Avatar Therapy Eases Psychosis-Related Paranoia, Anxiety

Megan Brooks

February 14, 2018

Virtual reality–based cognitive-behavioral therapy (VR-CBT) can reduce paranoia and anxiety in patients with psychotic disorders, results of a multicenter randomized controlled trial show.

"VR-CBT is actually still being used by some clinics in the Netherlands, mainly mental health centers who participated in the study," study investigator Chris Geraets, MSc, a PhD student at the University of Groningen, the Netherlands, told Medscape Medical News.

The study was published online February 8 in Lancet Psychiatry.

VR Boosts CBT Impact on Paranoia

CBT is the most effective psychological treatment for people with psychosis, but its ability to reduce paranoia and improve social functioning has been limited.

Geraets, with lead investigator Roos Pot-Kolder, MSc, VU University, the Netherlands, and colleagues investigated the effects of VR-CBT on paranoid thoughts and social participation in 116 outpatients who in the past month had received a diagnosis of psychotic disorder and paranoid ideation on the basis of criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Half of patients received 16 VR-CBT sessions delivered by CBT-trained therapists during an 8- to 12-week period in addition to usual treatment. The other half received only usual treatment (control patients).

During each VR-CBT session, the therapist created exercises that included use of various computer-generated humanlike avatars that interacted with the patient in four virtual environments (street, bus, cafe, and supermarket).

The therapist could alter the number of avatars, their appearance, and their response to the patient (neutral or hostile). The therapist spoke directly with the patient during the therapy, helping them to explore and challenge their feelings within the virtual social situations, to stop using "safety" behaviors, such as avoidance of eye contact, and to challenge their concerns that others wish to harm them.

Compared with usual treatment, VR-CBT reduced momentary paranoia and anxiety at the 3-month posttreatment assessment (Cohen's d, -1.49 and -0.75, respectively) and at a 6-month follow-up visit (Cohen's d, -1.24 and -0.52, respectively).

VR-CBT did not significantly increase the amount of time patients spent with other people at 3 months compared with control patients. However, after 6 months, for patients in the VR-CBT arm, time spent with others had increased marginally in comparison with control patients (+0.3% vs -2.4%).

"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," Pot-Kolder said in a statement.

Patients who received VR-CBT also displayed fewer safety behaviors and had fewer social cognition problems at 3 and 6 months, which mediated the decrease in paranoia. No adverse events related to the therapy or assessments were reported.

"In the case of using VR-CBT for paranoia or social avoidance in patients with a psychotic disorder, I definitely see VR as a tool for therapists," Geraets told Medscape Medical News. "However, for VR to become really clinic-ready, more research is needed.

"The next important step will be to study whether VR-CBT is more efficient or effective than regular CBT, and whether it is more cost-effective. If the results of such research are positive, I think the treatment will become more widely available. Moreover, some important limitations of the VR program we used, which was developed in 2014, have been overcome, Geraets said.

"For example, the conversation possibilities were limited. Now we developed a system that does offer conversation options. This is also a good step to make VR-CBT more clinic-ready," he added.

Fine-tuned Approach

Writing in a linked comment, Kristiina Kompus, PhD, Department of Biological and Medical Psychology, University of Bergen, Norway, says use of VR environments in which patients interact with computer-controlled situations or avatars provides a more "fine-tuned approach" to exposure in the context of CBT.

The reduction in paranoia in this study is "an encouraging finding" that is in line with other studies in which VR was used to reduce delusions in patients with psychosis. However, "the lack of effect on measured social participation and perceived social threat suggests that everyday benefits could be more difficult to achieve in people with psychotic disorders than in those with anxiety disorders," Kompus notes.

"Nevertheless, this study adds to the evidence suggesting that virtual reality can be a useful tool to help patients with psychotic disorders. The development of safe and appropriate virtual-reality-based interventions combined with mobile technology and telemedicine approaches could provide a useful way to achieve better quality of life for patients with psychosis," Kompus writes.

The study was funded by Fonds NutsOhra and Stichting tot Steun VCVGZ. The authors have disclosed no relevant financial relationships.

Lancet Psychiatry. Published online February 8, 2018. Abstract, Comment

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