Creative Intervention for Acrophobia Sufferers through AIVE Concept

Round 1

Reviewer 1 Report

This article proposed the creative Intervention for Acrophobia Sufferers through AIVE Concept. First of all, English writing of this article is difficult to understand and not fluent. Some sentences need to be revised and English proofread by a native speaker is required. E.g. “Smartphone technology has been developing …. And therefore this research motivation is to create a creative intervention ……” the argument is problematic and lack of details.
Reviews on the VR training can be included in the article. For example:
Tang, YM, Ng, GWY, Chia, NH, So, EHK, Wu, CH, Ip, WH. Application of virtual reality (VR) technology for medical practitioners in type and screen (T&S) training. J Comput Assist Learn. 2021; 37: 359– 369. https://0-doi-org.brum.beds.ac.uk/10.1111/jcal.12494

AIVE abbreviation is used in the title of this article, full name is required to illustrate this. Acrophobia should be elaborated further, especially in the evidence-based therapist with VR. Related studies should be elaborated, and what does the contribution of this article compare with existing works?
How this AIVE is related to the creative intervention? It requires to be further elaborated.

Figure 1 is not clear. What is the nature asset? How is it related to AIVE? What message do you want to deliver in figure 1? It is important for the development VR therapy program, it should be elaborated and make it understandable.
The design section is too simple and lack of details.

For the participants, what are the selection criteria? They are suffering from the acrophobia? What is the severity? What are the questionnaire details? The research model is too simple. In table 1, what are the frequency 13 and 7 stands for? What are the pre test and pro test?

The topic of this article is interesting, but lack of technical details. The research models are not explained in details and the article is difficult to understand. An extensive revision is required before publication.

Author Response

Response to Reviewer 1 Comments

Point 1: This article proposed the creative Intervention for Acrophobia Sufferers through AIVE Concept. First of all, English writing of this article is difficult to understand and not fluent. Some sentences need to be revised and English proofread by a native speaker is required. E.g. “Smartphone technology has been developing …. And therefore this research motivation is to create a creative intervention ……” the argument is problematic and lack of details.Reviews on the VR training can be included in the article. For example:
Tang, YM, Ng, GWY, Chia, NH, So, EHK, Wu, CH, Ip, WH. Application of virtual reality (VR) technology for medical practitioners in type and screen (T&S) training. J Comput Assist Learn. 2021; 37: 359– 369. https://0-doi-org.brum.beds.ac.uk/10.1111/jcal.12494

Response 1: Thank you for your advice. We have made a revised regarding abstract and added some latest review that you suggest to us in this paper.

Abstract: This research applies exposure to the visual appearance technology of Virtual Reality (VR). The motivation for this research is to generate a creative intervention by using regular smartphone devices and implement them in VR using Google cardboard as a medium visual display for exposure therapy at high altitudes. The VR application in this research exists called AIVE (Acrophobia Immersive Virtual Exposure) which utilizes the Unity3D software as the development of this treatment therapy application. The utilization of exposure therapy was carried out as a therapeutic medium for acrophobia sufferers. A commissioner was given to measure the usefulness of applications and devices in the VR environment that was created, and as many as 20 users had tested the VR device. The existing questionnaire was revised to develop a questionnaire for acro-phobia sufferers, which was then used as an index measurement in the VR environment. The re-search is expected to be used to design a simulator and as a therapeutic medium using immersive VR devices in future studies.

Acrophobia is classified as a specific phobia [1],

Therapists also see potential in VR technology and state various advantages such as increased accessibility and control over frightening triggers [2,3].

Immersive from VR environment simulation allows medical practitioners to practice in their work environment in a hospital or clinic, as well as practice without distraction [4]. Stereoscopic content also allows the therapist to help users to practice with a deeper sense of visualization and to avoid the possibility of injury is more dangerous compared to when performing a real situation.

Immersive VR technology works when capable of sensory estrangement with the user from the physical world and replacing the sensory flow with simulation circumstances generated by the computer [5].

1. Park, S.-C.; Kim, Y.-K. Anxiety Disorders in the DSM-5: Changes, Controversies, and Future Directions. In Anxiety Disorders: Rethinking and Understanding Recent Discoveries, Kim, Y.-K., Ed.; Springer Singapore: Singapore, 2020; pp. 187-196.
2. Bentz, D.; Wang, N.; Ibach, M.K.; Schicktanz, N.S.; Zimmer, A.; Papassotiropoulos, A.; de Quervain, D.J.F. Effectiveness of a stand-alone, smartphone-based virtual reality exposure app to reduce fear of heights in real-life: a randomized trial. npj Digital Medicine 2021, 4, 16, doi:10.1038/s41746-021-00387-7.
3. Boeldt, D.; McMahon, E.; McFaul, M.; Greenleaf, W. Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles. Frontiers in psychiatry 2019, 10, 773-773, doi:10.3389/fpsyt.2019.00773.
4. Tang, Y.M.; Ng, G.W.Y.; Chia, N.H.; So, E.H.K.; Wu, C.H.; Ip, W.H. Application of virtual reality (VR) technology for medical practitioners in type and screen (T&S) training. Journal of Computer Assisted Learning 2021, 37, 359-369, doi:https://0-doi-org.brum.beds.ac.uk/10.1111/jcal.12494.
5. Riva, G. Virtual Reality in Clinical Psychology. Reference Module in Neuroscience and Biobehavioral Psychology 2022, B978-970-912-818697-818698.800006-818696, doi:10.1016/B978-0-12-818697-8.00006-6.

