**Meet the editor**

Dr. Cecília Sik Lányi studied Mathematics and Computer Science (M.S.) – József Attila University (1984), and Teacher of Mathematics - Berzsenyi Dániel Teacher Training College in 1988. She obtained the degree of Dr. Univ. at the University of Veszprém, Hungary in Physical-chemistry (1993), and PhD at the University of Veszprém, Hungary in Computer Science (2000). She has

worked as a software engineer and as an associate professor for program languages at the University of Pannonia. Currently she is teaching: Virtual Reality and its application, user interface design, and computer graphics for informatics engineering students. PhD and Masters' supervision has an emphasis on Virtual Reality for the rehabilitation of children with disabilities and patients with mental health issues. She got the "Master teacher" award of the Hungarian Ministry of Education in 2001. She has published more than 300 refereed articles and conference papers, and worked as guest editor for many renowned journals and books. Her research area is Virtual Reality, Human Computer Interaction, Design for All.

### Contents




### Preface

Chapter 7 **Neural Network Modelling and Virtual Reality 129**

Chapter 8 **Mobile Virtual Reality — An Approach for Safety**

Igor Belič

**VI** Contents

Dong Zhao

**Management 153**

Virtual Reality (VR) has thousand faces. Why? Because from the moment of VR's birth we use it in every field of our life. VR is based on the development of information technology, computer graphics, and strong high speed hardware. Virtual Reality has emerged as a major new technology in the mid 1990s. It became commonplace in our increasingly technological world in recent years. These Virtual Reality Applications comprise almost all fields of the real life activities. VR has high impact not only on research, but on our daily living as well. In this book we have chosen certain areas to cover, which we believe to have potential sig‐ nificant impact on VR and its applications. This book has an aim to present applications, trends and newest development in three main disciplines: health sector, education and in‐ dustry. In this book several new applications are presented in three sections. The first part of the book deals with health care applications. It is followed by a literature review of Aug‐ mented Reality (AR). The second section contains industry field education disciplines. The last part shows several industry applications and research.

The main features of the book can be summarised as follows:


This book provides a definitive resource for wide variety of people including academicians, designers, developers, educators, engineers, practitioners, researchers and graduate students.

We would like to thank the authors for their contributions. Without their expertise and ef‐ fort, this book would have never been born. InTech editors and staff also deserve our sincere recognition for their support throughout the project.

Finally, the editor would like to thank her family for their patience, Professor Janos Schanda, the head of the Virtual Environments and Imaging Technologies Research Laboratory, for giving her the freedom of research, for the help of all her co-workers at the Laboratory and, last but not least, the work for her students.

> **Cecília Sik Lányi** Associate professor at the University of Pannonia Veszprém, Hungary

**Health Care Applications and AR**

## **Using Virtual Reality to Provide a Naturalistic Setting for the Treatment of Pathological Gambling**

Stéphane Bouchard, Claudie Loranger, Isabelle Giroux, Christian Jacques and Geneviève Robillard

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59240

### **1. Introduction**

Recent studies reveal psychotherapy is effective in reducing gambling behaviours [1, 2]. However, an important issue in treating pathological gambling is that, despite understanding the negative consequences of continued gambling, problem gamblers at times experience an overwhelming craving to gamble [3]. Furthermore, the therapeutic work carried out when patients are emotionally distant from the gambling situation, such as in a therapist's office, is hard to transfer to real-life tempting situations.

Previous researches have studied the efficacy of imaginal [4, 5]; and *in vivo* exposure to gambling-related cues in order to reduce gamblers' cravings [6-9] either in cue exposure therapy or as part of a broader Cognitive-Behaviour Therapy (CBT) package where skills are developed or strengthened while confronted to the addictive stimuli [10, 11]. In imaginal exposure, patients are asked to imagine different stimuli, while *in vivo* exposure requires the physical presentation of the stimuli. Results from these studies indicate that these two forms of exposure therapy can help reduce cravings among pathological gamblers [4, 9] and generate broader therapeutic impact such as significant improvements on other gambling variables and psychopathological symptoms [4, 8].

Since the 90s, a new kind of exposure tool has appeared in clinical psychology: Virtual Reality (VR) or *in virtuo* exposure [12, 13, 14]. VR can be defined as "an application that makes it possible for the user to navigate and to interact in real time with an environment in three dimensions generated by a computer" [15]. *In virtuo* exposure is usually conducted using a Head Mounted Display (HMD or helmet) which is a pair of goggles allowing the presentation

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

of images in stereoscopy, combined with audio stimuli and a motion tracker that follows the user's head movements [13,14]. Both for cue exposure and broader CBT package, VR presents the same advantages as imaginal exposure since it offers great control over different stimuli and the rhythm of exposure in a context that assures patients' confidentiality and eliminates many ethical problems unlike *in vivo* exposure. However, VR also presents some advantages over imaginal exposure because it reduces problems related to lack of memory, difficulties inducing emotions solely with thoughts or patients' refusal to fully access their memories [13,14]. Finally, VR allows therapists to control the impact of stimuli related to patients' other addictions on the course of therapy. For example, alcohol, cigarettes or drugs could also be found in a virtual environment to provide specific cues for a patient. VR also offers the possibility to conduct exposure and relapse prevention in various locations (for example, a bar or casino) that could provoke different reactions in the same person. The fact that VR is interactive and very similar to real-life situations could also positively influence gamblers' perceptions about therapy and encourage them to seek treatment. But they key argument in favor of using VR is its potential to replicate an environment where addictive behavior is usually taking place, thereby allowing to witness pathological gamblers' emotions and dysfunctional behaviors, and accessing their mental state as it is operating in gambling situations. Replicating gambling situations with a naturalistic setting in the safety of the therapist's office should be quite an advantage to treatment efficacy.

A significant number of outcome studies have been conducted where CBT is combined with VR to treat anxiety disorders [16]. Indeed, VR exposure has shown its efficacy in the treatment of acrophobia, claustrophobia, arachnophobia, fear of driving, fear of flying, social anxiety disorder (fear of speaking in public) and posttraumatic stress disorder [17]. Less work has been done with addictions, but researchers have shown that VR can be used with pathological gamblers, either for experimental research, to induce cravings or in single-case trials.

In 2008, a study using VR by Young and colleagues [3] revealed that for pathological gamblers, the desire to gamble was influenced by wins, losses and the different amounts won which was not the case for non-gamblers. This research is interesting because it shows VR can induce a desire to gamble, but it didn't use VR as a treatment tool. The first study using VR in a CBT program for pathological gambling was realized in Spain [18]. Unfortunately, results from this research were never officially published.

In the current chapter, two virtual environments and their clinical applications for patholog‐ ical gambling and co-occurring problems will be detailed. First, data from a validation study and a pilot clinical trial with gamblers will be presented. Then, a presentation of a CBT manual for using VR will follow. The two virtual environments described in this chapter, a bar and a casino, were the first in North America designed for the treatment of patholog‐ ical gambling to be empirically tested [19, 20]. Note that the choice of Video Lottery Terminals (VLT) in bars and slot machines in casinos was based on epidemiological data on gambler's playing habits [21].

Before using these two environments in treatment (see section 2.1.2 for a detailed description), a validation study was conducted in order to determine if they could induce a desire to gamble [19,20]. First, a training immersion in VR was performed to allow participants learning how to navigate in VR and manipulate the equipment. All immersions were performed on a PC computer with an nVisor SX HMD, a pair of computer loudspeakers, an Intersence Cube2 motion tracker for measuring head rotations, a wireless mouse for translations / navigation in the virtual environments, and a box with push-buttons allowing the user to physically interface and play with the VLT and slot machines. Second, participants removed the HMD and had to physically play a game of ScrabbleTM (a control condition where the game is not significantly based on chance) with the experimenter for a period of 7 minutes. Then, participants were randomly assigned to 7 minutes of playing on: a real VLT (gold standard control condition), playing VLT in a virtual bar (VR bar condition), and playing slot machines in a virtual casino (VR casino condition). Subjects' desire to gamble was assessed after each game with the Gambling Craving Scale (GACS) [22] and physiological reactions (skin conductance and heart rate) were measured throughout the experiment. It is noteworthy that participants recruited for this validation study (*n*=67) had prior experience with games of chance and VLTs but were not pathological gamblers. Participants presenting a potential gambling problem according to the South Oaks Gambling Screen (SOGS) [23] were excluded from the project and referred to proper resources. Accepted participants were divided in two categories according to selfreported frequency of gambling: frequent gamblers (played at least once a month with VLT or slot machines) or non-gamblers (played a maximum of twice a year). Results show that physiological arousal (according to the skin conductance), desire to gamble, and anticipation of positive mood while gambling were statistically higher in the frequent gamblers group than in the non-gamblers group for the real VLT and the two virtual environments. The Time by Condition interaction was significant [F(3,186)=11.53, p <.001] and revealed that, compared to playing ScrabbleTM, the craving to gamble was increased as significantly in the two virtual conditions than with the real VLT for the gamblers group. In sum, the two virtual environments seemed to provoke among gamblers the same desire to gamble than a real machine, even if no real money was involved [19,20].

of images in stereoscopy, combined with audio stimuli and a motion tracker that follows the user's head movements [13,14]. Both for cue exposure and broader CBT package, VR presents the same advantages as imaginal exposure since it offers great control over different stimuli and the rhythm of exposure in a context that assures patients' confidentiality and eliminates many ethical problems unlike *in vivo* exposure. However, VR also presents some advantages over imaginal exposure because it reduces problems related to lack of memory, difficulties inducing emotions solely with thoughts or patients' refusal to fully access their memories [13,14]. Finally, VR allows therapists to control the impact of stimuli related to patients' other addictions on the course of therapy. For example, alcohol, cigarettes or drugs could also be found in a virtual environment to provide specific cues for a patient. VR also offers the possibility to conduct exposure and relapse prevention in various locations (for example, a bar or casino) that could provoke different reactions in the same person. The fact that VR is interactive and very similar to real-life situations could also positively influence gamblers' perceptions about therapy and encourage them to seek treatment. But they key argument in favor of using VR is its potential to replicate an environment where addictive behavior is usually taking place, thereby allowing to witness pathological gamblers' emotions and dysfunctional behaviors, and accessing their mental state as it is operating in gambling situations. Replicating gambling situations with a naturalistic setting in the safety of the

A significant number of outcome studies have been conducted where CBT is combined with VR to treat anxiety disorders [16]. Indeed, VR exposure has shown its efficacy in the treatment of acrophobia, claustrophobia, arachnophobia, fear of driving, fear of flying, social anxiety disorder (fear of speaking in public) and posttraumatic stress disorder [17]. Less work has been done with addictions, but researchers have shown that VR can be used with pathological

In 2008, a study using VR by Young and colleagues [3] revealed that for pathological gamblers, the desire to gamble was influenced by wins, losses and the different amounts won which was not the case for non-gamblers. This research is interesting because it shows VR can induce a desire to gamble, but it didn't use VR as a treatment tool. The first study using VR in a CBT program for pathological gambling was realized in Spain [18]. Unfortunately, results from this

In the current chapter, two virtual environments and their clinical applications for patholog‐ ical gambling and co-occurring problems will be detailed. First, data from a validation study and a pilot clinical trial with gamblers will be presented. Then, a presentation of a CBT manual for using VR will follow. The two virtual environments described in this chapter, a bar and a casino, were the first in North America designed for the treatment of patholog‐ ical gambling to be empirically tested [19, 20]. Note that the choice of Video Lottery Terminals (VLT) in bars and slot machines in casinos was based on epidemiological data

Before using these two environments in treatment (see section 2.1.2 for a detailed description), a validation study was conducted in order to determine if they could induce a desire to gamble [19,20]. First, a training immersion in VR was performed to allow participants learning how

gamblers, either for experimental research, to induce cravings or in single-case trials.

therapist's office should be quite an advantage to treatment efficacy.

research were never officially published.

