Virtual-reality CBT Limits Paranoia, Anxiety in Patients With Psychosis

February 27, 2018

By Anne Harding

NEW YORK—Virtual-reality-based cognitive behavioral therapy (VR-CBT) that mimics exposure to social situations can help reduce momentary paranoia and anxiety in patients with psychotic disorders, new findings published in Lancet Psychiatry show.

“Virtual reality therapy is a safe and effective treatment for patients with a psychotic disorder. We find similar results to previous studies on the use of VR for light to moderate psychological problems,” Roos M.C.A. Pot-Kolder told Reuters Health by email. He led the study, which is his main PhD project at VU University and Amsterdam Public Health Research Institute.

Psychotic disorders can lead a person to sharply limit social activities and networks, and up to 90% of people with these disorders have paranoid ideation, Pot-Kolder and his colleagues note in their February 9 report. Anxiety due to paranoia worsens social avoidance, they add, and may not be helped by antipsychotic drugs.

CBT is the most effective psychotherapeutic treatment for psychotic disorders, with small to medium effects. To determine if VR might help boost these effects by exposing patients to social situations virtually, the authors built four environments - a street, bus, cafe and supermarket - that patients could navigate with a gamepad. The therapist could adjust the number of avatars in the environments (0 to 40), and could also vary avatars’ gender, ethnicity and other characteristics, and the avatar’s response to the patient.

Pot-Kolder and his team randomly assigned 116 patients with a DSM-IV-diagnosed psychotic disorder (more than 80% with schizophrenia) to 16 one-hour individual VR-CBT sessions from a trained therapist or to a wait-list control group. Patients were assessed at baseline, at three months (post-treatment), and at six months (follow-up).

The study’s primary outcome, social participation, had not increased at follow-up for patients who received the intervention. However, receiving VR-CBT was associated with lower momentary paranoid ideation (effect size, -1.49) and momentary anxiety (-0.75) after treatment, and the differences remained significant at follow-up. Both safety behavior and social cognition problems mediated changes in paranoid ideation.

“The avoidance behavior of participants, such as not looking at people’s faces and avoiding eye contact, interfered with the collection of important social information,” Pot-Kolder said. “When they learned to reduce avoidance behaviors, they started to experience that most people are actually alright, or at least neutral and not trying to harm them.”

“Participants reported reaching their personal treatment goals, such as going to see Star Wars in 3D, going to the supermarket alone instead of going with a family member, or being able to use public transportation to visit a friend,” he added. “We also saw that if there was still some social network available, people were able to reconnect.”

Longer-term follow-up is needed, and patients may need additional help to restore social connections, he said.

“It’s important that we understand virtual reality in the context of what it can and what it can’t do,” Dr. Kriistina Kompus of the University of Oslo, who wrote a comment accompanying the study, told Reuters Health in a telephone interview.

VR-CBT “has a unique benefit as a tool for exposure to socially risky situations,” offering a “nice middle ground” between imagining the exposure with a therapist and facing the exposure in real life, she added. “Virtual reality does not replace the therapy, but it’s just one tool a therapist can use.”

VR-CBT could also one day be delivered by telemedicine, she noted, making it available to people with such severe social difficulties that they cannot leave home.


Lancet Psychiatry 2018.

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