Point 2: AIVE abbreviation is used in the title of this article, full name is required to illustrate this. Acrophobia should be elaborated further, especially in the evidence-based therapist with VR. Related studies should be elaborated, and what does the contribution of this article compare with existing works?
How this AIVE is related to the creative intervention? It requires to be further elaborated.

Response 2: We have explained the AIVE concept in page 3, meaning of AIVE is simulation program of situation concept in therapy with the assistance of VR. It focuses on the integration of visual techniques in VR (VR visualization) and ET (Exposure Therapy) in an immersion environment using a regular mobile phone, especially with 3D visualization method that can assist or train someone who has a fear of height. In this context, this therapeutic application interprets the environmental virtual vision.

The resulting AIVE related with a creative intervention is the usage of hardware that has limited specifications, is able to display a simulation that is felt by the user with a more "real" feeling when using it. useful as a cognitive behavioral intervention to increase the user's self-efficacy in visualizing a situation. The inventions also identify a sense between higher levels of presence in the virtual environment and lower levels of fatigue and anxiety. In addition, the therapists can also be assisted in simulating a situation by using only a makeshift device, to their patients without endangering the situation of the patient or the therapist himself.

Point 3: Figure 1 is not clear. What is the nature asset? How is it related to AIVE? What message do you want to deliver in figure 1? It is important for the development VR therapy program, it should be elaborated and make it understandable.
The design section is too simple and lack of details.

Response3: Nature asset is an item used in Unity project such as 3D model, audio file, image, or any other type files that Unity support-based material rendering validator, using albedo validate method is an image mode in Scene View. This allows to ensure the material uses values that fall within the proposed reference values for materially based shaders. If the pixel values in a particular material fall outside the reference range, the Material Validator highlights the pixels in different colours to indicate differences. The red colour on the material validator has a minimum luminance value, meaning that this scene is performed with an environment that is deeper than the other areas.

Point 4: For the participants, what are the selection criteria? They are suffering from the acrophobia? What is the severity? What are the questionnaire details? The research model is too simple. In table 1, what are the frequency 13 and 7 stands for? What are the pre test and pro test?

Response 4: Criteria for participants here who have a productive age, namely 19 years and over. Acrophobia sufferers who are stated through a doctor's diagnosis according to DSM V or the public who subjectively feel that they are acrophobic for at least 6 months and have felt disturbed by these symptoms. As well as acrophobia sufferers who have been willing to be a sample of this study. they also had or had not received previous therapy, with a degree of severity ranging from mild to moderate as well as for its prevention.

13 is stand for participant who agreed on this app can assist the phobia treatment, and 7 is frequency for participant who disagreed to this app for assist phobia treatment.

The pre-test was carried out at the beginning of the experiment. Participants are presented with an application model that visually has a more lagging impression when interacting in it or delays for a while when a movement occurs. Graphically it is also not smoother, and the virtual environment is less palatable to the participants.

The post test is done on all participants who have undergone the pre-test. where, visually the application model for the post-test differs in terms of:

- Natural conditions around which has been in the fox with the use of the Unity Asset

- Colour, blur level, level of the graphic which is very different from the pre-test application

This makes several points to be able to create immersion in this exposure therapy.

We have improved a Table 1, more easily to understand.

Table 1. Effects of AIVE Device Based Treatment.

The topic of this article is interesting, but lack of technical details. The research models are not explained in details and the article is difficult to understand. An extensive revision is required before publication.

Author Response File: Author Response.docx

Reviewer 2 Report

In this paper, the authors present an interesting research that aims to usage of virtual reality-based mobile devices using immersive exposure therapy and visual techniques to create engaging and meaningful therapies for acrophobic patients.

The paper is well-organized with a good state-of-the-art (Adequate references to related and previous work). However, I think more current references (last five years) (preferable JCR journals) should be included. Likewise, the work is scientifically sound and the English is correct and readable.

On the other hand, I think that it would be desirable to include much more details of AIVE virtual reality application with Unity3D software.

