Acrophobia Manual – Psious Professionals

Index Manual Acrophobia

Phobia of heights
Virtual environments of Psious
1. Videos
Treatment Protocol based on Psious
Comments for suggestion
Recommended bibliography

1. Phobia of heights

Fear of heights —also known as acrophobia— is a condition that affects 3–5% of 1. Phobia of heights 1. Phobia at heights Manual Acrophobia the general population. It is not necessarily pathologic, and it only implies a problem if the anxiogenic response is uncontrollable, if it can drive the patient into a panic attack or into suffocation sensations, etc. This phobia belongs to the category of “specific phobias”, which may provoke an intense and anxious response to a specific stimulus —in this case, when people are exposed to heights.

Fear of heights is considered natural, even adaptative, since the avoidance response could be positive when people feel they are in a risk environment.

There are several agents implied in the development and maintenance of this phobia and Coelho, Waters, Hine and Wallis (2009) consider both non associative —hereditary— and associative —conditioned— factors in their model. So, it is considered as a multi-causal phenomena because not all the patients that seem tosuffer this phobia have developed it in a conditioned or learned way. Moreover, it was found in a longitudinal study realized by Poulton , Davies, Menzies, Langley and Silva (1998) that those who took part in the study and suffered significant lesions and falls before the age of 9 do not show a phobic response when they are 18.

However, some people manifest a phobic behavior pattern when they are exposed to heights, such as feeling anxious or even presenting panic attacks. In these cases, treating the patient is essential since it is shown a high level of acrophobia, so one could try to avoid any place not situated at ground level. The avoidance response intensity depends on the patient’s particular condition but it is particularly important to understand how the avoidance response intensity manifests itself through a continuum, which is a scale of high positions going from climbing up stairs to situate the patient on a cli. This is an important indicator and it has to be taken into account not just when analyzing the impact and the relevancy of the disorder but when the stage.

Finally, it is worth mentioning that Virtual Reality is a good alternative compared to traditional exposure techniques in the treatment of acrophobia because of several reasons.

Firstly, the therapist holds greater control of exposure variables, as opposed to the difficulty of obtaining an optimal environment to treat this phobia.

Secondly, it is less expensive in terms of logistics, treatment time and effort because it does not require the patient and therapist to move around to find suitable places for in vivo exposure: the situation is modeled in a virtual environment . And, last but not least , there are fewer probabilities of the patient not wishing to be exposed to this treatment. Moreover, the use of VR exposure as a technique is at least equally efficient as in vivo exposure treatment (Emmelkamp, & cols; 2002).

2. Virtual environments of Psious

Psious currently offers three scenarios and nine videos for treating acrophobia. In 2.1 New York The patient is located in the highest part of a skyscraper. Furthermore, thanks to RV viewer and to Psious platform, the patient can look around a 360 degrees angle. Moreover, the therapist can control exposure to anxiogenic interoceptive sensations (Figure 2) two of them, the patient is placed at the top of a building: the first one is New York (figure 1) and the second one is Barcelona (figure 1).

Both environments are thought to work on the cognitive aspect, hence the lack of events. On the other hand, if the therapist wants to proceed with gradual exposure, there is a third environment: an Elevator (figure 1).

On the other hand, the videos depict different places located at a certain height: a castle’ s moat, a ferris wheel in an amusement park, a ferris wheel in the city, a fifth floor balcony, an Indoor glass elevator, an outdoor glass elevator, train bridge anda cliff (figure 1)

These virtual environments are very useful for the examination of the patientʼs current state as well as their anxiety response when facing a feared situation.

Figure 1

HOW TO APPLY COGNITIVE BEHAVIORAL TECHNIQUES WITH PSIOUS?

The virtual reality environments and especially the last two can be used for verbal and behavioral questioning of the negative thoughts of the patient.

The fact of being in the situation will facilitate the evocation of recurrent thoughts that it produces. Thus, the therapist will be able to question them and the patient will internalize the procedure, which he will be able to apply more easily when in his real life he finds himself facing the feared situation. In the same way, the patient will be able to test the most feared consequences of the situation, previously discussed with the therapist, and verify that they are not being complied with.

For example, the therapist has an acrophobic patient who believes that if his or her eyesight is clouded, he or she will probably faint, fall and eventually die. In this case, patient and therapist can prove repeatedly in the virtual environment ( New York or Barcelona) that in spite of experiencing these sensations, they are controllable, and their predictions are erroneous and are not fulfilled.

3. Treatment Protocol based on Psious

As detailed below, a treatment protocol is offered as an example. It includes the SESSION 1: PSYCHOEDUCATION SESSION 2 and 3 : RELAXATION SESSION 4: COGNITIVE RESTRUCTURING 3. Treatment protocol based on Psious Manual Acrophobia use of Psious combined with traditional techniques, nevertheless we recommend the therapist to adjust the VRʼs strategies to the techniques he already uses in his clinic practice. Moreover, the techniques will have to be adjusted to the needs and evolution of the patient, but especially to the exposure hierarchy, which therapist and patient should elaborate in the first session

SESSION 1: PSYCHOEDUCATION

Information about acrophobia is provided (origin, upkeep and appearance the triple system cognitive, physiological and motor).

