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

Psychological interventions for post-stroke anxiety and depression: Current approaches and future perspectives

Psychological interventions have demonstrated efficacy in improving patients’ emotional state, cognition, and thinking abilities, thereby enhancing their quality of life and survival. This review examines literature from the China National Knowledge Infrastructure, Wanfang Data, Web of Science, and PubMed databases published over the past decade, focusing on the use of psychotherapy for post-stroke anxiety and depression. The prevalence of anxiety and depression is significantly higher among patients who have experienced a stroke than in the general population, possibly due to vestibular dysfunction following brain injury. Current psychological interventions for stroke patients include cognitive behavioral therapy, supportive psychotherapy, music and art therapy, and exercise therapy. These approaches have been shown to promote psychological wellbeing and physical rehabilitation.

The evolving field of digital mental health: current evidence and implementation issues for smartphone apps, generative artificial intelligence, and virtual reality

The expanding domain of digital mental health is transitioning beyond traditional telehealth to incorporate smartphone apps, virtual reality, and generative artificial intelligence, including large language models. While industry setbacks and methodological critiques have highlighted gaps in evidence and challenges in scaling these technologies, emerging solutions rooted in co-design, rigorous evaluation, and implementation science offer promising pathways forward. This paper underscores the dual necessity of advancing the scientific foundations of digital mental health and increasing its real-world applicability through five themes. First, we discuss recent technological advances in digital phenotyping, virtual reality, and generative artificial intelligence. Progress in this latter area, specifically designed to create new outputs such as conversations and images, holds unique potential for the mental health field. Given the spread of smartphone apps, we then evaluate the evidence supporting their utility across various mental health contexts, including well-being, depression, anxiety, schizophrenia, eating disorders, and substance use disorders. This broad view of the field highlights the need for a new generation of more rigorous, placebo-controlled, and real-world studies. We subsequently explore engagement challenges that hamper all digital mental health tools, and propose solutions, including human support, digital navigators, just-in-time adaptive interventions, and personalized approaches. We then analyze implementation issues, emphasizing clinician engagement, service integration, and scalable delivery models. We finally consider the need to ensure that innovations work for all people and thus can bridge digital health disparities, reviewing the evidence on tailoring digital tools for historically marginalized populations and low- and middle-income countries. Regarding digital mental health innovations as tools to augment and extend care, we conclude that smartphone apps, virtual reality, and large language models can positively impact mental health care if deployed correctly.

Five canonical findings from 30 years of psychological experimentation in virtual reality

Virtual reality (VR) is an emerging medium used in work, play and learning. We review experimental research in VR spanning three decades of scholarship. Instead of exhaustively representing the landscape, our unique contribution is providing in-depth reviews of canonical psychological findings balanced across various domains within psychology. We focus on five findings: the benefit of being there depends on the activity; self-avatars influence behaviour; procedural training works better than abstract learning; body tracking makes VR unique; and people underestimate distance in VR. These findings are particularly useful to social scientists who are new to VR as a medium, or those who have studied VR but have focused on specific psychological subfields (for example, social, cognitive or perceptual psychology). We discuss the relevance for researchers and media consumers and suggest future areas for human behaviour research.

Levodopa-synergistic CBT intervention improves Parkinson's disease with anxiety disorder by regulating the BDNF/PI3K/AKT pathway

BACKGROUND

Anxiety disorder is one of the most common and disabling neuropsychiatric syndromes in patients with Parkinson's disease (PD), seriously affecting the quality of life and prognosis of PD patients.

OBJECTIVE

The objective of this study was to analyze the risk factors for anxiety in PD patients and to evaluate the effectiveness of cognitive behavioral therapy (CBT) in treating PD with anxiety disorder (PDAD).

METHODS

Baseline data were recorded for 211 PD patients and 139 PDAD patients, and multi-factorial and independent risk factors for anxiety disorder in PD patients were analyzed. ​The 139 PDAD patients were divided into clinical testing (CMO) and CBT groups. Assessments were taken at baseline and after the end of the intervention. A 5-month follow-up survey was conducted after the intervention. The mouse PD model was induced by MPTP, and the anxiety state of mice was detected by rotarod test and open-field test. The expression of BDNF/PI3K/Akt protein in serum and mouse brain was detected by western blot.

RESULTS

PDAD patients had significantly higher HAMA scores than PD patients. PSQI, ESS, HAMD, SCOPA-AUT, UPDRS-III and Hoehn-Yahr were independent risk factors for anxiety disorder in PD patients. After the intervention, the psychological state, cognitive function and quality of life improved in both the CMO and CBT groups, with the CBT group showing better improvement Results from follow-up showed that the number and frequency of falls was lower in the CBT group than in the CMO group, and that patients were more satisfied with the CBT intervention than the CMO group. L-dopa treatment alleviated anxiety in PD mice. L-dopa treatment increased BDNF, p-PI3K, and p-Akt protein levels. Moreover, the combination of L-dopa and CBT enhanced the boosting effect of L-dopa on these proteins.

CONCLUSION

CBT is an effective treatment for anxiety in patients with Parkinson's disease. Medications combined with CBT have been shown to be effective in improving depression, anxiety and quality of life in PDAD patients.

Abnormal resting-state functional connectivity in panic disorder: An exploratory whole-brain MRI study

BACKGROUND

Panic disorder (PD) is characterized by prolonged anxiety about panic attacks, significantly impairing social functioning. Despite this impact, resting-state brain function anomalies in PD are insufficiently understood. We conducted a data-driven investigation of resting-state functional connectivity (rsFC) in PD.

METHODS

MRI scans and clinical assessments were performed on PD patients and healthy controls (HCs). Differences in rsFC were analyzed using the cluster-wise analysis of 9045 connections among 135 regions across the brain. For significant clusters, correlations between rsFC and clinical scores for panic and anxiety symptoms were examined.

RESULTS

Thirty-nine patients and 44 HCs were included in the analyses. A significant cluster-level difference in rsFC was observed between groups, involving connections between the medial occipital region and the paracingulate gyrus within the anterior cingulate cortex (ACC). In this cluster, PD patients exhibited higher rsFC in 11 connections, with eight of these showing positive correlations with State-Trait Anxiety Inventory scores.

LIMITATIONS

The comprehensive analysis of 9045 connections may have diluted statistical power, potentially obscuring other relevant connections.

CONCLUSIONS

Increased rsFC between the medial occipital region and the ACC was observed in PD. This suggests that anxiety-evoking visual imagery generated in the occipital lobe may disproportionately influence self-referential thought process mediated by the ACC. Interventions targeting visual imagery may help alleviate daily anxiety in PD patients.

Underlying Working Mechanisms of Virtual Reality Exposure: Exploring the Role of Fearful Expectancies and Habituation

While research has primarily focused on establishing the efficacy of virtual reality (VR) exposure, relatively scant attention has been paid to the underlying working mechanisms that drive the effects. The present study examined the role of fearful expectancies and fear reduction (habituation) in VR exposure. Fearful expectancies were measured before, during (retrospectively), and after a VR exposure session in 121 participants with elevated fear of spiders. In addition, skin-conductance and heart rate were measured throughout the exposure session to examine fear reduction within the exercises and across the session. Fearful expectancies decreased after VR exposure. Larger decreases were associated with better outcomes 1 week (in the verbal and behavioral measures) and 3 months (in one of the verbal measures) after exposure. Levels of expectancies during exposure were not associated with the outcome. We did not find evidence that expectancies about own reactions were better testable in VR exposure than expectancies about the spider. Fear reduction within the exercises or across the session did generally not predict VR exposure outcome. It is recommended to focus on various operationalizations and experimental manipulations of the mechanisms, as well as to compare these mechanisms between VR and in vivo exposure in future research.

