Virtual reality applications in mental health: Challenges and perspectives

The past two decades has witnessed the emergence of virtual reality (VR) as a major tool for investigation, assessment, and management of medical and psychiatric disorders. The growing interest in medical applications of VR is highlighted by the fact that the number of scientific articles published in Medline every year on this topic increased from 45 in 1995 to 951 in 2003 to 3,203 in 2010.[1,2,3] There are many definitions of VR, one of which is given here: “Virtual reality refers to immersive, interactive, multi-sensory, viewer-centered, three dimensional computer generated environments and the combination of technologies required to build these environments.”[4,5]

VR: HISTORICAL BACKGROUND

Though the term VR was coined by Jaron Lanier in 1987, the development of VR can be traced to 1957 when Morton Heilig, a cinematographer, conceptualized that audiences would be more effectively drawn into the stories if all their senses are stimulated. In 1960 he built the Sensorama that included a stereoscopic color display, fans to provide wind, odor emitters, stereo-sound system, and a moving chair to simulate motion. However, the system was not interactive. The first head-mounted display (HMD) named as Headsight was developed by Philco Corporationin 1961. It incorporated a video screen and tracking system linked to a closed circuit camera system. The HMD was mainly intended for use in dangerous situations as the user could observe a real environment remotely. It was used in military training operations and by helicopter pilots to have a clear field of view while flying in the dark.[6]

The next important advance occurred in 1966 when Ivan Sutherland developed the Sword of Damocles system using a HMD connected to a computer, in which a person could look into a virtual world that would appear as real as the actual world the user lived in. The computer maintained the virtual world in real time by tracking the user's head movements so that the field of view would change appropriately as the user looked around. In addition, for the first time the user could manipulate virtual objects in a realistic way. The combined effect was the substitution of sensory data from the natural world with sensory data about an imaginary world. The sensorydata from the imaginary or virtual world changed in response to the user's actions, resulting in a “sense of presence” in an interactive three-dimensional virtual environment.[7]

Early applications of the technology were in designing vehicle simulators. The technology was mainly used for training military personnel, pilots, and astronauts; but largely remained out of the public eye. The first applications of VR in medical teaching occurred in the 1990s with colonoscopy and upper gastrointestinal tract endoscopy simulation. It is also widely used in the arts and entertainment. Today, VR systems are based on personal computers that are sophisticated enough to run the software necessary to create virtual environments. To display images many systems use headsets that contain two separate monitors for eacheye. This creates a stereoscopic effect, giving the illusion of depth. The Cave Automatic Virtual Environments (CAVE), developed at the University of Illinois in 1992, uses a rear projection technique to display images on the walls, floor, and ceiling of a small room. Wearing special glasses users can move around in a CAVE display room to give the illusion of moving through a virtual environment.[6,7]

APPLICATION OF VR IN HEALTHCARE

There are two different focuses of VR in healthcare: VR as a simulation tool and VR as an interaction tool. Physicians and surgeons mainly use VR as a simulation tool, while in behavioral medicine the interaction focus predominates.

In the field of healthcare, VR techniques has wide applications ranging from diagnosis, treatment, counseling and rehabilitation, to designing of hospitals. It can be used for education and instruction in medical, dental, nursing, and paramedical schools. Students can acquire knowledge of human body in a virtual environment. VR has also been used to teach the skills of recording a12-lead electrocardiogram electrocardiogram (ECG). Students can interact with and examine a virtual patient and learn skills which they can apply in the real world. Students can perform procedures and even surgery on a virtual patient in a safe and controlled environment. They can make mistakes and learn from them, without any risk to the patients. Skill acquisition would therefore be faster and without any risk to patients. Similarly dental students can hone their skills on a virtual patient.[8,9]

