applied

sciences
Article
Virtual Reality Exposure Therapy for Driving Phobia
Disorder: System Design and Development
Amy Trappey 1, * , Charles V. Trappey 2 , Chia-Ming Chang 3 , Routine R.T. Kuo 1 ,
Aislyn P.C. Lin 1 and C.H. Nieh 3,4
1 Department of Industrial Engineering and Engineering Management, National Tsing Hua University,
Hsinchu 300, Taiwan; s108034518@m108.nthu.edu.tw (R.R.T.K.); s105034013@m105.nthu.edu.tw (A.P.C.L.)
2 Department of Management Science, National Chiao Tung University, Hsinchu 300, Taiwan;
trappey@faculty.nctu.edu.tw
3 Psychiatry Department, Chang Gung Memorial Hospital, Taipei 333, Taiwan;
cmchang58@cgmh.org.tw (C.-M.C.); 408456055@gapp.fju.edu.tw (C.H.N.)
4 Department of Clinical Psychology, Fu Jen Catholic University, Taipei 242, Taiwan
* Correspondence: trappey@ie.nthu.edu.tw; Tel.: +886-3572-7686




Received: 25 June 2020; Accepted: 13 July 2020; Published: 15 July 2020


Abstract: Driving phobia is an anxiety disorder. People are greatly impaired in their daily lives when
suffering from driving phobia disorders. The anxieties can be triggered under various conditions,
such as driving over bridges, driving at high speeds, or driving in close proximity to large trucks.
Traditional cognitive behavioral therapy (CBT) and exposure therapy are the most common approaches
used in the treatment of psychological disorders, such as anxiety disorder (AD) and panic disorder
(PD). This research focuses on virtual reality (VR)-based exposure therapy, called VRET, and describes
the design and development of a system which uses alternating levels of fear-based driving scenarios
that can be recorded and automatically adjusted to maximize exposure effectiveness without causing
the subjects to panic. The proposed VRET integrates an advanced feedback database module for
tracing and analyzing the system, along with the user’s bio-data to show the valid data collection
of the system and its effectiveness for future use in clinical trials. The research conducts a system’s
pre-test analysis using 31 subjects to demonstrate the effectiveness of the system. This research
demonstrates the systematic development of the VRET for driving phobia disorder by depicting the
system framework, key system modules, system integration, bio-database management, and pre-test
data analysis to support our next research efforts in hospital-based clinical trials and for additional
VRET development applications for clinical psychology.

Keywords: virtual reality exposure therapy; driving phobia; post-traumatic stress disorder;
physiological signal

1. Introduction
Post-traumatic stress disorder (PTSD) is a general term for any mental health issue that is triggered
by a traumatic event experienced or witnessed by the patient. Many types of assaults can result in PTSD,
such as physical or mental abuse, sexual assault, and serious physical accidents. People that suffer
from PTSD have problems with daily, societal, and work-related activities. The condition interferes
with one’s ability to deal with normal life tasks. In 1980, PTSD was officially recognized as a mental
illness by the American Psychiatric Association after the analysis of soldiers injured and exposed to
traumatic experiences during the Vietnam war [1].
Cognitive behavioral therapy (CBT) and exposure therapy (ET) are the most common approaches
for treating PTSD, anxiety disorder (AD), and panic disorder (PD) [2]. The goal of therapies is to change

Appl. Sci. 2020, 10, 4860; doi:10.3390/app10144860 www.mdpi.com/journal/applsci

Appl. Sci. 2020, 10, 4860 2 of 16

patterns of thinking or behavior that cause mental disorders. CBT works by changing people’s attitudes
and their behaviors by focusing on the thoughts, images, beliefs and attitudes. Because there is no
invasive treatment or psychoactive drugs used while conducting CBT, it is generally recommended
by medical institutions [3]. The challenges of CBT are that it requires patient cooperation, is time
consuming, and is difficult to execute as a standard procedure.
An emerging treatment approach for PTSD takes advantage of immersive-based information
technology to advance exposure therapy using virtual reality (VR) and more sophisticated physical
measuring devices (called VR-based exposure therapy (VRET)). VRET allows patients to slowly
expose themselves to different levels of traumatic stimuli using immersions of vision, sound and
tactile feedback, which matches the principle of systematic desensitization (SD). SD is evaluated by
researchers to be as effective as CBT [2,4]. Using VRET, patients interact and are exposed to a simulation
of the phobic surroundings, but do not physically encounter the feared situations and the immersive
condition can be immediately adjusted to reduce additional harm that can be caused by stress and
panic attacks resulting from overexposure. The curative effects of VRET are more significant (and more
realistic) then CBT [5]. There are some issues to be considered when designing VRET as a therapeutic
treatment [6]. First, VRET is an evolving technology, psychiatrists and psychotherapists have to
experiment with designs and configurations of therapy, develop base scenes, changing scenarios,
and integrate complex monitoring equipment while demonstrating that the treatment is effective,
reliable, and valid. The development costs and design thresholds of VRET are considerably more
challenging than traditional CBTs. Further, researchers must consider the realism of the immersive
environments. If the immersive environment is not realistic, the patients will lack exposure and the
curative effect (or an effective meta-analytic effect size for clinical trials) will be compromised. If the
immersive environment is too realistic, it could trigger severe phobic reactions during the experiments
and endanger the subject’s safety. Finally, some patients may not be familiar with VR hardware and
software settings. Thus, severe dizziness during the experiment may hinder the VRET results. Thus,
patients’ physical conditions and their suitability for VRET need to be carefully investigated to ensure
the effectiveness of VRET implementations and applications [6].
Section 2 presents a literature review of immersive applications in PTSD, including traditional
ET, CBT, and VRET. Section 3 introduces the methodology framework and the approaches used
in this research. Section 4 demonstrates the system architecture and the hardware and software
components that are adopted and integrated to build the immersive environment. Section 5 performs
statistical analysis to the pre-test data, using the correlation coefficients between system and bio-data,
nonparametric testing for gender difference and anxiety group difference, and an ANOVA test for ET
level effects. A Shewhart control chart was applied to monitor the subjects’ emotional arousal. Section 6
summarizes the VRET systematic research, describes the research contributions, and highlights the
next phase VRET research for controlled clinical trials.
In principle, this research focuses on VRET design and development using seven increasingly
frightening driving scenario levels. The proposed VRET integrates with an advanced system and
bio-database module for tracing and analyzing the system and user’s bio-data. The research conducts
the system’s pre-test analysis to demonstrate the effectiveness of the system. The main objectives
of this research are to present the systematic development of the VRET for driving phobia disorder,
including the VRET system framework, key system modules, system design theory, bio-feedback
database management, and pre-test data analysis. The research outcomes will support our next efforts
in using VRET for hospital based clinical trials for driving phobia disorders, and potentially extending
VRET development to other applications in clinical psychology.

