Virtual Reality Based Treatments in Eating Disorders and Obesity: A Review

Since the late 1990s the use of virtual reality (VR) has expanded in the field of mental disorders. During this time, several VR-based applications have been developed for the treatment of eating disorders (ED) and obesity. Both these pathologies involve disturbances related to eating behavior, weight, and body image. Although effective and well-established protocols are now available for the treatment of ED and obesity, relapses are frequent and a proportion of patients do not improve after intervention. In this context, VR has been shown to be a useful technology for enhancing traditional cognitive-oriented therapies. The main objective of this review was therefore to examine the evidence regarding the efficacy of VR-based treatments as a component of therapeutic interventions for ED and obesity. To this end, three databases (PsycInfo, Medline, and PsycArticles) were searched for the period 1986–2012. Only research articles and case studies were selected. Although several methodological deficiencies were detected in the reviewed studies, there is fair evidence for the effectiveness of VR-based treatments in ED and obesity. VR-based interventions usually combine exposure to VR environments with cognitive therapies. The VR component seems to be especially suitable for reducing body image disturbances, such as body image dissatisfaction, and for increasing self-esteem and self-efficacy. The rationale for the use of VR in these areas is also presented and discussed.     

虚拟现实暴露疗法在社交焦虑中的应用:效果、机制及展望

由于传统干预方法的诸多局限,虚拟现实暴露疗法(virtual reality exposure therapy,VRET)逐渐应用于对社交焦虑的干预,VRET是将虚拟现实技术与传统行为暴露治疗相结合而形成的一种新的干预方法。文章总结了VRET的三个发展阶段及其研究范式,述评了在VRET过程中的作用机制。未来研究可致力于设计更加自然的人机交互技术,实现技术与社交焦虑治疗的深度融合以及关注第三人称视角应用的作用及机制。     

Enhancing quality of life in medical populations: a vision for body image assessment and rehabilitation as standards of care

This article presents a vision and framework for establishing body image assessment and rehabilitation as a standard of care for patients with medical disorders. Making this vision a reality depends upon: (1) a thorough understanding of the body image construct; (2) application of many new forms of body image assessment; (3) refined understanding of body image disorder and dysfunction in the context of medical conditions; and (4) a clear plan to implement and evaluate prevention, rehabilitation, and treatment programs. Applying the many important developments that have occurred in body image theory, assessment, and intervention over the past decade holds promise for enhancing the quality of life of many individuals with medical conditions.     

A standardized set of 3-D objects for virtual reality research and applications

The use of immersive virtual reality as a research tool is rapidly increasing in numerous scientific disciplines. By combining ecological validity with strict experimental control, immersive virtual reality provides the potential to develop and test scientific theories in rich environments that closely resemble everyday settings. This article introduces the first standardized database of colored three-dimensional (3-D) objects that can be used in virtual reality and augmented reality research and applications. The 147 objects have been normed for name agreement, image agreement, familiarity, visual complexity, and corresponding lexical characteristics of the modal object names. The availability of standardized 3-D objects for virtual reality research is important, because reaching valid theoretical conclusions hinges critically on the use of well-controlled experimental stimuli. Sharing standardized 3-D objects across different virtual reality labs will allow for science to move forward more quickly.     

Exposure Therapy for Posttraumatic Stress Disorder: A Meta-Analysis

This meta-analysis compares the findings of empirical studies that employ either a traditional form of cognitive–behavioral-based exposure therapy or virtual reality exposure therapy (VRET) for the treatment of posttraumatic stress disorder (PTSD) to determine which is more viable and effective. Statistical analyses were performed on 26 studies to determine pre- to posttreatment effect sizes and interactions. Results demonstrated a trend toward significance in favor of traditional exposure therapy showing lower posttreatment PTSD. Limitations included a restricted number of relevant studies; future research on VRET for PTSD should orient more to experimental designs, larger samples, and increased use of control groups.     

