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A Serious Game for Hemophobia Treatment - Phobos: First insights



This paper addresses the development process of a serious game - PHOBOS - for hemophobia treatment. Hemophobia, also known as blood phobia, is the fear of blood, wounds, injuries, amongst others. The game addresses the issue through applied-tension exercise combined with exposure therapy on a virtual reality environment. One of the main challenges was to design a game that reconciliate in a balanced way an immersive narrative and plot with the treatment of a phobia that causes great tensions and find the best mechanics to allow a gradual exposure to blood. Artistically we wanted to create the more realistic environment possible, in tune with the sound de-sign. This process was done with the help of a team of psychologists that in conjunction with the team of game developers created a plot that helps the player to adjust his discomfort and challenge himself in his path to deal with this phobia. We present an early stage development process of a virtu-al reality phobia game, from the brainstorming concept of the game to the development to the first prototype with its requirements and hardware used.
A Serious Game for Hemophobia Treatment
Phobos: first Insights
João Petersen1, Vítor Carvalho1-2, João Tiago Oliveira3, Eva Oliveira1
12Ai Laboratory – School of Technology, IPCA, Barcelos, Portugal
2 Algoritmi Research Center, University of Minho, Guimarães, Portugal
3School of Psychology, University of Minho, Braga, Portugal
Blood-injection-injury phobia (also known as
Hemophobia), is a specific phobia characterized by an
intense fear of being exposed to blood or invasive
medical procedures [1]. It is a relatively common disorder
[1] [2] where up to 80% of suffers experience a vasovagal
response when they face the stimuli [3]. Considering that
the intense fear can be generalized to other associated
stimuli such like doctors, nurses, hospitals, syringes or
dentists, hemophobia can lead to serious effects on
individual’s health due to the avoidance of these settings
1 - Problem
People who suffer from specific phobias tend to be
hesitant to seek treatment, Despite this reluctance,
research suggests that specific phobia is one of the most
treatable of psychological disorders.
2 - Target
Exposure techniques are often considered the first line
treatment and widely used with phobic patients [4]
presenting robust evidence of efficacy.
3 - Treatment
Computer-based tools may present an attractive tool to
potentiate and amplify the range and effectiveness of
psychological treatments and reduce the attrition [5].
Research has been describing the potential effectiveness
of using computer games as an adjunct to psychotherapy
So, virtual reality exposure therapy (VRET) has become a
new medium for exposure therapy presenting good results
in terms of efficacy, especially with specific phobias [6]
[7] and several advantages over in vivo or imaginal
4 - Solution
5 - PHOBOS – A serious game for dealing with hemophobia
Phobos is a serious game to help with the treatment of hemophobic patients through a controlled VRET. This allows the patients to be exposed to their phobia in a controlled environment, in the
psychologist room, that in most phobia cases is impossible. We use Unity engine and the STEAM®VR SDK (Software Development Kit) for the development of the game because it is one of the most
used platforms in game development and the background we had on developing on Unity.
6 - Game Design
Requirement assessment conference with our peers from
the psychology department, where we discussed which
types of games could be suitable to this type of phobia,
and which mechanics we should explore. Brainstorming
technique [8], which allowed the developers to start with
aseries of ideas narrowing them down to a narrative,
some mechanics and a gameplay.
The goal was to create a plot that could put the patient
controlling the phobia stimuli but motivating the patient
to exceed himself, in a progressive way. The patient
knows that he needs to expose himself to know the truth
but also know that he can control that exposure, which
allow the patient to mentally prepare himself to the inner
challenge. Concerning this aspect, we developed an
educational tutorial to help the patient dealing with his
own phobia.
7 - The goal
9 - The narrative
The patient is the detective that arrives to a penthouse that
has been the scene of a murder, with no body, and has to
solve it (Fig. 1). He/she has to pick up clues in order to
progress in the game, which have phobic stimuli, in this
case, blood. In the beginning of the game these phobic
stimuli are very few and of small impact to the user, as
the detective progresses throughout the crime scene, the
phobic stimuli increase gradually leading to more realistic
and strong impact blood exposure, so the user gets a
paced exposure to his fear.
8 - The gameplay
First person, virtual reality and role-playing genres as the
player is in the role of the detective that can freely
explore an apartment in virtual reality (VR), can gather
clues, read the items gathered, get further knowledge on
his phobia and the techniques used to treat it, as well as
confront their phobia by controlled phobia exposure, as is
the patient who decides if he/she wants to expose
10 - The tutorial
The opinion from our peers from the psychology department was that one of the key features should be a tutorial that can explain to patients all the physical reactions that our bodies feel during the
exposition with blood, and how to overcome some of those effects like for example, to apply tension on hands, arms and legs, so that the patient can prevent faint which occurs from exposure to blood
due to the increase in blood pressure followed by its the rapid drop.
