Virtual Reality Therapy Shows Promise for Paranoia

MADRID — Virtual reality (VR)–based cognitive behavioral therapy (CBT) may be an alternative treatment option for patients with paranoia based on results of a new randomized, controlled trial.

The Face Your Fears study compared VR-CBT with regular CBT in patients with schizophrenia spectrum disorder, schizotypal disorder, or other psychoses. Investigators found both approaches were similarly effective, suggesting either one could be offered.

“When determining treatment choice, we should not only factor in quantity or quality of the intervention but also factors such as patient preference, and cost effectiveness — which we will be looking more into in planned papers,” lead investigator Louise Birkedal Glenthøj, PhD, from the University of Copenhagen, Copenhagen, Denmark, said.

The findings were presented on April 8 at the European Psychiatric Association Congress (EPA) 2src25 annual meeting.

The study included 254 participants, mean age approximately 29-31 years, with schizophrenia spectrum disorder (7src%-75%), schizotypal disorder (16%-21%) or other psychoses (8.5%-9.5%). Participants had a baseline score of 41 on the Green Paranoid Thoughts Scale (GPTS) for persecution and were on an olanzapine equivalent dose of 11.7-13.2 mg/d.

Patients completed 1src sessions of either VR-CBT or standard CBT, with both interventions using individually tailored case simulation and goal setting. The control group received symptom-specific CBT for psychosis, with in-vivo exposure therapy in session when possible.

In the VR-CBT group, patients were exposed to simulated social situations controlled by the therapist in real-time. The virtual social environments (a bus, café, street, park, and supermarket) were chosen based on their general capacity to elicit paranoid ideations in patients with schizophrenia spectrum disorders.

“We have more than 1srcsrc avatars to choose from and we can have them expressing a multitude of emotions and gestures, and we can also transform the therapist’s voice into different characters for the patient to engage in role plays with these avatars,” she explained.

A core focus in the VR sessions was reducing patients’ dependence on safety behaviors. About 2src-4src minutes of each session involved virtual exposure to paranoid-inducing situations as the therapist facilitated a CBT dialog aimed at generating alternative thinking and coping strategies.

In the traditional CBT group, the core focus was on patients re-appraising paranoid beliefs, she said.

Equally Effective

For the primary outcome — changes in the GPTS-persecution score — there was no statistically significant difference between the groups, “but we found that both interventions groups improved over time, corresponding to an effect size of src.9 — so quite a huge change,” Glenthøj reported.

For the secondary outcome, patients in the traditional CBT group had better scores on the emotional recognition latency measure. This was “rather unexpected and difficult to explain as the CBT manual did not comprise any aspect of training facial emotional recognition,” Glenthøj said.

Finally, on the exploratory outcomes of the Suicidal Ideation Attributes Scale (SIDAS) and Cognitive Disturbances Scale (COGDIS), the VR-CBT group had better scores, “but this must of course be seen in the context of potential multiple testing,” Glenthøj noted.

“You always have to interpret exploratory findings cautiously because when you have many outcomes, you are likely to get some positive findings that might be more or less random,” she told Medscape Medical News.

The findings suggest the possibility of equally effective, yet different options for this patient population.

“In clinical practice we found some patients benefitted highly from the VR approach because it was too difficult for them to work mainly with their cognition, as you do in regular CBT,” Glenthøj said. “Also, for some patients, the in-vivo exposure of regular CBT was too overwhelming, whereas the VR-therapy could deliver a highly fine-tuned and gradual exposure.”

Small Differences

While the differences between the two groups in the primary outcome were small, “this is not too surprising, as both deliver a treatment already known to be effective,” said Tom K. J Craig, MD, a pioneer of avatar therapy for this indication and emeritus professor of social psychiatry at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, England, who commented on the findings for Medscape Medical News.

“However, participants receiving VR-CBT improved more rapidly, particularly in terms of paranoid fears and avoidance, so needed fewer sessions. This gives a hint that VR-CBT may be more efficient way of delivering the therapy,” said Craig, who was not part of the study.

For the small but significant benefit for VR-CBT on the exploratory outcomes of the SIDAS and COGDIS subscores, he said, “it is a very small difference — but not no difference.”

VR offers another treatment option for psychiatric illness, but the technology won’t replace human therapists, Craig said.

“There is already an automated VR-treatment for paranoia that has a virtual coach instead of a therapist, so you can see that there’s directions and possibility for this, but we’ll always need therapists,” Craig said.

“When you’re working with something very hot, like threatening voices, that tell people to kill themselves or others, handing that over to automation feels too much. So even in our dream about AI, we will have a mental health professional on side with a patient, just watching what’s happening and being able to stop it or to change it, if we need to,” Craig added.

Study funding was not disclosed. Glenthøj reported consultancies for Lundbeck Pharma, Boehringer-Ingelheim, and Khora VR. Craig reported research support from Wellcome Trust, and the National Institute fo