Introduction
Virtual reality (VR) applications for mental health offer artificial sanctuaries for meditation in the form of relaxation and mindfulness. Psychotic patients can be effectively treated at the very first episode by add-on therapy to treatment as usual. VR cognitive-behavioral psychotherapy proved more feasible in aiding patients who confronted with persistent audio-verbal hallucinations. Although the possible dissociative adverse effects associated with virtual reality exposure might make it the ultimate digital addiction, there were no significant side effects encountered in the exposure of psychotic patients to VR environments.
Virtual reality is yet another business that benefits from Moore’s law of technical progress, especially in emulating computer-simulated worlds. This development is primarily supported by tech firms’ efforts in bringing high-end head-mounted displays from idea to mass-market affordability. This comes at a cost since it influences the construction of the virtual reality environment known as Metaverse.
Virtual reality offers a standardized means for cognitive behavioral interventions, aiding ultra-resistant psychotic patients in coping with constant hallucinations. Immersive and distracting, VR has the potential to become the future gold standard of exposure treatment for certain phobias and craving triggers in addiction treatment. Currently available virtual reality applications for mental health offer artificial sanctuaries for meditation and aid those with psychotic diseases in coping with constant hallucinations. The possible dissociative adverse effects associated with virtual reality exposure might make it the ultimate digital addiction.
Virtual reality applicability for cognitive disorders of the elderly
Virtual reality technological development made the hardware accessible. The graphical processing power of existing machines has the potential to turn VR into a standardized means of geriatric research, especially in the field of cognitive disorders, being effective when applied from mild cognitive impairment to Alzheimer’s dementia(1). Another growing perspective is represented by VR cognition clinical trials test development in preclinical Alzheimer’s dementia (AD) suspected individuals(2) or for the development of cognition tests(3), as VR is reliable when assessing even complex cognitive functions such as prospective memory(4).
Immersive virtual reality (iVR) allows the realistic engagement with a virtual environment, which has the potential to provide an accurate differentiation of AD pathology on spatial cognitive tasks. Spatial cognition tasks may provide earlier detection of Alzheimer’s disease than the current gold standard of episodic memory tests. iVR makes use of expansive vistas that would not be conceivable with other methods.
Still, current literature does not differentiate non-immersive VR from two-dimensional VR when it comes to interventions regarding the elderly population suffering from cognitive disorders(5,6).
Wais et al., in 2021, developed a software called Labyrinth-VR to assess the potential of VR for improving spatial navigation skills in a randomized control trial (RCT) involving 48 older persons with average cognitive capacities who were randomly allocated to either 12 hours of Labyrinth-VR or to placebo computer gameplay over four weeks, reporting promising results that open the way for future research(7).
Although the impact of fully immersive VR cognitive training is dependent on the patient’s existing cognitive reserve(8), currently there is weak evidence that digital technologies may be less effective for people diagnosed with dementia than for those with mild cognitive impairment(9), and similar results were reported during semi-immersive VR assisted cognitive training for patients with mild cognitive impairment, with improving naming ability, memory delayed recall, phonemic fluency, but also apathy, affect and overall quality of life(10).
The possibility of monitoring a patient’s eye gaze during the VR intervention through embedded eye-tracking technology could determine particularities regarding dementia patients’ traits. Davis and Sikorskii, in 2021, reported that Alzheimer’s dementia patients might have a lower ability to fixate on salient cues and a higher percentage of fixation on building features, therefore explaining the difficulties encountered while searching for relevant information specific to Alzheimer’s dementia patients(11).
People with cognitive impairment who are hospitalized in acute wards constitute a highly vulnerable population. “Agitation” is a regularly used clinical word, often used as a shorthand for “problematic or aggressive” behavior while it marks patient distress(12,13).
Furthermore, VR treatment for terminally ill patients is a growing area of research in the field of palliative care, being reported as both feasible and safe(14). Johnson et al., in 2020, assessed the efficacy of VR for palliative care patients, through pilot research involving 12 hospice facility residents. The impact of VR was evaluated through the Edmonton Symptom Assessment Scale and showed a diminishing of acute symptom burden, good tolerability, enjoyability and overall usefulness(15).
