Virtual reality: a new tool for panic disorder therapy

Review

© Future Drugs Ltd. All rights reserved. ISSN 1473-7175 377

CONTENTS

Traditional therapy

Expert opinion

Five-year view

Key issues

Information resources

References

Affiliations

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Virtual reality: a new tool for panic disorder therapyFrancesco Vincelli† and Giuseppe Riva

The use of a multicomponent cognitive–behavioral 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 experiential–cognitive therapy, that integrates the use of virtual reality in a multicomponent cognitive–behavioral treatment strategy. The goal of experiential–cognitive therapy is to decondition fear reactions, to modify misinterpretational cognition related to panic symptoms and to reduce anxiety symptoms.

Expert Rev. Neurotherapeutics 2(3), 377–383 (2002)

†Author for correspondenceLaboratorio Sperimentale di Ricerche Psicologiche, Istituto Auxologico Italiano, Casella Postale 1, 28900 Verbania, ItalyTel.: +39 0323 514246Fax: +39 0323 [email protected]

KEYWORDS:Agoraphobia, anxiety disorders, cognitive–behavioral therapy (CBT), experiential–cognitive 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 affects1.6–2% of the general population [1].

According to DSM-IV, the essential featureof PD is the occurrence of panic attacks [2]. 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 [3]. However, an isolated panic

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Vincelli & Riva

378 Expert Rev. Neurotherapeutics 2(3), (2002)

attack does not necessarily lead to the development of PD, asevidenced by the scientific literature [4]. 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 cognitive–behavioral therapy (CBT), pharmacological therapyand possibly, a combination of CBT and medication [7].

Clark, Salkovskis, Barlow and other colleagues have outlinedthe traditional cognitive–behavioral treatment for PD with ago-raphobia [3–6]. 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 12–15 sessions.

These treatments seem to be well accepted by patients andtypically involve weekly sessions for 8–12 weeks (12–15 ses-sions). Initial improvement is noted in many patients within 3–6 weeks of beginning treatment. Longer term follow-up ofthese interventions suggests a low relapse rate [6].

Pharmacologic treatments include: tricyclic antidepres-sants (not easily tolerated by a significant proportion ofpatients), monoamine oxidase inhibitors and high-potencybenzodiazepines [8].

Benzodiazepines have a rapid onset of action with immediatereduction of panic symptoms, whereas antidepressants require3–6 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 cognitive–behavioral 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 6–8 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 [9]. 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 computer’smemory. 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 [10–14]. 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 [15].

It has been hypothesized that treatment recidivism and drop-out, commonly observed in PD patients, may result from pro-grammatic attempts to produce symptom reduction in individ-uals who are not yet ready to change. In fact, up to 70% ofpatients with PD may have a comorbid psychological or psychi-atric condition that will need to be included in the treatmentplanning and perhaps addressed therapeutically concomitantlyor at a later point, including: major depression, post-traumaticstress disorder, bipolar mood disorder, dissociative disorders,other anxiety disorders, such as obsessive–compulsive disorderor social phobia, eating disorders, or complex personality disor-ders [8]. In this sense, an effective PD program has to deal withboth the treatment of concurrent disturbances and with theambivalent and fluctuating motivation to recovery.

Virtual reality & panic disorder

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A framework for conceptualizing readiness for change intreatment-resistant individuals is provided in the transtheoreti-cal model of change [16–18]. According to Prochaska and DiCle-mente, motivation cannot be considered as a trait or personal-ity: motivation is not something one has, but rather what onedoes [19]. According to this approach, change happens alongtwo interrelated dimensions, stage and process [16]:

• Stage refers to an individual’s readiness status at a particularmoment in time

• Process refers to what an individual is doing to work on theproblem and bring about change

Based on their research with smokers, these authors identifiedfive stages of change that people face in replacing problematicbehavior [19]. These stages can be considered predictable and stablesubprocesses within the therapeutic process. The five stages are:

• Precontemplation: being unaware of or unwilling to changesymptoms

• Contemplation: seriously thinking about change• Preparation: having the intention of changing soon

• Action: actively modifying behavior and experiences toovercome a problem

• Maintenance: working to prevent relapse

Prochaska and DiClemente hypothesize that drop-outsoccur when ‘therapists and clients are too far apart in theirexpectations on which stage of change they will be working’[17]. In fact, the problem behavior does not mean the samething to the client as it does to the therapist. Moreover, twostages of change are particularly critical for therapy: precontemplation and contemplation.

