Virtual reality exposure therapy for adolescents with fear of public speaking: a non-randomized feasibility and pilot study

Assessment and treatment of mental health conditions in children and adolescents: A systematic scoping review of how virtual reality environments have been used

BACKGROUND

There is growing interest in the use of virtual reality environments (VREs) in psychological treatment and assessment. Most research has focused on the application of VREs in adult psychological disorders with fewer studies focusing on its applicability with children and adolescents. A systematic scoping review was undertaken of research assessing how VREs have been used in the treatment and assessment of childhood mental health disorders to provide an overview of the current state of the literature and identify future research directions.

METHOD

Systematic searches of online databases were conducted in PsycInfo, PubMed, Embase, Scopus, and Web of Science.

RESULTS

Eleven studies met eligibility criteria and were included in this review, with the majority focusing on VRE interventions for anxiety-related disorders. There is also emerging support for VRE deep breathing training for anxiety, VRE assisted treatment of internet gaming disorder and anorexia nervosa, and VRE assessment of body image evaluation in anorexia nervosa. Most studies were pilot and feasibility studies with only three randomised-controlled trials (RCT).

CONCLUSIONS

The current literature shows some promise for the use of VRE assessments and interventions of childhood mental health problems, particularly for anxiety-related disorders such as social anxiety and specific phobias. However, high-quality RCTs are now needed to establish effectiveness of VREs in this population, and how it compares to existing evidence-based approaches, given its promise to improve both engagement and outcomes.

Perfectionism as a predictor of change in digital self-guided interventions for public speaking anxiety in adolescents: A secondary analysis of a four-armed randomized controlled trial

Public Speaking Anxiety (PSA) interventions targeting adolescents exist; however, not all gain improvement. This exploratory study investigated whether PSA interventions resulted in a decrease in perfectionism and whether pre-treatment level and changes in perfectionism moderated the effects on PSA and social anxiety. The sample consisted of 100 adolescents from junior high schools randomized to four groups: 1) VR only (n = 20), 2) VR + online exposure program (n = 20), 3) online psychoeducation and online exposure program (n = 40), 4) waitlist and online psychoeducation program (n = 20). Self-reported symptoms of PSA, social anxiety, and perfectionism were measured at pre, week 3, post, and 3-months follow-up. Level and change in outcome variables were analyzed using latent growth curve modeling. Results revealed that the interventions did not lead to a reduction in perfectionism. Reduction in perfectionism was associated with a larger reduction in all outcome measures from post to follow-up. No interaction was found between pre-treatment perfectionism and PSA symptoms. High pre-treatment levels of perfectionism were associated with poorer outcomes on social anxiety symptoms from post to follow-up for online exposure groups. The results indicate that one should assess and address high pre-treatment levels of perfectionism during PSA interventions.

Can peripheral psychophysiological markers predict response to exposure-based cognitive behavioral therapy in youth with severely impairing irritability? A study protocol

BACKGROUND

Irritability, an increased proneness to anger, is a primary reason youth present for psychiatric care. While initial evidence supports the efficacy of exposure-based cognitive behavioral therapy (CBT) for youth with clinically impairing irritability, treatment mechanisms remain unclear. Here, we propose to measure peripheral psychophysiological indicators of arousal-heart rate (HR)/electrodermal activity (EDA)-and regulation-heart rate variability (HRV)-during exposures to anger-inducing stimuli as potential predictors of treatment efficacy. The objective of this study is to evaluate whether in-situ biosensing data provides peripheral physiological indicators of in-session response to exposures.

METHODS

Blood volume pulse (BVP; from which HR and HRV canl be derived) and EDA will be collected ambulatorily using the Empatica EmbracePlus from 40 youth (all genders; ages 8-17) undergoing six in-person exposure treatment sessions, as part of a multiple-baseline trial of exposure-based CBT for clinically impairing irritability. Clinical ratings of irritability will be conducted at baseline, weekly throughout treatment, and at 3-month and 6-month follow-ups via the Clinical Global Impressions Scale (CGI) and the Affective Reactivity Index (ARI; clinician-, parent-, and child-report). Multilevel modeling will be used to assess within- and between-person changes in physiological arousal and regulation throughout exposure-based CBT and to determine whether individual differences are predictive of treatment response.

