Testing virtual reality-based cue-exposure software: Which cue-elicited responses best discriminate between patients with eating disorders and healthy controls?

Exploring the effects of habituation and scent in first-person 360-degree videos on consumption behavior

Although immersive virtual environments can influence food-related thoughts, emotions and behavior, the influence of repeated exposure to food cues in such environments has rarely been explored. This study seeks to understand if habituation, a decrease in one's physiological and behavioral response that results from repeated simulation, can take place while repeatedly watching 360-degrees of food being consumed. The influence of scent as an olfactory cue is further explored, based on past research on embodied cognition. In Study One (n = 42), participants who viewed 30 repetitions of someone eating an M&M ate significantly fewer M&Ms than those who viewed three repetitions. Study Two (n = 114) used a 2 (behavior: eating M&M/inserting a coin) × 2 (repetitions: 3/30) between-subjects experiment to confirm that results from Study One were due to habituation of the consumption video, finding that there were only significant differences between repetitions in the M&M condition. Finally, Study Three (n = 161) comprised a 2 (repetition: 3/30) × 2 (scent: present/absent) between-subjects experiment. Participants in the 30-repetition condition and those in the scent-present condition ate significantly fewer M&Ms respectively, but no interaction effects were found. The theoretical and practical implications of these findings are discussed.

Eliciting real cravings with virtual food: Using immersive technologies to explore the effects of food stimuli in virtual reality

In this paper, we explore the current technical possibilities of eating in virtual reality (VR) and show how this could be used to influence eating behaviors. Cue-based exposure therapy is a well-known method used to treat eating disorders. There are several benefits to using VR in combination with cue-based therapy. However, before VR-based cue-exposure can be used for therapeutic purposes, the ability of the VR environment to elicit craving responses in participants must be assessed. This was the objective of the first part of the study, where we assessed whether our VR environment elicited food craving responses in participants. Results showed that our VR environment elicited food craving responses: Salivation Magnitude, Food Craving State and Urge to Eat was significantly different from the neutral baseline. In addition, results showed that food cravings measured through the salivation magnitude in response to the virtual condition were not significantly different from the real condition, thus showing that VR had a comparable effect on producing food cravings. The second part of the study was conducted to determine whether the addition of olfactory and interaction cues in VR increased the development of food cravings. The results of this part showed that adding synthetic olfactory cues, paired with visual cues, to our system, provided a significant further increase in food cravings. Our results demonstrate that the use of food cues in VR can increase the development of food cravings and that it is possible to provide a simple yet convincing eating experience in VR. Inevitably, food interaction in VR is still underexplored territory and further research is needed to improve utility and application in disciplines related to food and eating.

Various Types of Virtual Reality-Based Therapy for Eating Disorders: A Systematic Review

(1) Background: Interactive VR (virtual reality) environments (i.e., using three-dimensional graphics presented with a head-mounted display) have recently become a popular professional tool for the treatment of patients with eating disorders (EDs). However, there are no published review reports that have analyzed the original papers between 2015 and 2021, which additionally focused only on HMD (head-mounted display) 3DVR (three-dimensional virtual reality) exposure and included only three therapeutic categories for ED patients. (2) Methods: The EbscoHost and Scopus databases were searched to identify relevant papers on VR research employing VR in the assessment and treatment of eating disorders. (3) Results: In addition to the known therapeutic divisions for ED, there are new forms of therapy based on 360 cameras, eye-tracking, and remote therapy. (4) Conclusions: The potential of VR in combination with different therapies may offer an alternative for future research. More rigorous testing, especially in terms of larger sample sizes, the inclusion of control groups or multisessions, and follow-up measures, is still needed. The current state of research highlights the importance of the nature and content of VR interventions for ED patients. Future research should look to incorporate more home-based and remote forms of VR tools.

