Psychological trauma

Psychological trauma is lasting harm to a person's functioning and mental, physical, social or emotional well-being that follows an event, series of events or set of circumstances experienced as physically or emotionally harmful or life-threatening. In Virtual Reality (VR), the subject has two sides. One is the risk that frightening, violent or abusive experiences inside a headset harm the user, since immersive content can provoke reactions like those caused by real events. The other is the clinical use of VR to treat post-traumatic stress disorder (PTSD) with exposure therapy, a use studied in clinical trials since at least 2001.

Encountering gory, creepy, frightening or otherwise distressing content in an unwanted or unexpected context is one of the risks researchers have named. In a 2020 paper on the ethics of realism in VR and AR, Mel Slater and colleagues warned that people may be exposed to horrors they "did not expect and of which they were not forewarned, resulting in a kind of post-traumatic stress response". Children are considered especially vulnerable to this type of content, because younger users may find it harder to understand that a virtual experience is not happening in the physical world. As web-based VR through WebVR and its successor WebXR and browsing the web through VR devices became possible, the standard for immersive web content also had to address how users stay in control of when immersive content starts.

Reviewed 27 September 2026. Checked every citation against its source: SAMHSA and NIMH definitions, Madary-Metzinger, Slater, Meehan, McIntosh-Allen and Bailey-Bailenson papers, the Rothbaum, Difede, Rizzo, Kothgassner and Eshuis study abstracts, the USC ICT BRAVEMIND page, the WebXR spec and MDN, Meta safety, Personal Boundary and preteen-account pages, and the Kotaku, Time, CCDH, Euronews, Road to VR and TechCrunch reports. About review dates.

Definition

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) published a working concept of trauma in 2014 after reviewing existing definitions with an expert panel. It describes individual trauma as resulting from "an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being." SAMHSA summarizes the concept as three "E's": the event or events, the individual's experience of them, and their effects. The document notes that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) requires every condition classified as a "trauma and stressor-related disorder" to include exposure to a traumatic or stressful event as a diagnostic criterion.

One of these conditions is PTSD. The U.S. National Institute of Mental Health (NIMH) lists natural disasters, acts of violence and serious accidents among the traumatic events that can precede it, and states that people are diagnosed with PTSD when their symptoms last for an extended period after a traumatic event and begin to interfere with daily life, such as relationships or work.

Immersion and distressing content

VR differs from film and flat-screen games because a head-mounted display replaces the user's view of the physical world and responds to head and body movement, producing the sense of being in the virtual place known as presence. A 2002 study at the University of North Carolina at Chapel Hill tested the idea that a virtual environment which seems real will evoke physiological responses similar to those of the corresponding real environment. Participants walked from a non-threatening virtual room into a "pit room" with an unguarded drop in the floor; across three experiments, the change in heart rate met the researchers' requirements for a measure of presence, and adding a physical (passive haptic) element to the scene increased presence.

Researchers in VR ethics have argued that the same effect makes disturbing content more harmful than in older media. In their 2016 code of ethical conduct for VR, Michael Madary and Thomas Metzinger wrote: "As compared to the viewing of traditional movies containing graphic violence or pornography, the impact of full immersion settings and the associated risk of users suffering psychological trauma will steadily increase as VR technology advances. Users have to be made aware of this possibility." Slater and co-authors, writing in 2020 about increasingly realistic ("superrealistic") VR and AR, listed "unexpected horror" and exposure to realistic violence and sexual assault among the psychological risks. They also noted that putting on a headset normally marks a clear boundary between reality and VR, which they called the "device-gap", but that this boundary may weaken for AR devices worn for long periods and may not operate for very young children.

Headset makers address the issue in their safety documentation. Meta's health and safety warnings for the Meta Quest 3 tell users to "Choose your app and content carefully because virtual content can seem very realistic" and state that "Users may react to frightening, violent, disorienting, or anxiety-provoking content as if it were happening in the physical world." The same document advises consulting a doctor before use for people with psychiatric disorders, among other conditions.

Harassment and abuse in social VR

In social VR each user appears as an embodied avatar whose movements follow the user's physical actions, and researchers have argued that this immersive and embodied quality is likely to intensify the impact of harassment and abuse. In October 2016 a player writing under the pseudonym Jordan Belamire described on Medium how another player in the multiplayer mode of the HTC Vive archery game QuiVr repeatedly chased her avatar and virtually groped it. She wrote that the player's "floating hand approached my body, and he started to virtually rub my chest." QuiVr co-creator Aaron Stanton said his team's first response was "Let's make sure this never happens again." The developers added a "personal bubble" that makes other players' hands disappear when they come close to a user's face, and a "power gesture" that creates a force field removing nearby players from view.

