Virtual Reality in Psychology and Experiments

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Virtual reality (VR) is a term used to describe a 3D, computer generated environment. In this environment, participants can explore areas, create new objects, and manipulate their surroundings. This environment is often viewed through a VR headset that wraps around the participants head and has goggles in which they see the environment through. The Oculus headset, now owned by Meta, is an example of a VR headset. The product was created by Palmer Luckey, and became the company OculusVR in June 2012. Currently, these headsets are used for many activities like video games, listening to music, virtual tours, therapy, and more. Virtual reality is often confused with augmented reality (AR). Augmented reality is a framework based on our world where objects, images, and things are placed. Participants don't always need to wear headsets in AR. An example of an AR mobile app is Pokemon Go. Additionally, mixed reality (MR) is a combination of VR and AR where virtual things are placed in an augmented reality. Mixed reality can make the virtual world indistinguishable from the real world.

Virtual reality can be used for entertainment, communication, learning, therapy, experimentation, and much more. Advancements in VR technology have led to patients being able to have therapy sessions in any environment without being in real life. This can also be translated to experiments that may be unethical or implausible to run in reality.

VR helping patient overcome fear of spiders

Technology

Field of View and Frame Rate

Most humans can see around a 220 degree radius of surrounding content. VR technology works to emulate this field of view within a virtual world. Currently, most VR headsets only have a 180 degree frame of view. Frame rate refers to how quickly a number of frames appear within a second. The more frames captured, the better the quality of the video (FPS). However, computers can only handle a certain amount of fps, and getting too high of a fps could cause malfunctions. Most television shows and movies are shot at 24-30fps, while video games are usually between 30-60fps. Many video game players opt for higher fps because lower fps on games could lead to choppy game play and a disadvantage against people with higher fps. In VR, frame rate is even more important because having a lower fps can cause users nausea. Additionally, higher frame rates help users feel more immersed into the virtual world. These higher frame rates require a more powerful GPU.

Spatial Audio

VR attempts to use 360 degree audio to make users feel like they are immersed in a virtual world. This surround sound is often obtained by surrounding the user with multiple speakers for a more precise listening experience. This method is also used in movie theaters. Many VR headsets have adopted head-related transfer function (HRTF) sound to mimic how humans hear sounds in everyday life. This 3D technology allows designers to place sounds around the user, prompting them to look in that direction. It also allows far away sounds to be quieter and closer sounds to be louder.

Head and Eye Tracking

VR tracks user's head and eye movements to help them see the virtual world in real time. All objects in a 3D space can move in six ways. There are three directional axes and three rotational axes. These are the six degrees of freedom (DOF). VR either uses 3DOF or 6DOF. 3DOF uses microscopic electromechanical gyroscopes and allows users to look around the virtual setting, but doesn't track body movements. 6DOF does track body movements and requires more expensive and powerful hardware and software implementations.

Software

Human behavior studies are often based on a common model of trials, blocks, and sessions. Trials include a stimulus and the human response. They can be repeated many times for individual patients. Blocks are a way to group similar trials. This was researchers can compare blocks with different stimuli or response to each other. A session is a single iteration of a task with an individual. These types of experiments lend themself to computers because of the organized structure. To help researchers without knowledge of computer software or hardware, programs have been created to run these experiments. PsychoPy uses python to expose patients to stimuli and has data storage capabilities to gather patient response.

Unity Experiment Framework

Unity is a union of a game engine that allows games to be run (played) in different environments, a platform where pieces of a game can be put together and tested, and a code editor (MonoDevelop). With knowledge of programming and game design, users can create and test games in Unity's integrated development environment (IDE). Unity created the Unity Experiment Framework (UXF) for human behavioral experiments using C# (the programming language that Unity uses). UXF provides a high level environment that is catered to behavioral experiments. The objects are sessions, blocks, and trials and they are pre-programmed to contain all the necessary properties they need. For example, trials are automatically generated in number order and contain begin and end functions. Timestamps are also recorded in the background to keep track of when trials occur. UXF can be used to run behavioral experiments on PC's and VR technology.

History

The development of VR technology started around the 1950-60's with the Sensorama. This gave users a multi-sensory experience. Throughout the 1960's headsets were created with the advancements of tracking motion and working with computer interfaces. VR was formally conceptualized in 1989, and throughout the 1990's and early 2000's, VR started to be used for psychiatric purposes. Psychiatrists used VR for exposure theory, and studies were conducted to determine if virtual reality exposure therapy (VRET) worked better than traditional therapy. The first study of VRET was focused on the treatment of acrophobia, the extreme fear of heights.