4 The Thousand Faces of Virtual Reality

on gambler's playing habits [21].

A pilot clinical trial was then conducted with 28 pathological gamblers participating in a 28 day residential CBT program with group and individual interventions [20]. A more affordable HMD was used and the treatment was adapted from an already validated CBT program developed by Ladouceur [24]. Only two sessions of the CBT program were modified to include VR (the first and last sessions described further in this chapter), allowing to compare the use of imaginal exposure (standard technique) with immersions in virtual reality in the bar. Participants were randomly assigned either to the virtual reality condition or the imaginal exposure condition. Results revealed that the first VR immersion allowed finding significantly more high risk situations and more dysfunctional thoughts than the standard imaginal exposure exercise [20]. In the second experimental therapy session, devoted to relapse prevention, immersion in the virtual bar was associated with stronger changes in urges to gamble compared with the imaginal exposure condition. Furthermore, a multiple regression predicting pre to post-treatment improvements revealed that the strength of changes in urges to gamble induced during the relapse prevention session significantly predicted patients' improvements [F (1,19)=5.13, p <.025]. Finally, another interesting finding from this clinical trial is that no ethical issue or adverse events were reported following the use of VR [20] (e.g., inducing cravings that would be too intense).

### **2. Description of a treatment manual using VR**

Following the pilot clinical trial described above [19,20], a randomized control trial was launched, this time using four sessions devoted to immersions in VR. Two additional sessions devoted to conducting cognitive restructuring were added. These sessions were not included in the pilot studies due to logistical constraints and were positively anticipated by the thera‐ pists. Their advantage is to allow conducting cognitive restructuring while patients are emotionally aroused and operate on an "emotional mode" instead of a "cold logical mode" that translates poorly to what happens in potential gambling situations. The treatment illustrated in this chapter refers to the virtual bar in the examples, but details about using the virtual casino in therapy are also mentioned. Detailing how to effectively treat pathological gambling is outside the scope of this book and, therefore, using our program requires profes‐ sionals to become familiar with traditional CBT programs (e.g., such as the one developed by Ladouceur et al [24]) and this clinical population. The following sections will: (a) briefly introduce the equipment required and different features of the virtual environments; (b) suggest sessions when to use immersion in virtual reality; (c) describe in details the four therapy sessions where virtual reality can be exploited (identifying high risk situations, conducting cognitive restructuring and practicing relapse prevention techniques); and (d) address potential problems during immersion and related solutions.

### **2.1. Description of the equipment and of the virtual environments**

#### *2.1.1. Equipment*

In the pilot [20] and current clinical trials, immersion in VR is conducted with an immersive version of the virtual bar with the help of a HMD (iWear VR920 from Vuzix), head-tracking system (Cube2 from Intersence), speakers, a wireless mouse, and a box with pushbuttons replicating the interface panel of a real VLT. Visual and audio stimuli from the virtual environment were controlled by the user's movements and external stimuli were essentially blocked when wearing the HMD. This immersive version allowed the user to feel completely present in the virtual environment and make him forget that he or she is actually in his therapist's office1 . The pushbutton control box does not have to be used if therapists do not feel comfortable allowing their patients to actually play at a game of chance.

This immersive equipment provides a visual field of view of 32-degrees and a reliable 3 degrees-of-freedom head tracking, allowing the user to explore with the mouse a rather large area and interacting with virtual objects and virtual characters in the environments. Sound files are triggered and their loudness modulated by the proximity of various stimuli (e.g., music starts when entering the bar, sounds from the reels of the slot machines in the casino become louder as you approach the machines) or by the therapist (i.e., to have the barman talk with

<sup>1</sup> A less immersive version of the system is also available but it has not been tested with patients yet. In the non-immersive version, the virtual environments are simply presented on a computer screen, without the need of a HMD and motion tracking. However, there is no data documenting that a non-immersive VR system could be effective in the treatment.

the user), and the pushbutton box allows selecting how many lines to bet on, how much credits to bet, and to start / stop the VLT machines.

#### *2.1.2. Virtual environments*

**2. Description of a treatment manual using VR**

6 The Thousand Faces of Virtual Reality

address potential problems during immersion and related solutions.

**2.1. Description of the equipment and of the virtual environments**

feel comfortable allowing their patients to actually play at a game of chance.

*2.1.1. Equipment*

therapist's office1

Following the pilot clinical trial described above [19,20], a randomized control trial was launched, this time using four sessions devoted to immersions in VR. Two additional sessions devoted to conducting cognitive restructuring were added. These sessions were not included in the pilot studies due to logistical constraints and were positively anticipated by the thera‐ pists. Their advantage is to allow conducting cognitive restructuring while patients are emotionally aroused and operate on an "emotional mode" instead of a "cold logical mode" that translates poorly to what happens in potential gambling situations. The treatment illustrated in this chapter refers to the virtual bar in the examples, but details about using the virtual casino in therapy are also mentioned. Detailing how to effectively treat pathological gambling is outside the scope of this book and, therefore, using our program requires profes‐ sionals to become familiar with traditional CBT programs (e.g., such as the one developed by Ladouceur et al [24]) and this clinical population. The following sections will: (a) briefly introduce the equipment required and different features of the virtual environments; (b) suggest sessions when to use immersion in virtual reality; (c) describe in details the four therapy sessions where virtual reality can be exploited (identifying high risk situations, conducting cognitive restructuring and practicing relapse prevention techniques); and (d)

In the pilot [20] and current clinical trials, immersion in VR is conducted with an immersive version of the virtual bar with the help of a HMD (iWear VR920 from Vuzix), head-tracking system (Cube2 from Intersence), speakers, a wireless mouse, and a box with pushbuttons replicating the interface panel of a real VLT. Visual and audio stimuli from the virtual environment were controlled by the user's movements and external stimuli were essentially blocked when wearing the HMD. This immersive version allowed the user to feel completely present in the virtual environment and make him forget that he or she is actually in his

This immersive equipment provides a visual field of view of 32-degrees and a reliable 3 degrees-of-freedom head tracking, allowing the user to explore with the mouse a rather large area and interacting with virtual objects and virtual characters in the environments. Sound files are triggered and their loudness modulated by the proximity of various stimuli (e.g., music starts when entering the bar, sounds from the reels of the slot machines in the casino become louder as you approach the machines) or by the therapist (i.e., to have the barman talk with

1 A less immersive version of the system is also available but it has not been tested with patients yet. In the non-immersive version, the virtual environments are simply presented on a computer screen, without the need of a HMD and motion tracking. However, there is no data documenting that a non-immersive VR system could be effective in the treatment.

. The pushbutton control box does not have to be used if therapists do not

The virtual bar (named *Chez Fortune / At Fortunes*) and the virtual casino (named *Les 3Dés / The 3Dices*) were created at the Cyberpsychology Lab of UQO with the intention of simulating a gambling situation without the use of real money (see Figure 1 and 2). Any resemblance with real locations and these fictive locations is fortuitous.

**Figure 1.** Screenshots of the virtual bar Chez Fortune / At Fortune

**Figure 2.** Screenshots of the virtual casino Les 3Dés / The 3Dices

A hierarchy has been constructed in the virtual bar to guide interventions, with users pro‐ gressively approaching the machines where they can gamble (see steps 1 to 7 on Figure 3) and, in the last two steps of the hierarchy, actually sitting and playing. Users are invited to walk to each step of the hierarchy and apply various CBT techniques described later in the chapter: (1) at the starting point outside of the bar, in front of the ATM machine; (2) at the entrance doors of the bar, with two people smoking outside; (3) at the bar, in front of the waitress; (4) further inside the bar, in front of the barman; (5) even further inside the bar and closer to the VLTs; (6) close to the washroom, very near of the VLTs; (7) right in front of two available VLTs (one VLT becomes available after the therapist activates an animation where a frustrated player leaves his seat); (8) the user is now allowed to sit and gamble 20 virtual dollars; (9) the user continues gambling more money and keeps playing as long as desired.

**Figure 3.** Birds-eye view of the virtual bar and first seven steps of the hierarchy

The objective with the hierarchy of pre-identified steps is to allow the user to progress gradually in the environment. During the immersion, the therapist can invite the user to stop at each step and observe the environment. Users can also be encouraged to share their thoughts and feelings at different steps. Users should always be told they can end their progression or the immersion whenever they want. It is noteworthy that the two last steps of the hierarchy were not used in the pilot clinical trial because gambling was not permitted in the treatment centers [20], but they are used in one center involved in the current randomized clinical trial. Therapists should use their clinical judgement when assessing gambler's urges to gamble, emotional stability and readiness to move to the next steps, as they always remain accountable for the safety of their patients.

### **2.2. Before using VR with pathological gamblers**

in the last two steps of the hierarchy, actually sitting and playing. Users are invited to walk to each step of the hierarchy and apply various CBT techniques described later in the chapter: (1) at the starting point outside of the bar, in front of the ATM machine; (2) at the entrance doors of the bar, with two people smoking outside; (3) at the bar, in front of the waitress; (4) further inside the bar, in front of the barman; (5) even further inside the bar and closer to the VLTs; (6) close to the washroom, very near of the VLTs; (7) right in front of two available VLTs (one VLT becomes available after the therapist activates an animation where a frustrated player leaves his seat); (8) the user is now allowed to sit and gamble 20 virtual dollars; (9) the user

continues gambling more money and keeps playing as long as desired.

8 The Thousand Faces of Virtual Reality

**Figure 3.** Birds-eye view of the virtual bar and first seven steps of the hierarchy

The objective with the hierarchy of pre-identified steps is to allow the user to progress gradually in the environment. During the immersion, the therapist can invite the user to stop at each step and observe the environment. Users can also be encouraged to share their thoughts and feelings at different steps. Users should always be told they can end their progression or the immersion whenever they want. It is noteworthy that the two last steps of the hierarchy Before introducing patients to VR, therapists should always assess the presence of any health conditions that could provoke or aggravate VR-induced unwanted side-effects, often called cybersickness [25,26]. Cybersickness is not a disease but a reaction which could occurs during or after an immersion in a virtual environment. It is similar to motion sickness and essentially includes three categories of symptoms: (1) visual symptoms (eyestrains, blurred vision, headaches), (2) disorientation (vertigo, imbalance) and (3) nausea (vomiting, dizziness) [25]. These symptoms are normal, temporary and can be prevented to some extent. For example, people under the influence of alcohol or other psychoactive drugs should not be immersed in a virtual environment. Also, VR shouldn't be used with patients presenting medical conditions such as serious cardiac problems, epilepsy, vestibular problems, and migraines (see [26] for a more exhaustive list). People suffering from comorbid psychotic disorders should probably not be immersed in VR because of their difficulties with reality testing.

Even in users in good health condition, cybersickness have to be assessed throughout the immersions. Different questionnaires, such as the Simulator Sickness Questionnaire [25], allow clinicians to monitor these symptoms when they use VR. In sum, the therapist's evaluation of his patient's health and his clinical judgement are always necessary before conducting immersion in VR and to pursue the immersions. In research settings, in order to prepare the patient to *in virtuo* exposure to gambling-related cues and control for the effect of novelty, it is common to start with an immersion in a training environment. The purpose of a training environment is to allow the user to learn how to use the equipment in a context devoid of stimuli eliciting strong emotions or cravings. It also offers a good opportunity for clinicians to assess the presence of cybersickness, as some symptoms may be confounded with physiolog‐ ical symptoms of arousal and cravings (e.g., sweating).