DISCUSSION

This study protocol leverages a wearable biosensor (Empatica) to continuously record HR/HRV (derived from BVP) and EDA during in-person exposure sessions for youth with clinically impairing irritability. Here, the goal is to identify changes in physiological arousal (EDA, HR) and regulation (HRV) over the course of treatment in tandem with changes in clinical symptoms.

TRIAL REGISTRATION

The participants in this study come from an overarching clinical trial (trial registration numbers: NCT02531893 first registered on 8/25/2015; last updated on 8/25/2023). The research project and all related materials were submitted and approved by the appropriate Institutional Review Board of the National Institute of Mental Health (NIMH).

Immersive Virtual Reality Exposures for the Treatment of Childhood Anxiety

Exposure-based cognitive behavior therapy (CBT) has demonstrated efficacy and is recommended as a front-line treatment for childhood anxiety. Unfortunately, challenges exist that impact the effective implementation of exposure-based CBT in clinical practice. One of the primary challenges is the accessibility and availability of exposure stimuli (e.g., spiders, storms, heights) in CBT sessions. Immersive virtual reality (VR) has shown promise as a scalable and sustainable solution to address this clinical need, but remains largely untested in youth with anxiety disorders. Here, we examine the use of VR exposures in the treatment of youth with an anxiety disorder (i.e., specific phobias). We aimed to investigate: (1) the feasibility and clinical benefit of VR exposures; (2) whether VR exposures elicit changes in physiological arousal and/or subjective distress; and (3) whether habituation serves as a mechanism across physiological and subjective outcomes for VR exposures. Three youth and their parents completed a clinical evaluation, which was followed by a one session treatment (OST) with VR exposures. Afterward, youth and parents completed clinical assessments one-week and 1-month after treatment. Immersive VR exposures were found to be feasible and demonstrated clinical benefit for reducing anxiety severity. Additionally, VR exposures elicited changes in both physiological and subjective outcomes. Finally, physiological habituation to VR exposures was observed among participants who exhibited treatment response at follow-up. Collectively, these findings demonstrate preliminary evidence that VR exposures are feasible, tolerable, and show some therapeutic benefit for treating youth with anxiety.

Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study

BACKGROUND

Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders.

OBJECTIVE

This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders.

METHODS

Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes.

RESULTS

The quantitative data regarding the usability of the system associated with participants' immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant's attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology.

CONCLUSIONS

Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities.

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 Interventions for Mental Health

Virtual Reality (VR) is a growing field in psychological research and therapy. While there is strong evidence for the efficacy of exposure therapy in VR (VRET) to treat anxiety disorders, new opportunities for using VR to treat mental health disorders are emerging. In this chapter, we first describe the value of VRET for the treatment of several anxiety disorders. Next, we introduce some recent developments in research using VR investigating schizophrenia, neurodevelopmental disorders, and eating disorders. This includes therapeutic strategies beyond VRET, including avatar-based therapies or those combining VR with biofeedback approaches. Although VR offers many convincing advantages, contraindications in treatment must be considered when implementing VR-supported therapy in clinical practice. Finally, we provide an outlook for future research, highlighting the integration of augmented reality and automation processes in VR environments to create more efficient and tailored therapeutic tools. Further, future treatments will benefit from the gamification approach, which integrates elements of computer games and narratives that promote patients' motivation and enables methods to reduce drop-outs during psychological therapy.

Characterizing Consumer Smartphone Apps for Virtual Reality-Based Exposure Therapy: Content Analysis (Preprint)

BACKGROUND

In vivo exposure therapy is the most effective treatment for phobias but is often impractical. Virtual reality exposure therapy (VRET) can help overcome critical barriers to in vivo exposure therapy. However, accessible mobile software related to VRET is not well understood.

OBJECTIVE

The purpose of our study is to describe the landscape of accessible smartphone apps with potential utility for clinical VRET.

METHODS

We conducted a content analysis of publicly available smartphone apps related to virtual reality on the Google Play Store and the Apple App Store as of March 2020.

RESULTS

The initial search yielded 525 apps, with 84 apps (52 on the Google Play Store and 32 on the Apple App Store) included for analysis. The most common phobic stimulus depicted was bodies of water or weather events (25/84, 29.8%), followed by heights (24/84, 28.6%), and animals (23/84, 27.4%). More than half of the apps were visually abstract (39/84, 53.5%). Most apps were free to use (48/84, 57.1%), while the rest were free to try (22/84, 26.2%) or required payment for use (14/84, 16.7%), with the highest cost for use being US $6. The average overall app rating was 2.9 stars out of 5, but the number of ratings ranged from 0 to 49,233. None of the 84 apps advertised compliance with the Health Insurance Portability and Accountability Act, offered the ability to monitor data, provided clinician control over variables in the app experiences, or explicitly stated use by or development with clinicians.

