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

Generalization of exposure therapy: Systematic review and recommendations for future research

Limited generalization of exposure therapy effects from treatment-related to treatment-unrelated contexts and/or stimuli is a potential factor contributing to relapse after successful exposure treatment. Investigating the processes underlying exposure therapy generalization (ETG) and developing strategies to promote ETG has become a significant research area. This systematic review provides an overview of the current state of ETG research, outlining its operationalization and the methodological diversity used to detect changes in ETG. We also summarize and discuss findings from studies aimed at enhancing ETG through pharmacological and behavioral interventions. A total of 34 studies were identified, investigating ETG across therapy-related and unrelated contexts and fear stimuli. These studies primarily used physical and/or social context/stimuli manipulations to investigate ETG. Multiple response systems (subjective, psychophysiological, behavioral) were used as indices of diminished ETG, but most studies found increased subjective fear in treatment-unrelated contexts/stimuli compared to treatment-related ones. We conclude that clear definitions and criteria for assessing ETG are urgently needed. Behavioral interventions, such as multiple context exposure or sleep after exposure, seem effective in promoting ETG across different contexts/stimuli. In contrast, findings from pharmacological approaches are less encouraging, but more research is needed. We identify research gaps that require further investigation to better understand the mechanisms governing and promoting ETG. Experimental paradigms offer a clear advantage for this purpose and for screening novel strategies to maximize ETG.

Transition ability to safe states reduces fear responses to height

Previous studies on fear extinction have primarily focused on repeated exposure to fear-inducing context without negative consequences. However, it is also possible that an individual can reduce fear responses by predicting that they can transition to a safe environment through their own actions, even if a fear-inducing context appears. Here, by conducting two virtual reality (VR) experiments (Exp 1 and Exp 2) involving height and flight scenarios, we examined whether participants' fear responses to height decrease after actively experiencing low-altitude VR flight, which allowed them to predict that they would be in a safe state by flying even if they fell from a height. Specifically, participants in the flight group (n = 44 and 46) flew over a city at altitudes below 5 m for 7 min, while participants in the control group (n = 41 and 28) watched a video of a flight group participant's experience. Before and after the active flight or passive viewing task, both groups walked on a plank while having their skin conductance response (SCR) and subjective fear score (SFS) measured. In both Exp 1 and Exp 2, the active flight group exhibited a greater reduction in both SCR and SFS compared to the control group. Additionally, a multivariate regression of SCR using the questionnaires collected in Exp 2 revealed that the action-dependent safety prediction has a positive contribution to the SCR reduction in the flight group. These results clarified that the ability to transition to safe states by self-actions can reduce physiological and subjective fear responses.

Fear not: Combining digital and virtual reality interventions for the treatment of social anxiety disorder - a randomized controlled trial

INTRODUCTION

Social anxiety disorder (SAD) poses a significant mental health challenge. Despite cognitive behavior therapy being the first-line treatment for SAD, its accessibility remains limited. Internet- and mobile-based interventions (IMIs) offer approaches to enhance accessibility and reduce waiting times. As part of this, some recent approaches have incorporated virtual reality (VR) to enable behavioral experiments and exposure. This pilot study aimed to explore the efficacy of an IMI, including CBT interventions via smartphone apps and VR to alleviate the severity of SAD symptoms.

METHODS

Thirty-two patients diagnosed with SAD were randomly assigned to either an experimental group (n = 16) receiving the IMI or an active control group (n = 16). The number of therapeutic appointments was held constant across conditions to account for unspecific treatment effects. The primary outcome was SAD severity, obtained at baseline, interim, post-treatment, and follow-up assessments. The secondary outcome remission was evaluated through a diagnostic interview at follow-up. The trial was registered with ISRCTN (ID: ISRCTN18013983).

RESULTS

Regarding the differential effectiveness between the active control condition and the IMI, two different results were found: There was a higher remission rate in the experimental group compared to the control group, while no significant differences in SAD severity were found.

CONCLUSION

While SAD severity showed a comparable reduction in both groups, significantly fewer patients in the experimental group were still diagnosed with SAD at follow-up. This suggested a difference between self-report and clinical evaluation. Despite the mixed results, IMIs provide a low-barrier intervention and could be used to increase access to therapy and reduce waiting times.

Blended Mobile-Based Interventions With Integrated Virtual Reality Exposure Therapy for Anxiety Disorders: Thematic Analysis of Patient Perspectives

BACKGROUND

Guided mobile-based interventions may mitigate symptoms of anxiety disorders such as panic disorder, agoraphobia, or social anxiety disorder. With exposure therapy being efficacious in traditional treatments for these disorders, recent advancements have introduced 360° videos to deliver virtual reality exposure therapy (VRET) within mobile-based interventions.

OBJECTIVE

Despite ongoing trials evaluating the treatment's efficacy, research examining patient perceptions of this innovative approach is still scarce. Therefore, this study aimed to explore patient opinions on specific treatment aspects of mobile-based interventions using mobile VRET and psychotherapeutic guidance for anxiety disorders.

METHODS

A total of 11 patients diagnosed with panic disorder, agoraphobia, or social anxiety disorder who had previously taken part in the experimental conditions of 2 randomized controlled trials for a mobile intervention including mobile VRET participated in cross-sectional, retrospective interviews. Using a semistructured interview format, patients were asked to reflect on their treatment experiences; personal changes; helpful and hindering aspects; their motivation levels; and their encounters with the mobile-based intervention, manualized treatment sessions, and the mobile VRET.

RESULTS

Thematic analysis led to the formation of 14 themes in four superordinate categories: (1) perceived treatment outcomes, (2) aspects of the mobile intervention, (3) experiences with mobile VRET, and (4) contextual considerations. Patients offered their insights into factors contributing to treatment success or failure, delineated perceived treatment outcomes, and highlighted favorable aspects of the treatment while pointing out shortcomings and suggesting potential enhancements. Most strikingly, while using a blended app-based intervention, patients highlighted the role of psychotherapeutic guidance as a central contributing factor to their symptom improvement.

CONCLUSIONS

The findings of the thematic analysis and its diverse patient perspectives hold the potential to guide future research to improve mobile-based treatment options for anxiety disorders. Insights from these patient experiences can contribute to refining mobile-based interventions and optimizing the integration of VRET in accordance with patients' preferences, needs, and expectations.

Integrating Virtual Reality, Neurofeedback, and Cognitive Behavioral Therapy for Auditory Verbal Hallucinations (Hybrid): Protocol of a Pilot, Unblinded, Single-Arm Interventional Study

BACKGROUND

Current treatments for schizophrenia and other psychotic disorders have limited efficacy, with high rates of nonresponse to "gold standard" treatments. New approaches are therefore urgently required.

OBJECTIVE

The aims of this pilot study are to investigate the feasibility, acceptability, safety, and usability of Hybrid treatment (primary aim); and to explore Hybrid's treatment efficacy and engagement of treatment targets (secondary aim). The primary aim will be assessed via face-to-face user experience surveys on a (self-assessed) 5-point Likert scale (and qualitative open-ended questions) examining: (1) acceptability, (2) helpfulness, (3) engagement, and (4) perceived safety. We will also examine consent and completion rates, and the number of sessions attended. Our threshold for moving on to efficacy trials will be at least 70% of our participants to rate 3 and above (which corresponds to agree or strongly agree) that the intervention package was acceptable, feasible, and safe. The secondary aims will be assessed by observing whether individuals achieve self-directed modulation of high-β neurophysiological activity (neural target) and progression upwards through the VR-based exposure hierarchy (psychological target), and by assessing symptom change scores. This study developed a new treatment approach for auditory verbal hallucinations, a major symptom of psychotic disorders, that integrates advances in psychological therapy (cognitive behavioral therapy for psychosis), technology (virtual reality, VR), and neuroscience (electroencephalography-based neurofeedback).

METHODS

Hybrid takes a "symptom capture" approach using individually tailored VR-based exposure exercises. Participants (N=10) will receive the intervention package weekly over 12 face-to-face sessions. Here, participants will be progressively exposed to symptom triggers and develop methods of downregulating neural activity associated with these symptoms (neurofeedback component) while concurrently receiving clinician-delivered cognitive behavioral therapy for psychosis.

RESULTS

As of February 2025, Hybrid has commenced (unblinded) recruitment activities from Orygen clinical services in Northwestern Melbourne, Australia. A total of 75 individuals have been approached and 64 individuals have been prescreened (41 individuals were deemed eligible, 15 individuals were ineligible, and 8 individuals declined or did not respond to contact attempts) and 5 individuals have been included in the study. Of the 5 individuals who have commenced the Hybrid treatment, 4 are actively engaged in the program and 1 individual has withdrawn. We expect recruitment to conclude in July 2025 and for the results to be published in 2026.

