Virtual reality can help to develop a new reality

So much of our work as psychiatrists involves attempts to alter our patients’ distorted sense of reality. In an attempt to make public places appear less threatening to patients with agoraphobia, Malbos et al. (2012) used a virtual reality technique called virtual reality exposure therapy (VRET). Their positive findings give us optimism that in the near future we may have another tool to assist our patients on their challenging journey towards the discovery of a new reality. The use of technology that is expensive, complicated and limited to expert centres can give us an illusion of superior efficacy, and although the study by Malbos et al. (2012) does not promote VRET as a more efficacious treatment, it is important to examine the potential additional benefits of VRET, the specific indications for the use of VRET, and where VRET fits among our current psychotherapeutic armamentarium.

VRET involves the use of 3D graphical environments that simulate the feared environment by using computer-generated visual, auditory and tactile sensory inputs. An illusion of being immersed within the digitally created environment is further assisted by input devices that sense a subject’s reactions and motions and accordingly modify the sensory inputs that they receive (Gorini and Riva, 2008). This no doubt provides a more realistic form of exposure than any attempts to imagine the situation in the office environment. Perhaps the closest psychotherapeutic technique to VRET that can currently be employed in the office setting is role play. Role play can simulate a feared situation (particularly in patients with social phobia) and the therapist detects reactions and gives modified responses in an even more sensitive way than a computer. However, role play can only simulate a small range of situations, unlike VRET that can simulate a wide range of different situations and environments.

There are situations where an intermediate step between imagined and direct exposure would be useful, and where this step cannot easily be obtained by establishing a hierarchy of exposure tasks. For example, a patient with flying phobia may need to travel on an aeroplane in a certain number of weeks for a special occasion. Although one may plan trips to the airport or short flights as preparatory exposure tasks, VRET may be more practical and possibly less costly. Hence, VRET may be incorporated within a hierarchy of exposure.

VRET has been used for a wide variety of psychiatric disorders. Despite studies often being small and fraught with methodological issues (Powers and Emmelkamp, 2008), considerable benefits have been demonstrated for flying phobia and acrophobia (Meyerbroker and Emmelkamp, 2010). Studies involving panic disorder and social phobia have shown promise, but often fail to adequately represent patients with more severe symptoms. There are also several studies of patients with post-traumatic stress disorder, but situations are often too idiosyncratic to be represented by generic VRET programs. There have also been studies using VRET to assist patients with body dysmorphic disorder, eating disorders, phobias, generalised anxiety disorder, hallucinations, persecutory delusions, social skills training, stress management and pain syndromes (Ferrer-Garcia and Gutierrez-Maldonado, 2012; Morris et al., 2011; Parsons and Rizzo, 2008).

Virtual reality technology can assist us with more than exposure therapy. It can be used in assessment, enhance education, provide biofeedback and help researchers better understand the underlying phenomena associated with psychiatric disorders. Virtual reality has been used to assess survivors of traumatic events for post-traumatic stress disorder (PTSD) (Kramer et al., 2010). Virtual reality can assist in illustrating the fight/flight response and in identifying physical signs of anxiety. Providing biofeedback regarding the extent of patients’ increased heart rate and skin conductance has assisted patients with generalised anxiety to learn relaxation techniques (Repetto et al., 2009). In a study where VRET was used to treat acrophobia, it was found that anxiety arose not only in the context of height, but as a result of the combined effect of height with motion (Coelho et al., 2009). Thus, VRET can help patients and clinicians understand the disorder they hope to defeat.

Although VRET remains largely confined to research centres, it is a technological advance that is being used to assist patients to face the situations and environments that they fear. VRET has proven to be particularly useful in situations where direct exposure is difficult. In such situations VRET has helped patients reduce their perceived level of threat, and so virtual reality can help to develop a new reality.

See Research by Malbos et al., 2013, 47(2): 160–168.