Virtual reality exposure therapy for anxiety disorders: A meta-analysis

[What do virtual reality tools bring to child and adolescent psychiatry?]

Virtual reality is a relatively new technology that enables individuals to immerse themselves in a virtual world. It offers several advantages including a more realistic, lifelike environment that may allow subjects to "forget" they are being assessed, allow a better participation and an increased generalization of learning. Moreover, the virtual reality system can provide multimodal stimuli, such as visual and auditory stimuli, and can also be used to evaluate the patient's multimodal integration and to aid rehabilitation of cognitive abilities. The use of virtual reality to treat various psychiatric disorders in adults (phobic anxiety disorders, post-traumatic stress disorder, eating disorders, addictions…) and its efficacy is supported by numerous studies. Similar research for children and adolescents is lagging behind. This may be particularly beneficial to children who often show great interest and considerable success on computer, console or videogame tasks. This article will expose the main studies that have used virtual reality with children and adolescents suffering from psychiatric disorders. The use of virtual reality to treat anxiety disorders in adults is gaining popularity and its efficacy is supported by various studies. Most of the studies attest to the significant efficacy of the virtual reality exposure therapy (or in virtuo exposure). In children, studies have covered arachnophobia social anxiety and school refusal phobia. Despite the limited number of studies, results are very encouraging for treatment in anxiety disorders. Several studies have reported the clinical use of virtual reality technology for children and adolescents with autistic spectrum disorders (ASD). Extensive research has proven the efficiency of technologies as support tools for therapy. Researches are found to be focused on communication and on learning and social imitation skills. Virtual reality is also well accepted by subjects with ASD. The virtual environment offers the opportunity to administer controlled tasks such as the typical neuropsychological tools, but in an environment much more like a standard classroom. The virtual reality classroom offers several advantages compared to classical tools such as more realistic and lifelike environment but also records various measures in standardized conditions. Most of the studies using a virtual classroom have found that children with Attention Deficit/Hyperactivity Disorder make significantly fewer correct hits and more commission errors compared with controls. The virtual classroom has proven to be a good clinical tool for evaluation of attention in ADHD. For eating disorders, cognitive behavioural therapy (CBT) program enhanced by a body image specific component using virtual reality techniques was shown to be more efficient than cognitive behavioural therapy alone. The body image-specific component using virtual reality techniques boots efficiency and accelerates the CBT change process for eating disorders. Virtual reality is a relatively new technology and its application in child and adolescent psychiatry is recent. However, this technique is still in its infancy and much work is needed including controlled trials before it can be introduced in routine clinical use. Virtual reality interventions should also investigate how newly acquired skills are transferred to the real world. At present virtual reality can be considered a useful tool in evaluation and treatment for child and adolescent disorders.

Virtual Reality as a Promising Strategy in the Assessment and Treatment of Bulimia Nervosa and Binge Eating Disorder: A Systematic Review

Several lines of evidence suggest that Virtual Reality (VR) has a potential utility in eating disorders. The objective of this study is to review the literature on the use of VR in bulimia nervosa (BN) and binge eating disorder (BED). Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for reporting systematic reviews, we performed a PubMed, Web of Knowledge and SCOPUS search to identify studies employing VR in the assessment and treatment of BN and BED. The following search terms were used: "virtual reality", "eating disorders", "binge eating", and "bulimia nervosa". From the 420 articles identified, 19 were selected, nine investigated VR in assessment and 10 were treatment studies (one case-report, two non-controlled and six randomized controlled trials). The studies using VR in BN and BED are at an early stage. However, considering the available evidence, the use of VR in the assessment of those conditions showed some promise in identifying: (1) how those patients experienced their body image; and (2) environments or specific kinds of foods that may trigger binge-purging cycle. Some studies using VR-based environments associated to cognitive behavioral techniques showed their potential utility in improving motivation for change, self-esteem, body image disturbances and in reducing binge eating and purging behavior.

["Mirror, mirror on the wall", the issue of digital technology in adolescent mental healthcare]

The digital revolution is turning lifestyles and mentalities upside down. The intuitiveness, immediacy and connectivity which characterise new information and communication technologies appeal to teenagers who find in them ways to gain recognition from their peers and to exchange with each other, without having to yield to adults. However, they expect mental health professionals to talk to them, to be engaged in their discussions and to agree to use connected tools as platforms for exchange. A wide variety of such methods can form part of the therapeutic relationship, from smartphones to chat rooms, from teleconsultations to 'cybertherapies', and from video games to serious games.

Targeting memory reconsolidation to prevent the return of fear in patients with fear of flying

BACKGROUND

When a memory is recalled, it may again exist in a labile state and stored information becomes amenable to change, a psychobiological process known as reconsolidation. Exposure therapy for anxiety disorders involves accessing a fear memory and modifying it with less fearful information. A preclinical study reported that providing a reminder of a fear memory 10 min prior to extinction training in humans decreased fear up to 1 year later (Schiller et al., 2010).

METHODS

For this pilot clinical study, we used virtual reality exposure therapy (VRE) for fear of flying (FoF) to determine if using a cue to reactivate the memory of the feared stimulus 10 min prior to exposure sessions leads to fewer anxiety-related behaviors and a more durable response compared to a neutral cue. FoF participants (N = 89) received four sessions of anxiety management training followed by four sessions of VRE. Participants were randomly assigned to receive an FoF cue (reactivation group) or a neutral cue (control group) prior to the VRE sessions. Heart rate (HR) and skin conductance levels (SCLs) were collected during posttreatment and 3-month follow-up assessments as objective markers of fear responding.

