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Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review

Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations. Objective: The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world. (JMIR Serious Games 2018;6(4):e10965) doi: 10.2196/10965 KEYWORDS virtual reality; virtual reality exposure therapy; phobic disorders; anxiety disorders http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott immerses the user with sensory stimuli. These stimuli are often Introduction limited to the user’s visual and auditory senses but may sometimes incorporate tactile stimuli through an apparatus (eg, Background force feedback gloves, toy spiders) to allow VR users to feel Anxiety-related disorders such as specific phobias, posttraumatic objects with their hands. By utilizing a customizable virtual stress disorder (PTSD), and general or specific anxiety (eg, environment, VRET offers an unparalleled level of control for public speaking or social anxiety) disorders stand as 1 of the the therapist to manipulate factors that could not be controlled most common, growing mental health disorders worldwide [1]. in a standard IVE session and tailor the sessions based on the In 2014, 19.5% of individuals above the age of 16 years had patient’s needs—all in the confines of the therapist’s office shown signs of anxiety or depression, with the United Kingdom [9,13]. alone experiencing a 1.5% increase from 2013 [1]. To combat Despite a major interest in VR during its inception, VR was the symptoms of anxiety-related disorders, 1 of the most often expensive, uncomfortable, and required special training effective treatment methods has been exposure therapy, which to operate. The computers used to run VR were barely able to stems from the broader practice of cognitive behavioral therapy do so, leading to low-quality VR experiences (eg, jagged (CBT) [2]. In exposure therapy, patients undergo a process of graphics and inconsistent and low frame rates) that could lead systematic desensitization, where a series of systematic steps to simulator sickness, characterized by symptoms of nausea, are employed to gradually expose the patient to an anxiety- or headaches, and dizziness [6]. In addition to simulator sickness, fear-inducing stimulus, with the ultimate goal of minimizing early HMDs were also heavy, resulting in users experiencing the patient’s intense and adverse behavior toward the stimulus. neck pain after prolonged use. Furthermore, without adequate Furthermore, the therapists may employ methods to change the software distribution systems to sell or share VR programs, patient’s cognitions about the stimulus, such as through special training would often be required to create VR programs psychoeducation, to reinforce treatment gains from systematic to suit the research or therapists’ needs. These limitations desensitization [3]. ultimately restricted the use and research of VR-based Traditionally, stimuli in exposure therapy are presented through psychotherapy to well-funded or specialized institutions [14]. in vivo exposure (IVE) or imaginal exposure (IE), each of which Although early VR technologies have been largely inaccessible carries its own set of advantages and disadvantages. IVE to a mass audience, recent developments in VR technologies involves live exposure to the stimuli, often being utilized to have addressed many of the issues that plagued legacy units. treat specific phobias or anxieties such as arachnophobia (fear Both the HTC Vive and Oculus Rift, which released in 2016, of spiders) [4], acrophobia (fear of heights) [5], and social were lighter and powerful enough to render high-quality visual anxiety [6]. Although IVE is considered to be the most effective and auditory stimuli. Both HMDs were also integrated with method for helping the patient overcome their anxiety or fear, major digital distribution services such as Steam, which has disorders such as aviophobia (fear of flying) and social anxiety attracted both small, independent developers and large, may require sessions to be conducted in public, therefore posing professional developers alike to create high-quality VR a risk of breaking patient confidentiality; become too expensive programs. Renewed interest in VR also led to a push for mobile to perform single or repeated exposure sessions; and introduce VR, a less powerful yet inexpensive version of computer-based uncontrollable variables that may hinder the overall treatment VR that could run on modern mobile phones (e.g. iPhone, (eg, behavior of living organisms and weather conditions) [7-9]. Google Pixel, etc.). Even if these issues can be addressed, some individuals may feel that confronting an anxiety- or fear-inducing stimulus may Objective be too aversive, which may lead to participants dropping out of The aim of this systematic review was to explore previously treatment or not seeking treatment at all [5]. IE can address established VR studies within psychotherapy to inform future many of the limitations of IVE, as patients are tasked with VR research. Although modern VR HMDs are still relatively generating the stimulus in his or her imagination rather than new, evaluating how past studies have utilized the VR confronting a live version of the stimulus; however, the patient technologies of their era can serve as a comprehensive guide as may be potentially unable or unwilling to generate a vivid to how VR-based psychotherapy programs can improve in the imaginal representation of the stimulus [10]. future as well as whether the limitations observed in past studies Since the early to mid-1990s, therapists have attempted to seek are still relevant with the current iteration of VR systems. Topics an alternative to IVE and IE through the use of virtual reality covered in this review will mainly cover the efficacy of VRET (VR) technologies through a process known as virtual reality treatment, its uses as a diagnostic or assessment tool, and exposure therapy (VRET). VR technology includes a wide range innovations in the pursuit of greater VR experiences in relation of configurations, including head-mounted displays (HMDs), to psychological disorders in which anxiety is a key symptom, external projection setups such as the CAVE Automatic Virtual including specific phobias, PTSD and acute stress disorder Environment [11], and simulators [12], all of which vary in (ASD), specific and general anxiety disorder, and paranoid terms of technical specifications (eg, display resolution, tracking ideations. accuracy, and field of view). Regardless of the form of VR, VRET generally follows the same treatment protocols as traditional exposure therapy but renders the anxiety or fear-inducing stimulus within a virtual environment that http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott Search Terms Methods The command line used for the search was as follows: “virtual Databases Searched reality” AND (phobia OR anxiety) AND (treatment OR therapy). Although VR is a common referential acronym for virtual ProQuest Central, PsycINFO, and PsycARTICLES were the reality, the full term was exclusively used during the search to databases used to conduct a comprehensive search of the past streamline the search process and avoid any other terms that literature. Studies must have been published before August 31, may use the VR acronym (eg, variable reward and voice 2017, peer-reviewed, published in a scholarly journal, written recognition). An initial 2419 studies were collected from the 3 in English, and have full-text availability. databases used to conduct this search. Figure 1. Systematic Review Search Prisma. HMD: head-mounted display; VR: virtual reality. http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott Table 1. Specific phobia treatments. Author Phobia type Methodology Sessions, n Session length Follow-up Intervention (patients, n) Botella et al [17] Claustrophobia Case 8 35-45 min 1 month VRET (n=1) Botella et al [18] Agoraphobia Controlled 9 1 hour 12 months VRET (n=12); IVE (n=12); WL (n=13) Carlin et al [9] Arachnophobia Case 12 50 min None VRET (n=1) Emmelkamp et al [19] Acrophobia Controlled 3 1 hour 6 months VRET (n=17); IVE (n=16) Garcia-Palacios et al [7] Arachnophobia Controlled 3-10 (4) 1 hour None VRET (n=12); WL (n=11) Maltby et al [13] Aviophobia Controlled 5 50 min 6 months VRET (n=20); EGT (n=23) Moldovan and David [20] Multiple Controlled 1 60 min None VRET (n=16); WL (n=16) Muhlberger et al [8] Aviophobia Controlled 1 180 min None VRET (n=15); RT (n=13) Rothbaum et al [21] Acrophobia Controlled 7 35-45 min None VRET (n=12); WL (n=8) Rothbaum et al [22] Acrophobia Case 5 35-45 min None VRET (n=1) Rothbaum et al [23] Aviophobia Case 6 35-45 min 1 month VRET (n=1) Rothbaum et al [24] Aviophobia Controlled 8 1 hour 6 months VRET (n=15); IVE (n=15); WL (n=15) Rothbaum et al [25] Aviophobia Controlled 8 1 hour 12 months VRET (n=13); IVE (n=11) Rothbaum et al [26] Aviophobia Controlled 8 6 and 12 VRET (n=25); IVE (n=25); WL N/A months (n=25) h i Shiban et