Treating Anxiety with Virtual Reality Exposure with Larry Hodges, PhD, Barbara Rothbaum, PhD, and Kenneth Graap BS, ME

Last Editorial Review: 10/23/2003

WebMD Live Events Transcript

Fear of flying have you grounded? Fear of heights have you down? Does the prospect of public speaking leave you speechless? Join Dr. Barbara Rothbaum, Larry Hodges, PhD and Ken Grapp, MEd, to learn how virtual reality is being used to treat anxiety .

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to Atlanta Live Events. Our guests today are Dr. Barbara Rothbaum, Larry Hodges, Ph.D., and Ken Grapp, M.Ed., experts from Virtually Better, Inc. Learn how virtual reality is being used to treat anxiety and post-traumatic stress disorder.Welcome everyone. Thank you for joining us today.

Dr. Rothbaum: Hello. Welcome to our live chat on virtual reality.

Grapp: I'm Ken Grapp at Virtually Better. Thanks for being here.

Dr. Hodges: I'm Dr. Hodges from Virtually Better.

Moderator: What is virtual reality?

Dr. Hodges: Virtual reality is the use of computer graphics, audio, and sometimes tactile feedback to produce a computer-generated environment that people experience as a real environment. People feel immersed in virtual reality. It is more than just multimedia because you can look around 360 degrees. It soon becomes your reality.

Dr. Rothbaum: Most of the virtual environments are animated and people very often respond, initially, to that animated quality, but within about 20 to 30 seconds, that becomes their reality. Certainly, by their second session in VR, they become accustomed to it, and if it's going to scare them it scares them, and they can interact with it more.

Moderator: Dr. Rothbaum, please give us a bit of your background.

Dr. Rothbaum: I have been treating anxiety disorders for close to two decades now, and I do a lot of what's called "exposure therapy." In exposure therapy, we help people confront what they are scared of in a therapeutic way. In 1993, Dr. Hodges called me, and asked what I thought of using VR for exposure therapy, and I said, You want to do what? But then we designed our first study with the fear of heights, and it worked. People actually exposed themselves to real life height situations after going through VT (virtual therapy), so we have continued ever since applying it to new disorders every year.

Moderator: How did all of you get together?

Dr. Hodges: I have a PhD in computer engineering, and work primarily in computer graphics and VR since 1984. Someone actually came into my office in 1993 and suggested  that we use VR to treat public speaking, which I thought was a silly idea at the time, because creating VR people was very difficult with technology at that time. But I happened to mention the idea to my brother in law, who is a psychiatrist, and he called me every weekend for a month trying to convince me that this was a good idea. I just hadn't thought about it deeply enough yet. So what happened was that eventually, he asked me what can you do in VR? I said, well, we can do manmade structures like buildings, so we came up with the idea of doing fear of heights, and after we roughed out the rough idea, and we had an opportunity to get funding, but we needed a principal investigator, not only from Georgia Tech, but also Emory. So I asked my brother in law to call Emory and find out who was the best person in behavior therapy, and they recommended Barbara. So I had my brother in law call Barbara first, because if VR calls, they just think some nut is on the phone. We did the proposal together, it got funded, and we began working together. 

I think it's important that when we began, no one knew that if you were afraid of heights in the real world, that you would also be afraid in VR. That was an open question. No one knew whether or not if you got anxious in a VR and habituated and got better, whether or not that would carry over to the real world, so when we began we had no idea if this would be effective at all. But as it turned out, all of these things were true. People got anxious in the Virtual environment, they got better, and it carried over to the real world.

Moderator: Please give us an outline of how you create a virtual environment (VE).

Dr. Rothbaum: I met with Dr. Hodges and his brilliant computer scientist graduate student, and explained what were some of the important aspects of a therapeutic exposure. So for example, with the fear of heights, we discussed what high places I would take people to in Atlanta, and they went back and built them in VR.

Grapp: I think you have to look at what is being done clinically presently, and then look for commonalities in the virtual world. The idea is you have to create an environment that will work for a lot of people

smersh_WebMD: This might be a geek questions -- but what OS/hardware are you using to do the VR rendering?

Dr. Hodges: This is completely pc based, using Windows 98. The software that's used to develop VE is two aspects. The software used is 3d Studio Max, which is a commercial CAD program. And then for all of the software support for realtime VR, we use something called Simple Virtual Environment toolkit, which was developed at Georgia Tech. The environments are all presented in head mounted displays, and currently we use something called 3D-fx. It's from IIS.

Moderator: Plenty of people suffer from "fear of flying" or can't face the prospect of public speaking. Can you outline the major anxieties or phobias and the extent of the problem.

Dr. Rothbaum: The number one phobia is fear of public speaking. For fear of flying, it's estimated that approximately 25 million people in the US are sufferers.

