Assessment of virtual reality as an anxiety and disgust provoking tool: The use of VR exposure in individuals with high contamination fear
Preliminary studies have provided promising results on the feasibility of virtual reality (VR) interventions for Obsessive-Compulsive Disorder. The present study investigated whether VR scenarios that were developed for contamination concerns evoke anxiety, disgust, and the urge to wash in individuals with high (n = 33) and low (n = 33) contamination fear. In addition, the feasibility of VR exposure in inducing disgust was examined through testing the mediator role of disgust in the relationship between contamination anxiety and the urge to wash. Participants were immersed in virtual scenarios with varying degrees of dirtiness and rated their level of anxiety, disgust, and the urge to wash after performing the virtual tasks. Data were collected between September and December 2019. The participants with high contamination fear reported higher contamination-related ratings than those with low contamination fear. The significant main effect of dirtiness indicated that anxiety and disgust levels increased with increasing overall dirtiness of the virtual scenarios in both high and low contamination fear groups. Moreover, disgust elicited by VR mediated the relationship between contamination fear and the urge to wash. The findings demonstrated the feasibility of VR in eliciting emotional responses that are necessary for conducting exposure in individuals with high contamination fear. In conclusion, VR can be used as an alternative exposure tool in the treatment of contamination-based OCD.
Abramowitz, J. S., Fabricant, L. E., Taylor, S., Deacon, B. J., McKay, D., & Storch, E. A. (2014). The relevance of analogue studies for understanding obsessions and compulsions. Clinical Psychology Review, 34(3), 206–217. https://doi.org/10.1016/j.cpr.2014.01.004
Adams, T. G. Jr., Willems, J. L., & Bridges, A. J. (2011). Contamination aversion and repeated exposure to disgusting stimuli. Anxiety, Stress & Coping, 24(2), 157–165. https://doi.org/10.1080/10615806.2010.506953
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596
Ball, S. G., Baer, L., & Otto, M. W. (1996). Symptom subtypes of obsessive-compulsive disorder in behavioral treatment studies: A quantitative review. Behaviour Research and Therapy, 34(1), 47–51. https://doi.org/10.1016/0005-7967(95)00047-2
Belloch, A., Cabedo, E., Carrió, C., Lozano-Quilis, J. A., Gil-Gómez, J. A., & Gil-Gómez, H. (2014). Virtual reality exposure for OCD: Is it feasible? Journal of Psychopathology and Clinical Psychology, 19(1), 37–44. http://doi.org/10.5944/rppc.vol.19.num.1.2014.12981
Botella, C., Quero, S., Baños, R. M., Perpiñá, C., Garcia-Palacios, A., & Riva, G. (2004). Virtual reality and psychotherapy. In G. Riva, C. Botella, P. Légeron, & G. Optale (Eds.), Cybertherapy: Internet and VR as assessment and rehabilitation tools for clinical psychology and neuroscience (Vol. 99, pp. 37–54). IOS Press. https://doi.org/10.3233/978-1-60750-943-1-37
Botella, C., Serrano, B., Baños, R. M., & Garcia-Palacios, A. (2015). Virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: A review of its efficacy, the adequacy of the treatment protocol, and its acceptability. Neuropsychiatric Disease and Treatment, 11, 2533–2545. https://doi.org/10.2147/NDT.S89542
Brady, R. E., Adams, T. G., & Lohr, J. M. (2010). Disgust in contamination-based obsessive–compulsive disorder: A review and model. Expert Review of Neurotherapeutics, 10(8), 1295–1305. https://doi.org/10.1586/ern.10.46
Burns, G. L., Keortge, S. G., Formea, G. M., & Sternberger, L. G. (1996). Revision of the Padua Inventory of obsessive compulsive disorder symptoms: Distinctiveness between worry, obsessions, and compulsions. Behavior Research and Therapy, 34(2), 163–173. https://doi.org/10.1016/0005-7967(95)00035-6
Bush, J. (2008). Viability of virtual reality exposure therapy as a treatment alternative. Computers in Human Behavior, 24(3), 1032–1040. https://doi.org/10.1016/j.chb.2007.03.006
Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., Asmundson, G. J. G., Carlbring, P., & Powers, M. B. (2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36. https://doi.org/10.1016/j.janxdis.2018.08.003
Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (2009). Disgust, fear, and the anxiety disorders: A critical review. Clinical Psychology Review, 29(1), 34–46. https://doi.org/10.1016/j.cpr.2008.09.007
Coelho, J., & Whittal, M. (2001, July). Are subtypes of OCD differentially responsive to treatment? [Poster presentation]. 3rd World Congress of Behavioural and Cognitive Therapies, Vancouver, BC.