Since the virtual environments induce real cravings to gamble [19], it is very important for the clinician to determine if the patient is ready for such an exercise and implement strategies to cope with strong urges if they occur. The immersion in a gambling situation has to be con‐ ducted by trained therapists. Gamblers who's cravings have been stimulated during a therapy session should be followed closely by the staff to ensure that this experience is positively integrated emotionally, is not destabilizing the patient too much, and is leading to a positive therapeutic outcome instead of a worsening of the situation. Because it is more difficult to check on gamblers after an immersion session that elicited urges to gamble in an outpatient setting, clinical wisdom suggest using this technique in inpatients settings until its safety has been documented. In addition to urges induced by the immersion, other factors could put the gambler at risk for discomfort or relapse. These risks are usually implicitly controlled in a residential treatment facility, where access to cues associated with gambling and other addictions are absent. However, although VLT are not available on the premises of a residential facility, they are in the virtual environments, and this environment may be accessible if it is stored in an unlocked room of the residence. Seeing alcoholic beverages during an immersion in VR could elicit emotional reactions in a gambler who also has issues with alcohol. Witnessing people enjoying gambling in a virtual casino can trigger sadness in a person who must accept to become abstinent. Again, the take home message is that VR is a clinical tool that must be used by mental health professional using their clinical judgment.

As mentioned earlier, in the context of the treatment of pathological gambling, three specific moments are suggested for the use of VR immersion: (a) at the beginning of treatment, to identify high risk situations and erroneous perceptions about gambling, (b) at mid treatment, to implement cognitive restructuring of dysfunctional beliefs, and (c) at the end of therapy, to practice relapse prevention techniques.

#### **2.3. Illustration of the four sessions of VR immersion in the virtual bar**

#### *2.3.1. First immersion: Identifying high risk situations*

Before the identification of high risk situations with the help of the virtual environment, it is important to prepare the patient for the immersion. As mentioned previously, an evaluation of the user's health condition should be done before using VR. Cybersickness should also be discussed with patients and it is recommended to use a training environment to allow users to feel more comfortable with the equipment. Since the virtual environments induce a desire to gamble, therapists have to inform their patients of this possible consequence. It is also important to discuss the objective of the session with the patient before starting the immersion. Users should be encouraged to express out loud their feelings and thoughts during the immersion. Communication with the user is always possible during immersion in VR and is important to pace the progression of the immersion. However, constant verbal interventions from therapist could make some users feel less present in the virtual environment since it could be a continuous reminder that the situation is not real. Clinicians can use brief questions or 0-10 scales to measure users' desire to gamble, self-efficacy or cybersickness for example. Since the patient in the virtual environment doesn't have a visual contact with his therapist, every questionnaire or scale used should be presented in detail before the immersion.

For this first immersion in VR, 20 minutes should be enough to go through the identified steps in the virtual environment. It is also possible to repeat the user's progression through the environment multiple times. The goal of the session is to detect as many stimuli, behaviors and dysfunctional thoughts associated with situations that represent a high risk of gambling. During the immersion, the therapist says: "*Please behave naturally and say openly what comes through your mind during this visit in the bar. You can describe what you see that triggers the desire to gamble, your thoughts and ideas, your observations, what you would do in such a situation, or it you think of situations you would avoid because you could lose control of your desire to gamble.*" The therapist is encouraged to explore the situation with the patient, ask if some elements could trigger urges (e.g., walking pass an ATM located close to a place where it is possible to gamble, on a payday). The therapist must pay attention to patient's behaviors that would be represen‐ tative of gambling patterns (e.g., a patient once checked both his left and right pocket for money, revealing his habit of putting some money in his right pocket to increase his winning chances). When the therapist has gathered enough information, or if the patient asks to end the immersion, the patient should be asked to walk out of the bar before actually taking off the HMD. In some case, it has been revealing to ask patient to go back to the ATM and return the money they didn't use. Since the first session of immersion takes place at the beginning of therapy, it is normal for most gamblers to feel an urge to gamble during or after exposure to gambling related cues. Thus, therapists can decide to discuss more thoroughly the identified high risk situations with their patients, and it is wise to dedicate the last minutes of the session to try to reduce the gambler's craving. Some patients are shocked by the strength of their reactions; despite the fact this is a simulation. This can be explored as a motivation for the therapy (e.g., starting the discussion with "*If this makes you react so strongly, imagine how it would be in a real life situation. What conclusion can we draw from this regarding your own situation?"*). Table 1 summarizes the essential instructions for the first session of immersion.


**Table 1.** Key points for therapists to remember for the first immersion in VR

addictions are absent. However, although VLT are not available on the premises of a residential facility, they are in the virtual environments, and this environment may be accessible if it is stored in an unlocked room of the residence. Seeing alcoholic beverages during an immersion in VR could elicit emotional reactions in a gambler who also has issues with alcohol. Witnessing people enjoying gambling in a virtual casino can trigger sadness in a person who must accept to become abstinent. Again, the take home message is that VR is a clinical tool that must be

As mentioned earlier, in the context of the treatment of pathological gambling, three specific moments are suggested for the use of VR immersion: (a) at the beginning of treatment, to identify high risk situations and erroneous perceptions about gambling, (b) at mid treatment, to implement cognitive restructuring of dysfunctional beliefs, and (c) at the end of therapy, to

Before the identification of high risk situations with the help of the virtual environment, it is important to prepare the patient for the immersion. As mentioned previously, an evaluation of the user's health condition should be done before using VR. Cybersickness should also be discussed with patients and it is recommended to use a training environment to allow users to feel more comfortable with the equipment. Since the virtual environments induce a desire to gamble, therapists have to inform their patients of this possible consequence. It is also important to discuss the objective of the session with the patient before starting the immersion. Users should be encouraged to express out loud their feelings and thoughts during the immersion. Communication with the user is always possible during immersion in VR and is important to pace the progression of the immersion. However, constant verbal interventions from therapist could make some users feel less present in the virtual environment since it could be a continuous reminder that the situation is not real. Clinicians can use brief questions or 0-10 scales to measure users' desire to gamble, self-efficacy or cybersickness for example. Since the patient in the virtual environment doesn't have a visual contact with his therapist, every

used by mental health professional using their clinical judgment.

**2.3. Illustration of the four sessions of VR immersion in the virtual bar**

questionnaire or scale used should be presented in detail before the immersion.

For this first immersion in VR, 20 minutes should be enough to go through the identified steps in the virtual environment. It is also possible to repeat the user's progression through the environment multiple times. The goal of the session is to detect as many stimuli, behaviors and dysfunctional thoughts associated with situations that represent a high risk of gambling. During the immersion, the therapist says: "*Please behave naturally and say openly what comes through your mind during this visit in the bar. You can describe what you see that triggers the desire to gamble, your thoughts and ideas, your observations, what you would do in such a situation, or it you think of situations you would avoid because you could lose control of your desire to gamble.*" The therapist is encouraged to explore the situation with the patient, ask if some elements could trigger urges (e.g., walking pass an ATM located close to a place where it is possible to gamble, on a payday). The therapist must pay attention to patient's behaviors that would be represen‐

practice relapse prevention techniques.

10 The Thousand Faces of Virtual Reality

*2.3.1. First immersion: Identifying high risk situations*

#### *2.3.2. Second and third immersions: Conducting cognitive restructuring*

It is now time for therapists to exploit VR to challenges patients' dysfunctional beliefs while emotionally aroused. Dysfunctional thoughts contributing to the pathological gambling [2,6,21] fall into two large categories: (a) those about specific maintaining factors underlying pathological gambling and, (b) those about perceived control toward one's own gambling behavior. The second category plays a significant role to maintain pathological gambling but is addressed more thoroughly in the session devoted to relapse prevention [21] and should not be targeted before enough therapy time has been allocated to other maintaining factors. Several erroneous and dysfunctional beliefs are involved in the treatment of gambling addiction [21], including illusory perception of control2 regarding games of chance (e.g., "I have a trick to beat the odds and make money"), gambling as a positive source of pleasure (e.g., "I feel good when I'm playing"), gambling as an effective solution to avoid negative mood (e.g., "Gambling allows me to forget my problems"), facilitating / permissive beliefs (e.g., "It's all right to play today and I'll bet only 20\$"), going to a gambling place to socialize with other gamblers (e.g., "I have fun with other people sharing my passion"), superstitions (e.g., "If I press the button quickly three times I have more chances to win because 3 is a lucky number"), and beliefs specific each game (e.g., for VLT, "This machine is due to pay because it has not been used for a while and the previous player lost a lot of money on it").

The assessment, case conceptualisation and previous therapy sessions, including the first immersion in VR, should have provided the therapist with a good understanding of the specific beliefs that maintain the patients gambling addiction. These beliefs are usually addressed by therapists using traditional cognitive restructuring techniques, which essentially involves helping patients identifying core beliefs and challenging them. Exercises that have been developed for traditional CBT packages [for more information, see 1,6,7,10, 21] can be used during the immersions in the virtual bar. At immersions 2 and 3, the patient is invited to wear the HMD and walk through the nine steps previously explored, until he or she reaches a desire to gamble that is sufficiently strong yet manageable. The therapists can then ask about thoughts that give the urge to gamble, challenge them, and help the patient come with thoughts that give control over the urge to gamble. Dysfunctional thoughts occurring before, during and after typical gambling sessions should be questioned. Because these thoughts are strongly believed in, it will probably take more than one session to counteract all of them, which explains why two sessions are devoted to this step. Exercises to conduct after the immersion are important to continue master the skills of cognitive restructuring and gain confidence in the more adaptive and functional beliefs. Moreover, having the patient emotionally aroused makes it even more difficult to create doubt, revise erroneous beliefs and reframe the situation. Presenting the technique of cognitive restructuring, detailing the key role of dysfunctional thoughts and initiating cognitive restructuring should either be introduce before the immer‐ sion, or *in virtuo* at the first step of the hierarchy, before emotional arousal influences objec‐ tivity. Finally, it is important to underline that cognitive restructuring is not a heated logical debate between the patient and the therapist; it is a set of tool where the therapist constructively guide the patient to develop thoughts reflecting more accurately the realities of gambling and that are in line with their goal of putting an end to pathological gambling. When the session is over, we again encourage the patient to exit the bar and go to the ATM to put back the money in his or her bank account. This is another interesting moment to observe dysfunctional thoughts and behaviors and to foster motivation.

These two immersions are good opportunities for therapists to: (a) have access to emo‐ tions in patients that appear very rational; (b) work on potential situations of denial (e.g., when patients are describing reactions that do not correspond to what is observed *in virtuo*);

<sup>2</sup> Note the distinction between illusion of control towards the possibility to win at a game of chance, which is targeted during immersions 2 and 3, and the illusion of control toward oneself that is addressed during the immersion devoted to relapse prevention.

(c) observe physiological reactions associated with cravings, (d) catch dysfunctional beliefs and behaviors associated with expectations to win; (e) increase perceived self-efficacy to challenges strongly held beliefs when emotions are blurring logical thinking, and (f) tests the believability and strength of alternative more functional beliefs. More than two sessions may be necessary and future research will show what are the most efficient ways to use VR for cognitive restructuring.

