Cognitive-Behavioral treatment and antidepressants combined with virtual reality exposure for patients with chronic agoraphobia

Peñate Castro, W., Roca Sánchez, M. J., Pitti González, C. T., Bethencourt, J. M., de la Fuente Portero, J. A., & Gracia Marco, R. (2014). Cognitive-behavioral treatment and antidepressants combined with virtual reality exposure for patients with chronic agoraphobia. International Journal of Clinical and Health Psychology, 14(1), 9–17. https://doi.org/10.1016/S1697-2600(14)70032-8

Summary by: Alba Basholi

The Exposure Dilemma 

Cognitive Behavioral Therapy (CBT) in combination with in vivo exposure—which means confronting feared situations directly in real life—is considered by many as the best possible treatment for agoraphobia. But this "best treatment" also has a problem: the therapy itself is often very scary. A lot of patients feel so overwhelmed by the idea of being exposed to real-world stimuli that they either refuse to take the treatment or drop out very early. This problem has been magnified in cases of "chronic" patients—those who have been in agony for several years and might have already tried exposure a few times unsuccessfully. 

In 2014, Peñate Castro and his colleagues studied this dilemma in therapy by using Virtual Reality Exposure Therapy (VRET) as a test case. They suggested that VRET would not act as a replacement for real-world exposure; instead, it would be a vital intermediate that would not only improve adherence but also long-term outcomes for stubborn patients. 

Targeting the "Chronic" Sufferer 

The clinical trial was carried out with the utmost care, and it was mainly directed towards a difficult-to-treat population: long-term agoraphobic patients. They had been in distress for an average time of 11.46 years, with some cases lasting for as long as 30 years. To be on the safe side and for the sake of scientific rigor, the study accounted for drug variables; every participant was treated with antidepressants that had been proven effective against anxiety (Paroxetine or Venlafaxine). 

Out of 80, the subjects were assigned randomly to one of the three groups as follows: 

• CBT + Medication: They took part in the CBT with in vivo exposure, where they confronted the actual environments along with the therapists. 
• VRET + Medication: The patients were those who received the significant approach combined with a Virtual Reality system to confront the phobic scenarios (e.g., airports, squares, elevators) gradually and subsequently to the real-life exposure. 
• Medication Only: They received only medications and no psychological intervention during the study. 

A Crisis of Adherence in Standard CBT 

About clinical efficacy, the research validated that the treatment through medication alone is not enough for this group of patients. The "Medication Only" group did not have any remarkable symptom improvement between pre-treatment and post-treatment; rather, some anxiety scores slightly went up. 

The two therapy groups were compared to the drug-only group, and statistically significantly, the two therapy groups were better off. However, there was a marked difference over time, and that difference was in favor of the VRET group. At the six-month follow-up, the VRET group achieved "clinical improvement" (50% reduction in scores) for most variables, including fear and avoidance. Above all, VRET patients had a very big score decrease on the "Agoraphobia Inventory - Alone" scale, which reflects a patient`s greater ability to attend the feared places without a safety partner—a main characteristic of independence. 

The "Intermediate Step" 

The authors consider VRET to be an effective treatment because it serves as an "intermediate procedure.” A virtual simulation can be a very small but very important first step for a patient who has not used elevators for ten years. The patient boosts his self-efficacy and confronts fear in a safe environment by mastering the virtual analogue. This "scaffolding" guarantees that when they finally confront the real world, they are armed with confidence, not fear, which leads to fewer dropouts and creates a path for permanent recovery.