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CLOSING EDITORIAL
Neuroscience of Virtual Reality:
From Virtual Exposure to Embodied Medicine
Giuseppe Riva, PhD,
1,2
Brenda K. Wiederhold, PhD, MBA, BCB, BCN,
3,4
and Fabrizia Mantovani, PhD
5
Abstract
Is virtual reality (VR) already a reality in behavioral health? To answer this question, a meta-review was
conducted to assess the meta-analyses and systematic and narrative reviews published in this field in the last
twenty-two months. Twenty-five different articles demonstrated the clinical potential of this technology in both
the diagnosis and the treatment of mental health disorders: VR compares favorably to existing treatments in
anxiety disorders, eating and weight disorders, and pain management, with long-term effects that generalize to
the real world. But why is VR so effective? Here, the following answer is suggested: VR shares with the brain
the same basic mechanism: embodied simulations. According to neuroscience, to regulate and control the body
in the world effectively, the brain creates an embodied simulation of the body in the world used to represent and
predict actions, concepts, and emotions. VR works in a similar way: the VR experience tries to predict the
sensory consequences of an individual’s movements, providing to him/her the same scene he/she will see in the
real world. To achieve this, the VR system, like the brain, maintains a model (simulation) of the body and the
space around it. If the presence in the body is the outcome of different embodied simulations, concepts are
embodied simulations, and VR is an embodied technology, this suggests a new clinical approach discussed in
this article: the possibility of altering the experience of the body and facilitating cognitive modeling/change by
designing targeted virtual environments able to simulate both the external and the internal world/body.
Virtual Reality in Behavioral Health: A Meta-Review
This special issue presented and discussed different
virtual reality (VR) applications for behavioral health.But
is VR already a reality in behavioral health? To answer this
question, a meta-review was conducted to assess the meta-
analyses and systematic and narrative reviews (see Fig. 1 for
the methodology) published in this field in the last 22 months.
Twenty-five different articles
1–25
(see Table 1 for the ar-
ticles’ list and a summary of their conclusions) demonstrated
the clinical potential of this technology in both the diagno-
sis and the treatment of mental health disorders. Nine arti-
cles
1,2,6,9,14,15,19,18,22
reviewed the available literature on the
effectiveness of VR in psychiatric/mental health treatment.
All of the articles suggest that VR is suitable for the treat-
ment of mental health problems and could make an important
contribution in many different areas, from anxiety and eating
disorders to psychosis and addiction.
The most common use of VR in behavioral health is for
exposure therapy (VR exposure [VRE]). VRE is similar to
classic exposure therapy
10,16,26
—the patient is exposed to a
graded exposure hierarchy—with the only difference being
that VR is substituted for other exposure techniques (e.g.,
in vivo or imaginal exposure). In the treatment of complex
anxiety disorders, the use of VRE is often combined with
other techniques such as breathing or relaxation exercises,
27
attentional and autonomic control training,
28
biofeedback,
29,30
and/or cognitive restructuring.
31
Five articles,
5,8,10
including a meta-analysis,
11,16
spe-
cifically explored the use of VRE in the treatment of anx-
iety disorders. The available data show that VR is able to
reduce anxiety symptoms significantly in different anxiety
1
Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano, Milan, Italy.
2
Department of Psychology, Universita
`Cattolica del Sacro Cuore, Milan, Italy.
3
Virtual Reality Medical Center, La Jolla, California.
4
Virtual Reality Medical Institute, Brussels, Belgium.
5
Department of Human Sciences for Education, Universita
`degli Studi di Milano-Bicocca, Milan, Italy.
ªGiuseppe Riva et al. 2019; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative
Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
CYBERPSYCHOLOGY,BEHAVIOR,AND SOCIAL NETWORKING
Volume 22, Number 1, 2019
Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2017.29099.gri
82
disorders: phobias,
32
post-traumatic stress disorders,
33
panic
disorder and agoraphobia,
34
social anxiety disorders,
35
psy-
chological stress,
36
and generalized anxiety disorders.
37
The clinical outcome is generally superior to waitlist con-
trol conditions and comparable to in vivo exposure-based
interventions.
A second group of five articles
3,12,13,17,23
evaluated the
efficacy of VR in the treatment of eating and weight disor-
ders. In this field, VR is used in two different ways.
38
First,
VR cue exposure to critical stimuli (e.g., food or human
bodies) allows both a reduction in the level of anxiety eli-
cited by them and disruption of the reconsolidation of
negative memories.
39,40
Second, VR is used to facilitate the
update of existing body representations.
41,42
According to a
recent theory,
43–47
eating and weight disorders may be the
outcome of a broader impairment in multisensory body in-
tegration that locks the individuals to an old memory of the
body.
48
In this view, even if the subject is able to lose weight
after a diet, the multisensory impairment does not allow
her/him to experience the new body and reduce the level of
body dissatisfaction. VR allows a wrong representation
of the body to be updated through two different strategies.
In the first—‘‘reference frame shifting’’
49,50
—the subject re-
experiences in VR a negative situation related to the body
(e.g., teasing) in both the first and third person (e.g., seeing and
supporting her/his avatar in the VR world). In the second—
‘‘body swapping’’
51,52
—VR is used to induce the illusory
feeling of ownership of a virtual body with a different shape
and/or size. Even if the number of available controlled stud-
ies is less than for anxiety disorders, the field has rapidly
evolved.