al [27] Arachnophobia Controlled 2 N/A None MCE VRET (n=15); SCE VRET (n=15) Whitney et al [28] Acrophobia Case 8 N/A None VRET+VPT (n=1) VRET: virtual reality exposure therapy. IVE: in vivo exposure. WL: waiting list. Mean value. EGT: exposure group therapy. RT: relaxation therapy. N/A: not applicable. MCE: multiple context exposure. SCE: single context exposure. VPT: vestibular physical therapy. “virtual reality” alongside terms related to fear, anxiety, or a Inclusion and Exclusion Criteria specific phobia, as well as having explicitly used an HMD within For the initial 2419 studies collected, the following inclusion the study itself. A total of 27 additional studies were collected and exclusion criteria were implemented. Parameters were set through these criteria, although 1 study appeared to have been to limit the studies only to those whose subject was on VR published twice in 2 years with some minor differences; (n=217) and whose document type was either an article or a therefore, the most recent version of that study was kept [15], case study (n=203). Studies that did not perform an experiment whereas the older version was excluded [16], resulting in only using an HMD for treating or examining a specific phobia or 26 additional studies. In total, 49 studies were examined for this anxiety were excluded (n=177) as were other systematic reviews review. or meta-analyses (n=3). HMDs were chosen as the VR system Information found in Figure 1 exhibits the process in which the of choice for this review as the systems were the most accessible studies in this review were obtained based on the inclusion compared with CAVE and simulator-type systems, alongside criteria as well as the number of studies excluded based on the the notion that the most prominent modern VR systems are initial exclusion criteria. HMDs. In total, 23 eligible studies met the inclusion criteria. Studies were also placed into 1 of the 5 categories for the Another search was conducted based on the references detailed purposes of this review: phobia treatments (see Table 1), PTSD in each of the initial 23 eligible studies. Inclusion criteria for treatments (see Table 2), anxiety treatments (see Table 3), this search were that the reference title must have mentioned http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott paranoia evaluation (see Table 4), and innovations and quality of each of the 49 studies was also appraised through the evaluation (see Table 5). mixed methods appraisal tool (2011), which was designed to assess the methodological quality of quantitative (randomized, Quality Assessment nonrandomized, and descriptive), qualitative, and Quality assessment of the collected studies was examined by mixed-methods studies used within systematic reviews [60]. both authors using the inclusion and exclusion criteria. The Table 2. Posttraumatic stress disorder and acute stress disorder treatments. Author Study type Trauma type Follow-up Interventions and patients, n Gerardi et al [29] Case War None VRET (n=1) Cardenas-Lopez et al [30] Uncontrolled Assault None VRET (n=6) McLay et al [31] Controlled War None VRET (n=10); TAU (n=10) Reger et al [32] Uncontrolled War None VRET (n=24) c d Reger et al [33] Controlled War 3 and 6 months VRET (n=54); IE (n=54) ; MA (n=54) Cardenas Lopez and de la Rosa-Gomez [34] Case Assault None VRET (n=1) Rothbaum et al [35] Case War 3 and 6 months VRET (n=1) Rothbaum et al [36] Controlled War 3, 6, and 12 months VRET with D-cycloserine (n=53); VRET with alprazolam (n=50); VRET with placebo (n=53) VRET: virtual reality exposure therapy. TAU: treatment as usual. IE: imaginal exposure. MA: minimal attention. Table 3. Anxiety treatments. Author Anxiety type Study type Sessions, n Session length Follow-up Comparisons and patients, n Alsina-Jurnet et al [37] Performance Uncontrolled 1 90 min None High test anxiety (n=11); Low test anxiety (n=10) Anderson et al [38] Social Case study 6 to 10 Unknown Unknown VRET (n=2) b c Anderson et al [6] Social Controlled 8 Unknown 3 and 12 VRET (n=25); EGT (n=25); WL Months (n=25) Harris et al [39] Social Controlled 4 12-15 min/exposure None VRET (n=8); WL (n=6) Padrino-Barrios et al [40] Dental Controlled 1 Unknown Unknown VR exposure first half (n=15); VR exposure second half (n=15) Repetto et al [41] General Controlled 8 Unknown Unknown VRET with biofeedback (n=9); VRET without biofeedback (n=8); WL (n=8) Tanja-Dijkstra et al [42] Dental Controlled 1 Unknown 1 week Active VR (n=22); Passive VR (n=23); No VR (n=24) Wallach et al [43] Social Controlled 12 1 hour None VRET (n=28); CBT (n=30); WL (n=30) VRET: virtual reality exposure therapy. EGT: exposure group therapy. WL: waiting list. VR: virtual reality. CBT: cognitive behavioral therapy. http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott Table 4. Paranoia or paranoid ideations evaluation. Author and population Pateints, n Age in years, mean (SD) Analysis Fornells-Ambrojo et al [44] Qualitative Early psychosis (clinical) 10 24.2 (2.3) Healthy (Nonclinical) 10 23.8 (2.3) Freeman et al [45]: Assaulted 1 month before 106 34.4 (11.6) Quantitative Freeman et al [46]: Local adult 200 37.5 (13.3) Quantitative Freeman et al [47] Quantitative Low nonclinical paranoia 30 44.2 (11.2) High nonclinical paranoia 30 36.0 (11.7) Persecutory delusions 30 44.2 (11.7) Table 5. Virtual reality evaluations and innovations. Author Disorder Aim Cornwell et al [48] Social anxiety Evaluating the relationship between trait social anxiety and startle reactivity Geuss et al [49] Acrophobia Assessing perceptual estimates and actions of gaps within VR Hartanto et al [50] Social anxiety Evaluating the efficacy of various social stressors within VR Orman [51] Performance anxiety Assessing effects of VR exposure on performing musicians Owens and Beidel [52] Social anxiety Evaluating the efficacy of VR stimuli for social anxiety VRET Park et al [53] Social anxiety Assess the virtual interactions of patients with schizophrenia with digital avatars Pertaub et al [15] Public speaking anxiety Evaluate participant responses toward positive, negative, and static virtual audiences Powers et al [54] Social anxiety Evaluate a VR-based interactive dialogue system to elicit the same level of fear from an in vivo conversation Price et al [55] Social phobia Evaluate the importance of presence within VR as a predictor of treatment response for social anxiety VRET Qu et al [56] Social phobia Evaluate the influence of virtual bystanders on the participant’s self-efficacy, anxiety, social evaluation, vicarious experience, and cognitive consistency Regenbrecht et al [57] Acrophobia Assessing the relationship between presence and fear of heights within VR Slater et al [58] Social anxiety Assessing the efficacy of low-fidelity VR on social anxiety VRET Veling et al [59] Social anxiety Evaluate the effects of childhood trauma on social stress reactivity and psychopathology within VR VR: virtual reality. VRET: virtual reality exposure theory. arrival, information-gathering procedures were used to assess Results the patient’s phobic level, and a stimulus hierarchy would be established based on the information gathered. Levels of the Quality Assessment Outcomes stimulus hierarchy would vary based on the phobia being treated The 49 studies received an average rating of 86.73% and a but generally would incorporate a new level or factors as the modal rating of 100% (n=30). A total of 10 studies were patient progresses. For example, acrophobia patients undergoing classified as qualitative, 21 studies as quantitative randomized, VRET would often progress through greater heights [19,21,22], 15 studies as quantitative nonrandomized, and 3 studies as whereas aviophobia patients would experience the next stage quantitative descriptive based on the parameters set by the mixed of a flight (eg, stationary and take-off) [8,23,24,26]. In short, methods appraisal tool [60]. regardless of the research methodology used or the specific phobia examined, treatment procedures were consistent across Summary of Papers the 16 specific phobia studies. Specific Phobias A few studies compared the efficacy of VRET with that of a The implementation of VRET for the treatment of specific pre-established treatment including standard IVE [18,19,24], phobias typically mirrors traditional phobia treatment protocols; relaxation therapy [8], or exposure group therapy [13]. In 1 treatment rationale was explained upon or before the patient’s http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott study comparing treatment outcomes of VRET, IVE, and a differences in treatment outcomes for any of the groups based waiting list condition for participants with agoraphobia, no on CAPS scores; however, participants who were dosed with significant differences were observed at the posttreatment and D-cycloserine experienced significant extinction learning that 12-month follow-up assessments between those that underwent was not observed in the alprazolam and placebo groups, VRET or IVE, but both groups did demonstrate significant