virtual reality-based multidimensional therapy -

CYBERPSYCHOLOGY amp BEHAVIOR

Volume 4 Number 4 2001Mary Ann Liebert Inc

Virtual RealityndashBased Multidimensional Therapy for theTreatment of Body Image Disturbances in Obesity

A Controlled Study

GIUSEPPE RIVA PhD12 MONICA BACCHETTA PsyD1

MARGHERITA BARUFFI PsyD1 and ENRICO MOLINARI PsyD12

ABSTRACT

The main goal of this paper is a preliminary evaluation of the efficacy of a virtual realityVRndashbased multidimensional approach to the treatment of body image attitudes and relatedconstructs The female obese patients (n 5 28) involved in a residential weight control treat-ment including low-calorie diet (1200 kcalday) and physical training were randomly as-signed either to the VR treatment or to psychonutritional groups based on the cognitive-be-havior approach Patients were administered a battery of outcome measures assessing eatingdisorders symptomatology attitudes toward food body dissatisfaction level of anxiety mo-tivation for change level of assertiveness and general psychiatric symptoms In the short-term the VR treatment was more effective than the traditional cognitive-behavioral psy-chonutritional groups in improving the overall psychological state of the patients Inparticular it was more effective in improving body satisfaction self-efficacy and motivationfor change The improvement was associated with a reduction in problematic eating and so-cial behaviors The possibility of inducing a significant change in body image and its asso-ciated behaviors using a VR-based short-term therapy can improve body satisfaction in tra-ditional weight reduction programs However given that this research that does not includea follow-up study the obtained results are preliminary

511

INTRODUCTION

IN CONTRAST TO THE EFFORTS to document thephysical consequences of obesity much less

is known about the psychological correlates ofexcess weight Existing studies suggest severalbroad conclusions the most important beingthat obesity is not associated with general psy-chological problems12 This conclusion how-ever as noted by Friedman and Brownell3 is

ldquoinimical to clinical impression reports fromoverweight individuals and a consistent liter-ature showing strong cultural bias and nega-tive attitudes toward obese personsrdquo To in-vestigate this issue these authors used ameta-analysis study to examine the validity ofprevious conclusions in the field In particularthey examined mean effect sizes across groupsof studies measuring the relationship betweenobesity and a specific psychological variable

1 Applied Technology for Neuro-Psychology Laboratory Istituto Auxologico Italiano Verbania Italy2 Department of Psychology Catholic University of Sacred Heart Milan Italy

The most interesting result of that study is re-lated to body image ldquothere is somewhat con-sistent body image disturbance in the form ofbody image distortion in obese individualsrdquo3

Moreover although body image disparage-ment appears to vary across populationsldquobody image disparagement may in fact behigh in obese individualsrdquo3

It is also well known that the desire to im-prove body image is often the motivation toembark on weight reduction attempts4 How-ever one of the most intriguing lapses in re-search until the past few years is the lack ofstudies about the link between obesity andbody image5 Standard weight reduction pro-grams usually provide less therapy and havea smaller treatment effect for body image com-pared with eating behavior67 Moreover fewclinical trials with these patients have incorpo-rated body image interventions and measure-ments568 Probably this situation can be ex-plained by the common belief that the best wayto improve onersquos body image is to lose weightIndeed weight reduction is probably the mostused remedy for body image dissatisfaction Asreported by Rosen4 the most common reasonfor attempting to lose weight in women is thedesire to improve physical appearance

However recent studies have questionedthis belief dietary intervention even if accom-panied by significant weight loss may be inef-fective in reducing total body dissatisfaction6ndash9

For instance Cash et al10 found that obese sub-ject who had lost weight were similar in ap-pearance evaluation to a currently overweightsample and more distressed than a group ofnonobese subjects

Given the importance of body image satis-faction for the quality of life of obese personsthese findings argue for the potential benefitsof treatment strategies for improving appear-ance satisfaction for obese individuals regard-less of the success of their weight-managementefforts5 Unfortunately obesity researchershave not added yet body image interventionsin their programs In a recent review on the be-havioral obesity treatment literature Rosen4

didnrsquot find any study including psychologicaltechniques specifically designed to modifybody image

There are two different approaches to the

treatment of body image disturbances that areactually used from leading researchers andclinicians cognitive-behavioral and feministmethodologies 5

Cash and Rosen are the leading figure in thedevelopment of cognitive-behavioral strategiesfor the treatment of body image in eating dis-orders461112 Their approach is based on as-sessment education exposure and modifica-tion of body image The therapy both identifyand challenge appearance assumptions andmodify self-defeating body image behaviorsMoreover the approach involves the develop-ment of body image enhancement activitiesused to support relapse prevention and main-tenance of changes and the integration withweight reduction programs41112

The feminist approach tries to help womento accept and celebrate the body they have1314

However feminist therapy in general variesfrom traditional forms of therapy in number ofways Feminists believe that traditional therapyperpetuates the central role of men in the formof the doctorndashpatient relationship15 So this ap-proach place the therapist and client in equi-table roles Moreover feminist therapists usu-ally include more experiential techniques suchas guided imagery movement exercises andart and dance therapy1516 Other experientialtechniques include free-associative writing re-garding a problematic body part stage perfor-mance or psychodrama15ndash17

Even if both methods are actually used bymany therapists the treatment of body imagedisturbance is moving ldquoin the area of multi-component intervention methodsrdquo5 A recentmodel proposed by Thompson and colleagues5

underlines the complexity behind the develop-ment of body image disturbances In the pro-posed model self-esteem and depression me-diate among three formative influences (peersparents and media) and the frequency of com-parison and internalization in the developmentof the disturbance In this sense this modelsuggests ldquothat individuals low in self-esteemand high in depression are more vulnerable tofactors that produce an awareness of appear-ance pressures and thus are more likely to en-gage in social comparison and internalizationleading to body dissatisfactionrdquo5

In this study we proposed an integrated ap-

RIVA ET AL512

proach to the treatment of body image distur-bances in obesity based on an exciting newtechnology virtual reality (VR) Such choice ofwould make it possible to use the psy-chophysiological effects induced by the virtualexperience on the body schema for therapeuti-cal purposes1819

Previous studies have suggested that VR canbe effective in clinical treatment20ndash24 One of themain advantages of a virtual environment (VE)for clinical psychologists is that it can be usedin a medical facility thus avoiding the need toventure into public situations In fact in mostof the previous studies VEs were used in or-der to simulate the real world