On 30 December 2021 the Center for Countering Digital Hate (CCDH) published research on VRChat, which it described as the most-reviewed social app in Facebook's VR metaverse. Its researchers reported that users, including minors, were exposed to abusive behavior every seven minutes, and identified 100 potential violations of Facebook's policies for VR in 11 hours and 30 minutes of recording, including minors exposed to graphic sexual content, bullying and sexual harassment.

In January 2024 Euronews reported that British police were investigating a case in which the avatar of a girl, allegedly under 16, was "sexually attacked" by a group of strangers in a VR game. She had no physical injuries, but a senior officer told the Daily Mail that "There is an emotional and psychological impact on the victim that is longer-term than any physical injuries." Home Secretary James Cleverly told LBC: "I know it is easy to dismiss this as being not real, but the whole point of these virtual environments is they are incredibly immersive." British authorities feared that prosecution might prove impossible under existing law, which defines sexual assault in terms of physical touching.

A 2024 policy review by Verity McIntosh (University of the West of England) and Catherine Allen (Limina Immersive) collected the evidence on how such experiences affect users. It cites a 2018 survey of more than 600 users in which 49% of regular female VR users reported sexual harassment or abuse in virtual social spaces. The review describes "phantom touch", in which users report feeling a touch on their body that matches a simulated touch in VR, and suggests that people who experience it could be at greater risk of traumatic impact from harassment. It also answers the common question of why victims do not simply remove the headset: preliminary research suggests that rapid disengagement from VR under stress can provoke panic or dissociative episodes, and the question ignores trauma responses such as freezing.

Children

Madary and Metzinger pointed out in 2016 that most VR research had been done with adult subjects over short sessions, and that the risks they described "are especially troublesome for these younger users who are not yet psychologically and neurophysiologically fully developed." In a 2017 commentary, Stanford researchers Jakki Bailey and Jeremy Bailenson noted how little was known about VR's psychological effects on children. They described a 2009 study by K. Y. Segovia and Bailenson in which young elementary school children who watched a virtual version of themselves swimming with orca whales later confused the event with something that had happened in real life, and suggested that immersive VR may make fiction harder for children to tell from reality than television does.

Meta's Quest safety warnings state that "Younger children may have difficulty understanding that virtual experiences are not happening in the physical world. They may respond both physically and psychologically based on what they experience in the virtual world." In June 2023 Meta announced parent-managed accounts that lowered the minimum age for Meta Quest accounts from 13 to 10. The accounts began rolling out on 21 September 2023 for ages 10 to 12; parents control which apps a preteen can download or use, set daily time limits, and the preteen's profile is private by default. At launch Meta said Horizon Worlds would remain a 13+ app in the US and Canada (18+ in Europe) and would not be available to preteens. In August 2024 Meta began letting parents approve individual worlds, or all worlds rated 10+, for their preteens in Horizon Worlds, with the Personal Boundary feature permanently on for those accounts.

Prevention methods

One suggested method is to render untrustworthy sites smaller, further away or with lower resolution.

For web content, the WebXR Device API, which replaced the never-ratified WebVR API, builds user control into the start of every immersive session. The specification states that "Users must be in control of when immersive sessions are created". A browser must refuse a request for an immersive session unless it was made during a user activation, such as a click on an "enter VR" button, or while launching a web application, and unless user intent is established through explicit or implicit consent. Browsers must also be able to show "trusted UI" that a page cannot spoof and that indicates where the displayed content comes from; while the user interacts with such interfaces, the page's session is hidden or blurred.

In social VR, platforms have added boundaries around avatars. After QuiVr's personal bubble in 2016, Meta introduced Personal Boundary in Horizon Worlds and Horizon Venues on 4 February 2022. At launch it kept roughly four feet of distance between avatars by halting another avatar's forward movement at the boundary, and built on an earlier measure that made an avatar's hands disappear when they entered someone's personal space. Meta turned it on by default, saying this would "help to set behavioral norms"; a March 2022 update added three settings: on for people the user does not know (the default), on for everyone, or off. A December 2023 update made avatars fade faster and adjusted the barrier to allow gestures such as high fives while still keeping "roughly a few feet of distance". McIntosh and Allen list personal space bubbles alongside block, mute and report tools among the design responses developers have adopted.

Researchers have also proposed general safeguards. Slater and colleagues wrote that "Clear warnings are always advisable and minimum age requirements may be adequate in some instances." Because the sense of presence may lead participants to forget that they can close their eyes or take off the device, they suggested "Some form of training to remind users of their ability to 'opt-out,' or else a stop button" to respect the participant's right to stop. Madary and Metzinger recommended that research subjects be screened for conditions that prolonged immersion could aggravate, such as depersonalization/derealization disorder, and that users be told about the risk of psychological trauma from risky content.