#### *2.3.3. Fourth immersion: Practicing relapse prevention techniques*

addiction [21], including illusory perception of control2

12 The Thousand Faces of Virtual Reality

thoughts and behaviors and to foster motivation.

to relapse prevention.

been used for a while and the previous player lost a lot of money on it").

have a trick to beat the odds and make money"), gambling as a positive source of pleasure (e.g., "I feel good when I'm playing"), gambling as an effective solution to avoid negative mood (e.g., "Gambling allows me to forget my problems"), facilitating / permissive beliefs (e.g., "It's all right to play today and I'll bet only 20\$"), going to a gambling place to socialize with other gamblers (e.g., "I have fun with other people sharing my passion"), superstitions (e.g., "If I press the button quickly three times I have more chances to win because 3 is a lucky number"), and beliefs specific each game (e.g., for VLT, "This machine is due to pay because it has not

The assessment, case conceptualisation and previous therapy sessions, including the first immersion in VR, should have provided the therapist with a good understanding of the specific beliefs that maintain the patients gambling addiction. These beliefs are usually addressed by therapists using traditional cognitive restructuring techniques, which essentially involves helping patients identifying core beliefs and challenging them. Exercises that have been developed for traditional CBT packages [for more information, see 1,6,7,10, 21] can be used during the immersions in the virtual bar. At immersions 2 and 3, the patient is invited to wear the HMD and walk through the nine steps previously explored, until he or she reaches a desire to gamble that is sufficiently strong yet manageable. The therapists can then ask about thoughts that give the urge to gamble, challenge them, and help the patient come with thoughts that give control over the urge to gamble. Dysfunctional thoughts occurring before, during and after typical gambling sessions should be questioned. Because these thoughts are strongly believed in, it will probably take more than one session to counteract all of them, which explains why two sessions are devoted to this step. Exercises to conduct after the immersion are important to continue master the skills of cognitive restructuring and gain confidence in the more adaptive and functional beliefs. Moreover, having the patient emotionally aroused makes it even more difficult to create doubt, revise erroneous beliefs and reframe the situation. Presenting the technique of cognitive restructuring, detailing the key role of dysfunctional thoughts and initiating cognitive restructuring should either be introduce before the immer‐ sion, or *in virtuo* at the first step of the hierarchy, before emotional arousal influences objec‐ tivity. Finally, it is important to underline that cognitive restructuring is not a heated logical debate between the patient and the therapist; it is a set of tool where the therapist constructively guide the patient to develop thoughts reflecting more accurately the realities of gambling and that are in line with their goal of putting an end to pathological gambling. When the session is over, we again encourage the patient to exit the bar and go to the ATM to put back the money in his or her bank account. This is another interesting moment to observe dysfunctional

These two immersions are good opportunities for therapists to: (a) have access to emo‐ tions in patients that appear very rational; (b) work on potential situations of denial (e.g., when patients are describing reactions that do not correspond to what is observed *in virtuo*);

2 Note the distinction between illusion of control towards the possibility to win at a game of chance, which is targeted during immersions 2 and 3, and the illusion of control toward oneself that is addressed during the immersion devoted

regarding games of chance (e.g., "I

This session occurs toward the end of the treatment and by then gamblers should already have learned different skills to build their self-efficacy about refraining from gambling. Before this last immersion in VR, the therapist should always verify with their patients if they wants to proceed with the immersion since it will confront them with gambling situations and could induce cravings. The main goal of this immersion is to increase patients' feeling of control over the desire to gamble. Relapse prevention exercises can be practiced in multiple contexts with the virtual environments. In the virtual bar, the user can rate his self-efficacy at any of the nine hierarchy steps in order to determine which situations to choose for the exercise. It is recom‐ mended to pick an easier situation to start with (i.e. where the gambler thinks he could easily resist temptation to engage in the behavioral chain of excessive gambling) and to follow with a more difficult situation (i.e. the gambler believes he would have a hard time resisting urges to gamble). For example, one relapse prevention technique could be to replace thoughts that increase the user's desire to gamble with thoughts that increase his feeling of control over himself in situation [10, 11, 21, 24]. The last session of immersion could also be very helpful for gamblers who believe they still can gamble small amounts of money without losing control. The therapist could allow the patient to virtually gamble 20\$ and encourage him to observe his reactions in this situation. An important arousal or an overwhelming urge to gamble more money could be good indicators for the patient that he can't allow himself to gamble even small amounts without relapsing. The ability of the patient to resist his desire to gamble should be strongly reinforced by the therapist during and after the VR immersion. As it was the case for all other immersions, the immersion should end with the patient walking out of the bar. At this moment, if the user's desire to gamble is still high, more CBT interventions should be proposed. In this context, the virtual environment could also be considered as an assessment tool to verify gambler's readiness to end the treatment. The patient and the therapist can use the last immersion to identify the most appropriate behavioral techniques in different contexts and discuss the gambler's preferred exercises. The advantage of VR is to offer a naturalistic environment to test the skills acquired during the treatment, without actually having to leave the office and go in a place where it is possible to play at games of chance.

A few potential difficulties have been identified from experience with pathological gamblers or *in virtuo* exposure for other disorders. The next section describes these problems and proposes clinical strategies to facilitate the intervention.

### **2.4. Potential problems during immersion and possible solutions**

#### *2.4.1. The patient presents an intense desire to gamble after the immersion*

If the gambler feels an important craving to gamble after leaving the virtual environment, many strategies are available. First, therapists should anticipate this situation and plan their sessions to have enough time after the immersion to complete other interventions (e.g., at least 20 minutes). Sometimes, reviewing previous exercises or discussing other matters less related to gambling is enough to significantly reduce the desire to gamble. During the session, the therapist can also discuss with the patient his motivation to stop gambling and write down the negative consequences of this behaviour in his life. It can also be interesting for the therapist to ask his patient what he usually does when he has an urge to gamble (talking to someone, sports, breathing exercises, reading therapy notes). Finally, if the desire to gamble is still present at the end of the session it might be important to involve other experienced profes‐ sionals (e.g. in a residential facility) or a patient's relative or members of support group (with his permission) to refrain engaging in gambling behaviors.

#### *2.4.2. The patient doesn't want to stop at the different steps and consistently asks to gamble on the VLT*

First, the therapist can disable the possibility to use the VLT by simply unpluging the pushbutton playing interface. Thus, the immersion in the virtual environment can be pursued and if the user sits in front of a VLT to gamble it will not be possible to activate the VLT. Since this strong desire to gamble is very similar to what the patient might face in real-life situations, it is a powerful context for interventions. Thus, it is important that the therapist helps the gambler realize that his craving to gamble and his loss of control over the situation are not virtual. Finally, the emotional arousal of the gambler can be helpful in the identification of high risk situations and erroneous perceptions about gambling. Once the automatic thoughts are identified, the therapist can apply cognitive restructuring to reduce the desire to gamble.

#### *2.4.3. The patient doesn't feel any desire to gamble and is indifferent to the environment*

Some patients have negative appraisals about the use of VR. For example, if the patient keeps telling himself that "it is not real" during the immersion, the possibility to practice *in virtuo* effective interventions is unlikely. Some gamblers might also think that the immersion is a "trap" or a "test". Thus, it is important for the therapist to verify the presence of these automatic thoughts and apply cognitive restructuring if necessary. If the patient is indifferent despite the absence of such automatic thoughts, it can also be helpful to ask the patient to narrate a previous session of gambling before the immersion or while he is in the virtual environment. The therapist can try to induce a desire to gamble with specific questions about favourite games, previous wins, etc… This last strategy should only be used with the patient's permis‐ sion. If the gambler does not want or is not ready to face his desire to gamble, the therapist should respect his decision and focus on other interventions that do not involve VR.

### *2.4.4. The patient is uncomfortable with VR technology*

**2.4. Potential problems during immersion and possible solutions**

14 The Thousand Faces of Virtual Reality

*2.4.1. The patient presents an intense desire to gamble after the immersion*

his permission) to refrain engaging in gambling behaviors.

restructuring to reduce the desire to gamble.

If the gambler feels an important craving to gamble after leaving the virtual environment, many strategies are available. First, therapists should anticipate this situation and plan their sessions to have enough time after the immersion to complete other interventions (e.g., at least 20 minutes). Sometimes, reviewing previous exercises or discussing other matters less related to gambling is enough to significantly reduce the desire to gamble. During the session, the therapist can also discuss with the patient his motivation to stop gambling and write down the negative consequences of this behaviour in his life. It can also be interesting for the therapist to ask his patient what he usually does when he has an urge to gamble (talking to someone, sports, breathing exercises, reading therapy notes). Finally, if the desire to gamble is still present at the end of the session it might be important to involve other experienced profes‐ sionals (e.g. in a residential facility) or a patient's relative or members of support group (with

*2.4.2. The patient doesn't want to stop at the different steps and consistently asks to gamble on the VLT*

First, the therapist can disable the possibility to use the VLT by simply unpluging the pushbutton playing interface. Thus, the immersion in the virtual environment can be pursued and if the user sits in front of a VLT to gamble it will not be possible to activate the VLT. Since this strong desire to gamble is very similar to what the patient might face in real-life situations, it is a powerful context for interventions. Thus, it is important that the therapist helps the gambler realize that his craving to gamble and his loss of control over the situation are not virtual. Finally, the emotional arousal of the gambler can be helpful in the identification of high risk situations and erroneous perceptions about gambling. Once the automatic thoughts are identified, the therapist can apply cognitive

*2.4.3. The patient doesn't feel any desire to gamble and is indifferent to the environment*

should respect his decision and focus on other interventions that do not involve VR.

Some patients have negative appraisals about the use of VR. For example, if the patient keeps telling himself that "it is not real" during the immersion, the possibility to practice *in virtuo* effective interventions is unlikely. Some gamblers might also think that the immersion is a "trap" or a "test". Thus, it is important for the therapist to verify the presence of these automatic thoughts and apply cognitive restructuring if necessary. If the patient is indifferent despite the absence of such automatic thoughts, it can also be helpful to ask the patient to narrate a previous session of gambling before the immersion or while he is in the virtual environment. The therapist can try to induce a desire to gamble with specific questions about favourite games, previous wins, etc… This last strategy should only be used with the patient's permis‐ sion. If the gambler does not want or is not ready to face his desire to gamble, the therapist If the patient is worried by the use of the virtual environment, more time could be needed to answer questions about the equipment or cybersickness, for example. The immersion in the training environment could also last longer to allow the user to navigate comfortably with the equipment.

### *2.4.5. Patient's high risk situations are not reproducible in VR*

Even if the patient's high risk situations are not similar to what is occurring in the virtual environments, an immersion in VR can still be useful. The therapist can encourage the patient to at least try the immersion to verify his feelings in this context. The immersion in the virtual environment could then be presented as a new situation the patient might face one day (e.g. "An old friend asks you to go out at the bar even if you don't usually like going there"). However, in some cases, the relevant gambling stimuli are simply not there in the virtual environment (e.g., for a patient addicted to Poker or other games of cards). In these cases, the immersion may be irrelevant and the therapist has to rely on traditional tools such as imaginal exposure.

#### *2.4.6. The therapist can't help the patient to verbalize his thoughts*

The verbalization of high risk situations and perceptions about gambling is essential in the treatment of pathological gamblers. Therapists who feel less competent with this strategy should consult classical CBT treatment manuals [10, 21, 24] or seek clinical supervision with more experienced professionals.

#### *2.4.7. The patient is hesitant to try the immersion*

Multiple studies have shown that exposure with pathological gamblers can have positive effects. A research by Echeburúa, Báez and Fernández-Montalvo [6] has indicated that an individualized intervention focused on stimulus control with graded *in vivo* exposure was better than cognitive restructuring or the combined use of these two treatment modalities. Two single case studies presented by Symes and Nicki [9] have resulted in considerable reductions in gambling behaviours after a treatment with exposure and response prevention. Therefore, if the patient is hesitant, the therapist must assess his fears, see if they are justified, and either not use VR or reassure the gambler and reframe his worries.