However it seems likely that VR can be morethan a tool to provide exposure and desensiti-sation25 As noted by Glantz et al ldquoVR tech-nology may create enough capabilities to pro-foundly influence the shape of therapyrdquo26 Inparticular they expect that VR may enhancecognitive therapy

In practically all VR systems the human op-eratorrsquos normal sensorimotor loops are alteredby the presence of distortions time delays andnoise27 Such alterations that are introducedunintentionally and usually degrade perfor-mance affect body perceptions too The somes-thetic systems has a proprioceptive subsystemthat senses the bodyrsquos internal state such theposition of limbs and joints and the tension ofthe muscles and tendons Mismatches betweenthe signals from the proprioceptive system andthe external signals of a virtual environmentsalter body perceptions and can cause discom-fort or simulator sickness28 Perceptual distor-tions leading to a few seconds of instabilityand a mild sense of confusion were also ob-served in the period immediately following thevirtual experience

Such effects attributable to the reorganisa-tional and reconstructive mechanisms neces-sary to adapt the subjects to the qualitativelydistorted world of VR could be of great helpduring the course of a therapy aimed at influ-encing the way the body is experienced29 be-cause they lead to a greater awareness of theperceptual and sensorymotorial processes as-sociated with them When a particular event orstimulus violates the information present in thebody schema (as occurs during a virtual expe-

rience) the information itself becomes accessi-ble at a conscious level30 This facilitates theprocess of modification and by means of themediation of the self (which tries to integrateand maintain the consistency of the differentrepresentations of the body) also makes it pos-sible to influence body image

In previous studies a preliminary version ofthis approach (Virtual Environment for BodyImage Modification [VEBIM] for a detailed de-scription see Thompson and colleagues5) wastested on nonclinical subjects181931 and clinicalsubjects32 in uncontrolled studies The resultsindicated that the virtual experience induced inthe subjects a significantly more realistic viewof their body Starting from these assumptionsthis paper describes the characteristics and pre-liminary controlled clinical evaluation of theVirtual Reality for Eating Disorders Modifica-tion (VREDIM) a VR-based treatment to beused for body image therapy in obesity Theapproach was developed to support an in-pa-tient weight-reduction program

SUBJECTS AND METHODS

Subjects

Subjects were consecutive patients seekingtreatment at the Obesity Unit of the IstitutoAuxologico Italiano Verbania Italy

The individuals included were 28 women(mean weight 11086 6 1896 kg mean height159 6 586 cm mean BMI 4397 6 814) betweenthe ages of 18 and 45 years Potential participantswere excluded if they were taking antidepres-sant medication or any medication that might in-fluence weight if they abused drugs or alcoholif they had a current major psychiatric conditionsuch as a psychosis if there was a history ofpurging within the previous 6 months or if theirbody mass index (BMI) was below 35

The sample was randomly divided into twogroups the experimental group (mean age3214 6 873 mean weight 11250 6 1592 kgmean height 161 6 450 cm mean BMI 4350 6597) and the control group (mean age 3029 61262 mean weight 10921 6 2208 kg meanheight 157 6 661 cm mean BMI 4444 61007)

To ensure the equivalence of the two groups

VR THERAPY IN OBESITY 513

we examined the differences among them onweight BMI and all the pretherapy assess-ment measures by using one-way analysis ofvariance No significant differences betweengroups were obtained on any of the measuresand therefore it can be assumed that the twogroups were equivalent at the beginning of theintervention

Measures

Subjects were assessed by one of three inde-pendent assessment clinicians who were not in-volved in the direct clinical care of any subjectThey were two MA level chartered psycholo-gists and a PhD level chartered psychothera-pist All the subjects were assessed at pretreat-ment and upon completion of the clinical trial

The following psychometric tests were ob-tained at entry to the study

Italian version of the Minnesota Multi-phasic Personality Inventory 2 (MMPI 2)33

Italian version of the Eating Disorders In-ventory 2 (EDI 2)34

In Table 1 are reported the mean EDI 2 andMMPI 2 scores obtained by the two groups

Moreover the following psychometric testswere administered at each assessment point(entry to the study end of the treatment)

Italian version35 of the Dieterrsquos Inventoryof Eating Temptations36 The inventoryhas 30 items each presenting a situationaldescription along with a competent re-sponse The subject rates the percentage oftime he or she would behave as describedin similar situations A total score and sixsubscales are computed The subscales areResisting Temptation Positive SocialFood Choice Exercise Overeating andNegative Emotions The inventory wasoriginally designed for use with obese in-dividuals who are trying to lose weight inbehavioral weight loss programs but ac-cording to the authors it may be useful foridentifying situations most likely to trig-ger loss of control by bulimic patients36

Italian version37 of the State-Trait AnxietyInventory (STAI)38

RIVA ET AL514

TABLE 1 MEAN MMPI 2 AND EDI 2 SCORES IN THE TWO GROUPS

Experimental group Control group

MMPI-2 Score (T) EDI-2 Score MMPI-2 Score (T) EDI-2 Score

HS 6021 DT 721 HS 6010 DT 555D 5621 B 236 D 5280 B 264HY 5579 BD 1943 HY 5850 BD 1691PD 5829 I 450 PD 5520 I 409MF 4664 P 436 MF 5410 P 227PA 5486 ID 350 PA 5360 ID 300PT 5657 IA 564 PT 5530 IA 364SC 5821 MF 536 SC 5850 MF 509MA 5350 A 507 MA 5850 A 527SI 5021 IR 336 SI 4860 IR 200ANX 5871 SI 371 ANX 5530 SI 327FRS 6014 FRS 6120OBS 5329 OBS 5590DEP 5571 DEP 5390HEA 6029 HEA 6130BIZ 5671 BIZ 5650ANG 5278 ANG 4690CYN 5693 CYN 5750ASP 5214 ASP 5340TPA 5064 TPA 4820LSE 5250 LSE 5260SOD 5043 SOD 4970FAM 5243 FAM 5150WRK 5307 WRK 5200TRT 5350 TRT 5640

Italian version39 of the Assertion Inven-tory (AI)40

Italian version41 of the Weight EfficacyLife-Style Questionnaire (WELSQ)42 TheWELSQ is composed of 20 items that mea-sure the confidence of the subjects aboutbeing able to successfully resist the desireto eat using a 10-point scale ranging from0 (not confident) to 9 (very confident) Thequestionnaire was used to predict bothacute change and long-term maintenanceof weight loss across a range of ages inmen and women42