Virtual Reality Exposure in the Treatment of Panic Disorder With Agoraphobia: A Case Study

In this work we present a case example of the use of virtual reality exposure for the treatment of panic disorder with agoraphobia. The assessment protocol and procedure (including a baseline period) and the cognitive-behavioral treatment program are described. The clinical measures were categorized into target behaviors, panic and agoraphobia measures, global functioning, and general psychopathology measures. The patient’s expectations and satisfaction with regard to the virtual treatment were also assessed. The results showed an important reduction in all clinical measures after treatment with virtual exposure and the patient reached the therapeutic goals established during the pretreatment assessment. The patient also reported a good acceptance of virtual exposure. The goals achieved in the virtual environment generalized to real agoraphobic situations and to other real situations not treated. Three-, 6-, and 12-month follow-up assessments were conducted and long-term therapeutic gains were maintained.     

An order of pure decision: growing up in a virtual world and the adolescent's experience of being-in-a-body

Technological advances and the dominant values of contemporary culture make it possible and acceptable to alter, extend, or altogether bypass the body and its functions in actuality and in virtual space. This has contributed to a split between the body and the self, leading to a disembodied subjectivity that may encourage a neglect of the body's unconscious meaning for the individual. Due to the psychic requirement during adolescence to accommodate the reality of the changing body, some vulnerable adolescents are especially primed for the seductions of virtual space--a "space" that is nowadays not only culturally sanctioned, but also idealized. The use of cyberspace can become a psychic refuge from the challenge of integrating the reality and meaning of the sexual body into the image of the self. Two case examples illustrate how for some vulnerable adolescents it is through the use of cyberspace that confusion about the real body can be denied or disavowed; for them the integrity of the self is sustained through pseudorepresentations of the body defensively experienced in terms of "play" rather than pathology.     

Validity of virtual reality as a method of exposure in the treatment of test anxiety

This is a validation study, aiming to explore the effectiveness of a set of virtual environments forproducing emotionally significant responses in students with high levels of test anxiety in order to be able to implement them later in treatment. Twenty-one students agreed to take part, 11 with high test anxiety and 10 with low test anxiety. The virtual environments were prepared in chronological order: the student's home, then the metro, and finally the corridor and lecture hall where the examination takes place. The results showed that the high-test-anxiety group presented higher levels of anxiety and depression than the low-test-anxiety group during exposure to the virtual environments. This study shows that virtual reality is able to provoke emotional responses in students with high test anxiety. This validation study should be followed up with treatment studies to evaluate the efficacy of virtual reality therapy for treating testanxiety.     

Body schema, gender, and other correlates in nonclinical populations

The link between body image and eating disorders has been extensively discussed, but investigations using nonclinical populations have not been systematically reviewed. In this article, a model to guide future researchers has been provided, and an attempt has been made to organize and synthesize the existing findings, with special attention to gender differences. Future researchers should more carefully delineate behavioral, emotional, cognitive, motivational, and evaluative components of body schema and should explore the relationship between body schema and outcomes other than eating disturbances. Conclusions in this review include the following: (a) Verbal measures of body schema are more successful than visual assessment tools; (b) measures of body distortion have been less successful than measures of dissatisfaction; (c) gender differences are prevalent; (d) behavioral outcomes can be successfully predicted; and (e) pubertal development plays a critical role in the gender differentiation of body schemas.     

Self-objectification,body image disturbance,and eating disorder symptoms in young Australian children

Self-objectification has been examined extensively in adult populations. Despite theoretical evidence suggesting that children may also be vulnerable to experiencing self-objectification, whether children do self-objectify has not been determined. Accordingly, the present study examined the degree to which children self-objectify. The prevalence of body image and eating disturbances in this population, and the relationship between self-objectification and these disturbances, were also investigated. Results from over 250 boys and girls aged 6–11 years revealed that young girls report levels of self-objectification that are similar to those observed among older girls and women. Self-objectification was also found to be meaningfully related to body image and eating disturbances in children. A significant proportion of children reported body dissatisfaction and a minority engaged in disordered eating behaviours in the four weeks prior to the assessment. These results suggest that children may be at risk of experiencing the negative psychological outcomes associated with self-objectification.     

Assessment of emotional reactivity produced by exposure to virtual environments in patients with eating disorders.

