A Randomized Trial of Virtual Reality-Based Cue Exposure Second-Level Therapy and Cognitive Behavior Second-Level Therapy for Bulimia Nervosa and Binge-Eating Disorder: Outcome at Six-Month Followup

The Effectiveness of Immersive Virtual Reality-Based Treatment for Mental Disorders: A Systematic Review With Meta-Analysis

BACKGROUND

The increasing number of studies of immersive virtual reality (VR) interventions for mental disorders call for an examination of the current level of evidence on their effectiveness. The findings may guide scalability and contribute to the advancement and optimization of immersive VR-based interventions for mental disorders.

METHODS

A systematic literature search across four databases screened 2443 studies. Outcomes were disorder-specific symptoms, cognition, function, and quality of life. The study is registered on PROSPERO (CRD42023465845) and follows the reporting standards outlined in the PRISMA guidelines.

RESULTS

Fifty-five studies involving a total of 3031 participants covering 10 mental disorders were included in the analysis. VR interventions demonstrated statistically significant effects of post-treatment compared to active control conditions for alcohol use disorder (reduced state anxiety, g = 0.89, 95% CI[0.24, 1.55]) and schizophrenia spectrum disorders (reduced psychotic symptoms, g = 0.37, 95% CI[0.04, 0.70]). Compared to passive control conditions, statistically significant effects of VR interventions were observed for panic and agoraphobia (g = 1.28, 95% CI [0.47, 2.10]), social anxiety disorder (g = 0.83, 95% CI [0.49, 1.17]), specific phobias (g = 1.07, 95% CI[0.22, 1.92]), depression symptoms in PTSD (g = 0.67, 95% CI [0.22;1.13]). In contrast, no significant differences were found between VR interventions and active control conditions for functioning and quality of life in schizophrenia spectrum disorder and panic or agoraphobia. No meta-analyses were conducted on cognition due to insufficient data. Over 50% of the included studies were assessed as having a high risk of bias. According to the GRADE assessment, evidence for VR-based interventions across various mental disorders was generally of low to very low certainty, with a few exceptions rated as moderate certainty.

CONCLUSION

VR interventions may potentially have benefits, particularly when compared to passive control conditions, however, the evidence remains uncertain necessitating more large-scale, methodologically robust studies. Current findings can thus only be considered indicative. Recommendations on future directions of the VR field are discussed.

Established and emerging treatments for eating disorders

Eating disorders (EDs) are common mental health conditions that carry exceedingly high morbidity and mortality rates. Evidence-based treatment options include a range of psychotherapies and some, mainly adjunctive, pharmacological interventions. However, around 20-30% of people fail to respond to the best available treatments and develop a persistent treatment-refractory illness. Novel treatments for these disorders are emerging, but their efficacy and clinical relevance need further investigation. In this review article, we first outline the evidence-base for the established treatments of the three 'classical' EDs [anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)]. We then review research on some of the most promising emerging treatment modalities, discussing the questions and challenges that remain.

Mixed Reality for a collective and adaptive mental health metaverse

This research paper explores the significant transformative potential of Mixed Reality (MR) technology as enabler of the metaverse, specifically aimed at enhancing mental health therapies. The emerging world of the metaverse, a multiuser, adaptive, three-dimensional digital space, paired with the interactive and immersive benefits of MR technology, promises a paradigm shift in how mental health support is delivered. Unlike traditional platforms, MR allows for therapy within the comfort of the user's familiar surroundings, while incorporating the benefits of social collaboration and interactions. The metaverse environment fosters heightened personalization and deeper user engagement, thereby offering a more tailored approach to computerized therapy. Beyond its immersive capabilities, MR offers potential for real-time, smart adaptations to the users' psycho-physiological state, targeting unique patients' needs on a diverse spectrum of therapeutic techniques, thus broadening the scope of mental health support. Furthermore, it opens avenues for continuous emotional support in everyday life situations. This research discusses the benefits and potentials of integrating MR within a mental health metaverse, highlighting how this innovative approach could significantly complement traditional therapeutic methods, fostering improved treatment efficacy, focusing on social and collective experiences, and increasing patient engagement.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

[An Integrated Audio-Visual-Olfactory Virtual Reality False Feeding Device: Research, Development, and Design]

Objective

To resolve the problem of the lack of sensory stimulation from the colors and aromas of food when patients are given enteral nutrition support by tube feeding or simple oral administration, an immersive virtual reality (VR) sham feeding device integrating audio, visual, and olfactory sense perceptions was developed independently and the usability of the device was tested.