Italian version43 of the University ofRhode Island Change Assessment Scale(URICA)4445 The URICA consists of 32items designed to measure four stages ofchange in psychotherapy pre-contempla-tion contemplation action and mainte-nance Each item is scored using a five-point Likert-type format higher scoresindicate greater agreement with state-ments The URICA was originally devel-oped for use with clients in psychotherapyreporting on their problems45 Howeverthe instrument is also used for measuringreadiness to change across a wide rangeincluding smoking cessation alcohol useand cocaine use44

Italian version46 of the Body SatisfactionScale (BSS)47 The scale consists of a list of16 body parts half involving the head(above the neck) and the other half in-volving the body (below the head) Thesubjects rate their satisfaction with each ofthese body-parts on a seven-point scalethe higher the rating the more dissatisfiedthe individual A total score and three sub-scale scores are computed for head torsoand limb items46 The scale was designedfor work in health-related fields In par-ticular the scale was used by the authorsto assess body dissatisfaction in eating dis-orders to monitor changes in body satis-faction in subjects undergoing surgicaltreatment for breast cancer and to deter-mine the psychological effects of eithermaxillary or mandibular joint surgery46

Italian version48 of the Body Image Avoid-ance Questionnaire (BIAQ)49 The BIAQ is 19-item self-report questionnaire on

avoidance of situations that provoke con-cern about physical appearance suchavoidance of tight-fitting clothes socialoutings and physical intimacy In partic-ular the questionnaire measures the avoid-ance behaviors and grooming habits asso-ciated with negative body image49 Thequestionnaire uses a six-point scale to ratefrequency of behavior never rarelysometimes often usually and always Atotal score and four subscales are com-puted for clothing social activities eatingrestraint and groomingweighing

The Figure Rating Scale (FRS)50 a set ofnine male and female figures which varyin size from underweight to overweight

The Contour Drawing Rating Scale(CDRS)51 a set of nine male and femalefigures with precisely graduated incre-ments between adjacent sizes

In the last two tests subjects rate the figuresbased on the following instructional protocol(1) current size and (2) ideal size The differ-ence between the ratings is called the self-idealdiscrepancy score and is considered to repre-sent the individualrsquos dissatisfaction

The findings of Keeton et al52 support theusefulness of the self-ideal discrepancy score inthe assessment of body image as it was shownto relate to other body-image indices and otherclinically relevant measures All the scales havegood testndashretest reliability47ndash49

Treatment

For the virtual reality sessions VREDIM wasused VREDIM is an enhanced version of theoriginal VEBIM immersive virtual environ-ment previously used in different preliminarystudies on clinical32 and nonclinical sub-jects18ndash31

VREDIM is implemented on a Thunder866C virtual reality system by VRHealthcomSan Diego CA (httpwwwvrhealthcom)The Thunder 866C is a Pentium III based im-mersive VR system (866mhz 128 mega RAMgraphic engine Matrox MGA 450 32MbWRam) including a head mounted display(HMD) subsystem The HMD used is theGlasstron from Sony Inc The Glasstron uses


LCD technology (two active matrix colourLCDrsquos) displaying 180000 pixels each Sony hasdesigned its Glasstron so that literally no opti-cal adjustment at all is required aside fromtightening a two ratchet knobs to adjust for thesize of the wearerrsquos head Therersquos enough ldquoeyereliefrdquo (distance from the eye to the nearestlens) that itrsquos possible to wear glasses under theHMD

The motion tracking is provided by Inter-sense through its InterTrax 30 gyroscopic

tracker (azimuth 6180 degrees elevation 680degrees refresh rate 256 Hz latency time 38 62 msec)

We used a two-button joystick-type input de-vice to provide a easy way of motion pressingthe upper button the operator moves forwardpressing the lower button the operator movesbackwards The direction of the movement isgiven by the rotation of operatorrsquos head

The virtual environment is composed byseven 3D Healing Experiencestrade (zones) each

RIVA ET AL516

TABLE 2 THERAPEUTICAL METHODS INTEGRATED IN VREDIM

Methods Procedures

Socratic style The therapist uses different questions usually hypothetical inverse andthird-person ones to help patients synthesize information and reachconclusions on their own

Miracle question The therapist asks the patient to imagine what life would be like withoutherhis complaint Answering to this question the patient constructsherhis own solution which then guides the therapeutical process

Cognitive Countering Once a list of distorted perceptions and cognitions isdeveloped the process of countering these thoughts and beliefs begins Incountering the patient is taught to recognise the error in thinking andsubstitute more appropriate perceptions and interpretations

Alternative interpretation The patient learns to stop and consider otherinterpretations of a situation before proceeding to the decision-makingstage The patient develops a list of problem situations evoked emotionsand interpretative beliefs The therapist and patient discuss eachinterpretation and if possible identify the kind of objective data that wouldconfirm one of them as correct

Label shifting The patient first tries to identify the kinds of negative wordsshe uses to interpret situations in her life such as bad terrible obeseinferior and hateful The situations in which these labels are used are thenlisted The patient and therapist replace each emotional label with two ormore descriptive words

Deactivating the illness belief The therapist first helps the client list herbeliefs concerning eating disorders The extent to which the illness modelinfluences each belief is identified The therapist then teaches the client acognitivebehavioural approach to interpreting maladaptive behaviour andshows how bingeing purging and dieting can be understood from thisframework

Behavioral Temptation exposure with response prevention The rationale of temptationexposure with response prevention is to expose the individual tothe environmental cognitive physiological and affective stimuli that elicitabnormal behaviours and to prevent them from occurring The TERPprotocol is usually divided into three distinct phases (1) comprehensiveassessment of eliciting stimuli (2) temptation exposure extinction sessionsand (3) temptation exposure sessions with training in alternative responses

Visual motorial Awareness of the distortion The patients are instructed to develop anawareness of the distortion This is approached by a number of techniquesincluding the presentation of feedback regarding the patientrsquos self-imageVideotape feedback is also usually used Patients are videotaped engagingin a range of activities

Modification of the body image The patients are instructed to imaginethemselves as different in several aspects including size race and beinglarger or smaller in particular areas They also are asked to imaginethemselves as younger and older and to imagine what they look and feellike before and after eating as well as before and after academic-vocational and social successes and failures

one individually used by the therapist duringa 50-min session with the patient A detaileddescription of the clinical approach used in thedifferent 3D Healing Experiencestrade is reportedin Table 2

