Development of Intelligent Virtual Reality Therapy System (IVRTS) and Testing Its Clinical Efficacy: Revolutionizing Evidence-Based Psychotherapy
Phase: PHASE1
Conditions: Phobias, Acrophobia, Anxiety
Sponsor: University College of Medical Sciences, India

22/10/2020 
 
Cover Letter 
 
 
Dear reviewers, 
It is a pleasure to connect. Hope you are safe and well. 
This is regarding the submission Protocol ID: 3/1/333011/HRD 
Indian Council of Medical Research Registration id: 3/1/333011/HRD 
 
Study Title: Development of Intelligent Virtual Reality Therapy System (IVRTS) and Testing Its 
Clinical Efficacy: Revolutionizing Evidence-Based Psychotherapy 
 
 
This is to request registration of clinical trials. This novel development is extremely relevant in 
today’s world. When the world is sitting on the verge of a Mental Health Crisis. We need to 
revolutionize the Psychotherapy modality for two reasons, first being the shortage of Mental Health 
Professionals compared the huge number of cases that would need help and secondly accessibility. 
When social isolation has become the new norm, one needs innovative tools to be able to effectively 
handle the situation sitting at home, and yet be equally effective, if not more. This project has huge 
potential as well has huge social impact for the treatment of Anxiety Disorders which currently effects 
80% of the world population according to the World Health Organization. Science and Technology is 
the only way this situation can be tackled. The development of this novel technology would reduce 
the cost of treatment of Anxiety disorders, PTSD and Phobias considerably. Also, it would make the 
accessibility of treatment widely available and more comfortable for the masses. This is a much 
needed technological development in the field of Psychiatry. 
 
 
The Documents attached are: 
1. Research article (Protocol + Statistical plan) Dated 01/08/2020 
 
 
Thank you. 
 
 
Warm regards, 
Dr. Akshay Kumar 

1 
 
 
01/08/2020 
 
Development of Intelligent Virtual Reality Therapy System and Testing Its 
Clinical Efficacy: Revolutionizing Evidence-Based Psychotherapy 

2 
 
 
 
01/08/2020 
 
Development of Intelligent Virtual Reality Therapy System and Testing Its Clinical 
Efficacy: Revolutionizing Evidence-Based Psychotherapy 
 
 
Akshay Kumar 1 and Sule Yildirim Yayilgan 2 
 
 
1Assistant Professor and Head SG, IIIT Delhi University 
 
Clinical Consultant and Department Head, Mental health - Artemis Health Sciences 
 
 
2Associate Professor 
 
Norwegian University of Science and Technology (NTNU) 
 
 
 
 
 
 
 
 
 
 
Author Note 
 
Akshay Kumar 
IIIT Delhi University 
Declaration: Have no known conflict of interest to disclose 
 
Funding: No funding to report as of now. Funding by The Research Council of Norway is proposed 
after evaluation the developed prototype mentioned in this article. 
Correspondence concerning this article should be addressed to Akshay Kumar 
IIIT Delhi University, New Delhi - 110021. 
Email: akshay@iiitd.ac.in 

3 
 
 
01/08/2020 
 
 
 
ABSTRACT 
 
 
Background: To take the existing VR technology to the next level, we developed a 
novel Intelligent Virtual Reality Therapy System (IVRTS). Aim: The objective of this project 
had three aspects: Namely, development of the novel IVRTS technology involving the 
development of a hardware device, development of Artificially Intelligent Psychotherapeutic 
software-interface and testing it’s clinical efficacy. Methods: It used a two-phased 
methodology; Development of the novel technology and testing its Clinical Efficacy. After 
development of Novel IVRTS. A 7-week intervention was designed for each subject. 
The sample of 500 patients, meeting the criteria of Acrophobia and Anxiety, underwent the 
interventions at The GTB hospital (The University of Delhi), for a total 3500 sessions, 
ranging 5250 hours for over 2 years. The subjects were randomly divided into 4 groups: 
IVRTS Group, Mindfulness group, CBT group and Control Group. Registration: The ethics 
committee and clinical trial registration number is 3/1/333011/HRD. Results: The IVRTS 
group reported significant reduction in Acrophobic and Anxiety symptoms. The Pre and Post 
intervention, mean and SD reduced from 28.60±8.45 to 11.10±4.03 on HAMA; from 
8.10±1.56 to 3.73±1.23 on SUDS and increased from 72.87±6.21 to 87.07±3.79 on WHO- 
QOL-BREF. It was also seen the mean comparison of reduction was significantly higher 
compared to the CBT and Mindfulness Groups. It also indicated enhanced Quality of Life (p 
< .001) compared to The Mindfulness Group and CBT Group. Conclusion: IVRTS decreased 
symptoms of Acrophobia and Anxiety, enhanced Quality of Life significantly than other 
treatment groups. Development of this technology is a land-mark innovation. 
 
