Does engagement with exposure yield better outcomes? Components of presence as a predictor of treatment response for virtual reality exposure therapy for social phobia
Open accessAbstract
Virtual reality exposure (VRE) has been shown to be effective for treating a variety of anxiety disorders, including social phobia. Presence, or the level of connection an individual feels with the virtual environment, is widely discussed as a critical construct both for the experience of anxiety within a virtual environment and for a successful response to VRE. Two published studies show that whereas generalized presence relates to fear ratings during VRE, it does not relate to treatment response. However, presence has been conceptualized as multidimensional, with three primary factors (spatial presence, involvement, and realness). These factors can be linked to other research on the facilitation of fear during exposure, inhibitors of treatment response (e.g., distraction), and more recent theoretical discussions of the mechanisms of exposure therapy, such as Bouton's description of expectancy violation. As such, one or more of these components of presence may be more strongly associated with the experience of fear during VRE and treatment response than the overarching construct. The current study (N=41) evaluated relations between three theorized components of presence, fear ratings during VRE, and treatment response for VRE for social phobia. Results suggest that total presence and realness subscale scores were related to in-session peak fear ratings. However, only scores on the involvement subscale significantly predicted treatment response. Implications of these findings are discussed.
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Although presence is linked to the anxiety experienced during exposure, there is no direct relationship between sense of presence and treatment outcomes.
“In terms of treatment efficacy, research has also suggested that, although presence is linked to the anxiety experienced during the exposure, there is no direct relationship between sense of presence and treatment outcomes (Price et al., 2011; Price and Anderson, 2007; Tardif et al., 2019).”
From An Internet-based treatment for Flying Phobia using 360° images: Study protocol for a feasibility pilot study (2021) · cites this paper as Price et al., 2011
Results §3.1 links overall presence to peak fear during exposure. Results §3.2 finds no significant relationship between total presence and treatment response, but finds that involvement—a component of presence—predicts improvement. The claim is therefore supported for overall presence, but its unqualified statement overlooks the involvement finding. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe current subjective presence measures do not capture the essential sense of presence that is responsible for activating fear related to social anxiety in individuals.
“As several trials have demonstrated the potential of VRET for social anxiety disorder [27], [28], [75], one might conclude that the current subjective presence measures do not capture the essential sense of presence that is responsible for activating fear related to social anxiety in individuals.”
From A Meta-Analysis on the Relationship between Self-Reported Presence and Anxiety in Virtual Reality Exposure Therapy for Anxiety Disorders (2014) · cites this paper as [75]
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Virtual Reality Tool Simulates MRI Experience
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“There have been many studies showing that desensitization therapy using virtual reality (VR) as a tool is an effective means of treating phobias (6-10).”
BackgroundThe impact of virtual reality versus 2D pornography on sexual arousal and presence
Elsey, J. W. B., van Andel, K., Kater, R. B., Reints, I. M., & Spiering, M. (2019) · Computers in Human Behavior · doi:10.1016/j.chb.2019.02.031 · Cited by 53 · see citing works
The Effects of Virtual Audience Size on Social Anxiety during Public Speaking
Mostajeran, F., Balci, M. B., Steinicke, F., Kühn, S., & Gallinat, J. (2020) · IEEE Conference on Virtual Reality and 3D User Interfaces (VR) · doi:10.1109/vr46266.2020.00050 · Cited by 53 · see citing works
Pallavicini, F., Pepe, A., Ferrari, A., Garcea, G., Zanacchi, A., & Mantovani, F. (2018) · PRESENCE Virtual and Augmented Reality · doi:10.1162/pres_a_00325 · Cited by 52 · see citing works
The Impact of Virtual Reality on Curiosity and Other Positive Characteristics
Schutte, N. S. (2019) · International Journal of Human-Computer Interaction · doi:10.1080/10447318.2019.1676520 · Cited by 49 · see citing works
“Further, engagement with an activity encourages flow (Csikszentmihalyi, 2014) and virtual reality fosters engagement (Price et al., 2011).”
BackgroundTips for effective implementation of virtual reality exposure therapy in phobias-A systematic review
Krzystanek, M., Surma, S., Stokrocka, M., Romańczyk, M., Przybyło, J., Krzystanek, N., & Borkowski, M. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.737351 · Cited by 46 · see citing works
Latu, I. M., Mast, M. S., Bombari, D., Lammers, J., & Hoyt, C. L. (2018) · Sex Roles · doi:10.1007/s11199-018-0911-y · Cited by 46 · see citing works
“First, consistent with previous research using virtual reality technology (Bombari et al. 2015; Price et al. 2011), we assessed the degree to which participants subjectively perceived the virtual environment as being Breal^ while completing the task.”