The first 3D Healing Experiencetrade is used toassess any stimuli that could elicit abnormaleating behavior In particular attention is fo-cused on the patientrsquos concerns about food eat-ing shape and weight This assessment is nor-mally part of the Temptation Exposure withResponse Prevention protocol53 At the end ofthe first 3D Healing Experiencetrade the therapistuses the miracle question a typical approachused by the solution-focused brief therapy5455

According to this approach the therapist asksthe patient to imagine what life would be likewithout her or his complaint Answering to thisquestion in writing the patient constructs heror his own solution which then guides the ther-apeutical process56 According to deShazer56

this approach is useful for helping patients es-tablish goals that can be used to verify the re-sults of the therapy Using VR to experience theeffects of the miracle the patient is more likelynot only to gain an awareness of her need todo something to create change but also to ex-perience a greater sense of personal efficacy(Figs 1 and 2)

The next 3D Healing Experiencestrade are usedto assess and modify

The symptoms of anxiety related to food expo-sure This is done by integrating differentcognitive-behavioral methods (Table 2)Countering Alternative InterpretationLabel Shifting Deactivating the Illness Be-lief and Temptation Exposure with Re-sponse Prevention19ndash53

The body experience of the subject To do thisthe virtual environment integrated thetherapeutic methods (Table 2) used by


FIG 1 Screen shoot from the VREDIM zone 2

Butter and Cash57 and Wooley and Woo-ley16 In particular in VREDIM we usedthe virtual environment in the same wayas guided imagery58 is used in the cogni-tive and visualmotorial approach

In all the sessions the therapists follow theSocratic style they use a series of questions re-lated to the contents of the virtual environmentto help clients synthesize information andreach conclusions on their own

The experimental group received seven ses-sions of VREDIM plus a low-calorie diet(1200 kcalday) and physical training (30min of walking two times a week as a mini-mum)

For the control group the inpatient treat-ment consisted of the same low-calorie diet(1200 kcalday) and physical training as theexperimental group plus psychonutritionalgroups (three times a week) aimed at helpingthe patients to understand the importance oftheir life-style and to modify unhealthy and de-structive behavior patterns The psychonutri-tional groups were based on the cognitive-be-

havior approach59 and focused on teaching pa-tients methods for improving their stress man-agement problem-solving and eating

The treatment for both group lasted approx-imately 65 weeks (mean length for the exper-imental group 67 6 03 weeks mean lengthfor control group 65 6 04 weeks)

The study received ethical approval by Eth-ical Committee of the Istituto Auxologico Ital-iano Before starting the trial the nature of thetreatment was explained to the patients and herwritten informed consent was obtained

Statistical analysis

A power calculation was made to verify thepossibility of obtaining statistically significantdifferences both between the two groups (in-dependent measures) and the pre- and post-treatment scores (repeated measures) Giventhe lowmedium statistical power due to therelatively small number of subjects and thehigh standard deviation we decided to use theexact methods a series of nonparametric sta-tistical algorithms developed by the Harvard

RIVA ET AL518


School of Public Health that enable researchersto make reliable inferences when data aresmall sparse heavily tied or unbalanced60

The exact method used to compare the meanscoresmdashboth for repeated and independent mea-suresmdashwas the marginal homogeneity test61

RESULTS

In Table 3 are reported the means and stan-dard deviations for the testsrsquo scores obtainedby the experimental group before and after thetherapy The marginal homogeneity test re-

ported significant (p 007) differences in theBSS Torso and Limbs scores in the DIETOvereating score in the STAI Total score in theAI Anxiety and Ability scores and in theWELSQ Total score

The results show that the therapy was ableimprove the overall psychological status of thepatients In particular the therapy reducedboth the level of body dissatisfaction and thelevel of anxiety in the patients Moreover it in-creased their self-efficacy This reflected also onthe eating behavior of the subjects who reducedovereating At the end of the therapy the ex-perimental group experienced a mean weight


TABLE 3 MEAN BIAQ BSS CDRS FRS DIET STAI AI WELSQ AND URICA SCORES BEFORE AND AFTER TREATMENT (ECT GROUP)

Before treatment After treatment p

BIAQTotal score 3079 2914 mdashEating Restraint 586 550 mdashClothing 1229 1179 mdashGroomingWeighing 514 500 mdashSocial Activities 750 686 mdash

BSSTotal score 5007 4636 mdashHead 1107 1164 mdashTorso 1921 1750 0056Limbs 1979 1721 0026

CDRSReal Body 836 793 mdashIdeal Body 521 514 mdashBody Satisfaction Index 168 159 mdash

FRSReal Body 650 629 mdashIdeal Body 429 421 mdashBody Satisfaction Index 156 152 mdash

DIETTotal score 4336 4138 mdashPositive Social 4520 3878 mdashOvereating 3929 3155 0065Negative Emotions 4385 4043 mdashResisting Temptations 4321 5054 mdashExercise 4214 4464 mdashFood Choice 3839 3679 mdash

STAITotal score 3964 3993 0025

AIAnxiety 8943 7571 0035Ability 8993 6893 0014

WELSQTotal score 12950 15221 0029

URICATotal score 10500 10550 mdashPrecontemplation 1264 1193 mdashContemplation 3364 3450 mdashAction 3193 3221 mdashMaintenance 2679 2686 mdash

reduction of 1133 kg No subjects experiencedsimulation sickness

In Table 4 are reported the means and stan-dard deviations for the testsrsquo scores obtainedby the control group before and after the ther-apy The only significant changes were in theDIET Exercise score and in the AI Ability andAnxiety score However the reduction in theanxiety level was not confirmed by the STAIscore The mean weight reduction for the con-trol group was 758 kg

Then we compared the differences preposttherapy in the mean BIAQ BSS CDRS FRSDIET STAI AI WELSQ and URICA scores be-

tween the two groups (Table 5) The statisticaltests showed significantly (p 007) higher dif-ferences in the ECT group for the followingscales BSS Total score DIET Positive Socialscore AI Ability and Anxiety score No sig-nificant differences were found in the self-effi-cacy and motivation for changes scores How-ever at least for the WELSQ Total score and forthe URICA Maintenance score the experimen-tal group showed a marked difference in rela-tion to the control group

These data showed that experimental wasmore effective than the traditional low-caloriediet plus cognitive-behavioral nutritional

RIVA ET AL520

TABLE 4 MEAN BIAQ BSS CDRS FRS DIET STAI AI WELSQ AND

URICA SCORES BEFORE AND AFTER TREATMENT (CONTROL GROUP)



BSSTotal score 4250 4186 mdashHead 843 871 mdashTorso 1693 1657 mdashLimbs 1714 1657 mdash



