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Psicologia: Teoria e Pesquisa Jan-Mar 2010, Vol. 26 n. 1, pp. 131-137

Exposio por Realidade Virtual no Tratamento do Medo de Dirigir1

RafaelThomazdaCosta2MarceleReginedeCarvalho

Antonio Egidio NardiUniversidade Federal do Rio de Janeiro

Instituto Nacional de Cincia e Tecnologia - Translational Medicine (CNPq)

RESUMO - Umcrescentenmerodepesquisastmsurgidosobreaaplicaodaterapiadeexposioporrealidadevirtual(VRET)paratranstornosansiosos.OobjetivodesteestudofoirevisaralgumasevidnciasqueapoiamaeficciadaVRETparatratarfobiadedirigir.Osestudosforamidentificadospormeiodebuscascomputadorizadas(PubMed/Medline,WebofScienceeScielodatabases)noperodode1984a2007.Algunsachadossopromissores.ndicesdeansiedade/evitaocaramentreoincioeofimdotratamento.VRETpoderiaserumprimeiropassonotratamentodafobiadedirigir,umavezquepodefacilitaraexposioaovivo,evitando-seosriscoseelevadoscustosdessaexposio.Entretanto,maisestudosclnicosrandomizados/controladossonecessriosparacomprovarsuaeficcia.

Palavras-chave:reviso;realidadevirtual;fobiadedirigir.

Virtual Reality Exposure Therapy in the Treatment of Driving Phobia

ABSTRACT - Agrowingnumberofresearcheshasappearedonvirtualrealityexposuretherapy(VRET)totreatanxietydisorders.ThepurposeofthisarticlewastoreviewsomeevidencesthatsupporttheVRETefficacytotreatdrivingphobia.Thestudieswereidentifiedthroughcomputerizedsearch(PubMed/Medline,WebofScience,andScielodatabases)from1984to2007.Somefindingsarepromising.Anxiety/avoidanceratingsdeclinedfrompretopost-treatment.VRETmaybeusedasafirststepinthetreatmentofdrivingphobia,aslongasitmayfacilitatethein vivoexposure,thusreducingrisksandhighcostsofsuchexposure.Notwithstanding,morerandomized/controlledclinicaltrialsarerequiredtoproveitsefficacy.

Keywords:review;virtualreality;drivingphobia.

1 EstetrabalhorecebeuoapoiodoConselhoNacionaldeDesenvolvi-mentoCientficoeTecnolgico(CNPq),Processo:554411/2005-9,edoInstitutoNacionaldeCinciaeTecnologia-TranslationalMedicine-INCT-TM(CNPq).

2 Endereoparacorrespondncia:InstitutodePsiquiatria,UniversidadeFederaldoRiodeJaneiro.R.daMatriz,336/201,Centro.SoJoodeMeriti,RJ.CEP25520-640.Tel:(21)2756-0965/(21)9509-4461.E-mail:faelthomaz@ig.com.br.

Drivingisaskillthatfrequentlyfacilitatesthemainte-nanceof independence andmobility, and enables contactwithawidevarietyofimportantactivities(Taylor,Deane&Podd,2002). Drivingphobiaisaserioussocialandpersonalissue.Thisfear-relatedavoidancehasseriousconsequencessuchasrestrictionoffreedom,careerimpairmentsandsocialembarrassment(Ku,Jang,Lee,Lee,Kim&Kim,2002).

Drivingphobiaisdefinedasaspecificphobia,situationaltype, in theDSM-IV (APA,1994). It is characterizedbyintense, persistent fear of driving,which increases as theindividualanticipates,orisexposedtodrivingstimuli.Peoplewithdrivingphobiarecognizethattheirfearsareexcessiveorunreasonable.However,theyareeitherunabletodriveortoleratedrivingwithconsiderabledistress(Wald&Taylor,2000).Drivingphobiadoesnottypicallydecreaseorbeco-messpontaneouslyasymptomaticwithouttreatmentandcanbecomechronic(Mayou,Tyndel&Bryant,1997;Taylor&Deane,1999;Wald&Taylor,2003).Thisspecificphobiatypicallyoccursinyoungtomiddleadultfemales(Ehlers,Hofmann,Herda&Roth,1994;Taylor&Deane,1999).

Themajorityofresearchpointstopost-traumaticstressdisorder(typicallyrelatedtomotor-vehicleaccidentinvol-vement),panicdisorder,oragoraphobiaasthepsychiatric disordersmost commonly associated withdrivingphobia(Taylor&Deane,1999;Taylor&Deane,2000).Ehlersetal.(1994)andHerda,EhlersandRoth(1993)addsocialphobiaasacontributingfactoroffearofdriving.

Peoplewith fear of drivingoften engage inmaladap-tive safety behaviors in an attempt to protect themselvesfromunpredicteddangerswhendriving(Antony,Craske& Barlow,1995;Taylor,Deane&Podd,2007). Aboutone-fifthofaccidentsurvivorsdevelopacutestressreaction;outofthissubgroup,10%goontodevelopamooddisorder,20%de-velopphobictravelanxiety,and11%developpost-traumaticstressdisorder(Mayouetal.,1997).