### **3. Using VR with gambling and co-occuring disorders**

The validation study [19] and the pilot clinical trial [20] have indicated that the two virtual environments developed for the treatment of pathological gambling have a therapeutic potential for this specific addiction. Because a significant proportion of gamblers also suffer from substance abuse or dependence problems, the impact of other addictions on gambling behaviours and patients' reaction to stimuli in the environment need to be considered in VR sessions.

The possibility of immersion in VR to induce cravings has been demonstrated for different substances. Virtual environments including specific stimuli have been shown to produce strong cue responses to cigarette [27], alcohol [28], cannabis [29], methamphetamine [30], and crack cocaine [31]. Recent studies have explored the possibility to use VR in the treatment of addictions as well. A research by Bordnick and colleagues [32] assessed the feasibility of VR skills training in a CBT smoking cessation program. Their results show that smokers who completed a VR skills training treatment (in addition of a nicotine replacement therapy) had lower cravings and self-reported smoking than participants who received nicotine replace‐ ment therapy only. Their self-efficacy ratings were also higher after treatment and at followup [32]. These results are promising, but more research is clearly needed to measure VR's efficacy as a tool in the treatment of addictions.

Nevertheless, this study and others show that VR can induce cravings for other addictions, which has two implications for the treatment of gambling: (a) the possibility of gamblers reacting emotionally to cues that are irrelevant to games of chances while in the virtual environment due to co-occurring disorders (e.g., co-occurring alcoholism and seeing an open bottle of beer on a table); and (b) the possibility for skilled therapist to use stimuli irrelevant to games of chance to conduct treatment that either target both gambling and the co-occurring disorder (e.g., practicing relapse prevention skills for gambling while close to a table with an open bottle of beer) or target the treatment of gambling in the context of emotions elicited by a co-occurring disorder.

Because virtual situations are designed to replicate the complex nature of day to day stressors, learning and practicing CBT skills in VR may be more representative of real life situations than in the therapist's office. Naturalistic settings like the virtual bar and casino described in this chapter include various stimuli that are associated with other addictions and could trigger unexpected reactions that are irrelevant to games of chances, such as cravings in people addicted to tobacco (e.g., two people are smoking at the entrance of bar), to alcohol (e.g. there are many open bottles of beer on tables and people drinking), to sex (e.g., the sexy waitress), etc. People suffering from co-occurring disorders unrelated to addictions can also react to cues in the virtual environments, as the virtual bar and casino include people from a variety of ages, skin tone, gender and revenues (which could trigger reactions in people suffering from social phobia or schizophrenia), a cat (e.g., for people suffering from cat phobia), food and people with various body shape (e.g., for people who are dissatisfied with their body image), a dark city atmosphere (e.g., for people suffering from agoraphobia), and an aggressive man hitting his VLT and leaving (e.g., for people suffering from posttraumatic stress disorder). Although these stimuli were not meant to be salient and strong enough to elicit reactions in the user, it is important for therapists to be aware of their existence. Actually, some therapist may even use these environments with people who suffer from a primary disorder other than gambling (e.g., practicing relapse prevention skills for alcohol using the open bottle of beer in the virtual bar, or using the virtual bar for *in virtuo* exposure with a phobic). It is important to recognize the existence of these contextual stimuli. It can help therapists preventing some unexpected reactions in gamblers, but most of all it gives the opportunity to practice CBT skills in settings that resemble complex real life situations.

For the skilled therapist, the existence of stimuli related to other substances or to other mental disorders offer opportunities to practice CBT skills and reinforce gamblers' self-efficacy in more challenging situations. The virtual casino and bar [19,20] offer multiple possibilities for working on multiple targets at the same time. For example, seeing the smokers at the door could provoke a nicotine craving in some patients, or a desire to drink could be induced by the multiple bottles of alcohol and people drinking at the bar. Therapists may have access to more dysfunctional beliefs and observe interactions between the two addictions when people with comorbid pathological gambling and alcoholism are in certain areas of the bar. Being in a virtual bar can facilitate the therapist's task of transferring skills learned with gambling with VLTs to addiction to alcohol. Practicing cognitive restructuring may become more difficult in the presence of several emotional triggers, but also richer in clinical material. Second, patho‐ logical gamblers with comorbid social phobia can work on interpersonal issues by using the virtual characters discussing in the casino. They can also use the proximity and attitude of virtual characters to make relapse prevention exercises more challenging. In these naturalistic contexts, VR presents the advantage of offering standardized environments in multiple declinations to conduct research or tailor exposure to patients' needs. Finally, a better under‐ standing of contextual elements in situations leading to cravings (e.g., seeing signs indicating the presence of a VLT, accessibility of an ATM, seeing other people drinking) could lead to develop stronger CBT skills in pathological gambling and co-occurring disorders.

### **4. Conclusion**

behaviours and patients' reaction to stimuli in the environment need to be considered in VR

The possibility of immersion in VR to induce cravings has been demonstrated for different substances. Virtual environments including specific stimuli have been shown to produce strong cue responses to cigarette [27], alcohol [28], cannabis [29], methamphetamine [30], and crack cocaine [31]. Recent studies have explored the possibility to use VR in the treatment of addictions as well. A research by Bordnick and colleagues [32] assessed the feasibility of VR skills training in a CBT smoking cessation program. Their results show that smokers who completed a VR skills training treatment (in addition of a nicotine replacement therapy) had lower cravings and self-reported smoking than participants who received nicotine replace‐ ment therapy only. Their self-efficacy ratings were also higher after treatment and at followup [32]. These results are promising, but more research is clearly needed to measure VR's

Nevertheless, this study and others show that VR can induce cravings for other addictions, which has two implications for the treatment of gambling: (a) the possibility of gamblers reacting emotionally to cues that are irrelevant to games of chances while in the virtual environment due to co-occurring disorders (e.g., co-occurring alcoholism and seeing an open bottle of beer on a table); and (b) the possibility for skilled therapist to use stimuli irrelevant to games of chance to conduct treatment that either target both gambling and the co-occurring disorder (e.g., practicing relapse prevention skills for gambling while close to a table with an open bottle of beer) or target the treatment of gambling in the context of emotions elicited by

Because virtual situations are designed to replicate the complex nature of day to day stressors, learning and practicing CBT skills in VR may be more representative of real life situations than in the therapist's office. Naturalistic settings like the virtual bar and casino described in this chapter include various stimuli that are associated with other addictions and could trigger unexpected reactions that are irrelevant to games of chances, such as cravings in people addicted to tobacco (e.g., two people are smoking at the entrance of bar), to alcohol (e.g. there are many open bottles of beer on tables and people drinking), to sex (e.g., the sexy waitress), etc. People suffering from co-occurring disorders unrelated to addictions can also react to cues in the virtual environments, as the virtual bar and casino include people from a variety of ages, skin tone, gender and revenues (which could trigger reactions in people suffering from social phobia or schizophrenia), a cat (e.g., for people suffering from cat phobia), food and people with various body shape (e.g., for people who are dissatisfied with their body image), a dark city atmosphere (e.g., for people suffering from agoraphobia), and an aggressive man hitting his VLT and leaving (e.g., for people suffering from posttraumatic stress disorder). Although these stimuli were not meant to be salient and strong enough to elicit reactions in the user, it is important for therapists to be aware of their existence. Actually, some therapist may even use these environments with people who suffer from a primary disorder other than gambling (e.g., practicing relapse prevention skills for alcohol using the open bottle of beer in the virtual bar, or using the virtual bar for *in virtuo* exposure with a phobic). It is important to recognize the existence of these contextual stimuli. It can help therapists preventing some unexpected

sessions.

16 The Thousand Faces of Virtual Reality

efficacy as a tool in the treatment of addictions.

a co-occurring disorder.

In sum, early experiments with two virtual environments have not only allowed our research team to measure the potential of an intervention tool that can induce cravings to gamble, but have also helped therapists discover new possibilities in the treatment of pathological gamblers. Multiple advantages of using immersion in VR have been identified by the therapists after the pilot clinical trial [20]. For example, therapists believed they could access more spontaneous reactions in more "rational" patients. It was also easier for them to access gamblers' emotional reactions and dysfunctional thoughts. Furthermore, the use of VR allowed them to reveal contradictions between patients' expressed ideas and their reactions or behaviours in the virtual environment. According to the therapists, the immersions in VR offered a great opportunity to assess patients' comprehension of new techniques, observe the integration of learned skills and reinforce self-efficacy. In addition, therapists believed immersion in VR allowed gamblers to acknowledge the physiological reactions associated with cravings and to properly evaluate their ability to control their cravings. Finally, therapists believed the use of VR could also eventually facilitate the identification of possible interven‐ tions for co-occurring disorders.

Taken altogether, results of the validation study, the clinical trial and clinicians' observations reveal that the integration of virtual reality in the treatment of pathological gamblers may leads to significant therapeutic improvements. In addition, the available data suggest this modality is innocuous, at least in the context of a residential treatment facility.

More research still needs to be done to assess the true potential of immersion in VR for pathological gamblers. Future studies should measure the efficacy of virtual reality as a treatment tool in different contexts of intervention, such as: (a) in a complete CBT pack‐ age, which includes cognitive restructuring, (b) physiological assessment of gamblers' reactions in high risk situations to identify risk of relapse and the need to pursue treat‐ ment, (c) patients allowed to gamble on the virtual VLTs or slot machines to observe their emotions, thoughts and behaviours, (d) increasing or optimizing the number of immer‐ sions, and (e) exploiting more efficiently the assets of the virtual casino. Future investiga‐ tion could also address questions such as: (a) the difference between the immersive and less immersive version of the virtual environments, (b) the distinction between cybersick‐ ness and physiological signs of craving or withdrawal, (c) the influence of virtual realityrelated variables such as presence, and (d) the systematic integration of cues associated to other addictions. It is important for researchers to understand that virtual reality is not only a treatment tool, but it also offers a standardized and controlled context to conduct research. For example, virtual environments could be used to observe the neurophysiology of gamblers during cravings while using an fMRI scan or measure the impact of alcohol consumption on gambling behaviours.

Finally, the dissemination of virtual environments for psychological intervention is another important concern. First, the costs of the equipment required for the immersive version of the virtual environments need to be considered. Second, proper training is prerequisite to use VR adequately and insure patients' safety. However, the benefits of such technology seem to outweigh its downsides. The control over the stimuli, interest of patients for this new kind of treatment, ease to access emotions, and possibility to work in a context similar to real-life while staying in a safe situation, are all great advantages of using VR with people suffering from pathological gambling.

### **Acknowledgements**

This chapter was made possible thanks to: (a) a grant awarded from the Fondation Mise Sur Toi to the Fondation de l'UQO to support the work from the Cyberpsychology Lab; (b) financial support from the Canada Research Chair in clinical cyberpsychology; (c) from an internal grant from the Centre de réadaptation en dependence de Montréal – IUD; and (d) a scholarship from the Fond de Recherche du Québec en Santé awarded to the second author. The authors wish to thank J. Boulanger, L. Brisson, A.C. Charrette, R. Fraser, L. Laniel, L. Poirier, A. Goulet, P.- M. Fournier, É. Fortin‐Gagnon, and M. Beaulieu for their contribution in the development of the virtual environments and the original version of the treatment manual.

