مواجهه درمانی واقعیت مجازی ومواجهه درمانی استاندارد (در داخل بدن) در درمان ترس از پرواز

This controlled clinical trial tested virtual reality exposure (VRE) therapy for the fear of flying (FOF), a relatively new and innovative way to do exposure therapy, and compared it to standard (in vivo) exposure therapy (SE) and a wait list (WL) control with a 6- and 12-month follow-up. Eighty-three participants with FOF were randomly assigned to VRE, SE, or WL. Seventy-five participants, 25 per group, completed the study. Twenty-three WL participants completed randomly assigned treatment following the waiting period. Treatment consisted of 4 sessions of anxiety management training followed either by exposure to a virtual airplane (VRE) or an actual airplane at the airport (SE) conducted over 6 weeks. Results indicate that VRE was superior to WL on all measures, including willingness to fly on the posttreatment flight (76% for VRE and SE; 20% for WL). VRE and SE were essentially equivalent on standardized questionnaires, willingness to fly, anxiety ratings during the flight, self-ratings of improvement, and patient satisfaction with treatment. Follow-up assessments at 6 and 12 months indicated that treatment gains were maintained, with more than 70% of respondents from both groups reporting continued flying at follow-up. Based on these findings, the use of VRE in the treatment of FOF was supported in this controlled study, suggesting that experiences in the virtual world can change experiences in the real world.

The best estimate of fear of flying (FOF) is 10% to 40% (Dean & Whitaker, 1982 and Van Gerwen & Diekstra, 2000), or approximately 25 million adults in the U.S., many of whom avoid flying entirely. As many as 20% of all flyers depend on alcohol or sedatives to reduce anxiety symptoms during flights (Griest & Griest, 1981 and Howard et al., 1983). Since the September 11 terrorist attacks, there has been a 10% to 30% decrease in airline travel, affecting the airline industry, the business community, and the overall economy (Ito & Lee, 2004). FOF treatment programs are increasingly popular and lucrative. Most of these programs use a CBT approach including both anxiety management (e.g., relaxation training, cognitive restructuring, psychoeducation) and exposure (i.e., flying) (Van Gerwen, Spinhoven, Diekstra, & Van Dyck, 2002). Many FOF programs affiliated with the airlines (see Van Gerwen & Diekstra, 2000, for a review) report positive outcomes but do not conduct standardized research, with the exception of Van Gerwen et al. (2002). Virtual reality (VR) has developed as one of several new computer-based formats for the delivery of exposure therapy (Anderson, Jacobs, & Rothbaum, 2004). The use of VR in the treatment of anxiety disorders is receiving increasing scientific (Anderson et al., 2000, Zimand et al., 2002 and Zimand et al., 2003) and public (Carmichael et al., 2001, Hoffman, 2004 and Szegedy-Maszak, 2004) attention. VR is a human-computer interaction paradigm in which users are active participants within a computer-generated three-dimensional virtual world. To become part of the virtual world, the user wears an immersive head-mounted display (HMD) that consists of a display screen for each eye, earphones, and a head-tracking device, while sitting or standing on a low platform atop a bass speaker, thus placing the user within a multisensory, 360-degree environment that can provide visual, auditory, and kinesthetic cues (i.e., vibrations). Natural body and head motion by the user corresponds to change within the virtual world. The image seen by the user in the HMD is displayed on a computer monitor for the therapist to view. A sense of presence, essential to conducting exposure therapy, distinguishes VR from an interactive computer graphics display. Regenbrecht, Schubert, and Friedmann (1998) studied the sense of presence in which arousal is elicited by the user “developing a mental representation of the virtual stimuli as one's own environment” (p. 246). Although the user's experience is entirely computer-generated, the individual's perception overlooks the role of technology in the experience (Krijn, Emmelkamp, Olafsson, & Biemond, 2004). There are several advantages to VR for FOF and other exposures. VR exposure (VRE) takes place in a therapy office, which is more convenient and provides an intermediate step between the therapy office and the real world (Botella, Osma, Garcia-Palacios, Quero, & Banos, 2004). As a result, researchers have suggested that VR exposure has greater appeal over in vivo exposure and may help more individuals who meet criteria for an anxiety disorder to seek treatment (Garcia-Palacios, Hoffman, See, Tsai, & Botella, 2001). For FOF, it is less expensive to pay for VR sessions in a therapist's office than to purchase airline tickets and pay for the therapist to accompany the client. Confidentiality can more easily be maintained relative to in vivo exposure conducted in a public place. Finally, VR can effectively meet the basic criteria for exposure, including a high degree of control, the ability to present anxiety-producing stimuli over and over, and the ease of prolonging the exposure in order to achieve habituation (Foa & Kozak, 1986 and Foa et al., 1989). A body of research is accumulating supporting the use of VRE within a comprehensive treatment program for anxiety disorders. Case studies support the use of VRE in the treatment of anxiety disorders, including specific phobia of flying (North et al., 1997, Rothbaum et al., 1996, Smith et al., 1999 and Wiederhold et al., 1998), specific phobia of spiders (Carlin, Hoffman, & Weghorst, 1997), claustrophobia (Botella et al., 1998 and Botella et al., 2000), acrophobia (Choi et al., 2001 and Rothbaum et al., 1995b), and social anxiety (Anderson, Rothbaum, & Hodges, 2003). Two case studies have reported that VRE was successful at reducing PTSD symptoms: one in a Vietnam veteran (Rothbaum et al., 1999) and another in a survivor of the 9/11 World Trade Center attacks (DiFede & Hoffman, 2002). These case studies were followed by successful open clinical trials without comparison groups for combat-related PTSD (Rothbaum, Hodges, Ready, Graap, & Alarcon, 2001), social anxiety (Anderson, Rothbaum, Hodges, & Zimand, submitted for publication), acrophobia (Emmelkamp, Bruynzeel, Drost, & van der Mast, 2001), post-earthquake traumatic stress (Basoglu, Livanou, & Salcioglu, 2003), and FOF (Botella et al., 2004). A recent application of VR to fear of driving (Wald, 2004) with five participants in a multiple-baseline across-subjects design yielded only modest outcome in anxiety reduction and did not result in generalization to actual driving behavior. Randomized clinical trials comparing VRE to wait list (WL) control groups have been conducted for several of the anxiety disorders. The first published controlled study used VRE therapy compared to WL for the treatment of acrophobia (Rothbaum et al., 1995a). Another controlled study demonstrated the efficacy of VRE therapy compared to WL for reducing public speaking anxiety among university students (Harris, Kemmerling, & North, 2002). A drawback to these studies is the small sample sizes, ranging from 10 to 20 participants. Several controlled trials using VRE for fear of heights and flying have been conducted by independent researchers around the world. Emmelkamp and colleagues (2002) compared in vivo exposure with an exact replication of the environment in VR for acrophobia (N = 33). Participants in both treatments reported reduced anxiety, avoidance, and distress, and were able to confront real-life heights situations following treatment, maintaining treatment gains at 6-month follow-up. A drawback to this study was the absence of a no-treatment control group. The same researchers tested VRE for acrophobia in two different formats believed to vary in degree of presence. VRE using a PC delivered through an HMD was compared to a computer automatic virtual environment (CAVE), a multi-user projection-based VR system in which the patient and therapist were surrounded by stereoscopic computer-generated images on four sides of a room. These two active VRE interventions were compared to a WL control group (Krijn, Emmelkamp, Biemond, et al., 2004; N = 37). Findings indicated that both active treatments were equally effective in helping individuals overcome a fear of heights and both were more effective than the control group, but there were a high number of dropouts (n = 10), all of whom reported less presence, the sense that they were “there” and immersed in the virtual environment. These results suggested that VR could be effectively delivered through an HMD, which is exponentially less expensive than the CAVE system; however, individual users may differ in the extent to which they can develop a sense of presence. VRE has been tested extensively for treatment of FOF in well-controlled designs by independent researchers. The first of these studies compared VRE to standard in vivo exposure therapy (SE) and WL control (Rothbaum, Hodges, Smith, Lee, & Price, 2000; N = 45). Both treatments were found to be equally effective and significantly better than the control group. Treatment gains were maintained at a 12-month follow-up with over 90% of respondents reporting continuing to fly ( Rothbaum, Hodges, Anderson, Price, & Smith, 2002). In another controlled study using VR for FOF, long-term follow-up (i.e., 3 years) data suggested that VRE continued to be more effective than imaginal exposure ( Wiederhold & Wiederhold, 2003; N = 30). Muhlberger and researchers (2001) compared VRE with relaxation training (N = 30). Both treatments were found to be helpful related to negative cognitions regarding flying, but VRE was more effective for specific flying-related behavior. In an attempt to dismantle the components of treatment for FOF, these researchers compared: (a) cognitive therapy plus VRE with motion simulation, (b) cognitive therapy plus VRE without motion simulation, and (c) cognitive therapy alone ( Muhlberger, Wiedemann, & Pauli, 2003; N = 45). VRE with or without motion simulation was more effective than cognitive therapy alone for FOF. Another group of researchers compared VRE to attention-placebo group therapy (N = 45), which consisted of psychoeducation about flying and sharing of fears among group members ( Maltby, Irving, Mayers, & Allen, 2002). VRE led to a significant decline in FOF compared to the group therapy, although its superiority was not maintained at 6-month follow-up. Results from all these studies suggested that VRE therapy is more effective than nontreatment control groups and at least as effective as other forms of exposure therapy. The randomized controlled clinical trial reported here is a replication and extension of a previous clinical trial completed by Rothbaum and colleagues (2000). This study extends the previous study with a larger sample size, 6- and 12-month follow-up data, and randomization of the WL group to the two active treatments following completion of the WL period. The following primary hypotheses were tested: VRE and SE would be equally effective and more effective than WL control in reducing participants' fears of flying and avoidance behavior, and treatment gains would be maintained at 6- and 12-month follow-ups.