Managing COVID-19 Anxiety Without Benzodiazepines (Part 4)  

The promise of virtual reality, AI avatars, and applied gaming.

At the time of writing news reports describe rapid advances in vaccines that, we are told, will soon eradicate the COVID-19 pandemic. However, as we wait for a promised cure to the most serious public health crisis of the 21st century, countless millions must continue to deal with day to day stresses caused by social isolation, worries over job security, and very real concerns about becoming ill or dying from SARS-Cov2, the virus that causes COVID-19. The result has been a steady upsurge in the prevalence of generalized anxiety and panic attacks on a global scale.

In the context of "COVID-19 anxiety," benzodiazepines such as alprazolam (Xanax), clonazepam (Klonopin), and lorazepam (Ativan) are being widely prescribed. While benzodiazepines and other drugs are sometimes helpful for the short-term management of anxiety, such conventional treatments have limited overall efficacy and potentially serious safety risks.

In the first three posts in this series I described the risks of chronic benzodiazepine use, reviewed research evidence for Kava and l-theanine for anxiety, and discussed the anxiety- and stress-reducing benefits of relaxation techniques, guided imagery, meditation-including mindfulness-based stress reduction (MBSR)-and yoga. In this post I review the evidence for virtual reality graded exposure therapy (VRGET) a high-tech approach to stress and anxiety. I also comment on the emerging use of AI chatbots and '˜serious' games for enhancing well-being and reducing symptoms of anxiety.

Virtual Reality (VR) a very short overview

Early work on the concept of Virtual reality (VR) began in 1960s. After multiple failed attempts, VR is now widely used in gaming, and is rapidly emerging as a platform for a range of healthcare applications including surgery, pain management, and mental health care. VR provides an '˜immersive' virtual environment in which users can interact with a computer-generated world that is updated moment to moment adjusting to the user's movements. Advances in mobile phone technology and broadband internet have led to affordable VR '˜head-mounted displays' (HMD) capable of high resolution. 

Virtual Reality Graded Exposure Therapy (VRGET) for anxiety disorders

In the domain of mental health care, VR technology is used to provide virtual reality graded exposure therapy (VRGET), a high-tech alternative to conventional '˜imaginal' exposure therapy in which an individual habituates to a fear-inducing mental image, and '˜in-vivo' exposure therapy in which an individual with a phobia or OCD is guided through '˜exposure' to a feared stimulus. In both conventional techniques a skilled therapist helps the client '˜habituate' to a fear-inducing object or situation, '˜extinguishing' a maladaptive fear response. Many individuals who struggle with generalized anxiety or phobias can't tolerate the stress of conventional exposure therapy and remain chronically impaired because they are never able to become desensitized to a feared object or situation.  It has been suggested that health and mental health benefits achieved through VRGET are related to cognitive modeling and change caused by interactions between the user and targeted virtual environments that simulate both the external world and the internal body (Riva, Wiederhold & Mantovani 2019).

In recent years VRGET protocols have been extensively investigated in controlled studies and found to be beneficial for reducing symptoms of specific phobias, generalized anxiety disorderADHDdepression, and PTSD (Maples-Keller et al 2017Jerdan et al 2018CieÅ›lik et al 2020). In one study VRGET and conventional cognitive-behavioral therapy were found to be equally effective treatments of panic disorder and agoraphobia, however individuals who underwent VRGET required 1/3 fewer sessions to achieve the same level of symptomatic improvement (Vincelli 2003). In another study 2/3 of adults diagnosed with a specific anxiety disorder reported significant reductions in 4 of 5 anxiety measures (Maltby 2002). VRGET is also beneficial for severely traumatized patients diagnosed with PTSD. A virtual environment that simulates the devastation that took place following the September 11, 2001 attacks of the World Trade Towers has been successfully used to treat individuals who suffered from severe PTSD following the attacks (Difede 2002). VGRET is also proving to be an effective treatment of PTSD in combat veterans returning from the middle-east conflicts.

Recent findings show that individuals who use VRGET achieve significant reductions in both the level of stress and the severity of depressed mood (Shah et al 2015Shiban et al 2016). An important recent development is the incorporation of VR technology in mindfulness training Apps which may enhance the efficacy of such Apps for stress reduction (Cikajlo et al  2017). Personal computers with high-end graphics and fast microprocessors are requirements for VR-based interventions whether they are used by psychotherapists working with clients, or by individuals  self-treating symptoms of stress and anxiety.

Safety issues

Some individuals report transient disorientation, nausea, dizziness, headache and blurred vision when in a virtual environment. "Simulator sleepiness' is sometimes reported following VRGET. In rare cases, VRGET has been reported to trigger migraine headaches, seizures, or gait abnormalities in individuals and should not be used by individuals with these pre-existing medical problems. Individuals who abuse alcohol or narcotics should not use VRGET. Finally, individuals diagnosed with schizophrenia or another psychotic disorder should not use VRGET because immersion in a virtual environment can make delusions worse and (further) impair a psychotic individual's ability to distinguish reality from fantasy.

