state of art of therapeutic graphical simulations

University of Colombo School ofComputing

Literature Survey

State of Art of the TherapeuticGraphical Simulations

Author:

H.A.T. Kumara

Supervisor:

Dr. Prasad Wimalaratne

Tools Used: writreLATEX, Mendeley Reference Management Tool,

Mindmup

IEEE REFERENCING

Word Count: 4797

SCS3017

December 2014

http://www.ucsc.cmb.ac.lk

http://www.ucsc.cmb.ac.lk

Declaration of Authorship

I hereby declare that this literature survey report has been prepared by, H.A.T.

Kumara, based on mainly the reference material listed under the bibliography of

this report. No major components (sentences/paragraphs etc.) of other publica-

tions are directly inserted into this report without being duly cited.

Signed:

Date:

i

Abstract

Simulations of reality have been used for over 30 years by the military for training

and performance evaluations in a variety of tasks. Graphical simulations com-

bines real-time computer graphics, body tracking devices, visual displays, and

other sensory input devices to immerse patients in a computer-generated virtual

environment. Due to the uniqueness of virtual environments, many researches

have started to ask questions concerning the use of virtual environments for med-

ical applications. Advanced simulators for surgical training are one example of

a well-developed application using virtual reality approaches. In this article, we

review the literature and explore the possibility of using graphical simulations

as a therapeutic tool for anxiety disorders and psychological disorders. Initial

studies treating specific phobias with graphical simulations based approaches are

described. Issues relating to potential applications and possible side effects, as

well as clinical outcomes and cost effectiveness, are also discussed.

Contents

Declaration of Authorship i

Abstract ii

Contents iii

List of Figures iv

Abbreviations v

1 Introduction 1

1.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Virtual Reality and Immersion . . . . . . . . . . . . . . . . . . . . . 2

2 Graphical Simulations based Exposure Therapy for Phobias 4

2.1 Exposure Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.2 Acrophobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.3 Fear of Flying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.4 Fear of Spiders/Cockroaches . . . . . . . . . . . . . . . . . . . . . . 7

2.5 Agoraphobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.6 Social Phobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.7 Advantages of Virtual Reality Exposure Therapy vs. Other Expo-sure Treatments for Phobias . . . . . . . . . . . . . . . . . . . . . . 10

3 Other Employments of Virtual Reality Exposure Therapy 13

3.1 Post Traumatic Stress Disorder . . . . . . . . . . . . . . . . . . . . 13

4 Other Graphical Simulations based exposure techniques 15

4.1 Virtual Reality Cue Exposure Treatment . . . . . . . . . . . . . . . 15

4.2 Virtual Reality in Eating Disorders Treatment . . . . . . . . . . . . 16

5 Limitations of Therapeutic Graphical Simulations 18

5.1 Precautions of Graphical Simulations Use . . . . . . . . . . . . . . . 18

6 Conclusion 20

iii

List of Figures

1.1 CAVE System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.2 HMD System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.1 Virtual classroom for the fear of public speaking . . . . . . . . . . . 9

3.1 Virtual Vietnam scenarios . . . . . . . . . . . . . . . . . . . . . . . 14

iv

Abbreviations

VRET Virtual Reality Exposure Therapy

VRGET Virtual Reality Graded Exposure Therapy

CBT Cognitive Behavior Therapy

SUD Subjective Units of Discomfort

PTSD Post Traumatic Stress Disorder

CET Cue Exposure Therapy

HMD Head Mounted Display

CAVE Computer Automatic Virtual Environment

ET Exposure Therapy

v

Chapter 1

Introduction

1.1 Overview

The very nature of graphical simulations implies a set of interesting approaches

and tools that can be used to explore the human psyche and emotional reac-

tions. The capabilities that are inherent in artificial environment can prompt

more prominent creativity and the ability to manipulate the virtual world in a

controlled manner and afterward present a fear-relevant stimuli or challenges can

in theory parallel the standard model of office-based psychotherapy. The flexibility

and controllability in the artificial environment can prompt greater understanding

of a patient’s individual issues, concerns and basic health relates problems. Prior

to this methodology can be generally utilized, a few imperative issues must be ad-

dressed, and a greater understanding of the effects of virtual worlds on “normal”

individuals must be determined. In recent years, several intriguing studies have

been completed that exhibit successful utilization of graphical simulations for the

treatment of simple phobias [1] [2] [3] [4].