ResultVoinescu, A., Morgan, P. L., Alford, C., & Caleb-Solly, P. (2020) · Transportation Research Part F Traffic Psychology and Behaviour · doi:10.1016/j.trf.2020.05.003 · Cited by 46 · see citing works
Comparing the effects of immersive and non-immersive real estate experience on behavioral intentions
Mauri, M., Rancati, G., Riva, G., & Gaggioli, A. (2023) · Computers in Human Behavior · doi:10.1016/j.chb.2023.107996 · Cited by 47 · see citing works
Chard, I., & van Zalk, N. (2022) · Frontiers in Digital Health · doi:10.3389/fdgth.2022.842460 · Cited by 46 · see citing works
“As such, presence may also have less of an impact on treatment effectiveness and symptom change (87).”
BackgroundA Palette of Deepened Emotions: Exploring Emotional Challenge in Virtual Reality Games
Peng, X., Huang, J., Denisova, A., Chen, H., Tian, F., & Wang, H. (2020) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3313831.3376221 · Cited by 42 · see citing works
“presence and emotion are still rather complex [11], there is a commonly regarding that presence is a necessary mediator that allows real emotions to be activated by a virtual environment [33,38,40].”
Landowska, A., Roberts, D., Eachus, P., & Barrett, A. (2018) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2018.00362 · Cited by 43 · see citing works
Realism and Field of View Affect Presence in VR but Not the Way You Think
Jicol, C., Clarke, C., Tor, E., Dakin, R. M., Lancaster, T. C., Chang, S. T., Petrini, K., O'Neill, E. J., Proulx, M. J., & Lutteroth, C. (2023) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3544548.3581448 · Cited by 41 · see citing works
“Note that mathematically, it makes no difference in which order the variables in a moderation are specified, i.e. to say that “X moderates Y” is the same as saying “Y moderates X”: H6A [21, 35, 38, 72, 76] and is backed up by its strong evolutionary importance [65].”
BackgroundBessa, M., Melo, M., de Sousa, A. A., & Vasconcelos-Raposo, J. (2017) · Computers & Graphics · doi:10.1016/j.cag.2017.11.003 · Cited by 37 · see citing works
Azadeh, S. M., Kazemi-Zahrani, H., & Besharat, M. A. (2015) · Global journal of health science · doi:10.5539/gjhs.v8n3p131 · Cited by 35 · see citing works
Qu, C., Ling, Y., Heynderickx, I. E. J., & Brinkman, W. (2015) · PLoS ONE · doi:10.1371/journal.pone.0125279 · Cited by 35 · see citing works
“Virtual reality exposure therapy (VRET) for the treatment of social anxiety disorder is such an application, and currently receives increasing scientific and public attention [6, 9, 14, 15].”
Virtual Reality for Anxiety Disorders: Rethinking a Field in Expansion
Fernández‐Álvarez, J., Lernia, D. D., & Riva, G. (2020) · Advances in experimental medicine and biology · doi:10.1007/978-981-32-9705-0_21 · Cited by 33 · see citing works
Beverly, E. A., Love, C., Love, M., Williams, E. R., & Bowditch, J. (2020) · JMIR Diabetes · doi:10.2196/23708 · Cited by 33 · see citing works
“Finally, presence describes the extent to which a participant feels present or immersed in a virtual environment [35,36] and is commonly regarded as a necessary mediator that allows real emotions to be activated [37,38].”
BackgroundScheveneels, S., Boddez, Y., Van Daele, T., & Hermans, D. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.02849 · Cited by 33 · see citing works
“…a sense of presence (i.e., the connection an individual feels with the VR environment) can explain why an individual experiences VR “as if it is real” and might come to expect certain outcomes to occur even though it is actually impossible (Price and Anderson, 2007; Price et al., 2011).”
BackgroundFull-Body Ownership Illusion Can Change Our Emotion
Jun, J., Jung, M., Kim, S.-Y., & Kim, K. K. (2018) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3173574.3174175 · Cited by 31 · see citing works
“It is an important mediator of emotional activation in VR exposure therapy, and may have a link with emotion activation in virtual environments [10, 33].”
