what are sufferers’ experiences and unintended effects?


On a regular basis actions that the majority of us take without any consideration corresponding to visiting retailers, travelling on a bus, or strolling on the street, may be intensely anxiety-provoking for some sufferers with psychosis (Freeman et al., 2022). Concern of being negatively judged, embarrassed, or rejected could lead these with psychosis to keep away from these conditions altogether.

When there’s a marked worry of public locations and makes an attempt to actively keep away from such conditions, agoraphobia could develop (American Psychiatric Affiliation, 2013). Within the UK, one examine discovered that 65% of 1,809 non-affective psychosis sufferers attending NHS psychological well being providers had signs of agoraphobia (Freeman et al., 2019a).

gameChange, a digital actuality (VR) remedy, was developed to focus on psychosis sufferers’ nervousness in direction of on a regular basis conditions (Lambe et al., 2020). It permits sufferers to judge their fears in numerous situations with the assistance of a digital coach.

The VR surroundings permits the remedy to be performed in a managed, modifiable, and interesting means. gameChange has demonstrated its effectiveness in lowering nervousness and misery in on a regular basis conditions for psychosis sufferers (Freeman et al., 2022 – blogged final 12 months by Imogen Bell) and its potential use inside psychiatric wards has been highlighted (Brown et al., 2022). Regardless of these promising findings, there may be restricted analysis on the potential unintended effects and sufferers’ experiences of VR for psychosis.

Virtual reality is an emerging technology for mental health treatments, including targeting generalised anxiety among people with psychosis.

Digital actuality is an rising know-how for psychological well being remedies, together with concentrating on nervousness in on a regular basis conditions amongst folks with psychosis.


The examine had a randomised managed design with randomisation to both a VR cognitive remedy (gameChange) along with remedy as common or simply remedy as common. The VR remedy lasted for thirty minutes and was continued over six periods.

Individuals had been aged 16 or older, attended NHS providers with a medical analysis of schizophrenia spectrum psychosis or an affective analysis with psychotic signs measured utilizing the ICD-10 (World Well being Group, 2004) and had difficulties being exterior their residence because of nervousness. The examine was pre-registered and a protocol was revealed at the beginning of the trial (Freeman et al., 2019b).

The first consequence measure was the Oxford Agoraphobic Avoidance Scale (O-AS) (Lambe et al., 2021). The O-AS measures nervousness and misery for on a regular basis conditions corresponding to travelling on a bus or sitting in a GP ready room.  The outcomes of this consequence measure had been reported elsewhere (Freeman 2022).

Satisfaction and unintended effects had been addressed utilizing a battery of questionnaires particular to the domains (VR, agoraphobia, melancholy, hopelessness and psychosis).

The assessments had been taken at baseline and 6 weeks and 26 weeks after randomisation.


The examine included 122 of the 161 trial individuals who accomplished no less than one VR session and supplied consequence information.

Satisfaction with VR remedy

Nearly all individuals rated the standard of the VR remedy pretty much as good or wonderful (98%), discovered the employees supporting them to be very useful (98%), had been both very happy or largely happy with the VR remedy (97%) and had been extraordinarily doubtless or more likely to suggest it to pals or household (91%).

Simply over half of the individuals stated the VR remedy helped them to be extra assured in on a regular basis conditions (51%) and over two-thirds felt they acquired simply the precise variety of periods (78%). Only a few individuals had been dissatisfied with the VR remedy and rated the standard as honest (3%), that it didn’t actually assist (4%) or that it appeared to make issues worse (1%). Only some individuals had been detached/mildly dissatisfied (3%) or fairly dissatisfied (1%) with the VR remedy.

Unwanted side effects

Potential unintended effects of the VR remedy had been grouped into optimistic and unfavorable gadgets. The very best endorsement for a unfavorable aspect impact was “I couldn’t focus on my session as a result of I used to be always enthusiastic about what else is likely to be occurring within the room” (14%) and for a optimistic aspect impact: “I felt pleased with myself for having the ability to use the VR” (82%).

The unintended effects had been grouped into 4 distinct components for evaluation: worries following VR, emotions of panic utilizing VR, feeling valued and difficulties concentrating when carrying a headset.

There have been no associations between baseline symptom scores (e.g., paranoia, voices, melancholy and nervousness) with the incidence of unintended effects. The one statistically vital affiliation with baseline measures was for individuals that reported higher hopelessness, measured on the Beck Hopelessness Scale (Beck & Steer, 1988), that had fewer emotions of panic when in VR (R = -0.21, p = 0.028, n = 107).

Most patients were satisfied with gameChange Virtual Reality therapy and had minimal side effects.

Most sufferers had been happy with gameChange Digital Actuality remedy and had minimal unintended effects.


