Clinical Psychology: Research and Practice Innovations

Clinical Psychology: Research and Practice Innovations"

evaluating efficiently exposure therapy based on virtual reality on the symptoms of behavioral and cognitive of obsessive-compulsive disorder(Case study)

Document Type : Original Article

Authors
Saeideh Jabbari 1
Touraj Hashemi 2
Zeynab Khanjani 2
1 Ph.D Candididate in Psychology, Department of Psychology, Faculty of Educational Science and Psychology, University of Tabriz, Tabriz, Iran.
2 Professor, Department of Psychology, Faculty of Educational Science and Psychology, University of Tabriz, Tabriz, Iran.
10.22075/jcp.2025.38380.3253
Abstract
Abstract
Background: The present study aimed to examine the effectiveness of Virtual Reality Exposure Therapy (VRET) in alleviating behavioral and cognitive symptoms in individuals with OCD.
Method: This study employed a single-case experimental design with multiple baselines (three baseline phases, nine intervention sessions, and two follow-up assessments). Three female participants diagnosed with OCD based on the Structured Clinical Interview for DSM-5 were selected through purposive sampling. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Kobori and Salkovskis' Reassurance-Seeking Questionnaire, the Wisconsin Card Sorting Test (WCST), and the Stroop Response Inhibition Task were used to assess target variables. Data were analyzed using visual inspection of time-series graphs, the Reliable Change Index (RCI), and percentage of clinical improvement.
Results: Findings revealed a clinically significant reduction in both behavioral and cognitive symptoms, which persisted through the follow-up period (RCI ≥ 1.96). Clinical improvement exceeding 50% supported the efficacy of the intervention. These outcomes were maintained post-treatment.
Conclusion: The intervention proved effective not only in reducing overt OCD symptoms such as compulsive washing and reassurance-seeking, but also in enhancing underlying cognitive functions including response inhibition and psychological flexibility. The persistence of treatment gains at follow-up highlights the stability and clinical value of VRET as a promising therapeutic approach for OCD.
Keywords
Virtual Reality Exposure Therapy
Behavioral Symptoms
Reassurance-Seeking
Response Inhibition
Psychological Flexibility
Subjects
  1. Veale D, Roberts A. Obsessive-compulsive disorder. Bmj. 2014;348:g2183. Doi.org/10.1136/bmj.g2183
  2. Murphy DL, Timpano KR, Wheaton MG, Greenberg BD, Miguel EC. Obsessive-compulsive disorder and its related disorders: a reappraisal of obsessive-compulsive spectrum concepts. Dialogues in clinical neuroscience. 2010;12(2):131–48. Doi:10.31887/DCNS.2010.12.2/dmurphy
  3. 3. Nance M, Abramowitz JS, Blakey SM, Reuman L, Buchholz JL. Thoughts and thoughts about thoughts: the relative contribution of obsessive beliefs and metacognitive beliefs in predicting obsessive-compulsive symptom dimensions. International Journal of Cognitive Therapy. 2018;11(2):234–48. Doi: 10.1007/s41811-018-0013-1
  4. Rachman S. A cognitive theory of compulsive checking. Behaviour research and therapy. 2002;40(6):625–3962. Doi:10.1016/S0005-7967(01)00028-6
  5. Bannon S, Gonsalvez CJ, Croft RJ, Boyce PM. Response inhibition deficits in obsessive–compulsive disorder. Psychiatry research. 2002;110(2):165–74. Doi: 10.1002/jclp.22998