2. Literature Review
In this section, the literature review focuses on the latest state of immersive technologies
and applications in PTSD-related psychotherapies. Publications from the American Psychological
Association (APA), the Institute of Electrical and Electronics Engineers (IEEE) Xplore, and the Web of
Appl. Sci. 2020, 10, 4860 3 of 16

Science (WoS) digital library are searched using keywords Cognitive Behavior Therapy, Post Traumatic
Stress Disorder, and Exposure Therapy. The results were further refined to include Virtual Reality
Exposure Therapy and Driving Phobia. The two groups of literature are simply divided into VRET
and traditional treatments. The traditional treatment types are further divided into CBT and ET.
CBT and ET are commonly used to treat PTSD, depression, anxiety, and panic disorders.
CBT reduces cognitive anxiety by letting patients understand the causes of their reactions and
how to manage and change reactions that may exasperate their mental condition. The efficacy of CBT
on anxiety-related mental disorders, especially PTSD, has been confirmed by many studies [7–10].
Exposure therapy exposes patients to various levels of stimulating situations and continuously
increases the intensity of the exposure to gradually induce a tolerance toward the exposure. Subjects
are taught to self-analyze their reactions and change their behavioral response to better adapt to the
changing conditions of exposure. Exposure therapy includes both imaginary and in vivo exposure.
For imagined exposure, the therapist may ask the patient to imagine what they are afraid of. On the
other hand, in vivo exposure allows patients to face the phobia directly. Some clinical trials have
confirmed the effectiveness of exposure for treating PTSD. For example, Bryant et al. [11] divided 45
patients with PTSD into three groups—waiting list, exposure or counseling. The results showed that
only 14% and 20% of the group members that received prolonged exposure and prolonged exposure
plus anxiety management still suffered from symptoms of PTSD after treatment. Fifty-six percent of
the supportive counseling group members were not affected by the PTSD treatment. The findings
indicated that prolonged exposure may be a critical approach in the treatment of PTSD [11].
Aside from treating phobias, one of the successful applications of virtual reality technology is in
the field of education. In one study, researchers have conducted a bibliometric study of the last twenty
years from the Scopus database, and conclude that the use of virtual reality in education can improve
the quality of the teaching and learning processes [12]. In Jesús López Belmonte’s research, he asserted
that digital technology has become a part most of people’s lives and entered various fields of society.
For example, he applies VR to education and reports that VR yields many benefits such as optimizing
teaching and learning processes, timely access to new information, greater mobility, ubiquitous access,
and adaptable to the uniqueness of each student [13].
At present, there are many studies on the applications of VRET for various kinds of phobias such
as acrophobia, arachnophobia, and aviophobia [14]. In one study, a 50-year-old officer who suffered
from PTSD caused by the Vietnam War underwent VRET. After 14 treatments of up to 90 min over
seven weeks, his PTSD symptoms fell 34% under standard clinical measures. Self-assessment decreased
by more than 45% [15]. Another study of flying phobia ET confirmed that VRET and traditional
ET have no difference in statistical effect size. Seventy-five patients with fear of flying (FOF) were
divided into three groups (25 people in each group): VRET, traditional ET and the waitlist (do nothing).
After treatment, the results of VRET and traditional ET were almost equivalent while both groups were
superior to those on the waitlist [16]. Another study used meta-analysis to integrate effects from 21
clinical studies with a total of 300 subjects. The analysis results (effect size) demonstrated that VRET
effectively reduces anxiety [17]. Finally, our research studied the application of VRET in arachnophobia
treatment, incorporating Arduino bio-sensors to collect real-time bio-data from subjects. Bio-data are
integrated with the VRET system data and stored in SQL database for data mining and real-time VRET
level adjustment is used to minimize over-exposer to the treatment [18].
Driving is an essential skill that facilitates independence and mobility of individuals in modern
society and is often a requirement of employment. Being diagnosed with a driving phobia limits an
individual’s work options and creates issues associated with social interaction when mass transportation
or transportation for hire is not available or unaffordable. According to emotional processing
theory, successful exposure therapy leads to new and more neutral memory structures that overrule
old memories that provoke and heighten anxiety [19]. In a VRET for driving phobia pilot study,
14 subjects with serious driving phobia were placed into a series of experimental conditions, including
psychotherapeutic, medical examination, psychotherapy sessions, VRET sessions, and a final behavioral
Appl. Sci. 2020, 10, 4860 4 of 16

avoidance test (BAT) when driving in traffic. The therapy session for each subject required 10 days
to complete the 10,
Appl. Sci. 2020, experiment.
x After 6 to 12 weeks, follow-up tracking of the subjects was performed 4 of 16

