Social anxiety changes the way we move-A social approach-avoidance task in a virtual reality CAVE system

Altered representation of peripersonal and interpersonal space in psychopathology

The space surrounding the body, and the regulation of this buffer zone play a central role in adaptive behavior, with direct implications for psychopathology. The physical distance that we choose to maintain between ourselves and others for social comfort is known as Interpersonal Distance (IPD), whereas the action space that marks the perceptual border between the self and the external world is known as Peripersonal Space (PPS ). While both IPD and PPS represent personal space, they are distinct constructs, each associated with different methodologies. Here we review the existing literature on IPD and PPS to elucidate their distinct and common contributions to psychiatric conditions including schizophrenia, autism, anxiety, and others. Altered representation and regulation of IPD and PPS were associated with clinical symptoms and social impairments across a wide range of psychiatric disorders, underscoring the important role of the self-other boundary and personal space regulation in adaptive social behavior. Future research should clarify the relationship between IPD and PPS and specify risk factors for self-other boundary dysregulation and associated psychopathologies.

Revealing motor insensitivity to food in Anorexia Nervosa as a potential mechanism contributing to calorie restriction: A mobile Approach Avoidance Task study

A change in implicit behavioural tendencies toward foods may contribute to the maintenance of calorie restriction in Anorexia Nervosa (AN). To test this hypothesis, we assessed approach-avoidance tendencies toward different categories of stimuli using a novel mobile version of the approach-avoidance task (AAT). The sample included 66 patients with restrictive AN and 84 healthy controls, all females. All participants performed the AAT in which they were required to approach or avoid stimuli (high-calorie foods, low-calorie foods, and neutral objects) by respectively pulling their phone towards themselves of pushing it away. Both the response time and the force of each movement were collected by means of the smartphone's accelerometer. The results revealed that patients with AN had a reduced tendency to approach food stimuli compared to healthy controls, who instead presented faster and stronger movements in approaching rather than avoiding foods as compared to neutral objects. This finding was particularly pronounced in patients with greater levels of malnutrition. No differences were instead observed comparing high-calorie and low-calorie foods. The observed reduction in the natural tendency to approach food stimuli is consistent with patients' eating behaviour and may contribute to the maintenance of calorie restriction, thus representing a possible target for novel therapeutic approaches.

I can't feel your face: callous-unemotional traits, social anxiety, and approach-avoidance behaviour in conduct disorder

BACKGROUND AND OBJECTIVES

Conduct disorders are associated with deficits in interpersonal behaviour. Both, callous-unemotional traits and social anxiety are often elevated in patients with conduct disorder and are associated with aggressive approach or disproportional avoidance. Previous studies have focused mainly on questionnaire reports of interpersonal behaviour, whereas direct explicit and implicit interpersonal behaviour in social contexts has not been considered sufficiently. Therefore, explicit and implicit interpersonal behaviour were investigated in children and adolescents with conduct disorder in the current study.

METHODS

Forty male adolescent inpatients with conduct disorder and 30 typically developing controls (Mage = 12.5, SD = 1.39) took part in a virtual reality task in which they approached virtual agemates, displaying different facial expressions under the pretext of a cover story while interpersonal distance and walking speed were assessed (indirect condition). In addition, they were asked to move to a comfortable distance for conversation toward the agent (direct condition). Callous-unemotional traits and social anxiety were assessed via questionnaires.

RESULTS

In the indirect condition, no differences between the groups emerged. In the direct condition, typically developing children adjusted their interpersonal distance to the respective expression that the virtual classmate displayed. They showed significantly greater interpersonal distances to angry classmates than to happy classmates. In contrast, conduct disorder patients' interpersonal distance, did not differ between emotions. Interpersonal distance preferences were also associated with social anxiety and callous-unemotional traits.

CONCLUSION

The findings suggest that conduct disorder patients fail to adjust their interpersonal behaviour to the facial expression of social interaction partners and that this is associated with social anxiety and callous-unemotional traits. A lack of adjustment to social cues might contribute to and maintain problems with peers in individuals with conduct disorder.