Patients in the precontemplation stage are not even thinkingabout modifying their behavior. In fact, they do not believetheir eating or restricting is a problem and usually take greatpride in their level of self-discipline. To move the patient to thenext stage of change, the therapist works with the client todetermine if there is another complaint or goal on which theclient wishes to work and for which she can become a customer[20]. VR can support the therapist in identifying possible com-plaints by immersing the patient in real-life situations notdirectly connected with the panic-eliciting situations. Using theresponses of the patients to the situation proposed, the therapistcan help them in identifying a salient goals.

Contemplation is a paradoxical stage of change, since thepatient is open to the possibility of change, but is stopped byambivalence. The characteristic style of the contemplator is,‘yes, but.’ Two key techniques are used in facilitating a shiftfrom the contemplation stage to the determination stage ofchange [20]. The first is the use of the miracle question, a typi-cal approach used by the solution-focused brief therapy [20,21].The miracle question is used to help the client identify howtheir life would be different if their PD were miraculouslygone. The second technique is the search for exceptions: situa-tions in which the patient has been able to manage the prob-lematic situation more successfully. Using VR to experience

the effects of the miracle and the successful situations, thepatient is more likely not only to gain an awareness of her needto do something to create change, but also to experience agreater sense of personal efficacy.

In general, these techniques are used as triggers for abroader empowerment process. In psychological literature,empowerment is considered a multifaceted construct reflect-ing the different dimensions of being psychologically ena-bled and is conceived of as a positive additive function ofthe following three dimensions [22]:

• Perceived competence: reflects role-mastery, which besidesrequiring the skillful accomplishment of one or more assignedtasks, also requires successful coping with nonroutine role-related situations

• Perceived control: includes beliefs about authority, decision-making latitude, availability of resources, autonomy in thescheduling and performance of work

• Goal internalization: this dimension captures the energizingproperty of a worthy cause or exciting vision provided by theorganizational leadership

VR can be considered the preferred environment for theempowerment process, since it is a special, sheltered settingwhere patients can start to explore and act without feelingthreatened. In this sense, the virtual experience is an ‘empower-ing environment’ that therapy provides for patients. As notedby Botella, nothing the patient fears can ‘really’ happen to themin VR [23]. With such assurance, they can freely explore, experi-ment, feel, live, experience feelings and/or thoughts. VR thusbecomes a very useful intermediate step between the therapistand the real world.

It is unnecessary to wait for situations to happen in the realworld because any situation can be modeled in a virtual environ-ment, thus greatly increasing self-training possibilities. In addi-tion, VR allows the situation to be graded so the patient canstart at the easiest level and progress to the most difficult. Due tothe knowledge and control afforded by interaction in the virtualworld, the patient will gradually be able to face the real world.

Rothbaum et al. conducted the first controlled study apply-ing VR to the treatment of a psychological disorder: VR wasincorporated in the treatment of acrophobia [12]. Participantswere repeatedly exposed to virtual foot bridges of varyingheights and stability, outdoor balconies of varying heights and aglass elevator that ascended 50 floors. VR was effective in sig-nificantly reducing fear of and improving attitudes towardheights, whereas no change was noted in the control group.

Given its flexibility, VR is an excellent source of informationon self-efficacy. In fact, as underlined by Botella and colleagues,‘different environments can be designed to practically ensure suc-cess in all of the patient’s virtual adventures and occasional diffi-culties, challenges and failures can be posed for the patient toovercome [23]. This means that patients are able to discover thatdifficulties can be defeated. They also have the experience of acompetent, effective, empowered self and can attribute all thispersonal competence to internal factors: perseverance and effort.’