In this tutorial, first we teach the player the basic
mechanics on VR controls (Fig. 2), which include how to
move, how to grab items as well as how to interact with
the game inventory system then we incorporated the
tutorial with the beginning of the game, the introductory
part, example in the suitcase file, in the lobby before
entering the house, the user gets access to information
about the description of the phobia.
The key points of information to be presented are an
explanation of the phobia, the natural body reactions, the
hypersensitivity, the panic attacks and the treatment
process. These key points were chosen and validated by
the psychology team, since it was the most relevant
information to be passed to the player.
11 -The artistic aspect of the game
To simulate a realistic environment, the realism was explored by creating a modern and comfortable apartment exploring the light (Fig. 3) and sounds and by creating an immersive plot. The goal was
not to scare, nor to daunt but to defy the patient to his own fear.
12 - Where to play
We designed the game to be played like therapy sessions, so the patient can process the
information gathered in that session and feel the accomplishment of passing another stage of the
game and of overcoming their phobia as well as the description of each session, for example, the
player having grabbed the key in the plant vase, now opens the door and starts searching for clues
in the living room, being exposed to the first phobic stimuli a bloodied broken wine glass.
13 - Validation
Since the game is still under development, we still haven’t done the functionality and usability
testing on a large sample. Both tests will first be done on colleagues and afterwards only the
usability test will be done on phobic patients to ensure the validity of the project. The functionality
tests consist on trying to break the game, using force to see every possible existing bug, while the
usability tests consist on seeing if the game doesn’t cause motion sickness, if the UI can be read
properly without causing strain on the eyes and assess the space required for room-scale virtual
reality. After these tests we will test if the game can really help phobic patients in dealing with
their phobias.
14 - Final Remarks
This project started to be developed for the master’s in engineering of Digital Game Development, Project I and Project II classes, which will now be continued for the master’s dissertation, where we
will test the interaction of biometric sensors for data acquisition on physical responses to the phobia and an AI (artificial intelligence) dynamic control of the phobic stimuli. The development can
some-times be strenuous due to the unknown methods of developing for virtual reality making us go through a series of trial and error implementations to make the game perfect. In the undergoing
phases of the development we want to include biometric sensor data acquisition to help us understand the stress inputted on the patient and also to make the phobic stimuli appear gradually and their
intensity linked to their blood pressure so that we can warn the user to apply the applied tension method and prevent fainting from happening.
Fig. 1 – Folder with the case information
Fig. 2 – Folder with the tutorial on VR controls
Fig. 3 – Realistic environment
15 - References
[1] - Puri, B. K.: Blood‐injection‐injury phobias. International Journal of Clinical Practice, 61: 358-359. doi:10.1111/j.1742-1241.2006.01149.x (2007).
[2] - Pitkin, M. R., Malouff, J. M.: Self-arranged exposure for overcoming blood-injection-injury Phobia: a case study. Health Psychology and Behavioral Medicine 2(1), 665-669, DOI: 10.1080/21642850.2014.916219 (2014).
[3] - Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., Telch, M. J.: Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review 28(6), 1021-1037. DOI: 10.1016/j.cpr.2008.02.007
[4] - Andrews, G., et al.: Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLoS ONE 5(10): p. e13196 (2010).
[5] - Griffiths, M.: The therapeutic value of videogames. In: Goldstein, J. Raessens, J.: Handbook of Computer Game Studies. MIT Press: Boston. p. 161-173 (2005).
[6] - Meyerbröker K., Emmelkamp, P. M. G.: Virtual reality exposure therapy in anxiety disorders: A systematic review of process-and-outcomes studies. Depression and Anxiety. 27, 933-944. doi: 10.1002/da.20734 (2010).
[7] - Rothbaum, B. O., Hodges, L., Smith S., Lee, J. H., Price, L.: A Controlled Study of Virtual Reality Exposure Therapy for the Fear of Flying. Journal of Consulting and Clinical Psychology Vol. 68, No. 6, 1020-1026, (December 2000).
[8] - Wilson, C.: Brainstorming And Beyond: A User-Centered Design Method. Morgan Kaufmann Publishers Inc. San Francisco, CA, USA 2013.
