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

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.

Extended Reality for Mental Health Evaluation: Scoping Review

BACKGROUND

Mental health disorders are the leading cause of health-related problems worldwide. It is projected that mental health disorders will be the leading cause of morbidity among adults as the incidence rates of anxiety and depression grow worldwide. Recently, "extended reality" (XR), a general term covering virtual reality (VR), augmented reality (AR), and mixed reality (MR), is paving the way for the delivery of mental health care.

OBJECTIVE

We aimed to investigate the adoption and implementation of XR technology used in interventions for mental disorders and to provide statistical analyses of the design, usage, and effectiveness of XR technology for mental health interventions with a worldwide demographic focus.

METHODS

In this paper, we conducted a scoping review of the development and application of XR in the area of mental disorders. We performed a database search to identify relevant studies indexed in Google Scholar, PubMed, and the ACM Digital Library. A search period between August 2016 and December 2023 was defined to select papers related to the usage of VR, AR, and MR in a mental health context. The database search was performed with predefined queries, and a total of 831 papers were identified. Ten papers were identified through professional recommendation. Inclusion and exclusion criteria were designed and applied to ensure that only relevant studies were included in the literature review.

RESULTS

We identified a total of 85 studies from 27 countries worldwide that used different types of VR, AR, and MR techniques for managing 14 types of mental disorders. By performing data analysis, we found that most of the studies focused on high-income countries, such as the United States (n=14, 16.47%) and Germany (n=12, 14.12%). None of the studies were for African countries. The majority of papers reported that XR techniques lead to a significant reduction in symptoms of anxiety or depression. The majority of studies were published in 2021 (n=26, 30.59%). This could indicate that mental disorder intervention received higher attention when COVID-19 emerged. Most studies (n=65, 76.47%) focused on a population in the age range of 18-65 years, while few studies (n=2, 3.35%) focused on teenagers (ie, subjects in the age range of 10-19 years). In addition, more studies were conducted experimentally (n=67, 78.82%) rather than by using analytical and modeling approaches (n=8, 9.41%). This shows that there is a rapid development of XR technology for mental health care. Furthermore, these studies showed that XR technology can effectively be used for evaluating mental disorders in a similar or better way that conventional approaches.

CONCLUSIONS

In this scoping review, we studied the adoption and implementation of XR technology for mental disorder care. Our review shows that XR treatment yields high patient satisfaction, and follow-up assessments show significant improvement with large effect sizes. Moreover, the studies adopted unique designs that were set up to record and analyze the symptoms reported by their participants. This review may aid future research and development of various XR mechanisms for differentiated mental disorder procedures.

Virtual Reality and Stress Management: A Systematic Review

Amidst the growing prevalence of chronic stress and its potential negative impacts on mental health, this review explores the use of virtual reality (VR) as a stress management solution, aiming to assess its viability and effectiveness in this context. A comprehensive search was conducted on MEDLINE, PsycINFO, and Embase from inception until February 2024. Eligible studies were primary research papers that focused on the use of VR as an intervention to mitigate psychological stress and/or distress. We included studies where the assessment of stress levels primarily relied on self-report measures. A total of 50 studies involving 2885 participants were included in our systematic review. VR-based interventions varied across studies, implementing tools such as cognitive behavioural therapy, exposure therapy, mindfulness and relaxation, repetition tasks, and psychoeducation. The reviewed studies yielded mixed results; however, a strong indication was present in highlighting the promising potential of VR-based interventions. Many studies observed a decrease in psychiatric symptoms in participants and reported increased quality of life. Various studies also found VR to be a valuable tool in promoting stress reduction and relaxation. VR was proven useful in exposing participants to stressors in a safe, controlled way. These potential benefits appear to come with no risk of harm to the participants. Although the findings are heterogenous, there is sufficient evidence supporting the use of VR for stress management across a range of contexts and populations. Overall, VR appears to be a generally low-risk, feasible intervention for those struggling with stress.