Generality or specificity? Examining the mechanism of the transdiagnostic associations between different aspects of emotion dysregulation and various anxiety-related disorders

OBJECTIVES

Different aspects of emotion dysregulation (ED) have been found to be broadly associated with various anxiety-related disorders (ADs), but the mechanism underlying these transdiagnostic associations is largely unknown. There are at least two possible hypotheses. The generality hypothesis suggests that the associations are better explained by the link between a general ED factor and the general vulnerability factor derived from various ADs. The specificity hypothesis posits that specific ED facets make a unique contribution beyond the general ED factor.

METHODS

In a treatment-seeking sample of 351 patients with a primary diagnosis of an AD, we simultaneously examined both the general and facet-specific effects of ED, as assessed by the Difficulties in Emotion Regulation Scale (DERS), on the general vulnerability factor underlying ADs over the course of treatment using a bifactor latent change modelling approach.

RESULTS

Supporting the generality hypothesis, we found decreases in the general DERS factor were associated with symptoms reduction and improvement in life functioning. Except for emotional clarity, specific DERS factors had limited effects beyond the general factor.

CONCLUSIONS

Our findings suggested that the well-documented broad associations between ED and various ADs are best explained by the relationship between the general ED factor, rather than specific facets, and the general vulnerability factor to ADs. Thus, assessing overall ED, rather than focusing on specific facets, may be more effective for screening individuals at risk for ADs and monitoring therapeutic progress in the treatment of ADs.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Online-Based and Technology-Assisted Psychiatric Education for Trainees: Scoping Review

BACKGROUND

The concept of online learning in medical education has been gaining traction, but whether it can accommodate the complexity of higher-level psychiatric training remains uncertain.

OBJECTIVE

This review aims to identify the various online-based and technology-assisted educational methods used in psychiatric training and to examine the outcomes in terms of trainees' knowledge, skills, and levels of confidence or preference in using such technologies.

METHODS

A comprehensive search was conducted in PubMed, Cochrane, PsycINFO, Scopus, and ERIC to identify relevant literature from 1991 until 2024. Studies in English and those that had English translations were identified. Studies that incorporated or explored the use of online-based or technology-assisted learning as part of psychiatric training in trainees and had outcomes of interest related to changes in the level of knowledge or skills, changes in the level of preference or confidence in using online-based or technology-assisted learning, and feedback of participants were included. Studies were excluded if they were conducted on populations excluding psychiatric trainees or residents, were mainly descriptive of the concept of the intervention without any relevant study outcome, were not in English or did not have English translations, or were review articles.

RESULTS

A total of 82 articles were included in the review. The articles were divided into 3 phases: prior to 2015, 2015 to 2019 (prepandemic), and 2020 onward (postpandemic). Articles mainly originated from Western countries, and there was a significant increase in relevant studies after the pandemic. There were 5 methods identified, namely videoconference, online modules/e-learning, virtual patients, software/applications, and social media. These were applied in various aspects of psychiatric education, such as theory knowledge, skills training, psychotherapy supervision, and information retrieval.

CONCLUSIONS

Videoconference-based learning was the most widely implemented approach, followed by online modules and virtual patients. Despite the outcome heterogeneity and small sample sizes in the included studies, the application of such approaches may have utility in terms of knowledge and skills attainment and could be beneficial for the training of future psychiatrists, especially those in underserved low- and middle-income countries.

The application of metaverse in mental health

Rapid technological progress is reshaping human existence globally. The metaverse, a 3D digital realm merging virtual reality (VR) with physical space, exemplifies this fusion. Users can replicate and customize real-world elements within this immersive environment. Over the past decade, VR, augmented reality (AR), and mixed reality (MR) have become effective tools for addressing mental health conditions, offering solutions to the shortage of mental health professionals and limited access to care. However, extensive participation in 3D immersive gaming and social media can lead to insecurity, anxiety, depression, and addictive behaviors, particularly among young adults. This engagement may also impair attention spans, exacerbating symptoms in adolescents with attention deficit hyperactivity disorder. This research examines the impact of expanding metaverse applications on mental health, exploring both risks and benefits.

The impact of extended reality cognitive behavioral therapy on mental disorders among children and youth: A systematic review and meta-analysis protocol

BACKGROUND

The prevalence of mental disorders among children and youth has significantly increased, with rising rates of anxiety, depression, and other psychological disorders globally. Despite the widespread adoption of cognitive behavioral therapy (CBT) as a standardized treatment for various mental disorders, its efficacy can be constrained due to limited patient engagement, lack of commitment, and stigma, all challenges pronounced among children and youth. In this context, extended reality (XR) technologies (including virtual, augmented, and mixed reality) have emerged as innovative therapeutic tools offering immersive and engaging environments to overcome the limitations of traditional CBT.

OBJECTIVES

This protocol aims to outline the methodology for conducting a systematic review and meta-analysis to evaluate the impact of XR-CBT on symptoms of mental disorders among children and youth.

METHODS

This systematic review and meta-analysis will follow PRISMA-P 2015 guidelines. A comprehensive search will be conducted in PsycINFO, PubMed, EMBASE, Scopus, and Web of Science to identify relevant studies published between January 2014 and June 2024. Eligible studies must involve children and youth (ages 24 years or younger) diagnosed with a mental disorder (e.g., anxiety, depression, ADHD, PTSD) and compare XR-CBT interventions (virtual, augmented, or mixed reality) with traditional therapy or control groups (e.g., no treatment). The primary outcome will be the change in symptoms of mental disorders, measured using standardized instruments (e.g., PHQ-9, GAD-7, PSS). Data will be extracted on post-intervention means, standard deviations, and 95% confidence intervals. Effect sizes, calculated using Hedges' g, will be pooled with a random-effects model. Moreover, an a priori meta-regression within a random-effects framework will be conducted to examine how study-level characteristics influence effect sizes and address heterogeneity across studies. Heterogeneity will be assessed using the I2 statistic and the Cochran's Q test. Risk of bias in individual studies will be evaluated using the Cochrane risk-of-bias tool.

CONCLUSIONS

This protocol establishes a structured approach for assessing the efficacy of XR-CBT interventions on mental disorders among children and youth. The results of the systematic review and meta-analysis will fill a gap in current research and inform future therapeutic applications for mental health interventions among children and youth.

The Effectiveness of Immersive Virtual Reality-Based Treatment for Mental Disorders: A Systematic Review With Meta-Analysis

BACKGROUND

The increasing number of studies of immersive virtual reality (VR) interventions for mental disorders call for an examination of the current level of evidence on their effectiveness. The findings may guide scalability and contribute to the advancement and optimization of immersive VR-based interventions for mental disorders.

METHODS

A systematic literature search across four databases screened 2443 studies. Outcomes were disorder-specific symptoms, cognition, function, and quality of life. The study is registered on PROSPERO (CRD42023465845) and follows the reporting standards outlined in the PRISMA guidelines.

RESULTS

Fifty-five studies involving a total of 3031 participants covering 10 mental disorders were included in the analysis. VR interventions demonstrated statistically significant effects of post-treatment compared to active control conditions for alcohol use disorder (reduced state anxiety, g = 0.89, 95% CI[0.24, 1.55]) and schizophrenia spectrum disorders (reduced psychotic symptoms, g = 0.37, 95% CI[0.04, 0.70]). Compared to passive control conditions, statistically significant effects of VR interventions were observed for panic and agoraphobia (g = 1.28, 95% CI [0.47, 2.10]), social anxiety disorder (g = 0.83, 95% CI [0.49, 1.17]), specific phobias (g = 1.07, 95% CI[0.22, 1.92]), depression symptoms in PTSD (g = 0.67, 95% CI [0.22;1.13]). In contrast, no significant differences were found between VR interventions and active control conditions for functioning and quality of life in schizophrenia spectrum disorder and panic or agoraphobia. No meta-analyses were conducted on cognition due to insufficient data. Over 50% of the included studies were assessed as having a high risk of bias. According to the GRADE assessment, evidence for VR-based interventions across various mental disorders was generally of low to very low certainty, with a few exceptions rated as moderate certainty.