Driving Phobia

Somecontroversieslieuponcategorizingfearofdriving,andsomediagnosisaspanicdisorder,agoraphobia,posttrau-maticstressdisorderandsocialphobiaareconsideredtobepartofthedrivingphobia(Lewis&Walshe,2005).AlthoughdrivingphobiaisdefinedasaspecificphobiaintheDSM-IV(APA,1994),BlanchardandHickling(1997)pointoutsomeproblemswithclassification:(a)anxietymaybebetteraccountedforbyanothermentaldisorder;(b)anxietymaynotinvariablyprovokeanimmediateanxietyresponse;(c)

132 Psic.:Teor.ePesq.,Braslia,Jan-Mar2010,Vol.26n.1,pp.131-137

R. T. Costa & Cols.

theremaybetimeswhendrivingdoesnotevoketheparti-culartriggersrequiredforaphobicresponse;and(d)suchresponsemaynotberegardedasfearasmuchasasituationthatelicitsanxietyanduncomfortableaffect(Blanchard&Hickling,1997;Taylor&Deane2000).

Anotherpointofconflictiswhetherornotfearofdrivingisconsideredacomponentofwideragoraphobicavoidance.Someauthorsshowthatsituationalpanicattacksexperiencedbypeoplewithspecificphobiaareverysimilartothoseexpe-riencedbypeoplewithagoraphobia(Taylor,Deane&Podd,2000).Othersindicatethatdrivingphobiascanalsodevelopaftertheindividualexperiencesanunexpectedpanicattackinthefearedsituation(Tayloretal.,2000).CurtisandHimle(citadoporTayloretal.,2000)distinguishspecificphobiasandagoraphobiaintermsoffocusofapprehension.Individu-alswithagoraphobiahaveavoidancebehaviorsbecausetheyfearpanicanditsconsequences(anxietyexpectancy),whereaspeoplewithspecificphobiafeardanger(dangerexpectancy)(AntonyBrown&Barlow,1997;Tayloretal.,2000).

Theonsetofdriving-relatedfearsisattributedtodiffe-rentvariables.Most frequently, panic attacks are cited astheonsetofdriving fears (Tayloretal.,2000).Othercir-cumstancescorrespondtotraumaticexperience(accidents,dangeroustrafficsituations,beingassaultedwhiledriving),seeingsomeoneelseexperiencingatraumaticeventwhendriving, being a generally anxious individual and beinggenerally afraid of high speed (Munjack, 1984;Ehlers etal.,1994).Otherpsychologicalproblemsreported inroadtraumaincludeirritability,anger,insomnia,nightmares,andheadaches(Blaszczynski,Gordon,Silove,Sloane,Hilman&Panasetis,1998).

Interestingly,TaylorandDeane(2000)noticedthatmanynon-motorvehicleaccidents(MVA)-onsetdriving-fearfulsindividualshavefearsofsimilarseverityastheirMVA-onsetdriving-fearfulcounterparts.Intheirresearch,nosignificantdifferenceswerefoundbetweenthesegroupsonmeasuresof physiological and cognitive symptoms, state anxiety,degreeofinterferenceindailyfunctioning,priorhelpfromamentalhealthprofessional,andavoidanceofobtainingadriverslicense.

Themostfeareddrivingsituationcitedbydrivingpho-bicsisMVA(Blanchard,Hickling,Taylor,Loos&Gerardi,1994;Blanchard,Hickling,Taylor&Loos,1995),buttheyalsomentionissuesofcontrol(losingcontrolofthecar,notbeing in control of thedriving situation, being in controlofapowerfulvehicle),specificdrivingsituations(drivingat high speed, at night, in unfamiliar areas, over bridges,throughtunnels,onsteeproads,onopenroads,merging,andchanginglanes),andtheskillsrequiredfordriving(reactiontime,judgmenterrors,weatherconditions,roadconditions)(Taylor&Deane,2000;Tayloretal.,2000;Tayloretal.,2007b).Concerns about anxiety symptomswhile drivingmayalsobepresent(Wald&Taylor,2003).DrivinginthecompanyofsomeonewhocriticizesonesdrivingwasratedwiththehighestscoreofanxietyandavoidanceinTaylorandDeanesstudy(2000),eventhoughitwasunclearwhethertherespondentratedaperceivedorrealcriticism.

Cognitiveerrorsarelikelytoincreasefeelingsofvulne-rabilityandmaintainanxietyandfearreactions(Tayloretal.,

2007).Itissuggestedthatcognitiveerrorsofdrivingphobiamayinvolvethetendencytooverestimatetheamountoffearthatwillbeenduredinasubjectivelythreateningsituation(Rachman&Bichard,1998).Inaddiction,peoplewithdri-vingphobiaunderestimatetheirownskillsandabilitiesandthoseofotherdrivers.Asaresult,theyexperienceincreasedanticipatoryanxietybeforeattemptingtodrive,aswellasavoidancebehavior(Koch&Taylor,1995;Taylor&Deane,2000).Avoidancebehaviormayrangefromanoccasionalreluctancetodriveinparticularsituations(e.g.heavytrafficorbadweather)toaglobalavoidanceofvehiculartravelal-together.Itcanmaintainphobiasymptomstotheextentthatitpreventsexposuretothefearstimuli(Tayloretal.,2007).

