Virtual reality exposure therapy for social anxiety disorder: a randomized controlled trial

The efficacy of psychotherapy for social anxiety disorder, a systematic review and meta-analysis

BACKGROUND

Given the growth in research examining the effects of psychotherapy on social anxiety disorder (SAD), an up-to-date comprehensive meta-analysis in this field is needed.

METHODS

We selected studies from a database of randomized trials (RCTs) on psychotherapies for anxiety disorders (last updated search of PubMed, PsycINFO, Embase, and Cochrane (CENTRAL): 1 January 2024) We included RCTs comparing psychotherapy to a control condition for adults with SAD and conducted random effects meta-analyses to examine the efficacy of psychotherapy compared to control conditions at post-treatment.

RESULTS

Sixty-six RCTs were included with 5560 participants and 98 comparisons between psychotherapy and control groups. Psychotherapy was effective in reducing SAD symptoms, with a large effect size (g = 0.88; 95 % CI: 0.76 to 1.0; I2 = 74 %; 95 % CI: 69 to 79, NNT = 3.8). Effects remained robust across sensitivity analyses. However, there was evidence for significant risk of bias in the included trials. The multivariable meta-regression indicated significant differences in treatment delivery formats, type of recruitment strategy, target group, and number of sessions.

CONCLUSION

Psychotherapy is an effective treatment for SAD, with moderate to large effect sizes across all treatment types and formats. Future research is needed to determine the long-term effects.

Sociodemographic representation in randomized controlled trials for anxiety-related disorders in the U.S.: A systematic review (1993-2023)

Cognitive behavioral therapies have been identified as evidence-based treatments for anxiety-related disorders. However, data supporting the effectiveness of these treatments have been largely collected from participants with majoritized identities, potentially limiting the extent to which they can be considered "evidence-based" for clients from minoritized groups. The current review examined sociodemographic representation and quality of sociodemographic reporting in randomized controlled trials for anxiety-related disorders in the U.S. between 1993 and 2023. We conducted a systematic literature review of U.S.-based randomized controlled trials of cognitive behavioral therapies for anxiety-related disorders, extracted data on sociodemographic variables, and rated quality of reporting. Data from 55 eligible studies (N = 4492) indicated that white and female identities were overrepresented relative to the U.S. population, with variables like disability status, sexual orientation, and religious identification consistently ignored. In addition, quality of reporting was generally poor (mean = 3.6 out of 10), with many studies failing to account for demographic variables in their analyses or description of study limitations. Publication year, sample size, and NIH funding status did not significantly predict gender representation (% women), ethnoracial representation (% white), or quality of reporting. These findings underscore the importance of critically evaluating to whom "evidence-based" treatments apply and increasing diversity of clinical samples, to ensure that evidence-based treatments are inclusive. Recommendations for future research, clinical implications, and limitations are discussed.

Real-Time Classification of Anxiety in Virtual Reality Therapy Using Biosensors and a Convolutional Neural Network

Virtual Reality Exposure Therapy is a method of cognitive behavioural therapy that aids in the treatment of anxiety disorders by making therapy practical and cost-efficient. It also allows for the seamless tailoring of the therapy by using objective, continuous feedback. This feedback can be obtained using biosensors to collect physiological information such as heart rate, electrodermal activity and frontal brain activity. As part of developing our objective feedback framework, we developed a Virtual Reality adaptation of the well-established emotional Stroop Colour-Word Task. We used this adaptation to differentiate three distinct levels of anxiety: no anxiety, mild anxiety and severe anxiety. We tested our environment on twenty-nine participants between the ages of eighteen and sixty-five. After analysing and validating this environment, we used it to create a dataset for further machine-learning classification of the assigned anxiety levels. To apply this information in real-time, all of our information was processed within Virtual Reality. Our Convolutional Neural Network was able to differentiate the anxiety levels with a 75% accuracy using leave-one-out cross-validation. This shows that our system can accurately differentiate between different anxiety levels.

Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review

BACKGROUND

Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD.

OBJECTIVE

The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD.

METHODS

The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items.

RESULTS

The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria.

CONCLUSIONS

The findings showed that VR exposure therapy-based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues.

TRIAL REGISTRATION

PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353891.

Patient experience of a virtual reality calm room in a psychiatric inpatient care setting in Sweden: a qualitative study with inpatients

OBJECTIVE

Calm rooms have been developed and implemented in psychiatric inpatient care settings to offer patients a dedicated space for relaxation in a convenient and safe environment. Recent technology developments have enabled virtual reality (VR) equivalents of calm rooms that can be feasibly deployed in psychiatric care settings. While research has shown VR environments to be efficacious in inducing relaxation, little is known how these virtual calm rooms are perceived by patients. The aim of this study was to elucidate patient experiences of using a VR calm room in a psychiatric inpatient setting.

DESIGN

Qualitative interview study. Semi-structured interviews were analysed using qualitive inductive content analysis, which focuses on the interpretation of texts for making replicable and valid inferences.

SETTING

Swedish hospital psychiatric inpatient care setting with a wireless, three degrees-of-freedom VR head-mounted display running a calm room application simulating nature environment.

PARTICIPANTS

20 adult patients (12 women) with bipolar disorder (n=18) or unipolar depression (n=2).

RESULTS

Participants experienced the use of the VR calm room as having a positive impact on them, inducing awareness, calmness and well-being. They were thankful to be offered a non-pharmacological alternative for anxiety relief. Participants also expressed that they had some concerns about how they would react emotionally before using the VR device. However, after use, they highlighted that their overall experience was positive. They also expressed that they could see potential for further development of VR technology in psychiatric care.

CONCLUSIONS

VR technology has the potential to solve pressing logistic issues in offering calm rooms in psychiatric inpatient care. VR calm rooms appear to be appreciated by psychiatric inpatients, who value their accessibility, convenience and variety of modalities offered. Participants perceived an increase in their well-being after use.

Virtual reality interventions for the treatment of anxiety disorders: A scoping review

BACKGROUND

& Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults.

METHODS

This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses.

RESULTS

The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans.

LIMITATIONS

Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded.

CONCLUSION

VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important.

Impact of virtual reality applications in the treatment of anxiety disorders: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND AND OBJECTIVES

Anxiety disorders are the most prevalent mental disorders worldwide. Virtual reality (VR) treatment approaches have increasingly been studied. Before clinical implementation, it is necessary to evaluate the treatment effect of VR applications. The objective is to evaluate the treatment effect of virtual reality applications in the treatment of anxiety disorders compared to conventional therapy.

METHODS

A systematic literature review with meta-analysis was conducted. Four databases were used to identify randomized controlled trials published between April 2011 and April 2021 which compare VR applications with non-VR interventions or waiting lists. Study characteristics, pre- and post-treatment data were extracted. Hedges g was calculated as effect size. Primary outcome was anxiety symptoms.

RESULTS

Data from 17 studies from 827 participants was extracted. The studies examined specific phobia (n = 9), social anxiety disorder (n = 4), agoraphobia (n = 2) and panic disorder (n = 2). 16 out of 17 studies used head-mounted displays as VR application. A non-significant effect size with significant heterogeneity was observed in favor of the use of VR applications in anxiety symptoms (g, 0.33; 95%-CI, -0.20-0.87). Compared to passive control groups, VR applications are associated significant with lower anxiety symptoms (g, 1.29; 95%-CI, 0.68-1.90).

LIMITATIONS

The study and patient characteristics varied between the individual studies which is reflected in a high statistical heterogeneity of the effect sizes.

CONCLUSIONS

The added value of VR applications over waiting-list or psychoeducation only control groups is obvious. VR applications can be used as part of the treatment of anxiety disorders, especially when conventional therapy is unavailable.