Therapeutic use

Exposure therapy treats PTSD by having a patient, guided by a trained therapist, confront and reprocess memories of the traumatic event. VR exposure therapy (VRE or VRET) presents a simulated version of the setting instead of relying only on the patient's imagination, and was proposed as an alternative for patients who cannot or will not recall painful images on their own.

An open clinical trial by Barbara Rothbaum and colleagues, published in 2001, treated 10 male Vietnam combat veterans in 8 to 16 sessions using two virtual environments: a Huey helicopter flying over a virtual Vietnam and a jungle clearing. At six-month follow-up, clinician-rated PTSD symptoms were significantly lower than at baseline, and all 8 participants interviewed reported reductions ranging from 15% to 67%. After the September 11 attacks, Difede and Hoffman treated a survivor who had not improved with imaginal exposure, gradually exposing her over six one-hour sessions to virtual planes crashing into the World Trade Center and the towers collapsing; they reported a 90% reduction in PTSD symptoms and an 83% reduction in depression. A controlled study of mostly middle-aged male disaster workers followed, conducted between February 2002 and August 2005.

BRAVEMIND is a VR exposure therapy system developed at the University of Southern California Institute for Creative Technologies (ICT) since 2005 under Albert "Skip" Rizzo, Arno Hartholt and Sharon Mozgai. Its original application depicted Afghan and Iraqi city, village, mountain and desert road environments and scenarios for combat medics; later versions added content for PTSD caused by military sexual trauma and a virtual gathering space for people displaced by the war in Ukraine. In 2010 Rizzo and colleagues described the development of the related Virtual Iraq/Afghanistan system, a set of customizable scenarios including a city and a desert road convoy, built with feedback from returning service members and from a system deployed in Iraq. Besides the headset image, BRAVEMIND delivers directional 3D audio, vibrations and smells, while a trained clinician controls the stimuli through a separate interface and stays in audio contact with the patient. ICT states that BRAVEMIND has been distributed to more than 170 clinical sites.

Selected studies of VR exposure therapy for PTSD

Year	Study	Population	Design	Reported result
2001	Rothbaum et al.	10 male Vietnam combat veterans	Open clinical trial	Significant reduction in clinician-rated PTSD symptoms at six-month follow-up
2002	Difede and Hoffman	One World Trade Center attack survivor	Case report	90% reduction in PTSD symptoms, 83% reduction in depression
2007	Difede et al.	21 participants, mostly disaster workers (13 VR, 8 waitlist)	Controlled comparison with waitlist	Significant decline in CAPS scores versus waitlist; between-group effect size 1.54
2010	Rizzo et al.	20 treatment completers (Virtual Iraq)	Open clinical trial	16 no longer met PTSD checklist-military criteria for PTSD after treatment
2022	Difede et al.	192 military personnel with PTSD	Multisite double-blind randomized controlled trial, VR versus prolonged imaginal exposure, with D-cycloserine or placebo	Similar clinical improvement in both groups; VR more effective for participants with depression, imaginal exposure more effective for those without

The 2022 trial found no overall difference between VR exposure and prolonged imaginal exposure across nine weeks of treatment. ICT reports that 76% of incoming patients in the trial preferred VR exposure therapy over traditional therapy.

Research

Two meta-analyses have summarized the controlled evidence. Kothgassner and colleagues (2019) pooled nine controlled studies with 296 participants and found that VR exposure therapy produced significantly better PTSD outcomes than waitlist controls (Hedges' g = 0.62) but did not differ significantly from active treatments (g = 0.25). They cautioned that the trials were few and consisted largely of male military service members. Eshuis and colleagues (2021) found eleven studies of VR exposure therapy for PTSD (438 participants), most of them of low quality, and reached similar conclusions. They found no studies at all on the efficacy of augmented reality exposure therapy for PTSD, and called for trials that report side effects and adverse events.

On the risk side, the evidence is thinner. Madary and Metzinger called for longitudinal studies of long-term immersion, and warned that such studies will exclude, for ethical reasons, the users who may be most vulnerable, such as children or people with latent mental illness. Slater and co-authors wrote in 2020 that the short- and long-term effects of realistic XR are unknown and that guidelines will need to change as research produces new findings. McIntosh and Allen noted that "phantom touch" remains largely unresearched in formal settings.

See also

• Violence
• Presence
• Social VR
• Horror
• Cybersickness