suggesting that the use of D-cycloserine helped to enhance improvements over those in the waiting list condition [18]. The learning effects during VRET [36]. comparison for VRET and relaxation therapy yielded similar Anxiety results; however, it was found that although VRET was more Studies that focused on general or specific (social, public effective in reducing flying avoidance in participants, it was speaking, dental, or test) anxiety utilized VR as a method to only marginally better at reducing the participants’ fear of flying deliver VRET or VR distraction interventions. Although VRET ratings compared with relaxation therapy [8]. Finally, in a for general and specific anxiety largely mirrored the same comparison of VRET and exposure group therapy, more VRET procedural format as the VRET done for specific phobias, PTSD, participants experienced clinically significant change compared and ASD, VR distraction was used to comfort patients during with exposure group therapy participants based on posttreatment a dental procedure. Although VRET aims to address problematic assessments, but the significant difference disappeared between behaviors and cognitions by exposing patients to a virtual the 2 groups during the 6-month follow-up [13]. simulation, VR distraction serves to give patients a more positive Posttraumatic Stress Disorder and Acute Stress Disorder experience during an otherwise anxiety-inducing situation [40]. Studies investigating the efficacy of VRET on PTSD and ASD A comparison was conducted for the efficacy of VRET to CBT typically focused on patients who developed the disorder due and waiting list conditions for the treatment of public speaking to wartime combat or physical assault. Initial sessions followed anxiety, and findings were largely concurrent with the specific the same format and components as the ones used for specific phobia studies; both treatment groups experienced significant phobias, but VRET sessions were more personalized for each improvements over the waiting list, but did not significantly patient. For example, veterans were given a virtual environment differ with each other based on posttreatment assessments [43]. that matched the war environment that they had participated in, A similar finding was reported when VRET was compared with which included a jungle for the Vietnam War [35] and a desert EGT as an intervention for public-speaking anxiety across city for Middle Eastern wars [29,31-33,36]; victims of physical posttreatment, 3-month, and 12-month follow-up assessments; abuse unrelated to war were placed in an urban environment however, the study had a small sample size that limited the [30,34]. findings [6]. A comparison of VRET, IE, and waiting list conditions found A study that evaluated VRET for the treatment of general that, although VRET and IE both led to significant anxiety disorder incorporated biofeedback and a mobile, rather improvements in PTSD symptoms compared with the waiting than a computer-based, VR system. The virtual environments list, IE was superior based on the Clinician-Administered PTSD for the biofeedback group, which depicted various scenes Scale (CAPS), a structured interview performed by the clinician associated with relaxation, could change based on the patient’s to gauge the severity of PTSD-related symptoms [61]. Follow-up heart rate and physiological activation; a reduction in either assessments conducted at 3 and 6 months also indicated that results in a reduced intensity for certain stimuli within the virtual those who underwent IE experienced continual improvement, environment. Virtual environments for the VRET without whereas those who underwent VRET did not [33]. biofeedback and waiting list groups experienced the same scenes Another study sought to compare VRET with a but without the additional biofeedback features. Those who treatment-as-usual condition, which consisted of patients were in the biofeedback group were reported to have a performing their pre-established treatments, which included or significant decrease in behavioral avoidance and state anxiety, was a combination of prolonged exposure, eye movement whereas the VR without biofeedback group only experienced desensitization and reprocessing, and group therapy. A a significant decrease in behavioral avoidance, and the waiting posttreatment assessment using CAPS indicated that 70% (7/10) list group experienced no significant changes [41]. of patients that underwent VRET showed at least a 30% VR distraction was utilized for both dental anxiety studies in improvement, whereas only 11% (1/9) of treatment-as-usual this review, which were conducted during either a simulated patients showed the same level of improvement. Although this [40] or live [42] procedure. The stimulated dental procedure difference was deemed as significant, the authors noted that a study compared active VR, passive VR, and no VR; those in small sample size and wide variability in the treatment-as-usual the active VR condition could freely navigate around the virtual condition limited the interpretations of the study’s outcomes environment, whereas those in the passive VR condition could [31]. not. Those with higher levels of dental anxiety in both the active Finally, 1 study investigated whether augmenting VRET with and passive VR conditions were reported to have less vivid D-cycloserine, a glutamate receptor that had been demonstrated memories of the procedure compared with those that completed to improve the efficacy of exposure therapy for severe anxiety the procedure without VR [40]. Similar findings were reported disorders, would also benefit VRET. All participants in the for the live procedure study in which an oral prophylaxis (teeth study underwent VRET but were given D-cycloserine, cleaning) was performed. Participants were randomly assigned alprazolam (used primarily as a pharmacological treatment for to 1 group that received VR distraction during the first half of anxiety), or a placebo pill. The study reported no significant the procedure and another group that received the VR distraction http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott during the second half. Participants in both groups experienced experienced real fear when exposed to a virtual cliff [57], a significantly greater calmness during the portion of the study on woodwind performance anxiety found inconsistencies procedure when they received VR distraction compared with in subjective anxiety ratings during a performance in a virtual the portion when they did not [42]. concert hall [51]. For the latter, the authors speculated that an increase in heart rate during VR exposure may have been due Paranoia or Paranoid Ideations to the nature of performing on a wind instrument rather than The process of diagnosing paranoia has been difficult to do in due to the VR exposure, and the inconsistent subjective anxiety real settings, as therapists must be able to discern whether an ratings could have been due to performers finding the act of individual’s claims are legitimate or based on true paranoid performing to be psychologically calming rather than beliefs. Through the use of VR, the diagnostic process for anxiety-inducing. paranoia can be more reliable as the therapist has more control over the virtual stimuli, environment, and situational factors; Discussion avatars in the virtual environment cannot physically harm nor be harmed by the patient, and paranoid beliefs that surface Principal Findings during VR exposure can be verified [47]. As there were not a In relation to VRET, there appears to be an overwhelming lot of studies dedicated to this topic, each study employed the amount of positive evidence that the VR-based treatment has same task within the same virtual environment: participants an equal or greater efficacy toward the treatment of specific rode a London Underground train for a few minutes surrounded phobias and anxiety, but not as much for PTSD and ASD. This by avatars with neutral expressions and mannerisms. evidence comes from a mix of experimental designs, including case studies, controlled randomized trials, and within-group In 1 study, individuals were found to be twice as likely to designs, with some studies also offering follow-up results as experience some form of persecutory thoughts during VR evidence of VRET’s effects beyond posttreatment. Although exposure if they reported paranoid ideations in day-to-day life the use of VRET for PTSD and ASD was effective, it appeared [46]. This finding provided support toward the notion that that some patients seemed to gain continual improvement when neutral avatars were capable of eliciting paranoid thoughts, treated with another treatment option such as IE [33]. which was further confirmed in another study that compared Regardless, those who underwent VRET consistently showed the reactions of individuals belonging to clinical paranoia, high significant improvement over those in the waiting list groups nonclinical paranoia, and low nonclinical paranoia groups [47]. in the