Methods

Relying on the multidisciplinary cooperation of nursing, mechanical engineering, and computer science and using as a reference the characteristics of gastric tube and oxygen tube placement in clinical patients, we carried out 3D modeling and printing of the exterior framework of the odor box. Unity 3d.5.x, a mainstream virtual engine tool, was used to create scenarios. The device could create visual stimulation through 3 VR dining scenarios, 23 kinds of food, and comfortable dining environment. The sound of chewing was played to simulate the dining process and provide auditory stimulation. Through the independently researched and developed olfactory odor box, corresponding food aromas were sprayed out for olfactory stimulation. After the equipment prototype was created, 10 patients were recruited to perform users' subjective evaluation of the usability of the equipment.

Results

A VR sham feeding device integrating audio-visual-olfactory stimulation was successfully developed. In the visual effect evaluation, all users commented that the vision was clear and unimpeded, and that the menu program could follow their rotation movement. Eight people considered the scenes to be rather realistic. In the auditory effect evaluation, all users stated that the volume of the sound was appropriate, and that they would hear a chewing sound being played when the food was approaching. In the olfactory effect evaluation, 9 people stated that they smelled the food aromas when the food was approaching, and that they thought the odor was real or partially real. On the whole, the equipment was convenient to use and all users thought that the equipment had clear presentation and could run stably and smoothly. No adverse reactions, such as dizziness, occurred in any users.

Conclusion

Successfully presenting visual, auditory, and olfactory stimuli, the prototype device passed the subjective usability test. The prototype device effectively expands the application prospects of VR in the medical field. In the future, it will be applied to patient populations, including surgical patients, patients with eating disorders, obesity, and loss of appetite, and other patients who cannot take in food through their mouths. The prototype device provides new ideas for promoting enhanced recovery after surgery and improving patient experience.

Obtaining long-term recovery: advances in optimizing treatment outcomes in patients with binge-eating disorder

INTRODUCTION

Binge-eating disorder (BED) is a complex and disabling eating disorder (ED) associated with considerable burden and impairments in quality of life and physical/mental health. It has been recognized as a formal ED category since 2013, however BED is still underdetected and undertreated.

AREAS COVERED

This review summarizes the advances in the understanding of the pathophysiology of BED as well as the evidence on the efficacy of the existing treatments. The authors searched Scopus, PubMed, ClinicalTrials.Gov, and ANZCTR with terms including 'assessment' OR 'treatment' OR 'diagnosis' OR 'mechanisms' AND 'binge eating' OR 'binge-eating disorder' for manuscripts published between January 2013 and April 2023.

EXPERT OPINION

Most of the trials on treatments of BED have been in people of high weight with weight loss as an outcome. Nevertheless, less is known about the treatment of this condition in people with body mass index (BMI) within the normal range where weight stabilization may be a more appropriate goal. Moreover, there is a need for an enhanced appreciation of the role of combination treatment to improve overall outcomes. Also, there are important opportunities for future research in understanding the mechanisms of action and effectiveness of BED treatments.

Complementary and Integrative Medicine and Eating Disorders in Youth: Traditional Yoga, Virtual Reality, Light Therapy, Neurofeedback, Acupuncture, Energy Psychology Techniques, Art Therapies, and Spirituality

Eating disorders (EDs) are a non-heterogeneous group of illnesses with significant physical and mental comorbidity and mortality associated with maladaptive coping. With the exception of lisdexamfetamine (Vyvanse) for binge eating disorder, no medications have been effective for the core symptoms of ED. ED requires a multimodal approach. Complementary and integrative medicine (CIM) can be helpful as an adjunct. The most promising CIM interventions are traditional yoga, virtual reality, eye movement desensitization and reprocessing, Music Therapy, and biofeedback/neurofeedback.