1

Chapter 1. Introduction 2

1.2 Virtual Reality and Immersion

Virtual reality, can be identified as a computer generated three dimensional ar-

tificial environment, in which users are immersed within a graphical simulation

or virtual environment (VE), that updates in a natural way to the users head

and/or body motion. In simple terms, VR can be defined as a synthetic or virtual

environment which gives a person a sense of reality. So the immersion is called

the objective description of the aspects of the application, such as field of view,

display resolution, and so forth [5].

The main approaches utilized to immerse participants in the virtual environment

are a head mounted display (HMD) or computer automatic virtual environment

(CAVE). HMD and CAVE vary in many immersion perspectives [6].

Figure 1.1: CAVE System

The CAVE is a multi-person, projection-based, high-resolution, room-sized VR

system. In the system, both the patient and therapist are surrounded by stereo-

scopic graphics on four to six sides (floor, roof and four walls). The patients wear

special glasses (shutter glasses) synchronized with the stereoscopic graphics gen-

erated by projectors. An electromagnetic tracking system is utilized, and a sensor

is connected to the viewers’ shutter glasses to align the view perspective. The

Chapter 1. Introduction 3

patient can navigate freely within the system, the correct perspective and stereo

projections of the environment are updated, the image moves with and surrounds

the patient and longer distances are travelled with the use of a wand.

An HMD system is only for single person utilization. A patient is staying in a room

wearing the HMD. The HMD uses small monitors placed in front of each eye which

can provide stereo, bi-ocular or monocular images and speakers near the ears or

headphones. The view of the patient is focused on graphics on the screens, and the

real world is not shown and not perceived. The sensors and trackers connected to

the HMD allow the patient’s sight of the virtual environment to update according

to the head movements made in the real world. When the patient moves his/her

head, the system uses the position of the sensor to simulate the movement and

new graphics are generated on the screens. For example, if a patient looks right,

the right side of the VE is displayed, if a patient looks up, the system simulates

graphics of a virtual sky, if s/he turns head down, the patient sees the graphics of

a virtual floor (Fig. 2).

Figure 1.2: HMD System

Chapter 2

Graphical Simulations based

Exposure Therapy for Phobias

2.1 Exposure Therapy

Exposure therapy is an approach that is widely used for a variety of anxiety dis-

orders. Exposure therapy is a process in which a person is exposed to specific

feared stimuli (scene or object) that trigger anxiety. Generally speaking, expo-

sure treatment involves confronting a patient with fear-relevant stimuli for a long

enough time to decrease the intensity of their emotional reaction. The exposure to

the feared objects, activities, or situations in a safe environment repeatedly, helps

reduce fear and decrease avoidance.

2.2 Acrophobia

One of the first case reports on the treatment of acrophobia by means of immersive

VR was published by Hodges, Kooper and Rothbaum, in 1995[1] [2]. Each subject

was given an acrophobia questionnaire to ascertain whether the subject meth the

Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R)

criteria for acrophobia [7]. He was also given a pre- and post- treatment BAT

4

Chapter 2. Graphical Simulations based Exposure Therapy for Phobias 5

assessment and rated his subjective units of discomfort (SUDs) while ascending

in a virtual glass elevator, similar to a real one. Treatment consisted in five

Virtual reality graded exposure therapy sessions twice a week for 3 weeks, each

lasting 35 – 45 minutes in length. The subject’s scores at post-treatment showed

a significant reduce in anxiety and distress. Avoidance behavior and negative

attitude toward height showed an improvement after treatment. Moreover, the

participants reported a generalization of this achievement to real life situations.

Hodges and associates [3] designed three VEs (a glass elevator, a series of bridges

with varying heights and degrees of stability, and a series of balconies with vary-

ing heights), which were evaluated by 17 undergraduate students suffering from

mild to strong acrophobia. Subjects were given a screening survey to determine

whether they fit the criteria for a simple phobia as depicted in the DSM-III-R.