“Exergames” (exercise games) or virtual reality-based gadgets, such as the Nintendo Wii and the X Box Kinect, are increasingly popular in older adults. Studies have shown the effectiveness of exergames on the mobility, balance and cognitive functioning of older adults while also being financially affordable. In addition, those who participate in this sort of exercise have stated their aim to modify their behavior by continuing to utilize exergames to enhance cognitive and physical skills(16-18). Even one single exergame session was found to improve the verbal fluency of participants with dementia. Therefore, exergames may induce an ultrafast prefrontal cortical adaptation, resulting in a modest improvement in the cognition of the institutionalized elderly population(19).
Virtual reality application in schizophrenia and other psychotic disorders
Current digital health technologies improve the quality of life and promote functional recovery of patients suffering from psychotic disorders through standalone computer programs, smartphone applications, internet-based technologies and, more recently, virtual reality. VR-delivered treatment manages to deliver learning similar to real-world training(20) and, therefore, improves social cognition(21).
The pre-psychosis phase is the time between the first obvious behavioral alterations and the advent of overt psychotic symptoms. The prodromal phase, which may last days to five years, is a valuable time to begin the treatment for a better prognosis. Research has demonstrated that shortening the duration of untreated psychosis can improve outcomes, and virtual reality is considered a valuable tool in this aspect(22). Initiatives to design such virtual worlds for young individuals with early psychosis were shown promising regarding young users’ agility in using the platforms, promoting specific designs ready to be tested in proof-of-concept clinical trials(23).
Virtual reality tools were used to quantify the level of impairment regarding the integration of visual and auditory stimuli, managed to measure the executive functions in a virtual environment(24), and also monitor the patients’ behavior in a somewhat standardized manner when a certain task is being carried out(25). The current state of VR application development could benefit from a more standardized framework and, until then, VR assessments should only be conducted in parallel with validated psychometric scales(26).
Up to seventy per cent of patients suffering from psychosis share the common paranoid delusions that cause social isolation, distress and finally encourage hospital admission. Berkhof et al., in 2021, reported the superiority of VR-based CBT compared to the current gold standard of CBT in improving paranoid delusions, especially when psychotic individuals also share high social anxiety(27), and other studies suggested a synergistic effect of VR combined to CBT(28). The level of perceived anxiety is associated with a greater interpersonal distance in psychosis(29).
Psychotic patients commonly have anxiety and depression in addition to paranoid ideations. Disrupting the interaction between negative emotional states and paranoia may be crucial to treating paranoia. Using a network approach, the effects of VR-CBT may hasten mental recovery, improving outcomes compared to CBT in the treatment as usual (control group)(30).
Another approach for using VR to treat paranoia was successfully enhancing compassion. Such an RCT was conducted by Brown et al., in 2022, and included healthy individuals who scored higher for paranoia, which were split into two separate studies – one aiming at self-compassion through a coach and one aiming at compassion for others through loving kindness and meditation. The results revealed that an increase in compassion for self and others statistically significant lowered paranoia levels(31).
Therefore, although VR is associated with dissociative side effects, Monaghesh et al., in 2022, revealed through a systematic search of current research papers that VR-facilitated interventions are currently considered safe and effective in treating paranoid ideation(32).
AVATAR – an audio-visual resemblance of the source of the hallucination
AVATAR treatment offers “face-to-face” communication between a person and a computerized voice representation. Bespoke software alters the therapist’s voice to fit the desired voice’s pitch and tone. The goal is for the voice-hearer to establish a sensation of power and control in the discussion(33).
People who have been diagnosed with schizophrenia may see considerable improvements in their working memory and executive function by the addition of intensive training using active VR serious games to their usual treatment(34).
A systematic review evaluating the ability to improve the therapeutic outcomes of interventions targeting auditory hallucinations through dialogical interventions compared to the current gold standard of cognitive-behavioral therapy reveals the superiority of Relating Therapy and AVATAR Therapy or Virtual Reality Assisted Therapy regarding lesser voice distress and an improvement of affective symptoms.
Therefore, dialogical therapies may represent an effective alternative to the current gold standard treatment of CBT(35). Dellazizzo et al., in 2021, reported a higher improvement of affective functions of treatment-resistant schizophrenia patients after one year of treatment in the VR group compared to the CBT group, with effects persisting at the one-year follow-up(36). Isolated case reports show promising results of AVATAR therapy in ultra-resistant schizophrenia patients, lowering the impact of persistent audio-verbal hallucinations(37,38).