specific phobia, specific anxiety, and PTSD and ASD Innovations and Evaluations studies that compared the 2 together. Although previous sections covered how VR has been used to The use of VR to aid in the diagnosis of paranoia was also treat or study certain anxiety-based disorders, it is worth noting largely shown to be effective and was further reinforced due to the studies that have sought to either study VR-specific features every study related to the topic in this review using the same or create innovative programs to enhance VR-based treatment. procedures and virtual environment to study or differentiate For example, an interactive dialogue system for a study on social between individuals with varying levels of paranoia. Although anxiety was developed to elicit fear responses during VR VR was not used as a treatment tool for paranoia, it does provide exposure to match the fear response levels observed in in vivo a safe environment for the patient while simultaneously giving conversations. Although the study reported that participants therapists and researchers a way to accurately identify any believed in vivo conversations were more realistic than the ones paranoid ideations that may arise due to VR exposure. held in VR, fear ratings were found to be significantly higher for VR conversations than for in vivo ones. Although realism Finally, there have been many innovations to bolster the user’s is an important factor, the authors considered that fear was a sense of immersion, or the feeling of being present, within an more important factor in the context of treating symptoms of environment afforded by VR technology, at least for programs social anxiety [54]. focused on treating social anxiety disorders. These innovations were largely focused on making VR avatars more realistic and Another study sought to use dynamic social dialogue systems sociable, ranging from increasing the realism of a to manipulate the participant’s feelings of anxiety in real time person-to-avatar conversation to the manipulative behaviors of and effectively demonstrated that different ratios of positive multiple avatars that comprise a virtual audience. In general, and negative responses could serve as effective anxiety stressors these innovations achieved their purpose by eliciting a greater to manipulate the participant’s anxiety level in any direction amount of fear within the participant [54] or providing a (low to high) at any time [50]. Other studies aimed to evaluate dynamic manipulation of participant anxiety levels [50,52,59]. changes in audience behaviors and other social stressors (eg, As for the evaluation of VR elements, simply recreating an number of avatars present and ethnic diversity) and object that the participant fears, such as a virtual cliff for those demonstrated similar levels of efficacy in manipulating the with acrophobia [57], is enough to generate real fear, although patient’s anxiety levels [52,59]. testing VR’s efficacy on some tasks, such as performing on a Several studies were also conducted to evaluate whether VR woodwind instrument [51], may prove to be difficult due to the stimuli were capable of eliciting real emotions, a crucial factor nature of the task itself and how it may conflict with common for the treatment and assessment of specific phobias and other psychological or biometric measures. anxiety disorders. There are some mixed findings; although a study on acrophobia found evidence that participants http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott One area of research that would be worth pursuing is a Limitations self-directed rendition of VRET that can be done within a Although a large number of studies were included in this review, patient’s home with little to no therapist interaction. As there some topics appeared to be more researched than others, thus is an overwhelming amount of positive evidence toward the providing varying levels of quality and quantity. In particular, efficacy of VRET, at least in relation to specific phobias and there were a small number of studies dedicated to paranoia, and anxieties, the next step toward evolving VRET may be to although every study included in this review related to paranoia evaluate whether those with mild to moderate anxiety-based utilized the same virtual environments and procedures, the systems may benefit from merely exposing themselves to results may have been strengthened with more variety in the anxiety-inducing stimuli within a virtual environment. Self- types of virtual environments used beyond the London directed interventions provide patients with care in areas with Underground. limited to no access to therapists as well as to those who may This issue also persists for the specific anxiety and PTSD and be reluctant to see a therapist [62]. By utilizing a self-directed ASD studies in this review, where there was 1 clear subject that approach to VRET, it may be possible to allow individuals with dominated, whereas there were only a few studies that ventured low anxiety severity to treat themselves at their own pace, within beyond what was commonly researched. For specific anxiety, their own home, and without the need for a therapist. there were more studies focused on social or public speaking Conclusions anxiety, with only a couple of studies focused on dental anxiety, and the PTSD and ASD studies largely focused on war-induced This review evaluated a variety of topics related to the use of trauma rather than physical assault–induced trauma. VR for anxiety-based disorders, including VRET for specific phobias, specific anxieties, PTSD and ASD, and paranoia, while Future Research also outlining various innovations and evaluations conducted The landscape of modern VR has changed drastically compared by studies to either improve the experiences afforded by VR or with the VR systems used in most of the studies included in this investigate the various factors that contribute to its efficacy review. Although legacy VR systems were expensive, required toward anxiety-based treatments. These studies provided users to receive special training to operate or create VR generally positive evidence toward the diagnostic and treatment programs, and were limited to facilities that could invest in the capabilities of VR for anxiety-based disorders; however, technology, modern VR has provided cheaper entry points, a research into VR has generally been limited to institutions that vast library accessible through popular digital storefronts such had the resources to invest in it. With the advent of more as Steam or Google Play and Apple App Store, and user-friendly affordable, user-friendly, and supported commercial VR experiences. Although the most powerful VR systems available systems, more VR research can finally be done by building on today are mostly geared toward gaming, the same systems can the foundation laid out by the early studies to both replicate past provide some use toward the study, diagnosis, or treatment of findings and establish new uses for VR within psychotherapy. various anxiety-based disorders. Conflicts of Interest None declared. References 1. Mental Health Foundation. Fundamental Facts About Mental Health. London: Mental Health Foundation; 2016. 2. López GC, Gómez AR, Figueroa RD, Baca XD. Virtual reality exposure for trauma and stress-related disorders for city violence crime victims. Int J Child Health Hum Dev 2016;9(3):315-322 [FREE Full text] 3. Hoffman HG, Garcia-Palacios A, Carlin A, Furness TA, Botella-Arbona C. Interfaces that heal: coupling real and virtual objects to treat spider phobia. Int J Hum Comput Interact 2003;16(2):283-300. [doi: 10.1207/S15327590IJHC1602_08] 4. 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Freeman D, Pugh K, Vorontsova N, Antley A, Slater M. Testing the continuum of delusional beliefs: an experimental study using virtual reality. J Abnorm Psychol 2010 Feb;119(1):83-92 [FREE Full text] [doi: 10.1037/a0017514] [Medline: 20141245] 48. Cornwell BR, Johnson L, Berardi L, Grillon C. Anticipation of public speaking in virtual reality reveals a relationship between trait social anxiety and startle reactivity. Biol Psychiatry 2006 Apr 01;59(7):664-666. [doi: 10.1016/j.biopsych.2005.09.015] [Medline: 16325155] 49. Geuss MN, McCardell MJ, Stefanucci JK. Fear similarly alters perceptual estimates of and actions over gaps. PLoS One 2016;11(7):e0158610 [FREE Full text] [doi: 10.1371/journal.pone.0158610] [Medline: 27389399] 50. Hartanto D, Kampmann IL, Morina N, Emmelkamp PG, Neerincx MA, Brinkman WP. Controlling social stress in virtual reality environments. PLoS One 2014 Mar 26;9(3):e92804 [FREE Full text] [doi: 10.1371/journal.pone.0092804] [Medline: 24671006] 51. Orman EK. 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[doi: 10.1007/s11920-007-0034-6] [Medline: 17880859] Abbreviations ASD: acute stress disorder CBT: cognitive behavioral therapy CAPS: Clinician-Administered PTSD Scale EGT: exposure group therapy HMD: head-mounted display IE: imaginal exposure IVE: in vivo exposure MA: minimal attention MCE: multiple context exposure PTSD: posttraumatic stress disorder RT: relaxation therapy SCE: single context exposure TAU: treatment as usual VPT: vestibular physical therapy VR: virtual reality VRET: virtual reality exposure therapy WL: waiting list Edited by G Eysenbach; submitted 09.05.18; peer-reviewed by A Rathbone, D Leightley; comments to author 07.06.18; revised version received 20.07.18; accepted 07.08.18; published 07.11.18 Please cite as: Oing T, Prescott J JMIR Serious Games 2018;6(4):e10965 URL: http://games.jmir.org/2018/4/e10965/ doi: 10.2196/10965 PMID: 30404770 ©Theodore Oing, Julie Prescott. Originally published in JMIR Serious Games (http://games.jmir.org), 07.11.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 13 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review