Impact of face trustworthiness on approach-avoidance behavior of adolescents with varied social anxiety traits

Approach/avoidance behavior is a basic human behavior pattern. However, more recent studies have demonstrated that this behavior pattern greatly differs among individuals. This heterogeneity has promoted research on exploring the predictive value of individual differences. Based on Person-Context Interaction Theory, the current study focused on the impact of face trustworthiness on adolescents' approach/avoidance behavior with varied social anxiety traits. Results revealed that the avoidance behavior of highly anxiety individuals was affected by face trustworthiness, while in contrast, individuals with low levels of anxiety were only affected by face trustworthiness in their approach behavior. This indicates that adolescents tend to be more responsive to external influences in behaviors where they have greater proficiency, whereas external factors have a less significant impact on behaviors in which they lack skill. Results were also interpreted in terms of two independent social motivations, which may benefit the development of adolescents' interpersonal relationships and the solution of extended problems caused by social problems.

Social threat avoidance depends on action-outcome predictability

Avoiding threatening individuals is pivotal for adaptation to our social environment. Yet, it remains unclear whether social threat avoidance is subtended by goal-directed processes, in addition to stimulus-response associations. To test this, we manipulated outcome predictability during spontaneous approach/avoidance decisions from avatars displaying angry facial expressions. Across three virtual reality experiments, we showed that participants avoided more often when they could predict the outcome of their actions, indicating goal-directed processes. However, above-chance avoidance rate when facing unpredictable outcomes suggested that stimulus-response associations also played a role. We identified two latent classes of participants: the "goal-directed class" showed above-chance avoidance only in the predictable condition, while the "stimulus-response class" showed no credible difference between conditions but had a higher overall avoidance rate. The goal-directed class exhibited greater cardiac deceleration in the predictable condition, associated with better value integration in decision-making. Computationally, this class had an increased drift-rate in the predictable condition, reflecting increased value estimation of threat avoidance. In contrast, the stimulus-response class showed higher responsiveness to threat, indicated by increased drift-rate for avoidance and increased muscular activity at response time. These results support the central role of goal-directed processes in social threat avoidance and reveal its physiological and computational correlates.

Social Motivation Differentiates Social Anxiety and Depression: A Daily Diary Study

Because social anxiety and depression commonly co-occur, it can be challenging to disentangle the emotional and motivational features of these conditions in everyday life contexts. In this daily diary study, we sought to understand the interplay between daily social anxiety and depression symptoms and emotion and motivation, determining whether daily symptoms are independently linked with positive affect, negative affect, and social motivation (desire to approach or to withdraw from others). Community-dwelling adults (N = 269) with a wide range of social anxiety and depression symptoms completed daily assessments for 14 consecutive days (a total of 2,986 daily surveys). Within-person analyses found that increases in social anxiety and depression symptoms were uniquely associated with elevated negative affect; only increases in depression symptoms were associated with diminished positive affect. Increases in social anxiety symptoms were associated with an elevated desire to approach others but not a desire to withdraw from others. By contrast, increases in depression symptoms were associated with a diminished desire to approach others and an elevated desire to withdraw from others. Desire for social connection may distinguish social anxiety from depression. Examining patterns of daily social motivation may enhance clinicians' ability to differentiate the difficulties that arise from social anxiety from those that arise from depression.

