VR in Eating Disorders and Obesity

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The objective of this research activity is the development and use of virtual environments for the study and the treatment of body experience disturbances.

 

Cognitive Behavioral Therapy in Eating Disorders: Some Challenges for the future

Cognitive-behavioral therapy (CBT) for eating disorders can be described as "a symptom-oriented approach that focuses on the beliefs, values, and cognitive processes that maintain the eating disordered behavior". This approach is based on the theory that certain cognitive characteristics such as low self-esteem, distorted beliefs about the "meaning" of weight, shape, and appearance, dichotomous logic and perfectionism lead to an over concern about one's body size. This preoccupation leads to the use of compensatory behaviors, such as self-induced vomiting, fasting, excessive exercise and abuse of diuretics or laxatives.

The widespread use of CBT derives directly from Fairburn's publication of a detailed treatment manual for the treatment of Bulimia Nervosa. As described by Fairburn and Cooper, CBT consists of 19 sessions of individual treatment lasting about 20 weeks. The treatment has three stages. The phase one incorporates the use of psycho-educational principles and behavioral techniques designed to disrupt the cycle of binge eating and purging and help the individual normalize their eating patterns. Self-monitoring, through the use of daily food journals, is firmly established during this phase of treatment.In phase two, cognitive restructuring and problem solving are used to help the individual nidentify and challenge distorted thoughts, beliefs, and values that are maintaining the eating disorder. Interpersonal and environmental stressors that trigger bulimic episodes are explored and alternative methods of coping are identified. The final phase of treatment focuses on relapse prevention strategies and the maintenance of progress.

In the cognitive-behavioral approach to the treatment of anorexia nervosa, the therapist focuses on using cognitive restructuring to change distorted beliefs and attitudes. Targets of the treatment are the "meaning" of weight, shape and appearance, which are  believed to underlie dieting and fear of weight gain. Recovery from anorexia nervosa is achieved by coupling the use of specific behavioral techniques, which address the normalization of eating patterns and weight restoration (e.g., the use of food diaries, meal plans incremental weight gain), with the use of cognitive techniques (e.g., cognitive restructuring, problem solving, identification and expression of affect), designed to improve self-esteem and develop a sense of personal effectiveness [30].

However, as noted by Mizes, some aspects of the actual practice guidelines for CBT "...are based on a combination of research-based recommendations and clinical consensus because of significant gaps in the extant research" (p. 387). In particular there are at least four themes that are somehow neglected by current guidelines for eating disorders: body experience disturbances, self efficacy and motivation for change, interpersonal relationships and the integration between all the different professional figures involved in the treatment.

Even if all these themes are widely discussed in literature, the recommended clinical pratice for them are more based on "expert consensus" than on scientific data. Infact, little empirical work has been done to point out the content of clinical guidelines and to validate their efficacy in treatment. It is well known that few eating disordered patients are not over concerned with their physical body. It is also known that for most patients, changing the body experience is the hardest part of their recovery. However, standard eating disorder programs provide less therapy and have a smaller treatment effect for body image compared with eating behavior.

 

1. Rationale of the system

2. Bibliography

3. Clinical protocol (full version - 33 pages)

The latest clinical papers

4.  Papers on the link between VR and body experience

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1. Rationale of the system

For many years, research and practice in eating disorders and weight management have been based largely on an unidimensional, simplistic, weight-loss/weight-gain paradigm because of the common assumption that the major cause of obesity is overeating [55]. In spite of this widespread assumption, however, a review of the literature does not support the notion that fat individuals consume more calories than their lean counterparts. A review of 20 studies by Wooley and colleagues [56] and the findings of two more reviews [57, 58] suggest that, generally, fat people probably do not consume more calories than people who are not overweight. Thus, if fat people do not necessarily eat any more than thinner people, the prescription of a diet may not be warranted or reasonable. 

This is probably why the long-term success rate for persons using this paradigm has been low [59]. Moreover, more recent follow-up studies after a weight-loss intervention have shown how frequent dieters usually have significantly more weight regain than less frequent dieters [60, 61] To overcome this unsuccessful approach, our work follows some new thinking in this area of weight and eating disorders treatment [62, 63] that recognizes the dangers of chronic dieting and proposes a focus on body image, motivation for change, self-efficacy, self-acceptance and better nutrition. Specifically our program stresses the following: (a) understanding the origins and reinforcement of negative attitudes toward body image; (b) redefining beauty with regard to fatness and thinnes; (c) examining, treating, and decreasing the restriction in activities and negative feelings many eating disordered patients experience; (d) teaching clients empowerment techniques to support motivation to change and self-efficacy, and (e) developing individualized treatment plans regarding eating behaviors and exercise. We hypothesize that the proposed approach would be effective in increasing the number and variety of clients' daily activities, decreasing their fat phobic attitudes and depression, and increasing their self-esteem.