Oing, Theodore; Prescott, Julie
JMIR Serious Games , Volume 6 (4) – Nov 7, 2018
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10.2196/10965
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Abstract

Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations. Objective: The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world. (JMIR Serious Games 2018;6(4):e10965) doi: 10.2196/10965 KEYWORDS virtual reality; virtual reality exposure therapy; phobic disorders; anxiety disorders http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott immerses the user with sensory stimuli. These stimuli are often Introduction limited to the user’s visual and auditory senses but may sometimes incorporate tactile stimuli through an apparatus (eg, Background force feedback gloves, toy spiders) to allow VR users to feel Anxiety-related disorders such as specific phobias, posttraumatic objects with their hands. By utilizing a customizable virtual stress disorder (PTSD), and general or specific anxiety (eg, environment, VRET offers an unparalleled level of control for public speaking or social anxiety) disorders stand as 1 of the the therapist to manipulate factors that could not be controlled most common, growing mental health disorders worldwide [1]. in a standard IVE session and tailor the sessions based on the In 2014, 19.5% of individuals above the age of 16 years had patient’s needs—all in the confines of the therapist’s office shown signs of anxiety or depression, with the United Kingdom [9,13]. alone experiencing a 1.5% increase from 2013 [1]. To combat Despite a major interest in VR during its inception, VR was the symptoms of anxiety-related disorders, 1 of the most often expensive, uncomfortable, and required special training effective treatment methods has been exposure therapy, which to operate. The computers used to run VR were barely able to stems from the broader practice of cognitive behavioral therapy do so, leading to low-quality VR experiences (eg, jagged (CBT) [2]. In exposure therapy, patients undergo a process of graphics and inconsistent and low frame rates) that could lead systematic desensitization, where a series of systematic steps to simulator sickness, characterized by symptoms of nausea, are employed to gradually expose the patient to an anxiety- or headaches, and dizziness [6]. In addition to simulator sickness, fear-inducing stimulus, with the ultimate goal of minimizing early HMDs were also heavy, resulting in users experiencing the patient’s intense and adverse behavior toward the stimulus. neck pain after prolonged use. Furthermore, without adequate Furthermore, the therapists may employ methods to change the software distribution systems to sell or share VR programs, patient’s cognitions about the stimulus, such as through special training would often be required to create VR programs psychoeducation, to reinforce treatment gains from systematic to suit the research or therapists’ needs. These limitations desensitization [3]. ultimately restricted the use and research of VR-based Traditionally, stimuli in exposure therapy are presented through psychotherapy to well-funded or specialized institutions [14]. in vivo exposure (IVE) or imaginal exposure (IE), each of which Although early VR technologies have been largely inaccessible carries its own set of advantages and disadvantages. IVE to a mass audience, recent developments in VR technologies involves live exposure to the stimuli, often being utilized to have addressed many of the issues that plagued legacy units. treat specific phobias or anxieties such as arachnophobia (fear Both the HTC Vive and Oculus Rift, which released in 2016, of spiders) [4], acrophobia (fear of heights) [5], and social were lighter and powerful enough to render high-quality visual anxiety [6]. Although IVE is considered to be the most effective and auditory stimuli. Both HMDs were also integrated with method for helping the patient overcome their anxiety or fear, major digital distribution services such as Steam, which has disorders such as aviophobia (fear of flying) and social anxiety attracted both small, independent developers and large, may require sessions to be conducted in public, therefore posing professional developers alike to create high-quality VR a risk of breaking patient confidentiality; become too expensive programs. Renewed interest in VR also led to a push for mobile to perform single or repeated exposure sessions; and introduce VR, a less powerful yet inexpensive version of computer-based uncontrollable variables that may hinder the overall treatment VR that could run on modern mobile phones (e.g. iPhone, (eg, behavior of living organisms and weather conditions) [7-9]. Google Pixel, etc.). Even if these issues can be addressed, some individuals may feel that confronting an anxiety- or fear-inducing stimulus may Objective be too aversive, which may lead to participants dropping out of The aim of this systematic review was to explore previously treatment or not seeking treatment at all [5]. IE can address established VR studies within psychotherapy to inform future many of the limitations of IVE, as patients are tasked with VR research. Although modern VR HMDs are still relatively generating the stimulus in his or her imagination rather than new, evaluating how past studies have utilized the VR confronting a live version of the stimulus; however, the patient technologies of their era can serve as a comprehensive guide as may be potentially unable or unwilling to generate a vivid to how VR-based psychotherapy programs can improve in the imaginal representation of the stimulus [10]. future as well as whether the limitations observed in past studies Since the early to mid-1990s, therapists have attempted to seek are still relevant with the current iteration of VR systems. Topics an alternative to IVE and IE through the use of virtual reality covered in this review will mainly cover the efficacy of VRET (VR) technologies through a process known as virtual reality treatment, its uses as a diagnostic or assessment tool, and exposure therapy (VRET). VR technology includes a wide range innovations in the pursuit of greater VR experiences in relation of configurations, including head-mounted displays (HMDs), to psychological disorders in which anxiety is a key symptom, external projection setups such as the CAVE Automatic Virtual including specific phobias, PTSD and acute stress disorder Environment [11], and simulators [12], all of which vary in (ASD), specific and general anxiety disorder, and paranoid terms of technical specifications (eg, display resolution, tracking ideations. accuracy, and field of view). Regardless of the form of VR, VRET generally follows the same treatment protocols as traditional exposure therapy but renders the anxiety or fear-inducing stimulus within a virtual environment that http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott Search Terms Methods The command line used for the search was as follows: “virtual Databases Searched reality” AND (phobia OR anxiety) AND (treatment OR therapy). Although VR is a common referential acronym for virtual ProQuest Central, PsycINFO, and PsycARTICLES were the reality, the full term was exclusively used during the search to databases used to conduct a comprehensive search of the past streamline the search process and avoid any other terms that literature. Studies must have been published before August 31, may use the VR acronym (eg, variable reward and voice 2017, peer-reviewed, published in a scholarly journal, written recognition). An initial 2419 studies were collected from the 3 in English, and have full-text availability. databases used to conduct this search. Figure 1. Systematic Review Search Prisma. HMD: head-mounted display; VR: virtual reality. http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott Table 1. Specific phobia treatments. Author Phobia type Methodology Sessions, n Session length Follow-up Intervention (patients, n) Botella et al [17] Claustrophobia Case 8 35-45 min 1 month VRET (n=1) Botella et al [18] Agoraphobia Controlled 9 1 hour 12 months VRET (n=12); IVE (n=12); WL (n=13) Carlin et al [9] Arachnophobia Case 12 50 min None VRET (n=1) Emmelkamp et