Future Drugs Ltd. All rights reserved. ISSN 1473-7175 377
Virtual reality: a new tool for panic disorder therapyFrancesco Vincelli and Giuseppe Riva
The use of a multicomponent cognitivebehavioral treatment strategy for panic disorder with agoraphobia is actually one of the preferred therapeutical approach for this disturbance. This method involves a mixture of cognitive and behavioral techniques which are intended to help patients identify and modify their dysfunctional anxiety-related thoughts, beliefs and behavior. Emphasis is placed on reversing the maintaining factors identified in the cognitive and behavioral patterns. The treatment protocol includes exposure to the feared situation, interoceptive exposure and cognitive restructuring. The paper presents a treatment protocol for panic disorder and agoraphobia, named experientialcognitive therapy, that integrates the use of virtual reality in a multicomponent cognitivebehavioral treatment strategy. The goal of experientialcognitive therapy is to decondition fear reactions, to modify misinterpretational cognition related to panic symptoms and to reduce anxiety symptoms.
Expert Rev. Neurotherapeutics 2(3), 377383 (2002)
Author for correspondenceLaboratorio Sperimentale di Ricerche Psicologiche, Istituto Auxologico Italiano, Casella Postale 1, 28900 Verbania, ItalyTel.: +39 0323 514246Fax: +39 0323 firstname.lastname@example.org
KEYWORDS:Agoraphobia, anxiety disorders, cognitivebehavioral therapy (CBT), experientialcognitive therapy (ECT), panic disorders, virtual reality therapy (VRT)
Panic disorder (PD) is a serious condition thatusually appears during the teens or earlyadulthood. While the exact determinants areunclear, there does seem to be a strict linkwith stressful major life changes: graduatingfrom college, getting married, having a firstchild and so on. It is estimated that PD affects1.62% of the general population .
According to DSM-IV, the essential featureof PD is the occurrence of panic attacks . Apanic attack is a sudden onset period of intensefear or discomfort associated with at least foursymptoms that include: palpitations, breath-lessness, dizziness, trembling, a feeling ofchoking, nausea, derealization, chest pain andparaesthesias. The panic is characterized by acluster of physical and cognitive symptoms,which occurs unexpectedly and recurrently,such as: pervasive apprehension about panicattacks, persistent worry about future attacks,worry about the perceived physical, social ormental consequences of attacks, or majorchanges in behavior in response to attacks.
PD is often associated with circumscribedphobic disorders, such as specific phobias,social phobias and especially with agorapho-bia. Agoraphobia is described separately from
PD in the DSM-IV to highlight the occur-rence of agoraphobic avoidance in individualswith or without a history of panic disorder.
Agoraphobia consists of a group of fears ofpublic places, such as: going outside, usingpublic transportation and being in publicplaces, for example supermarkets, theatres,churches and football stadia, which causes seri-ous interference in daily life. Other fears mayspring from this core phobia, such as: goingthrough tunnels, using lifts and crossingbridges, as well as other internal fears, such as:excessive worry about physical sensations (pal-pitations, vertigo, dizziness), or an intense fearof panic attacks, including fear of social inter-action. The results of these psychopathologicalsymptoms are that the patient tends to avoidthe feared situation and from then on thisavoidance carries over into other situations.Indeed, avoidance of public places in order toreduce fear or panic becomes the main cause ofincapacity in patients, who in more seriouscases are confined to their homes.
Barlow describes the initial panic attack as amisfiring of the fear system under stressfullife circumstances in physiologically vulnera-ble individuals . However, an isolated panic
Vincelli & Riva
378 Expert Rev. Neurotherapeutics 2(3), (2002)
attack does not necessarily lead to the development of PD, asevidenced by the scientific literature . The individuals whodeveloped a PD had a physiological vulnerability, a sort of anx-ious apprehension, conceptualized by Barlow as a set of dan-ger-laden beliefs about the symptoms of panic and about themeaning of panic attacks. After the initial panic attack, theunrealistic interpretations persist because patients engage incognitive and behavioral strategies that are intended to preventthe feared events from occurring. As the fears are unrealistic,the main effect of these strategies is to prevent patients fromdisconfirming their negative beliefs. As in many anxiety disor-ders, the symptoms of anxiety are then additional sources ofperceived danger and produce a series of vicious circles thatfurther contribute to the maintenance of the disorders [5,6].