17
Specifically, four different randomized controlled
trials—one with eating disorders,
53
onewithmorbidobesity,
54
one with binge-eating,
55
and one with binge-eating and
bulimia
56
—have shown after 6-month and 12-month follow-
ups that VR had a higher efficacy than the gold standard in the
field, that is, cognitive–behavioral therapy.
A third group of three articles
20,21,24
analyzed the use of VR
in pediatric psychology, with a specific focus on VR applica-
tions for the assessment of children suspected of having autism
spectrum disorder
57
or other neurodevelopmental disorders
58,59
(e.g., attention-deficit hyperactivity disorder). In this field, dif-
ferent from the previous ones, the level of clinical evidence
available is still low, even if the existing data suggest moderate
evidence about the effectiveness of VR-based treatments.
24
In
relation to this topic, another article specifically explored the
use of VR for the assessment of psychiatric disorders,
4
finding
that virtual worlds are able to induce and assess psychiatric
symptoms simultaneously, with significant correlations be-
tween VR measures and traditional diagnostic tools. Moreover,
VR is also effective in assessing cue reactivity
60
: its use is able
to increase subjective craving in smokers,
61,62
alcohol drink-
ers,
63
eaters,
64
and cocaine-dependent individuals.
65
Articles identified through database
searching (N= 1,220) Number of duplicates (N= 345)
Articles screened after duplicates
removed (N= 875)
Articles not meeting inclusion
criteria (N= 848)
Full-text articles assessed for
eligibility (N=27)
Studies included in qualitative
synthesis (N= 25)
Reasons for exclusion: review had
a limited focus on virtual reality
(N=2)
FIG. 1. Meta-review methodology. Using the Google Scholar and Scopus databases, a systematic search was conducted to
identify reviews (both systematic and narrative) and meta-analyses that reported on the effects of virtual reality (VR) in the
assessment and treatment in behavioral health: anxiety disorders, pain management, schizophrenia spectrum disorders,
eating and weight disorders, autism spectrum disorders, personality disorders, and substance use disorders. Guidelines for
conducting a systematic review discussed by Uman
162
were followed. The ‘‘free-form’’ question was as follows: ‘‘Do
virtual environments perform equal-to-or-better-than traditional modalities in behavioral health?’’ The outcome of interest
was reviews and meta-analyses answering this question in any area of behavioral health. The following search terms were
used: ((‘‘Virtual Reality’’ AND (‘‘Review’’ OR ‘‘Meta-analysis’’ OR ‘‘metaanalysis’’)) AND (‘‘anxiety’’ OR ‘‘phobia’’ OR
‘‘fear’’ OR ‘‘stress’’ OR ‘‘pain’’ OR ‘‘schizophrenia’’ OR ‘‘psychosis’’ OR ‘‘obesity’’ OR ‘‘eating disorders’’ OR ‘‘bu-
limia’’ OR ‘‘binge eating’’ OR ‘‘anorexia’’, OR ‘‘autism’’ OR ‘‘Asperger’’ OR ‘‘substance’’ OR ‘‘drug’’ OR ‘‘nicotine’’
OR ‘‘cocaine’’ OR ‘‘opioids’’). The search targeted articles published between November 2, 2016, and August 1, 2018.
Inclusion criteria included (a) reviews or meta-analyses, (b) English language journals, and (c) peer-reviewed journals.
Exclusion criteria included (a) articles related to the use of VR in surgery or in physical and cognitive rehabilitation; and (b)
articles lacking basic information about the selection of the discussed articles. The meta-review flow diagram is shown.
NEUROSCIENCE OF VIRTUAL REALITY 83
Table 1. Meta-Analyses and Systematic and Narrative Reviews Published in the Last 12 Months Related
to the Use of Virtual Reality in the Diagnosis and Treatment of Mental Health Disorders
Review type Article Included studies Conclusions (from the articles)
Systematic
meta-review
Riva G, Ban
˜os RM, Botella C, et al.
Transforming experience: the potential of
augmented reality and virtual reality for
enhancing personal and clinical change.
Frontiers in Psychiatry 2016; 7:164.
1
27 systematic
reviews and
meta-analyses
‘‘The available data support the use of this technology in the treatment
of anxiety disorders, pain management, obesity and eating disorders,
and stress-related disorders. But still, there is no clear good quality
evidence for or against using VR for the treatment of depression and
schizophrenia.’’
Systematic review (mental
health)
Freeman D, Reeve S, Robinson A, et al.
Virtual reality in the assessment,
understanding, and treatment of mental
health disorders. Psychological Medicine
2017; 47:2393–2400.
2
285 studies ‘‘VR environments can elicit psychiatric symptoms, manipulation of VR
can inform the understanding of disorders, and simpler psychological
treatments can be successfully administered in VR.
The most established finding is that VR exposure-based treatments can
reduce anxiety disorders, but there are numerous research and
treatment avenues of promise.’’
Reply to the above systematic
review (eating and weight
disorders)
Riva G. Letter to the editor: virtual reality in
the treatment of eating and weight
disorders. Psychological Medicine 2017;
47:2567–2568.
