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Virtual reality exposure therapy for social anxiety disorder: a systematic review and meta-analysis

Published online by Cambridge University Press:  19 October 2020

Toshiro Horigome ,
Shunya Kurokawa ,
Kyosuke Sawada ,
Shun Kudo ,
Kiko Shiga ,
Masaru Mimura  and
Taishiro Kishimoto Open the ORCID record for Taishiro Kishimoto [Opens in a new window]
Toshiro Horigome*
Affiliation:
Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
Shunya Kurokawa
Affiliation:
Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
Kyosuke Sawada
Affiliation:
Asaka Hospital, Fukushima, Japan
Shun Kudo
Affiliation:
Department of Neuropsychiatry, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
Kiko Shiga
Affiliation:
Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
Masaru Mimura
Affiliation:
Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
Taishiro Kishimoto
Affiliation:
Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan Psychiatry at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
*
Author for correspondence: Taishiro Kishimoto, E-mail: taishiro-k@mti.biglobe.ne.jp
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Abstract

Background

Virtual reality exposure therapy (VRET) is currently being used to treat social anxiety disorder (SAD); however, VRET's magnitude of efficacy, duration of efficacy, and impact on treatment discontinuation are still unclear.

Methods

We conducted a meta-analysis of studies that investigated the efficacy of VRET for SAD. The search strategy and analysis method are registered at PROSPERO (#CRD42019121097). Inclusion criteria were: (1) studies that targeted patients with SAD or related phobias; (2) studies where VRET was conducted for at least three sessions; (3) studies that included at least 10 participants. The primary outcome was social anxiety evaluation score change. Hedges' g and its 95% confidence intervals were calculated using random-effect models. The secondary outcome was the risk ratio for treatment discontinuation.

Results

Twenty-two studies (n = 703) met the inclusion criteria and were analyzed. The efficacy of VRET for SAD was significant and continued over a long-term follow-up period: Hedges' g for effect size at post-intervention, −0.86 (−1.04 to −0.68); three months post-intervention, −1.03 (−1.35 to −0.72); 6 months post-intervention, −1.14 (−1.39 to −0.89); and 12 months post-intervention, −0.74 (−1.05 to −0.43). When compared to in vivo exposure, the efficacy of VRET was similar at post-intervention but became inferior at later follow-up points. Participant dropout rates showed no significant difference compared to in vivo exposure.

Conclusion

VRET is an acceptable treatment for SAD patients that has significant, long-lasting efficacy, although it is possible that during long-term follow-up, VRET efficacy lessens as compared to in vivo exposure.

Keywords

Dropout ratein vivo exposurelong-term efficacysocial anxiety disordervirtual reality exposure
Type
Review Article
Information
Psychological Medicine , Volume 50 , Issue 15 , November 2020 , pp. 2487 - 2497
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Copyright
Copyright © The Author(s) 2020. Published by Cambridge University Press