DIETTotal score 4076 4350 mdashPositive Social 3765 4071 mdashOvereating 4107 4143 mdashNegative Emotions 4129 4400 mdashResisting Temptations 4054 4786 mdashExercise 4304 4768 0035Food Choice 3482 3357 mdash

STAITotal score 3486 3643 mdash


WELSQTotal score 14200 14307 mdash


groups in reducing body dissatisfaction andthe anxiety level of the patients Moreover ex-perimental patients experienced an highereven if not significant weight reduction 1133versus 758 kg

DISCUSSION

Although there is much potential for the useof immersive virtual reality environments inclinical psychology some problems have lim-ited their application in this field Some users

have experienced side effects during and afterexposure to virtual reality environments62 Thesymptoms experienced by these users are sim-ilar to those which have been reported duringand after exposures to simulators with widefield-of-view displays63 These side effects havebeen collectively referred to as ldquosimulator sick-nessrdquo64 and are characterized by three classesof symptoms ocular problems such as eye-strain blurred vision and fatigue disorienta-tion and balance disturbances and nausea Ex-posure duration of less than 10 min toimmersive virtual reality environments has


TABLE 5 MEAN DIFFERENCES IN THE BIAQ BSS CDRS FRS DIET STAI AIWELSQ AND URICA SCORES (BEFORE AND AFTER TREATMENT)

ECT group Control group p


BSSTotal score 371 064 0056Head 2057 2028 mdashTorso 171 036 mdashLimbs 257 057 mdash



DIETTotal score 198 2274 mdashPositive Social 643 2306 0031Overeating 774 2036 mdashNegative Emotions 343 2271 mdashResisting Temptations 2732 2732 mdashExercise 2250 2464 mdashFood Choice 161 125 mdash





been shown to result in significant incidencesof nausea disorientation and ocular prob-lems65

The first interesting result of this study is thelack of side effects and simulation sickness inour samples after the experience in the virtualenvironment confirming the possibility of us-ing VREDIM for body image treatment

This result is even more interesting given thesample used In fact females tend to be moresusceptible to motion sickness than males66

Next our experience with the use ofVREDIM suggests that this treatment was moreeffective than the traditional low-calorie dietplus cognitive-behavioral nutritional groups inimproving body satisfaction and in reducingovereating and the anxiety level of the patientsFinally VREDIM induced an improved level ofself-efficacy in the patients associated to anhigher motivation for change

Its multidisciplinary approach seems to besuitable to the peculiar characteristics of bodyimage disturbances in obesity In particularVREDIM was effective in dealing with two keyfeatures of these disturbances not always ade-quately addressed by cognitive-behavioraltherapy body experience disturbances andself-efficacy

First VREDIM allows the integration of dif-ferent methods (cognitive behavioral and vi-sual-motorial) commonly used in the treatmentof body experience disturbances within a vir-tual environment29 In particular VREDIM in-tegrates the cognitive methods of CounteringAlternative Interpretation Label Shifting andDeactivating the behavioural method of Temp-tation Exposure with Response Prevention andthe visual motorial approach (Table 2) usingthe virtual environment in the same way as im-ages in the well-known method of guided im-agery58 According to this method the thera-pist after introducing a selected imageencourages the patient to associate to it in pic-tures rather than in word and to give a de-tailed description of them

A choice of this type makes it possible bothto evoke latent feelings and to use the psy-chophysiological effects provoked by the ex-perience for therapeutic purposes29ndash31 In prac-tically all VR systems the human operatorrsquosnormal sensorimotor loops are altered by the

presence of distortions time delays andnoise27 Such effects attributable to the reor-ganisational and reconstructive mechanismsnecessary to adapt the subjects to the qualita-tively distorted world of VR could be of greathelp during the course of a therapy aimed atinfluencing the way the body is experienced29

because they lead to a greater awareness of theperceptual and sensorymotorial processes as-sociated with them

As noted by Glantz26 one of the main rea-sons it is so difficult to modify patientsrsquo atti-tudes towards their body is that change oftenrequires a prior stepmdashrecognizing the distinc-tion between an assumption and a perceptionldquoUntil revealed to be fallacious assumptionsconstitute the world they seem like percep-tions and as long as they do they are resistantto change We anticipate using VR to help peo-ple in distress make the distinction between as-sumptions and perceptionsrdquo

This is particularly true for body experienceWhen a particular event or stimulus violatesthe information present in the body schema (asoccurs during a virtual experience) the infor-mation itself becomes accessible at a consciouslevel30 This facilitates the process of modifica-tion and by means of the mediation of the self(which tries to integrate and maintain the con-sistency of the different representations of thebody) also makes it possible to influence bodyimage

Second using VREDIM therapists can im-prove the self-efficacy and motivation forchange in their patients According to Pro-chaska and DiClemente67 it is possible to iden-tify five stages of change that people face in al-tering problematic behaviour These stages canbe considered predictable and stable sub-processes within the therapeutic process Thefive stages are precontemplation contempla-tion determination action and mainte-nancerelapse

In particular a stage of change is critical forthe therapy of body image disturbances con-templation Contemplation is a paradoxicalstage of change since the patient is open to thepossibility of change but is stopped by am-bivalence The characteristic style of the con-templator is ldquoyes but ldquo Two key techniquesare usually in facilitating a shift from the con-

RIVA ET AL522

templation stage to the determination stage ofchange55 The first technique is the use of themiracle question a typical approach used bythe solution-focused brief therapy5455 The mir-acle question is used to help the client identifyhow her life would be different if her eatingdisorder were miraculously gone The secondtechnique is the search for exceptions situa-tions in which the patient has been able to man-age the problematic eating behaviors more suc-cessfully

Using the VR sessions to experience the ef-fects of the miracle and the successful situa-tions the patient is more likely not only to gainan awareness of her need to do something tocreate change but also to experience a greatersense of personal efficacy

According to Vitousek et al68 another well-suited approach to face denial and to supportself-efficacy is the Socratic method In thismethod the therapist uses different questionsto help patients synthesize information andreach conclusions on their own Usually thetherapist poses hypothetical inverse andthird-person questions68 for example wouldthe significance of body shape change if theobese patient became stranded on a desert is-land Would a patient swallow a magic potionthat could remove her fear of normal weight