### **Author details**

to significant therapeutic improvements. In addition, the available data suggest this modality

More research still needs to be done to assess the true potential of immersion in VR for pathological gamblers. Future studies should measure the efficacy of virtual reality as a treatment tool in different contexts of intervention, such as: (a) in a complete CBT pack‐ age, which includes cognitive restructuring, (b) physiological assessment of gamblers' reactions in high risk situations to identify risk of relapse and the need to pursue treat‐ ment, (c) patients allowed to gamble on the virtual VLTs or slot machines to observe their emotions, thoughts and behaviours, (d) increasing or optimizing the number of immer‐ sions, and (e) exploiting more efficiently the assets of the virtual casino. Future investiga‐ tion could also address questions such as: (a) the difference between the immersive and less immersive version of the virtual environments, (b) the distinction between cybersick‐ ness and physiological signs of craving or withdrawal, (c) the influence of virtual realityrelated variables such as presence, and (d) the systematic integration of cues associated to other addictions. It is important for researchers to understand that virtual reality is not only a treatment tool, but it also offers a standardized and controlled context to conduct research. For example, virtual environments could be used to observe the neurophysiology of gamblers during cravings while using an fMRI scan or measure the impact of alcohol

Finally, the dissemination of virtual environments for psychological intervention is another important concern. First, the costs of the equipment required for the immersive version of the virtual environments need to be considered. Second, proper training is prerequisite to use VR adequately and insure patients' safety. However, the benefits of such technology seem to outweigh its downsides. The control over the stimuli, interest of patients for this new kind of treatment, ease to access emotions, and possibility to work in a context similar to real-life while staying in a safe situation, are all great advantages of using VR with people suffering from

This chapter was made possible thanks to: (a) a grant awarded from the Fondation Mise Sur Toi to the Fondation de l'UQO to support the work from the Cyberpsychology Lab; (b) financial support from the Canada Research Chair in clinical cyberpsychology; (c) from an internal grant from the Centre de réadaptation en dependence de Montréal – IUD; and (d) a scholarship from the Fond de Recherche du Québec en Santé awarded to the second author. The authors wish to thank J. Boulanger, L. Brisson, A.C. Charrette, R. Fraser, L. Laniel, L. Poirier, A. Goulet, P.- M. Fournier, É. Fortin‐Gagnon, and M. Beaulieu for their contribution in the development of

the virtual environments and the original version of the treatment manual.

is innocuous, at least in the context of a residential treatment facility.

consumption on gambling behaviours.

pathological gambling.

18 The Thousand Faces of Virtual Reality

**Acknowledgements**

Stéphane Bouchard1\*, Claudie Loranger1 , Isabelle Giroux2 , Christian Jacques2 and Geneviève Robillard1


2 Université Laval, Québec, Canada

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20 The Thousand Faces of Virtual Reality

lag.


### **Virtual Reality in Medicine — Going Beyond the Limits**

### Florin Graur

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/59277

**1. Introduction**

In the last years technology had an explosive evolution in the development of new minimal invasive medical instruments and led to a novel need and a brand new field: virtual medicine.

Virtual reality is an "in silico" simulation of a real situation. In particular, in surgery, dimen‐ sional modeling of deformable objects with spatial characteristics and specific elastic-dynamic behavior is required. In addition, simulation of tools and their action against the organs in the virtual environment is also required.

The purpose of virtual medicine is to minimize the direct exploration of the human body in order to provide a virtual model for those who want to learn new techniques and to provide advanced treatment options for those who perform delicate maneuvers or in areas inaccessible by conventional methods: in short to minimize the invasiveness of treatment.

Also a number of virtual techniques tend to be held in the virtual environment of the Internet, allowing remote accessibility and an increased number of users.

This chapter is a literature review that explores the current virtual techniques used in research, education, treatment and development trends of these methods in the future.

### **2. Short history**

First virtual system proposed in medicine was developed by Robert Mann in 1965 [1]. It was used to decide what the best procedure for a orthopedic disease would be. Also this system was used for training residents [2].

In the 60s, the first simulators with 3D images appeared. In the 80s the head mounted display (HDM) were developed and the term "virtual reality" was defined. Over a decade later came

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the application of virtual reality used in medical education (simulator of colonoscopy and upper gastrointestinal endoscopy) and the first simulator for laparoscopy appeared. The simulation systems became more advanced in time, but it was necessary to develop tactile interaction between man and machine. Haptic systems involve the transmission of information from human to computer and vice versa. Virtual reality nowadays is closely linked to haptic devices with force-feedback [2].

### **3. Research methods using virtualization in medicine**

Among research methods using virtual medicine there are a number of examples of software that is used for the three-dimensional reconstruction of protein molecules. Understanding how proteins (whose structure of amino acids is known) are "packed" to reach the three-dimensional structure of the molecule and especially understanding errors of "packing", helps researchers in deciphering the molecular biology of diseases such as: Alzheimer's disease, mad cow disease, Huntington's disease, Parkinson's disease, cystic fibrosis and cancers.

The need for high computing power has led to the creation of online communities such as Rosetta@Home, Human Proteome Folding and Folding@Home. Within these communities an internet user can offer their unused computing capacity of its personal computer to participate in these projects [3-5].

The usefulness of these programs is to understand the physico-chemical properties of different types of proteins and different types of interactions between amino-acids, as well as the evaluation of local energy of short sequences of amino acids. This way the researchers could identify the structures with the lowest energy (i.e., the greatest stability) resulting in the most stable structure of the native protein. Moreover, one can understand the most predictable possibilities of packing for abnormal proteins that can cause diseases. Using computational power of multiple systems generates more structures and several search strategies are tested in order to identify the most effective one.

Foldit game is based on the Rosetta platform. The player or groups of players are able to manipulate the amino acid chain to achieve minimum energy conformations, those that achieve the most favorable energy structure win [6].

Another application helps to identify ways in which a number of drugs bind to a receptor of known 3D structure of a HIV component [7].

### **4. Methods in medical education that utilizes virtualization**

As a method of education, virtual medicine is used in various ways: either to explore the human body, without interacting with the analyzed structures, or by performing maneuvers on simple or complex structures (up to simulate human organs) to quantify gestures.

Satava describes the features of ideal simulator: high fidelity, capacity to simulate the physicdynamic characteristics of organs, to be interactive and to provide haptic feedback [8].

Some examples of the exploration of the human body for anatomical study are: Visible Human Project [9, 10], The Virtual Body [11]; The Virtual Human Embryo [12]; The Visible Human Server [13]. Most of these resources are online atlases of three-dimensional reconstruction images obtained from computerized tomography or MRI. These sites allow interactive navigation and detailed anatomical study of the structures concerned, including relations with other organs.

the application of virtual reality used in medical education (simulator of colonoscopy and upper gastrointestinal endoscopy) and the first simulator for laparoscopy appeared. The simulation systems became more advanced in time, but it was necessary to develop tactile interaction between man and machine. Haptic systems involve the transmission of information from human to computer and vice versa. Virtual reality nowadays is closely linked to haptic

Among research methods using virtual medicine there are a number of examples of software that is used for the three-dimensional reconstruction of protein molecules. Understanding how proteins (whose structure of amino acids is known) are "packed" to reach the three-dimensional structure of the molecule and especially understanding errors of "packing", helps researchers in deciphering the molecular biology of diseases such as: Alzheimer's disease, mad cow

The need for high computing power has led to the creation of online communities such as Rosetta@Home, Human Proteome Folding and Folding@Home. Within these communities an internet user can offer their unused computing capacity of its personal computer to participate

The usefulness of these programs is to understand the physico-chemical properties of different types of proteins and different types of interactions between amino-acids, as well as the evaluation of local energy of short sequences of amino acids. This way the researchers could identify the structures with the lowest energy (i.e., the greatest stability) resulting in the most stable structure of the native protein. Moreover, one can understand the most predictable possibilities of packing for abnormal proteins that can cause diseases. Using computational power of multiple systems generates more structures and several search strategies are tested

Foldit game is based on the Rosetta platform. The player or groups of players are able to manipulate the amino acid chain to achieve minimum energy conformations, those that

Another application helps to identify ways in which a number of drugs bind to a receptor of

As a method of education, virtual medicine is used in various ways: either to explore the human body, without interacting with the analyzed structures, or by performing maneuvers on simple

Satava describes the features of ideal simulator: high fidelity, capacity to simulate the physicdynamic characteristics of organs, to be interactive and to provide haptic feedback [8].

**4. Methods in medical education that utilizes virtualization**

or complex structures (up to simulate human organs) to quantify gestures.

**3. Research methods using virtualization in medicine**

disease, Huntington's disease, Parkinson's disease, cystic fibrosis and cancers.

devices with force-feedback [2].

24 The Thousand Faces of Virtual Reality

in these projects [3-5].

in order to identify the most effective one.

known 3D structure of a HIV component [7].

achieve the most favorable energy structure win [6].

Three-dimensional reconstruction of intracellular organelles for a better understanding of physiology is another area in which the research was conducted, allowing visualization of how these structures interact [14].

Rapid development of laparoscopic techniques require the implementation of special training and acquisition of special technical skills. Design and modeling of three-dimensional virtual environments that respect the anatomy and intraoperative conditions require close collabora‐ tion between dedicated surgeons and engineers in order to develop such platforms. The virtual environment is connected to a console that allows the surgeon to manipulate the virtual instruments through a dedicated joystick. Also some devices use a system for haptic feedback simulation. Simulation is now an integrated part of medical education. These simulators allow the trainee to make mistakes and to learn how to avoid or to solve them, in order to reduce complications in the real procedures.

Of these simulators the best known are: MIST-VR, The LaparoscopyVR [15]; LapMentor [16]; LapSim [17].

MIST-VR system allows the surgeon's training in a virtual space assimilated to a three dimensional cube where the student can perform different moves with a cylinder and balls and the difficulty can be graded in 6 steps. The time to accomplish the tasks as well as the errors are quantified. The system is used to learn simple gestures in laparoscopic surgery, but does not have force-feedback [18].

The surgical simulator LaparoscopyVR (LapVRTM) is a virtual reality simulation system that enables learning and updating skills needed in laparoscopic surgery. The LapVRTM system combines laparoscopic simulation software with haptic hardware, providing a complete unit for the virtual reality training. LapVRTM was designed to help surgeons in acquiring, main‐ taining, preserving and assessing movement skills and knowledge necessary to perform various laparoscopic surgery procedures. Clinical studies show that novice surgeons trained by laparoscopic simulation have skills that help them in real procedures. LapVRTM system allows both individual and team training and provides a basic technical module composed of five skills steps with increasing levels of difficulty: camera navigation, using the hook elec‐ trode, cutting, clipping, suturing and knot tying. The system also contains a module for laparoscopic cholecystectomy with 18 variants of cases and three levels of difficulty as well as one of obstetrics and gynecology that allows simulation of laparoscopic operations performed for ectopic pregnancy, tubal occlusion and adnexa's pathology [12].

