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Virtual reality exposure therapy for spider phobia
Stockholm University, Faculty of Social Sciences, Department of Psychology.ORCID iD: 0000-0002-9125-8060
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Exposure therapy for specific phobia involving systematic and repeated presentation of an aversive stimuli or situation is a highly effective treatment for reducing fear and anxiety. Dissemination of this evidence-based treatment has proved challenging, however, and for over 20 years an alternative method of delivery using virtual reality technology has been explored with positive results. This thesis consists of three empirical studies examining a new generation of virtual reality exposure therapy (VRET) that by using automation, inexpensive hardware, and downloadable software aims to ensure that a highly efficacious exposure therapy can be made available to almost anyone. Study I evaluated the efficacy of this novel automated VRET for spider phobia as compared to gold-standard in-vivo one-session treatment (OST) using a randomized non-inferiority design. Results indicated that large effect size reductions in self-reported fear were evident at post-assessment in both treatments and the automated VRET was not inferior to OST at 3- and 12-months follow-up according to behavioral approach test, but was significantly worse until 12-month follow-up. No significant difference was noted on a questionnaire measuring negative effects of treatment. Study II conducted a process measure evaluation of patient alliance towards the virtual therapist used in the VRET treatment with a purpose-built questionnaire entitled the Virtual Therapist Alliance Scale (VTAS). Exploratory factor analysis indicated a sound two-factor solution composed of a primary task, goal and co-presence factor and a secondary bond and empathy factor. Psychometric evaluation of the VTAS suggested good internal consistency, and a moderate correlation between the VTAS and change in self-reported fear over follow-up. Study III assessed what individuals with a fear of spiders found most frightening about spiders. Both quantitative ratings and qualitative descriptions indicated that movement characteristics were reported as most fear provoking and to a lesser extent appearance characteristics, however factor analysis of scores in these categories did not find a correlation with participant baseline self-reported fear. Overall, the above findings suggest that VRET is a potential alternative to OST for the treatment of spider phobia also with respect to therapist alliance, and spider movement characteristics should be emphasized in future VRET treatments.

Place, publisher, year, edition, pages
Stockholm: Department of Psychology, Stockholm University , 2020. , p. 114
Keywords [en]
Specific phobia, spider phobia, spider, fear, anxiety, virtual reality, exposure therapy, automated, alliance, psychometric, factor analysis, virtual therapist, RCT, randomized, non-inferiority, clinical trial, dissemination, 12-month follow-up
National Category
Psychology
Research subject
Psychology
Identifiers
URN: urn:nbn:se:su:diva-180746ISBN: 978-91-7911-114-4 (print)ISBN: 978-91-7911-115-1 (electronic)OAI: oai:DiVA.org:su-180746DiVA, id: diva2:1422664
Public defence
2020-05-29, David Magnussonsalen (U31), Frescati Hagväg 8, Stockholm, 10:00 (English)
Opponent
Supervisors
Available from: 2020-05-06 Created: 2020-04-08 Last updated: 2020-05-22Bibliographically approved
List of papers
1. Automated virtual reality exposure therapy for spider phobia vs. in-vivo one-session treatment: A randomized non-inferiority trial
Open this publication in new window or tab >>Automated virtual reality exposure therapy for spider phobia vs. in-vivo one-session treatment: A randomized non-inferiority trial
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2019 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 118, p. 130-140Article in journal (Refereed) Published
Abstract [en]

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).

Keywords
exposure therapy, one-session treatment, virtual reality, spider phobia
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-168841 (URN)10.1016/j.brat.2019.04.004 (DOI)000471738600014 ()
Available from: 2019-05-10 Created: 2019-05-10 Last updated: 2020-04-08Bibliographically approved
2. Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation
Open this publication in new window or tab >>Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation
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2020 (English)In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 22, no 3, article id e16660Article in journal (Refereed) Published
Abstract [en]

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.

Keywords
alliance, virtual reality, exposure therapy, automated treatment, psychometric, embodiment, virtual therapist, virtual coach, avatar, usability, presence, empathy
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-180522 (URN)10.2196/16660 (DOI)000521234700001 ()32207690 (PubMedID)
Available from: 2020-03-31 Created: 2020-03-31 Last updated: 2020-04-29Bibliographically approved
3. What is so frightening about spiders? Self‐rated and self‐disclosed impact of different characteristics and associations with phobia symptoms
Open this publication in new window or tab >>What is so frightening about spiders? Self‐rated and self‐disclosed impact of different characteristics and associations with phobia symptoms
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2019 (English)In: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 60, no 1, p. 1-6Article in journal (Refereed) Published
Abstract [en]

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.

Keywords
spider, phobia, text mining, biolocomotion, virtual reality
National Category
Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:su:diva-164594 (URN)10.1111/sjop.12508 (DOI)000459578300001 ()
Available from: 2019-01-17 Created: 2019-01-17 Last updated: 2020-04-08Bibliographically approved

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