Virtual reality in anxiety disorders: the past and the future

Effects of virtual reality motor games on motor skills in children with cerebral palsy: a systematic review and meta-analysis

Background

Enhancing motor skills is crucial for the functional development of children with cerebral palsy. Virtual reality has emerged as a promising technology for rehabilitating these children.

Objective

The objective of this study was to systematically evaluate the effects of virtual reality motor games on the gross and fine motor skills of children with cerebral palsy.

Methods

A comprehensive search was conducted in databases including PubMed, ProQuest, EBSCOhost, Web of Science, and Wanfang Data, covering publications from their inception to June 1, 2024, to identify randomized controlled trials (RCTs) investigating the effects of virtual reality motor games on the gross and fine motor skills of children with cerebral palsy. The quality of the included studies was assessed using the PEDro scale, and data were analyzed with RevMan software (version 5.4).

Results

Nineteen studies involving 850 children with cerebral palsy were included. The results indicated that virtual reality motor games significantly improved gross motor skills [mean difference (MD) 1.67, 95% confidence interval (CI): 0.75-2.56; P < 0.001] and fine motor skills [standardized mean difference (SMD) 0.73, 95% CI: 0.30-1.16; P = 0.00008] in children with cerebral palsy.

Conclusions

Virtual reality motor games have the potential to significantly enhance both gross and fine motor skills in children with cerebral palsy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, PROSPERO [CRD42024558713].

The impact of immersive virtual reality meditation for depression and anxiety among inpatients with major depressive and generalized anxiety disorders

Background

Mindfulness-Based Cognitive Therapy (MBCT) is a non-pharmacological approach to alleviating depression and anxiety. While technology based MBCT is a standardized cost-effective approach, there have been concerns about its feasibility and effectiveness in clinical settings.

Aims

The purpose of this study was to investigate the longitudinal relationship between improved emotional regulation resulting from participation in Immersive Virtual Reality Meditation (IVRM) and Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) as monitored by electrocardiogram.

Methods

This study was a longitudinal single-arm clinical trial in which the intervention was conducted three times a week for 10 weeks at a behavioral health unit in a community hospital (n = 26). We measured Coherence Achievement Score (CAS), depression, and anxiety. The relationships between CAS, anxiety, depression, and covariates were analyzed using a Generalized Estimated Equation (GEE).

Results

The findings of our study provide evidence that the CAS scores indicative of emotional regulation function after IVRM participation were associated with a reduction in depression and anxiety.

Conclusion

Among the many technology-based complementary health care interventions that are available to reduce depression and anxiety, IVRM program use increases emotional regulatory function and decrease depression and anxiety.

Perceptions and needs for a community nursing virtual simulation system for Chinese nursing students during the COVID-19 pandemic: A qualitative study

Background

Virtual simulation systems are being increasingly used in the field of nursing education. However, these systems are mostly designed based on the perspective of developers, and the needs of the end users are often neglected. The purpose of this study was to explore the perceptions and needs of Chinese undergraduate nursing students for the development of a community nursing virtual simulation system.

Methods

This was a descriptive qualitative study enrolling 12 undergraduate nursing students at a University in China. Data were collected through semi-structured interviews. The content analysis method was used for data analysis.

Result

Three themes and 15 sub-themes were extracted from this study: (1) Positive perceptions regarding virtual systems: a) Provides space for trials and errors, b) Not limited by time and space, c) Provides auxiliary tools; (2) Design and use requirements: a) Performance needs, b) Contents design needs, c) Appearance design needs, d) Support Needs; (3) Competency enhancement needs: a) Community nursing practice ability, b) Critical thinking ability, c) Independent thinking ability, d) Ability to deal with emergencies, e)Teamwork skills, f) Self-efficacy, g) Resilience, h)Interpersonal communication skills.

Conclusion

Designers and engineers should consider students' needs, aim to improve students' abilities, improve the diversity, the scientific and rigor of content, and enhance user immersion and interest. The system should be programmed to provide real-time feedback, timely technical and professional support, in order to optimize use experience of nursing students.

Virtual reality-guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study-a single-group feasibility trial

Background

Chronic cancer-related pain (CRP) can have a significant negative impact on quality of life. Mindfulness is hypothesized to mitigate chronic CRP by regulating both physical and emotional resistance to pain. In recent years, there has been interest in the use of virtual reality (VR) to deliver mindfulness meditation. VR provides an immersive and engaging environment, which may enhance one's focused attention to present-moment experiences, potentially making mindfulness less effortful and more efficacious for individuals with chronic pain. There has been little research in this area for people with a history of cancer.

Objective

The aim of this mixed methods study is to evaluate the feasibility of a VR-guided mindfulness (VRGM) intervention offered to adult cancer survivors with chronic CRP.

Methods

This mixed methods feasibility study will employ a single-arm, pretest-posttest design with semistructured interviews. In total, 15 cancer survivors will be enrolled in a 6-week home-based intervention that consists of 10-15 min of daily VRGM practice. The primary outcome is feasibility as assessed by accrual rates, retention in the study, intervention adherence, questionnaire completion, and side effect rates. Participants will be assessed on psychosocial outcome measures (i.e., pain, sleep, depressive and anxiety symptoms, fatigue, quality of life, and mindfulness) before and after the intervention, and 6 weeks post intervention (follow-up). Changes in pain will be described in relation to levels of immersion and presence in the virtual environment, trait mindfulness, and amount of VRGM practice. Qualitative information will provide subjective detail on participants' experience with VRGM to complement quantitative data. This study has been approved by the Health Research Ethics Board of Alberta Cancer Committee (HREBA.CC-20-0411).

Conclusions

This novel intervention provides a potential alternative treatment to pharmacological pain management. Results from this study may inform future larger VGRM trials for chronic CRP to help reduce suffering in people with cancer. Study findings will be disseminated through open access publications, traditional conference presentations, professional cancer organizations, and social media platforms.

Technologies for frailty, comorbidity, and multimorbidity in older adults: a systematic review of research designs

BACKGROUND

Frailty, neurodegeneration and geriatric syndromes cause a significant impact at the clinical, social, and economic level, mainly in the context of the aging world. Recently, Information and Communication Technologies (ICTs), virtual reality tools, and machine learning models have been increasingly applied to the care of older patients to improve diagnosis, prognosis, and interventions. However, so far, the methodological limitations of studies in this field have prevented to generalize data to real-word. This review systematically overviews the research designs used by studies applying technologies for the assessment and treatment of aging-related syndromes in older people.

METHODS

Following the PRISMA guidelines, records from PubMed, EMBASE, and Web of Science were systematically screened to select original articles in which interventional or observational designs were used to study technologies' applications in samples of frail, comorbid, or multimorbid patients.

