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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Self-guided virtual reality therapy for anxiety: A systematic review

BACKGROUND

Virtual reality (VR) technology can be used to treat anxiety symptoms and disorders. However, most VR interventions for anxiety have been therapist guided rather than self-guided.

OBJECTIVE

This systematic review aimed to examine the effectiveness and user experience (i.e., usability, acceptability, safety, and attrition rates) of self-guided VR therapy interventions in people with any anxiety condition as well as provide future research directions.

METHOD

Peer-reviewed journal articles reporting on self-guided VR interventions for anxiety were sought from the Cochrane Library, IEEE Explore Digital Library, PsycINFO, PubMED, Scopus, and Web of Science databases. Study data from the eligible articles were extracted, tabulated, and addressed with a narrative synthesis.

RESULTS

A total of 21 articles met the inclusion criteria. The findings revealed that self-guided VR interventions for anxiety can provide an effective treatment of social anxiety disorder, public speaking anxiety, and specific phobias. User experience outcomes of safety, usability, and acceptability were generally positive, and the average attrition rate was low. However, there was a lack of standardised assessments to measure user experiences.

CONCLUSION

Self-guided VR for anxiety can provide an engaging approach for effectively and safely treating common anxiety conditions. Nevertheless, more experimental studies are required to examine their use in underrepresented anxiety populations, assess their long-term treatment effects beyond 12 months, and compare their effectiveness against other self-help interventions for anxiety (e.g., internet interventions and bibliotherapy).

The roles of psychosocial resources in reducing the impact of gendered racism on worry among Black women attending an HBCU

Objective: The study ascertained the effects of Black college women's experiences of gendered racism on worry. Psychosocial resources were examined as factors expected to reduce the impact of gendered racial microaggressions on worry. Participants: The sample comprised 197 Black-identified students enrolled at a southern Historically Black College or University. Methods: A cross-sectional research design was used. After adjusting for covariates, Ordinary Least Squares (OLS) regression models evaluated the associations between gendered racial microaggressions, psychosocial resources, and worry. Results: Frequent experiences of gendered racial microaggressions were associated with heightened worry. The Angry Black Woman stereotype had the most robust relationship with worry. Psychosocial resources, specifically mastery, self-esteem, and resilience, reduced the impact of gendered racial microaggressions on worry. Conclusion: Gendered racism contributes to increased worry, and thus, heightens the risk of experiencing anxiety. High levels of mastery, self-esteem, and resilience reduce the effects of gendered racism on worry.

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.

A comparison of virtual reality and verbal imaginal exposure for childhood anxiety disorders

Virtual reality is a promising tool for improving efficacy of exposure therapy for childhood anxiety disorders (CADs), particularly for exposures that are challenging to orchestrate in vivo. The present study compared virtual reality exposure (VRE) to verbal imaginal exposure (IE) on anxiety elicited, homework completion, and preparation for subsequent exposures. Forty-five youth with CADs completed both types of exposure in session (order randomly assigned), practiced one form of exposure as homework (randomly assigned), and returned a week later to repeat both exposures (in randomized order), provide user feedback, and complete a related in vivo exposure. Both VRE and IE elicited moderate anxiety that decreased to mild during the exposure and were associated with lower initial anxiety ratings in subsequent exposures. These patterns did not differ across exposure type. The two techniques did not differ on homework completion. VRE was associated with greater simulator (motion) sickness symptoms. Participants rated VRE as more realistic than IE and noted pros and cons for both approaches. The present study supported use of VRE and IE in treatment of CADs without demonstrating superiority of either technique in effectiveness or homework completion.

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.

Machine learning prediction of anxiety symptoms in social anxiety disorder: utilizing multimodal data from virtual reality sessions

Introduction

Machine learning (ML) is an effective tool for predicting mental states and is a key technology in digital psychiatry. This study aimed to develop ML algorithms to predict the upper tertile group of various anxiety symptoms based on multimodal data from virtual reality (VR) therapy sessions for social anxiety disorder (SAD) patients and to evaluate their predictive performance across each data type.

