Attention guidance augmentation of virtual reality exposure therapy for social anxiety disorder: a pilot randomized controlled trial

The evidence was weak against an effect of condition on fear of public speaking.

“There was weak evidence against an effect of condition on fear of public speaking”

The attention guidance augmentation affected changes in visual attention to audience members.

“as well as an effect of the AGT augmentation on changes in visual attention to audience members.”

In this pilot trial, the intervention had a large overall effect on social anxiety symptoms.

“There was a large overall effect of the intervention on symptoms of social anxiety”

The evidence was weak in support of a mediation effect.

“weak evidence supporting a mediation effect”

The mediation estimates were strongly influenced by the model priors.

“however these estimates were strongly influenced by model priors.”

There was no meaningful difference between groups in overall change in proportion of fixations to uninterested audience members at one-week follow-up (b = 0.23, 95% HDI [−0.08, 0.53], BF = 2.00).

“or at one-week follow-up b = 0.23, 95% HDI [−0.08, 0.53], BF = 2.00.”

In the attention-guidance condition, participants allocated a greater proportion of gaze to audience members during treatment than in the standard-exposure condition (b = 0.27, 95% HDI [0.11, 0.41], BF = 70.14).

“There were meaningful differences in the proportion of gaze allocated to audience members during treatment in the standard-exposure compared to attention-guidance conditions b = 0.27, 95% highest posterior density interval (HDI) [0.11, 0.41], Bayes Factor (BF) = 70.14, with greater gaze allocated to audience members in the attention-guidance condition during the intervention trials.”

• Also stated in: § Discussion · hedged

  “Additionally, our data indicated that there was reduced avoidance of all audience members in the attention augmentation group.”

There was no effect of group on general social anxiety symptoms at one-week follow-up (b = −3.20, 95% HDI [−15.27, 22.15], BF = 0.44).

“or one-week follow-up b = −3.20, 95% HDI [−15.27, 22.15], BF = 0.44.”

There was no effect of group on fear of public speaking at one-week follow-up (b = 3.19, 95% HDI [−10.16, 16.57], BF = 0.37).

“or at one-week follow-up b = 3.19, 95% HDI [−10.16, 16.57], BF = 0.37.”

There was a meaningful group × assessment interaction on proportion of fixations to uninterested audience members at post-treatment (b = 0.16, 95% HDI [0.07, 0.26], BF = 2.52).

“There was a meaningful group (VRET vs. VRET + attention guidance) × assessment interaction at post-treatment b = 0.16, 95% HDI [0.07, 0.26], BF = 2.52”

There was a large effect of time for general symptoms of social anxiety at 1-week follow-up (b = −21.99, 95% HDI [−29.08, −14.70], BF = 615.78, dGMA-raw = −2.07, 95% HDI [−2.94, −1.16]).

“and large effect at 1-week follow-up b = −21.99, 95% HDI [−29.08, −14.70], BF = 615.78, dGMA-raw = −2.07 95% HDI [−2.94, −1.16].”

There was no effect of group on fear of public speaking at post-treatment (b = 6.14, 95% HDI [−1.57, 13.95], BF = 0.38).

“Moreover, we did find not find an effect of group at post-treatment b = 6.14, 95% HDI [−1.57, 13.95], BF = 0.38”

Greater proportion of fixations to uninterested audience members at post-treatment mediated the effect of group on general symptoms of social anxiety at one-week follow-up, with anecdotal evidence (partially standardized indirect effect = −0.097, 95% HDI [−0.197, −0.024], BF = 1.58).

“or general symptoms of social anxiety (partially standardized indirect effect = −0.097, 95% HDI −0.197, −0.024], BF = 1.58) at the one-week follow-up.”

• AssumptionRests on an assumption: Uninterested audience members in the 360° videos are perceived as socially threatening by participants.

There was a moderate main effect of time for general symptoms of social anxiety at post-intervention (b = −11.72, 95% HDI [−18.61, −4.58], BF = 6.45, dGMA-raw = −0.60, 95% HDI [−1.02, −0.15]).

“We found a moderate main effect of time for general symptoms of social anxiety at post-intervention b = −11.72, 95% HDI [−18.61, −4.58], Bayes Factor (BF) = 6.45, dGMA-raw = −0.60 95% HDI [−1.02, −0.15]”

There was no main effect of group on proportion of fixations to uninterested audience members (b = 0.09, 95% HDI [−0.30, 0.48], BF = 1.02).

“There was also no main effect of group b = 0.09, 95% HDI [−0.30, 0.48], BF = 1.02.”

There was a large main effect of time on fear of public speaking at 1-week follow-up (b = −13.16, 95% HDI [−21.28, −9.01], BF = 26.14, dGMA-raw = −1.68, 95% HDI [−2.68, −0.70]).

