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Virtual reality exposure therapy in anxiety disorders

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Tuuli Pöllänen

on 20 March 2013

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Transcript of Virtual reality exposure therapy in anxiety disorders

Virtual reality exposure therapy - VRET Virtual reality exposure to treat anxiety disorders 13,6% lifetime history of an anxiety disorder (Europe)
The evidence-based interventions movement: CBT as one of the best-validated and most successful treatments for anxiety disorders.
But: barriers of care (distance, money, time, motivation, client engagement...)
Also: new technologies - new horizons (or playgrounds) with new implications
Why not use a virtual reality engine or a simulator for exposure therapy?
systematic exposure within a contextually relevant setting
the exposure can be performed inside the therapist’s office (convenience and safety)
control over the content and the pace of the exposure
exposure can be repeated and customized
fear of flying - VRET is cost-effective
To what measures can VRET's results be generalized to the patient's real life experience and performance? state of research on VRET and anxiety disorders Lots of studies, several meta-analyses, numerous shortcomings
One extensive study with RCT comparing VRET to in vivo exposure (13 studies, meta-analysis)
VRET was used as a standalone treatment, no implications for combinations of VRET and CBT
VRET was shown to be equally effective as in vivo, in some studies slightly more efficient than in vivo treatment
Small number of studies, mostly on phobias -> do not allow generalization to anxiety disorders.
A recent systematic review - 20 studies, VRET on anxiety disorders
treatment protocols in the VRET studies included multiple components, some of which were not state-of-the art treatments for those specific disorders
impossible to determine individual contributions from VRET alone
only for fear of flying and acrophobia - enough data available to conclude that VRET is effective
Important finding: effect of VRET on the behavioral measures points toward a very good generalization of the results to the real world.
systematic review (not meta-analysis) -> no global effect sizes
More research necessary - hence the current meta-analysis! Research questions 1. Efficacy of VRET compared to wait list
2. Efficacy of VRET compared to evidence based interventions
3. Impact of VRET on real life (generalizability of progress to real-life situations)
4. Long-term effects of VRET
5. Dose-response relationship for VRET
6. Difference in drop-out rate in VRET and in vivo treatment
Article search - different online sources, references from selected articles
Strict inclusion and exclusion criteria

Final selection: 21 articles, reporting 23 studies, total sample size of 608 participants.

Dependent variables were classified as:
1) Primary outcomes (main outcomes to determine effects of the interventions)
Patients' subjective ratings and clinician-administered interviews
2) Real-life impact outcomes (e.g. actual flights, clinical improvement)
Control conditons:
1) Classical evidence-based interventions alone
2) Wait list The paper we will focus on Meta-analysis: classical evidence-based interventions + VRET vs. classical evidence-based interventions alone.
23 studies
The disorders and evidence-based practices are the following (extensive research and APA recommendation):
1. panic disorder—CBT
2. specific phobias—exposure therapies
3. social phobia and public speaking anxiety—CBT
4. PTSD—prolonged exposure and cognitive processing therapy
5. generalized anxiety disorder—CBT NOTE! focus on how effective the VRET enhanced evidence-based interventions are compared to the classical evidence-based interventions, and not on how effective VRET is by itself. 1) VRET + (C)BT does far better than wait list control
2) Post-treatment results are the same, with VRET or without
3) VRET+ (C)BT has similar real-life impact as classical evidence based treatments alone
4) There is a dose-response relationship to VRET (effect sizes depend on duration and frequency of treatment)
5) Stability of results for VRET +(C)BT is same as for the classical evidence-based treatments alone
6) No difference in drop out rate – data about dropouts in the studies was bad, though

Finding that efficacy for (C)BT + VRET is the same as for classical evidence-based treatments alone is different from findings of previous meta-analyses that (C)BT + VRET is superior.

There was an effect of (C)BT + VRET being favorable over (C)BT alone for fear of flying. Results for dummies The authors appear more enthusiastic about their findings than I – but they do bring out some good points
PTSD: mechanism of change: fear structure has to be activated first – then new and corrective information can be incorporated to the memory structure
VRET can help recall traumatic memories by allowing a return to the context.
Sometimes in vivo experience is impossible (e.g. terrorist attacks)
In vivo exposure might be dangerous (should we treat combat-related PTSD in Afghanistan?)

Some research suggests a lower drop out rate for VR than in vivo exposure
VR is less threatening and might increase the likelihood of a patient to be willing to start and complete an exposure treatment
Also studies reporting high preference of VR exposure in patients that are informed about both in vivo and VR exposure therapy

Necessity of comparing VRET with other kinds of Internet and Computer Technology-based treatments . Implications Botella, C., David, D., Garcia-Palacios, A., Opris, D., Pintea, S. & Szamoskozi, S. (2012). Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis. Depression and Anxiety, 29, 85-93
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