A Literature Review Examining Virtual Reality Exposure Therapy for Individuals Diagnosed With Social Anxiety Disorder

ABSTRACT

Social anxiety disorder (SAD) is a specific subtype of anxiety disorder where individuals experience uncomfortable social situations that induce anxious feelings including nervousness and panic. Computer technology has been applied in interventions for many mental health disorders. We aim to understand and explore the use of virtual reality exposure therapy (VRET) to treat adults with SAD. We conducted a literature search using relevant mesh keywords in PubMed and PsycINFO. Six studies met inclusion criteria in our final qualitative synthesis review. Results showed a significant reduction in SAD symptom severity based on primary measures in all studies, suggesting that VRET is an effective option in treating SAD. Studies have shown the success of VRET in formats such as a single-user implementation, one-session treatment, and self-training intervention. In conclusion, VRET is effective in reducing SAD symptoms. The limitations of most studies included a small sample size and weak ecological validity. Future research can examine VRET with a more extensive clinical sample and broader social behaviors.

Internet-Based Cognitive Behavioral Therapy and Virtual Reality Exposure Therapy for Social Anxiety Disorder: Protocol for a Randomized Controlled Trial in Hong Kong

BACKGROUND

Social anxiety disorder (SAD), also known as social phobia, is one of the most common mental disorders worldwide. In Hong Kong, the prevalence of SAD is high, but its treatment rate is low. SAD has immense impact on academic or work performance, social life, career development, and quality of life. One of the most effective treatments for SAD is cognitive behavioral therapy (CBT), with internet-based CBT (iCBT) and virtual reality exposure therapy (VRET) showing promise in treating SAD. However, internet interventions are underdeveloped in Chinese communities including Hong Kong.

OBJECTIVE

This study aims to develop an iCBT program that includes VRET, called "Ease Anxiety in Social Event Online" (Ease Online), for Hong Kong adults with SAD in a randomized controlled trial.

METHODS

The 14-week Ease Online program is a guided self-help iCBT program with a blended mode of service delivery. The program comprises 9 web-based modules and 5 individual counseling sessions (including 2 VRET sessions) conducted remotely or face-to-face with a therapist to provide therapist support, as guided iCBT shows superior effects than unguided iCBT. Other program components include therapist feedback on assignments, internal messages, forums, client portfolios, web-based questionnaires, reminders, and web-based bookings. The program can be accessed either through a mobile app or program website through a PC with an internet connection. The participants are openly recruited and screened using a questionnaire and through an intake interview. Eligible participants are randomized by placing them into a web-based iCBT group, app-based iCBT group, or a waitlist control (WLC) group. Participants in the WLC group are assigned to the app-based program upon completion of the service of the 2 experimental groups. Measurements of social anxiety, depression and anxiety symptoms, psychological distress, automatic thoughts, and quality of life are administered at pretest, posttest, and 3- and 6-month follow-ups. Multivariate ANOVA with repeated measures will be performed to determine the intervention effectiveness on the continuous variables over time.

RESULTS

Participant recruitment commenced in January 2021. As of February 2023, a total of 1811 individuals applied for the Ease Online program. In total, 401 intake interviews have been completed, and 329 eligible participants have joined the program, among whom 166 have completed the service. Data collection is still ongoing, which is expected to be completed in March 2024.

CONCLUSIONS

This study is the first of its kind in combining iCBT and VRET for the treatment of SAD in Hong Kong. At a theoretical level, this study contributes to the development and evaluation of internet-based psychological interventions in Hong Kong. At a practical level, the Ease Online program may serve as an alternative service option for SAD clients in Hong Kong if proven effective.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04995913; https://clinicaltrials.gov/study/NCT04995913.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48437.

Public speaking training in front of a supportive audience in Virtual Reality improves performance in real-life

Public speaking is a challenging task that requires practice. Virtual Reality allows to present realistic public speaking scenarios in this regard, however, the role of the virtual audience during practice remains unknown. In the present study, 73 participants completed a Virtual Reality practice session while audience was manipulated to be supportive or unsupportive or presentations were practiced without audience. Importantly, following the virtual practice, participants held the presentation during a real university course via Zoom. We measured emotional experience, self-efficacy, and the subjective evaluation of performance at baseline, after VR practice, and after the real presentation. Additionally, participants' performance in the real presentation was evaluated by instructors (blinded to condition). Supportive in contrast to unsupportive audiences led to more positive believes about one's own performance, while there were no changes in beliefs in the group without audience. Importantly, practice in front of a supportive compared to unsupportive audience resulted in a more positive evaluation of speaker confidence in real-life public speaking as rated by the instructors. These results demonstrate an impact of virtual social feedback during public speaking on subsequent subjective performance evaluation. This may increase self-confidence resulting in actual improved public speaking performance in real-life.

Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis

Importance

Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD.

Objective

To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD.

Data Sources

For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial.

Study Selection

Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD.

Data Extraction and Synthesis

Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models.

Main Outcomes and Measures

The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS.

Results

A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD).

Conclusions and Relevance

In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.

Interventions That Target or Affect Voice or Speech Production During Public Speaking: A Scoping Review

OBJECTIVES

Public speaking (PS) is frequently necessary in many professional, educational, and personal settings. Mastering this communication skill is particularly important in today's society. Training techniques for PS have been described in the literature. Given that PS anxiety affects performance, especially voice characteristics and speech fluency, the purpose of this scoping review is to examine, map, and narratively summarize the available evidence on PS interventions that target or affect voice or speech.

METHODS

An extensive literature search was conducted in three bibliographic databases: Medline ALL/Ovid, PsycINFO/Ovid, and Eric/Ovid. Of the 850 studies identified, 22 met the eligibility criteria, and one was added from the reference lists of the included studies.

RESULTS

A total of 23 studies were included. The interventions identified aim to improve speaking skills either by explicitly targeting the voice or speech (direct intervention, n = 15) or by targeting the cognitive, behavioral, psychological, or physical environment impacting the speaker's production (indirect intervention, n = 8).

CONCLUSIONS

This scoping review provides the first published methodological summary of the characteristics of existing PS interventions that target or affect voice and speech. Heterogeneous characteristics were observed. Further studies are needed to determine which interventions are most effective.

Engaging in Awkward Social Interactions in a Virtual Environment Designed for Exposure-Based Psychotherapy for People with Generalized Social Anxiety Disorder: An International Multisite Study

The effectiveness of in virtuo exposure-based treatment of performance-only social anxiety disorder (SAD) has been demonstrated in several studies. However, few studies have validated virtual environments with participants suffering from generalized SAD. The goal of this study is to confirm the potential of a virtual environment in inducing anxiety in adults suffering from generalized SAD, compared to adults without SAD, when engaged in awkward social interactions. Differences between participants from two different countries were also explored. The sample consisted of 15 participants with SAD from Canada, 17 participants without SAD from Canada, 16 participants with SAD from Spain, and 21 participants without SAD from Spain. All participants were immersed in a control virtual environment and in an experimental virtual environment considered potentially anxiety-inducing for individuals with generalized SAD. As hypothesized, results showed that the experimental virtual environment induced a higher level of anxiety than the control environment among participants with SAD compared to those without SAD. The impact on anxiety of each socially threatening task performed during the experimental immersion was statistically significant. In terms of anxiety responses, no significant differences were found between participants from Canada and Spain. However, spatial presence and ecological validity were higher in Canadians than in Spaniards. Unwanted negative side effects induced by immersions in virtual reality were higher in the SAD group. This study highlights the importance for therapists to engage people with SAD in clinically relevant tasks while immersed in VR psychotherapeutic applications.