Key Words: Anxiety; Virtual Reality; Phobias; Treatment Intervention. 

4 
 
 
01/08/2020 
 
INTRODUCTION 
 
There is no shortage of literature on Anxiety Disorders and how it disrupts lives 
of many across the world. There are also ample of researches around the world on 
various psychotherapeutic modalities that have proven to be effective interventions for 
the treatment of Anxiety. Hiller1 concluded the positive effects of Cognitive Behavior 
Therapy on symptoms of Anxiety. Mindfulness is another modality proven to be useful 
as an intervention for Anxiety2. However, despite plethora of research in the field of 
Anxiety Disorders and its treatment, according to recent report by The Anxiety and 
Depression Association of American released in 2020, the prevalence of Anxiety is 
ever increasing3. There is an urgent need of newer and novel modalities for three 
reasons; Firstly, the shortage of clinicians in comparison to the number of cases 
affected by technology and secondly, lack of accessibility of therapists by millions of 
people and finally to improve the efficacy and results of the treatment. Keeping these 
three in mind we have developed a technology that will take care of all of the three 
mentioned points. Also, with the current changing trends when people are now 
preferring or are even forced to avail services sitting at home, new technological 
innovations are imperative. The Institute of Medicine4 candidly cites the critical 
shortage of therapists trained in empirically based psychological treatments and how 
this remains a major public health concern. Another study argues that how is shortage 
is a major barrier to accessing these treatments by people across the world5. Taking this 
into consideration, A prominent study cites that the Use of new technologies is the only 
way overcome these issues and to improve widespread accessibility and quality of 
treatments 6-8. 

5 
 
Virtual Reality Technology: Rationale 
 
Many researchers have proved the usefulness of Virtual Reality Technology in 
the treatment of Psychological Disorders, and many studies have quoted efficacy of the 
treatment as well9. The research in the VR field is progressing but still is at a very 
nascent stage10. However, despite some VR projects being worked upon in the current 
times, the technology is not being used widely, due to its limited proven efficacy. The 
current VR technology that exists is only limited to placing a patient in his or her 
phobic situation virtually and not beyond that. In this current project we attempted to 
fill this gap by using 2 important novel technological developments. Firstly, we moved 
beyond just the visual imaging and added haptic touch sensors as well as motion 
sensors to the device. Secondly, we developed an automated intelligent interactive 
Psychotherapy software to compliment the virtual reality as a part of the device and 
finally we tested its clinical efficacy to make sure the novel technology is effective. 
When the world is sitting on the verge of a Mental Health Crisis due to the global 
pandemic. We need to revolutionize the Psychotherapy modality for two reasons, first 
being, the shortage of Mental Health Professionals compared the anticipated cases that 
would need help due to this unique global condition and secondly accessibility. When 
social isolation has become the norm for prevention, one needs innovative tools to be 
able to effectively handle the situation sitting at home, and yet be equally effective, if 
not more. This is the dire need of the society today and the project has immense 
potential as well has huge social impact for the treatment of Anxiety Disorders which 
currently effects 80% of the world population according to the World Health 
Organization11, which is predicted to grow further due to the current global pandemic. 
The development of this novel technology would reduce the cost of treatment of 
Anxiety disorders, PTSD and Phobias considerably, which would make interventions 

6 
 
viable for people across the world currently not being able to afford long term 
Psychological sessions. It would also reduce the treatment time by approximately half. 
It would make the accessibility of treatment widely available and more comfortable for 
the masses. 
The current Virtual Reality technology to treat Anxiety phobias and general 
stress was at a very nascent stage, where a subject was immersed into phobic situation 
and is expected to get stage-wise comfortable with it. The current existing Virtual 
Reality technology to treat phobia is still relatively new and lacks both theoretical and 
clinical research. VR applications need to go beyond only immersing the person into a 
phobic situation. Our proposed research & development project aimed to integrate 
complex and proven effective psychotherapies (visual, auditory, interactive, 
kinesthetic, motion sensing and tactile), automated, intelligent and integrated with the 
Virtual Reality Technology, which the subject or patient will be able to control and 
undergo themselves, then it’s initial clinical efficacy was examined. Keller and 
Bunnel12 explain, Virtual Reality being a technological system helps subjects to 
experience computer and machine generated situations in lab settings. The technology 
is being widely utilized in Psychological treatment and research. Rizzo13, mentions that 
people totally experience Virtual reality when it mimics real life at the highest possible 
level and the users start believing that the situation simulates the real actual world 
experience that it is recreating. This project developed new technology, devices, and 
intelligent psychotherapeutic software programs in VR for curing phobias, anxiety, 
stress and even stress management. The current technology in this field that existed is 
only at a level of immersing a subject in a realistic VR image/scene and is not beyond 
that. Currently, this technology was not useful in the treatment, and that is the reason 
had not entered widely in clinical settings yet. 