RESULTS

Thirty-four articles met the inclusion criteria. Most of the studies used diagnostic accuracy designs to test assessment procedures or retrospective cohort designs to build predictive models. A minority were randomized or non-randomized interventional studies. Quality evaluation revealed a high risk of bias for observational studies, while a low risk of bias for interventional studies.

CONCLUSIONS

The majority of the reviewed articles use an observational design mainly to study diagnostic procedures and suffer from a high risk of bias. The scarce presence of methodologically robust interventional studies may suggest that the field is in its infancy. Methodological considerations will be presented on how to standardize procedures and research quality in this field.

Virtual reality technology in the detection of mild cognitive impairment: A systematic review and meta-analysis

BACKGROUND

In recent years, virtual reality technology has developed the potential to help in the early detection of mild cognitive impairment (MCI). However, integrative evidence of its detection performance for mild cognitive impairment is lacking, and meta-analysis or systematic reviews are required to further determine the effectiveness of virtual reality technology in screening for MCI.

METHODS

Literature searches were performed for MCI screening tests in the Cochrane Library, Web of Science, PsycINFO, PubMed, EMBASE, CINAHL, and Scopus. The primary outcome was the performance of VR tests for MCI detection. A protocol for this systematic review was registered in PROSPERO (Registration number: CRD42022302139).

RESULTS

A total of 14 studies in 13 reports were eventually included. The combined data with the bivariate random-effects model gave a summary point of 0.89 sensitivity (95 % confidence interval [CI]: 0.82-0.94) and 0.91 specificity (95 % CI: 0.82-0.96). The SROC curve was plotted, the DOR was 79.25 (95 % CI: 22.59-277.99), and the AUC was 0.95 (95 % CI: 0.93-0.97).

CONCLUSIONS

Virtual reality-based tests have shown considerable detection performance in detecting MCI, and therefore, virtual reality-based tests can serve as recommended screening methods. Future studies can consider longitudinal assessment and follow-up programs to identify progressive changes.

A reliable and robust online validation method for creating a novel 3D Affective Virtual Environment and Event Library (AVEL)

This paper describes the development and validation of 3D Affective Virtual environments and Event Library (AVEL) for affect induction in Virtual Reality (VR) settings with an online survey; a cost-effective method for remote stimuli validation which has not been sufficiently explored. Three virtual office-replica environments were designed to induce negative, neutral and positive valence. Each virtual environment also had several affect inducing events/objects. The environments were validated using an online survey containing videos of the virtual environments and pictures of the events/objects. They survey was conducted with 67 participants. Participants were instructed to rate their perceived levels of valence and arousal for each virtual environment (VE), and separately for each event/object. They also rated their perceived levels of presence for each VE, and they were asked how well they remembered the events/objects presented in each VE. Finally, an alexithymia questionnaire was administered at the end of the survey. User ratings were analysed and successfully validated the expected affect and presence levels of each VE and affect ratings for each event/object. Our results demonstrate the effectiveness of the online validation of VE material in affective and cognitive neuroscience and wider research settings as a good scientific practice for future affect induction VR 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.

A data-centric artificial intelligent and extended reality technology in smart healthcare systems

Extended reality (XR) solutions are quietly maturing, and their novel use cases are already being investigated, particularly in the healthcare industry. By 2022, the extended reality market is anticipated to be worth $209 billion. Certain diseases, such as Alzheimer's, Schizophrenia, Stroke rehabilitation stimulating specific areas of the patient's brain, healing brain injuries, surgeon training, realistic 3D visualization, touch-free interfaces, and teaching social skills to children with autism, have shown promising results with XR-assisted treatments. Similar effects have been used in video game therapies like Akili Interactive's EndeavorRx, which has previously been approved by the Food and Drug Administration (FDA) as a treatment regimen for children with attention deficit hyperactivity disorder (ADHD). However, while these improvements have received positive feedback, the field of XR-assisted patient treatment is in its infancy. The growth of XR in the healthcare sphere has the potential to transform the delivery of medical services. Imagine an elderly patient in a remote setting having a consultation with a world-renowned expert without ever having to leave their house. Rather than operating on cadavers in a medical facility, a surgical resident does surgery in a virtual setting at home. On the first try, a nurse uses a vein finder to implant an IV. Through cognitive treatment in a virtual world, a war veteran recovers from post-traumatic stress disorder (PTSD). The paper discusses the potential impact of XR in transforming the healthcare industry, as well as its use cases, challenges, XR tools and techniques for intelligent health care, recent developments of XR in intelligent healthcare services, and the potential benefits and future aspects of XR techniques in the medical domain.

Exposure to Green, Blue and Historic Environments and Mental Well-Being: A Comparison between Virtual Reality Head-Mounted Display and Flat Screen Exposure

Improving the mental health of urban residents is a global public health priority. This study builds on existing work that demonstrates the ability of virtual exposure to restorative environments to improve population mental health. It compares the restorative effects of green, blue and historic environments delivered by both flat screen and immersive virtual reality technology, and triangulates data from psychological, physiological and qualitative sources. Results from the subjective measure analyses showed that exposures to all the experimental videos were associated with self-reported reduced anxiety and improved mood, although the historic environment was associated with a smaller reduction of anxiety (p < 0.01). These results were supported by the qualitative accounts. For two of the electroencephalography (EEG) frequency bands, higher levels of activity were observed for historic environments. In relation to the mode of delivery, the subjective measures did not suggest any effect, while for the EEG analyses there was evidence of a significant effect of technology across three out of four frequency bands. In conclusion, this study adds to the evidence that the benefits of restorative environments can be delivered through virtual exposure and suggests that virtual reality may provide greater levels of immersion than flat screen viewing.

Mediating Mindfulness-Based Interventions with Virtual Reality in Non-Clinical Populations: The State-of-the-Art

Mindfulness is one of the most popular psychotherapeutic techniques that help to promote good mental and physical health. Combining mindfulness with immersive virtual reality (VR) has been proven to be especially effective for a wide range of mood disorders for which traditional mindfulness has proven valuable. However, the vast majority of immersive VR-enhanced mindfulness applications have focused on clinical settings, with little evidence on healthy subjects. This narrative review evaluates the real effectiveness of state-of-the-art mindfulness interventions mediated by VR systems in influencing mood and physiological status in non-clinical populations. Only studies with an RCT study design were considered. We conclude that most studies were characterized by one single meditation experience, which seemed sufficient to induce a significant reduction in negative mood states (anxiety, anger, depression, tension) combined with increased mindfulness skills. However, physiological correlates of mindfulness practices have scarcely been investigated. The application of VR-enhanced mindfulness-based interventions in non-clinical populations is in its infancy since most studies have several limitations, such as the poor employment of the RCT study design, the lack of physiological measurements (i.e., heart rate variability), as well as the high heterogeneity in demographical data, technological devices, and VR procedures. We thus concluded that before applying mindfulness interventions mediated by VR in clinical populations, more robust and reliable methodological procedures need to be defined.

