Section C11 Paper 45 Disclaimer—

Post-Traumatic Stress Disorder can have crippling effects on the everyday life of an afflicted person as well as those who interact with them on a day to day basis. Symptoms of PTSD most commonly include night terrors, unprovoked flashbacks, and panic attacks brought on by what are referred to as “triggers” [3]. Triggers are stimulants that provoke one to relive an experience or event, even though these triggers may not have been directly involved in the traumatic occurrence [3]. On top of this, untreated PTSD can lead to other mental illnesses, such as depression and extreme anxiety. A patient may report constantly feeling nervous, as though everything were going to fall back into chaos at any moment. They may then be driven to avoid social interactions or activities that they once enjoyed for a fear that they will be too dangerous [3].

If left untreated, PTSD has the potential to push a patient to their limits, and after too long the disease can become deadly. Tragically, suicide among war veterans is all too common an occurrence; veterans account for 20.56% of suicides in the United States, with the majority of those suicides occurring among military personnel the age of 24 years old and younger [2]. In 2016, an estimated 18-22 veterans committed suicide each day that was in some way the side effect of an unresolved mental illness [1]. Traditional treatment methods have been met with varying success, but until now they were the only option for a patient seeking help.

Unlike PTSD, autism is not a disorder that is brought on by an experience, but rather it is a disability that is genetic. Autism is an illness that consists of various social blocks, speech impairment, and repetitive behaviors [4].  Similar to PTSD, autism affects every person in a unique way. The impairments are so broad and diverse that each individual case is judged based on the autism spectrum, which details the severity of a patient’s disability and reflects the strengths and weaknesses of that person [4]. The uniqueness of these cases and diversity of the types of impairments faced ultimately require every autism patient to undergo individualized treatment in order to attempt to become proficient in social situations. Treatment of autism requires quite a bit of time and money, with treatments costing between $1.4 and $2.4 million over a lifetime for individual patients [4]. This can prove to be very costly for the families of patients in both a monetary and an emotional sense.

Fortunately, recent years have seen the emergence of a new approach to psychiatric therapy in the form of virtual reality. This tool can help alleviate the burdens brought on by these two disorders that so many people face on a day-to-day basis. This new and innovative technology has the potential to revolutionize the therapeutic industry and drastically improve the success rates of psychiatric treatment as well as the overall quality of life of those currently afflicted by a mental disorder. Providing a platform for an easily adjustable and cost-efficient form of rehabilitation, virtual reality is soon to emerge at the forefront of mental health treatments.
HOW DOES VIRTUAL REALITY WORK?
Virtual Reality technology functions through a system of sensors and cameras that relay information to the device in order for it to produce and adjust an image in response to movements of the user.  For the technology to function, it must be able to recognize even slight movements of the head.  Most virtual reality technologies do this by having sensors, such as accelerometers, gyroscopes, and magnetometers [5].  These sensors each have specific functions within the VR headset that all contribute to the realism of the environment that is generated by the device.

Accelerometers measure the rate at which the head moves in order to relay back to the headset how quickly the picture being displayed must move. This movement must be precisely linked with the rate the head moves according to the accelerometer so that there is no apparent lag that would cause the user to be less immersed by the VR environment [5].  Accelerometers work in unison with magnetometers to tell the VR system where the head is moving and how quickly.  Magnetometers are devices that use sensors to measure the strength and direction of magnetic fields [5].  These can be used in VR headsets to determine the location of magnetic north and use that as a reference point for the visualization.  As the user faces away from magnetic north, the headset will change the image to reflect the rotation of the head [5].  As an accelerometer measures how fast the head is moving, a magnetometer tells the VR headset which direction it is moving.  Finally, a gyroscope is used to measure the exact orientation of the headset in relation to the ground.  This is critical because the displayed image must be at an angle that is very close to the angle of the head to keep the visualization of the environment realistic. Gyroscopes consist of an object, typically a disk shape, that is free to rotate in an axis that can also rotate [5]. The rotating disk is independent of the gyroscope’s orientation.  As the VR headset that contains the gyroscope tilts, so does the axis around the disk. Then, sensors record the orientation of the VR headset relative to the constant orientation of the disk and the visual display is adjusted accordingly.  These three devices work together to quickly adjust the visuals of the VR system to replicate a change in orientation for a smooth visual experience.