Probably the key novelty of this approach is the use of VR and telemedicine sessions in therapy. [64]. As we have seen in the Introduction, VR is widely used in the treatment of phobias [65-69]. However, it seems likely that VR can be more that a tool to provide exposure and desensitization [70]. As noted by Glantz et al., "VR technology may create enough capabilities to profound influence the shape of therapy" [71, p.92]. In particular, they expect that VR may enhance cognitive therapy. VR can in fact be described as a "cognitive technology", a technology created to  influence cognitive operations [72]. Also, the emergence of e-health could have a strong effect on health care. As we have seen, the key characteristic of e-health is the use of shared media. Using the Internet, therapists can present, from a remote site, a wide variety of stimuli and to measure and monitor a wide variety of responses made by the user.

Recently, some researchers have tried to use telehealth in the treatment of eating disorders. Particularly, an American group examined Student Bodies, an Internet-delivered computer-assisted health education program designed to improve body satisfaction and reduce weight/shape concerns [73-75]. In a controlled study they evaluated whether a 8-week program offered over the Internet was able to target body image dissatisfaction, disordered eating patterns, and preoccupation with shape/weight among women at high risk for developing an eating disorder. The results suggest that technological interventions may be helpful for reducing disordered eating patterns and cognitions among high-risk women [75].

Moreover, the findings of the next research coming from the same group showed that an Internet intervention with limited face-to-face contact was more effective in improving body imageand reducing disordered attitudes and behaviors than a purely face-to-face psychoeducational intervention [73].

As we have just seen, there are different key topics that are neglected by current CBT guidelines: body experience disturbances, motivation for change, empowerment and theintegration between all the different professional figures involved in the treatment. We think that VR and telemedicine have enough capabilities to profound influence the shape of therapy byoffering new approaches that can match the topics discussed above. In the clinical protocol is detailed the rationale for such assumption.

 


2. Bibliography

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3. The Latest Clinical Papers
(published on Indexed Scientific Journals)

 

Virtual Reality and Telemedicine Based Experiential Cognitive Therapy: Rationale and Clinical Protocol

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TeleTherapy for Eating Disorders, 26 October 2001, p.777

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Six-Month Follow-Up of In-Patient Experiential Cognitive Therapy for Binge Eating Disorders

Abstract: Treating binge eating disorders is not easy: the disordered eating is usually combined with a patient who is overweight and often obese. As underlined by the current literature, treatment outcome must focus, at a minimum, on the binge eating characterizing this disorder, on weight changes, and preferably also changes in co-morbid psychopathology. To address these issues, cognitive behavioral therapy (CBT) is still considered the best approach. However, if we check the results of follow-up studies, different authors reported some relapse in the frequency of binge eating and small weight gains over the follow-up period. This paper describes the 6-month follow-up outcome of the Experiential Cognitive Therapy (ECT), a multi factorial treatment for binge eating disorders, including virtual reality therapy. These results are compared in a randomized controlled trial (n = 36) with the ones obtained by CBT and nutritional groups only. The results showed that 77% of the ECT group quit binging after 6 months versus 56% for the CBT sample and 22% for the nutritional group sample. Moreover, the ECT sample reported better scores in most psychometric tests including EDI-2 and body image scores.

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Virtual-Reality-Based Multidimensional Therapy for the Treatment of Body Image Disturbances in Binge Eating Disorders: A Preliminary Controlled Study

Abstract: The main goal of this paper is to preliminarily evaluate the efficacy of a virtual-reality (VR)-based multidimensional approach in the treatment of body image attitudes and related constructs. The female binge eating disorder (BED) patients (n = 20), involved in a residential weight control treatment including low-calorie diet (1200 cal/day) and physical training, were randomly assigned either to the multidimensional VR treatment or to psychonutritional groups based on the cognitive-behavior approach. Patients were administered a battery of outcome measures assessing eating disorders symptomathology, attitudes toward food, body dissatisfaction, level of anxiety, motivation for change, level of assertiveness, and general psychiatric symptoms. In the short term, the VR treatment was more effective than the traditional cognitive-behavioral psychonutritional groups in improving the overall psychological state of the patients. In particular, the therapy was more effective in improving body satisfaction, self-efficacy, and motivation for change. No significant differences were found in the reduction of the binge eating behavior. The possibility of inducing a significant change in body image and its associated behaviors using a VR-based short-term therapy can be useful to improve the body satisfaction in traditional weight reduction programs. However, given the nature of this research that does not include a followup study, the obtained results are preliminary only.