Modification of the therapist's facial expressions using virtual reality technology during the treatment of social anxiety disorder: a case series

Exposure therapy is a mainstream of treatment for social anxiety disorder (SAD). However, effort and time are required to recreate interpersonal situations that produce moderate anxiety. On the other hand, virtual reality exposure therapy can easily control anxiety-inducing conditions and allow for graduated exposure. However, artificial intelligence and animations that speak as naturally as actual humans are not yet practical, adding to the limitations of these treatments. The authors propose the use of a virtual reality technology that can transform facial expressions into smiling or sad faces in real time and display them on a monitor, potentially solving the above-mentioned problems associated with virtual reality animations. This feasibility study was conducted to determine whether this system can be safely applied to the treatment of SAD patients. A total of four SAD patients received 16 exposure therapy sessions led by an experienced therapist over a monitor; throughout the sessions, the facial expressions of the therapist were modified using software to display expressions ranging from smiling to sad on the monitor that was being viewed by the patient. Client satisfaction, treatment alliance, and symptom assessments were then conducted. Although one patient dropped out of the study, treatment satisfaction and treatment alliance were scored high in all the cases. In two of the four cases, the improvement in symptoms was sustained over time. Exposure therapy in which the interviewer's facial expressions are modified to induce appropriate levels of anxiety in the patient can be safely used for the treatment of SAD patients and may be effective for some patients.

Virtual Reality Exposure Therapy as a Treatment Method Against Anxiety Disorders and Depression-A Structured Literature Review

Mental illness is a growing global health problem affecting individuals and society. In Sweden, the number of people suffering from mental health illnesses, such as anxiety and depression, is increasing and is expected to be one of the largest public health challenges in 2030. As mental illness increases, the area also needs effective forms of treatment. This study aims to investigate if Virtual Reality Exposure Therapy (VRET) works as a treatment method for adults suffering from anxiety disorders and depression. A structured literature review based on 24 articles found in the databases PubMed, MEDLINE, CINAHL and PsycInfo. Two reviewers independently reviewed and collectively extracted data from the included articles. The articles have been analyzed by using thematic analysis. The results suggest that Virtual reality exposure therapy can work as an effective treatment method for adults with anxiety disorders. It also indicates that VRET may act as a health-promoting intervention to reduce anxiety disorders, phobias, and depression symptoms. Virtual reality exposure therapy can be an effective treatment method and health-promoting effort against anxiety disorders in adults. An essential factor for the patients who accept VRET as a treatment is the initial information therapists give.

Systematic review and meta-analysis of randomised controlled trials for evaluating the effectiveness of virtual reality therapy for social anxiety disorder

OBJECTIVE

To evaluate the effectiveness of VR therapy (VRT) for symptoms related to social anxiety disorder (SAD), namely fear and avoidance of social interactions and performance situations (FASIP), fear of negative evaluation (FNE), anxiety and depression, a systematic review and meta-analysis were performed.

METHODS

Medline, PubMed, Science Direct, Web of Science, CINAHL, PsychINFO and Scopus were searched to include randomised controlled trials of VRT for SAD that met the criteria. A total of 15 RCTs with 720 participants published between 1998 and 2022 were included. Hedge's g with a 95 % confidence interval (CI) was adopted to compute the effect sizes.

RESULTS

Results showed no difference between the effect of VRT and CBT on FASIP, FNE, anxiety and depression and a large effect size for VRT versus the waitlist control group on FASIP (g = -1.170, 95 % CI: -2.056-0.283; p < 0.010). The moderator analysis demonstrated that VRT was superior to the controlled group in addressing FASIP, FNE and anxiety when the sample size was smaller than 50 and the number of sessions was five or fewer.

LIMITATIONS

Differences in hardware, software and intervention duration for VRT across studies.

CONCLUSION

This study confirmed the feasibility of VRT in alleviating the FASIP in patients with SAD, with the waitlist control group as a comparison. However, the effectiveness of VRT was not significant in FASIP, FNE, anxiety and depression compared to cognitive behavioural therapy (CBT). Additional social interaction scenarios should be developed in VRT, standardised hardware should be used and the proper length of exposure time to VR should be determined to enhance the efficacy of VRT.

A systematic review: Virtual-reality-based techniques for human exercises and health improvement

Virtual Reality (VR) has emerged as a new safe and efficient tool for the rehabilitation of many childhood and adulthood illnesses. VR-based therapies have the potential to improve both motor and functional skills in a wide range of age groups through cortical reorganization and the activation of various neuronal connections. Recently, the potential for using serious VR-based games that combine perceptual learning and dichoptic stimulation has been explored for the rehabilitation of ophthalmological and neurological disorders. In ophthalmology, several clinical studies have demonstrated the ability to use VR training to enhance stereopsis, contrast sensitivity, and visual acuity. The use of VR technology provides a significant advantage in training each eye individually without requiring occlusion or penalty. In neurological disorders, the majority of patients undergo recurrent episodes (relapses) of neurological impairment, however, in a few cases (60-80%), the illness progresses over time and becomes chronic, consequential in cumulated motor disability and cognitive deficits. Current research on memory restoration has been spurred by theories about brain plasticity and findings concerning the nervous system's capacity to reconstruct cellular synapses as a result of interaction with enriched environments. Therefore, the use of VR training can play an important role in the improvement of cognitive function and motor disability. Although there are several reviews in the community employing relevant Artificial Intelligence in healthcare, VR has not yet been thoroughly examined in this regard. In this systematic review, we examine the key ideas of VR-based training for prevention and control measurements in ocular diseases such as Myopia, Amblyopia, Presbyopia, and Age-related Macular Degeneration (AMD), and neurological disorders such as Alzheimer, Multiple Sclerosis (MS) Epilepsy and Autism spectrum disorder. This review highlights the fundamentals of VR technologies regarding their clinical research in healthcare. Moreover, these findings will raise community awareness of using VR training and help researchers to learn new techniques to prevent and cure different diseases. We further discuss the current challenges of using VR devices, as well as the future prospects of human training.

Virtual reality exposure therapy for reducing social anxiety in stuttering: A randomized controlled pilot trial

We report on findings from the first randomized controlled pilot trial of virtual reality exposure therapy (VRET) developed specifically for reducing social anxiety associated with stuttering. People who stutter with heightened social anxiety were recruited from online adverts and randomly allocated to receive VRET (n = 13) or be put on a waitlist (n = 12). Treatment was delivered remotely using a smartphone-based VR headset. It consisted of three weekly sessions, each comprising both performative and interactive exposure exercises, and was guided by a virtual therapist. Multilevel model analyses failed to demonstrate the effectiveness of VRET at reducing social anxiety between pre- and post-treatment. We found similar results for fear of negative evaluation, negative thoughts associated with stuttering, and stuttering characteristics. However, VRET was associated with reduced social anxiety between post-treatment and one-month follow-up. These pilot findings suggest that our current VRET protocol may not be effective at reducing social anxiety amongst people who stutter, though might be capable of supporting longer-term change. Future VRET protocols targeting stuttering-related social anxiety should be explored with larger samples. The results from this pilot trial provide a solid basis for further design improvements and for future research to explore appropriate techniques for widening access to social anxiety treatments in stuttering.

