➣ By Mark D. Wiederhold & Brenda K. Wiederhold
The combined use of virtual reality (VR) and medication is an emerging technique that has been gaining public notice. Clinical psychologists and neuroscientists have been studying this approach for the treatment and/or management of various types of medical conditions. These include chronic pain management, anxiety relief, and trauma recovery. Some studies have also shown the usefulness of VR as a tool for information dissemination and for the testing of new pharmaceutical products. Several pharmaceutical companies have used VR to educate individuals about a mental health disorder, patient’s perspective and state of mind. These companies then taught participants how medication may help with alleviating symptoms.
In a study by Schmitt et al. (2011) on using virtual reality exposure therapy (VRET) for analgesia/pain reduction in pediatric patients who have to undergo physical therapy for burn injuries, they found that the patients responded positively to VRET for pain reduction. The patients with VRET during physical therapy had reported significantly reduced pain sensation than the control group (patients who were not given VRET during physical therapy). Furthermore, both groups showed equivalent or comparable increase in range of motion, regardless of whether they were treated with VRET or not. Thus, this shows that VRET can be used in conjunction with physical therapy to relieve pain without any detriment to the patients’ physical recovery. Another interesting point in this study is that the level of analgesia experienced by patients during physical therapy with VRET did not diminish over time. Instead, the pain relief provided by VRET remained constant throughout the entire duration of the study.
VRET has been used to manage anxiety disorders over the last two decades by providing visual, auditory and kinesthetic stimulation. VRET places patients in a computer-generated world where they “experience” the various stimuli related to their fear or phobia. Its effectiveness in the treatment of multiple anxiety disorders has been established in controlled studies which have been replicated by researchers worldwide.
The benefits of pharmaceutical drugs such as selective serotonin re-uptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), beta-blockers, and other anxiolytic medications for the treatment of anxiety disorders have long been established. However, many recent studies have shown the increased effectiveness of combining medication therapy with cognitive behavioral therapy (including VRET) to teach the patient an alternative way of managing his or her symptoms while medication is reduced (or completely discontinued). Using VRET is ideal for testing the effectiveness of the medication since it allows systematic stimuli to be administered to the patient in a controlled clinical setting.
In a study published in March 2011 in the Proceedings of the National Academy of Sciences (PNAS), de Quervain et al. reported on combined VRET and hormonal therapy (cortisol) in treating acrophobia (fear of heights). The results indicated that cortisol enhanced the effects of the VRET. The patients who received cortisol together with VRET showed significantly greater reduction in anxiety and fear compared to patients who received placebo. The overall anxiety and fear reduction was seen both right after the treatment (post-treatment) and at a follow-up assessment done after one month of the procedure being conducted.
Patients undertaking treatment due to a fear of driving or PTSD due to a motor vehicle accident have responded positively to VR treatments while on medication therapy. If patients become nauseous within 90 to 120 seconds after the commencement of VR treatment, they are referred to a vestibular specialist to determine if there is a vestibular abnormality. In many instances, patients who feel nauseous 90 to 120 seconds after VR therapy starts do have vestibular abnormalities. If patients choose to continue with the VR therapy sessions, they can opt to take anti-nausea drugs such as dimenhydrinate (Dramamine) or ondansetron (Zofran) prior to VR therapy without diminishing the therapeutic benefits obtained from the treatment.
Other studies have also documented the use of beta-blockers and anxiolytic drugs in conjunction with VRET as effective treatments/therapies for glossophobia (fear of public speaking), aerophobia (fear of flying), and claustrophobia (fear of closed or narrow spaces).
Posttraumatic Stress Disorder (PTSD)
Apart from enhancing the effects of certain medications, the combined use of VR and pharmaceutical drugs has been utilized for the treatment of PTSD and so far has shown no negative effects in the general well-being of the patients. Veterans of the Iraq and Afghanistan wars (suffering from both PTSD and chronic pain) who were undergoing VRET treatment while on medication did not manifest any adverse reactions after the use of VRET.
In one study, VRET was utilized to reduce the retrieval of aversive memories in PTSD. By administering adrenaline along with glucocorticoids, which enhance the formation of new memories for emotionally arousing events, researchers were able to impair the memory retrieval processes. This seems to be effective in the reduction of excessive retrieval of traumatic/aversive memories, and consequently in the reduction of the re-experiencing or reliving of traumatic memories.
In another Virtual Reality Medical Center (VRMC) study conducted at Balboa Naval Hospital and Camp Pendleton (both in CA, USA), the VRET for PTSD symptoms proved successful in 80% of participants. Many of the individuals treated with VRET required medication in addition to therapy, but the medication did not diminish their ability to fully engage in and receive therapeutic benefits from VRET.