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.

Individual cognitive therapy reduces frontal-thalamic resting-state functional connectivity in social anxiety disorder

Introduction

Previous neuroimaging studies in social anxiety disorders (SAD) have reported potential neural predictors of cognitive behavioral therapy (CBT)-related brain changes. However, several meta-analyses have demonstrated that cognitive therapy (CT) was superior to traditional exposure-based CBT for SAD.

Objective

To explore resting-state functional connectivity (rsFC) to evaluate the response to individual CT for SAD patients.

Methods

Twenty SAD patients who attended 16-week individual CT were scanned pre- and post-therapy along with twenty healthy controls (HCs). The severity of social anxiety was assessed with the Liebowitz Social Anxiety Scale (LSAS). Multi-voxel pattern analysis (MVPA) was performed on the pre-CT data to extract regions associated with a change in LSAS (∆LSAS). Group comparisons of the seed-based rsFC analysis were performed between the HCs and pre-CT patients and between the pre-and post-CT patients.

Results

MVPA-based regression analysis revealed that rsFC between the left thalamus and the frontal pole/inferior frontal gyrus was significantly correlated with ∆LSAS (adjusted R2 = 0.65; p = 0.00002). Compared with HCs, the pre-CT patients had higher rsFCs between the thalamus and temporal pole and between the thalamus and superior/middle temporal gyrus/planum temporale (p < 0.05). The rsFC between the thalamus and the frontal pole decreased post-CT (p < 0.05).

Conclusion

SAD patients had significant rsFC between the thalamus and temporal pole, superior/middle temporal gyrus, and planum temporale, which may be indicators of extreme anxiety in social situations. In addition, rsFC between the thalamus and the frontal pole may be a neuromarker for the effectiveness of individual CT.

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.

Social virtual reality helps to reduce feelings of loneliness and social anxiety during the Covid-19 pandemic

Evidence shows that the Covid-19 pandemic caused increased loneliness, anxiety and greater social isolation due to social distancing policies. Virtual reality (VR) provides users with an easy way to become engaged in social activities without leaving the house. This study focused on adults, who were socialising in Altspace VR, a social VR platform, during the Covid-19 pandemic and it explored whether social VR could alleviate feelings of loneliness and social anxiety. A mixed-methods research design was applied. Participants (n = 74), aged 18-75, completed a questionnaire inside the social VR platform to measure levels of loneliness (UCLA 20-item scale) and social anxiety (17-item SPIN scale) in the social VR platform (online condition) and real world (offline condition). Subsequently, a focus group (n = 9) was conducted to gather insights into how and why participants were using the social VR platform. Findings from the questionnaire revealed significantly lower levels of loneliness and social anxiety when in the social VR platform. Lower levels of loneliness and social anxiety were also associated with participants who socialised with a regular group of friends. In addition, findings from the focus group suggested that being part of an online group facilitates stronger feelings of belonging. Social VR can be used as a valuable intervention to reduce feelings of loneliness and social anxiety. Future studies should continue to establish whether social VR can help to encourage group formation and provide people with enhanced social opportunities beyond the COVID-19 pandemic.

The Effects of Virtual Reality in Targeting Transdiagnostic Factors for Mental Health: A Systematic Review of the Literature

