Using Virtual Reality in Exposure-Based Treatment for Social Anxiety in Youth

Lifetime prevalence of social anxiety disorder in adolescents is estimated to be 8.6%, with the most common age of onset being ages 15-17. Social anxiety disorder is related to significant functional impairment and, if untreated, puts youth at risk for depression and substance abuse, and results in failure to meet important academic, social, and occupational milestones. The current literature supports cognitive behavioral therapy with exposure therapy, selective serotonin re-uptake inhibitor medications, and their combination for the treatment of anxiety disorders with good effects. However, even with gold standard treatment, a significant number of patients do not get better or experience relapse. Exposure therapy is based on the principles of fear extinction, such that cues associated with threat are presented in a safe and controlled way until they are experienced as safe and fear responses are reduced. Studies in mice and non-anxious humans have demonstrated cue-based fear extinction learning to be less robust in adolescence than it is in childhood or adulthood. However, mouse-models suggest that context-based extinction learning closes the gap between age-groups, with adolescents performing as well on extinction learning tasks when put back in the original environment where the fear was acquired.

Similarly, clinical research suggest that exposure therapy is most useful when exposures are conducted in the same or similar environments to where the fear is experienced in everyday life. However, there are many barriers to providing contextual based exposure therapy, particularly for social anxiety, including paucity of well-trained exposure therapists in many areas of the country, and difficulty generating or accessing realistic social situations for convincing exposures.

Virtual reality offers a promising avenue for contextual exposures, by increasing the availability of certain contexts that cannot be readily mimicked in therapy. Furthermore, in vivo exposure situations can feel overwhelming for some individuals (patients and therapists), resulting in refusal to engage in exposure altogether. Virtual reality technology could allow for more gradual titration of exposure for those patients that require lower intensity exposures, and can be done in the therapy office for clinicians who do not have the time, resources, experience, or comfort level to travel outside of their office in pursuit of appropriate exposure environments. Even for seasoned exposure therapists, virtual reality could serve as a practice step in preparation for in vivo exposures or could be used in lieu of in vivo exposures if necessary. There has been extensive research on the use of virtual reality in facilitating exposure in a variety of populations. However, its effectiveness has not been demonstrated in adolescents with social phobia, and research is limited in adolescent samples in general.

The pilot study proposed for this National Alliance for Research on Schizophrenia and Depression award would test the overall hypothesis that virtual reality technology is feasible, acceptable, and will enhance exposure-based therapy for socially anxious youth. Studies will be focused on testing the feasibility of integrating virtual reality technology into exposure-based treatment in adolescents and young adults (ages 13-23) diagnosed with social anxiety disorder with the goal of approximating equivalent efficacy with traditional cognitive behavioral therapy, and assessing feasibility, usability, and acceptability of the virtual reality technology with this population. In addition, we would pilot a fear conditioning and extinction learning paradigm with the subjects to explore the relationship between extinction learning and efficacy of virtual reality exposure therapy, using physiological assessment indicators to mark changes in fear response, including skin conductance, heart rate, heart rate variability, and startle. These physiological markers would also be used prior to the initiation of the therapy to assess the degree to which the virtual reality environments invoke a true fear response, comparing the 12 subjects with social phobia to 12 age-matched, non-anxious control subjects. If feasible and effective, these procedures would be used for a larger future study, and pilot data would be used for a K-award, R21, or R01 grant application, including neuroimaging to learn more about the neural circuitry involved in fear learning via virtual reality technology.

SPECIFIC AIMS