Vincelli & Riva


Five-year viewOne of the fundamental parameters in assessing the effective-ness of therapies is the ratio existing between the ‘cost’ ofadministration of the therapeutic procedure and the resulting‘benefits’ [24]. By cost, it is meant the expenditure not only interms of money and time, but also in terms of emotionalinvolvement by the person to whom the therapy is directed.Benefits regards the effectiveness of the treatment – the achieve-ment of the target set in the shortest time possible. Exposuretherapy is traditionally carried out ‘in imagination’ or else inthe real world (i.e., in vivo). With imagination exposure, thesubject is trained to produce the anxiety-provoking stimulithrough mental images – with in vivo exposure, the subjectactually experiences these stimuli in semistructured situations.Both of these methods present advantages and limitations asregards the cost–benefit ratio. In the first case, the prevalent dif-ficulty is represented by teaching the subject to produce theimages that regard experiences associated with anxiety – themajority of failures linked to this therapy are those subjects whopresent particular difficulties in visualizing scenes of real life.The cost of the application, however, is minimal because thetherapy is administered in the physician’s office, thus avoidingsituations that might be embarrassing for the patient and safe-guarding his privacy. In the second case, the difficulty lies instructuring, in reality, experiences regarding the hierarchicallyordered anxiety-provoking stimuli, with the result that the costin terms of time, money and emotions is high. At the sametime, the advantage of contending with real contexts increasesthe likelihood of effectiveness of the ‘in vivo’ procedure [25–27].

Using VR software, it is possible to recreate, together with thesubject undergoing treatment, a hierarchy of situations corre-sponding to reality, which they may experience in an authenticway thanks to the involvement of all their sensorimotor chan-nels. The realistic reproduction of virtual environments enablesthe interacting individual to immerse himself in a dimension ofreal presence. This makes it possible to limit the costs as com-pared with traditional procedures of treatment, as pointed outabove and to consolidate the effectiveness of the treatmentthanks to the possibility of recreating a ‘three-dimensionalworld’ within the walls of the clinical office [27].

Through the analysis of the current applications of virtualreality therapy (VRT) some conclusions can be drawn as to theeffectiveness of virtual experience [10–14].

First of all, individuals subjected to virtual environments haveexperienced the feeling of being present in real-like experiences,even when the virtual environment did not faithfully match thereal world situations. This statement was confirmed by the evi-dence that the reactions and emotions originating from virtualexperience were equal to those experienced by subjects involvedin real experience. Another rather frequent conclusion in theanalyzed studies concerns the fact that the concentration on atask shown by subjects engaged in virtual experience signifi-cantly increases if compared with the control groups treatedin vivo [11–13]. In addition, perceptions and behaviors connectedwith real world can be changed thanks to experience into virtual

experience. This last datum confirms that it is possible to extendthe results obtained by in vitro treatments, which make use ofVR, to in vivo situations as well.

Therefore, we can expect, in the next 5 years, the emergenceof a new therapeutic approach for the treatment of PD – theexperiential–cognitive therapy (ECT) – integrating VRT withthe classical cognitive–behavioral approach.

The goal of ECT is to decondition fear reactions, to modifymisinterpretational cognition related to panic symptoms and toreduce anxiety symptoms. This should possible in an average ofeight sessions of treatment plus an assessment phase andbooster sessions, through the integration of virtual experienceand traditional techniques of CBT.

The overall treatment is composed of eight sessions and bydifferent booster sessions for 6 months after the therapy (BOX 1).

The first goal of session 1 is to discuss the patient the etio-logic model of PD and agoraphobia and to describe the pro-gram of ECT. The description is necessary to obtain an activerole of the patient in the therapy.

The patient is then introduced to VR through the use of a headmounted display and joystick. The innovative principle of ECT isto integrate cognitive and behavioral techniques with the experien-tial possibilities offered by VR. Then the next step of the first ses-sion is to structure the graded exposure procedure to virtual envi-ronments: the patient is exposed to each of the four virtualenvironments, with the minimum level of difficulty (small numberof subjects present in the environments, ready access to the exits,plenty of room in the elevator) and is asked to evaluate the experi-ence on a SUD’s scale [6]. In this way, we will obtain a hierarchy ofvirtual environments, from the least anxiety-provoking to themost, that will be used along the treatment.

After a hierarchy of administration between the environmentshas been established, it is necessary, in order to guarantee gradu-alism of exposure, to establish a hierarchy of stimuli within eachenvironment. In the ECT treatment program, the virtual envi-ronments – an elevator, a supermarket, a subway ride and a largesquare – are designed to reach this goal. In the supermarket andon the underground, the increase in difficulty may be obtainedby increasing the number of persons present in the environmentand by moving away from the exits of the respective environ-ments. In the square, it is possible to increase the number ofpeople present and to approach narrower spaces that offer fewerways out. In the lift, it is possible to arrange for the presence ofother people and to enlarge or restrict the space inside the lift.

