Virtual environment for body image modification: virtual reality system for the treatment of body image disturbances

PII: S0747-5632(98)00018-1

Virtual Environment for Body ImageModification: Virtual Reality System for

the Treatment of Body ImageDisturbances

Giuseppe Riva

Applied Technology for Neuro-psychology Laboratory,Istituto Auxologico Italiano

Abstract Ð The paper describes the characteristics and preliminary evaluation ofthe Virtual Environment for Body Image Modification (VEBIM), a virtualreality environment aimed at treating body image disturbances and bodydissatisfaction associated with eating disorders. Two methods are commonly usedto treat body image: (a) a cognitive/behavioral therapy to influence patients'feelings of dissatisfaction and (b) a visual/motorial therapy with the aim ofinfluencing the level of bodily awareness. VEBIM tries to integrate these twotherapeutic approaches within an immersive virtual environment. This choicewould make it possible both to intervene simultaneously on all of the forms ofbodily representations, and to use the psycho-physiological effects provoked on thebody by the virtual experience for therapeutic purposes. As well as the descriptionof the VEBIM theoretical approach, the paper also presents a study on twopreliminary samples (71 normal subjects, uncontrolled study; 48 normal subjects,controlled study) to test the efficacy of VEBIM. # 1998 Elsevier Science Ltd. Allrights reserved

Keywords Ð virtual reality, body image disturbances, eating disorders

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Requests for reprints should be addressed to Giuseppe Riva, Applied Technology for Neuro-psychology Laboratory, Istituto Auxologico Italiano, PO Box 1, 28044 Verbania, Italy.E-mail: [email protected]

Computers in Human Behavior, Vol. 14, No. 3, pp. 477 ± 490, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0747-5632/98/$19.00 + 0.00

Pergamon

The physical world, including our body, is not given directly in our experiencebut is inferred through observation and critical reasoning. In fact, weexperience our bodies through two multidimensional cognitive constructs(Fisher, 1990; Gallagher, 1995): the body schema and the body image.According to Head (1926), the body schema is a model/representation of

one's own body that constitutes a standard against which postures and bodymovements are judged. This representation can be considered the result ofcomparisons and integration at the cortical level of past sensory experiences(postural, tactile, visual, kinaesthetic, and vestibular) with current sensations.This gives rise to an almost completely unconscious ``plastic'' reference modelthat makes it possible to move easily in space and to recognize the parts ofone's own body in all situations.If the body schema can be considered a perceptual model of the body, the

body image is a cognitive/social/emotional model. In fact, body image is notonly a cognitive construction but also a reflection of wishes, emotionalattitudes, and interactions with other. According to Schilder (1950), the bodyimage can be defined as ``the picture of our own body which we form in ourmind, that is to say, the way in which the body appears to ourselves'' (p. 11).Expanding on Schilder's idea, Allamani and Allegranzi (1990) refer to bodyimage as `à complex psychological organization which develops through thebodily experience of an individual and affects both the schema of behaviorand a fundamental nucleus of self-image'' (p. 121).Body experiences have a long and well-reported association with eating and

weight related problems (Barrios, Ruff, & York, 1989; Garfinkel & Garner,1982; Riva, 1997a; Rosen, 1990; Thompson, 1990, 1992, 1995). One index ofthe importance of body experience disturbance involves its relevance toagreed-on clinical disorders. The Diagnostic and Statistical Manual of MentalDisorders (4th edition; American Psychiatric Association, 1994) contains abody image criterion that is required for the diagnosis of anorexia nervosa orbulimia nervosa. It has also been suggested that, when there is psychologicalcomorbidity with obesity, it may be strongly due to problematic bodyexperience issues (Thompson, 1992). Today, researchers and clinicians agreethat including an assessment and evaluation of body experience disturbance iscrucial to any treatment program targeting obesity or eating disorders.Probably, the disturbances of body image associated with the eating

disorders can be conceptualized as a type of cognitive bias (Vitousek &Hollon, 1990; Williamson, 1996; Williamson, Cubic, & Gleaves, 1993). Theessence of this cognitive perspective is that the central psychopathologicalconcerns of an individual bias the manner in which information is processed.In most cases, it is presumed that this biased information processing occursautomatically. Also, it is generally presumed that the process occurs more orless outside the person's awareness unless the person consciously reflects uponhis/her thought processes (as in cognitive therapy). Mineka and Sutton (1992)

