The gold-standard treatment for social anxiety disorder: A roadmap for the future

Abstract

Exposure therapy (ET), which follows the Pavlovian extinction model, is regarded as the gold-standard treatment for social anxiety disorder (SAD). The prospect of virtual reality in lieu of a traditional laboratory setting for the treatment of SAD has not been rigorously explored. The aim of the review was to summarize, find gaps in the current literature, and formulate future research direction by identifying two broad research questions: the comparative efficacy between in vivo ET and virtual reality exposure therapy (VRET) and the effectiveness of the Pavlovian extinction model in treating SAD. The criteria for effectiveness were effect size, relapse prevention, attrition rate and ecological validity. A literature search on recent randomized controlled trials yielded a total of 6 original studies (N=358), excluding duplication and overlapping participants. All studies supported that VRET was as effective as in vivo ET. Behavioral therapy that follows classical conditioning principles has a high attrition and relapse rate. Comparisons were drawn between the efficacy of the Pavlovian extinction model and other existing models, including third-wave approaches. The neural markers are suggested to be included as efficacy measures in treating SAD. The gold-standard treatment for SAD requires a paradigm shift through rigorous longitudinal comparative studies.

Extinction and beyond: an expanded framework for exposure and response prevention for obsessive-compulsive disorder

“…For decades, experimental researchers have voiced concerns about the translational limitations of experimental paradigms that model extinction learning (Rachman, 1977;Poulton and Menzies, 2002;Mineka and Zinbarg, 2006;De Houwer, 2020) and avoidance (Krypotos et al, 2015). Echoing these concerns in the domain of clinical fear reduction, recent reviews have advised experimental researchers to "mind the gap" between fear reduction through extinction in the laboratory and the treatment of fear through exposure in the clinic (Carpenter et al, 2019) and urged the development of refined therapeutic models (Chowdhury and Khandoker, 2022;Nihei et al, 2023). Notably, Craske et al (2008) suggested that, in addition to extinction learning, investigators should consider "other clinically relevant cognitiveemotional processes" that contribute to the beneficial effects of exposure therapy.…”

Engaging in Awkward Social Interactions in a Virtual Environment Designed for Exposure-Based Psychotherapy for People with Generalized Social Anxiety Disorder: An International Multisite Study

“…Generalized SAD differs from the performance-only subtype in that it has a higher number of feared social situations and involves more interactive social situations than talking to an audience. The effectiveness of using in virtuo exposure in the treatment of performance-only SAD has been demonstrated in several studies [ 24 , 27 , 31 , 32 , 33 ]. Clinical trials have also shown that in virtuo exposure using real-time 3D rendering technology is just as effective as traditional in vivo exposure when treating patients with SAD that have broader social fears than only performance [ 14 , 34 , 35 , 36 ].…”