RESULTS

Treatment was effective and all clinical measures improved equally between groups at posttreatment with maintained gains through follow-ups. Significant differences were identified with regard to HR and SCL indices.

CONCLUSIONS

These results suggest that memory reactivation prior to exposure therapy did not have an impact on clinical measures but may enhance the effect of exposure therapy at the physiological level.

Recent Progress in Virtual Reality Exposure Therapy for Phobias: A Systematic Review

This review is designed to systematically examine the available evidence about virtual reality exposure therapy's (VRET) efficacy for phobias, critically describe some of the most important challenges in the field and discuss possible directions. Evidence reveals that virtual reality (VR) is an effective treatment for phobias and useful for studying specific issues, such as pharmacological compounds and behavioral manipulations, that can enhance treatment outcomes. In addition, some variables, such as sense of presence in virtual environments, have a significant influence on outcomes, but further research is needed to better understand their role in therapeutic outcomes. We conclude that VR is a useful tool to improve exposure therapy and it can be a good option to analyze the processes and mechanisms involved in exposure therapy and the ways this strategy can be enhanced. In the coming years, there will be a significant expansion of VR in routine practice in clinical contexts.

Virtual Reality-Enhanced Extinction of Phobias and Post-Traumatic Stress

Virtual reality (VR) refers to an advanced technological communication interface in which the user is actively participating in a computer-generated 3-dimensional virtual world that includes computer sensory input devices used to simulate real-world interactive experiences. VR has been used within psychiatric treatment for anxiety disorders, particularly specific phobias and post-traumatic stress disorder, given several advantages that VR provides for use within treatment for these disorders. Exposure therapy for anxiety disorder is grounded in fear-conditioning models, in which extinction learning involves the process through which conditioned fear responses decrease or are inhibited. The present review will provide an overview of extinction training and anxiety disorder treatment, advantages for using VR within extinction training, a review of the literature regarding the effectiveness of VR within exposure therapy for specific phobias and post-traumatic stress disorder, and limitations and future directions of the extant empirical literature.

Videogames as Therapy

There is a long history of using videogames in a therapeutic capacity including rehabilitation for stroke patients, people with traumatic brain injuries, burns victims, wheelchair users, Erb's palsy sufferers, children undergoing chemotherapy, children with muscular dystrophy, autistic children and individuals looking to overcome real-life challenges (including symptoms of depression) and boost their wellbeing (including boosting life satisfaction, self-efficacy and social support). This paper briefly and selectively examines a number of areas including: (1) videogames as physiotherapy and occupational therapy, (2) videogames as distractors in the role of pain management, (3) videogames and cognitive rehabilitation, (4) videogames and the development of social and communication skills among the learning disabled, (5) videogames and impulsivity/attention deficit disorders, (6) videogames and therapeutic benefits in the elderly, (7) videogames in psychotherapeutic settings, (8) videogames and health care, (9) videogames and anxiety disorders, and (10) videogames and psychological wellbeing. It is concluded that there has been considerable success when games are specifically designed to address a specific problem or to teach a certain skill. However, generalizability outside the game-playing situation remains an important consideration.

Enhanced Risk Aversion, But Not Loss Aversion, in Unmedicated Pathological Anxiety

BACKGROUND

Anxiety disorders are associated with disruptions in both emotional processing and decision making. As a result, anxious individuals often make decisions that favor harm avoidance. However, this bias could be driven by enhanced aversion to uncertainty about the decision outcome (e.g., risk) or aversion to negative outcomes (e.g., loss). Distinguishing between these possibilities may provide a better cognitive understanding of anxiety disorders and hence inform treatment strategies.

METHODS

To address this question, unmedicated individuals with pathological anxiety (n = 25) and matched healthy control subjects (n = 23) completed a gambling task featuring a decision between a gamble and a safe (certain) option on every trial. Choices on one type of gamble-involving weighing a potential win against a potential loss (mixed)-could be driven by both loss and risk aversion, whereas choices on the other type-featuring only wins (gain only)-were exclusively driven by risk aversion. By fitting a computational prospect theory model to participants' choices, we were able to reliably estimate risk and loss aversion and their respective contribution to gambling decisions.

RESULTS

Relative to healthy control subjects, pathologically anxious participants exhibited enhanced risk aversion but equivalent levels of loss aversion.

CONCLUSIONS

Individuals with pathological anxiety demonstrate clear avoidance biases in their decision making. These findings suggest that this may be driven by a reduced propensity to take risks rather than a stronger aversion to losses. This important clarification suggests that psychological interventions for anxiety should focus on reducing risk sensitivity rather than reducing sensitivity to negative outcomes per se.

Integrated Treatment of PTSD and Substance Use Disorders: Examination of Imaginal Exposure Length

Efforts to improve the efficiency of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) have demonstrated that reducing the length of imaginal exposures does not negatively affect treatment outcome. A recent adaptation of PE, called Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure [COPE], integrates substance use disorder treatment with PE in the same timeframe (twelve 90-minute sessions, 8 of which include imaginal exposure). The current study, which represents a subanalysis of a larger randomized controlled trial, examined how the length of imaginal exposures (nonrandomized and measured continually) related to PTSD, substance use, and depression in a sample of military veterans (N = 31) who completed the COPE treatment. Participants completed an average of 11.5 of the 12 therapy sessions and 7.2 of the 8 imaginal exposures during treatment. Results of 3 linear mixed models indicate that PTSD, substance use, and depressive symptoms all improved over the course of treatment (ps < .001; η² ranged between .17 and .40), and that the length of imaginal exposures did not significantly interact with any outcome. Although preliminary, the findings suggest that it may be feasible to shorten imaginal exposures without mitigating treatment gains. Implications for treatment are discussed.