  6. Martoni RM, Risso G, Giuliani M, De Filippis R, Cammino S, Cavallini C, et al. Evaluating proactive strategy in patients with OCD during stop signal task. Journal of the International Neuropsychological Society. 2018;24(7):703–14. Doi.org/10.1017/S1355617718000267
  7. Shirani, Z., Tamannaeifar, M. R., Tamizifar, B. Structural Equation Modeling of the Mediating Role of Self-Efficacy in the Relationship between Cognitive Flexibility and Psychological Well-Being of Patients with Irritable Bowel Syndrome. Journal of Clinical Psychology, 2024; 16(3): 17-31. [Persian]. Doi:10.22075/jcp.2024.33619.2869
  8. Twohig MP, Vilardaga JCP, Levin ME, Hayes SC. Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder. Journal of Contextual Behavioral Science. 2015;4(3):196–202. [Persian]. Doi: 10.22075/jcp.2024.33619.2869
  9. Schubert C, Hilbert S, Favreau M, Wolstein J, Voderholzer U. Psychological flexibility as a potential change factor in cognitive behavioural therapy of OCD. Behavioural and cognitive psychotherapy. 2022;50(4):381–91. Doi:10.1017/S1352465821000676
  10. Powers MB, Emmelkamp PM. Virtual reality exposure therapy for anxiety disorders: A meta-analysis. Journal of anxiety disorders. 2008;22(3):561–9. Doi:10.1016/j.janxdis.2007.04.006
  11. Maples-Keller JL, Bunnell BE, Kim S-J, Rothbaum BO. The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harvard review of psychiatry. 2017;25(3):103–13. Doi:10.1080/10673229.2017.1322580
  12. Yu C, Wang C, Xie Q, Wang C. Effect of virtual reality technology on attention and motor ability in children with attention-deficit/hyperactivity disorder: systematic review and meta-analysis. JMIR Serious Games. 2024;12(1):e56918. Doi:10.2196/56918
  13. Dellazizzo L, Potvin S, Bahig S, Dumais A. Comprehensive review on virtual reality for the treatment of violence: implications for youth with schizophrenia. NPJ schizophrenia. 2019;5(1):11. Doi:10.1038/s41537-019-0076-7
  14. Zadbar M, Manshaei G, Aghaei Joshaghani A. A Comparison of the Effectiveness of Virtual Reality Exposure Therapy with Cognitive-Behavioral Therapy on Ambiguity Tolerance in Individuals with Obsessive-Compulsive Disorder. Journal of Applied Psychological Research. 2024;15(3):331–47. Doi:10.22059/japr.2024.347053.644343
  15. Farnoush F, Khodadadi M, Noohi S. Comparison of the effectiveness of virtual reality-based therapy and mindfulness-acceptance therapy on social self-efficacy and symptoms of social anxiety disorder. J Clinical Psychology. 2019;11(1):13–25.[Persian]. Doi:10.22075/jcp.2019.17390.1642
  16. García-Batista ZE, Guerra-Peña K, Alsina-Jurnet I, Cano-Vindel A, Álvarez-Hernández A, Cantisano-Guzmán LM, et al. Design and validation of virtual environments for the treatment of cleaning obsessive-compulsive disorder. Heliyon. 2022;8(12). Doi:10.1016/j.heliyon.2022.e12331
  17. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown obsessive compulsive scale: I. Development, use, and reliability. Archives of general psychiatry. 1989;46(11):1006–11. Doi:10.1001/archpsyc.1989.01810110048007
  18. Castro-Rodrigues P, Camacho M, Almeida S, Marinho M, Soares C, Barahona-Corrêa JB, et al. Criterion validity of the Yale-Brown Obsessive-Compulsive Scale second edition for diagnosis of obsessive-compulsive disorder in adults. Frontiers in psychiatry. 2018;9:431. Doi:10.3389/fpsyt.2018.00431
  19. Mohammadi MR, Ahmadi N, Hooshyari Z, Khaleghi A, Yazdi FR, Mehrparvar AH. Prevalence, comorbidity, and predictors of obsessive-compulsive disorder in Iranian children and adolescents. Journal of Psychiatric Research. 2021;141:192–8. Doi:10.1016/j.jpsychires.2021.06.002