[Use of virtual reality in eating disorders]

Virtual reality is a new technology that can be used to model an environment with which an individual can interact using all five senses. It is notably used in psychiatry for anxiety disorders and addictions, and its use in eating disorders has been growing in recent years. Indeed, virtual reality offers interesting advantages, such as its ability to personalize any environment, which is also more secure and controllable. Recent studies show promising results in the understanding, evaluation, and therapeutic management of eating disorders. The use of avatars in anorexia nervosa allows for a correct assessment of the perceptual (body image distortion) and cognitive-affective (body dissatisfaction) components of the body image disorder in a similar way to conventional methods, but also for a better understanding of them. Moreover, avatars allow the development of innovative therapeutic protocols and are thus used in the context of exposure therapy. The new body swapping protocol, based on a multisensory illusion, offers particularly promising results in the reduction of body image disorder. For bulimia nervosa and binge eating disorder, virtual reality has made it possible to better characterize the triggering mechanisms of binge eating episodes through studies that have observed different responses to food-related environments and stimuli. At the therapeutic level, virtual reality cue exposure therapy has the most empirical support. Its aim is to reduce or eliminate the anxiety and craving felt by a patient in response to exposure to food or other food-related cues by preventing the patient from consuming food, and results show clear reductions in anxiety, craving and binge eating episodes. While all these results seem to indicate a bright future for virtual reality in eating disorders, further studies are needed to validate the positive impact of its use, but also its limitations. Notably, cyber sickness could alter the smooth running of virtual reality therapy sessions by causing nausea and disorientation. Moreover, it is important to verify that a therapeutic protocol does not lose its effectiveness when it is transposed into virtual reality. However, virtual reality seems to be a therapeutic tool that is better accepted by patients, and even better by adolescents, which is very interesting for eating disorders since adolescents are the most affected. Virtual reality could therefore help motivate patients to pursue treatment and reduce the dropout rate while offering good therapeutic results. Thus, studies conducted in recent years have shown that virtual reality is a promising tool in the understanding, assessment and treatment of eating disorders, and future research should confirm this, particularly in the adolescent population.

Electroencephalographic (EEG) alterations in young women with high subclinical eating pathology levels: a quantitative EEG study

PURPOSE

To explore electroencephalographic (EEG) alterations in young women with different eating disorder (ED) psychopathology levels.

METHODS

Thirty-seven young women completed general and ED psychopathology (i.e., the ED Examination Questionnaire; EDE-Q) measures. EEG power spectra data were investigated in two conditions: (a) 5 min of resting state (RS) and (b) 5 min of RS after a single taste of a milkshake (ML-RS). EEG analyses were performed using exact Low-Resolution Electromagnetic Tomography software (eLORETA).

RESULTS

Cluster analysis performed on the EDE-Q responses revealed a group of 17 women with high levels of ED pathology falling into the subclinical (i.e., sub-threshold) EDs category and a group of 20 women with low levels of ED pathology (controls). In the RS conditions, no significant modifications were observed between groups. Compared to controls, women with subclinical EDs showed an increase in theta activity in the parieto-occipital areas in the ML-RS condition. After controlling for body mass index and general psychopathology, theta activity in these brain structures was positively associated with EDE-Q global and subscale (restraint, shape and weight concern) scores.

CONCLUSIONS

Our results may reflect the neurophysiological substrate of ED psychopathology core features like shape/weight concerns. Previous brain imaging and qEEG studies with full-syndrome ED patients also underscored the involvement of parieto-occipital areas in ED pathophysiology. These studies also found brain alterations in the RS condition, not observed here. This is notable given that full-syndrome and subclinical EDs are considered as different manifestations of the same disease along a severity spectrum.

LEVEL OF EVIDENCE

Level V, cross-sectional, electroencephalographic, descriptive study.

Multi-method assessment of palatable food exposure in women with and without eating disorders

OBJECTIVE

Eating disorders (EDs) are characterized by dysregulated responses to palatable food. Using a multi-method approach, this study examined responses to palatable food exposure and subsequent ad libitum eating in women with binge-eating disorder (BED: n = 64), anorexia nervosa (AN: n = 16), and bulimia nervosa (BN: n = 35) and 26 healthy controls (HCs).

METHOD

Participants were exposed to palatable food followed by an ad libitum eating opportunity. Affective and psychophysiological responses were measured before and during the task.

