NIHR DC Discover

Immersive virtual reality being used in therapy

NIHR Signal Virtual reality therapy reduces fear of heights

Published on 2 October 2018

doi: 10.3310/signal-000653

Virtual reality therapy directed by a virtual therapist substantially reduced fear of heights compared to patients’ own usual care, which was mainly no treatment.

One hundred participants had moderate fear of heights or worse. After roughly six sessions of virtual reality treatment, participants’ fear of heights was lessened, and some said that it had improved how they coped with heights in their daily lives.

These results show that this intervention is effective and suggests potential for virtual reality therapy for other similar disorders or phobias. There is a national programme to improve access to psychological therapy by adopting digital therapy programmes with proven effects. The virtual reality programme to treat fear of heights may fit criteria for further testing or widespread use.

Share your views on the research.

Why was this study needed?

A phobia is a type of anxiety disorder affecting about 2.4% of people in England. A person can have a phobia about an object, place, situation, feeling or animal. It is an overwhelming and debilitating fear out of proportion to the risk posed. Symptoms of anxiety such as nausea, sweating, increased heart rate and shaking occur when the person encounters or thinks about the object or situation. This leads to avoidance of the source of the phobia. 

Phobias may be treated by gradually exposing the person to the trigger. The person remains at each level of exposure until their anxiety levels reduce. Exposure therapy in a virtual reality environment has been explored for around 25 years but only with the supervision of a psychologist. This study looked at whether a behavioural approach using automated virtual reality experiments (without asking the person to remain in the situation until their anxiety decreased) reduced height phobia.

What did this study do?

This randomised controlled trial assigned 100 people with a fear of heights either to virtual reality-based therapy or to continue with their usual care, which was generally no treatment. Participants were recruited by radio adverts and had at least a moderate fear of heights.

The software was designed to be used without support from a live therapist. However, a graduate psychologist was present to help set up the equipment and for health and safety. The treatment programme involved about six sessions of 30 minutes over two weeks. This varied depending on how quickly the person progressed. A virtual coach supported the person through the programme, with randomly ordered interactive tasks at each level of a virtual 10-story building.

What did it find?

  • At the four week follow-up, the average Heights Interpretation Score (range 18 to 80) had reduced in the virtual reality treatment group from 52.5 to 27.5. The score remained high at 52.6 in the control group (adjusted difference −24.3, 95% confidence interval [CI] −27.9 to −20.6).
  • People who had virtual reality therapy were less likely to avoid heights, as shown by participants’ comments. Additionally, reductions were seen in the Improving Access to Psychological Therapies phobia scale-avoidance, which ranges from 0 to 8. A score of eight represents ‘always avoid’. At four weeks this score was 1.7 with virtual reality therapy and 4.6 in the control group (adjusted difference −2.9, 95% CI −3.4 to −2.3).
  • The experience of virtual reality was associated with a small increase in discomfort measured with the Simulation Sickness Questionnaire (range 0 to 48). On average people scored 1.6 before entering, increasing slightly to 3.8 after their first session, and a similar increase was also seen after their last session.
  • Most people assigned to virtual reality therapy attended at least one session (47 of 49 [96%]), and on average attended 4.7 sessions.

What does current guidance say on this issue?

There is no guidance covering virtual reality therapy for treating phobias. Overall, little guidance is available for treating phobias.

NICE 2013 guidance on social anxiety disorder does not recommend the use of computerised cognitive behavioural therapy to treat specific phobias because of lack of effect compared with therapist-delivered treatment.

NICE and NHS England are working together to evaluate digital psychological treatments in practice and recommend whether they should be made available nationally within the Improving Access to Psychological Therapies programme.

What are the implications?

This small study showed a large effect of virtual reality therapy that was greater than that commonly found with face to face treatment. People responding to a radio advert may, however, have been more receptive than other people, and this might increase the effect of the treatment in the study.