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Virtual Reality–Based Multidimensional Therapy for the Treatment of Body Image Disturbances in Obesity: A Controlled Study

Abstract: The main goal of this paper is a preliminary evaluation of the efficacy of a virtual reality based multidimensional approach to the treatment of body image attitudes and relatedconstructs. The female obese patients (n = 28) involved in a residential weight control treatment, including low-calorie diet (1,200 kcal/day) and physical training, were randomly assigned either to the VR treatment or to psychonutritional groups based on the cognitive-behavior approach. Patients were administered a battery of outcome measures assessing eating disorders symptomatology, attitudes toward food, body dissatisfaction, level of anxiety, motivation for change, level of assertiveness, and general psychiatric symptoms. In the short-term, the VR treatment was more effective than the traditional cognitive-behavioral psychonutritional groups in improving the overall psychological state of the patients. In particular, it was more effective in improving body satisfaction, self-efficacy, and motivation for change. The improvement was associated with a reduction in problematic eating and social behaviors. The possibility of inducing a significant change in body image and its associated behaviors using a VR-based short-term therapy can improve body satisfaction in traditional weight reduction programs. However, given that this research that does not include a follow-up study, the obtained results are preliminary.

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Virtual Reality Based Experiential Cognitive Treatment of Obesity and Binge-Eating Disorders

Abstract: This paper describes the characteristics and preliminary evaluation of the Experiential Cognitive Therapy (Experiential CT), a VR based treatment to be used in obesity and binge-eating disorders' assessment and treatment. Experiential CT is a relatively short-term, integrated, patient oriented approach that focuses on individual discovery. Main characteristic of this approach is the use of Virtual Reality, a new technology that allows the user to be immersed in a computer-generated virtual world. Two preliminary clinical trials were carried out on female patients: 25 patients suffering from binge-eating disorders were included in the first study and 18 obese in the second one. At the end of the in-patient treatments, the patients of both samples modified significantly their bodily awareness. This modification was associated to a reduction in problematic eating and social behaviors. No subjects experienced simulation sickness.

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Experiential Cognitive Therapy: a VR Based Approach for the Assessment
and Treatment of Eating Disorders


Abstract: Even if there has been significant progress in research on eating disorders,
little empirical work has been done yet to specify the content of clinical guidelines and to validate their efficacy in treatment. In particular there are at least three themes that are somehow neglected by current guidelines: body experience disturbances, motivation for change and the integration between the different approaches used.
This chapter details the characteristics of the Experiential Cognitive Therapy (ECT), an integrated approach ranging from cognitive-behavioral therapy to virt ual realit y (VR)sessions. In particular, using VR, ECT is able to address both body experience dis turbances and motivation for change. In the chapter a description of all the phases of this approach are offered by using an actual clinical case: a 22-year old female anorectic patient.

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Virtual reality environment for body image modification: a multidimensional therapy for the treatment of body image in obesity and related pathologies

Abstract: Objective: To investigate the possibility of inducing a significant modification on body image attitudes and behavior in obesity and related pathologies using a virtual reality (VR) based psychological approach. Design: Clinical intervention study using 5 bi-weekly VR-based therapeutical sessions. Subjects: 57 female obese, BED and EDNOS patients seeking treatment at the Weight Reduction Unit of the Istituto Auxologico Italiano, Verbania, Italy. Measurements: Various body-image related psychometric tests (Body Satisfaction Scale, Body Image Avoidance Questionnaire, Figure Rating Scale, Contour Drawing Rating Scale) at baseline and after therapy . Results: In all samples the subjects improved their overall body satisfaction after the treatment. The improvement was always associated to a reduction in problematic eating and social behaviors. Conclusions: The possibility of inducing a significant change in body image and its associated behaviors using a VR based short term therapy can be useful to improve the body satisfaction in traditional weight reduction programs.

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Virtual Reality for the Treatment of Body Image Disturbances

Abstract:  This chapter describes the characteristics and preliminary evaluation of The Virtual Environment for Body Image Modification (VEBIM), a set of tasks aimed at treating body image disturbances and body dissatisfaction associated with eating disorders. Two methods are commonly used to treat body image: (1) a cognitive/behavioural therapy to influence patients' feelings of dissatisfaction; (2) a visual/motorial therapy with the aim of influencing the level of bodily awareness. 
VEBIM tries to integrate these two therapeutic approaches within an immersive virtual environment. This choice would not only make it possible to intervene simultaneously on all of the forms of bodily representations, but also to use the psycho-physiological effects provoked on the body by the virtual experience for therapeutic purposes.  The chapter, together with the description of the VEBIM theoretical approach, it also presents a study on two preliminary samples (71 normal subjects, uncontrolled study, 48 normal subjects, controlled study) to test its efficacy.