Regarding formal aspects:

1. There are two errors (percentage) in page 4 (line 163): Of the total 20 respondents, 9 (45%) were male, while 11 (55%) were female.
2. Please, include Table 1 in the text (do not appear in the text).
3. Please, improve the caption of Figure 2 (pre-test and post-tes) (green and blue).
4. Explain the acronym fps (page 6 line 231) (frames per second).

In general, more effort is required.

Author Response

Response to Reviewer 2 Comments

In this paper, the authors present an interesting research that aims to usage of virtual reality-based mobile devices using immersive exposure therapy and visual techniques to create engaging and meaningful therapies for acrophobic patients.

Point 1: The paper is well-organized with a good state-of-the-art (Adequate references to related and previous work). However, I think more current references (last five years) (preferable JCR journals) should be included. Likewise, the work is scientifically sound, and the English is correct and readable.

Response 1: Thank you for your advice. We have added some latest review that you suggest to us in this paper.

Acrophobia is classified as a specific phobia [1],

Therapists also see potential in VR technology and state various advantages such as increased accessibility and control over frightening triggers [2,3].

Immersive from VR environment simulation allows medical practitioners to practice in their work environment in a hospital or clinic, as well as practice without distraction [4]. Stereoscopic content also allows the therapist to help users to practice with a deeper sense of visualization and to avoid the possibility of injury is more dangerous compared to when performing a real situation.

Immersive VR technology works when capable of sensory estrangement with the user from the physical world and replacing the sensory flow with simulation circumstances generated by the computer [5].

1. Park, S.-C.; Kim, Y.-K. Anxiety Disorders in the DSM-5: Changes, Controversies, and Future Directions. In Anxiety Disorders: Rethinking and Understanding Recent Discoveries, Kim, Y.-K., Ed.; Springer Singapore: Singapore, 2020; pp. 187-196.
2. Bentz, D.; Wang, N.; Ibach, M.K.; Schicktanz, N.S.; Zimmer, A.; Papassotiropoulos, A.; de Quervain, D.J.F. Effectiveness of a stand-alone, smartphone-based virtual reality exposure app to reduce fear of heights in real-life: a randomized trial. npj Digital Medicine 2021, 4, 16, doi:10.1038/s41746-021-00387-7.
3. Boeldt, D.; McMahon, E.; McFaul, M.; Greenleaf, W. Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles. Frontiers in psychiatry 2019, 10, 773-773, doi:10.3389/fpsyt.2019.00773.
4. Tang, Y.M.; Ng, G.W.Y.; Chia, N.H.; So, E.H.K.; Wu, C.H.; Ip, W.H. Application of virtual reality (VR) technology for medical practitioners in type and screen (T&S) training. Journal of Computer Assisted Learning 2021, 37, 359-369, doi:https://0-doi-org.brum.beds.ac.uk/10.1111/jcal.12494.
5. Riva, G. Virtual Reality in Clinical Psychology. Reference Module in Neuroscience and Biobehavioral Psychology 2022, B978-970-912-818697-818698.800006-818696, doi:10.1016/B978-0-12-818697-8.00006-6.

Point 2: On the other hand, I think that it would be desirable to include much more details of AIVE virtual reality application with Unity3D software.

Response 2: We have added some details of building the AIVE using Unity3D engine in this article on section 4. Method.

Making this AIVE application is done by configuring the platform used. In this project using the Android platform, as a media project. The player menu in project settings is enabled with VR supported in XR Settings. The Lightmap encoding menu is in the config with a high-quality option, this functions as the activation of HDR lightmap support. For the android project target, can override the default texture compression format from Build Settings to one of the following formats: DXT1, PVRTC, ETC2, ASTC. The default format is ETC for RGB textures and ETC2 for RGBA textures. However, we chose to configure the default for this project. The next step is to create a terrain that is useful as an environment in the application. Assistance from the Unity game engine assets is very useful in creating and modifying an environment or state that you want to design and develop. The use of post-process is also chosen and is used as a filter and full screen image of the camera. post-processing package with version 2.1.7 contained in the Unity engine which functions as a post-processing effect to simulate the physical camera and improve the visuals. The position of the camera is useful as the placement of the user’s vision on the virtual environment, and for adapting the exposure to the virtual environment that has been developed, as a space of interaction between the user and other objects. the next stage of building a virtual player called Rigidbody. Rigidbody is a component that allows Game Object react to real-time physics. These include responses to forces and gravity, mass, drag and momentum on the built environment.

Regarding formal aspects:

1. There are two errors (percentage) in page 4 (line 163): Of the total 20 respondents, 9 (45%) were male, while 11 (55%) were female.

Response 3: We have recalculated and have revised the calculations according to the directions you have suggested. Thank you for the advice.

1. Please, include Table 1 in the text (do not appear in the text).

Response 4: we have edit and added some explanation regarding table1. An evaluation of the effect of using mobile devices on the AIVE application using cardboard media has been carried out to see the effects of users on simulated portable VR devices. In questions R2 and R3 there are 70% of the respondents stated that this simulation application can help to feel calmer when at altitude situation and more effective than conventional methods in treatment (Table 1).