to access the subjects’ driving performance and evaluate the effectiveness of the treatment for each
sessions, and a final behavioral avoidance test (BAT) when driving in traffic. The therapy session for
subject. The follow-up tracking indicated that 13 out of the 14 patients maintained successful treatment
each subject required 10 days to complete the experiment. After 6 to 12 weeks, follow-up tracking of
results [20]. Another VRET experiment for driving phobia used eight females who were willing to try
the subjects was performed to access the subjects’ driving performance and evaluate the effectiveness
VRETofbut theunwilling
treatment participants
for each subject.used The in follow-up
vivo exposure.tracking The VRET exposure
indicated that 13 outenvironment
of the 14 patientsconsisted
of eight
maintained successful treatment results [20]. Another VRET experiment for driving phobia used over
sessions which gradually exposed participants to increasingly uncomfortable exposure
50-minute intervals.
eight females who Factors, such as
were willing tomean
try VRET mood, butanxiety,
unwilling cognitive evaluation,
participants quality
used in vivo of life,The
exposure. sense of
VRETsubjective
presence, exposure environment
discomfort,consisted
and heart of rate
eightwere
sessions which gradually
recorded during the exposed participants
experiment. Thetoresult
showedincreasingly
that theuncomfortable
sense of presenceexposure over 50-minute
decreased as theintervals.
session Factors,
progressedsuch as meansubjects’
while mood, anxiety,
subjective
discomfort scores and heart rate increased. After the experiment, subjects were determined towere
cognitive evaluation, quality of life, sense of presence, subjective discomfort, and heart rate be more
recorded during the experiment. The result showed that the sense of presence decreased as the
confident with their driving ability. Six out of eight subjects were willing to conduct in vivo exposure
session progressed while subjects’ subjective discomfort scores and heart rate increased. After the
after VRET [21]. A VRET experiment for driving phobia related to fear of driving in tunnels was
experiment, subjects were determined to be more confident with their driving ability. Six out of eight
conducted.
subjectsIn the willing
were virtualtoreality environment,
conduct in vivo exposure the car passes
after VRETthrough a tunnel
[21]. A VRET with lighting
experiment for drivingadjusted
to resemble
phobia related to fear of driving in tunnels was conducted. In the virtual reality environment, the carupon
natural daylight on entry and exit, with increasing darkness and increasing lightness
exit. The
passes sound
throughof traffic was
a tunnel also
with included
lighting to enhance
adjusted the realism
to resemble of the simulations
natural daylight on entry and [22].
exit,The
with above
driving phobia darkness
increasing VRET studies provide alightness
and increasing solid basisuponforexit.
continued
The soundresearch. The
of traffic numbers
was of subjects
also included to in
theseenhance
studies the arerealism
generallyof the
toosimulations
small to draw [22]. The above driving
a decisive phobia
conclusion orVRET studies
provide provide a for
suggestions solid future
basis for continued research. The numbers of subjects in these studies are
VRET refinement. Moreover, most of the literature evaluated their VRET system based on subjects’ generally too small to draw
a decisive
driving conclusion
performance, andorfewprovide
focusedsuggestions for futurebiological
on the subjects’ VRET refinement.
senses and Moreover,
systemmost of the data
recorded
literature evaluated their VRET system based on subjects’ driving performance, and few focused on
analysis. Therefore, this pre-test experiment will examine the feasibility of using biological sensors and
the subjects’ biological senses and system recorded data analysis. Therefore, this pre-test experiment
system-data collection and analyses to measure subjects’ driving performance to ensure the safety and
will examine the feasibility of using biological sensors and system-data collection and analyses to
effectiveness
measure of VRET driving
subjects’ towardperformance
phobia treatment.
to ensure Further,
the safetyto ensure the VRETofisVRET
and effectiveness scientifically conducted,
toward phobia
collecting real-time
treatment. bio-data
Further, of patients
to ensure the VRET is vital during theconducted,
is scientifically ET sessions. Matured
collecting bio-sensor
real-time bio-data solutions,
of
such patients
as the Arduino micro-controller,
is vital during the ET sessions. can Matured
transmitbio-sensor
bio-data to a remote
solutions, computer
such or cloud
as the Arduino database
micro-
usingcontroller,
an XBee wireless network
can transmit [23].to a remote computer or cloud database using an XBee wireless
bio-data
network [23].
3. Methodology Applied in This Research
3. Methodology Applied in This Research
Figure 1 presents the research flow of this study for the driving phobia VRET design and
FigureThe
development. 1 presents
project the research flow
formulation madeof at
this
thestudy for the was
beginning driving phobiahow
to decide VRETto design and the
implement
development. The project formulation made at the beginning was to decide how to implement the
research, perform risk assessment, and hypothesize expected results. Literature related to VRET,
research, perform risk assessment, and hypothesize expected results. Literature related to VRET,
driving phobia, CBT, and PTSD were reviewed and referenced before designing the exposure treatment
driving phobia, CBT, and PTSD were reviewed and referenced before designing the exposure
scenario. The virtual reality immersive environments were constructed to model different fear levels
treatment scenario. The virtual reality immersive environments were constructed to model different
of scenarios.
fear levelsThe constructed
of scenarios. VRET prototype
The constructed has been has
VRET prototype examined by psychologists
been examined and an
by psychologists anditerative
an
modification
iterative modification process was executed until the psychologists were confident that the system the
process was executed until the psychologists were confident that the system matched
needsmatched
of ethical
theand medically
needs of ethical acceptable driving
and medically phobia
acceptable treatments.
driving phobia treatments.

Figure 1. The research flow of the virtual reality-based exposure therapy (VRET) system design
and development.
details of each level are highlighted as follows.
Level 1 Driving in the suburbs during the daytime, the speed limit is 40 km/hr.
Level 2 Driving in the suburbs at night, the speed limit is 40 km/hr.
Level 3 Driving on the highway during the daytime, the speed limit is 110 km/hr., and the
Appl. Sci. 2020, 10, 4860 5 of 16
system will ask subjects to drive faster if the driving speed is less than 90 km/hr.
Level 4 Driving on the highway at night, the speed limit is 110 km/hr., and the system will ask
The VRET subjects
systemtoisdrive faster ifusing
constructed the driving speedexposure
a seven-level is less than 90 km/hr.
therapy design as shown in Figure 2.
Level
Since some5 patients
Drivingareonextremely
the highway at night,
afraid the speed
of car crashes, limit is 110and
pedestrians km/hr.,
otherand the system
driving vehicleswill ask
do not
appear in the immersive environment for the initial test runs. All of the simulation scenes followbe
subjects to drive faster if the driving speed is less than 90 km/hr. Subjects will a
single route map. expected to traverse
Subjects a tunnel. distance to reach a destination before advancing to a higher
drive a specified
Level
level. 6 level
Each Driving onunique
has its a mountain road during
simulation the daytime,
environment, the treatment
time, and speed limit is 50 km/hr.
objectives. The details of
Level 7 Driving on the mountain
each level are highlighted as follows. road at night, the speed limit is 50 km/hr.

Figure 2. Scenario design level chart.

Figure 2. Scenario design level chart.
Level 1 Driving in the suburbs during the daytime, the speed limit is 40 km/h.
The VRET experiment flow is illustrated in Figure 3. The treatment begins with a detailed
Level 2 Driving in the suburbs at night, the speed limit is 40 km/h.
introduction about the experimental objective, method, procedure, expected risk, and relevant
Level 3 Driving on the highway during the daytime, the speed limit is 110 km/h, and the system will
disclaimer information. A pre-test questionnaire is completed by the subject before the experiment to
ask subjects to drive faster if the driving speed is less than 90 km/h.
measure the subject’s mental state. The questionnaire asks about the subject’s behavior, thoughts, and
Level 4 Driving on the highway at night, the speed limit is 110 km/h, and the system will ask subjects
emotions in regard to previous driving experiences. During the experiment, bio-data including heart
to drive faster if the driving speed is less than 90 km/h.
rate, skin conductance, body temperature, respiration, and head movement are recorded in the
Level 5 Driving on the highway at night, the speed limit is 110 km/h, and the system will ask subjects
computer database for statistical analysis. If virtual reality vertigo or other motion sickness symptoms
to drive faster if the driving speed is less than 90 km/h. Subjects will be expected to traverse
occur to the subject during the VRET session, an emergency stop is triggered and the experiment is
a tunnel.
Level 6 Driving on a mountain road during the daytime, the speed limit is 50 km/h.
Level 7 Driving on the mountain road at night, the speed limit is 50 km/h.

The VRET experiment flow is illustrated in Figure 3. The treatment begins with a detailed
introduction about the experimental objective, method, procedure, expected risk, and relevant
disclaimer information. A pre-test questionnaire is completed by the subject before the experiment
to measure the subject’s mental state. The questionnaire asks about the subject’s behavior, thoughts,
and emotions in regard to previous driving experiences. During the experiment, bio-data including
heart rate, skin conductance, body temperature, respiration, and head movement are recorded in the
computer database for statistical analysis. If virtual reality vertigo or other motion sickness symptoms
occur to the subject during the VRET session, an emergency stop is triggered and the experiment
is terminated. After the immersive treatment is finished, subjects are asked to complete a post-test
feedback form.
Appl. Sci. 2020, 10, x 6 of 16

terminated. After the immersive treatment is finished, subjects are asked to complete a post-test
Appl. Sci. 2020, 10, 4860 6 of 16
feedback form.

Figure
Figure 3. The
3. The driving
driving phobia
phobia VRET
VRET experiment
experiment flow.
flow.

