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Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial
Open accessAbstract
BACKGROUND: Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist. METHODS/DESIGN: Participants with specific phobia to spiders (N = 100) will be recruited from the general public, screened, and randomized to either VR exposure therapy (n = 50) or traditional OST (n = 50). A behavioral approach test using in vivo spiders will serve as the primary outcome measure. Secondary outcome measures will include spider phobia questionnaires and self-reported anxiety, depression, and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1, 12, and 52 weeks after treatment. DISCUSSION: VR exposure therapy has previously been evaluated as a treatment for specific phobias, but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices is being released that are advancing existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable for taking advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation. This study compares a market-ready, gamified VR spider phobia exposure application, delivered using consumer VR hardware, with the current gold standard treatment. Implications are discussed. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02533310. Registered on 25 August 2015.
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“and is more accessible, confidential, and resource-effective compared to traditional exposure in vivo (Carl et al., 2019; Emmelkamp, 2005; Miloff et al., 2016; Reeves et al., 2022).”
From Virtual Reality exposure therapy in the treatment of public speaking anxiety and social anxiety disorder (2024) · cites this paper as Miloff et al., 2016
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“A first step in that direction is the ongoing randomized controlled non-inferiority trial where a single-session gamified virtual reality exposure therapy for spider phobia is compared to traditional exposure therapy (Miloff et al., 2016).”
BackgroundSelf-citationVisual Complexity and Scene Recognition: How Low Can You Go?
Handali, J. P., Schneider, J., Gau, M., Holzwarth, V., & Brocke, J. V. (2021) · IEEE Conference on Virtual Reality and 3D User Interfaces (VR) · doi:10.1109/vr50410.2021.00051 · Cited by 11
“Unlike VEs for VR applications such as scientific visualization [26], data visualization [2], therapy [39], VEs for urban planning applications require a strong adherence to the modelled real-world location.”
BackgroundMartins, S., & Vairinhos, M. (2023) · Virtual Worlds · doi:10.3390/virtualworlds2040018 · Cited by 6
Extended reality for biomedicine
Yuan, J., Hassan, S. S., Wu, J., Koger, C. R., Packard, R. R. S., Shi, F., Fei, B., & Ding, Y. (2023) · Nature Reviews Methods Primers · doi:10.1038/s43586-023-00208-z · Cited by 13
Wechsler, T. F., Kocur, M., Schumacher, S., Rubenbauer, M., Ruider, A., Brockelmann, M., Lankes, M., Wolff, C. G., & Mühlberger, A. (2023) · Clinical Child Psychology and Psychiatry · doi:10.1177/13591045231194103 · Cited by 10
“There are already approaches integrating playful elements into VRET for adults with spider phobia (Go et al., 2020; Lindner et al., 2020; McMaster, 2020; Miloff et al., 2016).”
BackgroundKhaleghi, A., Narimani, A., Aghaei, Z., Banaraki, A. K., & Hassani‐Abharian, P. (2024) · JMIR Serious Games · doi:10.2196/34535 · Cited by 13
“The quality of fear elements’behaviors: studying the behavior quality of a stimulus is under investigation [31,32].”
BackgroundInnovations in CBT treatment for hoarding: Transcending office walls
Muroff, J. R., & Otte, S. (2019) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2019.100471 · Cited by 10
Ribé-Viñes, J. M., Gutiérrez‐Maldonado, J., Zabolipour, Z., & Ferrer‐García, M. (2023) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2023.101915 · Cited by 12
Go, C. T. T. H., Leis, E. G., Quiambao, M. J. D., Samonte, M. J. C., Fuentes, G. S., & Pascua, C. A. (2020) · International Conference on Frontiers of Educational Technologies (ICFET) · doi:10.1145/3404709.3404742 · Cited by 9
“Phobic people are gradually exposed to their fears at a distance and going closer as they progress [8][9].”
BackgroundMethodBanakou, D., Johnston, T., Beacco, A., Şenel, G., & Slater, M. (2024) · JMIR Formative Research · doi:10.2196/52212 · Cited by 12
“The paradigm was similar to an earlier one for treatment of spider phobia, which had similar positive results [50].”
ResultThe Disappearing Computer Science in Healthcare VR applications
Lundström, A., & Fernaeus, Y. (2019) · Halfway to the Future Symposium · doi:10.1145/3363384.3363398 · Cited by 9
Wechsler, T. F., Brockelmann, M., Kulik, K., Kopf, F. M., Kocur, M., Lankes, M., Mühlberger, A., & Wolff, C. G. (2021) · Annual Symposium on Computer-Human Interaction in Play · doi:10.1145/3450337.3483463 · Cited by 9
“Another approach transferred exposure therapy elements for spider phobia into a gamified VR application, asking users to focus on a moving spider to gain points, to keep a moving spider save by stopping objects from hitting it, or to keep focusing on an approaching spider which otherwise turns away [13, 16].”
