Diaphragmatic breathing during virtual reality exposure therapy for aviophobia: functional coping strategy or avoidance behavior? a pilot study

Youssef Shiban, Julia Diemer, Jana Müller, Johanna Brütting-Schick, Paul Pauli, Andreas Mühlberger, Youssef Shiban, Julia Diemer, Jana Müller, Johanna Brütting-Schick, Paul Pauli, Andreas Mühlberger

Abstract

Background: Although there is solid evidence for the efficacy of in vivo and virtual reality (VR) exposure therapy for a specific phobia, there is a significant debate over whether techniques promoting distraction or relaxation have impairing or enhancing effects on treatment outcome. In the present pilot study, we investigated the effect of diaphragmatic breathing (DB) as a relaxation technique during VR exposure treatment.

Method: Twenty-nine patients with aviophobia were randomly assigned to VR exposure treatment either with or without diaphragmatic breathing (six cycles per minute). Subjective fear ratings, heart rate and skin conductance were assessed as indicators of fear during both the exposure and the test session one week later.

Results: The group that experienced VR exposure combined with diaphragmatic breathing showed a higher tendency to effectively overcome the fear of flying. Psychophysiological measures of fear decreased and self-efficacy increased in both groups with no significant difference between the groups.

Conclusions: Our findings indicate that diaphragmatic breathing during VR exposure does not interfere with the treatment outcome and may even enhance treatment effects of VR exposure therapy for aviophobic patients.

Trial registration: Retrospectively registered. ClinicalTrials.gov NCT02990208 . Registered 07 December 2016.

Keywords: Aviophobia; Diaphragmatic breathing; Experimental study; Exposure therapy; Virtual reality.

Figures

Fig. 1
Fig. 1
Questionnaire ratings of the Fear of Flying Scale (FFS). Note. VRET = Virtual reality exposure therapy, DB = diaphragmatic breathing. Graphs represent the mean of the questionnaire ratings of the FFS for the five measurements for both groups (VRET + DB: N = 15, VRET: N = 14): pre exposure, post exposure, pre test (one week after exposure session), post test and follow up (after one year, VRET + DB: N = 12, VRET: N = 13). Standard errors are represented as error bars
Fig. 2
Fig. 2
Self-efficacy scores. Note. VRET = Virtual reality exposure therapy, DB = diaphragmatic breathing. Graphs represent the mean of the self-efficacy scores for the five measurements for both groups (VRET + DB: N = 15, VRET: N = 14): pre exposure, post exposure, pre test (one week after exposure session), post test and follow up (after one year, VRET + DB: N = 12, VRET: N = 14). Standard errors are represented as error bars
Fig. 3
Fig. 3
Fear ratings during the exposure (3a) and test session (3b). Note. VRET = Virtual reality exposure therapy, DB = diaphragmatic breathing, c1/c2 = calm, t1/t2 = turbulence. Graphs represent the mean of the fear ratings during the exposures (1–3) and the test sessions (1–2) for both groups. Standard errors are represented as error bars
Fig. 4
Fig. 4
Heart rate (HR) during the exposure (4a) and test session (4b). Note. VRET = Virtual reality exposure therapy, DB = diaphragmatic breathing, c1/c2 = calm, t1/t2 = turbulence. Graphs represent the mean of the heart rate during the exposures (1–3) and the test sessions (1–2) for both groups. Standard errors are represented as error bars
Fig. 5
Fig. 5
Skin conductance level (SCL) during the exposure (5a) and test sessions (5b). Note. VRET = Virtual reality exposure therapy, DB = diaphragmatic breathing, c1/c2 = calm, t1/t2 = turbulence. Graphs represent the mean of the SCL during the exposures (1–3) and the test sessions (1–2) for both groups. Standard errors are represented as error bars