Eating Disorders and Obesity
In a preliminary study conducted by Riva et al. (2001), the researchers assessed the feasibility of using VR for the treatment of body image issues of obese patients and found that patients who were treated using VR showed better body satisfaction and motivation for change than patients who were treated with the cognitive-behavior approach. While this study spanned only a short period of time, the promising results can be explored further to improve and develop VR treatments for the psychological and mental state of obese patients who are trying to become more fit and lose weight.
The FDA has recently approved several new drugs to combat obesity and eating disorders. Many studies have shown that weight loss medication when combined with cognitive behavioral therapy-based interventions dramatically improves adherence and success. Virtual environments offer an enhanced venue for the delivery for CBT-based protocols and may prove extremely useful when combined with these new pharmacological agents.
Test bed for New Medications and Medical Technologies
VR can also be used to test the effects of certain medications prior to release. This nascent field is on the rise for increasing the efficacy of combined treatment. Using VR, the precise stimulus is isolated. It is relatively simple to add physiological monitoring and analyze the patient’s objective response as well as asking for their subjective ratings. This technique is a perfect test bed for observing patients’ emotional and physical state. With the addition of fMRI technology, we can see the precise effect medication is having on an individual while navigating a stressful, relaxing, or rehabilitating environment, which will help to better tailor drug delivery and allow for more individualized care.
Cognitive Effects of Medications Already on the Market
Another use of VR is to test the possible side effects of medications which have already been released on the market. While manufacturers and physicians generally advise patients to avoid certain activities (e.g. driving) while taking specific medications, the actual side effects of these medications have not been tested on humans. VR allows testing of these drugs’ effects in a safe and controlled clinical setting.
In recent years, there has been a heightened interest among researchers and clinicians in using VR technology to address additional driving-related issues. One study led by R. Mager evaluated a driving simulator using a motorway test-track to investigate the impact of a single oral dose of the SSRI sertraline on various cognitive functions related to driving tasks and objective driving performance. Results showed no evidence of drug-induced impairment of drivability in the simulator.
Another study examined 37 adults with Type I diabetes and their ability to drive in VR driving simulation tests. Researchers manipulated participants’ blood glucose levels by giving them an intravenous insulin solution containing various amounts of sugar. At all three ranges of hypoglycemia, driving performance was found to be significantly impaired. Participants were more likely to swerve, brake inappropriately, and speed up in comparison to when their glucose levels were within normal limits. Even more surprising, less than 1/4 of the participants realized that their driving was impaired, while only 1/3 took corrective action by drinking soda or stopping driving, and most did not do so until their glucose levels were below 50 mg/dL. Non-invasive sensors were used to measure the patients’ blood glucose levels accurately during the task. By providing precise stimuli and measuring the participants’ reactions, more definitive results of the effect of medications were ascertained.
In another study, researchers at VRMC in San Diego enlisted 24 participants to compare the effects of three antihistamines: fexofenadine, loratadine, and cetirizine. At the beginning of each session, participants were given either one of the antihistamines or a sugar pill (placebo) to drink. After one hour (the time needed for the medications to take effect), the participants carried out a VR test of tracking ability while their heart rates and breathing patterns were monitored. They were then asked to fill out questionnaires rating their mood and sleepiness. After data gathering and analysis, the results showed that loratadine and/or fexofenadine affect drivers’ moods and cognition less than cetirizine, making loratadine or fexofenadine better choices for drivers who need to take antihistamines.
Educating and Providing Insights on Patient Conditions
A recent demonstration sponsored by Ortho Biotech Inc., utilized VR to make physicians feel what patients suffering from fatigue caused by cancer-related anemia felt. They named the simulator Insight to Cancer-related Anemia (ICRA). ICRA helped physicians really understand their patients by simulating a home with foot and hand controls which are designed to mimic and/or induce the fatigue felt by patients undergoing chemotherapy. Of course, this event was also used by the sponsoring pharmaceutical company to inform physicians that medications are available for chemotherapy-related anemia. Aside from that, this VR simulation did seem to help in educating physicians because 60% of them, after experiencing ICRA, said that it changed the way they would view and treat patients suffering from side effects of ongoing chemotherapy.
Virtual reality has so far shown a lot of promise in providing and/or supplementing medical treatment for patients. Not only that, it also helps physicians understand their patients by using VR to simulate patients’ conditions and/or side effects from medical treatments. Indeed, VR is a very promising tool that can help in the treatment, maintenance, and improvement of healthcare.
Mark D. Wiederhold, M.D., Ph.D., FACP
Virtual Reality Medical Center
San Diego, CA
Brenda K. Wiederhold, Ph.D., MBA, BCIA
Virtual Reality Medical Institute
President of Virtual Reality Medical Institute (VRMI) in Brussels, Belgium. Executive VP Virtual Reality Medical Center (VRMC), based in San Diego and Los Angeles, California. CEO of Interactive Media Institute a 501c3 non-profit Clinical Instructor in Department of Psychiatry at UCSD Founder of CyberPsychology, CyberTherapy, & Social Networking Conference Visiting Professor at Catholic University Milan.