Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure

Precision computerised cognitive behavioural therapy (cCBT) for adolescents with depression: a pilot and feasibility randomised controlled trial protocol for SPARX-UK

BACKGROUND

A serious game called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), originally developed in New Zealand and incorporating cognitive behavioural therapy (CBT) principles, has been shown to help reduce symptoms of depression and anxiety in adolescents with mild to moderate depression in studies undertaken in Australasia. However, SPARX has never been trialled in the United Kingdom (UK), and there have been issues relating to low engagement when it has been used in a real-world context.

AIMS

To conduct the first pilot and feasibility randomised controlled trial (RCT) in England to explore the use of SPARX in different settings. The trial will explore whether SPARX supported by an e-coach (assistant psychologists) improves adherence and engagement compared with self-directed (i.e. self-help) use. The trial results will be used to inform the optimal mode of delivery (SPARX supported vs. SPARX self-directed), to calculate an appropriate sample size for a full RCT, and to decide which setting is most suitable.

METHODS

Following consultation with young people to ensure study suitability/appropriateness, a total of 120 adolescents (11-19 years) will be recruited for this three-arm study. Adolescents recruited for the study across England will be randomised to receive either SPARX with human support (from an e-coach), self-directed SPARX, or a waitlist control group. Assessments will be conducted online at baseline, week 4, and 8-10-week post-randomisation. The assessments will include measures which capture demographic, depression (Patient Health Questionnaire modified for adolescents [PHQ-A]) and anxiety (Revised Child Anxiety and Depression Scale [RCADS]) symptomatology, and health-related quality-of-life data (EQ-5D-Y and proxy version). Analyses will be primarily descriptive. Qualitative interviews will be undertaken with a proportion of the participants and clinical staff as part of a process evaluation, and the qualitative data gathered will be thematically analysed. Finally, feasibility data will be collected on recruitment details, overall study uptake and engagement with SPARX, participant retention, and youth-reported acceptability of the intervention.

DISCUSSION

The findings will inform the design of a future definitive RCT of SPARX in the UK. If the subsequent definitive RCT demonstrates that SPARX is effective, then an online serious game utilising CBT principles ultimately has the potential to improve the provision of care within the UK's health services if delivered en masse.

TRIAL REGISTRATION

ISRCTN: ISRCTN15124804. Registered on 16 January 2023, https://www.isrctn.com/ISRCTN15124804 .

The effect of gender on emotional reactions and perceptions when individuals meet themselves in immersive virtual reality

Immersive virtual reality-based training and research are becoming more and more popular and are in continuous development. For instance, it is now possible to be trained by one's virtual self (i.e., doppelganger), meaning that a trainee can participate in a training program in which the trainer resembles the trainee. While past research involving doppelgangers showed promising results, findings revealed gender effects such that doppelganger-based training seems to be beneficial only for male trainees. In the present research, we contribute to this literature by investigating the emotional reactions and perceptions that people have when they meet a virtual human in immersive virtual reality. Specifically, we assess the extent to which the appearance of the virtual human (doppelganger vs. unknown avatar) and an individual's gender influence these reactions and perceptions. We found that males felt more positive emotions toward their doppelganger than toward the unknown avatar and that females perceived their doppelganger as less competent and warm than the unknown avatar. Our findings have important practical implications in terms of virtual reality-based training and research design such that the use of a doppelganger (unknown avatar) might be recommended in a training program or research setting involving men (women).

Preoperative Virtual Reality to Expose Patients With Breast Cancer to the Operating Room Environment: Feasibility and Pilot Case Series Study

BACKGROUND

Clinically elevated preoperative distress and anxiety are common among patients undergoing cancer surgery. Preoperative interventions have been developed to mitigate this distress and anxiety but are inconsistent in efficacy and feasibility for broad implementation.

OBJECTIVE

This preliminary pilot study aims to assess the feasibility and utility of a newly developed virtual reality (VR) intervention to expose patients awaiting breast cancer surgery to the operating room environment and a simulation of anesthetic induction.

METHODS

Patients undergoing breast cancer surgery (N=7) were assigned to the VR intervention or control (treatment as usual) group and completed self-report measures of distress and anxiety before surgery, on the day of surgery, and after surgery (5 and 30 d postoperatively). Those in the intervention group trialed the VR simulation 1 to 2 weeks preoperatively and provided qualitative and quantitative feedback. We assessed the feasibility of recruitment capability and study design and evaluated participants' impressions of the intervention using self-report rating scales and open-ended questions. We also descriptively examined distress and anxiety levels throughout the duration of the study.

RESULTS

Recruitment occurred between December 2021 and December 2022 and progressed slowly (rate: 1 participant/7 wk on average; some hesitancy because of stress and being overwhelmed). All participants who consented to participate completed the entire study. All participants were female and aged 56 (SD 10.56) years on average. In total, 57% (4/7) of the participants were assigned to the intervention group. On average, intervention participants spent 12 minutes engaged in the VR simulation. In general, the intervention was rated favorably (eg, clear information, enjoyable, and attractive presentation; mean% agreement 95.00-96.25, SD 4.79-10.00) and as helpful (mean% agreement 87.50, SD 25.00). Participants described the intervention as realistic (eg, "It was realistic to my past surgical experiences"), impacting their degree of preparedness and expectations for surgery (eg, "The sounds and sights and procedures give you a test run; they prepare you for the actual day"), and having a calming or relaxing effect (eg, "You feel more relaxed for the surgery").