“and at 1-week follow-up b = −13.16, 95% HDI [−21.28, −9.01], BF = 26.14, dGMA-raw = −1.68, 95% HDI [−2.68, −0.70].”

There was no meaningful difference between groups in overall change in proportion of fixations to uninterested (socially threatening) audience members at post-treatment (b = 0.14, 95% HDI [−0.16, 0.44], BF = 1.02).

“There were no meaningful differences in the overall change in proportion of fixations to uninterested (socially threatening) audience members at post-treatment b = 0.14, 95% HDI [−0.16, 0.44], BF = 1.02”

There was moderate evidence against a main effect of group on fear of public speaking (b = −5.55, 95% HDI [−13.88, 2.53], BF = 0.28).

“We found moderate evidence against a main effect of group (standard exposure vs. attention augmentation) on fear of public speaking b = −5.55, 95% HDI [−13.88, 2.53], BF = 0.28.”

Greater proportion of fixations to uninterested audience members at post-treatment mediated the effect of group on fear of public speaking at one-week follow-up, with anecdotal evidence (partially standardized indirect effect = −0.218, 95% HDI [−0.605, 0.026], BF = 2.85).

“We found anecdotal evidence (based on the BFs) that greater proportion of fixations to Uninterested audience members at the post-treatment assessment, mediated the effect of group (standard exposure vs. attention guidance augmentation) on fear of public speaking (partially standardized indirect effect = −0.218, 95% HDI [−0.605, 0.026], BF = 2.85)”

• AssumptionRests on an assumption: Uninterested audience members in the 360° videos are perceived as socially threatening by participants.

There was no main effect of group on general social anxiety symptoms (b = −4.86, 95% HDI [−17.08, 11.48], BF = 0.84).

“We did not find a main effect of group on general social anxiety symptoms b = −4.86, 95% HDI [−17.08, 11.48], BF = 0.84”

In the current context, the divergence between gaze and head orientation was sufficiently large to make comparisons between them extremely problematic.

“In the current context the divergence between gaze and head orientation was sufficiently large to make such comparisons extremely problematic.”

There was no effect of group on general social anxiety symptoms at post-treatment (b = −2.05, 95% HDI [−13.48, 18.18], BF = 0.24).

“similarly, we found no effect of group at post-treatment b = −2.05, 95% HDI [−13.48, 18.18], BF = 0.24”

The estimation of the indirect effect had a large degree of bias.

“the large degree of bias further emphasizes the importance of obtaining a larger sample to evaluate the stability of the estimates of these effects.”

There was a large main effect of time on fear of public speaking, with a meaningful reduction post-treatment (b = −17.37, 95% HDI [−21.64, −9.63], BF = 510.80, dGMA-raw = −1.11, 95% HDI [−1.58, −0.63]).

“There was a large main effect of time on fear of public speaking, with a meaningful reduction in fear of public speaking post-treatment b = −17.37, 95% highest posterior density interval (HDI) [−21.64, −9.63], Bayes Factor (BF) = 510.80, dGMA-raw = −1.11, 95% HDI [−1.58, −0.63]”

Across groups, there was a large reduction in cognitions related to public speaking anxiety.

“There was a large reduction in fear of public speaking, general symptoms of social anxiety, and cognitions related to public speaking anxiety across groups.”

There was a meaningful group × assessment interaction on proportion of fixations to uninterested audience members at one-week follow-up (b = 0.30, 95% HDI [0.20, 0.39], BF = 0.91).

“and at one-week follow-up b = 0.30, 95% HDI [0.20, 0.39], BF = 0.91.”

It is possible to change attention during a course of VRET.

“our findings suggest that attention can be modified within and during VRET”

Less avoidance of looking at others may lead to lower social anxiety.

“modification of visual gaze avoidance may be casually linked to reductions in social anxiety.”

VRET is a highly effective intervention for social anxiety disorder.

“There is substantial evidence that virtual reality exposure therapy (VRET) for SAD is a highly effective intervention modality (Carl et al., 2019; Chesham et al., 2018).”

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The groups did not differ meaningfully at baseline.

“there were no meaningful differences between groups at baseline”

Recent work has shown that 360°-video VRET is effective.

“Recent research has demonstrated the use of 360°-video for VRET to be effective (Reeves et al., 2021).”

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Changing visual attention during exposure therapy provides a direct way to test whether biased attention is a mechanism in social anxiety disorder.

“Modifying visual attention during exposure therapy offers a direct test of this mechanism.”

Attention bias modification has moderate efficacy for reducing social anxiety symptoms.

