مواجهه با واقعیت مجازی در درمان اختلال هراس با موقعیت هراسی: مطالعه موردی

In this work we present a case example of the use of virtual reality exposure for the treatment of panic disorder with agoraphobia. The assessment protocol and procedure (including a baseline period) and the cognitive-behavioral treatment program are described. The clinical measures were categorized into target behaviors, panic and agoraphobia measures, global functioning, and general psychopathology measures. The patient’s expectations and satisfaction with regard to the virtual treatment were also assessed. The results showed an important reduction in all clinical measures after treatment with virtual exposure and the patient reached the therapeutic goals established during the pretreatment assessment. The patient also reported a good acceptance of virtual exposure. The goals achieved in the virtual environment generalized to real agoraphobic situations and to other real situations not treated. Three-, 6-, and 12-month follow-up assessments were conducted and long-term therapeutic gains were maintained.

Cognitive-behavioral programs (CBT) have demonstrated efficacy in the treatment of panic disorder with and without agoraphobia (Barlow et al., 1998, Barlow et al., 2000, Barlow et al., 2002 and Botella, 2001). CBT for panic disorder includes different components, mainly situational and interoceptive exposure, cognitive restructuring, and breathing or relaxation training. These programs are considered empirically supported treatments meeting most of the requirements of the Task Force on Promotion and Dissemination of Psychological Procedures (American Psychological Association Task force on Promotion and Dissemination of Psychological Procedures, 1993, American Psychological Association Task force on Psychological Intervention Guidelines, 1995, Chambless et al., 1996, Chambless et al., 1998 and Nathan and Gorman, 2002). The National Institutes of Health (NIH, 1991) recommended these programs as the treatment of choice for this disorder. However, there are some difficulties in the effective dissemination of empirically validated treatments among mental health professionals (Barlow, Levitt, & Bufka, 1999) and in the use of some therapeutic strategies included in these programs. For example, 20% to 25% of participants reject in vivo exposure because they find it too aversive to confront the feared situations (García-Palacios et al., 2001 and Marks and O’Sullivan, 1992). Therefore, it is important that researchers develop strategies to increase the availability, attractiveness, and acceptance of these treatment programs, and consider ways to maximize cost benefit. One promising research line is the use of virtual reality (VR) as exposure therapy in the treatment of phobias, such as claustrophobia (Botella et al., 2000 and Botella et al., 1999), fear of heights (Emmelkamp, Krijn, Hulsbosch, Vries, Schuemie, & van der Mast, 2002), spider phobia (García-Palacios, Hoffman, Carlin, Furness, & Botella, 2002b), and flying phobia (Maltby et al., 2002, Mühlberger et al., 2001, Mühlberger et al., 2003, Rothbaum et al., 2002 and Wiederhold et al., 2002). These studies and others (see Anderson et al., 2004 and Krijn et al., 2004; and Pull, 2005, for a review) show that VR is a useful tool that allows for a high degree of control over virtual situations. For example, in exposing a patient to a virtual mall, we can control the amount of people who are inside the mall, ensuring that the mall is not too crowded during the exposure task—unless we want the mall to be crowded. This is not always possible in real situations. Another advantage is the fact that we can conduct exposure to different situations (a bus, a train, a tunnel, an elevator) without leaving the consultation room. At the same time, we think that this new tool can help to increase patients’ acceptance of exposure. García-Palacios et al. (2001) offered preliminary data of the preference for VR exposure over in vivo exposure in a sample of subclinical phobics. In two former studies our research team observed that a VR exposure program for the treatment of claustrophobia produced benefits in agoraphobic behaviors not specifically treated (Botella et al., 1999 and Botella et al., 2000). These results allowed us to consider the possibility of using VR for the treatment of panic disorder with agoraphobia. With specific phobias it is often the case that VR exposure constitutes the only active component of the program. In the case of panic disorder with agoraphobia, VR would be used to apply one of the active components of the CBT program: situational and interoceptive exposure. A few studies offer descriptions and noncontrolled data on the use of VR in panic and agoraphobic in nonclinical samples (Moore et al., 2002, North et al., 1996 and Vincelli et al., 2000). There are three works that included clinical samples of panic disorder and agoraphobia. Jang, Ku, Shin, Choi, and Kim (2000) reported negative efficacy data from a noncontrolled study, where the VR environments designed were not able to elicit an anxiety response in seven participants. Vincelli et al. (2003) compared the efficacy of a VR program with a standard program and a waiting-list condition. They reported that both treatment groups improved significantly from pretest to posttest. However, this study presented some methodological limitations that make it difficult to draw definitive conclusions. It is not clear how much improvement in the VR group could be attributed to the VR exposure or to the in vivo exposure, given that the participants assigned to the VR condition also received instructions to practice in vivo exposure between sessions. Furthermore, the participants in each condition received a different amount of exposure. The authors noticed that VR produced results using 33% fewer sessions than CBT (the VR group received 8 sessions, whereas the CBT group received 14 sessions); however, the absence of an assessment session after Session 8 in the CBT group (in order to compare the improvement achieved in both groups after the same number of sessions) limits the value of this conclusion. Our research team has just completed a controlled study that offers pre-post efficacy data comparing in vivo exposure, VR exposure, and a waiting-list condition (Botella et al., 2002). However, in this work we only present short-term efficacy data and the description of the clinical protocol is limited. Our VR program was designed to treat the main features of panic disorder and agoraphobic avoidance (situational and interoceptive avoidance). This program allows us to conduct interoceptive exposure (by simulation of bodily sensations like shortness of breath, blurred vision, or palpitations) while the patient is immersed in a virtual agoraphobic situation (a shopping mall, a train, or a bus). Another characteristic of our virtual environment is the flexibility of the scenarios, including six meaningful agoraphobic situations where it is possible to practice numerous exposure tasks, with the possibility of introducing at the therapist and patient’s will several elements in order to adapt the VR environment to the patient’s needs (for a more detailed description of the VR environments, see Botella et al., 2004). The aim of this work is to illustrate, using a case study, the utility of VR exposure in the treatment of panic disorder with agoraphobia. The contribution of this study to the VR exposure literature is to offer a detailed clinical description of the use of the program and to offer the first preliminary data of the long-term efficacy of VR exposure for the treatment of panic disorder with agoraphobia.