CONCLUSIONS

This preoperative VR intervention demonstrated preliminary feasibility among a sample of patients undergoing breast cancer surgery. Results and participant feedback will inform modifications to the VR intervention and the study design of a large-scale randomized controlled trial to examine the efficacy of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04544618; https://clinicaltrials.gov/study/NCT04544618.

A Virtual Reality Courtroom for Survivors of Sexual Violence: A Mixed-Method Pilot Study on Application Possibilities

This mixed-method pilot study examined the application possibilities of a virtual courtroom to support survivors of sexual violence who may experience courtroom-associated distress. Female sexual violence survivors (n = 13) who had testified in court following victimization entered an interactive virtual courtroom replica. Their reactions were measured quantitatively and qualitatively. The virtual courtroom evoked both subjective and physiological stress. Participants perceived the virtual reality environment as similar to the real-life courtroom. Most reported negative experiences from interacting with the criminal justice system. The virtual courtroom is a possible future strategy to support survivors when reporting violence to the justice system.

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

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

Psychology and technology: how Virtual Reality can boost psychotherapy and neurorehabilitation

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Social Virtual Reality: Neurodivergence and Inclusivity in the Metaverse

Whereas traditional teaching environments encourage lively and engaged interaction and reward extrovert qualities, introverts, and others with symptoms that make social engagement difficult, such as autism spectrum disorder (ASD), are often disadvantaged. This population is often more engaged in quieter, low-key learning environments and often does not speak up and answer questions in traditional lecture-style classes. These individuals are often passed over in school and later in their careers for not speaking up and are assumed to not be as competent as their gregarious and outgoing colleagues. With the rise of the metaverse and democratization of virtual reality (VR) technology, post-secondary education is especially poised to capitalize on the immersive learning environments social VR provides and prepare students for the future of work, where virtual collaboration will be key. This study seeks to reconsider the role of VR and the metaverse for introverts and those with ASD. The metaverse has the potential to continue the social and workplace changes already accelerated by the pandemic and open new avenues for communication and collaboration for a more inclusive audience and tomorrow.

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

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

Who Makes Your Heart Beat? What Makes You Sweat? Social Conflict in Virtual Reality for Educators

Though educators often deal with stressful social conflicts, many face them ad hoc without much training. We studied if and how virtual agents can help University staff manage student-teacher conflicts. We explored educators' verbal, behavioral, and physiological reactions to a virtual agent that brought up a student-teacher conflict and held exit-interviews. Our qualitative analysis revealed that virtual agents for conflict training were positively received, but not for conflict mediation with cross-cultural differences. Those with non-Western backgrounds felt that an agent could help "save face," whereas Westerners preferred to resolve conflicts in person. In line with this, participants with a Western background rated the virtual agent to be less competent compared to those with non-Western backgrounds. While physiological measures only allow for limited conclusions, we found that participants who believed that the agent was controlled by a human had higher normalized hear rate variability (for the entire conversation in total) than people who thought that the agent was autonomous. We discuss implications for implementing virtual agents for training purposes, the impact of physiological signals, and the need to consider cultural and individual differences.

Development of the Food Allergy Anxiety Scale in an Adult Population: Psychometric Parameters and Convergent Validity

BACKGROUND

Food allergy (FA) affects up to 10% of young children and 2% to 3% of adults, and appears to be increasing in prevalence across the world. The adverse and growing impact of FAs warrants that closer attention is needed to the psychological mechanisms underlying FA and quality of life, to provide benefits for both clinicians and patients. One of these psychological mechanisms, frequently present in individuals struggling with FA, is anxiety.

OBJECTIVE

To provide an FA-specific measure to properly assess the impact of anxiety, the present research proposed the novel Food Allergy Anxiety Scale in an adult population.

METHODS

Two studies were conducted (n = 412), and the psychometric properties of the measure were extensively assessed through several robust statistical techniques (eg, exploratory factor analysis, confirmatory factor analysis, and item response theory).

RESULTS

Our findings indicated a reliable 1-factor structure, significantly associated with other constructs such as general anxiety, depression, and FA quality of life.

CONCLUSIONS

We are confident that the Food Allergy Anxiety Scale is a powerful tool to assess this specific role of FA within anxiety, which might lead to a better comprehension on how this psychological distress works, and consequently, the development of better strategies to reduce its impact.

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.

An overview of the digital solutions for helping people with aphasia through bibliometric analysis

This paper gives insights into recent research developments in the field of digital solutions for people with aphasia and tries to analyse its impact on their rehabilitation. A bibliometric research approach is used for data collection. Relevant studies were extracted from seven major academic databases from years 2000 to 2019 inclusive. The systematic process resulted in 986 studies. The average growth in this field is 4%, which is less compared to other research areas. However, the average citations per paper is 7.27, which represents a medium level of publication quality. Scopus and Web of Science are leading databases for the number of studies (379 and 264) and quality of publications (P-Index: 49.26 and 32.85), respectively. The USA, with 42% of publications, leads this research field, followed by the UK with 15%. Both countries have national aphasia strategies in place through charities (not government level strategies), which potentially contributed to their research leadership. The results show that recent advances in digital solutions have the potential to support people with aphasia. However, further work is needed at both academic and government levels to deliver more research contributions and funding for the rehabilitation of people with aphasia.

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The countries with clear national aphasia strategies in place lead this research field.

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Western countries carry most of the research for aphasia; the global view of this research area is still messing.

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Personal care, in combination with digital solutions, can yield better results.

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The fully immersive virtual reality solutions offer close to real-life interaction experience for the people with aphasia and their surroundings inside the virtual space.

