Neuroscience of Virtual Reality and Behavioral Change - Giuseppe Riva, Ph.D

NeuroscienceofVRandBehavioralChange

Prof. Giuseppe Riva, Ph.D.

Università Cattolica del SacroCuore, Milan, Italy

www.giusepperiva.com

Keynote SpeakerSTANFORD, 3rd AIPBH, 2017

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Giuseppe Riva, Ph.D.Università Cattolica del Sacro Cuore, Milan, Italy

- Full Professor of GeneralPsychology

- Director of the Applied Technologyfor Neuro-Psychology Lab. atIstituto Auxologico Italiano, Milan

- European Editor of the scientificjournal “Cyberpsychology Behaviorand Social Networking”

- President of the InternationalAssociation of CyberPsychology,Training, and Rehabilitation –iActor

The open challenge for mental healthSTANFORD, 3rd AIPBH, 2017

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As underlined by this recent Naturepaper, we need better ideas andtools for mental health.

My solution: Technology, and in particular Virtual Reality

The goal of this presentationSTANFORD, 3rd AIPBH, 2017

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The changing potentialof technology

Virtual Reality as Positive Technology

Virtual RealityIn practice

Technology can help us to change. How

and Why

Virtual Reality can improve our personal

experience

A significant application of VR: the treatment of obesity and eating disorders

The changing potential of technologyTechnology can help us to change: How and Why

Technology is evolving… But its use?STANFORD, 3rd AIPBH, 2017

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One computer for many users

One computer for each user

Many computers for each user

Thousands computers for

each user

1960: Mainframe Era

1980: Personal Computer Era

2000: Mobility Era

2020+: Ubiquity Era

Source: Abigail Sellen, Yvonne Rogers, Richard Harper, Tom Rodden: Reflecting human values in the digital age. Commun. ACM 52(3): 58-66 (2009)

Technology is not making us better…STANFORD, 3rd AIPBH, 2017

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Privacy and Security

Ethics and Values

Multitasking And Technostress

Open Challenge:Using technology, and in particular virtual technologies, I want tochange people lives for better…

But what is change?

What is change?STANFORD, 3rd AIPBH, 2017

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Even if this question has many possible answers in general change occurs through an intense focus on a particular instance or experience (Wolfe, 2002).

By exploring this experience as thoroughly

as possible, the patient can relive all of the

significant elements associated with it (i.e., conceptual, emotional,

motivational, and behavioral) and make

them available for reorganization.

§ Within this general model we have many specificmethods in clinical psychology:

§ the insight-based approach of psychoanalysis,

§ the schema-reorganization of cognitive therapy,

§ the functional analysis of behavioral therapy,

§ the interpersonal relationship focus of interpersonaltherapy,

§ and the enhancement of experience awareness inexperiential therapies.

What are the differences between them?

What is changeSTANFORD, 3rd AIPBH, 2017

11According to Safran andGreenberg (1991), behind thespecific therapeutic approachthere are two different models ofchange: bottom-up and top-down.

Bottom-up processing begins withthe focus on sensations and leadsto change at the behavioral andconceptual level;

Top-down change usually involvesexploring and challenging tacitrules and beliefs that guide theprocessing of behavioral planningand leads eventually to changes insensation processing.

Top Down

Bottom Up

Source: Safran, J.D. & Greenberg, L.S.(Eds.) (1991). Emotion, psychotherapy and change. New York:

Guilford Press.


12These two models of change arefocused on two different cognitivesystems (Kahneman, Nobel PrizeLecture, 2002):

System 1 (Intuition): it generatesimpressions of the attributes ofobjects of perception and thought.These impressions are notvoluntary and need not beverbally explicit.

System 2 (Reasoning): it generatesjudgments, that are always explicitand intentional, whether or notthey are overtly expressed.

System 2: Reasoning

System 1: Intuition

Top Down

Bottom Up


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System 2: ReasoningRules/Beliefs

System 1: IntuitionEmotions/Simulation


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The existence of two different cognitive systems is clearly shown by the dissociation between verbal knowledge and task performance:

•people learn to control dynamic systems intuitively without being able to specify the nature of the relations within the system (e.g. Bicycling), and •they can describe the rules by which the system operates without being able to put them into practice (e.g. Driving Exams).

