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Screenshots from the virtual reality exposure therapy (VRET) app. (A) Example of a spider featured in an early, gaze-based level. (B) Example of a gamified exposure task (preventing the spider from being washed off the wall by moving the umbrella using gaze focused on the moving spider). (C) Example of realistic spider in a subsequent, boss-type level. (D) Example of a realistic spider used in higher levels.
Source publication
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 th...
Context in source publication
Context 1
... the beginning and end of each sublevel, the user was prompted to rate subjective units of distress using a 0-100 scale. See Figure 2 for representative app screenshots. In addition to the virtual therapist, a voiceover spider expert was also included who presented facts about spiders (eg, descriptions of different spider species along with their biology and role in the ecosystem). ...
Similar publications
Many children around the globe suffer from spider phobia. Virtual reality exposure therapy is an effective phobia treatment, but so far predominantly tailored for adults. A gamified approach utilizing gaze interaction would allow for a more child-friendly and engaging experience, and provide the possibility to foster working mechanisms of exposure...
Citations
... The VR-STINAT was iteratively developed with the involvement of end-users (CBT therapists, psychiatrists, patients with depression, and healthy individuals), based on cognitive load theory -learning from worked example (33), and Mayer's cognitive theory of multimedia learning (34). Gamification elements such as feedback and achievements were incorporated to enhance enjoyment, and engagement (35). ...
Background
Cognitive restructuring (CR) is an evidence-based psychological technique for depression. However, face-to-face CR is not easily accessible. Digital CR interventions often overlook the difficulties individuals experiencing depression encounter in identifying their negative automatic thoughts (NAT), leading to suboptimal outcomes. Virtual Reality (VR) has potential advantages in assisting the identification of NAT in CR intervention.
Objective
The aim of this preliminary feasibility study is to assess the efficacy, acceptability and safety of a VR-based self-guided training on the identification of negative automatic thoughts (VR-STINAT) for depression, as well as to evaluate the user experience.
Methods
In a mixed methods study, 20 healthy participants underwent VR-STINAT and completed a semi-structured interview, followed by post-training homework. The VR-STINAT includes three modules: psychological education, NAT identification training in VR scenarios, and practice in personally experienced scenarios. Effectiveness was measured via Thought Record Skills Assessment (TRSA) of homework and Cognitive Therapy Awareness Scale (CTAS). Acceptability was measured using an adapted Technology Acceptance Model and duration of training. Safety was measured via Simulator Sickness Questionnaire and self-reported negative emotions. Qualitative material was analyzed using thematic analysis.
Results
The VR-STINAT was acceptable, with an average rating of 80.68%. The accuracy of NAT identification in TRSA reached 84.55%, and CTAS correctness reached 76.67%. The majority of participants experienced minimal or no side effects, although a few (10%, 2/20) reported relatively severe fatigue and craniofacial pain. Thematic analysis reviewed four themes: effectiveness, acceptability, advantages of VR, difficulties in use and suggestions for improvement. Most participants indicated that they’ve learned how to identify their NAT through VR-STINAT (85%, 17/20), which was engaging (90%, 18/20) and easy to use (60%, 12/20).
Conclusion
This study provides preliminary evidence that self-guided training for the identification of negative automatic thoughts related to depression using VR is feasible. Future studies are needed to compare the efficacy of VR with other intervention modalities in people with depression.
... Several VRET systems for the treatment of spider phobia have been described in the literature over time [19][20][21][22], highlighting advantages such as continuous exposure of individuals to the object of their fear [23] and better control of anxiety due to the absence of a real threat [24]. In some cases, participants showed a reduction in both subjective anxiety and spider cognitions in a more comfortable way than in vivo exposure therapy (IVET). ...
... Among participants with scorpion phobia, real findings are expected [23]. This study could have benefited from initially using an adaptation of the fear spider questionnaire, and by using the specialized psychological diagnosis, it could avoid using self-reported fear of scorpions [74]. ...