BackgroundRealism in Audiovisual Stimuli for Phobias Treatments Through Virtual Environments
Ortiz, J. S., Velasco, P. M., Quevedo, W. X., Álvarez, M., Sánchez, J. S., Carvajal, C. P., Cepeda, L. F., & Andaluz, V. H. (2017) · Lecture notes in computer science · doi:10.1007/978-3-319-60928-7_16 · Cited by 8
Ørskov, P. T., Runge, E., Holmberg, T. T., Ernst, M. T., Clemmensen, L., Dalsgaard, C., Lichtenstein, M. B., & Bouchard, S. (2025) · Frontiers in Virtual Reality · doi:10.3389/frvir.2025.1588181 · Cited by 7
Freize, V. V., Malyshko, L. V., Grachev, G. I., Борисович, Д. В., Semenova, N. V., & Незнанов, Н. Г. (2021) · V M BEKHTEREV REVIEW OF PSYCHIATRY AND MEDICAL PSYCHOLOGY · doi:10.31363/2313-7053-2021-1-18-24 · Cited by 7
Babatunde, Y. O., Adegbite, M. A., Oladipo, H. J., Omojuyigbe, J. O., Sampson‐Oladipupo, E., Ibrahim, A. A., Oziama, B., Adedeji, O. J., & Ibrahim, A. (2023) · Pharmacy Education · doi:10.46542/pe.2023.231.717 · Cited by 7
Meaningful Spaces, Meaningful Places: Co-creating VR Experiences with People Living with Dementia
Cheung, E. T. H., Ppali, S., Xygkou, A., Covaci, A., Jawharieh, H., Thomas, C. L., & Ang, C. S. (2023) · Designing Interactive Systems Conference · doi:10.1145/3563703.3596624 · Cited by 6
Co-watching 360-Films in Nursing Homes
Lundström, A., Ghebremikael, S., & Fernaeus, Y. (2021) · Lecture notes in computer science · doi:10.1007/978-3-030-85623-6_30 · Cited by 6
Naeem, F., Munshi, T. A., Gratzer, D., Rodie, D. J., Irfan, M., Rao, S., Husain, N., Farooq, S., Sanches, M., Ayub, M., et al. (2019) · BJPsych Open · doi:10.1192/bjo.2019.59 · Cited by 6
Detecting Public Speaking Stress via Real-Time Voice Analysis in Virtual Reality: A Review
Arushi, Dillon, R., Teoh, A. N., & Dillon, D. (2023) · Springer eBooks · doi:10.1007/978-981-99-2909-2_7 · Cited by 5
A Comparative Study Between Different Treatments for Spider Phobia
Ramírez-Fernández, C., Morán, A. L., & Meza-Kubo, V. (2021) · Mexican Conference on Human-Computer Interaction (MexIHC) · doi:10.1145/3492724.3492726 · Cited by 6
“Finally, in condition C4 (IVET), the participant observed an actual spider and interacted with it by touching it directly with his/her hand/fingers.”
BackgroundInfluentialŠalkevičius, J., & Navickas, L. (2018) · International Conference on Future Internet of Things and Cloud Workshops (FiCloudW) · doi:10.1109/w-ficloud.2018.00040 · Cited by 5
“Miloff et al. describes a methodology how VRET can reduce cost of traditional one-session exposure therapy (OST) [12].”
BackgroundInfluentialRamírez-Fernández, C., Morán, A. L., & Meza-Kubo, V. (2018) · International Conference on Ubiquitous Computing and Ambient Intelligence · doi:10.3390/proceedings2191252 · Cited by 5
“With respect to their effectiveness, there are several studies that have shown that both VRET and ARET are equally effective as IVET for the treatment of specific phobias [9–13].”
BackgroundInfluentialOGrES Welcome! Toward a Systematic Theory for Serious Game Design
Blackburn, N. N., & Cardona-Rivera, R. E. (2021) · Annual Symposium on Computer-Human Interaction in Play · doi:10.1145/3450337.3483460 · Cited by 4
“analyses broadly converge on the same findings [9, 12, 16, 28].”