USES OF VR IN PSYCHIATRY

VR has been used in conjunction with counseling and cognitive behavior therapy for the treatment of addictions. The scenario where addiction behavior is very likely to occur is replicated using VR, so that the counselor can observe their behavior and reaction to it. This information is used to plan appropriate therapy. The effectiveness of VR has been verified in the treatment of acrophobia, spider phobia, panic disorder and agoraphobia, body image disturbances, binge eating disorders, and fear of flying.[10] It has also been useful in the treatment of agoraphobia, social phobia, claustrophobia, trypanophobia, tonitrophobia, and fear of driving. VR has also been used in cognitive rehabilitation. It is used to help autistic adults or children develop the skills necessary for independence viz how to cross a road, to how to identify different facial expressions in patients with psychosis, the incorporation of VR into delusional systems is a possibility,[11] and how to pick up visual cues or the need to pay attention to another person whilst they speak.[12]

The other uses of VR are application in the treatment of posttraumatic stress disorder (PTSD). Using the VR technology the patient is exposed to the source of their disorder, for example, a battlefield. The rationale for this form of therapy is that exposing the patient to the source of their condition combined with relaxation training will enable them to adapt to the stress. Further as they are exposed to this gradually, the level of threat is removed, which then decreases their feelings of anxiety. It is expected that over time the patient will lose the feelings of anxiety caused by their condition.[13] In patients with psychosis, VR has been used for a number of purposes including symptom assessment, establishing symptoms correlates, identifying predictive variables, establishing causal factors, identification of differential predictors, and identifying environmental predictors. Study conducted by researchers found that the use of VR may lead to rapid advances in our understanding of paranoia.[14] VR also has applications in the treatment for psychosis. VR is used as an educational component to teach individuals about the factors that worsen or improve symptoms. Another use of VR is exposure to persecutory fears. Study was conducted to assess the efficacy of VR therapy in PTSD cases on a 6-month follow-up. Clinician-rated PTSD symptoms as measured by the Clinician Administered PTSD Scale, the primary outcome measure, at 6-month follow-up indicated an overall statistically significant reduction from baseline (P = 0.0021) in symptoms associated with specific reported traumatic experiences. The 6-month follow-up on patients found reductions in PTSD symptoms ranging from 15 to 67%. Significant decreases were seen in all three symptom clusters (P < 0.02). Patient self-reported intrusion symptoms as measured by the Impact of Event Scale were significantly lower (P < 0.05) at 3 months than at baseline, but not at 6 months; although there was a clear trend toward fewer intrusive thoughts and somewhat less avoidance.[15] VR-based exposure therapy has shown results in the assessment and treatment of various mental problems including the treatment of anxiety disorder and specific phobias such as the fear of heights,[16] fearoff lying,[17,18] driving phobia, spider phobia,[19,20] social phobia, and agoraphobia.[21,22] Infact, the domain of coping with symptoms of the disorder has also been experimented. However, clinical studies of these techniques in psychosis are lacking. VR has been used in rehabilitation from schizophrenia and few other disorders.[23] Social skills training intervention is an effective method to improve social dysfunction in patients with psychosis; however, it is difficult to implement the new skills into patients’ everyday functioning. A recent study reported that VR program contributed to the generalization of new skills into the patient's everyday functioning.[24,25]

VR-based applications can possibly be useful in forensic psychiatry. Preliminary studies indicate its usefulness in assessment of individuals with pedophilia. Another application is the use of VR to evaluate the behavior of forensic inpatients in crime-related situations.[26]

SIDE EFFECTS

The major side effect of this technology is VR-induced sickness which can present with dizziness, nausea, headache, eye strain, reduced limb control, reduced postural control, decreased sense of presence, and the development of responses inappropriate to the real world. Subjects who develop seizures when watching television or playing video games, should not be exposed to VR.[27]

CONCLUSIONS

At present, on the basis of evidence, VR can be considered as a useful tool for medical education, training, diagnosis, and therapy. However, the technique is still in its infancy and much work is needed including controlled trials before they can be put to routine use. Another factor not addressed in the article is the substantial cost of these systems. This is another barrier that has to be surmounted before VR can be introduced in routine clinical use.