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-vivotransitioning components.

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

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

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

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

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

Virtual reality 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.

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).

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.

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.

Objectives: To survey attitudes towards, knowledge of and familiarity with Virtual Reality (VR) technology and VR exposure therapy among practicing cognitive behavior therapists, after the recent release of consumer VR platforms, with the aim of identifying potential human barriers to implementing this technology and therapeutic method in regular care. Participants: 185 practicing cognitive behavior therapists attending a conference.Measures: Self-rated likelihood of future use of VR in a clinical setting, applicability of VR to treating specific mental disorders, as well as ratings of different positive and negative aspects of VR exposure therapy – all assessed using a standardized survey.Results: Very few respondents reported having used VR clinically. 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, a high financial cost was no longer a 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.Conclusions: We conclude that therapist’s attitudes towards VRET appear to have evolved in recent years, coinciding with the release of consumer VR platforms, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.

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.

BACKGROUND: Virtual Reality exposure therapy (VRET) is an efficacious treatment of phobias and allows for automatic data collection during standardized yet naturalistic exposure paradigms, yet next to no research has explored the clinical potential of such data. GOALS: To explore the predictive potential of using gaze proxy data collected during VRET to predict treatment outcomes. METHODS: Gaze focus proxy data from n=29 participants undergoing gamified, self-help VRET for spider phobia were extracted, compiled, and modeled. The VRET session featured eight levels with increasingly frightening spiders, each with an approach task requiring participants to keep looking at the phobic object for a specified time. Relative spider gaze focus was defined as time spent looking at each spider at each level (derived from head movement and overlap) divided by total time in level. High- versus low-improvement was defined using median-split on subsequent improvements on an in-vivo behavioral approach task. RESULTS: During the final three levels of the exposure session, relative spider focus time was initially lower among high-improvers (p=.039) and the decrease was lower over levels than among the low-improvers (p=.029). This suggests that non-improvers experienced a fear level mismatch during the final exposure phase. There were no differences in gaze patterns during other phases of the session. CONCLUSIONS: These preliminary results suggest that gaze proxy data automatically collected during VRET, even when rudimentary, can be used to predict treatment outcomes, and may thus be used to automatically personalize the exposure design of VRET self-help applications during actual use, to increase efficacy.

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.