Virtual Reality for the Treatment of Anxiety Disorders: A Scoping Review

Authors: Miranda R. Donnelly, Renee Reinberg, Kaori L. Ito, David Saldana, Meghan Neureither, Allie Schmiesing, Esther Jahng, Sook-Lei Liew
Published in: American Journal of Occupational Therapy, November/December 2021, Vol. 75, No. 6

Importance of HMD-VR in Occupational Therapy

  • HMD-VR as Therapeutic Tool:
      - Virtual reality in head-mounted displays (HMD-VR) offers a significant opportunity for occupational therapy to address anxiety disorders.

  • Findings from Literature:
      - Evidence from virtual reality exposure therapy (VRET) literature may provide insights applicable to occupational therapy psychosocial practices.

Objective

  • Main Aim:
      - To explore the use of HMD-VR in treating anxiety through VRET and how it can be integrated into occupational therapy practices.

Data Sources

  • Database Search:
      - Conducted in seven electronic databases for publications from 2000 to 2020: CINAHL, Cochrane Library, Embase, ERIC, Ovid MEDLINE, PsycINFO, Web of Science.

  • Search Terms:
      - Included various HMD-VR constructs, products, therapy concepts.

Study Selection and Data Collection

  • Methodology:
      - Followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
      - At least two reviewers assessed each citation; a third resolved disagreements.

  • Inclusion Criteria:
      - Articles must be published in English, report experimental data, and involve HMD-VR.

  • Exclusion Criteria:
      - Excluded letters, commentaries, book chapters, technical descriptions, theoretical papers, conference proceedings (≤4 pages), and reviews.

Findings

  • Total Number of Studies:
      - Identified 28 studies using HMD-VR to treat anxiety, focusing on:
        - Posttraumatic Stress Disorder (PTSD): 3 studies
        - Specific Phobias: 19 studies
        - Performance-Based Social Anxiety: 6 studies

  • Levels of Evidence:
      - Randomized controlled trials (RCTs): 11
      - Controlled trials without randomization: 6
      - Case–control or cohort studies: 11

  • Qualitative Findings:
      - HMD-VR is an effective treatment tool for anxiety disorders.

Conclusions and Implications

  • Value of HMD-VR in Therapy:
      - Ideal for simulating environments for clients with anxiety disorders, enhancing participation outcomes through multisensory features and body representation.

  • Ecologically Valid Environments:
      - Important for clients to cope with anxiety triggers in daily contexts.

  • Prevalence of Anxiety Disorders:
      - One-third of adults may experience anxiety disorders in their lifetime, leading to moderate to severe impairments (Bandelow & Michaelis, 2015).

  • Occupational Therapy Goals:
      - Aimed at community reintegration and participation in daily activities for individuals with anxiety disorders (Davis, 2011).

Additional Insights From VRET

  • Method of VRET:
      - Guided exposure to anxiety-provoking thoughts/activities challenges cognitive beliefs and dissociates stimuli from anxious responses (AOTA, 2014; Phillips et al., 1997).

  • Primary Goals in Treatment:
      - Integrating clients back into communities and facilitating their daily activities in natural settings.

Gaps in Mental Health Care Settings

  • Limitations:
      - Traditional mental health care struggles to guide therapeutic participation in natural environments effectively due to constraints such as time and safety (Exley et al., 2011).

  • Need for Effective Alternatives:
      - Immersive VR offers realistic simulations of environments to enhance patient outcomes by providing sensory information similar to real-world experiences (Wilson et al., 1997).

Urgency of VR in Addressing Mental Illness

  • Growing Need:
      - Increasing demand for remote and virtual therapy options due to disparities in mental health access (Cook et al., 2013).

  • Exposure Therapy Approach:
      - Helps clients confront fear-inducing stimuli through guided experiences, often paired with cognitive-behavioral therapy (CBT; APA-SCP, 2017).
      - Types of exposure include:
        - In Vivo Exposure: Facing fears in real life.
        - Imaginal Exposure: Vivid imagining of the fear stimulus.
        - Interoceptive Exposure: Replicating physiological signs of anxiety (APA-SCP, 2017).

