The Zen Garden Virtual Reality App for eating disorders: description and preliminary results

Author/s
Davide Gravina, Suvaathiga Kirupakaran, Mohammad Badr, Alexander Meaburn, Milos Kresojevic, Liliana Dell'Osso, Janet Treasure, Hubertus Himmerich
Citation
Focus Issue 6: Eating disorders
CEPiP.2024.1.207-213
Abstract

Virtual reality (VR) represents an emerging and promising tool to enhance standard care for patients with eating disorders. This small, uncontrolled, pilot study aims to provide a preliminary evaluation of the Zen Garden VR App in patients with anorexia nervosa (AN). The primary aim was to assess changes in mood, relaxation, anger, anxiety and weight and shape concerns. A secondary aim was to assess feedback from participants about the VR experience, its components and its possible application for people with AN. Self-reported baseline and post-intervention data were collected from a sample of inpatients with AN recruited at the Eating Disorders Service at the Bethlem Royal Hospital of the South London and Maudsley NHS Foundation Trust. Changes in clinical variables such as quality of mood, state of relaxation, anger, anxiety and weight and shape concerns from pre- to post-intervention were extracted, qualitatively revised and descriptively reported. Findings showed a global improvement after the VR Zen Garden App session, mainly in reducing levels of anxiety (Cohen's d = 1.07) and promoting relaxation (Cohen's d = 0.95). The music that was played during the intervention had a particularly positive effect. Despite promising and positive clinical implications, further studies are needed to confirm these preliminary results on wider samples of patients.

Keywords: virtual reality, anorexia nervosa, eating disorders

Cite as: Cutting Edge Psychiatry in Practice 2025, 6(1):207-213; https://doi.org/10.65031/tufp7791

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-5-TR). Arlington, VA. American Psychiatric Association (2022). https://doi.org/10.1176/appi.books.9780890423349
  2. Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors. Current Opinion in Psychiatry. 2016;29(6):340-5. https://doi.org/10.1097/yco.0000000000000278
  3. Favaro A, Caregaro L, Tenconi E, Bosello R, Santonastaso P. Time trends in age at onset of anorexia nervosa and bulimia nervosa. The Journal of Clinical Psychiatry. 2009;70(12):21711. https://doi.org/10.4088/jcp.09m05176blu
  4. Nicholls DE, Lynn R, Viner RM. Childhood eating disorders: British national surveillance study. The British Journal of Psychiatry. 2011;198(4):295-301. https://doi.org/10.1192/bjp.bp.110.081356
  5. Herpertz-Dahlmann B. Adolescent eating disorders: update on definitions, symptomatology, epidemiology, and comorbidity. Child and Adolescent Psychiatric Clinics. 2015;24(1):177-96. https://doi.org/10.1016/j.chc.2008.07.005
  6. Micali N, Hagberg KW, Petersen I, Treasure JL. The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database. BMJ Open. 2013;3(5):e002646. https://doi.org/10.1136/bmjopen-2013-002646
  7. Smink FR, Van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports. 2012;14(4):406-14. https://doi.org/10.1007/s11920-012-0282-y
  8. Zipfel S, Giel KE, Bulik CM, Hay P, Schmidt U. Anorexia nervosa: aetiology, assessment, and treatment. The Lancet Psychiatry. 2015;2(12):1099-111. https://doi.org/10.1016/s2215-0366(15)00356-9
