The sense of embodiment in virtual reality (VR) is commonly understood as the subjective experience that one\'s physical body is substituted by a virtual counterpart, and is typically achieved when the avatar\'s body, seen from a first-person view, moves like one\'s physical body. Embodiment can also be experienced in other circumstances (e.g., in third-person view) or with imprecise or distorted visuo-motor coupling. It was moreover observed, in various cases of small or progressive temporal and spatial manipulations of avatars\' movements, that participants may spontaneously follow the movement shown by the avatar. The present work investigates whether, in some specific contexts, participants would follow what their avatar does even when large movement discrepancies occur, thereby extending the scope of understanding of the self-avatar follower effect beyond subtle changes of motion or speed manipulations. We conducted an experimental study in which we introduced uncertainty about which movement to perform at specific times and analyzed participants\' movements and subjective feedback after their avatar showed them an incorrect movement. Results show that, when in doubt, participants were influenced by their avatar\'s movements, leading them to perform that particular error twice more often than normal. Importantly, results of the embodiment score indicate that participants experienced a dissociation with their avatar at those times. Overall, these observations not only demonstrate the possibility of provoking situations in which participants follow the guidance of their avatar for large motor distortions, despite their awareness about the avatar movement disruption and on the possible influence it had on their choice, and, importantly, exemplify how the cognitive mechanism of embodiment is deeply rooted in the necessity of having a body.

BACKGROUND: Trauma-focused cognitive behavioral therapy (TF-CBT) strategies are common interventions to treat child trauma and a posttraumatic stress disorder (PTSD) diagnosis in children with histories of sexual and physical abuse. With the advent of COVID-19, the disruption of child development combined with intense exposure to technology and screen time indicate a need for delivering other novel approaches to treat pediatric PTSD. Virtual reality (VR) has been used with evidence-based TF-CBT as an intervention in lab-based settings, but never as telehealth. Such technologies, including a VR head-mounted device (HMD) programmed with novel TheraVR software, for psychotherapy and treating trauma-related symptoms could redefine how pediatric populations respond to treatment.
OBJECTIVE: The aim of this exploratory single-case study was to reflect symptom improvement and patient engagement using VR as telehealth.
METHODS: The patient was a 10-year-old girl of Middle Eastern descent diagnosed with trauma and comorbid medical conditions. The patient was in divorced joint parental custody and a Child Protective Services report was made with referral for therapy. Night terrors, hallucinations, depression, anxiety, isolation, and encopresis symptoms were assessed at the beginning of treatment. Clinical analysis met the criteria for a diagnosis of early onset PTSD, which was treated over the course of 7 months using TF-CBT. A cross-analysis design was used to compare improved effectiveness in treatment and patient outcomes when moving from delivery of care with telehealth using desktop and tablet synchronous technology to 2D VR desktop telehealth with TheraVR software and subsequently HMD VR telehealth with TheraVR software. Sessions were conducted in private practice providing psychotherapy for remote patient care, collateral care with the family, and coordination of clinical care with the patient\'s pediatrician. Safety and protocols for reducing triggers were clinically monitored by the provider.
RESULTS: Over the course of treatment, and moving from standard telehealth to 2D VR to TheraVR with a standalone HMD, there was a significant reduction in PTSD symptoms. The transfer from using the standard video conferencing with face-to-face video to using customizable avatar technology with an assigned scene environment presented an increase in patient retention and follow-through with the treatment goals. The continuous use of delivery of care using VR with the TheraVR software demonstrated breakthrough clinical observations where the patient devised her own interventions for coping with mood, emotional regulation, and negative cognitive processes using the 10 different VR environments.
CONCLUSIONS: This study shows the potential efficacy in using VR specifically for younger populations as a better modality of pediatrics care, while improving engagement with the provider through telehealth. These findings suggest the value of further research through larger clinical trials including pediatric patients diagnosed with severe trauma or trauma-related symptoms to assess the effectiveness of TheraVR software.

BACKGROUND: Patients with anorexia nervosa tend to experience an inner \"eating disorder\" voice. They struggle to recognise and assert their own identity over the illness\'s identity and relate to it from a powerless and subordinate position. AVATAR therapy was developed to help patients with psychosis to gain greater power and control over distressing voices. The goal of this study was to test the feasibility, acceptability, safety and preliminary efficacy of an adaptation of AVATAR therapy for anorexia nervosa.
METHODS: Twelve adult patients with anorexia nervosa were recruited. Ten completed an assessment session and between five to seven therapy sessions. The assessment session consisted in the creation of an avatar to represent the \"eating disorder\". This was accomplished by manipulating auditory and visual characteristics through a specialist computer software. During the therapy sessions, patients interacted with the avatar to assert their own desires and will. Patients completed baseline, end of intervention and follow-up (4-week) online questionnaires. A non-concurrent multiple baselines single case experimental design (SCED) was used (A1BA2). Feasibility, acceptability, safety and preliminary efficacy of the intervention were assessed.
RESULTS: The therapy met pre-specified criteria relating to (1) Feasibility: sample recruited within three months; retention rate at the end of the treatment phase = 81.9%; therapy completion rate = 90.1%. (2) Safety: no serious adverse events associated with the intervention. (3) Acceptability: mean ratings = 7.5 (SD = 2.61) out of ten, on a 0-10 scale of acceptability (10 = complete satisfaction). With regards to efficacy, participants reported significantly lower levels of distress associated with the eating disorder voice and higher levels of self-compassion at the end of treatment. No other significant changes were observed in frequency of the eating disorder voice, voice\'s characteristics, such as omnipotence and malevolence, eating disorder symptoms and symptoms of anxiety, depression and stress. Patients\' feedback indicated that the therapy had helped with their ability to stand up to the illness, make positive changes around eating, and increase their motivation to recover and self-compassion.
CONCLUSIONS: AVATAR therapy for anorexia nervosa is feasible, acceptable and safe for patients. Larger studies are needed to test clinical efficacy.
BACKGROUND: The study was pre-registered on the clinicaltrials.gov registry (https://clinicaltrials.gov/ct2/show/NCT04778423).
People with anorexia nervosa often struggle with connecting to their identity beyond the illness. They tend to relate to the eating disorder from a powerless and submissive position. The aim of this study was to test AVATAR therapy for anorexia nervosa. The goal of the intervention was to help patients to assert themselves, their identity, will, power and desires, when confronted with the “voice” of the illness. Twelve patients with anorexia nervosa were recruited and 10 completed one assessment session and five to seven therapy sessions. During the assessment session, patients were guided by the therapist to create a representation of their illness (“the avatar”) by manipulating visual and auditory characteristics through a computer software. During treatment, they were supported by the therapist to assert themselves over the illness, responding to the abusive and critical comments of the eating disorder delivered by “the avatar”. Patients’ qualitative feedback indicated that the therapy was meaningful to them, and that it helped to recognise their own voice as distinct from the illness. The distress perceived in relation to the eating disorder voice decreased over time, and feelings of self-compassion increased at the end of therapy. Findings point towards the acceptability and usefulness of AVATAR therapy for anorexia nervosa. Larger studies are needed expand these results.