The key to unlocking the virtual body: virtual reality in the treatment of obesity and eating disorders

Exploring the moderating roles of dispositional mindfulness and body image flexibility in the association between body dissatisfaction and disordered eating in Chinese adolescents

OBJECTIVES

Previous research suggests potential moderating roles of dispositional mindfulness and body image flexibility in the association between body dissatisfaction and disordered eating. However, relevant research is mainly conducted on adult women from Western countries, and limited evidence exists for adolescent samples, especially from non-Western contexts (e.g., China). Thus, this study aimed to examine the moderating roles of dispositional mindfulness and body image flexibility in the relationship between body dissatisfaction and disordered eating in Chinese adolescents.

METHOD

We recruited 545 Chinese adolescents (53.9% boys, aged 12-16 years) who completed measures of body dissatisfaction, dispositional mindfulness, body image flexibility, and disordered eating. Moderation analyses were examined with PROCESS macro on SPSS.

RESULTS

In separate models, both higher dispositional mindfulness and body image flexibility weakened relationships between body dissatisfaction and disordered eating. However, when both dispositional mindfulness and body image flexibility were entered into the same moderation model, only body image flexibility showed a significant moderating effect.

DISCUSSION

Both dispositional mindfulness and body image flexibility may weaken the association between body dissatisfaction and disordered eating in adolescents. However, body image flexibility might have a stronger effect than dispositional mindfulness. These findings suggest that interventions aimed at reducing body dissatisfaction to prevent disordered eating in adolescents may pay more attention to adolescents' body image flexibility.

Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial

BACKGROUND

In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing.

QUESTIONS/PURPOSES

Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal?

METHODS

This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes.

RESULTS

There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99).

CONCLUSION

During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Perceived Body Size in Relation to 10-Year Weight Change in the Swedish Obese Subjects Intervention Study

INTRODUCTION

Body size underestimation in patients with obesity may be associated with long-term weight increase. In the current report, we analyse changes in body size perception in patients with obesity undergoing either bariatric surgery or usual obesity care, and in subgroups of patients who gain weight or maintain their body weight over 10 years.

MATERIALS AND METHODS

A total of 2,504 patients with obesity from the prospective, controlled Swedish Obese Subjects (SOS) intervention study were included in this report, 1,370 patients underwent bariatric surgery and 1,134 patients were usual care controls. Weight was measured and body size was self-estimated using the Stunkard's figure rating scale at baseline and after 0.5, 1, 2, 3, 4, 6, 8 and 10 years of follow-up. A body perception index (BPI) was calculated as estimated/measured BMI. Weight (re)gain was defined as ≥10% increase between 1 and 10 years of follow-up.

RESULTS

Body size was underestimated by 12% in the surgery and 14% in the control group (i.e., >5 BMI units) at baseline and underestimation largely persisted over 10 years in both intervention groups. When stratified by long-term weight development, weight regainers from the surgery group underestimated their body size to a larger degree compared to weight maintainers (12 vs. 9%, p < 0.001) after 10 years. Likewise weight gainers in the control group also underestimated their body size to a larger degree (17% vs. 13%, p < 0.001). In both groups, the change in BPI was significantly different between weight regainers and maintainers during follow-up (time-BPI interactions both p < 0.001).

CONCLUSION

Patients with obesity underestimate their body size and this underestimation remains long-term even after major weight loss induced by bariatric surgery. In patients with obesity who maintain their weight, regardless of treatment, underestimation of body size persists but body size perception is slightly more accurate compared to patients who gain or regain weight long-term.

Defining digital coaching: a qualitative inductive approach

The term 'digital coaching' is widely used but ill-defined. The present study therefore investigates how digital coaching is defined and how it differentiates from face-to-face coaching and other digital-technology-enabled (DT-enabled) formats, such as digital training, digital mentoring, or digital consulting. A qualitative inductive approach was chosen for more in-depth and open-minded content. Based on previous studies on the importance of asking coaches working in the field, 260 coaches working in the field of digital coaching were surveyed. The given answers depict the importance of differing between forms of DT-enabled coaching. Thus, digital coaching is a DT-enabled, synchronous conversation between a human coach and a human coachee, which is different to artificial intelligence (AI) coaching and coaching that is supported by asynchronous digital and learning communication technologies. Due to this definition and differentiation, future studies can explore the digital coaching process and its effectiveness - particularly in comparison to other formats. Furthermore, this clear definition enables practitioners to maintain professional standards and manage client's expectations of digital coaching while helping clients understand what to expect from digital coaching.

Eating Behavior and Satiety With Virtual Reality Meals Compared With Real Meals: Randomized Crossover Study

BACKGROUND

Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment.

OBJECTIVE

This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women.

METHODS

The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires.

RESULTS

There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=-5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals.

CONCLUSIONS

Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209.

Digital communication and virtual reality for extending the behavioural treatment of obesity - the patients' perspective: results of an online survey in Germany

BACKGROUND

CBT has been found effective for the treatment of EDs and obesity. However not all patients achieve clinically significant weight loss and weight regain is common. In this context, technology-based interventions can be used to enhance traditional CBT but are not yet widespread. This survey therefore explores the status quo of pathways of communication between patients and therapists, the use of digital applications for therapy as well as attitudes towards VR from the perspective of patients with obesity in Germany.

METHODS

This cross-sectional online survey was conducted in October 2020. Participants were recruited digitally through social media, obesity associations and self-help groups. The standardized questionnaire included items concerning current treatment, paths of communication with their therapists, and attitudes toward VR. The descriptive analyses were performed with Stata.

RESULTS

The 152 participants were mostly female (90%), had a mean age of 46.5 years (SD = 9.2) and an average BMI of 43.0 kg/m² (SD = 8.4). Face-to-face communication with their therapist was considered of high importance in current treatment (M = 4.30; SD = 0.86) and messenger apps were the most frequently used digital application for communication. Participants were mostly neutral regarding the inclusion of VR methods in obesity treatment (M = 3.27; SD = 1.19). Only one participant had already used VR glasses as part of treatment. Participants considered VR suitable for exercises promoting body image change (M = 3.40; SD = 1.02).

DISCUSSION

Technological approaches in obesity therapy are not widespread. Face-to-face communication remains the most important setting for treatment. Participants had low familiarity with VR but a neutral to positive attitude toward the technology. Further studies are needed to provide a clearer picture of potential treatment barriers or educational needs and to facilitate the transfer of developed VR systems into clinical practice.

