Presented by Kim Bullock, MD
Clinical Associate Professor of Psychiatry & Behavioral Sciences
November 1, 2018
Some people have a fear of flying. Others may have a fear of getting into elevators. Still others have eating disorders–or body-image fears–that make thin people feel like they are fat.
All of them could be helped by virtual reality. New developments in virtual reality are making it a potentially valuable tool for treating some anxiety disorders and mental health conditions, as described by Kim Bullock, MD, in a recent presentation at the Stanford Health Library.
Virtual reality (VR) is a technology that enables people to feel like they have been taken to a new environment somewhere else. This enables people to see their environment or themselves from a different perspective. Sometimes they can practice thinking or behaving in a new way.
While virtual reality started with computer games, it’s now being used for far more. Medical and social researchers have found it useful for training, learning, and changing behavior. VR can help people with certain mental health conditions like anxiety disorders, eating disorders, panic attacks, or phobias.
Virtual reality is anything that’s a computer-generated 3-dimensional (3D) experience. That includes everything from playing a computer game on a screen to wearing the latest wraparound visor on your head that delivers simulated sights and sounds.
“It’s usually a life-sized experience where you really feel like you’ve been taken somewhere else,” said Dr. Bullock, a psychiatrist who is the director of Stanford’s Virtual Reality-Immersive Technology (VR-IT) Clinic & Laboratory. “What it does is replace visual reality.”
When people get immersed in virtual reality, their wraparound headsets deliver sights and sounds that replace their sense of the real environment around them. People vary, but the average time most VR users need to adjust to this simulated environment is about 5 to 6 seconds.
In the roughly 20 years since researchers started studying virtual reality as a way to improve mental health, the technology has improved dramatically. Now VR can be delivered to patients by off-the-shelf retail headsets instead of equipment only available from multimillion dollar labs in previous years.
The headsets range from a $3 cardboard visor to pricier models like Oculus Rift. Most must be connected to a smartphone, a laptop, or desktop computer, but that is changing and many stand-alone devices are hitting the markets.
VR should never be used alone for mental health treatment, however, without medical supervision, Dr. Bullock said. In practice, it’s just one additional part of treatment that includes talk therapy and medicine. A therapist must make sure vulnerable people are not over-exposed to fearful simulated environments they’re not ready to handle.
“We’re not sticking people into therapy and leaving the room and letting the VR do the therapy,” Dr. Bullock said. “In practice, it might be 5 percent of what is happening in a psychotherapy session. It really is just a tool within psychotherapy.”
The cornerstone of mental health treatment, even when it includes VR therapy, is the bond between therapist and the patient, Dr. Bullock said. “VR is just a tool in therapy. Just like a chair or Kleenex box would be just an enhancement or a nice addition.”
So far, studies have found that VR content developed to date is more effective for some mental health conditions than others. “Sadly, for mood disorders—depression and other mood disorders—there doesn’t seem to be a great effect unless there’s an anxiety component,” Dr. Bullock said.
Anxiety disorders helped
The strongest evidence of VR’s benefit so far comes from using it to improve anxiety disorders. Anxiety disorders often lead people to avoid certain situations or activities that cause fear, whether rational or irrational. Treatment usually requires the person to be exposed gradually to their fear-inducing situation in order to learn to control it.
VR can offer a simulated environment to help people practice how to control their fears when it’s not practical for them to face the real environment that caused their anxiety–or at least not right away.
Anxiety disorders include:
- Social anxieties (like fear of public speaking)
- Panic or agoraphobia (fear of crowded spaces or enclosed public spaces)
- Fear of flying
- Spider phobia
Some pilot studies have found preliminary evidence of VR benefits for:
- Post-traumatic stress disorder (PTSD)
- Obsessive compulsive disorder (OCD)
About one-third of the population is affected in their lifetime with an anxiety disorder, Dr. Bullock said.
Fear of flying
For example, Dr. Bullock said she developed a fear of flying after taking one long flight that was severely turbulent—with no explanation or reassurance from the airline pilots. “For 6 hours, we were in pure terror,” she said.
