Fear of hypoglycemia (FOH) refers to phobic avoidance reactions associated with hypoglycemia. FOH is associated with poor glycemic control and its consequences, necessitating the development of effective methods to address this condition. We present a pilot study, combining biofeedback (BF) with a virtual reality (VR) smartphone application.
Patients with type 1 diabetes suffering from FOH as evaluated by the "Hypoglycemia Fear Survey-II" questionnaire [composed of two subscales; Behaviors (HFS-B) and Worries (HFS-W)] were randomly assigned to either treatment with BF or BF+VR.
All participants were instructed to use a smartphone application daily for two weeks. They were exposed to virtual stimuli: mild low glucometer readings (85-125) and practiced reducing their physiological arousal using a galvanic skin response (GSR) biofeedback system. In the BF+VR arm successful relaxation was reinforced by exposure to their own virtual smile; this stimulus has the potential of activating brain reward mechanisms. Primary outcome was defined as the change in the HFS-Worries scale.
Five participants were recruited and randomly assigned to receive BF+VR (n=3) or BF alone (n=2). Participants demonstrated a significant improvement in their HFS score (an average reduction of 7.4 points from a baseline of 83.4), mostly attributed to a reduction in the HFS-Worries subscale (5.8 points). This improvement was durable for a 2 month period. There was no clear trend towards superiority of the BF+VR over BF alone.
The results of this feasibility study, using a smartphone-based virtual reality application to treat FOH, call for a larger randomized controlled trial.