Predictors of Changes in Alcohol Craving Levels during a Virtual Reality Cue Exposure Treatment among Patients with Alcohol Use Disorder

Study on the efficiency of virtual reality in the treatment of alcohol use disorder: study protocol for a randomized controlled trial : E-Reva

CONTEXT

According to the World Health Organization, alcohol is a major global public health problem, leading to a significant increase in illness and death. To treat alcohol use disorders, new therapeutic tools are being promoted, among which virtual reality (VR) shows promise. Previous research has demonstrated the efficacy of VR in reducing alcohol cravings in patients, but there is a lack of data on its effectiveness in maintaining abstinence or reducing consumption in recently abstinent individuals. The E-Reva study aims to compare the efficacy of a treatment strategy combining virtual reality cue exposure therapy (VR-CET) and cognitive behavioral therapy (CBT) with conventional CBT in reducing alcohol consumption and craving in patients with alcohol use disorder (AUD). In addition to this primary objective, the study will compare the effects of VR-CET combined with CBT on anxiety, depression, rumination, and feelings of self-efficacy versus conventional CBT.

METHODS

This prospective randomized controlled trial will be conducted over 8 months in four addiction departments in France. It includes two parallel groups: i) the VR-CET + CBT group, and ii) the CBT-only group, which serves as a control group. Participants will be recruited by the investigating doctor in the addiction centers. The sample will consist of 156 patients diagnosed with AUD and abstinent for at least 15 days. Both treatment groups will participate in four group CBT sessions followed by four individual sessions: i) the VR-CET group will be exposed to virtual environments associated with alcohol-related stimuli, ii) the CBT-only group will receive traditional CBT sessions. After completion of the 8 sessions, patients will be followed up for 6 months. The primary outcome is the cumulative number of standard drinks consumed at 8 months, assessed using the TLFB method.

DISCUSSION

Despite the promise of VR-CET to reduce the desire to drink, the effect on alcohol consumption remains uncertain in the existing literature. Our protocol aims to address the limitations of previous research by increasing sample size, targeting consumption reduction, and incorporating neutral environments. E-Reva aims to enrich the literature on the use of VR in the treatment of AUD and open new perspectives for future interventions.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT06104176, Registered 2023/11/13 ( https://clinicaltrials.gov/study/NCT06104176?id=NCT06104176&rank=1 ). N° IDRCB: 2022-A02797-36. Protocol version 1.0, 12/05/2023.

Feasibility trial of a technology-based intervention (TI) among men with alcohol dependence from rural settings in India

This feasibility study utilized two-arm randomized controlled trial (RCT), conducted in a de-addiction unit of tertiary mental care setting, India, between August 2021 and January 2022. Sixty-one participants diagnosed with alcohol dependent syndrome was randomly assigned to receive TI (n = 31) or Treatment as usual (TAU) (n = 30). Participants of both groups were initially assessed for craving, quantity and frequency of alcohol consumption and severity of alcohol use. TI participants received 8 video enabled cue exposure group sessions and periodic mobile phone interventions along with text message reminders after discharge along with routine treatment at de-addiction wards. TAU group participants received only routine treatment. All the participants were followed up over 3 months post-discharge. Results showed that majority (77 %) participants attended all 8-video enabled cue exposure group sessions. Rural men were willing to engage in the program and participated in behavioral rehearsals. Mobile intervention and text messages were accepted. We observed that at 3 months follow-up TI group subjects reported lesser mean craving scores, fewer drinking days, lesser quantity of alcohol consumption and less AUDIT scores compared to TAU group participants. This study provides preliminary support for the hypotheses that it is feasible to implement technology-based alcohol intervention for men with alcohol dependence.

Virtual reality efficiency as exposure therapy for alcohol use: A systematic literature review

Virtual reality is an immersive technology that can be used as a tool in the treatment of disorders linked to substance use disorders, such as alcohol use disorder. This systematic review of the literature examines the effectiveness of virtual reality as exposure therapy for heavy social drinkers, defined as people who regularly consume alcohol in a variety of social contexts, with or without a diagnosis of alcohol use disorder. The current review includes ten studies with a total of 377 participants. Most participants were adult men (61.03%), with an age average of 44.1 years [± 7.42] and alcohol use ranging from light to heavy. Although studies show heterogeneous results, the use of virtual reality cue exposure therapies has shown greater improvement in terms of craving reduction for patients suffering from alcohol use disorder. Studies have also shown that the realism of the virtual environment can influence levels of craving and anxiety, both in heavy social drinkers. In addition, the use of virtual reality has proven to increase feeling of self-efficacy and decrease the tendency to engage in automatic drinking behaviors. However, the review also mentions the necessity of larger research to determine the efficiency of virtual reality as a therapeutic treatment for alcohol use disorder, whilst considering comorbidities and treatment background, especially for resistant patients.