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have identified four common types of cognitive bias in research related todepression and anxiety disorders: attentional bias, memory bias, judgmentalbias, and associative bias. Three of these four types of cognitive bias have beenthe focus of research related to eating disorders: preoccupation with body size,body dysphoria, and related problems.In contrast to the great number of publications on body image, only a few

papers focus on the treatment of a disturbed body image in eating disorders.In general, two direct and specific approaches can be distinguished: acognitive/behavioral approach aimed at influencing patients' feelings ofdissatisfaction with different parts of their bodies by means of individualinterviews, relaxation, and imaginative techniques (Butters & Cash, 1987),and a visual/motorial approach which makes use of video recordingsof particular gestures and movements with the aim of influencing the levelof bodily awareness (Wooley & Wooley, 1985).An interesting possibility that we tried to address in the Virtual

Environment for Body Image Modification (VEBIM) is the integration ofthe different methods (cognitive, behavioral, and visual/motorial) commonlyused in the treatment of body experience disturbances (Riva, 1997b; Riva &Melis, 1997; Riva, Melis, & Bolzoni, 1997; Schlundt & Johnson, 1990) withina virtual environment. In particular we tried to integrate the cognitivemethods of Countering, Alternative Interpretation, Label Shifting andDeactivating, the behavioral method of Temptation Exposure with ResponsePrevention and the visual motorial methods of Awareness of the Distortionand Body Image Modification (Table 1) using the virtual environment in thesame way as images in the well-known method of guided imagery (Leuner,1969). It is Leuner's belief that the imagery evokes intense latent feelings thatare relevant to the patient's problems. Guided imagery has been found to be apowerful tool in treatment approach ranging from psychoanalytic therapy(Reyker, 1977) to behaviorism (Wolpe, 1958). A choice of this type wouldmake it possible not only to evoke latent feelings, but also to use the psycho-physiological effects provoked by the experience for therapeutic purposes. Inpractically all virtual reality (VR) systems the human operator's normalsensorimotor loop is altered by the presence of distortions, time delays, andnoise. Such alterations, that are introduced unintentionally and usuallydegrade performance, affect body perceptions too. The somaesthetic systemshas a proprioceptive subsystem that senses the body's internal state, such asthe position of limbs and joints and the tension of the muscles and tendons.Mismatches between the signals from the proprioceptive system and theexternal signals of a virtual environments alter body perceptions and cancause discomfort or simulator sickness (Sadowsky & Massof, 1994).Such effects, attributable to the reorganizational and reconstructive

mechanisms necessary to adapt the subjects to the qualitatively distortedworld of VR, could be of great help during the course of therapy aimed at

Virtual reality for the treatment of body image disturbances 479

influencing the way the body is experienced, because they lead to a greaterawareness of the perceptual and sensory/motorial processes associated withthem. When a particular event or stimulus violates the information present inthe body schema (as occurs during a virtual experience), the information itselfbecomes accessible at a conscious level (Baars, 1988). This facilitates theprocess of modification and, by means of the mediation of the self (which triesto integrate and maintain the consistency of the different representations ofthe body), also makes it possible to influence body image.However, until now some problems have existed with VR. There are

anecdotal reports that immersive VR can lead to symptoms similar to motionsickness symptoms. Visually induced motion sickness is a syndrome thatoccasionally occurs when physically stationary individuals view compelling