3
3 studies ‘‘Three different RCTs have shown at 1-year follow-up that VR for
eating and weight disorders has a higher efficacy than the gold
standard in the field, i.e. cognitive–behavioral therapy (CBT).’’
Narrative review (mental
health therapy)
Mishkind MC, Norr AM, Katz AC, et al.
Review of virtual reality treatment in
psychiatry: evidence versus current
diffusion and use. Current Psychiatry
Reports 2017; 19:80.
19
Not reported ‘‘More research is needed before VRE may be considered standard of
care in some areas; however, for patients with PTSD or anxiety, and
especially patients not responding or not willing to participate in
traditional therapy, the use of VRE may be considered as an option.
The use of VR for other conditions such as chronic pain,
rehabilitation, and addictions also shows clinical promise.’’
Systematic review (mental
health assessment)
van Bennekom MJ, de Koning PP, Denys D.
Virtual reality objectifies the diagnosis of
psychiatric disorders: a literature review.
Frontiers in Psychiatry 2017; 8:163.
4
39 studies ‘‘Nearly all VR environments studied were able to simultaneously
provoke and measure psychiatric symptoms. Furthermore, in 14
studies, significant correlations were found between VR measures and
traditional diagnostic measures. Relatively small clinical sample sizes
were used, impeding definite conclusions.’’
Narrative review (anxiety
disorders)
Lindner P, Miloff A, Hamilton W, et al.
Creating state of the art, next-generation
virtual reality exposure therapies for
anxiety disorders using consumer
hardware platforms: design considerations
and future directions. Cognitive Behaviour
Therapy 2017; 46:404–420.
5
Not reported ‘‘While having been researched for decades and proven efficacious for
the treatment of anxiety disorders, the pending and ongoing release of
consumer-targeted VR hardware platforms signals an opportune time
to develop the next generation of VR exposure therapies for
widespread dissemination as self-help applications and integration
into regular health care settings.’’
Systematic review (mental
health)
Massetti T, Crocetta TB, Silva TDD, et al.
Application and outcomes of therapy
combining transcranial direct current
stimulation and virtual reality: a
systematic review. Disability &
Rehabilitation: Assistive Technology
2017; 12:551–559.
6
11 studies ‘‘The use of tDCS combined with VR showed positive results in both
healthy and impaired patients including pain management. Future
studies with larger sample sizes and homogeneous participants are
required to confirm the benefits of tDCS and VR.’’
(continued)
84
Table 1. (Continued)
Review type Article Included studies Conclusions (from the articles)
Systematic review (mental
health)
Jerdan SW, Grindle M, van Woerden HC,
Kamel Boulos MN. Head-Mounted Virtual
Reality and Mental Health: Critical
Review of Current Research. JMIR
Serious Games 2018; 6:e14.
82 studies ‘‘Our review demonstrated that VR is effective in provoking realistic
reactions to feared stimuli, particularly for anxiety; moreover, it
proved that the immersive nature of VR is an ideal fit for the
management of pain. However, the lack of studies surrounding
depression and stress highlight the literature gaps that still exist.’’
Systematic review and meta-
analysis (acrophobia)
Arroll B, Wallace HB, Mount V, et al.
A systematic review and meta-analysis
of treatments for acrophobia. Med J Aust
2017; 206:263–267.
16 studies ‘‘A range of therapies are effective for acrophobia in the short term but
not in the long term. Many of the comparative studies showed
equivalence between therapies, but this finding may be due to a type II
statistical error. The quality of reporting was poor in most studies.’’
Narrative review (psychosis) Rus-Calafell M, Garety P, Sason E, et al.
Virtual reality in the assessment and
treatment of psychosis: a systematic
review of its utility, acceptability and
effectiveness. Psychological Medicine
2017 Jul 24 [Epub ahead of print].
7
50 studies ‘‘Virtual reality is a promising method to be used in the assessment of
neurocognitive deficits and the study of relevant clinical symptoms.
Furthermore, preliminary findings suggest that it can be applied to the
delivery of cognitive rehabilitation, social skills training interventions
and virtual reality-assisted therapies for psychosis.’’
Systematic reviews (phobias) Botella C, Ferna
´ndez-A
´lvarez J, Guille
´nV,etal.
Recent progress in virtual reality exposure
therapy for phobias: a systematic review.
Current Psychiatry Reports 2017; 19:42.
8
11 studies ‘‘VRET applications have become an effective alternative that can equal
the results of traditional treatments for phobias from an efficacy point
of view. However, they are also tools capable of enhancing the
psychological treatment field.’’
Narrative review (anxiety
disorders)
Maples-Keller JL, Yasinski C, Manjin N,
et al. Virtual reality-enhanced extinction
of phobias and post-traumatic stress.
Neurotherapeutics 2017; 14:554–563.
10
Not reported ‘‘VRE is consistent with models of extinction learning and provides
several advantages for use within exposure-based interventions.
Broadly, extant research provides support for the effectiveness of
VRE in reducing symptoms of specific phobias and PTSD, with
outcomes generally superior to waitlist controls and comparable with
traditional exposure therapy.’’
Meta-analysis (flight anxiety) CardosxRAI, David OA, David, DO. Virtual
reality exposure therapy in flight anxiety: a
quantitative meta-analysis. Computers in
Human Behavior 2017; 72:371–380.