If they met the criteria, they were then given an acrophobia questionnaire with

scales measuring anxiety, distress and avoidance. The questionnaire by Cohen

[4] has been shown to discriminate between phobic and non-phobic persons. An

attitude-toward heights questionnaire [6] adopted from DSM IV [7] and a fear

questionnaire were also administered. In the treatment acrophobic university stu-

dents were assigned to VRET (N= 10) receiving the treatment just described or

to a waiting-list control condition (N= 7). The SUD’s were rated during therapy

sessions. The control group also took the same assessments 7 weeks later. The

treatment group received 35 to 45-min sessions weekly for 7 weeks. Subjects were

confronted to different height situations according to the ranked order of avoiding

and distressing height situations that each subject stated at pre-treatment test.

The therapist observed each subject’s presentation on a screen and could inquire

with reference to how the subject was feeling while in the graphical simulation.

During the therapy session, SUDs were taken to ascertain whether the VE was

actually sensing the feeling of presence in an actual height situation. At post-

treatment indices of anxiety, avoidance, distress and attitude toward the feared

situation were significantly improved in the treatment group, while the measures

of the control group did not show any change. Some of the participants in the

treatment group even presented themselves to actual height scenarios, despite the


fact that they were not needed to do so. This appears to demonstrate that prepa-

ration in the virtual world does continue to the real world scenarios. Exposure

therapy using a virtual environment provides a safe, confidential setting in which

to become desensitized to one’s fears and phobias.

In sum, graphical simulations based exposure therapy has been found to be an

effective treatment for patients with fear of heights and successful results happened

at a much quicker rate than with traditional exposure therapy and desensitization

[1] [2]. It has been found to be as effective as the gold standard exposure in vivo

and results generalize to real life.

2.3 Fear of Flying

Fear of Flying is a widespread mental disorder, with a lifetime prevalence of ap-

proximately rates for specific phobias as 10%—11.3%, with other surveys estimat-

ing that fear of flying exists in 10%-20% of the population [8]. People with fear of

flying as a specific phobia fear crashing, whereas those who develop fear of flying

as part of agoraphobia fear having a panic attack while on an airplane [9] [8].

The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) [7]

classifies fear of flying as a specific phobia, situational subtype, which is included

in the larger classification of anxiety disorders.

There have been few case studies reported in the literature indicating that VRGET

can be used as an alternative treatment for fear of flying [10] [9]. In the first study,

a forty two year old phobic female who had become increasingly fearful of flying

and had not flown at all for two years due to her fear. Treatment consisted of

seven sessions of anxiety management approaches and then given six sessions of

VRGET. The virtual-flight scenarios included a fixed-wing aircraft that performed

a sequence of events including sitting at the runway, taxiing, taking off, flying at

altitude, and landing. Most important, just days after treatment, the subject

was able to complete an actual flight with her family and reported less fear upon

exposure [9] [8]. A case study involved an individual who had previously received


VRGET for his fear of heights. The individual received five exposure sessions in a

virtual helicopter, accompanied by a virtual therapist. The subject’s SUDs ratings

decreased over the course of treatment, indicating a reduction in fear. Long term

follow-up is pending in this case report [11].

Rothbaum and colleagues [12] conducted a controlled study on forty nine patients

suffering from fear of flying. Treatment consisted in four sessions of anxiety man-

agement approaches and then given four sessions of exposure therapy. After the

completion of the treatment, results measured by phobic questionnaires adopted

from (4th ed.; DSM-IV) [7] were found to be more effective than control group.

2.4 Fear of Spiders/Cockroaches

Botella and colleagues conducted a case study to determine the effectiveness of

AR in the treatment of fear of spiders [13]. The treatment was tested on thirty

three year old woman who suffered from phobia of spiders/cockroaches since she

was thirteen years old. She was first asked to rate her maximum level of anxiety

on a 0 to 10 scale (0=no anxiety, 10=high anxiety) to measure SUDs. After

that she was given therapy session to describe the nature of anxiety. After initial

therapy, the treatment consisted in several exposure sessions followed in which she

viewed photographs of spiders and plastic replicas of spiders. Then the subject

given thirty minutes of exposure therapy sessions of interacting with a virtual

spider. Outcomes of the treatment showed an important change in the avoidance

of spider/cockroaches. After completion of therapy, the subject was able to go

camping (an activity she had not done for 16 years because of her fear of spiders),

and she killed a spider found in her home (despite the fact that not particularly

asked by the researchers to do so) [14].


