Social Anxiety Disorder (SAD) is a common yet underreported mental disorder with an estimated lifetime prevalence of 3–13% [1,2,3], and low rates of spontaneous remission [4]. Patients with SAD experience intense and persistent fear during social interactions, where he or she might be negatively evaluated by others (e.g. public speaking, shopping). Symptoms include a high degree of bodily symptoms, such as sweating, trembling and increased heart rate, causing avoidance behavior when exposed to social situations (e.g. education, work) and significant functional impairment [5]. SAD is therefore highly debilitating, and the majority of individuals with social anxiety reports numerous problems with individual and social adjustments, as well as impairment in academic and professional functioning [6].
SAD often co-occurs with other psychiatric conditions such as additional mood disorders, substance use disorders, and is significantly associated with suicidal ideation [7, 8]. Despite its frequency and severity, only between one third and half of people with SAD seek treatment [5, 9]. This may be linked to the nature of the disorder itself, as people with SAD avoid healthcare services like they would any other social interaction [7]. Factors such as embarrassment associated with help-seeking and fear of what others might think have been found to prevent individuals with SAD from seeking treatment [7]. In addition to the disorder-specific issues, futher barriers exists in regards to accessing treatment such as the lack of skilled therapists, lack of evidence-based treatments and long waiting lists [10]..
The recommended psychological treatment for SAD is the exposure technique imbedded in Cognitive Behavioral Therapy (CBT) [2, 5]. CBT for SAD combines cognitive restructuring with exposure [11]. In exposure-based therapy, exposures to social situations are used to test and disprove the patient’s predictions about the danger in a particular situation thereby developing new, realistic mental representations associated with the feared stimuli [12, 13]. Patients with SAD often have excessively high standards for social performance, and a strong fear of ridicule [12, 14]. Thus, it can be particularly helpful to encourage patients to behave in ways that they would consider unacceptable. i.e. intentionally acts against their excessively rigid rules for social interaction while observing the consequences [12, 14].
Exposure has traditionally taken place as either.
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a)
In vivo: directly facing the feared situation.
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b)
Imaginary exposure: imagining the feared situation (can be facilitated through pictures or videos).
In vivo exposure is effective [14] but is costly, time-consuming and situational elements, such as the reaction of others, are difficult to control [15, 16]. Furthermore, many patients are rather unwilling to expose themselves to the real situation since it is considered too frightening [17], and there is a risk of encountering familiar people revealing that the person is in therapy.
Conversely, imaginary exposure may lack realism and intensity [18], and can be difficult for people who are unable to imagine vividly, it is also easy to avoid imagining their phobia-inducing situations, or for the patient to overwhelm themselves with images [17, 19]. Recently, researchers and clinicians have started to use Virtual Reality (VR) to overcome these difficulties [15, 16].
Virtual reality- based exposure
VR is the use of computer and behavioral interfaces to simulate the behavior of 3D entities that interact in real time with each other and with a user immersed via sensorimotor channels [20]. It immerses the user in a computer generated or video-based virtual environment [21] . This enviroment can be created using either computer graphics or 360° 3D videos [21,22,23]. Studies on the effect of VR-based treatment for different types of phobias (e.g. agoraphobia and fear of flying) have revealed great potential [21], and a study showed that 76% of participants preferred VR-based exposure over in vivo exposure [24]. In addition to high levels of preference, VR-based exposure does have several advantages:
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Virtual exposure scenarios can be very similar to real life situations [25], and it is possible to control and regulate situational factors, such as degree of exposure for the patient and the reactions of other people in the scenario [26].
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Exposure scenarios can be presented to the patients, while still in the comfort and safety of a therapeutic room [25],
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The flexibility of VR allows the patient to experience situations that are worse and more exaggerated than those that are likely to be encountered in real life [17]. Thus it is possible to expose patients to others’ negative reactions, in a safe environment where they can learn that this is not dangerous, and that they can handle even the social ridicule they fear the most.
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Patients know that it is not real but their minds and bodies behave as if it is real. Hence people will more easily face difficult situations in VR than in real life and be able to engage in more adaptive behaviors [27].