Effects of rhythmic eye movements during a virtual reality exposure paradigm for spider-phobic patients

Rhythmic eye movements performed during eye movement desensitization and reprocessing (EMDR) therapy have been shown to evoke a physiological de-arousal pattern.

OBJECTIVES

Here, we examined whether the efficacy of a virtual reality exposure therapy (VRET) paradigm for phobic patients could be improved by adding rhythmic eye movements.

DESIGN

Spider-phobic patients (N = 53) were randomly assigned to either a group performing rhythmic eye movements or a control group undergoing exposure without such eye movements.

METHODS

During the VRET session, heart rate, electrodermal activity, eye movements, and subjective fear ratings were recorded. Participants underwent behavioural avoidance tests before and after treatment as well as a follow-up 10-14 days later. Questionnaire data were assessed before exposure and at follow-up.

RESULTS

There were clear treatment effects in both groups with almost no group differences (i.e., the subjective fear ratings and the skin conductance response).

CONCLUSIONS

Contrary to our expectation, the implementation of rhythmic eye movements during virtual exposure did not enhance the effectiveness of the treatment. However, the eye movement group did show a significantly lower heart rate during exposure compared with the control group which might indicate a less stressful treatment.

PRACTITIONER POINTS

One-session Virtual Reality Exposure Therapy reduced fear of spiders effectively. Performing rhythmic eye movements during exposure did not enhance therapy effects. Rhythmic eye movements during exposure resulted in lower heart rate than standard exposure.

Effectiveness of virtual reality in the management of paediatric anxiety during the peri‑operative period: A systematic review and meta-analysis

BACKGROUND

Children undergoing surgery generally experience anxiety during the perioperative period, which could impact the surgical outcome, cause long-term psychological consequences and result in later healthcare avoidance. Preoperative anxiety in children is managed using both pharmacological and non-pharmacological therapies. The latter include distraction, a tour of the operating room and parental presence until the induction of anaesthesia. A novel and effective non-pharmacological therapies is the use of virtual reality to reduce anxiety and pain in children scheduled for medical procedures. However, the effectiveness of virtual reality in paediatric surgery has yet to be evaluated in a systematic review.

OBJECTIVE

To evaluate the effectiveness of virtual reality in the management of anxiety in paediatric patients during the perioperative period.

DESIGN

Both a systematic review and a meta-analysis of randomised controlled trials were performed according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions Section 8.5 and in accordance with the Cochrane Effective Practice and Organisation of Care. The results are reported as prescribed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

DATA SOURCES

A systematic search of randomised controlled trials was conducted using Medline, SCOPUS, Web of Science, Ovid MEDLINE and CINAHL.

REVIEW METHODS

Two researchers screened potentially eligible articles and then assessed the quality of the reported studies using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions Section 8.5 and according to Cochrane Effective Practice and Organisation of Care. The data were synthesised using the random-effects models to incorporate the estimated heterogeneity in the weighting. Heterogeneity was tested using the Q and I² statistics. The τ² statistic, an estimate of the amount of variation between the included studies, was also determined. Studies whose heterogeneity with respect to primary outcome measurements hindered pooling of the results for meta-analysis were summarised narratively.

RESULTS

Seven studies were eligible for inclusion in this systematic review. An effect size for anxiety could be determined in six. The results support the effectiveness of virtual reality in reducing anxiety in paediatric patients undergoing elective surgery. The overall effect was supported by a confidence interval < 0 (PL = -0.341, 95% confidence interval: -0.620 to -0.107) and by heterogenity indexes that were non significant (Q = 9.49, p = 0.091) or not important (I² = 38.64%).

CONCLUSIONS

Paediatric patients undergoing elective surgery may benefit from virtual reality as a distraction method that can reduce anxiety. PROSPERO register, number: (blinded for Referee).

Virtual reality for tinnitus management: a randomized controlled trial

OBJECTIVE

Sound therapy (ST) and stress reduction regimens have been successfully used to manage tinnitus. Virtual reality (VR) has been used to manage chronic conditions like intractable pain. The aim of the present study was to investigate whether the use of VR in conjunction with ST revealed additional improvements in tinnitus attributes as compared to ST alone.

DESIGN

This study was a randomised controlled trial (RCT) with a cross-over design. All participants received two interventions - ST alone (control) and ST with VR stimuli (experimental). ST consisted of fractal tones while VR stimuli comprised of nature videos presented via VR goggles. A multilevel mixed-effects linear regression model was used to estimate the intervention effect.

STUDY SAMPLE

Twenty adults with subjective, continuous, chronic tinnitus participated in the study.

RESULTS

After adjusting for period and baseline tinnitus loudness, significant improvements were observed in tinnitus loudness and Tinnitus Functional Index scores. Although not statistically significant, mean minimum masking levels were lower after the experimental intervention.

CONCLUSIONS

Study participants benefitted from the use of VR in conjunction with ST in a laboratory setting. Additional effectiveness trials and blinded RCTs will be needed before validating the use of VR for tinnitus management in clinical settings.

A study of the use of virtual reality headsets in Chinese adolescents with intellectual disability

Background: Virtual reality technologies (VRTs) present many characteristics that can facilitate learning, especially in individuals with intellectual disabilities (ID). The VRT head-mounted display (HMD) has recently shown significant technological improvement. This study aims to prove the suitability of the newer commercially available VRT HMDs used in interventions for adolescents with ID in China. To this end, we explored the acceptance, immersion, and negative effects for adolescents with ID in a series of virtual environments. Methods: Forty-nine adolescents with ID (33 boys and 16 girls, IQ < 70), aged 11 to 21, from three special schools participated in this study. Questionnaires, observations, and interviews were used to investigate their views while using a VR HMD. Results: Our analysis found that most participants narrated a pleasant experience using HMD and a series of VR experiences and experienced a high level of immersion accompanied by low negative effects. In addition, our study found that the gender variable was independent of the acceptance of HMDs and the immersion experience. Conclusions: Overall, this study suggests that the HMD is accepted by most Chinese adolescents with ID; thus, its application has great potential in China.