Virtual Reality-Assisted Cognitive Behavioral Therapy for Anxiety Disorders: A Systematic Review and Meta-Analysis

Objective: We aim to explore the effectiveness of virtual reality-assisted cognitive behavioral therapy (VRCBT) in the treatment of anxiety and depression in patients with anxiety disorders. We further compare the therapeutic effect of VRCBT with that of standard cognitive behavioral therapy (CBT), as well as investigate the long-term efficacy of VRCBT. Methods: As of March 3, 2020, a total of four databases (Web of Science, PubMed, PsycINFO, and Scopus) were retrieved, and two researchers independently conducted literature retrieval and research selection and performed data extraction. Methodological quality assessment was performed using the Cochrane risk of bias tool and Grading of Recommendation, Assessment, Development, and Evaluation tool (GRADE). Results: A total of 11 studies were included (n = 626; range, 25.3-43.8), and six randomized controlled trials were quantitatively analyzed. The main outcome was anxiety and depression, and the secondary outcome was the withdrawal rate and long-term effects. Meta-analysis showed that the therapeutic effect of VRCBT on anxiety was better than that of the waiting list group (WLG) (SMD = -0.92; 95% CI: -1.34, -0.50; p = 0.005, I ² = 66%, n = 276), while the therapeutic effect of VRCBT on anxiety was similar to that of standard CBT treatment (SMD = -0.26; 95% CI: -0.50, -0.01; p = 0.77, I ² = 0%, n = 150). We further found that the therapeutic effect of VRCBT on depression was better than that of the WLG (SMD = -1.29; 95% CI: -2.26, -0.32; p = 0.09, I ² = 58%, n = 74), while the effect of VRCBT was similar to that of standard CBT (SMD = -0.30; 95% CI: -0.67, -0.07; p = 0.39, I ² = 1%, n = 116). Of the five studies that reported withdrawal rates of patients during the VRCBT and CBT treatment process, the withdrawal rates of the VRCBT group and CBT group did not reach statistical significance (OR = 0.70, 1.48, p > 0.05); only two studies reported the long-term effectiveness of VRCBT in anxiety and depression on patients with anxiety disorders. Conclusion: VRCBT treatment has a specific positive effect on patients with anxiety disorders (anxiety and depression). Compared with standard CBT, similar therapeutic effects can be achieved in the treatment of anxiety disorders. However, limited randomized controlled trials were included, requiring that these results be treated with caution.

Therapists Make the Switch to Telepsychology to Safely Continue Treating Their Patients During the COVID-19 Pandemic. Virtual Reality Telepsychology May Be Next

Before COVID-19, most therapists had concerns about telepsychology, and only treated patients in person. During the COVID-19 lockdown, patients still needed therapy, but in-person therapy sessions became unsafe. The current study measured how many therapists are using online therapy before vs. during COVID-19, how much training they have received, and their knowledge about legal restrictions on using telepsychology. A sample of 768 U.S.A. mental health professionals completed a 29-item online survey. Results show that before COVID-19, most therapists only saw their patients in person (e.g., at the therapists office), but during the COVID-19 pandemic, nearly all therapists used a wide range of telecommunication technologies to communicate with their quarantined patients, including texting, telephones, video conferences, and even virtual reality. According to within-subject related samples comparisons, 39% of survey respondents used telepsychology before COVID-19, vs. 98% during COVID-19 (χ² = 450.02, p< 0.001). Therapists reported high treatment effectiveness using telepsychology (7.45 on 0-10 scale). However, overall, on a 0-10 scale, therapists reported a significant increase in feeling burned out during the COVID-19 pandemic, Mean = 3.93 (SD = 1.93) before vs. 6.22 (SD = 2.27) during the pandemic (Z = -18.57, p < 0.001). Although the APA ethics guidelines encourage therapists to use telepsychology with their patients during the crisis, gaps in respondents' knowledge identify a need for increased specialized training and education. Although the current study showed that virtual reality is rarely used by the therapists surveyed, virtual reality is a promising new telepsychology technology. Billions of dollars are currently being invested in mass producing immersive virtual reality systems. In the future, as networked immersive Virtual Reality becomes more widely available, therapists and patients in physically different locations will be able to "meet" in a shared computer-generated world designed for therapy sessions, potentially including group sessions. Telepsychology and virtual reality have the potential to be increasingly valuable tools to help therapists mitigate the consequences of COVID-19. Research, development and training is recommended.

Cognitive behavioural therapy in virtual reality treatments across mental health conditions: a systematic review

Background

Virtual reality (VR) has been effectively used in the treatment of many mental health disorders.However, significant gaps exist in the literature. There is no treatment framework for researchers to use when developing new VR treatments. One recommended treatment across a range of diagnoses, which may be suitable for use in VR treatments, is Cognitive Behavioural Therapy (CBT). The aim of this systematic review is to investigateCBT treatment methods that utilize VR to treat mental health disorders.

Objectives

To investigate how CBT has been used in VR to treat mental health disorders and to report onthe treatment characteristics (number of sessions, duration, and frequency) that are linked to effective and ineffective trials.

Methods

Studies were included if patients had a mental health diagnosis and their treatment included immersiveVR technology and CBT principles. Data were extracted in relation to treatment characteristics and outcomes,and analysed using narrative synthesis.

Results

Ninety-three studies were analysed. Exposure-based VR treatments were mainly used to treat anxiety related disorders. Treatments generally consisted of eight sessions, once a week for approximately one hour. VR treatments were commonly equal to or more effective than traditional face-to-face methods. No specific treatment characteristics were linked to this effectiveness.