The aim of this study was to assess the usefulness of virtual environments representing situations that are emotionally significant to subjects with eating disorders (ED). These environments may be applied with both evaluative and therapeutic aims and in simulation procedures to carry out a range of experimental studies. This paper is part of a wider research project analyzing the influence of the situation to which subjects are exposed on their performance on body image estimation tasks. Thirty female patients with eating disorders were exposed to six virtual environments: a living-room (neutral situation), a kitchen with high-calorie food, a kitchen with low-calorie food, a restaurant with high-calorie food, a restaurant with low-calorie food, and a swimming-pool. After exposure to each environment the STAI-S (a measurement of state anxiety) and the CDB (a measurement of depression) were administered to all subjects. The results show that virtual reality instruments are particularly useful for simulating everyday situations that may provoke emotional reactions such as anxiety and depression, in patients with ED. Virtual environments in which subjects are obliged to ingest high-calorie food provoke the highest levels of state anxiety and depression.     

Virtual reality for the psychophysiological assessment of phobic fear: responses during virtual tunnel driving

An overall assessment of phobic fear requires not only a verbal self-report of fear but also an assessment of behavioral and physiological responses. Virtual reality can be used to simulate realistic (phobic) situations and therefore should be useful for inducing emotions in a controlled, standardized way. Verbal and physiological fear reactions were examined in 15 highly tunnel-fearful and 15 matched control participants in 3 virtual driving scenarios: an open environment, a partially open tunnel (gallery), and a closed tunnel. Highly tunnel-fearful participants were characterized by elevated fear responses specifically during tunnel drives as reflected in verbal fear ratings, heart rate reactions, and startle responses. Heart rate and fear ratings differentiated highly tunnel-fearful from control participants with an accuracy of 88% and 93%, respectively. Results indicate that virtual environments are valuable tools for the assessment of fear reactions and should be used in future experimental research.     

焦虑障碍的虚拟现实暴露疗法研究述评

虚拟现实暴露疗法(VRET)是传统的行为疗法的一种转换形式, 也是经典的现实情境暴露疗法的替代性治疗形式。虚拟现实整合了即时计算机图形学、身体感觉传感、视觉成像技术, 给来访者提供近似真实的、可以沉浸(immersion)和交互作用的虚拟环境。研究者采用虚拟现实暴露疗法治疗幽闭恐怖症、恐高症、飞行恐怖症、创伤后应激障碍、惊恐障碍等焦虑障碍, 并且关注虚拟现实暴露疗法的认知机制以及心理生理机制。实验研究表明, 虚拟现实暴露疗法在治疗焦虑障碍时是有效的。被试经过治疗之后, 对情境的控制感和自我效能感提升, 消极自我评价降低, 对创伤事件的容忍力提高, 重新获得对情境的控制感。与心率指标相比, 皮肤电是预测虚拟现实暴露疗法治疗效果更好的指标。虚拟现实暴露疗法还处于实验验证阶段, 并没有应用到实际临床中, 需要更加规范的实验设计验证该疗法的认知机制以及心理生理机制。虚拟现实暴露疗法结合功能磁共振成像(FMRI)用于心理治疗, 会是未来发展的新方向。     

The virtual body of Christ and embrace of the seriously ill

ABSTRACT

Since the time of the Apostle Paul, the body of Christ has always been a virtual body, made up of members who were not always physically present to one another but were nevertheless part of the same catholic community. Virtual presence in today’s society comes most often via digital technology, a reality that prompts many Christian leaders and theologians to warn of the dangers of disembodied existence. This paper challenges the claim that virtual presence via digital technology is necessarily an inferior form of presence. Using autoethnographic research of living with advanced-stage cancer, the author explores how virtual connection via technology can sometimes be a superior form of presence for those undone by illness and other traumas. The article concludes with a call to churches to draw on biblical, theological, and liturgical resources to help imagine how digital devices can be used to practice healing forms of attentiveness to those who need it most.     