In this study, we present a framework to develop and evaluate a virtual reality exposure therapy system with biofeedback toward scorpion phobia treatment. The system is developed based on the methodology for the development of virtual reality educational environments; usability is evaluated with the System Usability Scale (SUS), the affects are measured with the Positive and Negative Affect Schedule (PANAS), and the biofeedback heart rate is measured in real time using a wearable device and the HypeRate app. A descriptive study was conducted with a non-probabilistic convenience sample of undergraduate students. The non-clinical sample consisted of 51 participants (11 women and 40 men) (mean = 20.75, SD = 2.42 years). The system usability score was 75.49, higher than the average of 68. For positive affects, the average value of the overall sample was 28.18, while for negative affects it was 13.67. The results of this preliminary study, while not determining that the system could currently be applied in clinical settings, demonstrate however that the system can initially be considered as a pre-feasibility study, and if the limitations of the unbalanced non-clinical sample are addressed, it could be used in the future for this purpose. The main contribution is the proposed framework to integrate usability and affects evaluation, as well as biofeedback in a VRET system toward scorpion phobia treatment.
... This process requires both quantitative measures of usefulness and qualitative measures to gauge factors that may not be covered by any one combination of preexisting questionnaires. Few studies have addressed the clinical considerations of using VR exposure, particularly those that include qualitative feedback from the patients being treated [28,29]. While studies have been made on the efficacy of VR exposure in the treatment of SAD, few studies have applied 360° environments [28,[30][31][32]. ...
Background
Social anxiety disorder (SAD) is a long-term and overwhelming fear of social situations that can affect work, school, and other daily activities. Although cognitive behavioral therapy is effective, few seek treatment, and many who do start often drop out. This may be due to the component of exposure inherent to cognitive behavioral therapy, where the patient confronts feared stimuli outside the therapist’s office, which they otherwise try to avoid. As an alternative, research has explored the effectiveness of virtual reality (VR)–based exposure therapy with promising results. However, few studies have investigated the feasibility of VR tools using mixed methodologies before assessing their efficacy.
Objective
This study aims to assess the usability, feasibility, and presence of four 360° virtual environments and whether these were able to evoke anxiety in patients with SAD.
Methods
A total of 10 adult participants with SAD and 10 healthy controls were recruited for 1 experimental session (age range 21-32 y; 12/20, 60% male participants). Questionnaire and interview data were collected and analyzed. A mixed methods triangulation design was applied to analyze and compare the data.
Results
Participants with SAD experienced increased anxiety when exposed to VR, and environments were considered relevant and useful as an exposure tool. Participants with SAD reported significantly higher average anxiety levels (P=.01) and peak anxiety levels (P=.01) compared with controls during exposure; however, significant differences in anxiety when accounting for baseline anxiety levels were only found in 2 of 4 environments (P=.01, P=.01, P=.07, and P=.06). While presence scores were acceptable in both groups, participants with SAD scored significantly lower than controls. Qualitative analyses highlight this finding within the SAD group, where some participants experienced presence reduction due to being observed while in VR and in situations with reduced interaction in VR.
Conclusions
VR exposure with 360° videos seems to be useful as a first step of exposure therapy for patients with SAD. Future exploration in the clinical application of VR-based exposure for SAD, as well as means of increasing presence within the virtual environments, may be useful.
... The design of such systems must consider several aspects. For starters, the chosen VRET platform should be readily accessible to the cohort and relevant to current consumer hardware; according to Lindner, utilizing consumer hardware is readily available to patients and designed to improve their access and compliance [151,152]. The timeline of exposure therapy should be structured programmatically to maintain a graded confrontational experience that can be adjusted according to patient progress. ...
Background: Specific phobias impact over 400 million people worldwide. Digitalizing mental health could alleviate the burden. Still, although the corporate-driven Metaverse is expanding rapidly, there needs to be more momentum in harnessing virtual reality exposure therapy uptake. Objective: This study aims to conceptualize, develop, and deploy a free Virtual Reality Exposure Therapy (VRET) application specifically designed for treating acrophobia and claustrophobia. This pilot study, which holds the promise of a future where mental health is more accessible and effective, explores the feasibility of leveraging transdisciplinary collaboration among specialists to create a safe, accessible, and effective VRET solution. Methods: We conducted a Delphi heuristic approach involving bioethicists, neuroscientists, and tech developers. Second, we reviewed the existing psychological theories and therapeutic strategies for addressing phobias in VR. Third, we conceptualized a thematic analysis-derived framework for a safe, adaptive-gamified free exposure to virtual reality acrophobia and claustrophobia (SAFEvR ACT). Finally, we provide an overview of the iterative improvements made during 12 workshops and 76 weekly briefings on developmental implementations. Results: We developed the SAFEvR ACT into a proof-of-concept application freely deployed on the MentalVerse app platform. Our safety-focused approach can benefit from prevalidation perspectives within future randomized control trials. Conclusions: The resulting application derived from the SAFEvR ACT framework represents a blueprint to counter the current lack of iVR mental health uptake by offering a free VRET alternative. Future research should aim towards developing similar free platforms to lessen mental health burdens and gather quantitative data. We conclude with a call to action to researchers to fine-tune our current approach and take a stand for free digital mental health within MentalVeRse.app.