The gold-standard treatment for social anxiety disorder: A roadmap for the future

Exposure therapy (ET), which follows the Pavlovian extinction model, is regarded as the gold-standard treatment for social anxiety disorder (SAD). The prospect of virtual reality in lieu of a traditional laboratory setting for the treatment of SAD has not been rigorously explored. The aim of the review was to summarize, find gaps in the current literature, and formulate future research direction by identifying two broad research questions: the comparative efficacy between in vivo ET and virtual reality exposure therapy (VRET) and the effectiveness of the Pavlovian extinction model in treating SAD. The criteria for effectiveness were effect size, relapse prevention, attrition rate and ecological validity. A literature search on recent randomized controlled trials yielded a total of 6 original studies (N=358), excluding duplication and overlapping participants. All studies supported that VRET was as effective as in vivo ET. Behavioral therapy that follows classical conditioning principles has a high attrition and relapse rate. Comparisons were drawn between the efficacy of the Pavlovian extinction model and other existing models, including third-wave approaches. The neural markers are suggested to be included as efficacy measures in treating SAD. The gold-standard treatment for SAD requires a paradigm shift through rigorous longitudinal comparative studies.

Virtual Reality Interventions for Mental Health

Virtual Reality (VR) is a growing field in psychological research and therapy. While there is strong evidence for the efficacy of exposure therapy in VR (VRET) to treat anxiety disorders, new opportunities for using VR to treat mental health disorders are emerging. In this chapter, we first describe the value of VRET for the treatment of several anxiety disorders. Next, we introduce some recent developments in research using VR investigating schizophrenia, neurodevelopmental disorders, and eating disorders. This includes therapeutic strategies beyond VRET, including avatar-based therapies or those combining VR with biofeedback approaches. Although VR offers many convincing advantages, contraindications in treatment must be considered when implementing VR-supported therapy in clinical practice. Finally, we provide an outlook for future research, highlighting the integration of augmented reality and automation processes in VR environments to create more efficient and tailored therapeutic tools. Further, future treatments will benefit from the gamification approach, which integrates elements of computer games and narratives that promote patients' motivation and enables methods to reduce drop-outs during psychological therapy.

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.

Bağlanma Stilleri ve Sosyal Fobi Arasındaki İlişkide Kişilerarası İlişkiler ve Benliğin Ayrımlaşmasının Aracı Rolü

Bu çalışmanın amacı sosyal fobi, bağlanma stilleri, kişilerarası ilişkiler ve benliğin ayrımlaşması arasındaki ilişkilerin incelenmesi ve bağlanma stilleri ile sosyal fobi arasındaki ilişkide kişilerarası ilişkiler ve benliğin ayrımlaşmasının aracı rolünün belirlenmesidir. İstanbul ilinde yapılan araştırmaya, 18-70 yaş aralığında (30.60±11.66) olan 197 (%62.7) kadın ve 117 (%37.3) erkek olmak üzere toplam 314 kişi dahil edilmiştir. Veri toplama aracı olarak Liebowitz Sosyal Fobi Ölçeği, Kişilerarası İlişki Boyutları Ölçeği, İlişki Ölçekleri Anketi ve Benliğin Ayrımlaşması Ölçeği kullanılmıştır. Paralel aracılık rolleri Hayes’in PROCESS makro eklentisiyle Bootstrap yöntemi temel alınarak test edilmiştir Korelasyon analizi sonuçlarına göre değişkenler arasında zayıf ve orta düzeyde anlamlı ilişkiler bulunmuştur. Aracılık analizi bulguları ise güvenli bağlanma ve sosyal fobi-kaygı arasındaki ilişkide onay bağımlılığı, başkalarına güven ve duygusal tepkiselliğin paralel aracılık etkisinin olduğu; güvenli bağlanma ve sosyal fobi-kaçınma arasındaki ilişkide onay bağımlılığı ve başkalarına güvenin paralel aracılık etkisi olduğu; kayıtsız bağlanma ve sosyal fobi-kaygı ve kaçınma arasındaki ilişkide başkalarına güven ve duygusal tepkiselliğin paralel aracılık etkisi olduğu; korkulu bağlanma ve sosyal fobi-kaygı ve kaçınma arasındaki ilişkide onay bağımlılığı ve başkalarına güvenin paralel aracılık etkisinin olduğu; saplantılı bağlanma ve sosyal fobi-kaygı arasındaki ilişkide onay bağımlılığı, başkalarına güven ve duygusal tepkiselliğin paralel aracılık etkisi, saplantılı bağlanma ve sosyal fobi-kaçınma arasındaki ilişkide ise onay bağımlılığı ve başkalarına güvenin paralel aracılık etkisinin olduğu tespit edilmiştir. Toplam 8 anlamlı modelin, varyansın %4 ila %19’unu açıkladığı görülmüştür. Çalışmanın bulgularının bağlanma ve sosyal fobi arasındaki ilişkiye aracılık eden değişkenlerin belirlenmesi ve bu değişkenlere yönelik klinik müdahalelerin geliştirilmesi konularında çıkarımlar yapılmasına katkı sağlayabileceği söylenebilir.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Long-term outcomes of cognitive behavioural therapy for social anxiety disorder: A meta-analysis of randomised controlled trials

Cognitive Behavioural Therapy (CBT) is effective in treating Social Anxiety Disorder (SAD). However, less is known about whether gains achieved in disorder-specific and secondary outcomes (e.g., depression, general anxiety, quality of life, and self-esteem) are maintained 12 months or longer. A systematic literature search yielded 25 relevant studies that administered CBT to participants with SAD. Multivariate meta-analyses of post-treatment assessments, found that CBT was superior to control conditions in reducing social anxiety (g =.74), depression (g =.52), general anxiety (g =.69) and improving quality of life (g =.39). The within-groups effect sizes revealed that 12 months or more after CBT treatment, symptoms continued to improve for social anxiety (g_av =.23) and quality of life (g_av =.17), and gains were maintained for depressive (g_av =.06) and general anxiety symptoms (g_av =.03). However, meta-analyses of long-term outcomes lack comparison groups. Moderation was non-significant for the treatment model, format, number of sessions, treatment duration, or inclusion of booster sessions. Future research may investigate what drives improvement after treatment cessation and how CBT affects other co-occurring symptomatology. Taken together, CBT produces many benefits for SAD and individuals with co-occurring symptoms can benefit from extant SAD-focused treatments.

Standard CBT versus integrative and multimodal CBT assisted by virtual-reality for generalized anxiety disorder

Introduction

Generalized Anxiety Disorder (GAD) is a prevalent emotional disorder associated with increased dysfunctionality, which has a lasting impact on the individual’s quality of life. Besides medication, Cognitive-Behavioral Therapy (CBT) represents the golden standard psychotherapeutic approach for GAD, integrating multilevel techniques and various delivery formats that enable the development of tailored treatment protocols. The objective of this study was to compare the efficiency of a standard CBT protocol targeting worries, dysfunctional beliefs, and intolerance of uncertainty with an integrative and multimodal CBT intervention augmented with Virtual Reality (VR).

Materials and methods

This study included 66 participants (M_age = 22.53 years; SD = 2.21) with moderate GAD symptoms that were randomized to the standard CBT group (CBTs; N = 32) and the Integrative and Multimodal CBT augmented with VR (IM-VRCBT; N = 34) group. The interventions comprised 10 weekly sessions conducted by trained CBT therapists, including cognitive restructuring, problem-solving, behavioral exposure, and relaxation techniques. Baseline and post-assessments were conducted with both groups. Primary outcome measures included the Hamilton Anxiety Rating Scale (HARS) and Penn-State Worry Questionnaire (PSWQ) to evaluate the severity of GAD symptoms and worries, respectively. Secondary outcomes involved the administration of Automatic Thoughts Questionnaire (ATQ), Dysfunctional Attitudes Scale (DAS) and Unconditional Self-Acceptance Questionnaire (USAQ).