Multidisciplinary laparoscopic surgical simulator LapMentorTM provides training opportuni‐ ties for beginners and experienced surgeons from basic laparoscopic skills to complete laparoscopic operations. LapMentorTM was designed to meet the needs of training and practice of physicians as well as the assessment and management of their instructors. The system is characterized by life-like view of human anatomy and perception of tactile sensations using laparoscopic instruments that mimic reality (haptic system). Application modules provide a relaxing environment outside the operating room to help learning essential skills for a variety of laparoscopic procedures: basic techniques module, suturing module, laparoscopic chole‐ cystectomy module, ventral hernia module, gastric bypass module and gynecology module. The basic techniques module was designed to train surgeons in basic skills in minimally invasive procedures: camera navigation (with 0º and 30º laparoscope), handling of usual instruments, manipulating objects, clipping and cutting. Suture techniques module allows surgeons to learn intracorporeal suturing and knot tying, providing a perfect training envi‐ ronment similar to real-life practice. Laparoscopic cholecystectomy module includes virtual patient reconstructions obtained from CT / MRI images of real patients with multiple ana‐ tomical variants and thus training surgeons in recognition of anatomical variants and suc‐ cessful resolution of surgical complications. The Ventral hernias module represents the first opportunity to train surgeons with skills necessary to perform laparoscopic hernia repair procedures and inserting prostheses of different shapes and sizes. The gastric bypass module helps surgeons accustomed with basic laparoscopic surgery in learning, performing and perfecting stages of this bariatric procedure in a safe and monitored environment. The gynecological laparoscopic module trains surgeons in learning different methods applied in the treatment of ectopic pregnancy, tubal sterilization and adnexal disease. Videos of all laparoscopic interventions are available before or during simulation. The skills and knowledge acquired during the virtual training increases surgeon's experience, allowing them to cope with intraoperative complications, such as: bleeding from the implantation site of trocars, organ rupture, flooding the abdominal cavity with blood. LapMentorTM system provides all the elements necessary to validate acquired skills and recorded performances. Detailed information on handling tissue, handling tools, time and movements efficiency are collected during the training session to allow evaluation of the level of skill. Performance indicators are recorded in a file and can be viewed on simulator [19].

LapSimTM system provides a virtual environment very similar to the real one as well as extremely useful simulations for common practice. The skills acquired through this system are directly transferable to the operating room. The interface is easy to use and practical sessions vary in complexity depending on the chosen level. Courses can be modified by an instructor according to specific needs. Functions can be imported and exported to be transferred between instructors and institutions. Standard modules of this system are: the basics skills, anastomosis and suture, laparoscopic cholecystectomy and one dedicated to gynecology [14].

SINERGIA is a new type of simulator for laparoscopic surgery composed of seven teaching modules: eye-hand coordination, handling the camera, grasping, pulling, cutting, dissection and section. It also can achieve differentiation between levels of student skills. Yet, even this simulator does not have an integrated haptic system [20].

Compared to physical simulators (artificial or animal model), virtual simulators stimulate the learner to perform all duties listed and evaluated by software, it does not require the presence of a permanent trainer to verify the correctness of performing the tasks and evaluates more accurate the gestures of the surgeon. Virtual systems for surgical training can be used for assessing the competence of the surgeon. In addition, warm-up concept can bring increased surgical performance. This concept allows the warm-up by making virtual preoperative procedure and later, the surgeon will perform the actual procedure. To improve this concept for preoperative phase in virtual environment, three-dimensional reconstructions created from CT of the patient to be operated can be used, thus simulating more accurately the patient's own anatomical variations in the virtual environment.

of physicians as well as the assessment and management of their instructors. The system is characterized by life-like view of human anatomy and perception of tactile sensations using laparoscopic instruments that mimic reality (haptic system). Application modules provide a relaxing environment outside the operating room to help learning essential skills for a variety of laparoscopic procedures: basic techniques module, suturing module, laparoscopic chole‐ cystectomy module, ventral hernia module, gastric bypass module and gynecology module. The basic techniques module was designed to train surgeons in basic skills in minimally invasive procedures: camera navigation (with 0º and 30º laparoscope), handling of usual instruments, manipulating objects, clipping and cutting. Suture techniques module allows surgeons to learn intracorporeal suturing and knot tying, providing a perfect training envi‐ ronment similar to real-life practice. Laparoscopic cholecystectomy module includes virtual patient reconstructions obtained from CT / MRI images of real patients with multiple ana‐ tomical variants and thus training surgeons in recognition of anatomical variants and suc‐ cessful resolution of surgical complications. The Ventral hernias module represents the first opportunity to train surgeons with skills necessary to perform laparoscopic hernia repair procedures and inserting prostheses of different shapes and sizes. The gastric bypass module helps surgeons accustomed with basic laparoscopic surgery in learning, performing and perfecting stages of this bariatric procedure in a safe and monitored environment. The gynecological laparoscopic module trains surgeons in learning different methods applied in the treatment of ectopic pregnancy, tubal sterilization and adnexal disease. Videos of all laparoscopic interventions are available before or during simulation. The skills and knowledge acquired during the virtual training increases surgeon's experience, allowing them to cope with intraoperative complications, such as: bleeding from the implantation site of trocars, organ rupture, flooding the abdominal cavity with blood. LapMentorTM system provides all the elements necessary to validate acquired skills and recorded performances. Detailed information on handling tissue, handling tools, time and movements efficiency are collected during the training session to allow evaluation of the level of skill. Performance indicators are

LapSimTM system provides a virtual environment very similar to the real one as well as extremely useful simulations for common practice. The skills acquired through this system are directly transferable to the operating room. The interface is easy to use and practical sessions vary in complexity depending on the chosen level. Courses can be modified by an instructor according to specific needs. Functions can be imported and exported to be transferred between instructors and institutions. Standard modules of this system are: the basics skills, anastomosis

SINERGIA is a new type of simulator for laparoscopic surgery composed of seven teaching modules: eye-hand coordination, handling the camera, grasping, pulling, cutting, dissection and section. It also can achieve differentiation between levels of student skills. Yet, even this

Compared to physical simulators (artificial or animal model), virtual simulators stimulate the learner to perform all duties listed and evaluated by software, it does not require the presence of a permanent trainer to verify the correctness of performing the tasks and evaluates more accurate the gestures of the surgeon. Virtual systems for surgical training can be used for

and suture, laparoscopic cholecystectomy and one dedicated to gynecology [14].

recorded in a file and can be viewed on simulator [19].

26 The Thousand Faces of Virtual Reality

simulator does not have an integrated haptic system [20].

The VERT system is a virtual environment used in the training of radiotherapy physician and provides a platform for acquiring the skills necessary for doctors, nurses and auxili‐ ary staff [21, 22].

VirRAD project is an online platform that includes a virtual laboratory where the radiophar‐ macy community members can experience and learn different aspects of practice [23].

A team from the United States has developed a virtual learning system used for EndoStitch device suture learning and performing laparoscopic nodes. It includes in addition to the virtual environment a working console and a haptic feedback [24].

The usefulness of virtual medicine as a diagnostic method is exemplified through a relatively known example: virtual colonoscopy. This examination allows inspection of virtual colonic lumen obtained using three-dimensional reconstruction based on computed tomography images acquired from a patient. The range of examinations is currently expanded to virtual gastrointestinal exploration, three-dimensional assessment of vascular lumen-especially if coronary obstruction. Also the new geometry of the damaged heart wall after a myocardial infarction could be explored.

For intravenous catheter insertion, CathSim system was developed, that provides the student, besides the virtual environment, with a working console with tactile feedback and a series of simulations of complications that may occur during the real procedure [25].

A large number of simulators were developed for: endoscopic sinus surgery, endoscopic gastrointestinal procedures, bronchoscopy, arthroscopy, cardiac catheterization and ophthal‐ mic surgery [26-29].

By integrating knowledge in the field of acupuncture and three-dimensional reconstruction based on images obtained from computer tomography, Chinese Visible Human was created, which is useful in education and research in Chinese medicine [30].

In dentistry there are 3D models of teeth or of an entire human head simulating the details of anatomy of the teeth or mouth. The trainee could perform drills having a haptic feedback. Also a Virtual Reality Dental Chair system (HapTEL) enables the trainee to test and learn various skills [31].

### **5. Methods of diagnostic and treatment using virtualization in medicine**

There are a number of softwares for three-dimensional reconstruction of organs using 3D ultrasound images or 4D CT or MRI images, acquired for a more accurate evaluation of diseases. Some software even allows a simulation of the proposed intervention thus achieving preoperative planning.

During remote interventions, the surgeon acts on a virtual environment, the operation itself is performed by a surgical robot. This kind of procedure was performed in September 7, 2001 and was called "Lindbergh operation" during which Professor J. Marescaux located in Strasbourg performed a laparoscopic cholecystectomy on a patient who was in New York (at a distance of approx. 15000 km) using a ZEUS robot (Computer Motion), the surgeon's presence being virtual [32].

The utility of this technology is to use the expertise of a specialist at a great distance (i.e. space station) to perform surgery (telemedicine) or to help a less experienced surgeon during interventions with high difficulty (telementoring).

The use of robots in surgery allows more accurate movements, avoiding surgeon's tremor, smaller incisions, decreased blood loss, quicker postoperative recovery, etc.

The new models of modified DaVinci robot uses three-dimensional immersion type image, allowing detailed visualization of the operative field, besides haptic feedback [33].

Virtual reality refers not only to virtualization of visual perception but also to virtualization of tactile perception, the touch feeling being essential in surgery. Haptic systems are designed as a virtual environment for the sense of touch, allowing artificial tactile perception of objects created in the virtual environment or of real objects touched by surgical robot, the sensations being transmitted to the interface with the surgeon.

VerroTouch system is an extension of DaVinci robot proposed by Kuchenbecker et al [34] which makes transfer of vibrations measured by surgical instruments attached to the robotsurgeon interface, allowing haptic sensation to the operator.

Augmented reality facilitates surgical intervention by projecting in the operative field inner images of the organs located in the visual field. These images are obtained by three-dimen‐ sional reconstruction from CT or MRI after acquisition and processing. The projected images are adjusted according to the position of organs, instruments and actions of the surgeon in the operating field. For example, large intrahepatic vessels can be projected on the surface of the liver capsule, showing a useful map to the surgeon in order to avoid injuries. This is called also "intraoperative navigation" and it shows the surgeon where he can find important elements and also the anatomic variations.

Navigation systems have been proposed for NOTES (Natural Orifice Transluminal Endoscopic Surgery) surgery [35, 36] which reduce intraoperative accidental injuries. It uses threedimensional reconstruction from images captured by CT and data of real-time location of the endoscope. The main problem with augmented reality is identifying common reference points of real images and of those obtained by preoperative three-dimensional reconstruction. Augmented reality is very useful during minimally invasive interventions, where the visual field is diminished and thus the orientation of the surgeon in the operating field is hampered.

The current systems of virtual reality and augmented reality fail to perfectly simulate the interaction between surgical instruments and organs. In the future, the researchers aim to improve the interaction between surgeon and interface with the virtual system, getting feedback for surgeons, synchronization of virtual reality with operative field, etc.

diseases. Some software even allows a simulation of the proposed intervention thus achieving

During remote interventions, the surgeon acts on a virtual environment, the operation itself is performed by a surgical robot. This kind of procedure was performed in September 7, 2001 and was called "Lindbergh operation" during which Professor J. Marescaux located in Strasbourg performed a laparoscopic cholecystectomy on a patient who was in New York (at a distance of approx. 15000 km) using a ZEUS robot (Computer Motion), the surgeon's

The utility of this technology is to use the expertise of a specialist at a great distance (i.e. space station) to perform surgery (telemedicine) or to help a less experienced surgeon during

The use of robots in surgery allows more accurate movements, avoiding surgeon's tremor,

The new models of modified DaVinci robot uses three-dimensional immersion type image,

Virtual reality refers not only to virtualization of visual perception but also to virtualization of tactile perception, the touch feeling being essential in surgery. Haptic systems are designed as a virtual environment for the sense of touch, allowing artificial tactile perception of objects created in the virtual environment or of real objects touched by surgical robot, the sensations

VerroTouch system is an extension of DaVinci robot proposed by Kuchenbecker et al [34] which makes transfer of vibrations measured by surgical instruments attached to the robot-

Augmented reality facilitates surgical intervention by projecting in the operative field inner images of the organs located in the visual field. These images are obtained by three-dimen‐ sional reconstruction from CT or MRI after acquisition and processing. The projected images are adjusted according to the position of organs, instruments and actions of the surgeon in the operating field. For example, large intrahepatic vessels can be projected on the surface of the liver capsule, showing a useful map to the surgeon in order to avoid injuries. This is called also "intraoperative navigation" and it shows the surgeon where he can find important

Navigation systems have been proposed for NOTES (Natural Orifice Transluminal Endoscopic Surgery) surgery [35, 36] which reduce intraoperative accidental injuries. It uses threedimensional reconstruction from images captured by CT and data of real-time location of the endoscope. The main problem with augmented reality is identifying common reference points of real images and of those obtained by preoperative three-dimensional reconstruction. Augmented reality is very useful during minimally invasive interventions, where the visual field is diminished and thus the orientation of the surgeon in the operating field is hampered. The current systems of virtual reality and augmented reality fail to perfectly simulate the interaction between surgical instruments and organs. In the future, the researchers aim to

smaller incisions, decreased blood loss, quicker postoperative recovery, etc.

allowing detailed visualization of the operative field, besides haptic feedback [33].

preoperative planning.