Tayloretal.(2007b)usedtheDrivingCognitionsQues-(2007b)usedtheDrivingCognitionsQues-tionnaire(DCQ)todetectthemostfrequentcognitionsoffearfulparticipantswhiledriving.Themostrateditemswerereactingtooslowly,beingperceivedasabaddriver,holdinguptrafficandmakingpeopleangry.Inthesamestudy,socialconcernswere evident on the FearQuestionnaire (FQ).TaylorandDeane(2000)havealreadymentionedevidenceoftheinfluenceofsocialfactorsindrivingfear,emphasizingfeelingsofhumiliationorembarrassmentasaconsequenceofperceivednegativeperformanceevaluationbyothers.

Virtual Reality Exposure Therapy in the Treatment of Driving Phobia

Accordingtotheemotionalprocessingtheory,success-fulexposuretherapyleadstonewandmoreneutralmemorystructuresthatoverruletheoldanxiety-provokingones(Foa&Kozak,1986). If avirtual environmentcanelicit fearresponsesandactivatetheanxiety-provokingmechanism,itmightbeeffectiveasanalternativetechniquetoaddressexposureinterventions.Inthissense,VirtualRealityEx-posureTherapy(VRET)canbeaviablealternativetoin vivoexposuretherapy(Foa&Kozak,1986).

Virtual reality exposure integrates real-time computergraphics,soundsandothersensoryinputstocreateacom-puter-generatedworldwithwhichtheindividualcaninteract(Anderson,Jacobs&Rothbaum.,2004;Riva,2002;Riva&Wiederhold,2002;Rothbaum&Hodges,1999;Wiederhold&Rizzo, 2005).A successful virtual experienceprovidesuserswithasenseofpresence,asthoughtheywerephysicallyimmersedinthevirtualenvironment(Gregg&Tarrier,2007;Krijnetal.,2004;Krijn,Emmelkamp,Olafsson&Biemond,2004).Thissensationisachievedbyshuttingoutrealworldstimulisothatonlycomputer-generatedstimulicanbeseenandheard.Somesensoryvirtualrealitymodalitiesalsoin-cludetactileandolfactorysensorystimulationaselementsofreality(Gregg&Tarrier,2007;Krijnetal.,2004b).Ithasbeenobservedthat,forphobicsubjects,anincreaseinthesenseofpresenceconsequentlyincreasesanxiety.Ontheotherhand,ithasalsobeennoticedthatincreasingstresslevelsincreasethesenseofpresence(Walshe,Lewis&Kim,2004;Walshe,Lewis,OSullivan&Kim,2005).

Littlecontrolledtreatmentresearchondrivingphobiahasbeenfound,althoughsomecasereportsofaccidentandnonaccident-relateddrivingfearpointoutthatdesensiti-

133Psic.: Teor. e Pesq., Braslia, Jan-Mar2010,Vol.26n.1,pp.131-137

RV Medo de dirigir

zationcanbeaneffectivetreatment,whereasotherstudiesshowthatvariouscombinationsofin vivo andimaginaryexposureweresuccessful(Wald&Taylor,2003;Tayloretal.,2007;Walsheetal.,2005). ResultsfromrecentstudiesusingVRETsuggestthatthistreatmentmightbeappropriatefordrivingphobia(Wald&Taylor,2000;Wald&Taylor,2003).

VREThassomepotentialadvantagesoverin vivo and imaginaryexposure.AccordingtoWaldandTaylor(2000),individualswithintensedrivingfearsmayrefusetopartici-pateinin vivoexposureordropoutoftreatmentearly.Fortheseauthors,in vivoexposurehasanumberoflimitationsand risks because exposure occurs on public roadways,whereas driving situations are often unpredictable, timelimited,anddifficulttocontrol.Theauthorsalsoassertthatin vivoexposureraisesspecialsafetyandethicalconcernsbecausehighlyanxiouspatientsmaybeatanincreasedriskofmakingdrivingerrorsandbeinginvolvedinaMVAasaconsequenceofreducedattentionandinformationprocessingcapacities(Wald&Taylor,2000).VRET,ontheotherhand,occursinacliniciansoffice,sotheconsequencesofdrivingerrorsorunsafeavoidancebehaviorsareminimizedaswellastheriskofarealmotorvehicleaccident.Italsoreducespotentialembarrassmentthatcanbeassociatedwithinitialin vivodrivingexposure.Otheradvantageisthatfeareddri-vingsituationsareabletobecontrolledbytheclinician,andadjusted,repeated,andprolongedaccordingtotheclientsneeds(Wald&Taylor,2000).

Sometimes,inimaginaryexposure,itisdifficultforpho-bicsubjectstoimagineafearedstimulus,soitishardertoinduceanxiety(Wald&Taylor,2000).Formostindividuals,virtualrealitystimuliaremoreconcreteandrealistic thanimaginary exposure, reducing the possibility of avoidan-cebehaviors.Thus,VRET ismentionedas an alternativetreatmenttobeusedbeforethein vivoexposure(Wald&Taylor,2000).