RESULTS

Participants with EDs reported greater negative affect, particularly fear, following the food cue exposure, whereas HCs reported no change. BN and BED groups reported greater urge to binge after the food cue exposure, whereas AN and HC groups reported no change. Respiratory sinus arrhythmia levels, skin conductance and tonic skin conductance levels increased during food exposure for all groups. Across baseline and during the food exposure, the BED group had lower respiratory sinus arrhythmia levels relative to the BN and HC groups. The BED group consumed significantly more palatable food than the AN group.

CONCLUSIONS

'Palatable' food stimuli elicited more negative affect, particularly fear, in individuals with EDs; and this, rather than psychophysiological responses, distinguishes individuals with EDs from those without.

Virtual Reality Body Exposure Therapy for Anorexia Nervosa. A Case Report With Follow-Up Results

Objective

Exposure-based therapies such as mirror exposure may help to improve the results of classic cognitive behavioral therapy in anorexia nervosa (AN). Virtual reality (VR)-based procedures provide interesting novelties for targeting body-related concerns. This study aimed to provide preliminary evidence of the usefulness of a VR body exposure therapy in a patient diagnosed with AN.

Method

Fear of gaining weight (FGW), body anxiety, drive for thinness, body image disturbances, body mass index and body-related attentional bias were assessed before and after the intervention, as well as 5 months later. Five sessions of VR body exposure therapy were included within the standard course of cognitive behavioral therapy. The sessions involved a systematic and hierarchical exposure of the patient to a virtual representation of her own silhouette, with the body mass index of the avatar progressively increasing in subsequent sessions.

Results

After the intervention, there was a clear reduction in AN symptoms such as the FGW, drive for thinness, body-related anxiety and dissatisfaction. Body mass index values rose continuously during the intervention and reached healthy levels. Finally, there was a notable change in the dysfunctional body-related attentional bias. Almost all these improvements were maintained after 5 months, except for the FGW.

Conclusion

To the best of our knowledge, this study is the first to focus on treating the FGW and body-related concerns in AN using a VR-based paradigm. To pursue this study further and assess the effectiveness of this new VR software, larger controlled clinical trials are needed.

Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy

Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally.

Diagnostic, clinical, and personality correlates of food anxiety during a food exposure in patients diagnosed with an eating disorder

BACKGROUND

Eating disorders are characterized by high levels of anxiety, especially while eating. However, little is known about anxiety experienced during meals and specifically what other variables may impact such anxiety.

OBJECTIVE

We sought to further quantify and understand the relationship between food anxiety, eating disorders, and related correlates (e.g., comorbid diagnoses, personality).

METHODS

In the current study [N = 42 participants diagnosed with an eating disorder (n = 36 participants with anorexia nervosa)], we quantified anxiety before, during, and after a meal using data from a food exposure session in a partial hospital eating disorder center. We examined diagnostic, personality, and clinical factors as correlates of food anxiety.

RESULTS

Participants were more likely to experience higher food anxiety if they had a current diagnosis of major depression, obsessive-compulsive disorder, or post-traumatic stress disorder (PTSD). Concern over mistakes was the strongest and most consistent correlate of food anxiety regardless of time during the meal that anxiety was assessed. Other significant correlates were fear of positive evaluation, social appearance anxiety, BMI, and trust.

CONCLUSIONS

These findings show how diagnoses, perfectionism (concern over mistakes), and other correlates relate to anxiety during meals. Food exposure interventions may benefit from personalizations that address these factors.

LEVEL OF EVIDENCE

IV Evidence from a randomized control trial, but from the first session before effects of the design would be present.

Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study

BACKGROUND

This study is part of a larger project aiming to develop a virtual reality (VR) software to be implemented as a clinical tool for patients diagnosed with alcohol use disorder (AUD). The study is based on previous research in which we identified factors that elicit craving for alcohol in a sample of AUD patients, and which led to the development of a virtual reality software to be used in cue exposure treatments of alcohol use disorder (ALCO-VR). The main objective of this study was to test the effectiveness of ALCO-VR to elicit cue-induced craving and anxiety responses among social drinkers (SD) and AUD patients. Our secondary objective was to explore which responses (cue-induced craving or anxiety) can best differentiate between AUD patients and the SD group.

