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 . It is a relatively common disorder
  where up to 80% of suffers experience a vasovagal
response when they face the stimuli . 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 
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 .
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 
 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 , 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
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
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
 - 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).
 - 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).
 - 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
 - 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).
 - Griffiths, M.: The therapeutic value of videogames. In: Goldstein, J. Raessens, J.: Handbook of Computer Game Studies. MIT Press: Boston. p. 161-173 (2005).
 - 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).
 - 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).
 - Wilson, C.: Brainstorming And Beyond: A User-Centered Design Method. Morgan Kaufmann Publishers Inc. San Francisco, CA, USA 2013.