Traditional therapyAccording to the National Institutes of Health (NIH) and NationalInstitutes of Mental Health (NIMH), PD can be treated effectivelywith cognitivebehavioral therapy (CBT), pharmacological therapyand possibly, a combination of CBT and medication .
Clark, Salkovskis, Barlow and other colleagues have outlinedthe traditional cognitivebehavioral treatment for PD with ago-raphobia . The traditional protocol involves a mixture ofcognitive and behavioral techniques that are intended to helppatients identify and modify their dysfunctional anxiety-relatedthoughts, beliefs and behavior. Emphasis is placed on reversingthe maintaining factors identified in the cognitive and behavio-ral patterns. The treatment protocol includes: exposure to thefeared situation, interoceptive exposure, cognitive restructur-ing, breathing retraining and applied relaxation. On average,the duration of the protocol is 1215 sessions.
These treatments seem to be well accepted by patients andtypically involve weekly sessions for 812 weeks (1215 ses-sions). Initial improvement is noted in many patients within 36 weeks of beginning treatment. Longer term follow-up ofthese interventions suggests a low relapse rate .
Pharmacologic treatments include: tricyclic antidepres-sants (not easily tolerated by a significant proportion ofpatients), monoamine oxidase inhibitors and high-potencybenzodiazepines .
Benzodiazepines have a rapid onset of action with immediatereduction of panic symptoms, whereas antidepressants require36 weeks to achieve therapeutic effect. In addition, the actionof benzodiazepines in reducing anxiety between attacks isthought advantageous by some clinicians.
Patients who tolerate tricyclics show significant improvement,with a reduced number of panic attacks during the period oftreatment, ranging from 8 to 32 weeks in controlled trials.
Careful titration of medication to effective therapeutic doseswith gradual increase in dosage is necessary. Very gradualincreases may be particularly important with tricyclics, in orderto reduce attrition.
The relapse rate following termination of medication forantidepressants is moderate, but is probably higher for benzo-diazepines. The relatively high response rate to the controlconditions (placebo) needs further examination.
In general, both for cognitivebehavioral and pharmacologi-cal treatment, patients begin to respond quickly to appropriatetreatment. However, some treatments may work better thanothers for certain patients. Therefore, it is important to moni-tor the response to treatment closely and reassess the treatmentstrategy if there is no improvement after 68 weeks. A combi-nation of CBT and pharmacotherapy may offer rapid relief,high effectiveness and a low relapse rate. The combination maybe particularly helpful for patients with agoraphobia.
Expert opinionIn the past decade, medical applications of virtual reality(VR) technology have been rapidly developing and the tech-nology has changed from a research curiosity to a commer-cially and clinically important area of medical informaticstechnology. As noted by Szekely and Satava Computermodeling and simulation have become increasingly impor-tant in many scientific and technological disciplines owingto the wealth of computational power . Likewise, thedevelopment of techniques for acquiring data (for example,medical imaging) has enabled the easy generation of highresolution copies of real world objects from the computersmemory. The development of imaging technologies, such asMRI, CT and ultrasound, has made the acquisition ofhighly detailed anatomical and partially functional modelsof three dimensional human anatomy a routine componentof daily clinical practice.
However, there is a growing recognition that VR can playan important role in clinical psychology, too . One ofthe main advantages of a virtual environment for clinicalpsychologists is that it can be used in a medical facility, thusavoiding the need to venture into public situations. In fact,in most of the existing applications, VR is used to simulatethe real world and to allow the researcher full control of allthe parameters implied. VR constitutes a highly flexible toolwhich makes it possible to program an enormous variety ofprocedures of interventions on psychological distress. Thepossibility of structuring a large amount of controlled stim-uli and simultaneously, of monitoring the possible responsesgenerated by the user of the program, offers a considerableincrease in the likelihood of therapeutic effectiveness ascompared with traditional procedures .
It has been hypothesized that treatment recidivism and drop-out, commonly observed in PD pa