VR is well suited to this approach for its abil-ity of immersing the patient in a life-like situ-ation that she or he is forced to face In fact thekey characteristic of VR is the high level of con-trol of the interaction with the environmentwithout the constrains usually found in reallife VR is highly flexible and programmable Itenables the therapist to present a wide varietyof controlled stimuli and to measure and mon-itor a wide variety of responses made by theuser69 Both the synthetic environment itselfand the manner in which this environment ismodified by the userrsquos responses can be tai-lored to the needs of each client andor thera-peutic application Moreover VR is highly im-mersive and can cause the participant to feelldquopresentrdquo in the virtual rather than real envi-ronment It is also possible for the psychologistto follow the user into the synthesised world

The advantages of a VR-based Socraticmethod are clear It minimizes distortion inself-report since there is no script for con-

forming clients to parrot or oppositional clientsto reject a typical behavior of anorexic indi-viduals

Moreover it circumvents power strugglesbecause the therapist can be invisible to the pa-tient and presents no direct arguments to op-pose Finally evidence is more convincing andconclusions better remembered because theyare onersquos own As noted by Miller and Roll-nick70 people are ldquomore persuaded by whatthey hear themselves say than by what otherpeople tell themrdquo

As we have seen before change often re-quires the recognition of the distinction be-tween an assumption and a perception25 Byusing VR the therapist can actually demon-strate that what looks like a perception doesnrsquotreally exist This gets across the idea that a per-son can have a false perception Once this hasbeen understood individual maladaptive as-sumptions can then be challenged more easily

Usually the traditional body-image treat-ment involves a cognitivebehavioural or afeminist therapy that require many sessionsThe possibility of inducing a significant changein body image and its associated behaviors us-ing a VR-based short-term therapy (seven bi-weekly sessions) can be useful to improve thebody satisfaction in traditional weight reduc-tion programs

As such VREDIM can be considered as a mul-tifactorial treatment package aimed at breakingthrough the ldquoresistancerdquo to treatment in clinicalsubjects7172 Nevertheless an alteration of thebody image toward a more realistic ldquoproportionrdquomight also be decisive for the long-term outcomeof the weight reduction therapy

Of course given the nature of this researchthat does not include a follow-up study the ob-tained results are preliminary only Moreoverthe cost of the VR system used in the study isabout $7000 This price even if affordable fordepartments or hospitals is still high for a sin-gle therapist especially without a clearcostbenefit ratio From a clinical view pointthe main issues that we have to address in asystematic way in the future are

Further testing of ECT in controlled clini-cal trials by comparing it with different ap-proaches (eg interpersonal therapy)


A follow-up study to check the long-termefficacy of the therapy

We have already planned an extention of thestudy as a part of the Telemedicine andPortable Virtual Environments for Clinical Psy-chology European Communityndashfunded re-search project (IST-2000-25323)

ACKNOWLEDGMENTS

The present work was supported by theCommission of the European Communities(CEC) in particular by the IST programme(Project VEPSY Updated IST-2000-25323) Moreover I have benefited from the supportand contributions of many colleagues includ-ing Eugenia Borgomainerio StefaniaFontaneto Stefano Marchi Letizia Petroni Sil-via Rinaldi and Francesco Vincelli

REFERENCES

1 Stunkard AJ amp Wadden TA (1992) Psychologicalaspects of severe obesity American Journal of ClinicalNutrition 55524Sndash532S

2 Wadden TA amp Stunkard AJ (1985) Social and psy-chological consequences of obesity Annals of InternalMedicine 1031062ndash1067

3 Friedman MA amp Brownell KE (1995) Psycholog-ical correlates of obesity moving to the next researchgeneration Psychological Bulletin 1173ndash20

4 Rosen JC (1996) Improving body image in obesityIn JK Thompson (Ed) Body image eating disorders andobesity (pp 425ndash440) Washington DC APAmdashAmer-ican Psychological Association

5 Thompson JK Heinberg LJ Altabe M amp Tant-leff-Dunn S (1999) Exacting beauty theory assessmentand treatment of body image disturbance WashingtonDC American Psychological Association

6 Rosen JC (1996) Body image assessment and treat-ment in controlled studies of eating disorders Inter-national Journal of Eating Disorders 19341ndash343

7 Rosen CJ amp Ramirez E (1998) Comparison of eat-ing disorders and body dysmorphic disorders onbody image and psychological adjustment Journal ofPsychosomatic Research 44441ndash449

8 Cash TF amp Grant JR (1995) The cognitive behav-ioral treatment of body-image disturbances inanorexia nervosa and bulimia nervosa In V Van Has-selt amp M Hersen (Eds) Sourcebook of psychologicaltreatment manuals for adults (pp 567ndash614) New YorkPlenum Press

9 Rosen JC Orosan P amp Reiter J (1995) Cognitive

behavior therapy for negative body image in obesewomen Behavior Therapy 2625ndash42

10 Cash TF Counts B amp Huffine CE (1990) Currentand vestigial effects of overweight among womenfear of fat attitudinal body image and eating behav-iors Journal of Psychopathology and Behavioral Assess-ment 12157ndash167

11 Cash TF (1995) What do you see when you look in themirror Helping yourself to a positive body image NewYork Bantam Books

12 Cash TF (1997) The body image workbook an eight-stepprogram for learning to like your looks Oakland CANew Harbinger

13 Bergner M Remer P amp Whetsell C (1995) Trans-forming womenrsquos body image a feminist counselingapproach Women and Therapy 425ndash38

14 Dionne M Davis C Fox J amp Gurevich M (1995)Feminist ideology as a predictor of body dissatisfac-tion in women Sex Roles 33277ndash287

15 Wooley SC (1995) Feminist influences on the treat-ment of eating disorders In KD Brownell amp CGFairburn (Eds) Eating disorders and obesity a compre-hensive handbook (pp 294ndash298) New York Guilford

16 Wooley SC amp Wooley OW (1985) Intensive out-patient and residential treatment for bulimia In DMGarner amp PE Garfinkel (Eds) Handbook of psy-chotherapy for anorexia and bulimia (pp 120ndash132) NewYork Guilford Press

17 Kearney-Cooke A amp Striegel-Moore R (1994)Treatment of childhood sexual abuse in anorexia ner-vosa and bulimia nervosa a feminist psychodynamicapproach International Journal of Eating Disorders15305ndash319

18 Riva G (1998) Modifications of body image inducedby virtual reality Perceptual and Motor Skills86163ndash170

19 Riva G (1998) Virtual reality vs virtual body theuse of virtual environments in the treatment of bodyexperience disturbances CyberPsychology amp Behavior1129ndash137