2.5 Agoraphobia

According to the DSM-IV, agoraphobia involves ”anxiety about being in places or

situations from which escape might be difficult (or embarrassing) or in which help

may not be available in the event of having an unexpected or situational predisposed

Panic Attack or panic-like symptoms” [8]

Due to Agoraphobia, the person with this phobia may become avoidant of some

situations or will endure those situations with much distress [7]. In a controlled

study [15], thirty college students with agoraphobia were treated with VRGET.

Each participant was given an agoraphobia questionnaire and those who met the

minimum criteria of agoraphobia questionnaire were included for the treatment.

Subjects were treated with eight 15 minutes sessions of VRGET. Each session

consisting of exposure to eight different virtual scenes: balconies, an empty room,

a dark barn, a dark barn with a black cat, a covered bridge, an elevator, a canyon

with a series of bridges, and a series of hot-air balloons at different heights. Af-

ter conclusion of the exposure therapy sessions, 24 subjects stated a decrease in

both SUDs scores and scores on an agoraphobia questionnaire. Due to the simple

phobias individuals may have can include diverse subject matter, one can see the

inherent advantage and flexibility of using a virtual world for desensitization. It

seems that graphical simulations based exposure therapy may be useful in treating

this disorder; however, quantitative measures of physiology and long-term follow-

up should be used to help refine future studies.

2.6 Social Phobia

Social phobia is a widespread mental disorder. The DSM-IV lists lifetime preva-

lence rates for specific phobias as 5%—8%, with other surveys estimating that fear

of flying exists in 7%-11% of the population. [16].

“This kind of anxiety disorder can be observed in two forms: specific social phobia,

when an individual experiences excessive anxiety in a circumscribed situation, e.g.,


public speaking; and a generalized social phobia, occurring when an individual feels

uncomfortable in a variety of social situations. Traditional therapeutic approach

of choice is CBT; in particular, treatment should be addressed to the modifica-

tion of anxiety-provoking thoughts and beliefs, the acquisition of social skills, and

overcoming avoidance by means of graded exposure to social situations.”[17]

Figure 2.1: Virtual classroom for the fear of public speaking

One of the preliminary reports on the treatment of social phobia by means of

immersive VR was published by a group at Clark Atlanta University. In the

study twelve university students with a fear of public speaking were treated using

graphical simulations. Participants were placed in front of a virtual audience and

experienced many of the same symptoms as subjects do when in front of a real

audience, such as a dry mouth, increased heart rate, and sweaty palms. A SUDs

scale and an Attitude toward Public Speaking questionnaire were used to assess

anxiety. Self-reported anxiety decreased after treatment [17]. Studies are also

underway by the group at Clark Atlanta University to test the effectiveness of

virtual reality in the treatment of obsessive-compulsive disorder.


2.7 Advantages of Virtual Reality Exposure Ther-

apy vs. Other Exposure Treatments for Pho-

bias

All the studies exhibited above compared results obtained by VRET and by in-

vivo therapy, showing a considerably similar effectiveness of the two procedures.

This section is devoted to the studies particularly addressing the advantages of

embracing the VRET procedure rather than the traditional in-vivo exposure ther-

apy, going past the effectiveness criterion, and after considering different angles

for patients’ acceptance, safety, or comfort.

Garcia-Palacios, Hoffman, Kwong See, Tsai and Botella [18] concentrated on the

more prominent likelihood for spider phobics to acknowledge VR exposure con-

trasted with in-vivo. In the first of the trials described, they gathered information

from eighty-seven undergraduates with spider phobia their preference between in-

vivo and VRET, and members came about altogether more eager to take part in a

treatment involving VR as opposed to in-vivo exposure therapy. Considering the

percentage of participants who refused to participate to the therapy, 17.4% would

unquestionably not get included in the in-vivo exposure, but only 4.6% reported a

refusal to get included in VRET. Then again 31% reported a definite willingness

to participate to the VRET, but only 7% reported the same for in-vivo exposure.

Eighty-one percent of the participants selected VRET when compelled to pick be-

tween treatments (in-vivo and VRET), therefore demonstrating a factually huge

preference for VR treatment. In a second experiment, authors experimented par-

ticipants’ preferences for one three-hour in-vivo single session treatment or three

one-hour VR exposure sessions. Regardless of the high achievement rate demon-

strated in literature, Ost [19] evaluated that 90% of patients would have declined

the quickened one-session treatment therapy if told in advance they were going to

let live spiders crawl on their arm. In this study seventy-five participants with high

spiderphobia reported again an altogether more prominent preference to VRET

treatment, contrasted with an in-vivo exposure treatment. And 34.7% of the


reported a decline to be included in the accelerated, single session in-vivo intro-

duction exposure, while just 8% unquestionably declined VRET. Then again, 27%

of participants reported a distinct eagerness to undergo VR exposure treatment,

yet just 10.7% reported the same for the in-vivo exposure. Compelled to pick

between the procedures, 89.2% of participants picked VRET and 10.8% picked

in-vivo exposure treatment, demonstrating a statistically significant noteworthy

distinction between these extents.

