REVIEW ARTICLE: Virtual Reality in Anxiety Disorders by Gorini, A & Riva, G

Virtual reality is a method for exposing phobic drivers to the situations they fear under controlled, interactive and safe conditions. The paper described below explains how virtual reality is used in the treatment of a range of phobias and provides a good background before tackling the more detailed experimental papers relating to the use of virtual reality in treating driving phobia (such as Ward & Taylor, 2000). Free full text of this review article is available online.

TITLE: Virtual reality in anxiety disorders: the past and present
AUTHOR: Gorini, A & Riva, G
JOURNAL: Expert Reviews of Neurotherapeutics, 2008, 8, 215-33.
ABSTRACT: "One of the most effective treatments of anxiety is exposure therapy: a person is exposed to specific feared situations or objects that trigger anxiety. This exposure process may be done through actual exposure, with visualization, by imagination or using virtual reality (VR), that provides users with computer simulated environments with and within which they can interact. VR is made possible by the capability of computers to synthesize a 3D graphical environment from numerical data. Furthermore, because input devices sense the subject's reactions and motions, the computer can modify the synthetic environment accordingly, creating the illusion of interacting with, and thus being immersed within the environment. Starting from 1995, different experimental studies have been conducted in order to investigate the effect of VR exposure in the treatment of subclinical fears and anxiety disorders. This review will discuss their outcome and provide guidelines for the use of VR exposure for the treatment of anxious patients." [PUBMED abstract, Full Text pdf]

SUMMARY/TAKE HOME MESSAGE:
This article provides a good overview of the theoretical purpose of virtual reality treatemnt for phobias, the equipment and procedures used, and research to date. There is relatively breif coverage of driving phobia, specifically:

"Driving phobia, defined as a specific phobia, situational type in Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV, is characterized by intense and persistent fear of driving, which increases as a person anticipates or is exposed to driving stimuli. People with driving phobia acknowledge that their fears are excessive or unreasonable, yet are unable to drive, or tolerate driving with considerable distress. The inability to drive results in a major loss of mobility and independence, which interferes with daily activities.

Currently, the only three studies we have found in literature suggest that VRET may be a quite promising intervention for treating driving phobia, but obviously, more controlled trials and follow-up evaluations are necessary to support these preliminary findings" (p218).

The studies referred to are:
* Wald J. Efficacy of virtual reality exposure therapy for driving phobia: a multiple
baseline across-subjects design. Behav. Ther. 35, 621–635 (2004).
* Wald J, Taylor S. Efficacy of virtual reality exposure therapy to treat driving phobia: a case report. J. Behav. Ther. Exp. Psychiatry 31(3–4), 249–257 (2000).
* Walshe DG, Lewis EJ, Kim SI, O’Sullivan K, Wiederhold BK. Exploring the use of computer games and virtual reality in exposure therapy for fear of driving following a motor vehicle accident. Cyberpsychol. Behav. 6(3), 329–334 (2003).

Inconsiderate stores

One side effect of having an ambiguous relationship with automobiles is that you spend more time getting around by other methods--including your feet. On a routine short walk to the local bookstore I saw evidence of the increasing car-centrism of our society.

As I walk past the Marriott hotel I see that the path from the street to the from door is immaculately cleared, as is the carpark in its entirety. The footpath along the road, however, is snow covered and has been for days. In fact it is easier to walk along the outside edge of the carpark then on the path (although if you do so while walking your dog, a security guard will evict you from the grounds).

As I cross the overpass I see that the roadway is in perfect condition. The pavement, however, is completely covered in slick ice. The Wildberry eatery has also not shoveled the public pavement directly outside their building, although the pathway from the carpark to their front door is carefully cleared.

I suppose the logic is that, on some basis, pedestrian traffic does not count. We are not numerous enough, rich enough, or afforded enough alternatives. We aren't customers worth considering or caring for. But pedestrian, especially pedestrains with long memories and cold feet can be very contrary. Marriot and Wildberry go on my list of places not to shop.

Car-mares

One of the weird things I had always thought was part of having a driving phobia is my driving nightmares. The exact appearance of the dream varies but I am in a car and driving. Then somehow I either lose the ability to break, or the car starts to accelerate beyond my control. I try desperately to make turns and stay on the road, but inevitably crash, and wake with a start.

But a recent XKCD comic made me wonder whether having dreams like this is really pretty normal, whether you have driving anxiety or not.

What surviving drivers learn from a fatal road accident

AUTHOR: Rajalin S & Summala H
JOURNAL: Accident Analysis and Prevention 1997; 29: 277-283.