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References

Anderson, P. L., Edwards, S. M., & Goodnight, J. R. (2017). Virtual reality and exposure group therapy for social anxiety disorder: Results from a 4–6 year follow-up. Cognitive Therapy and Research, 41(2), 230–236.Google Scholar
Anderson, P. L., Price, M., Edwards, S. M., Obasaju, M. A., Schmertz, S. K., Zimand, E., & Calamaras, M. R. (2013). Virtual reality exposure therapy for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 81(5), 751.CrossRefGoogle ScholarPubMed
Anderson, P., Zimand, E., Schmertz, S. K., & Ferrer, M. (2007). Usability and utility of a computerized cognitive-behavioral self-help program for public speaking anxiety. Cognitive and Behavioral Practice, 14(2), 198–207.Google Scholar
Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, E., Forget, H., … Roucaut, F. X. (2017). Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: A three-arm randomised controlled trial. The British Journal of Psychiatry, 210(4), 276–283.CrossRefGoogle ScholarPubMed
Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., … Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36.Google ScholarPubMed
Chesham, R. K., Malouff, J. M., & Schutte, N. S. (2018). Meta-analysis of the efficacy of virtual reality exposure therapy for social anxiety. Behaviour Change, 35(3), 152–166.Google Scholar
Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of specific phobia in adults. Clinical Psychology Review, 27(3), 266–286.Google ScholarPubMed
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Heimberg, R. G., Liebowitz, M. R., Hope, D. A., & Schneier, F. R. (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press.Google Scholar
Denizci Nazligul, M., Yilmaz, M., Gulec, U., Yilmaz, A. E., Isler, V., O'Connor, R. V., … Clarke, P. (2019). An interactive 3d virtual environment to reduce the public speaking anxiety levels of novice software engineers. IET Software, 13(2), 152–158.CrossRefGoogle Scholar
Duval, S., & Tweedie, R. (2000). Trim and fill: A simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis. Biometrics, 56(2), 455–463.CrossRefGoogle ScholarPubMed
Egger, M., Smith, G. D., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634.CrossRefGoogle ScholarPubMed
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316.Google ScholarPubMed
Furukawa, T. A., Barbui, C., Cipriani, A., Brambilla, P., & Watanabe, N. (2006). Imputing missing standard deviations in meta-analyses can provide accurate results. Journal of Clinical Epidemiology, 59(1), 7–10.CrossRefGoogle ScholarPubMed
Garcia-Palacios, A., Botella, C., Hoffman, H., & Fabregat, S. (2007). Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. Cyberpsychology & Behavior, 10(5), 722–724.CrossRefGoogle ScholarPubMed
Gebara, C. M., Barros-Neto, T. P. D., Gertsenchtein, L., & Lotufo-Neto, F. (2016). Virtual reality exposure using three-dimensional images for the treatment of social phobia. Brazilian Journal of Psychiatry, 38(1), 24–29.CrossRefGoogle ScholarPubMed
Geraets, C. N., Veling, W., Witlox, M., Staring, A. B., Matthijssen, S. J., & Cath, D. (2019). Virtual reality-based cognitive behavioural therapy for patients with generalized social anxiety disorder: A pilot study. Behavioural and Cognitive Psychotherapy, 47(6), 745–750.Google ScholarPubMed
Grillon, H., Riquier, F., Herbelin, B., & Thalmann, D. (2006). Virtual reality as therapeutic tool in the confines of social anxiety disorder treatment. International Journal in Disability and Human Development, 5(3), 243–250.CrossRefGoogle Scholar
Harris, S. R., Kemmerling, R. L., & North, M. M. (2002). Brief virtual reality therapy for public speaking anxiety. Cyberpsychology & Behavior, 5(6), 543–550.CrossRefGoogle ScholarPubMed
Haug, T., Nordgreen, T., Öst, L. G., Tangen, T., Kvale, G., Hovland, O. J., … Havik, O. E. (2016). Working alliance and competence as predictors of outcome in cognitive behavioral therapy for social anxiety and panic disorder in adults. Behaviour Research and Therapy, 77, 40–51.CrossRefGoogle ScholarPubMed
Heimberg, R. G., & Becker, R. E. (2002). Cognitive-Behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York: Guilford Press.Google Scholar
Heimberg, R. G., Becker, R. E., Goldfinger, K., & Vermilyea, J. A. (1985). Treatment of social phobia by exposure, cognitive restructuring and homework assignments. Journal of Nervous and Mental Disease, 173(4), 236–245.CrossRefGoogle ScholarPubMed
Higgins, J. P., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Oxman, A. D., … Sterne, J. A. (2011). The Cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ, 343, d5928.CrossRefGoogle ScholarPubMed