11
11 studies ‘‘Results pointed out significant overall efficiency of VRET in flight
anxiety at post-test and follow-up. Analysis highlighted the
superiority of VRET vs. control conditions at post-test and follow-up
and the superiority of VRET vs. classical evidence-based
interventions at post-test and follow-up.’’
Narrative review (weight
disorders)
Castelnuovo G, Pietrabissa G, Manzoni GM,
et al. Cognitive behavioral therapy to aid
weight loss in obese patients: current
perspectives. Psychology Research &
Behavior Management 2017; 10:165–
173.
12
Not reported ‘‘Another current and future scenario where CBT could be improved in
the management of obesity is represented by virtual reality (VR)
applications, such as the VR-enhanced CBT that is a sort of enhanced
CBT of obesity with a VR module focused on unlocking the negative
memory of the body, changing its dysfunctional behavioral correlates,
and managing negative emotional states.’’
(continued)
85
Table 1. (Continued)
Review type Article Included studies Conclusions (from the articles)
Narrative review (weight
disorders)
Paul L, Van Der Heiden C, Hoek HW.
Cognitive behavioral therapy and
predictors of weight loss in bariatric
surgery patients. Current Opinion in
Psychiatry 2017; 30:474–479.
13
Not reported ‘‘Although empirical evidence is still scare, results show that CBT is
effective in reducing disordered eating disorders and depression in
bariatric patients. New techniques for applying CBR by virtual reality
potentially make CBT more accessible and less costly.’’
Systematic review (clinical
medicine)
Dascal J, Reid M, Ishak WW, et al. Virtual
reality and medical inpatients: a
systematic review of randomized,
controlled trials. Innovations in Clinical
Neuroscience 2017; 14:14–21.
14
11 studies ‘‘Data from 11 eligible studies provide insight into three current medical
applications of VR technology: pain distraction, eating disorders, and
cognitive/motor rehabilitation. Overall, a majority of studies from the
past decade found VR to be efficacious, easy to use, safe, and
contributing to high patient satisfaction.’’
Systematic review and meta-
analysis (procedural pain)
Chan E, Foster S, Sambell R, Leong P.
Clinical efficacy of virtual reality for acute
procedural pain management: A
systematic review and meta-analysis.
PLoS ONE 2018; 13:e0200987.
20 studies ‘‘VR may have a role in acutely painful procedures, however included
studies were clinically and statistically heterogenous. Further research
is required to validate findings, establish cost efficacy and optimal
clinical settings for usage. Future trials should report in accordance
with established guidelines.’’
Narrative review (clinical
medicine)
Li L, Yu F, Shi D, et al. Application of virtual
reality technology in clinical medicine.
American Journal of Translational
Research 2017; 9:3867–3880.
15
Not reported ‘‘VR has shown to be effective in reduction of burn-induced pain and
management of pain in other situations .Virtual reality exposure therapy
and virtual reality cognitive behavior therapy have become effective
choices for patients with anxiety disorders and other phobias like fear of
flying, claustrophobia, acrophobia or generalized social phobia’’
Narrative review (mental
health)
Maples-Keller JL, Bunnell BE, Kim SJ, et al.
The use of virtual reality technology in the
treatment of anxiety and other psychiatric
disorders. Harvard Review of Psychiatry
2017; 25:103–113.
9
Not reported ‘‘VR has emerged as a viable tool to help in a number of different
disorders, with the most strength of evidence for use in exposure
therapy for patients with anxiety disorders, cue exposure therapy for
patients with substance use disorders, and distraction for patients with
acute pain requiring painful procedures.’’
Systematic review (eating
disorders)
de Carvalho M, Dias T, Duchesne M, et al.
Virtual reality as a promising strategy in
the assessment and treatment of bulimia
nervosa and binge eating disorder: a
systematic review. Behavioral Sciences
2017; 7:43.
17
19 studies ‘‘Two different randomized, controlled trials have shown at one-year
follow-up that VR had a higher efficacy than the gold standard in the
field, i.e., cognitive behavioral therapy (CBT). In conclusion, based
on the current available data VR-based environments may be
considered a promising strategy for the assessment and treatment of
BN and BED.’’
Systematic review (clinical
medicine)
Pourmand A, Davis S, Lee D, et al.
Emerging utility of virtual reality as a
multidisciplinary tool in clinical medicine.
Games for Health Journal 2017; 6:263–
270.
18
45 studies ‘‘These articles provide data, which strongly support the hypothesis that
VR simulations can enhance pain management (by reducing patient
perception of pain and anxiety), can augment clinical training
curricula and physical rehabilitation protocols (through immersive
audiovisual environments), and can improve clinical assessment of
cognitive function (through improved ecological validity).’’
(continued)
86
Table 1. (Continued)
Review type Article Included studies Conclusions (from the articles)
Systematic review (autism) Duffield TC, Parsons TD, Landry A, et al.
Virtual environments as an assessment
modality with pediatric ASD populations:
a brief report. Child Neuropsychology
2017 Sep 13 [Epub ahead of print].
20
5 studies ‘‘Psychometric comparisons of these tools for the neuropsychological
assessment of pediatric individuals with ASD are lacking as the
current review demonstrated, although the use of VEs. This is a
particularly important area of future research considering most
identification, and thus testing, treatment, and training occur in
childhood for ASD.’’
