EXPOSURE IN VIRTUAL REALITY FOR SOCIAL ANXIETY DISORDER - A Randomized Controlled Superiority Trial Comparing Cognitive Behavioral Therapy With Virtual Reality Based Exposure to Cognitive Behavioral Therapy With in Vivo Exposure.

Introduction Social Anxiety Disorder (SAD) is a common yet underreported mental disorder with an estimated lifetime prevalence of 3-13%, and low rates of spontaneous remission. Patients with SAD experience intense and persistent fear in social interactions, during which he or she might be judged or negatively evaluated by others (e.g. public speaking, shopping). Symptoms include overwhelming bodily symptoms, such as sweating, trembling and increased heart rate, leading to avoidance of social situations (e.g. education, work) and significant functional impairment. SAD is highly debilitating, with the majority of socially anxious persons reporting numerous problems in individual and social adjustment, and with associated impairment in academic and professional functioning. Moreover, SAD often co-occurs with other psychiatric conditions such as mood disorders and substance use disorders, and is significantly associated with suicidal ideation. Despite its frequency and severity, only between one third and half of people with SAD seek treatment.

The recommended psychological treatment for SAD is the exposure technique imbedded in Cognitive Behavioral Therapy (CBT). CBT for SAD combines cognitive restructuring with exposure. In exposure-based therapy, exposures to social situations are used to test the patient's predictions about the danger in a particular situation. Further, it helps the patient develop new, realistic mental representations associated with the feared stimuli. Patients with SAD often have excessively high standards for social performance, and a strong fear of ridicule. 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.

Exposure has traditionally taken place as either:

1. In vivo: directly facing the feared situation.
2. Imaginary exposure: imagining the feared situation (can be facilitated through pictures or videos).

In vivo exposure is effective, but is costly, time-consuming and situational elements, such as the reaction of others, are difficult to control. Furthermore, many patients are rather unwilling to expose themselves to the real situation since it is considered too frightening. Furthermore, there is a risk of encountering familiar people revealing that the person is in therapy. Conversely, imaginary exposure may lack realism and intensity , and can be difficult for people who are unable to imagine vividly, avoid imagining their phobia-inducing situations, or tend to overwhelm themselves with images. Recently, researchers and clinicians have started to use Virtual Reality (VR) to overcome these difficulties.