[The application of virtual reality in the treatment of mental disorders]

BACKGROUND

Virtual reality (VR) enables immersion in an interactive digital world with realistic experiences, that can be applied for controlled and personalized interventions. This review summarizes the current research on VR in the treatment of mental disorders.

METHODS

Selective literature search in PubMed and Google Scholar.

RESULTS

An increasing number of publications report the therapeutic application of VR for the treatment of mental disorders. Most VR applications are based on established therapy approaches, such as exposure therapy. According to meta-analytic data, virtual exposure therapy (VRET) for specific phobia and agoraphobia with panic disorder is as effective as traditional in vivo exposure therapy. VRET for the treatment of social phobia is significantly more effective than waitlist and placebo control groups with, however, currently inconsistent metanalytic results when compared to in vivo exposure therapy. VRET for the treatment of posttraumatic stress disorder (PTSD) is similar in effectiveness compared to active psychotherapy. For psychosis, positive results have been reported for the VR-based treatment of auditory verbal hallucinations. For patients with a substance use disorder, VR can induce craving, with still unverified diagnostic and therapeutic relevance.

CONCLUSIONS

VRET can broaden the psychotherapy options for anxiety disorders. Encouraging results of VR-based treatments for psychosis and PTSD indicate the need for further research concerning its effectiveness and safety. In the field of substance use disorders, evaluation of clinical-orientated VR applications is needed.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Personality-Related Factors and Depressive Symptomatology Predict Behavioral Control in Patients With Alcohol Use Disorders

In the face of increasing social, economic, and health consequences of alcohol use disorders (AUDs) and limited effects of available treatment options, the search for novel prevention and management methods continues to remain a timely and valid endeavor. This, however, requires a better grasp of the theoretical framework underlying addiction mechanisms. With the goal to extend the existing body of evidence on AUDs, we set out to investigate the effect of personality-related factors and depressive symptomatology on (i) impulsivity, (ii) cognitive response inhibition, and (iii) the links between the two measures of behavioral control (different facets of impulsivity and response inhibition) in a treatment-seeking AUD sample. To this end, 53 male (n = 45) and female (n = 8) inpatients at an alcohol rehabilitation center completed three self-report questionnaires: the International Personality Item Pool (IPIP-50), the Beck Depression Inventory Second Edition (BDI-II) and the Barratt Impulsiveness Scale (BIS-11) and performed one behavioral task-an alcohol go/no go task. Regression analyses revealed conscientiousness, intellect, and depression level to be important potential predictors of self-report impulsivity and processing speed in recovering drinkers. No significant links were observed between the two measures of behavioral control, thus complementing evidence that while they both encompass behavioral under-regulation, they may indeed represent distinct psychological constructs.

Virtual reality: a powerful technology to provide novel insight into treatment mechanisms of addiction

Due to its high ecological validity, virtual reality (VR) technology has emerged as a powerful tool for mental health research. Despite the wide use of VR simulations in research on mental illnesses, the study of addictive processes through the use of VR environments is still at its dawn. In a systematic literature search, we identified 38 reports of research projects using highly immersive head-mounted displays, goggles, or CAVE technologies to provide insight into treatment mechanisms of addictive behaviors. So far, VR research has mainly addressed the roles of craving, psychophysiology, affective states, cognition, and brain activity in addiction. The computer-generated VR environments offer very realistic, dynamic, interactive, and complex real-life simulations requesting active participation. They create a high sense of immersion in users by combining stereoscopic three-dimensional visual, auditory, olfactory, and tactile perceptions, tracking systems responding to user movements, and social interactions. VR is an emerging tool to study how proximal multi-sensorial cues, contextual environmental cues, as well as their interaction (complex cues) modulate addictive behaviors. VR allows for experimental designs under highly standardized, strictly controlled, predictable, and repeatable conditions. Moreover, VR simulations can be personalized. They are currently refined for psychotherapeutic interventions. Embodiment, eye-tracking, and neurobiological factors represent novel future directions. The progress of VR applications has bred auspicious ways to advance the understanding of treatment mechanisms underlying addictions, which researchers have only recently begun to exploit. VR methods promise to yield significant achievements to the addiction field. These are necessary to develop more efficacious and efficient preventive and therapeutic strategies.

