# Validating the Threat of a Virtual Reality Clinical Environment: A Mixed Methods Study
## 4 Discussion  
The primary of aim of this study was to validate two custom-designed VR clinical consultation rooms for their threat value, using a mixed methods approach. The 2 QT results indicated that subjects experienced greater threat in the VR room that was designed and hypothesised to be threatening. Subjects in the threat group recorded significantly higher survey scores than those in the non-threat group in the 2 QT, and they more highly ranked the negative adjectives 'threatening','stressful' and 'unpleasant'. Subjects allocated to the non-threat VR room found their environment to be less threatening and more strongly associated with the adjectives 'calming','safe' and'reassuring'. Within the threat group, there was a change in the cortisol concentration over time, albeit in a direction we did not anticipate. There was no change in cortisol over time in the non-threat group, nor was there a statistically significant difference in cortisol concentration change between the two conditions. The most immediate clinical application of the VR conditions established here would be to use the non-threatening setting to provide comfort and safety to someone in acute pain or discomfort, for example, when performing painful joint mobilisation exercises early after a surgical joint replacement. To date, VR has typically been employed as a distraction,  
Figure 3: Cortisol concentrations in both the threatening and non-threatening conditions at 0 min (pre-virtual reality (VR) exposure) and at 20 min and 26 min post-VR exposure. Cortisol expressed in micrograms per decilitre; all values are medians. Note the significant decrease in cortisol concentration in the threatening condition at both 20 min and 26 min post-VR exposure. No significant change in cortisol was seen in the non-threatening group. * \(p\) < 0.05 corrected; * \(p\) = 0.001 corrected. immersing subjects in natural calming environments such as beaches for patients with fibromyalgiaalgia [34] or forests and mountains for (unspecified) chronic pain patients [35], reducing pain intensity during VR immersion to varying degrees. Alternatively, VR games involving ice and throwing virtual snowballs have been shown to reduce perceived pain intensity in chronic [36] and acute pain [37] (see [1] for a review). We propose that VR immersion of chronic pain patients in realistic settings, e.g., in nature or, indeed, in a pleasant clinical environment like the one tested here, is potentially more suitable than distraction via gaming. Short-term distraction is unlikely to pose a sustainable long-term solution for chronic (i.e., long-term) pain conditions [38]. Whether or not someone feels threatened in any given situation is subjective, and as such, it was an important aim of this study to determine the subjective experience of threat in the VR clinical rooms. In comparing the endorsed items across the two conditions, the moderate-to-large effect sizes indicate that the design of the threatening VR condition did elicit the feelings of threat and stress as intended. Pain is an entirely subjective experience [28]; in research studies and in the clinic, we rely on someone's self-report [39] (for instance, rating their pain out of 10). Now that this investigation has provided some confirmation of the subjective threatening nature of the VR threat condition, the tool can be used in pain experiments and holds potential to help us understand what goes into someone's pain report. Our finding of a significant reduction in cortisol from baseline to post-VR exposure in the threat condition is intriguing. One would assume an elevation in cortisol following a threatening stimulus [40], if there were to be any change. It is, of course, possible that the threat was adequate for the subjects to perceive it as threatening but not adequate to result in an increase in salivary cortisol.