Body Image and Virtual Reality in Eating Disorders: Is Exposure to Virtual Reality More Effective than the Classical Body Image Treatment?

Abstract

Body image (BI) disturbances are considered to be central in eating disorders (ED) psychopathology. There are few studies focused on the treatment of BI disturbances in ED, and most of them have used "traditional methods." The purpose of the present study was to probe the effectiveness of one specific component in the assessment and treatment of BI in ED by means of virtual reality (VR). Two treatment conditions were applied: (a) The Standard Body Image Treatment Condition (SBIT) and (b) the VR Condition. Thirteen eating disordered patients were randomly assigned to one of those conditions. No differences between both conditions were found in general ED measures, but patients treated in the VR condition showed a greater significant improvement in specific BI measures. These results suggest that BI treatment with VR could be more targeted to its disturbances. than traditional techniques are.

Full text

CyberPsychology
&
Behavior
Volume
2,
Number
2,
1999
Mary
Ann
Liebert,
Inc.
Body
Image
and
Virtual
Reality
in
Eating
Disorders:
Is
Exposure
to
Virtual
Reality
More
Effective
than
the
Classical
Body
Image
Treatment?
C.
PERPIÑÁ,
Ph.D.,1
C.
BOTELLA,
Ph.D.,2
R.
BAÑOS,
Ph.D.,1
H.
MARCO,2
M.
ALCAÑIZ,
Ph.D.,3
and
S.
QUERO2
ABSTRACT
Body
image
(BI)
disturbances
are
considered
to
be
central
in
eating
disorders
(ED)
psy¬
chopathology.
There
are
few
studies
focused
on
the
treatment
of
BI
disturbances
in
ED,
and
most
of
them
have
used
"traditional
methods."
The
purpose
of
the
present
study
was
to
probe
the
effectiveness
of
one
specific
component
in
the
assessment
and
treatment
of
BI
in
ED
by
means
of
virtual
reality
(VR).
Two
treatment
conditions
were
applied:
(a)
The
Standard
Body
Image
Treatment
Condition
(SBIT)
and
(b)
the
VR
Condition.
Thirteen
eating
disordered
pa¬
tients
were
randomly
assigned
to
one
of
those
conditions.
No
differences
between
both
con¬
ditions
were
found
in
general
ED
measures,
but
patients
treated
in
the
VR
condition
showed
a
greater
significant
improvement
in
specific
BI
measures.
These
results
suggest
that
BI
treat¬
ment
with
VR
could
be
more
targeted
to
its
disturbances·
than
traditional
techniques
are.
INTRODUTION
Eating
disorders
(ED)
are
clinical
syn¬
dromes
characterized
by
an
altered
eating
behavior
as
a
consequence
of
dramatic
efforts
that
patients
make
to
control
their
weight
and
shape.
However,
such
as
Rosen1
said,
body
im¬
age
disturbance
is
what;
essentially
distin¬
guishes
ED
from
other
psychological
condi¬
tions
which
occasionally
involve
eating
abnormalities
and
loss
of
weight.
Body
image
(BI)
is
a
term
coined
by
Schilder2
referring
to
the
picture
of
our
own
body
that
we
form
in
our
mind;
that
is,
the
way
in
which
the
body
appears
to
ourselves.
Particularly,
two
aspects
of
BI
can
be
distinguished:
accu-
^niversity
of
Valencia, Valencia,
Spain.
2Jaume
I
University,
Castellón,
Spain.
3Polithecnic
University
of
Valencia,
Valencia,
Spain.
racy
of
body
size
estimation
and
feelings
to¬
wards
the
body.3
In
ED,
both
aspects
are
dis¬
turbed
because
overestimation
is
frequent
and
body
dissatisfaction
is
a
constant.
The
severity,
course,
and
relapses
of
ED
sug¬
gest
that
we
do
not
have
effective
treatments
yet
that
contemplate
the
complexity
of
these
disorders.
Current
treatments
of
ED
have
as
a
first
aim
the
stabilization
of
eating
habits
in
or¬
der
to
obtain
a
regulation
in
weight
and
bod¬
ily
functions.
The
treatment
of
BI
remains
in
second
place,
although
this
element
is
consid¬
ered
to
be
central
in
ED
psychopathology.
In
fact,
dissatisfaction
and
distortion
of
BI
are
not
only
a
part
of
the
diagnostic
criteria
in
ED,
but
their
first
manifestation.
The
review
of
the
studies
on
treatment
for
BI
in
ED
carried
out
by
Cash
and
Grant4
revealed
that
we
can
not
treat
ED
without
correcting
the
BI
and
it
is
necessary
to
treat
specifically
BI
dis¬
turbances
within
the
general
treatment
of
ED.
149