... The power and benefits of VR are particularly prominent in the field of therapy. For example, VR can be used in psychology to treat fear of heights (Abdullah and Shaikh, 2018;Bălan et al., 2020), of spiders Hildebrandt et al. (2016); Miloff et al. (2016); Lindner et al. (2020), of speaking in front of an audience (Barreda-Ángeles et al., 2020;Glémarec et al., 2022), or of disorders of body perception by leveraging personalized photorealistic avatars (Wolf et al., 2021;. It is also used to treat neurological disorders, for example, gait impairments as a result of Parkinson's disease or strokes (Hamzeheinejad et al., 2019;Kern et al., 2019), as well as in orthopedics for the physical recovery after surgery (Gianola et al., 2020;Bartl et al., 2022;Gazendam et al., 2022). ...
Cybersickness is still a prominent risk factor potentially affecting the usability of virtual reality applications. Automated real-time detection of cybersickness promises to support a better general understanding of the phenomena and to avoid and counteract its occurrence. It could be used to facilitate application optimization, that is, to systematically link potential causes (technical development and conceptual design decisions) to cybersickness in closed-loop user-centered development cycles. In addition, it could be used to monitor, warn, and hence safeguard users against any onset of cybersickness during a virtual reality exposure, especially in healthcare applications. This article presents a novel real-time-capable cybersickness detection method by deep learning of augmented physiological data. In contrast to related preliminary work, we are exploring a unique combination of mid-immersion ground truth elicitation, an unobtrusive wireless setup, and moderate training performance requirements. We developed a proof-of-concept prototype to compare (combinations of) convolutional neural networks, long short-term memory, and support vector machines with respect to detection performance. We demonstrate that the use of a conditional generative adversarial network-based data augmentation technique increases detection performance significantly and showcase the feasibility of real-time cybersickness detection in a genuine application example. Finally, a comprehensive performance analysis demonstrates that a four-layered bidirectional long short-term memory network with the developed data augmentation delivers superior performance (91.1% F1-score) for real-time cybersickness detection. To encourage replicability and reuse in future cybersickness studies, we released the code and the dataset as publicly available.
... Therefore, it would be interesting to investigate more closely how the effectiveness of different XR modalities differs from each other in the same study. By way of illustration, recent studies have indicated that VRET is effective in the treatment of specific phobias [53][54][55][56] and the mixed-method study by Mayer et al. included in this review found improvements when employing VR exposure for patients with claustrophobia [46]. Giglioli et al.'s systematic review [26] as well as this present systematic review identified AR as a useful tool for specific phobia treatment. ...
(1) Background: Anxiety disorders are among the most common psychiatric conditions and have a rising prevalence. Patients with anxiety disorders can, however, be deterred from seeking treatment due to associated stigmas and medication side effects. Evidence indicates that promising digital health solutions to address those concerns reside in the growing field of extended reality (XR). The limited literature synthesis from the perspectives of patients and healthcare professionals (HCPs) regarding the experiences and effectiveness of XR-based anxiety disorder therapies motivated the undertaking of this systematic review. (2) Methods: A systematic search of the literature was conducted according to the PRISMA 2020 guidelines on the following databases: CINAHL, APA PsycNet and PubMed. The search was completed on 23 January 2024 with no restriction on the time of publication. Studies were screened based on a predetermined selection criteria relevant to the research aims. (3) Results: Five studies fulfilled the inclusion requirements. The majority investigated the use of XR tools for individual therapy and indicated that they can be as effective for patients as traditional methods and can aid in HCPs’ therapeutic tasks. (4) Conclusions: XR-based anxiety disorder therapies are generally perceived as immersive and with minimal side effects by patients, while HCPs mostly consider XR tools as practical and assistive. However, refinements with the XR setup could further improve the experience. Such modalities represent potent drug-free alternatives or supplements to traditional therapy and could be considered for remote, individual care. The findings’ generalisability requires further research into more conditions within the anxiety disorder group, as well as larger sample sizes.