Metaverse!

This study aimed to synthesize the literature on Metaverse to highlight its current research, opportunities, and applications in e-healthcare and education to reduce inequalities and for delivering fair and equal opportunities and solutions. The authors employed preferred reporting items for systematic reviews and meta-analyses (PRISMA) to rapidly map the field of a metaverse in health and education. Two major application domains emerged in the literature from the 88 research publications, which include (1) Metaverse in healthcare and (2) Metaverse in education. This study will act as a road map to help academics who desire to continue their research work in the Metaverse for various healthcare and educational services. However, its implementation is required in the future to improve mental healthcare and the effectiveness of mental health services, particularly in low and medium-income (LMIC) and conflict-affected areas.

Long-term changes in body image after bariatric surgery: An observational cohort study

BACKGROUND

While body image improves in the first few months after surgery, data on long-term changes in body image after bariatric surgery are scarce and contradictory.

METHODS

We assessed body image through the Stunkard Figure Rating Scale and the Multidimensional Body-Self Relations Questionnaire-Appearance Scale, which measures appearance evaluation and orientation, overweight preoccupation, and self-classified weight. Surveys were conducted before surgery and at regular intervals until 5 years after bariatric surgery.

RESULTS

61 patients were included in the study. No patients were lost to follow-up until 18 months after bariatric surgery. At 5 years, there were 21 patients (34%) lost to follow-up. We detected an overall improvement in body image until 12-18 months post-surgery. Scores declined after 5 years post-surgery but were still higher than preoperative evaluations. Overweight preoccupation did not change throughout the follow-up period. There was a positive correlation between body weight lost and appearance evaluation. There was also a positive correlation between weight loss and the Body Areas Satisfaction Scale. There was a negative correlation between weight loss and overweight preoccupation. Appearance orientation and self-classified weight were not correlated with weight loss.

CONCLUSIONS

Body image improved after bariatric surgery but was not maintained for all 5 years after surgery.

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.

Virtual Reality-Based Immersive Rehabilitation for Cognitive- and Behavioral-Impairment-Related Eating Disorders: A VREHAB Framework Scoping Review

Virtual reality (VR) technology is one of the promising directions for rehabilitation, especially cognitive rehabilitation. Previous studies demonstrated successful rehabilitation in motor, cognitive, and sensorial functions using VR. The objective of this review is to summarize the current designs and evidence on immersive rehabilitation interventions using VR on cognitive- or behavioral-related eating disorders, which was mapped using a VREHAB framework. Two authors independently searched electronic databases, including PubMed, Web of Science, Scopus, CINAHL, EMBASE, and Cochrane Library. Ten (n = 10) articles were eligible for review. Treatments for anorexia nervosa and binge eating disorder/bulimia nervosa were reported through enhanced/experimental cognitive behavior therapy (ECT), cue exposure therapy (CET), and body exposure therapy (BET) via the virtual environment. Some studies reported that the VR effects were superior or comparable to traditional treatments, while the effects may last longer using VR technology. In addition, VR was perceived as acceptable and feasible among patients and therapists and could be valuable for supplementing existing therapies, relieving manpower and caregiver burdens. Future studies may consider incorporating haptic, smell, and biofeedback to improve the experience, and thus the effects of the treatments for the users.

Development of an Extended-Reality (XR)-Based Intervention to Treat Adolescent Obesity

Public health policies aimed at obesity reduction are more often directed toward adults than children. This is alarming given that rates of childhood obesity have been steadily increasing, and, if not treated early, adolescents with obesity may develop comorbidities into adulthood. Lifestyle-based interventions are the cornerstone of childhood obesity treatment. Recently, extended-reality (XR)-based interventions have been incorporated into the treatment of obesity, and parents and adolescents perceive virtual reality (VR) interventions as a promising approach to increasing physical activity levels and improving eating habits. VR is a tool that fits perfectly with contemporary adolescent culture, which is radically different from that of just two generations ago. It is plausible that an XR-based intervention for treating adolescents with obesity could have a profound influence on obesity management over the long-term. An understanding of adolescents’ preferences, wants, and needs must be considered in the development of new interventions. We suggest that VR interventions can provide a new approach to weight management for children and adolescents and provide recommendations to assess adolescents’, caregivers’, and primary care providers’ needs. These needs could then be used for the development of an XR-based intervention aimed at inducing sustained lifestyle changes in adolescents with obesity.

eLoriCorps Immersive Body Rating Scale and eLoriCorps Mobile Versions: Validation to Assess Body Image Disturbances from Allocentric and Egocentric Perspectives in a Nonclinical Sample of Adolescents

A growing number of studies have used virtual reality (VR) for the assessment and treatment of body image disturbances (BIDs). This study, conducted in a community sample of adolescents, documents the convergent and discriminant validity between (a) the traditional paper-based Figure Rating Scale (paper-based FRS), (b) the VR-based Body Rating Scale (eLoriCorps-IBRS 1.1), and (c) the mobile app-based Body Rating Scale (eLoriCorps-IBRS 1.1-Mobile). A total of 93 adolescents (14 to 18 years old) participated in the study. Body dissatisfaction and body distortion were assessed through the paper-based FRS, the eLoriCorps-IBRS 1.1 and the eLoriCorps-IBRS 1.1-Mobile. Eating disorder symptoms, body image avoidance, and social physique anxiety were also measured. Correlation analyses were performed. Overall, the results showed a good and statistically significant convergence between allocentric perspectives as measured by the paper-based FRS, the eLoriCorps-IBRS 1.1 and the eLoriCorps-IBRS 1.1-Mobile. As expected, the egocentric perspective measured in VR produced different results from the allocentric perspective, and from cognitive–attitudinal–affective dimensions of BIDs, with the exception of body distortion. These differences support the discriminant validity of the egocentric perspective of eLoriCorps-IBRS 1.1 and are consistent with emerging evidence, highlighting a difference between experiencing the body from an egocentric (i.e., the body as a subject) and allocentric (i.e., the body as an object) perspective. The egocentric perspective could reflect a perceptual–sensory–affective construction of BIDs, whereas allocentric measures seem to be more related to a cognitive–affective–attitudinal construction of BIDs. Moreover, the results support the validity of the eLoriCorps-IBRS 1.1-Mobile with promising perspectives of implementation among young populations.

