Need and Justification

for the oVRcome Smartphone App (VRET)

The oVRcome Smartphone App (VRET) was developed with the understanding that exposure therapy (ET) is the undisputed first line of treatment in treating anxiety disorders such as specific phobia and Social Anxiety Disorder (Kaczkurkin & Foa, 2015; Steinman et. al., 2016; Wechsler et. al., 2019).

 

As advised by Boeldt et. al. (2019), providing access to ET via virtual reality (VR) for psychologists gives patients opportunities to reap maximum benefits from psychotherapy sessions. This helps save patient, clinic, and therapist time. Additionally, it allows psychologists to manage their caseloads while focusing resources on individuals with clinical anxiety.

 

Although most phobias respond well to ET, due to the discomfort, inconvenience, and lack of motivation in seeking out fears to expose oneself to, in vivo ET is associated with high dropout rates and low treatment acceptance by patients (Choy, Fyer & Lipsitz, 2007; Garcia-Palacios et. al., 2007; Clemmensen et. al., 2020). Garcia-Palacios et. al. (2007), reported that 76% of people prefer VR over in vivo exposure, while the refusal rate for in vivo exposure is 9 times higher than the refusal rate for VR exposure. 

 

With VR however, users have increased control in how gradually they expose themselves to their fears, as well as when and where they undergo VRET. As a result of being more accessible, private, scaleable, practical, customizable, and more effective and tangible than imaginal exposure, VRET helps increase the number of people who seek therapy for phobias (Bouchard et. al., 2017; Boeldt et. al., 2019; Maples-Keller et. al., 2017; Clemmensen et. al., 2020; Garcia-Palacios et. al., 2007).

 

In terms of efficacy, VRET was found to be not significantly different to in vivo ET (Fodor et. al., 2018; Wechsler et. al., 2019; Morina et. al., 2015), while being more effective at maintaining results over a 6-month period than in vivo ET (Bouchard et. al., 2017).

 

oVRcome uses high definition 5.7k video to create the most immersive environment possible as the importance of feeling present in a VR environment is associated with significantly better outcomes, even without a therapist present (Donker et. al., 2020).

 

We attempt to claim efficacy and VR immersiveness through (1) findings from the oVRcome clinical trial (Ethics ref 21/STH/1) conducted by Dr. Cameron Lacey in conjunction with the University of Otago, New Zealand, and (2) through user and psychologist responses collected before, during, and after undergoing VR exposure through the oVRcome psychologists’ application.

 

Users will need to complete two psychometric questions before and after working through the programme. These questions relate to how they would rate the present state of their phobic symptoms on a Likert scale (Marks & Mathews, 1979), and how often they have felt anxious in the last 2 weeks due to their phobia (American Psychiatric Association, 2013). We will also collect users’ self-reports on how they feel at the end of every module for efficacy purposes using a Subjective Units of Distress Scale (SUDS) (Wolpe, 1969).

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For immersiveness, the feeling of presence is measured post-immersion using the first question from the ​​Gatineau Presence Questionnaire (Witmer & Singer, 1998). Users are asked to rate the realism of being in the VR environment out of 100 on a sliding scale after their first use of the VR headset. 

 

Below, is an annotated bibliography of the research studies which back the viability of the oVRcome project and efficacy of VR exposure therapy.

Boeldt, D., McMahon, E., McFaul, M., & Greenleaf, W. (2019). Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles. Frontiers in Psychiatry, 10, 773. https://doi.org/10.3389/fpsyt.2019.00773

Incorporating VR in therapy can increase the ease, acceptability, and effectiveness of treatment for anxiety. 

 

VR exposure therapy (VRET) permits individualized, gradual, controlled, immersive exposure that is easy for therapists to implement and often more acceptable to patients than in vivo or imaginal exposure. 

 

VR is a scalable tool that can augment access to and effectiveness of exposure therapy thus improving treatment of anxiety disorders.

Bouchard, S., Dumoulin, S., Robillard, G., Guitard, T., Klinger, É., Forget, H., Loranger, C., & Roucaut, F. X. (2017). Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: A three-arm randomised controlled trial. British Journal of Psychiatry, 210(4), 276–283. 

 

https://doi.org/10.1192/bjp.bp.116.184234

Conducting exposure in VR was more effective at post-treatment than in vivo. 

 

Improvements were maintained at the 6-month follow-up. VR was significantly more practical for therapists than in vivo exposure.

 

Using VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.

Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of specific phobia in adults. Clinical Psychology Review, 27(3), 266–286. https://doi.org/10.1016/j.cpr.2006.10.002

Comprehensive review of treatment studies in specific phobia. Acute and long-term efficacy studies of in vivo exposure, virtual reality, cognitive therapy and other treatments from 1960 to 2005.


Most phobias respond robustly to in vivo exposure, but it is associated with high dropout rates and low treatment acceptance.

Clemmensen, L., Bouchard, S., Rasmussen, J., Holmberg, T. T., Nielsen, J. H., Jepsen, J. R. M., & Lichtenstein, M. B. (2020). Study protocol: Exposure in virtual reality for social anxiety disorder - a randomized controlled superiority trial comparing cognitive behavioral therapy with virtual reality based exposure to cognitive behavioral therapy with in vivo exposure. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-2453-4

Cognitive Behavioral Therapy (CBT) is recommended for treatment, but a substantial part of individuals with SAD either do not seek treatment or drop-out. 