Given that VR and in-vivo exposure lead to comparable therapeutic results, it is

helpful to bring up the particular favorable circumstances of picking VR rather

than an in-vivo. Botella and associates [20] summarized the advantages of VRET

with respect to traditional treatments for psychological disorders include:

Finally, in a recent meta-analysis of studies on applying exposure therapy to treat

anxiety disorders, Rizzo and Albert [1], found that in-vivo exposure therapy seems

to be more viable than other approaches of exposure, such as imaginal and VRET,

instantly after therapy, but this advantage is no longer available at follow-up and

effect of the treatment reduces over time. Therefore, initially in-vivo may prompt

to an accelerated development, but patients following other forms of exposure

therapy continue to improve after treatment. Then, if both in-vivo and VRET

prompt to produce the same outcomes over a long period of time, therapists and

patients can decide to use the most cost and time effective approach.


Traditional treatement VR treatement

The place where the treatment takes

place is real, and the elements that

patient fears also real. Therefore,

these elements may not behave as the

therapist desires.

The elements that the patient fears

are virtual, so they cannot hurt

him/her

It might be necessary to actually go

to the location that the patient fears,

or to recreate it. Access to this place

is could be complicated and the ther-

apy might require several sessions.

In VR scenes, the virtual elements

can appear whenever the therapist

wants. Access to the scene is as easy

as running the program.

The order that stimuli are produced

in is not controlled by the therapists.

Stimuli generation is controlled by

the therapist and stimuli can be re-

peated as many times as necessary.

The order of appearance of virtual

elements can also be controlled. The

therapist can start/stop the program

at any time.

The therapist cannot assure that the

patient will be completely safe during

treatment.

The virtual elements are not real,

which means that is no real danger

to the patient

The real place could be public. The

patient might suffer a panic attack

during the treatment, and it might

be embarrassing for both the thera-

pist and the patient

The place where the program is run

is chosen by the therapist, so he/she

can control all the possibilities.

Table 2.1: Advantages of VRET with respect to traditional treatments forpsychological disorders[20]

Chapter 3

Other Employments of Virtual

Reality Exposure Therapy

3.1 Post Traumatic Stress Disorder

In addition to phobia treatment described in previous sections, VRET has been

broadly utilized to treat an exceptionally unconventional anxiety disorder, Post-

Traumatic Stress Disorder (PTSD).

Almost 15% to 25% of survivors of traumatic events suffer side effects connected

with continuous PTSD. Twenty-one of Vietnam veterans, 450,000 (15%) meet

the DSM-IV [7] criteria for PTSD at 15 years post-Vietnam [21]. Due to its

changed symptomatology and refusal to treatment, numerous treatment modalities

have been researched. In a survey of treatment modalities for PTSD [22], it

was demonstrated that most studies have utilized some type of exposure therapy

based approaches to treat PTSD and that fractional development has happened

in many ways [23]. Virtual reality has additionally been researched as a tool

for utilization in those suffering from PTSD. Since exposure based treatment has

been shown relatively good evidence to work with PTSD, by immersive scenes in a

virtual environment, therapist could more effectively provide the patient a better

treatment to reduce PTSD more gradually [23].

13

Chapter 3. Other Employments of Virtual Reality Exposure Therapy 14

Figure 3.1: Virtual Vietnam scenarios

In a 1983 study [14], Vietnam veterans experiencing PTSD were contrasted with

veterans not experiencing PTSD and to veterans experiencing other mental is-

sues. The three sets were examined on behavioral, physiological, and self-report

measures. It was discovered that the set of participants experiencing PTSD varied

from the other two sets when exposed to varying audiovisual fear relevant stimulus

of a combat environment yet not when exposed to a neutral audiovisual. They

showed a more prominent increment in heart rate, a more prominent avoidance

behavior (needing to end the stimuli as evidenced by pressing a terminate button),

and higher self-report levels of anxiety and fear than did the other two sets.