A total of thirty-one subjects including 14 males and 17 females at the university participated
A total of thirty-one subjects including 14 males and 17 females at the university participated in
in the pre-test of the VRET prototype. The inclusion criteria are aged between 20 and 25 years old,
the pre-test of the VRET prototype. The inclusion criteria are aged between 20 and 25 years old,
possession of a valid driving license, and described a fear of at least one type of driving phobias such
possession of a valid driving license, and described a fear of at least one type of driving phobias such
as driving on highways, mountain roads, or congested traffic.
as driving on highways, mountain roads, or congested traffic.
4. System Architecture
4. System Architecture
The overview system architecture of this VRET research is presented in Figure 4. The VRET system
The overview
(software) system
consists of fourarchitecture of this
modules: the VRETtherapy
exposure research is presented
(ET) in Figure
scenario module 4. The VRET
(7 scenario levels),
system
the VR(software) consists
environment of four
module, the modules: the exposure
data collection module,therapy
and the (ET) scenario module.
data analysis module (7 scenario
The VR–User
levels), the (hardware)
interface VR environment module,
includes the datasteering
a VR headset, collection module,
wheel, and the dataAanalysis
and bio-sensors. module.
database The
management
VR–User interface (hardware) includes a VR headset, steering wheel, and bio-sensors. A database
system is developed to collect and integrate system and bio-data from the VRET system and the
management system is developed to collect and integrate system and bio-data from the VRET system
VR-User interface. The system’s hardware, software, and database designs are described in the
and the VR-User interface. The system’s hardware, software, and database designs are described in
following paragraphs. For more technical details, please refer to [16].
the following paragraphs. For more technical details, please refer to [16].
Appl. Sci. 2020, 10, 4860 7 of 16
Appl. Sci. 2020, 10, x 7 of 16

Figure
Figure 4. 4. The
The system
system architecturefor
architecture forthe
thedriving
drivingphobia
phobiaVRET
VRETprototype
prototype(refer
(referto
toFigure
Fig. 2 for Module
2 for Module
1 details). 1 details).

4.1. Hardware
4.1. Hardware
The
Thehardware
hardwarecomponents
componentsused used by
by the system includethe
system include theVRVRheadset
headset(HTC,
(HTC, VIVE
VIVE Pro,Pro, Taipei,
Taipei,
Taiwan),
Taiwan),thethe
steering wheel
steering wheel(Guillemot Co.,Co.,
(Guillemot Thrustmeter
Thrustmeter T300T300
RS GT,
RS Carentoir, France),
GT, Carentoir, and bio-sensors
France), and bio-
sensors (Thought
(Thought Technology Technology Ltd., ProComp
Ltd., ProComp Infiniti, Montreal,
Infiniti, Montreal, Canada). Canada).
The HTC TheVIVE
HTCPro VIVEis aPro is a
popular
popular virtual reality immersive headset. The kit headset includes VR HMD,
virtual reality immersive headset. The kit headset includes VR HMD, two base stations for movementtwo base stations for
movement
tracking, andtracking,
two motionand controllers
two motion forcontrollers for virtual
virtual world world interaction.
interaction. The two base The stations
two baseare stations
able to
are able
connect thetoimmersive
connect theenvironment
immersive environment with the
with the subject’s subject’storeactions
reactions to scene
scene objects viaobjects
motion via motion
controllers.
controllers.
The Thrustmeter The T300
Thrustmeter T300 RS is
RS GT Edition GT Edition is racing
a high-end a high-end racing
steering steering
wheel wheel equipped
equipped with
with a feedback
a feedback mechanism, a specialized T3PA acceleration pedal that is integrated
mechanism, a specialized T3PA acceleration pedal that is integrated with steering wheel motion to with steering wheel
motionrealistic
provide to provide realistic
driving driving
feedback to feedback to the
the subjects. The subjects.
ProComp TheInfiniti
ProComp is anInfiniti is an eight-channel
eight-channel biofeedback
biofeedback system for real-time data acquisition that can be used with
system for real-time data acquisition that can be used with combinations of sensors includingcombinations of sensorsEEG,
including EEG, EKG, RMS EMG, skin conductance, heart rate, blood volume, pulse, respiration,
EKG, RMS EMG, skin conductance, heart rate, blood volume, pulse, respiration, temperature, force,
temperature, force, and voltage.
and voltage.
4.2.
4.2. Software
Software
The software components adopted into the system include the development engine (Unity
The software components adopted into the system include the development engine (Unity
Technologies, Unity, San Francisco (HQ), CA, USA) and the distribution platform (Valve Corp.,
Technologies, Unity, San Francisco (HQ), CA, USA) and the distribution platform (Valve Corp., Steam,
Steam, Bellevue, Washington, USA). Unity is a well-known real-time 3D development platform
Bellevue, Washington, USA). Unity is a well-known real-time 3D development platform which enables
which enables users to develop both 2D and 3D games and models in Windows, iOS, Android, and
users to develop both 2D and 3D games and models in Windows, iOS, Android, and over twenty
over twenty types of systems. Microsoft C# is used as the programming language; users are allowed
types of systems. Microsoft C# is used as the programming language; users are allowed to control
to control actions of virtual objects using specific C# scripts. Unity is compatible with other design
actions of virtual objects using specific C# scripts. Unity is compatible with other design software and
software and gaming platforms that have external operating devices also compatible with Unity.
gaming
Steam platforms that
is one of the have video
largest external operating
game devices alsoservice
digital distribution compatible withinUnity.
platforms Steamand
the world is one
alsoof
the largest video game digital distribution service platforms in the world and also provides
provides a virtual reality service called SteamVR to support the HTC VIVE virtual reality headset. a virtual
reality
Data service called
collection and SteamVR to support
data management usethe HTC(SQLite.org)
SQLite VIVE virtual
as reality headset.
the database Dataand
engine collection
BioGraphand
data management use SQLite (SQLite.org) as the database engine and BioGraph Infinite software to
Appl. Sci. 2020, 10, 4860 8 of 16

Appl. Sci.
record 2020, 10, The
bio-data. x VRET database management system (DBMS)’s entity-relation diagram is8shown
of 16

in Figure 5.
Infinite software to record bio-data. The VRET database management system (DBMS)’s entity-
relation diagram is shown in Figure 5.

Figure 5. The entity-relation (ER) diagram for the VRET database.

Figure 5. The entity-relation (ER) diagram for the VRET database.
4.3. Database
4.3. Database
SQLite is a relational database management system (DBMS) contained in the C library. The reason
SQLite is a relational database management system (DBMS) contained in the C library. The
for choosing SQLite over MySQL is because SQLite is a popular choice as an DBMS for client storage.
reason for choosing SQLite over MySQL is because SQLite is a popular choice as an DBMS for client
SQLite is used to collect head motion, steering wheel rotation angle, and driving speed data in real
storage. SQLite is used to collect head motion, steering wheel rotation angle, and driving speed data
time. These data are accessed from the database using the Python programming script. Th database
in real time. These data are accessed from the database using the Python programming script. The
storage model is shown in Figure 6. BioGraph Infinite is a software platform that is specifically used for
database storage model is shown in Figure 6. BioGraph Infinite is a software platform that is
ProComp Infiniti data access, allowing high end users to create their own screens, scripts and channel
specifically used for ProComp Infiniti data access, allowing high end users to create their own
sets. The purpose
screens, of BioGraph
scripts and Infinite
channel sets. The ispurpose
to collect
of heart rate, Infinite
BioGraph skin conductance,
is to collectbody
hearttemperature,
rate, skin
and respiration rate data during ET experiments. The biological and system data
conductance, body temperature, and respiration rate data during ET experiments. The biologicalare integrated
and
forsystem
analysis.
data are integrated for analysis.

