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.

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.

Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation.

BACKGROUND: Automated virtual reality exposure therapies (VRETs) are self-help treatments conducted by oneself and supported by a virtual therapist embodied visually and/or with audio feedback. This simulates many of the nonspecific relational elements and common factors present in face-to-face therapy and may be a means of improving adherence to and efficacy of self-guided treatments. However, little is known about alliance toward the virtual therapist, despite alliance being an important predictor of treatment outcome. OBJECTIVE: In this study, we aimed to evaluate the first alliance instrument developed for use with embodied virtual therapists in an automated treatment format-the Virtual Therapist Alliance Scale (VTAS)-by (1) assessing its psychometric properties, (2) verifying the dimensionality of the scale, and (3) determining the predictive ability of the scale with treatment outcome. METHODS: A psychometric evaluation and exploratory factor analysis of the VTAS was conducted using data from two samples of spider-fearful patients treated with VRET and the help of an embodied, voice-based virtual therapist (n=70). Multiple regression models and bivariate correlations were used to assess the VTAS relationship with treatment outcome, according to self-reported fear and convergence with presence and user-friendliness process measures. RESULTS: The VTAS showed a sound two-factor solution composed of a primary factor covering task, goal, and copresence; adequate internal consistency; and good convergent validity, including moderate correlation (r=.310, P=.01) with outcomes over follow-up. CONCLUSIONS: These preliminary results suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome, favors the importance of a task-goal over bond-factor, and should be explored in studies with larger sample sizes and in additional forms of embodiment.

Automated virtual reality exposure therapy for spider phobia vs. in-vivo one-session treatment: A randomized non-inferiority trial.

OBJECTIVE: This study compared the efficacy of a technician-assisted single-session virtual reality exposure therapy (VRET) for the treatment of spider phobia featuring low-cost consumer-available hardware and novel automated software to gold-standard in-vivo one-session treatment (OST), using a parallel group randomized non-inferiority design. Method Participants (N = 100) were randomized to VRET and OST arms. Assessors blinded to treatment allocation evaluated participants at pre- and post-treatment as well follow-up (3 and 12 months) using a behavioral approach test (BAT) and self-rated fear of spider, anxiety, depression and quality-of-life scales. A maximum post-treatment difference of 2-points on the BAT qualified as non-inferiority margin. Results Linear mixed models noted large, significant reductions in behavioral avoidance and self-reported fear in both groups at post-treatment, with VRET approaching the strong treatment benefits of OST over time. Non-inferiority was identified at 3- and 12- months follow-up but was significantly worse until 12-months. There was no significant difference on a questionnaire measuring negative effects. Conclusions Automated VRET efficaciously reduced spider phobia symptoms in the short-term and was non-inferior to in-vivo exposure therapy in the long-term. VRET effectiveness trials are warranted to evaluate real-world benefits and non-specific therapeutic factors accruing from the presence of a technician during treatment. ClinicalTrials.gov (NCT02533310).

Attitudes Toward and Familiarity With Virtual Reality Therapy Among Practicing Cognitive Behavior Therapists: A Cross-Sectional Survey Study in the Era of Consumer VR Platforms.

Virtual reality exposure therapy (VRET) is an efficacious treatment for fear and anxiety and has the potential to solve both logistic issues for therapists and be used for scalable self-help interventions. However, VRET has yet to see large-scale implementation in clinical settings or as a consumer product, and past research suggests that while therapists may acknowledge the many advantages of VRET, they view the technology as technically inaccessible and expensive. We reasoned that after the 2016 release of several consumer virtual reality (VR) platforms and associated public acquaintance with VR, therapists' concerns about VRET may have evolved. The present study surveyed attitudes toward and familiarity with VR and VRET among practicing cognitive behavior therapists (n = 185) attending a conference. Results showed that therapists had an overall positive attitude toward VRET (pros rated higher than cons) and viewed VR as applicable to conditions other than anxiety. Unlike in earlier research, high financial costs and technical difficulties were no longer top-rated negative aspects. Average negative attitude was a larger negative predictor of self-rated likelihood of future use than positive attitude was a positive predictor and partially mediated the positive association between VRET knowledge and likelihood of future use, suggesting that promotional efforts should focus on addressing concerns. We conclude that therapist's attitudes toward VRET appear to have evolved in recent years, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.