Cougle, J. R., Wolitzky-Taylor, K. B., Lee, H.-J., & Telch, M. J. (2007). Mechanisms of change in ERP treatment of compulsive hand washing: Does primary threat make a difference? Behaviour Research and Therapy, 45(7), 1449–1459. https://doi.org/10.1016/j.brat.2006.12.001
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27. https://doi.org/10.1016/j.brat.2007.10.003
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006
Deacon, B., & Olatunji, B. O. (2007). Specificity of disgust sensitivity in the prediction of behavioral avoidance in contamination fear. Behaviour Research and Therapy, 45(9), 2110–2120. https://doi.org/10.1016/j.brat.2007.03.008
Fink-Lamotte, J., Lüders, J., & Exner, C. (2020). Enhancing motivation for exposure to disgust - A feasibility study with a non-clinical sample. Journal of Obsessive-Compulsive and Related Disorders, 25, Article 100524. https://doi.org/10.1016/j.jocrd.2020.100524
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. http://dx.doi.org/10.1037/0033-2909.99.1.20
Garcia-Palacios, A., Botella, C., Hoffman, H., & Fabregat, S. (2007). Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. CyberPsychology & Behavior, 10(5), 722–724. https://doi.org/10.1089/cpb.2007.9962
Gega, L. (2017). The virtues of virtual reality in exposure therapy. The British Journal of Psychiatry, 210(4), 245–246. https://doi.org/10.1192/bjp.bp.116.193300
Geslin, E., Bouchard, S., & Richir, S. (2011). Gamers’ versus non-gamers’ emotional response in virtual reality. Journal of CyberTherapy & Rehabilitation, 4(4), 489-493.
Huang, M. P., & Alessi, N. E. (1999). Mental health implications for presence. CyberPsychology & Behavior, 2(1), 15–18. https://doi.org/10.1089/cpb.1999.2.15
IJsselsteijn, W. A., de Ridder, H., Freeman, J., & Avons, S. E. (2000). Presence: Concept, determinants, and measurement. In B. E. Rogowitz & T. N. Pappas (Eds.), Human Vision and Electronic Imaging V (Vol. 3959, pp. 520–529). SPIE. https://doi.org/10.1117/12.387188
Inozu, M., Celikcan, U., Akin, B., & Cicek, N. M. (2020). The use of virtual reality (VR) exposure for reducing contamination fear and disgust: Can VR be an effective alternative exposure technique to in vivo? Journal of Obsessive-Compulsive and Related Disorders, 25, Article 100518. https://doi.org/10.1016/j.jocrd.2020.100518
Inozu, M., Ulukut, F. O., Ergun, G., & Alcolado, G. M. (2014). The mediating role of disgust sensitivity and thought‐action fusion between religiosity and obsessive compulsive symptoms. International Journal of Psychology, 49(5), 334–341. https://doi.org/10.1002/ijop.12041
Jones, M. K., & Menzies, R. G. (1997). The cognitive mediation of obsessive-compulsive handwashing. Behaviour Research and Therapy, 35(9), 843–850. https://doi.org/10.1016/S0005-7967(97)00035-1
Kim, K., Kim, C.-H., Cha, K. R., Park, J., Han, K., Kim, Y. K., Kim, J.-J., Kim, I. Y., & Kim, S. I. (2008). Anxiety provocation and measurement using virtual reality in patients with obsessive-compulsive disorder. CyberPsychology & Behavior, 11(6), 637–641. https://doi.org/10.1089/cpb.2008.0003