METHOD

Twenty-seven individuals (13 AUD patients and 14 SD) participated in this study after giving written informed consent. Their anxiety and alcohol craving levels were measured by different instruments at different stages of the procedure. The VR equipment consisted of Oculus Rift technology, and the software consisted of the ALCO-VR platform.

RESULTS

Our data indicate that the ALCO-VR software can elicit responses of anxiety and alcohol craving, especially in the group of AUD patients. The cue-induced anxiety response differentiated AUD patients and the SD group better than the cue-induced craving response.

CONCLUSIONS

The general interest in applying new technologies to the assessment and treatment of mental health disorders has led to the development of immersive real-life simulations based on the advantages of VR technology. Our study concluded that the ALCO-VR software can elicit anxiety and craving responses and that cue-induced anxiety responses can distinguish between AUD and SD groups better than cue-induced craving. The data on craving and anxiety were assessed consistently by different instruments. In addition, we consider that ALCO-VR is able to ecologically assess cue-induced anxiety and alcohol craving levels during exposure to VR alcohol-related environments.

Identifying Triggers of Alcohol Craving to Develop Effective Virtual Environments for Cue Exposure Therapy

Background: Many studies have indicated that alcohol craving is a core mechanism in the acquisition, maintenance, and precipitation of relapse in alcohol use disorder (AUD). A common treatment approach in AUD is cue exposure therapy (CET). New technologies like virtual reality (VR) have the potential to enhance the effectiveness of CET by creating realistic scenarios in naturalistic environments. In this study, we aimed to determine relevant triggers of alcohol craving in patients with AUD.

Methods: We enrolled 75 outpatients diagnosed with AUD according to the DSM-5 criteria Participants completed the Alcohol Use Disorder Identification Test and a self-administered questionnaire to assess alcohol craving. The variables included in the craving questionnaire were as follows: presence of others, situations, time of the day, day of the week, mood, and type of alcoholic beverage.

Results: Greater levels of alcohol craving were seen in many situations, including being at a party, in a restaurant, in a bar or pub, and at home. Drinking alone and drinking with two or more friends were equally associated with higher levels of craving. Drinking at night and drinking at weekends also emerged as triggers for alcohol craving. Emotional states like anxiety or tension, sadness, stress, frustration, or irritability were highly associated with urges to drink alcohol. The alcoholic drinks most highly associated with increased levels of craving were beer, wine, and whisky. Gender and age implications were discussed.

Conclusion: This study is part of a larger project aiming to develop and validate CET based on VR technology for patients with AUD who are resistant to classical treatment. The identified triggers have been used to develop relevant VR environments for CET, and further research is ongoing to implement our findings.

Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine

Is virtual reality (VR) already a reality in behavioral health? To answer this question, a meta-review was conducted to assess the meta-analyses and systematic and narrative reviews published in this field in the last twenty-two months. Twenty-five different articles demonstrated the clinical potential of this technology in both the diagnosis and the treatment of mental health disorders: VR compares favorably to existing treatments in anxiety disorders, eating and weight disorders, and pain management, with long-term effects that generalize to the real world. But why is VR so effective? Here, the following answer is suggested: VR shares with the brain the same basic mechanism: embodied simulations. According to neuroscience, to regulate and control the body in the world effectively, the brain creates an embodied simulation of the body in the world used to represent and predict actions, concepts, and emotions. VR works in a similar way: the VR experience tries to predict the sensory consequences of an individual's movements, providing to him/her the same scene he/she will see in the real world. To achieve this, the VR system, like the brain, maintains a model (simulation) of the body and the space around it. If the presence in the body is the outcome of different embodied simulations, concepts are embodied simulations, and VR is an embodied technology, this suggests a new clinical approach discussed in this article: the possibility of altering the experience of the body and facilitating cognitive modeling/change by designing targeted virtual environments able to simulate both the external and the internal world/body.