Methods

This study included 32 SAD-diagnosed individuals, and finalized a dataset of 132 samples from 25 participants. It utilized multimodal (physiological and acoustic) data from VR sessions to simulate social anxiety scenarios. This study employed extended Geneva minimalistic acoustic parameter set for acoustic feature extraction and extracted statistical attributes from time series-based physiological responses. We developed ML models that predict the upper tertile group for various anxiety symptoms in SAD using Random Forest, extreme gradient boosting (XGBoost), light gradient boosting machine (LightGBM), and categorical boosting (CatBoost) models. The best parameters were explored through grid search or random search, and the models were validated using stratified cross-validation and leave-one-out cross-validation.

Results

The CatBoost, using multimodal features, exhibited high performance, particularly for the Social Phobia Scale with an area under the receiver operating characteristics curve (AUROC) of 0.852. It also showed strong performance in predicting cognitive symptoms, with the highest AUROC of 0.866 for the Post-Event Rumination Scale. For generalized anxiety, the LightGBM's prediction for the State-Trait Anxiety Inventory-trait led to an AUROC of 0.819. In the same analysis, models using only physiological features had AUROCs of 0.626, 0.744, and 0.671, whereas models using only acoustic features had AUROCs of 0.788, 0.823, and 0.754.

Conclusions

This study showed that a ML algorithm using integrated multimodal data can predict upper tertile anxiety symptoms in patients with SAD with higher performance than acoustic or physiological data obtained during a VR session. The results of this study can be used as evidence for personalized VR sessions and to demonstrate the strength of the clinical use of multimodal data.

An initial test of a new self-guided internet-based intervention for social anxiety: iExposure

Social anxiety is a prevalent mental health concern that impacts approximately 12% of the US population. There is a need for targeted mechanism-focused interventions for social anxiety that are also highly scalable. Using a recently developed naturalistic paradigm with simulated teleconferencing interactions as the central treatment element, we developed a new self-guided internet-based intervention for social anxiety called iExposure. This randomized clinical trial aimed at testing two mechanism-driven exposure augmentation strategies for social anxiety. Participants (N = 53) were randomized to four sessions of either (a) standard iExposure (n = 18), (b) iExposure +Attention Control (n = 22), or (c) iExposure + Attention Guidance (n = 13) and administered over two weeks. At follow-up across conditions, there were large reductions in communication anxiety d = -1.51 and moderate reductions in social anxiety d = -0.60. The attention control condition led to larger reductions in social anxiety compared to standard iExposure d = -0.81 and attention guidance did not enhance iExposure for general symptoms of social anxiety, d = -0.27. These findings provide preliminary support for the utility of iExposure. Further research is needed with a larger sample to understand its efficacy with regard to the role of attention augmentation strategies.

Do the effects of internet-delivered cognitive-behavioral therapy (i-CBT) last after a year and beyond? A meta-analysis of 154 randomized controlled trials (RCTs)

Although the short-term efficacy of internet-delivered cognitive-behavioral therapy (i-CBT) is well-established, its long-term efficacy remains understudied. Robust variance estimation meta-analysis was thus conducted across guided and self-guided i-CBT, synthesizing data from 154 randomized controlled trials (N = 45,335) with ≥ 12-month follow-ups. For binary outcomes, guided (52.3% vs. 38.6%; log-risk ratio [LOG-RR] = 1.15 95% confidence interval [1.04, 1.26]) yielded higher remission, reliable improvement, and response rates, and lower suboptimal treatment outcome rates (9.3% vs. 10.8%; LOG-RR = 0.63 [0.45, 0.80]) than treatment-as-usual, active controls, and waitlists at ≥12 months. Insufficient studies precluded testing the efficacy between self-guided i-CBT and controls for binary outcomes. For baseline-to-12-month dimensional outcomes, guided i-CBT produced greater reductions in anxiety, depressive, post-traumatic stress disorder (PTSD) symptoms, and repetitive negative thinking (Hedge's g = -1.86 to -0.31), and self-guided i-CBT yielded stronger reductions in depressive symptoms (g = -0.51) than all controls. For outcome scores aggregated at ≥ 12-month follow-ups, guided i-CBT alleviated anxiety, depression, distress, insomnia, PTSD symptoms, role impairment, emotion regulation, and quality of life (g = -0.31 to 0.26), and self-guided i-CBT yielded lower anxiety and depressive symptoms (g = -0.16 to -0.09) than all controls. No significant differences in efficacy emerged between guided and self-guided i-CBT when sufficient studies existed for a meta-analysis. There was no evidence for publication bias. Long-term efficacy was similar to short-term efficacy for most outcomes. Implementing scalable i-CBTs should entail transparency about their long-term benefits and drawbacks.