Biofeedback-Based Connected Mental Health Interventions for Anxiety: Systematic Literature Review

Background

Connected mental health, which refers to the use of technology for mental health care and technology-based therapeutic solutions, has become an established field of research. Biofeedback is one of the approaches used in connected mental health solutions, which is mainly based on the analysis of physiological indicators for the assessment and management of the psychological state. Biofeedback is recommended by many therapists and has been used for conditions including depression, insomnia, and anxiety. Anxiety is associated with several physiological symptoms, including muscle tension and breathing issues, which makes the inclusion of biofeedback useful for anxiety detection and management.

Objective

The aim of this study was to identify interventions using biofeedback as a part of their process for anxiety management and investigate their perceived effectiveness.

Methods

A systematic literature review of publications presenting empirically evaluated biofeedback-based interventions for anxiety was conducted. The systematic literature review was based on publications retrieved from IEEE Digital Library, PubMed, ScienceDirect, and Scopus. A preliminary selection of papers was identified, examined, and filtered to include only relevant publications. Studies in the final selection were classified and analyzed to extract the modalities of use of biofeedback in the identified interventions, the types of physiological data that were collected and analyzed and the sensors used to collect them. Processes and outcomes of the empirical evaluations were also extracted.

Results

After final selection, 13 publications presenting different interventions were investigated. The interventions addressed either primarily anxiety disorders or anxiety associated with health issues such as migraine, Parkinson disease, and rheumatology. Solutions combined biofeedback with other techniques including virtual reality, music therapy, games, and relaxation practices and used different sensors including cardiovascular belts, wrist sensors, or stretch sensors to collect physiological data such as heart rate, respiration indicators, and movement information. The interventions targeted different cohorts including children, students, and patients. Overall, outcomes from the empirical evaluations yielded positive results and emphasized the effectiveness of connected mental health solutions using biofeedback for anxiety; however, certain unfavorable outcomes, such as interventions not having an effect on anxiety and patients’ preferring traditional therapy, were reported in studies addressing patients with specific physical health issues.

Conclusions

The use of biofeedback in connected mental health interventions for the treatment and management of anxiety allows better screening and understanding of both psychological and physiological patient information, as well as of the association between the two. The inclusion of biofeedback could improve the outcome of interventions and boost their effectiveness; however, when used with patients suffering from certain physical health issues, suitability investigations are needed.

Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study

Background

Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders.

Objective

The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders.

Methods

Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment.

Results

The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall “good” rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the “accuracy” item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks.

Conclusions

Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges.

Doppelganger-based training: Imitating our virtual self to accelerate interpersonal skills learning

Interpersonal skills require mastering a wide range of competencies such as communication and adaptation to different situations. Effective training includes the use of videos in which role models perform the desired behaviours such that trainees can learn through behavioural mimicry. However, new technologies allow new ways of designing training. In the present study, given that virtual reality is emerging as a valuable training setting, we compare two different demonstration conditions within virtual reality by investigating the extent to which the use of doppelgangers as role models can boost trainees' interpersonal skills development as compared to a role model that does not resemble the trainees. We also assess trainees' level of self-efficacy and gender as potential moderators in this relationship. Participants delivered a speech in front of a virtual audience twice. Before delivering their second speech, they watched a role model giving a speech in front of the same audience. The role model was either their doppelganger or an avatar of the same gender depending on the condition they were randomly assigned to. Results showed that the doppelganger-based training was the most beneficial for male trainees low in self-efficacy. These findings have important implications for training design, suggesting that doppelganger-based training might be effective only for a specific subset of trainees.

What can virtual reality offer to stroke patients? A narrative review of the literature

BACKGROUND

Studies demonstrated the efficacy of virtual reality (VR) as a method supporting the post-stroke neuro-rehabilitation process by activating motor learning processes. Nevertheless, stroke is frequently accompanied by serious psychological problems including depression, which is associated with an increased risk of mortality, lower post-stroke physical activity, and higher disability in stroke patients.

OBJECTIVES

To explore the current use of VR as a method supporting the neuro-rehabilitation process, both in physical and psychological dimensions.

METHODS

An exploratory review was conducted with a narrative synthesis. PubMed was used for literature search. Search includes the use of VR in physical rehabilitation, and as support therapy in psychiatric disorders. Both primary research and systematic reviews were included.

RESULTS

In neurological disorders rehabilitation, out of 22 studies, 16 concerned stroke survivors. In psychiatric disorders, 44 literature reviews were included.

CONCLUSION

The studies confirmed the effectiveness of various forms of VR treatment in the alleviation of psychological and behavioral problems and psychiatric disorders. There is a shortage of VR-based technological solutions that would, besides physical rehabilitation, offer stroke patients therapeutic tools to alleviate psychological disturbance and improve the patient's mood and motivation. Such solutions will most likely become a field of intensive research in the coming years.

The Effectiveness of Virtual Reality in Managing Acute Pain and Anxiety for Medical Inpatients: Systematic Review

Background

Virtual reality is increasingly being utilized by clinicians to facilitate analgesia and anxiolysis within an inpatient setting. There is however, a lack of a clinically relevant review to guide its use for this purpose.

Objective

To systematically review the current evidence for the efficacy of virtual reality as an analgesic in the management of acute pain and anxiolysis in an inpatient setting.

Methods

A comprehensive search was conducted up to and including January 2019 on PubMed, Ovid Medline, EMBASE, and Cochrane Database of Systematic reviews according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms included virtual reality, vr, and pain. Primary articles with a focus on acute pain in the clinical setting were considered for the review. Primary outcome measures included degree of analgesia afforded by virtual reality therapy, degree of anxiolysis afforded by virtual reality therapy, effect of virtual reality on physiological parameters, side effects precipitated by virtual reality, virtual reality content type, and type of equipment utilized.

Results

Eighteen studies were deemed eligible for inclusion in this systematic review; 67% (12/18) of studies demonstrated significant reductions in pain with the utilization of virtual reality; 44% (8/18) of studies assessed the effects of virtual reality on procedural anxiety, with 50% (4/8) of these demonstrating significant reductions; 28% (5/18) of studies screened for side effects with incidence rates of 0.5% to 8%; 39% (7/18) of studies evaluated the effects of virtual reality on autonomic arousal as a biomarker of pain, with 29% (2/7) demonstrating significant changes; 100% (18/18) of studies utilized a head mounted display to deliver virtual reality therapy, with 50% being in active form (participants interacting with the environment) and 50% being in passive form (participants observing the content only).