  9. Carlson CG. Virtual and augmented simulations in mental health. Current Psychiatry Reports. 2023;25(9):365-71.               
  10. Wei S, Freeman D, Rovira A. A randomised controlled test of emotional attributes of a virtual coach within a virtual reality (VR) mental health treatment. Scientific Reports. 2023;13(1):11517. https://doi.org/10.1038/s41598-023-38499-7
  11. Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne A-K, Pramme L, et al. Virtual reality in the diagnostic and therapy for mental disorders: a systematic review. Clinical Psychology Review. 2022;98:102213. https://doi.org/10.1016/j.cpr.2022.102213
  12. Hawajri O, Lindberg J, Suominen S. virtual reality exposure therapy as a treatment method against anxiety disorders and depression - a structured literature review. Issues in Mental Health Nursing. 2023;44(4):245-69. https://doi.org/10.1080/01612840.2023.2190051
  13. Vasodi E, Saatchian V, Ghahfarokhi AD. Virtual reality-based exercise interventions on quality of life, some balance factors and depression in older adults: a systematic review and meta-analysis of randomized controlled trials. Geriatric Nursing. 2023;53:227-39. https://doi.org/10.1016/j.gerinurse.2023.07.019
  14. Orr E, Arbel T, Levy M, Sela Y, Weissberger O, Liran O, et al. Virtual reality in the management of stress and anxiety disorders: a retrospective analysis of 61 people treated in the metaverse. Heliyon. 2023;9(7). https://doi.org/10.1016/j.heliyon.2023.e17870
  15. Schröder D, Wrona KJ, Müller F, Heinemann S, Fischer F, Dockweiler C. Impact of virtual reality applications in the treatment of anxiety disorders: a systematic review and meta-analysis of randomized-controlled trials. Journal of Behavior Therapy and Experimental Psychiatry. 2023:101893. https://doi.org/10.1016/j.jbtep.2023.101893
  16. Zeka F, Clemmensen L, Arnfred BT, Nordentoft M, Glenthøj LB. Examination of gaze behaviour in social anxiety disorder using a virtual reality eye-tracking paradigm: protocol for a case–control study. BMJ Open. 2023;13(8):e071927. https://doi.org/10.1136/bmjopen-2023-071927
  17. Folke S, Roitmann N, Poulsen S, Andersen SB. Feasibility of virtual reality exposure therapy in the treatment of Danish veterans with posttraumatic stress disorder: a mixed method pilot study. Cyberpsychology, Behavior, and Social Networking. 2023;26(6):425-31. https://doi.org/10.1089/cyber.2022.0236
  18. Vázquez-de Sebastián J, Anastasiadou D, Cano Porras D, Friedman D, Castellano-Tejedor C, Lusilla-Palacios P. Can virtual reality be a solution for assessing and treating psychological symptoms caused by eating and weight disorders? Frontiers in Psychology. 2023;14:1225454. https://doi.org/10.3389/fpsyg.2023.1225454
  19. Perra A, De Lorenzo V, Zaccheddu R, Locci A, Piludu F, Preti A, et al. Cognitive remediation virtual reality tool a recovery-oriented project for people with bipolar disorder: protocol of a feasibility randomized clinical trial. Clinical Practice and Epidemiology in Mental Health. 2022;18:e174501792208220. https://doi.org/10.2174/17450179-v18-e2208220
  20. Lan L, Sikov J, Lejeune J, Ji C, Brown H, Bullock K, et al. A systematic review of using virtual and augmented reality for the diagnosis and treatment of psychotic disorders. Current Treatment Options in Psychiatry. 2023:1-21. https://doi.org/10.1007/s40501-023-00287-5
  21. Aasen J, Galaaen K, Nilsson F, Sørensen T, Lien L, Leonhardt M. Promoting social participation and recovery using virtual reality-based interventions among people with mental health and substance use disorders: qualitative study. JMIR Formative Research. 2023;7(1):e46136. https://doi.org/10.2196/46136
  22. Soltiyeva A, Oliveira W, Madina A, Adilkhan S, Urmanov M, Hamari J. My Lovely Granny's Farm: an immersive virtual reality training system for children with autism spectrum disorder. Education and Information Technologies. 2023:1-21. https://doi.org/10.1007/s10639-023-11862-x