Augmenting self-guided virtual-reality exposure therapy for social anxiety with biofeedback: a randomised controlled trial

Introduction

We previously found that self-guided Virtual Reality Exposure Therapy (VRET) improved Public Speaking Anxiety (PSA) and reduced heartrate. Elevated heartrate characterises social anxiety and the self-guided VRET seemed to reduce heartrate. Thus, receiving continuous biofeedback about physiological arousal during the VRET could help socially anxious individuals to manage their anxiety. The present study aimed to determine whether biofeedback enhances the responsiveness of VRET.

Methods

Seventy-two individuals with high self-reported social anxiety were randomly allocated to VRET-plus-biofeedback (n=38; 25 completers) or VRET alone (n=35; 25 completers). Three hour-long VRET sessions were delivered over three consecutive weeks. During each session, participants delivered a 20-minute public speech in front of a virtual audience. Participants in the VRET-plus-biofeedback group received biofeedback on heartrate and frontal alpha asymmetry (FAA) within the virtual environment and were asked to lower their arousal accordingly. Participants in both groups completed psychometric assessments of social anxiety after each session and at one-month follow-up.

Results

PSA improved by the end of treatment and overall social anxiety improved one month after the VRET across both groups. The VRET-plus-biofeedback group showed a steadier reduction in FAA in the first VRET session and a greater reduction in self-reported arousal across the three sessions than the VRET-alone group.

Conclusion

Biofeedback can steady physiological arousal and lower perceived arousal during exposure. The benefits of self-guided VRET for social anxiety are sustained one month after therapy.

Research hot topics and frontiers in social anxiety over the past decade: a CiteSpace bibliometric analysis based on Web of Science database from 2013 to 2023

Objective

To understand the current study of social anxiety (SA) over the past decade, and to analyze the research hot topics and frontiers in this field.

Methods

CiteSpace 6.2.R3 was used to analyze the literature on SA collected in the Web of Science Core Collection database from 2013 to 2023.

Results

A total of 9940 literature were included after the screening, and the annual publication volume showed a steady increase. The results emphasize that Zvolensky MJ, Pine DS, and Heimberg RG are important authors in the field of SA. The United States has the highest number of publications, with the University of California System contributing the most. Research hotspots include cognitive impairment, risk factors, complications, neuroimaging, and intervention strategies. SA related to the "theory of mind", "bullying victimization", "mobile phone", "network analysis", "technology", and "satisfaction" are emerging research foci.

Conclusion

This study identifies the current situation and trends of SA research, and provides a reference for future research topics and directions.

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.

Beyond Pharmacology: A Narrative Review of Alternative Therapies for Anxiety Disorders

BACKGROUND

Anxiety disorders significantly reduce patients' quality of life. Current pharmacological treatments, primarily benzodiazepines and antidepressants, are associated with numerous side effects. Consequently, there is a continual search for alternative methods to traditional therapies that are less burdensome for patients and broaden their therapeutic options. Our objective was to determine the role of selected alternative methods in the treatment of anxiety disorders.

METHODS

In this review, we examined recent evidence on alternative treatments for anxiety disorders, including physical activity, mindfulness, virtual reality (VR) technology, biofeedback, herbal remedies, transcranial magnetic stimulation (TMS), cryotherapy, hyperbaric therapy, vagus nerve stimulation (VNS), 3,4-methylenedioxymethamphetamine (MDMA), electroconvulsive therapy (ECT), and eye movement desensitization and reprocessing (EMDR) therapy. For this purpose we reviewed PubMed and after initial search, we excluded works unrelated to our aim, non-orginal data and animal studies. We conducted second search to cover all minor methods.

RESULTS

We included 116 studies, which data is presented in Tables. We have investigated which methods can support treatment and which can be used as a stand-alone treatment. We assessed the risks to benefits of using alternative treatments.

