From the Journals

Virtual reality–based CBT may improve social participation in psychosis



Virtual reality–based cognitive-behavioral therapy could help reduce momentary paranoia and anxiety, and improve social cognition in individuals with psychotic disorders.

Dr. Roos M.C.A. Pot-Kolder

Dr. Roos M.C.A. Pot-Kolder

Roos M.C.A. Pot-Kolder, a PhD candidate in the department of clinical psychology at the VU University and Amsterdam Public Health Research Institute, and coauthors found that, among patients who were randomized to 16 virtual reality therapy sessions, each an hour long, there was a significant reduction in patient reports of momentary paranoia, both at the posttreatment assessment and the 6-month follow-up from baseline. In contrast, the control group – who received usual care, including antipsychotic medication, regular psychiatric consultations, and social and community functioning – showed a slight increase in momentary paranoia.

Similarly, the group that received virtual reality therapy showed significantly larger decreases in momentary anxiety, compared with those in the control group. Those decreases remained significant at follow-up.

Researchers also observed a significant drop in safety behaviors – such as lack of eye contact – in the group who received the virtual reality therapy. At follow-up, this group showed less paranoid ideation in the form of lower levels of ideas of persecution and social reference.

The treatment also was associated with a small increase in time spent with others at the 6-month follow-up; a decrease was seen in the control group. Patients who underwent virtual reality therapy also showed improvements in self-stigmatization and social functioning.

The authors noted that the benefits for social functioning might take some time to emerge after therapy, as patients in symptomatic remission do not immediately start spending more time with other people.

“When patients increasingly feel more comfortable in social situations and learn that other people are less threatening than anticipated, they might try and succeed to make and maintain social contacts and find hobbies and jobs,” the authors wrote.

However, no significant differences were found between the two groups in terms of depression and anxiety, or in quality of life measurements posttreatment and at follow-up.

Virtual reality–based CBT is intended to get around some of the limitations of exposure-based therapeutic exercises for paranoid ideation. In virtual reality settings, the environment and characters can be completely controlled by the therapist, and the therapy is real time rather than retrospective and therefore not as vulnerable to patient bias.

“Finally, many patients are reluctant or unable to undergo exposure because of strong paranoid fears or negative symptoms,” the authors wrote.

The therapy took place in four virtual social environments – a street, bus, café, and supermarket. The therapist was able to control the characteristics and responses of up to 40 human avatars, enabling personalized treatment exercises for each patient.

“Patients and therapists communicated during virtual reality sessions to explore and challenge suspicious thoughts during social situations, drop safety behaviors during social situations (such as avoiding eye contact with, keeping distance from, and refraining from communication with avatars), and test harm expectancies,” they wrote.

The sessions also were designed to target safety behaviors, such as avoiding eye contact, because such behavior prevents individuals from receiving social information that can improve social cognition and reduce the chance of incorrect paranoid appraisals.

Several limitations were cited. For example, because follow-up was restricted to 6 months, it was not possible to access the long-term effects of virtual reality-based CBT. Also, some of the patients opted not to participate in the study because traveling to the therapy location proved too frightening. “Thus our sample might have been biased, because some of the most paranoid and avoidant patients could not participate,” they wrote.

The study was supported by Fonds NutsOhra and Stichting tot Steun VCVGZ. No conflicts of interest were declared.

SOURCE: Lancet Psychiatry. 2018 Feb 8. doi: 10.1016/S2215-0366(18)30053-1.

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