To improve VR capabilities beyond what these three components are able to produce, virtual reality apparatuses of today have largely been constructed using Time-of-Flight (ToF) cameras [6]. These cameras are equipped with an RGB sensor, a depth sensor, and two microphones that take in enough input for the program to generate four different types of images that, when used in tandem, produce a more realistic and vivid image than any of the four could generate on their own. These four image types include an RGB representation, a depth map, a basic avatar generation (blobman), and an advanced avatar generation (stickman), which can be seen in Figure 1 below [6].  Of these four, the most crucial two are the basic and advanced avatar generations [6].

FIGURE 1 [6]

The four image types utilized in generating a virtual image of a person in an interactive virtual environment
The first of these, the blobman, is used to generate a virtual representation of the user as seen in Figure 1c [6]. By doing this, the user is able to interact in real time with their virtual surroundings and a silhouette representation of themselves in the computer generation. The second of these, the stickman, depicted in figure 1d, is most useful when tracking the movements of the body [6]. This model of the human body is minimalistic, with a focus on joints and their range of motion. In combining the two, virtual reality programs are able to produce realistic representations of a user within a virtual setting, and ultimately this can be used to put the user through a series of therapeutic exercises, whether physical or mental.

Though until this point the integration of virtual reality in therapy has been a difficult transition for medical professionals with little to no technical background, new techniques are being employed to lessen these troubles. Through what is referred to as an integrated/framework design, virtual reality programs can now be adjusted by therapists to generate individualized treatments with little trouble [6]. This new program structure leaves the bulk of the technical design and manipulation to the engineers involved in the product’s development, leaving aspects such as the individual exercise evaluations to the therapists [6]. Ultimately, this removes much of the uncertainty and room for human error when integrating VR into the medical field.

Unlike most other virtual reality programs available, Bravemind is unique in that it goes beyond the usual senses of sight and sound. In order to produce the most immersive environment possible, Bravemind’s creators developed a system that can emit smells at specified points in the program [7]. This added level of sensory stimulation furthers the immersive experience of the user, and helps to establish a more in-depth and realistic experience. When dealing with PTSD through exposing the afflicted to a situation similar to that which caused their disorder, though, the potential rises for overstimulation to occur.

If overstimulated, a patient can begin to fear or reject their treatment methods [3]. They may begin to experience flashbacks or lose their sense of what is real and what is virtual. In attempts to prevent these setbacks, Bravemind was designed with a step-like treatment setup that will progressively integrate more and more stimulants into a patient’s treatment sessions as they progress through the designated plan [7]. This progressive immersion allows for patients to adjust to each stimulus one at a time, and allows for therapists to monitor trigger sensations that may need further inquiry before treatment may progress.

Overall, the Bravemind program provides a safe and controlled environment for a user to face the events that lead to their disorder while comfortably under the supervision of a trained medical professional. The design of the program removes much of the uncertainty associated with traditional exposure therapy, and although still in the prototyping phase, initial testing has yielded positive results that predict a bright future for the user of Bravemind in psychiatric therapy [7].

The study was conducted with eight subjects participating in multiple VR sessions that focused on improving their social skills.  Each session had the participant enter a VR environment and interact in mock social situations that they could potentially experience in daily life.  These situations included mock job interviews, blind dates, or issues with a friend or roommate [8].  Each VR session consisted of three participants in the environment.  The first was an avatar of the participant that is designed to resemble them.  Second, there is a therapist identified as the “coach” that has an avatar that resembles himself or herself as well.  The purpose of the “coach” is to instruct the participant where to go for each scenario and then critique and provide feedback for the participant after each role-played activity is completed [8].  Finally, there is another therapist that is identified as the “confederate” who participates in each scenario with the subject.  They can change their avatar depending on the situation and conditions [8].  Figure 2 below displays the VR environment with the subject involved in a mock interview with the confederate while the coach looks on from the doorway.  The image is taken from the perspective of another individual outside of the three previously mentioned. Each participant in the sessions views the VR environment through the eyes of their avatar. Following a critique of their interactions, the subject will participate in the same type of activity to try and implement what they just learned.  An example of this session would be a participant attending multiple mock job interviews in a session with critiques after each.  This allows the subject to attempt to improve with each successive scenario.  The ultimate goal of the sessions is to teach the participant how to interact in common social situations so they are better prepared when the situations arise outside the VR environment.

Following the sessions that each subject participated in, there were examinations that were used to compare the scores of participants before their sessions.  Figure 3 below shows the tabularized results and the corresponding p-values for each area of social aptitude.  As depicted in the results, all of the average social aptitude tests saw improvement in the means of the participants.  The tests were run at a 95% confidence interval and multiple tests had a p-value that was less than 0.05 [8].  