CONCLUSION

Alternative treatments significantly expand the options available to patients and clinicians, with many serving as adjuncts to traditional therapies. Among the methods presented, mindfulness has the most significant therapeutic potential.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is a brief mindfulness ecological momentary intervention more efficacious than a self-monitoring app for social anxiety disorder? A randomized controlled trial

Despite their proliferation, limited knowledge exists regarding possible benefits of brief mindfulness ecological momentary interventions (MEMIs) for social anxiety disorder (SAD). Propositions that MEMIs could alleviate SAD symptoms and related clinical outcomes remain untested. This trial evaluated a 14-day MEMI for SAD. Participants with self-reported SAD were randomized to MEMI (n = 96) or self-monitoring app (SM; n = 95). Whereas MEMI instructed mindfulness exercises, SM prompted only self-monitoring five times daily for 14 days. Participants completed state-level self-reports of depression, anxiety, and mindfulness pre-post-mindfulness practice and SAD symptoms, worry, depression severity, repetitive negative thinking, and trait mindfulness at pre-randomization, post-intervention, and 1-month follow-up (1MFU). Hierarchical linear modeling was conducted. The MEMI yielded statistically significantly larger improvements in momentary depression, anxiety, and mindfulness (Cohen's d = -0.10-0.11). Although no between-group effects emerged in alleviating SAD fear and avoidance, excessive worry, depression severity, repetitive negative thinking, and trait mindfulness (-0.13-0.15), within-group effects were significantly small-to-large from pre-post and pre-1MFU (-4.62-0.67). A significant reduction in depression severity occurred in MEMI (-0.63--0.60) but not SM (-0.31--0.29). Brief MEMI and SM yielded nondifferent sustained effects on SAD, comorbid symptoms, and risk factors, highlighting its potential value within stepped-care delivery settings.

Testing the Efficacy of a Brief, Self-Guided Mindfulness Ecological Momentary Intervention on Emotion Regulation and Self-Compassion in Social Anxiety Disorder: Randomized Controlled Trial

BACKGROUND

Theories propose that brief, mobile, self-guided mindfulness ecological momentary interventions (MEMIs) could enhance emotion regulation (ER) and self-compassion. Such changes are posited to be mechanisms of change. However, rigorous tests of these theories have not been conducted.

OBJECTIVE

In this assessor-blinded, parallel-group randomized controlled trial, we aimed to test these theories in social anxiety disorder (SAD).

METHODS

Participants with SAD (defined as having a prerandomization cut-off score ≥20 on the Social Phobia Inventory self-report) were randomized to a 14-day fully self-guided MEMI (96/191, 50.3%) or self-monitoring app (95/191, 49.7%) arm. They completed web-based self-reports of 6 clinical outcome measures at prerandomization, 15-day postintervention (administered the day after the intervention ended), and 1-month follow-up time points. ER and self-compassion were assessed at preintervention and 7-day midintervention time points. Multilevel modeling determined the efficacy of MEMI on ER and self-compassion domains from pretrial to midintervention time points. Bootstrapped parallel multilevel mediation analysis examined the mediating role of pretrial to midintervention ER and self-compassion domains on the efficacy of MEMI on 6 clinical outcomes.

RESULTS

Participants demonstrated strong compliance, with 78% (149/191) engaging in at least 80% of the MEMI and self-monitoring prompts. MEMI was more efficacious than the self-monitoring app in decreasing ER goal-directed behavior difficulties (between-group Cohen d=-0.24) and lack of emotional clarity (Cohen d=0.16) and increasing self-compassion social connectedness (Cohen d=0.19), nonidentification with emotions (Cohen d=0.16), and self-kindness (Cohen d=0.19) from pretrial to midintervention time points. The within-group effect sizes from pretrial to midintervention were larger in the MEMI arm than in the self-monitoring app arm (ER goal-directed behavior difficulties: Cohen d=-0.73 vs -0.29, lack of emotional clarity: Cohen d=-0.39 vs -0.21, self-compassion domains of social connectedness: Cohen d=0.45 vs 0.19, nonidentification with emotions: Cohen d=0.63 vs 0.48, and self-kindness: Cohen d=0.36 vs 0.10). Self-monitoring, but not MEMI, alleviated ER emotional awareness issues (between-group Cohen d=0.11 and within-group: Cohen d=-0.29 vs -0.13) and reduced self-compassion acknowledging shared human struggles (between-group Cohen d=0.26 and within-group: Cohen d=-0.23 vs 0.13). No ER and self-compassion domains were mediators of the effect of MEMI on SAD symptoms (P=.07-<.99), generalized anxiety symptoms (P=.16-.98), depression severity (P=.20-.94), repetitive negative thinking (P=.12-.96), and trait mindfulness (P=.18-.99) from pretrial to postintervention time points. Similar nonsignificant mediation effects emerged for all of these clinical outcomes from pretrial to 1-month follow-up time points (P=.11-.98).

