April 2, 1999

Been there, done that.

That may be easy for most of us to say, but for those suffering from phobias or symptoms of posttraumatic stress, returning to a terrifying situation-virtually if not actually-may hold the key to recovery, psychologist Barbara Rothbaum, Ph.D., told members of the American College of Psychiatrists (ACP) at ACP's annual meeting in San Francisco in February.

Although virtual environments need not be so authentic as to be indistinguishable from reality, they must be authentic enough to evoke fear, according to Rothbaum, an associate professor in psychiatry at the Emory University School of Medicine in Atlanta, Ga.

"If the environments don't scare 'em, they don't get better," she said. Although her main focus is treating posttraumatic stress disorder (PTSD), Rothbaum and colleagues have successfully helped people overcome phobias including acrophobia and fear of flying. Her study of 20 college students with acrophobia, published in the April 1995 American Journal of Psychiatry, was the first controlled study of virtual reality in the treatment of a psychiatric disorder, according to Rothbaum. In that study, the VRE group showed a decline in anxiety and avoidance while there was no change in the control group. Seven out of 10 in the study voluntarily exposed themselves to real-life height environments by the end of the study.

The positive impact of successful treatment can be dramatic, as in the case of a patient who had entered treatment when his fear led him to walk up 72 stories of stairs at an Atlanta hotel rather than ride in a glass elevator. After VRE therapy, he returned to the hotel and rode the elevator.

The technology continues to evolve and has become more readily affordable and accessible, according to Rothbaum. A complete setup sufficient for therapy now costs about $22,000, but the price will probably decline as computers and virtual reality hardware become less costly.

VRE therapy may ultimately become routine for clinicians whose practice revolves around treating anxiety disorders, although clinicians whose practice leans heavily on prescribing psychotropic drugs may be less inclined to employ VRE, said Rothbaum. For her, the capacity to conduct VRE on site "makes my life much easier, improves the ease of treatment, and decreases costs for patients," Rothbaum commented.

The National Institute of Mental Health (NIMH) is currently conducting a controlled study of VRE for fear of flying, Rothbaum noted. The simulated therapy is especially welcome for fear of flying, since standard exposure therapy requires costly and time-consuming trips to the airport and having people take actual flights accompanied by a therapist. It is easy to understand the tremendous savings in time, money, and energy that can be achieved through use of VRE in combating fear of flying, she noted. Following both VRE therapy and standard exposure therapy, comparable numbers of flight-phobic individuals are able to fly, said Rothbaum.

VRE therapy is invariably safer than actual exposure therapy, and in the case of combat-induced stress, is the only realistic option for recreating sensory aspects of the original combat situation, Rothbaum observed.

On most measures, VRE is comparable to standard exposure therapy in reducing anxiety and avoidance. "We don't need to beat standard exposure therapy" to make the case for VRE given all the advantages of cost, control, convenience, and safety, she noted.

In her therapy for people with PTSD, Rothbaum is working both with rape victims and Vietnam veterans. For rape victims, the actual sexual assault is not recreated, but settings related to the assault-such as parking lots or alleys-are recreated. For Vietnam veterans, Rothbaum has worked with technicians to develop a virtual Vietnam complete with Vietnam-era helicopters, jungle sounds, clearings, rivers, and bursts of gunfire. The results of the therapy have not been formally published but are promising.

Rothbaum is particularly excited about use of VRE for Vietnam veterans, as the prevalence of PTSD in that group is high, with 49 percent, or 830,000 veterans, currently suffering clinically significant distress and disability from PTSD symptoms.

In her ongoing work with veterans, she exposes them to virtual Vietnam 10 to 14 times in twice weekly, 60- to 90-minute sessions conducted on an outpatient basis.