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Effectiveness of Self-guided App-Based Virtual Reality Cognitive Behavior Therapy for Acrophobia: A Randomized Clinical Trial

Educational Objective
To examine the effectiveness of ZeroPhobia, a fully self-guided app-based virtual reality cognitive behavior therapy using low-cost virtual reality goggles compared with a wait-list control group and to determine its user friendliness.
1 Credit CME
Key Points

Question  Is fully self-guided app-based virtual reality cognitive behavior therapy using low-cost (cardboard) virtual reality goggles user friendly and effective in reducing acrophobia symptoms compared with a wait-list control group?

Findings  In a single-blind randomized clinical trial that included 193 participants with acrophobia symptoms, app-based therapy demonstrated a large and significant reduction in acrophobia symptoms compared with wait-list controls and was rated as user friendly.

Meaning  Acrophobia cognitive behavioral therapy can be effectively delivered without therapist intervention through standard smartphones and low-cost virtual reality goggles at a fraction of the cost of current face-to-face treatment or high-end virtual reality exposure therapy.


Importance  Globally, access to evidence-based psychological treatment is limited. Innovative self-help methods using smartphone applications and low-cost virtual reality have the potential to significantly improve the accessibility and scalability of psychological treatments.

Objective  To examine the effectiveness of ZeroPhobia, a fully self-guided app-based virtual reality cognitive behavior therapy (VR CBT) using low-cost (cardboard) virtual reality goggles compared with a wait-list control group and to determine its user friendliness.

Design, Setting, and Participants  In a single-blind randomized clinical trial, participants were enrolled between March 24 and September 28, 2017, and randomly assigned (1:1) by an independent researcher to either VR CBT app or a wait-list control group. A total of 193 individuals aged 18 to 65 years from the Dutch general population with acrophobia symptoms and access to an Android smartphone participated. The 6 animated modules of the VR-CBT app and gamified virtual reality environments were delivered over a 3-week period in participants’ natural environment. Assessments were completed at baseline, immediately after treatment, and at 3-month follow-up. Analysis began April 6, 2018, and was intention to treat.

Intervention  Self-guided app-based VR CBT.

Main Outcomes and Measures  The primary outcome measure was the Acrophobia Questionnaire. The hypothesis was formulated prior to data collection.

Results  In total, 193 participants (129 women [66.84%]; mean [SD] age, 41.33 [13.64] years) were randomly assigned to intervention (n = 96) or a wait-list control group (n = 97). An intent-to-treat analysis showed a significant reduction of acrophobia symptoms at posttest at 3 months for the VR-CBT app compared with the controls (b = –26.73 [95% CI, −32.12 to −21.34]; P < .001; d = 1.14 [95% CI, 0.84 to 1.44]). The number needed to treat was 1.7. Sensitivity and robustness analysis confirmed these findings. Pretreatment attrition was 22 of 96 (23%) because of smartphone incompatibility. Of the 74 participants who started using the VR-CBT app, 57 (77%) completed the intervention fully.

Conclusions and Relevance  A low-cost fully self-guided app-based virtual reality cognitive behavioral therapy with rudimentary virtual reality goggles can produce large acrophobia symptom reductions. To our knowledge, this study is the first to show that virtual reality acrophobia treatment can be done at home without the intervention of a therapist.

Trial Registration  Trialregister.nl identifier: NTR6442

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Article Information

Corresponding Author: Tara Donker, PhD, Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, the Netherlands, (t.donker@vu.nl).

Accepted for Publication: January 7, 2019.

Published Online: March 20, 2019. doi:10.1001/jamapsychiatry.2019.0219

Author Contributions: Drs Cornelisz and van Klaveren had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Donker and van Gelder.

Acquisition, analysis, or interpretation of data: Donker, Cornelisz, van Klaveren, van Straten, Carlbring.

Drafting of the manuscript: Donker, Cornelisz, van Klaveren.

Critical revision of the manuscript for important intellectual content: van Klaveren, van Straten, Carlbring, Cuijpers, van Gelder.

Statistical analysis: Cornelisz, van Klaveren.

Obtained funding: Donker.

Administrative, technical, or material support: van Gelder.

Supervision: Donker, van Straten, Cuijpers.

Conflict of Interest Disclosures: Dr Donker reports grants from NWO Toegepaste en Technische Wetenschappen and NWO Creative Industrie-KIEM during the conduct of the study. Drs Donker and van Gelder have developed the virtual reality application ZeroPhobia, which is used in the present study in collaboration with Vrije Universiteit. ZeroPhobia is intended for commercial release. Hence, Drs Donker and van Gelder have not been involved in data analysis or any decisions related to the publication of findings. No other disclosures were reported.

Funding/Support: This study has been funded by NWO Toegepaste en Technische Wetenschappen (2016/STW/00099738) and NWO Creative Industrie-KIEM (314-98-076).

Role of the Funder/Sponsor: The funders of the study had no role in study design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, writing of the report, review or approval of the manuscript; and the decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We extend our gratitude to all the participants of the study; Bruno de Vos, BA (Studio Barbaar), for designing ZeroPhobia; Wouter Houwen (Fontys Hogescholen Eindhoven), Ruud op den Kelder, MSc (Robo Ruud), Bas van Loon (Fontys Hogescholen Eindhoven), and Doruk Eker, MSc (Orb Amsterdam), for programming ZeroPhobia; Rufus van Baardwijk, MSc, for ZeroPhobia sound; and Stefanie van Esveld, MSc (Vrije Universiteit Amsterdam), and Niclas Fischer, MSc (Vrije Universiteit Amsterdam), for assistance in data recruitment and data collection. Bruno de Vos, BA; Wouter Houwen; Ruud op den Kelder, MSc; Bas van Loon; Doruk Eker, MSc; and Rufus van Baardwijk, MSc, recieved financial compensation.

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