al [19] Acrophobia Controlled 3 1 hour 6 months VRET (n=17); IVE (n=16) Garcia-Palacios et al [7] Arachnophobia Controlled 3-10 (4) 1 hour None VRET (n=12); WL (n=11) Maltby et al [13] Aviophobia Controlled 5 50 min 6 months VRET (n=20); EGT (n=23) Moldovan and David [20] Multiple Controlled 1 60 min None VRET (n=16); WL (n=16) Muhlberger et al [8] Aviophobia Controlled 1 180 min None VRET (n=15); RT (n=13) Rothbaum et al [21] Acrophobia Controlled 7 35-45 min None VRET (n=12); WL (n=8) Rothbaum et al [22] Acrophobia Case 5 35-45 min None VRET (n=1) Rothbaum et al [23] Aviophobia Case 6 35-45 min 1 month VRET (n=1) Rothbaum et al [24] Aviophobia Controlled 8 1 hour 6 months VRET (n=15); IVE (n=15); WL (n=15) Rothbaum et al [25] Aviophobia Controlled 8 1 hour 12 months VRET (n=13); IVE (n=11) Rothbaum et al [26] Aviophobia Controlled 8 6 and 12 VRET (n=25); IVE (n=25); WL N/A months (n=25) h i Shiban et al [27] Arachnophobia Controlled 2 N/A None MCE VRET (n=15); SCE VRET (n=15) Whitney et al [28] Acrophobia Case 8 N/A None VRET+VPT (n=1) VRET: virtual reality exposure therapy. IVE: in vivo exposure. WL: waiting list. Mean value. EGT: exposure group therapy. RT: relaxation therapy. N/A: not applicable. MCE: multiple context exposure. SCE: single context exposure. VPT: vestibular physical therapy. “virtual reality” alongside terms related to fear, anxiety, or a Inclusion and Exclusion Criteria specific phobia, as well as having explicitly used an HMD within For the initial 2419 studies collected, the following inclusion the study itself. A total of 27 additional studies were collected and exclusion criteria were implemented. Parameters were set through these criteria, although 1 study appeared to have been to limit the studies only to those whose subject was on VR published twice in 2 years with some minor differences; (n=217) and whose document type was either an article or a therefore, the most recent version of that study was kept [15], case study (n=203). Studies that did not perform an experiment whereas the older version was excluded [16], resulting in only using an HMD for treating or examining a specific phobia or 26 additional studies. In total, 49 studies were examined for this anxiety were excluded (n=177) as were other systematic reviews review. or meta-analyses (n=3). HMDs were chosen as the VR system Information found in Figure 1 exhibits the process in which the of choice for this review as the systems were the most accessible studies in this review were obtained based on the inclusion compared with CAVE and simulator-type systems, alongside criteria as well as the number of studies excluded based on the the notion that the most prominent modern VR systems are initial exclusion criteria. HMDs. In total, 23 eligible studies met the inclusion criteria. Studies were also placed into 1 of the 5 categories for the Another search was conducted based on the references detailed purposes of this review: phobia treatments (see Table 1), PTSD in each of the initial 23 eligible studies. Inclusion criteria for treatments (see Table 2), anxiety treatments (see Table 3), this search were that the reference title must have mentioned http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott paranoia evaluation (see Table 4), and innovations and quality of each of the 49 studies was also appraised through the evaluation (see Table 5). mixed methods appraisal tool (2011), which was designed to assess the methodological quality of quantitative (randomized, Quality Assessment nonrandomized, and descriptive), qualitative, and Quality assessment of the collected studies was examined by mixed-methods studies used within systematic reviews [60]. both authors using the inclusion and exclusion criteria. The Table 2. Posttraumatic stress disorder and acute stress disorder treatments. Author Study type Trauma type Follow-up Interventions and patients, n Gerardi et al [29] Case War None VRET (n=1) Cardenas-Lopez et al [30] Uncontrolled Assault None VRET (n=6) McLay et al [31] Controlled War None VRET (n=10); TAU (n=10) Reger et al [32] Uncontrolled War None VRET (n=24) c d Reger et al [33] Controlled War 3 and 6 months VRET (n=54); IE (n=54) ; MA (n=54) Cardenas Lopez and de la Rosa-Gomez [34] Case Assault None VRET (n=1) Rothbaum et al [35] Case War 3 and 6 months VRET (n=1) Rothbaum et al [36] Controlled War 3, 6, and 12 months VRET with D-cycloserine (n=53); VRET with alprazolam (n=50); VRET with placebo (n=53) VRET: virtual reality exposure therapy. TAU: treatment as usual. IE: imaginal exposure. MA: minimal attention. Table 3. Anxiety treatments. Author Anxiety type Study type Sessions, n Session length Follow-up Comparisons and patients, n Alsina-Jurnet et al [37] Performance Uncontrolled 1 90 min None High test anxiety (n=11); Low test anxiety (n=10) Anderson et al [38] Social Case study 6 to 10 Unknown Unknown VRET (n=2) b c Anderson et al [6] Social Controlled 8 Unknown 3 and 12 VRET (n=25); EGT (n=25); WL Months (n=25) Harris et al [39] Social Controlled 4 12-15 min/exposure None VRET (n=8); WL (n=6) Padrino-Barrios et al [40] Dental Controlled 1 Unknown Unknown VR exposure first half (n=15); VR exposure second half (n=15) Repetto et al [41] General Controlled 8 Unknown Unknown VRET with biofeedback (n=9); VRET without biofeedback (n=8); WL (n=8) Tanja-Dijkstra et al [42] Dental Controlled 1 Unknown 1 week Active VR (n=22); Passive VR (n=23); No VR (n=24) Wallach et al [43] Social Controlled 12 1 hour None VRET (n=28); CBT (n=30); WL (n=30) VRET: virtual reality exposure therapy. EGT: exposure group therapy. WL: waiting list. VR: virtual reality. CBT: cognitive behavioral therapy. http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott Table 4. Paranoia or paranoid ideations evaluation. Author and population Pateints, n Age in years, mean (SD) Analysis Fornells-Ambrojo et al [44] Qualitative Early psychosis (clinical) 10 24.2 (2.3) Healthy (Nonclinical) 10 23.8 (2.3) Freeman et al [45]: Assaulted 1 month before 106 34.4 (11.6) Quantitative Freeman et al [46]: Local adult 200 37.5 (13.3) Quantitative Freeman et al [47] Quantitative Low nonclinical paranoia 30 44.2 (11.2) High nonclinical paranoia 30 36.0 (11.7) Persecutory delusions 30 44.2 (11.7) Table 5. Virtual reality evaluations and innovations. Author Disorder Aim Cornwell et al [48] Social anxiety Evaluating the relationship between trait social anxiety and startle reactivity Geuss et al [49] Acrophobia Assessing perceptual estimates and actions of gaps within VR Hartanto et al [50] Social anxiety Evaluating the efficacy of various social stressors within VR Orman [51] Performance anxiety Assessing effects of VR exposure on performing musicians Owens and Beidel [52] Social anxiety Evaluating the efficacy of VR stimuli for social anxiety VRET Park et al [53] Social anxiety Assess the virtual interactions of patients with schizophrenia with digital avatars Pertaub et al [15] Public speaking anxiety Evaluate participant responses toward positive, negative, and static virtual audiences Powers et al [54] Social anxiety Evaluate a VR-based interactive dialogue system to elicit the same level of fear from an in vivo conversation Price et al [55] Social phobia Evaluate the importance of presence within VR as a predictor of treatment response for social anxiety VRET Qu et al [56] Social phobia Evaluate the influence of virtual bystanders on the participant’s self-efficacy, anxiety, social evaluation, vicarious experience, and cognitive consistency Regenbrecht et al [57] Acrophobia Assessing the relationship between presence and fear of heights within VR Slater et al [58] Social anxiety Assessing the efficacy of low-fidelity VR on social anxiety VRET Veling et al [59] Social anxiety Evaluate the effects of childhood trauma on social stress reactivity and psychopathology within VR VR: virtual reality. VRET: virtual reality exposure theory. arrival, information-gathering procedures were used to assess Results the patient’s phobic level, and a stimulus hierarchy would be established based on the information gathered. Levels of the Quality Assessment Outcomes stimulus hierarchy would vary based on the phobia being treated The 49 studies received an average rating of 86.73% and a but generally would incorporate a new level or factors as the modal rating of 100% (n=30). A total of 10 studies were patient progresses. For example, acrophobia patients undergoing classified as qualitative, 21 studies as quantitative randomized, VRET would often progress through greater heights [19,21,22], 15 studies as quantitative nonrandomized, and 3 studies as whereas aviophobia patients would experience the next stage quantitative descriptive based on the parameters set by the mixed of a flight (eg, stationary and take-off) [8,23,24,26]. In short, methods appraisal tool [60]. regardless of the research methodology used or the specific phobia examined, treatment procedures were consistent across Summary of Papers the 16 specific phobia studies. Specific Phobias A few studies compared the efficacy of VRET