CONCLUSIONS

The Hybrid study is piloting a novel approach that has the potential to address the shortcomings of current treatments for psychotic symptoms. If there is favorable evidence for the acceptability, feasibility, safety and usability of Hybrid, the study team will move on to efficacy trials.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12624000357550; https://tinyurl.com/24ey8hpy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/63405.

Efficacy of exposure scenario in virtual reality for the treatment of acrophobia: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Individuals with acrophobia (fear of heights) can experience severe anxiety or panic attacks when they are located at height. This randomized controlled study aimed to verify the effects of a novel scalable virtual reality-based exposure (VR exposure) tool in individuals with acrophobia, by exposing them to a predefined set of situations they usually tend to avoid.

METHODS

Forty-three adults were randomly assigned to one of the two groups: the experimental group or the waitlist group. Both groups attended initial short online education. The experimental group consecutively attended three VR-based exposure therapy (VRET) intervention sessions over 3-5 weeks during which the therapist encouraged participants to enter the predefined feared situations, while the control group on the waitlist had no additional intervention.

RESULTS

The findings show that a 3-session VR exposure intervention with a standardized set of tasks effectively reduces the level of experienced height intolerance and particularly avoidance behavior compared to the control waitlist group limited to psychoeducation only. Results were maintained at the 2 months follow-up. The higher the sense of presence after the VR exposure was, the lower the avoidance level rated in the follow-up.

LIMITATIONS

Our study has some limitations, such as potential sample selection bias and tracking of only medium-term effects in the 2-month follow-up.

CONCLUSIONS

The findings show that three sessions of VR exposure intervention with a standardized set of VR-based scenarios are effective in reducing the level of height intolerance and associated avoidance behavior and led to improvement of the outcome measures two months after the procedure. The role of presence was implicated in the prolonged outcome of the VR exposure intervention.

Research on the extension of respiratory interaction modalities in virtual reality technology and innovative methods for healing anxiety disorders

The timely alleviation and healing of anxiety is crucial for preventing anxiety disorders. This study explores innovative digital approaches for anxiety relief by integrating virtual reality (VR) and multimodal interaction theories and technologies with psychodrama therapy and breathing therapy from psychology. The research proposes an innovative method of breathing interaction based on olfactory interaction modalities and designs breathing interaction semantics aimed at anxiety healing through three types of breathing therapy. Using the Unreal Engine, VR gamified scenarios and interaction logic for levels were constructed, leading to the development of a multimodal immersive software interaction system and a prototype for VR hardware interaction that extends the breathing interaction modality. The effectiveness of the system for anxiety relief was validated through an EEG experiment involving 38 participants, supported by analysis of Topographic Maps, Band-Power Reports, ERP analysis, and qualitative data from the USE scale. This research confirms that the innovative integration of VR and breathing interaction modalities is effective for anxiety therapy, aiding users in promptly alleviating anxiety and simplifying the psychological healing process.

Virtual reality exposure therapy for social anxiety disorders: a meta-analysis and meta-regression of randomized controlled trials

BACKGROUND AND OBJECTIVES

Virtual reality exposure therapy offers a unique opportunity to treat social anxiety disorder. This meta-analysis aims to evaluate the effectiveness of virtual reality exposure therapy compared to waitlist comparators or other interventions for individuals with social anxiety disorder in alleviating anxiety symptoms.

METHODS

A three-step comprehensive search for the randomized controlled trials of virtual reality exposure therapy was conducted from inception to 7 December 2023. The overall effect was measured using Hedges' g and determined using t-statistics at a significance level of p < 0.05. Sensitivity, subgroup, and meta-regression analyses were carried out.

RESULTS

A total of 17 randomized control trials were retrieved from nine electronic databases. Virtual reality exposure therapy has greater efficacy than waitlist comparators in reducing anxiety symptoms at post-intervention and follow-up assessment. Virtual reality exposure therapy demonstrates a similar effect to other interventions at post-intervention and follow-up assessment. We observed a greater effect for participants with symptomatic social anxiety when we combined the intervention with cognitive behavioral therapy compared to its counterpart. Meta-regression analyses found no significant covariate.

CONCLUSIONS

Overall, virtual reality exposure therapy can provide supplementary therapy for improving anxiety symptoms. Additional high-quality and large-scale trials with long-term follow-up are needed.

Digital nature: Unveiling the impact and safety of FlowVR group intervention for depression in a feasibility trial

OBJECTIVE

This study addresses the limitations of existing interventions for depression, such as a deficit-oriented focus, overlooking the utilization of positive elements such as nature, and neglecting the incorporation of group effects. The present feasibility study examines FlowVR, a resource-oriented, nature-inspired virtual reality (VR)-based group therapy. Previously tested individually in a pilot study for non-clinical participants, FlowVR has demonstrated positive effects on depressive symptoms. This study assesses the impact and safety of FlowVR in a group setting within a clinical sample using a one-armed study design.

METHOD

Forty-two inpatients and day patients with depression were recruited. Before and after the FlowVR intervention period of 4 weeks (two sessions per week), depressive symptoms were assessed (Beck Depression Inventory-II; BDI). Symptomatology (i.e., depressive symptoms), depression-associated variables (i.e., self-efficacy), intervention-specific variables (feeling of flow), and VR-specific variables (simulator sickness) were assessed before and after each session.

RESULTS

Linear mixed effect models showed that symptomatology (depression, negative affect, current anxiety), depression-associated constructs (self-efficacy, motivation), and intervention-specific variables (flow) improved over the course of the sessions. No variable deteriorated more in one session compared to any other session. The lasso regression identified five potential predictors for the change in depression (BDI-II), yet these could not be validated in a subsequent linear regression analysis.

CONCLUSION

To conclude, FlowVR had the hypothesized positive impact over the course of the sessions, showing, for example, improvements in symptomatology. The sessions have demonstrated safety with no notable deteriorations. Therefore, FlowVR is deemed safe for clinical patients and group settings. However, further research is needed to explore predictors for the change in depression.

The Dark Side of the Self: When Family is Highly Related to Mental Health Deterioration

This study aims to empirically test whether family has a unique significance for the self that cannot be captured by the social self alone. Specifically, it examines whether family self-concept, compared to social self-concept, is more closely related to family-specific indicators (i.e., parent-child communication and family functioning) as well as to indicators of emotional maladjustment like mental health deterioration (i.e., psychological distress and depressive symptoms). The sample comprised 4,953 Mexican adolescents, including 2,551 men (51.5%) and 2,402 women, aged 14-17 years (M = 15.60, SD = 0.92). Confirmatory factor analysis was applied to evaluate the proposed big five-dimensional self-concept model. Cohen's d confidence intervals, derived from the shared variance of Pearson's r correlations, were analyzed to relate self-concept dimensions to parent-child communication, family functioning, and mental health deterioration. Results from factorial confirmatory analysis showed that the five-dimensional oblique model (i.e., academic, social, emotional, physical, and family, as different from social) provided a better fit than competing unidimensional and orthogonal models. Correlation analyses showed that family self-concept was significantly associated with both parent-child communication and family functioning, as well as with psychological distress (d = -1.10, confidence interval [CI] -1.21 to -1.02) and depressive symptoms (d = -1.24, CI -1.31 to -1.22). These findings add evidence that family is not accurately represented within the social self-concept. Furthermore, perceiving oneself as unloved and undervalued at home (i.e., low family self-concept) is strongly associated not only with dysfunctional family processes but also with mental health deterioration.

Therapeutic Interventions for Music Performance Anxiety: A Systematic Review and Narrative Synthesis

The aim of this systematic review was to summarise and evaluate the published literature on interventions for treating music performance anxiety (MPA). Adhering to the PRISMA guidelines, a comprehensive literature search of three electronic databases was conducted: PubMed, Web of Science, and PsychInfo (Ovid). Records were included in this review if they were quantitative pre-post interventional studies that utilised a recognised outcome measure or a clinical diagnosis for evaluating MPA. A narrative synthesis was orchestrated on 40 extracted studies assessing 1365 total participants. The principal intervention types observed included cognitive behavioural therapy, acceptance and commitment therapy, music therapy, yoga and/or mindfulness, virtual reality, hypnotherapy, biofeedback, and multimodal therapy. Although most of the reviewed studies demonstrated encouraging improvements in musicians' MPA following delivered interventions, the current evidence base remains in its infancy, and numerous methodological weaknesses exist across studies. Small sample sizes, heterogeneity amongst treatment programmes, lack of follow-up data, a scarcity of standardised MPA assessments, and few randomised controlled designs render it imprudent to draw definitive recommendations concerning the interventions' efficacy.

Virtual reality exposure therapy for sexual aversion: a proof-of-concept study on acceptability, adequacy, and clinical effects

BACKGROUND

Sexual dysfunctions impair the intimate relationships of up to one-third of the population. Virtual reality (VR) offers innovative treatment options for both mental and sexual disorders, such as female orgasmic disorder and erectile disorder. Sexual aversion disorder (SAD)-the anxiety, disgust, and avoidance of sexual contexts-is a chronic condition commonly treated with anxiety-reducing strategies, such as exposure-based therapy. Despite exposure's efficacy in reducing SAD symptoms, VR exposure therapy's (VRET) effectiveness remains unexplored for this condition.