Conclusion

The number, frequency and duration of the VR treatment sessions identified in this review, could be used as a treatment framework by researchers and clinicians. This could potentially save researchers time and money when developing new interventions.

Coping styles associated with glucose control in individuals with type 2 diabetes mellitus

AIMS/OBJECTIVES

Glycemic control varies according to stress level and the efficacy of control measures, affecting the outcomes of diabetes. Although detailed coping styles have not been well studied in patients with type 2 diabetes mellitus, problem-focused coping strategies are believed to be related to better control of blood glucose. Associations between coping profiles/dimensions and blood glucose control were examined in individuals with type 2 diabetes.

MATERIALS AND METHODS

The participants included 503 Japanese patients (mean age 63.9 ± 12.6 years) with type 2 diabetes. The average glycated hemoglobin A1c (HbA1c) levels were calculated from HbA1c levels measured more than four times within the 12 months before the assessment. Coping profiles were assessed using the Brief Scale for Coping Profile. Lifestyle factors were also included in the analyses.

RESULTS

Factors other than age were not associated with HbA1c levels in patients who used insulin. Conversely, habitual alcohol consumption, single status, the adaptive emotion-focused coping dimension, and changing mood and changing one's point of view profiles were associated with HbA1c levels.

CONCLUSIONS

These findings suggest that adaptive emotion-focused coping supports glycemic control in type 2 diabetes patients who do not use insulin. Additional studies using a longitudinal design are required to further examine the relationships between psychological factors and glycemic control.

Conversational Therapy through Semi-Immersive Virtual Reality Environments for Language Recovery and Psychological Well-Being in Post Stroke Aphasia

Aphasia is a highly disabling acquired language disorder generally caused by a left-lateralized brain damage. Even if traditional therapies have been shown to induce an adequate clinical improvement, a large percentage of patients are left with some degree of language impairments. Therefore, new approaches to common speech therapies are urgently needed in order to maximize the recovery from aphasia. The recent application of virtual reality (VR) to aphasia rehabilitation has already evidenced its usefulness in promoting a more pragmatically oriented treatment than conventional therapies (CT). In the present study, thirty-six chronic persons with aphasia (PWA) were randomly assigned to two groups. The VR group underwent conversational therapy during VR everyday life setting observation, while the control group was trained in a conventional setting without VR support. All patients were extensively tested through a neuropsychological battery which included not only measures for language skills and communication efficacy but also self-esteem and quality of life questionnairies. All patients were trained through a conversational approach by a speech therapist twice a week for six months (total 48 sessions). After the treatment, no significant differences among groups were found in the different measures. However, the amount of improvement in the different areas was distributed over far more cognitive and psychological aspects in the VR group than in the control group. Indeed, the within-group comparisons showed a significant enhancement in different language tasks (i.e., oral comprehension, repetition, and written language) only in the VR group. Significant gains, after the treatment, were also found, in the VR group, in different psychological dimensions (i.e., self-esteem and emotional and mood state). Given the importance of these aspects for aphasia recovery, we believe that our results add to previous evidence which points to the ecological validity and feasibility of VR treatment for language recovery and psychosocial well-being.

Virtual Reality Treatment for Public Speaking Anxiety in Students. Advancements and Results in Personalized Medicine

Public speaking anxiety (PSA) is a common phobia in the student population. Traditionally, exposure therapy has been used as a treatment. However, the use of virtual reality (VR) is increasingly common to treat PSA. The purpose of this paper was to analyze the published scientific literature on VR as a treatment for PSA in students. The articles indexed in two databases (Web of Science and Scopus) were analyzed, with a time period from the beginning of the first publications until 2019 included. The systematic literature review was based on fixed inclusion and exclusion criteria. A total of 13 studies were identified which included 481 students. The results collected indicate that the duration of treatments to have positive effects was at least one week, where the number of sessions was between one and twelve. Furthermore, most VR treatments reported positive effects. Finally, this study showed evidence that VR treatment for PSA is effective while being less invasive than in vivo exposure.

Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?-A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials Specifically Comparing the Efficacy of Virtual Reality Exposure to Gold Standard in vivo Exposure in Agoraphobia, Specific Phobia, and Social Phobia

Background: Convincing evidence on Virtual Reality (VR) exposure for phobic anxiety disorders has been reported, however, the benchmark and golden standard for phobia treatment is in vivo exposure. For direct treatment comparisons, the control of confounding variables is essential. Therefore, the comparison of VR and in vivo exposure in studies applying an equivalent amount of exposure in both treatments is necessary. Methods: We conducted a systematic search of reports published until June 2019. Inclusion criteria covered the diagnosis of Specific Phobia, Social Phobia, or Agoraphobia, and a randomized-controlled design with an equivalent amount of exposure in VR and in vivo. We qualitatively reviewed participants' characteristics, materials, and the treatment procedures of all included studies. For quantitative synthesis, we calculated Hedges' g effect sizes for the treatment effects of VR exposure, in vivo exposure, and the comparison of VR to in vivo exposure in all studies and separately for studies on each diagnosis. Results: Nine studies (n = 371) were included, four on Specific Phobia, three on Social Phobia, and two on Agoraphobia. VR and in vivo exposure both showed large, significant effect sizes. The comparison of VR to in vivo exposure revealed a small, but non-significant effect size favoring in vivo (g = -0.20). Specifically, effect sizes for Specific Phobia (g = -0.15) and Agoraphobia (g = -0.01) were non-significant, only for Social Phobia we found a significant effect size favoring in vivo (g = -0.50). Except for Agoraphobia, effect sizes varied across studies from favoring VR to favoring in vivo exposure. Conclusions: We found no evidence that VR exposure is significantly less efficacious than in vivo exposure in Specific Phobia and Agoraphobia. The wide range of study specific effect sizes, especially in Social Phobia, indicates a high potential of VR, but also points to the need for a deeper investigation and empirical examination of relevant working mechanisms. In Social Phobia, a combination of VR exposure with cognitive interventions and the realization of virtual social interactions targeting central fears might be advantageous. Considering the advantages of VR exposure, its dissemination should be emphasized. Improvements in technology and procedures might even yield superior effects in the future.

