VRET Contraindications: When Not to Use It With a Patient

Why Contraindication Screening Is Protocol, Not Caution

The VR headset is safe for most healthy adults. Most is not all. In private practice, roughly one patient a month out of every 30-50 will present at least one relative contraindication, and one in every 200-300 an absolute contraindication.

Without systematic screening, these contraindications are usually caught during the first session, in the worst possible scenario: the patient already has the headset on, has paid for the session, and the psychologist discovers the problem right at the moment of the incident. Screening happens during the intake session, on paper, before even considering the VRET option.

There are three clinical domains where VR introduces added risk compared with classic therapy: the vestibular and visual system (motion sickness, headache, vertigo), the neurological system (epilepsy, migraine), and the cognitive-emotional system (psychosis, dissociation, cognitive impairment). Each has specific contraindications worth reviewing.

Absolute Contraindications: VR Is Not an Option

There are patient profiles where, outside a specific clinical research framework, VR should not be used in psychology practice.

1. Photosensitive epilepsy or active seizures. Although modern headsets don't flicker at the classic seizure-triggering frequencies, scenarios with flashes, rapid transitions, or intense contrast can still be triggers. Without a favorable neurological assessment and stabilized treatment, do not use VR.

2. Active psychosis or recent psychotic symptoms. Hallucinations, delusional ideation, or disorganized thinking are amplified by sensory immersion. VR introduces a layer of sensory unreality that can be incorporated into the psychotic presentation in an iatrogenic way. Also not applicable in unstabilized psychotic prodromes.

3. Severe dissociation (DID, PTSD with peak dissociative symptomatology). A patient who dissociates easily can enter deep dissociative states during VR immersion. In PTSD, the risk markers are: DES-II ≥30, clinically significant depersonalization episodes, and a history of dissociation during prior exposure. For PTSD without these markers, VR is a treatment option; with them, it is not.

4. Severe cognitive impairment (moderate-to-severe dementia, severe intellectual disability). The inability to understand the procedure, communicate discomfort, or distinguish the real environment from the virtual one makes clinical control unfeasible. In mild cognitive impairment, assess individually with neuropsychology.

5. Active benign paroxysmal positional vertigo (BPPV) or unstabilized acute vestibulopathy. Any active vestibular condition turns VR into a predictable trigger for intense dizziness or falls.

Relative Contraindications: VR Is Possible With Adjustments

Other patient profiles don't rule out VR, but they call for adapted protocols, shorter sessions, or scenario adjustments — see our related piece on VR for complicated grief.

1. Prior severe cybersickness (significant motion sickness in cars, boats, elevators, or reading while in transit). The patient shouldn't be ruled out, but the protocol changes: shorter sessions (10-15 min of headset time), static scenarios (no avatar locomotion), extended acclimatization (10-15 min before exposure), and headset-off breaks every 8-10 minutes.

2. Pregnancy. The literature is scarce and inconclusive. The prudent approach: avoid VR in the first trimester due to heightened motion-sickness sensitivity and to minimize confounding variables; in the second and third trimesters, consider short sessions and static scenarios, with specific informed consent that acknowledges the limited evidence. High-risk pregnancy: do not apply.

3. Migraine with aura. Visual overload can precipitate an attack. If the patient reports an attack in the last three months, avoid VR. In migraines stabilized with treatment, use short sessions, low contrast, and scenarios without intense motion.

4. Active ophthalmological conditions. Uncontrolled glaucoma, recent retinal detachment, eye surgery in the last six months. These require prior ophthalmological clearance.

5. Hearing aids or cochlear implants. Not a contraindication, but it requires adjusting the scenario's audio and confirming compatibility with the patient's device.

6. Significant cardiovascular disease. Severe uncontrolled hypertension, active ischemic heart disease, history of vasovagal syncope. VR exposure to phobic stimuli activates the autonomic nervous system in a way similar to classic exposure; evaluate case by case with the treating physician.

7. Active eating disorders with low body weight. The associated fatigue, dehydration, and vestibular instability increase the risk of dizziness and fainting. Stabilize weight before starting VR.