7 
 
To take this technology to the next level, one needed to develop a novel VR 
technology/device, which is intelligent, as well as which would interact and stimulate 
"Whole brain activation" and help the subject overcome phobia/stress/anxiety 
effectively. This required developing a device which had motion sensors, interactive 
sensors which allowed the subject to feel and interact with the image, scenario, 
program real- time and other psychotherapeutic intelligent technological hardware 
components and intelligent interactive psychotherapeutic software programs fostering 
this process, all built in one integrated compact device. 
Furthermore, the main components of this project included –Hardware, 
software, system interfaces and data. The data being collected by the wireless sensor 
contains information about the health status of the user is stored in a database. Health 
status data included information about blood pressure, heart rate and other 
physiological parameters as well. 
This project is aimed to develop both hardware and software technology and 
finally test its clinical efficacy to treat Phobias, General Anxiety, Stress and PTSD. 
According to the DSM 5 published by the American Psychiatry Association14, specific 
phobias are associated with fear or Anxiety attached to a specific situation or Object 
Like water, animals, animals, public speaking, needles, heights, blood etc. DSM Also 
defines Generalized anxiety disorder (GAD) as a condition in which a person Feels 
intrusive, excessive, and persistent worrying to the extent that daily functioning 
becomes difficult. 
Anxiety and Stress is becoming a global epidemic, The World Health 
Organization15, estimates that 1 in 3 from Clinical Anxiety and 1 in 5 individuals are 
suffering from Clinical Depression. About 80% of the world is suffering from general 
stress. 

8 
 
It is said that situation improves with pumping in of resources and putting in 
efforts; but in this situation despite putting in huge funds, highest quality of resources, 
the best human minds and fierce efforts, the problem is only increasing. The 
development of this novel technology will be a landmark step towards the intervention 
of these conditions the world is battling in present times. 
Existing Work in VR 
 
According to Garcia Et al16, Virtual Reality has gained widespread acceptance 
in the field of psychiatry. Mainly pertaining to phobias within anxiety disorders, VR 
has been found to be useful in the treatment of phobia of spiders17, heights18, flying19 
and claustrophobia20, to name a few. As VR allows for the creation of images and 
scenarios, the subject can be taken back to the fearful or anxiety-provoking situation. 
The therapist can then guide and monitor the subjects’ responses and thereby treat 
anxiety. Walshe and Lewis et al21 mentions in their research that VR has thus also been 
successfully utilized to treat phobia of driving in patients who have Post-Traumatic 
Stress Disorder (PTSD) after an accident. Also, Horváthová and Siládi 22 proved in 
their research how Virtual environments created by virtual reality (VR) tools can help 
to make the treatment of certain types of phobias more efficient. Further Keller and 
Bunnel eta al23, using systematic literature search analyzed VR based treatments and 
emphasized on their benefits viz-a-viz psychiatric and Psychological research and 
intervention to overcome anxiety. 
NOVELTY OF THE PROJECT 
 
The approach of the Novel Intelligent Software interface approaches 
follows the basic premise that human beings think in terms of images rather than 
words. While the existing modes of treatment for phobias rely mainly on talk 
therapies and counseling; This novel intelligent software treatment methodology 

9 
 
deals with the development of VR programs integrated with hardware for 
simulating various phobia-inducing situations, followed by novel automated 
integrated most effective psychotherapy; altering these images to reduce the 
anxiety experienced. Our treatment package includes a VR device integrated with 
easily comprehensible voice commands, along with a user manual and easy user 
interface, thereby reducing the effort of training required for operating the device. 
The framework is a combination of the therapy methodologies with VR, motion 
sensors, biofeedback and fNIRS. This would eliminate the need for a therapist by 
making the patient self-sufficient in handling the overall treatment themselves. In 
the long run, this would prove to be more cost-effective and socially accessible. 
METHODOLOGY 
 
Objective, Approaches, hypotheses and choice of method 
 
 
 
Figure 1: Conceptualization of research and development of project 

10 
 
 
 
 
 
 
 
Figure 2: Intelligent Interactive Psychotherapy Program Software (IIPPS) 
 
Objective 
 
To develop Novel Technology, Intelligent Virtual Reality Therapy System (IVRTS) 
and test its Clinical Efficacy to treat phobias and anxiety, compared to Mindfulness 
Meditation and Cognitive Behavior Therapy (Talk Therapy). 
Concept 
 