CONCLUSION

VR interventions may potentially have benefits, particularly when compared to passive control conditions, however, the evidence remains uncertain necessitating more large-scale, methodologically robust studies. Current findings can thus only be considered indicative. Recommendations on future directions of the VR field are discussed.

Effectiveness of virtual reality therapy in the treatment of anxiety disorders in adolescents and adults: a systematic review and meta-analysis of randomized controlled trials

Background

To evaluate the effect of virtual reality therapy on anxiety disorders in adolescents and adults by Meta-analysis.

Methods

A comprehensive literature search was conducted by PubMed, Web of Science, Embase, CINAHL, Scopus, Cochrane (from inception to November 2024). Two researchers independently performed literature screening, quality evaluation and data extraction, and Stata16.0 and Review Man 5.4 software were used for Meta-analysis.

Results

A total of 33 studies involving 3182 adolescents and adults with anxiety disorders were included. The results of Meta-analysis showed that compared with conventional interventions, virtual reality therapy significantly improved the symptoms and level of anxiety in patients with anxiety disorder [SMD = -0.95, 95%CI (-1.22,-0.69), Z = 7.05, P < 0.00001].

Conclusion

The current findings suggest that VR therapy interventions have a positive effect on improving the anxiety state of patients with anxiety disorders. The aforementioned research findings must be confirmed by more high-caliber studies due to the number and quality limitations of the contained literature.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display, identifier CRD42024574772.

Experience of breast cancer patients participating in a virtual reality psychological rehabilitation: a qualitative study

OBJECTIVE

Breast cancer is one of the most common types of cancer in China and worldwide. Apart from cancer, a majority of breast cancer patients suffer from various psychological disorders concurrently. The purpose of this study is to understand the actual experiences of breast cancer patients participating in Virtual Reality (VR) for psychological intervention, and to provide a theoretical basis for the development of VR psychological rehabilitation in China.

METHODS

Twenty-three breast cancer patients who met the inclusion criteria were selected using purposive sampling method for this qualitative study. Semi-structured interviews were conducted to explore their experiences with VR psychological rehabilitation. The data were analyzed, summarized, and generalized using the Colaizzi analysis method.

RESULTS

The results of the interviews were consistent with the PAC structural analysis. Three themes and six sub-themes captured how patients felt about adopting VR for their psychological rehabilitation, including parent ego state (the feeling of loss when expectations are not met, improvement of sleep), adult ego state (relief of psychological stress, optimization, and recommendations for VR therapy), and child ego state (novel and fun immersive experience, contagiousness of variable emotions).

CONCLUSION

Breast cancer patients participating in the VR psychological rehabilitation had a favorable experience. To maximize the benefit of VR psychological rehabilitation, healthcare professionals should comprehensively assess the psychological state of breast cancer, optimize VR technology, and enable patients to enter the adult ego state. The new model of VR psychological rehabilitation needs to be further explored.

Global, regional, and national burden of anxiety disorders during the perimenopause (1990-2021) and projections to 2035

PURPOSE

Perimenopause is associated with an increased risk of anxiety disorders, largely due to hormonal changes affecting the body's regulatory feedback mechanisms. This study aims to provide a comprehensive analysis of the global burden of anxiety disorders among perimenopausal women.

METHODS

Data from the 2021 Global Burden of Disease (GBD) database were utilized to assess disability-adjusted life years associated with anxiety disorders linked to perimenopause. We calculated trends using the estimated average percent change, and future projections were made using the Bayesian age-period-cohort model to estimate disability-adjusted life year trends for anxiety disorders from 2022 to 2035.

RESULTS

Between 1990 and 2021, the global age-standardized disability-adjusted life year rate for anxiety disorders among perimenopausal women increased from 625.51 (95% uncertainty interval: 429.1-891.09) to 677.15 (95% uncertainty interval: 469.45-952.72), indicating a rising trend with an estimated average percent change of 0.081 (95% confidence interval: 0.0043-0.143). Regional differences were noted, with anxiety disorder burdens varying across areas with different sociodemographic index levels. Projections suggest that by 2035, the global burden of anxiety disorders in perimenopausal women will rise to 1,180.43 per 100,000, a 40.67% increase compared with 2021 levels.

CONCLUSION

The burden of anxiety disorders during perimenopause is a growing global concern, with a significant increase anticipated in the coming years. Targeted prevention and intervention strategies are urgently needed to mitigate this rising burden and improve mental health outcomes during perimenopause.

Intermittent theta burst stimulation of the left dorsolateral prefrontal cortex has no additional effect on the efficacy of virtual reality exposure therapy for acrophobia. A randomized double-blind placebo-controlled study

Anxiety disorders are among the most common mental disorders. Treatment guidelines recommend pharmacotherapy and cognitive behavioral therapy as standard treatment. Although cognitive behavioral therapy is an effective therapeutic approach, not all patients benefit sufficiently from it. In recent years, non-invasive brain stimulation techniques, such as transcranial magnetic stimulation, have been investigated as promising adjuncts in the treatment of affective disorders. The aim of this study is to investigate whether a combination of intermittent theta burst stimulation (iTBS) and virtual reality exposure therapy leads to a significantly greater reduction in acrophobia than virtual reality exposure with sham stimulation. In this randomized double-blind placebo-controlled study, 43 participants with acrophobia received verum or sham iTBS over the left dorsolateral prefrontal cortex prior to two sessions of virtual reality exposure therapy. Stimulation of the left dorsolateral prefrontal cortex with iTBS was motivated by an experimental study showing a positive effect on extinction memory retention. Acrophobic symptoms were assessed using questionnaires and two behavioral approach tasks one week before, after treatment and six months after the second diagnostic session. The results showed that two sessions of virtual reality exposure therapy led to a significant reduction in acrophobic symptoms, with an overall remission rate of 79 %. However, there was no additional effect of iTBS of the left dorsolateral prefrontal cortex on the therapeutic effects. Further research is needed to determine how exactly a combination of transcranial magnetic stimulation and exposure therapy should be designed to enhance efficacy.

Acceptance and commitment therapy for nurses' sleep, rumination, psychological flexibility, and it's neural mechanism: A randomized controlled fNIRS study

BACKGROUND

Given nurses often face sleep problems, this study compares two internet-delivered Acceptance and Commitment Therapy (ACT) interventions to improve sleep quality (SQ), psychological flexibility (PF), reduce rumination, and explore neural mechanisms. Methods: 477 nurses were randomly assigned to ACT linear psychotherapy model (LINEAR), ACT loop psychotherapy model (LOOP) and wait-list group. SQ, rumination, and PF were assessed with questionnaires. Prefrontal cortical activation changes were measured using functional near-infrared spectroscopy. Results: The linear mixed-effects model demonstrated significant improvements in SQ, PF, and reduced rumination compared to pre-intervention for both models through enhanced psychological flexibility. LOOP showed a significantly superior effect compared to LINEAR. DLPFC activation increased following both interventions, with LOOP additionally stimulating the frontopolar area. Changes in the DLPFC mediated the relationship between intervention and outcome improvements. Frontopolar changes mediated SQ improvements but not rumination or PF. No significant changes in functional connectivity were observed during the verbal fluency task. Conclusions: Both interventions improved outcome variables, with LOOP being notably more effective, offering a novel approach. Mediation analyses highlight the role of DLPFC activation in understanding ACT's mechanisms and targeting insomnia treatment, while the mechanisms of LOOP's superior effect warrant further research. Trial Registration: Chinese Clinical Trial Registry (ChiCTR2200063533). https://www.chictr.org.cn/.

