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

A Smartphone-Gamified Virtual Reality Exposure Therapy Augmented With Biofeedback for Ailurophobia: Development and Evaluation Study

BACKGROUND

To the best of our knowledge, no specialized research has been conducted to address ailurophobia (fear of cats) in Iran or globally. This has driven our project, along with the prevalence of ailurophobia and the absence of a gamified virtual reality exposure therapy (VRET) that incorporates affordable and easily accessible biofeedback (BF) tools. We hypothesize that a gamified VRET augmented with BF will yield more positive effects than a similar device lacking BF.

OBJECTIVE

This study primarily focuses on the development and preliminary evaluation of a smartphone-gamified VRET integrated with BF, targeting animal phobia, with a specific case study on ailurophobia. The secondary objectives are using affordable and readily available BF found in devices such as smart bands and smartwatches and creating a mobile virtual reality gamified app to improve patients' adherence to treatments while simultaneously enhancing the app's accessibility, scalability, and outreach.

METHODS

Evaluations encompassed 3 methods. First, we identified the tool's potential positive effects on phobia interventions, exploring 4 effects: intrinsic motivation, simulation of fearful situations, management of stressful circumstances without therapists' presence and mitigation of catastrophic thoughts, and preliminary effects on ailurophobia treatment. Participants were divided into BF and non-BF groups. Second, we gathered user preferences and opinions about the treatment. Third, we conducted heuristic evaluations using 44 heuristics from existing system usability scales assessing user interfaces, virtual reality platforms, and video games' playability. To interpret the data, mean scores; ANOVA, single factor; and ANOVA, 2-factor with replication were used. A total of 29 individuals were identified, of which 10 met the eligibility criteria or were accessible.

RESULTS

The smartphone-gamified VRET augmented with BF exhibited better results on the identified effects compared with the non-BF version and contributed to normalizing encounters with cats. Moreover, 41 of the 44 heuristics achieved a percentage above 62%, indicating its potential as a therapeutic product and its ability to enhance patient adherence to treatments. Patient preferences on the treatment and its strengths and weaknesses were provided for further improvement.

CONCLUSIONS

The tool has the potential to evolve into a comprehensive solution by incorporating various types of cats and their behaviors, simulating environments in which they are commonly found, and enhancing its appeal through an increased sense of adventure without inducing unrealistic fears. By adapting fear elements, the game can be tailored to treat various animal phobias. Phobia-focused games should avoid action and combat scenarios to prevent reinforcement of fear responses. After rigorous evaluation, further exploration is required to provide remote use beyond clinical settings.

Patient experience of a virtual reality calm room in a psychiatric inpatient care setting in Sweden: a qualitative study with inpatients

OBJECTIVE

Calm rooms have been developed and implemented in psychiatric inpatient care settings to offer patients a dedicated space for relaxation in a convenient and safe environment. Recent technology developments have enabled virtual reality (VR) equivalents of calm rooms that can be feasibly deployed in psychiatric care settings. While research has shown VR environments to be efficacious in inducing relaxation, little is known how these virtual calm rooms are perceived by patients. The aim of this study was to elucidate patient experiences of using a VR calm room in a psychiatric inpatient setting.

DESIGN

Qualitative interview study. Semi-structured interviews were analysed using qualitive inductive content analysis, which focuses on the interpretation of texts for making replicable and valid inferences.

SETTING

Swedish hospital psychiatric inpatient care setting with a wireless, three degrees-of-freedom VR head-mounted display running a calm room application simulating nature environment.

PARTICIPANTS

20 adult patients (12 women) with bipolar disorder (n=18) or unipolar depression (n=2).

RESULTS

Participants experienced the use of the VR calm room as having a positive impact on them, inducing awareness, calmness and well-being. They were thankful to be offered a non-pharmacological alternative for anxiety relief. Participants also expressed that they had some concerns about how they would react emotionally before using the VR device. However, after use, they highlighted that their overall experience was positive. They also expressed that they could see potential for further development of VR technology in psychiatric care.

CONCLUSIONS

VR technology has the potential to solve pressing logistic issues in offering calm rooms in psychiatric inpatient care. VR calm rooms appear to be appreciated by psychiatric inpatients, who value their accessibility, convenience and variety of modalities offered. Participants perceived an increase in their well-being after use.

