A virtual tool for real problems of the human mind: VR and Psychiatry
VR has been a part of psychological and psychiatric research since the 1960’s and has been published about, and mentioned in peer-reviewed papers, quite early on.
But as graphics cards, their cost and computational power left much to be desired in the 1990's, the VR boom in psychology/psychiatry research has only now taken off exponentially due to products such as Playstation VR, Gear VR, Oculus Rift and HTC Vive. And more is to come as Oculus Go and Quest enter, along with mixed reality headsets from e.g. Microsoft and Asus take the market.
Many research institutions and clinics use VR on a regular basis as a compliment or extended tool in cognitive behavioral therapy (CBT), and now even in dialectic behavior therapy (DBT) as well as more psychodynamic therapy.
Here are some prime examples.
The term Virtual Reality is used broadly in research, that is why we most often add Head Mounted Display (HMD) e.g. headset and glasses.
Things such as Second Life and 2D renditions of reality are also labelled as VR in early research (and still is). Most of the research cases used her will be HMD VR.
VR and Treatment of Addiction
The University of Huston, Graduate School of Social Work is very prominent in using VR technology and has been researching the use of immersive VR for dealing with different types of addiction for more than a decade.
Even Dr Phil in on board in using this type of therapy.
How: The research, both from University of Huston and other research institutions focuses mostly on behavioral modification though addressing social, emotional and visual triggers of addiction. Recently mixed reality in which objects that trigger, such as needles, cigarettes or bottles, can be held in VR by a patient in order to maximize the realness of the exposure.
Why VR: Some triggers are easy to work with, some are more elaborate and need a setting, such as a heroin cave, or a co-addict. For practical and ethical purposes it is not possible to take a person in to an actual situation where other heroin addicts reside. So the next best thing is to create an immersive environment that focuses on the triggers.
Just because you become clean from a substance in a biochemical sense, does not mean you become “clean” of friends and environments that trigger the addiction.
The same can be said with alcohol, which often occurs in social situations. That is why the lab has a party set up with alcohol so that the therapist and the patient can work though triggers together in a safe immersive environment.
360 video or programmed environments?: In the case of addiction treatment and cravings exposure, both strategies are equally applied. 360 video has it’s broadest use in this field. Many of the programs which are commercially sold to psychologists/psychiatrists are semi-interactive 360 videos.
Go to Systematic Review: https://www.researchgate.net/publication/325553738_Trends_and_Future_of_Virtual_Reality_for_Addiction_Treatment_of_Substance_Use_Disorders_A_Review_of_Systematic_Literature
VR and Psychosis
Using VR to simulate psychosis has two benefits; exposure treatment with the patient through “avatar therapy” and empathy training for the caregivers.
Being exposed to what a psychosis feels like is nothing new. In fact, psychosis simulators were one of the first real user cases regarding VR in psychiatry with experiences such as this simulator by Danson Pharmacuticals in the late 90’s early 2000’s.
Another great example is a study by the Philippe Pinel Institute in Canada:
Or research from Kings College London by Lucia Valmaggia and group:
How: Most often therapy consists of exposure to a visual or auditory hallucination that frequently disrupts a patients ability to function and creates negative feelings, thoughts and actions in the patient. In most studies, patients describe their visual and auditory hallucinations which are recreated in a virtual reality environment. In some studies, a replica of their inpatient facility, others in a neutral environment. The patients are then placed in VR where they confront voices and hallucinations together with a therapist.
Why VR: It is an effective way of taking something which previously only was an abstract phenomena and placing it in a tangible setting for the patient, thus being able to effectively allow the patient to regain control of the auditory or visual hallucination.
It is also an effective teaching tool which allows the therapist, family and caregivers to experience and get a deeper insight in to a patient’s condition.
360 video or programmed environments?: For auditory hallucinations and demonstrations, 360 videos such as the one linked below are most common. For treatment purposes, programmed environments are most commonly used and are more likely to be effective.
Go to Systematic Review:
https://www.ncbi.nlm.nih.gov/pubmed/28735593
VR and Eating Disorders
How: According to research, about 2% of the population suffer from some form of eating disorder (lifetime prevalence between 1–4% for anorexia for women and <1% among men of all ages (although when it comes to men, other eating disorders may dominate, and anorexia might manifest differently). The mortality rate for eating disorders is high.
Anorexia and Bulimia: A core negative body image and distortion in sensory perception of ones own body are two components which are important to address in order to begin the treatment process.
Over-eating, emotional eating and other eating related disorders: A core symptom is loss of control and lack of insight. Both can be addressed by making the issue concrete and formulating the problem in a virtual environment.
Anorexia: The treatment is based on remodeling ones perception of one’s body size through the “body transfer illusion”. Tactile, mixed reality, treatment is most common as mentioned in video above.
Other eating disorders and over-eating: Treated through simulated environments that remodel one’s cravings, thoughts and behavioral patterns regarding food and food-consumption.
Why VR?: Trying to achieve a body swap illusion in an immersive way is very difficult without a programmed environment and an avatar body for optimal impressiveness. It has been achieved with mannequin bodies at the Klingberg Lab, but it is not feasible in treatment of anorexia.
VR offers a wide variety of possibilities to work on three important features of eating disorders: body image, behavioral patterns and sensory-motor control.
360 video or programmed environments?: Both are used, however, programmed environments still dominate the treatment strategy as treatment entails interactive components such as virtual lunch room scenarios in which patients have to prepare or consume a virtual meal.