Conclusions

Available evidence suggests that virtual reality therapy can be applied to facilitate analgesia for acute pain in a variety of inpatient settings. Its effects, however, are likely to vary by patient population and indication. This highlights the need for individualized pilot testing of virtual reality therapy’s effects for each specific clinical use case rather than generalizing its use for the broad indication of facilitating analgesia. In addition, virtual reality therapy has the added potential of concurrently providing procedural anxiolysis, thereby improving patient experience and cooperation, while being associated with a low incidence of side effects (nausea, vomiting, eye strain, and dizziness). Furthermore, findings indicated a head mounted display should be utilized to deliver virtual reality therapy in a clinical setting with a slight preference for active over passive virtual reality for analgesia. There, however, appears to be insufficient evidence to substantiate the effect of virtual reality on autonomic arousal, and this should be considered at best to be for investigational uses, at present.

Virtual reality in psychiatric disorders: A systematic review of reviews

BACKGROUND

Virtual reality (VR) is being used more and more often as a therapeutic tool in psychology or psychiatry. In recent years, VR interventions appear more extensively also in disorders such as depression, anxiety and phobia. However, there has yet to be a comprehensive synthesis and critical review of the literature to identify future directions to advance the field in this area.

OBJECTIVES

To broadly characterize the literature to date on the application of VR in psychiatric disorders by conducting a systematic review of reviews, describe the limitations of existing research, suggest avenues for future research to address gaps in the current literature and provide practical recommendations for incorporating VR into various treatments for psychiatric disorders.

METHODS

PubMed and Web of Science databases were searched for reviews on VR use in psychiatric disorders (e.g. various pain perceptions, post-traumatic stress disorder, phobias, attention deficit hyperactivity disorder, psychosis, depression). The methodological quality of each literature review was assessed using AMSTAR.

RESULTS

The original search identified 848 reviews, of which 70 were included in the systematic review of reviews. Broadly, the literature indicates that various VR interventions could be useful in different psychiatric disorders.

CONCLUSION

This study provides evidence supporting the positive impact of VR therapy in psychiatric disorders. However, the impact is defined differently according to the studied area. Nevertheless, due to the continuous development of VR hardware and software, it is essential to conduct further research in the area of psychiatric disorders, especially as no review has concluded that VR does not work.

Psychological and Physiological Responses in Patients with Generalized Anxiety Disorder: The Use of Acute Exercise and Virtual Reality Environment

Virtual exercise therapy is considered a useful method by which to encourage patients with generalized anxiety disorder (GAD) to engage in aerobic exercise in order to reduce stress. This study was intended to explore the psychological and physiological responses of patients with GAD after cycling in a virtual environment containing natural images. Seventy-seven participants with GAD were recruited in the present study and randomly assigned to a virtual nature (VN) or a virtual abstract painting (VAP) group. Their electroencephalogram alpha activity, perceived stress, and levels of restorative quality and satisfaction were assessed at baseline and after an acute bout of 20 min of moderate-intensity aerobic exercise. The results showed that both the VN and VAP groups showed significantly higher alpha activity post-exercise as compared to pre-exercise. The VN group relative to the VAP group exhibited higher levels of stress-relief, restorative quality, and personal satisfaction. These findings imply that a virtual exercise environment is an effective way to induce a relaxing effect in patients with GAD. However, they exhibited more positive psychological responses when exercising in such an environment with natural landscapes.

Social Anxiety Can Be Triggered by 360-Degree Videos in Virtual Reality: A Pilot Study Exploring Fear of Shopping

Social anxiety disorder (SAD) involves intense fear of being scrutinized, judged, or embarrassed in public. Virtual reality exposure therapy (VRET) is an exposure tool for SAD. Previous studies have developed computer-generated avatars and virtual environments, but this method is time-consuming and expensive. Preliminary evidence shows that 360-degree virtual reality (VR) videos with real-life situations may be an easy, relatively cheap, and effective alternative. This study aimed to develop VR videos with real-life content from a shopping situation and to evaluate participants' anxiety responses and feelings of presence. Three 360-degree VR videos were filmed in a shopping center. Nine patients with SAD and nine controls matched on gender and age participated in the study. The participants' levels of anxiety during the VR videos were assessed using the Subjective Unit of Discomfort Scale and through semistructured interviews. The SAD patients reported higher levels of presence and significantly increased anxiety levels before, during, and after the videos, whereas controls reported no symptom of anxiety. The patients found the videos authentic and recommended VRET to be integrated into the early stages of treatment before in vivo exposure. Anxiety responses can be triggered in patients with SAD by 360-degree shopping videos. Further studied are needed to investigate the potential of using 360-degree videos for VRET in anxiety disorders.

Technologically-enhanced psychological interventions for older adults: a scoping review

BACKGROUND

The world population is getting older. As life expectancy increases, traditional health care systems are facing different challenges in terms of cost reduction and high-quality service delivery capability. New ways to improve older adults' quality of life have been explored, taking advantage of new technological solutions. Our focus is on the integration of technology in clinical treatments to facilitate or deliver psychological interventions meant to improve well-being in older adults. Our aims were to describe the main technology-based interventions supporting seniors' quality of life or psychological well-being and to provide greater clarity to what is described in the current literature as their effects on seniors' cognitive and psychological outcomes and healthcare policies.

METHODS

We reviewed the scientific literature looking for studies that investigated how technology can be implemented into clinical psychology treatments for older adults. Our search was conducted using the following databases: PubMed, PsycINFO, Scopus, ISI Web of Science, and CINAHL. The search provided 350 articles, mostly (≈90%) dated after 2002. Abstract analysis narrowed the selection to 150 papers, according to their relevance and actuality as judged by a restricted group of independent researchers.

RESULTS

Through a thematic analysis, we found that virtual reality (VR), robots, telemedicine, software, video games, and smartphone applications could potentially support older adults' psychological treatment with a positive impact on healthcare systems.

CONCLUSION

Findings from the literature are encouraging, although most of these results are only preliminary.

Usability Issues of Clinical and Research Applications of Virtual Reality in Older People: A Systematic Review

Aging is a condition that may be characterized by a decline in physical, sensory, and mental capacities, while increased morbidity and multimorbidity may be associated with disability. A wide range of clinical conditions (e.g., frailty, mild cognitive impairment, metabolic syndrome) and age-related diseases (e.g., Alzheimer's and Parkinson's disease, cancer, sarcopenia, cardiovascular and respiratory diseases) affect older people. Virtual reality (VR) is a novel and promising tool for assessment and rehabilitation in older people. Usability is a crucial factor that must be considered when designing virtual systems for medicine. We conducted a systematic review with Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines concerning the usability of VR clinical systems in aging and provided suggestions to structure usability piloting. Findings show that different populations of older people have been recruited to mainly assess usability of non-immersive VR, with particular attention paid to motor/physical rehabilitation. Mixed approach (qualitative and quantitative tools together) is the preferred methodology; technology acceptance models are the most applied theoretical frameworks, however senior adapted models are the best within this context. Despite minor interaction issues and bugs, virtual systems are rated as usable and feasible. We encourage usability and user experience pilot studies to ameliorate interaction and improve acceptance and use of VR clinical applications in older people with the aid of suggestions (VR-USOP) provided by our analysis.