Hofmann, S. G., & Otto, M. W. (2008). Cognitive-behavior therapy of social anxiety disorder: Evidence-based and disorder specific treatment techniques. New York: Routledge.Google Scholar
Kampmann, I. L., Emmelkamp, P. M., Hartanto, D., Brinkman, W. P., Zijlstra, B. J., & Morina, N. (2016a). Exposure to virtual social interactions in the treatment of social anxiety disorder: A randomized controlled trial. Behaviour Research and Therapy, 77, 147–156.CrossRefGoogle Scholar
Kampmann, I. L., Emmelkamp, P. M., & Morina, N. (2016b). Meta-analysis of technology-assisted interventions for social anxiety disorder. Journal of Anxiety Disorders, 42, 71–84.CrossRefGoogle Scholar
Keller, M. B. (2006). Social anxiety disorder clinical course and outcome: Review of Harvard/Brown Anxiety Research Project (HARP) findings. The Journal of Clinical Psychiatry, 67, 14–19.Google ScholarPubMed
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602.CrossRefGoogle ScholarPubMed
Kim, H. E., Hong, Y. J., Kim, M. K., Jung, Y. H., Kyeong, S., & Kim, J. J. (2017). Effectiveness of self-training using the mobile-based virtual reality program in patients with social anxiety disorder. Computers in Human Behavior, 73, 614–619.CrossRefGoogle Scholar
Klinger, E., Bouchard, S., Légeron, P., Roy, S., Lauer, F., Chemin, I., & Nugues, P. (2005). Virtual reality therapy versus cognitive behavior therapy for social phobia: A preliminary controlled study. Cyberpsychology & Behavior, 8(1), 76–88.CrossRefGoogle ScholarPubMed
Kovar, I. (2018). Virtual reality as support of cognitive behavioral therapy in social anxiety disorder. International Journal on Advanced Science, Engineering and Information Technology, 8(4), 1343–1349.CrossRefGoogle Scholar
Krijn, M., Emmelkamp, P. M., Biemond, R., de Ligny, C. D. W., Schuemie, M. J., & van der Mast, C. A. (2004). Treatment of acrophobia in virtual reality: The role of immersion and presence. Behaviour Research and Therapy, 42(2), 229–239.Google ScholarPubMed
Liebowitz, M. R. (1987). Social phobia. Modern Problems of Pharmacopsychiatry, 22, 141–173.CrossRefGoogle ScholarPubMed
Ling, Y., Nefs, H. T., Morina, N., Heynderickx, I., & Brinkman, W. P. (2014). A meta-analysis on the relationship between self-reported presence and anxiety in virtual reality exposure therapy for anxiety disorders. PLoS ONE, 9(5), e96144.CrossRefGoogle ScholarPubMed
Lister, H. A., Piercey, C. D., & Joordens, C. (2010). The effectiveness of 3-D video virtual reality for the treatment of fear of public speaking. Journal of CyberTherapy and Rehabilitation, 3(4), 375–381.Google Scholar
Meyerbröker, K., & Emmelkamp, P. M. (2010). Virtual reality exposure therapy in anxiety disorders: A systematic review of process-and-outcome studies. Depression and Anxiety, 27(10), 933–944.CrossRefGoogle ScholarPubMed
Mishkind, M. C., Norr, A. M., Katz, A. C., & Reger, G. M. (2017). Review of virtual reality treatment in psychiatry: Evidence versus current diffusion and use. Current Psychiatry Reports, 19(11), 80.CrossRefGoogle ScholarPubMed
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Annals of Internal Medicine, 151(4), 264–269.CrossRefGoogle ScholarPubMed
Morina, N., Brinkman, W. P., Hartanto, D., & Emmelkamp, P. M. (2014). Sense of presence and anxiety during virtual social interactions between a human and virtual humans. PeerJournal, 2, e337.Google ScholarPubMed
North, M. M., North, S. M., & Coble, J. R. (1998). Virtual reality therapy: An effective treatment for the fear of public speaking. International Journal of Virtual Reality, 3(3), 1–6.CrossRefGoogle Scholar
Phan, K. L., Fitzgerald, D. A., Nathan, P. J., & Tancer, M. E. (2006). Association between amygdala hyperactivity to harsh faces and severity of social anxiety in generalized social phobia. Biological Psychiatry, 59(5), 424–429.CrossRefGoogle ScholarPubMed
Ponniah, K., & Hollon, S. D. (2008). Empirically supported psychological interventions for social phobia in adults: A qualitative review of randomized controlled trials. Psychological Medicine, 38(1), 3–14.CrossRefGoogle ScholarPubMed
Pot-Kolder, R. M., Geraets, C. N., Veling, W., van Beilen, M., Staring, A. B., Gijsman, H. J., … van der Gaag, M. (2018). Virtual-reality-based cognitive behavioural therapy versus waiting list control for paranoid ideation and social avoidance in patients with psychotic disorders: A single-blind randomised controlled trial. The Lancet Psychiatry, 5(3), 217–226.CrossRefGoogle ScholarPubMed