Analyzing the Sociodemographic Factors Impacting the Use of Virtual Reality for Controlling Obesity

Obesity is one of the most pressing issues in society today. Virtual reality has been used in the design of tools that promotes obesity control. However, the design of current VR tools lacks the involvement of prospective users and health practitioners. Such engagement is crucial in gathering semantic information that identifies stakeholders’ needs and ensures that all aspects of health are considered. Therefore, this paper aims to study the sociodemographic factors and individual-level characteristics and preferences that make the design of any obesity-control VR tool effective and satisfactory for a wide range of users. The paper also aims to solicit opinions of health practitioners to identify best health aspects that should be available in the design of any VR tool for obesity control. Organizations, businesses, and people will be able to readily augment such VR technologies on the semantic web, as well as on personal and mobile devices.

Attitude of Nutrition Experts Toward Psychotherapy and Virtual Reality as Part of Obesity Treatment-An Online Survey

BACKGROUND

The management of obesity requires lifestyle-based interventions covering nutrition, physical activity, and behavior. As part of cognitive behavioral therapy (CBT), body image therapy approaches can be used not only by psychotherapists. One tool to conduct behavioral therapy is virtual reality (VR). It is unknown, whether nutrition experts conduct behavioral therapy, and whether they would like to use VR technology as a tool to conduct body image therapy as part of obesity management.

OBJECTIVE

This survey aimed to collect data from nutrition experts treating people with obesity about the status quo regarding behavioral and body image therapy as part of obesity management, and regarding their attitude toward VR in obesity therapy.

METHODS

The survey was conducted online in autumn 2020. Participants were recruited digitally through expert and professional associations. The standardized questionnaire included items concerning sociodemographic, professional status, behavioral therapy, body image, and VR. The descriptive analysis was performed with Excel, the subgroup analyses with R.

RESULTS

Data from 158 nutrition experts was analyzed. Participants were mostly female (98/102, 96.1%) and had a mean age of 45.6 ± 11.3 years (n = 101). Most of the survey participants (93/124, 75.0%) stated to use behavioral treatment methods in case of weight reduction as the primary target. More than half of the participants stated to address body image (99/150, 66.0%). Almost all (111/112, 99.1%) nutrition experts have never used VR-glasses. The suitability and importance of VR technology as part of obesity therapy was estimated as neutral by around 50%. Overall, no statistically significant difference could be shown between age groups regarding attitudes toward VR in obesity treatment.

CONCLUSION

The results of this non-representative survey indicate that nutrition experts do not use VR technology in nutrition counseling sessions to treat obesity. In addition, survey participants have a positive attitude to VR technology, whereas they are not familiar with this technology. In future, VR technology might support nutrition experts of every age using elements of body image therapy.

SURVEY REGISTRATION

The German Register of Clinical Studies (Registration Number: DRKS00022853).

Dyslexia Telerehabilitation during the COVID-19 Pandemic: Results of a Rhythm-Based Intervention for Reading

The COVID-19 outbreak necessitated a reorganization of the rehabilitation practices for Learning Disorders (LDs). During the lockdown phase, telerehabilitation offered the possibility to continue training interventions while enabling social distancing. Given such an advantage of telerehabilitation methods for LDs, clinical research is still needed to test the effectiveness of diverse teletraining approaches by comparing their outcomes with those of face-to-face interventions. To compare the effectiveness of telerehabilitation vs. in-presence rehabilitation of dyslexia, a rhythm-based intervention for reading, called Rhythmic Reading Training (RRT), was tested in a small-scale clinical trial during the lockdown phase of the COVID-19 pandemic. Thirty children aged 8-13 with a diagnosis of developmental dyslexia were assigned to either a telerehabilitation or an in-presence rehabilitation setting and received RRT for 10 biweekly sessions of 45 min, supervised by a trained practitioner. The results showed that both telerehabilitation and in-presence rehabilitation were effective in improving reading and rapid automatized naming in children with dyslexia and that the effects were comparable between settings. Therefore, RRT was found to be effective in spite of the administration method (remote or in-presence). These results confirm the potential of telemedicine for the rehabilitation of LDs. Clinical Trial ID: NCT04995471.

Mapping out the philosophical questions of AI and clinical practice in diagnosing and treating mental disorders

How to classify the human condition? This is one of the main problems psychiatry has struggled with since the first diagnostic systems. The furore over the recent editions of the diagnostic systems DSM-5 and ICD-11 has evidenced it to still pose a wicked problem. Recent advances in techniques and methods of artificial intelligence and computing power which allows for the analysis of large data sets have been proposed as a possible solution for this and other problems in classification, diagnosing, and treating mental disorders. However, mental disorders contain some specific inherent features, which require critical consideration and analysis. The promises of AI for mental disorders are threatened by the unmeasurable aspects of mental disorders, and for this reason the use of AI may lead to ethically and practically undesirable consequences in its effective processing. We consider such novel and unique questions AI presents for mental health disorders in detail and evaluate potential novel, AI-specific, ethical implications.

Zebrafish and Flavonoids: Adjuvants against Obesity

Obesity is a pathological condition, defined as an excessive accumulation of fat, primarily caused by an energy imbalance. The storage of excess energy in the form of triglycerides within the adipocyte leads to lipotoxicity and promotes the phenotypic switch in the M1/M2 macrophage. These changes induce the development of a chronic state of low-grade inflammation, subsequently generating obesity-related complications, commonly known as metabolic syndromes. Over the past decade, obesity has been studied in many animal models. However, due to its competitive aspects and unique characteristics, the use of zebrafish has begun to gain traction in experimental obesity research. To counteract obesity and its related comorbidities, several natural substances have been studied. One of those natural substances reported to have substantial biological effects on obesity are flavonoids. This review summarizes the results of studies that examined the effects of flavonoids on obesity and related diseases and the emergence of zebrafish as a model of diet-induced obesity.

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.

Virtual Body Ownership Illusions for Mental Health: A Narrative Review

Over the last 20 years, virtual reality (VR) has been widely used to promote mental health in populations presenting different clinical conditions. Mental health does not refer only to the absence of psychiatric disorders but to the absence of a wide range of clinical conditions that influence people’s general and social well-being such as chronic pain, neurological disorders that lead to motor o perceptual impairments, psychological disorders that alter behaviour and social cognition, or physical conditions like eating disorders or present in amputees. It is known that an accurate perception of oneself and of the surrounding environment are both key elements to enjoy mental health and well-being, and that both can be distorted in patients suffering from the clinical conditions mentioned above. In the past few years, multiple studies have shown the effectiveness of VR to modulate such perceptual distortions of oneself and of the surrounding environment through virtual body ownership illusions. This narrative review aims to review clinical studies that have explored the manipulation of embodied virtual bodies in VR for improving mental health, and to discuss the current state of the art and the challenges for future research in the context of clinical care.