SomelimitationsarepresentedinVRET.Insomecases,similardifficultiesasthoseexperiencedinimaginaryexpo-sure can arise in virtual environments. For some individuals, for example, itmight not be sufficiently realistic, so it ismoredifficulttofeelthesenseofpresence;asaresult,theexperienceisnotrealenoughtoinduceanxiety(Walsheetal., 2005).According toWald andTaylor (2003),VREThasotherlimitations:itmaynotbecost-effectivegiventhecurrent cost of virtual reality technology, it is notwidelyaccessibletotherapistsandclients,andsometimesitisnotabletosufficientlytargettheclientsidiosyncraticdrivingfears(Wald&Taylor,2003).

Recently,theliteratureshowsaconsiderablenumberofpublicationsonvariousaspectsofVRET,whichhasbeenappliedtothetreatmentofanxietydisorders,especiallypho-bias(Ct&Bouchard,2005;Jang,Kim,Nam,Wiederhold,Wiederhold&Kim,2002;Pull,2005;Rothbaum&Hodges,1999;Rothbaum,Hodges&Kooper,1997;Rothbaum,Hod-ges&Smith,1999;Wilhelmetal.,2005).Thepurposeofthisarticleistoreview,bymeansofasystematicmethodology,the literature that supports the potential effectiveness ofVRETinthetreatmentofdrivingphobia.

Method

A systematic on-line searchwas performed on thePubMed/MedlineandWebofScience(ISI)databases.Thekeywords used in the searchwere: virtual reality andfear of driving; virtual reality and driving phobia.We reviewed articles published between1984 and 2007.Among thearticlesweselected thoseapproachingvirtualrealityapplied todrivingphobia treatmentand trialswithVRETforanxietydisorders.Anothersearchwasmadefortherelevantreferencescitedin thesepapers.WeincludedpapersinEnglish,Portuguese,French,GermanandSpanish.

Results

Forty-sevenarticleswereselectedandreviewed,ofwhich34datedfromthelast10years.Twenty-fourstudiescitingVRETforthetreatmentofdrivingphobiawereidentified.Tenstudiestestedthesenseofpresenceinthevirtualenvi-ronmentsorusedvirtualrealitytechnologiesforthetreatmentofthisfear,withorwithoutthedevelopmentandvalidationofanyinstrumentfordrivingfearevaluation.Tenliteraturereviewswereincluded:twoonVRETfordrivingphobiaandeightonVRETforanxietydisorders.Unfortunately,therearefewsystematicstudiespublishedontheeffectivenessofVRETinthetreatmentofdrivingphobia.Infact,onlythreepapersrepresentedsystematicstudiesonVRETofdrivingphobia(oneofthemwasacasestudy),andcauseofthattheywereselectedtobedescribedhere(seeTable1).

Jang et al. (2002) analyzed non-phobic participantsphysiological reactions todrivingandflyingvirtual envi-ronments.Elevenparticipantswereexposedtoeachvirtualenvironmentfor15min.Physiologicalmeasuresconsistedinheartrate,skinresistance,andskintemperaturemonitoring.Aftereachexposure,participantswereevaluatedbymeansofthePresence&RealismQuestionnaire(PRQ)andSimulatorSicknessQuestionnaire (SSQ).Results demonstrated thatskinresistanceandheartratevariabilitycanbeusedtoshowarousalinparticipantsexposedtovirtualenvironments,and,therefore,canbeusedasobjectivemeasuresinmonitoringthereactionofnon-phobicparticipantstotheseenvironments.Theauthorsalsoconcludedthatheartratevariabilitycouldbeusefulforassessingemotionalstates.

OnestudybyWaldandTaylor(2003)examinedtheeffi-cacyofVRETfordrivingphobiawithamultiplebaselineacross-subjectsexperimentaldesign.Thisdesignincludedaninterventionphaseconsistingofeightweeklytreatmentses-sionsandfollow-upassessments.Sevenadultswithaspecificphobiadiagnosiswererecruitedfromthecommunitybyme-ansofmediaadvertisements.Fiveparticipantscompletedthetreatmentwith1-and3-monthfollow-upassessments.Fromthosefiveparticipants,threeshowedadecreaseinscoresonmanyoftheoutcomemeasures(seeTable1),andhence,nolongermetthecriteriafordrivingphobiaatpost-treatment.Thosethreepatientspresentedlossoftreatmentgainsinthefirstandsecondfollow-upassessments,and improvementindrivingfrequencyinthelastfollow-upassessment.Onepatient showedmarginal improvement and another one

134

Tabl

e 1.

StudiesonVirtualRealityExposureTreatment(VRET)forthetreatm

entofdrivingphobia.

Aut

hors

Par

tici

pant

sG

oals

Inte

rven

tions

Num

ber

of s

es-

sion

s

Fol

low

-up

Eval

uatio

nR

esul

ts

Jang

et a

l. (2002).

11non-phobics

(0F/11M

)To

analyzenon-phobic

participantsphysiological

reactionstotwovirtual

envi

ronm

ents

: driv

ing

and

flying.

- VR

ET1

sess

ion

(15min)

Nofollow

-up

-Ph

ysiologicalresponse(heartrate,

skinresistanceandskintempera

-ture)

-SimulatorSickn

essQuestionn

aire

(SSQ

)- P

rese

nce

& R

ealis

m Q

uest

ionn

ai-

re(PR

Q)

-TellegenAbsorptionScale(TAS)

-DissociativeExperiencesScale

(DES)

-Sk

inresistanceandheartrateva

-riabilitycanbeusedtoshowarousal

ofparticipantsexposedtoth

evirtual

environm

entexperience

Wal

d an

d Taylor

(2003).