Table 1. Therapeutical Methods Integrated in VEBIM

Methods Procedures

Cognitive Countering: Once a list of distorted perceptions and cognitions is developed, theprocess of countering these thoughts and beliefs begins. In countering,the patient is taught to recognise the error in thinking, and substitute moreappropriate perceptions and interpretations.Alternative interpretation: The patient learns to stop and consider otherinterpretations of a situation before proceeding to the decision-making stage.The patient develops a list of problem situations, evoked emotions, andinterpretative beliefs. The therapist and patient discuss each interpretation and ifpossible identify the kind of objective data that would confirm one of them ascorrect.Label shifting: The patient first tries to identify the kinds of negative words he/sheuses to interpret situations in his/her life, such as bad, terrible, obese, inferior, andhateful. The situations in which these labels are used are then listed. The patientand therapist replace each emotional label with two or more descriptive words.Deactivating the illness belief: The therapist first helps the client list his/herbeliefs concerning eating disorders. The extent to which the illness modelinfluences each belief is identified. The therapist then teaches the client acognitive/behavioral approach to interpreting maladaptive behavior and showshow bingeing, purging, and dieting can be understood from this framework.

Behavioral Temptation exposure with response prevention (TERP): The rationale oftemptation exposure with response prevention is to expose the individual tothe environmental, cognitive, physiological, and affective stimuli that elicitabnormal behaviors and to prevent them from occurring. The TERP protocol isusually divided into three distinct phases: (a) comprehensive assessment ofeliciting stimuli, (b) temptation exposure extinction sessions, and (c) temptationexposure sessions with training in alternative responses.

Visual/motorial Awareness of the distortion: The patient is instructed to develop an awareness ofthe distortion. This is approached by a number of techniques including thepresentation of feedback regarding one's self-image. Videotape feedback is alsousually used. The patient is videotaped engaging in a range of activities.Modification of the body image: The patient is instructed to imagine him/herselfas different on several dimensions including size, race, and being larger orsmaller in particular areas. The patient is also asked to imagine him/herself asyounger, older, what the patient looks and feels like before and after eating, aswell as before and after academic/vocational and social successes and failures.

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visual representations of self motion. It may also occur when detectable lagsare present between head movements and presentation of the visual display inthe head-mounted display (HMD). Motion sickness is characterized by adiverse set of symptoms but is primarily exemplified by nausea and vomiting.In the case of VEBIM, with adults and adolescents as possible subjects, bothincluding people with psychological and physical problems, the need to verifythe problems associated with operating in a virtual environment has to beaddressed.A first study was designed to: (a) verify the effects provoked by VEBIM on

blood pressure and heart rate and (b) verify the effects provoked by VEBIMon the body experience. A second controlled study was set-up to confirm theresults obtained in the first study.

METHOD

Subjects

In the first study, 71 subjects (47 males and 24 females; mean age: 23.18�7.54years; mean weight: 67.34�15.42 kg; mean height: 173.3�7.97 cm) partici-pated.A total of 48 women participated in the second study. The sample was

randomly divided into two groups: the experimental group (mean age:22.6�5.84 years; mean weight: 55.1�4.43 kg; mean height: 168.29�6.20 cm)and the control group (mean age: 23.1�4.63 years; mean weight:55.8�3.98 kg; mean height: 171.01�5.80 cm). All the 119 subjects wererecruited from the participants at a VR conference.

Characteristics of the Virtual Reality Systems

VEBIM is based on a Pentium-based immersive VR system (166 Mhz; 32 MBRAM; graphic engine: Matrox Millennium with 4 MB Warm) including anHMD subsystem with head-tracking and a two-button joystick-type motioninput device.A head mounted display, specially developed by Virtual.sys (Milan, Italy)

was used. The HMDdisplays 624 lines of 210 pixel to each eye (52 H and 41 Vfield of view) and uses LCD technology (two active matrix color LCDs). ALogitech 3D mouse provided head tracking.In VEBIMwe did not use a stereoscopic display. Previous researches regard

stereoscopy as important because it provides the user with a good cue of depth(Barham &McAllister, 1991). However, the refresh rate of graphics decreasesby 50% for the need of two different images, one for each eye. Consequently,