Behavioral Counseling Training for Primary Care Providers: Immersive Virtual Simulation as a Training Tool

Behavioral counseling represents an efficacious approach for improving health behaviors on a population level, and the primary care setting is an appropriate context in which to implement this approach. However, evidence suggests that the utilization of behavioral counseling techniques in primary care, including those informed by motivational interviewing, is sub-optimal. Insufficient training has been cited as a barrier to utilizing counseling in the primary care setting. Recent work has evaluated the effectiveness of virtual simulations that can provide access to "virtual" patients while retaining the scalability inherent to a digital medium. However, these educational interventions have been limited to simulations delivered through a two-dimensional screen. More immersive simulations delivered through a head-mounted display can create a realistic practice environment that encompasses a learner's entire field of view, which may confer additional benefits with respect to training outcomes. The purpose of this short article is to briefly review the relevant literature across disciplines to conceptualize the potential effectiveness of this technology as a training tool for behavioral counseling. Immersive virtual simulations are designed to induce a psychological phenomenon referred to as presence, whereby a learner perceives themselves as existing within the virtual environment. As such, immersive virtual simulations can provide opportunities for practice, coaching, and feedback in an environment that closely approximates the clinical setting in which counseling will be delivered. Through its effects on presence, this technology may be particularly useful for developing empathy, which is an important component of counseling. Recommendations for future research are also provided.

Current understanding of fear learning and memory in humans and animal models and the value of a linguistic approach for analyzing fear learning and memory in humans

Fear is an emotion that serves as a driving factor in how organisms move through the world. In this review, we discuss the current understandings of the subjective experience of fear and the related biological processes involved in fear learning and memory. We first provide an overview of fear learning and memory in humans and animal models, encompassing the neurocircuitry and molecular mechanisms, the influence of genetic and environmental factors, and how fear learning paradigms have contributed to treatments for fear-related disorders, such as posttraumatic stress disorder. Current treatments as well as novel strategies, such as targeting the perisynaptic environment and use of virtual reality, are addressed. We review research on the subjective experience of fear and the role of autobiographical memory in fear-related disorders. We also discuss the gaps in our understanding of fear learning and memory, and the degree of consensus in the field. Lastly, the development of linguistic tools for assessments and treatment of fear learning and memory disorders is discussed.

Empowering Mimicry: Female Leader Role Models Empower Women in Leadership Tasks Through Body Posture Mimicry

In two studies we investigated the behavioral process through which visible female leader role models empower women in leadership tasks. We proposed that women tend to mimic the powerful (open) body postures of successful female role models, thus leading to more empowered behavior and better performance on a challenging leadership task, a process we called empowering mimicry. In Study 1, we experimentally manipulated the body posture of the male and female role models and showed that 86 Swiss college women mimicked the body posture of the female (ingroup) but not the male (outgroup) role model, thus leading to more empowered behavior and better performance on a public speaking task. In Study 2, we investigated the boundary conditions of this process and showed that empowering mimicry does not extend to exposures to non-famous female models among 50 Swiss college women. These findings suggest that nonverbal mimicry is one important mechanism through which female leader role models inspire women performing a challenging leadership task. From a practice perspective, our research underscores the importance of female leaders' visibility because visibility can drive other women's advancement in leadership by affording women the opportunity to mimic and be empowered by successful female role models.

A meta-analytic examination of attrition in virtual reality exposure therapy for anxiety disorders

A proposed advantage of virtual reality exposure therapy for anxiety disorders is that people will be less likely to drop out of treatment prematurely if the treatment involves facing one's fear in a virtual world rather than the real world, but this has yet to be empirically tested. The present meta-analyses assess the odds of dropout from virtual reality exposure therapy compared to in vivo exposure therapy, estimate the overall rate of dropout from virtual reality exposure treatment, and test potential moderating variables. The odds ratio meta-analysis indicated that there was no significant difference in the likelihood of attrition from virtual reality exposure therapy relative to in vivo exposure therapy. The overall attrition rate for virtual reality exposure therapy across 46 studies with a combined sample size of 1057 participants was 16%. This rate is slightly lower than other estimates of dropout from in vivo therapy and from cognitive-behavioral therapy for anxiety disorders. Incorporation of between-session intervention (i.e., homework) was identified as a moderator; specifically, inclusion of between-session interventions in the treatment was associated with better retention. Overall, the findings of the present study indicate that virtual reality exposure and in vivo exposure therapy show similar rates of attrition.

Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: A randomized controlled trial

Public speaking anxiety (PSA) is a common condition which can be treated effectively with exposure therapy. However, inherent difficulties in stimuli presentation and control limits dissemination and the therapeutic potential. Virtual Reality (VR) technology has the potential to resolve these issues and provide a scalable platform for self-help interventions. No previous study has examined whether this can be achieved using the first generation of consumer VR hardware and software. In the current trial, n = 25 + 25 participants were randomized to either one-session therapist-led VR exposure therapy for PSA followed by a four-week internet-administered VR to in-vivo transition program, or a waiting-list. Linear mixed effects modeling revealed significant, large (within Cohen's d = 1.67) decreases in self-reported PSA. The waiting-list was then given access to an internet-administered, self-led version of the same VR exposure therapy to be conducted at home, followed by the same transition program. Dual-slope mixed effects modeling revealed significant, large (d = 1.35) decreases in self-reported PSA. Results were maintained or improved at six- and twelve-month follow-ups. We show for the first time that low-cost, off-the-shelf consumer VR hardware and software can be used to conduct exposure therapy for PSA, both in the traditional, previously impractical one-session format, and in a novel self-led, at-home format.

The Impact of Irrational Beliefs on Paranoid Thoughts

BACKGROUND

Although the ABC model proposed by cognitive behavioral theory has strong empirical support for a wide range of psychological problems, little is known about the role of irrational beliefs (IBs), a central concept of the ABC model, in the aetiology of paranoid thoughts, one of the most common psychotic symptoms.

AIMS

The present study aimed to investigate the impact of IBs on paranoid thoughts and people's perceptions of others.

METHOD

Eighty-one non-clinical participants (m age = 21.21 years, SD = 2.72, range 18-33; 83.95% female) recruited for this study were randomly assigned to one of the two conditions: IBs or rational beliefs (RBs). In a role-play paradigm, subjects were asked to imagine holding a list of IBs or RBs, respectively, while being exposed to a neutral social context in a virtual reality environment.

RESULTS

In line with the ABC model, results indicate that IBs lead to significantly higher levels of state paranoid thoughts and more negative perceptions of others than RBs, even after controlling for participants' baseline irrationality and trait paranoia [F (5,68) = 11.23, p &lt; .001, Wilk's λ = .54, partial η2 = .45].

CONCLUSIONS

The findings of this paper suggest that IBs might play an aetiological role in the occurrence of paranoid thoughts. Practical and theoretical implications of these results are also considered.

Experiencing EVA Park, a Multi-User Virtual World for People with Aphasia

Virtual worlds are used in wide-ranging ways by many people with long-term health conditions, but their use by people with aphasia (PWA) has been limited. In contrast, this article reports the use of EVA Park, a multi-user virtual world designed for PWA to practice conversations, focusing on people's emotional, social, and conversational experiences. An analysis of observation and interview data collected from 20 people with aphasia who participated in a 5-week therapy intervention revealed key themes related to user experience. The themes offer a rich insight into aspects of the virtual world experience for PWA that go beyond therapeutic outcomes. They are as follows: affect (positive and negative); types of conversation, miscommunication, and misunderstanding; immersion in the virtual world; social presence and initiative and flow. Overall, the study showed that participants experienced positive emotional and social outcomes. We argue that this was achieved as a consequence of EVA Park being not only accessible but also a varied and entertaining environment within which PWA experienced both the realistic and the quirky while engaging with others and having fun.

Soziales Kompetenztraining in Virtueller Realität bei sozialer Angst

Zusammenfassung. Theoretischer Hintergrund: Soziale Kompetenztrainings sind wichtige Werkzeuge bei der Psychotherapie der Sozialen Angststörung. Die Durchführung in Virtueller Realität (VR) könnte die Verfügbarkeit und Effektivität erhöhen, allerdings besteht ein Bedarf an validierten VR-Szenarien. Fragestellung: Geprüft wird die Validität von zwei in Anlehnung an das Gruppentraining sozialer Kompetenzen von Hinsch und Pfingsten (2015) entwickelten VR-Szenarien. Es wird angenommen, dass die durch das Szenario ausgelösten Komponenten sozialer Angst auf subjektiver, psychophysiologischer und kognitiver Ebene signifikant zwischen höher (HSA) und niedriger (NSA) sozial ängstlichen Personen differenzieren. Methode: Insgesamt durchliefen N = 55 HSA und NSA Studierende zwei VR-Szenarien vom Typ „Recht durchsetzen“. Zusätzlich wurde experimentell die Blickkontaktdauer des virtuellen Gesprächspartners variiert. Hauptoutcome war die erlebte Angst in den Rollenspielen. Zusätzlich wurden Herzschlagfrequenz, Hautleitfähigkeit sowie die Einschätzung der eigenen Kompetenz erfasst. Ergebnisse: HSA im Vergleich zu NSA berichteten für beide Szenarien signifikant höhere Angst sowie negative Verzerrungen in Bezug auf die Einschätzung der eigenen Kompetenz. Zusätzlich zeigte sich eine physiologische Aktivierung während der Rollenspiele, aber keine Differenzierung zwischen beiden Gruppen. Beide VR-Szenarien wurden als realistisch empfunden. Schlussfolgerungen: Virtuelle Interaktionsszenarien können zu Trainingszwecken genutzt werden und Soziale Kompetenztrainings in VR haben ein großes Potential für den Einsatz als psychotherapeutisches Verfahren bei Sozialer Angststörung.

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.

Re-Thinking Anxiety: Using Inoculation Messages to Reduce and Reinterpret Public Speaking Fears

Inoculation theory offers a framework for protecting individuals against challenges to an existing attitude, belief, or state. Despite the prevalence and damaging effects of public speaking anxiety, inoculation strategies have yet to be used to help individuals remain calm before and during public speaking. We aimed to test the effectiveness of an inoculation message for reducing the onset of public speaking anxiety, and helping presenters interpret their speech-related anxiety more positively. Participants (M_age = 20.14, SD = 2.72) received either an inoculation (n = 102) or control (n = 128) message prior to engaging a public speaking task and reported a range of anxiety-related perceptions. Accounting for personality characteristics and perceptions of task importance, and relative to control participants, those who received the inoculation message reported significantly lower pre-task anxiety, and following the task, reported that they had experienced lower somatic anxiety, and that the inoculation message had caused them to view their nerves in a less debilitating light. Inoculation messages may be an effective strategy for helping participants reframe and reduce their apprehension about public speaking, and investigating their efficacy in other stress-inducing contexts may be worthwhile.