By obtaining physiological response present in the VE via noninvasive sensors,

the system itself or therapist could know exactly when to terminate the traumatic

scene and avoid occurring a too much distressful situations to the patient. Re-

cently, the therapist must depend on the patient’s subjective feelings (and the

therapist’s perception of these feelings) to guide the length of therapy and expo-

sure.

A group led by Hodges and Rothbaum [24] has just started work on treating

PTSD with VRET. The study will include Vietnam veterans at the Veteran’s

Administration Hospital in Atlanta. Due to the varied symptoms suffered by

veterans experiencing PTSD, this study will serve to stretch the limits of current

virtual-reality technology.

Chapter 4

Other Graphical Simulations

based exposure techniques

4.1 Virtual Reality Cue Exposure Treatment

Cue exposure is a treatment in which a substance (drug, liquor, nicotine, and so

forth.) patient is continuously exposed to substance-related stimuli (cues) con-

nected with his/her addictive conduct. Subjective, physiological, and behavioral

response to these cues is usually considered a conditioned response, impacting the

probability of substance self-manipulation. Continuous exposure to these cues not

took after by substance administration ought to advance the termination of the

conditioned response, hence reducing the main attitude towards the addiction, and

minimizing the likelihood to relapse [25] [26] [27].

Recently VR has been employed to provide safe Cue Exposure Therapy (VR CET)

to people suffering from various forms of addiction. Several studies addressed the

effectiveness of immersive VEs in eliciting substance craving in addicted people. A

group headed by Stoermer [27] designed a VE including objects related to heroin

injection, such as heroin powder, swab, syringe, needle, and used material with

and without blood which were evaluated by five heroin addicts. Outcomes of

15

Chapter 3. Other Graphical Simulations based exposure techniques 16

this VRCET showed that VR was effective in discovering eliciting physiological

activation and subjective craving symptoms of heroin addicts.

In 2006 Rothbaum and associates [28] designed an immersive virtual ”crack house”

with crack cocaine related cues, and assessed its viability in prompting substance

craving in eleven crack cocaine addicts. Both subjective evaluations of addiction

on a 0 to 100 scale and physiological measurements recommended a more extreme

substance desiring after ”crack house” VR immersion than after immersion in an

normal VE.

Recently, Wiederhold and associates [29] developed an application of a virtual

bar simulating the craving environment, craving objects (alcoholic drink, pack

of cigarettes, lighter, ashtray, and mug of beer). The study is conducted with

participation of the sixty-four smokers and each subject was given a nicotine-

craving questionnaire. Treatment consisted in five VRCET sessions three times a

day for 2 weeks, each lasting 20 – 30 minutes in length. Outcomes demonstrated

that this VR system attained inspiring outcomes at eliciting nicotine craving, as

measured by a 0 to 100 visual-analog scale, than photographs.

4.2 Virtual Reality in Eating Disorders Treat-

ment

In addition to work with anxiety disorders, work has been done in the application

of virtual- reality technologies to other mental disorders such as eating disorders,

including anorexia nervosa, bulimia nervosa, and obesity. The Virtual Environ-

ment for Body Image Modification (VEBIM) is a system being developed in Italy

by Riva and his associates [30] to treat body dissatisfaction and body-image dis-

turbances that may be present in eating disorders. The two most commonly used

methods of treatment for eating disorders are cognitive behavioral therapy and

imaginal therapy. The VEBIM system seeks to incorporate both methods to of-

fer a more effective treatment system. The system consists of a set of ”zones”

Chapter 3. Other Graphical Simulations based exposure techniques 17

the subject can pass through after performing certain tasks. Some zones give the

subject the opportunity to ”eat” and some zones require that the subject weight

himself or herself before exiting to the next zone. The subject’s real body is dig-

itized into the virtual-reality world, and the subject can view this body while in

the virtual world and also create an image of his or her ideal body by using a

morphing system. Finally, the subject must choose among various sized doors,

one of which corresponds to the subject’s real body size, before being allowed to

exit to the final zone.