Virtual Reality has a vast potential in healthcare. One such area where VR is 
becoming a promising technique is the treatment of Phobias and Anxiety Disorders. 
There are various types of phobias, and amongst them, some occur more commonly in 
individuals, in general. In the treatment of phobia using VR, the patient re-enters a 
computer-generated environment that is the imitation of the situation or an object the 
patient possesses the fear of. It helps people to encounter situations or objects they fear 
while being in a completely safe and controlled environment. The environment is 

11 
 
controlled in a manner that the level of fear gradually rises for the patient as he/ she can 
overcome a prior level of that fear. Generally, a VR set-up is built to treat a specific 
kind of phobia. Furthermore, using such a set-up for the treatment of patients requires 
training to integrate VR into therapy. This project aimed to design and model a system 
with a simple user interface to treat all kinds of common phobias, Post Traumatic 
Stress, and General Anxiety. This system primarily aims to have the patient treated at 
the end of therapy unlike the short-term effectiveness of talk therapies, and could be an 
alternative to drug therapy. This system will lead to cost reduction for the patient and 
time saving for the therapist as taking outpatient in the actual stimulus environment 
would be eliminated. This system achieved its goal by combining intelligent software 
with various hardware which will excite all the four senses, namely, sense of sight, 
hearing, feelings, touch, and enable hand movements to control a certain part of the 
therapy, enabling whole brain activation for the process. Such an integrated system 
creates a more immersive environment to produce better stimulus and overcome the 
unwanted response to a feared object or situation. This project aimed to build a Virtual 
Reality Therapy System, which is beyond the currently existing Virtual reality phobic 
situation immersive systems. This project aimed to build a Novel ‘Intelligent Virtual 
Reality Therapy System’ (IVRTS), that has inbuilt automated and integrated complex 
and most effective intelligent psychotherapies and body Bio-feedback, with various 
therapy options and settings that a person or patient can select and operate themselves. 
Furthermore, the research project also aimed to test the clinical efficacy of the 
Intelligent Virtual Reality Therapy System (IVRTS) on Phobic Patients in actual 
clinical settings. 

12 
 
 
 
 
 
 
 
Figure 3: Image of the computer on which Developed Virtual vfx is being 
developed 
 
 
Technology Components and Clinical Trials 
 
The researchers specified VR scenarios for the simulation and treatment of 
these categories. The VR equipment that is being used is with the research partner, 
Innlandet hospital trust are (20 oculus go, 5 Lenovo mirage and 10 Samsung gear (7 
and 8), and 1 oculus rift) in their premises which has been used in cooperation with 
Gjøvik Hospital, Norway for various purposes. 
In this health-related research, the researchers first applied to health research 
ethics committees for permissions and once the permissions are taken, then the 
researchers identified the sample or user groups, through seminars at the Gjøvik 
hospital, using social media, etc. The researchers made sure that the user consent is 
received, the participation in our studies are voluntary and their participation can be 
ended any time by the user without any penalties for the user. Also, the Clinical Trials 
took place at The Psychiatry OPD of the Guru Tegh Bahadur Hospital of The 
University of Delhi. 

13 
 
 
 
 
 
 
Figure 4: The software detects the pupil, after detection it determines the focus 
point of gaze to control the virtual interaction 
Hypothesis: 
 
(i) The new novel developed technology Intelligent Virtual Reality Therapy System 
(IVRTS) is more effective in reducing symptoms of Phobia and Anxiety as compared 
to Mindfulness Meditation and Cognitive Behavior Therapy Groups. 
(ii) The novel IVRTS Group scores significantly lower on both Hamilton Anxiety 
Inventory (HAM-A) and Subjective Units of Dysfunction Scale (SUDS) compared to 
all three, The Control Group, The Mindfulness Group Cognitive Behavior Therapy 
(CBT) Group. 
(iii) The Novel IVRTS Group scores significantly higher on WHO Quality of Life 
Scale (WHO QOL BREF) compared to all three, The Control Group, The 
Mindfulness Meditation Group and The CBT Group. 
(iv) The new technology proves to be effective and a steppingstone towards a newer 
era in the treatment of Mental Health issues using Mental healthcare engineering. 
Sample 
The Clinical Trials were carried out on 500 adults with Acrophobia which is 
fear of heights co-morbid with Generalized Anxiety. The sample for the study was 
recruited from the patients/subjects attending the adult psychiatric OPD of the 
department of Psychiatry GTB Hospital of The University of Delhi and fulfilling the 

14 
 
ICD-10 diagnostic criteria for assessment of Acrophobia and generalized anxiety. The 
study was conducted on an initial 500 subjects attending the psychiatric OPD of the 
department of Psychiatry GTB Hospital of the University of Delhi. The subjects were 
equally and randomly assigned to three groups namely; Novel Intelligent Virtual 
Reality System (IVRTS) Group (n=125), Mindfulness Meditation Group (n=125), 
Cognitive Behavior Therapy (CBT) Group (n=125) and The Control Group (n=125). 
 
