State of art of the therapeutic graphical simulations

University of Colombo School of
Computing
Literature Survey
State of Art of the Therapeutic
Graphical 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

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 for
psychological 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

Bibliography 21
therapist. It is hoped that the virtual world will provide an extension of established
psychotherapeutic techniques and assist in the generation of new approaches.

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