Grapp: The fear of public speaking, there are estimates that there are between 26 and 57 million people could be affected by fear of public speaking.

Dr. Rothbaum: The difference between fears and phobias, is that everyone has fears. For it to be a real phobia, it has to cause excessive anxiety, it has to lead to avoidance, and it has to interfere with the person's life. That's when they seek treatment.

Grapp: For post traumatic stress, the estimates are about 830,000 Vietnam Era veterans who are diagnosed with PTSD (post traumatic stress disorder). There are some estimates that up to 20 percent of people who fly on a daily basis may be using alcohol or sedatives in order to cope with the anxiety associated with flying.

Moderator: How prevalent is fear of heights?

jgers01_WebMD: What kind of anxiety disorders can you treat with virtual reality?

Dr. Rothbaum: Right now, we have applications for the fear of flying, the fear of public speaking, the fear of heights, fear of thunderstorms, a virtual mall for agorophobia, virtual Vietnam for veterans with PTSD, and we are planning more. If anyone has a good idea, they should feel free to contact us, and we may build their environment.

Dr. Hodges: VR has been used for other phobias. IF we can build a VE that contains the feared stimulus, then we can do therapy with it. Fear of animals is something that can be done; fear of spiders has been done successfully, driving phobias, and so we are probably only limited by imagination and time to create the VE.

Moderator: Has it been used for claustrophobia?

Dr. Hodges: Yes, there have been reports in literature that it has been, but we haven't done that yet.

tenuli_WebMD: What is the success rate for treating different kinds of phobias with virtual reality?

Dr. Rothbaum: With the fear of heights, all of the people who received the VR exposure therapy improved more than the controls, and seven out of ten reported exposing themselves to real life height situations by the end of treatment. For the fear of flying, the VR treatment works as well as standard exposure therapy, and at six months following treatment, 90 percent of people had flown.

Moderator: What are the advantages to using VR instead of reality?

Grapp: One of the advantage are that you have a lot more control over the situation in VR. You also can schedule more efficiently because you are not meeting people outside of your office . You protect the confidentiality of your patients as a therapist because you don't leave your office.

marzel2_WebMD: Are there effective ways of getting over the fear of flying without therapy, especially for longer trips? It doesn't leave me incapacitated, but it does make me extremely nervous and agitated during the ride.

Dr. Rothbaum: You may want to try some anxiety management techniques, for example, slow breathing. You probably want to make sure that you are not scaring yourself, and acting or feeling as if you are facing death, and being thankful each time the plane lands that you narrowly escaped death. So watch your thinking.

marzel2_WebMD: Yes, I find that I always have to have a couple of drinks before boarding a plane. Would you call this self-medication, and is that the wrong way of going about easing anxieties?

Dr. Rothbaum: Yes, that is called self-medication. It is not my preferable way to deal with anxiety. Some people have told me that they have to fly the day before a business trip, because they're sloshed when they get off the plane and need to recover. I consider that interfering with their life, that maybe there are more effective ways to handle their anxiety.

tenuli_WebMD: How many treatment sessions does it take to get over a fear of public speaking?

Dr. Rothbaum: We are about to start that study and we are anticipating 10 to 12 sessions. For fear of flying, people are treated in eight sessions over six weeks. For the fear of heights, usually six sessions is sufficient. For PTSD, approximately eight to ten sessions are needed.

Moderator: Ken, how did you get involved?

Grapp: That's a good question. I guess it was about three years ago, I started work on my dissertation for screening veterans for participation for the VR project for Atlanta VA. I have a background in working in start up companies, and this seemed like a very exciting area to be involved in.

Moderator: Please tell us about your work with Vietnam veterans at the Atlanta VA hospital.

Grapp: Yes. The idea is to use VR to help get the veterans back into and reprocess the information from their war experience. There is a good history of using exposure therapy with trauma survivors to help overcome symptoms of PTS. So, Larry and Barbara built a VR environment that allows the therapist to control the amount of stimulation they provide. And that can be done in a very therapeutic manner.

Dr. Rothbaum: We have two VE for the Vietnam veterans that we use. One is a Virtual Huey helicopter that flies over different Vietnam terrains, such as rice paddies, rivers and jungle, and the other is a virtual clearing surrounded by jungle. We expose the veterans in a therapeutic manner to their most traumatic Vietnam memories, while immersed in this virtual Vietnam.

Dr. Hodges: The Vietnam war veteran experiences the VE wearing a head mounted display that has a position tracker that we can track what he sees and hears. We spent a lot of time on the audio effects so you can hear gunfire, helicopters overhead, you can see and hear them. And when they're riding in the helicopter, they're sitting in a special chair so they can feel the vibrations of the helicopter. We try to engage as many of the person's senses that we can to make it a more realistic experience.

Grapp: Dr. David Ready, at the Atlanta VA is still recruiting patients and doing this kind of work. There's another place, as well.