Figure 6. Example of VRET’s system database storage.

Figure 6. Example of VRET’s system database storage.
1
Appl. Sci. 2020, 10, 4860 9 of 16

5. Pre-Test and Pre-Test Data Analysis

In order to examine the effectiveness of the VRET system and to improve the VRET system
to facilitate future clinical trials, this study recruited 31 subjects for pre-testing. Before the pre-test
experiment, subjects were asked to fill out the “Self-rating fear of driving scale,” for the purpose
of measuring their degree of fear of driving. The rating scale was designed according to emerging
measures offered by American Psychiatric Association [24]. During the pre-test experiment, the system
data, bio-data, and subjects’ suggestions for refinement of the VRET system were recorded. This study
was approved by the Chang Gung Medical Foundation Institution Review Board (IRB), the institution’s
ethical commission, approval number 201901262B0.

5.1. Pre-Test Subjects’ Demographic Data

This study recruited 14 males and 17 females at the university participated in the pre-test of
the VRET prototype. Pre-testing subjects’ demographic data including gender, height, weight, age,
and the years of driving experience are presented in Table 1. 14 males with a mean height of 172.5 cm
(SD = 5.21 cm) and a mean weight of 64.29 kg (SD = 7.61 kg), 17 males with a mean height of 160.43 cm
(SD = 4.75 cm) and a mean weight of 52.71 kg (SD = 5.44 kg). All the subjects with a mean age of 22.39
years (SD = 0.95 year) and the mean duration of driving experience is 2.10 years (SD = 1.13 years).

Table 1. Pre-test subjects’ demographic data.

Subject No. Gender Height (cm) Weight (kg) Age Driving Experience (Years)
1 Female 164 52 23 4
2 Female 164 62 21 2
3 Male 173 57 24 3
4 Male 178 74 24 2
5 Male 160 48 22 1
6 Female 156 48 22 1
7 Male 174 75 22 2
8 Female 153 52 23 1
9 Female 152 47 22 1
10 Female 162 52 23 3
11 Male 167 69 22 3
12 Male 172 58 22 2
13 Female 164 49 22 1
14 Female 161 55 23 4
15 Female 167 49 22 2
16 Female 166 62 22 2
17 Female 158 50 22 1
18 Male 175 65 22 1
19 Male 170 65 22 2
20 Female 165 50 22 1
21 Male 171 60 22 3
22 Male 170 65 22 1
23 Female 162 53 22 3
24 Female 160 65 21 2
25 Female 164 52 22 1
26 Male 174 71 24 1
27 Male 177 71 24 2
28 Female 162 46 22 2
29 Male 172 65 22 3
30 Male 182 57 25 6
31 Female 162 52 21 2

5.2. Pre-Test Procedures

1. Explain the purpose and precautions of the experiment and ask subjects to sign the consent form.
 Appl. Sci.2020,
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Appl. Sci.
Sci. 2020, 10,
10, x 10
10 of
of 16

5.2.Pre-Test
5.2.
5.2. Pre-TestProcedures
Pre-Test Procedures
Procedures
Appl. Sci. 2020, 10, 4860 10 of 16
1.1.
1. Explainthe
Explain
Explain thepurpose
the purposeand
purpose andprecautions
and precautionsof
precautions ofofthe
theexperiment
the experimentand
experiment andask
and asksubjects
ask subjectsto
subjects totosign
signthe
sign theconsent
the consentform.
consent form.
form.
2.2.
2. Subjectsfilled
Subjects
Subjects filledout
filled outthe
out the“Self-rating
the “Self-ratingfear
“Self-rating fearof
fear ofofdriving
drivingscale.”
driving scale.”
scale.”
2. filled out the “Self-rating fear of for driving scale.”
3.3.
3. Subjects
Subjects were equipped with bio-sensors
Subjects were equipped with bio-sensors for the purpose of
were equipped with bio-sensors for the
the purpose
purpose ofofdetecting
detectingthe
detecting thereal-time
the real-timebio-data.
real-time bio-data.Bio-
bio-data. Bio-
Bio-
3. sensorsincluding
Subjects
sensors
sensors including
were
including equippedheartrate,
heart
heart rate,
with
rate, temperature,
temperature,
temperature, respiration,
bio-sensors respiration,
for the purpose
respiration, andskin
and
and skin
of
skin conductance.
detecting
conductance.
conductance. the real-time bio-data.
4.4.
4. Conducting
Conducting
Bio-sensors the
including pre-test VRET
VRET
heart rate, experiment
experiment
temperature, and
Conducting the pre-test VRET experiment and collect subjects’ real-time bio-
the pre-test and collect
collect
respiration, subjects’
subjects’
and real-time
real-time
skin bio-and
conductance.
bio- andsystem
and systemdata.
system data.
data.
5.5.
5.
4. After
After
Conducting the
the
After the pre-testpre-test
pre-test experiment,
experiment,
the pre-test
experiment, subjects
subjects
VRETsubjects
experiment were
were
wereand asked
asked
asked to
collectto fill
fill out
out
to fillsubjects’ the
the feedback
feedback form
form
real-time form
out the feedback and
and
bio- and provide
provide
andsystem some
some
providedata.
some
5. suggestions
suggestions
After totothe
to
the pre-test
suggestions the
the refinementsubjects
refinement
experiment,
refinement ofofVRET
of VRET
VRET system.
system.
were
system.asked to fill out the feedback form and provide some
suggestions to the refinement of VRET system.
5.3.Pre-Test
5.3.
5.3. Pre-TestData
Pre-Test DataAnalysis
Data Analysis
Analysis
5.3. Pre-Test Data Analysis
Thereal-time
The
The real-timeVRET
real-time VRETsystem
VRET systemdata,
system data,shown
data, shownin
shown ininFigures
Figures777and
Figures and8,
and 8,8,and
andthe
and thepre-test
the pre-testsubject’s
pre-test subject’sbio-data,
subject’s bio-data,
bio-data,
are
are shown
The in
real-time Figures
VRET 9 9 and
and 10.
system
10. For
Fordata, the
the current
shown
current in prototype
Figures
prototype 7
ofof
andVRET
are shown in Figures 9 and 10. For the current prototype of VRET for driving phobia, the bio-data of
shown in Figures VRET 8, andfor
for driving
the
drivingpre-testphobia, the
subject’s
phobia, the bio-data
bio-data,
bio-data ofof
each
are
each
eachshownsubject
subject
subject in arearemonitored
Figures
are monitored
9 and 10.
monitored and
and
andFor analyzed
the current
analyzed
analyzed fortrends
for
for trendsand
prototype
trends and
and correlations
ofcorrelations
VRET for driving
correlations between
between
between bio-data
phobia,
bio-data
bio-datatheandandsystem
system
bio-data
and of
system
data.
each
data. The
subject
The data
data are spike
monitored
spike abnormalities
and
abnormalities analyzedare
are monitored
for
monitored trends during
and
during the
correlations
data. The data spike abnormalities are monitored during the pre-testing experiment sessions. Thethe pre-testing
pre-testing between experiment
bio-data
experiment sessions.
and system
sessions. The
The
goalis
data.
goal
goal isto
The
is totodata
improve
improve
improve spikethe theeffectiveness
the effectiveness
abnormalities
effectiveness areof ofthethetherapy
ofmonitored
the therapy
therapy duringdesign
design
design theof ofthetheVRET
pre-testing
of the VRET
VRET immersive
experiment
immersive
immersive systembased
sessions.
system
system based
The
based goal
on
onon
isdata
data
data analyticthe
to improve
analytic
analytic outcomes
outcomes
outcomes totoavoid
effectiveness
to avoid
avoidof the levels
levels
levels ofofdriving
therapy
of driving
driving conditions
designconditions
of the VRET
conditions showing
immersive
showing
showing insignificant
system based
insignificant
insignificant bio-effects
on data
bio-effects
bio-effects or
or
or
causing
analytic
causing overly
outcomes
overly dramatic
to
dramatic avoid effects
levels
effects (i.e.,
of
(i.e., lacking
driving
lacking the
conditions
the feature
feature of
showing
of gradual
gradual
causing overly dramatic effects (i.e., lacking the feature of gradual systematic desensitization). The systematic
insignificant
systematic desensitization).
bio-effects or
desensitization).causingThe
The
following
overly
following
followingdramatic discussion
discussioneffects
discussion describes
(i.e., lacking
describes
describes thestatistical
the
the statistical
the feature
statistical analysis
of gradual
analysis
analysis results
results
results ofofthe
systematic
of thesystem’s
the system’s
system’s pre-testexperiments
desensitization).
pre-test
pre-test experiments
The following
experiments with
with
with
3131subjects.
31 subjects.
discussion
subjects. describes the statistical analysis results of the system’s pre-test experiments with 31 subjects.