150
PERPINA
ET
AL.
However
it
seems
unlikely
that
BI
improves
without
a
direct
intervention
on
it.
There
are
few
studies
focused
on
the
treat¬
ment
of
BI
disturbances
in
ED,
and
most
of
them
have
used
traditional
methods
such
as
movable
caliper,
silhouettes
tests,
distorting
mirror
or
video,
relaxation,
imagery
techniques,
and
cog¬
nitive
discussion.
There
is
one
pioneer
experi¬
ence
in
the
treatment
of
BI
by
VR:
The
Virtual
Body
Project
(VEBIM)
from
G.
Riva
and
colleges
in
1997.5
This
program
was
addressed
to
the
de¬
velopment
and
use
of
virtual
environments
(VE)
for
the
study
and
treatment
of
BI
distur¬
bances
but
in
a
nonclinical
population.
Later,
in
an
article
published
at
the
end
of
1998,
Riva's
team6
applied
VE
to
one
anorexic
patient
and,
in
spite
of
not
being
a
controlled
study,
their
re¬
sults
are
very
encouraging.
However,
given
the
novelty
of
this
topic,
there
are
still
many
aspects
to
study.
For
in¬
stance,
controlled
researches
with
clinical
sam¬
ples
are
needed.
Not
only
the
global
silhouette
should
be
taken
into
account,
but
also
specific
body
areas,
and
it
is
also
necessary
to
introduce
other
discrepancy
indexes
contemplating
sub¬
jective,
desired,
actual
and
healthy
BI.
Finally,
there
are
not
comparative
studies
on
the
effec¬
tiveness
of
VR
applications
and
traditional
treatment
of
BI.
The
purpose
of
the
present
study
was
to
probe
the
effectiveness
of
one
specific
compo¬
nent
in
the
assessment
and
treatment
of
BI
in
ED
by
means
of
VR.
Our
contribution
tried
to
fulfill
the
following
criteria:
to
be
a
controlled
study,
to
apply
VR
treatment
to
a
group
of
pa¬
tients
suffering
from
ED,
and
to
offer
a
com¬
parison
of
the
effectiveness
between
VR
and
the
classical
BI
treatment.
METHOD
Subjects
Initially,
18
outpatients
from
the
Provincial
Hospital
of
Castellón,
Spain
were
selected.
The
selection
criteria
were
established
on
the
base
of
(a)
suffering
from
an
eating
disorder
and
(b)
taking
into
account
that,
at
the
moment
of
the
study,
the
patients
were
not
in
a
critical
stage
of
their
disorder
(meaning
the
life
of
these
pa¬
tients
was
not
at
risk).
Their
participation
was
voluntary.
Written
informed
consent
was
ob¬
tained.
Measures
Patients
were
evaluated
by
different
mea¬
sures.
First,
a
semi-structured
clinical
interview
on
ED
according
DSM-IV
criteria
was
con¬
ducted,
and,
next,
several
questionnaires
were
filled
out.
These
questionnaires
can
be
grouped
in
three
blocks:
General
psychopathology
measures.
BDI
(Beck
Depression
Inventory)
and
PANAS
(the
Posi¬
tive
and
Negative
Affect
Schedule).
ED
general
measures.
EAT
(Eating
Attitudes
Test);
RS
(Restrained
Scale);
BITE
(Bulimic
In¬
vestigatory
Test
Edinburgh);
and
EDI2
(Eating
Disorder
Inventory).
BI
specific
measures.
BSQ
(Body
Shape
Ques¬
tionnaire);
BIAQ
(Body
Image
Avoidance
Questionnaire);
Body
Satisfaction
(EDI2
sub-
scale);
BAT
(Body
Attitudes
Test);
BES
(Body
Esteem
Scale);
BIATQ
(Body
Image
Automatic
Thoughts
Questionnaire);
ASI
(Appearance
Schemas
Inventory);
SIBID
(Situational
Inven¬
tory
of
Body
Image
Dysphoria);
BASS
(Body
Areas
Satisfaction
Scale);
Body
Interference;
and
Fear
of
putting
on
weight.
In
addition,
some
self-rating
scales
to
assess
VR
sessions
were
designed.
Treatment
components
There
were
three
treatment
components:
1.
BI
treatment
adapted
from
Cash.7
It
was
mainly
composed
of
education,
exposure,
and
cognitive
discussion.
The
program
was
developed
during
8
weekly
group
sessions
with
a
duration
of
3
hours
each.
2.
Relaxation
component.
The
relaxation
com¬
ponent
was
applied
in
a
parallel
way
to
the
BI
treatment
sessions
during
six
weekly,
in¬
dividual
sessions
with
a
duration
of
1
hour.
3.
VR
component.
The
VR
component
was
ap¬
plied
in
a
parallel
way
to
the
BI
treatment
sessions
during
six
weekly,
individual
ses¬
sions
with
a
duration
of
1
hour.
The
VE
consisted
of
six-setting,
the
first
one
being
used
for
learning
and
accommodation

