Virtual Reality, Augmented Reality, and in Vivo Exposure Therapy

Fear of Thunder

Fear and anxiety are natural parts of life, but for some individuals, phobias take extreme forms and interfere with their daily functioning. According to the Canadian Mental Health Association (2020), phobia disorders affect around two million Canadians, with two-thirds of them being female. The Canadian Mental Health Association (2020) defines phobia as an intense, irrational fear of something of little to no actual danger. Although individuals with phobias may realize the irrationality of their feelings, the fear trigger still brings a great deal of anxiety. There are two categories of phobias – specific and social (The Canadian Mental Health Association, 2020).

Fear of thunder belongs to the first category: in this case, an affected individual is aware of a specific trigger of fearful and anxious sensations. Other examples of specific phobias include dogs, spiders, heights, airplane flights, and others.

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There is no single answer as to why specific phobias emerge. Garcia (2017) argues that genetic, familial, environmental, or developmental factors contribute to the development of specific phobias. Non-experiential phobias may be a result of the so-called sensitization, which is a form of non-associative learning (Garcia, 2017). At the brain level, sensitization can be seen as a surge in neuronal responses associated with a specific stimulus, such as the sound of thunder.

In most children, an unknown external stimulus may increase amygdala activity, which is a natural mechanism of threat detection and self-protection. However, as pointed by Garcia (2017), some children have a different amygdala excitability threshold, so they experience exaggerated sensitization in response to a stimulus like thunder. In turn, experiential phobias stem from an unfortunate event involving a fear trigger (Garcia, 2017). In this case, classical conditioning may take place: a neutral stimulus (sound of thunder) is associated with an aversive stimulus (unfortunate event).

The neurophysiological nature of specific phobias provides cues to their treatment. Probably, the most popular modification technique for addressing phobias is fear extinction (FE). Extinction refers to a lessening of fear responses as a result of extinction training where individuals are repeatedly and gradually exposed to different presentations of the conditioned stimuli (CS) (An et al., 2017). At the brain level, the effectiveness of fear extinction depends on the inhibition mechanisms that have now been identified in the prefrontal cortex, the basolateral and lateral amygdala, and intercalated neurons (An et al., 2017).

New exposure experiences during FE training inhibit the original fear memory stored in the lateral amygdala. There is also evidence for complete erasure of original fear memories during FE. Regardless of which version is true, behavior modification should be based on habituation or decreasing amygdala activity through constant exposure.

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The type of phobia therapy that is based on the fear extinction strategy is called exposure therapy. This form of therapy implies that the therapist creates a safe environment for the client and exposes them to the conditioning stimuli. In graded exposure, the exposure is gradual as in, at first, it may be a picture of the feared object and only later the object itself. In contrast, flooding aims at overwhelming the person by starting with the most difficult tasks. Another common approach is systematic desensitization, in which exposure is complemented by mindfulness and relaxation techniques. Exposure therapy also varies in terms of setting: in vivo (directly, in real life), imaginal (imagining the feared object), virtual reality (VR) exposure (uses VR technology), and interoceptive (bringing on physical sensations).

Because exposure therapy types and techniques are diverse, it may be difficult to settle on one strategy. Suso-Ribera et al. (2019) compared exposure therapy (ET) in vivo to ET using virtual reality and augmented reality. The former technology allows the patient to interact with a computer-generated, three-dimensional model of the fear object. In turn, augmented reality superimposes a digitally generated virtual object onto reality to create the effect of full immersion. Suso-Ribera et al. (2019) reported that all three methods showed consistently good results judged by participants’ lowering levels of anxiety and desire to approach the object.

As for other classifications of ET, flooding was found to be more stressful both physiologically and psychologically than gradual exposure (Schumacher et al., 2015). Mindfulness-based exposure therapy that focuses on the “now” experiences was not found to be any less stress-inducing (Brake et al., 2016). Conversely, paying close attention to negative stimuli only raised the level of initial distress and increased the likelihood of avoidance behaviors.

Based on these findings, it is best to approach the fear of thunder in the form of exposure therapy drawing on the fear extinction mechanism. Gradual exposure may be a more optimal choice than flooding or systematic desensitization. First, the patient may be shown pictures of thunderstorms without any sound. The next step could be using virtual reality technology: for instance, the patient could explore a virtual environment depicting a city or a countryside during a thunderstorm. Since it is difficult to expose a person to thunder in vivo, augmented reality technology could be of use. It is important that the therapist accompanies the patient at all steps and provides reassurance. When after repeated exposure, the patient understands that there is no actual unwanted outcome, the stimulus may become neutral once and for all. The ultimate goal of such intervention will be to eliminate avoidance behaviors and improve the quality of life.

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Children’s Personal Hygiene

Hygiene has long-established ties with personal and public health. Out of all procedures, the Center for Disease Control and Prevention (2020) puts an emphasis on washing hands with soap. The Center for Disease Control and Prevention (2020) explains that hands can carry microscopic particles of human and animal feces, which are the major source of Salmonella, E. coli O157, and norovirus. These bacteria and viruses can cause acute food poisoning, diarrhea, nausea, and fever. As the ongoing COVID-19 pandemic has shown, the spread of respiratory infections can also be accelerated due to poor adherence to handwashing guidelines.