8. Active substance use (alcohol, heavy or unstable benzodiazepine use, opioids). VR is not the tool of choice during acute intoxication or withdrawal.

Pre-Session Screening: The Questionnaire You Should Add

A brief questionnaire, completed by the patient or administered by the psychologist, systematizes the screening. It fits on a single A4 page and is incorporated into the intake assessment.

Neurological block.

1. Have you ever had a seizure or convulsion? What was the date of the last one?

2. Have you or a first-degree relative ever been diagnosed with epilepsy?

3. Do you have migraines? If so, with or without visual aura? When was the last attack?

Vestibular and visual block.

4. Do you get motion sick easily in cars, boats, elevators, or while reading in transit?

5. Have you had vertigo in the last year? Have you been diagnosed with BPPV or another inner-ear condition?

6. Do you have any diagnosed eye condition (glaucoma, retinal detachment, amblyopia, strabismus)?

7. Have you had eye surgery in the last six months?

Psychiatric block.

8. Have you ever had episodes of hearing voices, seeing things others didn't see, or an intense feeling that people wanted to harm you?

9. Have you had episodes of feeling the world wasn't real, of observing yourself from outside, or of not remembering blocks of time?

10. Have you ever felt a loss of identity or confusion about who you are?

General block.

11. Are you pregnant or is there a possibility of pregnancy?

12. Are you currently taking any medication that affects balance, attention, or alertness?

13. Is there any other important medical condition your doctor has mentioned that you think we should know about?

Positive answers to questions 1-3 and 8-10 trigger additional clinical exploration before the decision about VR.

Clinical Decision: How the Screening Concludes

After screening, the psychologist should reach one of three conclusions, documented in the clinical record.

Conclusion A: clear indication for VRET. No absolute contraindications, no significant relative ones, the patient accepts the procedure, and the presentation fits the software's scenario offering. Plan: proceed to the first session per protocol.

Conclusion B: indicated with adjustments. There is some relative contraindication (cybersickness, controlled migraines, first-trimester pregnancy, hearing aids). Plan: adapted VR protocol, shorter sessions, extended acclimatization, scenarios without intense motion, and specific informed consent acknowledging the limitation.

Conclusion C: VRET not indicated. There is an absolute contraindication, or a combination of relative contraindications advising against starting. Plan: classic CBT, imaginal or in-vivo exposure, headset-free mindfulness, or other techniques. Document the reason in the clinical record for future reevaluation.

One additional good practice: in conclusion B, keep a written record of the specific adjustments agreed on (‘sessions of no more than 15 minutes with the headset, scenarios without avatar movement, a break every 8 minutes, immediate removal at the first sign of dizziness’). These adjustments are part of the informed consent, not a verbal agreement.

What Is Not a Contraindication (Even Though It Might Seem Like One)

Some patient profiles raise questions but are not contraindications in themselves. It's worth identifying them clearly so patients who would benefit from treatment aren't excluded unnecessarily.

1. Wearing glasses. This only requires a spacer or corrective lens insert for the headset. Not a contraindication. This blog has a dedicated guide on introducing VR to the patient that covers this point.

2. Being over 65. Age alone is not a contraindication. A longer acclimatization session, scenarios without abrupt avatar movement, and attention to balance during postural changes are advisable.

3. Personality disorders. Not a contraindication. They may require adjustments to the framing, especially in borderline profiles with mild dissociation or in extremely avoidant patients.

4. ASD without cognitive impairment. This is usually an indication, not a contraindication, provided the child or adult tolerates the headset. VR offers the predictability and control that many patients with ASD appreciate.

5. A single prior panic attack. Not a contraindication. This is exactly one of the presentations where VRET has the strongest clinical track record.

6. Prior OCD diagnosis. Not a contraindication per se. It's worth screening for rumination specifically about cleaning or contamination of the headset; if present, address it before starting.

Applying VR indiscriminately is not good practice. Excluding patients out of excessive caution isn't either. Systematic screening is the tool that tells the two apart.

This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.