5withspecific

phobiadiagn

o-sis(5F/0M)

Toevaluatetheefficacyof

VRETfortreatingdriving

phobia.

- VR

ET8

sess

ions

1-3-

12-

month

-MainTargetPhobiaandGlobal

PhobiaItemsfrom

theFearQues-

tionn

aire

-DrivingFrequency

-ClinicalS

tructuredInterview

(SCID

)

-Threepatientsshow

edim

provem

ent

indrivinganx

ietyandavoidanceand

atpost-treatm

entnolongermetcriteria

fordrivingphobia

-Onepatientshowedm

arginalimpro-

vem

ent

-Onepatientshowednotreatm

entg

ain

-Lossoftreatmentg

ainsweredetected

atfirstandsecondfollow

-upassess

-m

ents

Walsheet

al.(2003).

11withaspe-

cific

phobiadiag-

nosisthat

experienced

imm

ersio

n whenexposed

(9F/2M)

Toin

vestigatetheeffec-

tivenessofthecombined

useofcom

putergenerated

envi

ronm

ents

invo

lvin

g dr

ivin

g ga

mes

and

a v

irtu

al

realitydrivingenvironm

ent

inexposuretherapyforthe

treatm

entofdrivingphobia

follow

ingamotorvehicle

accidentprogram

.

- VR

ET

-Ph

ysiological

feedback

-Diaph

ragm

atic

breathing

-Cognitivereap-

praisal

121-h

sess

ions

Nofollow

-up

-Ph

ysiologicalresponse(heartrate)

-Su

bjectiveratingsofdistress

(SUDS)

-FearOfDrivingInventory(FDI)

-ClinicianAdm

inisteredPTSD

scale(CAPS)

-Ham

iltonDepressionScale

(HAM-D)

Achievementoftargetbehaviors

-Tenof11ofth

edrivingphobic

subjectsmetth

ecriteriaforim

mer

-sion

/presenceinth

evirtuald

riving

envi

ronm

ent.

- Pos

t-tre

atm

ent r

educ

tions

on

all

mea

sure

s -Participantsexpandedtheirdriving

practiceandstartedtravelingbyvehi

-clewithlessanx

iety

135Psic.: Teor. e Pesq., Braslia, Jan-Mar2010,Vol.26n.1,pp.131-137

RV Medo de dirigir

showednotreatmentgains.Accordingtotheauthors,theseresultssuggestthatVRETisapromisingtreatmentfordrivingphobia,althoughitmaynotbesufficientforsomepatients.

Walshe,Lewis,Kim,OSullivanandWiederhold(2003)investigatedtheeffectivenessofthecombineduseofcom-putergeneratedenvironmentsinvolvingdrivinggamesandavirtualrealitydrivingenvironmentasanexposuretherapyforthetreatmentofdrivingphobiafollowingamotorvehicleaccident program.Seven subjects,whomet theDSM-IVcriteria for SimplePhobia/Accident Phobia, experiencedimmersionwhenexposedtoavirtualdrivingenvironmentandcomputerdrivinggames,andtheywereselectedtopar-ticipateinacognitivebehavioraltreatment.Aftertreatment,significantreductionswerefoundinmeasuresofsubjectivedistress,drivinganxiety,post-traumaticstressdisorderrating,heartraterise,anddepressionratings.TheFearofDrivingInventory(FDI)findingswereconsistentwithclinicalreportsinwhichparticipantswereexpandingtheirdrivingpracticesandtravelingbyvehiclewithlessanxiety.Accordingtotheauthors, for somephobic drivers, computer game realityinducedastrongsenseofpresencesometimestothepointofinducingpanic.

Onlyonecasestudyusingvirtualrealityapplicationsfor driving phobia has been reported.Wald andTaylor(2000)describedacaseofapatientwhocompletedthreesessionsofVRET (onehour each).Thepeakof anxietydecreasedwithinandacrosssessions.Inthepost-treatmentassessment,herphobicsymptomshaddiminishedandsheno longermet thediagnostic criteria fordrivingphobia.Also,theclinicalimprovementwasmaintainedat1-,3-,and7-monthfollow-up.EvaluationwasmadebytheStructuredClinical Interview (First, Spitzer,Gibbon&Williams.,1996), theDrivingAnxietyTest (an in vivo behavioralmeasure),andadrivingdiary(minutesofdrivingperday).Thiscasestudyreportedsubstantialresults.VRETwassuc-cessfulinreducingfearofdriving.Ratingsofanxietyandavoidancedeclinedfrompre-treatmenttopost-treatment.Phobia-relatedinterferenceindailyfunctioningsimilarlydecreased.However,more case studies are necessary tocorroboratethesefindings.

Discussion

Itwasobservedthatthenumberofsessionsoftreatmentandfollowup,andthenumberofsessionsspentonVRETinterven-tionsdifferedimmenselyamongthedescribedstudies.Com-ponentsofthetreatmentprotocolsalsovariedamongstudies.Asaconsequence,comparingresearchresultswasimpossible.