Narrative review (pediatrics) Parsons TD, Riva G, Parsons S, et al. Virtual
reality in pediatric psychology. Pediatrics
2017; 140:S86–S91.
21
Not reported ‘‘VR can offer safe, repeatable, and diversifiable interventions that can
benefit assessments and learning in both typically developing children
and children with disabilities. Research has also pointed to VR’s
capacity to reduce children’s experience of aversive stimuli and
reduce anxiety levels.’’
Systematic review (autism) Mesa-Gresa P, Gil-Gomez H, Lozano-Quilis
JA, Gil-Gomez JA. Effectiveness of
virtual reality for children and adolescents
with autism spectrum disorder: an
evidence-based systematic review. Sensors
(Basel) 2018; 18:pii:E2486.
31 studies There is moderate evidence that VR-based treatments can help children
with ASD. The lack of definitive findings does not allow us to state
that VR-based treatments can improve the results of traditional
treatments. Nevertheless, the promising results and the advantages of
VR (especially considering ASD symptomatology) should encourage
the scientific community to develop new VR-based treatments.
Systematic review (eating
disorders)
Clus D, Larsen ME, Lemey C, Berrouiguet
S. The use of virtual reality in patients
with eating disorders: systematic review. J
Med Internet Res 2018; 20:e157.
26 studies Overall, VR techniques enable the evaluation of pathological eating
behaviors and body image distortions. In addition to CBT, use of VR
techniques by patients with eating disorders decreased their negative
emotional responses to virtual food stimuli or exposure to their body
shape.
87
Three final articles explored the use of VR in the assess-
ment and treatment of psychosis
7
and in pain manage-
ment.
6,25
For psychosis, the available studies confirm the
efficacy of VR for the multimodal assessment of cognitive
functioning,
7
including social cognition/competence
66
and
hallucinations/paranoid ideations.
67
For treatment, even if
the available studies are very promising,
68–70
there is a lack
of randomized controlled trials demonstrating whether VR is
more efficacious or efficient than other interventions.
7
In relation to the use of VR for pain management, older
systematic reviews
71,72
demonstrated the efficacy of VR
distraction
73–75
for reducing experimental pain,
76
as well as
the one generated by burn injury care,
77–79
chronic pain,
80–82
and procedural pain.
83–85
Hence, the first new one
6
focused
its analysis on the integrated use of VR with brain stimula-
tion (transcranial direct-current stimulation) in pain man-
agement. Again, even if the level of clinical evidence is still
low, a study
86
demonstrated the efficacy of this approach in
reducing the severity of neuropathic pain and various neu-
ropathic pain subtypes. Finally, the second new one,
25
sug-
gests that VR may have a role in acutely painful procedures,
even if further research is required.
Overall, this meta-review indicated that VR is a powerful
clinical tool for behavioral health, able to provide effective
assessment and treatment options for a variety of mental
health disorders. Specifically, the 25 meta-analyses and
systematic and narrative reviews indicated that VR compares
favorably to existing treatments in anxiety disorders, eating
and weight disorders, and pain management, with long-term
effects that generalize to the real world. Moreover, they show
the potential of VR as assessment tool with practical appli-
cations that range from social and cognitive deficits to ad-
diction. Finally, they suggest a clinical potential in the
treatment of psychosis and in the pediatric field, even if there
is no definitive evidence for or against the use of VR.
The Effectiveness of VR as a Clinical Tool
An open issue not directly addressed by most of these
articles is why VR is an effective clinical tool. In many
articles, attention is focused on the high level of control and
customization allowed by this technology.
1,2,9,10,87
VR al-
lows the level of fit between the content of the exposure and
the feared stimuli to be optimized. Moreover, using it, the
therapist has a total control—limited only by the specific
features of the used software—on the contents of the expe-
rience. Finally, it offers a safer and more private context for
the patient that facilitates his/her engagement.
Another important point suggested by different articles is
the level of ‘‘presence’’ provided by the virtual experience.
In fact, VR provides a digital place to the individual where
he/she can be placed and live a synthetic but realistic expe-
rience.
88
As noted by some colleagues, VR can be considered
an advanced imaginal system
89,90
: an advanced form of
imagery that is as effective as reality in inducing experiences
and emotions. For example, as demonstrated by a recent
meta-analysis, presence and anxiety are associated with each
other during VRE therapy for the treatment of anxiety.
91
This
allows a level of self-reflectiveness that is both more pre-
dictable and controllable than the one offered by reality, but
higher than the one provided by memory and imagination.
1
However, presence alone is necessary but not sufficient to
achieve benefit from VR therapy.
92
As noted by Price and
Anderson, ‘‘The results support presence as a conduit that
enabled phobic anxiety to be expressed during exposure to a
virtual environment. However, presence was not supported
as contributing to treatment outcome. This suggests feeling
present during exposure may be necessary but not sufficient
to achieve benefit from VR exposure.’’
92(p750)
A new argument that is introduced and discussed in this
article is that VR shares with the brain the same basic
mechanism: embodied simulations.