Figure7.
Figure
Figure
Figure 7.7.System
7. Systemdata—Steering
System
System data—Steeringwheel
data—Steering
data—Steering wheelrotation
wheel
wheel rotationdata
rotation
rotation datatracking.
data
data tracking.
tracking.
tracking.

Figure8.
Figure
Figure
Figure 8.8.System
8. Systemdata—Tracking
System
System data—Trackingdriving
data—Tracking
data—Tracking drivingspeeds
driving
driving speeds
speeds
speeds overtime.
over
over
over time.
time.
time.

Figure9.
Figure
Figure 9.9.Bio-data—Tracking
Bio-data—Trackingsubject’s
Bio-data—Tracking subject’sheart
subject’s heartrate
heart rateduring
rate duringexperiment
during experimentsession.
experiment session.
session.
Figure 9. Bio-data—Tracking subject’s heart rate during experiment session.
Appl. Sci. 2020, 10, 4860 11 of 16
Appl. Sci. 2020, 10, x 11 of 16

Figure 10.
Figure 10. Bio-data—Subject’s
Bio-data—Subject’s skin
skin conductance during the
conductance during the experiment
experiment session.
session.

correlation coefficient
The Pearson correlation coefficient has has been applied
applied to measure the strength of linear association
between the
between the VRET
VRETsystemsystemdatadataand andthe thesubject’s
subject’s bio-data.
bio-data. The The result
result indicates
indicates thatthat
the the correlations
correlations are
are relatively
relatively smallsmall
with with
mostmost coefficients
coefficients falling
falling between
between −0.3and
−0.3 and0.3.
0.3.Nonparametric
Nonparametrictest test for
for gender
differences compared
differences compared the the 14 males and 17 female subjects that participated participated in in the
the pre-test
pre-test experiment.
experiment.
The Mann–Whitney U test was used to test if there was a statistically statistically significant difference between between
overallsatisfaction
the overall satisfactionmedians
mediansofof thethemalemale
andand femalefemale groups.
groups. The The null hypothesis
null hypothesis is ηmaleis=ηη f emale=,
η
using a, significance level of αlevel
using a significance = 0.05, of the
α =p-values
0.05, therelated
p-values related
to four kindsto of
four kinds are
bio-data of bio-data
all higher are all
than
highervalue
alpha than alpha
(0.05),value (0.05),
so there so there is insufficient
is insufficient evidence toevidence concludetoa conclude
statistically a statistically
significant significant
difference
differencethe
between between
overall the overall satisfaction
satisfaction medians ofmediansthe maleof and thefemale
male and female groups.
groups.
The Mann–Whitney U test was also used to test if there is a statistically statistically significant difference
between the overall satisfaction medians of the high anxiety anxiety and and low
low anxiety
anxiety groups.
groups. Subjects were
divided into two groups, high anxiety groups and low anxiety groups, according to the rating of
“Self-ratingfear
“Self-rating fearofofdriving
drivingscale”
scale”filled
filledoutout before
before thethe pre-test
pre-test experiment.
experiment. Eleven
Eleven subjects
subjects were were in
in the
the high
high anxietyanxiety
groupgroupandand 20 subjects
20 subjects werewere
in thein low
the lowanxietyanxiety
group.group.
TheThe nullnull hypothesis
hypothesis is η= ηlow=,
is ηhigh
η , using
using a significance
a significance of αof
levellevel = α0.05, three
= 0.05, threeoutoutof ofthethe fourp-values
four p-valuesrelated
relatedto tobio-data
bio-data (heart rate,
respiration, and skin conductance) are lower than alpha value (0.05), so there is is statistical
statistical evidence
evidence
that there is a difference
difference between
between the the overall
overall satisfaction
satisfaction medians
medians of of the
the two
two anxiety
anxiety types.
types. The VRET
system does affect affect the
the subject’s
subject’s bio-data
bio-data according
according to to their
theirdegree
degreeof offear
fearof ofdriving.
driving.
One-way ANOVA ANOVA tests tests comparing
comparing means means of of bio-data
bio-data in in seven scenarios
scenarios are are used to estimate the
95% confidence
confidenceintervalinterval andanddetermine
determine whether
whetherthe associated
the associatedpopulation means inmeans
population differentin scenarios
different
are significantly
scenarios different. The
are significantly resultsThe
different. are results
presented are in Figure 11a,c,e,g.
presented in FigureFisher’s11a,c,e,g.least significant
Fisher’s least
difference
significantmethod
differencefor multiple
method for comparisons was applied to
multiple comparisons was examine
applied which means atwhich
to examine different levels
means at
are different,
different levelsas are
presented in Figure
different, 11b,d,f,h.
as presented in Figure 11b,d,f,h.
bio-feedbackdata
The bio-feedback dataofofthetheone-way
one-wayANOVA ANOVA interval
interval plots,
plots, presented
presented in Figure
in Figure 11, indicate
11, indicate that
pre-test subjects
that pre-test become
subjects increasingly
become increasingly anxious
anxiousas the as fear levellevel
the fear of the scenarios
of the scenariosincreases
increases (shown
(shown by
by heart
heart rate,rate, temperature,
temperature, andandskinskin conductivitytrends).
conductivity trends).For Fordetailed
detailedinformation
information from from the ANOVA
results, multiple comparisons analysis between different levels was also conducted, as higher fear
levels tend to be assigned to the same groups and lower fear levels tend to be assigned to the same
groups, a significant difference in the the sample
sample means
means between higher levels and lower levels was
demonstrated. This
demonstrated. Thistrend
trendsupports
supports thethe hypothesis
hypothesis that that increases
increases in thein the severity
severity of pre-existing
of pre-existing phobias
phobias increase
increase the subject’s
the subject’s bio-feedbackbio-feedback
responses. responses.
interesting observation
An interesting observation is is that
that the bio-feedback
bio-feedback data data in level 1 seems to be significantly
significantly higher
than level 2 data as shown in heart rate and temperature plots and the Fisher’s LSD method supports
the same result. A A possible
possible cause
cause of this phenomenon may be related to the the experimental
experimental design
where subjects never exposed to a VR environment may become more anxious during the initial ET
session. As
session. As the
theexperiment
experimentprogresses,
progresses, thethe subjects
subjects become
become acclimated
acclimated to the to VR
theenvironment
VR environment so
so there
there
is less is less tension
tension and greater
and greater ease of use easeofoftheuse of theInsystem.
system. order to Inprevent
order to prevent
this problem this
fromproblem from
happening,
ahappening,
ten-minuteastaticten-minute static VRcan
VR experience experience
be addedcan to thebe experiment
added to theflow experiment
between flow between
pre-test pre-test
questionnaire
questionnaire
and VRET interfaceand VRET interface
to stabilize thetosubject’s
stabilizebio-response
the subject’s before
bio-response before thebegins.
the experiment experiment begins.
Appl. Sci. 2020, 10, 4860 12 of 16
Appl. Sci. 2020, 10, x 12 of 16

