{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,27]],"date-time":"2026-03-27T17:49:21Z","timestamp":1774633761649,"version":"3.50.1"},"reference-count":59,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2022,1,1]],"date-time":"2022-01-01T00:00:00Z","timestamp":1640995200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001871","name":"Funda\u00e7\u00e3o para a Ci\u00eancia e Tecnologia","doi-asserted-by":"publisher","award":["UIDB\/05210\/2020"],"award-info":[{"award-number":["UIDB\/05210\/2020"]}],"id":[{"id":"10.13039\/501100001871","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Virtual reality exposure therapy (VRET) is an emerging treatment for people diagnosed with Post-Traumatic Stress Disorder (PTSD) due to the limited accessibility of psychotherapies. This research aims to determine the guidelines for developing a Virtual Reality\u2013War Scenario program for Armed Forces veterans with PTSD and encompasses two studies: Study 1, a systematic electronic database review; Study 2, a focus group of twenty-two Portuguese Armed Forces veterans. Results showed a positive impact of VRET on PTSD; however, there were no group differences in most of the studies. Further, according to veterans, new VRET programs should be combined with the traditional therapy and must consider as requirements the sense of presence, dynamic scenarios, realistic feeling, and multisensorial experience. Regardless, these findings suggest VRET as a co-creation process, which requires more controlled, personalized, and in-depth research on its clinical applicability.<\/jats:p>","DOI":"10.3390\/ijerph19010464","type":"journal-article","created":{"date-parts":[[2022,1,3]],"date-time":"2022-01-03T22:51:50Z","timestamp":1641250310000},"page":"464","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":31,"title":["Virtual Reality Exposure Therapy for Armed Forces Veterans with Post-Traumatic Stress Disorder: A Systematic Review and Focus Group"],"prefix":"10.3390","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1627-5669","authenticated-orcid":false,"given":"Ana","family":"Vianez","sequence":"first","affiliation":[{"name":"Psychosocial Rehabilitation Laboratory, Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-072 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8656-5023","authenticated-orcid":false,"given":"Ant\u00f3nio","family":"Marques","sequence":"additional","affiliation":[{"name":"Psychosocial Rehabilitation Laboratory, Center for Rehabilitation Research, School of Health, Polytechnic Institute of Porto, 4200-072 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4703-1712","authenticated-orcid":false,"given":"Raquel","family":"Sim\u00f5es de Almeida","sequence":"additional","affiliation":[{"name":"Occupational Therapy Department, Santa Maria Health School, 4049-024 Porto, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2022,1,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"102004","DOI":"10.1016\/j.cpr.2021.102004","article-title":"Preventing the onset of post traumatic stress disorder","volume":"86","author":"Bisson","year":"2021","journal-title":"Clin. Psychol. Rev."},{"key":"ref_2","first-page":"4","article-title":"Post-traumatic stress disorder: The burden to the individual and to society","volume":"61","author":"Kessler","year":"2000","journal-title":"J. Clin. Psychiatry"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1016\/j.euroneuro.2011.07.018","article-title":"The size and burden of mental disorders and other disorders of the brain in Europe 2010","volume":"21","author":"Wittchen","year":"2011","journal-title":"Eur. Neuropsychopharmacol."},{"key":"ref_4","first-page":"980","article-title":"A Prospective Study of Mortality and Trauma-Related Risk Factors Among a Nationally Representative Sample of Vietnam Veterans","volume":"182","author":"Schlenger","year":"2015","journal-title":"Am. J. Epidemiol."},{"key":"ref_5","unstructured":"American Psychiatric Association (2014). DSM-V: Manual Diagn\u00f3stico e Estat\u00edstico das Perturba\u00e7\u00f5es Mentais, Climepsi Editores. [5th ed.]."},{"key":"ref_6","first-page":"13","article-title":"Neurobiology of post-traumatic stress disorder","volume":"14","author":"Christine","year":"2009","journal-title":"CNS Spectr."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"748","DOI":"10.1037\/0022-006X.68.5.748","article-title":"Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults","volume":"68","author":"Brewin","year":"2000","journal-title":"J. Consult. Clin. Psychol."