The second step is to show the patient the role of avoidanceas the main source of agoraphobic and panic behaviors. Thetherapist underlines the importance of regular exposure tofeared situation and structures with his patient a self-exposureschedule. In vivo graded self-exposure as homeworks, initiallywith the cotherapist (when it is possible), is very important toempower the efficacy of the therapy. This step can be more eas-ily approached by graded exposure to virtual reality and pro-duce important advantages for the patient: reducing thenumber of sessions, reducing dependency on the therapist andhelping to maintain therapeutic achievements.



Each session starts with the review of the homeworks, to verifythe difficulties that have emerged during self-exposure and to rein-force the patient for the tasks that have been carried out. After thegraded exposure procedure, session three is based on cognitiverestructuring [6]. In PD, cognitive treatment focuses upon correct-ing misappraisals of bodily sensations as threatening. The cognitivestrategies reduce attentional vigilance for symptoms of arousal,level of chronic arousal and anticipation of the recurrence of panic.

Cognitive treatment starts by reviewing with the patient arecent panic attack and identifying the main negative thoughtsassociated with the panic sensations. Once patient and therapistagree that the panic attacks involve an interaction between bod-ily sensations and negative thoughts about the sensations, avariety of procedures are used to help patients challenge theirmisinterpretations of the symptoms.

A lot of patients interpret the unexpected nature of theirpanic attacks as an indication that they are suffering from somephysical abnormality. In these cases, a psychoeducation pro-gram presenting the nature of anxiety can be helpful, especiallyif it is tailored to patients’ idiosyncratic concerns. One of theprevalent errors in cognitions is overestimation. The panickersare inclined to jump to negative conclusions and to treat nega-tive events as probable when in fact they are unlikely to occur.Another type of cognitive error is misinterpreting events as cat-astrophic. Decatastrophizing means to realize that the occur-rences are not as ‘catastrophic’ as stated, which is achieved byconsidering how negative events are managed versus how ‘bad’they are. This is best done in a Socratic style so that clientsexamine the content of their statements and reach alternatives[6]. The cognitive strategies are conducted in conjunction withbehavioral technique of graded exposure in VR. The scheduleof session 4 is similar to that of session 3. The first part is dedi-cated to graded exposure and the second to the careful inquiryof cognitive distortions and their modification.

The key feature of session 5, 6 and 7 is interoceptive exposure[6]. The theoretical basis for interoceptive exposure is one of fearextinction, given the conceptualization of panic attacks as ‘condi-tioned’ alarm reactions to particular bodily cues. Since according tothe cognitive model, PD is considered as a ‘phobia of internal bod-ily cues’, the purpose is to modify associations between specificbodily sensations and panic reactions. This technique is also usedduring the exposure to the virtual environments.

After cognitive restructuring, prevention relapse is an impor-tant step of the last session. In this session, we have to schedulethe self-exposure homeworks and reinforce the patient for thetasks that have been carried out and for future tasks.

The feeling of actual presence offered by the realistic repro-duction of cybernetic environments and by the involvement ofall the sensorimotor channels, enables the subject undergoingtreatment to live the virtual experience in a more vivid and real-istic manner than he could through his own imagination. VRconstitutes a highly flexible tool, which makes it possible toprogram an enormous variety of procedures of intervention onpsychological distress. The possibility of structuring a largeamount of controlled stimuli and at the same time, of monitor-ing the possible responses generated by the user of the programoffers a considerable increase in the likelihood of therapeuticeffectiveness, as compared with traditional procedures.

Through virtual environments it is possible to graduallyexpose the patient to feared situation: VR consent to recreate inour clinical office a real experiential world. The patient facesthe feared stimuli in a context that is nearer to reality thanimagination. Other significant advantages are the supervised

Box 1. Experiential–cognitive therapy protocol for the treatment of panic disorder with agoraphobia.

Session 1Discuss the etiologic model of PDA with the patientConnection between the model and a recent PDA of the patientIntroduction to virtual environmentsGraded exposure to virtual environments and hierarchy of the virtual stimulus setHomework: diary of panic attacks

Session 2Homework reviewCognitive assessment assisted through graded exposure to virtual environmentsIntroduction and scheduling of in vivo self-exposureHomework: diary of panic attacks, in vivo self-exposure

Session 3Homework review.Cognitive restructuring assisted through graded exposure to virtual environmentsHomework: diary of panic attacks, in vivo self-exposure

Session 4Homework reviewGraded exposure to virtual environmentsCognitive restructuring face-to-faceHomework: diary of panic attacks, in vivo self-exposure

