BUENO, CRISTINALOSA, CRISTINARAMON, ANNA

SÁNCHEZ, CRISTINA

VR in Bulimia Nervosa

WHAT IS BULIMIA NERVOSA?

Bulimia nervosa is a mental disorder characterized by an abnormal eating model with voracious eating episodes followed by different practices to eliminate calories.

After the episode, the subject feels moody, with sadness, guilt, etc..

Between bulimic episodes, eating may not be normal in the sense that it may be restricted or in a continuous cycle high ingestions and vomiting.

ANTECEDENTS

Talking about the VR studies in eating disorders and, specifically in Bulimia Nervosa, it can be found these two main and actual applications:

VEBIM: (Virtual Environment for Body Image Modification) developed by Riva et al. in the European context. (Riva et al., 1997, 2007, 2009, 2011), this application has several updates like VEBIM2 or VREDIM.

Virtual & Body: developed by Perpiñá et al. (Perpiñá, Botella y Baños 2000).

ADVANTAGES

● VR allows the patient to model and reflect his or her body image

that reflects the patient mental representation.

● Permits patients to face and deal with their body image

disturbances.

● Encourages patients to face their fears in a protected

environment before being exposed to the real situation. All this

increases their motivation to take part in treatment.

● The use of new technologies can be attracted and improve

therapeutic adherence.

DISAVANTAGES

● New technologies in the treatment of mental disorders,

becoming a security/safe symbol.

● Methodological limitation: lack of a control or comparison group

mean that the findings should be considered as preliminary.

● Some authors doubt the validity of the virtual stuffing and rely

on the fact that eating behavior is very complex. They defend

that is necessary to carry out more comprehensive studies about

how can generalize what is learned in a virtual environment in

the real life.

THE IMPORTANCE OF INVESTIGATION

● Therapy must be more studied and it is necessary to know more

about it for applied more exactly and obtain more positive results

and benefits in patients.

● It is necessary that this RV is farmed in a global investigation

design that meets basic ethical principles.

● The etiology of eating disorders is multidimensional and tends to

become chronic. It required the combination of different treatment

strategies (an integrating model). VR can be useful and can produce

improvements in some aspects of bulimia, but always within a

complete and multidisciplinary therapy, never use it in isolation.

THE FUTURE OF VR

● To treat not only the primary symptoms. Importance of

work in the secondary aspects of this disorder, like low

self-esteem or enhance social skills of the patients.

● Include this type of tool of treatment in public

healthcare and reach a larger percentage of the

population.

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

VR gives to the patients the possibility to interact with the virtual environment, facing some fearful stimuli.

VR therapy has been most successful when is used as an adjunct to both inpatient and outpatient treatment programs.

VR gives: immersion, interaction and imagination.

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

VR environments allow the repeated and systematic presentation, being more predicable, controllable and reliable.

VR can simulate situations that can be difficult to control or simulate in real life.

VR can introduce distractions.

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

VR allows the patient to go beyond reality. There is the possibility to change the situations.

VR can be adapted to the individual characteristics of the patient with BN.

Therapist can change some parameters, highlight those that generate more anxiety, negative thoughts or distorted thoughts to the patient.

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

VR can objective the grade of anxiety, comparing it with the subjective self-reported responses. It helps to awareness of disease. Patients are monitored measuring the changes that

may experience.

VR is a unique setting where patients can explore and act without feeling threatened (lower self-steem and corporal distortions are common in BN).

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

To increase the therapeutic adherence, VR in BN offers a protected environment, with the sense of individualism and confidenciality.

VR allows grading the situation, where the patient can move from the easiest to the most difficult performances.

The VR doesn’t alter the essential elements in Psychotherapy.

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

VR it’s an excellent source of information about the efficacy in the development of the different situations, because there are some practical situations that describe the exit or the fails. Therapist know what the patient is seeing and can

modify the look of the patient, forcing him ho fix in the anxiety stimuli.

In VR there is a total control over the exposure parameters.

VR : AN INTERESTING TOOL FOR BULIMIA NERVOSA

VR overcome spatial and temporal barriers that can limit a psychotherapeutic process (patients with a low IMC, who are moderately weak, for example).

Attractive to teenager patients (digital natives). More attractive.

VR can induce some necessary habits or guidelines related to food, extrapolating it in the future with similar situations.

OBJECTIVES OF THE VR APPLICATION

The VR reduce negative or distortional thoughts that present the patient toward his body.

Reeducating about their food using Psych education.

The patient will successfully overcome the virtual environments hierarchy ordered, from less to higher anxiety, so the patient will extrapolate the methods and tools used in the virtual world to reduce anxiety in the real world.

OUR VR APPLICATION (I)

FIRST SESSION (60 minutes): The therapist inquires about how the patient feels,

what are your fears and what do you think are due.

The therapist asks about behavior that makes the person facing their fears, anxieties or concerns.

The therapist diagnosed him a feeding disorder, specifically bulimia nervosa (BN).

OUR VR APPLICATION (II)

SECOND SESSION (30 minutes):

The therapist proposes to make a specific test related with the psychopathological problem (BN), to rule out dual diagnosis.