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VR sessions often requires less time than in vivo sessions, and can be planned more flexibly and for less costs [28]
Seven meta-analyzes [9, 29,30,31,32,33,34] have been published on CBT with VR-based exposure for anxiety, and six of these include studies on SAD [9, 29,30,31, 33, 34]. All found superior effect of CBT with VR-based exposure compared to imaginary exposure, and similar effects when compared to in vivo exposure, with a recent study finding superior effect of CBT with VR-based exposure even when compared to in vivo [28]. Treatment effects have been shown to persist over a number of years [27], and a recent meta-analysis found persistent benefits of treatment after CBT with VR-based exposure comparableto face-to-face therapy [17]. Furthermore, a meta-analysis found that the CBT with VR-based exposure promoted benefits which carry over to real life, and leads to significant behavior change in real-life situations, [32] this analysis however, did not include SAD specific studies [32].
These meta-analyzes include only five [28, 35,36,37,38] randomized controlled trials (RCTs) on VR-based treatment for SAD which, however, all found significant improvements in SAD after VR-based treatment. Regarding the individual studies, one study comparing VR exposure with a waitlist group found a significant higher improvement in measures of anxiety in the VR exposure group [35]. Two studies found no significant difference between VR-based and in vivo exposure [36, 37], and Bouchard et al. (2017) [28] found VR exposure to be superior to in vivo exposure, whereas Kampmann et al. (2016) [38] found that in vivo exposure without CBT was more effective than VR-based exposure without CBT. However, as exposure was not performed in the context of CBT, direct comparison to the other studies is not possible.
The current evidence thus supports the clinical efficacy of CBT with VR-based exposure, and it is suggested that if the potential of VR is fully explored it might be more effective than in vivo [28]. However, the fact that these meta-analyzes include a total of only six [28, 35,36,37,38,39] (RCTs) and only four of these compare CBT with VR-based exposure to both an in vivo and a control group [28, 37,38,39]. The strength of the evidence base is also weakened by the use of small sample sizes (n < 30) [29] [32, 40] and the use of waiting lists patients as control groups [41], as waiting list control designs may overestimate intervention effects [42]. Patients assigned to a waiting list appear to improve less than would be expected for people who are concerned about their behavior and are taking steps to change. This contrasts with studies not employing waiting list designs in which control group patients tend to improve [43].
So far, CBT with VR-based exposure for SAD has been conducted by the use of computer-generated social environments. This method requires the computer to recreate (render) in real time all the virtual stimuli in order to adapt the user’s movements and interactions with the virtual stimuli. The advantage of real time 3D rendering is that the user can explore the virtual environment at will and at his her or her own pace. The disadvantages it that it takes computer power and time, and all stimuli has to be synthetic (digitized). Also, it is difficult and expensive to develop [44]. Using 360° videos avoids some limitations of real time rendering of 3D stimuli as it is more realistic, less expensive and requires minimal training, and developers can use real stimuli. All this contributes to making it easier to implement. However, the user cannot fully explore the environment (i.e., cannot go in directions that were not filmed in the video) or at his or her own pace (i.e., event will occur as already planned and filmed in the video). Video-based CBT with VR-based exposure has not yet been applied to SAD, but a study on social anxiety in the context of psychosis revealed positive results [45].
In 2017 Centre for Telepsychiatry did a pilot study (manuscript submitted) investigating the ability of 360° videos to trigger an anxiety response in patients with SAD. We developed and produced three videos in a shopping center and tested them on nine SAD patients and nine matched controls. Our main finding was that the videos were effective in producing anxiety in SAD patients while the control group did not report any anxiety. Furthermore, the participants reported high levels of presence. Presence is the person’s subjective sensation of being there in the Virtual Environment (VE) and appears to be key when inducing emotions such as anxiety through technology [46].
Aims and hypotheses
The aims of the study that will use the clinical protocol described in the paper are to develop a complete program of CBT with VR exposure based on 360° videos for adult patients suffering from SAD, and to evaluate the treatment effect on SAD symptoms. We plan to compare a group receiving CBT with VR-based exposure immersed in an environment based on 360 videos stimuli to a group receiving CBT with in vivo exposure and a group receiving VR relaxation treatment. Having VR relaxation treatment as control group is methodologically superior to a comparison to a waiting list and controls for any placebo effect.
It is hypothesized that:
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CBT with VR-based exposure will significantly reduce symptoms of SAD
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CBT with VR-based exposure will be more effective than both CBT with in vivo exposure and VR relaxation therapy at the end of treatment
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An effect on symptom reduction will sustain at 6 months follow-up