An internet-based self-applied rat phobia treatment using a Virtual Therapy Assistant: Study protocol for a randomized controlled trial

Specific phobias are a common anxiety disorder that deteriorates the lives of people who suffer from them. To reduce the symptoms produced by this mental disorder exposure therapies have been used. However, low- and middle-income countries, including Mexico, have the lowest rate of treatment due to multiple barriers that prevent addressing mental health problems. Self-applied treatments have been explored in previous studies, nevertheless, high dropout rates are a common problem in this kind of treatment. An alternative is using immersive self-applied treatments that could help increase adherence to the treatment. This article aims to present a study protocol to explore the feasibility of an Internet self-applied exposure treatment for rat phobias, using four types of immersive multimedia elements: images, videos, video games, and 360° videos. Also, the satisfaction and perception of a Virtual Therapy Assistant (VTA) that provides information and support to the user are described. The study protocol will compare two groups of participants, one on the waiting list, and the other will receive the self-applied treatment for rat phobia supported by the VTA. For this study, 45 participants will be recruited and the evaluation measures will be taken at four different times: baseline, post-treatment, and follow-ups at 3 and 6 months. The levels of anxiety and avoidance of the user manifested during the exposure to the multimedia elements, the improvement of the user's clinical symptoms, the level of satisfaction, the perception of effectiveness, and ease of use of the self-applied system will be evaluated. This study is expected to support the viability of self-applied treatment for rat phobias and the use of a VTA, showing the impact on treatment adherence. To the best of our knowledge, this is the first study to explore an exposure treatment for rats using different multimedia elements with the support of a VTA. The work will serve as a basis for the development of new virtual assistants that help in the treatment of other types of specific phobias. This research has been registered in Clinical Trials NCT (NCT05081323).

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.

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.

Neuronal activity in the dorsal dentate gyrus during extinction regulates fear memory extinction and renewal

Memory extinction and renewal are major factors that limits the efficacy of exposure therapy. The dorsal dentate gyrus (dDG) plays a crucial role in spatial memory, and epigenetic modifications in the dDG play an important role in fear memory renewal. However, whether dDG activity regulates fear memory extinction and renewal remains unclear. In this study, we showed that an extinction procedure that prevents fear memory renewal (extinction within the reconsolidation window) leads to increased c-fos expression in the dDG. Chemicogenetic activation of dDG excitatory neurons during extinction training elevated fear memory extinction and prevented renewal, whereas inhibition of dDG excitatory neurons inhibited fear memory extinction. We also demonstrated that inhibiting fear engram cells (neurons active during fear acquisition) during extinction training inhibits fear memory extinction. Therefore, dDG activity during fear extinction plays an important role in fear memory extinction and renewal.

The effectiveness of reality therapy on sexual satisfaction and marital intimacy of infertile women

BACKGROUND

Infertility is one of the most important challenges in the modern life that can damage the sexual satisfaction and marital intimacy of couples. The present study was aimed to investigate the effectiveness of reality therapy on sexual satisfaction and marital intimacy of infertile women.

MATERIALS AND METHODS

This quasi-experimental study was conducted with a pretest-posttest design and follow-up. The statistical population was infertile women who were referred to Imam Sajjad Shahriyar Hospital in 2019-2020. 15 infertile women selected by purposive sampling and underwent reality therapy (8 sessions of 90 min). Data were collected using index sexual satisfaction (ISS) and marital intimacy questionnaire. Data analysis was performed using SPSS-24 software, analysis of variance with repeated measures and post hoc Bonferroni test.

RESULTS

The results of analysis of variance showed that there was a significant difference between the scores of sexual satisfaction and marital intimacy in posttest and follow-up stages compared to pretest (P < 0.05).

CONCLUSIONS

Based on the results, reality therapy can be used as an effective intervention to improvement sexual satisfaction and marital intimacy of infertile women.

Virtual Reality in the Neurosciences: Current Practice and Future Directions

Virtual reality has made numerous advancements in recent years and is used with increasing frequency for education, diversion, and distraction. Beginning several years ago as a device that produced an image with only a few pixels, virtual reality is now able to generate detailed, three-dimensional, and interactive images. Furthermore, these images can be used to provide quantitative data when acting as a simulator or a rehabilitation device. In this article, we aim to draw attention to these areas, as well as highlight the current settings in which virtual reality (VR) is being actively studied and implemented within the field of neurosurgery and the neurosciences. Additionally, we discuss the current limitations of the applications of virtual reality within various settings. This article includes areas in which virtual reality has been used in applications both inside and outside of the operating room, such as pain control, patient education and counseling, and rehabilitation. Virtual reality's utility in neurosurgery and the neurosciences is widely growing, and its use is quickly becoming an integral part of patient care, surgical training, operative planning, navigation, and rehabilitation.

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.