BackgroundIndividual variables related to craving reduction in cue exposure treatment
Pericot-Valverde, I., García-Rodríguez, O., Gutiérrez-Maldonado, J., & Secades-Villa, R. (2015) · Addictive Behaviors · doi:10.1016/j.addbeh.2015.05.013 · Cited by 29 · see citing works
Virtual reality versus face-to-face practice: a study into situational apprehension and performance
Davis, A. J., Linvill, D. L., Hodges, L. F., Costa, A. F. D., & Lee, A. (2019) · Communication Education · doi:10.1080/03634523.2019.1684535 · Cited by 31 · see citing works
“Speci fi c to issues most relevant to public-speaking pedagogy, Price, Mehta, Tone, and Anderson (2011) explored the use of VR in treating social phobias.”
BackgroundPolechoński, J., Szczechowicz, B., Ryśnik, J., & Tomik, R. (2024) · BMC Sports Science Medicine and Rehabilitation · doi:10.1186/s13102-024-00818-4 · Cited by 30 · see citing works
“These features promote greater user involvement, enhance their emotions, while eliminating distracting elements from the outside world [7, 8].”
BackgroundJicol, C., Cheng, H. Y., Petrini, K., & O'Neill, E. J. (2023) · PLoS ONE · doi:10.1371/journal.pone.0280390 · Cited by 32 · see citing works
“Several studies have assumed that presence drives emotion and not the other way around [50, 61, 62].”
BackgroundVisual modality research in virtual and mixed reality simulation
Stevens, J. A., Kincaid, P., & Sottilare, R. A. (2015) · The Journal of Defense Modeling and Simulation Applications Methodology Technology · doi:10.1177/1548512915569742 · Cited by 28 · see citing works
Palombi, T., Galli, F., Giancamilli, F., D’Amico, M., Alivernini, F., Gallo, L., Neroni, P., Predazzi, M., Pietro, G. D., Lucidi, F., et al. (2023) · Scientific Reports · doi:10.1038/s41598-023-40510-0 · Cited by 27 · see citing works
Peperkorn, H. M., Diemer, J., Alpers, G. W., & Mühlberger, A. (2016) · Frontiers in Psychology · doi:10.3389/fpsyg.2016.00268 · Cited by 28 · see citing works
“Our results shed light on the significance of different fear triggers (visual, conceptual) in interaction with body representations.”
BackgroundResultBehavioral Therapy and Virtual Reality Exposure for Public Speaking Anxiety
Zacarin, M. R. J., Borloti, E., & Haydu, V. B. (2019) · Temas em Psicologia · doi:10.9788/tp2019.2-14 · Cited by 26 · see citing works
New Directions in Virtual Reality-Based Therapy for Anxiety Disorders
David, D., Matu, S.-A., & David, O. A. (2013) · International Journal of Cognitive Therapy · doi:10.1521/ijct.2013.6.2.114 · Cited by 25 · see citing works
Cortez-Vázquez, G., Adriaanse, M. C., Burchell, G. L., Ostelo, R., Panayiotou, G., & Vlemincx, E. (2024) · Applied Psychophysiology and Biofeedback · doi:10.1007/s10484-023-09611-4 · Cited by 31 · see citing works
“Previous research has shown that greater involvement in a virtual environment exposure treatment is linked to improved treatment response for public speaking fear (Price et al., 2011).”
BackgroundVirtual Reality Therapy for Social Phobia: A Scoping Review
Elham, S., Mehrabi, M., Fatehi, F., & Salehi, A. (2020) · Studies in health technology and informatics · doi:10.3233/shti200253 · Cited by 25 · see citing works
“During the talk, their heart rate is monitored and the content of the presentation is recorded [10, 12, 14, 15, 20, 21].”
BackgroundMethodHawajri, O., Lindberg, J., & Suominen, S. (2023) · Issues in Mental Health Nursing · doi:10.1080/01612840.2023.2190051 · Cited by 26 · see citing works
“This shows that VRET has a sustained effect even after the end of treatment (Anderson et al., 2013; Price et al., 2011; Zainal et al., 2021).”
BackgroundA Comparison of Active and Passive Virtual Reality Exposure Scenarios to Elicit Social Anxiety
Sekhavat, Y. A., & Nomani, P. (2017) · International Journal of Serious Games · doi:10.17083/ijsg.v4i2.154 · Cited by 24 · see citing works
“According to [42], different aspects of presence are associated with the experience of fear.”