Rodent tests of depression and anxiety: Construct validity and translational relevance

Behavioral testing constitutes the primary method to measure the emotional states of nonhuman animals in preclinical research. Emerging as the characteristic tool of the behaviorist school of psychology, behavioral testing of animals, particularly rodents, is employed to understand the complex cognitive and affective symptoms of neuropsychiatric disorders. Following the symptom-based diagnosis model of the DSM, rodent models and tests of depression and anxiety focus on behavioral patterns that resemble the superficial symptoms of these disorders. While these practices provided researchers with a platform to screen novel antidepressant and anxiolytic drug candidates, their construct validity-involving relevant underlying mechanisms-has been questioned. In this review, we present the laboratory procedures used to assess depressive- and anxiety-like behaviors in rats and mice. These include constructs that rely on stress-triggered responses, such as behavioral despair, and those that emerge with nonaversive training, such as cognitive bias. We describe the specific behavioral tests that are used to assess these constructs and discuss the criticisms on their theoretical background. We review specific concerns about the construct validity and translational relevance of individual behavioral tests, outline the limitations of the traditional, symptom-based interpretation, and introduce novel, ethologically relevant frameworks that emphasize simple behavioral patterns. Finally, we explore behavioral monitoring and morphological analysis methods that can be integrated into behavioral testing and discuss how they can enhance the construct validity of these tests.

Exploring the Nexus between Moderate-to-Vigorous Physical Activity, Self-Disclosure, Social Anxiety, and Adolescent Social Avoidance: Insights from a Cross-Sectional Study in Central China

Objectives: Psychological issues among adolescents represent a prevalent challenge in today's society. The purpose of this study is to explore the associations among moderate-to-vigorous physical activity, self-disclosure, social anxiety, and social avoidance in adolescents. Methods: This study collected cross-sectional data from 427 students in eight provincial key junior and senior high schools in the central China region of three provinces using snowball sampling and convenience sampling from July to August 2023. A structural equation model was employed to investigate the relationship between moderate-to-vigorous physical activity and social avoidance among adolescents. Results: The findings indicate that moderate-to-vigorous physical activity is negatively correlated with social anxiety (standardized coefficient = -0.219, p < 0.001) and positively correlated with self-disclosure (standardized coefficient = 0.454, p < 0.001). Social anxiety is negatively correlated with self-disclosure (standardized coefficient = -0.220, p < 0.001). Social avoidance is positively correlated with social anxiety (standardized coefficient = 0.461, p < 0.001) and negatively correlated with self-disclosure (standardized coefficient = -0.331, p < 0.001). Conclusions: The chain-mediated dual-path model between moderate-to-vigorous physical activity and social avoidance is facilitated by social anxiety and self-disclosure. In other words, adolescents who engage in more moderate to high-intensity physical activities exhibit lower levels of social anxiety, and those who have a stronger inclination for self-disclosure tend to demonstrate lower levels of social avoidance. In light of these findings, it is recommended that the government, society, schools, and families collaborate synergistically to promote the holistic well-being of adolescents and advance the development of a healthier China.

Comparison of two reaction-time-based and one foraging-based behavioral approach-avoidance tasks in relation to interindividual differences and their reliability

Approaching rewards and avoiding punishments is a fundamental aspect of behavior, yet individuals differ in the extent of these behavioral tendencies. One popular method to assess differences in approach-avoidance tendencies and even modify them, is using behavioral tasks in which spontaneous responses to differently valenced stimuli are assessed (e.g., the visual joystick and the manikin task). Understanding whether these reaction-time-based tasks map onto the same underlying constructs, how they predict interindividual differences in theoretically related constructs and how reliable they are, seems vital to make informed judgements about current findings and future studies. In this preregistered study, 168 participants (81 self-identified men, 87 women) completed emotional face versions of these tasks as well as an alternative, foraging-based paradigm, the approach-avoidance-conflict task, and answered self-report questionnaires regarding anxiety, aggression, depressive symptoms, behavioral inhibition and activation. Importantly, approach-avoidance outcome measures of the two reaction-time-based tasks were unrelated with each other, showed little relation to self-reported interindividual differences and had subpar internal consistencies. In contrast, the approach-avoidance-conflict task was related to behavioral inhibition and aggression, and had good internal consistencies. Our study highlights the need for more research into optimizing behavioral approach-avoidance measures when using task-based approach-avoidance measures to assess interindividual differences.