AIM

This proof-of-concept study examines the acceptability, adequacy, and clinical effects of a VRET's simulation protocol for SAD.

METHODS

In the laboratory, 15 adults suffering from SAD (Mage = 35.00; SD = 11.36) viewed 15 virtual sexual scenarios of increasing intensity (eg, flirting, nudity, genital stimulation) adjusted to their sexual preferences and gender identities.

OUTCOMES

Levels of anxiety, disgust, and catastrophizing beliefs were measured throughout the scenarios using standard self-report measures. Participants also completed validated questionnaires on sexual presence and simulation realism, as well as open-ended questions on scenarios' representativeness and adequacy immediately after immersion. Six months after the laboratory visit, participants completed a negative effects questionnaire and were screened for SAD symptoms again. Repeated-measures ANOVAs and descriptive analyses were performed.

RESULTS

Levels of anxiety and disgust significantly increased with the intensity of sexual scenarios. Catastrophizing levels were high and tended to augment with increasing exposure levels. A significant reduction in symptoms of SAD was found from pre-simulation to the 6-month follow-up assessment. Sexual presence and realism scores were moderate. Qualitative assessment revealed that all participants reported the sexual scenarios were representative of real-life situations that tend to elicit SAD symptoms for them. Reported negative effects were generally mild.

CLINICAL IMPLICATIONS

This proof-of-concept study suggests that VRET may have the potential to elicit self-reported emotional and cognitive manifestations of SAD (sex-related anxiety, disgust, and catastrophizing), while also hinting at its acceptability, adequacy, and benefits in alleviating SAD symptoms.

STRENGTHS & LIMITATIONS

While this study marks the first exploration of the clinical relevance of gender-inclusive virtual sexual scenarios for SAD, its design and sample composition may impact observed effects and the generalizability of findings.

CONCLUSION

This study invites future clinical trials to assess VRET efficacy for SAD.

Battle Against Your Fears: Virtual Reality Serious Games and Physiological Analysis for Phobia Treatment

Advancements in virtual reality (VR) technology have enabled its use to assist in multiple fields. This study introduces a comprehensive framework designed to support exposure therapy through a series of VR serious games and physiological monitoring. It relies on a generic architecture, allowing for the modification of VR stimuli according to different phobias (e.g., arachnophobia, acrophobia), while the remaining modules can be reused for data collection and analysis. Furthermore, the framework incorporates customizable biofeedback mechanisms that trigger specific events or adjust stimulus levels based on physiological responses. Prior to integration into the overall architecture, the proposed VR serious games underwent assessment in various events with a total of 56 participants. In addition, the framework's ability to capture diverse biosignals and synchronize them with other relevant metrics was evaluated through two user studies involving a total of 23 participants.

The Effectiveness of Virtual Reality Application for Women Undergoing Episiotomy Repair: A Systematic Review and Meta-analysis

Introduction

Virtual reality (VR) is effective in several healthcare domains. As of date, there have been no systematic reviews investigating the efficacy of VR technology in episiotomy repair in women. This systematic review and meta-analysis examined the effects of using VR on pain, anxiety and satisfaction in women under episiotomy repair.

Methods

For the original articles, six databases were searched using relevant keywords without restriction on time or languages until June 6, 2024. The Cochrane risk-of-bias tool for randomized trials (RoB) and the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS) were both used to assess the risk of bias in randomized and non-randomized studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) also determined the quality of our evidence. All analyses employed Comprehensive Meta-Analysis (CMA) V.2.

Results

Five randomized clinical trial and two quasi-experimental studies with poor-to high-quality met the inclusion criteria. The VR significantly decreased perineal pain during [MD (95% CI)=-1.622 (-2.598, -0.645), P=0.001], immediately after [MD (95% CI)=-1.931 (-2.785, -1.076), P<0.001], and one hour after [MD (95% CI)=-1.596 (-2.436, -0.765), P<0.001]. It also significantly decreased anxiety [SMD (95% CI)=-1.48 (-2.451, -0.509), P=0.003] after repair. VR group participants were significantly more satisfied than the control group. The quality of was moderate for perineal pain intensity one hour after episiotomy repair and anxiety after episiotomy repair.

Conclusion

Given the efficacy of VR on pain, anxiety, and satisfaction, it is suggested that it be utilized as a novel modality to enhance the quality of maternity hospital care.

A double-blind trial of decoded neurofeedback intervention for specific phobias

AIM

A new closed-loop functional magnetic resonance imaging method called multivoxel neuroreinforcement has the potential to alleviate the subjective aversiveness of exposure-based interventions by directly inducing phobic representations in the brain, outside of conscious awareness. The current study seeks to test this method as an intervention for specific phobia.

METHODS

In a randomized, double-blind, controlled single-university trial, individuals diagnosed with at least two (one target, one control) animal subtype-specific phobias were randomly assigned (1:1:1) to receive one, three, or five sessions of multivoxel neuroreinforcement in which they were rewarded for implicit activation of a target animal representation. Amygdala response to phobic stimuli was assessed by study staff blind to target and control animal assignments. Pretreatment to posttreatment differences were analyzed with a two-way repeated-measures anova.

RESULTS

A total of 23 participants (69.6% female) were randomized to receive one (n = 8), three (n = 7), or five (n = 7) sessions of multivoxel neuroreinforcement. Eighteen (n = 6 each group) participants were analyzed for our primary outcome. After neuroreinforcement, we observed an interaction indicating a significant decrease in amygdala response for the target phobia but not the control phobia. No adverse events or dropouts were reported as a result of the intervention.

CONCLUSION

Results suggest that multivoxel neuroreinforcement can specifically reduce threat signatures in specific phobia. Consequently, this intervention may complement conventional psychotherapy approaches with a nondistressing experience for patients seeking treatment. This trial sets the stage for a larger randomized clinical trial to replicate these results and examine the effects on real-life exposure.

CLINICAL TRIAL REGISTRATION

The now-closed trial was prospectively registered at ClinicalTrials.gov with ID NCT03655262.

Global research trends of virtual simulation technology in public health education and training: A visual analysis based on CiteSpace and VOSviewer

BACKGROUND

In response to global health challenges, implementing innovative educational strategies is crucial for preparing public health professionals with the required skills. This study employed CiteSpace and VOSviewer to visually analyze 3 decades of research on virtual simulation technology in public health education and training. The visual knowledge map created aimed to uncover the research trends, key areas of interest, and emerging frontiers in this domain.

METHODS

Leveraging the Web of Science core collection database and employing bibliometric methods, the CiteSpace and VOSviewer softwares were used to analyze the annual publication, literature distribution, country/institution distribution, author distribution, co-cited literature, and keywords related to the virtual simulation technology in public health education and training over the past 30 years. A visual map was then created.

RESULTS

A total of 1241 research articles were involved in the analysis. The yearly publication count and citations had an overall upward trend, with a significant increase in the number of publications since 2019. The studies in this domain are mainly concentrated in developed countries, particularly in Europe and the United States. The United States emerged as the frontrunner in terms of the number of publications, while both the United Kingdom and the United States exhibited the highest mediation centrality and exerted the greatest international influence. Harvard University made the most substantial contribution with 50 articles and exhibited an institutional cooperation centrality of 0.12. The paper entitled "Using thematic analysis in psychology" had the highest number of citations (28). The primary research hotspots included disaster medicine, telehealth, and virtual reality, while aspects such as digital health, augmented reality, and serious games had consistent continuity. An emerging research frontier, Post-2020, included several topics such as medicine, COVID-19, quality, virtual learning, rehabilitation, depression, and strategy.

CONCLUSION

This study presents the inaugural comprehensive analysis of global trends, hotspots, frontiers, and advancements in the implementation of virtual simulation technology in public health education and training, utilizing CiteSpace and VOSviewer software. The research findings reveal a significant surge in publications since 2019, with a particular emphasis on disaster medicine, telehealth, and virtual reality, indicating the versatility and promise of virtual simulation in the changing educational environments. These findings emphasize the significance of virtual simulation as a dynamic and progressive tool in public health education, proposing a promising direction for future research and practical applications.

Virtual Reality-Based Exposure With 360° Environments for Social Anxiety Disorder: Usability and Feasibility Study

BACKGROUND

Social anxiety disorder (SAD) is a long-term and overwhelming fear of social situations that can affect work, school, and other daily activities. Although cognitive behavioral therapy is effective, few seek treatment, and many who do start often drop out. This may be due to the component of exposure inherent to cognitive behavioral therapy, where the patient confronts feared stimuli outside the therapist's office, which they otherwise try to avoid. As an alternative, research has explored the effectiveness of virtual reality (VR)-based exposure therapy with promising results. However, few studies have investigated the feasibility of VR tools using mixed methodologies before assessing their efficacy.