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Virtual Reality as Assessment Tool in Psychology

Abstract:  Virtual environments (VEs), offering a new human-computer interaction paradigm, have attracted much attention in clinical psychology, especially in the treatment of phobias. However, a possible new application of VR in psychology is as assessment tool: VEs can be considered as an highly sophisticated form of adaptive testing.
This chapter describes the context of current psychological assessment and underlines possible advantages of a VR based assessment tool. The chapter also details the characteristics of BIVRS, Body Image Virtual Reality Scale, an assessment tool designed to assess cognitive and affective components of body image. It consists of a non-immersive 3D graphical interface through which the patient is able to choose between 9 figures of different size which vary in size from underweight to overweight. The software was developed in two architectures, the first (A) running on a single user desktop computer equipped with a standard virtual reality development software and the second (B) splitted into a server (B1) accessible via Internet and actually running the same virtual ambient as in (A) and a VRML client (B2)so that anyone can access the application. 

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4.  Papers on the link between VR and body experience

 

The Cyborg's Dilemma: Progressive Embodiment in Virtual Environments

Abstract: How does the changing representation of the body in virtual environments affect the mind? This article considers how virtual reality interfaces are evolving to embody the user progressively. The effect of embodiment on the sensation of physical presence, social presence, and self presence in virtual environments is discussed. The effect of avatar representation on body image and body schema distortion is also considered. The paper ends with the introduction of the cyborg's dilemma, a paradoxical situation in which the development of increasingly "natural" and embodied interfaces leads to "unnatural" adaptations or changes in the user. In the progressively tighter coupling of user to interface, the user evolves as a cyborg.

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Avatars in Clinical Psychology: A framework for the clinical use of Virtual Humans

Abstract: Early applications of virtual reality (VR) technology in psychological assessment, treatment, and research have yielded promising results. In particular, an increasing number of studies analyze the unique features of the experience made by patients during their exposure to virtual environments. However, the majority of these studies explore how patients navigate in the virtual spaces and interact with virtual objects. Only a few of them investigate the features of inhabited virtual environments, where real people and autonomous virtual humans are able to interact and to cooperate. In particular, there is a lack of discussion of the role that such autonomous virtual humans could have in VR-aided psychotherapy. The main goal of this paper is to identify a framework for future research in this area. Three levels of analysis are identified. The purpose of the first two levels is the identification of the key "physical" features (e.g., appearance, structure) and "internal" characteristics (e.g., behavior, degree of autonomy, perceptual capabilities) needed by an effective simulation. The third level is concerned with the evaluation of the interaction characteristics required for a successful relationship between the patient and the virtual human.

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Virtual Eyes Can Rearrange Your Body: Adaptation to Visual Displacement In See-Through Head-Mounted Displays

Abstract: Among the most critical issues in the design of immersive virtual environments are those that deal with problem of technologically induced intersensory conflict and one of the results, sensorimotor adaptation. An experiment was conducted to support the design of a prototype see-through head-mounted display (HMD). When wearing video see- through HMDs in augmented reality systems, subjects see the world around them through a pair of head-mounted video cameras. The study looked at the effects of sensory rearrangement caused by a HMD design that displaced the user's "virtual" eye position forward (165 mm) and above (62 mm) toward the spatial position of the cameras. The position of the cameras creates images of the world that are slightly downward and inward from normal. Measures of hand-eye coordination and speed on a manual pegboard task revealed substantial perceptual costs of the eye displacement initially, but also evidence of adaptation. Upon first wearing the video see-through HMD, subjects' pointing errors increased significantly along the spatial dimensions displaced (the y dimension, above-below the target, and z dimension, in front-behind the target). Speed of performance on the pegboard task decreased by 43% compared to baseline performance. Pointing accuracy improved by about a 1/3 as subjects adapted to the sensory rearrangement, but it did not reach baseline performance. When subjects removed the see-through HMD there was evidence that their hand-eye coordination had been altered. Negative aftereffects were observed in the form of greater errors in pointing accuracy compared to baseline. Although these aftereffects are temporary, the results may have serious practical implications for the use of video see-through HMDs by user populations (e.g., surgeons) who depend on very accurate hand-eye coordination.

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Virtual reality and the human body

Abstract: While computer scientists create virtual environments, humanists and social scientists are beginning to speculate on the impact that visualization technologies will have on popular culture. In an essay entitled "The Virtual Body in Cyberspace," Assistant Professor Anne Balsamo of Georgia Tech's School of Literature, Communication, and Culture examines the impact of virtual reality (VR) on how we view the human body.

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