 
Figure 5: Consort Diagram 
 
Inclusion Criteria 
 
The Inclusion criteria included patients visiting the Psychiatry OPD of University College 
of Medical Sciences of the University of Delhi and the attached GTB Hospital. 
Furthermore, those patients were selected who reported fear of heights and scored mild, 
moderate and Severe anxiety as assessed on Hamilton Anxiety Inventory. The patients 
were in the age group between 18 to 60 years of age. 

15 
 
Exclusion Criteria 
 
Patients who had any Psychotic disorder or symptoms co-morbid were not selected for the 
study. Furthermore, patients below 18 years of age and aver 60 years of age were also not 
selected for the program 
Registration 
 
All procedures involving human subjects/patients were jointly approved by The 
University College of Medical Sciences (University of Delhi) and Delhi Psychiatry 
Society Ethics Committee registration. Registration number 3/1/333011/HRD. The 
patients were first recruited on 5th February 2018 for the project. 
Procedure and Approaches 
 
To achieve the stated objective, a two-fold approach comprising of qualitative and 
quantitative analysis was undertaken. A 7-week intervention course was designed for each 
subject to reduce symptoms and enhance quality of life as well as to establish clinical 
efficacy. The intervention was conducted on a sample of 500 patients diagnosed with 
Acrophobia co-morbid with generalized anxiety who underwent the intervention at 
The GTB hospital of The University of Delhi, for a total of 3500 sessions, ranging up 
to 5250 Hours over a period of 2 years. Written informed consent was obtained from all 
participants. The authors assert that all procedures contributing to this work comply with 
the ethical standards of the relevant national and institutional committees on human 
experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All 
procedures involving human subjects/patients were jointly approved by The University 
College of Medical Sciences (University of Delhi) and Delhi Psychiatry Society Ethics 
Committee registration. Registration number 3/1/333011/HRD. Further study carried out 
A-B-A research design which mainly involved establishing a baseline condition, 
introducing an experimental treatment and then returning to the baseline. The subjects 

16 
 
completed standardized self-report measures of Hamilton Anxiety Inventory (HAM-A), 
Subjective Units of Dysfunction (SUDS) and WHO Quality of Life - BREF Questionnaire 
(QOL-BREF) at baseline, after seven intervention sessions post assessments on the same 
scales were repeated to assess the efficacy. 
The Therapeutic Software of IVRTS 
 
The researchers developed four different technological approaches to 
develop the Psychotherapeutic Software. (1) Since phobias are known to stem from 
mental images of situations or objects which an individual has learned to be fearful of. 
Thus, the most effective way to treat them, then, would be to alter these anxiety- 
provoking images with the help of graded exposure of an image of a situation or object 
which induces maximum pleasure and positive emotions within the individual. This 
was achieved with the help of development of motion sensors to detect the wrist 
movements of the subjects, which aided in achieving the desired goal of stimulating the 
pleasure-inducing stimulus to reduce anxiety. This was accompanied by monitoring the 
subject’s physiological parameters through body biofeedback and fNIRS depicting the 
changes brought about by VR therapy and keeping the record of the same. (2) When an 
individual encountered a fearful stimulus, certain kind of neurotransmitters are released 
in the brain and over time, the body and mind of the individual learn to associate the 
release of these neurotransmitters with fear. This association was altered by flooding 
the individual’s mind with pleasurable memories in the form of positive images using 
Virtual Reality Technology and thereby replacing unpleasant memories attached to the 
neurotransmitter release with pleasant memories. It was followed by guided instruction 
from the IVRTS device along the concept of ‘Whole Brain Thinking’ wherein all the 
five sense organs are used to exercise all the parts of the brain to take advantage of a 
wide spectrum of thinking. (3) As described in Figure 1, Cognitive Behavioral Therapy 

17 
 
(CBT) states that it is not the situation itself but the thought associated with the 
situation (stimulus) which makes an individual fearful. Altering this thought and the 
emotions related to it is hence helpful in treating phobias. This was achieved by 
integrating an automated intelligent Cognitive Behavior Therapy software program 
with the VR device. 4) Finally, the researchers used Mindfulness Relaxation as a 
treatment for phobia. This was implemented by making the subject face the anxiety- 
provoking situation with the help of VR equipment and simultaneously working on 
reducing the anxiety emotions with the help of guided mindfulness meditation 
accompanied by meditation music, along with the developed automated intelligent 
therapy software interface. This methodology was intended to put the subject in a 
peaceful state of mind, detaching them from negative thoughts and fears, working on 
the principle that anxiety and relaxation cannot coexist. 
 