When a p-value is less than 0.05 for 95% confidence that means that the results are significant.  Significance in this case means that there is greater than a 95% chance that the results from the study were not caused by chance.  In statistics, this value is viewed as an indication that the variable that was being measured, in this case it is social aptitude characteristics, was affected by the independent variable or another confounding variable.  In this particular case, there is not a possible confounding variable that would explain most or all of the participants improving in their social skills, which means that the VR sessions must have been the source of the social aptitude improvements in the subjects.  The areas that particularly saw improvement and had significance were SP-total, SP-prosody, EKMAN 60, and Triangles [8].  These areas being significant means that patients improved upon the combination of auditory, visual, and facial recognition of emotions, and the inference of emotions from the actions of objects or others [8].  Other values showed improvement but did not reach the necessary p-value to become significant.  Overall, there was no area of social interactions that saw an average decrease for the participants.  The study must be replicated on a larger group before extrapolations can be made to the entire population of high-functioning individuals with autism.

The data from the study shows promise in the fact that virtual reality can effectively treat patients on the autism spectrum and improve their quality of life, but more studies must be conducted.  A major positive that is not necessarily in the data, but can be inferred was that the patients were not intimidated by the idea of using VR.  Some people can find the experience overwhelming and ineffective.  That did not happen in this case, which also shows promise that the VR therapy could be a viable treatment that patients are willing to participate in.  Additionally, patients from the study were surveyed on their opinions of the effectiveness of the VR.  The results tended to be positive, with 100% of those surveyed saying that they would recommend the sessions to others [8].  Figure 4 below shows the survey results from patients on their opinion of the effectiveness of the treatment after they finished their sessions.  


FIGURE 4 [8]

The table shows survey responses of participants. The percentages indicate the proportion of subjects that feel their social skill was improved in each category
From the responses of the participants we can conclude that the issue of VR being too intimidating for people may not be applicable in this case.  More study in this area must be done that corroborate these results before sweeping generalizations can be made, but the results of this study are promising so far.  If similar results appear in future studies, VR will most likely expand to become a viable option for the treatment of autism.
THE DEXMO GLOVE AND OTHER VR SUPPLEMENTS
Virtual reality programs of today already possess a great deal of potential, but perhaps VR’s greatest strength is its ability to function in tandem with other revolutionary tools. Not only are programs adjustable for their users but companies, such as Dexta Robotics, are already in the process of producing technologies that can pair with the VR system to further immerse users into the program.  Other groups have been researching and developing their own haptic gloves, each with a different approach.  A haptic glove is a device that stimulates a user’s sense of touch by simulating the grasping of objects displayed by the VR system. Examples of other gloves are Gloveone and Hands Omni [9].  Currently, there are no haptic gloves being widely used, so there is no design that has established itself as being the best yet.

Dexta Robotics are designing and promoting their design, Dexmo, before it is released to the open market.  Dexmo is designed to provide realism by using force-feedback sensors [10].  The goal of this feedback is to make the virtual object feel as though a user is actually holding it.  This is done by the sensors applying a resistive force to the fingers as they grasp the object.  Each item is coded with its own properties that determine the size and hardness of the object, which is used to determine when and how hard the glove must apply a resistive force [10].  Dexta claims that their sensors allow users to be able to feel a noticeable difference between a rock and a rubber duck through the resistivity of Dexta [10].  Dexta has published studies that show users favor Dexmo over competing haptic gloves.  However, a study done by the company that produces the product being studied must be recognized to have implicit bias.  Regardless, Dexta’s approach to designing Dexmo is significantly different from other glove designs and shows potential for greater immersion than competing designs.

Gloveone and Hands Omni are possible competitors to Dexmo, but they are not as far along the development process.  Gloveone is in the crowdfunding stage, but the proposed design is worth taking note of.  The glove is designed to provide haptic feedback through the use of actuators [10].  In total, the glove is designed to have ten actuators around the hand that vibrate to provide “touch sensations” [10].  The goal of these actuators is to provide sensations of touch but not attempt to replicate the feeling of the object.  Proposers of Gloveone view the touch sensations as easier to create and sufficient to produce an in-depth effect than trying to replicate the exact feeling of an object.  Gloveone is planned to be sold for $199 per glove when it is released [10].  This relatively low cost product shows that virtual reality technologies will be accessible to a large number of people when it is released.  Additionally, this low cost means it will be possible to integrate the technologies into therapy sessions without drastically raising the cost of the sessions for patients.