Easy to get, difficult to avoid: Behavioral tendencies toward high-calorie and low-calorie food during a mobile approach-avoidance task interact with body mass index and hunger in a community sample

In recent years, different studies highlighted the importance of assessing behavioral tendencies toward different food stimuli in healthy and pathological samples. However, heterogeneities in experimental approaches and small sample sizes make this literature rather inconsistent. In this study, we used a mobile approach-avoidance task to investigate the behavioral tendencies toward healthy and unhealthy foods compared to neutral objects in a large community sample. The role of some contextual and stable subjective variables was also explored. The sample included 204 participants. The stimuli comprised 15 pictures of unhealthy foods, 15 pictures of healthy foods, and 15 pictures of neutral objects. Participants were required to approach or avoid stimuli by respectively pull or push the smartphone toward or away from themselves. Accuracy and reaction time of each movement were calculated. The analyses were conducted using a generalized linear mixed-effect model (GLMMs), testing the two-way interaction between the type of movement and the stimulus category and the three-way interactions between type of movement, stimulus, and specific variables (BMI, time passed since the last meal, level of perceived hunger). Our results evidenced faster approaching movement toward food stimuli but not toward neutrals. An effect of BMI was also documented: as the BMI increased, participants became slower in avoiding unhealthy compared to healthy foods, and in approaching healthy compared to unhealthy stimuli. Moreover, as hunger increased, participants became faster in approaching and slower in avoiding healthy compared to unhealthy stimuli. In conclusion, our results show an approach tendency toward food stimuli, independent from caloric content, in the general population. Furthermore, approach tendencies to healthy foods decreased with increasing BMI and increased with perceived hunger, indicating the possible influence of different mechanisms on eating-related behavioral tendencies.

Testing Design Bioethics Methods: Comparing a Digital Game with a Vignette Survey for Neuroethics Research with Young People

BACKGROUND

Over the last decades, the neurosciences, behavioral sciences, and the social sciences have all seen a rapid development of innovative research methods. The field of bioethics, however, has trailed behind in methodological innovation. Despite the so-called "empirical turn" in bioethics, research methodology for project development, data collection and analysis, and dissemination has remained largely restricted to surveys, interviews, and research papers. We have previously argued for a "Design Bioethics" approach to empirical bioethics methodology, which develops purpose-built methods for investigation of bioethical concerns. In this paper we compare a research tool created using a design bioethics approach to a "methods-as-usual" approach in empirical bioethics.

METHODS

Our study compared dimensions of engagement with a digital game we created, called "Tracing Tomorrow," to a standard vignette survey. The two tools investigated the same subject matter, digital phenotyping for mental health, in a sample of 301 UK adolescents.

RESULTS

Participants who played the game reported a greater sense of presence, emotional engagement, cognitive absorption, and mental health ethics insight, compared to participants who completed the vignette survey. Perceived authenticity and curiosity/motivation to learn more was equivalent for both methods.

CONCLUSION

The results of this study highlights the importance of purpose-built methodology for empirical bioethics research.

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.

I C U but I don't care: Callous-unemotional traits and approach-avoidance behaviour in conduct disorder

BACKGROUND AND OBJECTIVES

Conduct disorder (CD) is associated with deficits in social-emotional behaviour, such as increased levels of aggression. Callous-unemotional (CU-) traits foster those deficits and contribute to severe rates of instrumental aggression in CD. Previous studies of that increase in aggression have mainly focused on intentional aspects of behaviour. Unintentional behaviour, such as automatic approach and avoidance, has not been taken into account despite being highly relevant for behaviour. Therefore, the relevance of CU-traits for automatic actions and the feasibility of an approach-avoidance-task to measure those actions in CD-patients were investigated in a study series.

METHODS

Study 1 22 CD-patients executed an approach-avoidance task, where participants pushed or pulled pictures of emotional faces using a joystick. CU-traits were assessed via parent-report. Study 2 28 CD-patients and 19 typically developing children (TD) executed the AAT. Again, CU-traits were assessed via parent-report.