Without proper hygiene, people can easily get themselves sick by touching their eyes, mouth, and nose. Germs from unwashed hands can be transferred to food and drinks in the process of preparation as well as stay on clothes, handrails, and other objects that other people touch. As simple as it is, handwashing helps to prevent contracting infections as well as spreading germs to others.

By now, handwashing has been proven to be an evidence-based intervention for improving public health. As the Center for Disease Control and Prevention (2020) reports, handwashing reduces the number of people who suffer from diarrhea by 23-40%. For vulnerable people with weakened immune systems, hand hygiene lowers the risk of getting diarrhea by 58%. The burden of respiratory illnesses is reduced by 16-21%, and the rate of school absenteeism due to gastrointestinal illness is down by 29-57% (Centers for Disease Control and Prevention, 2020). Even though these facts are now public knowledge, reportedly, only 19% of people wash their hands after the toilet. The situation may be even direr with kids who may not be able to understand health concepts and consequences of poor hygiene.

To better understand what the best intervention would be, one needs to take a look at the cases of unsatisfactory hygiene in children. The American Cleaning Institute (ACI) conducted a survey among 521 primary school children and concluded that 43% do not wash their hands as often as it was required (Johnson, 2020). Sixteen percent of students named the lack of reminders, such as posters, as the reason for their non-adherence (Johnson, 2020). Another twenty percent reported that they did not see others wash hands, which is why they did not follow suit (Jonson, 2020). Lastly, one-fifth of all respondents complained about the lack of supplies in school bathrooms. In other words, physical surroundings and external stimuli play a role in shaping hygiene behaviors.

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Naluonde et al. (2020) write that the growing field of behavioral economics has promising prospects with regard to modifying behavior. Within its theoretical underpinnings, the environment is given the role of the driver in shaping habitual behavior. This assumption hinges on the findings made by neuroscientists showing that habits are often associated with external stimuli or cues. Therefore, new behavior that is different from what a person is used to has to be triggered by an unknown stimulus. In their study, Naluonde et al. (2020) introduced an intervention where the teacher would give a threaded soap (soap-on-a-rope) as a hall pass.

Therefore, whenever a student would go to the bathroom, they would have hygienic supplies that would also serve as an external cue to wash hands. As a result, the handwashing adherence was higher in the intervention than in control schools.

Wichaidit et al. (2019) conducted a similar study in which they combined physical equipment and an intervention campaign to set up at selected schools. The researchers set up portable handwashing stations with running water and soap dispensers to tackle the issue of hygiene products availability. The intervention campaign appealed to students’ sense of disgust as the materials clarified the mechanisms of germ transmission and associated diseases. Wichaidit et al. (2019) also empowered the intervention by strengthening the role of social norms and making handwashing socially desirable. The study was successful as more students than before adhered to hand hygiene guidelines.

Drawing on these findings, the behavior-modifying technique that may be used for improving handwashing is fading conditioning. Fading is a strategy found in behavior therapy, particularly behavior modification, where an initial prompting to perform an action is gradually withdrawn. In relation to a school campaign, such prompting may be the constant reminders about hand washing. In the beginning, the initial campaign makes sense as children need to understand the importance of good hygiene. It is also possible to announce that it is time to wash hands before lunch and after the gym through loudspeakers.

Other external environmental cues may include posters illustrating the hand washing sequence, as requested by children in the American Cleaning Institute (ACI) survey. However, constant reminders are not sustainable and should become ever rarer as students learn the desired behavior. In contrast, physical supplies, such as soap, should not shrink in amount or reduce in availability.

Putting Off Doing This Assignment

Procrastination may seem like a simple behavior, but it is a complex phenomenon. A delay between intention and action, that is procrastination, is common in all areas of life but especially in academia. Statistics show that 80% of students procrastinate from time to time, while 50% describe themselves as chronic procrastinators (Davis & Abbitt, 2013). The consequences of delaying tasks have been widely documented in modern scientific literature and generally come down to elevated levels of stress, poor self-esteem, and anxiety. Underperforming academically and receiving negative feedback on one’s tasks are some other common outcomes of procrastination (Davis & Abbitt, 2013). Fighting procrastination is especially challenging because the phenomenon depends on cognitive, behavioral, and psychological factors.

Apart from that, it is not uncommon for procrastinators to find advantages in their otherwise detrimental behaviors. For instance, some students admit that they like the challenge of completing everything on time after taking longer breaks. Others see rushing to the deadline as an opportunity to refine their time-efficiency and organizing skills.

As a complex phenomenon, procrastination may not respond to a single strategy or technique, therefore, multiple should be considered. Davis and Abbitt (2013) conducted an intervention study in which participants, all of whom were studying in college, were offered to join a support program. The researchers developed a system that was automatically sending SMS text messages with a text to the effect of “[Student name], do not forget about the assignment.” When designing the study, Davis and Abbitt (2013) also took into account an evidence-based assumption that students are more effective when deadlines are set externally, not internally.