OBJECTIVE

This study aims to assess the usability, feasibility, and presence of four 360° virtual environments and whether these were able to evoke anxiety in patients with SAD.

METHODS

A total of 10 adult participants with SAD and 10 healthy controls were recruited for 1 experimental session (age range 21-32 y; 12/20, 60% male participants). Questionnaire and interview data were collected and analyzed. A mixed methods triangulation design was applied to analyze and compare the data.

RESULTS

Participants with SAD experienced increased anxiety when exposed to VR, and environments were considered relevant and useful as an exposure tool. Participants with SAD reported significantly higher average anxiety levels (P=.01) and peak anxiety levels (P=.01) compared with controls during exposure; however, significant differences in anxiety when accounting for baseline anxiety levels were only found in 2 of 4 environments (P=.01, P=.01, P=.07, and P=.06). While presence scores were acceptable in both groups, participants with SAD scored significantly lower than controls. Qualitative analyses highlight this finding within the SAD group, where some participants experienced presence reduction due to being observed while in VR and in situations with reduced interaction in VR.

CONCLUSIONS

VR exposure with 360° videos seems to be useful as a first step of exposure therapy for patients with SAD. Future exploration in the clinical application of VR-based exposure for SAD, as well as means of increasing presence within the virtual environments, may be useful.

Virtual reality assessment of a high-calorie food bias: Replication and food-specificity in healthy participants

BACKGROUND

Theoretical models and behavioural studies indicate faster approach behaviour for high-calorie food (approach bias) among healthy participants. A previous study with Virtual Reality (VR) and online motion-capture quantified this approach bias towards food and non-food cues in a controlled VR environment with hand movements. The aim of this study was to test the specificity of a manual approach bias for high-calorie food in grasp movements compared to low-calorie food and neutral objects of different complexity, namely, simple balls and geometrically more complex office tools.

METHODS

In a VR setting, healthy participants (N = 27) repeatedly grasped or pushed high-calorie food, low-calorie food, balls and office tools in randomized order with 30 item repetitions. All objects were rated for valence and arousal.

RESULTS

High-calorie food was less attractive and more arousing in subjective ratings than low-calorie food and neutral objects. Movement onset was faster for high-calorie food in push-trials, but overall push responses were comparable. In contrast, responses to high-calorie food relative to low-calorie food and to control objects were faster in grasp trials for later stages of interaction (grasp and collect). Non-parametric tests confirmed an approach bias for high-calorie food.

CONCLUSION

A behavioural bias for food was specific to high-calorie food objects. The results confirm the presence of bottom-up advantages in motor-cognitive behaviour for high-calorie food in a non-clinical population. More systematic variations of object fidelity and in clinical populations are outstanding. The utility of VR in assessing approach behaviour is confirmed in this study by exploring manual interactions in a controlled environment.

A double-blind trial of decoded neurofeedback intervention for specific phobias

Aim

A new closed-loop fMRI method called multi-voxel neuro-reinforcement has the potential to alleviate the subjective aversiveness of exposure-based interventions by directly inducing phobic representations in the brain, outside of conscious awareness. The current study seeks to test this method as an intervention for specific phobia.

Methods

In a randomized, double-blind, controlled single-university trial, individuals diagnosed with at least two (1 target, 1 control) animal subtype specific phobias were randomly assigned (1:1:1) to receive 1, 3, or 5 sessions of multi-voxel neuro-reinforcement in which they were rewarded for implicit activation of a target animal representation. Amygdala response to phobic stimuli was assessed by study staff blind to target and control animal assignments. Pre-treatment to post-treatment differences were analyzed with a 2-way repeated-measures ANOVA.

Results

A total of 23 participants (69.6% female) were randomized to receive 1 (n=8), 3 (n=7), or 5 (n=7) sessions of multi-voxel neuro-reinforcement. Eighteen (n=6 each group) participants were analyzed for our primary outcome. After neuro-reinforcement, we observed an interaction indicating a significant decrease in amygdala response for the target phobia but not the control phobia. No adverse events or dropouts were reported as a result of the intervention.

Conclusion

Results suggest multi-voxel neuro-reinforcement can specifically reduce threat signatures in specific phobia. Consequently, this intervention may complement conventional psychotherapy approaches with a non-distressing experience for patients seeking treatment. This trial sets the stage for a larger randomized clinical trial to replicate these results and examine the effects on real-life exposure.

Clinical Trial Registration

The now-closed trial was prospectively registered at ClinicalTrials.gov with ID NCT03655262.

Desensitizing Anxiety Through Imperceptible Change: Feasibility Study on a Paradigm for Single-Session Exposure Therapy for Fear of Public Speaking

BACKGROUND

Exposure therapy (ET) for anxiety disorders involves introducing the participant to an anxiety-provoking situation over several treatment sessions. Each time, the participant is exposed to a higher anxiety-provoking stimulus; for example, in the case of fear of heights, the participant would successively experience being at a greater height. ET is effective, and its counterpart, virtual reality (VR) exposure therapy (VRET), where VR substitutes real-world exposure, is equally so. However, ET is time-consuming, requiring several sessions.

OBJECTIVE

This study aimed to compare the results of single-session exposure with those of traditional VRET with regard to reducing public speaking anxiety.

METHODS

We introduced a paradigm concerned with public speaking anxiety where the VR exposure occurred in a single session while the participant interacted with a virtual therapist. Over time, the therapist transformed into an entire audience with almost imperceptible changes. We carried out a feasibility study with 45 participants, comparing 3 conditions: single-session exposure (n=16, 36%); conventional multiple-session exposure (n=14, 31%), where the same content was delivered in successive segments over 5 sessions; and a control group (n=15, 33%), who interacted with a single virtual character to talk about everyday matters. A week later, the participants were required to speak on a stage in front of a large audience in VR.

RESULTS

Across most of the series of conventional public speaking anxiety measures, the single-session exposure was at least as effective in reducing anxiety as the multiple-session exposure, and both these conditions were better than the control condition. The 12-item Personal Report of Confidence as a Speaker was used to measure public speaking anxiety levels, where higher values indicated more anxiety. Using a Bayesian model, the posterior probabilities of improvement compared to a high baseline were at least 1.7 times greater for single- and multiple-session exposures compared to the control group. The State Perceived Index of Competence was used as a measure of anticipatory anxiety for speaking on a stage in front of a large audience, where lower values indicated higher anxiety. The probabilities of improvement were just over 4 times greater for single- and multiple-session exposures compared to the control group for a low baseline and 489 (single) and 53 (multiple) times greater for a middle baseline.

CONCLUSIONS

Overall, the results of this feasibility study show that for moderate public speaking anxiety, the paradigm of gradual change in a single session is worth following up with further studies with more severe levels of anxiety and a larger sample size, first with a randomized controlled trial with nonpatients and subsequently, if the outcomes follow those that we have found, with a full clinical trial with patients.

Lack of evidence for predictive utility from resting state fMRI data for individual exposure-based cognitive behavioral therapy outcomes: A machine learning study in two large multi-site samples in anxiety disorders

Data-based predictions of individual Cognitive Behavioral Therapy (CBT) treatment response are a fundamental step towards precision medicine. Past studies demonstrated only moderate prediction accuracy (i.e. ability to discriminate between responders and non-responders of a given treatment) when using clinical routine data such as demographic and questionnaire data, while neuroimaging data achieved superior prediction accuracy. However, these studies may be considerably biased due to very limited sample sizes and bias-prone methodology. Adequately powered and cross-validated samples are a prerequisite to evaluate predictive performance and to identify the most promising predictors. We therefore analyzed resting state functional magnet resonance imaging (rs-fMRI) data from two large clinical trials to test whether functional neuroimaging data continues to provide good prediction accuracy in much larger samples. Data came from two distinct German multicenter studies on exposure-based CBT for anxiety disorders, the Protect-AD and SpiderVR studies. We separately and independently preprocessed baseline rs-fMRI data from n = 220 patients (Protect-AD) and n = 190 patients (SpiderVR) and extracted a variety of features, including ROI-to-ROI and edge-functional connectivity, sliding-windows, and graph measures. Including these features in sophisticated machine learning pipelines, we found that predictions of individual outcomes never significantly differed from chance level, even when conducting a range of exploratory post-hoc analyses. Moreover, resting state data never provided prediction accuracy beyond the sociodemographic and clinical data. The analyses were independent of each other in terms of selecting methods to process resting state data for prediction input as well as in the used parameters of the machine learning pipelines, corroborating the external validity of the results. These similar findings in two independent studies, analyzed separately, urge caution regarding the interpretation of promising prediction results based on neuroimaging data from small samples and emphasizes that some of the prediction accuracies from previous studies may result from overestimation due to homogeneous data and weak cross-validation schemes. The promise of resting-state neuroimaging data to play an important role in the prediction of CBT treatment outcomes in patients with anxiety disorders remains yet to be delivered.