References

    1. Ekeberg Ø, Fauske B, Berg‐Hansen B. Norwegian airline passengers are not more afraid of flying after the terror act of September 11. The flight anxiety, however, is significantly attributed to acts of terrorism. Scand J Psychol. 2014;55:464–468. doi: 10.1111/sjop.12137.
    1. Mühlberger A, Weik A, Pauli P, Wiedemann G. One-session virtual reality exposure treatment for fear of flying: 1-Year follow-up and graduation flight accompaniment effects. Psychother Res. 2006;16:26–40. doi: 10.1080/10503300500090944.
    1. Corbin WR, Farmer NM, Nolen-Hoekesma S. Relations among stress, coping strategies, coping motives, alcohol consumption and related problems: A mediated moderation model. Addict Behav. 2013;38:1912–1919. doi: 10.1016/j.addbeh.2012.12.005.
    1. Parrish CL, Radomsky AS, Dugas MJ. Anxiety-control strategies: is there room for neutralization in successful exposure treatment? Clin Psychol Rev. 2008;28:1400–1412. doi: 10.1016/j.cpr.2008.07.007.
    1. Rougemont-Bücking A, Grivel J. Risk perception and emotional coping: a pathway for behavioural addiction? Eur Addict Res. 2014;20:49–58. doi: 10.1159/000353589.
    1. Dymond S, Schlund MW, Roche B, De Houwer J, Freegard GP. Safe from harm: Learned, instructed, and symbolic generalization pathways of human threat-avoidance. PLoS ONE. 2012;7:e47539. doi: 10.1371/journal.pone.0047539.
    1. Sheynin J, Beck KD, Servatius RJ, Myers CE. Acquisition and extinction of human avoidance behavior: attenuating effect of safety signals and associations with anxiety vulnerabilities. Front Behav Neurosci. 2014;8:323. doi: 10.3389/fnbeh.2014.00323.
    1. Gangemi A, Mancini F, van den Hout M. Behavior as information: “If I avoid, then there must be a danger”. J Behav Ther Exp Psychiatry. 2012;43:1032–1038. doi: 10.1016/j.jbtep.2012.04.005.
    1. van den Hout M, Gangemi A, Mancini F, Engelhard IM, Rijkeboer MM, van Dams M, Klugkist I. Behavior as information about threat in anxiety disorders: A comparison of patients with anxiety disorders and non-anxious controls. J Behav Ther Exp Psychiatry. 2014;45:489–495. doi: 10.1016/j.jbtep.2014.07.002.
    1. Oliver NS, Page AC. Fear reduction during in vivo exposure to blood-injection stimuli: distraction vs. attentional focus. Br. J. Clin. Psychol. 2003;42:13–25. doi: 10.1348/014466503762841986.
    1. Johnstone KA, Page AC. Attention to phobic stimuli during exposure: the effect of distraction on anxiety reduction, self-efficacy and perceived control. Behav Res Ther. 2004;42:249–275. doi: 10.1016/S0005-7967(03)00137-2.
    1. Kamphuis JH, Telch MJ. Effects of distraction and guided threat reappraisal on fear reduction during exposure-based treatments for specific fears. Behav Res Ther. 2000;38:1163–1181. doi: 10.1016/S0005-7967(99)00147-3.
    1. Craske MG, Kircanski K, Zelikowsky M, Mystkowski J, Chowdhury N, Baker A. Optimizing inhibitory learning during exposure therapy. Behav Res Ther. 2008;46:5–27. .
    1. Fentz HN, Arendt M, O'Toole MS, Hoffart A, Hougaard E. The mediational role of panic self-efficacy in cognitive behavioral therapy for panic disorder: A systematic review and meta-analysis. Behav Res Ther. 2014;60:23–33. doi: 10.1016/j.brat.2014.06.003.
    1. Hazlett-Stevens, H., & Craske, M. G. (2009). Breathing retraining and diaphragmatic breathing techniques. In W. O'Donohue & J. E. Fisher (Eds.), General Principles and Empirically Supported Techniques of Cognitive Behavior Therapy (pp. 166): John Wiley & Sons, Inc.
    1. Biggs QM, Kelly KS, Toney JD. The effects of deep diaphragmatic breathing and focused attention on dental anxiety in a private practice setting. J Dent Hyg. 2003;77:105–113.
    1. Wiederhold BK, Jang DP, Gevirtz RG, Kim SI, Kim IY, Wiederhold MD. The treatment of fear of flying: a controlled study of imaginal and virtual reality graded exposure therapy. IEEE Trans Inf Technol Biomed. 2002;6:218–23. .
    1. Opris D, Pintea S, Garcia-Palacios A, Botella C, Szamoskozi S, David D. Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis. Depress Anxiety. 2012;29:85–93. .