BackgroundOrru, K., Kask, S., & Nordlund, A. M. (2018) · Journal of Ecotourism · doi:10.1080/14724049.2018.1526290 · Cited by 24 · see citing works
“Existing research has shown the low feeling of authenticity and immersion in an experience to be the key impediment to emotional responses and feelings of presence while on a virtual tour (Guttentag, 2010; Price et al., 2011; Seth et al., 2012).”
BackgroundPresence and simulator sickness predict the usability of a virtual reality attention task
Voinescu, A., Petrini, K., & Fraser, D. S. (2023) · Virtual Reality · doi:10.1007/s10055-023-00782-3 · Cited by 25 · see citing works
“Some studies identified a positive relationship between presence and performance across various environments and tasks (Cooper et al. 2018; Price et al. 2011; Stevens and Kincaid 2015).”
BackgroundResultKerouš, B., Barteček, R., Román, R., Sojka, P., Bečev, O., & Liarokapis, F. (2020) · Journal of Ambient Intelligence and Humanized Computing · doi:10.1007/s12652-020-01858-7 · Cited by 23 · see citing works
Libera, C. D., Simon, J., Larøi, F., Quertemont, É., & Wagener, A. (2023) · Virtual Reality · doi:10.1007/s10055-023-00779-y · Cited by 26 · see citing works
“This study, as well as a few others (Felnhofer et al. 2019; Gamito et al. 2014; Price et al. 2011; Simon et al. 2020), is part of this approach.”
ResultMalihi, M., Nguyen, J. L., Cardy, R. E., Eldon, S., Petta, C., & Kushki, A. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00669 · Cited by 22 · see citing works
“Engagement re fl ects attention to the virtual stimuli and has been associated with enhanced intervention effectiveness (66).”
BackgroundSpagnolli, A., Bracken, C. C., & Orso, V. (2014) · Virtual Reality · doi:10.1007/s10055-013-0241-x · Cited by 23 · see citing works
“Price (2011) [61] Social phobia During the last 3 sessions of the treatment patients were exposed to three different virtual scenarios: a conference room, a classroom and a large auditorium.”
BackgroundSong, Y., Jordan, J., Shaffer, K. A., Wing, E. K., McRae, K., & Waugh, C. E. (2018) · Cognition & Emotion · doi:10.1080/02699931.2018.1541789 · Cited by 26 · see citing works
Clemmensen, L., Bouchard, S., Rasmussen, J., Holmberg, T. T., Nielsen, J. H., Jepsen, J. R. M., & Lichtenstein, M. B. (2020) · BMC Psychiatry · doi:10.1186/s12888-020-2453-4 · Cited by 21 · see citing works
Virtual reality exposure therapy for reducing school anxiety in adolescents: Pilot study
Beele, G., Liesong, P., Bojanowski, S., Hildebrand, K., Weingart, M., Asbrand, J., Correll, C. U., Morina, N., & Uhlhaas, P. J. (2024) · JMIR Mental Health · doi:10.2196/56235 · Cited by 20 · see citing works
“It may therefore also be relevant for therapeutic efficacy [55].”
BackgroundResultInfluentialVugts, M. A. P., Zedlitz, A. M. E. E., Joosen, M. C. W., & Vrijhoef, H. J. (2019) · Journal of Medical Internet Research · doi:10.2196/14766 · Cited by 18 · see citing works
Lobbestael, J., & Cima, M. (2021) · Brain Sciences · doi:10.3390/brainsci11121653 · Cited by 19 · see citing works
“environment and avatars and telepresence were rated between 17 and 47/100 and, thus, comparable to the results of some other studies [81,82], but lower than observed in other studies [79,80,83–85].”
ResultLee, J., Kang, D.-Y., & Kim, J. (2023) · Cyberpsychology, Behavior, and Social Networking · doi:10.1089/cyber.2022.0243 · Cited by 17 · see citing works
Bloch, F., Rigaud, A., & Kemoun, G. (2013) · European Geriatric Medicine · doi:10.1016/j.eurger.2013.10.005 · Cited by 16 · see citing works
“Several experiments have also been conducted with VRET to treat various psychological disorders [14] such as agoraphobia [15], body image disorders [16] and fear of flying [17].”
BackgroundArnfred, B. T., Svendsen, J. K., Adjorlu, A., & Horthøj, C. (2023) · Frontiers in Virtual Reality · doi:10.3389/frvir.2023.952741 · Cited by 15 · see citing works
“21 studies examining SAD were included.”