(a) (b)

(c) (d)

(e) (f)

(g) (h)
Figure11.
Figure 11. (a)
(a) One-way
One-way ANOVAANOVA interval
interval plot
plot of
of heart
heart rate
rate vs.
vs. level;
level; (b)
(b) Fisher’s
Fisher’s least
least significant
significant
difference (LSD) method for multiple comparisons of heart rate vs. level;
difference (LSD) method for multiple comparisons of heart rate vs. level; (c) One-way ANOVA (c) One-way ANOVA
interval
plot of temperature vs. level; (d) Fisher’s LSD method for multiple comparisons of temperature of
interval plot of temperature vs. level; (d) Fisher’s LSD method for multiple comparisons vs.
temperature
level; vs. level;
(e) One-way ANOVA (e) One-way ANOVA
interval plot interval vs.
of respiration plotlevel;
of respiration
(f) Fisher’svs. level;
LSD (f) Fisher’s
method LSD
for multiple
method for multiple
comparisons comparisons
of respiration vs. level;of(g)
respiration
One-wayvs. level; (g)
ANOVA One-way
interval plotANOVA interval plotvs.
of skin conductance of skin
level;
conductance vs. level; (h) Fisher’s LSD method for multiple comparisons
(h) Fisher’s LSD method for multiple comparisons of skin conductance vs. level. of skin conductance vs. level.
Appl. Sci. 2020, 10, 4860 13 of 16
Appl. Sci. 2020, 10, x 13 of 16
Appl. Sci. 2020, 10, x 13 of 16

According to
According to Dawson’s
Dawson’sresearch,
research,ifif
ifthe
theamplitude
amplitude ofofskin conductance
skin conductance is larger than
is larger
larger 0.1 0.1
than thenthen
µs, μs, the
According to Dawson’s research, the amplitude of skin conductance is than 0.1 μs, then
skin conductance
the skin
skin conductance indicates
conductance indicates a larger emotional
indicates aa larger response
larger emotional [25].
emotional response In
response [25].this
[25]. Inresearch,
In this skin
this research, conductance
research, skin data
skin conductance
conductance are
the
converted
data into the form
are converted
converted into of
theamplitude
form of data. A Shewhart
of amplitude
amplitude data. AAcontrol
Shewhart chart of amplitude
control chart ofofdata is presented
amplitude data in
is
data are into the form data. Shewhart control chart amplitude data is
Figure 12.
presented If
in four out
Figure of
12. five
If data
four outpoints
of five exceed
data 0.1µs,
points it is marked
exceed 0.1μs, in red,
it is which
marked means
in red,the subject
which has
means
presented in Figure 12. If four out of five data points exceed 0.1μs, it is marked in red, which means
a larger
the emotional
subject response
has aa larger
larger at this response
emotional point of time. thisSixteen
at this point of of time.
of the thirty-one
Sixteen of ofsubjects meet the
the thirty-one
thirty-one above
subjects
the subject has emotional response at point time. Sixteen the subjects
conditions
meet and have
the above
above data points
conditions and marked
have data in red.
data These
points data points
marked red.frequently
in red. These data appeared
data points for the 6th,
frequently
meet the conditions and have points marked in These points frequently
21st, 25th,
appeared for and
for the32nd
the 6th,subjects.
6th, 21st,
21st, 25th,
25th, and
and 32nd
32nd subjects.
subjects.
appeared

Figure 12.
Figure 12. Shewhart control
Shewhart control
12. Shewhart chart
control chart of
chart of skin
of skin conductance
skin conductance amplitude
conductance amplitude data.
amplitude data.
data.
Figure

The heart
The heart rate
rate data
data are
are standardized
standardized according
according toto individual
individual data
data distribution and a
distribution and a Shewhart
Shewhart
control chart
control of the
chart of the standardized
standardized datadata is
is presented
presented inin Figure
Figure 13. If four
13. If four out
out of
of five
five points
points exceed
exceed two
two
standard deviations, the data points are marked in red indicating the subject has experienced
standard deviations, the data points are marked in red indicating the subject has experienced a larger a larger
emotional response
emotional responseatat
response atthis
this
this point
point of time.
time.
of time.
point of Twenty-one
Twenty-one of
of theof
Twenty-one the thirty-one
thirty-one
thirty-one
the subjects
subjectssubjects met the
met the above
met the above
condition
above
condition
with their with
hearttheir
rate heart
data rate
pointsdata points
marked in marked
red. in
condition with their heart rate data points marked in red. red.

Figure 13. Shewhart control chart of standardized heart rate data.