Classification of Gamers Using Multiple Physiological Signals: Distinguishing Features of Internet Gaming Disorder

The proliferating and excessive use of internet games has caused various comorbid diseases, such as game addiction, which is now a major social problem. Recently, the American Psychiatry Association classified “Internet gaming disorder (IGD)” as an addiction/mental disorder. Although many studies have been conducted on the diagnosis, treatment, and prevention of IGD, screening studies for IGD are still scarce. In this study, we classified gamers using multiple physiological signals to contribute to the treatment and prevention of IGD. Participating gamers were divided into three groups based on Young’s Internet Addiction Test score and average game time as follows: Group A, those who rarely play games; Group B, those who enjoy and play games regularly; and Group C, those classified as having IGD. In our game-related cue-based experiment, we obtained self-reported craving scores and multiple physiological data such as electrooculogram (EOG), photoplethysmogram (PPG), and electroencephalogram (EEG) from the users while they watched neutral (natural scenery) or stimulating (gameplay) videos. By analysis of covariance (ANCOVA), 13 physiological features (vertical saccadic movement from EOG, standard deviation of N-N intervals, and PNN50 from PPG, and many EEG spectral power indicators) were determined to be significant to classify the three groups. The classification was performed using a 2-layers feedforward neural network. The fusion of three physiological signals showed the best result compared to other cases (combination of EOG and PPG or EEG only). The accuracy was 0.90 and F-1 scores were 0.93 (Group A), 0.89 (Group B), and 0.88 (Group C). However, the subjective self-reported scores did not show a significant difference among the three groups by ANCOVA analysis. The results indicate that the fusion of physiological signals can be an effective method to objectively classify gamers.

Clinical Relevance of Immersive Virtual Reality in the Assessment and Treatment of Addictive Disorders: A Systematic Review and Future Perspective

(1) Background: Virtual reality (VR) has been investigated in a variety of psychiatric disorders, including addictive disorders (ADs); (2) Objective: This systematic review evaluates the current evidence of immersive VR (using head-mounted displays) in the clinical assessment and treatment of ADs; (3) Method: PubMed and PsycINFO were queried for publications up to November 2020; (4) Results: We screened 4519 titles, 114 abstracts and 85 full-texts, and analyzed 36 articles regarding the clinical assessment (i.e., diagnostic and prognostic value; n = 19) and treatment (i.e., interventions; n = 17) of ADs. Though most VR assessment studies (n = 15/19) showed associations between VR-induced cue-reactivity and clinical parameters, only two studies specified diagnostic value. VR treatment studies based on exposure therapy showed no or negative effects. However, other VR interventions like embodied and aversive learning paradigms demonstrated positive findings. The overall study quality was rather poor; (5) Conclusion: Though VR in ADs provides ecologically valid environments to induce cue-reactivity and provide new treatment paradigms, the added clinical value in assessment and therapy remains to be elucidated before VR can be applied in clinical care. Therefore, future work should investigate VR efficacy in randomized clinical trials using well-defined clinical endpoints.

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose

Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches.

Findings

There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances.

Summary

This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required.

Is Virtual Reality Cue Exposure a Promising Adjunctive Treatment for Alcohol Use Disorder?

This narrative review presents recent developments in virtual reality (VR)-based interventions for alcohol use disorders (AUDs). The latest advances in mental healthcare hail an imminent cyber revolution, ushering in novel treatment options, with immersive virtual technology at the very forefront of expected change. With an aim to (a) provide a background on VR use in mental healthcare of AUD patients, (b) summarize existing evidence on conventional approaches to the treatment of AUDs and a trending paradigm shift towards VR applications in their management, and (c) describe key issues and future directions in research on craving assessment and VR cue-induced therapy in AUDs, a search for experimental and meta-analytic evidence was performed in six databases: PubMed and EBSCO (Medline, ERIC, PsychINFO, Academic Search Ultimate, and Health Source: Nursing/Academic Edition). Pooled results were screened for eligibility, and relevant papers were selected for inclusion. The analysis revealed VR’s promising effects in the treatment of AUDs. Its remarkable potential to simulate cues underlying subsequent addictive behaviors makes its application in the assessment and treatment of AUDs an attractive alternative to researchers and clinicians alike. Nevertheless, more evidence is needed before virtual reality cue exposure therapy (VR-CET) can become a clinical standard of care.