An Attentional Bias Modification Task, through Virtual Reality and Eye-Tracking Technologies, to Enhance the Treatment of Anorexia Nervosa

Mirror exposure therapies (METs) have been shown to be effective in reducing body image disturbances through the habituation process. Virtual reality (VR) combined with eye-tracking techniques can provide innovative solutions to some of METs’ limitations reported with patients with anorexia nervosa (AN), especially the negative influence of body-related attentional bias (AB). This pilot study aimed to assess the preliminary efficacy of a new VR-based AB modification task (ABMT) among healthy women and the procedure’s user experience. AB levels towards weight- and non-weight-related body parts, using complete fixation time (CFT) and number of fixations (NF), were assessed throughout the ABMT procedure (300 trials). The user experience was evaluated at the end of the procedure. The results showed that VR-based ABMT was effective in reducing AB significantly after 150 trials for both CFT- and NF-based measures, although 225 trials were necessary to get the same result for women with an NF initially more oriented towards weight-related body parts. Overall, the software received a “C-rating” on a scale from “A” (most usable) to “F” (least usable). These results provide evidence of the opportunity to use a VR-based ABMT procedure to reduce AB and improve existing treatments for AN.

Clinical and Peripheral Biomarkers in Female Patients Affected by Anorexia: Does the Neutrophil/Lymphocyte Ratio (NLR) Affect Severity?

Anorexia Nervosa (AN) is a disabling disorder characterized by extreme weight loss and frequent chronicization, especially in its most severe forms. This condition is associated with a pro-inflammatory state; however, the role of immunity in symptom severity remains unclear. Total cholesterol, white blood cells, neutrophils, lymphocytes, platelets, iron, folate, vitamin D and B12 were dosed in 84 female AN outpatients. Mildly severe (Body Mass Index-BMI ≥ 17) versus severe (BMI < 17) patients were compared using one-way ANOVAs or χ² tests. A binary logistic regression model was run to investigate the potential association between demographic/clinical variables or biochemical markers and the severity of AN. Patients with severe anorexia (compared to mild forms) were older (F = 5.33; p = 0.02), engaged in more frequent substance misuse (χ² = 3.75; OR = 3.86; p = 0.05) and had a lower NLR (F = 4.12; p = 0.05). Only a lower NLR was predictive of severe manifestations of AN (OR = 0.007; p = 0.031). Overall, our study suggests that immune alterations may be predictive of AN severity. In more severe forms of AN, the response of the adaptive immunity is preserved, while the activation of the innate immunity may be reduced. Further studies with larger samples and a wider panel of biochemical markers are needed to confirm the present results.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

From Virtual Reality to Regenerative Virtual Therapy: Some Insights from a Systematic Review Exploring Inner Body Perception in Anorexia and Bulimia Nervosa

Despite advances in our understanding of the behavioral and molecular factors that underlie the onset and maintenance of Eating Disorders (EDs), it is still necessary to optimize treatment strategies and establish their efficacy. In this context, over the past 25 years, Virtual Reality (VR) has provided creative treatments for a variety of ED symptoms, including body dissatisfaction, craving, and negative emotions. Recently, different researchers suggested that EDs may reflect a broader impairment in multisensory body integration, and a particular VR technique-VR body swapping-has been used to repair it, but with limited clinical results. In this paper, we use the results of a systematic review employing PRISMA guidelines that explore inner body perception in EDs (21 studies included), with the ultimate goal to analyze the features of multisensory impairment associated with this clinical condition and provide possible solutions. Deficits in interoception, proprioception, and vestibular signals were observed across Anorexia and Bulimia Nervosa, suggesting that: (a) alteration of inner body perception might be a crucial feature of EDs, even if further research is needed and; (b) VR, to be effective with these patients, has to simulate/modify both the external and the internal body. Following this outcome, we introduce a new therapeutic approach-Regenerative Virtual Therapy-that integrates VR with different technologies and clinical strategies to regenerate a faulty bodily experience by stimulating the multisensory brain mechanisms and promoting self-regenerative processes within the brain itself.

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.