Figure
Figure 13.
13. Shewhart
Shewhart control
control chart
chart of
of standardized
standardized heart
heart rate
rate data.
data.
5.4. Discussion
5.4. Discussion of
Discussion of Pre-Test
of Pre-Test
Pre-Test
The proposed
The proposed VRETVRET system
system has
has integrated
integrated system
system andand bio-data
bio-data collection
collection for
for real-time
real-time datadata
analytics compared
analytics compared to to previous
previous VRET
VRET research.
research. InIn the
the Kaussner
Kaussner et et al.
al. VRET
VRET pilot
VRET pilot study,
pilot study, anxiety and
study, anxiety and
habituation
habituation during
habituation during
during thethe VRET sessions
the VRET sessions were assessed
sessions were assessed using
assessed using ratings
using ratings on subjective
ratings on subjective units of a distress
subjective units of a distress
scale as
scale as well
well as
as the
the heart
heart rate
heart rate [20].
rate [20]. Costa
[20]. Costa etet al.
al. used
used subjective
used subjective discomfort
subjective discomfort scores
discomfort scores and
scores and heart
and heart rate to
heart rate to
measure subjects’
measure subjects’ physiological
physiological response
response andand sense
sense of
of presence
presence [21].
[21]. Additionally,
Additionally,
Additionally, in in Claudio
Claudio et et al.’s
al.’s
fear of driving in tunnels research, questionnaires measured the outcome of
fear of driving in tunnels research, questionnaires measured the outcome of the experiment and no the experiment and no
real-time data was collected [22].
real-time data was collected [22]. Most Most pervious
Most pervious VRET
pervious VRET literature
VRET literature uses
literature uses heart
uses heart rate
heart rate for real-time
rate for real-time data data
tracking. Temperature,
tracking. Temperature, respiration, and
Temperature, respiration, and skin
skin conductance
conductance are are for
for real-time
real-time data
data tracking
tracking inin our
our VRET
VRET
system. These
system. These preliminary
These preliminary design
preliminary design and
design and development
and development efforts
development efforts are for the construction of a self-adaptive
efforts are for the construction of a self-adaptive
VRET system that will automatically adjust
VRET system that will automatically adjust the levelsthe levels of
levels of exposure
ofexposure according
exposureaccording
accordingto to real-time
toreal-time data
real-timedata tracking.
datatracking.
tracking.
The proposed
The proposed future
proposedfuture system
futuresystem
systemwillwill
will be
bebe tested
tested
tested for
for for improvements
improvements
improvements to theto the immersive
to immersive
the immersive experience
experience
experience and
and toand to
to
better
better
better ensure
ensureensure subjects’
subjects’
subjects’ safety.
safety. safety.
Compared
Compared to to previous
previous VRET
VRET research
research which
which only
only demonstrates
demonstrates the the development
development of of VRET
VRET
without verification, this research has uniquely combined VRET design
without verification, this research has uniquely combined VRET design and development with theand development with the
verification of its efficacy through pre-test. According to the results of Mann–Whitney
verification of its efficacy through pre-test. According to the results of Mann–Whitney U test, there is U test, there is
Appl. Sci. 2020, 10, 4860 14 of 16

Compared to previous VRET research which only demonstrates the development of VRET without
verification, this research has uniquely combined VRET design and development with the verification
of its efficacy through pre-test. According to the results of Mann–Whitney U test, there is a significant
difference between the overall satisfaction medians of high anxiety groups and low anxiety groups.
Moreover, the results of ANOVA analysis show that bio-data and level are positively correlated except
for Level 1. Therefore, through pre-test data analysis, VR is demonstrated to provide the subject with a
sense of authenticity and can indeed cause anxiety similar to actual driving.
The problem of high level 1 bio-data is also emerging within pre-test data analysis. For this
problem, follow-up studies may consider adding a ten minutes of VR experience before the experiment
starts to assist the subjects to adapt to the VR environment and to improve the VRET system for official
clinical trials.

6. Conclusions
The immersive technologies, most typically referred to as virtual reality (VR) and lately also to
include augmented reality (AR) enabling technologies, are popularly researched and developed to
improve healthcare and treatments for physical, psychological and social wellbeing with respect to
different populations and their health issues (e.g., elderly, autism spectrum disorder, PTSD, phobia,
etc.) [26,27]. For example, Lee et al. [24] have comprehensively reviewed VR and AR technologies
developed for physical, psychological and social wellbeing of an elderly population. The review article
discovers that plenty of R&D has been deployed for improving physical healthcare and treatments.
Nonetheless, considering the rising psychological (mental and social) health issues, there are great needs
to pursue immersive technologies and design immersive solutions for psychological therapies and
treatments. The research presents the systematic design and development of virtual reality exposure
therapy applied to fear of driving. Therapeutic treatments for this phobia remain as a major clinical
challenge for psychiatrists, psychotherapists, and their patients. A VR headset, a high specification
steering wheel, bio-sensors, and software are integrated to develop a realistic driving experience in
an immersive environment for effective exposure therapy. The subjects are exposed to varying levels
of fear inducing driving levels for treatment. Thirty subjects provided pre-test data for the system.
The bio-feedback data and suggestions for improvement were derived from the experiments. Through
pre-test data analysis, VR convincingly causes anxiety like actual driving. Furthermore, some systemic
problems are discovered, so the follow-up research can improve the VRET system and improve the
system design. Carefully crafted experimental design is required for collecting valid and reliable data
for the VRET analytical models and system modification. The clinical psychiatrists’ feedback is critical
to improve the design before the VRET can be used for clinical trials.
In summary, this research has presented the VRET technical components, the system framework,
key modules for implementation, and the experiment database design and development for the
research. Specifically, the bio- and system-data analysis demonstrates the efficacy of the VRET for
use in initial hospital-based clinical trials with continued improvement as the trails are analyzed.
In the future, the research team hopes to extend the VRET treatments to other phobias, such as
acrophobia, arachnophobia, and claustrophobia. The future research direction also includes the
intelligent development of self-adaptive VRET systems incorporating progressive brain neurology
and brain computer interface (BCI) technologies. When the degree of a subject’s fears are detected
through advanced BCI sensors, the self-adaptive VRET system will have sufficient knowledge and
intelligence to automatically adjust the levels of exposure to ensure safe and effective gradual
systematic desensitization.

Author Contributions: A.T.: Constructed the research framework and incorporated VR and IoT technologies
for the system; C.V.T.: CBT and ET literature overview for anxiety disorders and panic disorders, interpretation
of meta-analysis studies; C.-M.C.: PTSD, OCD, and PD theories and clinical ET design; R.R.T.K.: VRET system
development and implementation, data analysis; A.P.C.L.: VR and VRET literature search, VRET prototype testing,
data validation; C.H.N.: CBT and ET literature review and data validation. All authors have read and agreed on
the published version of the manuscript.
Appl. Sci. 2020, 10, 4860 15 of 16

Funding: This research is partially supported by the joint research grant of National Tsing Hua University and
Chang Gong Memorial Hospital and the individual research grants of Ministry of Science and Technology, Taiwan
(Grant numbers: MOST-108-2221-E-007-075-MY3 and MOST-108-2410-H-009-025-MY2).
Conflicts of Interest: The authors declare no conflict of interest.

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