Learning by doing: where Intuition and Reasoning meetSTANFORD, 3rd AIPBH, 2017

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Learning by doingThe best way to learn how to dosomething is trying to do it and reflectingon the outcome (metacognition)

Engage and Motivate in Active Exploration(Intuition)To make individuals active participants by creatingsituations that challenge them to solve problems.

Apply Metacognition (Reasoning)To make individuals active participants by creatingsituations that challenge them to solve problemsand apply new knowledge.

To facilitate change we need to develop experiences able to engage (intuition) and apply metacognition

to them (reasoning)

Virtual Reality as Positive TechnologyVirtual Reality can improve our personal experience

This question is at the heart of the “positive technology”approach, which is the scientific and applied approach to the use of technology for improving the quality of our personal experience.

WHAT IS RIGHT ABOUT TECHNOLOGY?

The concepts of Positive Technologies are rooted in the research work of Positive and Cognitive Psychology

Technology can change personal experienceSTANFORD, 3rd AIPBH, 2017

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using a goal, rules, and a feedback system (reasoning)

•The goal provides subjects with a sense of purpose focusing attention .•The rules, push subjects to see the experience in a different way. •The feedback system tells individuals how close they are to achieving the goal

By Structuring it By Replacing itBy Augmenting it

to achieve multimodal and mixed experiences

(intuition/reasoning)

•Technology allows multisensory experiences in which content and its interaction are offered through more than one of the senses. •It is possible to use technology to overlay virtual objects onto real scenes

By replacing it with a synthetic one (intuition)

•Using VR, it is possible to simulate physical presence in a synthetic world that reacts to the action of the subject as if he/she was really there.•It is even possible tp provde illusion of ownership over a virtual arm or a virtual body

20 Virtual Reality: the best positive technologySTANFORD, 3rd AIPBH, 2017

The added value of Virtual Reality:

the high level of personal efficacy and

self-reflectivenessgenerated by its

sense of presence and emotional engagement

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THE USER IS PRESENTThe virtual reality fully absorbs the user and

replaces his/her reality

Engagementand Presence

Social RelationshipsInteraction

THE USER ACTSThe virtual experience is not passive but active allowing

Learning by Doing

THE USER IS NOT ALONEThe virtual experience is also

a social and collaborative experience (Avatars)

Virtual Reality as Experiential TechnologySTANFORD, 3rd AIPBH, 2017

22 To Virtual Reality as Experience…STANFORD, 3rd AIPBH, 2017

However, VR can also be considered: An experiential technology: VR allows thereproduction of situations and contexts in a life-likesetting=> I’m “present” in the simulationA cognitive technology: in immersive VR all thebody – including the proprioceptive system - isinvolved in the action=> The experience of the body is modified byVirtual Reality (Sensory re-integration between thevisual and proprioceptive systems)

VR as Cognitive/Experiential TechnologyThe Neuroscience of Virtual Reality

24 Virtual Reality as Cognitive TechnologySTANFORD, 3rd AIPBH, 2017

Different visions from cognitive sciences –Situated Cognition, Embodied Cognition, Enactive Approach - suggest that:

1.Cognition is no more the simple performance of formal operations on abstract symbols, but has instead deep roots in sensorimotor processing. 2. this is allowed by a common coding – the motor code – shared by perception, action and concepts.


This vision is supported by the discovery of Bimodal Neurons:-Mirror neurons are a specific class of neurons that discharge during a motor act execution and the observation of a similar action by others.-Canonical neurons are a specific class of neurons that discharge during motor act execution and in response to the presentation of 3-D objects supporting the same motor act;


How do these

neurons work?

Using Predicitive

Coding


During the enaction of a learned skill a sensory prediction of theoutcome of the action (simulation) is produced along with the actualmotor command.The results of the comparison (which occurs prereflexively)between the sensory prediction and the sensory consequences of the actcan then be used to track any possible variation in its course (break).


2) This simulation is also used for

concepts: thinking an apple produces the simulation of

an action related to the

apple in a specific context of use.


On one side, concepts are embodied simulations of actions

On the other side virtual reality allows embodied simulations of actions.