RESULTS

The AAT was a feasible instrument to measure automatic action tendencies and revealed that, while TD-children showed an avoidance bias towards angry faces, CD-patients showed a lack of automatic avoidance of anger. Across the whole sample (TD and CD combined), CU-traits predicted less threat avoidance.

LIMITATIONS

The small sample size may have limited the power to detect smaller approach-avoidance tendencies towards other emotions.

CONCLUSIONS

The findings suggest that CD is associated with a lack of automatic avoidance of social threat and that CU-traits predict that lack of avoidance. Divergent automatic threat responding might underlie the extreme levels of instrumentally aggressive behaviour observed in CD-patients with distinctive CU-traits.

Value priorities and value conflicts in patients with mental disorders compared to a general population sample

Personal values are considered as guiding principles for humans’ attitudes and behavior, what makes them an essential component of mental health. Although these notions are widely recognized, investigations in clinical samples examining the link between values and mental health are lacking. We assessed n = 209 patients with affective disorders, neurotic disorders, reaction to severe stress, and adjustment disorders and personality disorders and compared them to a stratified random sample (n = 209) drawn from the European Social Survey. Personal values were assessed using the Portraits Value Questionnaire. Severity of psychopathology was assessed using the Beck Depression Inventory and the Brief Symptom Inventory. Clinical participants showed a higher preference for the values power, achievement and tradition/conformity and a lower preference for hedonism compared to controls. Patients exhibited more incompatible value patterns than controls. Across diagnostic groups, patients with neurotic disorders reported incompatible values most frequently. Value priorities and value conflicts may have the potential to contribute to a better understanding of current and future actions and experiences in patients with mental disorders.

A circuit from dorsal hippocampal CA3 to parvafox nucleus mediates chronic social defeat stress-induced deficits in preference for social novelty

The preference for social novelty is crucial to the social life of humans and rodents. However, the neural mechanisms underlying social novelty preference are poorly understood. Here, we found that chronic social defeat stress (CSDS) reduced the preference for social novelty in mice by impairing the response of CaMKIIα⁺ neurons in the CA3 region of dorsal hippocampus (dCA3) during approach to an unfamiliar mouse. The deficits of social novelty preference in CSDS-treated mice were reversed by activating the output from dCA3 to the GABAergic neurons in the lateral septum (LS). The activation of GABAergic projection from LS recruited a circuit that inhibited the Foxb1⁺ neurons in the parvafox nucleus (PFN), which drove social avoidance by projecting to the lateral periaqueductal gray (lPAG). These results suggest that a previously unidentified circuit of dCA3^CaMKIIα+→LS^GABA+→PFN^Foxb1+→lPAG mediates the deficits of social novelty preference induced by CSDS.

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.

The Development of Explicit and Implicit Game-Based Digital Behavioral Markers for the Assessment of Social Anxiety

Social relationships are essential for humans; neglecting our social needs can reduce wellbeing or even lead to the development of more severe issues such as depression or substance dependency. Although essential, some individuals face major challenges in forming and maintaining social relationships due to the experience of social anxiety. The burden of social anxiety can be reduced through accessible assessment that leads to treatment. However, socially anxious individuals who seek help face many barriers stemming from geography, fear, or disparities in access to systems of care. But recent research suggested digital behavioral markers as a way to deliver cheap and easily accessible digital assessment for social anxiety: As earlier work shows, players with social anxiety show similar behaviors in virtual worlds as in the physical world, including tending to walk farther around other avatars and standing farther away from other avatars. The characteristics of the movement behavior in-game can be harnessed for the development of digital behavioral markers for the assessment of social anxiety. In this paper, we investigate whether implicit as well as explicit digital behavioral markers, proposed by prior work, for social anxiety can be used for predicting the level of social anxiety. We show that both, explicit and implicit digital behavioral markers can be harnessed for the assessment. Our findings provide further insights about how game-based digital behavioral markers can be used for the assessment of social anxiety.