1. Please, improve the caption of Figure 2 (pre-test and post-tes) (green and blue).

Response 5: We have improved the caption for Figure 2, also the chart for more easily to understand. Thank you for your advice.

Figure 2. Mean value of the effectiveness test at the pre-test and post-test.

In Q2, which states that the virtual environment that has been awakened is more effective in feeling the feeling of browsing in this virtual world better than before. Users also stated that this VR media can help in the field of psychological therapy, this is in question Q4. It produces a much smoother process, making the participants feel more relaxed and happier in a challenge on the application.

1. Explain the acronym fps (page 6 line 231) (frames per second).

Response 6: The frames per second (fps) is the rate of recurrence at which successive illustrations termed frames appear on the screen. This term has something to do with film and video cameras, computer graphics, and motion capture systems. The fps setting in this simple VR simulation using smartphones and Google cardboard allows the handphone to become a screen display and graphic rendering device tasked with creating an immersive virtual environment. Also, as boosting factor of sophistication and comfort, while providing a more robust virtual environment.

In general, more effort is required.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Figure 1 is still not clear, what is the original environment? How you perform the experiment and how to obtain the results? For instance, this scene is performed with an 155 environment that is deeper than the other areas ..

What is “this scene”? what is other areas? What means by deeper?

When you are talking about the VR environment, I can even not able to see what is that VR scene is? In Figure 3, is the scene is related to AIVE? How is it related to AIVE?

Figure 3 is just illustrating a very simple statistic. It can be illustrated in other ways.

Why a productive age, namely 19 years and over is selected?

The higher frequency means what? Any comparison? Statistically significant? It is not scientific enough. The research model is very superficial.

Author Response

Response to Reviewer 1 Comments

Point 1: Figure 1 is still not clear, what is the original environment? How you perform the experiment and how to obtain the results? For instance, this scene is performed with an 155 environment that is deeper than the other areas..

Response 1:

                                             (a)                                                                                                    (b)

Figure 1. Nature Manafacture asset. a. Original environment of Nature manafacture asset. b. Nature Manafacture asset base on albedo validate renderer

This terrain is performed with almost 1520 material assets (sound and light effects, stump roots, branches, leaves, etc.). The deeper arch than the rest of the area (red colour on Fig 1 b), which serves as the simulation area for a lake traversed by a root above it. Where later the participants will start walking on these roots. the sensation of a natural environment simulation makes this experiment different from the others. After completing this simulation, the participants were asked to answer the questionnaire questions as shown in Table 1 and Table A1.

Point 2: What is “this scene”? what is other areas? What means by deeper?

Response 2: This scene, leads to figure 1 where this is the rendering result of the VR visualization that has been rendered using the validate albedo. information of this has also been explained on lines 151-156.  By making the spot, it also aims to make a task for the participants to walk uphill above the roots across a lake below. This area of the lake using albedo rendering material has been seen as a lower area than other environmental surfaces.

Point 3: When you are talking about the VR environment, I can even not able to see what is that VR scene is? In Figure 3, is the scene is related to AIVE? How is it related to AIVE?

Point 4: Figure 3 is just illustrating a very simple statistic. It can be illustrated in other ways.

Response 3 & 4: we have revised to complete the description of the AIVE scene. Where the environmental simulation is made like a forest in which there are trees, branches, leaves, rivers, lakes, roots that cross the lake, the sound of water, birds chirping, the roar of the wind and other effects (Figure 2). With the initial stages of the simulation, namely walking to enjoy the scenery and the surrounding environment. In the end, the participants were asked to be able to cross the roots above the lake with a minimum height of about 50 feet. The roots of trees across the lake is becomes a task to the participants to walk uphill over roots across a lake beneath it.

Figure 2. Visualization environment of AIVE

Point 5: Why a productive age, namely 19 years and over is selected?

Response 5: Consideration for this age are:

- Visual function is still good and within normal limits

- More responsive if you have clinical phobia symptoms, because usually adults will feel phobic symptoms interfere with their daily activities, even though they do not directly interfere with it.

Point 6: The higher frequency means what? Any comparison? Statistically significant? It is not scientific enough. The research model is very superficial.

Response 6: the higher frequency means of majority opinion of the participants' responses to the AIVE application they have used. for comparison and significance please refer to table 1 and this has also been assessed by experts in the field of psychiatry and IT, therefore this is quite scientific.

Author Response File: Author Response.docx

Reviewer 2 Report

Now, the authors have improved the manuscript according the suggestions. Therefore, I recommend its publication in current form.

Author Response

Thank you so much for your review and suggestion.

Round 3

Reviewer 1 Report

Can be accepted in current form.