Virtual reality has the potential to treat other phobias or similar disorders. The cost of developing and testing software for individual conditions may be high, but on-going costs are predicted to be low. Efforts to increase access to effective digital services mean that virtual reality-based psychological therapies could become widely available in the future.

Citation and Funding

Freeman D, Haselton P, Freeman J, et al. Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial. Lancet Psychiatry. 2018;5(8):625-32.

This project was funded by the National Institute for Health Research Oxford Health Biomedical Research Centre and Oxford VR.

Bibliography

Baker C. Mental health statistics for England: prevalence, services and funding. London: House of Commons Briefing Paper; 2018.

NHS. Phobias. London: Department of Health; updated 2016.

NICE. Improving access to psychological therapies (IAPT). London: National Institute for Health and Care Excellence.

NICE. Social anxiety disorder: recognition, assessment and management. CG159. London: National Institute for Health and Care Excellence; 2013.

Why was this study needed?

A phobia is a type of anxiety disorder affecting about 2.4% of people in England. A person can have a phobia about an object, place, situation, feeling or animal. It is an overwhelming and debilitating fear out of proportion to the risk posed. Symptoms of anxiety such as nausea, sweating, increased heart rate and shaking occur when the person encounters or thinks about the object or situation. This leads to avoidance of the source of the phobia. 

Phobias may be treated by gradually exposing the person to the trigger. The person remains at each level of exposure until their anxiety levels reduce. Exposure therapy in a virtual reality environment has been explored for around 25 years but only with the supervision of a psychologist. This study looked at whether a behavioural approach using automated virtual reality experiments (without asking the person to remain in the situation until their anxiety decreased) reduced height phobia.

What did this study do?

This randomised controlled trial assigned 100 people with a fear of heights either to virtual reality-based therapy or to continue with their usual care, which was generally no treatment. Participants were recruited by radio adverts and had at least a moderate fear of heights.

The software was designed to be used without support from a live therapist. However, a graduate psychologist was present to help set up the equipment and for health and safety. The treatment programme involved about six sessions of 30 minutes over two weeks. This varied depending on how quickly the person progressed. A virtual coach supported the person through the programme, with randomly ordered interactive tasks at each level of a virtual 10-story building.

What did it find?

  • At the four week follow-up, the average Heights Interpretation Score (range 18 to 80) had reduced in the virtual reality treatment group from 52.5 to 27.5. The score remained high at 52.6 in the control group (adjusted difference −24.3, 95% confidence interval [CI] −27.9 to −20.6).
  • People who had virtual reality therapy were less likely to avoid heights, as shown by participants’ comments. Additionally, reductions were seen in the Improving Access to Psychological Therapies phobia scale-avoidance, which ranges from 0 to 8. A score of eight represents ‘always avoid’. At four weeks this score was 1.7 with virtual reality therapy and 4.6 in the control group (adjusted difference −2.9, 95% CI −3.4 to −2.3).
  • The experience of virtual reality was associated with a small increase in discomfort measured with the Simulation Sickness Questionnaire (range 0 to 48). On average people scored 1.6 before entering, increasing slightly to 3.8 after their first session, and a similar increase was also seen after their last session.
  • Most people assigned to virtual reality therapy attended at least one session (47 of 49 [96%]), and on average attended 4.7 sessions.

What does current guidance say on this issue?

There is no guidance covering virtual reality therapy for treating phobias. Overall, little guidance is available for treating phobias.

NICE 2013 guidance on social anxiety disorder does not recommend the use of computerised cognitive behavioural therapy to treat specific phobias because of lack of effect compared with therapist-delivered treatment.

NICE and NHS England are working together to evaluate digital psychological treatments in practice and recommend whether they should be made available nationally within the Improving Access to Psychological Therapies programme.

What are the implications?

This small study showed a large effect of virtual reality therapy that was greater than that commonly found with face to face treatment. People responding to a radio advert may, however, have been more receptive than other people, and this might increase the effect of the treatment in the study.

Virtual reality has the potential to treat other phobias or similar disorders. The cost of developing and testing software for individual conditions may be high, but on-going costs are predicted to be low. Efforts to increase access to effective digital services mean that virtual reality-based psychological therapies could become widely available in the future.

