What does a typical day of a senior physician in a psychiatric clinic look like?
As it is usual in a university setting my work consists of clinical work, teaching, and research. For the first part, I’m responsible for supervising assistant physicians and psychologists in their work. I discuss the cases with them and visit patients. Secondly, I teach psychologists and psychiatrists. My research covers the use of virtual reality-based therapy and biological treatments, for example, deep brain stimulation for patients that have very grave afflictions that could not be treated with other methods. Our center offers inpatient and outpatient treatment. It has 110 beds, 50 day-clinic places and around 70 therapists working in the outpatient unit. The specialty of our center is that it eschews the classical division of work where psychologists deliver psychotherapy therapeutically and the psychiatrists mainly prescribe medications. This makes it attractive for psychiatrists that also want to learn and deliver modern cognitive behavioral therapy.

You are an expert for anxiety disorders. Recently I crossed a very high bridge across a valley and I had a queasy feeling. This fear was probably useful because I walked very carefully. At what point is fear no longer normal, but becomes a disorder?
Fear is controlling our behavior in certain situations. It protects us from danger. An anxiety disorder is present when the fear is inappropriate and arises in situations that most people have no problems with and when the fear becomes so intense and excessive that it significantly restricts the patient in their normal life. In your bridge example, you felt a bit uneasy, and then that feeling passed. But our patients have to deal with massive tension even when it comes to perfectly safe things such as getting on a bus or sitting at a table in a restaurant.

Is this always linked to something precise such as the fear of spiders or snakes?
No. What you mentioned belongs to specific phobias that are usually not subject to treatment. We’re mainly dealing with other disorders that are much more distressing in every-day life. One is the fear of certain situations, called agoraphobia. It is the fear of large crowds, be they in mass transport or department stores. Agoraphobia is characterized by the urge of the patient to avoid these situations and often, the disorder is accompanied by panic attacks. The heart begins to beat faster, the patient thinks their heart is going to stop, they start sweating or hyperventilating. Another important and prevalent affliction is called social anxiety disorder. These patients fear to be in the center of the attention of other people. This is far more than normal shyness. It can lead to a point where patients retire from the world, leave their home only at night or not at all anymore. As you can imagine, many of the people with social anxiety disorders are not treated at all, because face-to-face contact with a doctor or therapist is a massive burden for them.

 “Many of the people with social anxiety disorders are not treated at all”

Is there a typical age when such disorders appear?
To some degree, you can tell from the behavior of two-year-old’s that they may develop an anxiety disorder which typically begins from school age to young adulthood There is, however, one type of disorder that usually appears at an advanced age. It is called generalized anxiety disorder, and it is very intense and persistent. It is characterized by continuous worries about everyday problems like health and finances that become so omnipresent that patients can’t stop thinking about them.

All of this sounds very depressing. How do you cope with all of this?
For a psychiatrist, anxiety is one of the most grateful and fulfilling fields because it is a disorder that can be treated with a good chance of success. When people think about psychological disorders, they usually think about depression or schizophrenia or other things. But anxiety is the most prevalent of them all. 15% of the population will develop an anxiety disorder over the course of their life, millions of people in Germany alone. Many never get treated, and they suffer immensely, some to the point of becoming incapacitated to work. There is not only widespread personal suffering but also an enormous financial cost to the health system, think of people being admitted to emergency rooms when they have a panic attack. And contrary to depressions, anxiety tends not just to go away but persist. But the good thing is that you can achieve a very strong improvement of a patient’s situation with very little effort. One of our patients had a chronic agoraphobia and panic disorder and refused to leave his home for 27 years. His wife took care of everything. When his daughter became engaged, he had enough of it and got treated, and in the end, he successfully attended her wedding.

How do you treat anxiety?
First of all, we inform patients about the connection between what they do, what they think, and what they feel. The model that is used is the vicious circle of fear. Let’s take the example of social anxiety. Someone sits in a café and gets the impression that strangers look at him in a weird way. He starts to treat this mere impression as a fact: people disapprove of me. As a consequence, he gets nervous and uneasy and leaves the café. The symptoms disappear, the person gets rewarded for this coping strategy. Every time this happens again, the anxiety becomes stronger.