ABSTRACT: "The effects of involvement in a fatal accident on surviving drivers' subsequent driving behavior were studied. The quantity (mileage) and quality of driving (offences in driver records) of 245 surviving drivers were compared in three-year periods before and after the accident. A random sample of 253 drivers from the driver register were additionally used as controls. The data showed that about half of the car drivers decreased their driving, with greater reductions being associated with more serious injuries. However, the total number of convictions did not reduce but even showed a tendency to increase in proportion to the amount of driving. The proportion of car drivers with post-crash offences was approximately constant (27-32%) independent of any change in mileage. The data suggest that professional heavy-vehicle drivers incurred fewer convictions during the post-crash period in comparison to car drivers. Thirty-seven surviving drivers were further interviewed on the duration and specificity of the effects. With the exception of three drivers, all said that the fatal accident had affected their driving behavior, but only for a relatively short time. Most commonly, the drivers reported that the effect was limited to those circumstances and situations which led to the accident and did not generalize to safer driving practices. This study suggests that car drivers, if not seriously injured, typically return to their 'normal' driving within a few months, while heavy-vehicle drivers show a tendency towards more cautious behavior after a fatal crash in terms of violations, presumably due to the continuous reinforcement which the latter receive in their work community." [abstract]

SUMMARY/TAKE HOME MESSAGE: About 20% of driving involved in an accident where there was a fatalities permanently reduce or cease their driving behavior. Drivers who believed their own error caused the accident were more severely affected.

Psychiatric consequences of motor vehicle accidents

AUTHOR: Mayou RA
JOURNAL: Psychiatry in the Medically Ill 2002; 25: 27-41.

ABSTRACT: "Psychiatric complaints are frequent following motor vehicle accidents and may be major predictors of persistent pain and other complaints. Outcomes are not related closely to the nature or severity of any medical injury. Psychiatric problems often are unrecognized and untreated. There is a need for more behaviorally inferred routine care, early recognition of complications, and the use of psychological and pharmacological interventions."

SUMMARY/TAKE HOME MESSAGE: Motor vehicle accidents are relatively common and frequently have serious mental health consequences including driving-related phobia.

EXPERIMENTAL REPORT: Virtual Reality for the Psychophysiological Assessment of Phobic Fear: Responses During Virtual Tunnel Driving

PEER-REVIEWED

AUTHORS: Mühlberger, A., Bülthoff, H.H., Wiedemann, G., Pauli, P.
JOURNAL: Psychological Assessment 2007; 19: 340-346.

ABSTRACT: "An overall assessment of phobic fear requires not only a verbal self-report of fear but also an assessment of behavioral and physiological responses. Virtual reality can be used to simulate realistic (phobic) situations and therefore should be useful for inducing emotions in a controlled, standardized way. Verbal and physiological fear reactions were examined in 15 highly tunnel-fearful and 15 matched control participants in 3 virtual driving scenarios: an open environment, a partially open tunnel (gallery), and a closed tunnel. Highly tunnel-fearful participants were characterized by elevated fear responses specifically during tunnel drives as reflected in verbal fear ratings, heart rate reactions, and startle responses. Heart rate and fear ratings differentiated highly tunnel-fearful from control participants with an accuracy of 88% and 93%, respectively. Results indicate that virtual environments are valuable tools for the assessment of fear reactions and should be used in future experimental research."

SUMMARY: Most treatments for phobia involve some kind of counter conditioning. That is being placed in the feared situation, usually starting with low intensity, and replacing feelings of fear with feelings of relaxation. As the authors note, placing driving in a feared situation such as driving in a tunnel, is neither easy nor particularly safe.

This study further developed a virtual reality system as a fully controlled and safe substitute for real driving. The study shows that those with a specific fear of driving in tunnels did become more fearful during periods of simulation of tunnel driving, but not during open driving (there was also a control group that did not become afraid at all). this suggests that virtual reality systems may, in the future, have a useful role in treating driving phobias.

Fearfulness was measured from self-report, but also heart rate, and skin conductivity. Self report was the most useful measure, followed by heart rate with which it was moderately correlated. Skin conductivity was, well a bit rubbish all round.

MY THOUGHTS: This is all very nice... but can we move along with using it for actual treatments?

Mühlberger, A., Bülthoff, H., Wiedemann, G., & Pauli, P. (2007). Virtual reality for the psychophysiological assessment of phobic fear: Responses during virtual tunnel driving. Psychological Assessment, 19 (3), 340-346 DOI: 10.1037/1040-3590.19.3.340

See also:
Efficacy of virtual reality exposure therapy to treat driving phobia: a case report