What is so frightening about spiders? Self-rated and self-disclosed impact of different characteristics and associations with phobia symptoms.

Spider phobia is a common and impairing mental disorder, yet little is known about what characteristics of spiders that spider phobic individuals find frightening. Using screening data from a clinical trial, we explored which characteristics that spider-fearful individuals (n = 194) rated as having the greatest impact on fear, used factor analysis to group specific characteristics, and explored linear associations with self-reported phobia symptoms. Second, a guided text-mining approach was used to extract the most common words in free-text responses to the question: "What is it about spiders that you find frightening?" Both analysis types suggested that movement-related characteristics of spiders were the most important, followed by appearance characteristics. There were, however, no linear associations with degree of phobia symptoms. Our findings reveal the importance of targeting movement-related fears in in-vivo exposure therapy for spider phobia and using realistically animated spider stimuli in computer-based experimental paradigms and clinical interventions such as Virtual Reality exposure therapy.

Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Dental Anxiety: Open Trial.

BACKGROUND: Cognitive behavioral therapy (CBT) is an evidence-based method for treating specific phobias, but access to treatment is difficult, especially for children and adolescents with dental anxiety. Psychologist-guided Internet-based CBT (ICBT) may be an effective way of increasing accessibility while maintaining treatment effects. OBJECTIVE: The aim of this study was to test the hypothesis that psychologist-guided ICBT improves school-aged children's and adolescents' ability to manage dental anxiety by (1) decreasing avoidance and affecting the phobia diagnosis and (2) decreasing the dental fear and increasing the target groups' self-efficacy. The study also aimed to examine the feasibility and acceptability of this novel treatment. METHODS: This was an open, uncontrolled trial with assessments at baseline, posttreatment, and the 1-year follow-up. The study enrolled and treated 18 participants. The primary outcome was level of avoidance behaviors, as measured by the picture-guided behavioral avoidance test (PG-BAT). The secondary outcome was a diagnostic evaluation with the parents conducted by a psychologist. The specific phobia section of the structured interview Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime (K-SADS-PL) was used. Other outcome measures included level of dental anxiety and self-efficacy. The ICBT, which employed exposure therapy, comprised 12 modules of texts, animations, dentistry-related video clips, and an exercise package (including dental instruments). Participants accessed the treatment through an Internet-based treatment platform and received Web-based guidance from a psychologist. Treatment also included training at dental clinics. Feasibility and acceptability were assessed by measures of engagement, adherence, compliance, completed measures, patient and parent satisfaction scale, and staff acceptability. RESULTS: The level of avoidance (according to the primary outcome measure PG-BAT) and dental anxiety decreased and self-efficacy increased significantly (P<.001), within-group effect sizes for both the primary outcome (Cohen d=1.5), and other outcomes were large in the range of 0.9 and 1.5. According to K-SADS-PL, 53% (8/15) of the participants were free from diagnosable dental anxiety at the 1-year follow-up. At the 1-year follow-up, improvements were maintained and clinically significant, with 60% (9/15) of participants who had been unable to manage intraoral injection of local anesthetics before ICBT reporting having accomplished this task at a dental clinic. The target group showed improvement in all the outcome measures. High levels of feasibility and acceptability were observed for the treatment. CONCLUSIONS: ICBT is a promising and feasible treatment for dental anxiety in children and adolescents. Integrating it into routine pediatric dental care would increase access to an effective psychological treatment. The results of this open trial must be replicated in controlled studies.

The mediating role of changes in harm beliefs and coping efficacy in youth with specific phobias.

Individuals with specific phobias (SPs) often experience catastrophic cognitions and compromised efficacy regarding their ability to cope when in the presence of the phobic object/situation. In the current study, 165 children (7-16 years; 62% male) received either One Session Treatment or Educational Support Therapy for their SP. The children identified their feared belief and rated "how bad" it was, "how likely" it was to occur, and their ability to cope if it did occur. All of these ratings were reduced from pre-treatment to 6-month follow-up, across both treatment conditions. However, ratings of "how bad" and "how likely" reduced to a significantly greater degree for children who received OST. Greater change in each of the three beliefs predicted lower clinician severity ratings (CSRs) at post-treatment and 6-month follow-up. Additionally, changes in "how bad" and "how likely" the children rated their beliefs, and their reported ability to cope, partially mediated the relationship between treatment and post-treatment and follow-up CSRs. Overall, these findings suggest that although both treatment conditions produced changes in harm beliefs and coping efficacy, OST elicited greater changes and these changes may be important mechanisms in reduction of SP clinical severity.