In contrast to Gloveone, Hands Omni is slightly further along the development process.  It is currently being designed by students at Rice University and is sponsored by Virtuix.  Hands Omni’s approach to haptic feedback is the utilization of inflatable mini-bladders that provide pressure on the hand as a type of force feedback [10].  The inflation of the bladders is unique to other types of gloves, but also presents its own types of issues.  It allows for actual pressure to be put on the hand, which further increases the depth of immersion.  However, this further depth comes at a cost of lag in the time between the VR system registers touching the object and the pressure being felt on the hand.  For Hands Omni to be able to progress further and become marketable, the designers will have to find a solution to the lag time issue.

Dexmo, Gloveone, and Hands Omni show that there are many ways to approach the design of a haptic glove.  No design has proven itself to be superior to others yet, but as multiple haptic gloves become available for purchase, the best technologies will emerge.  Even without haptic gloves being widely available now, the sale prices that are being discussed show that the gloves will be widely accessible.  A more affordable glove means that it can be easily integrated into therapy sessions with little additional cost to the patient.  In exchange for a slight predicted increase in the cost of a therapy session, the patient gets great benefit.  The VR allows for immersion into situations that can be used for teaching situations.  Furthermore, the haptic gloves or other technologies can further immerse a patient and potentially increase the benefits and learning of the VR session.
THE SUSTAINABILITY OF VIRTUAL REALITY IN MEDICAL FIELDS
In incorporating VR technology into the field of medicine, one must first address the sustainability of the tool. In this case, sustainability will be defined as the impact on society of the product as well as the change in quality of life for patients. With sustainability in mind, it must be addressed that the implementation of Virtual Reality in psychiatric therapy still faces a number of unknowns and ethical issues that must be weighed and addressed before it can successfully transition into the field [11]. Recent developments in the technology have lessened many of the unintended side effects that have caused issues for patients in the past. Despite many potential issues being resolved, some continue to linger.

Two of the leading issues associated with the use of VR in any capacity are cybersickness and aftereffects. Cybersickness can be classified by feelings of nausea, dizziness, disorientation, mild vertigo, and eyestrain [11]. Aftereffects arise as a result of cybersickness and have the potential to be worse, even possibly lengthening the rehabilitation process of the patient. Brought on after extensive use of VR containing large amounts of motion or flashing imagery, these aftereffects may result in the development of motor disturbances, flashbacks, fatigue, and locomotive disruptions [11]. Accentuated in patients dealing with PTSD and autism, these aftereffects can prove to be extremely detrimental to the improvement of one’s condition due to the nature of the disorders. Should a veteran begin to experience flashbacks, as mentioned earlier, or an autism patient develop a negative response to their treatment, then their recovery process may be set back.

Along with these issues, the next most prevalent roadblock to the integration of VR in psychiatric treatment is the need for therapists to develop a proficient understanding of the technology and how to use it. According to the Ethical Standards for the field of psychology, professionals must adhere to the following principles. First, “Psychologists provide services, teach, and conduct research only within the boundaries of their competence, based on their education, training, supervised experience, or appropriate professional experience” [11]. Second, “In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect patients, clients, students, research participants, and others from harm” [11]. Despite the efforts to make VR technology easy to use, medical professionals would still need to undergo training before they could utilize this tool. This would also require extensive testing of a program before its release, which could increase both the cost and time required to create a treatment program, slowing the treatment process by a great deal.

Finally, the third and arguably most notable issue is the possibility that easy accessibility to VR treatments will lead to improper self-diagnosis of mental issues [11]. Traditional psychiatric treatment methods require patients to meet with a medical professional before starting their therapy. On a virtual platform, though, a patient has the ability to gain access to treatment without consulting a trained therapist. As a result, there is great potential for a patient to mistreat an ailment that they have, which can also set back their progress toward learning to control or cope with their disorder.