Family Functioning, Anxiety and Depression in Chinese Higher Vocational School Students: A Network Analysis

Purpose

Network analysis is a statistical method that explores the complex interrelationships among variables by representing them as nodes and edges in a network structure. This study aimed to examine the interconnections between family functioning, anxiety, and depression among vocational school students through network analysis approach.

Participants and Methods

A sample of 2728 higher vocational school students participated in a survey utilizing the Family APGAR Index Questionnaire (APGAR), Generalized Anxiety Disorder Scale (GAD-7), and Patient Health Questionnaire (PHQ-9). Meanwhile, a network analysis was conducted to investigate the interrelationships between family functioning, anxiety, and depression symptoms among the higher vocational school students.

Results

The network analysis revealed that node APGAR2 ("Partnership") exhibited the highest strength, followed by node GAD5 ("Restlessness"); node GAD7 ("Negative future anticipation"), PHQ9 ("Suicidal ideation"), and PHQ6 ("Guilty") were bridge nodes linking family functioning, anxiety and depressive symptoms in the sample. The results of the Network comparisons test between male and female indicated that the edge weights and global strength did not exhibit a statistically significant difference.

Conclusion

These results emphasized that certain anxiety symptoms and family functioning nodes are more central than others, and thus play a more critical role in the family functioning-anxiety-depression network, which highlight potential targeting symptoms to be considered in future interventions.

Evaluating a computer-based body exposure paradigm for the treatment of body image disturbance in adolescent Anorexia Nervosa: effects on the attentional bias and emotions

Background

A diagnostic criterion of Anorexia Nervosa (AN) is body image disturbance. Body exposure therapy is a widely used approach to treat this; however, it is unclear which part of body exposure therapy is relevant for regaining a realistic perspective on the own body. This study aimed to examine the role of the attentional bias (AB), which AN patients exhibit to the most disliked parts of their body. Additionally, emotional responses to the body exposure sessions were examined.

Methods

Participants were adolescent girls with a diagnosis of AN, who were randomly assigned to either an intervention (INT) or a treatment-as-usual (TAU) group. Both groups completed a pre and a post session, which included the completion of questionnaires to measure AN-psychopathology. The INT group received four sessions of a computer-based body exposure between the pre and the post session. The viewing pattern was recorded before and after each intervention session via an eyetracking (ET) device, as were emotional response scores on a visual analog scale (VAS; anxiety and disgust). The TAU group did not receive the intervention, but viewing patterns were recorded during the pre and the post session. All participants were asked to list their three least favorite body parts to be able to subsequently assess the AB.

Results

Fifty-eight adolescent girls with AN participated in the study. There were no differences in psychopathology pre to post session, as measured by administered questionnaires. The existence of an AB could be replicated, but there was no significant reduction in the AB pre to post session in the INT group, nor was there an interaction between group and time. Also, no changes in the AB were found within and between sessions in the INT group. Anxiety scores reduced significantly across sessions while disgust scores were significantly higher post session than they were pre session.

Conclusions

While the existence of an AB was demonstrated, the carried-out body exposures were neither sufficient to reduce the AB nor the psychopathology; nevertheless, a significant decrease in anxiety levels showed the usefulness of the exposure sessions. Future research might benefit from more exposure sessions and incorporating AB modification training (ABMT).

The Interplay Between Health Disparities and Acceptability of Virtual Reality: A Survey Study

Virtual reality (VR) has emerged as a nonpharmacological adjuvant to manage acute and chronic pain symptoms. The goal of this survey study was to determine the acceptability of VR among chronic pain participants hailing from distressed and prosperous neighborhoods in the state of Maryland. We hypothesized that pain severity and interference vary in groups experiencing health disparities, potentially influencing VR's acceptability. From March 11 to March 15, 2020, we surveyed a cohort of clinically phenotyped participants suffering from chronic orofacial pain. Participants were asked to express their willingness to participate in a longitudinal VR study and their expectation of pain relief from using VR. Seventy out of 350 participants with chronic pain completed the survey (response rate: 20%). There was no difference in the likelihood of responding to the survey based on their neighborhood distress. Among survey respondents and nonrespondents, similar proportions of participants were from distressed neighborhoods. Among the respondents, 63 (90%) and 59 (84.3%) were willing to participate and expected to experience pain relief from the VR intervention, respectively. Age, sex, race, neighborhood distress, severity of pain, and prior VR experience did not influence willingness to participate in the VR trial or the expectations of VR-induced improvement. These findings suggest that VR as an adjuvant intervention is potentially accepted by chronic pain participants, irrespective of neighborhood-level social determinants of health.

State of the Science: Using Digital Mental Health Interventions to Extend the Impact of Psychological Services

In recent years, digital mental health interventions (DMHIs) have emerged as a paradigm shift in care delivery that could expand the scale, efficiency, and effectiveness of psychological services. However, DMHI impact is constrained by issues related to limited reach, poor adoption, implementation barriers, and insufficient long-term maintenance. Organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance(RE-AIM) framework, this paper surveys the current state of DMHIs, highlighting research and practice gaps as well as potential strategies to move the field forward. Similarly, we discuss the role that emerging technologies and changes in the profession will play in shaping DMHIs in years to come. Finally, concrete and actionable steps to advance equity in the DMHI field are provided, with an emphasis on strategies to increase the representativeness of marginalized populations in DMHI research, the inclusion of these groups in the design and testing of DMHIs, and how to improve the contextual and cultural fit of DMHIs.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Technologies for Supporting Individuals and Caregivers Living With Fetal Alcohol Spectrum Disorder: Scoping Review

Background

Fetal alcohol spectrum disorder (FASD) is a common developmental disability that requires lifelong and ongoing support but is often difficult to find due to the lack of trained professionals, funding, and support available. Technology could provide cost-effective, accessible, and effective support to those living with FASD and their caregivers.

Objective

In this review, we aimed to explore the use of technology available for supporting people living with FASD and their caregivers.

Methods

We conducted a scoping review to identify studies that included technology for people with FASD or their caregivers; focused on FASD; used an empirical study design; were published since 2005; and used technology for assessment, diagnosis, monitoring, or support for people with FASD. We searched MEDLINE, Web of Science, Scopus, Embase, APA PsycINFO, ACM Digital Library, JMIR Publications journals, the Cochrane Library, EBSCOhost, IEEE, study references, and gray literature to find studies. Searches were conducted in November 2022 and updated in January 2024. Two reviewers (CZC and HW) independently completed study selection and data extraction.

Results

In total, 17 studies exploring technology available for people with FASD showed that technology could be effective at teaching skills, supporting caregivers, and helping people with FASD develop skills.

Conclusions

Technology could provide support for people affected by FASD; however, currently there is limited technology available, and the potential benefits are largely unexplored.