SAFEvR MentalVeRse.app: Development of a Free Immersive Virtual Reality Exposure Therapy for Acrophobia and Claustrophobia

Background: Specific phobias impact over 400 million people worldwide. Digitalizing mental health could alleviate the burden. Still, although the corporate-driven Metaverse is expanding rapidly, there needs to be more momentum in harnessing virtual reality exposure therapy uptake. Objective: This study aims to conceptualize, develop, and deploy a free Virtual Reality Exposure Therapy (VRET) application specifically designed for treating acrophobia and claustrophobia. This pilot study, which holds the promise of a future where mental health is more accessible and effective, explores the feasibility of leveraging transdisciplinary collaboration among specialists to create a safe, accessible, and effective VRET solution. Methods: We conducted a Delphi heuristic approach involving bioethicists, neuroscientists, and tech developers. Second, we reviewed the existing psychological theories and therapeutic strategies for addressing phobias in VR. Third, we conceptualized a thematic analysis-derived framework for a safe, adaptive-gamified free exposure to virtual reality acrophobia and claustrophobia (SAFEvR ACT). Finally, we provide an overview of the iterative improvements made during 12 workshops and 76 weekly briefings on developmental implementations. Results: We developed the SAFEvR ACT into a proof-of-concept application freely deployed on the MentalVerse app platform. Our safety-focused approach can benefit from prevalidation perspectives within future randomized control trials. Conclusions: The resulting application derived from the SAFEvR ACT framework represents a blueprint to counter the current lack of iVR mental health uptake by offering a free VRET alternative. Future research should aim towards developing similar free platforms to lessen mental health burdens and gather quantitative data. We conclude with a call to action to researchers to fine-tune our current approach and take a stand for free digital mental health within MentalVeRse.app.

Changes in dorsomedial striatum activity during expression of goal-directed vs. habit-like cue-induced cocaine seeking

A preclinical model of cue exposure therapy, cue extinction, reduces cue-induced cocaine seeking that is goal-directed but not habit-like. Goal-directed and habitual behaviors differentially rely on the dorsomedial striatum (DMS) and dorsolateral striatum (DLS), but the effects of cue extinction on dorsal striatal responses to cue-induced drug seeking are unknown. We used fiber photometry in rats trained to self-administer cocaine paired with an audiovisual cue to examine how dorsal striatal intracellular calcium and extracellular dopamine activity differs between goal-directed and habit-like cue-induced cocaine seeking and how it is impacted by cue extinction. After minimal fixed-ratio training, rats showed enhanced DMS and DLS calcium responses to cue-reinforced compared to unreinforced lever presses. After rats were trained on goal-promoting fixed ratio schedules or habit-promoting second-order schedules of reinforcement, different patterns of dorsal striatal calcium and dopamine responses to cue-reinforced lever presses emerged. Rats trained on habit-promoting second-order schedules showed reduced DMS calcium responses and enhanced DLS dopamine responses to cue-reinforced lever presses. Cue extinction reduced calcium responses during subsequent drug seeking in the DMS, but not in the DLS. Therefore, cue extinction may reduce goal-directed behavior through its effects on the DMS, whereas habit-like behavior and the DLS are unaffected.

A virtual reality paradigm simulating blood donation serves as a platform to test interventions to promote donation

Effective interventions that support blood donor retention are needed. Yet, integrating an intervention into the time-pressed and operationally sensitive context of a blood donation center requires justification for disruptions to an optimized process. This research provides evidence that virtual reality (VR) paradigms can serve as a research environment in which interventions can be tested prior to being delivered in blood donation centers. Study 1 (N = 48) demonstrated that 360°-video VR blood donation environments elicit a similar profile of emotional experience to a live donor center. Presence and immersion were high, and cybersickness symptoms low. Study 2 (N = 134) was an experiment deploying the 360°-video VR environments to test the impact of an intervention on emotional experience and intentions to donate. Participants in the intervention condition who engaged in a suite of tasks drawn from the process model of emotion regulation (including attentional deployment, positive reappraisal, and response modulation) reported more positive emotion than participants in a control condition, which in turn increased intentions to donate blood. By showing the promise for benefitting donor experience via a relatively low-cost and low-resource methodology, this research supports the use of VR paradigms to trial interventions prior to deployment in operationally-context field settings.

Salivary CRP predicts treatment response to virtual reality exposure therapy for social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) places a profound burden on public health and individual wellbeing. Systemic inflammation may be important to the onset and maintenance of SAD, and anti-inflammatory treatments have shown promise in relieving symptoms of SAD. In the present study, we conducted secondary analyses on data from a randomized clinical trial to determine whether C-reactive protein (CRP) concentrations and social anxiety symptoms decreased over the course of virtual reality exposure therapy, and whether changes in social anxiety symptoms as a function of treatment varied as a function of CRP.

METHOD

Adult participants (N = 78) with a diagnosis of SAD (59 % female) were randomized to receive exposure therapy alone, or exposure therapy supplemented with scopolamine. Social anxiety symptoms, salivary CRP, and subjective units of distress were measured across three exposure therapy sessions, at a post-treatment extinction retest, and at a 1-month follow-up.

RESULTS

CRP decreased over the course of treatment, b = -0.03 (SE = 0.01), p =.02 95 %CI [-0.06, -0.004], as did all social anxiety symptom domains and subjective distress. Higher CRP was associated with greater decreases from pre-treatment to 1-month follow-up in fear, b = -0.45 (SE = 0.15), p =.004 95 %CI [-0.74, -0.15], and avoidance, b = -0.62 (SE = 0.19), p =.002 95 %CI [-1.01, -0.23], and in-session subjective distress from pre-treatment to post-treatment, b = -0.42 (SE = 0.21), p =.05 95 %CI [-0.83, -0.001]. However, declines in CRP were not correlated with declines in fear, r = -0.07, p =.61, or avoidance, r = -0.10, p =.49, within-persons.

CONCLUSIONS

Virtual reality exposure therapy may be associated with an improvement in systemic inflammation in patients with severe SAD. Pre-treatment CRP may also be of value in predicting which patients stand to benefit the most from this treatment.

HCI Contributions in Mental Health: A Modular Framework to Guide Psychosocial Intervention Design

Many people prefer psychosocial interventions for mental health care or other concerns, but these interventions are often complex and unavailable in settings where people seek care. Intervention designers use technology to improve user experience or reach of interventions, and HCI researchers have made many contributions toward this goal. Both HCI and mental health researchers must navigate tensions between innovating on and adhering to the theories of change that guide intervention design. In this paper, we propose a framework that describes design briefs and evaluation approaches for HCI contributions at the scopes of capabilities, components, intervention systems, and intervention implementations. We show how theories of change (from mental health) can be translated into design briefs (in HCI), and that these translations can bridge and coordinate efforts across fields. It is our hope that this framework can support researchers in motivating, planning, conducting, and communicating work that advances psychosocial intervention design.

Fear in action: Fear conditioning and alleviation through body movements

Fear memories enhance survival especially when the memories guide defensive movements to minimize harm. Accordingly, fear memories and body movements have tight relationships in animals: Fear memory acquisition results in adapting reactive defense movements, while training active defense movements reduces fear memory. However, evidence in humans is scarce because their movements are typically suppressed in experiments. Here, we tracked adult participants' body motions while they underwent ecologically valid fear conditioning in a 3D virtual space. First, with body motion tracking, we revealed that distinct spatiotemporal body movement patterns emerge through fear conditioning. Second, subsequent training to actively avoid threats with naturalistic defensive actions led to a long-term (24 h) reduction of physiological and embodied conditioned responses, while extinction or vicarious training only transiently reduced the responses. Together, our results highlight the role of body movements in human fear memory and its intervention.

Virtual reality exposure with vibrotactile stimulation for the treatment of fear of flying: A pilot study

BACKGROUND AND OBJECTIVES

Virtual reality (VR) interventions are becoming more prevalent in treating fear of flying (FoF). Since multisensory stimulation can enhance the sense of presence in a virtual environment, the present study compared virtual reality exposure with and without vibrotactile cues to determine its contribution to the realism of the virtual experience.

METHODS

A repeated measures design was used. Thirty-one participants were exposed to two experimental conditions with a minimum of a one-week interval between them: one in which participants were exposed to the virtual environment with vibrotactile cues (smart chair, SC), and another in which participants were exposed to the virtual environment without vibrotactile cues (ordinary chair, OC). The administration order of both conditions was counterbalanced to avoid possible order effects.

RESULTS

Participants felt higher levels of sense of presence when using the SC than the OC. However, the addition of vibrotactile stimulation partially influenced experienced anxiety. Some personality traits were also associated with participants' sense of presence and anxiety responses during the exposure.