Figure 6: Understanding CBT Software 
 
Project Plan 
Figure 7: Project plan 

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01/08/2020 
 
OUTCOMES AND RESULTS 
 
The quantitative and qualitative results were analyzed with the appropriate 
statistical and analytical tools. Various statistical modalities were used to establish 
efficacy, efficiency and the frequencies evaluated. Paired sample t- test were 
conducted in this study to assess the statistical significance of the interventions. 
Independent sample t-test and ANOVA were tested in the data. Correlation analysis 
was also performed, The association between two categorical variables is enumerated 
by Chi-square test. 
Scale 
Mindfulness (n=118) 
Control (n=125) 
t- 
F- 
p-value 
Pre 
Post 
Pre 
Post 
value 
value 
Mean±SD 
Mean±SD 
HAMA 
32.86±5.76 19.62±4.24 33.70±6.08 28.00±6.49 8.350 
2.327 
0.000 
SUDS 
8.24±0.95 
5.69±1.04 
8.27±1.11 
6.03±1.29 
1.228 
0.178 
0.225 
QOL 
73.86±7.73 84.10±5.19 75.47±5.44 82.53±4.85 -2.229 
6.242 
0.030 
 
Table 1: Mean comparison between Mindfulness Meditation group (n=118) and control group 
(n=125) 
 
Table 1 represents the mean comparison between Mindfulness group and the Control 
Group of respondents while before and after intervention. On The Hamilton Anxiety scale, 
most of the respondents in The Mindfulness Group had very severe condition while before 
intervention with mean score (M=32.86), but it reduced to mean score (M=19.62). While in 
the control group, most of the respondents had very severe condition while before 
intervention with mean score (M=33.70) and moderate to severe condition while after 
intervention with mean score (M=28.00). The obtained t-value and p-value for Hamilton 
scale are 8.350 and 0.000 respectively. Here, p-value is less than 0.01; it indicates that there 
is a statistically significant difference between mindfulness and control group of respondents 
based on Hamilton scale. Similarly when considered the Subjective Unites of Dysfunction 
Scale (SUDS), most of the respondents of The Mindfulness Group, felt ‘Freaking out’ while 
before intervention with mean score (M=8.24) and ‘Moderately upset’ while after 

19 
 
intervention with mean score (M=5.69). But in the control group, most of the respondents 
felt ‘Freaking out’ while before intervention with mean score (M=8.27) and ‘bad’ while after 
intervention with mean score (M=6.03). The obtained t-value and p-value for SUDS are 
1.228 and 0.225 respectively. Here, p-value is greater than 0.05, and indicated that there is no 
significant difference between mindfulness and control group of respondents based on SUDS. 
Similarly, obtained t-value and p-value for Quality of life are -2.229 and 0.030. Here p-value 
is less than 0.05; and shows a statistically significant difference between Mindfulness and 
Control group in relation to WHO Quality of life (QOL - BREF) scale of respondents. 
 
 
t- 
F- 
p- 
 
Mean±SD 
Mean±SD 
value 
value 
value 
HAMA 32.52±5.24 21.03±4.29 33.70±6.08 28.00±6.49 6.905 
2.312 
0.000 
SUDS 
8.24±0.98 
5.34±1.14 
8.27±1.11 
6.03±1.29 
2.366 
0.344 
0.021 
QOL 
73.62±5.23 83.28±5.06 75.47±5.44 82.53±4.85 -2.714 
0.002 
0.009 
Table 1: Mean comparison between CBT group (n=106) and Control group (n=125) 
 
Table 2 presents the mean comparison between CBT group and control group of 
respondents before and after intervention. On the Hamilton Anxiety scale, most of the 
respondents of the CBT Group had very severe condition while before intervention with 
mean score (M=32.52), which reduced to mild to moderate severe after the intervention witj 
mean score (M=21.03). In control group, most of the respondents were in very severe 
condition while before intervention with mean score (M=33.70) and improved to moderate to 
severe condition after the intervention with mean (M=28.00). The obtained t-value and p- 
value for Hamilton scale are 6.905 and 0.000 respectively. Here, p-value is less than 0.01, it 
indicates a statistically significant difference between CBT and control group of respondents 
based on Hamilton Anxiety scale. Similarly, on the SUDS of respondents, most of the 
respondents felt ‘Freaking out’ while before intervention with mean (M=8.24) and 
CBT (n=106)
Control (n=125) 
Scale 
Pre 
Post 
Pre 
Post 

20 
 
‘Moderately upset’ after the intervention with mean (M=5.34). But in the control group, most 
of the respondents felt ‘Freaking out’ before the intervention with mean (M=8.27) and felt 
‘bad’ after intervention with mean (M=6.03). The obtained t-value and p-value for SUDS is 
2.366 and 0.021 respectively. Here, p-value is less than 0.05, indicating a statistically 
significant difference between CBT and control group of respondents based on SUDS. 
Similarly obtained t-value and p-value for Quality of life are -2.714 and 0.009. Here p-value 
is less than 0.01; indicating a statistically significant difference between CBT and Control 
group in relation to The WHO Quality of life (QOL- BREF) scale of respondents. 
 