},{"key":"ref_8","first-page":"205","article-title":"Cognitive behavioral intervention for PTSD in Colombian combat veterans","volume":"4","year":"2005","journal-title":"Univ. Psychol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1002\/jcad.12190","article-title":"A Systematic Review of the Posttraumatic Stress Disorder Checklist (PCL)","volume":"96","author":"Bressler","year":"2018","journal-title":"J. Couns. Dev."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Navarro-Mateu, F., Esc\u00e1mez, T., Koenen, K.C., Alonso, J., and S\u00e1nchez-Meca, J. (2013). Meta-Analyses of the 5-HTTLPR Polymorphisms and Post-Traumatic Stress Disorder. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0066227"},{"key":"ref_11","first-page":"407","article-title":"Development of a VR therapy application for Iraq war military personnel with PTSD","volume":"111","author":"Rizzo","year":"2005","journal-title":"Stud. Health Technol. Inform."},{"key":"ref_12","first-page":"1","article-title":"Trastorno por estr\u00e9s postraum\u00e1tico en el contexto m\u00e9dico militar","volume":"34","year":"2005","journal-title":"Revista Cubana de Medicina Militar"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., and Zhang, L. (2015). A Meta-Analysis of Risk Factors for Combat-Related PTSD among Military Personnel and Veterans. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0120270"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"M\u00fcller, J., Ganeshamoorthy, S., and Myers, J. (2017). Risk factors associated with posttraumatic stress disorder in US veterans: A cohort study. PLoS ONE, 12.","DOI":"10.1371\/journal.pone.0181647"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1037\/mil0000075","article-title":"Attachment Patterns as Mediators of the Link Between Combat Exposure and Posttraumatic Symptoms: A Study Among Portuguese War Veterans","volume":"27","author":"Oliveira","year":"2015","journal-title":"Mil. Psychol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1080\/08995605.2018.1525219","article-title":"Deployment trauma and seeking treatment for PTSD in US soldiers","volume":"31","author":"Paige","year":"2019","journal-title":"Mil. Psychol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1016\/j.cpr.2015.10.003","article-title":"Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis","volume":"43","author":"Cusack","year":"2016","journal-title":"Clin. Psychol. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"258","DOI":"10.3389\/fnbeh.2018.00258","article-title":"Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions","volume":"12","author":"Watkins","year":"2018","journal-title":"Front. Behav. Neurosci."},{"key":"ref_19","unstructured":"American Psychological Association (2021, December 18). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD). Available online: https:\/\/www.apa.org\/ptsd-guideline\/ptsd.pdf."},{"key":"ref_20","unstructured":"International Society for Traumatic Stress Studies (2021, December 18). Posttraumatic Stress Disorder Prevention and Treatment Guidelines: Methodology and Recommendations. Available online: http:\/\/www.istss.org\/treating-trauma\/new-istss-prevention-and-treatment-guidelines.aspx."},{"key":"ref_21","unstructured":"National Institute for Health and Care Excellence (2021, December 19). Post-Traumatic Stress Disorder NG116. Available online: https:\/\/www.nice.org.uk\/guidance\/ng116."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1016\/j.jpsychires.2020.11.030","article-title":"Efficacy of immersive PTSD treatments: A systematic review of virtual and augmented reality exposure therapy and a meta-analysis of virtual reality exposure therapy","volume":"143","author":"Eshuis","year":"2020","journal-title":"J. Psychiatr. Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2260","DOI":"10.1017\/S0033291717000708","article-title":"Posttraumatic stress disorder in the World Mental Health Surveys","volume":"47","author":"Koenen","year":"2017","journal-title":"Psychol. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1515\/IJDHD.2011.049","article-title":"Traumatic brain injury memory training: A virtual reality online solution","volume":"10","author":"Gamito","year":"2011","journal-title":"Int. J. Disabil. Hum. Dev."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Foa, E.B., Chrestman, K.R., and Gilboa-Schechtman, E. (2008). Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide, Oxford University Press.","DOI":"10.1093\/med:psych\/9780195331745.001.0001"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13012-020-01014-x","article-title":"The effects of a prolonged exposure workshop with and without consultation on provider and patient outcomes: A randomized implementation trial","volume":"15","author":"Foa","year":"2020","journal-title":"Implement. Sci."