Evaluation of a Mindfulness-Based Intervention With and Without Virtual Reality Dialectical Behavior Therapy® Mindfulness Skills Training for the Treatment of Generalized Anxiety Disorder in Primary Care: A Pilot Study

Generalized Anxiety Disorder (GAD) is a very prevalent disorder in primary care (PC). Most patients with GAD never seek treatment, and those who do seek treatment often drop out before completing treatment. Although it is an understudied treatment, Mindfulness-Based Interventions (MBIs) indicate preliminary efficacy for the treatment of GAD symptoms, but many patients with GAD present other associated symptoms (e.g., attention deficits) that complicate the treatment. Virtual Reality DBT® Mindfulness Skills learning has recently been developed to make learning mindfulness easier for patients with emotion dysregulation who have trouble concentrating. Virtual Reality (VR) might serve as a visual guide for practicing mindfulness as it gives patients the illusion of "being there" in the 3D computer generated world. The main goal of this study was to evaluate the effect of two MBIs (a MBI in a group setting alone and the same MBI plus 10 min VR DBT® Mindfulness skills training) to reduce GAD symptoms. A secondary aim was to explore the effect in depression, emotion regulation, mindfulness, and interoceptive awareness. Other exploratory aims regarding the use of VR DBT® Mindfulness skills were also carried out. The sample was composed of 42 patients (roughly half in each group) with GAD attending PC visits. After treatment, both groups of patients showed significant improvements in General Anxiety Disorder measured by the GAD-7 using mixed regression models [MBI alone (B = -5.70; p < 0.001; d = -1.36), MBI+VR DBT® Mindfulness skills (B = -4.38; p < 0.001; d = -1.33)]. Both groups also showed significant improvements in anxiety, depression, difficulties of emotion regulation and several aspects of mindfulness and interoceptive awareness. Patients in the group that received additional 10 min VR DBT Mindfulness Skills training were significantly more adherent to the treatment than those receiving only standard MBI (100% completion rate in MBI + VR vs. 70% completion rate in MBI alone; Fisher = 0.020). Although randomized controlled studies with larger samples are needed, this pilot study shows preliminary effectiveness of MBI to treat GAD, and preliminary evidence that adjunctive VR DBT® Mindfulness Skills may reduce dropouts.

[Virtual reality exposure therapy for anxiety disorders]

Anxiety disorders are among the most prevalent mental disorders in Germany. Exposure therapy has proven effective in treating anxiety disorders. During exposure therapy, patients are systematically confronted with the feared stimulus or situation. Exposure therapy can be conducted in vivo or in sensu. Recently, a considerable amount of research on virtual reality exposure therapy (VRET) in the treatment of anxiety disorders-especially phobias-has been published. During virtual reality exposure therapy, patients are confronted with a virtual representation of the feared stimulus or situation. There are many studies showing that virtual reality exposure therapy is effective-especially in treating specific phobias. One major advantage of virtual reality exposure therapy is that therapists can easily control the feared object or situation. Furthermore, virtual reality exposure therapy requires less organizational effort and is less time-consuming than exposure therapy in vivo. The principal disadvantage of virtual reality exposure therapy is the danger of cyber sickness. With the development of affordable user-friendly systems, therapists may increasingly use virtual reality exposure therapy to treat patients suffering from anxiety disorders. With respect to the future development of virtual reality exposure therapy, augmented reality seems to be a promising treatment alternative. Future studies need to confirm the efficacy of augmented reality exposure therapy in treating anxiety disorders.

The Immersive Virtual Reality Lab: Possibilities for Remote Experimental Manipulations of Autonomic Activity on a Large Scale

There is a need for large-scale remote data collection in a controlled environment, and the in-home availability of virtual reality (VR) and the commercial availability of eye tracking for VR present unique and exciting opportunities for researchers. We propose and provide a proof-of-concept assessment of a robust system for large-scale in-home testing using consumer products that combines psychophysiological measures and VR, here referred to as a Virtual Lab. For the first time, this method is validated by correlating autonomic responses, skin conductance response (SCR), and pupillary dilation, in response to a spider, a beetle, and a ball using commercially available VR. Participants demonstrated greater SCR and pupillary responses to the spider, and the effect was dependent on the proximity of the stimuli to the participant, with a stronger response when the spider was close to the virtual self. We replicated these effects across two experiments and in separate physical room contexts to mimic variability in home environment. Together, these findings demonstrate the utility of pupil dilation as a marker of autonomic arousal and the feasibility to assess this in commercially available VR hardware and support a robust Virtual Lab tool for massive remote testing.

The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate the literature regarding the effectiveness of incorporating virtual reality (VR) in the treatment of psychiatric disorders• Assess the use of exposure-based intervention for anxiety disorders ABSTRACT: Virtual reality (VR) allows users to experience a sense of presence in a computer-generated, three-dimensional environment. Sensory information is delivered through a head-mounted display and specialized interface devices. These devices track head movements so that the movements and images change in a natural way with head motion, allowing for a sense of immersion. VR, which allows for controlled delivery of sensory stimulation via the therapist, is a convenient and cost-effective treatment. This review focuses on the available literature regarding the effectiveness of incorporating VR within the treatment of various psychiatric disorders, with particular attention to exposure-based intervention for anxiety disorders. A systematic literature search was conducted in order to identify studies implementing VR-based treatment for anxiety or other psychiatric disorders. This article reviews the history of the development of VR-based technology and its use within psychiatric treatment, the empirical evidence for VR-based treatment, and the benefits for using VR for psychiatric research and treatment. It also presents recommendations for how to incorporate VR into psychiatric care and discusses future directions for VR-based treatment and clinical research.