20 Hodges LF Bolter J Mynatt E Ribarsky W ampVan Teylingen R (1993) Virtual environments re-search at the Georgia Tech GVU Center Presence Tele-operators and Virtual Environments 3234ndash243

21 Hodges LF Rothbaum BO Kooper R OpdykeD Meyer T North M de Graaff JJ amp WillifordJ (1995) Virtual environments for treating the fear ofheights IEEE Computer 2827ndash34

22 Hodges LF Rothbaum BO Watson B KesslerGD amp Opdyke D (1996) A virtual airplane for fear offlying therapy Presented at the Virtual Reality AnnualInternational SymposiummdashVRAIS rsquo96 Los AlamitosCA

23 North MM North SM amp Coble JR (1996) Effec-tiveness of virtual environment desensitization in thetreatment of agoraphobia Presence Teleoperators andVirtual Environments 5127ndash132

24 North MM North SM amp Coble JR (1997) Vir-tual reality therapy for fear of flying American Jour-nal of Psychiatry 154130

RIVA ET AL524

25 Glantz K Durlach NI Barnett RC amp Aviles WA(1996) Virtual reality (VR) for psychotherapy fromthe physical to the social environment Psychotherapy 33464ndash473

26 Glantz K Durlach NI Barnett RC amp Aviles WA(1997) Virtual reality (VR) and psychotherapy op-portunities and challenges Presence Teleoperators andVirtual Environments 687ndash105

27 Riva G (Ed) (1997) Virtual reality in neuro-psycho-physiology cognitive clinical and methodological issues inassessment and rehabilitation Amsterdam IOS Press

28 Sadowsky J amp Massof RW (1994) Sensory engi-neering the science of synthetic environments JohnHopkins APL Technical Digest 1599ndash109

29 Riva G amp Melis L (1997) Virtual reality for thetreatment of body image disturbances In G Riva(Ed) Virtual reality in neuro-psycho-physiology cogni-tive clinical and methodological issues in assessment andrehabilitation (pp 95ndash111) Amsterdam IOS Press

30 Baars BJ (1988) A cognitive theory of consciousnessNew York Cambridge University Press

31 Riva G (1997) The virtual environment for body-im-age modification (VEBIM) development and prelim-inary evaluation Presence Teleoperators and VirtualEnvironments 6106ndash117

32 Riva G Bacchetta M Baruffi M Cirillo G amp Moli-nari E (2000) Virtual reality environment for bodyimage modification a multidimensional therapy forthe treatment of body image in obesity and relatedpathologies CyberPsychology amp Behavior 3421ndash431

33 Butcher JN (1996) MMPI-2 Florence Italy Orga-nizzazioni Speciali

34 Garner DM (1995) EDI 2 Eating disorders inven-toryndash2 Florence Italy Organizzazioni Speciali

35 Riva G (1998) An examination of the reliability andvalidity of scores on the Italian version of the DieterrsquosInventory of Eating Temptations Perceptual and Mo-tor Skills 86435ndash439

36 Schlundt DG amp Zimering RT (1988) The DieterrsquosInventory of Eating Temptations a measure of weightcontrol competence Addictive Behavior 13151ndash164

37 Lazzari R amp Pancheri P (1980) Questionario di val-utazione dellrsquoansia di stato e di tratto [State-Trait AnxietyInventory] Firenze Italy Organizzazioni Speciali

38 Spielberger CD Gorsuch RL amp Lushene RE (1970)The State-Trait Anxiety Inventory Test Manual for FormX Palo Alto CA Consulting Psychologist Press

39 Rolandi A amp Bauer B (1981) La scala di Gambrille Richey per lrsquoassessment del comportamento as-sertivo [Gambrill and Richey inventory for the as-sessment of assertion] Giornale Italiano di Analisi eModificazione del Comportamento 2133ndash138

40 Gambrill ED amp Richey CA (1975) An assertion in-ventory for use in assessment and research BehaviorTherapy 6550ndash561

41 Riva G Bacchetta M amp Baruffi M (1999) Vali-dazione Italiana del Weight Efficacy Life Style Ques-tionnaire [Italian Validation of the Weight EfficacyLife Style Questionnaire] Medicina Psicosomatica (inpress)

42 Clark MM Abrams DB Niaura RS Eaton CAamp Rossi J (1991) Self-efficacy in weight management Journal of Consulting and Clinical Psychology 59739ndash744

43 Riva G Bacchetta M amp Baruffi M (1999) Italianvalidation of the University of Rhode Island ChangeAssessment Scale Acta Medica Auxologica (in press)

44 McConnaughy EA DiClemente CC ProchaskaJG amp Velicer WF (1989) Stages of change in psy-chotherapy a follow-up report Psychotherapy TheoryResearch and Practice 26494ndash503

45 McConnaughy EA Prochaska JG amp Velicer WF(1983) Stages of change in psychotherapy measure-ment and sample profiles Psychotherapy Theory Re-search and Practice 20368ndash375

46 Riva G amp Molinari E (1998) Factor structure of theItalian version of the Body Satisfaction Scale a mul-tisample analysis Perceptual and Motor Skills 861083ndash1088

47 Slade PD Dewey ME Newton T Brodie D ampKiemle G (1990) Development of the Body Satisfac-tion Scale (BSS) Psychology and Health 4213ndash226

48 Riva G amp Molinari E (1998) Replicated factor anal-ysis of the Italian version of the Body Image Avoid-ance Questionnaire Perceptual and Motor Skills 861071ndash1074

49 Rosen JC Srebnik D Saltzberg E amp Wendt S(1991) Development of a Body Image QuestionnairePsychological Assessment 132ndash37

50 Thompson JK amp Altabe MN (1991) Psychometricqualities of the Figure Rating Scale International Jour-nal of Eating Disorders 10615ndash619

51 Thompson MA amp Gray JJ (1995) Developmentand validation of a new body-image assessment scaleJournal of Personality Assessment 2258ndash269

52 Keeton WP Cash TF amp Brown TA (1990) Bodyimage or body images comparative multidimen-sional assessment among college students Journal ofPersonality Assessment 54213ndash230

53 Schlundt DG amp Johnson WG (1990) Eating disor-ders assessment and treatment Needham Heights MAAllyn and Bacon

54 deShazer S (1985) Keys to solutions in brief therapyNew York WW Norton

55 McFarland B (1995) Brief therapy and eating disordersSan Francisco Jossey-Bass Publishers

56 deShazer S (1988) Clues investigating solutions in brieftherapy New York WW Norton