CONCLUSIONS

None of the smartphone apps reviewed were explicitly developed for phobia therapy. However, 16 of the 84 included apps were considered ideal candidates to investigate further as part of treatment due to their accessibility, depiction of phobia-relevant stimuli, low or no cost, and high user scores. Most of these apps were visually abstract and free to use, making them accessible and potentially flexible as part of clinical exposure hierarchies. However, none of the apps were designed for clinical use, nor did they provide tools for clinician workflows. Formal evaluation of these accessible smartphone apps is needed to understand the clinical potential of accessible VRET solutions.

A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people

BACKGROUND

Cognitive Behavioural Therapy (CBT) is the gold standard intervention for anxiety and related mental health disorders among young people; however, the efficacy of individual elements of CBT (e.g., exposure to feared stimuli) have received little scrutiny.

AIMS

This scoping review, informed by three stakeholder groups and a scientific advisory group, aimed to identify the nature and extent of the available research literature on the efficacy of exposure to feared stimuli, moderators of effectiveness in young people aged 14-24 years.

METHOD

Three international stakeholder groups composed of clinicians (N = 8), parents/carers (N = 5) and youth with lived experience of anxiety (N = 7) provided input into study design and results. Using the PRISMA extension for scoping reviews, a search of MEDLINE/Ovid, PsycINFO, PubMed, CINAHL, SCOPUS, EMBASE, ERIC, and Health Collection (informit) was conducted using terms related to anxiety, ages 14-24, and exposure.

RESULTS

From 3508 unique abstracts, 64 papers were included for the review. While there was evidence for the efficacy of exposure as a treatment for youth anxiety disorders, fundamental gaps in knowledge of exposure in this age group were identified. Most studies examined post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias with no randomised clinical trials uniquely evaluating exposure for the treatment of DSM-5 anxiety disorders. Exposure was typically delivered accompanied by other anxiety management techniques. A multitude of optimisation strategies have been tested, yet only one of these effects (timing relative to sleep) showed preliminary evidence of replication.

CONCLUSIONS

A systematic and theoretically driven program of research investigating the efficacy of exposure in young people and factors that moderate its efficacy, along with methods to overcome barriers for delivery, is urgently needed.

Exploring the Effect of a Nature-based Virtual Reality Environment on Stress in Adolescents

Adolescent mental health is a growing public health issue, with 30% of teens reporting increased stress and 20% of adolescents suffering from depression. Given the scarcity and lack of scalability of mental health services available, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. We conducted a mixed-methods pilot study with 31 adolescents ages 14-19 (m = 17.97) to explore the self-administration of a nature-based virtual reality tool. Participant use of the VR environment ranged from 1 to 10 sessions (m = 6.6) at home over a 2-week period while reporting their daily stress and mood levels. All participants completed all of the study protocols, indicating our protocol was feasible and the VR environment engaging. Post-study interviews indicated that most participants found the VR tool to be relaxing and helpful with stress. The themes of Calm Down, Relaxation, and Escape emerged to articulate the participants' experiences using the VR environment. Additionally, participants provided rich data regarding their preferences and activity in the VR environment as well as its effect on their emotional states. Although the sample size was insufficient to determine the impact on depression, we found a significant reduction in momentary stress as a result of using the VR tool. These preliminary data inform our own virtual reality environment design, but also provide evidence of the potential for self-administered virtual reality as a promising tool to support adolescent mental health.

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.

