Virtual Reality-Based Cognitive and Behavioral Therapy for Anxiety and Depression

Post by Leanna Kalinowski

A need for anxiety and depression treatment

Anxiety and depression are the most commonly diagnosed mental disorders, impacting the lives of millions of adults across the globe. While they are distinct entities, up to 60% of adults with an anxiety disorder also suffer from depressive symptoms and vice versa. Cognitive-behavioral therapy is an effective treatment for both — either alone or in combination with pharmacotherapy.  

What is Cognitive-Behavioral Therapy?

Cognitive-behavioral therapy (CBT) is a form of psychotherapy comprising a wide range of cognitive and behavioral interventions. CBT is based on the idea that behavioral changes lead to changes in emotion and cognition, and that cognitive changes lead to changes in emotion and behavior. With both strategies combined, CBT teaches patients how to identify and change their thought patterns related to the behavioral and emotional reactions that cause harm.

There are a handful of CBT techniques commonly used for people with anxiety and depression, including:

1) Psychoeducation. This is often the first step in CBT, where patients are taught how CBT works and provided the rationale for why it will be beneficial to them. Once patients learn how CBT works, they are typically able to easily apply it to their own lives in the absence of any future intervention.

2) Behavioral Activation. People with depression often withdraw from activities that previously provided natural reinforcement, leading to a cycle in which they remain inactive and do not experience the reinforcement from these activities. Behavioral activation aims to work with patients to set goals to engage in these rewarding activities (e.g., exercising or hanging out with friends) and break them out of this cycle of inactivity. 

3) Cognitive Restructuring. People with anxiety and depression often engage in negative thought patterns, including overgeneralizing and catastrophizing. Cognitive restructuring aims to help patients notice when they are engaging in these negative thought patterns and empower them with the tools needed to change these thought patterns.  

4) Exposure-based Therapy, which is especially common for people with anxiety. This therapy is based on emotional processing theory, which states that fear is represented through associative networks that maintain information about the feared stimulus (e.g., public speaking), the response to the feared stimulus (e.g., escape, avoidance, physiological responses), and the meaning of the stimulus and response (e.g., public speaking = increased heart rate = danger). In this example, exposure to public speaking in a controlled environment provides new information to indicate that public speaking isn’t that scary or dangerous, leading to a decrease in fear. 

While CBT is an effective treatment for anxiety and depression, a variety of therapy gaps exist. CBT often helps with initial treatment but is not as effective at preventing relapse of symptoms. Furthermore, CBT typically requires 10 to 20 sessions, each up to an hour-long, with guidance from a mental health professional. These gaps pose a problem for many adults, which has led to a push from mental health professionals to develop accessible ways in which CBT can be delivered, such as through smartphone apps and virtual reality technology. 

What is virtual reality technology? 

Virtual reality (VR) is a wearable technology that allows the user to feel fully immersed in a virtual world. VR commonly consists of a head-mounted display that blocks out the outside world while displaying a computer-generated, yet realistic world. This technology allows users to look around, move around, and interact with objects within the virtual world. It is often supplemented with auditory and tactile (e.g., vibrations) stimuli to mimic the real world. VR has been used in video games, military training, and business meetings is relatively affordable, and is compatible with most modern smartphones. These features make it an attractive option to enhance CBT.

How can virtual reality be used for CBT?

VR therapy is a promising avenue for implementing CBT, and Lindner and colleagues provide a comprehensive review into how some of the common approaches to CBT outlined above can be tapped into using the VR world. For example, several VR games available on the market allow users to engage in physical activity (e.g., VR boxing and tennis) and social gatherings (e.g., VR karaoke and concerts). Engaging in these activities can help patients experience the natural reinforcement required for behavioral activation therapy. 

Another example of how CBT can be adapted for a VR world is seen with virtual cognitive restructuring therapy. When this type of CBT is utilized in person, the patient must imagine an example situation to practice these cognitive restructuring techniques. However, with VR, the patient can be placed directly into these situations, without needing to imagine them, report negative thoughts by placing them into speech bubbles, and manipulate those thoughts using a virtual eraser. Engaging in these activities can help patients practice cognitive restructuring techniques in a more realistic setting.

Exposure therapy can also easily be accomplished using VR by exposing the patient to stimuli that lead to anxiety. For example, someone with a fear of spiders can undergo a VR task in which they are placed in a room with virtual spiders. Like in-person exposure therapy, this empowers the patient to change the associative networks that associate spiders with fear, leading to a decrease in anxiety. 

However, not all approaches to in-person CBT are as easily transferable to a VR context. For example, it is difficult to simulate psychoeducation using VR; evidence suggests that this method is better suited to be administered in-person or through a smartphone app that does not utilize VR. 

What’s the bottom line?

Many of the approaches to treating anxiety and depression with CBT are easily achievable using VR technology. This, coupled with its cost and accessibility, makes VR a promising avenue for enhancing CBT. Further research is needed to determine the effectiveness of VR-based CBT (1) in contrast to in-person CBT, (2) in combination with pharmacotherapy, and (3) when treating initial symptoms in addition to relapse of symptoms.

References

Ballenger. Anxiety and depression: Optimizing treatments. 2000. The Primary Care Companion to the Journal of Clinical Psychiatry. Access the publication here. 

Hundt et al. The relationship between use of CBT and depression treatment outcome: A theoretical and methodological review of the literature. 2013. Behavior Therapy. Access the publication here. 

Ioannou et al. Virtual reality and symptoms management of anxiety, depression, fatigue, and pain: A systematic review. 2020. SAGE Open Nursing. Access the publication here.

Kaczkurkin & Foa. Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. 2015. Dialogues in Clinical Neuroscience. Access the publication here. 

Lindner et al. How to treat depression with low-intensity virtual reality interventions: Perspectives on translating cognitive behavioral techniques into the virtual reality modality and how to make anti-depressive use of virtual reality-unique experiences. 2019. Frontiers in Psychiatry. Access the publication here.

Maples-Keller et al. The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. 2017. Harvard Reviews Psychiatry. Access the publication here. 

Roshanaei-Moghaddam et al. Relative effects of CBT and pharmacotherapy in depression versus anxiety: Is medication somewhat better for depression, and CBT somewhat better for anxiety? 2011. Depression and Anxiety. Access the publication here.