Previous studies

Months after the 9/11 terrorist attacks, the Virtual Reality Research Center at University of Washington tested VRET on a survivor with PTSD from the event. Through six, hour long sessions, doctors exposed the patient to virtual planes crashing into the Twin Towers, virtual explosion noises, virtual people jumping to their death, and virtual towers collapsing. After the sessions, doctors used the Beck Depression Inventory and Clinician Administered PTSD Scale to measure and 83% reduction in depression and 90% reduction in PTSD symptoms respectively.

Reports show that one out of every six Iraq war veterans experience symptoms of depression, anxiety, or PTSD. A study in October 2009 at Naval Medical Center-San Diego (NMCSD) had twenty Iraq war veterans with PTSD symptoms. The patients were treated with VR exposure therapy, and 16 out of the 20 veterans didn't indicate diagnostic criteria for PTSD at post treatment.

Medical Use

Anxiety

Anxiety is one of the most prevalent mental health disorders in the world. It affects about 18.1% of adults, and many times it goes unnoticed or untreated. Additionally, it can cause distress, increased stress, and significant impact on quality of life. Therapists traditional have used psychotherapy (talk therapy) or medications to help cure anxiety. VR is starting to be used in therapy sessions to treat anxiety with VRET. This type of therapy is easy for therapists to set up, and more acceptable to patients than traditional exposure therapy. Although exposure therapy has been shown to be effective in lessening anxiety symptoms, many patients are reluctant to try it because of trauma associated with their anxieties. Patients are more willing to do imaginal (in vivo) exposure therapy, however, therapists have no control or view of what goes on in the patient's mind. VR provides therapists with a controllable and engaging environment, while also providing patients the comfort that their experience is virtual and not in real life. Additionally, therapists are able to change the virtual environment quickly and often. VRET helps patients with anxiety go through exposure in "practice" VR settings that train them to be better equipped to handle their anxieties in real life settings.

PTSD

Post traumatic stress disorder (PTSD) is a mental health disorder that effects people who have experienced or witnessed a traumatic events such as natural disasters, terrorism, war, rape, or being threatened by death. PTSD can affect any person of any age, and affects about 3.5% of United States adults each year. People with PTSD experience intense thoughts about their trauma during nightmares or flashbacks. These can be triggered by reliving the event in terms of location, sight, sound, or touch. However, diagnosing PTSD requires exposure to an upsetting event. PTSD is traditionally treated with psychotherapy and medication. Some types of talk therapy used are cognitive processing therapy (focuses on modifying negative emotions about the trauma), prolonged exposure therapy, and group therapy. VR treatment attempts to adjust the exposure therapy to make it more comfortable for patients to endure.

Depression

Depression is a mental disorder negatively affects how people feel, act, and think. It can cause feelings of sadness and a lack of enjoyment or interest in activities that one once enjoyed. It can also cause lack of energy, sleep, appetite, difficulties in focus, and thoughts of death or suicide. One in six people (16.6%) experience depression at some point in their life. Depression is commonly treated with antidepressants and psychotherapy. VR is starting to be used in some treatments of depression. When patients are going through depressive episodes, VR has been used to simulate gardening and playing with animals. These positive actions can counter negative depressive thoughts and improve patient's mental health. Another way VR has been used to help depressed patients is avatar therapy. This involves patients creating an avatar and verbalizing their depressive or self-critical thoughts to the avatar. Then, they virtually become the avatar, and hear themselves verbalizing their thoughts. Avatar therapy has not been proven to help treat depression and was originally created to help treat psychosis patients.

Rehab

Physical therapy helps patients recover from injuries and disease through the use of massage, heat therapy, and exercise rather than drugs or medicine. Physical therapists at Marianjoy Rehabilitation Hospital (part of Northwestern Medicine) are using VR technology to create real world situations for patients. One method physical therapists use for patients struggling with balance or coordination is IREX®, which virtually simulates sports, games, or everyday environments. This technology can help patients develop strength, better coordination, and endurance. Additionally, physical therapists have used the Bertec Balance Advantage™ System to help patients with dizziness or balance issues as a result of stroke, brain injury, or vestibular disorders. The Bertec system uses VR to simulate customizable environments that therapists can monitor and change. Marianjoy also uses the Armeo®Spring for mild or moderate impairment or the Armeo®Power for severe impairment. The robotic arm program assists patients in the early stages of their arm injuries when they unable to move their arm unassisted. It connects to a computer program that runs through everyday activities like grocery shopping or mini games that mimic natural arm movements for recovery.