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.

Extended Reality for the Clinical, Affective, and Social Neurosciences

Brain science research often involves the use of low-dimensional tools and stimuli that lack several of the potentially valuable features of everyday activities and interactions. Although this research has provided important information about cognitive, affective, and social processes for both clinical and nonclinical populations, there is growing interest in high-dimensional simulations that extend reality. These high-dimensional simulations involve dynamic stimuli presented serially or concurrently to permit the assessment and training of perceivers' integrative processes over time. Moreover, high-dimensional simulation platforms can contextually restrain interpretations of cues about a target's internal states. Extended reality environments extend assessment and training platforms that balance experimental control with emotionally engaging background narratives aimed at extending the affective experience and social interactions. Herein, we highlight the promise of extended reality platforms for greater ecological validity in the clinical, affective, and social neurosciences.

"eLoriCorps Immersive Body Rating Scale": Exploring the Assessment of Body Image Disturbances from Allocentric and Egocentric Perspectives

The first objective of this study was to test the convergent and discriminant validity between the “eLoriCorps Immersive Body Rating Scale” and the traditional paper-based figure rating scale (FRS). The second objective was to explore the contribution of the egocentric virtual reality (VR) perspective of eLoriCorps to understanding body image disturbances (BIDs). The sample consisted of 53 female and 13 male adults. Body size dissatisfaction, body size distortion, perceived body size, and ideal body size were assessed. Overall, outcomes showed good agreement between allocentric perspectives as measured via VR and the FRS. The egocentric VR perspective produced different results compared to both the allocentric VR perspective and the FRS. This difference revealed discriminant validity and suggested that eLoricorps’ egocentric VR perspective might assess something different from the traditional conception of body dissatisfaction, which an allocentric VR perspective generally assesses. Finally, the egocentric VR perspective in assessing BIDs deserves to be studied more extensively to explore the possibility of finding two types of body image distortion: (a) an egocentric perceptual body distortion, referring to internal body sensation affected by intra-individual changes, and (b) an allocentric perceptual body distortion, referring to external body benchmarks constructed by inter-individual comparison occurring in a given cultural context.

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.

Reduced Temporal Sensitivity in Obesity: Evidence From a Simultaneity Judgement Task

Preliminary evidence showed a reduced temporal sensitivity (i.e., larger temporal binding window) to audiovisual asynchrony in obesity. Our aim was to extend this investigation to visuotactile stimuli, comparing individuals of healthy weight and with obesity in a simultaneity judgment task. We verified that individuals with obesity had a larger temporal binding window than healthy-weight individuals, meaning that they tend to integrate visuotactile stimuli over an extended range of stimulus onset asynchronies. We point out that our finding gives evidence in support of a more pervasive impairment of the temporal discrimination of co-occurrent stimuli, which might affect multisensory integration in obesity. We discuss our results referring to the possible role of atypical oscillatory neural activity and structural anomalies in affecting the perception of simultaneity between multisensory stimuli in obesity. Finally, we highlight the urgency of a deeper understanding of multisensory integration in obesity at least for two reasons. First, multisensory bodily illusions might be used to manipulate body dissatisfaction in obesity. Second, multisensory integration anomalies in obesity might lead to a dissimilar perception of food, encouraging overeating behaviours.

The Virtual Hand Illusion in Obesity: Dissociation Between Multisensory Interactions Supporting Illusory Experience and Self-Location Recalibration

The Rubber Hand Illusion (RHI) is used widely to investigate the multisensory integration mechanisms that support bodily self-consciousness and, more specifically, body ownership and self-location. It has been reported that individuals affected by obesity show anomalous multisensory integration processes. We propose that these obesity-induced changes could lead to an unusual susceptibility to the RHI and anomalous bodily self-experience. To test this hypothesis, we administered a modified version of the RHI (using a picture of the participant's hand) to individuals affected by obesity and participants with a healthy weight. During synchronous and asynchronous stimulation, we compared the subjective experience of the illusion (using a questionnaire) and the effect of the illusion on self-location (i.e., proprioceptive drift). In accordance with the illusion phenomenology, both groups had a comparable subjective illusory experience after the synchronous stimulation. Nevertheless, individuals affected by obesity showed less recalibration of self-location than healthy weight participants. In light of a recent interpretation of the multisensory integration mechanisms that underpin the RHI, our findings suggest that in obesity visuo-tactile integration supporting the subjective experience of the illusion is preserved, whereas visuo-proprioceptive integration for self-location is reduced.

Explicit and Implicit Own's Body and Space Perception in Painful Musculoskeletal Disorders and Rheumatic Diseases: A Systematic Scoping Review

Background: Pain and body perception are essentially two subjective mutually influencing experiences. However, in the field of musculoskeletal disorders and rheumatic diseases we lack of a comprehensive knowledge about the relationship between body perception dysfunctions and pain or disability. We systematically mapped the literature published about the topics of: (a) somatoperception; (b) body ownership; and (c) perception of space, analysing the relationship with pain and disability. The results were organized around the two main topics of the assessment and treatment of perceptual dysfunctions.

Methods: This scoping review followed the six-stage methodology suggested by Arksey and O'Malley. Ten electronic databases and grey literature were systematically searched. The PRISMA Extension for Scoping Reviews was used for reporting results. Two reviewers with different background, independently performed study screening and selection, and one author performed data extraction, that was checked by a second reviewer.

Results: Thirty-seven studies fulfilled the eligibility criteria. The majority of studies (68%) concerned the assessment methodology, and the remaining 32% investigated the effects of therapeutic interventions. Research designs, methodologies adopted, and settings varied considerably across studies. Evidence of distorted body experience were found mainly for explicit somatoperception, especially in studies adopting self-administered questionnaire and subjective measures, highlighting in some cases the presence of sub-groups with different perceptual features. Almost half of the intervention studies (42%) provided therapeutic approaches combining more than one perceptual task, or sensory-motor tasks together with perceptual strategies, thus it was difficult to estimate the relative effectiveness of each single therapeutic component.