AVATAR therapy is reported to be usable by professional groups as a digital psychotherapeutic tool in correlation with their background, as Brander et al., in 2021, reported a statistically significant system usability scale of a therapeutic platform of psychotherapists compared to nursing staff(35,39).
Rault et al., in 2022, reported that VR-facilitated relaxation techniques were associated with good tolerance regarding lack of cybersickness or dissociative symptoms, and also anxiolytic effects in a pilot study including 13 schizophrenic patients(40).
Qualitative studies evaluating the acceptability of VR-assisted therapy in psychotic populations show promising results(41,42), and a qualitative study assessing the acceptability of VR-assisted CBTp among adolescents (10 of the 16 enrolled experienced VR before) reveals that 14 of the participants would prefer exposure through VR than real-life during social training(43).
Vass et al., in 2021, performed an RCT aimeds at a VR adaptation based on the theory of mind cognitive model for clinically stable schizophrenia diagnosed patients(44).
The perspective of using VR to diagnose certain non-affective psychoses shows promising ecological validity, although it needs calibration before validation as a means of diagnosis(45), and also differential diagnosis of schizophrenia and schizoaffective disorder from normal subjects(46).
The automatization perspective of social training could represent a means of facilitating cheap access, unbiased by human subjectivity to social training of psychotic patients. Also, VR environments could represent a valuable tool in the rehabilitation of movement abnormalities in schizophrenia patients, extrapolating from the transfer of learning to real-life situations encountered in other afflictions(47,48).
Freeman et al., in 2022, evaluated the satisfaction of 122 psychotic patients using such automated VR therapy. The results reported were a mostly high satisfaction encountered in 79 of the patients (65.8%), mostly satisfaction in 37 of them, and three of them were indifferent or mildly dissatisfied, while only one person was quite dissatisfied. The results also revealed that VR-associated reported side effects were low, and a positive correlation was established between difficulties concentrating in VR and dissatisfaction(49).
As a final perspective regarding the current state of the AVATAR techniques, a Cochrane systematic review states that to improve AVATAR, researchers should find a different direction than one of the creators of the intervention, emphasizing the need for a better-standardized means of implementation(50).
Implementation of virtual reality in anxiety disorders
One-third of the adult population’s functionality is impaired by experiencing a type of anxiety at some point(51), and 14% of the population is currently being affected by an anxiety disorder(52).
Phobias represent an exaggerated response of fear about the danger posed by a particular stimulus, that must consistently induce anxiety.
Exposure therapy helps clients address fear-inducing situations via therapeutic CBT guidance in vivo (facing fear inducing stimuli in real life), imaginary or interoceptive(53).
Although this therapy cognitive-behavioral therapy focused on exposure still stands as a gold standard treatment for anxiety disorders, half of the patients are non-responsive(54).
Compared to healthy controls, conditional stimuli-induced fear responses are significantly elevated in anxiety patients and are associated with a diminished capacity to regulate fear in the face of safety signals(55).
Avoidance is a prominent feature of anxiety disorders. Individuals with particular phobias respond deliberately to avoid or minimize interaction with the phobic item. This avoidance habit causes severe discomfort and impairment in key areas of functioning. In addition, avoidance behavior hinders the elimination of fear, therefore perpetuating it.
For reducing anxiety, VRET with motion tracking has proven more effective and feasible than true exposure. In addition to CBT sessions, participants engaged in virtual theatrical activities, such as standing on balconies, ladders and bridges.
Virtual reality represents a viable environment for the study of behavioral tasks during exposure, preliminary to a better understanding of patient response to stressful stimuli(56).
The possibility of delivering autonomous interventions that lower avoidance behavior at home and unsupervised through standalone VR applications represents a promising perspective for the treatment of agoraphobic patients(57).
Similar results were reported for use of an autonomous VR application for panic disorder(58) and also for HMD exposure to 360 degrees videos(59), and generalized social anxiety disorder(60).
The alternative of VR exposure therapy is a more practical and cost-effective kind of exposure treatment, as it is standardized and can be automatized. It employs well-crafted virtual environments to induce the same feelings of fear and presence that a client would experience during actual exposures(61). Furthermore, VRET-CBT is more effective than waiting list and shares a similar impact as CBT when treating severe anxiety disorders(62,63).