BODY
IMAGE
AND
VIRTUAL
REALITY
BDI
151
BASS
RV
EDSBIT
PRE
POST
FIG.
1.
Pretreatment
and
posttreatment
differences
on
the
Beck
Depression
Inventory.
purposes.
The
second
zone
consisted
of
a
food
area
with
a
virtual
balance
in
it.
In
the
scales
appeared
the
patient's
real
weight,
and
she
in¬
troduced
her
subjective
and
desired
weights.
The
balance
also
showed
her
healthy
weight.
The
purpose
was
to
obtain,
and
then
discuss,
several
discrepancy
indices.
Moreover,
there
were
forbidden
and
"diet"
foods.
Once
the
pa¬
tient
had
eaten,
she
had
to
introduce
into
the
balance
the
weight
she
thought
she
had
at
that
moment.
The
purpose
was
that
the
patient
did
not
overestimate
her
weight
after
eating.
Set¬
ting
three
was
an
exhibition
room
with
several
posters
showing
different
body
builds.
The
purpose
was
that
the
patient
understands
that
weight
is
a
relative
concept.
Setting
four
con-
IVR
1SBIT
PRE
POST
FIG.
3.
Pretreatment
and
posttreatment
differences
on
the
Body
Areas
Satisfaction
Scale.
sis
ted
of
two
mirrors.
The
patient
had
to
ma¬
nipulate
a
3D
human
figure
by
increasing
or
decreasing
different
body
areas
until
it
repre¬
sented
her
body
image.
In
the
other
mirror,
the
patient's
actual
body
appeared
in
a
translucent
2D-image
in
order
to
overlap
the
3D-figure.
If
both
figures
did
not
fit,
the
patient
had
to
cor¬
rect
the
3D-figure.
In
the
setting
five
there
was
a
doorframe
with
several
colored
strips
in
it.
The
objective
of
this
area
was
to
pass
through
the
door
in
profile,
in
such
a
way
that
it
was
necessary
to
eliminate
the
correct
number
of
strips
to
open
the
accurate
space.
Finally
in
set¬
ting
six,
the
patient
had
to
manipulate
differ¬
ent
body
areas,
but
this
time,
she
was
asked
to
model
her
subjective
and
desired
body,
and
the
PANAS
+
PRE
POST
PRE
SIBID
IVR
ISBIT
POST
FIG.
2.
Pretreatment
and
posttreatment
differences
on
FIG.
4.
Pretreatment
and
posttreatment
differences
on
the
Positive
and
Negative
Affect
Schedule.
the
Situational
Inventory
of
Body
Image
Dysphoria.

152
BIAQ
PERPINA
ET
AL.
FEAR
OF
PUTTING
ON
WEIGHT
IVR
1SBIT
PRE
POST
FIG.
5.
Pretreatment
and
posttreatment
differences
on
the
Body
Image
Avoidance
Questionnaire.
IVR
1SBIT
PRE
POST
FIG.
7.
Pretreatment
and
posttreatment
differences
on
the
fear
of
putting
on
weight.
shape
that,
according
to
her,
a
significant
per¬
son
would
have
of
her.
All
these
images
were
contrasted.
Patients
moved
through
the
set¬
tings
according
to
their
progress.
Treatment
conditions
Three
components
aforementioned
were
combined
resulting
in
two
treatment
condi¬
tions:
(A)
Standard
Body
Image
Treatment
Condition
(SBIT),
which
is
the
simultaneous
application
of
the
program
adapted
from
Cash
plus
relaxation
and
(B)
the
VR
Condition,
which
is
the
simultaneous
application
of
the
program
adapted
from
Cash6
plus
VR.
Apparatus
The
present
application
has
been
developed
using
the
WorldUp
software
from
Sense8.
The
hardware
consists
of
a
PC
Pentium
II
based
platform
with
an
AccelEclipse
Graphical
Card
from
AccelGraphics,
a
medium
quality
head-
mounted
display
(V6
from
Virtual
Research)
and
a
2D
mouse.
Procedure
Patients
had
already
been
diagnosed
in
the
hospital.
Later,
and
before
treatment,
patients
were
evaluated
over
two
sessions.
A
clinical
in-
BIATQ
IVR
1SBIT
PRE
POST
FIG.
6.
Pretreatment
and
posttreatment
differences
on
the
Body
Image
Automatic
Thoughts
Questionnaire.
BSQ
IVR
1SBIT
PRE
POST
FIG.
8.
Pretreatment
and
posttreatment
differences
on
the
Body
Shape
Questionnaire.

