Virtual-Reality-AssistedTreatment of Flight Phobia

Helene S. Wallach, PhD,1,2 and Margalit Bar-Zvi, MD3

1 Tsfat College, Tsfat, Israel2 Department of Behavioral Studies, Emek Yezreel College, Emek Yezreel, Israel3 Psychiatric Outpatient Clinic, Ziv Hospital Tsfat, Israel.

Abstract: Background: Flight phobia is a common and debilitating specific phobia. Recently, an effective technology,called Virtual Reality (VR), has been developed for the treatment of various anxiety disorders including flight phobia.Method: This article reports the results of a pilot study consisting of four subjects treated for Flight Phobia using Vir-tual Reality. Results: All four subjects flew post-treatment. They experienced a significant reduction in fear of flying ontwo measures anxiety about flying and global rating of fear of flying. Limitations: Due to the small sample size, thelack of a control group, and the lack of objective measures, caution must be exercised in interpreting the results. Con-clusions: The use of Virtual Reality psychotherapy is relatively new worldwide, as well as in Israel. This study suggeststhe utility of implementing this technology in Israel.

This paper will focus on a specific phobia fear offlying (1). Approximately 10%-25% of the popula-tion suffer from this specific phobia. The discomfortcreated by the phobia ranges from a mild annoyanceto a major disturbance. In addition, approximately20% of those who fly depend on sedatives or alcoholduring flights (2, 3).

The combination of cognitive and behavior ther-apy (CBT) has been found to be the treatment ofchoice for phobias (4). This combination is superiorto all other psychotherapeutic approaches, in thepercentages of people improving, degree of improve-ment as well as long-term effects in follow-upstudies.

Virtual Reality

Virtual reality (VR) is defined as a situation in whichthe information arriving through the senses is fedfrom a computer. The more senses involved, and thehigher the degree of accuracy in the presentation, thehigher the sense of immersion, and thus it becomesharder for the client to discriminate between thereal and the virtual reality. The use of VR in ther-apy is relatively new. Its advantage is opening up analternative to in-vivo exposure and increasing gener-alization (5).

In VR therapy for flight phobia, the client re-

ceives visual, audio and tactile (vibrations) inputfrom the program. The therapist monitors the cli-ents SUD level and thus can reduce the fear of theenvironment level, if needed.

Advantage Using VR Therapy

Research has repeatedly found that exposure in-vivois superior to exposure in imagination, although it isboth costly as well as difficult to control the ele-ments. For example, for flight phobia we need to rentan airplane and perform multiple takeoffs and land-ings. This entails traveling to an airport which inmost cases is far from the clinic, thus increasing timeand cost, the high costs in renting a plane and payinga pilot. An additional problem with in-vivo exposureis encountering people the client knows and thus ex-posing the fact s/he is in therapy.

The advantages of VR therapy over imaginaltherapy are for people who have difficulty imaginingsituations vividly, or for those who avoid staying inthe imagined fearful situation. In addition, with VRthe therapist has full knowledge of and control overthe exposure.

Research Using VR for Flight Phobia

VR therapy has been used for specific phobias (6).

Isr J Psychiatry Relat Sci Vol 44 No. 1 (2007) 2932

Address for Correspondence: Dr. Helene S. Wallach, Department of Behavioral Studies, Emek Yezreel College, EmekYezreel 19300, Israel. E-mail: helenwa@Yahoo.com, helenew@yvc.ac.il

Four controlled studies combining VR and CBThave found VR an effective tool for flight phobia (2,711). However, in one study the post-treatment ef-fect was lost by follow-up (7), in another only two-thirds of the patients actually flew by follow-up (8),and in the third no differences were found betweenthe treatment and waitlist group on actual flyingrates (9). Only one study found significant differ-ences both post-treatment and in follow-up (2, 10,11).

The present study proposed to examine the utilityof virtual reality psychotherapy for flight phobia inan Israeli population. The hypothesis was that VRpsychotherapy will reduce fear of flight ratings.

Method

SubjectsFour subjects (three women and one man), who metDSM-IV-TR criteria for specific phobia flight partic-ipated in this study.

Measures

1. Flight anxiety situations questionnaire (FAS).This questionnaire includes 31 questions relatingvarious flight situations and asks the subject torate the level of anxiety he/she feels in each, on afive-point Likert scale ranging from 1 (no anxi-ety) to 5 (overwhelming anxiety).

2. Flight anxiety modality questionnaire (FAM).This questionnaire includes 23 questions relatingto expression of fear during flying. Each questionis rated on a five-point Likert scale ranging from1 (not at all) to 5 (very intensely).

Both questionnaires (12) are used by the ValkInstitute and were translated into Hebrew byGalit Rosenberg. Both have high reliability intheir original language and after translation toHebrew.