Session 5Homework reviewInteroceptive exposureInteroceptive exposure assisted through graded exposure to virtual environmentsHomework: in vivo interoceptive exposure, diary of panic attacks

Session 6Homework reviewInteroceptive exposure assisted through graded exposure to virtual environmentsCognitive restructuring face-to-faceHomework: in vivo interoceptive exposure, diary of panic attacks

Session 7Homework reviewInteroceptive exposure assisted through graded exposure to virtual environmentsCognitive restructuring face-to-faceHomework: in vivo interoceptive exposure, diary of panic attacks

Session 8Homework reviewCognitive restructuring and prevention relapseFollow-up session scheduleRetest

Vincelli & Riva


exposure to agoraphobic situations and the possible boost tothe effectiveness of cognitive restructuring by practicing it inanxiety-inducing situations.

Information resources• Barlow DH. Anxiety and its disorders: The nature and treat-

ment of anxiety and panic. Guilford Press, New York, USA(1988).

• Hand I, Wittchen H. Panic and phobias II. Springer-Verlag,Berlin, Germany (1988).

• Riva G, Wiederhold BK, Molinari E. Virtual environments inClinical Psychology and Neuroscience. IOS Press, Amsterdam,The Netherlands (1998). www.psicologia.net/pages/book2.htm

• Riva G. Virtual Reality in Neuro-Psycho-Physiology. IOS Press,Amsterdam, (1997). www.psicologia.net/pages/book1.htm

• Vincelli F, Choi YH, Molinari E, Wiederhold BK, Riva G. AVR-Based Multicomponent Treatment for Panic Disorderswith Agoraphobia. In: Medicine meets Virtual Reality.Outer space, inner space, virtual space. Westwood Jet al. (Eds), IOS Press, Amsterdam, The Netherlands(2001).

• www.psicologia.net An interesting website for clinicalapplications in psychology and psychotherapy.

• www.apa.org/pubinfo/panic.html• www.panicdisorder.about.com/mbody.htm• www.nimh.nih.gov/anxiety/anxiety/panic

Key issues

• Panic disorder (PD) is a distinct condition with a specific presentation, course and positive family history and for which there are effective cognitive–behavioral and pharmacologic treatments.

• Patients with PD often have one or more comorbid conditions that require careful assessment and treatment.

• Actual barriers to treatment include: awareness, accessibility, affordability and side effects.

• A new possible treatment for PD is experiential-cognitive therapy (ECT), integrating different virtual reality experiences with traditional cognitive–behavioral techniques.

• ECT treatment is composed of eight sessions and by different booster sessions for 6 months after the therapy.

• Through the use of virtual environments, it is possible to gradually expose the patient to feared situation.

• The feeling of actual presence offered by the use of immersive virtual reality (VR) enables the patient to experience the treatment in a more vivid and realistic manner than they could through their own imagination.

• VR allows the situation to be graded so the patient can start at the easiest level and progress to the most difficult.

ReferencesPapers of special note have been highlighted as:• of interest•• of considerable interest

1 Weissman MM, Bland RC, Canino GJ et al. The cross-national epidemiology of panic disorder. Arch. Gen. Psychiatry 54, 305–309 (1997).

2 APA. Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV). American Psychiatric Press, Washington, DC, USA (1994).

3 Barlow DH. Anxiety and its disorders: The nature and treatment of anxiety and panic. Guilford Press, New York, USA (1988).

• Classical course book for cognitive–behavioral psychologists.

4 Telch MJ, Lucas JA, Nelson P. Nonclinical panic in college students: An investigation of prevalence and symptomatology. J. Abnormal Psychology 98, 300–306, (1989).

5 Barlow DH, Craske MG. Mastery of your anxiety and panic II. Harcourt Brace & Co., San Antonio, TX, USA (1994).

6 Clark DM, Salkovskis P, Gelder M et al. Tests of a cognitive theory of panic. In:

Panic and phobias II. Hand I, Wittchen H (Ed.), Springer-Verlag, Berlin, Germany (1988).

7 NIMH. Panic Disorders Treatment and Referral. NIH Publication No. 94-3642. Bethesda, MD, USA (1994).

8 NIH. Treatment of Panic Disorder. National Institutes of Health Consensus Development Conference Consensus Statement. (1991).

•• NIH guidelines for the treatment of panic disorders.

9 Székely G, Satava RM. Virtual reality in medicine. Br. Med. J. 319, 1305 (1999).

• Good review of medical applications of VR.