... However, VR alone may not address all exposure therapy disadvantages, and enhancing the attractiveness of VRETs is crucial for treatment success. Researchers have explored the potential of gamified VRETs in treating phobias [2,12,13]. Gamification, a strategy derived from video game-based approaches, has proven successful in achieving serious objectives across various fields, including the workplace [14], education [15], marketing [16], mental health [17][18][19], learning disabilities [20,21], and lazy eye treatment [22]. The primary inherent feature of digital games is their high-level motivational potential [23]. ...
... Attractiveness is beneficial for overcoming people's reluctance to seek treatment, broadening the reach of gamified interventions [18]. The engaging nature of gamification enhances users' experiences, as players are driven to win, explore stories, and ultimately reduce attrition rates [12,18,24]. The effectiveness aspect offers opportunities for achieving serious objectives such as behavior changes [18]. ...
... To our knowledge, no study has simultaneously used BF, VR, and gamification for the treatment of animal phobia. However, various studies have used VR and game concepts to address specific animal phobias, for example, spider phobia [12,32] and snake phobia [47]. Similar to these studies, our tool successfully induced anxiety and led to a reduction in fear levels, avoidance behaviors, and catastrophic thoughts related to phobias. ...
Background
To the best of our knowledge, no specialized research has been conducted to address ailurophobia (fear of cats) in Iran or globally. This has driven our project, along with the prevalence of ailurophobia and the absence of a gamified virtual reality exposure therapy (VRET) that incorporates affordable and easily accessible biofeedback (BF) tools. We hypothesize that a gamified VRET augmented with BF will yield more positive effects than a similar device lacking BF.
Objective
This study primarily focuses on the development and preliminary evaluation of a smartphone-gamified VRET integrated with BF, targeting animal phobia, with a specific case study on ailurophobia. The secondary objectives are using affordable and readily available BF found in devices such as smart bands and smartwatches and creating a mobile virtual reality gamified app to improve patients’ adherence to treatments while simultaneously enhancing the app’s accessibility, scalability, and outreach.
Methods
Evaluations encompassed 3 methods. First, we identified the tool’s potential positive effects on phobia interventions, exploring 4 effects: intrinsic motivation, simulation of fearful situations, management of stressful circumstances without therapists’ presence and mitigation of catastrophic thoughts, and preliminary effects on ailurophobia treatment. Participants were divided into BF and non-BF groups. Second, we gathered user preferences and opinions about the treatment. Third, we conducted heuristic evaluations using 44 heuristics from existing system usability scales assessing user interfaces, virtual reality platforms, and video games’ playability. To interpret the data, mean scores; ANOVA, single factor; and ANOVA, 2-factor with replication were used. A total of 29 individuals were identified, of which 10 met the eligibility criteria or were accessible.
Results
The smartphone-gamified VRET augmented with BF exhibited better results on the identified effects compared with the non-BF version and contributed to normalizing encounters with cats. Moreover, 41 of the 44 heuristics achieved a percentage above 62%, indicating its potential as a therapeutic product and its ability to enhance patient adherence to treatments. Patient preferences on the treatment and its strengths and weaknesses were provided for further improvement.
Conclusions
The tool has the potential to evolve into a comprehensive solution by incorporating various types of cats and their behaviors, simulating environments in which they are commonly found, and enhancing its appeal through an increased sense of adventure without inducing unrealistic fears. By adapting fear elements, the game can be tailored to treat various animal phobias. Phobia-focused games should avoid action and combat scenarios to prevent reinforcement of fear responses. After rigorous evaluation, further exploration is required to provide remote use beyond clinical settings.
... 10 It is possible that some of these negative experiences may be due to personal preferences, which might be avoidable by offering the user a variety of environments. 46 Patients admitted to psychiatric inpatient care experience low satisfaction with their influence on the choice of treatment and medication. 47 Non-pharmacological methods such as physical calm rooms have safety issues; therefore, healthcare workers may become risk averse and initially worried about letting patients stay on their own in calm rooms. ...
Objective
Calm rooms have been developed and implemented in psychiatric inpatient care settings to offer patients a dedicated space for relaxation in a convenient and safe environment. Recent technology developments have enabled virtual reality (VR) equivalents of calm rooms that can be feasibly deployed in psychiatric care settings. While research has shown VR environments to be efficacious in inducing relaxation, little is known how these virtual calm rooms are perceived by patients. The aim of this study was to elucidate patient experiences of using a VR calm room in a psychiatric inpatient setting.