3. Questionnaire on attitudes toward flying (QAF)(12). This questionnaire assesses history of fear offlying, previous treatment and attitudes towardsflying. It contains 36 questions rating the level offear in different flying situations on a Likert scaleranging from 011. Test retest reliability was .92and split half reliability was .99.

4. After treatment, subjects flew accompanied by a

research assistant on a short flight (30 minutes),waited at the airport for a couple of hours andflew back. They rated their anxiety using SUDS(0100) at various points from entrance to theterminal until leaving the plane at the end of theflight.

ProcedureSubjects were recruited through advertisements inlocal newspapers. They were interviewed by a psy-chiatrist (the second author). Exclusion criteriawere: psychotic disorders, psychoactive substanceabuse and seizures. Only those who suffered fromflight phobia were included. All subjects filled outthe questionnaires. Following treatment they flewwith the research assistant on a short (30 minutes)domestic flight, waited at the terminal for severalhours and flew back. They received eight sessionsof treatment administered according to a protocol(13).

Treatment: Subjects were taught relaxation, built ananxiety hierarchy, and performed virtual reality ex-posure for eight sessions lasting 45 minutes each ses-sion. Patients started in a stationary airplane andprogressed through the stages only when their SUDSlevel was below 30.

Results

The three fear of flight measures taken before treat-ment were compared to those taken after treatment(see Table 1). The difference in the flight anxiety mo-dality questionnaire (FAM) was not significant(t[3]=1.30, p=0.14). Therefore, VR therapy did nothelp patients reduce their expression of fear duringflying.

Two questionnaires were used for the level of fearduring flying situations. On one no significant dif-ference was found, yet on the other there was a sig-nificant difference. The difference for thequestionnaire on attitudes toward flying (QAF) wasnot significant (t[2]=1.45, p=0.14). The differencefor the flight anxiety situations questionnaire (FAS)was significant (t[3]=3.59, p=0.02).

Comparing the SUD level on the two post-treat-ment flights approached significance (t[3]=2.10,p=0.06).

30 VIRTUAL-REALITY TREATMENT OF FLIGHT PHOBIA

Table 1. Scores on Fear of Flight Measures (Pre- and Post-Scores)

Time FAM FAS QAF SUDa

N M SD N M SD N M SD N M SD

Pre 4 62.00 15.34 4 112.75* 6.02 3 226.67 60.14 4 26.70 13.63

Post 4 48.25 9.50 4 85.75* 10.63 3 173.67 63.09 4 20.34 17.03

a SUD pre = first flight after treatment, from Rosh Pina to Tel Aviv; post = second flight after treatment, from Tel Aviv to Rosh Pina.* p0.05

Lastly, rated global fear towards flying, pre-treat-ment, was compared to average SUD level in post-treatment flight (see Table 2). This yielded a signifi-cant difference (t[2]=3.75, p=0.03).

Table 2. Comparing Level of Felt Fear Prior to Treatmentto Average SUD Level on Post-Flight

Measure N M SD

Felt fear prior to treatment 3 70.00* 10.00

Average SUD level during post-treatment flight 3 15.55* 17.24

* p0.05

Discussion

The present study was conducted to assess VR treat-ment for flight phobia on an Israeli population. Allmeasures were reduced from pre- to post-treatment.One of two measures of fear of flying was reducedsignificantly from pre- to post-treatment, while thedifference in the other was not significant. An addi-tional measure of expression of fear during flyingwas reduced, but again not significantly. The com-parison of a global rating of fear of flying to the aver-age SUD level rated during an actual flight post-treatment was also significant. Lastly, this studycompared two post-treatment flights, performedone after the other with a short delay of 23 hours be-tween them, and found a close to significant result.Therefore, the fear of flight continues to be reducedwith continued exposure made possible by VR treat-ment.

The major limitations of this study are its smallsample size, the lack of a control group and objectivemeasures and the lack of a follow-up. It is importantto perform this study again with a large number ofsubjects, randomly assigned to treatment and con-

trol groups, to perform blind SUDs ratings onflights, as well as follow-up.

It is also important to compare VR therapy toCBT, as well as comparing VR therapy alone to VRwith cognitive elements, to discover whether cogni-tive elements are necessary for the success of VR ex-posure therapy for flight phobics.

This pilot study points to the utility of using ashort (eight session) therapy in virtual reality for fearof flying. As pointed out earlier, VR enables the pa-tient to benefit from an effective therapy at a lowercost and without the disadvantages of lack of ano-nymity and lack of control over external forces.

Acknowledgements

The authors wish to thank Daniela Shriki, TsachiMinerbo, Rachael Markovitz and Arik Cohen whoassisted in running the research.

This research project was made possible by theaid of a generous research grant, 4731, by the ChiefScientist of the Israeli Ministry of Health.

References

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HELENE S. WALLACH AND MARGALIT BAR-ZVI 31

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32 VIRTUAL-REALITY TREATMENT OF FLIGHT PHOBIA

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