Novel Approaches to Tackling Emotional Loss of Control of Eating Across the Weight Spectrum

Emotional overeating is a process that is particularly relevant to people within the binge spectrum of eating disorders. Approximately a third of people with overweight share this phenotype. In addition, this behaviour may occur in neurodevelopmental disorders (attention-deficit hyperactivity disorder (ADHD)) and other psychiatric disorders. The biopsychosocial underpinnings of emotional eating include a genetic vulnerability to a higher weight and various cognitive and emotional traits. The environment also plays a key role. For example, the commodification of food and beauty and exposure to weight stigma, unpleasant eating experiences and general adversity can set the scene. The majority of people with binge-eating disorder do not seek treatment (perhaps related to internalised stigma and shame). Hence opportunities for early intervention and secondary prevention are lost. Most guidelines for binge-eating disorder (based on the limited available research) recommend forms of cognitive psychotherapies and antidepressants. However, novel treatments that target underlying mechanisms are in development. These include interventions to improve emotional regulation and inhibitory control using neuromodulation and/or brain training. New technologies have been applied to talking therapies, including apps which can offer ‘just-in-time interventions’ or virtual reality or avatar work which can deliver more personalised interventions using complex scenarios. Drugs used for the treatment of ADHD, psychiatric and metabolic disorders may have the potential to be repurposed for binge-eating disorder. Thus, this is an area of rapid change with novel solutions being applied to this problem.

A tranquil virtual reality experience to reduce subjective stress among COVID-19 frontline healthcare workers

OBJECTIVE

The novel coronavirus-19 (COVID-19) has taken an immense physical, social, and emotional toll on frontline healthcare workers. Research has documented higher levels of anxiety, depression, and burnout among healthcare workers during the pandemic. Thus, creative interventions are needed now more than ever to provide brief, accessible support to frontline workers. Virtual reality is a rapidly growing technology with potential psychological applications. In this study, we piloted a three-minute Tranquil Cinematic-VR simulation of a nature scene to lower subjective stress among frontline healthcare workers in COVID-19 treatment units. We chose to film a nature scene because of the extensive empirical literature documenting the benefits of nature exposure and health.

METHODS

A convenience sample of frontline healthcare workers, including direct care providers, indirect care providers, and support or administrative services, were recruited from three COVID-19 units located in the United States. Inclusion criteria for participation included adults aged 18 years and older who could read and speak in English and were currently employed by the healthcare system. Participants viewed a 360-degree video capture of a lush, green nature preserve in an Oculus Go or Pico G2 4K head-mounted display. Prior to viewing the simulation, participants completed a brief demographic questionnaire and the visual analogue scale to rate their subjective stress on a 10-point scale, with 1 = 'Not at all stressed' to 10 = 'Extremely stressed.' We conducted paired t-tests to examine pre- and post-simulation changes in subjective stress as well as Kruskal-Wallis tests and Mann-Whitney U tests to examine differences by demographic variables. All analyses were conducted in SPSS statistical software version 28.0. We defined statistical significance as a p-value less than .05.

RESULTS

A total of 102 individuals consented to participate in the study. Eighty-four (82.4%) participants reported providing direct patient care, 73 (71.6%) identified as women, 49 (48.0%) were between the ages of 25-34 years old, and 35 (34.3%) had prior experience with VR. The pre-simulation mean stress score was 5.5±2.2, with a range of 1 to 10. Thirty-three (32.4%) participants met the 6.8 cutoff for high stress pre-simulation. Pre-simulation stress scores did not differ by any demographic variables. Post-simulation, we observed a significant reduction in subjective stress scores from pre- to post-simulation (mean change = -2.2±1.7, t = 12.749, p < .001), with a Cohen's d of 1.08, indicating a very large effect. Further, only four (3.9%) participants met the cutoff for high stress after the simulation. Post-simulations scores did not differ by provider type, age range, gender, or prior experience with virtual reality.

CONCLUSIONS

Findings from this pilot study suggest that the application of this Tranquil Cinematic-VR simulation was effective in reducing subjective stress among frontline healthcare workers in the short-term. More research is needed to compare the Tranquil Cinematic-VR simulation to a control condition and assess subjective and objective measures of stress over time.

The transdiagnostic role of food craving: An application of substance use models

Food craving is a transdiagnostic process underlying clinically significant disordered eating behaviors and eating disorder diagnoses. However, the lack of literature examining the role of food craving as it relates to the full spectrum of disordered eating behaviors, including restrictive eating and compensatory behaviors, may be due to the traditional definition of food craving as the desire to consume particular foods. Applying motivational models of substance use craving to food craving may help to explain inconsistencies within existing literature. Three motivational models of craving from the substance use literature may be particularly applicable to (1) provide a clear definition of food craving as a motivational process, (2) understand the role of that motivational process as it underlies the full spectrum of disordered eating behavioral patterns, (3) provide insight for the most appropriate ways in which to accurately assess food craving, and (4) establish ways in which food craving may represent a useful motivational process to target in eating disorder treatments. This narrative review describes three models of substance use craving and provides suggestions for utilizing motivational models to understand the transdiagnostic role of food craving as it relates to the full spectrum of disordered eating behaviors in both research and clinical work.