Results

Both interventions determined statistically significant effects on both primary and secondary outcomes (ps < 0.001) in the expected direction. However, CBTs was associated with higher effect sizes for anxiety (Cohen’s d = 2.76) and worries (Cohen’s d = 1.85), in contrast to IM-VRCBT. Also, secondary analyses revealed positive correlations between changes in anxiety and worries level and the reduction of dysfunctional cognitive processes.

Conclusion

This research emphasized the effectiveness of CBT interventions for treating adults with moderate GAD symptomatology. Specifically, both interventions were efficient for reducing anxiety symptomatology present at individuals with GAD. However, regarding cognitive dysfunctions like worries, the standard CBT protocol performed better, as compared to the IM-VRCBT. In addition, we conclude that VR could be integrated within CBT interventions in a single protocol for GAD treatment.

Digital literacy in contemporary mental healthcare: online assessments and mobile health apps

‘Digital’ is an omnipresent yet often vague, misunderstood or feared topic in health services. There are many current and potential gains for individual patients and local populations, clinicians and organisations through optimisation of digital technologies. We argue that understanding the various aspects of digital psychiatry is an essential contemporary need. This is the first of two articles on the subject, exploring the gains and challenges of virtual/online assessments, including ethical considerations and the use of virtual reality and electronic prescribing.

Eating disorder and social anxiety symptoms in Iranian preadolescents: a network analysis

PURPOSE

Network studies of eating disorder (ED) symptoms have identified central and bridge symptoms in Western samples, yet few network models of ED symptoms have been tested in non-Western samples, especially among preadolescents. The current study tested a network model of ED symptoms in Iranian preadolescents (ages 9 to 13), as well as a model of co-occurring social anxiety disorder (SAD) and ED symptoms.

METHOD

Preadolescent boys (n = 405) and girls (n = 325) completed the Children Eating Attitudes Test-20 and Social Anxiety Scale for Children. We estimated two network models (ED and ED/SAD networks) and identified central and bridge symptoms, as well as tested if these models differed by sex.

RESULTS

We found that discomfort eating sweets were the most central symptoms in ED networks. Concern over being judged was central in networks including both ED and SAD symptoms. Additionally, concern over being judged was the strongest bridge symptoms. Networks did not differ by sex.

CONCLUSION

Future research is needed to test if interventions focused on bridge symptoms (i.e., concern over being judged) as primary intervention points target comorbid ED-SAD pathology in preadolescents at risk for ED and SAD.

LEVEL OF EVIDENCE

Level III; Evidence obtained from well-designed observational study, including case-control design for relevant aspects of the study.

Self-guided virtual reality therapy for social anxiety disorder: a study protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) is a highly prevalent mental disorder associated with enormous stress and suffering. Cognitive behavior therapy (CBT) is the first-line treatment for SAD, yet its accessibility is often constrained with long waiting times. Digital therapeutic applications, including psychoeducation and self-guided behavioral experiments in virtual reality (VR), could facilitate access and reduce waiting times. The study aims to investigate if ultra-short-time therapy involving self-guided digital therapeutic applications with VR components can reduce the severity of SAD.

METHODS

Forty SAD patients will participate in this randomized controlled trial. Half will get access to a self-guided, digital therapeutic application with exposure-based behavioral experiments in VR, while the other half will receive a control treatment. Both treatments include four therapeutic appointments. Changes in the severity of SAD will be measured after each appointment and on a 6-week follow-up assessment and will be compared between groups, with the change in SAD measured at baseline- and post-assessment as primary outcome.

DISCUSSION

Self-guided digital therapeutic applications including ultra-short-time therapy combined with VR could help reduce the waiting time for patients and relieve the health system. The results of this study may inform psychotherapists regarding the potential of self-guided digital therapeutic applications including exposure-based behavioral experiments in VR for SAD and will provide important insight for future research on VR therapy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18013983 . Registered on 1 February 2022.

Neural effects of a short-term virtual reality self-training program to reduce social anxiety

BACKGROUND

Social anxiety disorder (SAD) is characterized by anxiety regarding social situations, avoidance of external social stimuli, and negative self-beliefs. Virtual reality self-training (VRS) at home may be a good interim modality for reducing social fears before formal treatment. This study aimed to find neurobiological evidence for the therapeutic effect of VRS.

METHODS

Fifty-two patients with SAD were randomly assigned to a VRS or waiting list (WL) group. The VRS group received an eight-session VRS program for 2 weeks, whereas the WL group received no intervention. Clinical assessments and functional magnetic resonance imaging scanning with the distress and speech evaluation tasks were repeatedly performed at baseline and after 3 weeks.

RESULTS

The post-VRS assessment showed significantly decreased anxiety and avoidance scores, distress index, and negative evaluation index for 'self', but no change in the negative evaluation index for 'other'. Patients showed significant responses to the distress task in various regions, including both sides of the prefrontal regions, occipital regions, insula, and thalamus, and to the speech evaluation task in the bilateral anterior cingulate cortex. Among these, significant neuronal changes after VRS were observed only in the right lingual gyrus and left thalamus.

CONCLUSIONS

VRS-induced improvements in the ability to pay attention to social stimuli without avoidance and even positively modulate emotional cues are based on functional changes in the visual cortices and thalamus. Based on these short-term neuronal changes, VRS can be a first intervention option for individuals with SAD who avoid society or are reluctant to receive formal treatment.

Visually sensitive seizures: An updated review by the Epilepsy Foundation

Light flashes, patterns, or color changes can provoke seizures in up to 1 in 4000 persons. Prevalence may be higher because of selection bias. The Epilepsy Foundation reviewed light-induced seizures in 2005. Since then, images on social media, virtual reality, three-dimensional (3D) movies, and the Internet have proliferated. Hundreds of studies have explored the mechanisms and presentations of photosensitive seizures, justifying an updated review. This literature summary derives from a nonsystematic literature review via PubMed using the terms "photosensitive" and "epilepsy." The photoparoxysmal response (PPR) is an electroencephalography (EEG) phenomenon, and photosensitive seizures (PS) are seizures provoked by visual stimulation. Photosensitivity is more common in the young and in specific forms of generalized epilepsy. PS can coexist with spontaneous seizures. PS are hereditable and linked to recently identified genes. Brain imaging usually is normal, but special studies imaging white matter tracts demonstrate abnormal connectivity. Occipital cortex and connected regions are hyperexcitable in subjects with light-provoked seizures. Mechanisms remain unclear. Video games, social media clips, occasional movies, and natural stimuli can provoke PS. Virtual reality and 3D images so far appear benign unless they contain specific provocative content, for example, flashes. Images with flashes brighter than 20 candelas/m² at 3-60 (particularly 15-20) Hz occupying at least 10 to 25% of the visual field are a risk, as are red color flashes or oscillating stripes. Equipment to assay for these characteristics is probably underutilized. Prevention of seizures includes avoiding provocative stimuli, covering one eye, wearing dark glasses, sitting at least two meters from screens, reducing contrast, and taking certain antiseizure drugs. Measurement of PPR suppression in a photosensitivity model can screen putative antiseizure drugs. Some countries regulate media to reduce risk. Visually-induced seizures remain significant public health hazards so they warrant ongoing scientific and regulatory efforts and public education.

Prediction of specific anxiety symptoms and VR sickness based on in-situ autonomic physiological signals during VR treatment in patients with social anxiety disorder: mixed-methods study (Preprint)

Background

Social anxiety disorder (SAD) is the fear of social situations where a person anticipates being evaluated negatively. Changes in autonomic response patterns are related to the expression of anxiety symptoms. Virtual reality (VR) sickness can inhibit VR experiences.

Objective

This study aimed to predict the severity of specific anxiety symptoms and VR sickness in patients with SAD, using machine learning based on in situ autonomic physiological signals (heart rate and galvanic skin response) during VR treatment sessions.