  23. Cardi V, Kan C, Roncero M, Harrison A, Lounes N, Tchanturia K, et al. Mealtime support in anorexia nervosa: a within-subject comparison study of a novel vodcast intervention. Psychotherapy and Psychosomatics. 2012;81(1):54. https://doi.org/10.1159/000329992
  24. Cardi V, Krug I, Perpiñá C, Mataix‐Cols D, Roncero M, Treasure J. The use of a nonimmersive virtual reality programme in anorexia nervosa: a single case‐report. European Eating Disorders Review. 2012;20(3):240-5. https://doi.org/10.1002/erv.1155
  25. Cardi V, Lounes N, Kan C, Treasure J. Meal support using mobile technology in anorexia nervosa. Contextual differences between inpatient and outpatient settings. Appetite. 2013;60:33-9. https://doi.org/10.1016/j.appet.2012.10.004
  26. Cardi V, Ward T, Aya V, Calissano C, Thompson A, Treasure J. A proof-of-concept study for the use of a computerised avatar to embody the eating disorder voice in anorexia nervosa. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2022;27(8):3499-506. https://doi.org/10.1007/s40519-022-01487-3
  27. De Carvalho MR, Dias TRdS, Duchesne M, Nardi AE, Appolinario JC. Virtual reality as a promising strategy in the assessment and treatment of bulimia nervosa and binge eating disorder: a systematic review. Behavioral Sciences. 2017;7(3):43. https://doi.org/10.3390/bs7030043
  28. Ferrer-Garcia M, Pla-Sanjuanelo J, Dakanalis A, Vilalta-Abella F, Riva G, Fernandez-Aranda F, et al. A randomized trial of virtual reality-based cue exposure second-level therapy and cognitive behavior second-level therapy for bulimia nervosa and binge-eating disorder: outcome at six-month followup. Cyberpsychology, Behavior, and Social Networking. 2019;22(1):60-8. https://doi.org/10.1089/cyber.2017.0675
  29. Leppanen J, Cardi V, Ng KW, Paloyelis Y, Stein D, Tchanturia K, et al. The effects of intranasal oxytocin on smoothie intake, cortisol and attentional bias in anorexia nervosa. Psychoneuroendocrinology. 2017;79:167-74. https://doi.org/10.1016/j.psyneuen.2017.01.017
  30. Levinson CA, Ralph‐Nearman C, Brown ML, Gardner T, Cardi V, Treasure J, et al. A pilot randomized control trial of online exposure for eating disorders and mechanisms of change delivered after discharge from intensive eating disorder care: a registered report. International Journal of Eating Disorders. 2021;54(11):2066-74. https://doi.org/10.1002/eat.23603
  31. Marco JH, Perpiñá C, Botella C. Effectiveness of cognitive behavioral therapy supported by virtual reality in the treatment of body image in eating disorders: one year follow-up. Psychiatry Research. 2013;209(3):619-25. https://doi.org/10.1016/j.psychres.2013.02.023
  32. Riva G, Bacchetta M, Cesa G, Conti S, Molinari E. Six-month follow-up of in-patient experiential cognitive therapy for binge eating disorders. Cyberpsychology and Behavior. 2003;6(3):251-8. https://doi.org/10.1089/109493103322011533
  33. Riva G, Bacchetta M, Cesa G, Conti S, Molinari E. The Use of VR in the Treatment of Eating Disorders. Cybertherapy. IOS Press (2004). p. 121- 63. https://doi.org/10.3233/978-1-60750-943-1-121
  34. Simonazzi C, Natali L, Valmaggia L, Rowlands K, Meregalli V, Rabarbari E, et al. Food-related aversion in a female sample of people with anorexia nervosa: cognitive-behavioural correlates, somatic and subjective anxiety, and early experiences. Appetite. 2023;180:106366. https://doi.org/10.1016/j.appet.2022.106366
  35. Clus D, Larsen ME, Lemey C, Berrouiguet S. The use of virtual reality in patients with eating disorders: systematic review. Journal of Medical Internet Research. 2018;20(4):e157. https://doi.org/10.2196/jmir.7898
  36. Ferrer‐García M, Gutiérrez‐Maldonado J, Pla‐Sanjuanelo J, Vilalta‐Abella F, Riva G, Clerici M, et al. A randomised controlled comparison of second‐level treatment approaches for treatment‐resistant adults with bulimia nervosa and binge eating disorder: assessing the benefits of virtual reality cue exposure therapy. European Eating Disorders Review. 2017;25(6):479-90. https://doi.org/10.1002/erv.2538