Conclusions: To our knowledge, this is the first attempt to systematically map and summarize this research area in the field of musculoskeletal disorders and rheumatic diseases. Although methodological limitations limit the validity of the evidence obtained, some strategies of assessment tested and therapeutic strategies proposed represent useful starting points for future research. This review highlights preliminary evidence, strengths, and limitations of the literature published about the research questions, identifying key points that remain opened to be addressed, and make suggestions for future research studies. Body representation, as well as pain perception and treatment, can be better understood if an enlarged perspective including body and space perception is considered.

Reconstructing Personal Stories in Virtual Reality sas a Mechanism to Recover the Self

Advances in virtual reality present opportunities to relive experiences in an immersive medium that can change the way we perceive our life stories, potentially shaping our realities for the better. This paper studies the role of virtual reality as a tool for the creation of stories with the concept of the self as a narrator and the life of the self as a storyline. The basis of the study is the philosophical notion of the self-narrative as an explanatory story of the events in one’s life that constitutes the notion of one’s self. This application is suitable for cases when individuals need to recreate their self, such as during recovery after traumatic events. The analysis of the effects of virtual reality shows that it enables a person to engage in a process of deeper self-observation to understand and explain adverse events and to give meaning to these events to form a new story, which can complement the therapeutic outcomes of exposure treatments. This study proposes concrete examples of immersive scenarios used to reconstruct personal stories. Several possible levels of experience are proposed to suggest that recovery can be achieved through the gradual retelling of the self-narrative, addressing all of the underlying narratives. Considering the ethical challenges that might arise, this paper explores the ways in which immersion in virtual reality can benefit a person’s view toward life as a story and his or her self as its author, comparing this idea with previous research on the application of virtual reality for trauma treatment. The analysis also emphasizes the perception of narrative authorship in virtual reality as an essential method for recovering the self-narrative and improving a patient’s mental health during self-actualization.

Virtual Reality-Based Biofeedback and Guided Meditation in Rheumatology: A Pilot Study

Objective

As technology continues to improve, it plays an increasingly vital role in the practice of medicine. This study aimed to assess the feasibility of the implementation of virtual reality (VR) in a rheumatology clinic as a platform to administer guided meditation and biofeedback as a means of reducing chronic pain.

Methods

Twenty participants were recruited from a rheumatology clinic. These participants included adults with physician‐diagnosed autoimmune disorders who were on a stable regimen of medication and had a score of at least 5 on the pain Visual Analog Scale (VAS) for a minimum of 4 days during the prior 30 days. VAS, part of most composite outcome measurements in rheumatology, is an instrument used to assess pain that consists of a straight line with the endpoints ranging from “no pain at all” and “pain as bad as it could be.” Patients were randomized into two groups that differed in the order in which they experienced the two VR modules. One module consisted of a guided meditation (GM) environment, whereas the other module consisted of a respiratory biofeedback (BFD) environment. Data on pain and anxiety levels were gathered before, during, and after the two modules.

Results

The three most common diagnoses among participants were rheumatoid arthiritis (RA), lupus, and fibromyalgia. There was a significant reduction in VAS scores after BFD and GM (P values = 0.01 and 0.04, respectively). There was a significant reduction in Facial Anxiety Scale after the GM compared with the BFD (P values = 0.02 and 0.08, respectively).

Conclusion

This novel study demonstrated that VR could be a feasible solution for the management of pain and anxiety in rheumatology patients. Further trials with varying treatment exposures and durations are required to solidify the viability of VR as a treatment option in rheumatology clinics.

Women With Obesity Are Not as Curvy as They Think: Consequences on Their Everyday Life Behavior

Two studies explore the impact of body size on daily life activities of women with obesity. In the first study, ethnographic techniques (first-person perspective video recordings) and subsequent interviews based on the video recordings were used. Results showed atypical behavior of women with obesity and ex-obese women related to memories of embarrassing experiences regarding personal body size (sitting, passing doors sideways, over-careful navigation in public space, and choosing clothes sizes too large.) Women with obesity seem to behave as if they thought they had a larger body than it actually was. These atypical behaviors are related to memories of embarrassing experiences regarding personal body size and stigma. Overweight women exhibit the same behavior but to a lesser and less systematic degree. In the second study, the represented (imagined) body size was compared to the perceived (in a mirror) body size with digital morphing techniques. In the mirror condition, the perceived image is accurate, while in the absence of a mirror women with obesity overestimate their body size by about 30%. Moreover, overestimation of imagined body size increased according to the weight status. Finally, women who had bariatric surgery had poorer estimates than women who had not. This would result of being continuously reminded of obesity and its stigma by daily embarrassing experiences, by being confronted with an environment designed for normal weight (e.g., narrow seats, turnstiles etc.) that makes obesity salient. We suggest that body size overestimation is a case of accentuation where things that matter are perceived bigger. These results could also been explained by the allocentric lock theory.

Using Virtual Interactive Training Agents (ViTA) with Adults with Autism and Other Developmental Disabilities

Conversational virtual human (VH) agents are increasingly used to support role-play experiential learning. This project examined whether a Virtual Interactive Training Agent (ViTA) system would improve job interviewing skills in individuals with autism and developmental disabilities (N = 32). A linear mixed model was employed to evaluate adjusted least square mean differences of means scores on the Marino Interview Assessment Scale (MIAS) across different time points. The mean score of MIAS over all questions increased between the first ViTA session and the final face-to-face interview. Participants developed the ability to identify strengths, self-promote, self-advocate, answer situational questions, and respond to behavioral/social questions as measured by multiple evaluations using the MIAS.

Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study

BACKGROUND

Therapeutic virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of health conditions. However, despite encouraging outcomes from early stage research, a consensus for the best way to develop and evaluate VR treatments within a scientific framework is needed.

OBJECTIVE

We aimed to develop a methodological framework with input from an international working group in order to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.

METHODS

A group of 21 international experts was recruited based on their contributions to the VR literature. The resulting Virtual Reality Clinical Outcomes Research Experts held iterative meetings to seek consensus on best practices for the development and testing of VR treatments.