Methods

This study included 32 participants with SAD taking part in 6 VR sessions. During each VR session, the heart rate and galvanic skin response of all participants were measured in real time. We assessed specific anxiety symptoms using the Internalized Shame Scale (ISS) and the Post-Event Rumination Scale (PERS), and VR sickness using the Simulator Sickness Questionnaire (SSQ) during 4 VR sessions (#1, #2, #4, and #6). Logistic regression, random forest, and naïve Bayes classification classified and predicted the severity groups in the ISS, PERS, and SSQ subdomains based on in situ autonomic physiological signal data.

Results

The severity of SAD was predicted with 3 machine learning models. According to the F1 score, the highest prediction performance among each domain for severity was determined. The F1 score of the ISS mistake anxiety subdomain was 0.8421 using the logistic regression model, that of the PERS positive subdomain was 0.7619 using the naïve Bayes classifier, and that of total VR sickness was 0.7059 using the random forest model.

Conclusions

This study could predict specific anxiety symptoms and VR sickness during VR intervention by autonomic physiological signals alone in real time. Machine learning models can predict the severe and nonsevere psychological states of individuals based on in situ physiological signal data during VR interventions for real-time interactive services. These models can support the diagnosis of specific anxiety symptoms and VR sickness with minimal participant bias.

Trial Registration

Clinical Research Information Service KCT0003854; https://cris.nih.go.kr/cris/search/detailSearch.do/13508

Acceptance of E-Mental Health Services for Different Application Purposes Among Psychotherapists in Clinical Training in Germany and Switzerland: Secondary Analysis of a Cross-Sectional Survey

Background

Despite solid evidence supporting the efficacy of electronic mental health (EMH) services, their acceptance among psychotherapists is limited and uptake rates remain low. However, the acceptance of different EMH services has yet barely been examined in future generations of psychotherapists in a differentiated manner. The aims of this study were (1) to elaborate the intention to use various EMH services for different application purposes and (2) to determine predictors of EMH service acceptance among psychotherapists in clinical training (PiT).

Materials and Methods

Our paper is based on a secondary data analysis of a cross-sectional survey. Respondents were recruited via recognized educational institutions for psychotherapy within Germany and the German-speaking part of Switzerland between June and July of 2020. The survey contained items on the intention to use different EMH services (i.e., guided and unguided programs, virtual reality, psychotherapy by telephone and videoconference) for various application purposes (i.e., prevention, treatment addition, treatment substitute, aftercare). Potential predictors of EMH service acceptance (e.g., barriers and advantages) were examined based on an extension of the Unified Theory of Acceptance and Use of Technology (UTAUT).

Results

Most of the n = 216 respondents were female (88.4%) and located in Germany (72.2%). General acceptance of EMH was moderate (M = 3.4, SD = 1.12, range 1-5), while acceptance of psychotherapy via videoconference was highest (M = 3.7, SD = 1.15) and acceptance of unguided programs was lowest (M = 2.55, SD = 1.14). There was an interaction effect of EMH service and application purpose (η2 = 0.21). Barriers and advantages both had a uniform influence on EMH service acceptance (Pr > 0.999), while impersonality, legal concerns, concerns about therapeutic alliance, simplified information provision, simplified contact maintenance, time flexibility, and geographic flexibility were significant predictors (all p < 0.05). Results showed that the extended UTAUT model was the best fitting model to predict EMH service acceptance (Pr > 0.999).

Conclusions

The intention to use different EMH services varied between application purposes among PiT. To increase acceptance of EMH services and reduce misconceptions, we identified predictors that should be addressed in future acceptance-facilitating interventions when educating PiT.

Virtual Reality Exposure Therapy for Treating Social Anxiety: A Scoping Review of Treatment Designs and Adaptation to Stuttering

Virtual Reality Exposure Therapy (VRET) has been shown to be an effective technique for reducing social anxiety. People who stutter are at greater risk of developing heightened social anxiety. Cognitive behavior therapy protocols have shown promise in reducing social anxiety in people who stutter, but no studies have investigated VRET targeting social anxiety associated with stuttering. The aim of the current review is to provide an overview of VRET techniques used to treat social anxiety and insights into how these techniques might be adopted in the case of comorbid stuttering and social anxiety. Twelve studies were reviewed to understand key distinctions in VRET protocols used to treat social anxiety. Distinctions include exercises targeting public speaking vs. general social anxiety, computer-generated virtual environments vs. 360° video, and therapist guided vs. automated VRET. Based on the review findings, we propose how certain features could be applied in the case of stuttering. Virtual therapists, inhibitory learning techniques and integration into speech therapy may be suitable ways to tailor VRET. Regardless of these different techniques, VRET should consider the situations and cognitive-behavioral processes that underlie the experience of social anxiety amongst people who stutter.

The Effectiveness of Virtual Reality Exposure-Based Cognitive Behavioral Therapy for Severe Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder: Meta-analysis

BACKGROUND

In recent years, virtual reality exposure-based cognitive behavioral therapy (VRE-CBT) has shown good treatment results in (subclinical) anxiety disorders and seems to be a good alternative to exposure in vivo in regular cognitive behavioral therapy (CBT). However, previous meta-analyses on the efficacy of VRE-CBT on anxiety disorders have included studies on specific phobias and subthreshold anxiety; therefore, these results may not be generalizable to patients with more severe and disabling anxiety disorders.

OBJECTIVE

The objective of our study is to determine the efficacy of VRE-CBT on more severe anxiety disorders, excluding specific phobias and subthreshold anxiety disorders. Meta-analyses will be conducted to examine the efficacy of VRE-CBT versus waitlist and regular CBT. Our secondary objectives are to examine whether the efficacy differs according to the type of anxiety disorder, type of recruitment, and type of VRE-CBT (virtual reality exposure either with or without regular CBT). Furthermore, attrition in VRE-CBT and CBT will be compared.

METHODS

Studies published until August 20, 2020, were retrieved through systematic literature searches in PubMed, PsycINFO, and Embase. We calculated the effect sizes (Hedges g) for the difference between the conditions and their 95% CIs for posttest and follow-up measurements in a random effects model. A separate meta-analysis was performed to compare attrition between the VRE-CBT and CBT conditions.

RESULTS

A total of 16 trials with 817 participants were included. We identified 10 comparisons between VRE-CBT and a waitlist condition and 13 comparisons between VRE-CBT and a CBT condition. With regard to risk of bias, information on random sequence generation, allocation concealment, and risk of bias for selective outcome reporting was often absent or unclear. The mean effect size of VRE-CBT compared with waitlist (n_co=10) was medium and significant, favoring VRE-CBT (Hedges g=-0.490, 95% CI -0.82 to -0.16; P=.003). The mean effect size of VRE-CBT compared with CBT (n_co=13) was small and nonsignificant, favoring CBT (Hedges g=0.083, 95% CI -0.13 to 0.30; P=.45). The dropout rates between VRE-CBT and CBT (n_co=10) showed no significant difference (odds ratio 0.79, 95% CI 0.49-1.27; P=.32). There were no indications of small study effects or publication bias.

CONCLUSIONS

The results of our study show that VRE-CBT is more effective than waitlist and as effective as CBT in the treatment of more severe anxiety disorders. Therefore, VRE-CBT may be considered a promising alternative to CBT for patients with more severe anxiety disorders. Higher-quality randomized controlled trials are needed to verify the robustness of these findings.