Each student was given seven days to complete the assignment, and the closer they were to the deadline, the more messages they were receiving from the server. On the last day, if the task was still not submitted, participants received thirteen messages. Once the assignment was complete, students were no longer receiving messages. The study findings suggested that external cues in the form of SMS were effective in reducing procrastination.

Based on these findings, one may consider fading in the form of providing external cues with decreasing intensity over time may help to fight procrastination. In real life, one can join a study group where all members support each other and send reminders about upcoming deadlines. Alternatively, a student can set up alarms or use any planning application that sends a notification as a source of external stimuli. Once a new behavioral pattern is established, fewer stimuli may be needed. It is worth noting that the study by Davis and Abbitt (2013) also used elements of negative reinforcement in which the program would annoy students with messages until they completed the task. Perhaps the same strategy could be replicated in real life and potentially empower the fading technique.

Speaking of reinforcement, a reward system aimed toward forming healthier habits has also been proven successful. Judah, Gardner, Kenward, DeStavola, and Aunger (2018) write that reward is one of the potential predictors of habit formation. The majority of psychological and health literature argues that the effectiveness of reward in forming new behaviors is mediated by repetition. Undoubtedly, if a person is satisfied with the outcomes, they will be more likely to do it again. Therefore, the leverage of the perceived reward is strengthened by the frequency of action (Judah et al., 2018). However, neuroscience literature indicates that the relationship may be reversed (Judah et al., 2018).

It is not impossible that the perceived value of reward moderates the impact of repetitions on habit formation. In other words, the better the reward, the fewer repetitions of the desired behavior it takes to establish a new habit. In their study, Judah et al. (2018) discovered that pleasure indeed strengthened the stimulus-behavior bond.

Therefore, positive reinforcement could be used for reducing academic procrastination. A student who cannot quite organize themselves enough to complete an assignment may want to introduce a reward system. A large, important task can be broken down into simple steps that do not look as intimidating. For example, a paper may require literature research, data analysis, writing, and making a PowerPoint presentation. There should be enough time allocated for each step, especially the initial stages.

After the successful completion of each step, a student can enjoy a treat that they can choose to their own liking. It is not the objective of reward that matters but the perceived pleasure and benefits. For some people, it may be their favorite meal, while for others, completing a task may be a pass to go to a party and socialize with friends. The reward should be something that a person looks forward to, an external cue that stands out from the regular environment. If a student fails to follow through, no reward is given.


An, B., Kim, J., Park, K., Lee, S., Song, S., & Choi, S. (2017). Amount of fear extinction changes its underlying mechanisms. Elife, 6, e25224.

Brake, C. A., Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Farchione, T. J., & Barlow, D. H. (2016). Mindfulness-based exposure strategies as a transdiagnostic mechanism of change: an exploratory alternating treatment design. Behavior Therapy, 47(2), 225-238.

The Canadian Mental Health Association. (2020). Phobias and panic disorders. Web.

Centers for Disease Control and Prevention. (2020). Show me the science: Handwashing. Web.

Davis, D. R., & Abbitt, J. T. (2013). An Investigation of the Impact of an Intervention to Reduce Academic Procrastination Using Short Message Service (SMS) Technology. Journal of Interactive Online Learning, 12(3), 1-25.

Garcia, R. (2017). Neurobiology of fear and specific phobias. Learning & Memory, 24(9), 462-471.

Johnson, J. (2020). School health study shows why children don’t wash their hands. Meritech. Web.

Judah, G., Gardner, B., Kenward, M. G., DeStavola, B., & Aunger, R. (2018). Exploratory study of the impact of perceived reward on habit formation. BMC Psychology, 6(1), 1-12.

Naluonde, T., Wakefield, C., Markle, L., Martin, A., Tresphor, C., Abdullah, R., & Larsen, D. A. (2019). A disruptive cue improves handwashing in school children in Zambia. Health Promotion International, 34(6), e119-e128.

Schumacher, S., Miller, R., Fehm, L., Kirschbaum, C., Fydrich, T., & Ströhle, A. (2015). Therapists’ and patients’ stress responses during graduated versus flooding in vivo exposure in the treatment of specific phobia: A preliminary observational study. Psychiatry Research, 230(2), 668-675.

Suso-Ribera, C., Fernández-Álvarez, J., García-Palacios, A., Hoffman, H. G., Bretón-López, J., Banos, R. M.,… & Botella, C. (2019). Virtual reality, augmented reality, and in vivo exposure therapy: a preliminary comparison of treatment efficacy in small animal phobia. Cyberpsychology, Behavior, and Social Networking, 22(1), 31-38.

Wichaidit, W., Steinacher, R., Okal, J. A., Whinnery, J., Null, C., Kordas, K.,… & Ram, P. K. (2019). Effect of an equipment-behavior change intervention on handwashing behavior among primary school children in Kenya: The Povu Poa school pilot study. BMC Public Health, 19(1), 1-12.

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