Virtual reality (VR) was found to be effective in the treatment of several specific psychopathologies. However, the effects of VR-based interventions beyond the disorder-specific approach and their ability to improve transdiagnostic factors of mental disorders are unknown. This PRISMA systematic review was conducted using databases PubMed and PsycINFO, searching articles published between 2010 and September 2022. Keywords “emotion regulation”, “cognitive reappraisal”, “avoidance”, “impulsivity”, “aggression”, and “disinhibition” were combined with “virtual reality” to retrieve studies showing the effects of VR-based interventions on these transdiagnostic factors. 29 experimental studies and seven case-studies were selected. A total of 23 considered avoidance, eight dealt with emotion regulation, three concerned aggression, two addressed impulsivity, two dealt with cognitive reappraisal, and none examined disinhibition. Most of the studies included anxiety disorder patients (n = 15), especially with specific phobias (n = 8) and social anxiety disorder (n = 4). VR managed to improve all transdiagnostic factors, with results often maintained at follow-ups (n = 21 studies; range: 1–12 months) and similar to traditional interventions (e.g., cognitive-behavioral therapy). Exploring the transdiagnostic potential of VR may help to reduce costs and improve applicability in clinical psychology. While results were promising, further studies are needed for aggression, impulsivity and cognitive reappraisal, especially including follow-ups, comparisons with first-line treatments, and understudied clinical populations.

The effect of virtual reality therapy and counseling on students' public speaking anxiety

Background and Aims

One of the barriers to effective communication between speaker and listeners is public speaking anxiety (PSA). Over recent years, PSA has become common among students as the most widespread social anxiety (SA). Virtual reality (VR) and counseling therapy help reduce PSA. Therefore, the present study aimed to investigate the effect of VR therapy and counseling on students' PSA and SA.

Methods

This quasi-experimental study was conducted on 30 students at three levels of undergraduate, postgraduate, and PhD at Kerman University of Medical Sciences and Shiraz University of Medical Sciences (15 students in the intervention group and 15 in the control group). The intervention group observed four virtual classroom scenarios in a 30-min session, and the control group attended a 90-min group counseling session. Data were collected using by Personal Report of Public Speaking Anxiety, Liebowitz Social Anxiety Scale, and Igroup Presence Questionnaire. The data analysis was done using SPSS version 21. Descriptive analysis (frequency and percentage, mean, standard deviation, and quartiles) and analytical tests (paired t-test and independent t-test) were used to analyze the data.

Results

The results showed that VR and counseling did not affect SA scores and statistical differences before and after the intervention were not statistically significant. However, VR and counseling reduced PSA. The mean of IPQ/IGP (physical presence) was 63.73. The participants' SA means (93.76) were higher than the mean PSA (73.4).

Conclusions

VR and counseling did not affect students' SA, but they reduced PSA. If the intervention duration in future studies are longer, the effect of VR and counseling on reducing SA is likely to become more apparent.

Alteration of resting-state functional connectivity network properties in patients with social anxiety disorder after virtual reality-based self-training

Social anxiety disorder (SAD) is a mental disorder characterized by excessive anxiety in social situations. This study aimed to examine the alteration of resting-state functional connectivity in SAD patients related to the virtual reality-based self-training (VRS) which enables exposure to social situations in a controlled environment. Fifty-two SAD patients were randomly assigned to the experimental group who received the VRS, or the control group who did not. Self-report questionnaires and resting-state functional magnetic resonance imaging (fMRI) were performed to assess clinical symptoms and analyze the resting-state network properties, respectively. Significant decrease in social anxiety and an increase in self-esteem was found in the experimental group. From the resting-state fMRI analysis, alteration of local network properties in the left dorsolateral prefrontal gyrus (-10.0%, p = 0.025), left inferior frontal gyrus (-32.3%, p = 0.044), left insula (-17.2%, p = 0.046), left Heschl's gyrus (-21.2%, p = 0.011), bilateral inferior temporal gyrus (right: +122.6%, p = 0.045; left:-46.7%, p = 0.015), and right calcarine sulcus (+17.0%, p = 0.010) were found in the experimental group. Average shortest path length (+8.3%, p = 0.008) and network efficiency (-7.6%, p = 0.011) are found to be altered from the global network property analysis. In addition, the experimental group displayed more positive and more negative changes in the correlation trend of average shortest path length (p = 0.004) and global network efficiency (p = 0.014) with the severity of social anxiety, respectively. These results suggest potential effectiveness of the VRS, which is possibly related to the change of aberrant processing and control of visual and auditory linguistic stimuli and the adaptive change in rumination pattern.