Towards adaptive technology in routine mental health care

This paper summarizes the information technology-related research findings after 5 years with the INTROducing Mental health through Adaptive Technology project. The aim was to improve mental healthcare by introducing new technologies for adaptive interventions in mental healthcare through interdisciplinary research and development. We focus on the challenges related to internet-delivered psychological treatments, emphasising artificial intelligence, human-computer interaction, and software engineering. We present the main research findings, the developed artefacts, and lessons learned from the project before outlining directions for future research. The main findings from this project are encapsulated in a reference architecture that is used for establishing an infrastructure for adaptive internet-delivered psychological treatment systems in clinical contexts. The infrastructure is developed by introducing an interdisciplinary design and development process inspired by domain-driven design, user-centred design, and the person based approach for intervention design. The process aligns the software development with the intervention design and illustrates their mutual dependencies. Finally, we present software artefacts produced within the project and discuss how they are related to the proposed reference architecture. Our results indicate that the proposed development process, the reference architecture and the produced software can be practical means of designing adaptive mental health care treatments in correspondence with the patients’ needs and preferences. In summary, we have created the initial version of an information technology infrastructure to support the development and deployment of Internet-delivered mental health interventions with inherent support for data sharing, data analysis, reusability of treatment content, and adaptation of intervention based on user needs and preferences.

In Case of an Emergency: The Development and Effects of a Digital Intervention for Coping With Distress in Norway During the COVID-19 Pandemic

Background: The COVID-19 pandemic and its consequences has been found to negatively affect the general population's psychological well-being. Objective: The objectives of this paper are to report on the development and clinical effects of a self-guided Internet-delivered intervention for adults in Norway who suffer from mild to moderate psychological distress during the COVID-19 pandemic. Methods: The participants, recruited between April and December 2020, were randomized to receive a new treatment module either every third or every fifth day. The clinical outcomes were self-reported depressive and anxiety symptoms and change in positive and negative emotions. Results: A total of 1256 individuals accessed the pre-screening survey, 407 were eligible and 92 provided contact information, where 82 were included in the study, n = 44 in the 3-day group and n = 38 in the 5-day group. Overall, the statistical analyses showed a significant decrease in depressive and anxiety symptoms and an increase in positive emotions, with small and moderate within group effect sizes. No significant differences between the groups were identified in clinical outcomes or adherence. Conclusion: These findings indicate that psychological distress in the general population during the COVID-19 pandemic may be reduced through the use of a scalable self-guided Internet-delivered intervention. Furthermore, the lack of significant differences between the 5-day and 3-day group may indicate that the intervention can be delivered at a more intensive pace without negatively affecting treatment outcomes. The results need to be interpreted with caution as the sample was self-selected, as well as the lack of passive control group. Hence the results may be attributed to external factors.

Virtual Reality for the Treatment of Anxiety Disorders: A Scoping Review

IMPORTANCE

Virtual reality in head-mounted displays (HMD-VR) may be a valuable tool in occupational therapy to address anxiety. Findings from the virtual reality exposure therapy (VRET) literature may facilitate translation of HMD-VR to occupational therapy psychosocial practice.

OBJECTIVE

To explore how HMD-VR has been used to treat anxiety through VRET and could be translated to occupational therapy.

DATA SOURCES

We searched seven electronic databases for articles published between 2000 and 2020: CINAHL, Cochrane Library, Embase, ERIC, Ovid MEDLINE, PsycINFO, and Web of Science. Search terms included HMD-VR constructs, products, and therapy concepts. Study Selection and Data Collection: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report studies implementing VRET to treat anxiety. At least two reviewers assessed each citation, and a third resolved disagreements. Articles were included if they were in English, reported experimental data, and used HMD-VR. Letters, commentaries, book chapters, technical descriptions, theoretical papers, conference proceedings (≤4 pages), and reviews were excluded.

FINDINGS

Twenty-eight studies used HMD-VR to treat posttraumatic stress disorder (n = 3), specific phobias (n = 19), and performance-based social anxiety (n = 6); protocols and levels of evidence varied (randomized controlled trials, n = 11; controlled trials without randomization, n = 6; case-control or cohort studies, n = 11). Qualitative examination indicates HMD-VR is an effective treatment tool.

CONCLUSIONS AND RELEVANCE

HMD-VR can be a valuable tool for occupational therapy to simulate environments where clients with anxiety disorders participate. Eliciting presence through multisensory features and body representation may enhance outcomes. What This Article Adds: Drawing from the VRET literature, this scoping review suggests that HMD-VR can be used by occupational therapy practitioners to simulate ecologically valid environments, evaluate client responses to fearful stimuli, and remediate anxiety though immersion in virtual tasks when participation in natural contexts is unfeasible. Having ecologically valid environments is particularly important for people with anxiety disorders because they need support to cope when they encounter triggers in everyday life environments.