10 Vincelli F, Riva G. Virtual reality as a new imaginative tool in psychotherapy. Studies in Health Technol. Informatics 70, 356–358 (2000).

11 Botella C, Baos R, Villa H, Perpi C, Garca-Palacios A. Virtual Reality in the treatment of claustrophobia: A controlled multiple baseline design. Behavior Therapy 31, 583–595 (2000).

• Good paper with interesting clinical data.

12 Rothbaum BO, Hodges LF, Kooper R, Opdyke D, Williford J, North MM. Effectiveness of virtual reality graded exposure in the treatment of acrophobia. Am. J. Psychiatry 152, 626–628 (1995).

•• First controlled study showing the efficacy of VRT.

13 Rothbaum BO, Hodges LF, Smith S, Lee JH, Price L. A controlled study of Virtual Reality Exposure therapy for fear of flying. J. Consult. Clin. Psychol. 68, 1020–1026 (2000).

•• Another controlled study showing the efficacy of VRT in the treatment of fear for flying.

14 Riva G, Bacchetta M, Baruffi M, Molinari, E. Virtual reality-based multidimensional therapy for the treatment of body image disturbances in obesity: a controlled study. Cyberpsychol. Behav. 4, 511–526 (2001).

•• Another controlled study showing the efficacy of VRT in the treatment of body image disturbances.

15 Vincelli F. From imagination to virtual reality: the future of clinical psychology. Cyberpsychol. Behav. 2, 241–248 (1999).

•• Good introduction to the VRT rationale.



16 Prochaska JO, DiClemente CC, Norcross JC. In search of how people change, Am. Psychologist 47, 1102–1114 (1992).

•• Description of the transtheoretical model of change.

17 Prochaska JO, DiClemente CC. Transtheoretical therapy: Toward a more integrative model of change. Psychother. Theory Res. Prac. 19, 212–216 (1982).

18 Prochaska JO. Systems of psychotherapy: A transtheoretical analysis. Dorsey Press, Homewood, IL, USA (1979).

19 Prochaska JO, DiClemente CC. Stages and processes of self-change in smoking toward an integrative model of change. J. Consult. Clin. Psychol. 5, 390–395 (1983).

20 McFarland B. Brief therapy and eating disorders. Jossey-Bass Publishers, San Francisco, USA (1995).

21 deShazer S. Keys to solutions in brief therapy. WW Norton, New York, USA (1985).

22 Menon ST. Psychological Empowerment: Definition, Measurement and Validation. Can. J. Behavioural Sci. 31, 161–164 (1999).

23 Botella C, Perpiña C, Baños RM and Garcia-Palacios A. Virtual reality: a new clinical setting lab. Studies in Health Technol. Informatics, 58, 73–81 (1998).

24 Vincelli F. Virtual reality as clinical tool: immersion and three-dimensionality in the relationship between patient and therapist. Studies in Health Technol. Informatics 81, 551–553 (2001).

25 Rothbaum BO, Hodges L, Kooper R. Virtual reality exposure therapy. J. Psychother. Pract. Res. 6, 219–226 (1997).

26 Riva G, Galimberti C. The psychology of cyberspace: a socio-cognitive framework to computer mediated communication. N. Ideas in Psychol. 15, 141–158 (1997).

27 Vincelli F, Molinari E. Virtual reality and imaginative techniques in Clinical Psychology. In: Virtual environments in Clinical Psychology and Neuroscience. Riva G, Wiederhold BK, Molinari E (Eds.) IOS Press Amsterdam, The Netherlands (1998). Online: www.psicologia.net/pages/book2.htm (Accessed 19 March 2002).

•• Good description of the potential of VRT in clinical psychology.

Affiliations• Francesco Vincelli, PsyD, Laboratorio

Sperimentale di Ricerche Psicologiche, Istituto Auxologico Italiano, Verbania, Italy, Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Milano, Italy, Tel.: +39 0323 514246, Fax: +39 0323 587694, [email protected]

• Giuseppe Riva, PhD, Dipartimento di Psicologia, Università Cattolica del Sacro Cuore, Milano, Italy, Applied Technology for Neuro-Psychology Lab., Istituto Auxologico Italiano, Verbania, Italy, Tel.: +39 0272 343734, Fax: +39 0323 514246, [email protected]

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Virtual reality: a new tool for panic disorder therapy