Novel IVRTS (n=115) 
Control (n=125) 
t- 
F- 
p- 
Scale 
Pre 
Post 
Pre 
Post 
Mean±SD 
Mean±SD 
value 
value 
value 
  HAMA 
28.60±8.45 11.10±4.03 
33.70±6.08 28.00±6.49 8.088 
23.503 
0.000 
 
SUDS 
8.10±1.56 
3.73±1.23 
8.27±1.11 
6.03±1.29 
7.503 
2.315 
0.000 
QOL 
72.87±6.21 87.07±3.79 
75.47±5.44 82.53±4.85 -6.313 4.519 
0.000 
 
Table 3: Mean comparison between IVRTS (n=115) and Control group (n=125) 
Table 3 presents the mean comparison between The Novel Intelligent Virtual Reality 
Therapy System (IVRTS) and control group of respondents. On the Hamilton Anxiety scale 
of, most of the respondents of the Novel IVRTS Group had a score representing moderate to 
severe condition before the intervention with mean (M=28.60), and reduced to mild condition 
after the intervention with mean (M=11.10). In the control group, most of the respondents 
were in very severe condition before intervention with mean (M=33.70) and moved to 
moderate to severe condition after intervention with mean (M=28.00). The obtained t-value 
and p-value for Hamilton Anxiety scale is 8.088 and 0.000 respectively. Here, p-value is less 
than 0.01, it indicates that there is a statistically significant difference between The Novel 
IVRTS Group and The Control Group on Hamilton scale. Similarly, on the SUDS of 
respondents, most of the respondents of The IVRTS Group felt ‘Freaking out’ before the 
intervention (M=8.10) and ‘No Significant Distress’ after the intervention with mean 

21 
 
(M=3.73). In the control group, most of the respondents felt ‘Freaking out’ before the 
intervention with mean (M=8.27) and moved to feeling ‘bad’ after the intervention with mean 
with mean (M=6.03). The obtained t-value and p-value for SUDS are 7.503 and 0.000 
respectively. Here, p-value is less than 0.01, it indicates that there is a statistically significant 
difference between The Novel IVRTS Group and The Control group based on SUDS. 
Similarly, the obtained t-value and p-value for The WHO Quality of life Scale were -6.313 
and 0.009. Here p-value is less than 0.01, and indicates a statistically significant difference 
between The Novel IVRTS and Control group on The WHO Quality of life (QOL-BRF) scale 
of respondents. 
 
Scale 
Mindfulness 
CBT 
Novel IVRTS
Pre 
Post 
Pre 
Post 
Pre 
Post 
Mean±SD 
Mean±SD 
Mean±SD 
 HAMA 32.86±5.76 19.62±4.24 32.52±5.24 21.03±4.29 28.60±8.45 
11.10±4.03 
SUDS 
8.24±0.95 
5.69±1.04 
8.24±0.98 
5.34±1.14 
8.10±1.56 
3.73±1.23 
QOL 
73.86±7.73 84.10±5.19 73.62±5.23 83.28±5.06 
72.87±6.21 
87.07±3.79 
 
Table 4: Efficacy of Interventions based on the HAMA, SUDS and WHO QOL scale 
 
Finally Table 4, shows the comparison analysis between the various interventions to 
show which intervention proved to be the most effective and efficient for the patients. 
Interventions namely, Mindfulness Meditation, CBT and Novel Intelligent Virtual Reality 
Therapy System (IVRTS). The mean scores after intervention on both The Hamilton Anxiety 
Scale and The Subjective Units of Dysfunction Scale for the Novel IVRTS Group is 
significantly less than the mean scores (HAMA=11.10, SUDS=3.73) of The Mindfulness 
Group (HAMA=19.62, SUDS=5.69) and the CBT Group (HAMA=21.03, SUDS=5.34). In 
addition, The Novel IVRTS Group has a higher mean score on The WHO Quality of Life 
Scale (QOL=87.07) compared to the Mindfulness Group (QOL=84.10) and the CBT Group 
(QOL=83.28). The p-value is less than 0.01 respectively indicating a significant difference 
between Novel IVRTS compared to other interventions including CBT, Mindfulness and 