“Results from Attention Bias Modification (ABM) have been promising with meta-analysis indicating that it has moderate efficacy for reducing symptoms of social anxiety (Heeren, Mogoase, et al., 2015).”

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Within people with social anxiety, attentional bias is not consistently present.

“there is some evidence that within individuals with social anxiety there is no consistent attentional bias (Kruijt et al., 2019).”

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Attentional biases, including avoidance of social threat, are implicated in social anxiety disorder.

“Biased attention to social threat has been implicated in social anxiety disorder.”

• Also stated in: § Abstract · plain

  “Attentional processes figure prominently in most contemporary models of SAD (Clark & Wells, 1995; Wong & Rapee, 2016) and have been the focus of considerable empirical work (Bögels & Mansell, 2004).”

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Avoidance of social threat may maintain social anxiety disorder.

“Both theoretical models of Social Anxiety Disorder (Clark & Wells, 1995; Wong & Rapee, 2016) and some prior research (Kim et al., 2018; Rubin et al., 2020) support the hypothesis that avoidance of social threat may serve as a maintaining factor of the disorder.”

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The findings offer further validation that VRET for social anxiety disorder is a highly effective treatment.

“Taken together our findings offer further validation that VRET for social anxiety disorder is a highly effective treatment.”

The sample size of the current study may have limited the possibility of detecting the indirect effect.

“It is important to acknowledge that the sample size of the current study may have limited the possibility of detecting this indirect effect.”

There was anecdotal evidence in favor of the null hypothesis that there was no difference between the two intervention groups.

“There was anecdotal (based on the BFs) evidence in favor of the null (that there was no difference between the two intervention groups).”

The study did not conduct a power analysis reflecting the sample size for the current pilot study.

“We did not conduct a power analysis that reflected the sample size for the current pilot study.”

Virtual environments with eye tracking can overcome the difficulty of assessing attention during in vivo exposure.

“However, this difficulty can be addressed with virtual environments that incorporate eye tracking.”

• AssumptionRests on an assumption: Clinicians cannot easily judge how much a patient looks at audience members during an in-person speech task.

Evidence regarding decreased avoidance as a potential mechanism maintaining social anxiety was slight.

“However, evidence regarding decreased avoidance as a potential mechanism maintaining social anxiety was slight.”

The results provide very weak evidence supporting the role of attention change on symptoms of fear of public speaking and general social anxiety.

“Taken together our results suggest that there is very weak evidence supporting the role of attention change on symptoms of fear of public speaking and general social anxiety, but further research is needed with larger samples.”

Due to COVID-19, enrollment ended before recruitment goals were met.

“However, due to COVID-19 enrollment ended before we could meet our recruitment goals.”

The study did not include at baseline a non-socially anxious group to confirm the presence of biased attention among individuals with social anxiety.

“Second, we did not include at baseline a non-socially anxious group to confirm the presence of biased attention among individuals with social anxiety.”

The findings highlight the utility of a Bayesian approach as the study was able to conduct a meaningful analysis despite a small sample size.

“Our findings highlight the utility of a Bayesian approach as we were able to conduct a meaningful analysis despite a small sample size and interpret our ambiguous findings in a way that serves to inform future research.”

A virtual reality setting makes it feasible to directly test whether attentional avoidance is causally involved in maintaining social anxiety disorder.

“A virtual reality context makes it practicable to directly test whether attentional avoidance is causally implicated as a mechanism maintaining SAD.”

• AssumptionRests on an assumption: It is difficult to test attentional change directly within psychotherapy.
• AssumptionRests on an assumption: Clinicians cannot easily judge how much a patient looks at audience members during an in-person speech task.

The intervention engaged the target mechanism: the exposure augmentation led to a meaningful change in attention allocation, with substantially greater proportion of gaze toward uninterested audience members compared to the standard exposure group following the intervention.

“There was strong evidence that our intervention engaged the target mechanism - the exposure augmentation led to a meaningful change in attention allocation, with a substantially greater proportion of gaze toward uninterested (socially threatening) audience members compared to the standard exposure group following the intervention.”

Preliminary evidence does not support an effect of the attention guidance augmentation on fear of public speaking or general symptoms of social anxiety.

“However, preliminary evidence does not support the presence of an effect of the attention guidance augmentation on fear of public speaking or general symptoms of social anxiety.”

Attentional processes can be directly altered during exposure therapy.

“Additionally, we showed that attentional processes can be directly altered during exposure therapy.”

The study screened participants based on self-reported fear following the pre-treatment public speaking challenge to ensure responsivity to the 360°-video stimuli during VRET.

“Finally, we screened participants based on their self-reported fear following the pre-treatment public speaking challenge. This was to ensure responsivity to the 360°-video stimuli during VRET.”