Group cognitive behavioural therapy with virtual reality exposure versus group cognitive behavioural therapy with in vivo exposure for social anxiety disorder and agoraphobia: a protocol for a randomised clinical trial

INTRODUCTION

Anxiety disorders have a high lifetime prevalence, early-onset and long duration or chronicity. Exposure therapy is considered one of the most effective elements in cognitive behavioural therapy (CBT) for anxiety, but in vivo exposure can be challenging to access and control, and is sometimes rejected by patients because they consider it too aversive. Virtual reality allows flexible and controlled exposure to challenging situations in an immersive and protected environment.

AIM

The SoREAL-trial aims to investigate the effect of group cognitive behavioural therapy (CBT-in vivo) versus group CBT with virtual reality exposure (CBT-in virtuo) for patients diagnosed with social anxiety disorder and/or agoraphobia, in mixed groups.

METHODS AND ANALYSIS

The design is an investigator-initiated randomised, assessor-blinded, parallel-group and superiority-designed clinical trial. Three hundred two patients diagnosed with social anxiety disorder and/or agoraphobia will be included from the regional mental health centres of Copenhagen and North Sealand and the Northern Region of Denmark. All patients will be offered a manual-based 14-week cognitive behavioural group treatment programme, including eight sessions with exposure therapy. Therapy groups will be centrally randomised with concealed allocation sequence to either CBT-in virtuo or CBT-in vivo. Patients will be assessed at baseline, post-treatment and 1-year follow-up by treatment blinded researchers and research assistants. The primary outcome will be diagnosis-specific symptoms measured with the Liebowitz Social Anxiety Scale for patients with social anxiety disorder and the Mobility Inventory for Agoraphobia for patients with agoraphobia. Secondary outcome measures will include depression symptoms, social functioning and patient satisfaction. Exploratory outcomes will be substance and alcohol use, working alliance and quality of life.

ETHICS AND DISSEMINATION

The trial has been approved by the research ethics committee in the Capital Region of Denmark. All results, positive, negative as well as inconclusive, will be published as quickly as possible and still in concordance with Danish law on the protection of confidentially and personal information. Results will be presented at national and international scientific conferences. The trial has obtained approval by the Regional Ethics Committee of Zealand (H-6-2013-015) and the Danish Data Protection Agency (RHP-2014-009-02670). The trial is registered at ClinicalTrial.gov as NCT03845101. The patients will receive information on the trial both verbally and in written form. Written informed consent will be obtained from each patient before inclusion in the trial. The consent form will be scanned and stored in the database system and the physical copy will be destroyed. It is emphasised that participation in the trial is voluntary and that the patient can withdraw his or her consent at any time without consequences for further and continued treatment.

TRIAL REGISTRATION NUMBER

NCT03845101.

Virtual reality and mental health in older adults: a systematic review

IMPORTANCE

Virtual reality (VR) is a promising tool with the potential to enhance care of cognitive and affective disorders in the aging population. VR has been implemented in clinical settings with adolescents and children; however, it has been less studied in the geriatric population.

OBJECTIVE

The objective of this study is to determine the existing levels of evidence for VR use in clinical settings and identify areas where more evidence may guide translation of existing VR interventions for older adults.

DESIGN AND MEASUREMENTS

We conducted a systematic review in PubMed and Web of Science in November 2019 for peer-reviewed journal articles on VR technology and its applications in older adults. We reviewed article content and extracted the number of study participants, study population, goal of the investigation, the level of evidence, and categorized articles based on the indication of the VR technology and the study population.

RESULTS

The database search yielded 1554 total results, and 55 articles were included in the final synthesis. The most represented study design was cross-sectional, and the most common study population was subjects with cognitive impairment. Articles fell into three categories for VR Indication: Testing, Training, and Screening. There was a wide variety of VR environments used across studies.

CONCLUSIONS

Existing evidence offers support for VR as a screening and training tool for cognitive impairment in older adults. VR-based tasks demonstrated validity comparable to some paper-based assessments of cognition, though more work is needed to refine diagnostic specificity. The variety of VR environments used shows a need for standardization before comparisons can be made across VR simulations. Future studies should address key issues such as usability, data privacy, and confidentiality. Since most literature was generated from high-income countries (HICs), it remains unclear how this may be translated to other parts of the world.

Virtual Reality Aided Therapy towards Health 4.0: A Two-Decade Bibliometric Analysis

Health 4.0 aligns with Industry 4.0 and encourages the application of the latest technologies to healthcare. Virtual reality (VR) is a potentially significant component of the Health 4.0 vision. Though VR in health care is a popular topic, there is little knowledge of VR-aided therapy from a macro perspective. Therefore, this paper was aimed to explore the research of VR in aiding therapy, thus providing a potential guideline for futures application of therapeutic VR in healthcare towards Health 4.0. A mixed research method was adopted for this research, which comprised the use of a bibliometric analysis (a quantitative method) to conduct a macro overview of VR-aided therapy, the identification of significant research structures and topics, and a qualitative review of the literature to reveal deeper insights. Four major research areas of VR-aided therapy were identified and investigated, i.e., post-traumatic stress disorder (PTSD), anxiety and fear related disorder (A&F), diseases of the nervous system (DNS), and pain management, including related medical conditions, therapies, methods, and outcomes. This study is the first to use VOSviewer, a commonly used software tool for constructing and visualizing bibliometric networks and developed by Center for Science and Technology Studies, Leiden University, the Netherlands, to conduct bibliometric analyses on VR-aided therapy from the perspective of Web of Science core collection (WoSc), which objectively and visually shows research structures and topics, therefore offering instructive insights for health care stakeholders (particularly researchers and service providers) such as including integrating more innovative therapies, emphasizing psychological benefits, using game elements, and introducing design research. The results of this paper facilitate with achieving the vision of Health 4.0 and illustrating a two-decade (2000 to year 2020) map of pre-life of the Health Metaverse.

Cognitive behavioral therapy with adaptive virtual reality exposure vs. cognitive behavioral therapy with in vivo exposure in the treatment of social anxiety disorder: A study protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) has a high prevalence and an early onset with recovery taking decades to occur. Current evidence supports the efficacy of cognitive behavioral therapy (CBT) with virtual reality (VR) exposure. However, the evidence is based on a sparse number of studies with predominantly small sample sizes. There is a need for more trials investigating the optimal way of applying VR based exposure for SAD. In this trial, we will test the efficacy of CBT with adaptive VR exposure allowing adjustment of the exposure based on real-time monitoring of the participants's anxiety level.

METHODS

The trial is a randomized controlled, assessor-blinded, parallel-group superiority trail. The study has two arms: (1) CBT including exposure in vivo (CBT-Exp), (2) CBT including exposure therapy using individually tailored VR-content and a system to track anxiety levels (CBT-ExpVR). Treatment is individual, manual-based and consists of 10 weekly sessions with a duration of 60 min. The study includes 90 participants diagnosed with SAD. Assessments are carried out pre-treatment, mid-treatment and at follow-up (6 and 12 months). The primary outcome is the mean score on the Social Interaction Anxiety Scale (SIAS) with the primary endpoint being post-treatment.

DISCUSSION

The study adds to the existing knowledge by assessing the efficacy of CBT with adaptive VR exposure. The study has high methodological rigor using a randomized controlled trial with a large sample size that includes follow-up data and validated measures for social anxiety outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT05302518.

Borderline Personality Traits and Emotion Regulation Strategies in Adolescents: The Role of Implicit Theories

Borderline Personality Disorder (BPD) is associated with emotion dysregulation. The emotion regulation strategies people adopt may depend on one's belief about emotion as either fixed or changeable (termed "implicit theory"). We test this experimentally by modifying beliefs about emotions using virtual reality (VR). A sample of 29 adolescents (ages 14-17 years) were recruited from two adolescent inpatient units for an uncontrolled pilot trial of a new brief intervention. We measured BPD traits, beliefs about emotion, treatment preference, cognitive reappraisal and rumination, before the VR game and 14-31 days later. Adolescents with higher levels of BPD traits endorsed fixed beliefs of emotion and reported higher levels of rumination and lower levels of cognitive reappraisal. After a one-time message delivered via VR, adolescents evidenced an increase in belief that their emotions were changeable. These findings suggest beliefs about emotions may have an important role in interventions for adolescents with BPD traits.