LIMITATIONS

The sample size was smaller than required. Moreover, only self-reported measures were used. Finally, a roller coaster instead of an airplane scenario was used for the exposure, which might not have been suitable enough for provoking anxiety in participants with FoF.

CONCLUSIONS

Vibrotactile cues enhanced the sense of presence. However, the addition of vibrotactile stimulation did not have a consistent effect on anxiety experienced during exposure. Therefore, the benefits of incorporating vibrotactile cues in virtual reality environments for exposure therapy are not clear.

Personalized virtual reality exposure for panic disorder and agoraphobia: A preliminary neurophysiological study

BACKGROUND

Personalization is considered an important principle in virtual reality (VR) exposure therapy. We aimed to identify whether personalized VR exposure could provoke increased anxiety in patients with panic disorder and agoraphobia as it is considered the first step in successful treatment for anxiety.

METHODS

We performed a double-arm, one-day preliminary study among 28 patients with panic disorder and agoraphobia. Three sessions of VR exposure, including a theater, train, and elevator scenario, were conducted in two groups. In the personalized group (n = 14), the brightness and crowd density were customized based on a pre-assessment. In the control group (n = 14), these conditions were fully randomized. Self-reported anxiety, heart rate, skin conductance, and electroencephalography were measured before, during, and after the VR sessions.

RESULTS

In the later VR sessions, higher self-reported anxiety levels measured by the Visual Analogue Scale were observed in the personalized exposure group. Increased heart rates during and after the VR sessions were observed in the personalized group. The changes in skin conductance peaks were not significantly different between the groups, but the increase in skin conductance was associated with the participants' perception of presence. The electroencephalogram showed widespread increases in alpha waves in the frontal and temporal areas of the brain in the personalized group than in the control group.

CONCLUSION

Personalized VR exposure elicits stronger anxiogenic effects in patients with panic disorder and agoraphobia as suggested by self-report and neurophysiological data. Personalization of VR exposure has the potential for effective behavioral therapy.

The impact of virtual reality scenes on stress response characteristics of individuals with different personality traits

Virtual reality based physical stress (VRPS) paradigms could eliminate the influence of social factors on participants, and it may be a desirable tool to explore the impact of personality traits on stress levels. In this study, we attempt to explore the effects of VRPS on stress response among individuals with different personality traits. Forty male participants with an average age of 22.79 ± 0.41 years were divided into two groups based on Harm Avoidance (HA) scores of Tridimensional Personality Questionnaire (TPQ), referred to as the Low-HA group and the High-HA group. The stress levels of the participants were assessed using salivary α-amylase (sAA) activity and heart rate variability (HRV) indices pre- and post-stress. The influence of personality traits on stress response among different groups was analyzed. VRPS significantly affected the sAA activity and HRV indicators of both groups. During and after stress, there were significant differences in sAA activity and HRV indicators between the two groups. The sAA levels and HRV indices of the Low-HA group were lower than those of the High-HA group. Furthermore, sAA levels and HRV indices were correlated with the scores of TPQ. VRPS scenarios elicit different stress responses on individuals with different harm avoidance personality traits. Stress evaluation based on VR scenarios presents potential in personality trait assessments, particularly for distinguishing between individuals with low and high HA tendencies.

Nurses' Perception of Using Cognitive Behavior Therapy for Death Anxiety and Ageism

Despite the effectiveness of cognitive behavior therapy (CBT) in relieving death anxiety and ageism among nurses, there is not a complete consensus on its acceptability, adherence, credibility, and expectancy in the literature. Therefore, this descriptive-comparative study aimed to examine Jordanian nurses' perception of using CBT in relieving death anxiety and ageism. Most participants perceived CBT as a credible and adherable treatment for death anxiety and ageism. Significant differences were found in the CBT credibility and expectancy between nurses grouped according to levels of perceived treatment adherence and acceptability of CBT. The findings provide a promising avenue for adopting CBT to target death anxiety and its associated ageism among nurses and for improving CBT adherence, acceptability, credibility, and expectancy. A better understanding of participants' perception of CBT is crucial for optimal clinical practice.

Mixed results for exposure and response prevention therapy in mixed reality for patients with contamination-related obsessive-compulsive disorder: A randomized controlled pilot study

INTRODUCTION

Technology-supported exposure and response prevention (ERP) for patients with obsessive-compulsive disorder (OCD) as tested in clinical research, holds promise but also has limitations. The present study aims to overcome these limitations by using mixed reality for ERP (MERP). The objectives of this pilot study were to evaluate the safety, feasibility, and acceptance of MERP and to identify possible obstacles.

METHODS

Twenty inpatients with contamination-related OCD were recruited and randomized to two conditions: MERP (six sessions in 3 weeks) and care as usual treatment. Patients were assessed before treatment (baseline), after the 3-week intervention period (post), as well as 3 months after post assessment (follow-up) regarding symptomatology (Y-BOCS).

RESULTS

Results showed a similar reduction in symptomatology in both groups from baseline to post. Regarding safety, no clinically significant deterioration was detected in the MERP group. Patients' evaluation of the MERP was heterogeneous. The qualitative feedback provided helpful indications for further development of the software. Sense of presence was below the midpoint of the scales.

CONCLUSION

This is the first study evaluating a MERP for patients with OCD that shows cautious evidence for the acceptance and safety of MERP. The results of the subjective evaluation suggest revisions of the software.

Virtual and Augmented Simulations in Mental Health

PURPOSE OF REVIEW

This examines significant trends and developments in the utilization of virtual reality (VR) and augmented reality (AR) simulations in the field of mental health and education. The objective is to gain insights into the emerging applications of VR/AR in mental health interventions and their potential impact on patient outcomes. The review also includes personal observations on the effectiveness and challenges associated with VR/AR simulations and the rise of exciting, disruptive artificial intelligence large language models. The findings of this review contribute to the understanding of the current state of VR/AR technology in mental health and highlight potential future directions in this rapidly evolving field.

RECENT FINDINGS

Recent studies have shown that VR/AR simulation is an effective and promising approach for treating various anxiety disorders, including specific phobias, social anxiety disorder, and post-traumatic stress disorder (PTSD). Simulated environments can be tailored to induce provoking situations, allowing individuals to learn from and gradually confront and grow in controlled and safe environments. Recent findings in the field of virtual reality simulations in mental health indicate that VR/AR exposure therapy is effective for treating anxiety disorders, while interventions show promise in improving social skills in individuals working with patients. In a broader sense, the use of VR/AR as an educational tool shows enormous potential now that functional generative artificial intelligence (AI) is recently available.

Changes in dorsomedial striatum activity mediate expression of goal-directed vs. habit-like cue-induced cocaine seeking

A preclinical model of cue exposure therapy, cue extinction, reduces cue-induced cocaine seeking when drug seeking is goal-directed but not habitual. Goal-directed and habitual behaviors differentially rely on the dorsomedial striatum (DMS) and dorsolateral striatum (DLS), but the effects of cue extinction on dorsal striatal responses to cue-induced drug seeking are unknown. We used fiber photometry to examine how dorsal striatal intracellular calcium and extracellular dopamine activity differs between goal-directed and habitual cue-induced cocaine seeking and how it is impacted by cue extinction. Rats trained to self-administer cocaine paired with an audiovisual cue on schedules of reinforcement that promote goal-directed or habitual cocaine seeking had different patterns of dorsal striatal calcium and dopamine responses to cue-reinforced lever presses. Cue extinction reduced calcium and dopamine responses during subsequent drug seeking in the DMS, but not in the DLS. Therefore, cue extinction may reduce goal-directed behavior through its effects on the DMS, whereas habitual behavior and the DLS are unaffected.

Does multisensory stimulation with virtual reality (VR) and smell improve learning? An educational experience in recall and creativity

Purpose

The purpose of this paper is to derive into practical recommendations from multisensory stimulation with virtual reality (VR) and scent to help educators develop effective teaching strategies geared toward aspects of the learning experience, recall, and creativity in a stereotypical learning context.

Design/methodology/approach

The paper is based on a randomized experiment in which student participants were subdivided into three treatment groups and one control group. Each group was stimulated by a different combination of visual, auditory, and olfactory stimuli (2D SMELL, VR, and VR SMELL) and the outcomes were compared against those of the control group (2D). Consistent with the Cognitive Theory of Multimedia Learning, hypotheses were constructed to study the effect of different combinations of stimuli on the learning experience and learning outcomes related to recall and creativity in a stereotypical learning context.

Findings

Traditional video content alone and bundled with a coherent olfactory stimulus prompted higher self-reported ratings of perceived quality of the sensory experience. Olfactory stimulus in combination with either VR or a traditional video prompted higher self-reported ratings on perceived immersion. In a stereotypical learning context, the highest recall scores were achieved with traditional video alone. Both VR alone and bundled with an olfactory stimulus resulted in enhanced creativity.