BackgroundAcrophobia and consumer-based automated virtual reality cognitive behavior therapy
Donker, T., & Heinrichs, M. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-85726-0.00035-1 · Cited by 4
VR Mobile Acrophobia Treatment
Alkurdi, A. H. (2017) · Academic Journal of Nawroz University · doi:10.25007/ajnu.v6n3a95 · Cited by 4
The future of virtual reality therapy for phobias: Beyond simple exposures
Miloff, A., Lindner, P., & Carlbring, P. (2020) · Clinical Psychology in Europe · doi:10.32872/cpe.v2i2.2913 · Cited by 4
“In the last few years our research team at Stockholm University have used the device to treat nearly 100 spider phobic patients with virtual reality exposure therapy (VRET) using the Itsy application, developed alongside VR-startup Mimerse (Miloff et al., 2016).”
MethodSelf-citationLewis-Fung, S. E., Tchao, D., Gray, H. G., Nguyen, E., Pardini, S., Harris, L. R., Calabia, D., & Appel, L. (2023) · Frontiers in Virtual Reality · doi:10.3389/frvir.2023.1209535 · Cited by 3
Extended Reality and Phobia Treatments: A Systematic Literature Review
Ferreira, T., Batista, T., Lopes, T., Malheiro, P., Vitorino, J., Vaz, R., & de Sousa, J. (2025) · Procedia Computer Science · doi:10.1016/j.procs.2025.02.213 · Cited by 5
Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint
Takemoto, J. K., Parmentier, B. L., Bratelli, R., & Merritt, T. A. (2020) · Journal of Contemporary Pharmacy Practice · doi:10.37901/jcphp18-00030 · Cited by 3
“VR experiences can be customized to individual phobias and can even be gamified to improve engagement.(31) A meta-analysis conducted by Morina et al.”
BackgroundConquer Catharsis – A VR Environment for Anxiety Treatment of Children and Adolescents
Lenz, A., Hlavacs, H., Kothgassner, O. D., & Felnhofer, A. (2020) · Lecture notes in computer science · doi:10.1007/978-3-030-65736-9_14 · Cited by 3
Smart Devices als Assistive Technologien
Lorenz, T., Pleger, M., & Schiering, I. (2022) · Gesundheit. Politik - Gesellschaft - Wirtschaft · doi:10.1007/978-3-658-34027-8_2 · Cited by 3
Yamauchi, Y., Ino, K., Sakaguchi, M., & Zempo, K. (2025) · ACM Transactions on Computing for Healthcare · doi:10.1145/3723048 · Cited by 2
A Gamified Virtual Reality Exposure Therapy for Individuals with Arachnophobia: A Pilot Study
Lopes, I. S., de Almeida, R. S., Gomes, P. V., & Marques, A. J. (2025) · Virtual Worlds · doi:10.3390/virtualworlds4020015 · Cited by 3
Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint
Takemoto, J. K., Parmentier, B. L., Bratelli, R., Merritt, T. A., & Coyne, L. (2019) · Journal of Contemporary Pharmacy Practice · doi:10.37901/2573-2765-66.4.33 · Cited by 2
Ramírez-Fernández, C., Morán, A. L., & Meza-Kubo, V. (2022) · Interacting with Computers · doi:10.1093/iwc/iwac026 · Cited by 2
Metadata
- Authors
- Miloff, A., Lindner, P., Hamilton, W., Reuterskiöld, L., Andersson, G., & Carlbring, P.
- Affiliations
- Stockholm University (SE)
- Linköping University (SE)
- Corresponding author
- Miloff, Alexander
- Venue
- Trials
- Published
- 2016-02-02
- Volume
- 17
- Issue
- 1
- Pages
- 60-60
- ISSN
- 1745-6215 (ISSN-L)
- PMC
- PMC4736108
- OpenAlex
- W2272558351
- Cited by
- 141
- References
- 61
- Citations by year
- 2026: 9 · 2025: 17 · 2024: 11 · 2023: 20 · 2022: 8 · 2021: 15 · 2020: 17 · 2019: 19 · 2018: 17 · 2017: 7 · 2016: 1
- FWCI
- 22.86
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Trials (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- KTH Publication Database DiVA (KTH Royal Institute of Technology) (submittedVersion, other-oa)
- Funders
- Vetenskapsrådet (2011-2913)
- Forskningsrådet om Hälsa, Arbetsliv och Välfärd (SE) (2011-2913)
- 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
- spider phobia, virtual reality exposure therapy, specific phobia, non-inferiority, anxiety, depression, quality of life
- MeSH terms
- Equivalence Trials as Topic, Adult, Animals, Clinical Protocols, Humans, Phobic Disorders, Spiders, Outcome Assessment, Health Care, Virtual Reality Exposure Therapy
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