57 Butters JW amp Cash TF (1987) Cognitive-behav-ioral treatment of womenrsquos body image satisfactiona controlled outcome-study Journal of Consulting andClinical Psychology 55889ndash897

58 Leuner H (1969) Guided affective imagery amethod of intensive psychotherapy American Journalof Psychotherapy 234ndash21

59 Telch CF Agras WS Rossiter EM Wilfley D ampKenardy J (1990) Group cognitive-behavioral ther-apy for the nonpurging bulimic an initial evaluationJournal of Consulting and Clinical Psychology 58629ndash635


60 SPSS I (1995) SPSS user manual exact tests ChicagoSPSS Inc

61 Agresti A (1990) Categorial data analysis New YorkJohn Wiley and Sons

62 Lackner JR (1992) Multimodal and motor influenceson orientation implications for adapting to weight-less and virtual environments Journal of Vestibular Re-search 2307ndash322

63 Kennedy RS Hettinger LJ Harm DL Ordy JMamp Dunlap WP (1996) Psychophysical scaling of cir-cular vection (CV) produced by optokinetic (OKN)motion individual differences and effects of practiceJournal of Vestibular Research 6331ndash341

64 Kennedy RS amp Stanney KM (1996) Postural in-stability induced by virtual reality exposure devel-opment of a certification protocol International Jour-nal of Human Computer Interaction 825ndash47

65 Regan EC amp Ramsey AD (1996) The efficacy ofhyoscine hydrobromide in reducing side-effects in-duced during immersion in virtual reality AviationSpace and Environmental Medicine 67222ndash226

66 Griffin MJ (1990) Handbook of human vibration Lon-don Academic Press

67 Prochaska JO amp DiClemente CC (1983) Stagesand processes of self-change in smoking toward anintegrative model of change Journal of Consulting Clin-ical Psychology 5390ndash395

68 Vitousek KB Watson S amp Wilson GT (1998) En-hancing motivation for change in treatment-resistanteating disorders Clinical Psychology Review 18391ndash420

69 Riva G (1998) Virtual reality in psychological as-sessment The Body Image Virtual Reality Scale Cy-berPsychology amp Behavior 137ndash44

70 Miller WR amp Rollnick S (1991) Motivational inter-viewing preparing people to change addictive behaviorNew York Guilford Press

71 Vandereycken W Probst M amp Meermann R(1988) An experimental video-confrontation proce-dure as a therapeutic technique and a research tool inthe treatment of eating disorders In KM Pirke WVandereycken amp D Ploog (Eds) The psychobiology ofbulimia nervosa (pp 120ndash126) Heidelberg Springer-Verlag

72 Vandereycken W (1990) The relevance of body-im-age disturbances for the treatment of bulimia In MMFichter (Ed) Bulimia nervosa Basic research diagnosisand treatment (pp 136ndash142) New York Wiley

Address reprint requests toDr Giuseppe Riva

Applied Technology for Neuro-PsychologyLaboratory

Istituto Auxologico ItalianoPO Box 1

28900 Verbania Italy

E-mail auxopsylabauxologicoit

RIVA ET AL526

The most interesting result of that study is re-lated to body image ldquothere is somewhat con-sistent body image disturbance in the form ofbody image distortion in obese individualsrdquo3

Moreover although body image disparage-ment appears to vary across populationsldquobody image disparagement may in fact behigh in obese individualsrdquo3

It is also well known that the desire to im-prove body image is often the motivation toembark on weight reduction attempts4 How-ever one of the most intriguing lapses in re-search until the past few years is the lack ofstudies about the link between obesity andbody image5 Standard weight reduction pro-grams usually provide less therapy and havea smaller treatment effect for body image com-pared with eating behavior67 Moreover fewclinical trials with these patients have incorpo-rated body image interventions and measure-ments568 Probably this situation can be ex-plained by the common belief that the best wayto improve onersquos body image is to lose weightIndeed weight reduction is probably the mostused remedy for body image dissatisfaction Asreported by Rosen4 the most common reasonfor attempting to lose weight in women is thedesire to improve physical appearance

However recent studies have questionedthis belief dietary intervention even if accom-panied by significant weight loss may be inef-fective in reducing total body dissatisfaction6ndash9

For instance Cash et al10 found that obese sub-ject who had lost weight were similar in ap-pearance evaluation to a currently overweightsample and more distressed than a group ofnonobese subjects

Given the importance of body image satis-faction for the quality of life of obese personsthese findings argue for the potential benefitsof treatment strategies for improving appear-ance satisfaction for obese individuals regard-less of the success of their weight-managementefforts5 Unfortunately obesity researchershave not added yet body image interventionsin their programs In a recent review on the be-havioral obesity treatment literature Rosen4

didnrsquot find any study including psychologicaltechniques specifically designed to modifybody image

There are two different approaches to the

treatment of body image disturbances that areactually used from leading researchers andclinicians cognitive-behavioral and feministmethodologies 5

Cash and Rosen are the leading figure in thedevelopment of cognitive-behavioral strategiesfor the treatment of body image in eating dis-orders461112 Their approach is based on as-sessment education exposure and modifica-tion of body image The therapy both identifyand challenge appearance assumptions andmodify self-defeating body image behaviorsMoreover the approach involves the develop-ment of body image enhancement activitiesused to support relapse prevention and main-tenance of changes and the integration withweight reduction programs41112

The feminist approach tries to help womento accept and celebrate the body they have1314

However feminist therapy in general variesfrom traditional forms of therapy in number ofways Feminists believe that traditional therapyperpetuates the central role of men in the formof the doctorndashpatient relationship15 So this ap-proach place the therapist and client in equi-table roles Moreover feminist therapists usu-ally include more experiential techniques suchas guided imagery movement exercises andart and dance therapy1516 Other experientialtechniques include free-associative writing re-garding a problematic body part stage perfor-mance or psychodrama15ndash17

Even if both methods are actually used bymany therapists the treatment of body imagedisturbance is moving ldquoin the area of multi-component intervention methodsrdquo5 A recentmodel proposed by Thompson and colleagues5

underlines the complexity behind the develop-ment of body image disturbances In the pro-posed model self-esteem and depression me-diate among three formative influences (peersparents and media) and the frequency of com-parison and internalization in the developmentof the disturbance In this sense this modelsuggests ldquothat individuals low in self-esteemand high in depression are more vulnerable tofactors that produce an awareness of appear-ance pressures and thus are more likely to en-gage in social comparison and internalizationleading to body dissatisfactionrdquo5

In this study we proposed an integrated ap-

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virtual reality-based multidimensional therapy -

Documents