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

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

Evaluating the Benefits of Aphasia Intervention Delivered in Virtual Reality: Results of a Quasi-Randomised Study

INTRODUCTION

This study evaluated an intervention for people with aphasia delivered in a novel virtual reality platform called EVA Park. EVA Park contains a number of functional and fantastic locations and allows for interactive communication between multiple users. Twenty people with aphasia had 5 weeks' intervention, during which they received daily language stimulation sessions in EVA Park from a support worker. The study employed a quasi randomised design, which compared a group that received immediate intervention with a waitlist control group. Outcome measures explored the effects of intervention on communication and language skills, communicative confidence and feelings of social isolation. Compliance with the intervention was also explored through attrition and usage data.

RESULTS

There was excellent compliance with the intervention, with no participants lost to follow up and most (18/20) receiving at least 88% of the intended treatment dose. Intervention brought about significant gains on a measure of functional communication. Gains were achieved by both groups of participants, once intervention was received, and were well maintained. Changes on the measures of communicative confidence and feelings of social isolation were not achieved. Results are discussed with reference to previous aphasia therapy findings.

Effectiveness of In Virtuo Exposure and Response Prevention Treatment Using Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: A Study Based on a Single-Case Study Protocol

Obsessive-compulsive disorder (OCD) is characterized by the presence of distressing, recurrent and intrusive thoughts, impulses, or doubts as well as behavioral or mental rituals. OCD has various subtypes, including the fear of contamination in which individuals fear bacteria, germs, disease, or bodily secretions, and engage in clinically significant cleaning and avoidance rituals. Cognitive-behavioral therapy (CBT) is an effective treatment for OCD and involves, among other therapeutic strategies, exposing patients to feared stimuli while preventing them to engage in compulsive behaviors. In recent years, virtual reality (VR) has shown the potential of in virtuo exposure with people suffering from anxiety disorders and OCD. The objective of this pilot study is to examine the effectiveness of a CBT program where exposure in conducted in virtuo. Three adults suffering from OCD with a dominant subtype of contamination were enrolled in a single-case design with multiple baselines across participants. The presence and intensity of obsessions and compulsions were assessed daily during baselines of 3-, 4-, or 5-week, and a 12-session treatment. Follow-up information was gathered after 4 and 8 months. Treatment outcome is assessed with visual inspection of the graphs and ARMA time-series analyses. Clinical information, self-reports, and details of the treatment are provided for each patient. Statistical analyses for the time-series data revealed a statistically significant improvement in all three participants, but global improvement is considered positive for only two. This study innovates in proving preliminary support for the usefulness of VR in the CBT of OCD with contamination features.

Exposure to virtual social interactions in the treatment of social anxiety disorder: A randomized controlled trial

This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposure intervention comprising verbal interaction with virtual humans to target heterogeneous social fears in participants with social anxiety disorder. Sixty participants (Mage = 36.9 years; 63.3% women) diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analyses revealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms, speech duration, perceived stress, and avoidant personality disorder related beliefs when compared to the waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation, speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. The iVET condition was further superior to the VRET condition regarding decreases in social anxiety symptoms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up. At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stress was significant. VRET containing extensive verbal interaction without any cognitive components can effectively reduce complaints of generalized social anxiety disorder. Future technological and psychological improvements of virtual social interactions might further enhance the efficacy of VRET for social anxiety disorder.

Gradual extinction reduces reinstatement

The current study investigated whether gradually reducing the frequency of aversive stimuli during extinction can prevent the return of fear. Thirty-one participants of a three-stage procedure (acquisition, extinction and a reinstatement test on day 2) were randomly assigned to a standard extinction (SE) and gradual extinction (GE) procedure. The two groups differed only in the extinction procedure. While the SE group ran through a regular extinction process without any negative events, the frequency of the aversive stimuli during the extinction phase was gradually reduced for the GE group. The unconditioned stimulus (US) was an air blast (5 bar, 10 ms). A spider and a scorpion were used as conditioned stimuli (CS). The outcome variables were contingency ratings and physiological measures (skin conductance response, SCR and startle response). There were no differences found between the two groups for the acquisition and extinction phases concerning contingency ratings, SCR, or startle response. GE compared to SE significantly reduced the return of fear in the reinstatement test for the startle response but not for SCR or contingency ratings. This study was successful in translating the findings in rodent to humans. The results suggest that the GE process is suitable for increasing the efficacy of fear extinction.

Evaluating changes in judgmental biases as mechanisms of cognitive-behavioral therapy for social anxiety disorder

Reductions in judgmental biases concerning the cost and probability of negative social events are presumed to be mechanisms of treatment for SAD. Methodological limitations of extant studies, however, leave open the possibility that, instead of causing symptom relief, reductions in judgmental biases are correlates or consequences of it. The present study evaluated changes in judgmental biases as mechanisms explaining the efficacy of CBT for SAD. Participants were 86 individuals who met DSM-IV-TR criteria for a primary diagnosis of SAD, participated in one of two treatment outcome studies of CBT for SAD, and completed measures of judgmental (i.e., cost and probability) biases and social anxiety at pre-, mid-, and posttreatment. Treated participants had significantly greater reductions in judgmental biases than not-treated participants; pre-to-post changes in cost and probability biases statistically mediated treatment outcome; and probability bias at midtreatment was a significant predictor of treatment outcome, even when modeled with a plausible rival mediator, working alliance. Contrary to hypotheses, cost bias at midtreatment was not a significant predictor of treatment outcome. Results suggest that reduction in probability bias is a mechanism by which CBT for SAD exerts its effects.