 

CBT with Virtual Reality (VR)-based exposure has several advantages compared to traditional exposure methods, mainly due to increased control of situational elements.

Donker, T., van Klaveren, C., Cornelisz, I., Kok, R. N., & van Gelder, J.-L. (2020). Analysis of Usage Data from a Self-Guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Controlled Trial. Journal of Clinical Medicine, 9(6), 1614. https://doi.org/10.3390/jcm9061614

Study examined user engagement with ZeroPhobia, a self-guided app-based virtual reality (VR) Cognitive Behavior Therapy for acrophobia symptoms using cardboard VR viewers.

 

Participants derive the most benefit when the practice time in the VR environment is 25.5 min irrespective of the amount of VR sessions. 

 

The importance of feeling present in the VR environment is stressed out as a higher reported presence was associated with better outcomes.


Self-guided VR acrophobia treatment is effective and leads to consistent reductions in self-reported anxiety both between levels and after treatment. Most participants progressed effectively to the highest self-exposure level, despite the absence of a therapist.

Fodor, L. A., Coteț, C. D., Cuijpers, P., Szamoskozi, Ștefan, David, D., & Cristea, I. A. (2018). The effectiveness of virtual reality based interventions for symptoms of anxiety and depression: A meta-analysis. Scientific Reports, 8(1). https://doi.org/10.1038/s41598-018-28113-6

Meta-analysis of virtual reality (VR) interventions for anxiety and depression outcomes, as well as treatment attrition. 


There were no significant differences between VR-based and other active interventions. VR interventions outperformed control conditions for anxiety and depression but did not improve treatment drop-out.

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. https://doi.org/10.1089/cpb.2007.9962

The present survey explored the acceptability of virtual reality (VR) exposure and in vivo exposure in 150 participants suffering from specific phobias. 

 

Seventy-six percent chose VR over in vivo exposure, and the refusal rate for in vivo exposure (27%) was higher than the refusal rate for VR exposure (3%). 


Results suggest that VR exposure could help increase the number of people who seek exposure therapy for phobias.

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. Dialogues in Clinical Neuroscience, 17(3), 337–346.

A review of 5 studies found that patients report satisfaction with VR based therapy and may find it more acceptable than traditional approaches.

 

VR eliminates a barrier for patients who may experience difficulty with imagining or visualization.

 

VR affords complete control over ET aspects.


VRET protects confidentiality while conducting exposures which might not be found in in-vivo exposures.

Morina, N., Ijntema, H., Meyerbröker, K., & Emmelkamp, P. M. G. (2015). Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments. Behaviour Research and Therapy, 74, 18–24. 

 

https://doi.org/10.1016/j.brat.2015.08.010

A meta-analysis of clinical trials applying VRET to specific phobias.

 

Patients undergoing VRET:

 

- Did significantly better on behavioral assessments following treatment than before treatment.

 

- Performed better on behavioral assessments at post-treatment than patients on wait-list.

 

Behavioral assessment at post-treatment and at follow-up revealed no significant differences between VRET and exposure in vivo.

 

Behavioral measurement effect sizes were similar to those calculated from self-report measures.


The findings demonstrate that VRET can produce significant behavior change in real-life situations and support its application in treating specific phobias.

Steinman, S. A., Wootton, B. M., & Tolin, D. F. (2016). Exposure Therapy for Anxiety Disorders. In Encyclopedia of Mental Health (pp. 186–191). Elsevier. https://doi.org/10.1016/B978-0-12-397045-9.00266-4

Exposure-based therapy is the gold-standard treatment for anxiety and related disorders. 

 

Research suggests that exposure, alone or in combination with cognitive restructuring, can significantly reduce anxiety symptoms across diagnoses. 

 

Further, treatment gains tend to be maintained over time.

Wechsler, T. F., Kümpers, F., & Mühlberger, A. (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. https://doi.org/10.3389/fpsyg.2019.01758

No evidence that VR exposure is significantly less efficacious than in vivo exposure in Specific Phobia and Agoraphobia. 

 

The wide range of study specific effect sizes, especially in Social Phobia, indicates a high potential of VR.

 

In Social Phobia, a combination of VR exposure with cognitive interventions and the realization of virtual social interactions targeting central fears might be advantageous. 

 

Considering the advantages of VR exposure, its dissemination should be emphasized. Improvements in technology and procedures might even yield superior effects in the future.

Other References

American Psychiatric Association (2013). Severity Measure for Specific Phobia—Adult. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Severity-Measure-For-Specific-Phobia-Adult.pdf

 

Marks, I. M., & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Research and Therapy, 17(3), 263–267. https://doi.org/10.1016/0005-7967(79)90041-X

 

Wiederhold, B. K., Gao, K., Sulea, C., & Wiederhold, M. D. (2014). Virtual Reality as a Distraction Technique in Chronic Pain Patients. Cyberpsychology, Behavior, and Social Networking, 17(6), 346–352. https://doi.org/10.1089/cyber.2014.0207

 

Witmer, B. G., & Singer, M. J. (1998). Measuring Presence in Virtual Environments: A Presence Questionnaire. Presence: Teleoperators and Virtual Environments, 7(3), 225–240. https://doi.org/10.1162/105474698565686

 

Wolpe, J. (1969). The practice of behavior therapy (1st ed.). Pergamon Press.