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The Lancet Psychiatry: Virtual reality-based CBT can reduce paranoia and anxiety for people with psychotic disorders

07 February 2018 The Lancet

Virtual reality-based cognitive behavioural therapy (CBT), in addition to usual treatment, can reduce paranoia and anxiety in people with psychotic disorders, according to the first randomised controlled trial of its kind, published in The Lancet Psychiatry.

The study of 116 people with psychosis across seven Dutch mental health centres suggests that virtual reality CBT does not immediately lead to participants spending more time with others, but helps them have more positive interactions by reducing anxiety and paranoia. All participants continued with their usual treatment (medication and therapy) during the trial.

While the trial shows promising early results, more research will be needed to confirm the long-term effects of virtual reality CBT before the treatment becomes widely available.

As many as 90% of people with psychosis have paranoid thoughts, such as beliefs that there is a threat towards them, or that others wish to cause them harm. As a result, many people with psychosis avoid public and social activities, have small social networks, and spend more time alone than people without psychosis.

CBT is the most effective psychological treatment for people with psychosis, but its benefits to reduce paranoia and social functioning can be limited.

The virtual reality CBT trialled in this study built on this by creating a controlled virtual environment. All 116 participants continued their treatment as usual, which included antipsychotic medication, regular contact with a psychiatrist, and with a psychiatric nurse to improve self-care, daytime activities, and social and community functioning. Half of the trial participants (58 people) practiced social exercises through a virtual environment with a therapist. The control group (58 people) only received treatment as usual.

The therapy consisted of 16 one-hour sessions over 8-12 weeks, where the therapist exposed the participant to the social cues that triggered their fear, paranoid thoughts, and safety behaviours in four virtual environments (a street, bus, café, and supermarket). The therapist could alter the number of avatars, their appearance, their response to the participant (neutral or hostile), and make them say pre-recorded sentences. The therapist also spoke directly with the participant during the therapy, helping them to explore and challenge their feelings during the virtual social situations, to stop using safety behaviours (such as avoiding eye contact), and challenge their concerns that others wish to harm them.

Social participation was assessed by measuring the amount of time spent with other people, momentary paranoia, perceived social threat, and momentary anxiety. Participants were assessed at the start of the trial, after treatment (at three months), and at six months.

Compared with the control group, virtual reality CBT did not increase the amount of time spent with other people after three months. However, there was a significant difference after six months because the control group spent much less time with others between baseline and six months, while the participants in the virtual reality CBT group slightly increased their time with others.

Participants’ paranoia and anxiety in social situations were also reduced in the virtual reality CBT group, compared to the control group at three months and at six months. However, the treatment did not reduce perceived social threat.

The virtual reality CBT group also used fewer safety behaviours and had fewer social cognition problems at three and six months, which in turn led to fewer paranoid feelings. The authors say that this could be because reducing safety behaviours meant that participants were more attentive and gained more social information from the situation, reducing the likelihood of them incorrectly perceiving a threat and becoming paranoid.

There were no adverse events related to the virtual reality CBT. However, 11 participants in the virtual reality CBT group dropped out of the study, including four who never started treatment and seven who discontinued treatment.

“The addition of virtual reality CBT to standard treatment reduced paranoid feelings, anxiety, and use of safety behaviours in social situations, compared with standard treatment alone,” says lead author, Roos Pot-Kolder, VU University, Netherlands. “It’s important to note that all patients on this trial continued with their usual treatment, and the virtual reality CBT was administered by trained therapists.”

“While we did not find that this therapy increased the amount of time that participants spent with others, we are hopeful that once patients feel more comfortable in social situations and learn that other people are less threatening than anticipated, they might make and maintain social contacts, and find hobbies and jobs. However, more research will be needed before the treatment becomes widely available in the clinic.” [1]

The authors note some limitations, including that the study did not include an active control group so it cannot be ruled out that having an additional treatment alone could have led to the improvements in this group, or that the CBT element of the therapy caused the improvements. The study is also slightly underpowered, and some participants did not take part because they were too frightened to travel to the centre, which means that the sample could be biased.

The controlled environment also does not fully mirror reality as it did not include unexpected surprises, and did not allow full conversations between the participants and the avatars. Finally, more research will be needed to confirm the long-term effects of virtual reality CBT.

Writing in a linked Comment, Dr Kristiina Kompus, Bergen University, Norway, says: “With the development of virtual reality and mobile technology, the range of tools available in psychotherapy is expanding. Use of virtual reality environments in which participants interact with computer-controlled situations or avatars enables a more fine-tuned approach to exposure in the context of cognitive behavioural therapy. Virtual-reality-based exposure therapy is effective for anxiety disorders according to the results of several meta-analyses, with most studies concentrating on simple phobias. It is important to establish whether the benefits that virtual reality can bring to therapy extend to complex challenges involving social cognition, such as positive and negative symptoms or social participation in patients with psychosis.”

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