The Use of Virtual Reality in Psychiatry and Psychology

Virtual Reality Exposure Therapy

Traditional Exposure Therapy

• exposure of the subject to anxiety producing stimuli while allowing the anxiety to attenuate
• stimuli are generated through a variety of modalities:
• imagined (subject generates stimulus via imagnation)
• in vivo (subject is exposed to real situations)
• an example:
• acrophobia (the fear of heights) - marked anxiety upon exposure to heights, avoidance of heights, and interference in normal every day activities as a result of the fear
• a therapist using an in vivo graded exposure approach to treating acrophobia would arrange therapy sessions in which the patient goes through a process of exposure and adjustment to anxiety causing situations (habituation)
• patients begin with less threatening situations and gradually work their way up a hierarchy of more anxiety producing situations (e.g. therapy sessions might begin by looking through a third floor window with the therapist present, in subsequent sessions the patient might move up to a window on the tenth floor)
• other common locations for in vivo therapy could be outside stairways, balconies, bridges, and elevators

Virtual Reality Exposure Therapy

• exposure of the patient to a virtual environment containing the feared stimulus in place of taking the patient into a real environment or having the patient imagine the stimulus

• advantages of VR Exposure Therapy:
1. Cost Effective
• many stimuli for exposure are difficult to arrange or control, and when exposure is conducted outside of the therapist's office, it becomes more expensive in terms of time and money
• the ability to conduct exposures of virtual airplanes for flying phobics or virtual highways for driving phobics, for example, without leaving the therapist's office would make better treatment available to more sufferers at a lower cost
2. Effective Therapy
• VRE Therapy can provide stimuli for patients who can not imagine well
• unlike therapist assisted in vivo techniques, VRE therapy will be performed within the confines of a room, thus avoiding public embarrassment and violation of patient confidentiality.
• virtual environments have the added advantage of giving the therapist greater control over multiple stimulus parameters as well as the ability to isolate the particular parameters that are most essential in generating the phobic response
• VRE therapy could also be used as an intermediate step in preparing patients for maintenance therapy involving self-directed in vivo exposure.
3. Patient Acceptance
• according to people's response after extensive cover of topic by the press (CBS News, National Public Radio, Associated Press, BBC, New York Times, etc.), they would be much more willing to undergo exposure therapy in a virtual environment than in a real physical environment
4. Telemedicine Applications
• virtual reality exposure therapy is appropriate for networked delivery of clinical psychology and psychiatry services to remote locations
• since the patient is receiving therapy within a virtual environment, the clinician conducting the therapy session could be present physically or participate via computer networks from a remote location

Related links:

•  Virtual Reality Exposure Therapy at Georgia Tech, USA

Post-traumatic Stress Disorder Treatment

Virtual Vietnam:

• created to treat Vietnam veterans suffering from post traumatic stress disorder
• currently under evaluation by psychotherapists at the Atlanta Veterans Administration hospital
• users wear a virtual reality helmet and ride (including landing and taking off from an open field) a combat helicopter over various Vietnam terrain like rice paddies, river, jungle

• additionally users can walk through a hostile helicopter landing zone

• immersion of a person in a synthetic world incorporates audio effects
• effects utilize Hollywood audio production libraries to create a high intensity soundscape highlighted by powerful bass explosions and three dimensional gunfire effects
• while riding in the Huey helicopter, the user is seated in a special chair (Thunderseat) with a 100 watt subwoofer speaker incorporated into its base providing helicopter vibration and explosion shock effects

Related links:

• The Virtual Vietnam at Georgia Tech, USA
• Thunderseat description

Fear of Flying Phobia Treatment

• PC based virtual reality system for treating individuals suffering from a fear of flying
• patients wear a head mounted display and are immersed into a virtual 3-D world
• virtual airplane
• duplicated a passenger seated by the window in a standard commercial jet
• during virtual exposure subject goes through various scenarios:
• sitting in the plane with engines off or on
• taxiing the runway
• smooth or rough takeoff
• smooth or turbulent flight
• close pass over the airport
• smooth or rough landing
• while patients took virtual trip, a counselor talked to them, helping them overcome their fears
• low cost system is currently being sold and marketed to practicing psychotherapists

Related links:

• The Virtual airplane at Georgia Tech, USA
• Virtual Flying at New Media News
• The Institute for Psychology of Air Travel in Boston, USA

Arachnophobia Treatment

• exposure desensitization treatment
• proved effective for a wide range of phobias, including spider phobia
• gradually and systematically exposing the phobic person to the feared object or situation, and calming them little by little their fear decreases and they become more comfortable with spiders
• advantage of VR over other phobia treatment techniques:
• greater freedom of the patient or therapist to control the feared stimulus
• unlike a real spider, virtual spiders obey computer commands, can be  placed in various positions and orientations by patient or therapist, and can be touched without danger
• VR allows the experimenter to control how frightening the spiders appear