Addressing virtual reality misclassification: A hardware-based qualification matrix for virtual reality technology

Through its unique sensory synchronized design, virtual reality (VR) provides a convincing, user-centred experience of highly controllable scenarios. Importantly, VR is a promising modality for healthcare, where treatment efficacy has been recognized for a range of conditions. It is equally valuable across wider research disciplines. However, there is a lack of suitable criteria and consistent terminology with which to define VR technology. A considerable number of studies have misclassified VR hardware (e.g. defining laptops as VR), hindering validity and research comparisons. This review addresses these limitations and establishes a standardized VR qualification framework. As a result of a comprehensive theoretical and literature review, the hardware-based VR qualification matrix is proposed. The matrix criteria consist of (1) three-dimensional (3D) synchronized sensory stimulation; (2) degrees of freedom tracking; and (3) visual suppression of physical stimuli. To validate the model and quantify the current scale/diversity of VR misclassification, a 2019 sectional review of health-related studies was conducted. Of the 115 studies examined against standardized criteria, 35.7% utilized VR, 31.3% misclassified VR, 18.3% were considered quasi-VR, and 14.8% omitted critical specifications. The proposed model demonstrates good validity and reliability for qualifying and classifying VR. Key Practitioner Messages Virtual reality (VR) therapy has gained rapid empirical support, although many practitioners do not understand the difference between genuine and less-realistic VR variations. That has resulted from an evident lack of suitable criteria to define VR across a range of studies and protocols. Our proposed hardware-based virtual reality qualification matrix addresses issues to do with misclassification, via the introduction of standardised criteria. Applying the matrix to existing literature has revealed that more than 30% of VR studies use hardware that does not fit the high standards of rigour required for immersion in a simulated space. The model is a practical tool researchers and practitioners can use to quality and verify VR standards across research studies.

Virtual reality in the treatment of eating disorders

Over the last 25 years, virtual reality (VR) has offered innovative solutions for targeting different key symptoms of eating disorders: from craving to negative emotions, from attentional biases to body dissatisfaction. The present narrative review assesses the existing literature in these areas trying to identify their different levels of clinical evidence. Specifically, the review presents four clinical approaches based upon VR and their implications in the treatment of eating disorders: VR cue exposure, VR reference frame shifting, VR for correcting body distortions and attentional biases. In general, existing findings demonstrate the clinical value of VR. On one side, the present review suggests that two VR-based techniques-VR exposure and reference frame shifting-have a significant research support and provide a possible advantage over traditional cognitive-behavioural therapy (CBT) for bulimia nervosa and binge eating disorder. On the other side, two emerging VR applications-multisensory body illusions and the use of VR for the modification of attentional biases-even if supported by preliminary data still need further research.

[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.

Translating Virtual Reality Cue Exposure Therapy for Binge Eating into a Real-World Setting: An Uncontrolled Pilot Study

Binge-eating disorder (BED) and bulimia nervosa (BN) have adverse psychological and medical consequences. Innovative interventions, like the integration of virtual reality (VR) with cue-exposure therapy (VR-CET), enhance outcomes for refractory patients compared to cognitive behavior therapy (CBT). Little is known about the feasibility and acceptability of translating VR-CET into real-world settings. To investigate this question, adults previously treated for BED or BN with at least one objective or subjective binge episode/week were recruited from an outpatient university eating disorder clinic to receive up to eight weekly one-hour VR-CET sessions. Eleven of 16 (68.8%) eligible patients were enrolled; nine (82%) completed treatment; and 82% (9/11) provided follow-up data 7.1 (SD = 2.12) months post-treatment. Overall, participant and therapist acceptability of VR-CET was high. Intent-to-treat objective binge episodes (OBEs) decreased significantly from 3.3 to 0.9/week (p < 0.001). Post-treatment OBE 7-day abstinence rate for completers was 56%, with 22% abstinent for 28 days at follow-up. Among participants purging at baseline, episodes decreased from a mean of one to zero/week, with 100% abstinence maintained at follow-up. The adoption of VR-CET into real-world clinic settings appears feasible and acceptable, with a preliminary signal of effectiveness. Findings, including some loss of treatment gains during follow-up may inform future treatment development.