Telemental health: A status update

A rather large body of literature now exists on the use of telemental health services in the diagnosis and management of various psychiatric conditions. This review aims to provide an up-to-date assessment of telemental health, focusing on four main areas: computerized CBT (cCBT), Internet-based CBT (iCBT), virtual reality exposure therapy (VRET), and mobile therapy (mTherapy). Four scientific databases were searched and, where possible, larger, better-designed meta-analyses and controlled trials were highlighted. Taken together, published studies support an expanded role for telepsychiatry tools, with advantages that include increased care access, enhanced efficiency, reduced stigma associated with visiting mental health clinics, and the ability to bypass diagnosis-specific obstacles to treatment, such as when social anxiety prevents a patient from leaving the house. Of technology-mediated therapies, cCBT and iCBT possess the most efficacy evidence, with VRET and mTherapy representing promising but less researched options that have grown in parallel with virtual reality and mobile technology advances. Nonetheless, telepsychiatry remains challenging because of the need for specific computer skills, the difficulty in providing patients with a deep understanding or support, concerns about the "therapeutic alliance", privacy fears, and the well documented problem of patient attrition. Future studies should further test the efficacy, advantages and limitations of technology-enabled CBT, as well as explore the online delivery of other psychotherapeutic and psychopharmacological modalities.

Real enough: using virtual public speaking environments to evoke feelings and behaviors targeted in stuttering assessment and treatment

PURPOSE

Virtual reality environments (VREs) are computer-generated, 3-dimensional worlds that allow users to experience situations similar to those encountered in the real world. The purpose of this study was to investigate VREs for potential use in assessing and treating persons who stutter (PWS) by determining the extent to which PWS's affective, behavioral, and cognitive measures in a VRE correlate with those same measures in a similar live environment.

METHOD

Ten PWS delivered speeches-first to a live audience and, on another day, to 2 virtual audiences (neutral and challenging audiences). Participants completed standard tests of communication apprehension and confidence prior to each condition, and frequency of stuttering was measured during each speech.

RESULTS

Correlational analyses revealed significant, positive correlations between virtual and live conditions for affective and cognitive measures as well as for frequency of stuttering.

CONCLUSIONS

These findings suggest that virtual public speaking environments engender affective, behavioral, and cognitive reactions in PWS that correspond to those experienced in the real world. Therefore, the authentic, safe, and controlled environments provided by VREs may be useful for stuttering assessment and treatment.

The Relationship between Virtual Self Similarity and Social Anxiety

In virtual reality (VR), it is possible to embody avatars that are dissimilar to the physical self. We examined whether embodying a dissimilar self in VR would decrease anxiety in a public speaking situation. We report the results of an observational pilot study and two laboratory experiments. In the pilot study (N = 252), participants chose an avatar to use in a public speaking task. Trait public speaking anxiety correlated with avatar preference, such that anxious individuals preferred dissimilar self-representations. In Study 1 (N = 82), differences in anxiety during a speech in front of a virtual audience were compared among participants embodying an assigned avatar whose face was identical to their real self, an assigned avatar whose face was other than their real face, or embodied an avatar of their choice. Anxiety differences were not significant, but there was a trend for lower anxiety with the assigned dissimilar avatar compared to the avatar looking like the real self. Study 2 (N = 105) was designed to explicate that trend, and further investigated anxiety differences with an assigned self or dissimilar avatar. The assigned dissimilar avatar reduced anxiety relative to the assigned self avatar for one measure of anxiety. We discuss implications for theories of self-representation as well as for applied uses of VR to treat social anxiety.

Stereotype confirmation concerns predict dropout from cognitive behavioral therapy for social anxiety disorder

BACKGROUND

There are high attrition rates observed in efficacy studies for social anxiety disorder, and research has not identified consistent nor theoretically meaningful predictors of dropout. Pre-treatment symptom severity and demographic factors, such as age and gender, are sometimes predictive of dropout. The current study examines a theoretically meaningful predictor of attrition based on experiences associated with social group membership rather than differences between social group categories--fear of confirming stereotypes.

METHODS

This is a secondary data analysis of a randomized controlled trial comparing two cognitive behavioral treatments for social anxiety disorder: virtual reality exposure therapy and exposure group therapy. Participants (N = 74) with a primary diagnosis of social anxiety disorder who were eligible to participate in the parent study and who self-identified as either "African American" (n = 31) or "Caucasian" (n = 43) completed standardized self-report measures of stereotype confirmation concerns (SCC) and social anxiety symptoms as part of a pre-treatment assessment battery.

RESULTS

Hierarchical logistic regression showed that greater stereotype confirmation concerns were associated with higher dropout from therapy--race, age, gender, and pre-treatment symptom severity were not. Group treatment also was associated with higher dropout.

CONCLUSIONS

These findings urge further research on theoretically meaningful predictors of attrition and highlight the importance of addressing cultural variables, such as the experience of stereotype confirmation concerns, during treatment of social anxiety to minimize dropout from therapy.