  20. Esfahani SR, Motaghipour Y, Kamkari K, Zahiredin A, Janbozorgi M. Reliability and Validity of the Persian version of the Yale-Brown Obsessive-Compulsive scale (Y-BOCS). Iranian journal of psychiatry and clinical psychology. 2012. Doi.org/10.1016/j.jocrd.2019.100450
  21. Kobori O, Salkovskis PM. Patterns of reassurance seeking and reassurance-related behaviours in OCD and anxiety disorders. Behavioural and Cognitive Psychotherapy. 2013;41(1):1–23. Doi:10.1017/S1352465812000665
  22. Haciomeroglu B. The role of reassurance seeking in obsessive compulsive disorder: the associations between reassurance seeking, dysfunctional beliefs, negative emotions, and obsessive-compulsive symptoms. BMC psychiatry. 2020;20(1):356. Doi:10.1186/s12888-020-02766-y
  23. Grant DA, Berg E. A behavioral analysis of degree of reinforcement and ease of shifting to new responses in a Weigl-type card-sorting problem. Journal of experimental psychology. 1948;38(4):404. Doi:10.1037/h0059831
  24. Kopp B, Lange F, Steinke A. The reliability of the Wisconsin card sorting test in clinical practice. Assessment. 2021;28(1):248–63. Doi:10.1177/1073191119837447
  25. Banimahdi R, Akhavan Hejazi SM, Hosseini SA, Akbarfahimi N, Vahedi M. Psychometric Properties of the Persian Version of the Frontal Assessment Battery in Patients With Traumatic Brain Injury. Function and Disability Journal. 2025;8(1). Doi:10.32598/fdj.8.332.1
  26. Al Kharusi N, Alkharusi H, Helmy M. The Meta-Analysis of Wisconsin Card Sorting Test Reliability. An-Najah University Journal for Research-B (Humanities). 2023;38(5):837–66. Doi:10.35552/0247.38.5.2188
  27. Lezak MD. Neuropsychological assessment: Oxford University Press, USA; 2004. Doi:10.1186/s12888-020-02766-y
  28. Fahimi MA, Ashayeri H, Doustdar H. The effect of musical activities on executive function in patients with schizophrenia. Annals of Military and Health Sciences Research. 2013;11(2). Doi:10.5812/amh.66295
  29. Stroop JR. Studies of interference in serial verbal reactions. Journal of experimental psychology. 1935;18(6):643. Doi:10.1037/h0054651
  30. Malek A, Amiri S, Hekmati I, Pirzadeh J, Gholizadeh H. A comparative study on diadochokinetic skill of dyslexic, stuttering, and normal children. International Scholarly Research Notices. 2013;2013(1):165193. [Persian]. Doi:10.1155/2013/165193
  31. Alamuti SE, Borjali A, Eskandari H, Mohammadi MR, Asgari M. Computer-Based Stroop Animal Size Test in Children: Construction, Validation and Psychometric Properties. Clinical Psychology Studies (2322-3189). 2024;15(54). Doi:10.22054/jcps.2024.77074.3003
  32. Soleymani E, Alipour M, Soleymani M. The Study of Automatic and Controlled Data Processing Speed Based on the Stroop Test in Students with Math Learning Disability. Shefaye Khatam. 2019;7(3):32–41. [Persian]. Doi:10.29252/shefa.7.3.32
  33. Inozu M, Celikcan U, Akin B, Cicek NM. The use of virtual reality (VR) exposure for reducing contamination fear and disgust: Can VR be an effective alternative exposure technique to in vivo? Journal of Obsessive-Compulsive and Related Disorders. 2020;25:100518. Doi:10.1016/j.jocrd.2020.100518
  34. Javaherirenani R, Mortazavi SS, Shalbafan M, Ashouri A, Farani AR. Virtual reality exposure and response prevention in the treatment of obsessive-compulsive disorder in patients with contamination subtype in comparison with in vivo exposure therapy: a randomized clinical controlled trial. BMC psychiatry. 2022;22(1):740. [Persian]. Doi:10.1186/s12888-022-04402-3