The system has been tested on a nonclinical sample of seventy-one subjects to de-

termine what effects the virtual-reality system would have on blood pressure, heart

rate, and body image. Subjects were given one 8 to 10 min virtual-reality session

and were asked to pass through different zones. Blood pressure and heart rate

measurements were taken before the virtual experience, immediately after treat-

ment and then again 10 min post-treatment. Prior to treatment, subjects were

asked to complete body experience scales that seek information on the subjects’

perception of current body size and ideal size. After the virtual-reality session, sub-

jects’ scores showed a reduction in body dissatisfaction and a smaller discrepancy

between ideal and actual body image. There was no significant change between

blood pressure and heart rate measurements before treatment, immediately after

treatment, or 10 min post-treatment [30].

Issues related to body image are very common in the United States, with the

prevalence for anorexia reported at 0.5% to 1%, bulimia at 1% to 3%, and obesity

at 25% (Thirty million Americans). Although comprising the smallest group, those

suffering from anorexia have the worst prognosis, with 10%-20% progressing to

severe morbidity or morality. Virtual-reality therapy promises to offer an alternate

treatment approach for this difficult clinical problem [30].

Chapter 5

Limitations of Therapeutic

Graphical Simulations

5.1 Precautions of Graphical Simulations Use

Virtual-reality techniques may not be applicable to all psychological disorders or

to all patients. It has been suggested that because schizophrenics suffer from a

detachment from reality, placing them in virtual worlds for therapy, then exposing

them back to reality, could actually increase their level of confusion [31]. For those

who suffer from claustrophobia, the confinement of a head-mounted display may

actually increase their symptoms. Those who suffer from agoraphobia may expe-

rience anxiety at viewing a virtual world with infinite horizons. Prescreening of

patients may be necessary to determine those individuals who are at increased risk

to adverse events in virtual systems. In light of the recent debate over ”implanted

memories,” the possibility that a virtual experience may become ingrained in one’s

memory and be indistinguishable from a real experience is possible. During ex-

posure therapy to desensitize an individual who has been traumatized, care must

be taken to avoid adding additional traumatic memories [31]. Others who may be

at risk are drug abusers or others with addictive personalities, those with various

other mental illnesses, and those who are emotionally unstable.

18

Chapter 5. Limitations of Therapeutic Graphical Simulations 19

In a virtual world, there is deliberate manipulation of a person’s senses and the

possibility for disembodiment, gender swapping, multiple identities, and parallel

communications. If someone were dissatisfied with their current reality, they may

prefer this new virtual reality to real life, causing social alienation and loneliness

[32]. As technology continues to improve, the quality and believability of virtual

worlds will continue to increase. Could the virtual world become indistinguish-

able from the real world? If this were the case, there would be no distinction

between fantasy and reality. The consequences of this situation are unknown at

this time but raise significant questions for discussion. The risk of becoming more

socially isolated also is possible with virtual reality. Will our sense of community

and neighborhood diminish? Without direct human interaction, will rudeness,

violence, or other negative consequences occur? These are interesting questions

that can provoke discussion and further investigation [33]. In addition, a variety

of physical problems can occur in virtual environments. These problems include

simulator sickness, eyestrain, flashbacks, tendonitis, and possible addiction.

Chapter 6

Conclusion

Virtual-reality techniques will provide many novel avenues for the evaluation and

treatment of psychological conditions. Several studies have already shown benefit

in the treatment of simple phobias. This improvement in symptoms was shown

to exist 6 months post-treatment. 6 It is clear, however, that some issues and

concerns must be addressed before widespread implementation of virtual therapy

becomes commonplace. It is not clear, for example, that all individuals will be

able to relate or function in a virtual environment. Because the virtual world is

so enveloping, it is not clear how to provide patients with a predictable means of

escape or some other methodology in which the patient can maintain control of

the session and environment.

An interesting approach is provided by the Virtual I/O multimedia company. In

this virtual world, if the patient looks to the far right or far left, a video screen

can be viewed. During therapy, the patient could either view a pleasant scene or

a real-time video image of the therapist if connection to ”real reality” is desired.

(This of course begs the existential question of what is reality.) Another issue is

allowing the patient to construct the virtual world, inviting the therapist into the

virtual world to experience what the patient thinks is important. This process

could redefine the nature of the doctor-patient interaction. It would be interesting

to speculate on how nonverbal information and cues could be enhanced in virtual

space in a way that gives more meaningful information to both the patient and the

20

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psychotherapeutic techniques and assist in the generation of new approaches.

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state of art of therapeutic graphical simulations

Engineering