Pr

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Virtual Reality based multidimensional
therapy for the treatment of body image
Paris, 10 April 2003
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PRESENTERS
G. Castelnuovo (1-2-3), M. Bacchetta (2), G. Cesa
(2), S. Conti (2), E. Molinari (1-2-3), G. Riva
(1-3) 1 ATN-P LAB, Applied Technology for
Neuro-Psychology Lab, Istituto Auxologico
Italiano, Milano, Italia, gianluca.castelnuovo_at_aux
ologico.it 2 ATN-P LAB, Applied Technology for
Neuro-Psychology Lab, Istituto Auxologico
Italiano, Verbania, Italia 3 Facoltà di
Psicologia, Università Cattolica, Milano, Italia
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Virtual Reality
Virtual reality (VR) is a technology that alters
the conventional way in which individuals
interact with computers.
It can be described as a fully three-dimensional
computer-generated 'world' in which a person can
move around and interact as if he actually was in
an imaginary place.




In VR users are no longer simply external
observers of images on a computer screen, but are
active participants within a computer-generated
three-dimensional virtual world.
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PC Based Virtual Reality

• Most of the VR applications in health care are
  based on high cost hardware not affordable for
  the single therapist
• Graphic workstation gt 50KEuros
• Cave systems gt 400KEuros

Due, in large part, to the significant advances
in PC hardware that have been made over the last
three years, PC based VR is approaching reality
Previous work from EU Projects (VREPAR and VREPAR
2 - HC 1053/1055) has shown that even relatively
simple (PC based) Virtual Reality tools can be
used in psycho-neurological assessment and
rehabilitation.
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Why using Virtual Reality in clinical psychology?

• Advantages of VR therapy (VRT)
• Is an innovative alternative/support treatment
  for patients.
• Gives the therapist greater control over
  multiple stimulus parameters.
• Provides the ability to isolate the specific
  parameters that determine the dysfunctional
  response.
• Like in vivo therapy, VRT can provide stimuli
  for patients who have problem with guided
  imagery.
• Can be used as an intermediate step in preparing
  patients for maintenance therapy involving
  self-directed in vivo exposure.
• Patient acceptance.

Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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VEPSY-UPDATED PROJECT
The Project VEPSY UPDATED (Telemedicine and
Portable Virtual Environments in Clinical
Psychology) involves 12 different research groups
from three European countries Italy, Spain and
France Start 1/1/2001 - Duration 30 Months -
Funds 1.9 M / 1.7M Main goal to prove the
technical and clinical viability of using
portable and shared Virtual Reality systems
(shared care) in clinical psychology. The
selected disorders are - anxiety - male sexual
disorders - obesity and eating disorders
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Project innovations (1)
New field of application Only a small number of
real-world applications have been developed for
use of VR in clinical psychology the largest
sample ever reported in any published study is 72
students In a positioning paper, the US National
Advisory Mental Health Council suggested that
"Research is needed to understand both the
positive and the negative effects of VEs... on
children's' and adult's perceptual and cognitive
skills... and to exploit the enormous clinical
potential of this technology" (1995, p.51).
Project goal test the efficacy of the
developed tools with no less than 270 patients in
a real clinical setting
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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Project innovations (2)
Creation of a critical mass To reach this goal
in 1999 and 2000 different US government
institutions (i.e. Office of Naval Research,
National Science Foundation, and Defence Advanced
Research Projects Agency) funded the research in
this area to the amount of 29 million US
(Source DARPA bullettin, Jan. 2001). In the
same year the European institutions funded
research in this field with less that 5 million
Euros (estimated from CORDIS database, 2001)
less than 1/5 of the US effort. Project goal
joining the researchers who authored the 52 of
all the scientific publications in this area
(Source Medline, PsycInfo, 2001)
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Project innovations (3)
Development and on-field trial of a low cost
VR/Telemedicine modular platform A typical low
cost VR based solution for clinical psychology is
now priced by the market leading US company about
15000. For a telemedicine solution the price
raises to no less than 32000 (Source Virtually
Better Inc., Sept. 2001) The use of telemedicine
application is limited to high-bandwidth
connections (2 ISDN lines or better). Project
goal develop an immersive modular
VR/telemedicine clinical platform, priced no more
than 6K Euros and working on low bandwith
connection (56Kb)
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VEPSY Technology
Therapist office Home (telemedicine)
Software High realism VE (Use of Virtools) Optimized VE XML based apps. Interactive video Images, text
CPU Intel based Desktop/Notebook Intel based Desktop/Notebook
Vision Cy-Visor, SVGA Screen, Stereoscopy
Tracker Intertrax II, inertial
Navigation Mouse Mouse
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VEPSY clinical innovations E-therapy

• Educational component that reduces 2 or 3
  sessions at therapist office
• Inter-sessions feedback and follow-up assessment
  using intelligent applications at home.
• Self-application at home for over learning and
  supporting exposure tasks coming from VE used in
  immersive sesions at therapist office
• Communication with therapist (videoconference,
  E-mail)

Paris, 10 April 2003
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VEPSY E-health system structure
Pathology Therapist office Home (telemedicine)
Eating disorders Immersive VR Non-immersive VR
Panic disorders Immersive VR XML guided apps.
Sexual disorders Immersive VR No telemedicine
Social Phobia Non-immersive VR No telemedicine
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The advantages of the VR approach