The potential of Second Life for university counseling: a comparative approach examining media features and counseling problems

This study explored the potential of Second Life (SL), a popular multi-user virtual online environment, for university counseling. University students (n = 312) were asked to evaluate three counseling channels (i.e., traditional face-to-face, internet, and SL) based on a range of media features deemed relevant and important to counseling and to assess their relative preferability when faced with different counseling problems. For the purposes of this study, counseling rooms with different styles were built, virtual counselors with different genders, ages, and styles were created, and short video recordings of scripted counseling sessions were produced in SL. For the media feature comparisons, the collected data were analyzed by the multivariate analysis of variance, followed by the analysis of variance and post hoc comparisons when significant differences were found, whereas for counseling problem comparisons, repeated-measure analysis of variance and post hoc comparisons were used. The results for the media feature comparisons showed that SL counseling significantly out-rated traditional counseling in all of the examined media features, with the exception of the interactivity dimension. Additionally, while SL and internet counseling were both perceived as significantly better than traditional counseling in areas that are unique to computer-mediated communications, including anonymity, convenience, and flexibility with regard to time and space, as well as privacy of the counseling site, SL was perceived as distinctly superior to internet counseling in five areas due to its unique affordances, including the choice of appearance, choice of counselors, interactivity, diversity of counseling sites, and availability of counseling object dimensions. Furthermore, traditional counseling was regarded as better able to support more fluent and versatile interaction between the counselor and client than the other two computer-mediated channels. As for the results of counseling problem comparisons, SL was rated as least preferred for six out of the seven counseling problems (except for gender identity issues), despite its media affordances. Suggestions for practitioners and future research are provided based on the current findings.

Brief Report: A Pilot Study of the Use of a Virtual Reality Headset in Autism Populations

The application of virtual reality technologies (VRTs) for users with autism spectrum disorder (ASD) has been studied for decades. However, a gap remains in our understanding surrounding VRT head-mounted displays (HMDs). As newly designed HMDs have become commercially available (in this study the Oculus Rift™) the need to investigate newer devices is immediate. This study explored willingness, acceptance, sense of presence and immersion of ASD participants. Results revealed that all 29 participants (mean age = 32; 33 % with IQ < 70) were willing to wear the HMD. The majority of the participants reported an enjoyable experience, high levels of 'presence', and were likely to use HMDs again. IQ was found to be independent of the willingness to use HMDs and related VRT immersion experience.

Computer tool to evaluate the cue reactivity of chemically dependent individuals

BACKGROUND AND OBJECTIVE

Anxiety is one of the major influences on the dropout of relapse and treatment of substance abuse treatment. Chemically dependent individuals need (CDI) to be aware of their emotional state in situations of risk during their treatment. Many patients do not agree with the diagnosis of the therapist when considering them vulnerable to environmental stimuli related to drugs. This research presents a cue reactivity detection tool based on a device acquiring physiological signals connected to personal computer. Depending on the variations of the emotional state of the drug addict, alteration of the physiological signals will be detected by the computer tool (CT) which will modify the displayed virtual sets without intervention of the therapist.

METHODS

Developed in 3ds Max® software, the CT is composed of scenarios and objects that are in the habit of marijuana and cocaine dependent individual's daily life. The interaction with the environment is accomplished using a Human-Computer Interface (HCI) that converts incoming physiological signals indicating anxiety state into commands that change the scenes. Anxiety was characterized by the average variability from cardiac and respiratory rate of 30 volunteers submitted stress environment situations. To evaluate the effectiveness of cue reactivity a total of 50 volunteers who were marijuana, cocaine or both dependent were accompanied.

RESULTS

Prior to CT, the results demonstrated a poor correlation between the therapists' predictions and those of the chemically dependent individuals. After exposure to the CT, there was a significant increase of 73% in awareness of the risks of relapse.

CONCLUSION

We confirmed the hypothesis that the CT, controlled only by physiological signals, increases the perception of vulnerability to risk situations of individuals with dependence on marijuana, cocaine or both.

The Brainarium: An Interactive Immersive Tool for Brain Education, Art, and Neurotherapy

Recent theoretical and technological advances in neuroimaging techniques now allow brain electrical activity to be recorded using affordable and user-friendly equipment for nonscientist end-users. An increasing number of educators and artists have begun using electroencephalogram (EEG) to control multimedia and live artistic contents. In this paper, we introduce a new concept based on brain computer interface (BCI) technologies: the Brainarium. The Brainarium is a new pedagogical and artistic tool, which can deliver and illustrate scientific knowledge, as well as a new framework for scientific exploration. The Brainarium consists of a portable planetarium device that is being used as brain metaphor. This is done by projecting multimedia content on the planetarium dome and displaying EEG data recorded from a subject in real time using Brain Machine Interface (BMI) technologies. The system has been demonstrated through several performances involving an interaction between the subject controlling the BMI, a musician, and the audience during series of exhibitions and workshops in schools. We report here feedback from 134 participants who filled questionnaires to rate their experiences. Our results show improved subjective learning compared to conventional methods, improved entertainment value, improved absorption into the material being presented, and little discomfort.

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

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

Using virtual reality to improve the efficacy of cognitive-behavioral therapy (CBT) in the treatment of late-life anxiety: preliminary recommendations for future research

Cognitive-behavioral therapy (CBT) using traditional exposure techniques (i.e. imaginal and in vivo) seems less effective to treat anxiety in older adults than in younger ones. This is particularly true when imaginal exposure is used to confront the older patient to inaccessible (e.g. fear of flying) or less tangible/controllable anxiety triggers (e.g. fear of illness). Indeed, imaginal exposure may become less effective as the person gets older since normal aging is characterized by the decline in cognitive functions involved in the creation of vivid/detailed mental images. One way to circumvent this difficulty is to expose the older patient to a virtual environment that does not require the ability to imagine the frightening situation. In virtuo exposure has proven to be efficient to treat anxiety in working-age people. In virtuo exposure could be employed to improve the efficacy of CBT with exposure sessions in the treatment of late-life anxiety? The current paper explores this question and suggests new research avenues.

Outcomes associated with virtual reality in psychological interventions: where are we now?

The impending commercial release of affordable VR systems is likely to accelerate both the opportunity and demand for VR applications that specifically target psychological conditions. The aim of this study was to conduct a meta-analysis of outcomes associated with VR psychological interventions and to examine the methodological rigour used in these interventions. Literature search was conducted via Ovid, ProQuest Psychology Journals and ScienceDirect (Psychology) databases. Interventions were required to: be published between 1980 to 2014; use a randomised controlled trial design; be published in a scholarly journal; focused primarily on psychological/behavioural intervention; include validated measures; include reported means and standard deviations of outcome measures; and include one group with clinical/subclinical disorders, syndromes or distressing behaviours. Thirty eligible studies were identified. Random effects meta-analysis found an overall moderate effect size for VR interventions. Individual meta-analyses found an overall large effect size against non-intervention wait-lists and an overall moderate effect size against active interventions. No correlation was found between treatment outcomes and methodological rigour. Limitations may include limited study numbers, the use of a single coder, a need for more in-depth analyses of variation in form VR intervention, and omission of presence as a moderating factor. The current review supports VR interventions as efficacious, promising forms of psychological treatment. Use of reporting guidelines such as the CONSORT and CONSORT-EHEALTH statements should promote greater emphasis on methodological rigour, providing a firm foundation for the further development of clinical VR applications.