Detecting Fear of Heights Response to a Virtual Reality Environment Using Functional Near-Infrared Spectroscopy

To enable virtual reality exposure therapy (VRET) that treats anxiety disorders by gradually exposing the patient to fear using virtual reality (VR), it is important to monitor the patient's fear levels during the exposure. Despite the evidence of a fear circuit in the brain as reflected by functional near-infrared spectroscopy (fNIRS), the measurement of fear response in highly immersive VR using fNIRS is limited, especially in combination with a head-mounted display (HMD). In particular, it is unclear to what extent fNIRS can differentiate users with and without anxiety disorders and detect fear response in a highly ecological setting using an HMD. In this study, we investigated fNIRS signals captured from participants with and without a fear of height response. To examine the extent to which fNIRS signals of both groups differ, we conducted an experiment during which participants with moderate fear of heights and participants without it were exposed to VR scenarios involving heights and no heights. The between-group statistical analysis shows that the fNIRS data of the control group and the experimental group are significantly different only in the channel located close to right frontotemporal lobe, where the grand average oxygenated hemoglobin Δ[HbO] contrast signal of the experimental group exceeds that of the control group. The within-group statistical analysis shows significant differences between the grand average Δ[HbO] contrast values during fear responses and those during no-fear responses, where the Δ[HbO] contrast values of the fear responses were significantly higher than those of the no-fear responses in the channels located towards the frontal part of the prefrontal cortex. Also, the channel located close to frontocentral lobe was found to show significant difference for the grand average deoxygenated hemoglobin contrast signals. Support vector machine-based classifier could detect fear responses at an accuracy up to 70% and 74% in subject-dependent and subject-independent classifications, respectively. The results demonstrate that cortical hemodynamic responses of a control group and an experimental group are different to a considerable extent, exhibiting the feasibility and ecological validity of the combination of VR-HMD and fNIRS to elicit and detect fear responses. This research thus paves a way toward the a brain-computer interface to effectively manipulate and control VRET.

Virtual reality biofeedback interventions for treating anxiety : A systematic review, meta-analysis and future perspective

Background

Virtual reality (VR)-based biofeedback is a relatively new intervention and is increasingly being used for the treatment of anxiety disorders. This is the first research synthesis regarding effects and efficacy of this novel mode of treatment.

Method

We conducted a systematic review and meta-analysis of the VR biofeedback literature on treating anxiety symptoms. The MEDLINE/PubMed, Scopus and Web of Science databases were searched for eligible pre-post comparisons and randomized controlled trials (RCTs). We used self-reported anxiety, heart rate (HR), and heart rate variability (HRV) as primary outcome measures.

Results

A total of 7 studies with 191 participants reported VR biofeedback interventions. Of these studies 5 were RCTs, with 103 participants receiving VR biofeedback and 99 control participants (either 2D biofeedback or waiting list controls). We found that VR biofeedback significantly lowers self-reported anxiety (g = −0.28) and HR (g = −0.45), but not HRV. Furthermore, there were no significant differences in outcomes between VR biofeedback and 2D biofeedback but a significant reduction in HR in the VR biofeedback group compared with the waiting list (g = −0.52).

Conclusion

While the first findings are optimistic, more controlled studies with a wider variety of samples are needed to bring this field forward. Particularly, children and adolescents may profit from the combination of gamification elements, VR, and biofeedback.

Creative Intervention for Acrophobia Sufferers through AIVE Concept

This research applies exposure to the visual appearance technology of virtual reality (VR). The motivation for this research is to generate a creative intervention by using regular smartphone devices and implementing them in VR using Google Cardboard as a medium visual display for exposure therapy at high altitudes. The VR application in this research is called acrophobia immersive virtual exposure (AIVE), which utilizes the Unity3D software to develop this treatment therapy application. The utilization of exposure therapy was carried out as a therapeutic medium for acrophobia sufferers. A commissioner was given to measure the usefulness of applications and devices in the VR environment created, and as many as 20 users had tested the VR device. The existing questionnaire was revised to develop a questionnaire for acrophobia sufferers, which was then used as an index measurement in the VR environment. The research is expected to be used to design a simulator and as a therapeutic medium using immersive VR devices in future studies.

Advances in immersive virtual reality interventions for mental disorders: A new reality?

Immersive virtual reality (VR) has been identified as a potentially revolutionary tool for psychological interventions. This study reviews current advances in immersive VR-based therapies for mental disorders. VR has the potential to make psychiatric treatments better and more cost-effective and to make them available to a larger group of patients. However, this may require a new generation of VR therapeutic techniques that use the full potential of VR, such as embodiment, and self-led interventions. VR-based interventions are promising, but further well-designed studies are needed that use novel techniques and investigate efficacy, efficiency, and cost-effectiveness of VR interventions compared with current treatments. This will be crucial for implementation and dissemination of VR in regular clinical practice.