Comorbiditieswerenotmentionedinanystudy.Comor-biditiesareimportantconfoundingfactorsintheevaluationoftreatmentplansandtheirresults.Besides,thestudiesdidnot specify the number of subjects onmedication or thathadpreviouslyattemptedanytreatment.Theassessmentofspecificdrivingvariables(e.g.,numberofaccidents,yearsofdriving)hasbeenrarelyreportedintheliterature,despitetheobviousclinicalrelevanceofthisinformationforconduc-tingacomprehensiveassessmentandplanningappropriateinterventiontargets.Forexample,thetreatmentforsomeonewhosedrivingfeardevelopedsubsequentlytotheonsetof

panicdisorderandagoraphobiaislikelytobedifferentfromthetreatmentforsomeonewhohasalwayshadaspecificpho-biaofdriving.Relevantvariablesofinterestheremayrelatetotheindividualshistoryasadriver,suchascircumstancessurroundinglearningtodrive,obtainingadriverslicense,andaccidenthistory.Theindividualsexperienceintheseandotherareascreatesacomplexsetofconditionsthatneedtobeconsideredindevelopinganinterventionthatistailoredtoeachclient(Tayloretal.,2007).

Althoughthedataarepromising,theysuggestthatVRETalonemaynotbesufficientinthetreatmentofdrivingphobiaforsomeindividuals.VRETmaybeusedasafirststepinthetreatmentforreducingdrivingfeartoadegreeappropriateforasubsequentin vivoexposuretherapy.

Fearoranxietysymptomscanbeassessedbyobjectivemeasures: heart rate, peripheral skin temperature, skinresistance (Jang et al., 2002), body posture, respirationrate,brainwaveactivity(Krijnetal.,2004b;Wiederhold&Wiederhold,1999),orsubjectivemeasures,usuallytheSubjectiveUnitsofDiscomfortScale(SUDS)(Krijnetal.,2004b;Wiederhold&Wiederhold,1999).Generally,VRETresearchersadministerawide rangeofquestionnaires toevaluatethesenseofpresence(Jangetal.,2002)ordrivingcognitions(Ehlersetal.,2007).Bothformsofevaluationwerefoundinthesestudies,notnecessarilyadministeredtogether.

Roth(2005)demonstratedthattheanxietyofpatientswith situational phobias is accompanied by autonomic,respiratory,andhormonalchanges in thefeared in vivo situation.AccordingtoRoth(2005)andAlpers,WilhelmandRoth(2005),phobicsdifferedfromcontrolsbothintermsofphysiologicallyandself-reportmeasuresbefo-re,during,andafterin vivoexposure.Thephysiologicalscoreswerehighlycongruentwithself-reportmeasuresofanxietyanddecreasedoversessionsinphobics,whatisinaccordancewiththeexpectedtherapeuticeffectsofrepeatedexposure,althoughtheexposuresweretoofewtoresultincompleteremission.Theseauthorsshowedsubs-tantial respiratorydisturbancesalongwith theexpectedelevationsinheartrateandinthefrequencyofnon-specificskinconductancefluctuations(avariablecontrolledbythesympatheticsystem).Inaddition,ameasureofrespiratoryvariabilitywashigher,withhyperventilation.InthestudyofAlpersetal.,salivarycortisolbeforeandafterdrivingwas greater than that of control levels, particularly inthe first exposure session.Also,multiple physiologicalmeasuresofphobicparticipantsandcontrolscontributedwithno redundant information, thusmaking itpossibleanaccurateclassificationof95%ofphobicandcontrolparticipants.

Thedatamentionedaboveillustratetheimportanceofphysiologicalmonitoring.However,noneofthestudiesusedmultiplephysiologicalmeasureswithphobics.Respiratoryvariationorsalivarycortisol levelwerenotconsidered intheanalysisoftheefficacyofVRETinJangetal.(2002),nevertheless they are effective physiologicalmeasures toassessanxietyandsenseofpresenceinstandardexposure.NoelectroencephalographicorneuroimagingdatawerefoundinfearofdrivingVRETstudies.

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R. T. Costa & Cols.

Final Considerations

Drivingphobiaisaseriouspersonalandsocialproblemwithseveralconsequences,includingcareerrepercussions,socialembarrassmentand restrictions. In the treatmentofthisdisorder,therearesomeevidencesoftheadvantagesofVRETbeforeapplyingin vivoexposuretherapybecauseitcanfunctionasanalternativewaytoinduceexposure.Thisidea is supportedby somestudies inwhichphysiologicalmeasureswereusedtoassesstheeffectivenessofthesenseofpresence(Alpersetal.,2005;Jangetal.,2002;Walsheet al., 2003). In those studies, the post-treatment showedreductionsinsuchmeasures,thussuggestingthatVREThasadirecteffectofhabituation.

Virtualrealityoffersmanypossibilitiesforpsychology,includingassessment,treatment,andresearch.Intheclinicalpsychologyfield,virtualrealityisasafe,inexpensive,accep-ted,andprobablysoonawidespreadtoolusedinexposuretreatmentsofphobicdisorders.However,morerandomizedclinicaltrials,inwhichVRETcouldbecomparedtostandardexposure,withmoreobjectivemeasures,arerequired.Wesuggestthatfurtherstudiesshouldbemade,usingeffectivephysiologicalmeasuresandin vivoexposuretoevaluatetheefficacyoftheVRETandthesenseofpresence.