BackgroundInfluentialScheveneels, S., Engelhard, I. M., & Meyerbröker, K. (2024) · Clinical Psychological Science · doi:10.1177/21677026241267945 · Cited by 15 · see citing works
“In a follow-up study considering the different components of presence, overall presence also did not predict VRET outcome (Price et al., 2011).”
Effects of system- and media-driven immersive capabilities on presence and affective experience
Standen, B., Anderson, J., Sumich, A. L., & Heym, N. (2021) · Virtual Reality · doi:10.1007/s10055-021-00579-2 · Cited by 14 · see citing works
“Indeed, presence has been associated with elicitation of greater levels of fear (Price et al. 2011) and anxiety (Ling et al. 2014), which are essential for exposure therapy to be successful (Benito and Walther 2015).”
BackgroundVR for Studying the Neuroscience of Emotional Responses
Andreatta, M., Winkler, M. H., Collins, P., Gromer, D., Gall, D., Pauli, P., & Gamer, M. (2023) · Current topics in behavioral neurosciences · doi:10.1007/7854_2022_405 · Cited by 14 · see citing works
Chard, I., Zalk, N. V., & Picinali, L. (2023) · Frontiers in Virtual Reality · doi:10.3389/frvir.2023.1159549 · Cited by 12 · see citing works
Predictors of Engagement in Virtual Reality Storytelling Environments about Migration
Avila, C., Bacca-Acosta, J., & Chaves-Rodríguez, J. (2023) · Applied Sciences · doi:10.3390/app131910915 · Cited by 12 · see citing works
Maymon, C., Crawford, M. T., Blackburne, K., Botes, A., Carnegie, K., Mehr, S. A., Meier, J., Murphy, J., Miles, N. L., Robinson, K., et al. (2024) · Journal of Experimental Psychology General · doi:10.1037/xge0001576 · Cited by 15 · see citing works
Johnson, S. B., & Anderson, P. L. (2016) · Anxiety Stress & Coping · doi:10.1080/10615806.2016.1138289 · Cited by 12 · see citing works
Heart Rate Prediction from Head Movement during Virtual Reality Treatment for Social Anxiety
Noori, F. M., Kahlon, S., Lindner, P., Nordgreen, T., Torresen, J., & Riegler, M. (2019) · 2019 International Conference on Content-Based Multimedia Indexing (CBMI) · doi:10.1109/cbmi.2019.8877454 · Cited by 11 · see citing works
Steinhaeusser, S. C., Eckstein, B., & Lugrin, B. (2022) · Entertainment Computing · doi:10.1016/j.entcom.2022.100539 · Cited by 11 · see citing works
Chang, Y.-C., & Yang, C. (2024) · Behavioral Sciences · doi:10.3390/bs14090781 · Cited by 13 · see citing works
“McLean et al. found that increasing immersion and sensory awareness during VR experiences can help improve VR presence [18], thereby stimulating emotions [22–26].”
Background
- Authors
- Price, M., Mehta, N., Tone, E. B., & Anderson, P. L.
- Affiliations
- Medical University of South Carolina (US)
- Georgia State University (US)
- Corresponding author
- Anderson, Page L.
- Venue
- Journal of Anxiety Disorders
- Publisher
- Elsevier BV
- Published
- 2011-08
- Volume
- 25
- Issue
- 6
- Pages
- 763-770
- ISSN
- 0887-6185 (ISSN-L)
- PMC
- PMC3401534
- OpenAlex
- W2006180230
- Cited by
- 187
- References
- 38
- Citations by year
- 2026: 6 · 2025: 13 · 2024: 19 · 2023: 23 · 2022: 13 · 2021: 8 · 2020: 19 · 2019: 19 · 2018: 19 · 2017: 10 · 2016: 7 · 2015: 13 · 2014: 8 · 2013: 9 · 2012: 1
- FWCI
- 10.17
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Anxiety Disorders (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Digital Archive @ GSU (submittedVersion)
- Funders
- National Institute of Mental Health (R42MH060506)
- Topics
- Physical Sciences › Computer Science › Human-Computer Interaction › Virtual Reality Applications and Impacts
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- virtual reality exposure therapy, social anxiety disorder, presence, spatial presence, involvement, realness, treatment response, expectancy violation, distraction, anxiety disorders
- MeSH terms
- Adult, Amygdala, Anxiety, Fear, Female, Humans, Implosive Therapy, Male, Phobic Disorders, Surveys and Questionnaires, User-Computer Interface, Treatment Outcome
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