Virtual Reality-based Exposure with 360° Video as part of Cognitive Behavioral Therapy for Social Anxiety Disorder: A Three-arm, Randomized Controlled Trial

Per Trads Ørskov^1*Eik Runge¹Trine Theresa Holmberg Sainte-Marie¹Mathias Ernst¹Lars Clemmensen¹Caroline Høier Dalsgaard¹Mia Beck Lichtenstein^1,2Stéphane Bouchard^3,4

• ¹Research Unit for Digital Psychiatry, Center for Digital Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
• ²Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
• ³Département de Psychoéducation et de Psychologie, Université du Québec Outaouais, Gatineau, Quebec, Canada
• ⁴Centre de recherche, Centre Intégré de Santé et de Services Sociaux de l’Outaouais, Gatineau, Canada

Background: Social anxiety disorder (SAD) has a high prevalence and an early onset. ItSAD often persists well into adulthood, turning into a chronic disorder. Cognitive behavioral therapy (CBT) is effective in treating SAD, but real-life . However, exposure conducted as part of CBT is often costly and time-consuming, when conducted in real life, and imaginary exposure might lack realism and intensity. Virtual reality (VR)-based exposure using 360˚ video offers a promising way to deliver exposure therapy.Objective: To develop a complete psychotherapeutic treatment program including CBT with VRbased exposure using tilizing 360° videos (CBT-ExpVR) for adult patients with SAD, and to test the treatment effect using the Social Interaction Anxiety Scale (SIAS) as the primary outcome.Methods: This three-arm randomized controlled trial involved 51 participants who were and was conducted at the Center for Digital Psychiatry in Denmark. Randomization was computer-generated. Rerecruitedment was through self-referral. The interventions took place at Center for Digital Psychiatry in Denmark. Participants were randomized via computer program to CBT-ExpVR, CBT with in vivo exposure (CBT-Exp), or an active control group offered VR relaxation (RlxVR). Afterwardss, participants assigned to RlxVR were re-randomized to one of the two CBT interventions. Allocation was not blinded.Results: Intention-to-treat analysis showed that participants receiving CBT-ExpVR reported significantly fewer symptoms of social anxiety at post-treatmentest compared to pre-treatmenttest, β = -14.89, 95% CI (-18.64, -11.14), 𝑝 < 0.0001. At post-treatmenttest, no difference in treatment effect was found between CBT-ExpVR and CBT-Exp, β = 3.643, 95% CI: (-1.727, 9.013), 𝑝 = 0.1839. However, CBT-ExpVR was more effective than RlxVR, β = -11.537, 95% CI: (-16.163, -6.911), 𝑝 < 0.0001. DThe dropout rates post-treatment werewhere 16% (CBT-ExpVR), 20% (RlxVR), and 38% (CBT-Exp), and 20% (RlxVR). No harms were registered during the study.CBT-ExpVR represents an effective treatment for SAD comparable to standard CBT treatment. CBT-ExpVR wasis reported as less costly and requiring less effort by the therapist compared to CBT-Exp. Thus, VR-based exposure might pave the way for a broader implementation of exposure in psychotherapeutic interventions for social anxiety by providing easy and low-cost access to exposure scenarios.