Tackling maladaptive memories through reconsolidation: From neural to clinical science

Behavioral neuroscience has greatly informed how we understand the formation, persistence, and plasticity of memory. Research has demonstrated that memory reactivation can induce a labile period, during which previously consolidated memories are sensitive to change, and in need of restabilization. This process is known as reconsolidation. Such findings have advanced not only our basic understanding of memory processes, but also hint at the prospect of harnessing these insights for the development of a new generation of treatments for disorders of emotional memory. However, even in simple experimental models, the conditions for inducing memory reconsolidation are complex: memory labilization appears to result from the interplay of learning history, reactivation, and also individual differences, posing difficulties for the translation of basic experimental research into effective clinical interventions. In this paper, we review a selection of influential animal and human research on memory reconsolidation to illustrate key insights these studies afford. We then consider how these findings can inform the development of new treatment approaches, with a particular focus on the transition of memory from reactivation, to reconsolidation, to new memory formation, as well as highlighting possible limitations of experimental models. If the challenges of translational research can be overcome, and if reconsolidation-based procedures become a viable treatment option, then they would be one of the first mental health treatments to be directly derived from basic neuroscience research. This would surely be a triumph for the scientific study of mind and brain.

Creating state of the art, next-generation Virtual Reality exposure therapies for anxiety disorders using consumer hardware platforms: design considerations and future directions

Decades of research and more than 20 randomized controlled trials show that Virtual Reality exposure therapy (VRET) is effective in reducing fear and anxiety. Unfortunately, few providers or patients have had access to the costly and technical equipment previously required. Recent technological advances in the form of consumer Virtual Reality (VR) systems (e.g. Oculus Rift and Samsung Gear), however, now make widespread use of VRET in clinical settings and as self-help applications possible. In this literature review, we detail the current state of VR technology and discuss important therapeutic considerations in designing self-help and clinician-led VRETs, such as platform choice, exposure progression design, inhibitory learning strategies, stimuli tailoring, gamification, virtual social learning and more. We illustrate how these therapeutic components can be incorporated and utilized in VRET applications, taking full advantage of the unique capabilities of virtual environments, and showcase some of these features by describing the development of a consumer-ready, gamified self-help VRET application for low-cost commercially available VR hardware. We also raise and discuss challenges in the planning, development, evaluation, and dissemination of VRET applications, including the need for more high-quality research. We conclude by discussing how new technology (e.g. eye-tracking) can be incorporated into future VRETs and how widespread use of VRET self-help applications will enable collection of naturalistic "Big Data" that promises to inform learning theory and behavioral therapy in general.

Perception of Peripersonal and Interpersonal Space in Patients with Restrictive-type Anorexia

This study examines whether the perception of peripersonal action-space and interpersonal social-space is modified in patients with restrictive-type anorexia in two experimental conditions using videos. First, participants stopped the video of an approaching stimulus when they felt the distance to be comfortable for interacting with it (first-person perspective). Second, participants stopped the video when an observed individual approaching a stimulus, or being approached by it, was at a comfortable distance (third-person perspective). In the first-person perspective, the results showed an estimation of peripersonal space that did not differ from controls when an object was approaching and an increase in interpersonal space compared with controls when a male or female individual was approaching. In the third-person perspective, both individual-object and individual-individual distances were larger in anorexic patients. These results indicate a specific deficit in adjusting interpersonal distances in both the first-person and third-person perspectives. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) military personnel has created a significant behavioural healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. The current article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004. A brief discussion of the definition and rationale for the clinical use of VR is followed by a description of a VR application designed for the delivery of prolonged exposure (PE) for treating Service Members (SMs) and Veterans with combat- and sexual assault-related PTSD. The expansion of the virtual treatment simulations of Iraq and Afghanistan for PTSD assessment and prevention is then presented. This is followed by a forward-looking discussion that details early efforts to develop virtual human agent systems that serve the role of virtual patients for training the next generation of clinical providers, as healthcare guides that can be used to support anonymous access to trauma-relevant behavioural healthcare information, and as clinical interviewers capable of automated behaviour analysis of users to infer psychological state. The paper will conclude with a discussion of VR as a tool for breaking down barriers to care in addition to its direct application in assessment and intervention.

DJINNI: A Novel Technology Supported Exposure Therapy Paradigm for SAD Combining Virtual Reality and Augmented Reality

The present paper explores the benefits and the capabilities of various emerging state-of-the-art interactive 3D and Internet of Things technologies and investigates how these technologies can be exploited to develop a more effective technology supported exposure therapy solution for social anxiety disorder. "DJINNI" is a conceptual design of an in vivo augmented reality (AR) exposure therapy mobile support system that exploits several capturing technologies and integrates the patient's state and situation by vision-based, audio-based, and physiology-based analysis as well as by indoor/outdoor localization techniques. DJINNI also comprises an innovative virtual reality exposure therapy system that is adaptive and customizable to the demands of the in vivo experience and therapeutic progress. DJINNI follows a gamification approach where rewards and achievements are utilized to motivate the patient to progress in her/his treatment. The current paper reviews the state of the art of technologies needed for such a solution and recommends how these technologies could be integrated in the development of an individually tailored and yet feasible and effective AR/virtual reality-based exposure therapy. Finally, the paper outlines how DJINNI could be part of classical cognitive behavioral treatment and how to validate such a setup.