RESULTS

The interactions were transcribed, and key themes were identified to develop a scientific framework in order to support best practices in methodology of clinical VR trials. Using the Food and Drug Administration Phase I-III pharmacotherapy model as guidance, a framework emerged to support three phases of VR clinical study designs-VR1, VR2, and VR3. VR1 studies focus on content development by working with patients and providers through the principles of human-centered design. VR2 trials conduct early testing with a focus on feasibility, acceptability, tolerability, and initial clinical efficacy. VR3 trials are randomized, controlled studies that evaluate efficacy against a control condition. Best practice recommendations for each trial were provided.

CONCLUSIONS

Patients, providers, payers, and regulators should consider this best practice framework when assessing the validity of VR treatments.

Assessing the Relationship Between Attitudinal and Perceptual Component of Body Image Disturbance Using Virtual Reality

Body image disturbance (BID) affects quality of life even in the absence of clinically diagnosable eating pathology, and numerous studies have shown its crucial role in the emergence and maintenance of eating disorders. This study aimed at exploring attitudinal and perceptual components of BID using a novel virtual reality (VR)-based paradigm. A community sample of women (N = 27) recreated in VR their perceived body in both an allocentric (third-person view) and egocentric (first-person view) perspective. Specifically, women were able to choose between a wide range of three-dimensional bodies spanning body mass index 12.5-42.5 kg/m². Attitudinal indexes of BID (body dissatisfaction, body uneasiness, and body image avoidance) were assessed through questionnaires. Attitudinal components predicted the perceptual BID only in the allocentric perspective. Specifically, overestimation was predicted by body image avoidance, while underestimation was predicted by body uneasiness. Furthermore, a common predictor of underestimation and overestimation was body dissatisfaction. In line with the allocentric lock hypothesis, the current results seem to confirm the presence of two different mechanisms underlying BID: one related to real-time perception-driven inputs (egocentric frame) and one related to abstract knowledge, beliefs, and attitudes related to a person's body (allocentric frame). These findings contribute to a better understanding of the nature and mechanisms underlying BID and provide additional evidence about the suitability of using VR for exploring and assessing body image-related components and disturbances.

Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation

Background

In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses. This represents a serious confounding factor that is leading to misleading, inconclusive outcomes in the interest of validating these new solutions.

Main body

Extending existing definitions of virtual reality, in this paper I put forward the concept of virtual reality experience (VRE), generated by virtual reality systems (VRS; i.e. a group of variable technologies employed to create a VRE). Then, I review the main components composing a VRE, and how they may purposely affect the mind and body of participants in the context of neurorehabilitation. In turn, VRS are not anymore exclusive from VREs but are currently used in videogames and other human-computer interaction applications in different domains. Often, these other applications receive the name of virtual reality applications as they use VRS. However, they do not necessarily create a VRE. I put emphasis on exposing fundamental similarities and differences between VREs and videogames for neurorehabilitation. I also recommend describing and evaluating the specific features encompassing the intervention rather than evaluating virtual reality or videogames as a whole.

Conclusion

This disambiguation between VREs, VRS and videogames should help reduce confusion in the field. This is important for databases searches when looking for specific studies or building metareviews that aim at evaluating the efficacy of technology-mediated interventions.

Incongruent multisensory stimuli alter bodily self-consciousness: Evidence from a first-person perspective experience

In our study, we aimed to reduce bodily self-consciousness using a multisensory illusion (MI), and tested whether this manipulation increases Self-objectification (the psychological attitude to perceive one's own body as an object). Participants observed their own body from a first-person perspective, through a head-mounted display, while receiving incongruent (or congruent) visuo-tactile stimulation on their abdomen or arms. Results showed stronger feelings of disownership, loss of agency and sensation of being out of ones' own body during incongruent compare to congruent stimulation. This reduced bodily self-consciousness did not affect Self-objectification. However, self-objectification (as measured by the appearance of control beliefs subscale of the Objectified Body Consciousness questionnaire) was positively correlated with the MI strength. Moreover, we investigated the impact of MI and Self-objectification on body size estimation. We found systematic body size underestimation, irrespective of type of stimulation or tendency to Self-objectification. These results document a simple yet effective approach to alter bodily self-consciousness, which however spare Self-objectification and body size-perception.

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.

The effect of body dissatisfaction on disordered eating: The mediating role of self-esteem and negative affect in male and female adolescents

This study aimed to determine whether self-esteem and negative affect sequentially mediate the relationship between body dissatisfaction and disordered eating. A total of 806 adolescents (61.8% females) completed the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory-2, the Anxiety and Depression subscales of the General Health Questionnaire-28, and the Negative Self-beliefs subscale of the Eating Disorder Belief Questionnaire. Mediational analyses showed that body dissatisfaction had both direct and indirect effects through self-esteem and negative affect on disordered eating. It was also observed that negative self-esteem mediated-completely in boys and partially in girls-the relationship between body dissatisfaction and negative affect.

Clinical Virtual Reality: Emerging Opportunities for Psychiatry

Virtual reality (VR) technology offers new opportunities for the development of innovative clinical research, assessment, and intervention tools. VR-based testing, training, teaching, and treatment approaches that would be difficult, if not impossible, to deliver with traditional methods are now being developed that take advantage of the assets that are available with VR technology. As research evidence continues to indicate clinical efficacy, VR applications are being increasingly regarded as providing innovative options for targeting the cognitive, psychological, motor, and functional impairments that result from various clinical health conditions. VR allows for the precise presentation and control of stimuli in dynamic, multisensory, 3D computer-generated simulations as well as providing advanced methods for capturing and quantifying behavioral responses. These characteristics support the rationale for the use of VR applications in clinical assessment, intervention, and training. This article begins with a brief review of the history of and rationale for the use of VR with clinical populations. It then details one use case for the clinical application of VR-the exposure-therapy treatment of anxiety disorders and posttraumatic stress disorder. Although significant work is cited in other areas of clinical VR (e.g., pain management, cognitive and physical assessment and rehabilitation, eating disorders, social skills, and clinical training), a full overview of such a broad literature is beyond the scope of this article. Thus, the authors have opted to provide more in-depth analysis of one specific clinical area that clearly illustrates how VR has been successfully applied and is supported by an encouraging and evolving scientific literature.