How to build a game for empirical bioethics research: The case of 'Tracing Tomorrow'

It is becoming increasingly clear that the field of empirical bioethics requires methodological innovations that can keep up with the scale and pace of contemporary research in health and medicine. With that in mind, we have recently argued for Design Bioethics-the use of purpose-built, engineered research tools that allow researchers to investigate moral decision-making in ways that are embodied and contextualized. In this paper, we outline the development, testing and implementation of a novel prototype tool in the Design Bioethics Workshop-with each step illustrated with collected data. Titled 'Tracing Tomorrow' (www.tracingtomorrow.org), the tool is a narrative game to investigate young people's values and preferences in the context of digital phenotyping for mental health. The process involved (1) Working with young people to discover, validate and define the morally relevant cases or problems, (2) Building and testing the game concept in collaboration with relevant groups and game developers, (3) Developing prototypes that were tested and iterated in partnership with groups of young people and game developers and (4) Disseminating the game to young people to collect data to investigate research questions. We argue that Design Bioethics yields tools that are relevant, representative and meaningful to target populations and provide improved data for bioethics analysis. PATIENT OR PUBLIC CONTRIBUTION: In planning and conducting this study, we consulted with young people from a diverse range of backgrounds, including the NeurOX Young People's Advisory Group, the What Lies Ahead Junior Researchers Team, Censuswide youth participants and young people from the Livity Youth Network.

Social processes and social environment during development

Social behavior involves many processes including cognitive functions. Altered social behaviors associated with many psychiatric disorders might have alterations in the processes. Poor social environment affects development and maturation of cognitive functions that are important for social cognition, possibly introducing social stress as well as vulnerability to the stress into the developing brain. Adolescence and early adulthood have higher sensitivity to social stress, which may be linked to the onset of psychiatric disorders during this time period. Understanding social behavioral processes in detail will be crucial for elucidating mechanisms of emerging the social behavior phenotypes in psychiatric disorders and for devising therapeutic and preventive interventions to introduce the resilience for the onset of psychiatric disorders through modulation of social circuitries.

Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review

BACKGROUND

Mental health conditions pose a major challenge to health care providers and society at large. The World Health Organization predicts that by 2030, mental health conditions will be the leading cause of disease burden worldwide. The current need for mental health care is overwhelming. In New Zealand, 1 in 6 adults has been diagnosed with common mental disorders, such as depression and anxiety disorders, according to a national survey. Cognitive behavioral therapy (CBT) has been shown to effectively help patients overcome a wide variety of mental health conditions. Virtual reality exposure therapy (VRET) might be one of the most exciting technologies emerging in the clinical setting for the treatment of anxiety and depression.

OBJECTIVE

This study aims to investigate the virtual reality (VR) technologies currently being used to help support the treatment of depression and anxiety. We also aim to investigate whether and how CBT is included as part of VRET and look at the VR technologies and interventions that have been used in recent studies on depression and anxiety.

METHODS

We performed a scoping review. To identify significant studies, we decided to use already aggregated sources from the Google Scholar database. Overall, the goal of our search strategy was to limit the number of initial results related to VR in mental health to only a relevant minimum.

RESULTS

Using our defined keywords, Google Scholar identified >17,300 articles. After applying all the inclusion and exclusion criteria, we identified a total of 369 articles for further processing. After manual evaluation, 34 articles were shortlisted; of the 34 articles, 9 (26%) reported the use of CBT with VR. All of the articles were published between 2017 and 2021. Out of the 9 studies, CBT was conducted within a VR environment in 5 (56%) studies, whereas in the remaining 4 (44%) studies, CBT was used as an addition to VRET. All 9 studies reported the use of CBT either in vivo or in a virtual environment to be effective in supporting the treatment of anxiety or depression.

CONCLUSIONS

Most studies demonstrated the use of VR to be effective for supporting the treatment of anxiety or depression in a range of settings and recommended its potential as a tool for use in a clinical environment. Even though standalone headsets are much easier to work with and more suitable for home use, the shift from tethered VR headsets to standalone headsets in the mental health environment was not observed. All studies that looked at the use of CBT either in vivo or in a virtual environment found it to be effective in supporting the treatment of anxiety or depression.