Utility of virtual reality environments to examine physiological reactivity and subjective distress in adults who stutter

PURPOSE

Virtual reality environments (VREs) allow for immersion in speaking environments that mimic real-life interactions while maintaining researcher control. VREs have been used successfully to engender arousal in other disorders. The purpose of this study was to investigate the utility of virtual reality environments to examine physiological reactivity and subjective ratings of distress in persons who stutter (PWS).

METHOD

Subjective and objective measures of arousal were collected from 10PWS during four-minute speeches to a virtual audience and to a virtual empty room.

RESULTS

Stuttering frequency and physiological measures (skin conductance level and heart rate) did not differ across speaking conditions, but subjective ratings of distress were significantly higher in the virtual audience condition compared to the virtual empty room.

CONCLUSION

VREs have utility in elevating subjective ratings of distress in PWS. VREs have the potential to be useful tools for practicing treatment targets in a safe, controlled, and systematic manner.

Monitoring physiology and behavior using Android in phobias

In this paper, we present an Android-based system Application - AWARE - for the assessment of the person's physiology and behavior outside of the laboratory. To accomplish this purpose, AWARE delivers context dependent audio-visual stimuli, embedded into the subject's real-world perception, via marker/vision-based augmented reality (AR) technology. In addition, it employs external measuring resources connected via Bluetooth, as well as the smartphone's integrated resources. It synchronously acquires the experiment's video (camera input with AR overlay), physiologic responses (with a dedicated ECG measuring device) and behavior (through movement and location, with accelerometer/gyroscope and GPS, respectively). Psychological assessment is heavily based on laboratory procedures, even though it is known that these settings disturb the subjects' natural reactions and condition. The major idea of this application is to evaluate the participant condition, mimicking his/her real life conditions. Given that phobias are rather context specific, they represent the ideal candidate for assessing the feasibility of a mobile system application. AWARE allowed presenting AR stimuli (e.g., 3D spiders) and quantifying the subjects' reactions non-intrusively (e.g., heart rate variation) - more emphatic in the phobic volunteer when presented with spider vs non phobic stimulus. Although still a proof of concept, AWARE proved to be flexible, and straightforward to setup, with the potential to support ecologically valid monitoring experiments.

In Pursuit of Generalization: An Updated Review

Stokes and Osnes (1989) outlined three principles to facilitate the generalization and maintenance of therapeutic gains. Use of functional contingencies, training diversely, and incorporating functional mediators were recommended. Our review, with most illustrations from studies of youth, updates Stokes and Osnes's original paper with a focus on evidence-based strategies to increase generalization of therapeutic gains across settings, stimuli, and time. Research since 1989 indicates that training for generalization by increasing the frequency of naturally occurring reinforcers for positive behaviors, and altering maladaptive contingencies that inadvertently reinforce problem behaviors, are associated with favorable treatment outcomes. Training diversely by practicing therapy skills across contexts and in response to varying stimuli is also implicated in clinical outcomes for internalizing, externalizing, and neurodevelopmental disorders. Preliminary research recommends the use of internal (e.g., emotion identification) and external (e.g., coping cards) functional mediators to prompt effective coping in session and at home. Strategies for increasing generalization, including the use of technology, are examined and future research directions are identified.

Using Virtual Reality in the Inference-Based Treatment of Compulsive Hoarding

The present study evaluated the efficacy of adding a virtual reality (VR) component to the treatment of compulsive hoarding (CH), following inference-based therapy (IBT). Participants were randomly assigned to either an experimental or a control condition. Seven participants received the experimental and seven received the control condition. Five sessions of 1 h were administered weekly. A significant difference indicated that the level of clutter in the bedroom tended to diminish more in the experimental group as compared to the control group F(2,24) = 2.28, p = 0.10. In addition, the results demonstrated that both groups were immersed and present in the environment. The results on posttreatment measures of CH (Saving Inventory revised, Saving Cognition Inventory and Clutter Image Rating scale) demonstrate the efficacy of IBT in terms of symptom reduction. Overall, these results suggest that the creation of a virtual environment may be effective in the treatment of CH by helping the compulsive hoarders take action over their clutter.

Meta-analysis of technology-assisted interventions for social anxiety disorder

This meta-analysis investigated the efficacy of technology-assisted interventions for individuals with social anxiety disorder (SAD). A systematic literature search in the databases Medline, PsychInfo, and Web of Science revealed 37 randomized controlled trials (2991 participants) that were grouped into internet delivered cognitive behavior therapy (ICBT; 21 trials), virtual reality exposure therapy (VRET; 3 trials), and cognitive bias modification (CBM; 13 trials). Patients undergoing ICBT and VRET showed significantly less SAD symptoms at postassessment than passive control conditions (g=0.84 and 0.82, respectively). Compared to active control conditions, ICBT had a small advantage (g=0.38) and VRET showed comparable effects (p>0.05). CBM was not more effective than passive control conditions, except when delivered in the laboratory (g=0.35). While the efficacy of CBM was limited, substantial evidence for ICBT and preliminary evidence for VRET suggests that both can effectively reduce SAD symptoms indicating the potential of technology-assisted interventions for SAD.