• VR therapy at the HITLab:
• patient is sometimes encouraged to pick up the virtual spider web with her cyberhand and place it in orientations that were most anxiety provoking
• experimenter controls the spider's movements
• by physically moving a position sensor
• by entering new position coordinates into the keyboard
• by using pre-programmed spider behaviors (unexpected jumps, etc.)
• spiders were placed in a cupboard with a web, were made to jump unpredictably upon being touched, climbed or dropped in incremental jumps between the ceiling and the virtual kitchen floor
• spiders were touched, held and manipulated by the subject
• patient could pull the spiders legs off
• a large brown virtual spider with photograph quality texture-mapped fur, and a smaller black spider and an associated 3-D web were employed

• tactile augmentation
• to maximize the level of presence achieved, and to maximize the transfer of training from VR to the real world
• the toy spider
1. a palm sized replica of a Guyana bird eating tarantula with fur from the tail of a stuffed toy dog
2. a form of mixed reality, subjects feel position-tracked real objects (with their hand) that correspond to virtual objects they see in the immersive virtual environment
3. attached to a polhemus position sensor, so that any movement of the toy spider caused a corresponding movement of the virtual spider
• during the course of therapy the patient could also squash the virtual spiders with a mixed reality ping pong paddle
• results
• dramatic reduction in the patient's fear

Related links:

• Desensitization in Virtual Environments at the University of Washington, USA
• HITL (Human Interface Technology Lab) at the University of Washington, USA
• Spiders at Scientific American Frontiers

Acrophobia Treatment

Acrophobia treatment at Georgia Tech

• fear of height treatment via Virtual Reality exposure to three virtual height situations:
1. elevator
1. series of bridges
1. series of balconies
• subject started in the least treatening situation and then progressed under his own control
• they stop at the floor where they feel unable to continue
• results
• shown to be very effective in reducing acrophobic subjects anxiety and avoidance of heights, and in improving attitudes toward heights.

Acrophobia treatment at the University of Michigan

• a realistic simulation of the elevator
• requirements of emotional and architectural realism
• emotional realism was necessary to evoke the fear of heights in acrophobes
• architectural realism for controlled studies (comparing it to the real environment)

• virtual environment is realised by CAVE
• a projection device where a person stands in a 10x10x10 foot room made of projection screens
• subject wears shutter glasses to create a three dimensional image, and a computer calculates what should be on each wall, based on the virtual model and the location and viewpoint of the subject

Related links:

• Phobia treatment in VR at the Delft University of Technology, Netherland
• Treatment of acrophobia at the University of Michigan, USA
• Acrophobia Virtual Reality  Project Report at the University of Michigan, USA

Virtual Reality Treatment for Burn Pain

• VR is used as non-pharmacological analgesia to help get burn pain down to a more manageable level during woundcare (i.e., distraction) by patient immersion into virtual world

 
• SpiderWorld
• originally designed to treat spider phobics, but is also quite distracting for burn victims
• patients go into a virtual kitchen where they can open drawers and cabinets, pick up teapots, and physically grope the plump furry body of a Guyana bird-eating tarantula
• SnowWorld
• created by Paradigm Simulations specifically for burn victims
• patients fly through an icy canyon with a river and frigid waterfall
• patients shoot snowballs at snowmen and igloos (with animated impacts)
• since patients often report reliving their original burn experience during wound care, SnowWorld was designed to help put out the fire

Why VR reduces pain:

• pain perception is largely psychological
• same incoming pain signal can be interpreted as painful or not, depending on what the patient is thinking
• pain requires conscious attention
• essence of VR is the illusion of going inside the computer generated environment
• being drawn into another world drains a lot of attention resources, leaving less attention available to process pain signals
• rather than having pain as the focus of their attention, for many patients in VR, the wound care becomes more of an annoyance, distracting them from their primary goal of exploring the virtual world

Related links:

• VR Treatment for Burn Pain at the University of Washington, USA
• Hospitals try VR techniques for pain management, CNN Interactive, May 21, 1999

Virtual Reality in Eating Disorders

Virtual Environment for Body Image Modification (VEBIM):

• integrates the two methods commonly used in the treatment of body experience disturbances within a virtual environment
1. cognitive-behavioural
1. influencing patients' feelings of dissatisfaction with different parts of their bodies by means of individual interviews, relaxation and imaginal techniques
2. visual-motorial
1. use of video recordings of particular gestures and movements with the aim of influencing the level of bodily awareness