A first possibility is the use virtual reality for modifying concepts and/or the emotions related to them through embodied simulations => behavior and cognitions are tied together


But we can do even more. Recent research suggested that predictive coding is a key brain process behind different cognitive processes (from the experience of the body to the self):


…on one side, we are in the body that, according to predictive coding, it is the most likely to be our one.


...on the other side, impairments of the predictive coding may be behind different pathologies (from autism and schizophrenia to eating disorders)…


...suggesting the possibility of using Virtual Reality for hacking and/or altering the predictive coding mechanisms.The final outcome will be ”Embodied Medicine”: the use of VR for altering the experience of being in a body with the goal of improving health and well-being.


Immersive VRmodifies the neural

areas of pain (measuredusing a PET): No effects

with videogame Why?

Hoffman, H. Scientific American, April 2004


In my view, Virtual Reality hacks the predictive coding system suggesting thatthe subject is no more present in his/her body: no body, no pain. It is the opposite of the phantom limb pain: after amputation the subject experiences painin the missing limb, in VR the subject does not experience more pain in the real body.

Virtual Reality in practiceRelevant applications of Embodied Medicine

37 Virtual Reality as Embodied MedicineSTANFORD, 3rd AIPBH, 2017

A first application of VR as Embodied Medicine:VR in the treatment of Obesity and Eating Disorders

38 Virtual Reality in Obesity and Eating DisordersSTANFORD, 3rd AIPBH, 2017

Problem 1:Effects of Diet and Exercize are difficult to maintain

Literature shows that fully 90%–95% of adult obese patients who lose weight during dietary and behavioral treatment will return to their baseline weight after 5 years;

Ten years after treatment only 34% of obese children had a decreased percentage overweight; only 30% were no longer obese.


Yee N, Bailenson, J.N., Ducheneaut (2009).

The Proteus Effect. Communicatin Research. 36(2):285-312.

Fox, J., Bailenson, J. (2010).

Virtual Self Modeling. Media Psychology.13 (3): 335-339.

Rewarding/Punishing Virtual Avatars improve motivation

VR allows the creation of ideal self-models that can motivate individualsto adopt new health practices or

positively modify existing ones

Solution 1: VR improves motivation and compliance


Solution 1: VR improves motivation and complianceGorini A, Gaggioli A, Riva G. (2007).

Virtual Worlds, Real Healing. Science. Dec 7;318(5856):1549.

Jin, S-A. (2010). Does imposing a Goal Always improve Exercise Intentions?.

CyberPsychology, Behavior and Social Networking.13 (3): 335-339.

Virtual Reality allows anonymous group sessions where individuals put into practice what they have learned.Exercizing Virtual Avatars improve

motivation


Problem 2: Being obese can be a symptom of a more serious eating problem

Binge Eating Disorder (BED) is reported to effect roughly 3% of the US population, leaving many people struggling with obesity and conventional weight loss methods unaware that they have an eating disorder that may not respond without appropriate treatment.

Binge eating is common both among people with diagnosed eating disorders and those who are obese so the difference may be indistinguishable to the untrained eye.


Solution 2: VR allows to assess EDFerrer-Garcia M., Guitierrez-Maldonado (2019)The validity of virtual environments for eliciting emotional responses in patients with

eating disorders and in controls. Behavior Modification, 33 (6): 830-854

VR is a useful vehicle for eliciting similar emotional reactions to those one would expect in real life situations: patients showed higher levels of anxiety and a more depressed mood after eating, especially high-calorie food, and after visiting the swimming pool than in the neutral room.


A. Gorini, E. Griez, A. Petrova, G.Riva (2010)Virtual Assessment of the emotional responses produced by exposure to real food, virtual food and photographs of food in patients affected by eating

disorders. Annals of General Psychiatry, 9:30doi:10.1186/1744-859X-9-30

Food presented in a virtual reality (VR) environment causes the same emotional responses as real food in ED patients: virtual food can be used for the evaluation and treatment of eating disorders.

Solution 2: VR allows to assess ED


Problem 3: How can we improve treatment of obesity and ED?

Eating disorders and obesity are usually seen as very different problems but actually share many similarities. In fact, eating disorders, obesity, and other weight-related disorders may overlap as girls move from one problem, such as unhealthy dieting, to another, such as obesity.In particular, body dissatisfaction and unhealthy dieting practices are linked to the development of eating disorders, obesity, and other problems.