Creating state of the art, next-generation Virtual Reality exposure therapies for anxiety disorders using consumer hardware platforms: design considerations and future directions.

Decades of research and more than 20 randomized controlled trials show that Virtual Reality exposure therapy (VRET) is effective in reducing fear and anxiety. Unfortunately, few providers or patients have had access to the costly and technical equipment previously required. Recent technological advances in the form of consumer Virtual Reality (VR) systems (e.g. Oculus Rift and Samsung Gear), however, now make widespread use of VRET in clinical settings and as self-help applications possible. In this literature review, we detail the current state of VR technology and discuss important therapeutic considerations in designing self-help and clinician-led VRETs, such as platform choice, exposure progression design, inhibitory learning strategies, stimuli tailoring, gamification, virtual social learning and more. We illustrate how these therapeutic components can be incorporated and utilized in VRET applications, taking full advantage of the unique capabilities of virtual environments, and showcase some of these features by describing the development of a consumer-ready, gamified self-help VRET application for low-cost commercially available VR hardware. We also raise and discuss challenges in the planning, development, evaluation, and dissemination of VRET applications, including the need for more high-quality research. We conclude by discussing how new technology (e.g. eye-tracking) can be incorporated into future VRETs and how widespread use of VRET self-help applications will enable collection of naturalistic "Big Data" that promises to inform learning theory and behavioral therapy in general.

Harm beliefs and coping expectancies in youth with specific phobias.

Catastrophic beliefs and lowered coping expectancies are often present in individuals with specific phobias (SPs). The current study examined these beliefs and expectancies in 251 youth who received One Session Treatment for one of the three most common types of SP in youth (animals, natural environment, and situational). We compared the children's subjective beliefs to objective ratings of the likelihood of occurrence and the dangerousness of the feared events. Results revealed pre-treatment differences in the youths' beliefs across phobia types and age. Specifically, children with animal phobias rated their beliefs as more likely to occur than did children with environmental and situational phobias. In addition, older children rated their beliefs as more dangerous than younger children. However, regardless of phobia type or child age, the beliefs improved following treatment. Changes in catastrophic beliefs and coping expectancies were related to changes in clinical severity following treatment but not 6-months following treatment. Moreover, at pre-treatment, children viewed their beliefs as significantly more catastrophic and likely to occur than did independent coders of these beliefs; however, these differences were no longer evident following treatment. Clinical implications are discussed, highlighting how changes in beliefs and expectancies might be associated with treatment outcomes.

Factor solutions of the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS) in a Swedish population.

Culturally validated rating scales for social anxiety disorder (SAD) are of significant importance when screening for the disorder, as well as for evaluating treatment efficacy. This study examined construct validity and additional psychometric properties of two commonly used scales, the Social Phobia Scale and the Social Interaction Anxiety Scale, in a clinical SAD population (n = 180) and in a normal population (n = 614) in Sweden. Confirmatory factor analyses of previously reported factor solutions were tested but did not reveal acceptable fit. Exploratory factor analyses (EFA) of the joint structure of the scales in the total population yielded a two-factor model (performance anxiety and social interaction anxiety), whereas EFA in the clinical sample revealed a three-factor solution, a social interaction anxiety factor and two performance anxiety factors. The SPS and SIAS showed good to excellent internal consistency, and discriminated well between patients with SAD and a normal population sample. Both scales showed good convergent validity with an established measure of SAD, whereas the discriminant validity of symptoms of social anxiety and depression could not be confirmed. The optimal cut-off score for SPS and SIAS were 18 and 22 points, respectively. It is concluded that the factor structure and the additional psychometric properties of SPS and SIAS support the use of the scales for assessment in a Swedish population.

Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial.