The Effects of a Brief Acceptance-Based Behavioral Treatment Versus Traditional Cognitive-Behavioral Treatment for Public Speaking Anxiety

Individuals with public speaking anxiety (PSA) experience fear and avoidance that can cause extreme distress, impaired speaking performance, and associated problems in psychosocial functioning. Most extant interventions for PSA emphasize anxiety reduction rather than enhancing behavioral performance. We compared the efficacy of two brief cognitive-behavioral interventions, a traditional cognitive-behavior treatment (tCBT) and an acceptance-based behavior treatment (ABBT), on public speaking performance and anxiety in a clinical sample of persons with PSA. The effects of treatment on prefrontal brain activation were also examined. Participants ( n = 21) were randomized to 90 min of an ABBT or a tCBT intervention. Assessments took place at pre- and post-treatment and included self-rated anxiety and observer-rated performance measures, a behavioral assessment, and prefrontal cortical activity measurements using functional near-infrared spectroscopy (fNIRS). Exploratory results indicated that participants in the ABBT condition experienced greater improvements in observer-rated performance relative to those in the tCBT condition, while those in the tCBT condition experienced greater reductions in subjective anxiety levels. Individuals in the ABBT condition also exhibited a trend toward greater treatment-related reductions in blood volume in the left dorsolateral prefrontal cortex relative to those who received tCBT. Overall, these findings preliminarily suggest that acceptance-based treatments may free more cognitive resources in comparison with tCBT, possibly resulting in greater improvements in objectively rated behavioral performances for ABBT interventions.

Realistic and interactive high-resolution 4D environments for real-time surgeon and patient interaction

BACKGROUND

Remote consultations that are realistic enough to be useful medically offer considerable clinical, logistical and cost benefits. Despite advances in virtual reality and vision hardware and software, these benefits are currently often unrealised.

METHOD

The proposed approach combines high spatial and temporal resolution 3D and 2D machine vision with virtual reality techniques, in order to develop new environments and instruments that will enable realistic remote consultations and the generation of new types of useful clinical data.

RESULTS

New types of clinical data have been generated for skin analysis and respiration measurement; and the combination of 3D with 2D data was found to offer potential for the generation of realistic virtual consultations.

CONCLUSION

An innovative combination of high resolution machine vision data and virtual reality online methods, promises to provide advanced functionality and significant medical benefits, particularly in regions where populations are dispersed or access to clinicians is limited. Copyright © 2016 John Wiley & Sons, Ltd.

Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction

BACKGROUND

Persecutory delusions may be unfounded threat beliefs maintained by safety-seeking behaviours that prevent disconfirmatory evidence being successfully processed. Use of virtual reality could facilitate new learning.

AIMS

To test the hypothesis that enabling patients to test the threat predictions of persecutory delusions in virtual reality social environments with the dropping of safety-seeking behaviours (virtual reality cognitive therapy) would lead to greater delusion reduction than exposure alone (virtual reality exposure).

METHOD

Conviction in delusions and distress in a real-world situation were assessed in 30 patients with persecutory delusions. Patients were then randomised to virtual reality cognitive therapy or virtual reality exposure, both with 30 min in graded virtual reality social environments. Delusion conviction and real-world distress were then reassessed.

RESULTS

In comparison with exposure, virtual reality cognitive therapy led to large reductions in delusional conviction (reduction 22.0%, P = 0.024, Cohen's d = 1.3) and real-world distress (reduction 19.6%, P = 0.020, Cohen's d = 0.8).

CONCLUSION

Cognitive therapy using virtual reality could prove highly effective in treating delusions.

Does a Combination of Virtual Reality, Neuromodulation and Neuroimaging Provide a Comprehensive Platform for Neurorehabilitation? - A Narrative Review of the Literature

In the last decade, virtual reality (VR) training has been used extensively in video games and military training to provide a sense of realism and environmental interaction to its users. More recently, VR training has been explored as a possible adjunct therapy for people with motor and mental health dysfunctions. The concept underlying VR therapy as a treatment for motor and cognitive dysfunction is to improve neuroplasticity of the brain by engaging users in multisensory training. In this review, we discuss the theoretical framework underlying the use of VR as a therapeutic intervention for neurorehabilitation and provide evidence for its use in treating motor and mental disorders such as cerebral palsy, Parkinson’s disease, stroke, schizophrenia, anxiety disorders, and other related clinical areas. While this review provides some insights into the efficacy of VR in clinical rehabilitation and its complimentary use with neuroimaging (e.g., fNIRS and EEG) and neuromodulation (e.g., tDCS and rTMS), more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations.

Olfactory Stimuli Increase Presence in Virtual Environments

BACKGROUND

Exposure therapy (EXP) is the most empirically supported treatment for anxiety and trauma-related disorders. EXP consists of repeated exposure to a feared object or situation in the absence of the feared outcome in order to extinguish associated anxiety. Key to the success of EXP is the need to present the feared object/event/situation in as much detail and utilizing as many sensory modalities as possible, in order to augment the sense of presence during exposure sessions. Various technologies used to augment the exposure therapy process by presenting multi-sensory cues (e.g., sights, smells, sounds). Studies have shown that scents can elicit emotionally charged memories, but no prior research has examined the effect of olfactory stimuli upon the patient's sense of presence during simulated exposure tasks.

METHODS

60 adult participants navigated a mildly anxiety-producing virtual environment (VE) similar to those used in the treatment of anxiety disorders. Participants had no autobiographical memory associated with the VE. State anxiety, Presence ratings, and electrodermal (EDA) activity were collected throughout the experiment.

RESULTS

Utilizing a Bonferroni corrected Linear Mixed Model, our results showed statistically significant relationships between olfactory stimuli and presence as assessed by both the Igroup Presence Questionnaire (IPQ: R2 = 0.85, (F(3,52) = 6.625, p = 0.0007) and a single item visual-analogue scale (R2 = 0.85, (F(3,52) = 5.382, p = 0.0027). State anxiety was unaffected by the presence or absence of olfactory cues. EDA was unaffected by experimental condition.

CONCLUSION

Olfactory stimuli increase presence in virtual environments that approximate those typical in exposure therapy, but did not increase EDA. Additionally, once administered, the removal of scents resulted in a disproportionate decrease in presence. Implications for incorporating the use of scents to increase the efficacy of exposure therapy is discussed.