Nearly all individuals within the examine reported satisfaction with the VR remedy and optimistic experiences had been extra widespread than unfavorable unintended effects. The authors consider that “over the approaching years VR interventions are extremely more likely to be supplied in medical providers for sufferers with psychosis.

These findings had been…

in keeping with our medical expertise, and research of affected person and employees views (e.g., Bond et al., 2021; Brown et al., 2022) that point out substantial enthusiasm for VR approaches or psychological well being difficulties.

The authors conclude:

Total the examine outcomes point out that affected person expertise is not going to hinder the implementation at scale of automated VR remedy however is as an alternative extra more likely to show a facilitator.

Nevertheless, these information additionally present that we must be aware of the potential unintended effects of VR remedy, and that not everybody could wish to have interaction with VR remedy within the first place.

gameChange allows psychosis patients to experience everyday situations within virtual reality that they often find distressing in the real world.

gameChange permits psychosis sufferers to expertise on a regular basis conditions inside digital actuality that they usually discover distressing in the true world.

Strengths and limitations

The examine was of top quality, utilizing a randomised managed design with good allocation concealment. The report of the first effectiveness consequence (the Oxford Agoraphobic Avoidance Scale) confirmed that it might be helpful for psychosis sufferers (Freeman et al., 2022).

To make sure that the intervention was related to the goal affected person group, gameChange was designed with folks with lived expertise, and included assist from psychological well being professionals.

Nevertheless, the examine individuals needed to have accomplished no less than one VR session. This will likely have skewed the findings in favour of optimistic attitudes in direction of the know-how.

One other limitation, as famous by the authors, is the usage of a brand new measure created by medical psychologists from the College of Oxford (Oxford – VR Aspect Results Guidelines). Additional research utilizing the measure are required to substantiate its validity, together with a bigger pattern dimension to check for polytomous and dichotomous responses. It might have been useful to match the VR remedy with a VR management group quite than solely remedy as common, to assist isolate the VR expertise from the remedy being delivered (Schroeder et al., 2022).

This study reinforced the idea that virtual reality environments offer a safe, controlled space for psychosis patients to receive therapy.

This examine bolstered the concept digital actuality environments supply a secure, managed house for psychosis sufferers to obtain remedy.

Implications for follow

VR could also be an efficient surroundings for psychosis sufferers with agoraphobia. Though sufferers are conscious that VR environments should not actual, they very intently match real-world experiences and permit for higher engagement with remedy (Lambe et al., 2020). Psychosis sufferers usually tend to enter conditions inside VR that they might in any other case discover extremely distressing in the true world and this enables a secure house for experimentation (Lambe et al., 2020).

Shortly after this examine was revealed, an additional trial reported that gameChange was efficient in lowering misery and nervousness from agoraphobia, and suggestions from sufferers was optimistic (Freeman et al., 2022).

Unwanted side effects from VR could possibly be a barrier to extra widespread adoption of the know-how.  Clinicians, researchers and repair customers must be knowledgeable about, and looking out for unintended effects throughout this remedy.

Complications and nausea can happen, particularly when utilizing the know-how for the primary time, however they had been a minor criticism for psychosis sufferers in this examine.

The authors notice that:

The unpleasantness of cybersickness could possibly be the aspect impact that the majority limits widespread adoption of VR.

There was no indication that this was at a scale to have an effect on adoption considerably.

VR interventions are likely to be provided in clinical services in the future, thus patients should be informed of the benefits and side effects compared with traditional treatments.

VR interventions are more likely to be supplied in medical providers sooner or later, thus sufferers must be knowledgeable of the advantages and unintended effects in contrast with conventional remedies.

Not everybody who is obtainable VR remedy will wish to have interaction with it.  We must always not neglect this group.

As VR turns into extra widespread inside psychological well being remedy, will probably be fascinating to collect observational information from follow, and examine whether or not different types of interactive remedy may be helpful, for instance, these delivered by way of interactive 2D screens (Riches et al., 2021).

Assertion of pursuits

None to reveal.


Main paper

Freeman, D., Rosebrock, L., Waite, F., Loe, B. S., Kabir, T., Petit, A., Dudley, R., Chapman, Ok., Morrison, A., O’Regan, E., Aynsworth, C., Jones, J., Murphy, E., Powling, R., Peel, H., Walker, H., Byrne, R., Freeman, J., Rovira, A., Galal, U., Yu, L.-M., Clark, D. M., & Lambe, S. (2022). Digital actuality (VR) remedy for sufferers with psychosis: satisfaction and unintended effects. Psychological Medication, 1-12. https://doi.org/10.1017/S0033291722001167

Different references

American Psychiatric Affiliation. (2013). Diagnostic and Statistical Handbook of Psychological Problems: DSM-5. American Psychiatric Affiliation.

Beck, A. T., & Steer, R. A. (1988). Handbook for the Beck hopelessness scale. Psychological Corp.