Mental health providers are inexperienced but interested in telehealth-based virtual reality therapy: survey study

Virtual reality (VR) is an emerging technology that can enhance experiences and outcomes in mental healthcare. However, mental health therapists have been slow to adopt VR into practice. Implementation of telehealth-based VR therapy (tele-VR) could catalyze adoption and innovation in mental healthcare. To explore therapists' perspectives on tele-VR, we conducted a cross-sectional survey of practicing mental health providers in the United States in June-July 2023. We analyzed 176 completed surveys from therapists, of whom 51.14% had no prior experience with VR, only 6.25% had used VR clinically, and 56.82% had neutral impressions of VR for therapy. Despite therapists' general inexperience with VR, therapists indicated a wide variety of tele-VR simulations (e.g., social situations, flying, heights) and features (e.g., personalized spaces, homework, interactivity) would be moderately to extremely useful for their practices. Therapists also requested additional VR simulations and features for their telehealth clients such as behavioral skills training, exposure therapy, gender identity therapy, and psychological assessments in VR. Therapists rated Health Insurance Portability and Accountability Act compliance, the ability to try VR before buying, affordability for therapists, accessibility for clients, and insurance coverage as the five most influential implementation factors for tele-VR. Overall, therapists were generally inexperienced and neutral about VR for telehealth therapy, but were interested in tele-VR for specific applications. These findings provide actionable directions for future research and collaborative development of therapeutic VR content and features.

State-trait anxiety levels and vital signs of pregnant women following intervention with virtual reality during the nonstress test: A randomized controlled trial

BACKGROUND

Pregnant women often experience anxiety due to pregnancy, negatively impacting their and their fetus' health. Non-pharmacological interventions, such as virtual reality (VR), could reduce anxiety levels, potentially impacting non-stress tests or the physiological responses of the pregnant woman and the fetus.

METHODS

A randomized clinical trial conducted between February and December 2022 involved 286 term pregnant women. They were divided into a VR intervention group (146 women) and a control group (140 women). The intervention consisted of 20 min of 3D glasses with images and sounds during a third-trimester nonstress test. Anxiety was measured using the Spielberg State-Trait Anxiety Inventory (STAI), alongside physiological parameters.

RESULTS

The VR group exhibited lower anxiety levels compared to controls (STAI score: Rosenthal's r: -0.54, p = 0.01; state anxiety: Rosenthal's r: -0.40, p = 0.001; trait anxiety: Rosenthal's r: -0.41, p = 0.001). Within the VR group, there was a significant reduction in trait anxiety (Rosenthal's r, 1.27; p < 0.001) and total anxiety (Rosenthal's r, 1.63; p < 0.001) post-intervention, along with decreased systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), and maternal heart rate (p = 0.02).

LIMITATIONS

Future research could explore additional pregnancy-related variables, such as postpartum anxiety.

CONCLUSIONS

The results confirm that the use of VR is beneficial for pregnant women and their fetuses, as it decreases anxiety levels, and improves physiological parameters such as blood pressure and maternal heart rate during the nonstress test. VR is a technique that is easy to integrate into the healthcare system due to its non-invasive and non-pharmacological nature.

Perioperative use of immersive head-mounted virtual reality display enhances patient satisfaction in great saphenous vein surgery: a single-center clinical observation study

OBJECTIVE

To explore the application effect of head-mounted virtual reality display immersive experience in improving the perioperative satisfaction of patients undergoing great saphenous vein surgery.

METHODS

A total of 158 patients undergoing saphenous vein surgery at the First Affiliated Hospital, Jiangxi Medical College, Nanchang University from January 2020 to January 2023 were randomly divided into an observation group and a control group in a 1:1 ratio, with 79 cases in each group. The observation group received head-mounted display virtual reality immersive experience, whereas the control group received midazolam. The study compared the perioperative satisfaction, changes in preoperative and postoperative anxiety and depression scores, intraoperative blood pressure and heart rate, postoperative visual analog scale (VAS) score, and the incidence of postoperative nausea and vomiting between the two groups. Additionally, the satisfaction of patients, anesthesiologists, and chief surgeons was compared.

RESULTS

All surgeries were completed successfully. Patients in the observation group exhibited higher perioperative satisfaction compared to those in the control group (P<0.001). There were no significant differences in anxiety or depression scores between the two groups before surgery (P>0.05). However, both groups showed a reduction in anxiety and depression scores postoperatively, with the observation group demonstrating lower scores than the control group (both P<0.05). The observation group also had lower intraoperative blood pressure, heart rate, postoperative VAS scores, and incidence of nausea and vomiting compared to the control group (all P<0.05). Furthermore, the satisfaction levels of the anesthesiologists and chief surgeons were higher in the observation group than in the control group (P=0.043, 0.012).

CONCLUSION

Head-mounted display virtual reality immersive experience can enhance perioperative satisfaction among patients undergoing great saphenous vein surgery, reduce anxiety and depression scores, and contribute to the stabilization of hemodynamics during surgery, thereby decreasing postoperative nausea and vomiting.

Virtual reality-based attention training in patients with neurological damage: A pilot study

Virtual Reality has been shown to be a valid tool to assess cognitive functions in an ecologically valid way. However, evidence regarding its effectiveness as a treatment option for cognitive rehabilitation has been limited. Furthermore, its potential to facilitate the transfer of training effects to patients' everyday life is still poorly studied. This study aimed to evaluate the efficacy of a VR-based attention training and its transfer to attentional functioning in everyday life. Nineteen inpatients with neurological disorders and attentional deficits underwent daily 30-min VR training sessions over a two-week period. Attentional functions were assessed before and after the training period using several computerized tests, two self-constructed behavioral tasks, and a questionnaire assessing patients' subjective attentional functioning. Pre-Post-analyses show significant decreases in reaction times in the computerized alertness and selective attention tests. Transfer to the behavioral tasks and self-report data could not be observed. Despite the specificity of the changes, confounding effects cannot entirely be ruled out due to the lack of a control group. Results suggest that training was effective in improving attentional functioning along neuropsychological measures, but did not elicit transfer to an ecologically valid or subjective level. Implications for the future development of VR interventions are discussed.

Pharmacotherapy and cognitive bias modification for the treatment of anxiety disorders

INTRODUCTION

Anxiety disorders are characterized by widespread and persistent anxiety or recurrent panic attacks. As a result of their high prevalence, chronicity, and comorbidity, patients' quality of life and functioning are severely compromised. However, several patients do not receive treatment.

AREAS COVERED

This review discusses the effectiveness, safety, and limitations of major medications and cognitive bias modification (CBM) for treating anxiety disorders. The possibility of combined treatment is also discussed in the literature. Furthermore, drawing on Chinese cultural perspectives, the authors suggest that anxiety can be recognized, measured, and coped with at three levels of skill (), vision (), and Tao ().

EXPERT OPINION

The combination of pharmacotherapy and CBM is possibly more effective in treating anxiety disorders than either treatment alone. However, clinicians and patients should participate in the joint decision-making process and consider comprehensive factors. Moderate anxiety has adaptive significance. In the coming years, by combining the downward analytical system of western culture with the upward integrative system of Chinese culture, a comprehensive understanding of anxiety and anxiety disorders should be established, rather than focusing only on their treatment.

[VR-supported therapy for anxiety and posttraumatic stress disorder: current possibilities and limitations]

BACKGROUND

Virtual reality (VR) is increasingly used in psychotherapy, and the speed of development of therapeutic VR tools is continuously increasing.

OBJECTIVE

This narrative review provides an overview of the state of the art regarding VR applications for psychotherapy.

MATERIAL AND METHODS

The current state of VR therapy research for anxiety disorders and posttraumatic stress disorder (PTSD) is summarized. The focus lies on VR exposure therapy. Current developments in the field are outlined.

RESULTS

For anxiety disorders, especially phobic disorders, there are already positive recommendations in the current German S3 guidelines. For PTSD, the development of VR therapy tools is still in a relatively early stage.