... Patients are asked to kill the cockroaches and throw their dead bodies into the trash. Joao Petersen et al. [30] proposed a serious game aimed at blood phobia. In this game, the patients play the role of a detective. ...
... It includes mechanics for shooting enemies, being attacked, rescuing teammates, and burying bodies. Similarly, First Insights [30] is a game for the treatment of blood phobia. Aesthetically, it is a serious game featuring exploration, narrative, fantasy, and challenge. ...
... Tracking technology: In the virtual reality system, the used devices have to be able to read and process natural movement data to complete the tracking of patients' movements and positions. One is gesture recognition, represented by the HTC Vive and Oculus Rift motion controllers.For example, the literature [32] proposed a serious game to cure acrophobia, in which they have to walk across a room to an open balcony door and use the Oculus Rift motion controller to touch the balcony railings and grab hanging objects.In First Sights [30] In order to collect clues at the murder scene, participants used the HTC Vive motion controller to pick up broken wine glasses, grab vases, and wipe blood.The second is location tracking.Microsoft Kinect is the most famous device to use this technology. It measures the distance between the sensor and the patient using CMOS infrared sensor. ...
Full-text available
Phobia is a widespread mental illness, and severe phobias can seriously impact patients daily lives. One-session Exposure Treatment (OST) has been used to treat phobias in the early days,but it has many disadvantages. As a new way to treat a phobia, virtual reality exposure therapy(VRET) based on serious games is introduced. There have been much researches in the field of serious games for phobia therapy (SGPT), so this paper presents a detailed review of SGPT from three perspectives. First, SGPT in different stages has different forms with the update and iteration of technology. Therefore, we reviewed the development history of SGPT from the perspective of equipment. Secondly, there is no unified classification framework for a large number of SGPT. So we classified and combed SGPT according to different types of phobias. Finally, most articles on SGPT have studied the therapeutic effects of serious games from a medical perspective, and few have studied serious games from a technical perspective. Therefore, we conducted in-depth research on SGPT from a technical perspective in order to provide technical guidance for the development of SGPT. Accordingly, the challenges facing the existing technology has been explored and listed.
Full-text available
The DSM-IV TR classifies phobias into three groups: 1) Agoraphobia, 2) Social Phobia, and 3) Specific Phobias. The further subdivision within Specific Phobias is: 1) Blood-Injection-Injury (BII), 2) Animal, 3) Natural Environment, 4) Situational, and 5) “Other”. 1 Although VR exposure therapy has been used successfully for more than a decade to treat phobias; including specific phobias, panic disorder and agoraphobia, and social phobia (4-13); only one study has attempted VR usage for injection phobia.2 Those who suffer from BII phobias may fear either the sight or the pain of the injection and often begin avoidance of any situation which may cause exposure to an injection, such as donating blood or going to the doctor. In extreme cases, the phobic may even begin to fear driving past a hospital.3 Because BII phobia involves not only visual stimuli which elicit the phobic response, but also tactile stimuli; it may differ from other specific phobias in how it will respond to VR. In the previous injection study, it was found that VR could be used to successfully elicit subjective (measured with Subjective Units of Distress (SUDs ratings) and physiological arousal (measured with heart rate (HR)) in those with needle phobia, however, the results indicated that the addition of tactile stimuli would have proven to be more advantageous. In addition, the previous study presented the VR environment via a desktop display instead of a more immersive head-mounted display (HMD). 2 The present study, therefore, sought to investigate elicitation of arousal via a HMD VR system to be used in treating those with BII phobias. As an initial first step, however, we have sought to establish a baseline with those who do not meet the DSM-IV TR criteria for a BII phobia in order to use this arousal level as a baseline comparison for phobic participants exposed to the VR world.
Full-text available
Blood-injection-injury (BII) phobia is both common and dangerous, because it can lead to avoidance of medical procedures for diagnosis and treatment. It also tends to prevent individuals from donating blood for use in the healthcare of others. BII phobia often has an unusual characteristic for a type of phobia - fainting. The typical treatment for BII phobia involves teaching the client how to avoid fainting and staging multiple gradual-exposure trials for the client. In this case report, an adult with the phobia obtained initial, mostly written, guidance from a psychologist, arranged her own applied muscle-tension practice sessions to learn how to keep from fainting, created her own fear hierarchy, and staged exposure trials herself, ending years of avoidance of blood withdrawal. By the end of the trials, she was able to give blood for a medical test and to donate blood for the first time in her life and to work as a volunteer at a blood-donation center. The results provide the first evidence that adults with BII phobia can end the phobia by arranging their own sessions of applied-tension practice and gradual self-exposure. The results suggest a new option for treating specific phobias in general with some adults: initial professional guidance followed by self-arranged gradual-exposure trials.