BODY
IMAGE
AND
VIRTUAL
REALITY
CHANGE
IN
FEAR
153
CHANGES
OF
BELIEFS
PRE
POST
DOF
WEIGHING
ONESELF
HOF
WEIGHING
AFTER
EATING
OF
HEALTHY
WEIGHT
FIG.
9.
Changes
in
fears
of
weighing
oneself,
weighing
oneself
after
eating,
and
a
healthy
weight
measured
be¬
fore
and
after
virtual
reality
sessions.
PRE
POST
ION
WEIGHT
STABILITY
ION
RELATIVITY
OF
WEIGHT
FIG.
11.
Changes
in
beliefs
on
weight
stability
and
rel¬
ativity
of
weight
measured
before
and
after
virtual
real¬
ity
sessions.
terview
was
conducted
to
confirm
the
diagno¬
sis
according
DSM-IV.8
Afterwards,
they
were
randomly
assigned
to
one
of
the
two
treatment
conditions.
Each
therapy
group
was
composed
from
4
to
5
patients.
Once
the
last
group
ses¬
sion
was
ended,
the
patients
filled
in
again
the
assessment
questionnaires.
We
had
indepen¬
dent
judges
blind
to
the
treatment
conditions
in
baseline
and
posttreatment.
RESULTS
From
the
18
initial
patients,
five
gave
up
treatment
in
different
phases,
so
the
final
sam¬
ple
was
composed
by
13
patients;
5
in
the
Stan-
CHANGES
ABOUT
WEIGHT
USUBJECTIVE
WEIGHT
DSUB.WEIGHT
AFTER
EATING
PATIENT'S
DESIRED
WEIGHT
PRE
POST
FIG.
10.
Changes
in
subjective
(perceived)
and
desired
weights
measured
before
and
after
virtual
reality
sessions.
dard
BI
treatment
(SBIT)
[3
patients
with
Anorexia
Nervosa
and
2
with
Buliumia
Ner¬
vosa.
Mean
age
16.6
(SD
=
1.3);
Mean
Body
Mass
Index:
22.4
(SD
=
3.0)],
and
8
in
the
VR
condition
[4
patients
with
A.N.
and
4
with
B.N.
Mean
age
18.38
(SD
=
2.9);
Mean
of
BMI:
21.5
(SD
=
3.2)].
Differences
between
conditions
at
baseline
The
differences
showed
by
the
patients
be¬
tween
treatment
conditions
at
baseline
were
analyzed
first.
There
were
no
significant
dif¬
ferences
between
both
conditions
in
any
mea¬
sure.
Differences
between
conditions
after
treatment
Analyses
of
variance
with
repeated
measures
on
the
second
factor
(2
condition
X
pre
/post
treatment)
were
applied.
After
treatment,
re¬
sults
showed
that
all
patients
improved
in
all
measures.
Most
importantly,
patients
in
VR
condition
showed
a
larger
significant
im¬
provement
in
depression
(BDI)
(F(i,io):
4.85;
<
.05),
and
anxiety
(PANAS+)
(F(U0):
6.28;
<
.03).
These
results
are
shown
in
Figures
1
and
2.
With
respect
to
BI
measures,
patients
in
the
VR
condition
were
more
satisfied
with
a
major
number
of
body
areas
(BAAS)
(F(i,io):
10-5;
<
.009);
felt
less
dysphoria
in
showing
their
body
in
different
situations
(SIBID)
(F(1
/10):
16.57;
<
.002);
showed
less
body
avoidance
(BIAQ)