Research limitations/implications

The findings of this study should be interpreted in the context of adopting multisensory stimulations combined with VR technology as part of stereotypical learning contexts. Most professional educators do not have robust knowledge or experience in using build-on-purpose multisensory stimuli but are increasingly engaged in using multisensory tools such as VR, as part of their teaching practice. In relation to recall, the results are consistent with the hypothesis that in a stereotypical learning context, a multisensory experience involving VR and olfactory stimuli can be related to an undesired cognitive load for learners. There exists a possibility that the low-technical version of the VR goggles used, as well as the contents of the instructional video may have influenced the learning outcomes in terms of recall. Hence, future research should consider such aspects and focus on richer learning contexts.

Originality/value

This work offers practical recommendations for instructional design strategies aiming to create multisensory stimulations with VR and olfactory components to foster a richer learning experience and enhanced learning outcomes, under the assumptions of a stereotypical learning context.

Does fear reduction predict treatment response to exposure for social anxiety disorder?

BACKGROUND AND OBJECTIVES

Fear activation and reduction have traditionally been considered important mechanisms of exposure therapy. Evidence to date is mixed and impeded by inadequate methodology. This study examined the extent to which fear activation and reduction within and across exposures predicted treatment outcomes for social anxiety disorder within a paradigm suitable for their measurement.

METHODS

Sixty-eight adults with social anxiety disorder and fear of public speaking completed seven exposure sessions, each consisting of seven speeches conducted in virtual reality. Exposures were identical in duration, task requirements, and virtual public speaking situation. Fear was measured with skin conductance and subjective distress ratings. At baseline and post-treatment, participants completed a public speaking behavioral approach test with a panel of confederate judges; subjective fear was measured. A standardized questionnaire of anxiety symptoms was administered at baseline, post-treatment, and one-month follow-up.

RESULTS

No indices of within- or between-session fear reduction, measured by subjective distress and skin conductance response, predicted treatment outcome. One measure of fear activation was associated with outcomes such that less activation predicted greater symptom reduction; remaining indices did not predict outcomes.

LIMITATIONS

Data were collected in the context of a randomized controlled trial of scopolamine; drug group was included in analytic models to account for drug influence. VR exposures elicited mild levels of distress that may underestimate levels of distress in clinical settings.

CONCLUSIONS

Findings failed to support fear activation or reduction within or across exposure sessions as significant predictors of treatment outcome for social anxiety. Treatment implications are discussed.

The Effect of Virtual Reality on the Reduction of Pain in Women with an Indication for Outpatient Diagnostic Hysteroscopy: A Randomized Controlled Trial

Background: The cognitive distraction caused by Virtual Reality (VR) seems to cause a decrease both in pain and its perception as in the time spent thinking about possible pain, among anxiety about hysteroscopy procedure. The main objective of this investigation was to evaluate the efficacy of virtual reality for pain relief during outpatient hysteroscopy. Method: A total of 83 patients underwent outpatient diagnostic hysteroscopy in a single-centre, open-label, randomized control trial. Overall, 180 women with medical indication for an outpatient diagnostic hysteroscopy were randomized. Ten were excluded due to the impossibility of entering the endometrial cavity caused by a cervical canal that was not permeable, and 15 did not tolerate the pain at the beginning and during the procedure, excluding themselves from the final model. Finally, 154 were analysed per protocol to use VR (n = 82, study group) or standard treatment (n = 72, control group) assessing the differences between both groups by reduction in pain using Visual Analogue Scale score (VAS: 0-10 cm) and clinical data (arterial pressure, heart rate, and oxygen saturation) at the end of hysteroscopy, at 15 and 30 min after hysteroscopy. Results: Women with VR outpatient diagnostic hysteroscopy experienced less pain at final (VAS score 2.451 vs. 3.972, standard mean difference (SMD) -1.521, 95% CI -2.601 to -0.440; p = 0.006), at 15 min (VAS 1.769 vs. 3.300, SMD -1.531, 95% CI -2.557 to -0.504; p = 0.004), and at 30 min (VAS 1.621 vs. 2.719, SMD -1.099, 95% CI -2.166 to -0.031; p = 0.044) after the ending of the hysteroscopy, compared with no VR. Conclusions: The use of VR during outpatient diagnostic hysteroscopy proved effective in the reduction of pain in this randomized control trial. It shows wide potential role in ambulatory gynaecologic procedures to avoid repeating tests, perform surgeries without anaesthesia, and the use of medication and its side effects.

Comparison between Standard Expository Cognitive Behavioral Therapy (CBT-E) and Immersive Virtual Reality CBT (CBT-VR) for Rehabilitation of Patients Affected by Occupational Stress Disorders: Study Protocol

Work-related stress presents a significant impact on work performance and physical health. It has been associated with the onset of a multitude of symptoms that can lead to occupational stress diseases, namely Adjustment Disorder and Post-Traumatic Stress Disorder. The literature has evidenced that "exposure therapy" of cognitive-behavioral training (CBT-E) seems to be the most effective technique to manage stress symptoms, including work stress diseases, and several studies have considered Virtual Reality (VR) as an adjuvant tool to exposure-based psychotherapy (CBT-VR) for the treatment of multiple psychiatric disorders. The aim of this study is to evaluate the effectiveness of CBT with exposure to stressful work scenarios in imaginative (CBT-E) and in immersive virtual reality (CBT-VR) scenarios in a group of workers affected by work-related stress disorders and compare the clinical and physiological outcomes between the two exposure techniques. A long-term goal would be to develop an evidence-based rehabilitation program as a treatment for the reintegration into work of patients affected by these psychiatric disorders.

Efficacy of exposure and response prevention therapy in mixed reality for patients with obsessive-compulsive disorder: study protocol for a randomized controlled trial

Many patients with obsessive-compulsive disorder (OCD) do not receive cognitive behavioral therapy with exposure and response prevention (first line treatment for OCD), for example, due to patients' fear of the exposure and reservations of the therapists. Technology-supported exposure (e.g., exposure therapy with response prevention in mixed reality [MERP]) for patients with OCD may help to overcome this obstacle. Building upon findings of our pilot study objectives of this study are to evaluate the efficacy, expectations of treatment success, feasibility, and acceptance of MERP as well as to identify possible limitations. In total, 64 outpatients with contamination-related OCD will be recruited and randomized to one of two conditions: MERP (six sessions in six weeks) and self-guided exposure therapy (six exercises in six weeks). Participants will be assessed before (baseline), after the six-week intervention period (post), as well as three months after post assessment (follow-up) regarding symptomatology (Yale-Brown Obsessive Compulsive Scale; Y-BOCS), their subjective evaluation of MERP (acceptance) and sense of presence. The planned study is the first to investigate MERP in patients with OCD.

Review of Psychophysiological and Psychotherapeutic Studies of Stress Using Virtual Reality Technologies

This review addresses the use of virtual reality technologies in the psychophysiology and psychotherapy of stress. Studies using virtual reality both to introduce subjects into a state of stress and to help reduce stress reactions are reviewed. Methods developed for treating patients suffering from stress-related disorders (in particular, PTSD and phobias) are described. In many cases, reductions in stress reactions with the help of virtual reality systems are achieved not only at the self-report (experiential) level, but also at the level of central and peripheral nervous system measures. This allows virtual reality to be regarded as a modern, inexpensive, and effective method, firstly, for introducing subjects into a state of stress with the aim of testing various hypotheses in psychophysiology and, secondly, to reduce stress reactions.

A Recovery-Oriented Program for People with Bipolar Disorder through Virtual Reality-Based Cognitive Remediation: Results of a Feasibility Randomized Clinical Trial

BACKGROUND

Cognitive impairment is a frequent consequence of bipolar disorder (BD) that is difficult to prevent and treat. In addition, the quality of the preliminary evidence on the treatment of BD through Cognitive Remediation (CR) with traditional methods is poor. This study aims to evaluate the feasibility of a CR intervention with fully immersive Virtual Reality (VR) as an additional treatment for BD and offers preliminary data on its efficacy.

METHODS

Feasibility randomized controlled cross-over clinical study, with experimental condition lasting three months, crossed between two groups. Experimental condition: CR fully immersive VR recovery-oriented program plus conventional care; Control condition: conventional care. The control group began the experimental condition after a three months period of conventional care (waiting list). After the randomization of 50 people with BD diagnosis, the final sample consists of 39 participants in the experimental condition and 25 in the control condition because of dropouts.

RESULTS

Acceptability and tolerability of the intervention were good. Compared to the waitlist group, the experimental group reported a significant improvement regarding cognitive functions (memory: p = 0.003; attention: p = 0.002, verbal fluency: p = 0.010, executive function: p = 0.003), depressive symptoms (p = 0.030), emotional awareness (p = 0.007) and biological rhythms (p = 0.029).

