Management of obsessive–compulsive disorder with virtual reality-based exposure

Abstract

Little information is available about use of virtual reality exposure for management of obsessive compulsive disorder (OCD). We present a patient with OCD, who presented with significant dysfunction related to his OC symptoms and was managed with virtual reality based exposure therapy. A 27-year-old male, presented with a history suggestive of OCD for last 8 years. His symptoms were characterized by obsessive images of known people, leading to significant anxiety and distress. To get rid of his anxiety and distress, he would repeat the acts at hand, multiple times till these images would subside or till he would be able to replace these images by desirable images. These symptoms led to marked socio-occupational dysfunction. The treatment history was suggestive of minimal response to adequate trials of multiple selective serotonin reuptake inhibitors and he was on capsule fluoxetine 80 mg/day at the time of presentation. Exposure and Response therapy was tried in the past by using imaginal exposure, but this was unsuccessful, as the patient would avoid imagining the anxiety-provoking images. Hence, he was exposed to the anxiety provoking images by using virtual reality which involved presenting him with videos containing pictures of known and unknown people arranged randomly, along with the anxiety-provoking images. Over a period of 2 months, 60 sessions of ERP were carried out and the whole hierarchy was completed. This case demonstrates that virtual reality can be used in behaviour therapy for OCD, by using virtual reality techniques, and there is a need to develop software and programs for assessment and management of OCD.

The lifetime prevalence of obsessive–compulsive disorder (OCD) is around 2.3%.[1] Besides, the use of pharmacotherapy, one of the important treatment strategies for management of OCD, involves behavior therapy in the form of exposure and response therapy (ERP). Depending on the stimulus, exposure can be live, imaginal, virtual, or interoceptive.[2] However, at times, it is not possible to expose patient to a real stimulus, because of the site of therapy (for example, inpatient setting – where it is not possible to bring the stimulus), and in such a situation, other kinds of exposures may be used. In general, virtual exposure can be considered as better than imaginal exposure, because imaginal exposure is often influenced by patients motivation, and ability to tolerate the anxiety.[3] Virtual reality is considered to be safe and cost-effective.

With the availability of technology, these days, virtual exposure is being increasingly tried for patients with OCD. However, little is known about practice of virtual exposure from India. In this case, we present a 27-year-old male, with obsessive images, managed with ERP by using virtual reality.

CASE REPORT

A 27-year-old male, married, graduate, presented with a history suggestive of OCD since the age of 19 years. The disorder was characterized by having obsessive images of known people, leading to significant anxiety and distress. To get rid of his anxiety and distress, the patient would repeat the acts at hand, such as crossing the doors and washing hands, multiple times till these images would subside or till he was able to replace these images by desirable images. These symptoms led to marked socio-occupational dysfunction to the level that he was not able to work and suffered losses in his business. There was no history suggestive of any comorbid physical or psychiatric illness including tics. His treatment history revealed that he had received adequate trials of multiple selective serotonin reuptake inhibitors (SSRIs) and currently was on capsule fluoxetine 80 mg/day with minimal improvement. Evaluation also revealed that in the past, ERP was tried by using imaginal exposure, but this was unsuccessful, as the patient would avoid imagining the anxiety-provoking images.

In view of the treatment resistance, he was considered for inpatient management. Initially, behavior analysis was done and behavior therapy in the form of ERP was planned.

The behavior analysis also involved construction of the hierarchies for exposure. Two separate hierarchies with ascending order of subjective units of distress were made. First hierarchy was created with the pictures of the persons which caused the distress, while the second hierarchy was created according to the tasks that the patient would repeat on experiencing obsessive images.

Before starting behavior therapy, the patient and his spouse were psychoeducated about the illness and treatment. This involved explaining them the causes, signs and symptoms, treatment options for OCD, and principles of ERP. In addition, the patient was taught Jacobson's Progressive Muscle Relaxation (JPMR) technique.

For the ERP, pictures of the persons whose images caused distress to the patient were collected. These pictures were incorporated in videos containing pictures of other people (known and unknown to the patient) that presented the anxiety-provoking images randomly. With each image, the name of the person (i.e., image presented) was recorded in patients' own voice and the same was also presented as part of the video used for exposure. The videos were of 15 min duration, which included images and audio recordings of names, played in a loop. Exposure was started from the least anxiety-provoking images clubbed with the hierarchy of tasks. The patient was made to watch the video by using the virtual reality headset and simultaneously made to do the task at hand as per the hierarchy. His parameters (i.e., vitals and subjective unit of distress) were noted every 5 min till the anxiety came down to zero. Each session lasted for about 45 min to 1 h. After all the task with one set of images was completed, we moved on to the next task in the hierarchy. Over a period of 2 months, 60 sessions of ERP were carried out and the whole hierarchy was completed. Gradually, he went through the whole sequence of images and videos, which were clubbed with response prevention. The experience of the patient was very satisfying as this kind of exposure was more close to his experience of obsessive images, and according to him, this helped in getting better with behavior therapy.

With each increasing step, for generalization, exposure to all the previous images along with addition of new images was continued. By the end of the therapy, his Yale Brown Obsessive Compulsive Scale severity score came down to 5 from baseline score of 28. During the whole therapy, the patient was allowed to practice JPMR, although this was not clubbed with ERP sessions. In addition, supportive psychotherapy and booster psychoeducation sessions were continued. In addition to the virtual reality exposure, he was also made to write the names of the people, whose names would provoke anxiety.

During the follow-up, booster sessions were carried out. The patient is currently maintaining 80% improvement in symptoms with no dysfunction in work.

DISCUSSION

Virtual reality integrates multimodal sensory inputs in the form of graphics, images, and sounds to create an environment, with which the user is expected to interact as in his/her normal life. Virtual reality has been used to assess, understand, and treat various disorders such as phobias, posttraumatic stress disorders, attention-deficit hyperkinetic disorder, and schizophrenia.[3,4] However, its use in OCD is less evaluated, possibly due to the variation in symptomatology and poor understanding in the use of virtual reality in OCD.[3,4] Available data suggest that computers have been used in the assessment of repetitive behaviors, reminding the patients about the behavior therapy and exposure to dirt and contamination.[3,4] Exposure by using virtual reality is based on the same principles as used in traditional methods of exposure. Available data suggests that compared to other methods of exposure, virtual exposure is considered to be cost-effective and offers more practical solution for exposing to difficult stimulus.[3] In the index case, the patient was exposed to the threatened situation, which was in the form of obsessive images and in whom imaginal exposure had failed. This case demonstrates that clinicians can carry out ERP by using virtual reality to improve the exposure to the stimulus.

This case also demonstrates that ERP can be done for OCD, by using virtual reality techniques, and there is a need to develop software and programs for assessment and management of OCD. These programs and software need to be developed in such a way, that these are user-friendly, can be used at home by using handheld devices such as smart phones, so that these are easily portable.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.