Bond, J., Robotham, D., Kenny, A., Pinfold, V., Kabir, T., Andleeb, H., Larkin, M., Martin, J. L., Brown, S., Bergin, A. D., Petit, A., Rosebrock, L., Lambe, S., Freeman, D., & Waite, F. (2021). Automated digital actuality cognitive remedy for folks with psychosis: protocol for a qualitative investigation utilizing peer analysis strategies. JMIR Analysis Protocols, 10(10), e31742. https://doi.org/10.2196/31742

Brown, P., Waite, F., Lambe, S., Jones, J., Jenner, L., Diamond, R., & Freeman, D. (2022). Automated digital actuality cognitive remedy (gameChange) in inpatient psychiatric wards: qualitative examine of employees and affected person views utilizing an implementation framework. JMIR Type Res, 6(4), e34225. https://doi.org/10.2196/34225

Freeman, D., Lambe, S., Kabir, T., Petit, A., Rosebrock, L., Yu, L.-M., Dudley, R., Chapman, Ok., Morrison, A., O’Regan, E., Aynsworth, C., Jones, J., Murphy, E., Powling, R., Galal, U., Grabey, J., Rovira, A., Martin, J., Hollis, C., Clark, D. M., Waite, F., Altunkaya, J., Andleeb, H., Bergin, A., Daring, E., Bond, J., Bransby-Adams, Ok., Brown, S., Chan, C., Chauhan, N., Craven, M., Freeman, J., Geddes, J., Goodsell, A., Jenner, L., Kenny, A., Leal, J., Mitchell, J., Peel, H., Pervez, M., Prouten, E., Roberts, E., Robotham, D., Walker, H., & West, J. (2022). Automated digital actuality remedy to deal with agoraphobic avoidance and misery in sufferers with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, managed trial in England with mediation and moderation analyses. The Lancet Psychiatry, 9(5), 375-388. https://doi.org/10.1016/S2215-0366(22)00060-8

Freeman, D., Taylor, Ok. M., Molodynski, A., & Waite, F. (2019a). Treatable medical intervention targets for sufferers with schizophrenia. Schizophrenia Analysis, 211, 44-50. https://doi.org/10.1016/j.schres.2019.07.016

Freeman, D., Yu, L.-M., Kabir, T., Martin, J., Craven, M., Leal, J., Lambe, S., Brown, S., Morrison, A., Chapman, Ok., Dudley, R., O’Regan, E., Rovira, A., Goodsell, A., Rosebrock, L., Bergin, A., Cryer, T. L., Robotham, D., Andleeb, H., Geddes, J. R., Hollis, C., Clark, D. M., & Waite, F. (2019b). Automated digital actuality (VR) cognitive remedy for sufferers with psychosis: examine protocol for a single-blind parallel group randomised managed trial (gameChange). BMJ Open, 9(8), e031606. https://doi.org/10.1136/bmjopen-2019-031606

Lambe, S., Fowl, J. C., Loe, B. S., Rosebrock, L., Kabir, T., Petit, A., Mulhall, S., Jenner, L., Aynsworth, C., Murphy, E., Jones, J., Powling, R., Chapman, Ok., Dudley, R., Morrison, A., Regan, E. O., Yu, L.-M., Clark, D., Waite, F., & Freeman, D. (2021). The Oxford Agoraphobic Avoidance Scale. Psychological Medication, 53(4), 1233-1243. https://doi.org/10.1017/S0033291721002713

Lambe, S., Knight, I., Kabir, T., West, J., Patel, R., Lister, R., Rosebrock, L., Rovira, A., Garnish, B., Freeman, J., M. Clark, D., Waite, F., & Freeman, D. (2020). Growing an automatic VR cognitive remedy for psychosis: gameChange VR remedy. Journal of Behavioral and Cognitive Remedy, 30(1), 33-40. https://doi.org/10.1016/j.jbct.2019.12.001

Riches, S., Pisani, S., Fowl, L., Rus-Calafell, M., Garety, P., & Valmaggia, L. (2021). Digital reality-based evaluation and remedy of social functioning impairments in psychosis: a scientific overview. Worldwide Evaluation of Psychiatry, 33(3), 337-362. https://doi.org/10.1080/09540261.2021.1918648

Schroeder, A. H., Bogie, B. J. M., Rahman, T. T., Thérond, A., Matheson, H., & Guimond, S. (2022). Feasibility and efficacy of digital actuality interventions to enhance psychosocial functioning in psychosis: systematic overview. JMIR Psychological Well being, 9(2), e28502. https://doi.org/10.2196/28502

World Well being Group. (2004). ICD-10: Worldwide statistical classification of illnesses and associated well being issues: Tenth revision (2nd ed.). World Well being Group.

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