360° Video virtual reality exposure therapy for public speaking anxiety: A randomized controlled trial

Public speaking anxiety (PSA) is a prevalent condition which is highly interrelated with social anxiety. PSA can be effectively treated with exposure therapy. Virtual reality exposure therapy (VRET) is increasingly being explored as a novel and cost-effective mode of treatment. No previous randomized controlled trial has examined whether stand-alone 360° video VRET is an effective intervention for treating PSA and interrelated disorder relevant fears. Further, studies have not explored whether 360° video content influences VRET outcomes. Participants with high PSA (n = 51) were randomly allocated to: 360° video VRET incorporating stimuli of audiences (360°Audience) (n = 17), 360° video VRET incorporating stimuli of empty rooms (360°Empty) (n = 16) and no treatment control (n = 18). Outcomes were measured over five time-points. Mixed ANOVA revealed a significant interaction between time and intervention group for PSA, social anxiety and fear of negative evaluation (FNE). Within-group analysis demonstrated there was a significant pre-intervention to post-intervention reduction across measures for both 360° video VRET groups: PSA 360°Audience (η_p² = .90, p<.001), 360°Empty (η_p² = .71, p < .001); social anxiety 360°Audience (η_p² = .49, p=.002), 360°Empty (η_p² = .39, p = .009); FNE 360°Audience (η_p² = .59, p<.001), 360°Empty (η_p² = .43, p = .006). Active intervention participants showed significant improvement from pre-intervention to 10-week follow-up on all measures. Findings illustrate that 360° video VRET is an efficacious way to significantly reduce PSA, social anxiety and FNE.

The Use of Virtual Reality for Managing Psychological Distress in Adolescents: Systematic Review

Acute and chronic psychological distress are prevalent during adolescence and can have negative impacts on adolescents in all life domains. The aim of this systematic review was to appraise the use of virtual reality (VR) interventions to manage symptoms of psychological distress symptoms among adolescents. MEDLINE, PubMed, PsycINFO, and Scopus databases were searched up to June 2020. Available citations were de-duplicated and screened by two authors using title and abstract information. A total of 301 articles were retained for full-text evaluation next to eligibility criteria. Empirical studies of all designs and comparator groups were included if these appraised the impact of an immersive VR intervention on any standardized measure indicative of psychological distress in an adolescent sample. Data were extracted into a standardized coding sheet. Results were tabulated and discussed with a narrative synthesis due to the heterogeneity between studies. A total of seven studies met inclusion criteria. There were four randomized controlled trials and three uncontrolled pilot studies on new VR interventions. Distress-related issues included: state-anxiety, venepuncture, risk taking, public speaking anxiety, social anxiety disorder, sexual victimization, and chemotherapy administration. All studies reported significant changes on outcome measures after VR treatment. Six studies reported small-to-large reductions in symptoms. The average attrition rate was 3.6 percent during the active VR treatment phase. Treatment acceptability was high in the studies that assessed user engagement factors. The VR technology can provide a safe, rapidly efficacious, and acceptable treatment modality for managing psychological distress in several key adolescent populations.

Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review

Background

Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents’ unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children.

Objective

The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research.

Methods

PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies.

Results

Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality.

Conclusions

Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents’ interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020198760

The use of virtual reality in assessment and treatment of anxiety and related disorders

In recent years the development of new virtual environments has been qualitatively high and fast at the same time, but the dissemination of virtual reality (VR) in clinical practice is still scarce. The aim of this review is to give an insight into the state of the art of the use of VR as an assessment tool and treatment intervention in anxiety and related disorders as posttraumatic stress disorder and obsessive-compulsive disorders. Besides an overview into the efficacy of VR, a summary will be given on assumed working mechanisms in virtual reality exposure therapy and how this aligns with current theoretical models. Further, it will be discussed how VR is accepted by patients and research into the reluctance of therapist to use this technology during treatment with focus on the therapeutic alliance and how it may be influenced by the use of VR. Finally, we discuss clinical and future issues as, for example, dissemination into clinical practice and what VR has to offer therapists in future. This not only in adult population but as well in younger patients, as young adolescents VR has a great potential as it connects easily with its playful elements to this population and might be a low threshold step to offer treatment or preventive interventions.