How do you break out from this vicious circle?
The therapist works with the patient on how to step out of this circle, and exposure therapy plays an important part in it. The patient usually needs motivation and support from the therapist, which means that they will accompany them to the situation that is problematic. Exposure therapy means staying in an uncomfortable situation despite the fear that triggers the urge to run away. When nothing bad happens even after some time, the initial construct of ideas begins to change. After a while, patients are able to do the next exercises themselves.

In your practice, you use Sympatient’s virtual reality-based exposure therapy alongside the traditional exposure therapy you just described. What is your experience with this modern method?
First of all, it is easily accessible. In maybe 20% of cases, patients simply say that there is no way they want to get exposed to a certain situation. These are typically the more severe cases of anxiety. But these same people will readily try out the same in virtual reality. They report after their dismissal that they could readily translate the lessons from virtual reality to reality. In some cases, we use VR to prepare real-life exposure, in others we use VR alone.

Is this anecdotal evidence or is there proof that VR exposure therapy works?
The arguments to use VR are compelling. Not only are there studies that prove that the efficacy is at least as good as real-life if not better, but VR is already included in the official guidelines on how to treat anxiety. And you have to keep in mind that these studies were conducted several years ago. The degree of realism and immersion you get from a smartphone and VR goggles today are miles away from what was technically possible five years ago with stationary systems.

A VR system probably can’t offer the tailor-made approach a therapist would use for different patients.
The situations that are relevant for agoraphobia and panic disorders are very uniform. A big multi-center study financed by the German Research Foundation found that exposure to just three standard situations – bus, the edge of the woods, and riding an escalator in a department store – worked very well. The effects of the treatment are generalizable, which means that what you learned in the situation of the department store is useful in a concert hall as well. The same is true for generalized anxiety disorders, where a few common preoccupations like health, love or finances are what ails most of the patients. This means that you don’t have to develop hundreds of different scenarios for virtual reality. Those parameters that are very personal, for example at what age and in which situation the disorder appeared, are irrelevant for the treatment.

Ok, but since real-life exposure therapy works perfectly fine as well the market might not even need VR solutions for the standard cases.
There are practical reasons why real-world exposure therapy is not readily offered by therapists. In an ambulatory setting, the day of the therapist is divided into sessions of 50 minutes, then there are 10 minutes to document work before the next patient comes in. Exposure therapy takes too much time for this setup. You need to go to a bridge, tunnel or tower, and by the time you get back 3 hours might already be gone. For a therapist, to make this effort and deal with the insurance company to get these hours reimbursed is an effort that many simply don’t want to do. Some therapists even readily bill hundreds of hours of psychoanalysis instead, something that would be impossible in England, for example, where only evidence-based methods are reimbursed. There is an inadequate supply situation here, and the number of people that are not treated at all is immense. VR therapy could help them.

Even if VR exposure therapy works and doesn’t have these practical constraints, are psychologists not vociferously against the use of VR? I mean, VR is a direct competition to what they do and could reduce their earnings going forward.
In theory, this argument might be valid, but the reality is different. First of all, a law was passed recently that says this form of telemedicine is possible and will be reimbursed. The critical voices in the run-up to this change were very sparse. The reason for this is that everybody is aware of the supply deficit and the incredibly long waiting times for a therapy spot. A colleague of mine recently opened a private practice. He told me that after just three weeks his calendar was full. Since then, he declines potential new patients every day. This is the reality for psychotherapists which theoretically compete with VR. Many of them even see VR, not as competition, but as an important tool they can use to either prepare patients for face-to-face contact or to renew the treatment effect after a while, and they are ready to use this tool. But the main first contact for patients are family doctors that rarely offer psychotherapy. They are more than happy to be able to offer their patients something that is not only evidence-based and evaluated, but also available right away. The alternative is a referral to a psychiatrist with an average waiting time of 6-9 months. But the patients are in need now and are desperate and discouraged if they hear about this waiting time. There are millions of people that are not adequately treated at the moment, and VR therapy is a solution to treat them that is welcomed not just by insurers, but by most members of the medical and psychological community.