with that of a The implementation of VRET for the treatment of specific pre-established treatment including standard IVE [18,19,24], phobias typically mirrors traditional phobia treatment protocols; relaxation therapy [8], or exposure group therapy [13]. In 1 treatment rationale was explained upon or before the patient’s http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott study comparing treatment outcomes of VRET, IVE, and a differences in treatment outcomes for any of the groups based waiting list condition for participants with agoraphobia, no on CAPS scores; however, participants who were dosed with significant differences were observed at the posttreatment and D-cycloserine experienced significant extinction learning that 12-month follow-up assessments between those that underwent was not observed in the alprazolam and placebo groups, VRET or IVE, but both groups did demonstrate significant suggesting that the use of D-cycloserine helped to enhance improvements over those in the waiting list condition [18]. The learning effects during VRET [36]. comparison for VRET and relaxation therapy yielded similar Anxiety results; however, it was found that although VRET was more Studies that focused on general or specific (social, public effective in reducing flying avoidance in participants, it was speaking, dental, or test) anxiety utilized VR as a method to only marginally better at reducing the participants’ fear of flying deliver VRET or VR distraction interventions. Although VRET ratings compared with relaxation therapy [8]. Finally, in a for general and specific anxiety largely mirrored the same comparison of VRET and exposure group therapy, more VRET procedural format as the VRET done for specific phobias, PTSD, participants experienced clinically significant change compared and ASD, VR distraction was used to comfort patients during with exposure group therapy participants based on posttreatment a dental procedure. Although VRET aims to address problematic assessments, but the significant difference disappeared between behaviors and cognitions by exposing patients to a virtual the 2 groups during the 6-month follow-up [13]. simulation, VR distraction serves to give patients a more positive Posttraumatic Stress Disorder and Acute Stress Disorder experience during an otherwise anxiety-inducing situation [40]. Studies investigating the efficacy of VRET on PTSD and ASD A comparison was conducted for the efficacy of VRET to CBT typically focused on patients who developed the disorder due and waiting list conditions for the treatment of public speaking to wartime combat or physical assault. Initial sessions followed anxiety, and findings were largely concurrent with the specific the same format and components as the ones used for specific phobia studies; both treatment groups experienced significant phobias, but VRET sessions were more personalized for each improvements over the waiting list, but did not significantly patient. For example, veterans were given a virtual environment differ with each other based on posttreatment assessments [43]. that matched the war environment that they had participated in, A similar finding was reported when VRET was compared with which included a jungle for the Vietnam War [35] and a desert EGT as an intervention for public-speaking anxiety across city for Middle Eastern wars [29,31-33,36]; victims of physical posttreatment, 3-month, and 12-month follow-up assessments; abuse unrelated to war were placed in an urban environment however, the study had a small sample size that limited the [30,34]. findings [6]. A comparison of VRET, IE, and waiting list conditions found A study that evaluated VRET for the treatment of general that, although VRET and IE both led to significant anxiety disorder incorporated biofeedback and a mobile, rather improvements in PTSD symptoms compared with the waiting than a computer-based, VR system. The virtual environments list, IE was superior based on the Clinician-Administered PTSD for the biofeedback group, which depicted various scenes Scale (CAPS), a structured interview performed by the clinician associated with relaxation, could change based on the patient’s to gauge the severity of PTSD-related symptoms [61]. Follow-up heart rate and physiological activation; a reduction in either assessments conducted at 3 and 6 months also indicated that results in a reduced intensity for certain stimuli within the virtual those who underwent IE experienced continual improvement, environment. Virtual environments for the VRET without whereas those who underwent VRET did not [33]. biofeedback and waiting list groups experienced the same scenes Another study sought to compare VRET with a but without the additional biofeedback features. Those who treatment-as-usual condition, which consisted of patients were in the biofeedback group were reported to have a performing their pre-established treatments, which included or significant decrease in behavioral avoidance and state anxiety, was a combination of prolonged exposure, eye movement whereas the VR without biofeedback group only experienced desensitization and reprocessing, and group therapy. A a significant decrease in behavioral avoidance, and the waiting posttreatment assessment using CAPS indicated that 70% (7/10) list group experienced no significant changes [41]. of patients that underwent VRET showed at least a 30% VR distraction was utilized for both dental anxiety studies in improvement, whereas only 11% (1/9) of treatment-as-usual this review, which were conducted during either a simulated patients showed the same level of improvement. Although this [40] or live [42] procedure. The stimulated dental procedure difference was deemed as significant, the authors noted that a study compared active VR, passive VR, and no VR; those in small sample size and wide variability in the treatment-as-usual the active VR condition could freely navigate around the virtual condition limited the interpretations of the study’s outcomes environment, whereas those in the passive VR condition could [31]. not. Those with higher levels of dental anxiety in both the active Finally, 1 study investigated whether augmenting VRET with and passive VR conditions were reported to have less vivid D-cycloserine, a glutamate receptor that had been demonstrated memories of the procedure compared with those that completed to improve the efficacy of exposure therapy for severe anxiety the procedure without VR [40]. Similar findings were reported disorders, would also benefit VRET. All participants in the for the live procedure study in which an oral prophylaxis (teeth study underwent VRET but were given D-cycloserine, cleaning) was performed. Participants were randomly assigned alprazolam (used primarily as a pharmacological treatment for to 1 group that received VR distraction during the first half of anxiety), or a placebo pill. The study reported no significant the procedure and another group that received the VR distraction http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott during the second half. Participants in both groups experienced experienced real fear when exposed to a virtual cliff [57], a significantly greater calmness during the portion of the study on woodwind performance anxiety found inconsistencies procedure when they received VR distraction compared with in subjective anxiety ratings during a performance in a virtual the portion when they did not [42]. concert hall [51]. For the latter, the authors speculated that an increase in heart rate during VR exposure may have been due Paranoia or Paranoid Ideations to the nature of performing on a wind instrument rather than The process of diagnosing paranoia has been difficult to do in due to the VR exposure, and the inconsistent subjective anxiety real settings, as therapists must be able to discern whether an ratings could have been due to performers finding the act of individual’s claims are legitimate or based on true paranoid performing to be psychologically calming rather than beliefs. Through the use of VR, the diagnostic process for anxiety-inducing. paranoia can be more reliable as the therapist has more control over the virtual stimuli, environment, and situational factors; Discussion avatars in the virtual environment cannot physically harm nor be harmed by the patient, and paranoid beliefs that surface Principal Findings during VR exposure can be verified [47]. As there were not a In relation to VRET, there appears to be an overwhelming lot of studies dedicated to this topic, each study employed the amount of positive evidence that the VR-based treatment has same task within the same virtual environment: participants an equal or greater efficacy toward the treatment of specific rode a London Underground train for a few minutes surrounded phobias and anxiety, but not as much for PTSD and ASD. This by avatars with neutral expressions and mannerisms. evidence comes from a mix of experimental designs, including case studies, controlled randomized trials, and within-group