Background The effectiveness of virtual reality exposure (VRE) in the treatment of anxiety disorders is well established. Several psychological mechanisms of VRE have been identified, whereby both emotional processing and the sense of presence play a key role. However, there are only few studies that contribute to our knowledge of examples of implementation in the case of VRE for claustrophobia based on patients' experiences and the perspective of therapists. Objective This study asks for key elements of a VRE app that are necessary for effective exposure for people with claustrophobic symptoms. Methods A mixed methods design was applied in which patients (n=15) and therapeutic experts (n=15) tested a VRE intervention of an elevator ride at 5 intensity levels. Intensity was varied by elevator size, duration of the elevator ride, and presence of virtual humans. Quantitative measures examined self-reported presence with the Igroup Presence Questionnaire (IPQ) ranging from 0 to 6 and 15 Likert-scaled evaluation items that had been developed for the purpose of this study, ranging from 1 to 5. In both measures, higher scores indicate higher levels of presence or agreement. Think-aloud protocols of the patients and semistructured interviews posttreatment of all participants were conducted to gain in-depth perspectives on emotional processes. Results The intervention induced a feeling of presence in patients and experts, posttreatment scores showed a high IPQ presence score (mean 3.84, SD 0.88), with its subscores IPQ spatial presence (mean 4.53, SD 1.06), IPQ involvement (mean 3.83, SD 1.22), and IPQ experienced realism (mean 2.75, SD 1.02). Patients preferred a setting in the presence of a therapist (mean 4.13, SD 0.83) more than the experts did (mean 3.33, SD 1.54). Think-aloud protocols of the patients revealed that presence and anxiety both were achieved. Qualitative interviews of patients and experts uncovered 8 topics: feelings and emotions, personal story, telepresence, potential therapeutic effects, barriers, conditions and requirements, future prospects, and realization. The intensity levels were felt to appropriately increase in challenge, with ambivalent results regarding the final level. Virtual humans contributed to feelings of fear. Conclusions Key elements of a VRE app for claustrophobic symptoms should include variation of intensity by adding challenging cues in order to evoke presence and anxiety. Virtual humans are a suitable possibility to make the intervention realistic and to provide a sense of closeness; however, some of the fears might then be related to symptoms of social phobia or agoraphobia. Patients may need the physical presence of a therapist, though not all of them share this view. A higher degree of sophistication in the intensity levels is needed to deliver targeted help for specific symptoms of anxiety.
BACKGROUND The effectiveness of virtual reality exposure therapy (VRET) in the treatment of anxiety disorders is well established. Several working mechanisms of VRET have been identified, whereby both emotional processing and the sense of presence play a key role. However, there are only few studies that contribute to our knowledge on the working mechanisms in the case of VRET for claustrophobia. OBJECTIVE The current study asks for the experiences and perspectives of patients, healthy subjects and therapeutic experts testing a VRET application with 5 intensity levels for symptoms of claustrophobia in order to detect working mechanisms and find suggestions for improvement. METHODS A mixed-methods design was applied in which patients (n=15), healthy subjects (n=15) and therapeutic experts (n=15) tested a VRET intervention of an elevator ride in 5 intensity levels. Intensity was varied by elevator-size, duration of elevator-ride, and presence of avatars. Quantitative measures examined pre-treatment state-anxiety (STAI-S), the technology commitment scale (TCS) and post-treatment self-reported presence with the igroup presence questionnaire (IPQ). Finally, a quality score was calculated on the basis of 15 Likert-scaled evaluation items that had been developed for the purpose of this study ranging from 0 to 5. Think-aloud protocols of the patients and semi-structured interviews post-treatment of all participants were conducted to gain in-depth perspectives on emotional processes. RESULTS Pre-treatment anxiety was highest in the patient group with a STAI-S score of M=45.79 (healthy subjects: M=35.47; experts: M=36.80). Technology commitment was M=4.02 among all participants. Post-treatment scores showed a high IPQ presence score (M=3.88, SD=0.90) with differences between the three groups (P=.03*), especially lower values for patients (M=3.77, SD=0.91). Overall evaluation was high with M=4.24 (SD=0.35). The think-aloud protocols of the patients revealed that anxiety and presence both were achieved. Qualitative interviews uncovered 8 topics including feelings & emotions, personal story, telepresence, therapeutic effects, barriers, conditions and requirements, future prospects and realization. CONCLUSIONS The VRET intervention for claustrophobia evoked anxiety in patients and tension in the controls. A feeling of presence was reported by all participants. Patients expressed to prefer the presence of a therapist while doing the intervention. Experts rated the intervention as clinically valuable. Due to the implementation of avatars some of the fears might be related to symptoms of social phobia or agoraphobia. A higher degree of sophistication in the intensity levels is needed to deliver targeted help for specific symptoms of anxiety.
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