VRET as a Convenient Therapy

  • Advantages:
      - Cost-effective, utilizing virtual environments to replicate anxiety-inducing experiences (Botella et al., 2017; Motraghi et al., 2014).

  • Presence in VRET:
      - User immersion in virtual environments is crucial for effectiveness. Presence affects the overall outcome of behavior change (Slater & Sanchez-Vives, 2016).
      - Influenced by sensory features, types of display, and motion simulation (Muhlberger et al., 2005).

Methodology of the Scoping Review

  • Scoping Review Structure:
      - Scoping methodology employed due to the evolving area of study and limited RCTs.

  • Objectives:
      - Identify implications for occupational therapy practices and discern literature gaps to guide future research.

Research Framework

  • Guiding Questions:
     1. How has HMD-VR been used in psychosocial rehabilitation for anxiety-related disorders?
     2. What principles from VRET in HMD-VR can be applied to occupational therapy practice?

Literature Search and Citation Review

  • Comprehensive Literature Search:
      - Collaboration with a research librarian to search databases.

  • Process Overview:
      - Initial search on July 25, 2018; supplemental search on January 6, 2020.

  • Results Compilation:
      - Studies uploaded to EndNote, duplicates removed, and citations reviewed via Covidence by independent reviewers.

  • Screening Criteria:
      - Included studies must report experimental data, involve an anxiety population, and be conducted within occupational therapy practice domains.

Statistics and Study Selection Process

  • Study Process Overview:
      - Initial search results: 8,415 abstracts; Supplemental search: 4,510 abstracts.
      - After removal of 1,038 duplicates from 11,887 abstracts: 10,775 did not meet inclusion criteria, 1,112 full-text reviews completed.
      - 28 articles qualified for the scoping review.

Evidence Level Classification

  • Level of Evidence Framework:
      - Level 1: Systematic reviews of RCTs.
      - Level 2: RCTs.
      - Level 3: Non-randomized controlled trials.
      - Level 4: Case–control and cohort studies.
      - Level 5: Systematic reviews of descriptive and qualitative reports.
      - Level 6: Single descriptive or qualitative studies.
      - Level 7: Expert opinions and reports.

  • Exclusion of Levels 1, 5, and 7:
      - These levels do not report novel experimental data.

Results Presentation

  • Statistical Findings:
      - Summarized data from included studies reports, organized by population types in a scoping review appendix.

  • Distribution by Anxiety Types:
      - PTSD (3 studies), Specific Phobias (19 studies), Performance-Based Social Anxiety (6 studies).
      - RCTs showed significant improvements in treated populations, establishing the effectiveness of VRET with various methodologies and exposure techniques.

Challenges in Implementation and Comorbidity

  • Clinical Implications for PTSD:
      - VRET produced significant outcomes in treating PTSD while facing challenges concerning individual trauma variability.
      - High comorbidity rates among anxiety and other mental disorders complicate treatment pathways (Brady et al., 2000).

Overview of Specific Phobias and VRET Studies

  • General Findings:
      - Studies included for phobias such as acrophobia, agoraphobia, arachnophobia, and others demonstrated varying effectiveness rates through detailed VRET protocols.

Acrophobia

  • Studies Reviewed:
      - Eight studies reported VRET effectiveness in treating acrophobia, with positive findings on reduced anxiety levels through immersive VR environments.

Performance-Based Social Anxiety

  • Overview of Findings:
      - Several studies indicated significant improvements in individuals with public speaking anxiety through structured VRET programs incorporating psychosocial frameworks.

Recommendations for Future Practice and Research

  • Identification of Best Practices:
      - Future research should focus on standardizing methodologies, reporting guidelines, and understanding interactions between client-specific factors and therapeutic outcomes.

  • Implication of HMD-VR in Everyday Occupational Therapy:
      - Use of HMD-VR as a therapeutic tool within intervention strategies to enhance daily occupation participation for individuals experiencing anxiety.

Conclusion

  • Final Reflections:
      - This scoping review supports the application of HMD-VR as an effective treatment modality for anxiety disorders, advocating for evidence-based practices in occupational therapy.

References:

  • Included extensive bibliographical references for studies analyzed in this scoping review.