In 1 study, individuals were found to be twice as likely to designs, with some studies also offering follow-up results as experience some form of persecutory thoughts during VR evidence of VRET’s effects beyond posttreatment. Although exposure if they reported paranoid ideations in day-to-day life the use of VRET for PTSD and ASD was effective, it appeared [46]. This finding provided support toward the notion that that some patients seemed to gain continual improvement when neutral avatars were capable of eliciting paranoid thoughts, treated with another treatment option such as IE [33]. which was further confirmed in another study that compared Regardless, those who underwent VRET consistently showed the reactions of individuals belonging to clinical paranoia, high significant improvement over those in the waiting list groups nonclinical paranoia, and low nonclinical paranoia groups [47]. in the specific phobia, specific anxiety, and PTSD and ASD Innovations and Evaluations studies that compared the 2 together. Although previous sections covered how VR has been used to The use of VR to aid in the diagnosis of paranoia was also treat or study certain anxiety-based disorders, it is worth noting largely shown to be effective and was further reinforced due to the studies that have sought to either study VR-specific features every study related to the topic in this review using the same or create innovative programs to enhance VR-based treatment. procedures and virtual environment to study or differentiate For example, an interactive dialogue system for a study on social between individuals with varying levels of paranoia. Although anxiety was developed to elicit fear responses during VR VR was not used as a treatment tool for paranoia, it does provide exposure to match the fear response levels observed in in vivo a safe environment for the patient while simultaneously giving conversations. Although the study reported that participants therapists and researchers a way to accurately identify any believed in vivo conversations were more realistic than the ones paranoid ideations that may arise due to VR exposure. held in VR, fear ratings were found to be significantly higher for VR conversations than for in vivo ones. Although realism Finally, there have been many innovations to bolster the user’s is an important factor, the authors considered that fear was a sense of immersion, or the feeling of being present, within an more important factor in the context of treating symptoms of environment afforded by VR technology, at least for programs social anxiety [54]. focused on treating social anxiety disorders. These innovations were largely focused on making VR avatars more realistic and Another study sought to use dynamic social dialogue systems sociable, ranging from increasing the realism of a to manipulate the participant’s feelings of anxiety in real time person-to-avatar conversation to the manipulative behaviors of and effectively demonstrated that different ratios of positive multiple avatars that comprise a virtual audience. In general, and negative responses could serve as effective anxiety stressors these innovations achieved their purpose by eliciting a greater to manipulate the participant’s anxiety level in any direction amount of fear within the participant [54] or providing a (low to high) at any time [50]. Other studies aimed to evaluate dynamic manipulation of participant anxiety levels [50,52,59]. changes in audience behaviors and other social stressors (eg, As for the evaluation of VR elements, simply recreating an number of avatars present and ethnic diversity) and object that the participant fears, such as a virtual cliff for those demonstrated similar levels of efficacy in manipulating the with acrophobia [57], is enough to generate real fear, although patient’s anxiety levels [52,59]. testing VR’s efficacy on some tasks, such as performing on a Several studies were also conducted to evaluate whether VR woodwind instrument [51], may prove to be difficult due to the stimuli were capable of eliciting real emotions, a crucial factor nature of the task itself and how it may conflict with common for the treatment and assessment of specific phobias and other psychological or biometric measures. anxiety disorders. There are some mixed findings; although a study on acrophobia found evidence that participants http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott One area of research that would be worth pursuing is a Limitations self-directed rendition of VRET that can be done within a Although a large number of studies were included in this review, patient’s home with little to no therapist interaction. As there some topics appeared to be more researched than others, thus is an overwhelming amount of positive evidence toward the providing varying levels of quality and quantity. In particular, efficacy of VRET, at least in relation to specific phobias and there were a small number of studies dedicated to paranoia, and anxieties, the next step toward evolving VRET may be to although every study included in this review related to paranoia evaluate whether those with mild to moderate anxiety-based utilized the same virtual environments and procedures, the systems may benefit from merely exposing themselves to results may have been strengthened with more variety in the anxiety-inducing stimuli within a virtual environment. Self- types of virtual environments used beyond the London directed interventions provide patients with care in areas with Underground. limited to no access to therapists as well as to those who may This issue also persists for the specific anxiety and PTSD and be reluctant to see a therapist [62]. By utilizing a self-directed ASD studies in this review, where there was 1 clear subject that approach to VRET, it may be possible to allow individuals with dominated, whereas there were only a few studies that ventured low anxiety severity to treat themselves at their own pace, within beyond what was commonly researched. For specific anxiety, their own home, and without the need for a therapist. there were more studies focused on social or public speaking Conclusions anxiety, with only a couple of studies focused on dental anxiety, and the PTSD and ASD studies largely focused on war-induced This review evaluated a variety of topics related to the use of trauma rather than physical assault–induced trauma. VR for anxiety-based disorders, including VRET for specific phobias, specific anxieties, PTSD and ASD, and paranoia, while Future Research also outlining various innovations and evaluations conducted The landscape of modern VR has changed drastically compared by studies to either improve the experiences afforded by VR or with the VR systems used in most of the studies included in this investigate the various factors that contribute to its efficacy review. Although legacy VR systems were expensive, required toward anxiety-based treatments. These studies provided users to receive special training to operate or create VR generally positive evidence toward the diagnostic and treatment programs, and were limited to facilities that could invest in the capabilities of VR for anxiety-based disorders; however, technology, modern VR has provided cheaper entry points, a research into VR has generally been limited to institutions that vast library accessible through popular digital storefronts such had the resources to invest in it. With the advent of more as Steam or Google Play and Apple App Store, and user-friendly affordable, user-friendly, and supported commercial VR experiences. 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[doi: 10.1007/s11920-007-0034-6] [Medline: 17880859] Abbreviations ASD: acute stress disorder CBT: cognitive behavioral therapy CAPS: Clinician-Administered PTSD Scale EGT: exposure group therapy HMD: head-mounted display IE: imaginal exposure IVE: in vivo exposure MA: minimal attention MCE: multiple context exposure PTSD: posttraumatic stress disorder RT: relaxation therapy SCE: single context exposure TAU: treatment as usual VPT: vestibular physical therapy VR: virtual reality VRET: virtual reality exposure therapy WL: waiting list Edited by G Eysenbach; submitted 09.05.18; peer-reviewed by A Rathbone, D Leightley; comments to author 07.06.18; revised version received 20.07.18; accepted 07.08.18; published 07.11.18 Please cite as: Oing T, Prescott J JMIR Serious Games 2018;6(4):e10965 URL: http://games.jmir.org/2018/4/e10965/ doi: 10.2196/10965 PMID: 30404770 ©Theodore Oing, Julie Prescott. Originally published in JMIR Serious Games (http://games.jmir.org), 07.11.2018. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Oing & Prescott provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2018/4/e10965/ JMIR Serious Games 2018 | vol. 6 | iss. 4 | e10965 | p. 13 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Nov 7, 2018

Keywords: virtual reality; virtual reality exposure therapy; phobic disorders; anxiety disorders

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