Virtual reality’s rapid growth and adaptability allows it to rectify potential issues as it is developed. The problems of cybersickness and aftereffects can be overcome in a variety of ways. Bravemind’s step-like treatment not only helps to prevent a patient from experiencing an overwhelming trigger, but also allows them to get used to the VR system. Slowly integrating a patient into usage of the Bravemind program means they will also be slowly adjusting to VR. As they use the program more and grow more comfortable, they will build up a tolerance to the device that prevents cybersickness and aftereffects. Additionally, programs like Bravemind were designed to be easy for the therapist to use. This means that the time it takes to be trained to properly utilize the technology should not be excessive. Preventing inappropriate usage and self-treatment by patients may be the toughest obstacle to overcome for VR therapies. Programs could possibly require a prescription before a patient can download them to their own VR devices. This would only apply to VR therapy programs that are intended for home use as well as in a therapeutic setting. Programs that are designed to have a therapist controlling the environment can be limited to exclusive sale to a licensed therapist. Companies should not be able to sell their therapeutic programs directly to the public because self-treatment or self-diagnosis could cause setbacks or trauma for users. However, limitation of the accessibility to these programs should be able to prevent this issue.

Once these problems have been addressed and resolved, the potential impact that VR can have on the medical industry will be profound. Providing easy access to those in need as well as customizable treatment methods that go beyond the capabilities of traditional therapeutic practices, the technology maintains its position as the future of psychiatric therapy [12].

[2] “Shocking PTSD, suicide rates for vets” George Washington University Face the Facts USA. 6.05.2013. Accessed 2.20.2017 http://www.facethefactsusa.org/facts/the-true-price-of-war-in-human-terms

[3] “PTSD: National Center for PTSD.” U.S. Department of Veterans Affairs. 7.13.2015. Accessed 1.30.2017 http://www.ptsd.va.gov/public/PTSD-overview/basics/symptoms_of_ptsd.asp

[4] “What is Autism?” Autism Speaks. 2017. Accessed 2.25.2017 https://www.autismspeaks.org/what-autism

[5] “Understanding Sensors: Magnetometers, Accelerometers, and Gyroscopes.” Virtual Reality Society.  Accessed 2.14.2017.  https://www.vrs.org.uk/virtual-reality-gear/motion-tracking/sensors.html  

[6] D. Avola, M. Spezialetti, G. Placidi. “Design of an efficient framework for fast prototyping of customized human–computer interfaces and virtual environments for rehabilitation” 6.01.2013. Accessed 2.05.2017 http://www.sciencedirect.com/science/article/pii/S0169260713000126

[7] “Bravemind.” USC Institute for Creative Technologies. 2016. Accessed 1.9.2017http://medvr.ict.usc.edu/projects/bravemind/

[8] M. Kandalaft, N. Didehbani, D. Krawczyk. “Virtual Reality Social Cognition Training for Young Adults with High-Functioning Autism.” 2012. Accessed 2.25.2017 http://www.brainhealth.utdallas.edu/pdfs/Virtual%20Reality%20Social%20Cognition%20Training%20for%20Young%20Adults%20with%20High-Functioning%20Autism.pdf

[9] S. Hayden. “2 VR Gloves Promising Haptic Feedback, 2 Different Approaches”  6.05.2015. Accessed 2.01.2017 http://www.roadtovr.com/2-vr-gloves-promising-haptic-feedback-2-different-approaches/

[10] P. James. “Dexmo Shows Off Latest Exoskeleton Gloves That Let You Touch VR” 7.23.2016. Accessed 2.3.2017 http://www.roadtovr.com/dexta-dexmo-exoskeleton-vr-glove-haptic-force-feedback-touch-vr/  

[11] A. Rizzo, M. Schultheis, B. Rothbaum. “Ethical Issues for the Use of Virtual Reality in the Psychological Sciences.” No date. Accessed 1.10.2017.http://www.virtuallybetter.com/af/documents/VR_Ethics_Chapter.pdf

[12] L. Valmaggia. “Virtual reality in the psychological treatment for mental health problems: A systematic review of recent evidence.” sciencedirect.com. 1.12.2016. Accessed 1.10.2017.http://www.sciencedirect.com/science/article/pii/S0165178116300257

A. Miloff. “Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial.” biomedcentral.com. 2.2.2016. Accessed 1.9.2017.http://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1171-1

A. Rizzo, A. Hartholt. “Bravemind: Virtual Reality Exposure Therapy.” USC Institute for Creative Technologies. 2016. Accessed 1.9.2017http://ict.usc.edu/prototypes/pts/

L. Whalley. “Ethical issues in the application of virtual reality to medicine.” sciencedirect.com. 1.27.2000. Accessed 1.10.2017.http://www.sciencedirect.com/science/article/pii/001048259500008R?via%3Dihub