VR was applied in the treatment of specific phobias, such as driving phobia(64), public speaking phobia(65,66), aviophobia(67) and arachnophobia(68-70), although non-inferiority compared to in vivo exposure seems to diminish after one year from the initial VRET exposure(71).
VRET-CBT is useful even for self-guided, applications such as ZeroPhobia – a VR application delivering through a low-end HMD treatment and producing a significant diminishing in acrophobic symptoms(72-74).
Virtual reality RCTs can also represent a means of better understanding why patients react exaggeratedly towards a phobic type of stimuli. For example, Bzdúšková et al., in 2022, reported that acrophobic patients respond to heights with maladaptive posture stiffness owing to the increased interpretation of visual input for balance regulation, and also that exposure to height in a realistic VR environment evokes a complex response comprising associated emotional and postural changes(75).
Furthermore, VRET treatment lowered activity within the frontopolar prefrontal cortex and orbitofrontal cortex in patients with social anxiety who reported symptom reduction, therefore partially explaining the mechanism of VRET effectiveness(76).
VRET has proven effective for the treatment of glossophobia patients(77) and follows a similar mechanism but also shares strong evidence of effectiveness in the treatment of other social anxiety disorders(78-81).
Recent studies have revealed the mechanism underlying the neural process associated with social anxiety disorder in the form of greater neural responses during positive self-referential processing compared to the control group. Activation throughout wide somatosensory regions was also observed to be greater during negative self-referential thinking after virtual reality treatment by comparison to baseline(82).
Regarding the duration of treatment, Krystanek et al., in 2021, systematically reviewed the current literature, reporting that the optimal interval for VRET therapy for phobias can be successful even when administered in one 45 to180 minutes session, while in agoraphobia and social phobia when administered for 8 to 12 sessions, on average once per week for at least 15 minutes(83), while social anxiety disorder should benefit from 9 to 10 sessions, although even five to six might prove efficient(84).
Even hough VR is less studied in the child and adolescent population(85), the current literature revealed that it can be used to deliver scenarios meant to facilitate mindfulness and self-compassion techniques to reduce the stress of the predisposed population, such as university students(86), and also lower academic performance worry(87).
Last but not least, VR may serve as an efficient autonomous relaxation means for psychiatric patients(88).
Perhaps one of the most efficient of immersive VR applications is VRET-CBT psychotherapy for post-traumatic stress disorder (PTSD). In PTSD, VRET may be a successful alternative to the existing therapies, as it is reported to be more efficient than waiting for control groups and comparable to other psychotherapies(89), as reported by prior research that has shown that the incorporation of sensory modalities is a vital way for modifying users’ sense of presence in a virtual world(90). Existing VRET in PTSD studies enhances the realism of combat scenarios by including aural elements, such as conflict sounds. According to studies, VRET is effective for lowering anxiety in PTSD patients. Still, VRET may not be appropriate for all clinical instances of PTSD since it may be costly and impracticable to build tailored immersions for people who have experienced a wide range of traumatic experiences.
VRET is currently added to treatment guidelines in Germany for anxiety disorders(91) but, although efficient, there is a growing need for professionals to implement VRET during clinical practice, for researchers to optimize the common frameworks, and to pursue outcomes following similar methods(92-94), to be able to gather similar, homogenous results.
Discussion
Regarding current digital technological trend implementation in healthcare, the fact that virtual reality is still near inception compared to social media and apps may offer a head start for the medical world to use it as a tool for promoting mental health, and not mental disorders. To use the lack of reaction psychiatry had towards technology in the past to our advantage, there is a strong need to build common research design frameworks, consider VR interventional, and make steps toward placebo group comparison. Last but not least, we must facilitate governmental policies regarding the guideline implementation of virtual reality, as through the autonomous and standardized interventions achieved in an environment that is perceived as real, VR may fill the gap of the current deficit of mental health professionals in an effective and cost-efficient manner. The question that stands is: Will we get out of the comfort zone contributing with ethical frameworks and use virtual reality as a treatment to counterbalance its negative effects, or will we let this emergent technology become malignant to its users, as social media and smartphones turned out to be?