Virtual Reality Therapy in Mental Health

Initially designed for the treatment of phobias, the use of virtual reality in phobic disorders has expanded to other mental health disorders such as posttraumatic stress disorder, substance-related disorders, eating disorders, psychosis, and autism spectrum disorder. The goal of this review is to provide an accessible understanding of why this approach is important for future practice, given its potential to provide clinically relevant information associated with the assessment and treatment of people suffering from mental illness. Most of the evidence is available for the use of virtual reality exposure therapy in anxiety disorders and posttraumatic stress disorder. There is hardly any evidence that virtual reality therapy is effective in generalized anxiety disorder and obsessive-compulsive disorder. There is increasing evidence that cue exposure therapy is effective in addiction and eating disorders. Studies into the use of virtual reality therapy in psychosis, autism spectrum disorder, and attention deficit hyperactivity disorder (ADHD) are promising.

Virtual Reality and Psychedelics for the Treatment of Psychiatric Disease: A Systematic Literature Review

OBJECTIVE

Hallucinogenic substances or psychedelic drugs have been historically used by humans worldwide for centuries, and interest grows around them because of the therapeutic potential that they pose for mental disease. Virtual Reality (VR), has been highly developed and improved in the last decade, and it is also gaining importance due to their potential as therapeutic tools. In this article, the most recent and relevant information regarding the medical applications of both VR and psychedelics was highlighted, and diverse potential therapeutic uses were explored in hope to set the ground for further research on this topic.

METHOD

A systematic literature review using the PRISMA methods was conducted in PubMed, Medline, Embase, Cochrane Library, Scopus and Web of Science, including only peer-reviewed clinical trials or case studies written in English, that address the use of psychedelics and/or VR for the treatment of psychiatric disorders and that measure the success of the therapies. A final selection of 23 manuscripts were used in this systematic review.

RESULTS

VR showed security and significant efficacy in the management of special cases of phobias (social, motion pain and spiders), eating disorder, post-traumatic stress disorder (PTSD), gambling disorder, preoperative anxiety and schizophrenia.

CONCLUSIONS

The hallucinogenic drugs evaluated exhibited positive effects in treatment of depressive and anxiety disorders, alcohol dependence and PTSD. More research is needed in order to test the effectiveness of these therapies (alone or together) in different mental illnesses and different populations.

The efficacy of virtual reality in the treatment of binge-purging eating disorders: A meta-analysis

OBJECTIVE

This paper aims to examine the efficacy of virtual reality (VR)-enhanced cognitive behavioural therapy (CBT) in the treatment of binge-purging type eating disorders compared to CBT.

METHOD

Four electronic literature databases were searched to retrieve eligible randomised controlled trials (RCTs). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to select eligible studies. Meta-analyses of extracted data were then conducted by RevMan 5.3 software.

RESULTS

Six RCTs totalling 297 participants were included. Results showed significantly larger decreases in the frequency of binges in participants who underwent VR-enhanced CBT compared to CBT. However, there was no statistically significant difference in the change in body mass index or frequency of purges. Additionally, there were significantly larger decreases in situation-induced body dissatisfaction in participants who underwent VR-enhanced CBT compared to CBT, but no significant difference in improvement of overall body satisfaction.

CONCLUSION

VR-enhanced CBT shows greater efficacy than CBT in reducing situation-induced body dissatisfaction and frequency of binges. Our results highlight the potential of VR in helping patients develop coping strategies to food/situational triggers. Future RCTs may benefit from recruiting more participants to reduce the impact of drop-outs on outcome data and blinding post-intervention assessors to reduce risk of bias.

Predictors of Changes in Alcohol Craving Levels during a Virtual Reality Cue Exposure Treatment among Patients with Alcohol Use Disorder

BACKGROUND/OBJECTIVE

Determining the predictive variables associated with levels of alcohol craving can ease the identification of patients who can benefit from treatments. This study aimed to describe changes (improvement or no change/deterioration) in alcohol craving levels and explore the predictors of these changes from admission to discharge in outpatients with alcohol use disorder (AUD) undergoing treatment-as-usual (TAU), or treatment-as-usual supplemented with virtual reality cue-exposure therapy (TAU + VR-CET).