Social Anxiety, Fear of Negative Evaluation, and Distress in a Virtual Reality Environment

According to cognitive theories of social anxiety, fear of negative evaluation (FNE) may be the mechanism whereby social anxiety induces distress. However, studying this can be challenging, as individuals with social anxiety may be reluctant to enter anxiety-provoking social situations, such as speaking in front of others. The present study used virtual reality (VR) to examine if giving a presentation in front of a virtual audience induced distress among undergraduate students and to test the hypothesis that FNE would mediate the relationship between social anxiety and distress. University students (N = 58, 70% female) entered a VR environment where they stood in front of a virtual audience and gave a short, impromptu presentation about their university. Participants also completed self-report measures of social anxiety, FNE, and distress (estimated before, during, and after VR). Distress and FNE had positive relationships with social anxiety and FNE fully mediated the relationship between social anxiety and distress. As far as we are aware, this is the first VR study to show this effect. The findings indicate that FNE could be a useful treatment target to reduce distress when presenting in front of an audience, either in VR or in person.

A Meta-Analysis of the Efficacy of Virtual Reality and In Vivo Exposure Therapy as Psychological Interventions for Public Speaking Anxiety

Public speaking anxiety (PSA) is a prevalent condition with disabling occupational, educational, and social consequences. Exposure therapy is a commonly utilized approach for treating PSA. Traditionally, this intervention has been delivered as in vivo exposure therapy (IVET). Limitations inherent to in vivo as a mode of delivery have been identified and studies have increasingly explored the use of Virtual Reality Exposure Therapy (VRET) as an alternative. Understanding the efficacy of both VRET and IVET as psychological interventions for PSA is important. A systematic search identified 11 studies with 508 participants. Meta-analysis yielded a large significant effect wherein VRET resulted in significant reductions in PSA versus control of -1.39 (Z = 3.96, p < .001) and a similar large significant effect wherein IVET resulted in significant reductions in PSA versus control of -1.41 (Z = 7.51, p < .001). Although IVET was marginally superior to VRET, both interventions proved efficacious. Given the advantages of utilizing VRET over IVET future research and clinical practice could explore VRET as a treatment option for PSA.

Is Continued Improvement After Automated Virtual Reality Exposure Therapy for Spider Phobia Explained by Subsequent in-vivo Exposure? A First Test of the Lowered Threshold Hypothesis

Consumer Virtual Reality (VR) technology offers a powerful, immersive medium for scalable dissemination of mental health interventions. Decades of research has shown VR exposure therapy to be efficacious in the treatment of anxiety disorders and that the fear reduction generalizes to real-world stimuli. Many studies also report continued improvement over time, after discontinuing VR use. The lowered threshold hypothesis states that this continued improvement is moderated by lowering the threshold to conduct subsequent in-vivo exposure. The current study is the first to formally test this hypothesis, using data from a recent trial on automated VR exposure therapy for spider phobia, in which participants (n = 49) were followed for 1 year, completing assessments 1 week, 3 and 12 months post-treatment. The assessment included validated self-report of phobia symptoms, a standardized behavioral approach test featuring a real spider, and a questionnaire for self-reporting frequency of in-vivo exposures since last assessment. Number of in-vivo exposures was found to be independently associated with greater symptom decrease in longitudinal outcome models. In sequential structural equation models, immediate post-treatment symptom reduction was associated with subsequent in-vivo exposures, which in turn was associated with continued symptom reduction. However, this applied only to self-reported phobia symptoms (not behavioral avoidance) and no associations were found past 3 months. Our findings offer preliminary, partial support for the lowered threshold hypothesis, suggesting that VR exposure interventions may benefit from including explicit in-virtuo to in-vivo transitioning components.

Computer Based Body Exposure in Adolescents With Anorexia Nervosa: A Study Protocol

Body dissatisfaction is a core feature of eating disorders (EDs) and plays an essential role in the development and maintenance of anorexia nervosa (AN). In the current study, a computer based body exposure intervention is conducted and evaluated regarding short-term effects on body dissatisfaction, psychopathology, viewing patterns, and stress reactivity. Within a randomized controlled trial (RCT) female adolescents and young women with AN are either receiving the intervention or treatment as usual (TAU). Furthermore, in a transdiagnostic approach, a highly body-dissatisfied group of clinical control participants obtaining the intervention will be surveyed to identify AN-specific processes. The standardized four-session body exposure intervention using photographs of the own body is adapted from a manualized body image treatment program for computer use. Psychopathology (body dissatisfaction, body image avoidance, body checking, depression, anxiety) is assessed via standardized questionnaires before and after the intervention. During each session, attentional biases regarding one's own body are measured via eye tracking, stress levels are measured via subjective ratings, heart rate variability, as well as salivary cortisol and alpha amylase. Between- and within-subject effects will be assessed. The pilot study aims to identify short-term effects of the intervention on body dissatisfaction and attentional bias, as well as to investigate the potential underlying mechanism of physiological habituation.