OUR VR APPLICATION (III)

THIRD SESSION (45 minutes): The therapist performs a psycho educational

approach about the characteristics of the disease (BN).

The therapist tells to the user in what will consist the psychotherapeutic process; what will work in these sessions and what they will try to achieve the goals.

The disease can be treated from a cognitive behavioral approach, but with a methodology based on the VR.

OUR VR APPLICATION (IV)

FOURTH AND FIFTH SESSION (60 minutes):

Psycho education toward relaxation techniques and training of these, so that the patient can know the methodology and extrapolate them to the future virtual situations generating more anxiety.

The two most common techniques are controlled breathing of Jacobson and muscle relaxation.

OUR VR APPLICATION (V)

SIXTH AND SEVENTH SESSION (60 minutes): Cognitive restructuring.

o Instrument: auto registers sheet.o Objective: change cognitive irrational thoughts to another

thought, realer and more objectives.

Hierarchy of negative thoughts. o Instrument: write down negative thoughts and situations that

have to deal with that provoke anxiety. o Objective: confronting the situations that cause anxiety .

OUR VR APPLICATION (VI)

SIXTH AND SEVENTH SESSION (60 minutes):

Technique of thought stopping.o Instrument: the own cognition.o Objective: divert the attention of the persevering thought to

another stimulus or idea.

OUR VR APPLICATION (VII)

EIGHT - THIRTEENTH SESSION (60min/session)

1. Familiarization of the patient with the VR.

2.Enter into the virtual world and face situations that will generate more anxiety (in order of least to most anxiety).

3.In these sessions the patient tells how he is and how he feels at the time, combining relaxation techniques and cognitive restructuring.

OUR VR APPLICATION (VIII)

EIGHT - THIRTEENTH SESSION (60min/session)

STAGE 1 (WC scale)o The patient has to get on the scale and weighed. Then,

introduces his weight (what he thinks) at that time and how much weight he would like to weigh.

o The virtual system shows him the current weight.o Working distortions and conscience of disease.

OUR VR APPLICATION (IX)

EIGHT - THIRTEENTH SESSION (60min/session)

STAGE 2 (Kitchen)o The patient choose the food and cook it.o Eating this food in front of family.o Objective: reduce anxiety when eat and psycho education in

healthy diet.

OUR VR APPLICATION (X)

EIGHT - THIRTEENTH SESSION (60min/session)

STAGE 3 (Toilet mirror, toiled)o The patient weighed and specify his weight (what he thinks)

after eat foods that he cooked.o The virtual system shows him the real weight.o The patient fixes his gaze anxiety stimuli (toilet and mirror).o Objectives: cognitive restructuring, work anxiety to go to the

bathroom after eating, accept their body, not relate WC with conduct purge.

OUR VR APPLICATION (XI)

EIGHT - THIRTEENTH SESSION (60min/session)

STAGE 4 (Supermarket)o The patient will face fact food selection that considers

convenient and suitable to eat during the weekend.o The situation may be graduated according to the degree of

anxiety that involves the patient. o Improved level anxiety, improve problem-solving process and

selection of healthy foods (psycho education healthy diet).

OUR VR APPLICATION (XII)

EIGHT - THIRTEENTH SESSION (60min/session)

STAGE 5 (Social situation: shopping with a friend)o The patient is exposed to what people tell her about his image

and the fact of buying clothes, try on it and have to look in the mirror.

o Objectives: working anticipatory anxiety, distress, cognitive restructuring and change behaviors of avoidance.

OUR VR APPLICATION (XIII)

FOURTEENTH SESSION (30 minutes): Relapse prevention. The therapist exposes the patient to more extreme

situations. The therapist performs the SUDS graphical

representation. Self-registries in real situations. Objectives: to extrapolate behaviors and cognitions

learned in RV to real situations.

BIBLIOGRAPHY

Jarne A., Talarn A.(2011) Manual de Psicopatología clínica. Herder Ferrer García, M.; Gutierrez Maldonado J.; i Riva G. (2013). Virtual Reality

based treatments in eating disorders and obesity: A review. Journal of Contemporary Psychotherapy, 43(4) 207-221.

Riva G. (2011). The key to Unlocking the Virtual Body: Virtual Reality in the Treatment of Obesity and Eating Disorders. Journal of Diabetes Science and Technology. 5: 2, 283-292.

Salorio del Morán, P.; Gómez Sánchez, R.; Morales Moreno, I.; Torres Ortuño, A.; Díaz Cuenca, A.; Alegria Capel, A. (2004). La realidad virtual, una nueva herramienta terapéutica. Tratamiento de la imagen corporal en los trastornos alimentarios. Servicio de Psiquiatria. Hospital General Universitario Reina Sofía y Escuela de Infermería UCAM. 1 – 17.

Mahíques, P. (2012). Nuevas tecnologías y tratamientos de los trastornos de la alimentación, ¿La realidad virtual o la virtud de la realidad?. Unidad de trastornos alimentarios del Hospital Provincial de Castellón. 1 – 15.