CONCLUSIONS

Brief, fully self-guided, mobile MEMIs efficaciously increased specific self-compassion domains and decreased ER difficulties associated with goal pursuit and clarity of emotions from pretrial to midintervention time points. Higher-intensity MEMIs may be required to pinpoint the specific change mechanisms in ER and self-compassion domains of SAD.

TRIAL REGISTRATION

Open Science Framework (OSF) Registries; osf.io/m3kxz https://osf.io/m3kxz.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

"In the Metaverse We (Mis)trust?" Third-Level Digital (In)equality, Social Phobia, Neo-Luddism, and Blockchain/Cryptocurrency Transparency in the Artificial Intelligence-Powered Metaverse

The Metaverse, powered by a variety of key innovative technologies including 3D virtual reality (VR)/augmented reality (AR), artificial intelligence (AI), blockchain/cryptocurrency-based non-fungible tokens (NFTs), and the Internet of Things, has been proposed as the future of a virtual universe for education, work, business, and commerce. This research (∑ N = 954) presents the results of three cross-sectional surveys that examine the influence of third-level digital (in)equality and consumer (mis)trust on Metaverse adoption intention. Study 1, focusing on the Metaverse for hybrid education, reports the mediating effect of (mis)trust in the Metaverse on the relationship between the educational dimension of third-level digital (in)equality and behavioral intention to adopt the Metaverse for virtual learning as well as the moderating effect of social phobia. Study 2, focusing on the Metaverse for remote working, reports the mediating effect of (mis)trust in the Metaverse on the relationship between the economic labor dimension of third-level digital (in)equality and Metaverse adoption for virtual working as well as the moderating effect of neo-Luddism. Study 3, focusing on the Metaverse for business, reports the mediating effect of (mis)trust in the Metaverse on the relationship between the economic commerce dimension of third-level digital (in)equality and Metaverse adoption for virtual commerce as well as the moderating effect of blockchain/cryptocurrency transparency perception. This research can provide theoretical frameworks to examine people's hopes and fears about the Metaverse and consequential adoption versus non-adoption of the Metaverse for hybrid education, hybrid remote working, and omni-channel virtual commerce. Practical, managerial, and policy implications for the Metaverse and the NFT market are also discussed.

A systematic review on the efficacy of virtual reality and gamification interventions for managing anxiety and depression

This systematic review aims to assess the effectiveness of virtual reality (VR) and gamification interventions in addressing anxiety and depression. The review also seeks to identify gaps in the current VR treatment landscape and provide guidelines for future research and development. A systematic literature search was conducted using Scopus, Web of Science, and PubMed databases, focusing on studies that utilized VR and gamification technology to address anxiety and depression disorders. A total of 2,664 studies were initially identified, 15 of those studies fulfilled the inclusion criteria for this systematic review. The efficacy of VR in addressing anxiety and depression was evident across all included studies. However, the diversity among VR interventions highlights the need for further investigation. It is advised to incorporate more diverse participant samples and larger cohorts and explore a broader spectrum of therapeutic approaches within VR interventions for addressing anxiety and depression to enhance the credibility of future research. Additionally, conducting studies in varying socioeconomic contexts would contribute to a more comprehensive understanding of their real-world applicability.

The effect of virtual reality exposure therapy on focus of attention, self-criticism, and interpretation bias in university students with social anxiety

BACKGROUND

The present research aims to investigate the effectiveness of virtual reality exposure therapy on the focus of attention, self-criticism, and interpretation bias among university students with social anxiety.

MATERIALS AND METHODS

The present research was conducted using quasi-experimental research with pre-test and post-test control group design. The participants were university students aged between 10 and 30 years old who had visited Isfahan counseling centers in 1399 HS. Among 53 patients referred to the counseling centers, 30 were randomly selected by convenience sampling and then assigned to an experimental group (15 individuals) and a control group (15 individuals). The experimental group received eight sessions of 30-minute and face-to-face virtual reality-based interventions. In contrast, the control group remained on the waiting list. A structured clinical interview and Social Phobia Inventory (SPIN) were used to select and screen students, and the Focus of Attention Questionnaire (FAQ), Levels of Self-Criticism Scale (LOSC), and revised interpretation bias inventory were applied for the pre-test and the post-test. Then, all the data were analyzed by a statistical analysis of covariance.