Tips for Effective Implementation of Virtual Reality Exposure Therapy in Phobias-A Systematic Review

Background: The high incidence of phobias and the limited accessibility of psychotherapy are the reasons for the search for alternative treatments that increase the availability of effective treatment. The use of virtual reality (VR) technology is an option with the potential to overcome the barriers in obtaining an effective treatment. VR exposure therapy (VRET) is based on a very similar rationale for in vivo exposure therapy. The study aimed to answer the question of how to perform exposure therapy in a virtual reality environment so that it is effective. Methods: A systematic review of the literature, using PRISMA guidelines, was performed. After analysis of 362 records, 11 research papers on agoraphobia, 28 papers on social phobia and 10 about specific phobias were selected for this review. Results: VRET in agoraphobia and social phobia is effective when performed from 8 to 12 sessions, on average once a week for at least 15 min. In turn, the treatment of specific phobias is effective even in the form of one longer session, lasting 45-180 min. Head mounted displays are an effective technology for VRET. Increasing the frequency of sessions and adding drug therapy may shorten the overall treatment duration. The effectiveness of VRET in phobias is greater without concomitant psychiatric comorbidity and on the condition of inducing and maintaining in the patient an experience of immersion in the VR environment. Long-term studies show a sustained effect of VRET in the treatment of phobias. Conclusion: A large number of studies on in VR exposure therapy in phobias allows for the formulation of some recommendations on how to perform VRET, enabling the effective treatment. The review also indicates the directions of further VRET research in the treatment of phobias.

Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy

Virtual reality (VR) is an immersive technology capable of creating a powerful, perceptual illusion of being present in a virtual environment. VR technology has been used in cognitive behavior therapy since the 1990s and accumulated an impressive evidence base, yet with the recent release of consumer VR platforms came a true paradigm shift in the capabilities and scalability of VR for mental health. This narrative review summarizes the past, present, and future of the field, including milestone studies and discussions on the clinical potential of alternative embodiment, gamification, avatar therapists, virtual gatherings, immersive storytelling, and more. Although the future is hard to predict, clinical VR has and will continue to be inherently intertwined with what are now rapid developments in technology, presenting both challenges and exciting opportunities to do what is not possible in the real world.

Virtual Reality exposure therapy for public speaking anxiety in routine care: a single-subject effectiveness trial

Virtual Reality (VR) can be used as a therapeutic tool to conduct efficacious in-session exposure therapy by presenting virtual equivalents of phobic stimuli, yet past hardware restrictions hindered implementation in routine care and effectiveness studies. The current study examines the effectiveness of a VR-assisted treatment protocol for public speaking anxiety with demonstrated efficacy, this time in routine care, using affordable VR hardware. Participants (n = 23) were recruited via a private clinic and treated by one of four psychologists with only minimal VR-training. Using a single-subject design and dual-slope modeling (adjusting the treatment-onset slope for treatment effects), we found a significant, large decrease in self-rated public speaking anxiety following the primary three-hour session, similar in magnitude to the previous efficacy trial. Multilevel modeling of in-session process measures suggests that the protocol works as intended, by decreasing catastrophic belief expectancy and distress, and increasing perceived performance quality. Adherence to the online transition program that followed-encouraging in-vivo exposure-was relatively poor, yet symptoms decrease continued. No change was observed over the three-month follow-up period. We conclude that VR exposure therapy can be effective under routine care conditions and is an attractive approach for future, large-scale implementation and effectiveness trials.

Virtual Reality Therapy in Social Anxiety Disorder

PURPOSE OF REVIEW

This review provides an overview of current methods and important aspects to consider when applying virtual worlds in the treatment of social anxiety disorder (SAD).