CONCLUSION

The development of mobile cost-effective VR solutions in recent years has enabled entirely new applications for VR. The empirical challenges of these new developments are considerable. Nevertheless, the chances for an improvement of psychotherapeutic routine care are good.

The impact of cognitive behavioural therapy-based psychological intervention on emotional improvement in elderly patients with extensive burns

To evaluate the efficacy of cognitive behavioural therapy (CBT) as a psychological intervention for elderly patients with extensive burns, focusing on its impact on emotional well-being, self-efficacy and quality of life. A prospective, randomized study involving 200 elderly burn patients was conducted from November 2021 to January 2023. The patients were randomly assigned to receive either standard care (control group) or burn care based on cognitive behavioural therapy (CBT-B) (study group), with 100 patients in each group. Outcome measures included the Visual Analog Scale (VAS) for pain assessment, 36-item Short Form Survey (SF-36) for quality of life, General Self-Efficacy Scale (GSES) and Rosenberg Self-Esteem Scale (RSES). The study revealed that CBT-based intervention significantly reduced anxiety and depression scores compared with standard care (p < 0.05). Additionally, patients in the CBT group exhibited improved self-efficacy, self-esteem and quality of life (p < 0.05). CBT proves to be a valuable intervention for elderly burn patients, effectively addressing emotional distress and enhancing their psychological well-being. By modifying negative cognitive patterns, providing coping mechanisms and fostering problem-solving skills, CBT-based care contributes to a more positive recovery experience and improved quality of life.

Towards a self-applied, mobile-based geolocated exposure therapy software for anxiety disorders: SyMptOMS-ET app

Objective

While exposure therapy (ET) has the potential to help people tolerate intense situation-specific emotions and change avoidance behaviours, no smartphone solution exists to guide the process of in-vivo ET. A geolocation-based smartphone software component was designed and developed to instrumentalize patient guidance in in-vivo ET and its psychological validity was assessed by a group of independent psychology experts.

Methods

A team of computer scientists and psychologists developed the ET Component for in-vivo ET using geolocation-based technology, following the process-centred design methodology. The ET Component was integrated into the SyMptOMS-ET Android application, which was developed following the co-design methodology. Next, nine independent psychology experts tested and evaluated the ET Component and the SyMptOMS-ET app in the field, following the think-aloud methodology. Participants also completed the Mobile Application Rating Scale (MARS) instrument to quantitatively evaluate the solutions.

Results

We present the SyMptOMS-ET app's main features and the ET Component exposure workflow. Next, we discuss the feedback obtained and the results of the MARS instrument. Participants who tested the app were satisfied with the ET Component during exposure scenarios (score of μ 4.32 out of 5 [ σ 0.28] on MARS quality aspects), agreed on the soundness of the theoretical foundations of the solutions developed (score of μ 4.57 [ σ 0.48] on MARS treatment support aspects), and provided minor think-a-loud comments to improve them.

Conclusions

The results of the expert evaluation demonstrate the psychological validity of the ET Component and the SyMptOMS-ET app. However, further studies are needed to discern the acceptability and efficacy of the mHealth tool in the target population.

What Is Medical Extended Reality? A Taxonomy Defining the Current Breadth and Depth of an Evolving Field

Medical extended reality (MXR) has emerged as a dynamic field at the intersection of health care and immersive technology, encompassing virtual, augmented, and mixed reality applications across a wide range of medical disciplines. Despite its rapid growth and recognition by regulatory bodies, the field lacks a standardized taxonomy to categorize its diverse research and applications. This American Medical Extended Reality Association guideline, authored by the editorial board of the Journal of Medical Extended Reality, introduces a comprehensive taxonomy for MXR, developed through a multidisciplinary and international collaboration of experts. The guideline seeks to standardize terminology, categorize existing work, and provide a structured framework for future research and development in MXR. An international and multidisciplinary panel of experts was convened, selected based on publication track record, contributions to MXR, and other objective measures. Through an iterative process, the panel identified primary and secondary topics in MXR. These topics were refined over several rounds of review, leading to the final taxonomy. The taxonomy comprises 13 primary topics that jointly expand into 180 secondary topics, demonstrating the field's breadth and depth. At the core of the taxonomy are five overarching domains: (1) technological integration and innovation; (2) design, development, and deployment; (3) clinical and therapeutic applications; (4) education, training, and communication; and (5) ethical, regulatory, and socioeconomic considerations. The developed taxonomy offers a framework for categorizing the diverse research and applications within MXR. It may serve as a foundational tool for researchers, clinicians, funders, academic publishers, and regulators, facilitating clearer communication and categorization in this rapidly evolving field. As MXR continues to grow, this taxonomy will be instrumental in guiding its development and ensuring a cohesive understanding of its multifaceted nature.

A 28-Year-Old Man with Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, and Dissociative Identity Disorder Responding to Aripiprazole Augmentation of Clomipramine Combined with Psychoeducation and Exposure and Response Prevention

BACKGROUND We report the case of a 28-year-old man with comorbidity of OCD, PTSD, and DID responding to aripiprazole augmentation of clomipramine combined with psychoeducation and exposure and response prevention (ERP). CASE REPORT A 28-year-old, well-educated man presented with depression, obsessive thoughts, behavioral impulsivity, and suicidal thoughts/behavior. He was known to be stubborn and sensitive to criticism since childhood. The obsessive thoughts and compulsive behaviors also started at an early age. He had 4 past psychiatric hospitalizations, mostly for dissociative episodes and bizarre behaviors, complicated with significant anxiety and distress from traumatic experiences during doctoral study. He had no-to-minimal responses to various psychotropics and traditional Chinese medicine. A thorough assessment showed he met the diagnostic criteria for OCD, PTSD, and DID. He was then treated with clomipramine in combination with aripiprazole, plus psychoeducation and exposure and response prevention (ERP). His anxiety and irritability significantly improved within 2 months and his obsessive thoughts faded away. At 6-month follow-up, the patient achieved clinical remission. One year later, he remained stable and reported having a normal life. CONCLUSIONS The case illustrates both how impairing the comorbidity of OCD, PTSD, and DID can be and how concurrent use of tricyclic antidepressant (TCA) clomipramine and partial dopamine agonist aripiprazole, together with psychoeducation and ERP, can improve outcomes when other treatment choices fail to be effective.

Neural correlates of virtual reality-based attention training: An fMRI study

THEORETICAL BACKGROUND

Virtual Reality technology is increasingly used in attention rehabilitation for functional training purposes. However, the neural mechanisms by which Virtual Reality can affect attentional functioning are still unclear. The current study's objective is to examine the effects of stereoscopic vs. monoscopic presentation on neural processing during a visual attention task.

METHOD

Thirty-two healthy participants performed a visual attention task in an immersive virtual environment that was displayed via MR-compatible video goggles in an MRI scanner. The paradigm altered between trials that required active engagement with the task and mere observation trials. Furthermore, the form of binocular presentation switched between monoscopic and stereoscopic presentation.

RESULTS

Analyses yielded evidence for increased activation in stereoscopic compared to monoscopic trials in the tertiary visual cortex area V3A as well as elevated activation in the dorsal attention network when engaging in the attention task. An additional ROI analysis of area V3A revealed significantly lower attentional engagement costs in stereoscopic conditions.

DISCUSSION

Results support previous findings suggesting that V3A is involved in binocular depth perception. Furthermore, heightened activation in V3A following stereoscopic presentation seemed to facilitate attentional engagement with the task. Considering that V3A is the origin of the dorso-dorsal, ventro-dorsal, and ventral visual processing pathways, we regard it as a gating area that decides which kind of visual perception is processed.