Go to systematic review:
VR and Personality Disorders
How: Personality Disorders have a great range and range in severity within the diagnosis it self. The diagnosis is in no way considered a disease, but the core symptoms of the personality disorders can be problematic such as: self-harm, self-destructive behavior, depression, addiction, violent and aggressive behavior to self and others.
One of the core difficulties for both patients and therapists is the issue of trust and hence compliance. Building trust and adapting treatment to increase efficacy can effectively be done through VR.
There are few studies to date, but many are ongoing and the body of data will undoubtedly increase.
One effective way in which VR has been used is to perform Dialectic Behavior Therapy (DBT) for patients with Borderline personality disorder.
Why VR?: In cases in which the patient wants to meet the therapist before a face to face meeting, a 360 video can be used to introduce the patient to the treatment setting, the therapy and the therapists. DBT, CBT and other treatment strategies CAN be performed from a distance and thus increase efficacy (See link under picture above).
360 video or programmed environments?: Both are used, however, programmed environments still dominate the treatment strategy. The use of 360 will be more prominent as patient education might be transported in to 360 video-based platforms rather than pamphlets and on site lectures.
VR and Depression
How: Depression is a very wide diagnosis. There are several sub-types, and sub-types of sub-types. In terms of diagnosis, depression is as much of a diagnosis in its own right as it is a symptom of other diagnoses: e.g. deficit of B12 and D vitamin.
Depression also comes with a spectrum. Back in the day we use to have endogenous and reactive depression, in which we’d think of one as biological (biochemical imbalance) or reactionary (as a part of a negative life change).
Today we don’t separate the two.
A person with a depression diagnosis can, and often does, have more than one diagnosis. For example, depression and anxiety are commonly co-occurring. The same with depression and suicidal ideation.
This makes it hard to pinpoint a treatment strategy in VR for some therapists, and opens a wide range of possibilities for others.
Why VR?: Patients with mild depression being treated in primary care can recieve treatment and preventive strategies through VR and group therapy such as in the work by Merve Dilgil. For patients in inpatient care, it can be an excellent way to offer recreational activity, painting and relaxation programs.
360 video or programmed environments?: Both are used, however, programmed environments still dominate the treatment strategy.
Go to review: https://www.ncbi.nlm.nih.gov/pubmed/29510528
VR and Anxiety
How: The use of VR as anxiety relief is one of the most researched VR-topics. It is quite self explanatory: VR offers a visual distraction, a distraction that works, but does it work better than medicine?
Currently there are several studies ongoing to see if VR can offer those suffering from anxiety or other mental health problems, a calming relaxation.
At the Sahlgrenska University Hospital in Sweden, inpatients are currently being recruited for a VR study in which VR (app Calm Place by Mimerse) will be compared to analogue methods for relaxation (sensory rooms and anxyolitycs)
During the past 10 years a large body of studies have shown that VR is an effective and long lasting tool which lowers anxiety.
Why VR?: Simple, cheap, can offer a number of environments which can distract and help levitate anxiety. Unlike many anxiolytics, it has few (if any) side effects and can be used almost anywhere at any time, especially during pregnancy when most anxiolytics are not recommended.
360 video or programmed environments?: 360 videos (often with low quality) are mostly used, however more and more indie developers and health tech companies are creating high quality programmed environments that are more immersive.
Go to systematic review: https://www.ncbi.nlm.nih.gov/pubmed/30404770
VR and PTSD
Military use
How :VR exposure therapies (VRET) are a common tool in the military. Since the mid 90’s researchers such as Scott Rizzo have brought forth both treatment advances and twerks to the technology that has made VRET more accessible.
By working though traumatic events, particularly those experienced in combat, soldiers can combat their PTSD symptoms, and in some cases, go back to active duty.
Civilian use
How: In terms of Civilian use, VRET is less commonly used. It is difficult to model an exposure therapy due to two very important factors 1) it is difficult to justify ethically and 2) it is difficult to do the trauma justice and recreate appropriately.
Some studies have focused on exposure therapies for patients with trauma related to sexual assault.
Instead, civilian PTSD treatment is more about decreasing the hyperactivity of the stress-system which contributes to health problems such as: pain, sleep problems, problems with metabolism and hormones etc.
Dr Iris Sarajlic Vukovic, a prominent researcher and psychiatrist based in Sahlgrenska University Hospital, is currently working with outpatients with PTSD using VR as a relaxation tool in connection with visits to the outpatient unit. She and I will be presenting our results at the World Psychiatric Congress in Lisbon i August.
Why VR: VR offers us a chance to visit a place, a memory or a situation we’d love to re-live. In the case of Post Traumatic stress disorder, the patient’s own mind becomes a virtual reality machine that replays a traumatic moment over and over again.
In a lot of ways, PTSD related flashbacks are much like a 360 video of ones worse nightmare.
Through VR the patient or subject is offered a chance to relive the trauma, and slowly take over the narrative, thus gaining control and reducing fear.
Of course, PTSD is much more complex than just flashbacks. The long list of symptoms can be found here: https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd/symptoms
360 video or programmed environments?: Programmed environments are most commonly used, but 360 videos which help PTSD patients confront certain environments which trigger an episode are becoming increasingly implemented.
Go to systematic review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3531396/
To summarize
For the past 30 years, VR has blossomed in Psychiatry. The area has received little traction due to the cost of hardware, and lack of validated software. Now that both software and hardware are cheaper and more validated through clinical trials and experimental research, the clinical usability has increased.
VR can be used as a tool for a therapeutic method (e.g. Cognitive Behavioral Therapy) or as a therapy method in itself.
Within 5 years, VR will become a standardized tool in psychiatry and added in the toolbox of available treatment strategies.