Dr. Rothbaum: The Boston VA at the National Center for PTSD they're offering this treatment.

Moderator: How do you gather the information to create such a realistic Vietnam environment?

Dr. Hodges: When we began, we interviewed Vietnam veterans, talked with therapists who worked with Vietnam veterans to see what their common experiences were. We can't create every environment, so we look for common experiences that they all went through, so we can use the software with the greatest number of veterans. We also measured and took photographs of real Huey helicopters to make it more realistic. We also looked at videos from the Vietnam war, and so we had 3 scenarios. One was you went everywhere as a Vietnam war participant on the helicopter. That's the way you were evacuated if wounded, and the way you were carried in to a battle zone. So that was a common experience. Being out in an open clearing was another experience because you don't know who is in the tree line. Helicopters usually landed in an open clearing, and your first job was to get into cover once you were deposited there. So we built those two environments in VR because they seemed like ones that we could build with today's technology, and could possibly be useful to the therapist in treatment.

Moderator: How have the veterans you've worked with responded to this therapy?

Dr. Rothbaum: Overall, well. We were worried before we started doing this that it would be too much, and too intense for the veterans. But we take it slow, and we explain everything that is going on, and most of the veterans have reported that after therapy, the memories that they worked on in therapy are no longer as distressing to them.

Moderator: If someone wants to participate in this treatment at the Atlanta VA hospital, how can he/she get in the study?

Grapp: They should contact Dr. David Ready at 404-321-6111, extension 7082. Also to go back to the previous question, we used a lot of screening measures to try and ensure that people who came in to the study would likely benefit from the environments that were created.

tenuli_WebMD: Where is this therapy available?

Grapp: The best way to find places is on our website. Our website is There's a list of clinics around the country that have this. They can reach us via email, or our phone number is 404-873-4404.

Moderator: Do you have a clinic in Atlanta?

Grapp: Yes.

marzel2_WebMD: How much does virtual reality therapy cost for fear of flying, and does insurance cover this?

Grapp: Our fee is $150 per session. It's my understanding that some insurance will pay for this. We don't take it here, but people can file that with their insurance companies.

Moderator: Which anxieties are you looking at focusing on in the future at Virtually Better?

Dr. Rothbaum: We currently have a study for the fear of flying and are about to start a study for the fear of public speaking. And I'm very anxious, no pun intended, to start treating the fear of driving in VR so I can get off of the Atlanta interstate with my patients. We also have on the list treatment of insects and small animals and possibly obsessive compulsive disorder. We are also using VR as a distractor for kids with cancer undergoing procedures.

Moderator: Fear of driving in Atlanta! We'll be having an expert on to talk about road rage and Atlanta driving in the near future! We are almost out of time. Do you have any final thoughts you'd like to share with us?

Dr. Hodges: The VR therapy, I think it's important to realize that we are just beginning this. My belief is that in a few years this is how much of therapy will be done, because it is so much easier to do it this way and although there are still just a few VR therapists, there's quite a large number of therapists who have shown interest in this, and have been from all over the world. So I meet at least once a year with therapists from Europe, Japan, all of whom are contributing to the development of these techniques and are very excited about its potential. One of the reasons that VB exists, is to provide software and hardware to therapists to help us better understand how and when to use VE therapy.

Grapp: Just to bring up a few things, the cost of hardware has really come down for VR. That allows us to put a VR system into a therapists office at a price they can afford, and bring this to a much wider audience. As Larry mentioned, we're beginning a clinical partners program, where we're looking for therapists around the country who are interested in adding VR to their practice. We are going to exhibit at the American Psychological Association Conference in Washington, DC, if people want to see this and try it. Also, they should feel free to call us.

Dr. Rothbaum: Our goal is to somehow enable more people to be treated and treated better, and treated cheaper. So we don't build environments just because we can, or because they're cool. We try to build environments that can make treatment better. For example, many patients are reluctant to enter into regular exposure therapy, because they are too scared to expose themselves to flying, driving or heights. Whereas they will enter into VR exposure therapy, because it allows them to keep their feet on the ground, but still expose themselves to airplanes, for example. So I'm hoping it will get more people treated. I'm also hoping it will encourage more therapists to conduct exposure therapy if we can make it easier for them. For example, before we had VR, and I had to treat someone for the fear of flying in Atlanta, it was a huge pain. We had to drive to the airport, park, and arrange for an airplane, and if I had to actually fly with them, it was very time consuming, and expensive. So many therapists won't treat the fear of flying. So we are hoping to make this therapy available to more patients and therapists who might be otherwise reluctant.

Moderator: We are out of time. I'd like to thank Dr. Barbara Rothbaum, Larry Hodges, Ph.D. and Ken Grapp, M.Ed., of Virtually Better. You've been a wonderful guests. Good luck with your studies.

For more information, please visit the Virtually Better website at 

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