Virtual reality measures in neuropsychological assessment: a meta-analytic review

OBJECTIVE

Virtual reality-based assessment is a new paradigm for neuropsychological evaluation, that might provide an ecological assessment, compared to paper-and-pencil or computerized neuropsychological assessment. Previous research has focused on the use of virtual reality in neuropsychological assessment, but no meta-analysis focused on the sensitivity of virtual reality-based measures of cognitive processes in measuring cognitive processes in various populations.

METHOD

We found eighteen studies that compared the cognitive performance between clinical and healthy controls on virtual reality measures.

RESULTS

Based on a random effects model, the results indicated a large effect size in favor of healthy controls (g = .95). For executive functions, memory and visuospatial analysis, subgroup analysis revealed moderate to large effect sizes, with superior performance in the case of healthy controls. Participants' mean age, type of clinical condition, type of exploration within virtual reality environments, and the presence of distractors were significant moderators.

CONCLUSIONS

Our findings support the sensitivity of virtual reality-based measures in detecting cognitive impairment. They highlight the possibility of using virtual reality measures for neuropsychological assessment in research applications, as well as in clinical practice.

Efficacy of virtual reality exposure therapy for treatment of dental phobia: a randomized control trial

Background

Virtual Reality Exposure Therapy (VRET) is found to be a promising and a viable alternative for in vivo exposure in the treatment of specific phobias. However, its usefulness for treating dental phobia is unexplored. The aims of the present study are to determine: (a) the efficacy of VRET versus informational pamphlet (IP) control group in terms of dental trait and state anxiety reductions at 1 week, 3 months and 6 months follow-up (b) the real-time physiological arousal [heart rate (HR)] of VRET group participants during and following therapy (c) the relation between subjective (presence) and objective (HR) measures during VRET.

Methods

This study is a single blind, randomized controlled trial with two parallel arms in which participants will be allocated to VRET or IP with a ratio of 1:1. Thirty participants (18-50 years) meeting the Phobia Checklist criteria of dental phobia will undergo block randomization with allocation concealment. The primary outcome measures include participants’ dental trait anxiety (Modified Dental Anxiety Scale and Dental Fear Survey) and state anxiety (Visual Analogue Scale) measured at baseline (T0), at intervention (T1), 1-week (T2), 3 months (T3) and 6 months (T4) follow-up. A behavior test will be conducted before and after the intervention. The secondary outcome measures are real-time evaluation of HR and VR (Virtual Reality) experience (presence, realism, nausea) during and following the VRET intervention respectively. The data will be analyzed using intention-to-treat and per-protocol analysis.

Discussion

This study uses novel non-invasive VRET, which may provide a possible alternative treatment for dental anxiety and phobia.

Trial registration number

ISRCTN25824611, Date of registration: 26 October 2015.

Virtual reality cue exposure for the relapse prevention of tobacco consumption: a study protocol for a randomized controlled trial

Background

Successful interventions have been developed for smoking cessation, but the success of smoking relapse prevention interventions has been limited. In particular, cognitive behavioural therapy (CBT) has been hampered by a high relapse rate. Because relapses can be due to the presence of conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality exposure therapy (VRET) can generate synthetic environments that represent risk situations for the patient in the context of relapse prevention. The primary objective of this study is to evaluate the effectiveness of CBT coupled with VRET, in comparison to CBT alone, in the prevention of smoking relapse. The secondary objectives are to assess the impact of CBT coupled with VRET on anxiety, depression, quality of life, self-esteem and addictive comorbidities (such as alcohol, cannabis, and gambling). A third objective examines the feasibility and acceptability of VR use considering elements such as presence, cybersickness and number of patients who complete the VRET program.

Method/design

The present study is a 14-month (2 months of therapy followed by 12 months of follow-up), prospective, comparative, randomized and open clinical trial, involving two parallel groups (CBT coupled with VRET versus CBT alone). The primary outcome is the proportion of individuals with tobacco abstinence at 6 months after the end of the therapy. Abstinence is defined by the total absence of tobacco consumption assessed during a post-test interview and with an apparatus that measures the carbon monoxide levels expired. A total of 60 individuals per group will be included.

Discussion

This study is the first to examine the efficacy of CBT coupled with VRET in the prevention of smoking relapse. Because VRET is simple to use and has a low cost, this interactive therapeutic method might be easily implemented in clinical practice if the study confirms its efficacy.

Trial registration

ClinicalTrials.gov Identifier: NCT02205060 (registered 25 July 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1224-5) contains supplementary material, which is available to authorized users.

In Vivo versus Augmented Reality Exposure in the Treatment of Small Animal Phobia: A Randomized Controlled Trial

Although in vivo exposure is the treatment of choice for specific phobias, some acceptability problems have been associated with it. Virtual Reality exposure has been shown to be as effective as in vivo exposure, and it is widely accepted for the treatment of specific phobias, but only preliminary data are available in the literature about the efficacy of Augmented Reality. The purpose of the present study was to examine the efficacy and acceptance of two treatment conditions for specific phobias in which the exposure component was applied in different ways: In vivo exposure (N = 31) versus an Augmented Reality system (N = 32) in a randomized controlled trial. "One-session treatment" guidelines were followed. Participants in the Augmented Reality condition significantly improved on all the outcome measures at post-treatment and follow-ups. When the two treatment conditions were compared, some differences were found at post-treatment, favoring the participants who received in vivo exposure. However, these differences disappeared at the 3- and 6-month follow-ups. Regarding participants' expectations and satisfaction with the treatment, very positive ratings were reported in both conditions. In addition, participants from in vivo exposure condition considered the treatment more useful for their problem whereas participants from Augmented Reality exposure considered the treatment less aversive. Results obtained in this study indicate that Augmented Reality exposure is an effective treatment for specific phobias and well accepted by the participants.

Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial

BACKGROUND

Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist.

METHODS/DESIGN

Participants with specific phobia to spiders (N = 100) will be recruited from the general public, screened, and randomized to either VR exposure therapy (n = 50) or traditional OST (n = 50). A behavioral approach test using in vivo spiders will serve as the primary outcome measure. Secondary outcome measures will include spider phobia questionnaires and self-reported anxiety, depression, and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1, 12, and 52 weeks after treatment.

DISCUSSION

VR exposure therapy has previously been evaluated as a treatment for specific phobias, but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices is being released that are advancing existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable for taking advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation. This study compares a market-ready, gamified VR spider phobia exposure application, delivered using consumer VR hardware, with the current gold standard treatment. Implications are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02533310. Registered on 25 August 2015.

Dynamic relationships of therapist alliance and group cohesion in transdiagnostic group CBT for anxiety disorders

OBJECTIVE

Little is known about the temporal variability of the alliance-symptom change and cohesion-symptom change relationships over the course of group therapy. These questions were examined in a sample of 373 clients receiving a transdiagnostic cognitive behavior therapy (tCBT), which culled the principle research-supported mechanisms of change for anxiety disorders.

METHOD

The authors examined relationships between the client versions of the Working Alliance Inventory and Group Cohesion Scale in predicting subsequent symptom change, as assessed by the state scale of the State-Trait Anxiety Inventory.

RESULTS

Alliance and cohesion were significant predictors of next session anxiety scores. The alliance was consistently associated with anxiety symptoms (rs = -.152 to -.198, ps < .05), but cohesion only showed significant relationships with anxiety symptoms at Sessions 8 and 10 (Session 8, r = -.233, p = .020, and 10, r = -.236, p = .027). Alliance-anxiety relations remained constant, whereas cohesion-anxiety relations substantially increased from earlier to later sessions.

DISCUSSION

Differences that were obtained in the relation of alliance and cohesion with anxiety symptoms suggests that these processes have different roles within group tCBT. If replicated, the present findings would suggest that the dynamic relationships between alliance and cohesion and symptoms within group CBT for anxiety disorders have been an important omission in process-outcome studies.

Integrating virtual reality with activity management for the treatment of fibromyalgia: acceptability and preliminary efficacy

OBJECTIVES

Cognitive-behavioral therapies (CBT) for fibromyalgia syndrome (FMS) are important interventions in the management of this condition. Empirical evidence reports that although the results are promising, further research is needed to respond more appropriately to these patients. This study focuses on exploring the use of Virtual Reality (VR) as an adjunct to the activity management component. The aim of this study is to present the results of a small-sized randomized controlled trial to test the preliminary efficacy and acceptability of this component.

MATERIALS AND METHODS

The final sample was composed of 61 women diagnosed with FMS according to the American College of Rheumatology. The sample was randomly allocated to 2 conditions: VR treatment and treatment as usual.

RESULTS

Participants in the VR condition achieved significant improvements in the primary outcome: disability measured with the FIQ. The improvement was also significant in secondary outcomes, such as perceived quality of life and some of the coping strategies included in the Chronic Pain Coping Inventory: task persistence and exercise. There were no differences in other secondary outcome measures like pain intensity and interference and depression. Participants reported high satisfaction with the VR component.

DISCUSSION

The effects were related to the psychological aspects targeted in the treatment. The component was well accepted by FMS patients referred from a public hospital. These findings show that the VR component could be useful in the CBT treatment of FMS and encourage us to continue exploring the use of integrating VR with CBT interventions for the treatment of FMS.

Influence of Music on Anxiety Induced by Fear of Heights in Virtual Reality

Music is a potent mood regulator that can induce relaxation and reduce anxiety in different situations. While several studies demonstrate that certain types of music have a subjective anxiolytic effect, the reported results from physiological responses are less conclusive. Virtual reality allows us to study diverse scenarios of real life under strict experimental control while preserving high ecological validity. We aimed to study the modulating effect of music on the anxiety responses triggered by an immersive virtual reality scenario designed to induce fear of heights. Subjects experienced a virtual scenario depicting an exterior elevator platform ascending and descending the total height of its 350 meters tall supporting structure. Participants were allocated to either a group that experienced the elevator ride with background music or without, in a between-groups design. Furthermore, each group included participants with different degrees of fear of heights, ranging from low to high fear. Recordings of heart rate, galvanic skin response, body balance, and head movements were obtained during the experiments. Subjective anxiety was measured by means of three questionnaires. The scenario produced significant changes in subjective and physiological measures, confirming its efficacy as a stressor. A significant increase in state anxiety was found between pre and post-assessment in the silence group, but not in the music group, indicating that post-stress recovery was faster in the musical group. Results suggest that music can ameliorate the subjective anxiety produced by fear of heights.

Fear of falling: efficacy of virtual reality associated with serious games in elderly people

OBJECTIVE

Fear of falling is defined as an ongoing concern about falling that is not explained by physical examination. Focusing on the psychological dimension of this pathology (phobic reaction to walking), we looked at how virtual reality associated with serious games can be used to treat this pathology.

METHODS

Participants with fear of falling were randomly assigned to either a treatment group or a waiting list. The therapy consisted of 12 weekly sessions of virtual reality exposure therapy associated with serious games.