43,93
VR as Simulative Technology
An increasingly popular hypothesis—predictive coding
94–96
—
suggests that the brain actively maintains an internal model
(simulation) of the body and the space around it, which pro-
vides predictions about the expected sensory input and tries to
minimize the amount of prediction errors (or ‘‘surprise’’). An
in-depth discussion of these concepts is not offered here be-
cause authoritative and thorough accounts have been provided
elsewhere.
94–99
However, herein, the focus is on the concept
of simulation introduced by this paradigm to understand better
the links between the brain and VR.
One of the main tenets of predictive coding is that to
regulate and control the body in the world effectively, the
brain creates an embodied simulation of the body in the
world. There are two main characteristics of this simulation.
First, different from other internal models used in cognitive
science—such as Tolman’s cognitive maps or Johhson–
Laird’s internal models—they are simulations of sensory
motor experiences. In this view, they include visceral/auto-
nomic (interoceptive), motor (proprioceptive), and sensory
(e.g., visual, auditory) information. Second, embodied sim-
ulations reactivate multimodal neural networks, which have
produced the simulated/expected effect before.
This approach is used not only for actions, but also for
concepts and emotions. Specifically, a concept is a group of
distributed multimodal ‘‘patterns’’ of activity across differ-
ent populations of neurons (motor, somatosensory, limbic,
and frontal areas) that support a goal achievement.
100,101
So,
the simulation of a concept involves its reenactment in
modality-specific brain areas. Moreover, the brain uses
emotion concepts to categorize sensations. As underlined by
Barrett, ‘‘That is, the brain constructs meaning by correctly
anticipating (predicting and adjusting to) incoming sensa-
tions. Sensations are categorized so that they are (a) ac-
tionable in a situated way and therefore (b) meaningful,
based on past experience. When past experiences of emotion
(e.g., happiness) are used to categorize the predicted sensory
array and guide action, then one experiences or perceives
that emotion (happiness).’’
100(p9)
In this view, the feeling of
presence in a space can be considered as an evolutive tool
used to track the difference between the predicted sensations
and those that are incoming from the sensory world, both
externally and internally.
93,102,103
VR works in a similar way: it uses computer technology to
create a simulated world that individuals can manipulate and
explore as if they were in it. In other words, the VR expe-
rience tries to predict the sensory consequences of your
movements, showing to you the same scene you will see in
the real world. Specifically, VR hardware tracks the motion
of the user, while VR software adjusts the images on the
88 RIVA ET AL.
user’s display to reflect the changes produced by the motion
in the virtual world. To achieve it, like the brain, the VR system
maintains a model (simulation) of the body and the space
around it. This prediction is then used to provide the expected
sensory input using the VR hardware. Obviously, to be realistic,
the VR model tries to mimic the brain model as much as
possible: the more the VR model is similar to the brain model,
the more the individual feels present in the VR world.
93,104
VR as Embodied Technology
As has just been seen, the brain creates multiple multi-
sensory simulations to predict
100
: (a) upcoming sensory
events both inside and outside the body, and (b) the best
action to deal with the impending sensory events. Moseley
et al. suggested that these simulations are integrated with
sensory data in the ‘‘body matrix,’’ a coarse supramodal
multisensory representation of the body and the space around
it.
105–107
Specifically, the contents of the body matrix are
defined by top-down predictive signals, integrating the
multisensory (motor and visceromotor) simulations of the
causes of perceived sensory events.
108
The different simu-
lations are then ranked and included in the body matrix ac-
cording to their relevance for the intentions of the self
(selective attention). At the same time, the content and the
priority of the different simulations are corrected by bottom-
up prediction errors that signal mismatches between pre-
dicted and actual contents of sensory events.
109
At the end of this process, the body matrix defines where
the self is present, that is, in the body that our brain considers
as the most likely to be its one.
110–112
As underlined by Apps
and Tsakiris, ‘‘The mental representation of the physical
properties of one’s self are, therefore, also probabilistic. That
is, one’s own body is the one that has the highest probability
of being ‘me,’ since other objects are probabilistically less
likely to evoke the same sensory inputs. In short, the notion
that there is a ‘self’ is the most parsimonious and accurate
explanation for sensory inputs.’’
110(p88)
If presence in the body is the outcome of different em-
bodied simulations, and VR is a simulation technology, this
suggests the possibility of altering the experience of the body
by designing targeted virtual environments.
113
In this view,
VR can be defined as an ‘‘embodied technology’’ for its
possibility of modifying the embodiment experience of its
users.
114–116
As noted by Riva et al., ‘‘using VR, subjects can
experience the synthetic environment as if it was ‘their sur-
rounding world’ (incarnation: the physical body is within a
virtual environment) or can experience their synthetic ava-
tars as if they were ‘their own body’ (embodiment: the
physical body is replaced by the virtual one).’’
1(p9)
In other
words, VR is able to fool the predictive coding mechanisms
used by the brain generating the feeling of presence in a
virtual body and in the digital space around it.
Up to now, VR has been used to simulate external reality,
that is, to make people feel ‘‘real’’ what is actually not really
there (i.e., the environment). However, the ability of VR to
fool the predictive coding mechanisms that regulate the ex-
perience of the body also allows it to make people feel
‘‘real’’ what they are not. In other words, VR can offer new
ways for structuring, augmenting, and/or replacing the ex-
perience of the body for clinical goals.