Mechanisms of action underlying virtual reality exposure treatment in spider phobia: Pivotal role of within-session fear reduction

Although virtual-reality exposure treatment (VRET) for anxiety disorders is an efficient treatment option for specific phobia, mechanisms of action for immediate and sustained treatment response need to be elucidated. Towards this aim, core therapy process variables were assessed as predictors for short- and long-term VR treatment outcomes. In a bi-centric study, n = 186 patients with spider phobia completed a baseline-assessment, a one-session VRET, a post-therapy assessment, and a 6-month-follow-up assessment (ClinicalTrials.gov, ID: NCT03208400). Short- and long-term outcomes regarding self-reported symptoms in the spider phobia questionnaire (SPQ) and final patient-spider distance in the behavioral avoidance test (BAT) were predicted via logistic regression models with the corresponding baseline score, age, initial fear activation, within-session fear reduction and fear expectancy violation as predictors. To predict long-term remission status at 6-month-follow-up, dimensional short-term changes in the SPQ and BAT were additionally included. Higher within-session fear reductions predicted better treatment outcomes (long-term SPQ; short- and long-term BAT). Lower initial fear activation tended to be associated with better long-term outcomes (SPQ), while fear expectancy violation was not associated with any outcome measure. Short-term change in the SPQ predicted remission status. Findings highlight that in VRET for spider phobia, the experience of fear reduction is central for short- and long-term treatment success and should be focused by therapists.

Wearable and Mobile Technologies for the Evaluation and Treatment of Obsessive-Compulsive Disorder: Scoping Review

BACKGROUND

Smartphones and wearable biosensors can continuously and passively measure aspects of behavior and physiology while also collecting data that require user input. These devices can potentially be used to monitor symptom burden; estimate diagnosis and risk for relapse; predict treatment response; and deliver digital interventions in patients with obsessive-compulsive disorder (OCD), a prevalent and disabling psychiatric condition that often follows a chronic and fluctuating course and may uniquely benefit from these technologies.

OBJECTIVE

Given the speed at which mobile and wearable technologies are being developed and implemented in clinical settings, a continual reappraisal of this field is needed. In this scoping review, we map the literature on the use of wearable devices and smartphone-based devices or apps in the assessment, monitoring, or treatment of OCD.

METHODS

In July 2022 and April 2023, we conducted an initial search and an updated search, respectively, of multiple databases, including PubMed, Embase, APA PsycINFO, and Web of Science, with no restriction on publication period, using the following search strategy: ("OCD" OR "obsessive" OR "obsessive-compulsive") AND ("smartphone" OR "phone" OR "wearable" OR "sensing" OR "biofeedback" OR "neurofeedback" OR "neuro feedback" OR "digital" OR "phenotyping" OR "mobile" OR "heart rate variability" OR "actigraphy" OR "actimetry" OR "biosignals" OR "biomarker" OR "signals" OR "mobile health").

RESULTS

We analyzed 2748 articles, reviewed the full text of 77 articles, and extracted data from the 25 articles included in this review. We divided our review into the following three parts: studies without digital or mobile intervention and with passive data collection, studies without digital or mobile intervention and with active or mixed data collection, and studies with a digital or mobile intervention.

CONCLUSIONS

Use of mobile and wearable technologies for OCD has developed primarily in the past 15 years, with an increasing pace of related publications. Passive measures from actigraphy generally match subjective reports. Ecological momentary assessment is well tolerated for the naturalistic assessment of symptoms, may capture novel OCD symptoms, and may also document lower symptom burden than retrospective recall. Digital or mobile treatments are diverse; however, they generally provide some improvement in OCD symptom burden. Finally, ongoing work is needed for a safe and trusted uptake of technology by patients and providers.

Evaluating the Feasibility of a Multiplayer Role-Playing Game as a Behavioral Health Intervention in Adolescent Patients With Chronic Physical or Mental Conditions: Protocol for a Cohort Study

BACKGROUND

Numerous studies have revealed that adolescents with chronic physical or mental conditions (CPMCs) are at an increased risk for depression and anxiety, with serious direct and indirect negative effects on treatment adherence, family functioning, and health-related quality of life. As game-based approaches are effective interventions in treating anxiety and depression, we propose to explore the use of a multiplayer role-playing game (RPG) as a potential intervention for social isolation, anxiety, and depression.

OBJECTIVE

The objectives of this study were to (1) determine the feasibility of using Masks, a multiplayer RPG, as an intervention for social isolation, anxiety, and depression in adolescents with CPMCs; (2) evaluate the viability of the research process; and (3) gauge participation in and engagement with RPG-based interventions.

METHODS

This study is a remote synchronous game-based intervention for adolescents with CPMCs aged 14-19 years. Eligible participants completed a web-based baseline survey to assess anxiety, depression, and social isolation and to identify their gaming habits. After completing the baseline survey, they participated in 5 moderated Masks game sessions. In Masks, players assume the roles of young superheroes; select their character types, superpowers; and perform actions determined by the game's rule system and dice rolls. All game sessions were played using Discord, a communication platform commonly used by gaming communities. Games were led and moderated by game masters (GMs). After each game session, participants completed surveys to assess changes in anxiety, depression, and social isolation, and their attitude toward the game and the user experience. The participants also completed an exit survey after all 5 game sessions (modified version of the Patient Health Questionnaire and the Generalized Anxiety Disorder Questionnaire, and 17 open-ended questions). The GMs rated each game session and reported on gameplay, player behavior, comfort, and engagement levels of the players.

RESULTS

As of March 2020, six participants were recruited for the pilot study to participate in moderated web-based game sessions of Masks; 3 completed all game sessions and all required assessments. Although the number of participants was too low to draw generalizable conclusions, self-reported clinical outcomes did seem to indicate a positive change in depression, anxiety, and social isolation symptoms. Qualitative analysis of postgame survey data from participants and GMs indicated high levels of engagement and enjoyment. Furthermore, the participants provided feedback about improved mood and engagement related to weekly participation in Masks. Lastly, responses to the exit survey showed interest in future RPG-related studies.

CONCLUSIONS

We established a workflow for gameplay and evaluated a research protocol for evaluating the impact of RPG participation on isolation, anxiety, and depression symptoms in adolescents with CPMCs. Preliminary data collected from the pilot study support the validity of the research protocol and the use of RPG-based interventions in larger clinical studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/43987.

Alleviating anxiety and taming trauma: Novel pharmacotherapeutics for anxiety disorders and posttraumatic stress disorder

Psychiatric disorders associated with psychological trauma, stress and anxiety are a highly prevalent and increasing cause of morbidity worldwide. Current therapeutic approaches, including medication, are effective in alleviating symptoms of anxiety disorders and posttraumatic stress disorder (PTSD), at least in some individuals, but have unwanted side-effects and do not resolve underlying pathophysiology. After a period of stagnation, there is renewed enthusiasm from public, academic and commercial parties in designing and developing drug treatments for these disorders. Here, we aim to provide a snapshot of the current state of this field that is written for neuropharmacologists, but also practicing clinicians and the interested lay-reader. After introducing currently available drug treatments, we summarize recent/ongoing clinical assessment of novel medicines for anxiety and PTSD, grouped according to primary neurochemical targets and their potential to produce acute and/or enduring therapeutic effects. The evaluation of putative treatments targeting monoamine (including psychedelics), GABA, glutamate, cannabinoid, cholinergic and neuropeptide systems, amongst others, are discussed. We emphasize the importance of designing and clinically assessing new medications based on a firm understanding of the underlying neurobiology stemming from the rapid advances being made in neuroscience. This includes harnessing neuroplasticity to bring about lasting beneficial changes in the brain rather than - as many current medications do - produce a transient attenuation of symptoms, as exemplified by combining psychotropic/cognitive enhancing drugs with psychotherapeutic approaches. We conclude by noting some of the other emerging trends in this promising new phase of drug development.