RESULTS

Sixteen participants were included. The mean age of the treatment group was 72 years and that of the control group was 69 years. Participants' scores on the fear of falling measure improved after treatment with virtual reality associated with serious games, leading to a significant difference between the two groups.

CONCLUSION

Virtual reality exposure therapy associated with serious games can be used in the treatment of fear of falling. The two techniques are complementary (top-down and bottom-up processes). To our knowledge, this is the first time that a combination of the two has been assessed. There was a specific effect of this therapy on the phobic reaction. Further studies are needed to confirm its efficacy and identify its underlying mechanism.

Transforming Experience: The Potential of Augmented Reality and Virtual Reality for Enhancing Personal and Clinical Change

During life, many personal changes occur. These include changing house, school, work, and even friends and partners. However, the daily experience shows clearly that, in some situations, subjects are unable to change even if they want to. The recent advances in psychology and neuroscience are now providing a better view of personal change, the change affecting our assumptive world: (a) the focus of personal change is reducing the distance between self and reality (conflict); (b) this reduction is achieved through (1) an intense focus on the particular experience creating the conflict or (2) an internal or external reorganization of this experience; (c) personal change requires a progression through a series of different stages that however happen in discontinuous and non-linear ways; and (d) clinical psychology is often used to facilitate personal change when subjects are unable to move forward. Starting from these premises, the aim of this paper is to review the potential of virtuality for enhancing the processes of personal and clinical change. First, the paper focuses on the two leading virtual technologies - augmented reality (AR) and virtual reality (VR) - exploring their current uses in behavioral health and the outcomes of the 28 available systematic reviews and meta-analyses. Then the paper discusses the added value provided by VR and AR in transforming our external experience by focusing on the high level of personal efficacy and self-reflectiveness generated by their sense of presence and emotional engagement. Finally, it outlines the potential future use of virtuality for transforming our inner experience by structuring, altering, and/or replacing our bodily self-consciousness. The final outcome may be a new generation of transformative experiences that provide knowledge that is epistemically inaccessible to the individual until he or she has that experience, while at the same time transforming the individual's worldview.

Fear and physiological arousal during a virtual height challenge--effects in patients with acrophobia and healthy controls

Virtual reality (VR) exposure therapy is becoming increasingly established, but the mode of action is not well understood. One potential efficacy factor might be physiological arousal. To investigate arousal during VR exposure, we exposed 40 patients with acrophobia and 40 matched healthy controls to a VR height challenge and assessed subjective (fear ratings) and physiological (heart rate, skin conductance level, salivary cortisol) fear reactions. Patients experienced a significant increase of subjective fear, heart rate and skin conductance level. Unexpectedly, controls, who reported no subjective fear, also showed an increase in heart rate and skin conductance. There was no increase in salivary cortisol levels in either group. Physiological arousal in acrophobic patients, in contrast to subjective fear, might not be stronger than that of controls confronted with height cues in VR, indicating marked discordance across symptom domains. The lack of a cortisol response in a clearly stressful paradigm warrants further study.

What Role Can Avatars Play in e-Mental Health Interventions? Exploring New Models of Client-Therapist Interaction

In the burgeoning field of e-mental health interventions, avatars are increasingly being utilized to facilitate online communication between clients and therapists, and among peers. Avatars are digital self-representations, which enable individuals to interact with each other in computer-based virtual environments. In this narrative review, we examine the psychotherapeutic applications of avatars that have been investigated and trialed to date. Five key applications were identified (1) in the formation of online peer support communities; (2) replicating traditional modes of psychotherapy by using avatars as a vehicle to communicate within a wholly virtual environment; (3) using avatar technology to facilitate or augment face-to-face treatment; (4) as part of serious games; and (5) communication with an autonomous virtual therapist. Across these applications, avatars appeared to serve several functions conducive to treatment engagement by (1) facilitating the development of a virtual therapeutic alliance; (2) reducing communication barriers; (3) promoting treatment-seeking through anonymity; (4) promoting expression and exploration of client identity; and (5) enabling therapists to control and manipulate treatment stimuli. Further research into the feasibility and ethical implementation of avatar-based psychotherapies is required.

Targeting pain catastrophization in patients with fibromyalgia using virtual reality exposure therapy: a proof-of-concept study

[Purpose] Pain catastrophizing is a key predictor of poor compliance to exercises among patients with fibromyalgia syndrome. Alteration of pain catastrophizing in this group is thus warranted. This study aimed to provide proof-of-concept of a novel virtual reality exposure therapy program as treatment for exercise-related pain catastrophizing in patients with fibromyalgia syndrome. [Subjects and Methods] An exploratory, case-controlled study was conducted (fibromyalgia syndrome group and matched control group). Functional magnetic resonance imaging was used to acquire neural correlates. The functional magnetic resonance imaging task consisted of two stimuli: active (exercise activity visuals) and passive (relaxing visuals). Structural images and blood-oxygenation-level-dependent contrasts were acquired for the conditions and compared within subjects/groups and between groups. Statistic images were thresholded using corrected clusters (determined by Z>2.3; level of significance: 0.05). [Results] Thirteen fibromyalgia syndrome subjects and nine healthy matched controls were included. The right inferior frontal gyrus, right middle frontal gyrus, right posterior cerebellum, left thalamus, and left supramarginal gyrus were activated in the fibromyalgia syndrome subjects. [Conclusion] The study results provide preliminary proof indicating that exposing patients with fibromyalgia syndrome to visuals of exercises elicits neurophysiological changes in functional brain areas associated with pain catastrophization and add to the current body of knowledge regarding the possibility of objectively identifying cognitive behavioral strategies like pain catastrophization.