114–116
Moreover, it
may offer new embodied ways for assessing the functioning
of the brain
117,118
by directly targeting the processes behind
real-world behaviors.
119–121
But what is the real clinical potential of VR as an em-
bodied technology? According to neuroscience, the body
matrix
105,106,122,123
serves to maintain the integrity of the
body at both the homeostatic and psychological levels by
supervising the cognitive and physiological resources nec-
essary to protect the body and the space around it. Specifically,
the body matrix plays a critical role in high-end cognitive
processes such as motivation, emotion, social cognition, and
self-awareness,
124–126
while exerting a top-down modulation
over basic physiological mechanisms such as thermoregula-
tory control
127,128
and the immune system.
123
In this view, different authors
114,116,129,130
have recently
suggested that an altered functioning of the body matrix and/
or its related processes might be the cause of different neu-
rological and psychiatric conditions. If this is true, VR can
be the core of a new trans-disciplinary research field—
embodied medicine
115,116
—the main goal of which is the use
of advanced technology for altering the body matrix, with the
goal of improving people’s health and well-being.
As has been seen in the first section of this article, two
different VR embodiment techniques—body swapping
51,52
and reference frame shifting
49,50
—arecurrentlyusedinthe
treatment of eating and weight disorders. The first one,
body swapping, replaces the contents of the bodily self-
consciousness with synthetic ones (synthetic embodiment).
This has been used in eating and weight disorders to im-
prove the experience of the body in both clinical (anorexia
and morbid obesity)
131,132
and non-clinical subjects.
133–135
Nevertheless, the potential of this approach is wider.
136
For
example, it may offer a non-pharmacological way to reduce
chronic pain. As has been seen in the first section of this
article, VR distraction is effectively used to reduce acute pain.
Nevertheless, according to Tsay et al., ‘‘available findings
present compelling evidence for a novel multisensory and
multimodal approach to therapies for chronic pain disor-
ders’’
137(p249)
In this view, the use of VR embodiment may
offer new treatment options for pain management.
138–140
Some studies have suggested the possibility of using VR body
swapping to improve body perception disturbance in patients
with complex regional pain syndrome.
141,142
The second technique, reference frame shifting, structures
the individual’s bodily self-consciousness through the focus
and reorganization of its contents (mindful embodiment).
50,143
It has been successfully used in different randomized trials in
patients with eating and weight disorders
54,55
to update the
contents of their body memory. But again, its applications are
probably wider. For example, Osimo et al. integrated body
swapping (in the avatar of Sigmund Freud) and reference
frame shifting to improve mood and happiness in a non-clinical
sample.
143
A final emerging approach is the use of VR to augment the
bodily experience through the awareness of internal (and
difficult to sense) bodily information, or the mapping of a
sensory channel to a different one—for example vision to
touch or to hearing (augmented embodiment).
144,145
For ex-
ample, Suzuki et al.
146
implemented an innovative ‘‘cardiac
rubber hand illusion’’ that combined computer-generated
augmented reality with feedback of interoceptive informa-
tion. Their results showed that the virtual-hand ownership is
enhanced by cardio-visual feedback in time with the actual
NEUROSCIENCE OF VIRTUAL REALITY 89
heartbeat, supporting the use of this technique to improve
emotion regulation.
VR as Cognitive Technology
VR is an embodied technology for its ability to modify the
experience of the body. However, the body is not simply an
object like any other; it has a special status.
93,147,148
It is
perceived in a multisensory way, from the outside (ex-
teroception, the body perceived through the senses) as well
as from within (inner body, including interoception, the
sense of the physiological condition of the body; proprio-
ception, the sense of the position of the body/body segments;
and vestibular input, the sense of motion of the body) and
from memory. This is true also for the simulative code used
by the brain for creating concepts. As has been seen before,
it integrates visceral/autonomic (interoceptive), motor (pro-
prioceptive), and sensory information. If concepts are em-
bodied simulations, and VR is an embodied technology, it
should be possible to facilitate cognitive modeling and
change by designing targeted virtual environments able to
modify concepts both from outside and from inside.
114
Nevertheless, there is a critical shortcoming that at the
moment is limiting this possibility: VR simulates the exter-
nal world/body but not the internal one. In fact, actual VR
technology is very effective in reproducing the exteroceptive
(external) features of the body using vision and hearing, but
less effective in reproducing the other senses (i.e., touch and
smell
149
). It is partially effective in reproducing the propri-
oceptive (motor) features of the body using haptic technol-
ogies,
150
but it is not yet able to reproduce the interoceptive/
vestibular (internal) features of the body.
Recently, Riva et al.
116
introduced the concept of ‘‘sono-
ception,’’ a novel noninvasive technological paradigm based
on wearable acoustic and vibrotactile transducers, as a pos-
sible approach to structure, augment, and/or replace the
contents of the inner body. This approach should be able to
modulate the inner body (interoception, proprioception, and
vestibular input) through the stimulation of both mechano-
receptors in different parts of the body—the stomach, the
heart, the muscles—and the otolith organs of the vestibular
system (see Fig. 2).