BACKGROUND: Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist. METHODS/DESIGN: Participants with specific phobia to spiders (N = 100) will be recruited from the general public, screened, and randomized to either VR exposure therapy (n = 50) or traditional OST (n = 50). A behavioral approach test using in vivo spiders will serve as the primary outcome measure. Secondary outcome measures will include spider phobia questionnaires and self-reported anxiety, depression, and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1, 12, and 52 weeks after treatment. DISCUSSION: VR exposure therapy has previously been evaluated as a treatment for specific phobias, but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices is being released that are advancing existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable for taking advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation. This study compares a market-ready, gamified VR spider phobia exposure application, delivered using consumer VR hardware, with the current gold standard treatment. Implications are discussed. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02533310. Registered on 25 August 2015.

Behavioral treatment of social phobia in youth: does parent education training improve the outcome?

Social phobia is one of the most common anxiety disorders in children and adolescents, and it runs a fairly chronic course if left untreated. The goals of the present study were to evaluate if a parent education course would improve the outcome for children with a primary diagnosis of social phobia and if comorbidity at the start of treatment would impair the outcome of the social phobia. A total of 55 children, 8-14 years old, were randomly assigned to one of three conditions: 1) Child is treated, 2) Child is treated and parent participates in the course, or 3) A wait-list for 12 weeks. The treatment consisted of individual exposure and group social skills training based on the Beidel, Turner, and Morris (2000) SET-C. Children and parents were assessed pre-, post-, and at one year follow-up with independent assessor ratings and self-report measures. Results showed that there was no significant difference between the two active treatments and both were better than the wait-list. The treatment effects were maintained or furthered at the follow-up. Comorbidity did not lead to worse outcome of social phobia. Comorbid disorders improved significantly from pre-to post-treatment and from post-to follow-up assessment without being targeted in therapy.

Cognitive sex differences are not magnified as a function of age, sex hormones, or puberty development during early adolescence.

Are cognitive sex differences magnified by individual differences in age, sex hormones, or puberty development? Cross-sectional samples of 12- to 14-year-old boys (n = 85) and girls (n = 102) completed tasks assessing episodic memory, face recognition, verbal fluency, and mental rotations. Blood estradiol, free testosterone, and self-rated puberty scores were obtained. Sex differences were found on all cognitive measures. However, the magnitude was not larger for older children, hormones and cognitive performance were not associated, and early maturers did not perform better than late maturers. Thus, cognitive sex differences were not associated with age, levels of sex hormones, or puberty development.

Comorbidity in youth with specific phobias: Impact of comorbidity on treatment outcome and the impact of treatment on comorbid disorders.

The purpose of the present study was twofold. In an analysis of data from an existing randomized control trial of brief cognitive behavioral treatment on specific phobias (One-Session Treatment, OST; Ollendick et al., 2009), we examined 1) the effect of comorbid specific phobias and other anxiety disorders on treatment outcomes, and 2) the effect of treatment of the specific phobia on these co-occurring disorders. These relations were explored in 100 youth presenting with animal, natural environment, situational, and "other" types of phobia. Youth were reliably diagnosed with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman & Albano, 1996). Clinician severity ratings at post-treatment and 6-month follow-up were examined as were parent and child treatment outcome satisfaction measures. Results indicated that the presence of comorbid phobias or anxiety disorders did not affect treatment outcomes; moreover, treatment of the targeted specific phobias led to significant reductions in the clinical severity of other co-occurring specific phobias and related anxiety disorders. These findings speak to the generalization of the effects of this time-limited treatment approach. Implications for treatment of principal and comorbid disorders are discussed, and possible mechanisms for these effects are commented upon.

One-session treatment of specific phobias in youth: a randomized clinical trial in the United States and Sweden.

One hundred and ninety-six youth, ages 7-16, who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for various specific phobias were randomized to a one-session exposure treatment, education support treatment, or a wait list control group. After the waiting period, the wait list participants were offered treatment and, if interested, rerandomized to 1 of the 2 active treatments. The phobias were assessed with semistructured diagnostic interviews, clinician severity ratings, and behavioral avoidance tests, whereas fears, general anxiety, depression, and behavior problems were assessed with self- and parent report measures. Assessments were completed pretreatment, posttreatment, and at 6 months following treatment. Results showed that both treatment conditions were superior to the wait list control condition and that 1-session exposure treatment was superior to education support treatment on clinician ratings of phobic severity, percentage of participants who were diagnosis free, child ratings of anxiety during the behavioral avoidance test, and treatment satisfaction as reported by the youth and their parents. There were no differences on self-report measures. Treatment effects were maintained at follow-up. Implications of these findings are discussed.