Economic analysis of implementing virtual reality therapy for pain among hospitalized patients

Virtual reality (VR) has emerged as a novel and effective non-pharmacologic therapy for pain, and there is growing interest to use VR in the acute hospital setting. We sought to explore the cost and effectiveness thresholds VR therapy must meet to be cost-saving as an inpatient pain management program. The result is a framework for hospital administrators to evaluate the return on investment of implementing inpatient VR programs of varying effectiveness and cost. Utilizing decision analysis software, we compared adjuvant VR therapy for pain management vs. usual care among hospitalized patients. In the VR strategy, we analyzed potential cost-savings from reductions in opioid utilization and hospital length of stay (LOS), as well as increased reimbursements from higher patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The average overall hospitalization cost-savings per patient for the VR program vs. usual care was $5.39 (95% confidence interval –$11.00 to $156.17). In a probabilistic sensitivity analysis across 1000 hypothetical hospitals of varying size and staffing, VR remained cost-saving in 89.2% of trials. The VR program was cost-saving so long as it reduced LOS by ≥14.6%; the model was not sensitive to differences in opioid use or HCAHPS. We conclude that inpatient VR therapy may be cost-saving for a hospital system primarily if it reduces LOS. In isolation, cost-savings from reductions in opioid utilization and increased HCAHPS-related reimbursements are not sufficient to overcome the costs of VR.

Implementing virtual reality (VR) programs for inpatient pain management can potentially save hospitals money. Recent studies have highlighted VR as an effective alternative to traditional opioid treatments for the management of pain. Brennan Spiegel, at Cedars-Sinai Medical Center in Los Angeles, and colleagues carried out an economic analysis to determine the cost implications of implementing inpatient VR therapy programs for acute pain management in different US hospital settings. They found that such programs are cost-saving when they reduce patients’ length of stay in the hospital. However, the projected costs for inpatient VR programs are higher than the savings that can be made from decreases in opioid use or additional income from Hospital Consumer Assessment of Healthcare Providers and Systems-related reimbursements through increased patient satisfaction alone.

Imagery rescripting and cognitive dissonance: A randomized controlled trial of two brief online interventions for women at risk of developing an eating disorder

OBJECTIVE

This pilot study compared two brief online interventions, imagery rescripting and cognitive dissonance, to an assessment-only control condition in a sample of body-dissatisfied young women at risk of developing an eating disorder. We examined the degree to which each intervention reduced disordered eating and modified risk and protective factors for eating disorders.

METHOD

Female university students (N = 107, 17-28 years of age) completed a screening questionnaire, followed by random allocation to one of the three conditions, followed by a baseline assessment, body dissatisfaction induction, and brief online intervention. Participants in the active conditions then completed online daily home practice and a postintervention questionnaire.

RESULTS

Findings provide qualified support for the imagery rescripting intervention, with participants reporting higher body image acceptance (Cohen's d = 0.49) than the cognitive dissonance condition, and higher self-compassion (d = 0.59) and lower levels of disordered eating (d = 0.59) than the control condition, at postintervention. There was no significant impact of cognitive dissonance on any factors. Change in body image acceptance and self-compassion mediated the relationship between allocated condition and change in disordered eating at postintervention.

DISCUSSION

These findings provide preliminary support for the use of online-adapted imagery-based techniques (e.g., imagery rescripting) to reduce risk for the development of an eating disorder by strengthening protective factors (i.e., body image acceptance and self-compassion) and reducing disordered eating. Further exploration of the use of imagery strategies in the prevention of disordered eating is required, including prospective tests of the mechanisms of action.

The Use of Virtual Reality in Patients with Eating Disorders: Systematic Review

Background

Patients with eating disorders are characterized by pathological eating habits and a tendency to overestimate their weight and body shape. Virtual reality shows promise for the evaluation and management of patients with eating disorders. This technology, when accepted by this population, allows immersion in virtual environments, assessment, and therapeutic approaches, by exposing users to high-calorie foods or changes in body shape.

Objective

To better understand the value of virtual reality, we conducted a review of the literature, including clinical studies proposing the use of virtual reality for the evaluation and management of patients with eating disorders.

Methods

We searched PubMed, PsycINFO, ScienceDirect, the Cochrane Library, Scopus, and Web of Science up to April 2017. We created the list of keywords based on two domains: virtual reality and eating disorders. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify, select, and critically appraise relevant research while minimizing bias.

Results

The initial database searches identified 311 articles, 149 of which we removed as duplicates. We analyzed the resulting set of 26 unique studies that met the inclusion criteria. Of these, 8 studies were randomized controlled trials, 13 were nonrandomized studies, and 5 were clinical trials with only 1 participant. Most articles focused on clinical populations (19/26, 73%), with the remainder reporting case-control studies (7/26, 27%). Most of the studies used visual immersive equipment (16/26, 62%) with a head-mounted display (15/16, 94%). Two main areas of interest emerged from these studies: virtual work on patients’ body image (7/26, 27%) and exposure to virtual food stimuli (10/26, 38%).

Conclusions

We conducted a broad analysis of studies on the use of virtual reality in patients with eating disorders. This review of the literature showed that virtual reality is an acceptable and promising therapeutic tool for patients with eating disorders.

A prescription for "nature" - the potential of using virtual nature in therapeutics

Many studies suggest that increased exposure to urban greenness is associated with better population health. Accessing nature can in some circumstances, however, be difficult, especially for individuals with mobility constraints. Therefore, a growing body of work is investigating the ways to replace the in vivo experience with forms of "virtual" contact, in order to provide these individuals with at least some benefits of the natural environment. The aim of this paper is to provide a review of previous use of virtual reality (VR) nature in health and care settings and contemplate the potential use of this technology in future. Our central question is whether engaging with virtual nature can contribute to enhanced physical and emotional well-being in housebound or mobility-constrained individuals. We conclude that while contact with real-world nature is preferred, VR use can be an alternative in cases when in vivo contact with nature is not possible. There are many possibilities for the use of VR technology in psychiatric and medical care; however, the risks, benefits, and cost efficiency of these attempts should be carefully assessed and the outcomes should be measured in a scientifically valid manner. The current review has nonetheless demonstrated that VR nature could play a role in each of the proposed mediating mechanisms linking natural environments and health.