The first outcome of an integrated VR platform able to
simulate both the external and the inner world is the possi-
bility of structuring, augmenting, and/or replacing all the
different experiential aspects of bodily self-consciousness,
with clinical applications in the treatment of psychiatric
disorders, such as depression
151,152
or schizophrenia,
153–155
and neurological disorders, such as chronic pain
137,156
and
neglect.
157,158
The final long-term outcome of this possibility may be the
embodied virtual training machine described by the science-
fiction thriller The Matrix. In this movie, the heroes, Trinity
and Neo, learned how to fight martial-arts battles and drive
motorcycles and helicopters by experiencing the bodily pro-
cesses and concepts related to the skill through an embodied
simulation.
Conclusions
The first article discussing a VR application in the field of
behavioral health was published in 1995.
159
Now, more than
20 years later, VR is a reality in this field. This is the result of
a meta-review presented in this article assessing the meta-
analyses and systematic and narrative reviews published in
this field in the last 22 months. Twenty-five different articles
have demonstrated the clinical potential of this technology in
both the diagnosis and the treatment of mental health dis-
orders. Specifically, they indicate that VR compares favor-
ably to existing treatments in anxiety disorders, eating and
weight disorders, and pain management, with long-term ef-
fects that generalize to the real world.
But why is VR so effective? Here, the following an-
swer is suggested: VR shares with the brain the same basic
mechanism—embodied simulations.
According to neuroscience, to regulate and control the
body in the world effectively, the brain creates an embodied
simulation of the body in the world used to represent and
predict actions, concepts, and emotions. Specifically, it is
used to predict: (a) upcoming sensory events both inside and
outside the body, and (b) the best action to deal with the
impending sensory events.
100
There are two main charac-
teristics of this simulation. First, it simulates sensory motor
experiences, including visceral/autonomic (interoceptive),
FIG. 2. The technology of
‘‘sonoception.’’
90 RIVA ET AL.
motor (proprioceptive), and sensory (e.g., visual, auditory)
information. Second, embodied simulations reactivate mul-
timodal neural networks which have produced the simulated/
expected effect before.
VR works in a similar way: the VR experience tries to
predict the sensory consequences of the individual’s move-
ments, providing to him/her the same scene he/she will see in
the real world. To achieve this, the VR system, like the brain,
maintains a model (simulation) of the body and the space
around it.
If presence in the body is the outcome of different em-
bodied simulations, and VR is a simulation technology, this
suggests the possibility of altering the experience of the
body by designing targeted virtual environments.
113
In this
view, VR can be defined as an ‘‘embodied technology’’ for
its possibility of modifying the embodiment experience of
its users.
114–116
In other words, VR is able to fool the pre-
dictive coding mechanisms used by the brain, generating the
feeling of presence in a virtual body and in the digital space
around it.
Moreover, if concepts are embodied simulations, and VR
is an embodied technology, it should be possible to facilitate
cognitive modeling and change by designing targeted virtual
environments able to modify concepts from both outside and
inside.
114
Nevertheless, at the moment, there is a critical shortcoming
that is limiting this possibility: VR simulates the external
world/body but not the internal one. Recently, Riva et al.
116
introduced the concept of ‘‘sonoception’’ (www.sonoception.
com), a novel noninvasive technological paradigm based on
wearable acoustic and vibrotactile transducers able to stim-
ulate both mechanoreceptors in different parts of the body—
the stomach, the heart, the muscles—and the otolith organs of
the vestibular system (see Fig. 2). The first outcome of this
approach is the development of an interoceptive stimulator
that is both able to assess interoceptive time perception in
clinical patients
160
and to enhance heart rate variability (the
short-term vagally mediated component—rMSSD) through
the modulation of the subjects’ parasympathetic system.
161
The integration of these technologies with VR in a multi-
sensory simulative platform will allow the modulation of both
the external and internal bodily information, to structure,
augment and/or replace the contents of our bodily self-
consciousness.
In conclusion, even if VR is already a reality in behavioral
health, the possibility of using it to simulate both the external
and internal world may open new clinical options in the near
future able to target the experience of the body and its related
processes directly. Psychosomatics is an interdisciplinary field
that explores the relationships between psychosocial, behavioral
factors, and bodily processes. The long-term goal of the vision
presented in this article is the use of simulative technologies—
both simulating the external world and the internal one—to
reverse engineer the psychosomatic processes that connect
mind and body. If achieved, this perspective will provide a
radically new meaning to the classical Juvenal’s Latin dictum
‘‘Mens sana in corpore sano’’ (a healthy mind in a healthy
body) by allowing a new trans-disciplinary research field—
‘‘Embodied Medicine’’
115,116
—that will use advanced multi-
sensory technologies to alter bodily processes for enhancing
homeostasis and well-being.
Acknowledgments
This article was supported by the Italian MIUR research
project ‘‘Unlocking the memory of the body: Virtual Reality
in Anorexia Nervosa’’ (201597WTTM) and by the Italian
Ministry of Health research project ‘‘High-end and low-end
virtual reality systems for the rehabilitation of frailty in the
elderly’’ (PE-2013-0235594).
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Prof. Giuseppe Riva
Department of Psychology
Universita
`Cattolica del Sacro Cuore
Largo Gemelli 1
20123, Milan
Italy
E-mail: giuseppe.riva@unicatt.it
96 RIVA ET AL.