Phobias

A phobia is an uncontrollable, irrational, and lasting fear of a certain object, situation, or activity. This fear can be so overwhelming that a person may go to great lengths to avoid the source of this fear. One response could be a panic attack, which is a sudden, intense fear that usually lasts for 5-20 minutes. About 19 million Americans have one or more phobias ranging from mild to severe. Most people discover they have phobias between 15 and 20 years old. Phobias can be specific to objects or situations that usually aren't harmful: flying, fear of dogs, small spaces (claustrophobia), or heights. They can also be social phobias like fear of public speaking, going to events, or meeting new people. A severe type of phobia is agoraphobia which involves the intense fear of being in crowded public spaces where having a panic attack would involve an embarrassing or difficult escape. Phobias are often treated with cognitive behavioral therapy (CBT), where the patient understands the negative thoughts behind their phobia, and begins to replace them with more positive thoughts. Phobias can also be treated with in-vivo therapy which involves exposing the patient to what they fear in gradual, small doses. Pairing both of these therapy strategies can often help patients overcome phobias.

CBT and in-vivo therapy can be combined into VR therapy where the patient experiences their phobia in a realistic virtual world without leaving the comfort of their therapist's office. For example, patients with fear of flight can be immersed into a realistic flight simulator with sounds, vibrations, and movements similar to that of actually being on a plane. VR therapy for phobias have been reported to have an 83% success rate.

Ethical Concerns

Cost

Therapists and administrators have to weigh the cost of buying many VR headsets and programs for therapy. VRET is early in its development, so cost is a limiting factor when determining whether to spend money on more VR equipment. If demand for VR therapy increases and research shows positive benefits, cost may become less of a barrier for therapists.

Availability

Many VR systems exist, but very few direct virtual reality therapy software's or products are on the market. Additionally, these programs or devices are often not covered by health insurance. Most companies that sell VR therapy software state that they should be used in the presence of a licensed clinician. However, if these products become readily available to consumers, they could purchase them and try them out themselves. If used improperly, these could aggravate traumatic symptoms, or give patients the false idea that they don't need therapeutic help.

Privacy

Records and sessions for therapy sessions are highly confidential. In 1996, US president Bill Clinton signed HIPAA which ensures the protection of patient's personal health records and medication. VR, like any computer system, has the potential for hacking which could lead to data leaks. Additionally, VR and computer companies track movements, programs used, and data from their users. Some virtual environments track all data and upload it to third party cloud databases. This could potentially breach the confidentiality of VR therapy.

Training

Clinicians who have never used VR or computer assisted psychotherapy programs will require additional training to learn how to use these technologies safely. Clinicians that decide to incorporate VR will need orientations to consult the HITECH act. The goal of the HITECH act is to incorporate technology into the medical field in a safe way.

Cybersickness

Cybersickness affects people similarly to how motion sickness affects people. It's a result of a sensitivity of being immersed in a virtual environment. Symptoms can include fatigue, nausea, headache, or eye strain. The symptoms usually occur during or after being immersed into the virtual environment. The exact causes of cybersickness are not yet known, but it's believed that people with prior neurological conditions like multiple sclerosis may be more susceptible. Approaches to decreasing cybersickness are being explored. These include placing static rest frames on virtual scenery, decreasing field of view, and limiting intense rotational movement.

Superrealism

VR has increasingly enhanced user's virtual worlds with visual, aural, tactile, and olfactory information. The technology has reached the point where virtual environments exhibit superrealism features that closely resemble the real world. This environment creates an ethical dilemma of whether or not the rules of the real world should apply to the virtual world. This is a philosophical and technological discussion, but is important when considering the health of patients being treated with VR.

Derealization

Even though simulations within VR aren't real, they can feel real to participants, and cause the feeling of derealization of the real world. For example, virtual reality exposure therapy (VRET) has been shown to help patients with fears of height. However, there is an ethical dilemma within these sessions when patients feel overwhelmed with the therapy. To prevent overwhelming patients, clinicians must be very specific about the VRET and get informed consent from the patient. Additionally, during the therapy, the clinician must continuously check in with the patient and stop the therapy if the patient is too overwhelmed. While, research hasn't shown that too much exposure to VR causes derealization, clinicians must be careful to not overuse VR so much so that patients have a hard time dissociating between VR and the real world.

Virtual Embodiment

Virtual embodiment is the ability for VR environments to substitute a person's real body into a virtual avatar of one. It could be seen from the first person perspective as if the user is the avatar. This is an advance feature of VR and has been used to help people understand what it's like to be in other's shoes. It is important to consider the ethical issues of virtual embodiment as it can lead to cognitive, affective, and behavioral changes. Clinician's use of virtual embodiment can lead to unintended results like pain or phantom limb.

Misconceptions

VRET has become increasingly popular and has been shown to help adults overcome anxiety, PTSD, and phobias. However, VRET has not had established success in treating children or adolescents with anxiety disorder. This will come into question when treating patients who may or may not need VRET. The use of VR and computer software can add expenses and is potentially harmful with risks of security or side effects of VR. Clinicians must find a way to balance the cost and benefits of VRET among the misconceptions that surround it.