References

Alpers, G.W.,Wilhelm, F. H., & Roth,W. T. (2005).Psychophysiologicalassessmentduringexposureindrivingphobicpatients.Journal of Abnormal Psychology, 114, 126-139.

American PsychiatricAssociation (1994).Diagnostic and statistical manual of mental disorders(4thed.).Washington,DC:AmericanPsychiatricAssociation.

Anderson,P.,Jacobs,C.,&Rothbaum,B.O.(2004).Computer-supported cognitive behavioral treatment of anxiety disorders.Journal of Clinical Psychology, 60, 253-267.

Antony,M.M., Brown,T.A.,&Barlow,D.H. (1997).HeterogeneityamongspecificphobiatypesinDSM-IV.Behaviour Research and Therapy, 35, 1089-1100.

Antony,M.M.,Craske,M.G.,&Barlow,D.H.(1995).Mastery of your specific phobia. SanAntonio,TX:The PsychologicalCorporation.

Blanchard,E.B.,&Hickling,E. J. (1997).After the crash: Assessment and treatment of motor vehicle accident survivors. Washington,DC:AmericanPsychologicalAssociation.

Blanchard,E.B.,Hickling,E. J.,Taylor,A.E.,&Loos,W.(1995). Psychiatricmorbidity associatedwithmotor vehicleaccidents. Journal of Nervous and Mental Disease, 183, 495-504.

Blanchard,E.B.,Hickling,E.J.,Taylor,A.E.,Loos,W.,&Gerardi,R.J.(1994).Psychologicalmorbidityassociatedwithmotorvehicleaccidents.Behaviour Research and Therapy, 32, 283-290.

Blaszczynski,A.,Gordon,K.,Silove,D.,Sloane,D.,Hilman,K.,&Panasetis,P.(1998).Psychiatricmorbidityfollowingmotorvehicleaccidents:Areviewofmetodologicalissues.Comprehensive Psychiatry, 39, 111-121.

Ct,S.,&Bouchard,S.(2005).Documentingtheefficacyofvirtualrealityexposurewithpsychophysiologicalandinformationprocessingmeasures.Applied Psychophysiology and Biofeedback, 30, 217-232.

Ehlers,A.,Hofmann,S.G.,Herda,C.A.,&Roth,W.T.(1994).Clinical characteristics of driving phobia. Journal of Anxiety Disorders,8,323339.

Ehlers,A.,Taylor, J.E.,Ehring,T.,Hoffman,S.G.,Deane,F.P.,Roth,W.T.,&Podd, J.V. (2007).Thedrivingcognitionsquestionnaire: Development and preliminary psychometricproperties.Journal of Anxiety Disorders, 21, 493-509.

First,M.B.,Spitzer,R.L.,Gibbon,M.,&Williams,J.B.W.(1996).Structured clinical interview for Axis 1 DSM-IV disorders - Patient edition (Version 2.0).NewYork:BiometricsResearchDepartment,NewYorkStatePsychiatricInstitute.

Foa,E.B.,&Kozak,M.J.(1986).Emotionalprocessingoffear:Exposuretocorrectiveinformation.Psychological Bulletin, 99, 2035.

Gregg,L.,&Tarrier,N.(2007).Virtualrealityinmentalhealth:A review of the literature.Social Psychiatry and Psychiatric Epidemiology, 42, 343-54.

Herda,C.A.,Ehlers,A.,&Roth,W.T. (1993).Diagnosticclassificationofdrivingphobia.Anxiety Disorders Practice Journal, 1,916.

Jang,D. P., Kim, I.Y., Nam, S.W.,Wiederhold, B.K.,Wiederhold,M.D.,&Kim,S.I.(2002).Analysisofphysiologicalresponsetotwovirtualenvironments:Drivingandflyingsimulation.Cyberpsychology and Behavior, 5, 11 -18.

Koch,W.J.,&Taylor,S.(1995).Assessmentandtreatmentofmotorvehicleaccidentvictims.Cognitive and Behavioral Practice, 2, 327-342.

Krijn,M.,Emmelkamp,P.M.G.,Biemond,R.,deLigny,C.W.,Schuemie,M.J.,&vanderMast,C.A.P.G.(2004a).Treatmentofacrophobiainvirtualreality:Theroleofimmersionandpresence.Behaviour Research and Therapy,42,229239.

Krijn,M.,Emmelkamp,P.M.G.,Olafsson,R.P.,&Biemond,R.(2004b).Virtualrealityexposuretherapyofanxietydisorders:Areview.Clinical Psychology Review, 24, 259-281.

Ku,J.H.,Jang,D.P.,Lee,B.S.,Lee,J.H.,Kim,I.Y.,&Kim,S.I.(2002).Developmentandvalidationofvirtualdrivingsimulatorfor the spinal injurypatient.Cyberpsychology and Behavior, 5, 151-156.