After that, she was afraid to get on a plane for 3 years. Over time, it got only a little better. Finally, she realized she needed to overcome her fear by exposing herself gradually to longer and more frequent flights.
“I think I would have gotten a lot faster if I’d had the virtual reality to help me. That way I could have received bigger doses of exposure without spending a fortune on unneeded flights,” Dr. Bullock said.
There is also solid evidence that virtual reality therapy can be effective for aspects of eating disorders, Dr. Bullock said.
People with eating disorders often get better with the standard treatments of cognitive behavior therapy and nutritional counseling. “But what’s hard to treat is the body image, and the body dissatisfaction, that remains,” Dr. Bullock said.
That’s where VR can help. VR can help people with an eating disorder like anorexia nervosa let go of their distorted view of their bodies, so they can accurately perceive their own body size compared to others.
If people are overweight, VR sessions can enable them to experience what it feels like inhabit a leaner body.
“People with obesity who inhabit a thin body in virtual reality,” Dr. Bullock said. “may once they leave the [virtual] environment actually feel more satisfied with their bodies. That tends to translate to [better] health behaviors.”
A virtual reality environment can be set up in different ways for the viewer to experience it:
- First-person perspective, the most common way, when the user sees the environment from their own viewpoint.
For example, a parent may learn new parenting skills from a VR simulation in which they practice talking to their children in a new way, learning new communication skills.
- Second-person perspective, when users watch themselves from another person’s perspective.
A parent might view a conversation as their sons or daughters see it (watching the parent talk).
- Third-person perspective, when the parent watches the conversation from outside, as all the family members talk with one another.
VR is being applied to mental health treatment in 4 major ways:
- Exposure: the way VR is most often applied, to desensitize people. It can help people learn to control and reduce their fears or reactions to specific situations or cues.
- Distraction: a way for VR to help people who are feeling acute pain, such as burn patients, or feeling emotional distress. When patients in pain were distracted by a VR session, they used fewer opiate drugs.
- Training: VR enhances learning of any kind, because it’s engaging.
“Anything you learn in VR and interact with, you’re going to retain more,” Dr. Bullock said. “You’re going to learn it, you’re going to enjoy it, you’re going to retain it more.”
- Research: studies can measure biological responses to exposure to virtual environments very precisely. Some researchers are exploring a way to link biofeedback with virtual reality exposure.
If virtual reality has been around for 20 years, why is it getting a new burst of attention in recent years? New developments in technology are making “embodied” VR available to almost anyone who wants it.
“We now have the ability to inhabit another body and feel like we’re in another body with a simulation,” Dr. Bullock said. “These avatar experiences are available on gaming devices now, and different programs.”
She added, “There’s one program, High Fidelity, where you can go pick your body, design your body. It’s free of charge, and you meet people from all over the world.”
Early experiments with embodied VR included Ramichandran mirror therapy, used for amputees who experienced phantom limb pain. Therapists placed a mirror opposite the patient’s healthy arm, and the mirror image looked like a second healthy arm (where the amputated arm would have been).
Patients getting this therapy reported that their phantom limb pain disappeared. Researchers say the visual appearance of a second healthy arm induced a response in brain neurons so they no longer registered pain.
Similar experiments, called “the rubber hand illusion,” placed a rubber hand on a table in front of a person while their real hand was hidden behind a tabletop wall.
When both the rubber hand and the person’s real hand were stroked simultaneously by someone else, the person’s brain began to perceive the rubber hand as his or her own. Eventually the person began to “feel” the rubber hand being stroked.
One disturbing finding of this kind of study is that, after a while, the real arm hidden behind the wall is affected by an immune response, Dr. Bullock said. The immune response causes the body to start biologically “rejecting” the real arm by releasing histamine.
“We need to be careful,” Dr. Bullock said. “The safety is unclear and undocumented at this point.”
As researchers explore this and similar ways to apply VR to medical therapy, the FDA is considering whether to start regulating VR devices. “I think they should,” Dr. Bullock said.
Some people may be more susceptible to side effects from using VR than others. Children are among those who should always be supervised.
Most therapists and device makers now recommend that people limit their VR experience to 20 or 30 minutes at a time, Dr. Bullock said.
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