Virtual reality smartphone application for the home treatment of fear of heights

A virtual reality app for smartphones reduces fear of heights, providing an accessible and low-threshold treatment for fear of heights in real-life.

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Fear of heights is a common phenomenon. Around 5% of the general population feel uncomfortable at high altitude to such an extent that their quality of life is impaired.1 Compared to other specific phobias, these triggers are widespread, including not only unusual encounters as high mountains or cliffs, but also daily life encounters, such as stairs, terraces, bridges, apartments, and offices located in high buildings.

However, highly effective treatment methods such as exposure therapy, in which those affected expose themselves to the dreaded situations under therapeutic guidance2,3, are rarely used4. On the one hand, those affected are reluctant to expose themselves to the unpleasant situations5; on the other hand, difficulties in creating suitable height situations in the therapeutic setting play a role6.

The implementation of virtual reality (VR), where individuals can expose themselves to the feared stimuli in VR, has the potential to counter many of the raised problems of exposure in real-life. Triggering stimuli can be simulated in the therapy room of a therapist at any time, which first reduces the preparation time for exposure and second makes its use more flexible and for example not dependent on time of day or weather conditions7.

The use of virtual reality to treat fear of heights has been researched for more than two decades. What is new, however, is the use of smartphones to generate the virtual scenarios.

In the current publication of npj Digital Medicine an interdisciplinary research team of the University of Basel, Switzerland has developed the smartphone-based virtual reality exposure app EASYHEiGHTS.

EASYHEIGHTS works with 360° images of real locations taken by a drone. During the height training, you stand on a virtual platform that is initially one meter above the ground. After you get accustomed to the height, the platform will automatically continue to raise. In this way the position above the ground increases slowly but steadily without an accompanying increase in your fear level.

The effectiveness of EASYHEiGHTS was examined in a randomised, controlled trial. Fifty trial participants with fear of heights (aged 18-60) either completed a four-hour height program (one 60-minute session and six 30-minute sessions over the course of two weeks) in virtual reality using EASYHEiGHTS or were assigned to a control condition, which did not complete these training sessions. Before and after the treatment – or the same period of time without training – the trial participants ascended the Uetliberg lookout tower as far as their fear of heights allowed them. The researchers recorded the height level reached by the participants along with their subjective fear level at each level of the tower.

In-App content of the EASYHEiGHTS mountain scenario on an advanced level from the perspective of the user.

At the six weeks follow-up the group that completed the training with the app EASYHEiGHTS was able to climb higher towards the top (Cohen’s d = 1.3, p = 0.0001) and showed less fear on the tower (Cohen’s d = 1.27, p = 0.0001). The control group showed no positive changes.

The study results suggest that repeated use of a stand-alone smartphone-based virtual reality exposure app leads to significant improvements in avoidance behaviour and subjective well-being at high altitude. The effectiveness of the height training with EASYHEiGHTS is comparable to the effectiveness of classic exposure therapy8 and other stand-alone VR apps.9,10 A strength of this study is the assessment of fear of heights not only on a subjective level, but in a real-life height situation.

Low costs of the necessary setup and easy accessibility of the app qualify it as a useful addition to the current mental health care services as well as a self-help option for people with subclinical fear of heights.

People who suffer from a mild fear of heights can download the free app EASYHEiGHTS from the Google play store and complete training sessions on their own. However, for those who suffer from a serious fear of heights it is recommended to only use the app with the supervision of a mental health care professional.

1 Eaton, W. W., Bienvenu, O. J. & Miloyan, B. Specific phobias. Lancet Psychiatry 5, 678–686 (2018).

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3 Wolitzky-Taylor, K., Horowitz, J., Powers, M. & Telch, M. Psychological approaches in the treatment of specific phobias: a meta-analysis. Clin. Psychol. Rev. 28, 1021–1037 (2008).

4 Schäffler, F. et al. Consequences of visual height intolerance for quality of life: a qualitative study. Qual. Life Res. 23, 697–705 (2014).

5 Öst, L. One-session treatment for specific phobias. Behav. Res Ther. 27, 1–7 (1989).

6 Pittig, A., Kotter, R. & Hoyer, J. The struggle of behavioral therapists with exposure: self-reported practicability, negative beliefs, and therapist distress about exposure-based interventions. Behav. Ther. 50, 355–363 (2018).

7 Botella, C., Fernández-Álvarez, J., Guillén, V., García-Palacios, A. & Baños, R. Recent progress in virtual reality exposure therapy for phobias: a systematic review. Curr. Psychiatry Rep. 19, 42 (2017).

 8 Carl, E. et al. Virtual reality exposure therapy for anxiety and related disorders: a meta-analysis of randomized controlled trials. J. Anxiety Disord. 61, 27–36 (2018).

 9 Donker, T. et al. Effectiveness of self-guided app-based virtual reality cognitive behavior therapy for acrophobia: a randomized clinical trial. JAMA Psychiatry 76, 682–690 (2019).

10 Freeman, D. et al. Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial. Lancet Psychiatry 5, 625–632 (2018).

Anja Zimmer

PhD Candidate, University of Basel