Design
Qualitative interview study. Semi-structured interviews were analysed using qualitive inductive content analysis, which focuses on the interpretation of texts for making replicable and valid inferences.
Setting
Swedish hospital psychiatric inpatient care setting with a wireless, three degrees-of-freedom VR head-mounted display running a calm room application simulating nature environment.
Participants
20 adult patients (12 women) with bipolar disorder (n=18) or unipolar depression (n=2).
Results
Participants experienced the use of the VR calm room as having a positive impact on them, inducing awareness, calmness and well-being. They were thankful to be offered a non-pharmacological alternative for anxiety relief. Participants also expressed that they had some concerns about how they would react emotionally before using the VR device. However, after use, they highlighted that their overall experience was positive. They also expressed that they could see potential for further development of VR technology in psychiatric care.
Conclusions
VR technology has the potential to solve pressing logistic issues in offering calm rooms in psychiatric inpatient care. VR calm rooms appear to be appreciated by psychiatric inpatients, who value their accessibility, convenience and variety of modalities offered. Participants perceived an increase in their well-being after use.
... In Lindner, Rozental et al. [85], various challenges are present. One challenge involves helping a spider by preventing it from being washed away from a wall by rain. ...
... However, even with 3DOF, a moderate sense of spatial immersion can still be achieved, depending on the believability of the VRE. Certain studies presented visually coherent and well-crafted scenarios in terms of aesthetics and detail, even though locomotion was not allowed [12,85,86,88]. These studies also presented variations in the realism of spiders, ranging from cartoon-like to more realistic appearances, while consistently maintaining visual and logical coherence. ...
... The use of time as a game mechanic is observed in 6 studies with game-like characteristics [12,[84][85][86][87][88]. In one of the studies, temporal immersion is generated via the "kill or be killed" mechanic [87]. ...
In the context of therapeutic exposure to phobias, virtual reality (VR) offers innovative ways to motivate patients to confront their fears, an opportunity not feasible in traditional non-digital settings. This systematic literature review explores the utilization of narratives and digital games in this context, focusing on identifying the most common ludic and narrative immersion features employed in studies dedicated to animal phobias. Via a search on the Scopus and Web of Science scientific databases, twenty-nine studies were selected for in-depth analysis. The primary objective was to evaluate the presence of ludic and narrative elements in each study to understand their immersive potential across both dimensions. Findings suggest that ludic elements are more commonly used than narrative elements, which are notably scarce, and the exploration of the emotional dimension of narrative immersion is limited. An essential takeaway is that features fostering narrative immersion are invariably linked to the ludic dimension, often functioning as secondary components. This study provides a guiding framework for developing therapeutic interventions in VR, emphasizing the incorporation of ludic and narrative aspects. Additionally, it identifies untapped research opportunities, particularly the integration of autonomous narratives that are less reliant on ludic elements.
... Gamified VR Exposure Therapy (VRET) does not only provide the possibility to offer an engaging experience for children especially, but also to implement playful mechanisms fostering working mechanisms of exposure therapy. There are already approaches integrating playful elements into VRET for adults with spider phobia (Go et al., 2020;Lindner et al., 2020;McMaster, 2020;Miloff et al., 2016). However, none of those is specifically developed for children. ...
Many children around the globe suffer from spider phobia. Virtual reality exposure therapy is an effective phobia treatment, but so far predominantly tailored for adults. A gamified approach utilizing gaze interaction would allow for a more child-friendly and engaging experience, and provide the possibility to foster working mechanisms of exposure therapy. We developed an application in which children make spiders change in positively connoted ways (e.g., make them dance or shrink) if sufficient visual attention towards them is captured via eye tracking. Thereby, motivation for and positive affects during exposure towards spiders are aspired. In this pilot study on 21 children without (n = 11) and with fear of spiders (n = 10), we examined positive and negative affect during exposure to a virtual spider and to different gaze-related transformations of the spider within a quasi-experimental design. Within a one-group design, we additionally examined fear of spiders in spider fearful children before and one week after the intervention. We found that significantly more positive than negative affect was induced by the spiders' transformations in children without and with fear of spiders. Fear of spiders was furthermore significantly reduced in spider-fearful children, showing large effect sizes (d > .80). Findings indicate eligibility for future clinical use and evaluation in children with spider phobia.