Virtual reality in the assessment, understanding, and treatment of mental health disorders

Mental health problems are inseparable from the environment. With virtual reality (VR), computer-generated interactive environments, individuals can repeatedly experience their problematic situations and be taught, via evidence-based psychological treatments, how to overcome difficulties. VR is moving out of specialist laboratories. Our central aim was to describe the potential of VR in mental health, including a consideration of the first 20 years of applications. A systematic review of empirical studies was conducted. In all, 285 studies were identified, with 86 concerning assessment, 45 theory development, and 154 treatment. The main disorders researched were anxiety (n = 192), schizophrenia (n = 44), substance-related disorders (n = 22) and eating disorders (n = 18). There are pioneering early studies, but the methodological quality of studies was generally low. The gaps in meaningful applications to mental health are extensive. The most established finding is that VR exposure-based treatments can reduce anxiety disorders, but there are numerous research and treatment avenues of promise. VR was found to be a much-misused term, often applied to non-interactive and non-immersive technologies. We conclude that VR has the potential to transform the assessment, understanding and treatment of mental health problems. The treatment possibilities will only be realized if - with the user experience at the heart of design - the best immersive VR technology is combined with targeted translational interventions. The capability of VR to simulate reality could greatly increase access to psychological therapies, while treatment outcomes could be enhanced by the technology's ability to create new realities. VR may merit the level of attention given to neuroimaging.

ASSOCIATION BETWEEN PERCEIVED STRESS IN ADOLESCENCE, BODY WEIGHT AND ROMANTIC RELATIONSHIPS

OBJECTIVE

To analyze the association between perceived stress in adolescence, body weight and romantic relationships.

METHODS

Participants were 2,571 adolescents (56.1% female), with mean age of 16.6±1.2 years, who were students of public schools in Amazonas. The adolescents answered a questionnaire with sociodemographic questions (sex, age group, school year, study shift, maternal schooling and family income) and related to body weight dissatisfaction, romantic relationships (identified by the relationship status - with or without a partner) and perceived stress (dependent variable). Binary Logistic Regression was used to test the association between perceived stress, body weight dissatisfaction and romantic relationships. The analysis was adjusted by sex and age group.

RESULTS

The prevalence of perceived stress was 19.0% (95% confidence interval - 95%CI 17.5-20.3), and was higher among girls (23.2%; 95%CI 21.5-24.5) than boys (13.6%; 95%CI 12.2-14.7). Adolescents with partners (OR 1.76; 95%CI 1.14-2.71) and those who wanted to lose body weight (OR 1.53; 95%IC 1.18-1.98) were more likely to perceive themselves as stressed.

CONCLUSIONS

There was an association between perceived stress, relationship status and body weight dissatisfaction. Regardless of sex and age group, the adolescents with a partner and those who wanted to lose weight were more likely to perceive themselves as stressed. Girls should receive special attention, as well as adolescents with partners and those who want to lose body weight.

Embodied Medicine: Mens Sana in Corpore Virtuale Sano

Progress in medical science and technology drastically improved physicians’ ability to interact with patient’s physical body. Nevertheless, medicine still addresses the human body from a Hippocratic point of view, considering the organism and its processes just as a matter of mechanics and fluids. However, the interaction between the cognitive neuroscience of bodily self-consciousness (BSC), fundamentally rooted in the integration of multisensory bodily inputs, with virtual reality (VR), haptic technologies and robotics is giving a new meaning to the classic Juvenal’s latin dictum “Mens sana in corpore sano” (a healthy mind in a healthy body). This vision provides the basis for a new research field, “Embodied Medicine”: the use of advanced technologies for altering the experience of being in a body with the goal of improving health and well-being. Up to now, most of the research efforts in the field have been focused upon how external bodily information is processed and integrated. Despite the important results, we believe that existing bodily illusions still need to be improved to enhance their capability to effectively correct pathological dysfunctions. First, they do not follow the suggestions provided by the free-energy and predictive coding approaches. More, they lacked to consider a peculiar feature of the human body, the multisensory integration of internal inputs (interoceptive, proprioceptive and vestibular) that constitute our inner body dimension. So, a future challenge is the integration of simulation/stimulation technologies also able to measure and modulate this internal/inner experience of the body. Finally, we also proposed the concept of “Sonoception” as an extension of this approach. The core idea is to exploit recent technological advances in the acoustic field to use sound and vibrations to modify the internal/inner body experience.

Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) military personnel has created a significant behavioural healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. The current article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004. A brief discussion of the definition and rationale for the clinical use of VR is followed by a description of a VR application designed for the delivery of prolonged exposure (PE) for treating Service Members (SMs) and Veterans with combat- and sexual assault-related PTSD. The expansion of the virtual treatment simulations of Iraq and Afghanistan for PTSD assessment and prevention is then presented. This is followed by a forward-looking discussion that details early efforts to develop virtual human agent systems that serve the role of virtual patients for training the next generation of clinical providers, as healthcare guides that can be used to support anonymous access to trauma-relevant behavioural healthcare information, and as clinical interviewers capable of automated behaviour analysis of users to infer psychological state. The paper will conclude with a discussion of VR as a tool for breaking down barriers to care in addition to its direct application in assessment and intervention.

Neurobiology of Anorexia Nervosa: Serotonin Dysfunctions Link Self-Starvation with Body Image Disturbances through an Impaired Body Memory

The etiology of anorexia nervosa (AN) is still unclear, despite that it is a critical and potentially mortal illness. A recent neurobiological model considers AN as the outcome of dysfunctions in the neuronal processes related to appetite and emotionality (Kaye et al., 2009, 2013). However, this model still is not able to answer a critical question: What is behind body image disturbances (BIDs) in AN? The article starts its analysis from reviewing some of the studies exploring the effects of the serotonin systems in memory (episodic, working, and spatial) and its dysfunctions. The review suggests that serotonin disturbances may: (a) facilitate the encoding of third person (allocentric) episodic memories; (b) facilitate the consolidation of emotional episodic memories (e.g., teasing), if preceded by repeated stress; (c) reduce voluntary inhibition of mnestic contents; (d) impair allocentric spatial memory. If we discuss these results within the interpretative frame suggested by the “Allocentric Lock Hypothesis” (Riva, 2012, 2014), we can hypothesize that altered serotoninergic activity in AN patients: (i) improves their ability to store and consolidate negative autobiographical memories, including those of their body, in allocentric perspective; (ii) impairs their ability to trigger voluntary inhibition of the previously stored negative memory of the body; (iii) impairs their capacity to retrieve/update allocentric information. Taken together, these points suggest a possible link between serotonin dysfunctions, memory impairments and BIDs: the impossibility of updating a disturbed body memory using real time experiential data—I'm locked to a wrong body stored in long term memory—pushes AN patients to control body weight and shape even when underweight.