RESULTS

The results showed that virtual reality exposure therapy significantly reduces the symptoms of the focus of attention, self-criticism, and interpretation bias in the experimental group compared to the control group. (P < 0/01).

CONCLUSION

The research showed that virtual reality exposure therapy reduced the symptoms of social anxiety. Therefore, this method can be applied to reduce some symptoms of social anxiety in university students.

Stand-alone virtual reality exposure therapy as a treatment for social anxiety symptoms: a systematic review and meta-analysis

Introduction

Social anxiety is common and can have far-reaching implications for affected individuals, both on social life and working performance. Usage of virtual reality exposure therapy (VRET) has gained traction. The aim of the present systematic review was to evaluate the effect of stand-alone VRET on social anxiety symptoms.

Method

We searched systematically in PubMed, Embase, PSYCinfo, and ERIC in May 2022 for studies with participants with social anxiety symptoms receiving stand-alone VRET. Two reviewers independently selected relevant studies in a two-step procedure, and the risk of bias was assessed.

Results

Of 158 hits, 7 studies were selected for full-text reading, 6 were chosen for evaluation, and 5 were included in meta-analyses. VRET resulted in a significantly lower anxiety score in treated individuals with a standard mean difference of -0.82, 95% confidence interval -1.52 to -0.13, compared to controls.

Conclusion

Stand-alone VRET may reduce social anxiety symptoms. However, despite promising results, there is still uncertainty as the effect estimate is based on few studies with few participants each and a high risk of bias.

Brief imaginal exposure exercises for social anxiety disorder: A randomized controlled trial of a self-help momentary intervention app

INTRODUCTION

Emerging technological interventions for psychological disorders are being developed continually. Offering imaginal exposure exercises as a self-help intervention presents the opportunity to acquire foundational skills to address social anxiety. The current study evaluates the feasibility and effectiveness of a novel smartphone application for social interaction anxiety.

METHODS

Participants (n = 82) were adults meeting criteria for social anxiety disorder. They were randomly assigned to imaginal exposure (IE; n = 39) or self-monitoring (n = 43) delivered multiple times daily via a smartphone application for a one-week trial. It was expected that participants using the IE exercises would demonstrate significantly greater declines in social anxiety in addition to increases in self-efficacy and that compliance would serve as a predictor of outcome. Mixed-effects models were utilized.

RESULTS

Participants using IE (vs. self-monitoring) evidenced significantly greater reductions in social anxiety from pre- to post-treatment and at 1-month follow-up. Similarly, IE (vs. self-monitoring) led to significantly greater increases in self-efficacy from pre- to post-treatment and 1-month follow-up. Further, more completed IE exercises predicted significantly greater changes in social anxiety and self-efficacy at subsequent timepoints compared with self-monitoring.

CONCLUSIONS

Findings suggest that a brief IE self-help intervention was effective in targeting social interaction anxiety.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

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.

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

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

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

BACKGROUND

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

OBJECTIVE

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

DATA SOURCE

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

ELIGIBILITY CRITERIA

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

STUDY EVALUATION

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

RESULTS

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

CONCLUSION

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

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

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

Preliminary Study of Efficacy and Safety of Self-Administered Virtual Exposure Therapy for Social Anxiety Disorder vs. Cognitive-Behavioral Therapy

Social anxiety disorder (SAD) is one of the most frequent mental disorders. Exposure to virtual reality can be a solution complementing standard CBT (cognitive-behavioral therapy) or can be used as an independent therapeutic tool. The study’s objective was to assess the safety and efficacy of using self-administered virtual reality exposure vs. CBT and CBT with virtual exposure. We assessed the efficacy of the applied intervention with the Leibowitz Social Anxiety Scale (LSAS). We compared three groups: CBT (n = 25), CBT + VR (n = 29), and self-administered therapy without aid of a therapist (n = 19). The results indicated that all three groups showed changes on the LSAS. The simple effect analysis showed that there were no differences between experimental conditions at T0 (session 1) and T1 (session 9) and that the only significant difference occurred at T2 (session 14). The pairwise comparisons showed that the participants in the VR condition scored higher on the LSAS score during the measurement at T2 than participants in CBT condition. Our study has several limitations. The presented initial study shows that the methods of CBT for social anxiety used so far are also effective, while the VR tool for self-therapy requires further research.

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

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT05302518.