In 496 adolescent girls who completed a baseline assessment at age 11-15 years and 4 annual follow-ups. The only significant predictors of Obesity are:- Dietary Restraint (p<.001);- Perceived Parental Obesity (p<.02).

Stice et al, (2005), Psychological and Behavioral Risk Factors for Obesity Onset in Adolescent Girls. A Prospective Study, Journal of Consulting and Clinical Psychology, Vol. 73, No. 2, 195-202.

“...I’m on diet because I don’t like my body”


The clear link between obesity and ED is body dissatisfaction,

leading to dietary restraint.

However even if most women do not like their body, only a minority of

women develop clinically diagnosable weight disorders. Why?


In short: For an impairment in the predictive coding ED/OB patients are unable to integrate the real-time sensory data of their body with the memorized ones

A possible explanation:a Multisensory Integration Deficit


This Multisensory Integration Deficit may have different causes: both environmental (stress) or organic (altered serotoninergic

activity).

Its outcome it is simple: the subject is locked to a to a negative body representation, that

perception is not able to update even after a demanding diet and a significant weight loss.


Solution 3:Integrate VR in a CBT treatment

If it is true, we don’t have to work only with our real body (diet) but also with ourvirtual body (predictive coding) to improve actual treatments.

I’m actually using the Integrated ExperientialTherapy (IET) that integrates CBT with different virtual reality sessions using threedifferent strategies to counter the multisensory integration deficit: •Cue Exposure;•Reference Frame Shifting;•Body Swapping.


• Cue Exposure: We use VR to reduce eating-related anxiety during and after exposure to virtual food, helping to disrupt the reconsolidation of adverse, food-related memories.

• More effective than CBT in a controlled trial with bulimic and binge patients


• Reference Frame shifting: The patient re-experience in VR a negative situation related to her/his body (e.g. teasing) both in first-person and in third person (seeing and supporting her avatar in the scene)

• More effective than CBT at 1Yr follow-up in two controlled trials with obese and binge patients.

FIRSTPERSON(Don’t see my body)

THIRDPERSON(Isee my avatar)


• Body Swapping: VR allows the patient to experience a totally different body


• Body Swapping: VR allows the patient to experience a body totally different from her/his one using a visuo/tactile syncronization.

• A case study with a super-super obesity case (BMI =60) and a study with anorectic patients provide a preliminary support to this technique.

My future challenge: SonoceptionSTANFORD, 3rd AIPBH, 2017

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Up to now VR has been used to simulate external reality, that is, to makepeople feel ‘real’ what is actually not really there (i.e., environment).

I recently proposed a foundational new approach: Sonoception(www.sonoception.com) the use of sound and vibration forsimulating/stimulating our internal reality (proprioception,interoception and vestibular input): to make people feel ‘real’ what theyare not feeling, by hacking directly the predictive coding mechanisms of our inner body(stomach, heart, ear).

Conclusions

Key Ideas to take home…STANFORD, 3rd AIPBH, 2017

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1) Personal Change requires bothIntuition and Reasoning. Learningby Doing and Metacognitionconnect/active both of them.

2) Virtual Reality is able to improvepersonal experience by structuring,augmenting and replacing it.

3) VR as a simulative technology is based on the same predictive approach (Predictive Coding) used by our brain. So, we can use VR for hacking and/or altering the predictive coding mechanisms

4) This possibility may open a newscientific paradigm, ”EmbodiedMedicine”: the use of VR foraltering the experience of being ina body with the goal of improvinghealth and well-being.

Four Free Books for you…STANFORD, 3rd AIPBH, 2017

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Interacting with PresenceHCI and the Sense of Presence inComputer-mediated Environmentshttp://www.degruyter.com/view/product/449569

Volutaren plus isa

Thank you for your attention

Enabling Positive ChangeFlow and Complexity in Daily Experience http://www.degruyter.com/view/product/449663

Active Ageing and Healthy Living: A Human Centered Approach in Research and

Innovation as Source of Quality of Lifehttp://www.activeaging.it/

Human Computer ConfluenceTransforming Human Experience through Symbiotic Technologieshttps://www.degruyter.com/view/product/469548

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Health & Medicine

Neuroscience of Virtual Reality and Behavioral Change - Giuseppe Riva, Ph.D