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1300\/J146v12n01_11","article-title":"Virtual Reality Exposure for Veterans with Posttraumatic Stress Disorder","volume":"12","author":"Ready","year":"2006","journal-title":"J. Aggress. Maltreatment Trauma"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"617","DOI":"10.4088\/JCP.v62n0808","article-title":"Virtual Reality Exposure Therapy for Vietnam Veterans with Posttraumatic Stress Disorder","volume":"62","author":"Rothbaum","year":"2001","journal-title":"J. Clin. Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1097\/PHM.0000000000001041","article-title":"V-Mart, a Virtual Reality Grocery Store: A Focus Group Study of a Promising Intervention for Mild Traumatic Brain Injury and Posttraumatic Stress Disorder","volume":"98","author":"Levy","year":"2019","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1186\/s13063-016-1171-1","article-title":"Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: Study protocol for a randomized controlled non-inferiority trial","volume":"17","author":"Miloff","year":"2016","journal-title":"Trials"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"26","DOI":"10.5765\/jkacap.190037","article-title":"The Use of Virtual Reality in Psychiatry: A Review","volume":"31","author":"Kim","year":"2020","journal-title":"J. Korean Acad. Child Adolesc. Psychiatry"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"b2535","DOI":"10.1136\/bmj.b2535","article-title":"Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement","volume":"339","author":"Moher","year":"2009","journal-title":"BMJ"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1136\/jech.52.6.377","article-title":"The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions","volume":"52","author":"Downs","year":"1998","journal-title":"J. Epidemiol. Community Health"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1089\/cyber.2009.0239","article-title":"Comparing virtual reality exposure therapy to present-centered therapy with 11 US Vietnam veterans with PTSD","volume":"13","author":"Ready","year":"2010","journal-title":"Cyberpsychol. Behav. Soc. Netw."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1111\/j.1749-6632.2010.05755.x","article-title":"Development and early evaluation of the Virtual Iraq\/Afghanistan exposure therapy system for combat-related PTSD","volume":"1208","author":"Rizzo","year":"2010","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1002\/jts.20574","article-title":"Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic","volume":"24","author":"Reger","year":"2011","journal-title":"J. Trauma. Stress"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1089\/cyber.2011.0003","article-title":"A Randomized, Controlled Trial of Virtual Reality-Graded Exposure Therapy for Post-Traumatic Stress Disorder in Active Duty Service Members with Combat-Related Post-Traumatic Stress Disorder","volume":"14","author":"McLay","year":"2011","journal-title":"Cyberpsychol. Behav. Soc. Netw."},{"key":"ref_38","first-page":"128","article-title":"The effectiveness of VR exposure therapy for PTSD in returning warfighters","volume":"181","author":"Miyahira","year":"2012","journal-title":"Stud. Health Technol. Inform."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"640","DOI":"10.1176\/appi.ajp.2014.13121625","article-title":"A Randomized, Double-Blind Evaluation ofd-Cycloserine or Alprazolam Combined With Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder in Iraq and Afghanistan War Veterans","volume":"171","author":"Rothbaum","year":"2014","journal-title":"Am. J. Psychiatry"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"946","DOI":"10.1037\/ccp0000134","article-title":"Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active duty soldiers with deployment-related posttraumatic stress disorder (PTSD)","volume":"84","author":"Reger","year":"2016","journal-title":"J. Consult. Clin. Psychol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1089\/cyber.2016.0554","article-title":"A Randomized, Head-to-Head Study of Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder","volume":"20","author":"McLay","year":"2017","journal-title":"Cyberpsychol. Behav. Soc. Netw."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/j.janxdis.2018.10.006","article-title":"When translational neuroscience fails in the clinic: Dexamethasone prior to virtual reality exposure therapy increases drop-out rates","volume":"61","author":"Jovanovic","year":"2019","journal-title":"J. Anxiety Disord."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/j.brs.2018.09.011","article-title":"Combined transcranial direct current stimulation with virtual reality exposure for posttraumatic stress disorder: Feasibility and pilot results","volume":"12","author":"Shea","year":"2019","journal-title":"Brain Stimul."