Krijn, M., Emmelkamp, P. M. G., Olafsson, R. P., & Biemond, R. (2004). Virtual reality exposure therapy of anxiety disorders: A review. Clinical Psychology Review, 24(3), 259–281. https://doi.org/10.1016/j.cpr.2004.04.001
Laforest, M., Bouchard, S., Bosse, J., & Mesly, O. (2016). Effectiveness of in virtuo exposure and response prevention treatment using cognitive–behavioral therapy for obsessive–compulsive disorder: A study based on a single-case study protocol. Frontiers in Psychiatry, 7, Article 99. https://doi.org/10.3389/fpsyt.2016.00099
Laforest, M., Bouchard, S., Cretu, A.-M., & Mesly, O. (2016). Inducing an anxiety response using a contaminated virtual environment: Validation of a therapeutic tool for obsessive–compulsive disorder. Frontiers in ICT, 3, Article 18. https://doi.org/10.3389/fict.2016.00018
Mathes, B. M., Day, T. N., Wilver, N. L., Redden, S. A., & Cougle, J. R. (2020). Indices of change in exposure and response prevention for contamination-based OCD. Behaviour Research and Therapy, 133, Article 103707. https://doi.org/10.1016/j.brat.2020.103707
McKay, D. (2006). Treating disgust reactions in contamination-based obsessive–compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, 37(1), 53–59. https://doi.org/10.1016/j.jbtep.2005.09.005
McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios, M., Radomsky, A., Sookman, D., Taylor, S., & Wilhelm, S. (2004). A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms. Clinical Psychology Review, 24(3), 283–313. https://doi.org/10.1016/j.cpr.2004.04.003
Moretz, M. W., & McKay, D. (2008). Disgust sensitivity as a predictor of obsessive-compulsive contamination symptoms and associated cognitions. Journal of Anxiety Disorders, 22(4), 707–715. https://doi.org/10.1016/j.janxdis.2007.07.004
Morina, N., Ijntema, H., Meyerbröker, K., & Emmelkamp, P. M. (2015). Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments. Behaviour Research and Therapy, 74, 18–24. https://doi.org/10.1016/j.brat.2015.08.010
Olatunji, B. O., Cisler, J., McKay, D., & Phillips, M. L. (2010). Is disgust associated with psychopathology? Emerging research in the anxiety disorders. Psychiatry Research, 175(1–2), 1–10. https://doi.org/10.1016/j.psychres.2009.04.007
Olatunji, B. O., Ebesutani, C., David, B., Fan, Q., & McGrath, P. B. (2011). Disgust proneness and obsessive–compulsive symptoms in a clinical sample: Structural differentiation from negative affect. Journal of Anxiety Disorders, 25(7), 932–938. https://doi.org/10.1016/j.janxdis.2011.05.006
Olatunji, B. O., Williams, N. L., Tolin, D. F., Abramowitz, J. S., Sawchuk, C. N., Lohr, J. M., & Elwood, L. S. (2007). The Disgust Scale: Item analysis, factor structure, and suggestions for refinement. Psychological Assessment, 19(3), 281–297. https://doi.org/10.1037/1040-3522.214.171.1241
Olatunji, B. O., Wolitzky-Taylor, K. B., Willems, J., Lohr, J. M., & Armstrong, T. (2009). Differential habituation of fear and disgust during repeated exposure to threat-relevant stimuli in contamination-based OCD: An analogue study. Journal of Anxiety Disorders, 23(1), 118–123. https://doi.org/10.1016/j.janxdis.2008.04.006
Öner, N. & Le Compte, V. A. (1985). State-Trait Anxiety Inventory handbook. Boğaziçi University Publishing.