Update on treatments for anxiety-related disorders

PURPOSE OF REVIEW

This review examines recent evidence that informs the treatment of anxiety-related disorders.

RECENT FINDINGS

In addition to selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines, agomelatine has demonstrated efficacy in treating generalized anxiety disorder (GAD). Other novel products, such as ketamine, psilocybin and cannabidiol, are in the process of gathering evidence in support of the treatment of anxiety disorders. In psychological therapy, various psychological treatments for anxiety disorders, such as mindfulness-based intervention, acceptance and commitment therapy, psychodynamic therapy, emotion-focused therapy and dialectical behavioural therapy, have been tried. Still, most therapies have not proven superior to cognitive behavioural therapy (CBT). In very preliminary findings: Repetitive transcranial magnetic stimulation (rTMS) was effective in GAD; transcranial direct current stimulation (tDCS) was effective for social anxiety disorder (SAD) and GAD and augmented exposure therapy for specific fears. Internet and mobile-based interventions have comparable efficacy to face-to-face therapy.

SUMMARY

Pharmacotherapy of anxiety disorders is expanding to novel products. Despite trying other psychological therapies for anxiety disorders, most therapies were comparable to but not superior to CBT. rTMS and tDCS were also used and show early promise for GAD, but further studies are needed. Most internet or mobile app based psychological therapies were based on CBT, and some can be considered as alternatives to in-person face-to-face therapy.

Effects of Fetal Images Produced in Virtual Reality on Maternal-Fetal Attachment: Randomized Controlled Trial

BACKGROUND

Maternal-fetal attachment (MFA) has been reported to be associated with the postpartum mother-infant relationship. Seeing the fetus through ultrasound might influence MFA, and the effect could be increased by more realistic images, such as those generated in virtual reality (VR).

OBJECTIVE

The aim was to determine the effect of fetal images generated in VR on MFA and depressive symptoms through a prenatal-coaching mobile app.

METHODS

This 2-arm parallel randomized controlled trial involved a total of 80 pregnant women. Eligible women were randomly assigned to either a mobile app-only group (n=40) or an app plus VR group (n=40). The VR group experienced their own baby's images generated in VR based on images obtained from fetal ultrasonography. The prenatal-coaching mobile app recommended health behavior for the pregnant women according to gestational age, provided feedback on entered data for maternal weight, blood pressure, and glucose levels, and included a private diary service for fetal ultrasound images. Both groups received the same app, but the VR group also viewed fetal images produced in VR; these images were stored in the app. All participants filled out questionnaires to assess MFA, depressive symptoms, and other basic medical information. The questionnaires were filled out again after the interventions.

RESULTS

Basic demographic data were comparable between the 2 groups. Most of the assessments showed comparable results for the 2 groups, but the mean score to assess interaction with the fetus was significantly higher for the VR group than the control group (0.4 vs 0.1, P=.004). The proportion of participants with an increased score for this category after the intervention was significantly higher in the VR group than the control group (43% vs 13%, P=.005). The feedback questionnaire revealed that scores for the degree of perception of fetal appearance all increased after the intervention in the VR group.

CONCLUSIONS

The use of a mobile app with fetal images in VR significantly increased maternal interaction with the fetus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04942197; https://clinicaltrials.gov/ct2/show/NCT04942197.

Extended reality for mental health: Current trends and future challenges

Virtual and augmented reality have been used to diagnose and treat several mental health disorders for decades. Technological advances in these fields have facilitated the availability of commercial solutions for end customers and practitioners. However, there are still some barriers and limitations that prevent these technologies from being widely used by professionals on a daily basis. In addition, the COVID-19 pandemic has exposed a variety of new scenarios in which these technologies could play an essential role, like providing remote treatment. Disorders that traditionally had received less attention are also getting in the spotlight, such as depression or obsessive-compulsive disorder. Improvements in equipment and hardware, like Mixed Reality Head Mounted Displays, could help open new opportunities in the mental health field. Extended reality (XR) is an umbrella term meant to comprise Virtual reality (VR), mixed reality (MR), and augmented reality (AR). While XR applications are eminently visual, other senses are being explored in literature around multisensory interactions, such as auditory, olfactory, or haptic feedback. Applying such stimuli within XR experiences around mental disorders is still under-explored and could greatly enrich the therapeutic experience. This manuscript reviews recent research regarding the use of XR for mental health scenarios, highlighting trends, and potential applications as well as areas for improvement. It also discusses future challenges and research areas in upcoming topics such as the use of wearables, multisensory, and multimodal interaction. The main goal of this paper is to unpack how these technologies could be applied to XR scenarios for mental health to exploit their full potential and follow the path of other health technologies by promoting personalized medicine.

Exposure and Response Prevention in Virtual Reality for Patients with Contamination-Related Obsessive-Compulsive Disorder: a Case Series

Exposure therapy in virtual reality is successful in treating anxiety disorders. Studies on exposure and response prevention in virtual reality (VERP) in obsessive-compulsive disorder (OCD) are rare, and it is unclear whether distress associated with other emotions than anxiety (e.g., disgust) can be evoked. The present study aimed to investigate whether distress can be induced during VERP in patients with contamination-related OCD (C-OCD) and a primary feeling of disgust. We treated eight female patients with C-OCD with the primary emotion of disgust over six weeks with VERP and assessed their OC symptoms before and after the intervention period with the Y-BOCS. We measured subjective units of distress (SUD), heart rate and skin conductivity (arousal), sense of presence, and simulator sickness during four consecutive exposure sessions. VERP was able to induce distress and arousal. The qualitative feedback was heterogeneous and sense of presence moderate. Patients' OC symptoms reduced over the treatment period with medium to large effect sizes, but only two patients were considered responders; two patients discontinued treatment due to lack of treatment success. Although VERP was able to induce distress and arousal associated with disgust and evoked a moderate sense of presence, the low rate of symptom reduction diminishes the positive results. Possible reasons for the heterogeneous results and implications are discussed. Trial registration: German Registry for Clinical Studies (DRKS00016929), 10.04.2019.

Effects of Restorative Environment and Presence on Anxiety and Depression Based on Interactive Virtual Reality Scenarios

Anxiety and depression have been growing global mental health problems. The following studies explored the effect of interactive VR scenarios to find a low-cost and high-efficiency solution. Study 1 designed a 2 (anxiety and depression state) × 4 (interactive VR scenarios) experiment, the results of 20 participants showed that the designed scenarios had good restoration and presence, assisting to improve depression mood for people with mild to moderate anxiety and depression. Study 2 further investigated the intervention effects of two environment types (urban and park) and four interactive activities (automatic viewing, free-roaming, fishing, and watering plants in the park environment), based on data from a 10-minute experiment conducted by 195 participants with mild to moderate anxiety and depression. The subjective scales, EEG and EMG, and scenario experience were analyzed and the results showed that: (1) the restorative and present VR scenarios were beneficial in alleviating state anxiety and depression; (2) the restorative environment and presence were significantly and positively related to the reduction of anxiety and depression respectively, moreover, presence mediated the restorative environment on the recovery from anxiety and depression; (3) the environmental settings, the complexity of interaction, human factors, and maturity of VR devices and technology were also key factors that influenced the effects of interactive VR scenario experience and intervention. These studies revealed VR psychological intervention scenarios could be designed with comprehensive factors. Moreover, they might help pave the way for future study in exploring the physiology and psychology mode in virtual and real spaces, enhancing intervention effectiveness.