22 
 
Control groups. Considering the all the above comparisons of statistical significance 
modalities namely, The Mean Scores, Standard Deviations, t-scores and p-scores. The study 
concludes that, The Novel Intelligent Virtual Reality Therapy System (IVRTS) intervention is 
the most effective and efficient intervention compared to Mindfulness and even CBT. 
Through the various approaches explained henceforth, the researchers aspired to create 
a more effective, image-based treatment system for phobias, based on the combination of 
principles of Psychology and Virtual Reality. The treatment methodologies thus aimed to 
automate the process oftherapy thereby making the process faster and more practical. 
Moreover, the new technology is for the first time used to develop human, AI interaction for 
treatment, using interactive sensors, intelligent automated psychotherapy interface, and VR 
imagery scenarios. 
DISCUSSION AND CONCLUSION 
 
Through the various approaches explained henceforth, the researchers aspired to create 
a more effective, image-based treatment system for phobias, based on the combination of 
principles of Psychology and Virtual Reality. The paper is a good step towards incorporating 
technology in Psychiatry. In today's age when the rest of the medical fraternity (Radiology, 
cardiology, neurology etc.) has moved towards Artificial Intelligence and robotics for 
diagnosis and interventions. Psychiatry is still at a nascent stage in using technology for its 
advantage. Not to forget, the subjectivity in the field of Psychiatry is also its biggest strength, 
which cannot do without the subjective empathetic human touch, this technology is not to 
replace but to complement the subjective human intervention. The treatment methodologies 
thus aimed to automate the process of therapy thereby making the process faster and more 
practical. Moreover, the new technology is for the first time used to develop human, AI 
interaction for treatment, using interactive sensors, intelligent automated psychotherapy 
interface, and VR imagery scenarios. The strengths of this technology are successful 

23 
 
development of novel new technology which uses Virtual Reality Imaging in combination 
with Artificially Intelligent Psychotherapy and Incorporated with tactile interactive sensors. a 
person will be able to touch the feel of water (In case of Hydrophobia) or experience the feel 
of air (in case of acrophobia) and so on through the tactile sensors. The Novel Technology 
proved be to highly effected, so much so that our clinical trials concluded the Novel 
Intelligent Virtual Reality Therapy System (IVRTS), to be significantly more effective than 
Cognitive Behavior Therapy, as well as Mindfulness Meditation. The Novel IVRTS, reduced 
Anxiety levels of patients and improved their Quality of Life, significantly more compared to 
CBT and Mindfulness. There is a need of new technology for treatment, keeping in view the 
acute shortage of manpower of trained mental health professionals, which can never keep 
pace with increasing population and psychiatric morbidity, especially challenges arising from 
COVID-19 pandemic. 
Relevance to society 
 
When the world is sitting on the verge of a Mental Health Crisis. We need to 
revolutionize the Psychotherapy modality for two reasons, first being; the shortage of Mental 
Health Professionals compared the huge number of cases that would need help and secondly 
accessibility. When social isolation has become the new norm, one needs innovative tools to 
be able to effectively handle the situation sitting at home, and yet be equally effective, if not 
more. According to Freeman24, there are large benefits of Psychological therapies using 
automated Virtual reality systems. This project has huge potential as well has huge social 
impact for the treatment of Anxiety Disorders which currently effects 80% of the world 
population according to the World Health Organization25. Science and Technology is the only 
way this situation can be tackled. The development of this novel technology would reduce the 
cost of treatment of Anxiety disorders, PTSD and Phobias considerably. It would also reduce 
the treatment time by approximately half. Also, it would make the accessibility of treatment 

24 
 
widely available and more comfortable for the masses. 
 
 
Limitations, Challenges and Future Scope 
 
The challenges the project could face both Nationally and Internationally a few, 
namely, Cross-Cultural reliability. The efficacy of the developed technology would need to 
be established cross-culturally, for which it would require subjects from Norway, India and 
also it could be extended to other regions and cultures to establish its validity for practical 
usage. Finding such a variety of subjects could prove to be a challenge but can be achieved. 
This project has immense advantages and enormous scope in un the coming future. This 
technology will be a landmark step in the way Psychotherapy is conducted across the world. 
The IVRTS, will increase the widespread availability of Psychotherapy to millions of 
individuals who are currently deprived of it, due to social taboo or shortage of Mental Health 
Consultants or just non-availability of resources. This novel technology would also reduce the 
cost of Psychotherapeutic interventions, and most importantly will be a major steppingstone 
towards a healthier world, because of its capability to touch masses in exponentially large 
numbers 

25 
 
 
 
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