we decided against implementing a stereoscopic display. To compensate forthe lack of depth cue, we included perspective cues (light and shade, relativesize, textural gradient, interposition and motion parallax) in the virtualenvironment.The data glove-type motion input device is very common in virtual

environments because of its ability to sense many degrees of freedomsimultaneously. However the operator is also frequently confused by thedifficulty in using it correctly, especially when there is a time delay containedin the feed-back loop.To provide a easy method of motion in VEBIM we used a two-button

joystick-type input device: pressing the upper button the operator movesforward, pressing the lower button the operator moves backwards. Thedirection of the movement is given by the rotation of operator's head.

Characteristics of the Virtual Environment

VEBIM is a five-zone virtual environment developed using the Sense 8 WorldToolKit for Windows (Version 2.02). VEBIM consists of two parts (Zones1 ± 2 and Zones 3 ± 5). The first two zones are designed both to give the subjecta minimum level of skill in perceiving, moving through, and manipulatingobjects in VR, and to focus attention on eating and food choice. Thetwo environments can also be used by the therapist for a comprehen-sive assessment of stimuli that could elicit abnormal eating behavior. Thisassessment is normally part of the Temptation Exposure with ResponsePrevention protocol. The next three zones are designed to modify the bodyexperience of the subject.

Zone 1. In this zone the subject becomes acquainted with the appropriatecontrol device, the head mounted display, and the recognition of collisions.To move into the next zone subjects have to weigh themselves on a virtualbalance. The balance is used for two functions:

1. it is intended to be an inevitable obstacle for the user, who must focus his/her attention on this object, representing the importance of the weightdimension in the experiences to come thereafter;

2. it can be used, if needed by the therapist, to display the initial weight of thesubject, as acquired in the dialog box at the beginning of the Body ImageVirtual Reality Scale (BIVRS).

Zones 2a and 2b. These zones show a kitchen (2a; Figure 1) and an office (2b).Each of these rooms is furnished with typical items, and contains differentfoods and drinks. When the user decide to eat or drink something, all he/shehas to do is to ``touch'' a specific item. In this way the food is `èaten'' and the

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corresponding caloric intake is automatically recorded in a text file, which isused later to calculate the total income of calories. Located at the end of thesecond zone is a second virtual balance. According to the `èaten'' food and tothe caloric intake inserted at the beginning of BIVRS the balance will show thenew weight of the subject (in kilograms).

Zone 3. In this zone the subject is exposed to a series of panels textured withpictures of models, in the typical way of the advertising world (Figure 2). Theimages are used as stimuli to support a cognitive approach: the elicited feelingsare subject to an analysis by the therapist according to the Label Shifting andObjective Counters methods. The feelings and their associated beliefs areidentified, broken down into their logical components, replaced with two ormore descriptive words, and then critically analyzed.

Zone 4. In this zone the user finds a large mirror. Standing by it the subjectcan look at his/her real body, previously digitized using an EPSON Photo PCcamera. The vision of her own body usually elicits in the user strong feelingsthat can be matched using the Counterattacking and the Countering cognitivemethods. The mirror is also used, as indicated by Wooley and Wooley (1985),to instruct the user to imagine him/herself as different on several dimensionsincluding size, race, and being larger or smaller in particular areas. The user isalso asked to imagine him/herself as younger, older, what they look and feellike before and after eating, as well as before and after academic/vocationaland social successes and failures.

Figure 1. View of Zone 2a showing the kitchen.


Zone 5. This zone consists of a long corridor ending with a room containingfour doors of different dimensions. The subject can move into the last zone

only by choosing the door corresponding exactly to his/her width. This

procedure is the same as indicated by Wooley and Wooley (1985) to improve

awareness of the body distortion.