METHOD

A prospective cohort study was conducted amongst 42 outpatients with AUD (n = 15 TAU + VR-CET and n = 27 TAU) from a clinical setting. Changes in the levels of alcohol craving between admission and discharge were assessed with the Multidimensional Alcohol Craving Scale. Sociodemographic characteristics (age, gender, education, and socioeconomic and civil status), cognitive-affective behavioral patterns (AUD severity, abstinence duration, psychiatric comorbidity, state anxiety, attentional bias, and substance use), and type of treatment (TAU + VR-CET and only TAU) were also evaluated.

RESULTS

The TAU + VR-CET group showed greater changes of improvement in the levels of alcohol craving than the TAU group (χ2 = 10.996; p = 0.001). Intragroup changes in alcohol craving from pre to post-treatment were significant in the TAU + VR-CET group (χ2 = 13.818; p = 0.003) but not within the TAU group (χ2 = 2.349; p = 0.503). The odds of an improvement in any of the craving levels between pre- and post-test was 18.18 (1/0.055) times higher in the TAU + VR-CET group with respect to the TAU group. The use of illicit drugs in the month prior to the test increased the odds of having a positive change by 18.18 (1/0.055) with respect to not having consumed.

CONCLUSIONS

Including VR-CET in TAU programs may provide benefits in the treatment of AUDs mainly among patients with intense alcohol craving and individuals having used illicit substances prior to treatment.

Advancing science and practice using immersive virtual reality: what behavioral medicine has to offer

Interest in immersive virtual reality (VR) technologies is burgeoning as the hardware becomes less costly and more accessible to users, including researchers and practitioners. This commentary outlines the field of immersive VR and highlights applications of its use relevant to translational behavioral medicine. We describe the challenges facing VR applications for health and medicine, and how the core strengths of behavioral medicine can advance theory, research, and practice using VR. By highlighting potential uses of immersive VR alongside the challenges facing the field, we hope to inspire researchers to apply robust theories, methods, and frameworks to generate stronger evidence about the feasibility, acceptability, efficacy, and effectiveness of using this technology in translational behavioral medicine.

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.

Eating disorders

Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes towards weight, body shape, and eating play a key role in the origin and maintenance of eating disorders. Eating disorders have been increasing over the past 50 years and changes in the food environment have been implicated. All health-care providers should routinely enquire about eating habits as a component of overall health assessment. Six main feeding and eating disorders are now recognised in diagnostic systems: anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant-restrictive food intake disorder, pica, and rumination disorder. The presentation form of eating disorders might vary for men versus women, for example. As eating disorders are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed.

The Effects of Viewing an Uplifting 360-Degree Video on Emotional Well-Being Among Elderly Adults and College Students Under Immersive Virtual Reality and Smartphone Conditions

Positive emotions are important for the physical and mental health of elderly adults. Previous research has suggested that the emotion processing mechanisms of elderly adults differ from those of young people. The current study used a mixed-methods approach to explore the emotional impacts of viewing an uplifting 360° videos under immersive (using a virtual reality [VR] headset) and nonimmersive (using a smartphone) conditions on elderly populations and young people. In Study 1, we conducted a pre-post treatment between-subject field experiment (smartphone vs. VR) among 58 seniors (aged 60 years and above) in a community center in Beijing, China. One-on-one semistructured interviews of each participant were conducted after the experiment. In Study 2, we conducted a between-subject laboratory experiment with the same design among college students. The results show that while both VR and smartphone viewing conditions led to a significant positive effect on the self-reported emotions of the college students, only the smartphone viewing condition had a significant impact on the emotional well-being of the elderly participants. For college students, immersive VR had a stronger effect on inducing positive emotions than smartphone, but for elderly people, the smartphone viewing condition was more effective in improving emotional wellbeing than immersive VR. An analysis of the qualitative data from interviewing the elderly participants also revealed a divergence in the acceptance of VR technologies among elderly adults, and the sense of telepresence had both positive and negative effects on the elderly participants' emotions and experiences.

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.

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.