• uses Thunder 166/C virtual reality system:
• Pentium based immersive VR system (166mhz, 32 mega RAM, graphic engine: Matrox Millenium 4Mb WRam)
• HMD subsystem
• two-button joystick-type motion input device
• The virtual environment VEBIM
• method of guided imagery - therapist, after introducing a selected image, encourages the patient to associate to it in pictures, rather than in word, and to give a detailed description of them
• 6-zone virtual environment developed using the Sense 8 World Toolkit for Windows consisting of two parts:
• zones 1-2
• designed both to give the subject a minimum level of skill in perceiving, moving through and manipulating objects in VR, and to focus attention on eating and food choice

• zones 3-4-5-6
• designed to modify the body experience of the subject

Related links:

• Virtual Body Project at Applied Technology for Psychology Laboratory - ATP Lab, Centro Auxologico Italiano

Virtual Reality Sand Box

• Sand Play Technique (Sandspiel):
• often used in psychological treatments, especially for diagnosis of the people with psychological and psychiatrical sicknesses such as autism and neurosis
• as these people generally dislike interacting with medical personnel, they are asked to play with a sand box and various figures to create the landscapes
• landscapes are then carefully analyzed by doctors and therapists to identify the patients' psychological and psychiatrical problems
• Virtual Sand Box system:
• users create virtual landscapes containing various objects and figures
• used for diagnosis and treatment of autism patients
• automatic logging function useful in aiding further psychotherapeutic analysis
• hardware:
• display system - large projection display
• input device - "wand" with a position/orientation sensor

Related Links:

• VR Sand Box at the Ojika Lab, Gifu University in Japan

Virtual Reality Medical Support System for Cancer Patients

• PsychoOncological VR Treatment (POVRT)
• the cancer patients sometime complaint insomnia and unrest especially when they are treated by chemotherapy
• the purpose of this application is to improve these psychooncological problems by VR technology
• in the virtual space patients can feel as if they are present in the nature outside of the hospital even when they lay down on the bed and see a picture of the scenery in nature produced by VR
• relaxation sound also can be chosen whenever they want
• future plans - use of VR for prevention of memorization of nausea by a first chemotherapy
• hardware
• HMD and 3D projector as an observation system
• stylus (fastrak) as pointing device in the virtual space
• SGI Onyx

Related links:

• VR Medical Support System for Cancer Patients  at the National Cancer Center in Japan
• Psychooncological Therapy Project at the National Cancer Center in Japan
• VR for the Palliative Care of Cancer at the National Cancer Center in Japan

VR Based Therapy for the Treatment of Impotence and Premature Ejaculation

• methods involved the use of a VR helmet, joystick and miniature television screens that projected specially-designed CD-ROM programs on psychological development
• while wearing the helmet, the patient feels free to act in complete privacy without being seen, avoiding cognitive defenses and favoring the psychodynamic "healing" process
• therapy consisted of 12 hour-long sessions over a 25-week period:
1. baseline session employing acoustic therapy
2. psychotherapy
3. four acoustic sessions alternated with six VR experiences
4. final discussion
• during the acoustic experience, the psychotherapist together with the patient listened to a recording of two voices (on a musical background) that described pathways through a forest
• patient's reactions, comments and body language were noted and, with the psychotherapist, he discussed his experience afterwards
• VR experience:
• 15-minutes long
• patients used a joystick and a stereophonic head mounted display to interact in a virtual environment (VE)
• developed using the VREAM toolkit software
• computer used was a PC Pentium 133 (16 Mb Ram)
• in the VE four different expandable pathways (similar to the ones described in the first audio session) opened up through a forest, taking them back to their childhood, adolescence and teen years when they started to get interested in the opposite sex
• included bits of non-erotic film related to the ontogenesis of male sexual identity
• psychotherapist was linked to the patient through headphones to overcome any technical interaction difficulties

Related links:

• VR for Treatment of Impotence  by G. Optale
• Multimedia and VR techniques in the treatment of male erectile disorders in International Journal of Impotence Research
• VR in the treatment of male erectile disorders by G. Optale

Other interesting links:

• Virtual Treatment (Prevention and Treatment of Psychiatric Conditions by Immersion in Virtual Reality Environments), a book from Dr. R.J. Lamson
• Virtual Reality in Neuro-Psycho-Physiology (Cognitive, clinical and methodological issues in assessment and rehabilitation), a book edited by G.Riva
• Virtual Environments in Clinical Psychology and Neuroscience (Methods and techniques in advances patient-therapist interaction),a book edited by G. Riva, B. Wiederhold and E. Molinari
• VR exposure treatment of phobia a survey by M.J. Schuemie and C.A.P.G. van der Mast
• The Phobia List , extensive list of phobia names
• Virtually Better Inc. , company that makes tools for VR exposure based treatments
• Virtual Environments Group at Georgia Tech

Created by Branislav Ulicny.