Procedures and Measures

All the subjects were submitted to VEBIM for no more than 10 min and no

less than 8 min. All the subjects included in the study reached Zone 5. Just

before entering the virtual environment and just after all subjects completed

three scales for assessing body experience:

1. The Figure Rating Scale (FRS; Thompson & Altabe, 1991) a set of 9 male

and female figures which vary in size from underweight to overweight.

2. The Contour Drawing Rating Scale (CDRS; Thompson & Gray, 1995), a

set of 9 male and female figures with precisely graduated increments

between adjacent sizes.

3. The Breast/Chest Rating Scale (BCRS; Thompson & Tantleff, 1992), a set

of 5 male and 5 female schematic figures, ranging from small to large

upper torso.For these tests, subjects rated the figures based on the

following instructional protocol: (a) current size and (b) ideal size. The

Figure 2. View of Zone 3 whose walls show images of female and male models.

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difference between the ratings is called the self-ideal discrepancy score andis considered to represent the individual's dissatisfaction.

The findings of Keeton, Cash, and Brown (1990), support the usefulness ofthe self-ideal discrepancy score in the assessment of body image, as it wasshown to relate to other body-image indices and other clinically relevantmeasures. All the scales have good test ± retest reliability.In the first study only, we recorded also blood pressure and heart rate.

Before the virtual experience the subjects were fitted with a blood pressurecuff and were asked to sit quietly during a 5-min baseline period. During thisperiod blood pressure and heart rate were recorded. After the virtualexperience and after a 10-min posttask period blood pressure and heart ratewere recorded again.

Statistical Analysis

A power calculation was made to verify the opportunity to obtain statisticallysignificant differences between the pre- and post-VR scores. Given the lowstatistical power, we decided to use in both studies the Exact methods, a seriesof statistical algorithms developed by the Harvard School of Public Healththat enable researchers to make reliable inferences when data are small,sparse, heavily tied, or unbalanced (SPSS, 1995).The Exact method used to compare the scores was the Marginal

Homogeneity Test (Agresti, 1990).

RESULTS

Study 1

Table 2 lists the means and standard deviations for the pressure and heart ratescores, across the three measurement occasions. No significant difference wasfound before and after the VR experience. Only two of the subjectsexperienced simulation sickness. Table 3 presents the means and standarddeviations for the body image scores obtained before and after the virtualexperience. The Marginal Homogeneity Test reported significant differences

Table 2. Means and Standard Deviations for the Pressure and Heart Rate Scores

Measurement 1 Measurement 2 Measurement 3

M SD M SD M SD

Systolic 134.61 20.06 133.09 20.8 124.13 18.56Diastolic 89.23 21.09 88.2 23.72 84.6 16.38Heart rate 74.01 15.68 72.11 11.06 72.09 14.14


in the Ideal FRS and Ideal CDRS scores: both scores were higher afterexperiencing VEBIM.An analysis of the three discrepancy indexes revealed significant lower

values for FRS and CDRS after the experience in the virtual environment.These results mean that VEBIM is able to reduce the body dissatisfaction ofthe subjects.

Study 2

Table 4 presents the means and standard deviations for the ratings of bodyimage. TheMarginal Homogeneity Test reported significant differences in theIdeal FRS scores obtained by the experimental group: the scores were higher(p<.005) after experiencing the procedure used. An analysis of thediscrepancy indexes showed a significant lower value for FRS (p<.05) afterthe virtual experience: body dissatisfaction of the subjects was reducedafter the virtual experience. No significant differences were found in thecontrol group (Table 5).

Table 5. Means and Standard Deviations for the Body Image Scores in the ControlGroup (Second Study)

Real FRS Ideal FRS Real CDRS Ideal CDRS Real BCRS Ideal BCRS

Before 3.18�1.03 2.71�0.8 3.8�1.1 3.48�0.73 3.01�1.01 2.68�0.95After 3.21�1.01 2.85�0.74 4.01�1.05 3.49�0.88 3�1.12 2.5�1.09

FRS=Figure Rating Scale; CDRS=Contour Drawing Rating Scale; BCRS=Breast/Chest RatingScale.