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Rozek, D.C., Baker, S.N., Rugo, K., Steigerwald, V., Sippel, L.M., Holliday, R., Roberge, E.M., Held, P., Mota, N., and Smith, N.B. (2021). Addressing Co-occurring Suicidal Thoughts and Behaviors and Posttraumatic Stress Disorder in Evidence-based Psychotherapies for Adults: A Systematic Review. PsyArXiv, preprint.","DOI":"10.31234\/osf.io\/2bcdw"},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Rizzo, A., Reger, G., Gahm, G., Difede, J., and Rothbaum, B.O. (2009). Virtual Reality Exposure Therapy for Combat-Related PTSD. Post-Traumatic Stress Disorder, Springer.","DOI":"10.1037\/e517292011-257"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.chb.2015.08.007","article-title":"Virtual reality and stimulation of touch and smell for inducing relaxation: A randomized controlled trial","volume":"55","author":"Serrano","year":"2016","journal-title":"Comput. Hum. Behav."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1097\/HRP.0000000000000138","article-title":"The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders","volume":"25","author":"Bunnell","year":"2017","journal-title":"Harv. Rev. Psychiatry"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Jerald, J. (2015). The VR Book: Human-Centered Design for Virtual Reality, Morgan & Claypool.","DOI":"10.1145\/2792790"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1007\/s10879-006-9008-y","article-title":"Emotional Processing Theory (EPT) and Exposure Therapy for PTSD","volume":"36","author":"Rauch","year":"2006","journal-title":"J. Contemp. Psychother."},{"key":"ref_50","unstructured":"Smelser, N.J., and Baltes, P.B. (2001). International Encyclopedia of the Social & Behavioral Sciences, Elsevier."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.jpsychires.2018.05.009","article-title":"Effects of prolonged exposure and virtual reality exposure on suicidal ideation in active duty soldiers: An examination of potential mechanisms","volume":"103","author":"Norr","year":"2018","journal-title":"J. Psychiatr. Res."},{"key":"ref_52","first-page":"235","article-title":"A virtual reality exposure therapy application for Iraq War military personnel with post traumatic stress disorder: From training to toy to treatment","volume":"6","author":"Rizzo","year":"2006","journal-title":"NATO Secur. Sci. Ser. E Hum. Soc. Dyn."},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Knaust, T., Felnhofer, A., Kothgassner, O.D., H\u00f6llmer, H., Gorzka, R.-J., and Schulz, H. (2020). Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review. Front. Psychol., 11.","DOI":"10.3389\/fpsyg.2020.562506"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1109\/MCG.2015.98","article-title":"Reducing Visual Discomfort with HMDs Using Dynamic Depth of Field","volume":"35","author":"Carnegie","year":"2015","journal-title":"IEEE Comput. Graph. Appl."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1518\/hfes.45.3.504.27254","article-title":"What to Expect from Immersive Virtual Environment Exposure: Influences of Gender, Body Mass Index, and Past Experience","volume":"45","author":"Stanney","year":"2003","journal-title":"Hum. Factors J. Hum. Factors Ergon. Soc."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1089\/cpb.2005.8.220","article-title":"Virtual Reality in Psychotherapy: Review","volume":"8","author":"Riva","year":"2005","journal-title":"CyberPsychol. Behav."},{"key":"ref_57","unstructured":"Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., and Schnurr, P.P. (2013). The PTSD Checklist for DSM-5 (PCL-5) Boston, National Center for PTSD."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"3549","DOI":"10.1098\/rstb.2009.0138","article-title":"Place illusion and plausibility can lead to realistic behaviour in immersive virtual environments","volume":"364","author":"Slater","year":"2009","journal-title":"Philos. Trans. R. Soc. B Biol. Sci."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1654782","DOI":"10.1080\/20008198.2019.1654782","article-title":"Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): A meta-analysis","volume":"10","author":"Kothgassner","year":"2019","journal-title":"Eur. J. Psychotraumatol."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/1\/464\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,13]],"date-time":"2025-10-13T13:35:54Z","timestamp":1760362554000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/19\/1\/464"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,1,1]]},"references-count":59,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,1]]}},"alternative-id":["ijerph19010464"],"URL":"https:\/\/doi.org\/10.3390\/ijerph19010464","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,1,1]]}}}