Citation and Funding

Freeman D, Haselton P, Freeman J, et al. Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial. Lancet Psychiatry. 2018;5(8):625-32.

This project was funded by the National Institute for Health Research Oxford Health Biomedical Research Centre and Oxford VR.

Bibliography

Baker C. Mental health statistics for England: prevalence, services and funding. London: House of Commons Briefing Paper; 2018.

NHS. Phobias. London: Department of Health; updated 2016.

NICE. Improving access to psychological therapies (IAPT). London: National Institute for Health and Care Excellence.

NICE. Social anxiety disorder: recognition, assessment and management. CG159. London: National Institute for Health and Care Excellence; 2013.

Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial

Published on 11 July 2018

D Freeman, P Haselton, J Freeman, B Spanlang, S Kishore, E Albery, M Denne, P Brown, M Slater, A Nickless

The Lancet Psychiatry , 2018

Background Engaging, interactive, and automated virtual reality (VR) treatments might help solve the unmet needs of individuals with mental health disorders. We tested the efficacy of an automated cognitive intervention for fear of heights guided by an avatar virtual coach (animated using motion and voice capture of an actor) in VR and delivered with the latest consumer equipment. Methods We did a randomised trial of automated VR versus usual care. We recruited adults aged older than 18 years with a fear of heights by radio advertisements in Oxfordshire, UK. We diagnosed fear of heights if participants scored more than 29 on the Heights Interpretation Questionnaire (HIQ). We randomly allocated participants by computer in a 1:1 ratio to either automated VR delivered in roughly six 30-min sessions administered about two to three times a week over a 2-week period (intervention group) or to usual care (control group). Randomisation was stratified by severity of fear of heights. The research team, who were unaware of the random allocation, administered three fear-of-height assessments, at baseline (0 weeks), at the end of treatment (2 weeks), and at follow-up (4 weeks). The primary outcome measure was HIQ score (range 16–80, with higher scores indicating greater severity). This trial is registered with the ISRCTN registry, number ISRCTN11898283. Findings Between Nov 25, 2017, and Feb 27, 2018, 100 individuals were enrolled and underwent randomisation, of whom 49 were assigned to the VR treatment group and 51 to the control group. All participants completed the 4-week follow-up. The mean total treatment time in VR was 124·43 min (SD 34·23). Compared with participants in the control group, the VR treatment reduced fear of heights at the end of treatment (mean change score −24·5 [SD 13·1] in the VR group vs −1·2 [7·3] in the control group; adjusted difference −24·0, 95% CI −27·7 to −20·3; Cohen's d=2·0; p<0·0001). The benefit was maintained at follow-up (mean change score −25·1 [SD 13·9] in the VR group vs −1·5 [7·8] in the control group; adjusted difference −24·3, 95% CI −27·9 to −20·6; Cohen's d=2·0; p<0·0001). The number needed to treat to at least halve the fear of heights was 1·3. No adverse events were reported. Interpretation Psychological therapy delivered automatically by a VR coach can produce large clinical benefits. Evidence-based VR treatments have the potential to greatly increase treatment provision for mental health disorders. Funding Oxford VR, and the National Institute of Health Research Oxford Health Biomedical Research Centre.

Expert commentary

This study provides interesting evidence of the effectiveness of the use of a virtual reality based intervention in the treatment of acrophobia (fear of heights). This single-blind, parallel group, randomised controlled trial demonstrated the superiority of the use of a virtual reality headset versus usual treatment (cognitive behaviour therapy) in the treatment of acrophobia. While acrophobia may be a distressing condition for those affected, fewer people are referred for NHS treatment in comparison with other phobias (agoraphobia, social phobia). It remains to be seen how cost-effective it would be to implement this intervention in an NHS setting where referral rates are low.

Dr Tomas Campbell, Consultant Clinical Psychologist, Cogito Psychological Services & NPsych Rehabilitation, London