Treatment techniques that will be used throughout the protocol are explained (emphasizing the exposure to the VirtualReality environments).

An exposure hierarchy is elaborated.

SESSION 2 and 3 : RELAXATION

The patient learns and practices two types of relaxation techniques: controlled breathing and Jacobson’s progressive muscular relaxation.

Familiarization with the Psious platform. The patient learns touse the VR helmets and navigate inside the virtual scenes.

Homework: Daily practice of relaxation techniques. The self registers of relaxation and negative thoughts are completed (see annex 6.2)

SESSION 4: COGNITIVE RESTRUCTURING

Revision and adjustment of the patient’s negative thoughts.

Cognitive restructuring for each of the negative thoughts. Two kinds of cognitive therapy may be used: the one proposed by Beck or the one belonging to Ellis.

Homework: Daily practice of relaxation techniques. Self-registers Versión de Prueba of relaxation and negative thoughts are completed (see annex 6.2)

SESSION 5: VIRTUAL EXHIBITION + RELAXATION

As of the fifth session of treatment the gradual and systematic exposure to the virtual environments begins. Throughout all exposure sessions, VR is combined with techniques of relaxation and cognitive restructuring.

The patient is exposed to:
- Bridge and/or Cliff
- Getting to the second level of the crystal elevator

Homework: Daily practice of the relaxation techniques, selfregister of relaxation and negative thoughts and tasks of self exposure to stimulus related to heights..

SESSION 6: EXHIBITION RV + TRADITIONAL TECHNIQUES

Homework review.

The patient is exposed to:
- Getting to the terrace by the crystal elevator introducing interoceptive exposure and leaning to the rail.
- Getting to the terrace by the crystal elevator introducing a breakdown

Homework: Daily practice of relaxation techniques, self-registers and tasks of self-exposure to height related stimuli.

SESSION 7: EXHIBITION RV + TRADITIONAL TECHNIQUES

Homework review.

The patient is exposed to:
- Getting to the terrace by the metal elevator.

Homework: Daily practice of relaxation techniques, self-registers and self-exposure tasks to height related stimuli.

SESSION 8: EXHIBITION RV + TRADITIONAL TECHNIQUES

Homework review

The patient is exposed to:
- Getting to the terrace by the metal elevator introducing interoceptive exposure.

Homework: Daily practice of relaxation techniques, self-registers and self-exposure tasks to height related stimuli.

SESSION 9: EXHIBITION RV + TRADITIONAL TECHNIQUES

As of the ninth session of treatment the exposure is re-started to the virtual environments but with a higher level of difficulty. With this scenario, we propose to examine the thoughts of the patient and the achieved results. Like in the rest of the exposure it is used in combination with relaxation and cognitive restructuring.

The patient is exposed to:
- New York or Barcelona.

Homework: Daily practice of relaxation techniques, self-registers and self exposure tasks to height related stimuli.

SESSION 10: RELAPSE PREVENTION

Homework review.

The therapeutic process is evaluated and future self-exposure tasks are programmed, as well as booster sessions.

Relapse management and prevention.

4. Comments for suggestion

It is important to follow the exposure with comments, questions or instructions 4. Comments for suggestion Manual Acrophobia for the patient to feel more exposed to the situation and to experience a much more realistic experience. Some suggestions for acrophobia:

Today we are going to climb up a building of 15 floors. You will be located at the balcony on the highest floor, from where you will observe the fall from above, paying attention to the movement of cars and to the ground distance.

Is it true that falling from this height could be deadly?

Do you feel that it is a risk situation?

We are now in a very high place. Do you feel anxious?

Move the head to both sides and look how we are in a very high place.

Is it hard not to look down?

Do you feel anxious or fearful looking down?

Do you feel fear? Is it more intense or less than before?

Do you feel like you are in danger right now? How real do you think it is?

(Inside the glass elevator) Notice that as the elevator goes up, the distance from the ground is increased and everything looks smaller. How does that make you feel?

5. Recommended bibliography

Antony, M., & Craske, M. (1995). Mastery of your specific phobia: Client workbook. Albany, New York: Graywind Publications.

Emmelkamp, P., Krijn, M., Hulsbosch, A. M., De Vries, S., Schuemie, M. J. & Van der Mast, C. (2002). Virtual reality treatment versus exposure in vivo: A comparative evaluation in acrophobia. Behaviour Research and Therapy. Vol. 40, 509-516.

Poulton, R., Davies, S., Menzies, R. G., Langley, J. D., & Silva, P. A. (1998). Evidence for a non-associative model of the acquisition of a fear of heights. Behaviour Research and Therapy, 36(5), 537–544.