A Decade in Review: A Systematic Review of Virtual Reality Interventions for Emotional Disorders

Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.

The Effects of Virtual Reality Treatment on Prefrontal Cortex Activity in Patients With Social Anxiety Disorder: Participatory and Interactive Virtual Reality Treatment Study

BACKGROUND

Attempts to use virtual reality (VR) as a treatment for various psychiatric disorders have been made recently, and many researchers have identified the effects of VR in psychiatric disorders. Studies have reported that VR therapy is effective in social anxiety disorder (SAD). However, there is no prior study on the neural correlates of VR therapy in patients with SAD.

OBJECTIVE

The aim of this study is to find the neural correlates of VR therapy by evaluating the treatment effectiveness of VR in patients with SAD using portable functional near-infrared spectroscopy (fNIRS).

METHODS

Patients with SAD (n=28) were provided with 6 sessions of VR treatment that was developed for exposure to social situations with a recording system of each participant's self-introduction in VR. After each VR treatment session, the first-person view (video 1) and third-person view (video 2) clips of the participant's self-introduction were automatically generated. The functional activities of prefrontal regions were measured by fNIRS while watching videos 1 and 2 with a cognitive task, before and after whole VR treatment sessions, and after the first session of VR treatment. We compared the data of fNIRS between patients with SAD and healthy controls (HCs; n=27).

RESULTS

We found that reduction in activities of the right frontopolar prefrontal cortex (FPPFC) in HCs was greater than in the SAD group at baseline (t=-2.01, P=.049). Comparing the frontal cortex activation before and after VR treatment sessions in the SAD group showed significant differences in activities of the FPPFC (right: t=-2.93, P<.001; left: t=-2.25, P=.03) and the orbitofrontal cortex (OFC) (right: t=-2.10, P=.045; left: t=-2.21, P=.04) while watching video 2.

CONCLUSIONS

Activities of the FPPFC and OFC were associated with symptom reduction after VR treatment for SAD. Our study findings might provide a clue to understanding the mechanisms underlying VR treatment for SAD.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS) KCT0003854; https://tinyurl.com/559jp2kp.

The Simulation Game-Virtual Reality Therapy for the Treatment of Social Anxiety Disorder: A Systematic Review

(1) Background: With the term Virtual reality (VR) we refer to a three-dimensional environment generated by the computer, in which subjects interact with the environment as if they were really inside it. The most used VR tools are the so-called HMD (head-mounted display) which make it possible to achieve what theorists define "direct mediated action". The aim of our systematic review is specifically to investigate the applications of virtual reality therapy for the treatment of social anxiety disorder, also known as social phobia. The most common treatment for social anxiety disorder is represented by "in vivo exposure therapy" (iVET). This method consists of exposing the participant, in a gradual and controlled way, to anxious stimuli, with the goal to change the subject's response to the object or situation that is causing the fear. However, the main flaw of "in Vivo therapies" is represented by both the huge costs involved and the possible disturbance variables that can hinder the execution of the therapeutic treatment. Virtual reality exposure therapy could therefore, if confirmed in its effectiveness, constitute a solution to eliminate these two defects demonstrated by "in vivo exposure therapy". The goal is to use VR as a means for the clinician to build a tailor-made path for the participant in order to make him acquire "in virtual" those skills necessary for a good adaptation in the "real" world. (2) Methods: From February 2021 until the date of submission of the article (September 2021), we conducted a systematic review aiming to verify the effectiveness of virtual reality exposure therapy (VRET) for the treatment of SAD. (3) Results: We identified a total of 205 unique articles. Among these, 20 full-text articles were assessed for eligibility and 5 of these met the eligibility criteria and were, therefore, included in the final systematic review. (4) Conclusions: Virtual reality therapies proved to be a valid alternative to the acquisition of social skills suitable for improving the symptoms of SAD. Although there has not been a significant difference between VRET and iVET, the low costs and flexibility of VRET open up new scenarios for achieving greater psychophysical well-being.

Pilot randomized trial of self-guided virtual reality exposure therapy for social anxiety disorder

BACKGROUND

Virtual reality exposure therapy (VRE) has shown promising efficacy for the treatment of social anxiety disorder (SAD) and related comorbidities. However, most trials conducted to date were therapist-led, and little is known about the efficacy of self-guided VRE. Therefore, this randomized controlled trial (RCT) aimed to determine the efficacy of a self-directed VRE for SAD.

METHOD

Forty-four community-dwelling or undergraduate adults diagnosed with SAD based on the Mini International Neuropsychiatric Interview were randomly assigned to VRE designed to last four sessions or more (n = 26) or waitlist (WL; n = 18). Self-reported SAD severity (Social Phobia Diagnostic Questionnaire and Social Interaction Anxiety Scale), job interview anxiety (Measure of Anxiety in Selection Interviews), trait worry (Penn State Worry Questionnaire), and depression symptoms (Patient Health Questionnaire-9) were administered at baseline, post-treatment, 3-month-follow-up (3MFU), and 6-month-follow-up (6MFU). Piecewise multilevel modeling analyses were conducted to manage clustering in the data.

RESULTS

VRE vs. WL resulted in greater reductions in SAD symptom severity, job interview fear, and trait worry, with moderate-to-large effect sizes (Hedge's g = -0.54 to -1.11) from pre-to-post treatment. Although significant between-group differences did not emerge for change in depression, VRE led to change in depression, whereas waitlist did not. These gains were also maintained at 3MFU and 6MFU. Further, facets of presence increased during the course of VRE (g = 0.36-0.45), whereas cybersickness decreased (g = -0.43).

DISCUSSION

Brief, self-guided VRE might ameliorate SAD and comorbid worry, for young-to-middle-aged adults with SAD. Other theoretical and practical implications were also discussed.

360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial

Public speaking anxiety (PSA) is a prevalent condition which is highly interrelated with social anxiety. PSA can be effectively treated with exposure therapy. Virtual reality exposure therapy (VRET) is increasingly being explored as a novel and cost-effective mode of treatment. No previous randomized controlled trial has examined whether stand-alone 360° video VRET is an effective intervention for treating PSA and interrelated disorder relevant fears. Further, studies have not explored whether 360° video content influences VRET outcomes. Participants with high PSA (n = 51) were randomly allocated to: 360° video VRET incorporating stimuli of audiences (360°Audience) (n = 17), 360° video VRET incorporating stimuli of empty rooms (360°Empty) (n = 16) and no treatment control (n = 18). Outcomes were measured over five time-points. Mixed ANOVA revealed a significant interaction between time and intervention group for PSA, social anxiety and fear of negative evaluation (FNE). Within-group analysis demonstrated there was a significant pre-intervention to post-intervention reduction across measures for both 360° video VRET groups: PSA 360°Audience (η_p² = .90, p<.001), 360°Empty (η_p² = .71, p < .001); social anxiety 360°Audience (η_p² = .49, p=.002), 360°Empty (η_p² = .39, p = .009); FNE 360°Audience (η_p² = .59, p<.001), 360°Empty (η_p² = .43, p = .006). Active intervention participants showed significant improvement from pre-intervention to 10-week follow-up on all measures. Findings illustrate that 360° video VRET is an efficacious way to significantly reduce PSA, social anxiety and FNE.