CONCLUSIONS

The results are preliminary and cannot be considered exhaustive due to the small sample size. However, the evidence of efficacy, together with the good acceptability of the intervention, is of interest. These results suggest the need to conduct studies with larger samples that can confirm this data.

TRIAL REGISTRATION

ClinicalTrialsgov NCT05070065, registered in September 2021.

Development and preliminary testing of a virtual reality measurement for assessing intake assessment skills

Objective structured clinical examinations (OSCEs) have been widely used in health care education to simultaneously assess knowledge, skill and attitude. Due to the high cost of running an OSCE, its application in professional psychology is still limited. To solve this problem, virtual standardised patient (VSP) implementations in creating psychology OSCEs can be a cost-effective method for administering a psychology OSCE regularly. This study aimed to develop and examine the psychometric properties of the VSP version of the Intake OSCE (VSP-Intake OSCE) in measuring psychologists' psychological assessment competencies (PACs) from entry to early practice. The initial development of the VSP-Intake OSCE contains a VSP station and a follow-up written station to measure PACs when conducting an intake assessment. To administer the VSP station, we built a new VSP system that allows psychologists to interact with a VSP verbally. A sample of 36 participants, including 27 graduate students and nine psychologists, were recruited to examine the psychometric properties of the VSP-Intake OSCE. As a newly developed instrument, the VSP-Intake OSCE revealed good inter-rater reliability and construct validity. We believe using VSP implementations to develop psychology OSCEs will be essential in promoting OSCE applications in professional psychology.

Describing epilepsy-related anxiety to inform the design of a virtual reality exposure therapy: Results from Phase 1 of the AnxEpiVR clinical trial

People with epilepsy (PwE) are at a greater risk of comorbid anxiety, which is often related to the fear of having another seizure for safety or social reasons. While virtual reality (VR) exposure therapy (ET) has been successfully used to treat several anxiety disorders, no studies to date have investigated its use in this population. This paper discusses Phase 1 of the three-phase AnxEpiVR pilot study. In Phase 1, we aimed to explore and validate scenarios that provoke epilepsy/seizure-specific (ES) interictal anxiety and provide recommendations that lay the foundation for designing VR-ET scenarios to treat this condition in PwE. An anonymous online questionnaire (including open- and closed-ended questions) that targeted PwE and those affected by it (e.g., through a family member, friend, or as a healthcare professional) was promoted by a major epilepsy foundation in Toronto, Canada. Responses from n = 18 participants were analyzed using grounded theory and the constant comparison method. Participants described anxiety-provoking scenes, which were categorized under the following themes: location, social setting, situational, activity, physiological, and previous seizure. While scenes tied to previous seizures were typically highly personalized and idiosyncratic, public settings and social situations were commonly reported fears. Factors consistently found to increase ES-interictal anxiety included the potential for danger (physical injury or inability to get help), social factors (increased number of unfamiliar people, social pressures), and specific triggers (stress, sensory, physiological, and medication-related). We make recommendations for incorporating different combinations of anxiety-related factors to achieve a customizable selection of graded exposure scenarios suitable for VR-ET. Subsequent phases of this study will include creating a set of VR-ET hierarchies (Phase 2) and rigorously evaluating their feasibility and effectiveness (Phase 3).

Preference of Virtual Reality Games in Psychological Pressure and Depression Treatment: Discrete Choice Experiment

BACKGROUND

Virtual reality (VR) can be used to build many different scenes aimed at reducing study-related stress. However, only few academic experiments on university students for preference testing have been performed.

OBJECTIVE

This study aims to assess the preference of VR games for stress and depression treatment using a discrete choice experiment (DCE).

METHODS

A total of 5 different attributes were selected based on the depression therapy parameters and attributes related to VR: (1) treatment modality; (2) therapy duration; (3) perceived remission rate; (4) probability of adverse events; and the (5) monthly cost of adding treatment to a discrete choice experiment. By comparing different attributes and levels, we could draw some conclusions about the depression therapy testing preference for university students; 1 university student was responsible for VR scene development and 1 for participant recruitment.

RESULTS

The utility value of different attributes for "0% Probability of adverse events" was higher than others (99.22), and the utility value of VR treatment as the most popular treatment method compared with counseling and medicine treatment was 80.95. Three parameter aspects (different treatments for depression) were statistically significant (P<.001), including "0%" and "50%" of "Probability of adverse events" and "¥500" (a currency exchange rate of ¥1 [Chinese yuan]=US $0.15 is applicable) of "The monthly cost of treatment." Most individuals preferred 12 months as the therapy duration, and the odds ratio of "12 months" was 1.095 (95% CI 0.945-1.270) when compared with the reference level (6 months). Meanwhile, the cheapest price (¥500) of depression therapy was the optimum choice for most students.

CONCLUSIONS

People placed great preference on VR technology psychological intervention methods, which indicates that VR may have a potential market in the treatment of psychological problems. However, adverse events and treatment costs need to be considered. This study can be used to guide policies that are relevant to the development of the application of VR technology in the field of psychological pressure and depression treatment.

Virtual reality for healthcare: A scoping review of commercially available applications for head-mounted displays

Objective

This scoping review aimed to describe the scope of commercially available virtual reality (VR) healthcare applications for mainstream head-mounted displays (HMD)s.

Methods

A search was conducted during late April and early May 2022 over five major VR app stores using "health," "healthcare," "medicine," and "medical" as keywords. Apps were screened based on their title and description sections. Metadata collected included: title, description, release date, price (free or paid), multilingual support, VR app store availability, and HMD support.

Results

The search yielded 1995 apps, out of which 60 met the inclusion criteria. The analysis showed that the number of healthcare VR apps has been steadily increasing since 2016, but no developer has released more than two apps so far. Most of the reviewed apps can run on HTC Vive, Oculus Quest, and Valve Index. Thirty-four (56.7%) apps had a free version, and 12 (20%) apps were multilingual, i.e., supported languages other than English. The reviewed apps fell into eight major themes: life science education (3D anatomy, physiology and pathology, biochemistry, and genetics); rehabilitation (physical, mental, and phobia therapy); public health training (safety, life-saving skills, and management); medical training (surgical and patient simulators); role-playing as a patient; 3D medical imagery viewing; children's health; and online health communities.

Conclusions

Although commercial healthcare VR is still in its early phases, end-users can already access a broad range of healthcare VR apps on mainstream HMDs. Further research is needed to assess the usefulness and usability of existing apps.

Cognition, criminal conduct, and virtual reality: Understanding and reducing offending using simulated environments

Over the past years, research has shown that virtual reality (VR) technology can be used to observe, interpret, and change human behavior and cognition in a variety of domains. This chapter explores the potential of VR as a tool to observe, interpret, and change human behavior and cognition as they relate to antisocial behavior. We review the criminological research literature as well as research literature from related disciplines on VR applications that has focused on observing and reducing antisocial behavior. The main findings of our review suggest that the key merits of VR in the domain of crime and antisocial behavior are its ability to provide safe learning environments that would otherwise involve risk, the possibility of generating ethical and ecologically valid virtual alternatives for real-life situations, and the development of stimuli that are impossible to create in real life. These unique characteristics make VR a promising tool to observe criminal behavior as it takes place and develop intervention programs to reduce antisocial behavior.

A Survey on Affective and Cognitive VR

In Virtual Reality (VR), users can be immersed in emotionally intense and cognitively engaging experiences. Yet, despite strong interest from scholars and a large amount of work associating VR and Affective and Cognitive States (ACS), there is a clear lack of structured and systematic form in which this research can be classified. We define "Affective and Cognitive VR" to relate to works which (1) induce ACS, (2) recognize ACS, or (3) exploit ACS by adapting virtual environments based on ACS measures. This survey clarifies the different models of ACS, presents the methods for measuring them with their respective advantages and drawbacks in VR, and showcases Affective and Cognitive VR studies done in an Immersive Virtual Environment (IVE) in a non-clinical context. Our article covers the main research lines in Affective and Cognitive VR. We provide a comprehensive list of references with the analysis of 63 research articles and summarize future works directions.

A virtual reality platform for memory evaluation: Assessing effects of spatial strategies

Human spatial memories are usually evaluated using computer screens instead of real arenas or landscapes where subjects could move voluntarily and use allocentric cues to guide their behavior. A possible approach to fill this gap is the adoption of virtual reality, which provides the opportunity to create spatial memory tasks closer to real-life experience. Here we present and evaluate a new software to create experiments using this technology. Specifically, we have developed a spatial memory task that is carried out in a computer-assisted virtual environment where participants walk around a virtual arena using a joystick. This spatial memory task provides an immersive environment where the spatial component is constantly present without the use of virtual reality goggles. The design is similar to that of tasks used for animal studies, allowing a direct comparison across species. We found that only participants who reported using spatial cues to guide their behavior showed significant learning and performed significantly better during a memory test. This tool allows evaluation of human spatial memory in an ecological environment and will be useful to develop a wide range of other tasks to assess spatial cognition.