• VR environments less threatening
• More control of feared situation
• No time/space restraints
• Higher levels of safety for the patient
• VR allows more privacy
• Cost-effectiveness

Paris, 10 April 2003
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The advantages of telepsychology

• Assessment and treatment materials on line
• Filling out post-treatment and follow-up
  assessements on line
• More support for the patient, self-help group
  chat meeting, e-mail contact with therapist
• Increase treatment efficiency

Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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Eating disorders and obesity

• ANOREXIA NERVOSA is characterized by
• - a refusal to maintain a minimally normal body
  weight
• - intense fear of gaining weight or becoming
  fat, even
• though underweight
• - a disturbance in perception of body shape and
  weight
• - amenorrhea.
• BULIMIA NERVOSA is characterized by
• - repeated episodes of binge eating
• - recurrent inappropriate compensatory behavior
• (self-induced vomiting misure of laxatives,
  etc.)
• - Self-evaluation is unduly influenced by body
  shape
• and weight.

Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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Eating disorders and obesity

• BINGE EATING DISORDER is characterized by
• - recurrent episodes of binge eating
• - feeling disgusted with oneself, depressed, or
  very
• guilty after overeating
• - marked distress regarding binge eating is
  present.
• EATING DISORDERS NOT OTHERWISE SPECIFIED
• OBESITY is characterized by
• - an excessive food consumption
• - feeling disgusted with oneself, depressed, or
  very
• guilty after overeating
• - low self-esteem.

Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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EXPERIENTIAL COGNITIVE TREATMENT for EATING
DISORDERS (1)

• ECT is a short-term integrated patient-oriented
  treatment that integrates virtual reality and
  telemedicine with different cognitive, behavioral
  and visuo-motor techniques
• Socratic method
• Miracle question
• Countering
• Alternative interpretation
• Label shifting
• Exposure with response prevention
• Awareness of the distortion

Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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EXPERIENTIAL COGNITIVE TREATMENT for EATING
DISORDERS (2)

• VR has different advantages for clinical
  psychologist
• it can be used in a medical situation thus
  avoiding the need to venture in public situation
• it can be more than a tool to provide exposure
  and desensitization
• it can challenge individual maladaptive
  assumptions more easily
• it can assure the researcher full control of all
  the parameters implied

Paris, 10 April 2003
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Therapy In-patient and Out-patient phases

• In-patient phase (4 weeks)
• - Psychological course
• (Assessment, VR therapy 10 sessions, groups)
• - Nutritional course
• (Assessment, balanced dieting, groups)
• - Physical course
• (Assessment, physical activities,
  Physiotherapy)
• Out-patient phase (6 months)
• - E-mail
• - Individual and group chat line
• - Tools online
• - Self-help group

Paris, 10 April 2003
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VR THERAPY

• 1 Assessment session (Balance, Sitting room)
• 8 Therapeutic sessions
• - Body Image (Balance, BIVRS, 9 Doors
• Room, Gymnasium, Clothess Shop,
• Swimming-Pool and Beach)
• - Eating Control (Kitchen, Bathroom,
• Bedroom, Supermarket, Pub, Restaurant)
• 1 Conclusive session
• (Kitchen, BIVRS, 9 Doors Room)

Paris, 10 April 2003
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CLINICAL TRIALS

• SAMPLES
• Experimental group
• Control groups
• - Waiting list group
• - Cognitive-Behavioral Therapy group
• - Traditional iter of the Hospital group

Paris, 10 April 2003
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, MENTAL HEALTH
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SESSIONS OF VIRTUAL REALITY
Paris, 10 April 2003
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Eating disorders and obesity virtual scripts

• Body Image Balance, BIVRS, 9 Doors Room,
  Gymnasium, Clothess Shop, Swimming-Pool, Beach.
• Eating Control Kitchen, Bathroom, Bedroom,
  Supermarket, Pub, Restaurant.
• Assertiveness Gymnasium, Clothess Shop, Pub,
  Restaurant, Beach.
• Social Skill Gymnasium, Clothess Shop, Pub,
  Restaurant, Swimming-Pool, Beach.

Paris, 10 April 2003
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VR Technology Future Trends
Graphic Processing

• Processing Power
• More HW functions
• Web 3D 3D streaming
• Rendering

• Mini Cave
• V. Retinal
• Per. Display

Vision

• Haptic functions
• Touchless technology

Navigation
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VEPSY Web Site An integrated approach (Promotion,
Place Service)

• VEPSY Web Site manages and delivers applications
  to multiple users (therapists and end users) from
  a data centre across a wide area network.
• The Web Site allows to
• distribute the developed protocols
• support therapists (in traditional therapy) with
  online tools
• support end users in the follow-up phase
• keep professional users updated (training
  online)
• promote VEPSY project among professionals

Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH
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VEPSY Web Site Approach
Web Site
Training Centres
Patients
Therapists
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Paris, 10 April 2003
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SESSION OF VIRTUAL REALITY
Paris, 10 April 2003
THIRD INTERNATIONAL SYMPOSIUM INTERNET PSYCHIATRY
, MENTAL HEALTH