What do users think about Virtual Reality relaxation applications? A mixed methods study of online user reviews using natural language processing

The advent of affordable Virtual Reality (VR) technology has spurred consumer and commercial interest in VR relaxation applications, which has quickly grown into a popular non-gaming genre on digital marketplaces. While laboratory studies have demonstrated efficacy of VR relaxation for mental health purposes, little is known about how users experience this type of intervention and no study has examined the reception of consumer versions among regular users in everyday life. Studying published user reviews offers a unique window into naturalistic user experiences that complements traditional qualitative methods by circumventing the sampling bias of interview studies, and allowing analyses on full samples, unconstrained by coding resources. Using an innovative, semi-automated Natural Language Processing technique, the current study analyzed 1379 published reviews (including star ratings) of 30 different VR relaxation applications available for the Oculus Go and Gear VR. The uncovered topic structure and sentiment analysis thereof suggests that users have an overall positive view of VR relaxation applications, describing them as successful in inducing immersion and relaxation, and having appreciated gamification elements. However, perceived quality varied substantially between applications that explained more variance in star ratings than specific features. Critical issues raised were both technical (e.g. "overheating") in nature and related to specific design elements and use. Implications for the design of consumer VR applications and future research are discussed.

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.

Correlates of Quality of Life in Anxiety Disorders: Review of Recent Research

PURPOSE OF REVIEW

Anxiety disorders are highly prevalent conditions that have a detrimental impact on quality of life (QOL), particularly when left untreated. In the present review, we summarize recent literature, published within the last 3 years, on QOL in anxiety disorders, with a focus on factors that may play a role in the relationship between anxiety and QOL.

RECENT FINDINGS

We organize our findings into four categories: (1) subjective distress, (2) behavioral responses, (3) functional impairment, and (4) clinical factors. Results indicate that greater anxiety symptom severity is linked with poorer QOL, and cognitive behavioral therapies for anxiety yield positive effects on QOL. Additional transdiagnostic mechanisms are highlighted, including anxiety sensitivity, distress tolerance, emotion regulation, and avoidant coping. We examine the role of functional impairment, and we discuss factors related to treatment, including comorbidity and longitudinal effects. We also consider early research from the COVID-19 pandemic. Understanding the underlying factors that contribute to QOL detriments provides important insight into the impact of anxiety disorders and identifies targets for enhancing QOL through treatment.

Testing a gamified Spider App to reduce spider fear and avoidance

Mobile applications are increasingly part of mental health programs and various apps have been developed for treating anxiety disorders. Typically, they aim to improve anxiety symptoms via established CBT techniques, such as exposure principles, which are considered extremely unpleasant for fearful individuals. We combined in a mobile application exposure principles with gamification elements (e.g. narrative background, level progression, points, and feedback). These elements should increase the motivation for confronting spider images and decrease the experienced distress. To evaluate the application, two groups of spider-fearful individuals played either the Spider App (experimental group) or a non-spider associated app (control group) twice a day for approximately 12 min for 7 days. After this week, participants of the experimental group showed less avoidance behavior of spiders (BAT), as well as lower anxiety of spiders (SPQ, FAS). Groups were not different in measures of depression or psychological distress. Interestingly, participants playing the Spider App reported higher anxiety, disgust and arousal ratings shortly after playing the app. However, anxiety, disgust, and arousal ratings decreased from day to day. We discuss our findings with respect to implications for the clinical practice.

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.

Recommendations for Implementing Gamification for Mental Health and Wellbeing

Gamification is increasingly being proposed as a strategy to increase engagement for mental health and wellbeing technologies. However, its implementation has been criticized as atheoretical, particularly in relation to behavior change theory and game studies theories. Definitions of the term “gamification” vary, sometimes widely, between and within academic fields and the effectiveness of gamification is yet to be empirically established. Despite this, enthusiasm for developing gamified mental health technologies, such as interventions, continues to grow. There is a need to examine how best to implement gamification in mental health and wellbeing technologies in a way that takes quick production cycles into account while still emphasizing empirical investigation and building a rigorous evidence base. With reference to game studies and the medical (eHealth/mHealth) literature, this article interrogates gamification for mental health and wellbeing by examining core properties of the game form. It then explores how gamification can best be conceptualized and implemented for mental health and wellbeing goals from conceptualization through to iterative co-development and evaluation that accommodates software development schedules. Finally, it summarizes its conceptual analysis into recommendations for researchers and designers looking to do so. These recommendations are: (1) assess suitability, (2) implement to support, (3) assess acceptability, (4) evaluate impact, and (5) document comprehensively. These recommendations aim to encourage clear language, unified terminology, the application and evaluation of theory, comprehensive and constant documentation, and transparent evaluation of outcomes.

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.

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.