Table 4. Means and Standard Deviations for the Body Image Scores in theExperimental Group (Second Study)


Before 3.14�0.93 2.61�0.8*** 4�1.18 3.5�0.83 2.98�1.49 2.75�1.13After 3.35�0.81 2.91�0.7*** 4.21�1.25 3.52�1.08 2.93�1.35 2.52�1.08

FRS=Figure Rating Scale; CDRS=Contour Drawing Rating Scale; BCRS=Breast/Chest RatingScale.*p<.05; **p<.01; ***p<.005.

Table 3. Means and Standard Deviations for the Body Image Scores (First Study)


Before 3.8�1.34 3.18+/0.72*** 4.79�1.49 4.11�0.95* 2.79�1.30 2.91�1.95After 3.84�1.28 3.53+/0.96*** 4.74�1.53 4.21�1.07* 2.82�1.27 2.94�0.97

FRS=Figure Rating Scale; CDRS=Contour Drawing Rating Scale; BCRS=Breast/Chest RatingScale.*p<.05; **p<.01; ***p< .005.

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DISCUSSION

Although there is much potential for the use of immersive VR environments inclinical psychology, some problems have limited their application in this field.Some users have experienced side-effects, during and after exposure to VRenvironments. The symptoms experienced by these users are similar to thosewhich have been reported during and after exposures to simulators with widefield-of-view displays (Cobb, Nichols, & Wilson, 1995; Kennedy, Lanham,Drexler, Massey, & Lilienthal, 1995; Regan, 1995; Regan & Price, 1994).These side-effects have been collectively referred to as ``simulator sickness''(Kennedy, Lilienthal, Baltzley, Allgood, & Gower, 1987) and are character-ized by three classes of symptoms: ocular problems, such as eyestrain, blurredvision and fatigue; disorientation and balance disturbances; and nausea.Exposure duration of less than 10 min to immersive VR environments hasbeen shown to result in significant incidences of nausea, disorientation, andocular problems (Regan & Price, 1993).The first interesting result of this study is the lack of side effects and

simulation sickness in our samples after the experience in the virtualenvironment, confirming the possibility of using VEBIM for therapeuticpurposes. This result, confirmed in both studies, is even more interesting giventhe sample used. In fact, females tend to be more susceptible to motionsickness than males (Griffin, 1990). However it is difficult to generalize thisresult to the VR systems at large given the peculiar technical characteristics ofVEBIM.The other obtained result is the reduction in the body dissatisfaction of the

subjects after the virtual experience. Usually body-image treatment involves acognitive/behavioral or a visuomotor therapy that requires many sessions.The possibility of inducing a change in the body dissatisfaction after a 8 ±10-min VR session can be useful to improve the efficacy of the existingapproaches. As such, the procedure might be helpful as a part of acomprehensive treatment package to break through the ``resistance'' totreatment in clinical subjects (Vandereycken, 1990).Of course these results are preliminary only. From a clinical view point the

issues that we have to address in the future are:

1. Further testing of VEBIM. Even if the data obtained in the twopreliminary studies using VEBIM are very promising, we have to testthe new environments with clinical and nonclinical subjects.

2. A follow-up study to check how long the influence of the virtual environmentlasts. In the preliminary studies we have limited the VR experience to justone session, but from a therapeutic viewpoint it seems more reasonable torepeat the procedure.


3. How to integrate VEBIM into the usual cognitive/behavioral treatments.Even if the procedure might be helpful as a part of a comprehensivetreatment package to break through the ``resistance'' to treatment inclinical subjects, it is important to define a specific therapeutic protocol tobe used by other clinicians and therapists.

Acknowledgments Ð This research is part of the Virtual Reality Environments for Psycho-neuro-physiological Assessment and Rehabilitation (VREPAR) Projects, two EuropeanCommission funded research projects (DGXIIIÐTelematics for Health Care).

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Virtual environment for body image modification: virtual reality system for the treatment of body image disturbances