Opriş, D., Pintea, S., García‐Palacios, A., Botella, C., Szamosközi, Ş., & David, D. (2012). Virtual reality exposure therapy in anxiety disorders: A quantitative meta‐analysis. Depression and Anxiety, 29(2), 85–93. https://doi.org/10.1002/da.20910
Öst, L.-G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156–169. https://doi.org/10.1016/j.cpr.2015.06.003
Powers, M. B., & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: A meta-analysis. Journal of Anxiety Disorders, 22(3), 561–569. https://doi.org/10.1016/j.janxdis.2007.04.006
Pratt, D. R., Zyda, M., & Kelleher, K. (1995). Virtual reality: In the mind of the beholder. Computer, 28(7), 17–19. https://doi.org/10.1109/MC.1995.10085
Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, 36(4), 717–731. https://doi.org/10.3758/BF03206553
Price, M., & Anderson, P. (2007). The role of presence in virtual reality exposure therapy. Journal of Anxiety Disorders, 21(5), 742–751. https://doi.org/10.1016/j.janxdis.2006.11.002
Rachman, S. (2004). Fear of contamination. Behaviour Research and Therapy, 42(11), 1227–1255. https://doi.org/10.1016/j.brat.2003.10.009
Rachman, S., & Shafran, R. (1998). Cognitive behavioural features of obsessive–compulsive disorder. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive–compulsive disorder: Theory, research, and treatment (pp. 51–78). The Guilford Press.
Riva, G. (2009). Virtual reality: An experiential tool for clinical psychology. British Journal of Guidance & Counselling, 37(3), 337–345. https://doi.org/10.1080/03069880902957056
Robillard, G., Bouchard, S., Fournier, T., & Renaud, P. (2003). Anxiety and presence during VR immersion: A comparative study of the reactions of phobic and non-phobic participants in therapeutic virtual environments derived from computer games. CyberPsychology & Behavior, 6(5), 467–476. https://doi.org/10.1089/109493103769710497
Schienle, A., Schäfer, A., Stark, R., Walter, B., & Vaitl, D. (2005). Gender differences in the processing of disgust-and fear-inducing pictures: An fMRI study. NeuroReport, 16(3), 277–280. https://doi.org/10.1097/00001756-200502280-00015
Smits, J. A. J., Telch, M. J., & Randall, P. K. (2002). An examination of the decline in fear and disgust during exposure-based treatment. Behaviour Research and Therapy, 40(11), 1243–1253. https://doi.org/10.1016/S0005-7967(01)00094-8
Spielberger, C. D. (1972). Current trends in theory and research on anxiety. In C. D. Spielberger (Ed.), Anxiety: Current trends in theory and research (pp. 3–19). Academic Press.
Taylor, S., (1998). Assessment of obsessive–compulsive disorder. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive–compulsive disorder: Theory, research, and treatment (pp. 229–257). The Guilford Press.
Tolin, D. F., Woods, C. M., & Abramowitz, J. S. (2006). Disgust sensitivity and obsessive–compulsive symptoms in a non-clinical sample. Journal of Behavior Therapy and Experimental Psychiatry, 37(1), 30–40. https://doi.org/10.1016/j.jbtep.2005.09.003
Tsao, S. D., & McKay, D. (2004). Behavioral avoidance tests and disgust in contamination fears: Distinctions from trait anxiety. Behaviour Research and Therapy, 42(2), 207–216. https://doi.org/10.1016/S0005-7967(03)00119-0
van Bennekom, M. J., Kasanmoentalib, M. S., de Koning, P. P., & Denys, D. (2017). A virtual reality game to assess obsessive-compulsive disorder. Cyberpsychology, Behavior, and Social Networking, 20(11), 718–722. https://doi.org/10.1089/cyber.2017.0107
Witmer, B. G., & Singer, M. J. (1998). Measuring presence in virtual environments: A Presence Questionnaire. Presence: Teleoperators and Virtual Environments, 7(3), 225–240. https://doi.org/10.1162/105474698565686
Yorulmaz, O., Karancı, A. N., Dirik, G., Baştuğ, B., Kısa, C., Göka, E., & Burns, G. L. (2007). Padua Envanteri-Washington Eyalet Üniversitesi Revizyonu: Türkçe Versiyonunun Psikometrik Özellikleri [Padua Inventory-Washington State University Revision: Psychometric properties of the Turkish version]. Türk Psikoloji Yazıları, 10(20), 75–85.