Avatars and 'applied' games

Two trends that will soon converge with VRGET and mental health care broadly, are rapid evolution of avatars and '˜applied' games. Avatars are digital representations of humans that permit clinicians and patients to interact with each other or with an AI-generated avatar in a virtual environment. Ongoing work suggests that avatar technology has advantages over conventional forms of communication between psychotherapists and clients, while providing clients with practical tools for enhancing wellness and addressing anxiety and other mental health problems (Rehm et al 2016). For example, avatars may result in a strong 'virtual' therapeutic alliance difficult to achieve for clients who are unable or reluctant to engage in conventional face-to-face care, while offering anonymous treatment avoiding the social stigma many individuals report when seeking mental health care. In the near future avatar chatbots generated by artificial intelligence (AI) software will evolve into 'virtual humans' permitting clients to engage in confidential 'conversations' with a socially intelligent Avatar that provides emotional support and expert advice customized to each unique client's symptoms and preferences (Burden & Savin-Baden 2019). 

It is estimated that 40% of the US population play computer games at least 3 hours every week, implying that millions of users are highly engaged with games. Applied games are highly interactive games designed to enhance wellness and lessen symptoms of anxiety and other mental health problems. '˜Applied' games use features that result in high levels of engagement such as scoring points or in-game rewards to help users achieve mental health goals by changing dysfunctional behaviors, learning stress coping skills, and engaging in game routines aimed at reducing symptoms of anxiety, depressed mood and other mental health problems. In addition to games addressed at a specific mental health problem, VRGET interventions based on cognitive-behavioral therapy or exposure therapy can be '˜gamified' by adding elements to enhance user motivation and engagement. A recently published review summarized rapid progress that is taking place in applied gaming (Fleming et al 2017). Large studies are needed to investigate the role of '˜applied' games for achieving beneficial effects in anxiety, depressed mood, ADHD and other common mental health problems, and to identify features that enhance user engagement and improve outcomes.

Bottom line

Benzodiazepines are now increasingly used to manage symptoms of stress and anxiety related to the COVID-19 pandemic. Although psychotropic drugs are sometimes helpful for short-term reduction of symptom severity benzodiazepines have limited efficacy over the long term and potentially serious safety issues, especially among the elderly and medically impaired. Virtual reality graded exposure therapy (VRGET) is an effective and safe intervention for management of many anxiety disorders. Commercially available head-mounted displays and software provide a reasonable evidence-based alternative to benzodiazepines for generalized anxiety and situational stress. In addition to VR-based technologies, widespread availability of broadband internet will soon lead to increased use of '˜serious' games for reducing stress and treating anxiety, depressed mood and other mental health problems. In the coming years as VR technologies, AI-driven avatars, and '˜applied' games will become seamlessly integrated and increasingly used both for enhancing wellness, treating and self-treating a range of mental health problems.

As costs continue to fall high-tech interventions will become affordable to millions of individuals who presently cannot access mental health services or do not seek care because they are too impaired or reluctant to seek help. Collectively these trends will transform mental health care into a paradigm that will be more accessible, more effective, safer and more cost-effective. 


Jerdan, S. W., Grindle, M., van Woerden, H. C., & Kamel Boulos, M. N. (2018). Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research. JMIR serious games, 6(3), e14. https://doi.org/10.2196/games.9226

Riva, G., Wiederhold, B. K., & Mantovani, F. (2019). Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine. Cyberpsychology, behavior and social networking, 22(1), 82-96. https://doi.org/10.1089/cyber.2017.29099.gri

Cieślik B, Mazurek J, Rutkowski S, Kiper P, Turolla A, Szczepańska-Gieracha J. Virtual reality in psychiatric disorders: A systematic review of reviews. Complement Ther Med. 2020 Aug;52:102480. doi: 10.1016/j.ctim.2020.102480. Epub 2020 Jun 9. PMID: 32951730.

Maples-Keller JL, Bunnell BE, Kim SJ, Rothbaum BO. The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders. Harv Rev Psychiatry. 2017 May/Jun;25(3):103-113. doi: 10.1097/HRP.0000000000000138. PMID: 28475502; PMCID: PMC5421394. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5421394/pdf/nihms829162.pdf

Vincelli F, Anolli L, Bouchard S, Wiederhold BK, Zurloni V, Riva G. Experiential cognitive therapy in the treatment of panic disorders with agoraphobia: a controlled study. Cyberpsychol Behav. 2003 Jun;6(3):321-8. doi: 10.1089/109493103322011632. PMID: 12855090.

Maltby N, Kirsch I, Mayers M, Allen GJ. Virtual reality exposure therapy for the treatment of fear of flying: a controlled investigation. J Consult Clin Psychol. 2002 Oct;70(5):1112-8. doi: 10.1037//0022-006x.70.5.1112. PMID: 12362961.

Difede J, Hoffman HG. Virtual reality exposure therapy for World Trade Center Post-traumatic Stress Disorder: a case report. Cyberpsychol Behav. 2002 Dec;5(6):529-35. doi: 10.1089/109493102321018169. PMID: 12556115.

Shah LB, Torres S, Kannusamy P, Chng CM, He HG, Klainin-Yobas P. Efficacy of the virtual reality-based stress management program on stress-related variables in people with mood disorders: the feasibility study. Arch Psychiatr Nurs 2015 Feb;29(1):6-13. [doi: 10.1016/j.apnu.2014.09.003] [Medline: 25634868]

Fleming, T. M., Bavin, L., Stasiak, K., Hermansson-Webb, E., Merry, S. N., Cheek, C., Lucassen, M., Lau, H. M., Pollmuller, B., & Hetrick, S. (2017). Serious Games and Gamification for Mental Health: Current Status and Promising Directions. Frontiers in psychiatry, 7, 215. https://doi.org/10.3389/fpsyt.2016.00215

Burden & Savin-Baden, (2019) Virtual Humans: Today and Tomorrow, Taylor & Francis, Ltd.  

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