Virtual Reality Can Reduce Anxiety, Improve Social Interactions in Psychosis

man with virtual reality goggles on
man with virtual reality goggles on
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 behavioral therapy.

Virtual reality-based cognitive behavioral therapy (VR-CBT) can reduce paranoia and anxiety in patients with psychotic disorders, according to research published in The Lancet Psychiatry.1

While CBT is the most effective psychological treatment for those with psychosis, it can be limited in its ability to reduce paranoia and increase social functioning. “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 behavioral therapy,” wrote Kristiina Kompus, PhD, from Bergen University in Norway, in an accompanying comment on the study. “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.”

Lead author Roos Pot-Kolder, MSc, from VU University in the Netherlands, and colleagues conducted a randomized controlled trial (ISRCTN number 12929657) at 7 Dutch mental health centers and recruited 116 outpatients aged 18 to 65 with a Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV)-diagnosed psychotic disorder and paranoid ideation in the past month. Participants were randomly assigned 1:1 to VR-CBT plus treatment as usual (medication and therapy; n=58) or to the waiting list control group (treatment as usual; n=58).

The VR-CBT sessions consisted of 16 individual therapy sessions of 1-hour duration conducted over 8 to 12 weeks during which trained therapists exposed participants to social cues that triggered fear in 4 environments (a street, a bus, a café, and a supermarket). Therapists could change the number and appearance of avatars, could alter their responses to the participant (neutral or hostile), and could make the avatars say pre-recorded sentences. Therapists also spoke directly with participants during the sessions, helping them explore and challenge their feelings during the simulations, helping them to stop using safety behaviors such as avoiding eye contact, and challenging their worries that others want to harm them.

Assessments were conducted at baseline, after treatment (3 months after baseline), and at a 6-month follow-up visit. The primary outcome was social participation, which included amount of time spent with others, momentary paranoia, perceived social threat, and momentary anxiety. The analysis was intention-to-treat.

At post-treatment assessment at 3 months, VR-CBT did not significantly increase the amount of time participants spent with other people compared with the control group. However, after 6 months, participants in the VR-CBT group slightly increased their time with others between baseline and 6 months compared with the control group.

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Momentary paranoid ideation (b=-0.331; 95% CI, -0.432 to -0.230; P <.0001; effect size -1.49) and momentary anxiety (-0.288; 95% CI, -0.438 to -0.1394; P =.0002; effect size -0.75) were also significantly reduced in the VR-CBT group compared with the control group at 3 months, and the improvements were maintained at 6 months. No adverse events were reported from the therapy or assessments.

At 3 and 6 months, participants in the VR-CBT group also used fewer safety behaviors and had fewer social cognition problems, which led to fewer feelings of paranoia. The researchers believe that reducing safety behaviors led participants to be more attentive in social situations and gain more information about the interaction, reducing the chance that they would incorrectly perceive something as a threat and become paranoid.

“The addition of virtual reality [CBT] to standard treatment reduced paranoid feelings, anxiety, and use of safety behaviors in social situations, compared with standard treatment alone,” said Mr Pot-Kolder. “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.”2

The researchers also noted that more research is needed to determine the long-term effects of virtual reality used in CBT before this treatment can become widely available in clinics.

Limitations of the study include lack of an active control group, so it cannot be ruled out that simply having an additional treatment could have led to the improvements in this VR-CBT group, or that it was the CBT itself that caused the improvements. The study is also slightly underpowered, and some patients did not participate because they were too scared to travel to the center; therefore, the sample could be biased. The controlled environment also did not fully mirror reality: it did not include unexpected surprises and did not allow for full conversations between the participants and the avatars.

This study was funded by Fonds NutsOhra, and Stichting tot Steun VCVGZ.


  1. Pot-Kolder RMCA, Geraets CNW, Veling W, et al. Virtual-reality-based cognitive behavioural therapy versus waiting list control for paranoid ideation and social avoidance in patients with psychotic disorders: a single-blind randomised controlled trial [published online February 8, 2018]. Lancet Psychiatry. doi:10.1016/S2215-0366(18)30053-1
  2. The Lancet Psychiatry: Virtual reality-based CBT can reduce paranoia and anxiety for people with psychotic disorders [press release]. The Lancet Psychiatry. Published February 7, 2018. Accessed February 7, 2018.