of encountering one of these multi-legged creatures? Intense fears, or phobias, are fairly common, affecting from 3-15% of the population. The technical definition (from the DSM-V) of phobia contains a number of criteria, but basically it is a persistent fear or anxiety provoked by a specific object or situation that is persistent, unreasonable and debilitating. In order to be considered a disorder:

“The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

The most effective treatment for phobias is exposure therapy, which gradually exposes the person suffering from a phobia to the thing or situation which provokes fear and anxiety. This allows them to slowly build up a tolerance to the exposure (desensitization), to learn that their fears are unwarranted and to reduce their anxiety. Exposure therapy works, and reviews of the research show that it is effective and superior to other treatments, such as cognitive therapy alone.

But there can be practical limitations to exposure therapy. One of which is the inability to find an initial exposure scenario that the person suffering from a phobia will accept. For example, you may be so phobic of spiders that any exposure is unacceptable, and so there is no way to begin the process of exposure therapy. For these reasons there has been a great deal of interest in using virtual/augment reality for exposure therapy for phobia. A 2019 systematic review including nine studies found that VR exposure therapy was as effective as “in vivo” exposure therapy for agoraphobia (fearing situations like crowds that trigger panic) and specific phobias, but not quite as effective for social phobia.

The effectiveness of virtual reality (VR) is not surprising. There appears to be a critical point of visual presentation beyond which the brain essentially is tricked into believing that what you are seeing represents physical reality. You can experience this with increasingly large and high resolution video screens. For example, if you are playing a game on your smart phone, with a small screen, nothing happening on that screen is likely to give you motion sickness. The same is true of even large computer monitors. But at some point, for very large monitors (for me, it my ultra-wide screen monitor) motion on the screen can produce motion sickness. At some point the brain goes from treating what is happening on the screen from looking at something to treating the visual information as if you are in the physical space of the computer screen. Once an image fills enough of your peripheral vision, the brain treats it as reality.

Virtual reality is clearly beyond this limit. Currently a 110 degree angle of view is standard, and this is more than enough for the brain to incorporate that visual information as if it were reality. This is why VR can so easily cause motion sickness, if there is a disconnect between the movement your eyes see and the what your vestibular system feels. But your brain treating VR as real goes way beyond just motion sickness. Once the visual input is treated as your actual physical environment (to construct your brain’s perception of reality), all the downstream brain networks are engaged, including fear.

I have played enough VR video games by now to attest to the fact that VR has a far greater potential to provoke fear and anxiety than smaller screens can. Even when you know it is all just VR, the more primitive parts of your brain react as if it is physical reality. Step out onto a virtual cliff, with nothing but air below you, and whatever fear you have of heights will be fully engaged. This is the idea behind VR exposure therapy.

Augmented reality (AR) is similar to VR, but instead of replacing the entire visual experience with a computer generated one, images are overlayed on top of reality. This can be accomplished with a smartphone (like in the Pokemon AR game) where the phone’s camera is used to display the real world around you and the software places virtual objects within and physical world. So it is as if you are looking through a window¬† seeing the virtual objects in real space. Another AR method is to wear transparent glasses (like Google Glass) that are also a monitor that can display objects and information superimposed onto the real world. Personally I think AR has a lot more potential than even VR for more applications.

To extent the research on VR exposure therapy, a recent study looked at AR exposure therapy, in this case involving phobia of spiders. The application uses a smartphone app which can create the image of spiders in your environment in the exact same way that the Pokemon game projected the little creatures onto the world. The study found that the AR spider phobia app was effective in reducing fear and anxiety, in a real world (not laboratory) setting. While this is an app anyone can download, the authors emphasized that those with diagnosable phobia should use the app under the guidance of a therapist.

Existing research shows that the bottom line is that VR and AR exposure therapy works, which is surprising to no one. This is a great new tool in the treatment of phobias, with several advantages over traditional exposure therapy. First, it can be extremely convenient. A VR airplane simulator you can use in your home is more convenient that reproducing the experience of flying in a plane in physical reality.

Virtual exposure can also be easily and automatically incorporated into a game-like sequence of incremental exposure. The user will have to progress successfully through each level to get to the next, representing progressive degrees of desensitization. A game-design approach is already optimized for this kind of training, and can be fully automated in the software. Apps can also be used to document progress, to help inform professionals involved in the treatment.

Finally, virtual exposure may represent an entry-level exposure for those who cannot bring themselves to begin the physical exposure therapy process. You have more control over an AR spider than a real spider, and you have the additional cognitive element that you know it is not real. At the same time, the AR experience is capable of provoking real fear and anxiety. For some people, the idea of being in a room with a real spider is too much, and they can never begin the exposure therapy process. In these cases, an AR spider might be acceptable. This also means that VR/AR exposure can be the beginning of the process, and for those who need it can be followed up by physical exposure. For example, if you have a fear of flying, at some point you are going to have to get into a real plane in order to conquer the fear. But the VR/AR desensitization can get you there.

It’s also worth mentioning that VR exposure therapy is just one aspect of using online and multimedia technology for mental health treatment. Research is also pointing in the direction of showing that online therapy can be as effective as in person therapy for many conditions. This can make therapy more accessible, convenient, and affordable to many people who need it. I suspect that in the near future, at least for some basic therapy applications, artificial intelligence (AI) therapists will also be a thing, and will likely be just as effective for some conditions. This is in no way to minimize the skill, knowledge and experience of actual therapists (full disclosure, my wife is a PhD counselor), but AI counseling may be effective for mild symptoms, as routine mental hygiene, or for those who otherwise would not have access to a live counselor. They can also be used for hybrid counseling to supplement a live professional, who might see their client once a month or so to monitor progress (with information synthesized from the AI) and for high-level diagnosis and feedback, while the AI therapist has unlimited availability.

It will be interesting to see how this all plays out, but I do think virtual, online, and AI mental health can be a very positive thing.

No responses yet