RECENT FINDINGS

Different aspects such as dialogs between avatars and patients have been investigated as well as virtual audiences, emotional facial expression, and verbal interaction with avatars. Results of these studies are promising. Few randomized controlled trials (RCTs) have investigated the efficacy of virtual reality exposure therapy (VRET) in SAD. Unfortunately, most RCTs into the efficacy of VRET in comparison with exposure in vivo in SAD have been conducted with a combination of cognitive interventions and VRET. No differences between these conditions were found, but the pure effect of VRET as a stand-alone treatment has only been investigated in one RCT, wherein VRET was not superior to exposure in vivo. Current research into different facets of SAD and VRET has produced promising results with respect to technological aspects. No differences in efficacy between cognitive behavior therapy and VRET were found, but there is a clear need for studies investigating the efficacy of VRET as a stand-alone treatment and the therapeutic processes involved before this therapy can be disseminated in routine clinical practice.

Lack of research on efficacy of virtual reality exposure therapy (VRET) for anxiety disorders in children and adolescents : A systematic review

Anxiety disorders are one of the most prevalent mental disorders in children and adolescents which may effectively be treated by several forms of exposure therapy. An emerging approach to exposure is virtual reality exposure therapy (VRET), but a literature search synthesis focusing specifically on the use of VRET in children and adolescents is still lacking. This systematic review sets out to provide an overview concerning VRET for the treatment of anxiety disorders in this age group. Four published trials covering an overall sample of 100 participants between the ages of 8 and 16 years were found during a systematic literature search and were included in the current review. Results reveal that participants show clinical improvements regarding anxiety symptoms after VRET. Nevertheless, the high potential of virtual reality as a tool for treating children and adolescents with anxiety disorders is contrasted by a considerable lack of controlled trials. Despite the evidence of VRET in adult samples, there is a need for more research with younger cohorts in order to be able to support this promising field of application.

Experiences of Gamified and Automated Virtual Reality Exposure Therapy for Spider Phobia: Qualitative Study

Background

Virtual reality exposure therapy is an efficacious treatment of anxiety disorders, and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention.

Objective

The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods.

Methods

Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis.

Results

Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal.

Conclusions

Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences.

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.

Gamified, Automated Virtual Reality Exposure Therapy for Fear of Spiders: A Single-Subject Trial Under Simulated Real-World Conditions

BACKGROUND

Virtual Reality exposure therapy (VRET) is an evidence-based treatment of phobias and recent research suggests that this applies also to self-contained, automated interventions requiring no therapist guidance. With the advent and growing adoption of consumer VR technology, automated VR intervention have the potential to close the considerable treatment gap for specific phobias through dissemination as consumer applications, self-help at clinics, or as blended treatment. There is however a lack of translational effectiveness studies on VRET treatment effects under real-world conditions.

METHODS

We conducted a single-arm (n = 25), single-subject study of automated, gamified VRET for fear of spiders, under simulated real-world conditions. After setup and reading instructions, participants completed the automated, single-session treatment by themselves. Self-rated fear of spiders and quality of life served as outcome measures, measured twice before, and one and two weeks after treatment, and at a six-month follow-up. Session characteristics and user experience measures were collected at the end of the session.

RESULTS

Mixed-effects modeling revealed a significant and large (d = 1.26) effect of treatment-onset on phobia symptoms (p < .001), and a small (d = 0.49) effect on quality of life (p = .025). Results were maintained at a six-month follow-up (p > .053). The intervention was tolerable and practical. There were no significant correlations between any user experience measure and decrease in phobia symptoms (p > .209).

CONCLUSIONS

An automated VRET intervention for fear of spiders showed equivalent effects on phobia symptoms under effectiveness conditions as previously reported under efficacy conditions. These results suggest that automated VRET applications are promising self-help treatments also when provided under real-world conditions.

PRE-REGISTRATION

Open Science Foundation, https://doi.org/10.17605/OSF.IO/78GUB.

In vivo 19F-NMR study of isoflurane elimination from brain

The time course of isoflurane elimination from rabbit brain was studied in vivo with 19F-NMR spectroscopy. Two exponential decay functions with different time constants were observed and assigned to two distinct brain compartments. Isoflurane has a 26 min time constant for one compartment (similar to a value of 25 min with halothane) but 174 min in the second one, compared with 320 min for halothane. The shorter half-life for isoflurane may be due to lower solubility of this agent in brain tissue. Comparison of isoflurane 19F chemical shifts in solvents in isolated brain lipids and in whole brain tissue indicates that the anesthetic present in the brain exists in a single environment (on the NMR time scale), which is a weighted average of both hydrophilic and hydrophobic environments.