Body image in eating disorders: the influence of exposure to virtual-reality environments

The aim of this article was to study the effect of virtual-reality exposure to situations that are emotionally significant for patients with eating disorders (ED) on the stability of body-image distortion and body-image dissatisfaction. A total of 85 ED patients and 108 non-ED students were randomly exposed to four experimental virtual environments: a kitchen with low-calorie food, a kitchen with high-calorie food, a restaurant with low-calorie food, and a restaurant with high-calorie food. In the interval between the presentation of each situation, body-image distortion and body-image dissatisfaction were assessed. Several 2?x?2?x?2 repeated measures analyses of variance (high-calorie vs. low-calorie food?x?presence vs. absence of people?x ED group vs. control group) showed that ED participants had significantly higher levels of body-image distortion and body dissatisfaction after eating high-calorie food than after eating low-calorie food, while control participants reported a similar body image in all situations. The results suggest that body-image distortion and body-image dissatisfaction show both trait and state features. On the one hand, ED patients show a general predisposition to overestimate their body size and to feel more dissatisfied with their body image than controls. On the other hand, these body-image disturbances fluctuate when participants are exposed to virtual situations that are emotionally relevant for them.     

Mixing realities? An application of augmented reality for the treatment of cockroach phobia.

Augmented reality (AR) refers to the introduction of virtual elements in the real world. That is, the person is seeing an image composed of a visualization of the real world, and a series of virtual elements that, at that same moment, are super-imposed on the real world. The most important aspect of AR is that the virtual elements supply to the person relevant and useful information that is not contained in the real world. AR has notable potential, and has already been used in diverse fields, such as medicine, the army, coaching, engineering, design, and robotics. Until now, AR has never been used in the scope of psychological treatment. Nevertheless, AR presents various advantages. Just like in the classical systems of virtual reality, it is possible to have total control over the virtual elements that are super-imposed on the real world, and how one interacts with those elements. AR could involve additional advantages; on one side it could be less expensive since it also uses the real world (this does not need to be modeled), and it could facilitate the feeling of presence (the sensation of being there), and reality judgment (the fact of judging the experience as real) of the person since the environment he or she is in, and what he or she is seeing is, in fact the "reality." In this paper, we present the data of the first case study in which AR has been used for the treatment of a specific phobia, cockroaches phobia. It addresses a system of AR that permits exposure to virtual cockroaches super-imposed on the real world. In order to carry out the exposure, the guidelines of Ost with respect to "one-session treatment" were followed. The results are promising. The participant demonstrated notable fear and avoidance in the behavioral avoidance test before the treatment, and not only was an important decrease in the scores of fear and avoidance observed after the treatment, but also the participant was capable of approaching, interacting, and killing live cockroaches immediately following the treatment. The results are maintained in a follow-up conducted 1 month after the termination of the treatment.     

Frequency of stuttering during challenging and supportive virtual reality job interviews

This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals’ time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants’ subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed.

Educational objectives: After reading this article, the reader will be able to—(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.     

Future-Oriented Positive Mental Imagery Reduces Anxiety for Exposure to Public Speaking

Exposure therapy is the recommended treatment for anxiety disorders, but many anxious individuals are unwilling to expose themselves to feared situations. Episodic simulation of future situations contributes to adaptive emotion regulation and motivates behavior. This study investigated whether future-oriented positive mental imagery reduces anticipatory anxiety and distress during exposure, and increases exposure willingness and duration. Forty-three individuals with moderate public speaking anxiety were randomized to a standardized positive mental imagery exercise about future public speaking or no-task. All participants were then asked to present in a virtual reality environment. Anticipatory anxiety reduced in the positive mental imagery group, but not in the control group. Additionally, the positive mental imagery group reported lower distress during exposure than the control group, but groups did not differ in exposure willingness. Due to limited variance, effects on exposure duration could not be tested. Future-oriented positive mental imagery is promising to prepare individuals for exposure to previously avoided situations.     

Virtual reality goes to war: a brief review of the future of military behavioral healthcare

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in returning OEF/OIF military personnel is creating a significant healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual Reality delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. This article details how virtual reality applications are being designed and implemented across various points in the military deployment cycle to prevent, identify and treat combat-related PTSD in OIF/OEF Service Members and Veterans. The summarized projects in these areas have been developed at the University of Southern California Institute for Creative Technologies, a U.S. Army University Affiliated Research Center, and this paper will detail efforts to use virtual reality to deliver exposure therapy, assess PTSD and cognitive function and provide stress resilience training prior to deployment.