A meta-analysis on the relationship between self-reported presence and anxiety in virtual reality exposure therapy for anxiety disorders

In virtual reality exposure therapy (VRET) for anxiety disorders, sense of presence in the virtual environment is considered the principal mechanism that enables anxiety to be felt. Existing studies on the relation between sense of presence and level of anxiety, however, have yielded mixed results on the correlation between the two. In this meta-analysis, we reviewed publications on VRET for anxiety that included self-reported presence and anxiety. The comprehensive search of the literature identified 33 publications with a total of 1196 participants. The correlation between self-reported sense of presence and anxiety was extracted and meta-analyzed. Potential moderators such as technology characteristics, sample characteristics including age, gender and clinical status, disorder characteristics and study design characteristics such as measurements were also examined. The random effects analysis showed a medium effect size for the correlation between sense of presence and anxiety (r = .28; 95% CI: 0.18-0.38). Moderation analyses revealed that the effect size of the correlation differed across different anxiety disorders, with a large effect size for fear of animals (r = .50; 95% CI: 0.30-0.66) and a no to small effect size for social anxiety disorder (r = .001; 95% CI: -0.19-0.19). Further, the correlation between anxiety and presence was stronger in studies with participants who met criteria for an anxiety disorder than in studies with a non-clinical population. Trackers with six degrees of freedom and displays with a larger field of view resulted in higher effect sizes, compared to trackers with three degrees of freedom and displays with a smaller field of view. In addition, no difference in effect size was found for the type of presence measurement and the type of anxiety measurement. This meta-analysis confirms the positive relation between sense of presence and anxiety and demonstrates that this relation can be affected by various moderating factors.

A controlled study of agoraphobia and the independent effect of virtual reality exposure therapy

OBJECTIVES

Past controlled clinical trials centred on virtual reality exposure therapy (VRET) for agoraphobia mostly used multicomponent therapy with success. However, the present paper aimed to evaluate the independent effect of VRET for agoraphobia.

METHODS

A controlled study involving 18 agoraphobic participants assigned to two groups: VRET only and VRET with cognitive therapy. Nine specific virtual environments were developed using an affordable game level editor.

RESULTS

Questionnaires, behavioural tests and physiological measures indicated a positive effect of VRET. Correlations supported the predictive value of presence towards treatment outcome. The addition of cognitive therapy did not provide significant additional benefit.

CONCLUSIONS

Overall, the isolated effects of VRET did not seem to be significantly less than the effects of VRET combined with cognitive therapy. Future research should explore the use of other components in addition to cognitive therapy and VRET for agoraphobia as well as its possible use in patients' homes.

Psychophysiology to Assess Impact of Varying Levels of Simulation Fidelity in a Threat Environment

There are many virtual environments found in the serious game community that simulate real world scenarios. There is a broad range of fidelity and experimental controls among these serious games. An important component to most evaluations is the extent to which level of fidelity impacts the persons immersed in the serious game. While a great deal of virtual environment and serious game research has assessed the subjective state or feeling of the participant (e.g., the participant’s sense of presence) through the use of questionnaires, the current study examines participant experience by examining psychophysiological responses of participants to their surroundings. The primary goal in this study was evaluative: will a virtual environment with arousing contents result in increased sensory arousal if it is presented in a highly immersive configuration? A secondary goal of this study was to investigate the utility of our environment to offer varying levels of stimulus threat to impact the user’s experience of the virtual environment. Increased simulation fidelity in an arousing environment resulted in faster heart rates and increased startle eyeblink amplitudes, suggesting that higher fidelity scenarios had great efficacy related to sensory arousal.

The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature

This article reviews research into the use of virtual reality in the study, assessment, and treatment of body image disturbances in eating disorders and nonclinical samples. During the last decade, virtual reality has emerged as a technology that is especially suitable not only for the assessment of body image disturbances but also for its treatment. Indeed, several virtual environment-based software systems have been developed for this purpose. Furthermore, virtual reality seems to be a good alternative to guided imagery and in vivo exposure, and is therefore very useful for studies that require exposure to life-like situations but which are difficult to conduct in the real world. Nevertheless, review highlights the lack of published controlled studies and the presence of methodological drawbacks that should be considered in future studies. This article also discusses the implications of the results obtained and proposes directions for future research.

Assessment of the emotional responses produced by exposure to real food, virtual food and photographs of food in patients affected by eating disorders

BACKGROUND

Many researchers and clinicians have proposed using virtual reality (VR) in adjunct to in vivo exposure therapy to provide an innovative form of exposure to patients suffering from different psychological disorders. The rationale behind the 'virtual approach' is that real and virtual exposures elicit a comparable emotional reaction in subjects, even if, to date, there are no experimental data that directly compare these two conditions. To test whether virtual stimuli are as effective as real stimuli, and more effective than photographs in the anxiety induction process, we tested the emotional reactions to real food (RF), virtual reality (VR) food and photographs (PH) of food in two samples of patients affected, respectively, by anorexia (AN) and bulimia nervosa (BN) compared to a group of healthy subjects. The two main hypotheses were the following: (a) the virtual exposure elicits emotional responses comparable to those produced by the real exposure; (b) the sense of presence induced by the VR immersion makes the virtual experience more ecological, and consequently more effective than static pictures in producing emotional responses in humans.

METHODS

In total, 10 AN, 10 BN and 10 healthy control subjects (CTR) were randomly exposed to three experimental conditions: RF, PH, and VR while their psychological (Stait Anxiety Inventory (STAI-S) and visual analogue scale for anxiety (VAS-A)) and physiological (heart rate, respiration rate, and skin conductance) responses were recorded.

RESULTS

RF and VR induced a comparable emotional reaction in patients higher than the one elicited by the PH condition. We also found a significant effect in the subjects' degree of presence experienced in the VR condition about their level of perceived anxiety (STAI-S and VAS-A): the higher the sense of presence, the stronger the level of anxiety.

CONCLUSIONS

Even though preliminary, the present data show that VR is more effective than PH in eliciting emotional responses similar to those expected in real life situations. More generally, the present study suggests the potential of VR in a variety of experimental, training and clinical contexts, being its range of possibilities extremely wide and customizable. In particular, in a psychological perspective based on a cognitive behavioral approach, the use of VR enables the provision of specific contexts to help patients to cope with their diseases thanks to an easily controlled stimulation.