Review
The use of virtual reality in acrophobia research and treatment

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Abstract

Acrophobia, or fear of heights, is a widespread and debilitating anxiety disorder affecting perhaps 1 in 20 adults. Virtual reality (VR) technology has been used in the psychological treatment of acrophobia since 1995, and has come to dominate the treatment of numerous anxiety disorders. It is now known that virtual reality exposure therapy (VRET) regimens are highly effective for acrophobia treatment. This paper reviews current theoretical understanding of acrophobia as well as the evolution of its common treatments from the traditional exposure therapies to the most recent virtually guided ones. In particular, the review focuses on recent innovations in the use of VR technology and discusses the benefits it may offer for examining the underlying causes of the disorder, allowing for the systematic assessment of interrelated factors such as the visual, vestibular and postural control systems.

Section snippets

Introduction and overview of acrophobia

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (APA, 1994), acrophobia, which is an extreme fear of heights, is considered a specific phobia of naturalistic type. Although long since recognized as a disorder, there is still some doubt about its typology due to its similarities to both panic disorder (Antony, Brown, & Barlow, 1997) and agoraphobia (Davey, Menzies, & Gallardo, 1997). Acrophobia appears closely related to the fear of elevators and

Contributing factors to the development and maintenance of acrophobia

This section reviews the available evidence on contributing factors to the development and maintenance of acrophobia. To date, this literature has tended to focus either on factors gleaned from the broader literature on specific phobias or on the role of specific factors in isolation, rather than on the development of a comprehensive model of acrophobia fear acquisition per se.

Fear of heights treatment models—an historical perspective

Mowrer (1939) proposed one of the first theoretical accounts of acrophobia to be used as a basis for treatment. The two-factor theory of phobia treatment is still in use today and has remained practically unchanged. Fundamentally, this theory states that phobic anxiety is a conditioned response, triggered by a conditioned stimulus (the phobic situation). However, it also adds that situational avoidance develops and remains due to the reinforcement of reduced anxiety (negative reinforcement).

Acrophobia therapy efficacy: early theory-based approaches

The earliest research on acrophobia treatment followed these early theoretical approaches. For example, Ritter (1969a) examined a “contact desensitization” treatment (CD) involving the use of contact with the therapist's hand and arm while engaging in approach responses to the desired behavior. The physical assistance was then gradually eliminated with eventual independent response rehearsal by the participant. Ritter considered the therapeutically effective components of CD to be: (a)

Acrophobia therapy efficacy: the role of cognitive processes

Other early treatment studies of acrophobia focused on the cognitive processes that occur during exposure to heights (Emmelkamp & Felten, 1985; Marshall, Bristol, & Barbaree, 1992; Sutton-Simon & Goldfried, 1979; Williams & Watson, 1985). Sutton-Simon and Goldfried (1979) found acrophobic thoughts in a clinical acrophobic group (N = 58) to be related to faulty thinking statements about themselves, but only when accompanied by reports of discomfort or stress. Moreover, in comparing social anxiety

The potential utility of VR in treating acrophobia

Since 1995, there has been a significant lack of studies on the treatment of acrophobia outside the field of virtual environments. This seems primarily due to the advent of virtual reality exposure therapy (VRET) in 1996, to which this review now turns. Although VR is only a recent field of technological application in research and clinical practice, many of its core concepts have been explored and developed over the past 50 years. Its roots go back to the development of the flight simulator in

Specific acrophobia treatments in virtual environments

According to Botella and colleagues (1998) and Schneider (1982) can be credited with the first use of VR in the treatment of the acrophobia, although one might better describe it as an altered, rather than virtual, reality. In that work, Schneider used binoculars with inverted lenses to alter the perception of depth, so as to magnify the sensation of height during a process of exposure in a real context. This procedure was published as a case study. The participant, a 40-year-old man who lived

Visuo-vestibular triggers

Some of the earliest attempts to understand fear of heights independently of cognitive factors were made by Brandt et al. (1980) and Bles, Kapteyn, Brandt, and Arnold (1980). The authors postulated a physiological mechanism for heights vertigo, separate from psychological factors. Similar to motion sickness, heights vertigo was, in their opinion, due to a conflict between vision and the somatosensory and vestibular systems. They postulated that such a discrepancy occurs when the vestibular and

Summary and conclusion

It emerges from the present review that numerous studies with acrophobic participants aimed to investigate the efficacies of different treatment models and not necessarily to study acrophobia itself. Between 1973 and 1992, research on participants with acrophobia was essentially focused on comparisons between the exposure model and the self-efficacy model. Treatment within the self-efficacy model was usually more structured and had more therapeutic components, such as the mastery of subtasks,

Acknowledgements

This work was funded by a grant from the Portuguese Science and Technology Foundation (ref. SFRH/BPD/26922/2006), awarded to the first author.

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