Full-text available
Fear of flying (FOF) affects an estimated 10-25% of the population. Patients with FOF (N = 49) were randomly assigned to virtual reality exposure (VRE) therapy, standard exposure (SE) therapy, or a wait-list (WL) control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane (VRE) or exposure to an actual airplane at the airport (SE). A posttreatment flight on a commercial airline measured participants' willingness to fly and anxiety during flight immediately after treatment. The results indicated that VRE and SE were both superior to WL, with no differences between VRE and SE. The gains observed in treatment were maintained at a 6-month follow up. By 6 months posttreatment, 93% of VRE participants and 93% of SE participants had flown. VRE therapy and SE therapy for treatment of FOF were unequivocally supported in this controlled study.
Full-text available
Depression and anxiety disorders are common and treatable with cognitive behavior therapy (CBT), but access to this therapy is limited. Review evidence that computerized CBT for the anxiety and depressive disorders is acceptable to patients and effective in the short and longer term. Systematic reviews and data bases were searched for randomized controlled trials of computerized cognitive behavior therapy versus a treatment or control condition in people who met diagnostic criteria for major depression, panic disorder, social phobia or generalized anxiety disorder. Number randomized, superiority of treatment versus control (Hedges g) on primary outcome measure, risk of bias, length of follow up, patient adherence and satisfaction were extracted. 22 studies of comparisons with a control group were identified. The mean effect size superiority was 0.88 (NNT 2.13), and the benefit was evident across all four disorders. Improvement from computerized CBT was maintained for a median of 26 weeks follow-up. Acceptability, as indicated by adherence and satisfaction, was good. Research probity was good and bias risk low. Effect sizes were non-significantly higher in comparisons with waitlist than with active treatment control conditions. Five studies comparing computerized CBT with traditional face-to-face CBT were identified, and both modes of treatment appeared equally beneficial. Computerized CBT for anxiety and depressive disorders, especially via the internet, has the capacity to provide effective acceptable and practical health care for those who might otherwise remain untreated. Australian New Zealand Clinical Trials Registry ACTRN12610000030077.
Full-text available
Data from 33 randomized treatment studies were subjected to a meta-analysis to address questions surrounding the efficacy of psychological approaches in the treatment of specific phobia. As expected, exposure-based treatment produced large effects sizes relative to no treatment. They also outperformed placebo conditions and alternative active psychotherapeutic approaches. Treatments involving in vivo contact with the phobic target also outperformed alternative modes of exposure (e.g., imaginal exposure, virtual reality, etc.) at post-treatment but not at follow-up. Placebo treatments were significantly more effective than no treatment suggesting that specific phobia sufferers are moderately responsive to placebo interventions. Multi-session treatments marginally outperformed single-session treatments on domain-specific questionnaire measures of phobic dysfunction, and moderator analyses revealed that more sessions predicted more favorable outcomes. Contrary to expectation, effect sizes for the major comparisons of interest were not moderated by type of specific phobia. These findings provide the first quantitative summary evidence supporting the superiority of exposure-based treatments over alternative treatment approaches for those presenting with specific phobia. Recommendations for future research are also discussed.
In recent years, virtual reality exposure therapy (VRET) has become an interesting alternative for the treatment of anxiety disorders. Research has focused on the efficacy of VRET in treating anxiety disorders: phobias, panic disorder, and posttraumatic stress disorder. In this systematic review, strict methodological criteria are used to give an overview of the controlled trials regarding the efficacy of VRET in patients with anxiety disorders. Furthermore, research into process variables such as the therapeutic alliance and cognitions and enhancement of therapy effects through cognitive enhancers is discussed. The implications for implementation into clinical practice are considered.
Psychological approaches in the treatment of specific phobias: A meta-analysis
  • K B Wolitzky-Taylor
  • J D Horowitz
  • M B Powers
  • M J Telch
Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., Telch, M. J.: Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review 28(6), 1021-1037. DOI: 10.1016/j.cpr.2008.02.007 (2008).
Brainstorming And Beyond: A User-Centered Design Method
  • C Wilson
Wilson, C.: Brainstorming And Beyond: A User-Centered Design Method. Morgan Kaufmann Publishers Inc. San Francisco, CA, USA 2013.