28 The Thousand Faces of Virtual Reality

presence being virtual [32].

interventions with high difficulty (telementoring).

being transmitted to the interface with the surgeon.

elements and also the anatomic variations.

surgeon interface, allowing haptic sensation to the operator.

Virtual reality can be very useful in bridging the gap between food and social behavior of patients with diabetes and/or obesity and the rules that they should follow. The software allows interaction with virtual environments that simulate both video and tactile sensations and other sensations (smell, taste). Patients can learn new habits such as the amount of food they should ingest, food choices and given encouragement to perform physical activities. Also in people with heart disease or morbid obesity it may stimulate performing progressive physical activity at home, even by increasing motivation.

Another direction in which virtual medicine interferes with spectacular results is the treatment of phobias. The patient is connected to a virtual environment that simulates situations that produce phobic states, everything being controlled and can be interrupted at any time of the simulation [37]. Phobias treated with such reality simulation programs are: post-traumatic stress, public speaking, arachnophobia, agoraphobia, acrophobia, claustrophobia, panic, social phobia, stress secondary vehicle crush accidents etc. [38]. A number of applications have also been developed, dedicated to various phobias or posttraumatic stress syndromes (Virtual Iraq/ Afghanistan, Virtual Airplane, Virtual Nicotine, Virtual Elevator, Hurricane Katrina Virtual, Virtual World Trade Center and Virtual Vietnam) [39]. Virtual Iraq / Afghanistan is used in more than 60 clinics and has demonstrated efficacy in reducing symptoms of posttraumatic stress [40].

STRIVE (Stress Resilience in Virtual Environments) is an application that is used to adapt future soldiers to fight stress. The body reactions to stress are described to the soldier and also he can learn how to cope with this stress [40].

VirtualPatients is an application used for the clinician involved in the learning process and interaction with the patient [40].

For trypanophobia treatment (fear of needles) a system with two lenses was developed which shows images to the patient. It can project different scenarios such as a visit to a health center where a nurse shall pick a blood sample. The whole system also provides feedback on the mental and emotional reactions [41].

To help patients with disabilities, along with dedicated systems which allow the patients to learn how to use wheelchairs in crowded cities, he can also use Second Life type virtual environments, where through an avatar, these patients can interact with others without the limitations encountered in the real world [42].

To avoid animal experiments there were developed digital models of rats, pigs and humans. For example, a virtual pig head [41] and also a model of a physiological rat [43] was developed, in order to use these models in virtual experiments.

Three-dimensional virtual reality combined with haptic feedback is used for motor recovery of patients with stroke sequelae. This technology is currently used in experimental studies, but it might extend in recovery clinics and even at home recovering. There are commercial systems used for related purposes with the ability to develop complex movements of the hand. These applications provide an assessment of movements and skills acquired in order to follow-up the evolution of these patients [44, 45].

A new area of research with direct implications in the therapy is currently developing: virtual rehabilitation. Also looming as a subdomain, virtual tele-rehabilitation allows the therapist to interact with the patient through a 3D avatar and guide them during therapy sessions. Haptic systems attached to such systems allow the doctor to examine the patient's muscle tone [46, 47].

Another application is the virtual prototyping technology that combines virtual modeling with rapid prototyping in order to be used in biomedical engineering (eg. for the development of prosthetic or medical devices) [48, 49].

### **6. Ethics in virtual reality medicine and telemedicine**

The rapid evolution of virtual reality and telemedicine may result in overcoming limits, more so in this area as yet there are no law or ethics rules. As the interactions between people from different countries become more and more globalized, the implementation of ethical codes should be considered. .

Implementation of very expensive virtual reality and augmented reality systems for use in therapy can create disparities in specialist's presence who will migrate toward the best equipped centers. Also there will be an imbalance in patients addressability, which also would prefer clinics with superior performance [50, 51].

Training therapists in centers with the possibility of using virtual reality will also be more efficient and also preoperative simulations leading to superior results. These issues are already visible in Eastern European countries with subfinanced health systems, where both patients and physicians migrate to Western European states.

Funding the development of such performant systems of virtual reality and telemedicine is not currently covered by health systems or government agencies but more often through projects or private sponsorships. These facts may lead to impairing of projects on longterm [52].

As virtual systems will gain autonomy in different degrees, the responsibility of creators and users of these systems will increase. There is currently no legislation to use autonomous robots or virtual systems. There arises the problem of such systems errors and who will be punished for them.

Some cultural and social problems may occur in telemedicine. Because the distance between doctor andpatient,the latter canbe reducedto amere "beneficiary" or, worse,"data source" [53].

Differences between health legislations in different countries may lead to situations such as: doctor without a license in a country may provide remote treatment in another country; some illegal procedures (cloning, abortion) in a country can be remotely performed in another country where they are allowed. These differences can lead to self-limitation of experts performing remote therapies in countries where laws are not familiar. It is therefore necessary to implement a symmetric legislation.

Storing data in information systems can lead to loss of confidentiality with repercussions on both the patient and the service providers.

Patients are usually informed of these systems by mass-media (stimulated by the industry) and these information is incomplete or insufficient.

### **7. Future directions**

applications provide an assessment of movements and skills acquired in order to follow-up

A new area of research with direct implications in the therapy is currently developing: virtual rehabilitation. Also looming as a subdomain, virtual tele-rehabilitation allows the therapist to interact with the patient through a 3D avatar and guide them during therapy sessions. Haptic systems attached to such systems allow the doctor to examine the patient's muscle tone [46, 47].

Another application is the virtual prototyping technology that combines virtual modeling with rapid prototyping in order to be used in biomedical engineering (eg. for the development of

The rapid evolution of virtual reality and telemedicine may result in overcoming limits, more so in this area as yet there are no law or ethics rules. As the interactions between people from different countries become more and more globalized, the implementation of ethical codes

Implementation of very expensive virtual reality and augmented reality systems for use in therapy can create disparities in specialist's presence who will migrate toward the best equipped centers. Also there will be an imbalance in patients addressability, which also would

Training therapists in centers with the possibility of using virtual reality will also be more efficient and also preoperative simulations leading to superior results. These issues are already visible in Eastern European countries with subfinanced health systems, where both patients

Funding the development of such performant systems of virtual reality and telemedicine is not currently covered by health systems or government agencies but more often through projects or private sponsorships. These facts may lead to impairing of projects on long-

As virtual systems will gain autonomy in different degrees, the responsibility of creators and users of these systems will increase. There is currently no legislation to use autonomous robots or virtual systems. There arises the problem of such systems errors and who will be punished

Some cultural and social problems may occur in telemedicine. Because the distance between doctor andpatient,the latter canbe reducedto amere "beneficiary" or, worse,"data source" [53].

Differences between health legislations in different countries may lead to situations such as: doctor without a license in a country may provide remote treatment in another country; some illegal procedures (cloning, abortion) in a country can be remotely performed in another country where they are allowed. These differences can lead to self-limitation of experts

the evolution of these patients [44, 45].

30 The Thousand Faces of Virtual Reality

prosthetic or medical devices) [48, 49].

prefer clinics with superior performance [50, 51].

and physicians migrate to Western European states.

should be considered. .

term [52].

for them.

**6. Ethics in virtual reality medicine and telemedicine**

Development of virtual reality in medicine aims in the following directions: increasing fidelity in order to reproduce the reality, haptic systems integration in the usual simulators and surgical robots, identifying new standards for evaluating student performance, expanding the use of simulators in the educational field, research and therapy. Virtual reality is likely to become the most common method of learning and training young surgeons and also for senior surgeons to acquire new skills [2].

The researchers also seek solutions to lower the costs of information systems and especially with force feedback haptic devices, but its price makes them prohibitive for general use.

A new direction is predicted, combining virtual reality with holographic projection which would improve the three-dimensional vision.

The combination of autonomous systems with virtual reality will be able to step into the future for autonomous surgical robots, autonomous systems for rehabilitation of people with disabilities, autonomous educational systems and complex software for virtual research.

### **8. Conclusion**

The spectrum of applications of virtual reality in medicine widens permanently and it is developing in various unexpected directions. The contribution of IT support in the develop‐ ment of medicine is huge but the possibilities and applications that will shape the future of medicine are still unknown.

Virtual reality finds its applications in various fields and its usefulness becomes more pre‐ dominant in training, preoperative evaluation and preparation of surgeons. Learning with virtual simulators increases the dexterity of the surgeons and reduces the number and severity of intraoperative complications. Also, in computer-assisted research, virtual reality brings benefits that other methods could not reach. Various models are developed for research purposes at different levels, from macro-models to micro-or even nano-levels allowing researchers to perform "in silico" experiments more rapidly and more cheaply.

The combination of virtual reality with the power of multiple computers as in online com‐ munities enhances the speed of research to a level otherwise unachievable at this time.

The use of virtual reality in the diagnosis and especially in treatment of certain diseases, widens the range of therapeutic procedures, increases operator safety, patient compliance and reduces the duration of applied treatment. Virtual environments used to treat phobias could not be achieved by any other means, leading to a unique mode of treatment in this field.

Using robot technology as well as telemedicine and telementoring systems will increase surgical accuracy and will reduce hospitalization and complications and on the other hand will increase medical expertise in disadvantaged areas or with difficult access (including inaccessible areas for experts: stations space, underwater).

As in all newly developed fields, the virtual reality domain needs some sound rules to be applied during its use, in order to avoid mistakes and/or injuries, especially in the field of diagnostics and therapeutics.

### **Author details**

Florin Graur1,2\*

Address all correspondence to: graurf@yahoo.com

1 University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Romania

2 Regional Institute of Gastroenterology and Hepatology "Octavian Fodor" Cluj-Napoca, Romania

The author has no conflict of interest.

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The use of virtual reality in the diagnosis and especially in treatment of certain diseases, widens the range of therapeutic procedures, increases operator safety, patient compliance and reduces the duration of applied treatment. Virtual environments used to treat phobias could not be

Using robot technology as well as telemedicine and telementoring systems will increase surgical accuracy and will reduce hospitalization and complications and on the other hand will increase medical expertise in disadvantaged areas or with difficult access (including

As in all newly developed fields, the virtual reality domain needs some sound rules to be applied during its use, in order to avoid mistakes and/or injuries, especially in the field of

achieved by any other means, leading to a unique mode of treatment in this field.

1 University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Romania

2 Regional Institute of Gastroenterology and Hepatology "Octavian Fodor" Cluj-Napoca,

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Address all correspondence to: graurf@yahoo.com

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