Coelho, C., Waters, A., Jine, T. & Wallis, G. (2009). The use of virtual reality in acrophobia research and treatment. Journal of Anxiety Disorders, 23 (5), 563-574. Recuperado de http://www. sciencedirect.com.sire.ub.edu/science/article/pii/S 0887618509000280

Cohen DC. Comparison of self-report and behavioral procedures for assessing acrophobia. Behavior Therapy. 1977;8:17–23.

Self-report hierarchy elevator environments Psious:

Ítem	Level malaise (0-100)
I walk into a glass elevator and stand near the railing.
I am in a glass elevator, placed near the railing, and we go up one floor
After a long journey in the metal elevator that looks like a work of art, we reached the terrace, and to access it I have to pass through a metal bridge and uncovered
I am going up in a glass elevator , and when we’ re on the first floor there’s a breakdown, so there’ s noise and the elevator moves a little bit. 3 minutes go by and the fault remains unsolved.
I walk into a glass elevator and stand away from the railing.
I am in a metal elevator that looks like a work of art, placed near the railing, and we go up one floor
I am in a glass elevator, placed away from the railing, and we go up four floors
I am going up in a glass elevator, and when we’ re on the third floor there’ s a breakdown, so there’ s noise and the elevator moves a little bit. After 30 seconds the fault is solved and the elevator continues.
I am in a glass elevator, placed near the railing, and we go up two floors
I am going up in a metal elevator that looks like a building site, and when we are on the first floor there is a breakdown, so there is noise and the elevator moves a bit. After 30 seconds the fault is solved and the elevator continues.
I a m in a glass elevator, placed away from the railing, and we go up three floors.
After a long journey in the glass elevator, we arrived at the terrace, and to access it I have to pass through a covered walkway.
I am going up in a metal elevator that looks like a work of art, and when we’ re getting to the top of the whole building there’s a breakdown, so I’ m going to go up in a metal elevator that looks like a work of art.
There is noise and the elevator moves a little. 3 minutes go by and the fault remains unsolved.
I am in a glass elevator, placed away from the railing, and we go up one floor
I am going up in a glass elevator, and when we’ re getting to the top of the whole building there’s a breakdown, so there’ s noise and the elevator moves a little bit. 3 minutes go by and the fault is still not solved.
I am in a metal elevator that looks like a work of art, placed away from the railing, and we go up a floor
I am in a glass elevator, placed away from the railing, and we go up five floors
I enter a metal elevator that looks like a work of art and I stand far from the railing.
I am in a glass elevator, placed near the railing, and we go up five floors
I am going up in a metal elevator that looks like a building site, and when we’ re getting to the top of the whole building there’s a breakdown, so there’ s noise and the elevator moves a bit. After 30 seconds the fault is solved and the elevator continues.
I am in a metal elevator that looks like a building site, placed away from the railing, and we go up two floors.
I am in a glass elevator, placed near the railing, and we go up four floors
I am going up in a metal elevator that looks like a building site, and when we’ re on the third floor there’ s a breakdown, so there’ s noise and the elevator moves a bit. After 30 seconds the fault is solved and the elevator continues.
I am in a metal elevator that looks like a building site, placed near the railing, and we go up three floors
I am in a glass elevator, placed near the railing, and we go up three floors
I am in a metal elevator that looks like a construction site, placed away from the railing, and we go up five floors.
I’ m going up in a metal elevator that looks like a building site, and when we are on the first floor there is a breakdown, so there is noise and the elevator Versión de Prueba moves a bit. 3 minutes go by and the fault remains unsolved.
I am in a metal elevator that looks like a construction site, placed away from the railing, and we go up four floors.
I am going up in a glass elevator, and when we’ re on the first floor there’ s a breakdown, so there’ s noise and the elevator moves a little bit. After 30 seconds the fault is solved and the elevator continues.
I enter a metal elevator that looks like a work of art and I stand near the railing
I am in a metal elevator that looks like a construction site, placed near the railing, and we go up four floors.
I am going up in a glass elevator, and when we’ re getting to the top of the whole building there’ s a breakdown, so there’ s noise and the elevator moves a little bit. After 30 seconds the fault is solved and the elevator continues.
I am in a glass elevator, placed away from the railing, and we go up two floors.
I am in a metal elevator that looks like a construction site, placed near the railing, and we go up five floors.
I am in a metal elevator that looks like a construction site, placed away from the railing, and we go up three floors.
I am going up in a glass elevator , and when we’ re on the third floor there ‘ s a breakdown, so there is noise and the elevator moves a little bit. 3 minutes go by and the fault remains unsolved.
I am going up in a metal elevator that looks like a building site, and when we’ re on the third floor there’s a breakdown, so there’ s noise and the elevator moves a bit. 3 minutes go by and the fault remains unsolved.
I am in a metal elevator that looks like a building site, placed near the railing, and we go up two floors.