    1. Mühlberger A, Herrmann MJ, Wiedemann GC, Ellgring H, Pauli P. Repeated exposure of flight phobics to flights in virtual reality. Behav Res Ther. 2001;39:1033–1050. doi: 10.1016/S0005-7967(00)00076-0.
    1. Mühlberger A, Wiedemann G, Pauli P. Efficacy of a One-session virtual reality exposure treatment for fear of flying. Psychother Res. 2003;13:323–336. doi: 10.1093/ptr/kpg030.
    1. Smahaj J, Prochazka R. Virtual reality as alternative for anxiety disorders treatment. Ceskoslovenska Psychologie. 2014;58:571–579.
    1. Triscari MT, Faraci P, Catalisano D, D’Angelo V, Urso V. Effectiveness of cognitive behavioral therapy integrated with systematic desensitization, cognitive behavioral therapy combined with eye movement desensitization and reprocessing therapy, and cognitive behavioral therapy combined with virtual reality exposure therapy methods in the treatment of flight anxiety: a randomized trial. Neuropsychiatr Dis Treat. 2015;11:2591.
    1. da Costa RT, Sardinha A, Nardi AE. Virtual reality exposure in the treatment of fear of flying. Aviat Space Environ Med. 2008;79:899–903. doi: 10.3357/ASEM.2277.2008.
    1. Rus-Calafell, M., Gutiérrez-Maldonado, J., Botella, C., & Baños, R. M. (2013). Virtual Reality Exposure and Imaginal Exposure in the Treatment of Fear of Flying: A Pilot Study. Behavior Modification. doi:10.1177/0145445513482969
    1. Tortella-Feliu M, Botella C, Llabrés J, Bretón-López JM, del Amo AR, Baños RM, Gelabert JM. Virtual reality versus computer-aided exposure treatments for fear of flying. Behav Modif. 2011;35:3–30. doi: 10.1177/0145445510390801.
    1. Kropf, A., & Schenk, V. Gruppenseminar. Retrieved from
    1. Polhemus. (2012). 3Space Fastrak User Manual. Retrieved from . Accessed 12 Dec 2016.
    1. Mühlberger A, Pauli P. Flugangst- und Flugphobie-Inventar: FAPI. Göttingen: Hogrefe; 2011.
    1. Wittchen H-U, Fydrich T. Strukturiertes Klinisches Interview für DSM-IV (SKID-I und SKID-II) Göttingen: Hogrefe; 1997.
    1. American Psychiatric Association. (2000). Diagnostic and statistical manual-text revision (DSM-IV-TRim, 2000). American Psychiatric Association
    1. Haug T, Berntzen D, Götestam K-G, Brenne L, Johnsen BH, Hugdahl K. A three-systems analysis of fear of flying: A comparison of a consonant vs a non-consonant treatment method. Behav Res Ther. 1987;25:187–194. doi: 10.1016/0005-7967(87)90045-3.
    1. Reiss S, Peterson RA, Gursky DM, McNally RJ. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther. 1986;24:1–8. doi: 10.1016/0005-7967(86)90143-9.
    1. Shiban Y, Pauli P, Mühlberger A. Effect of multiple context exposure on renewal in spider phobia. Behav Res Ther. 2013;51:68–74. doi: 10.1016/j.brat.2012.10.007.
    1. Milosevic I, Radomsky AS. Safety behaviour does not necessarily interfere with exposure therapy. Behav Res Ther. 2008;46:1111–1118. doi: 10.1016/j.brat.2008.05.011.
    1. Jones MK, Menzies RG. Danger expectancies, self-efficacy and insight in spider phobia. Behav Res Ther. 2000;38:585–600. doi: 10.1016/S0005-7967(99)00076-5.
    1. Diemer J, Lohkamp N, Mühlberger A, Zwanzger P. Fear and physiological arousal during a virtual height challenge—effects in patients with acrophobia and healthy controls. Journal of anxiety disorders. 2016;37:30–39. doi: 10.1016/j.janxdis.2015.10.007.
    1. Trimmel M, Burger M, Langer G, Trimmel K. Treatment of fear of flying: behavioral, subjective, and cardiovascular effects. Aviat Space Environ Med. 2014;85:550–562. doi: 10.3357/ASEM.3821.2014.
    1. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Adv Behav Res Ther. 1978;1:139–161. doi: 10.1016/0146-6402(78)90002-4.
    1. Martin, M., Seppa, M., Lehtinen, P., Toro, T., & Salmen, H. (2016). Breathing as a Tool for Self-Regulation and Self-Reflection: Karnac Books
    1. Van Gerwen LJ, Spinhoven P, Diekstra RFW, Van Dyck R. People who seek help for fear of flying: Typology of flying phobics. Behav Ther. 1997;28:237–251. doi: 10.1016/S0005-7894(97)80045-7.

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