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.

Approach bias retraining through virtual reality in smokers willing to quit smoking: A randomized-controlled study

Automatic approach biases toward smoking-related cues have been implicated in the development and maintenance of addictive behaviors. Studies aiming at modifying such biases have shown promise in changing maladaptive approach tendencies for smoking cues and reducing smoking behavior. However, training effects tend to be small and partly inconsistent. The present randomized-controlled trial incorporated virtual reality (VR) technology into Approach Bias Modification (ABM) to improve efficacy. One-hundred-eight smokers attended behavioral counseling for smoking cessation and were thereafter randomized to receive VR-ABM or VR-control training. During VR-ABM, participants trained to implicitly avoid smoking-related objects and to approach alternative objects, while no such contingency existed in the VR-control condition. Trainings were administered in six sessions within a two-week period. Assessments were conducted at baseline, post-intervention (three weeks after baseline), and at follow-up (seven weeks after baseline). VR-ABM did not change approach biases, nor other cognitive biases, but it was superior in reducing daily smoking. However, this effect was limited to the two-week training period. Both groups improved in other smoking- and health-related variables across time. Future work should continue to investigate working mechanisms of ABM, in particular crucial training ingredients. VR could prove valuable for public health as the potential of VR-based treatments is large and not fully explored.

Assessment of threat and negativity bias in virtual reality

Negativity bias, i.e., tendency to respond strongly to negative stimuli, can be captured via behavioural and psychophysiological responses to potential threat. A virtual environment (VE) was created at room-scale wherein participants traversed a grid of ice blocks placed 200 m above the ground. Threat was manipulated by increasing the probability of encountering ice blocks that disintegrated and led to a virtual fall. Participants interacted with the ice blocks via sensors placed on their feet. Thirty-four people were recruited for the study, who were divided into High (HN) and Low (LN) Neuroticism groups. Movement data were recorded alongside skin conductance level and facial electromyography from the corrugator supercilii and zygomaticus major. Risk-averse behaviours, such as standing on ‘safe’ blocks and testing blocks prior to movement, increased when threat was highest. HN individuals exhibited more risk-averse behaviour than the LN group, especially in the presence of high threat. In addition, activation of the corrugator muscle was higher for HN individuals in the period following a movement to an ice block. These findings are discussed with respect to the use of room-scale VE as a protocol for emotion induction and measuring trait differences in negativity bias within VR.

Interpersonal Distance During Real-Time Social Interaction: Insights From Subjective Experience, Behavior, and Physiology

Physical distance is a prominent feature in face-to-face social interactions and allows regulating social encounters. Close interpersonal distance (IPD) increases emotional responses during interaction and has been related to avoidance behavior in social anxiety. However, a systematic investigation of the effects of IPD on subjective experience combined with measures of physiological arousal and behavioral responses during real-time social interaction has been missing. Virtual Reality allows for a controlled manipulation of IPD while maintaining naturalistic social encounters. The present study investigates IPD in social interaction using a novel paradigm in Virtual Reality. Thirty-six participants approached virtual agents and engaged in short interactions. IPD was varied between 3.5 and 1 m by manipulating the distance at which agents reacted to the participant's approach. Closer distances were rated as more arousing, less pleasant, and less natural than longer distances and this effect was significantly modulated by social anxiety scores. Skin conductance responses were also increased at short distances compared to longer distances. Finally, an interaction of IPD and social anxiety was observed for avoidance behavior, measured as participants' backward motion during interaction, with stronger avoidance related to close distances and high values of social anxiety. These results highlight the influence of IPD on experience, physiological response, and behavior during social interaction. The interaction of social anxiety and IPD suggests including the manipulation of IPD in behavioral tests in Virtual Reality as a promising tool for the treatment of social anxiety disorder.

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.