Virtual Reality Exposure Therapy

Virtual reality (VR) describes a human-computer interaction that is a multimedia interactive display in which the user experiences a sense of presence or immersion in the virtual environment that changes in real time with head and body movements. In virtual reality exposure (VRE) therapy for posttraumatic stress disorder (PTSD), the patient describes the traumatic experience and the therapist attempts to match in the virtual environment what the patient is describing. Imaginal exposure entails the patient repeatedly telling of the traumatic experience with his or her eyes closed to enhance presence in the memory. However, the numbing and avoidance inherent in PTSD can serve as obstacles to emotional engagement in the memory, which is an essential ingredient for treatment success. VRE increases the intensity of exposure over that provided in imaginal exposure by providing the sights, sounds, smells, and movements in addition to the memory and the emotions. VR is a promising enhancement to empirically validated exposure treatment for PTSD.

The term exposure therapy refers to several behavioral and cognitive behavioral treatment programs that involve safely confronting feared thoughts, images, objects, situations, or activities to reduce pathological (unrealistic) fear, anxiety, and related symptoms. Exposure therapy typically involves the patient repeatedly confronting the feared stimulus in a graded manner, either in imagination or in vivo (i.e., “in real life”). In the treatment of PTSD, exposure therapy usually involves prolonged imaginal exposure to the patient's memory of the trauma and in vivo exposure to various reminders of the trauma.

VRE therapy is an alternative to more traditional exposure-based therapies that have been used in the treatment of acrophobia, claustrophobia, [Page 790]arachnophobia, driving phobia, fear of flying, social phobia (fear of public speaking), and PTSD. Exposure therapy in the virtual environment allows the participant to experience a sense of presence in an immersive, computer-generated, three-dimensional, interactive environment that minimizes avoidance behavior and facilitates emotional involvement. The VRE participant wears a head-mounted display with separate screens for each eye, stereo earphones, and a device that tracks head movements so that sounds and images change in a natural way with head motion. The environment allows the therapist to control the delivery of sensory stimulation, including visual, auditory, olfactory, and tactile cues. The patient confronts the feared stimuli, and through the processes of habituation and extinction, anxiety decreases with prolonged and repeated therapeutic exposures.

VRE for PTSD usually consists of five components typically administered in 9 to 12 sessions lasting approximately 90 minutes each: (1) psycho-education about the symptoms of PTSD and factors that maintain PTSD (e.g., avoidance, cognitive factors) along with a rationale for exposure therapy and the use of VR; (2) training in controlled breathing that patients may use as a stress management skill, although patients are discouraged from using it during exposure exercises, rather only during times that exposure would not be indicated, such as going to sleep or in the shower, because the goal is to have patients learn they can tolerate the distress and that it decreases with continued exposure; (3) prolonged exposure to the trauma memory conducted in therapy sessions and repeated as homework with the therapist matching what the patient is describing in the VR; (4) processing of the emotional material that emerges in the VRE; and (5) prolonged in vivo exposure implemented as homework. Edna B. Foa, Elizabeth Hembree, and Barbara Rothbaum provide detailed instructions for conducting exposure therapy with PTSD patients, and Barbara Rothbaum, JoAnn Difede, and Albert “Skip” Rizzo provide detailed instructions for conducting VRE therapy. It appears that for an exposure to be “therapeutic,” patients must learn new information, so it must be conducted long enough in each session and repeated for enough sessions to enable the patient to experience a reduction in anxiety and should be structured to generalize to other contexts in daily life.

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