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== Introduction ==
Anxiety disorders are the most common psychiatric disorders. The diagnostic and statistical manual of mental disorders (DSM-IV) (APA, 1994) labels several disorders as anxiety disorders, which are:

* Panic Disorder (With or Without Agoraphobia)
* Agoraphobia Without History of Panic Disorder
* Specific Phobia
* Social Phobia
* Obsessive-Compulsive Disorder
* Post-traumatic Stress Disorder
* Acute Stress Disorder
* Generalised Anxiety Disorder
* Anxiety Disorder Due to a General Medical Condition
* Substance-Induced Anxiety Disorder
* Anxiety Disorder Not Otherwise Specified

In this research project will be looked at one of the specific phobias, namely acrophobia and at social phobia and agoraphobia. First there will be an explanation of those three anxiety syndromes according to the DSM-IV. Then the treatment of those anxiety disorders will be explained shortly. Finally the aims of this research programme will be discussed.

== Phobias ==
Acrophobia (phobia for heights) is one of the specific phobias, for which several criteria (APA, 1994) are in order. First of all a person must have marked or persistent fear that is excessive or unreasonable and cued by the presence or anticipation of height situations. Secondly the exposure to those heights almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. Thirdly the person who is afraid of heights must recognise that his or her fear is excessive or unreasonable. High situations are avoided or else are endured with intense anxiety or distress. The avoidance, anxious anticipation or distress in the high situation(s) interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. Finally the anxiety for heights is not better accounted for by another mental disorder, like panic disorder or post traumatic stress disorder.

Social phobia is not a specific phobia but a different anxiety disorder according to the DSM-IV; although the criteria that have to be met are quite similar to those of a specific phobia. These criteria are the following: firstly there must be a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Secondly exposure to the feared social situation almost invariably provokes anxiety, which my take the form of a situationally bound or situationally predisposed panic attack. Thirdly the person recognises that the fear is excessive or unreasonable. The feared social or performance situations are avoided or else are endured with intense anxiety or distress. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder.

The last syndrome that will be described is agoraphobia. Agoraphobia is not a classifiable disorder on itself, but can be part of different anxiety disorders described in the DSM-IV. Those are (1) panic disorder with agoraphobia and (2) agoraphobia without history of panic disorder. Only the aspect of agoraphobia will be described because this will be the focus in this research project (see further paragraphs). Agoraphobia is an anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and travelling in a bus, train, or automobile. Those situations are avoided or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion. And the last criterion: the anxiety or phobic avoidance is not better accounted for by another mental disorder.

== Treatment ==
Fortunately acrophobia, social phobia and agoraphobia can be treated with the right professional care. Treatment periods vary. Some people with phobias require only a few sessions of treatment while others need many more. Moreover people with phobias can have other disorders as well, which can complicate the treatment.

Behavior therapy is often an effective treatment for phobias. Behavior therapy is built on the principle that behavior is directly connected to the way we feel. In order to change our feelings we have to change our behavior. Let’s take for example a patient with the phobia for heights. Such a patient is avoiding situations in which he/she can be in contact with height situations. Because they never expose themselves to the fearful situation(s) persons do not experience that anxiety. During behavioral therapy (exposure in vivo) patients learn that in order to be less fearful they have to practice in fearful situations. In a gradual order they are exposed to fearful situations. They are put in difficult situations for as long as it takes to let the anxiety attenuate. If the anxiety becomes less, a more fearful situation is created (or looked for) and so on.

A new form of therapy is created by using the same techniques as behavioral therapy, with the difference that real situations are not used but virtual environments. The techniques of VR are making it possible to treat patients in the therapist-office, in stead of in real situations in the outside world. It creates the possibility of treating more and different kinds of phobias. Stimuli in a virtual environment can be manipulated, which isn’t possible in the real world. Another advantage is that patients can be confronted with their fears in an environment that feels much safer then the real one with people watching for instance.

== Research project & aims ==
In this research project the University of Amsterdam will collaborate with the Technical University of Delft. Patients who have different kind of phobias which are described above (acrophobia, social phobia and agoraphobia) will be treated with two kinds of exposure therapy. Gradual exposure in vivo will be used, because it’s been proven effective for the phobias we will be treating. The other kind of therapy that will be used is gradual Virtual Reality Exposure Therapy (VRET). This form of treatment follows the same procedure as the other exposure therapies but the situations that patients will be exposed to will be virtual. Patients don’t have to imagine the situations, don’t have to look for them in real life, but will be exposed to them in virtual environments.

The aims of the research are the following:

# Examining the effectiveness of Virtual Reality Exposure Therapy (VRET). This will be done for the different phobias. First will be looked at the effectiveness of VRET versus gradual exposure in vivo for patients who are afraid of heights. The settings in real life are created in virtual environments as well and exposure in vivo will be compared to VRET in a randomised experiment. Later on the treatment for social phobia and agoraphobia will be compared in a similar way, by using exposure in vivo in one condition and using VRET in another one. A no-treatment control group will also be included.
# Furthermore different qualities of presenting the virtual worlds will be compared and their effect on treatment-effectiveness for people with acrophobia. The personal computer with head-mounted device (HMD) will be compared to a more advanced VR-system.
# At the same time the research will focus on the prediction of treatment effect and VR. There will be looked into classic psychological predictors as personality-traits and gravity but also into the attitude towards computers, the feeling of presence in the VR-world and the therapeutic alliance. It will be verified which features correlate with the effect of the VR-treatment just after treatment and at the 6 months follow-up.
# Some process-studies will be done as well. VR-exposure is an ideal paradigm to study the relationship between cognitions and physiological parameters. During VRET SUDS (Subjective Units of Discomfort), physiology and cognitions will be investigated and the relationship between them.

== Results ==
There are some preliminary results on treatment-effectiveness for acrophobia.

* Click here to find the preliminary results of the pilot study. 
* Click here to find the preliminary results of the study comparing exposure in vivo with VRE.