Lewis,E.J.,&Walshe,D.G.(2005).Isvideohomeworkofbenefitwhenpatientsdontrespondtovirtualrealitytherapyfordrivingphobia?Cyberpsychology and Behavior, 8, 342-342.

Mayou,R.,Tyndel,S.,&Bryant,B.(1997).Long-termoutcomeofmotor vehicle accident injury.Psychosomatic Medicine, 59, 578584.

Munjack, D. J., (1984). The onset of driving phobias.Journal of Behavior Therapy and Experimental Psychiatry, 15,305308.

Pull,C.B. (2005).Currentstatusofvirtual realityexposuretherapyinanxietydisorders:Editorialreview.Current Opinion in Psychiatry, 18, 7-14.

Rachman,S.,&Bichard,S.(1998).Theoverpredictionoffear.Clinical Psychology Review, 8, 303-312.

Riva,G.(2002).Virtualrealityforhealthcare:Thestatusofresearch.Cyberpsychology and Behavior, 5, 219-225.

Riva, G., &Wiederhold, B. K. (2002). Guest editorial:Introductiontothespecialissueonvirtualrealityenvironmentsinbehavioralsciences.IEEE TITB, 6, 193-197.

Roth,W.T.(2005).Physiologicalmarkersforanxiety:Panicdisorderandphobias.International Journal of Psychophysiology, 58, 190-198.

137Psic.: Teor. e Pesq., Braslia, Jan-Mar2010,Vol.26n.1,pp.131-137

RV Medo de dirigir

Rothbaum,B.O.,&Hodges,L.F.(1999).Theuseofvirtualreality exposure in the treatment of anxietydisorders.Behavior Modification, 23, 507-525.

Rothbaum,B.O.,Hodges,L.F.,&Kooper,R.(1997).Virtualrealityexposuretherapy.Journal of Psychotherapy Practice and Research, 6,291296.

Rothbaum,B.O.,Hodges,L.,&Smith, S. (1999).Virtualreality exposure therapy abbreviated treatmentmanual: Fear offlyingapplication.Cognitive and Behavioral Practice, 6, 234-244.

Taylor,J.E.,&Deane,F.P.(1999).Acquisitionandseverityof driving-related fears.Behaviour Research and Therapy, 37, 435449.

Taylor, J. E., & Deane, F. P. (2000). Comparison andcharacteristics ofmotor vehicle accident (MVA) andnon-MVAdrivingfears. Journal of Anxiety Disorders, 3,287298.

Taylor,J.E.,Deane,F.P.,&Podd,J.V.(2000).Determiningthefocusofdrivingfears.Journal of Anxiety Disorders, 14, 453-470.

Taylor,J.,Deane,F.&Podd,J.(2002).Driving-relatedfear:Areview.Clinical Psychology Review, 22, 631-645.

Taylor,J.E.,Deane,F.P.,&Podd,J.V.(2007a).Drivingfearanddrivingskills:Comparisonbetweenfearfulandcontrolsamplesusing standardized on-road assessment. Behaviour Research and Therapy, 45, 805-818.

Taylor, J. E.,Deane, F. P.,&Podd, J. (2007b).Diagnosticfeatures,symptomseverity,andhelp-seekinginamedia-recruitedsampleofwomenwithdrivingfear.Journal of Psychopatology and Behavioral Assessment, 29, 81-91.

Wald,J.,&Taylor,S.(2000).Efficacyofvirtualrealityexposuretherapytotreatdrivingphobia:Acasereport.Journal of Behavior Therapy and Experimental Psychiatry, 31, 249-257.

Wald, J.,&Taylor, S. (2003). Preliminary research on theefficacyofvirtualrealityexposuretherapytotreatdrivingphobia.Cyberpsychology and Behavior, 6, 459-465.

Walshe,D.G.,Lewis,E.J.,&Kim,S.I.(2004).CanMVAvictimswithdrivingphobiaimmerseincomputersimulateddrivingenvironments?Cyberpsychology and Behavior, 7, 317-318.

Walshe,D.G.,Lewis,E. J.,Kim, S. I.,OSullivan,K.,&Wiederhold,B.K.(2003).Exploringtheuseofcomputergamesandvirtualrealityexposuretherapyforfearofdrivingfollowingamotorvehicleaccident.CyberPsychology and Behavior, 6,329334.

Walshe,D.,Lewis,E.,OSullivan,K.,&Kim,S. I. (2005).Virtuallydriving:Arethedrivingenvironmentsrealenoughforexposure therapywith accident victims?An explorative study.Cyberpsychology and Behavior, 8, 532-537.

Wiederhold,B.K.,&Rizzo,A. S. (2005).Virtual realityand applied psychophysiology.Applied Psychophysiology and Biofeedback, 30, 183-185.

Wiederhold,B.K.,&Wiederhold,M.D. (1999).Clinicalobservations during virtual reality therapy for specific phobias.Cyberpsychology and Behavior, 2, 161-168.

Wilhelm, F.H., Pfaltz,M.C.,Gross, J. J.,Mauss, I. B.,Kim,S. I.,&Wiederhold,B.K. (2005).Mechanismsofvirtualreality exposure therapy:The role of the behavioral activationandbehavioralinhibitionsystems.Applied Psychophysiology and Biofeedback, 30, 271-284.

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