  35. Dehghan B, Saeidimehr S, Sayyah M, Rahim F. The effect of virtual reality on emotional response and symptoms provocation in patients with OCD: a systematic review and meta-analysis. Frontiers in psychiatry. 2022;12:733584. [Persian] Doi:10.1186/s12888-022-04402-3
  36. van Bennekom MJ, van Wingen G, Bruin WB, Luigjes J, Denys D. Brain Activation During Virtual Reality Symptom Provocation in Obsessive-Compulsive Disorder: Proof-of-Concept Study. JMIR XR and Spatial Computing. 2024;1:e47468.. Doi:10.2196/47468
  37. Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychological bulletin. 1986;99(1):20. Doi:10.1037/0033-2909.99.1.20
  38. Jolink A-TC, Nelson VS, Schipperus MR, Amini SN, Vidarsson G, van der Schoot CE, et al. Potential diagnostic approaches for prediction of therapeutic responses in immune thrombocytopenia. Journal of Clinical Medicine. 2021;10(15):3403. Doi:10.3390/jcm10153403
  39. Cullen AJ, Dowling NL, Segrave R, Carter A, Yücel M. Exposure therapy in a virtual environment: Validation in obsessive compulsive disorder. Journal of Anxiety Disorders. 2021;80:102404. Doi:10.1016/j.janxdis.2021.102404
  40. Hajahmadi S, Marfia G. Effects of the uncertainty of interpersonal communications on behavioral responses of the participants in an immersive virtual reality experience: A usability study. Sensors. 2023;23(4):2148. [Persian]. Doi:10.3390/s23042148
  41. De Wit S, Colleagues. Neural activity in response inhibition in OCD patients. Cogn Neurosci. 2012;23(9):2103-15. Doi:10.1176/appi.ajp.2012.12010073
  42. Kuleli D, Tyson P, Davies NH, Zeng B. Examining the comparative effectiveness of virtual reality and in-vivo exposure therapy on social anxiety and specific phobia: A systematic review & meta-analysis. Journal of Behavioral and Cognitive Therapy. 2025;35(2):100524. Doi:10.1016/j.jbct.2025.100524
  43. Fajnerová I, Francová A, Taranzová K, Darmová B, Kosová E, Stopková P. Virtual reality environment for exposure therapy in obsessive–compulsive disorder: a validation study. Virtual Reality. 2023;27(3):2691–701. Doi:10.1007/s10055-022-00711-4
  44. Zeng W, Xu J, Yu J, Chu X. Effectiveness of virtual reality therapy in the treatment of anxiety disorders in adolescents and adults: a systematic review and meta-analysis of randomized controlled trials. Frontiers in Psychiatry. 2025;16:1553290. Doi:10.3389/fpsyt.2025.1553290
  45. Martínez-Gonzálvez J, Lirola M-J, Gallego J, Díaz AJC. Virtu-act: a virtual reality program for mental health stigma. Current Psychology. 2024;43(35):28306–15. Doi:10.1007/s12144-023-04678-9
  46. Gorinelli S, Gallego A, Lappalainen P, Lappalainen R. Virtual reality acceptance and commitment therapy intervention for social and public speaking anxiety: A randomized controlled trial. Journal of Contextual Behavioral Science. 2023;28:289–99. Doi:10.1016/j.jpsychores.2023.110795
  47. Han K, Kim IY, Kim J-J. Assessment of cognitive flexibility in real life using virtual reality: a comparison of healthy individuals and schizophrenia patients. Computers in Biology and Medicine. 2012;42(8):841–7. Doi:10.1016/j.compbiomed.2012.03.012
  48. Seabrook E, Kelly R, Foley F, Theiler S, Thomas N, Wadley G, et al. Understanding how virtual reality can support mindfulness practice: mixed methods study. Journal of medical Internet research. 2020;22(3):e16106. Doi:10.2196/16106

  • Receive Date 18 July 2025
  • Revise Date 20 August 2025
  • Accept Date 23 August 2025
  • First Publish Date 03 June 2026
  • Publish Date 22 June 2026