Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 hours in a one-session format has been found effective for the treatment of specific phobias. However, many suffering from specific phobia are reluctant to seek help and access to care is lacking due to logistic challenges of accessing, collecting, storing and/or maintaining stimuli.

Virtual Reality (VR) exposure therapy may improve upon existing techniques by facilitating access, lowering cost, and increasing acceptability and effectiveness. We have now planned a study and the study protocol was accepted for publication in the journal Trials today.

The aim of our study (which is about to finish and we will have results in March) is to compare traditional one-session exposure therapy with in-vivo spiders and a human therapist to a newly developed single-session gamified VR exposure therapy application with modern Virtual Reality hardware, virtual spiders and a virtual therapist.

One hundred participants with specific phobia to spiders was recruited from the general public, screened and randomized to either VR exposure therapy (N=50) or traditional OST (N=50). A behavioural approach test using in-vivo spiders served as the primary outcome measure.

Secondary outcome measures will include spider phobia questionnaires, and self-reported anxiety, depression and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1,12 and 52 weeks after treatment.

Virtual Reality exposure therapy has previously been evaluated as a treatment for specific phobias but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices are being released which advance upon existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable to take advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation.

This study compares a market-ready gamified VR spider phobia exposure application, delivered using consumer VR hardware, to the current gold-standard treatment. Implications are discussed in detail in the paper.

The game: Itsy

Virtual reality one-session exposure therapy was designed as a serious game (made by Mimerse) with game progression entailing gradually increased stimuli intensity. The application consists of a number of zones, each containing three types of gamified tasks for the user to complete: (1) looking at spiders, (2) interacting with spiders to complete rudimentary game mechanics, and (3) a task where the user is approached by a spider.

With completion of tasks and progression through the zones, spider stimuli and the surrounding environment become increasingly more intense, from a cute cartoon-looking spider through to realistically depicted tarantulas. See some screenshots from the application below. Two virtual environments was be used: an indoor kitchen/living room environment and an outdoor suburban backyard environment.

User input is strictly gaze-derived and is used for the interactive game mechanics, reporting subjective units of distress (SUDs) and more. Once initiated, the application is fully automated (i.e. no therapist action required) and includes a system for saving and compiling SUDs and other input, a virtual therapist providing instructions through voice-over, support and summaries of progress, and information about spiders. Unlike in the OST treatment, participants in the VR condition will be seated throughout the duration of therapy but both groups will be time-limited to 3hrs duration. Although automated, a clinical psychologist will be in attendance (one-onone) with the participant in case of technical or other difficulties. In this study, the Samsung Gear VR platform (powered by a Samsung Galaxy Note 4 or Galaxy S6, both running Android 5.0) will be used to create the VR environment

Read the full paper:

Miloff, A., Lindner, P., Hamilton, W., Reuterskiold, L., Andersson, G., & Carlbring, P. (2016). Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial. Trials, 17(1), 60. doi:10.1186/s13063-016-1171-1