  37. Cesa GL, Manzoni GM, Bacchetta M, Castelnuovo G, Conti S, Gaggioli A, et al. Virtual reality for enhancing the cognitive behavioral treatment of obesity with binge eating disorder: randomized controlled study with one-year follow-up. Journal of Medical Internet Research. 2013;15(6):e113. https://doi.org/10.2196/jmir.2441
  38. Low TL, Ho R, Ho C, Tam W. The efficacy of virtual reality in the treatment of binge‐purging eating disorders: a meta‐analysis. European Eating Disorders Review. 2021;29(1):52-9. https://doi.org/10.1002/erv.2804
  39. Magrini M, Curzio O, Tampucci M, Donzelli G, Cori L, Imiotti MC, et al. Anorexia nervosa, body image perception and virtual reality therapeutic applications: state of the art and operational proposal. International Journal of Environmental Research and Public Health. 2022;19(5):2533. https://doi.org/10.3390/ijerph19052533
  40. Moulton CD, Strawbridge R, Tsapekos D, Oprea E, Carter B, Hayes C, et al. The Maudsley 3-item Visual Analogue Scale (M3VAS): validation of a scale measuring core symptoms of depression. Journal of Affective Disorders. 2021;282:280-3. https://doi.org/10.1016/j.jad.2020.12.185
  41. Melles H, Spix M, Jansen A. Avoidance in anorexia nervosa: towards a research agenda. Physiology and Behavior. 2021;238:113478. https://doi.org/10.1016/j.physbeh.2021.113478
  42. Bektas S, Natali L, Rowlands K, Valmaggia L, Di Pietro J, Mutwalli H, et al. Exploring correlations of food-specific disgust with eating disorder psychopathology and food interaction: a preliminary study using virtual reality. Nutrients. 2023;15(20):4443. https://doi.org/10.3390/nu15204443
  43. Cardi V, Esposito M, Clarke A, Schifano S, Treasure J. The impact of induced positive mood on symptomatic behaviour in eating disorders. An experimental, AB/BA crossover design testing a multimodal presentation during a test-meal. Appetite. 2015;87:192-8. https://doi.org/10.1016/j.appet.2014.12.224
  44. Colin C, Prince V, Bensoussan J-L, Picot M-C. Music therapy for health workers to reduce stress, mental workload and anxiety: a systematic review. Journal of Public Health. 2023;45(3):e532-41 https://doi.org/10.1093/pubmed/fdad059
  45. Haslam R, Heiderscheit A, Himmerich H. A systematic review of scientific studies on the effects of music in people with personality disorders. International Journal of Environmental Research and Public Health. 2022;19(23):15434. https://doi.org/10.3390/ijerph192315434
  46. Applewhite B, Priya AK, Cardi V, Himmerich H. A software-assisted qualitative study on the use of music in people with anorexia nervosa. Weight Management. IntechOpen (2020). p. 195. https://doi.org/10.5772/intechopen.92589
  47. Eseadi C, Ngwu MO. Significance of music therapy in treating depression and anxiety disorders among people with cancer. World Journal of Clinical Oncology. 2023;14(2):69. https://doi.org/10.5306/wjco.v14.i2.69
  48. Romano M, Archambault K, Garel P, Gosselin N. Music interventions with children, adolescents and emerging adults in mental health settings: a scoping review. Arts and Health. 2023;16(1):89-109 https://doi.org/10.1080/17533015.2023.2243288
  49. Thompson Z, Tamplin J, Vieira Sousa T, Carrasco R, Flynn L, Lamb KE, et al. Content development and validation for a mobile application designed to train family caregivers in the use of music to support care of people living with dementia. Frontiers in Medicine. 2023;10:1185818. https://doi.org/10.3389/fmed.2023.1185818
  50. Gargaro E, Guertin R, McFerran K, Punch S, Trondalen G, Cameron N, et al. Creative Arts Therapies and Clients with Eating Disorders. Jessica Kingsley Publishers (2015).
  51. Testa F, Arunachalam S, Heiderscheit A, Himmerich H. A systematic review of scientific studies on the effects of music in people with or at risk for eating disorders. Psychiatria Danubina. 2020;32(3-4):334-45. https://doi.org/10.31219/osf.io/xwv7e
  52. Abdulah DM, Miho Alhakem SS, Piro RS. Effects of music as an adjunctive therapy on severity of symptoms in patients with obsessivecompulsive disorder: randomized controlled trial. Nordic Journal of Music Therapy. 2019;28(1):27-40. https://doi.org/10.1080/08098131.2018.1546222