154
PERPINA
ET
AL.
(f
( , ):
5.27;
<
.04);
showed
less
negative
thoughts
with
respect
to
BI
(BIATQ)
(F(i,i0):
12.04;
<
.006);
felt
less
fear
or
putting
on
weight
(F(i40):
6.28;
<
.03);
and
showed
more
satisfaction
with
the
body
(BSQ)
(F(irwy
30.8;
<
.0001).
See
Figures
3-8.
Differences
in
the
VR
condition
after
treatment
Within
the
VR
condition,
applying
the
Stu¬
dent's
f-test
or
Wilcoxon
f-test,
we
observed
an
improvement
in
all
the
variables
that
were
reg¬
istered
in
VR
sessions,
although
we
will
com¬
ment
on
only
those
that
reached
statistical
sig¬
nificance.
First,
at
the
end
of
the
sessions,
patients
showed
less
fear
of
weighing
them¬
selves
(i(7);
2.71;
<
.03),
of
weighing
them¬
selves
after
eating
(f(7):
3.92;
<
.006),
and
of
reaching
their
healthy
weight
(i^
3.63;
<
.008).
Second,
patients
decreased
their
discrep¬
ancy
between
their
subjective
and
real
weight
(Z:
2.20;
<
.03);
their
subjective
weight
after
eating
was
reduced
(Z:
2.53;
<
.01),
and,
lastly,
their
desired
weight
was
closer
to
their
healthy
weight
(f(7):
3.33;
<
.01).
Finally,
changes
were
also
observed
in
basic
beliefs
re¬
garding
weight
concept:
about
its
stability
(Z:
1.80,
<
.03)
and
about
its
relativity
(trjy
2.76,
<
.03).
See
Figures
9-11.
DISCUSSION
As
it
is
shown
by
the
results,
VR
treatment
for
BI
has
an
important
value
in
the
ED
field.
Patients
treated
in
the
VR
condition
showed
a
greater
significant
improvement
not
only
in
those
specific
variables
of
BI,
but
also
in
de¬
pression
and
anxiety.
The
fact
of
not
having
found
differences
be¬
tween
both
conditions
in
general
ED
measures,
and
having
found
them
in
BI
measures,
make
us
think
that
BI
treatment
with
VR
is
more
tar¬
geted
to
its
disturbances
than
are
traditional
techniques.
The
VR
treatment
condition
has
been
de¬
signed
to
assess
and
treat
central
aspects
of
ED
that
have
been
difficult
to
manage
in
traditional
treatments.
To
capture
something
so
subjective
as
the
body
image
is
one
of
these
difficult
as¬
pects
because
it
is
a
mental
picture.
Among
the
advantages
of
this
virtual
lab,
we
find
that
it
allows
us
to
go
beyond
reality
as
helpful
tool
for
confronting
the
patient
with
her
BI
distor¬
tions.
Moreover,
as
well
could
observe,
the
vir¬
tual
system
turned
into
an
objective
judge
to
whom
patients
had
less
resistance.
They
were
able
to
accept
that
they
were
distorting
their
body.
We
could
see
the
high
degree
of
realism
that
VE
produced
in
the
patients
when
they
were
asked
how
real
they
thought
the
virtual
expe¬
rience
was,
all
of
them
scored
from
7
to
9
in
a
scale
ranged
from
0
to
10.
In
fact,
when
patients
ate
virtually,
in
addition
to
moving
their
mouth
and
swallowing,
they
reported
"I
feel
full,"
"If
I
keep
eating,
I
will
vomit,"
"I
have
to
move
to
get
rid
of
this"
and
they
started
to
move
anx¬
iously
on
their
seats.
At
this
moment
we
are
waiting
for
a
1-month
follow-up
and
offering
the
patients
in
the
SBIT
condition
the
possibil¬
ity
of
completing
their
treatment
with
VR.
To
conclude,
ED
are
very
complex
and
that
BI
treatment
is
only
a
part
of
the
general
treat¬
ment.
However,
as
Pruzinsky
and
Cash9
have
claimed,
BI
is
multifaceted.
It
refers
to
percep¬
tions,
thoughts,
and
feelings
about
the
body
and
bodily
experience;
is
intertwined
with
feel¬
ings
about
''self";
is
socially
determined;
is
not
entirely
static;
influences
information
process¬
ing;
and
influences
behavior.
Therefore,
inso¬
far
as
we
are
able
to
incorporate
the
different
factors
that
intervene
in
ED,
we
will
be
able
to
extend
VR
application
to
more
components
of
these
disorders.
ACKNOWLEDGMENT
This
article
was
partially
sponsored
by
I
+
D
programa
FEDER
(1FD97-0260-C02-01),
by
Ministerio
de
Sanidad
y
Consumo
(FIS)
(99/
0997),
and
by
Hospital
Provincial
de
Castellón.
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reprint
requests
to:
Conxa
Perpiñá
Departamento
de
Personalidad
Facultad
de
Psicología
Avda.
Blasco
Ibáñez,
21,
46010-Valenda,
Spain
E-mail:
perpinya@uv.es

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