Augmented tendency to act and altered impulse control in alcohol use disorders

Action preparation relies on the operation of control processes that modulate the excitability of the corticospinal tract. On the one hand, excitatory processes prepare the motor system for the forthcoming response; the stronger these influences, the stronger the tendency to act. On the other hand, inhibitory influences allow to suppress inappropriate actions and, more generally, to ensure some sort of impulse control. Because an impairment in these processes could foster inappropriate drinking behavior, the present study aimed at evaluating the motor correlates of such excitatory and inhibitory influences in non-treatment seeking heavy drinkers (HDs) and inpatients suffering from severe alcohol use disorder (SAUDs). Besides, as cue-elicited craving might further alter these processes, we also assessed the impact of an alcohol-related exposure. To do so, 15 healthy controls (HCs), 15 HDs and 15 SAUDs performed a choice reaction time task after having been immersed in a neutral or an alcohol-related environment, using virtual reality videos. Importantly, single-pulse transcranial magnetic stimulation was applied over the left and the right primary motor cortex during the task to elicit motor-evoked potentials in a set of hand muscles allowing us to specifically probe the impact of excitatory and inhibitory processes on motor activity. Our data indicate that excitatory influences are particularly high in both HDs and SAUDs, especially in the dominant hand, an effect that was not observed in HCs. By contrast, inhibitory influences were found to be perfectly normal in HDs, while they were lacking in SAUDs. Furthermore, the alcohol-related exposure enhanced the level of self-reported craving, but this effect only arose in HDs and did not significantly alter the strength of excitatory and inhibitory influences. Overall, although these results have to be taken with caution due to the small sample sizes, this study suggests that enhanced excitatory processes characterize both HDs and SAUDs, while weaker inhibitory influences only concern SAUDs. Hence, an abnormally strong tendency to act could represent a common feature of hazardous drinking, leading individuals to excessive alcohol consumption, whereas deficient impulse control would be a hallmark of more severe forms of AUD, potentially due to the chronic neurotoxic effects of alcohol. Finally, although an alcohol-related exposure does not seem to affect excitatory and inhibitory processes at play during action preparation per se, future works should evaluate changes in corticospinal excitability during the preparation of responses specifically targeting alcohol-related cues.

Attentional Bias, Alcohol Craving, and Anxiety Implications of the Virtual Reality Cue-Exposure Therapy in Severe Alcohol Use Disorder: A Case Report

Aims: Attentional bias (AB), alcohol craving, and anxiety have important implications in the development and maintenance of alcohol use disorder (AUD). The current study aims to test the effectiveness of a Virtual Reality Cue-Exposure Therapy (VR-CET) to reduce levels of alcohol craving and anxiety and prompt changes in AB toward alcohol content. Method: A 49-year-old male participated in this study, diagnosed with severe AUD, who also used tobacco and illicit substances on an occasional basis and who made several failed attempts to cease substance misuse. The protocol consisted of six VR-CET booster sessions and two assessment sessions (pre- and post-VR-CET) over the course of 5 weeks. The VR-CET program consisted of booster therapy sessions based on virtual reality (VR) exposure to preferred alcohol-related cues and contexts. The initial and final assessment sessions were focused on exploring AB, alcohol craving, and anxiety using paper-and-pencil instruments and the eye-tracking (ET) and VR technologies at different time points. Results: Pre and post assessment sessions indicated falls on the scores of all instruments assessing alcohol craving, anxiety, and AB. Conclusions: This case report, part of a larger project, demonstrates the effectiveness of the VR-CET booster sessions in AUD. In the post-treatment measurements, a variety of instruments showed a change in the AB pattern and an improvement in craving and anxiety responses. As a result of the systematic desensitization, virtual exposure gradually reduced the responses to significant alcohol-related cues and contexts. The implications for AB, anxiety and craving are discussed.