Price, M., & Anderson, P. (2007). The role of presence in virtual reality exposure therapy. Journal of Anxiety Disorders, 21(5), 742–751.CrossRefGoogle ScholarPubMed
Price, M., Mehta, N., Tone, E. B., & Anderson, P. L. (2011). Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia. Journal of Anxiety Disorders, 25(6), 763–770.CrossRefGoogle Scholar
Qu, C., Brinkman, W. P., Ling, Y., Wiggers, P., & Heynderickx, I. (2014). Conversations with a virtual human: Synthetic emotions and human responses. Computers in Human Behavior, 34, 58–68.CrossRefGoogle Scholar
Robillard, G., Bouchard, S., Dumoulin, S., Guitard, T., & Klinger, E. (2010). Using virtual humans to alleviate social anxiety: Preliminary report from a comparative outcome study. Studies in Health Technology and Informatics, 154, 57–60.Google ScholarPubMed
Robillard, G., Bouchard, S., Fournier, T., & Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. CyberPsychology & Behavior, 6(5), 467–476.CrossRefGoogle ScholarPubMed
Roy, S., Klinger, E., Légeron, P., Lauer, F., Chemin, I., & Nugues, P. (2003). Definition of a VR-based protocol to treat social phobia. Cyberpsychology & Behavior, 6(4), 411–420.CrossRefGoogle ScholarPubMed
Safir, M. P., Wallach, H. S., & Bar-Zvi, M. (2012). Virtual reality cognitive-behavior therapy for public speaking anxiety: One-year follow-up. Behavior Modification, 36(2), 235–246.CrossRefGoogle ScholarPubMed
Scholing, A., & Emmelkamp, P. M. (1993). Exposure with and without cognitive therapy for generalized social phobia: Effects of individual and group treatment. Behaviour Research and Therapy, 31(7), 667–681.CrossRefGoogle ScholarPubMed
Sharf, J., Primavera, L. H., & Diener, M. J. (2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 47(4), 637.Google ScholarPubMed
Stein, M. B., Goldin, P. R., Sareen, J., Zorrilla, L. T. E., & Brown, G. G. (2002). Increased amygdala activation to angry and contemptuous faces in generalized social phobia. Archives of General Psychiatry, 59(11), 1027–1034.CrossRefGoogle ScholarPubMed
Straube, T., Mentzel, H. J., & Miltner, W. H. (2005). Common and distinct brain activation to threat and safety signals in social phobia. Neuropsychobiology, 52(3), 163–168.CrossRefGoogle ScholarPubMed
Stupar-Rutenfrans, S., Ketelaars, L. E., & van Gisbergen, M. S. (2017). Beat the fear of public speaking: Mobile 360 video virtual reality exposure training in home environment reduces public speaking anxiety. Cyberpsychology, Behavior, and Social Networking, 20(10), 624–633.CrossRefGoogle ScholarPubMed
van Dis, E. A., van Veen, S. C., Hagenaars, M. A., Batelaan, N. M., Bockting, C. L., van den Heuvel, R. M., … Engelhard, I. M. (2020). Long-term outcomes of cognitive behavioral therapy for anxiety-related disorders: A systematic review and meta-analysis. JAMA Psychiatry, 77(3), 265–273.CrossRefGoogle ScholarPubMed
Wallach, H. S., Safir, M. P., & Bar-Zvi, M. (2009). Virtual reality cognitive behavior therapy for public speaking anxiety: A randomized clinical trial. Behavior Modification, 33(3), 314–338.CrossRefGoogle ScholarPubMed
Wallach, H. S., Safir, M. P., & Bar-Zvi, M. (2011). Virtual reality exposure versus cognitive restructuring for treatment of public speaking anxiety: A pilot study. The Israel Journal of Psychiatry and Related Sciences, 48(2), 91–97.Google ScholarPubMed
Wechsler, T. F., Mühlberger, A., & Kümpers, F. (2019). Inferiority or even superiority of virtual reality exposure therapy in phobias? A systematic review and quantitative meta-analysis on randomized controlled trials specifically comparing the efficacy of virtual reality exposure to gold standard In vivo exposure in agoraphobia, specific phobia and social phobia. Frontiers in Psychology, 10, 1758.CrossRefGoogle ScholarPubMed
Yonkers, K. A., Dyck, I. R., & Keller, M. B. (2001). An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women. Psychiatric Services, 52(5), 637–643.CrossRefGoogle ScholarPubMed
Yuen, E. K., Goetter, E. M., Stasio, M. J., Ash, P., Mansour, B., McNally, E., … Watkins, J. (2019). A pilot of acceptance and commitment therapy for public speaking anxiety delivered with group videoconferencing and virtual reality exposure. Journal of Contextual Behavioral Science, 12, 47–54.CrossRefGoogle Scholar
Yuen, E. K., Herbert, J. D., Forman, E. M., Goetter, E. M., Comer, R., & Bradley, J. C. (2013). Treatment of social anxiety disorder using online virtual environments in second life. Behavior Therapy, 44(1), 51–61.CrossRefGoogle ScholarPubMed
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