About Health Impact Studio
We are a dedicated team of developers and researchers with the mission to improve the health of individuals through novel technology including games, virtual reality, and role-playing simulations. We welcome input from the full range of stakeholders to create a customer experience with the broadest applicability to improving health outcomes.
In order to develop novel, game-based approaches to impact the health problem of obesity, especially contributing factors that resemble addiction, we earlier discussed Addiction Theory. Through understanding both addiction and its treatment, we are better able to design games that would support those who struggle with addictive aspects of overeating. In this blog, we look at the evidence-based psychotherapy for treating addiction, Cue Exposure Therapy.
Cue Exposure Therapy (CET) is a commonly used method in substance abuse treatment that uses repeated and controlled exposure to an addictive substance in order to change the patient’s response to it . We looked at CET in order to discover potential ways this therapy might be applied to decrease food cravings. CET operates in two ways:
- Extinction Response. The extinction response to treat addiction is evoked by exposing someone repeatedly to the substance that tempts them, so much that there response is basically tired out and they stop responding as strongly. The tempting substance in the case of obesity is high caloric, relatively unhealthy food. We theorize that conditioned responses to these unhealthy foods, often caused by the rewarding effects the food’s high fat and added sugar, might be reversed using the extinction response. The individual who is struggling with obesity would be exposed to food simulations repeatedly, which would initially evoke craving. However, being only a simulation and not real food, they would not be allowed to eat it and thus would experience no reward (which is called “response prevention”). Eventually the individual would have less reaction to the food when they encounter it in daily life . Through repeated exposure, the individual also learns that he or she can tolerate seeing foods they are trying to avoid, for example, in a store or at a party, and not responding by eating them.
- Counter-conditioning. In counter-conditioning, an unwanted behavior is replaced with a positive action and the new behavior is rewarded . As with extinction, the individual would be repeatedly exposed to unhealthy food stimuli, but this time they would be encouraged to respond with some alternative behavior to eating the food . The alternative response that is encouraged is often an adaptive, coping response. For instance in a game, rather than responding to an unhealthy but tempting food by eating it, the game structures could guide the player to reject the food physically by hitting it away. To further reinforce the alternative response, the player gains points and power-up privileges in the game. Another alternative response that could be presented via a game is a healthy substitute food. Choosing the alternative response of eating the healthy, alternative food would be rewarded in the game. Repeating these actions many times in a game may transfer to a real life change of making a similar alternative response when presented with the opportunity to choose foods to eat.
- Paris MM, Carter BL, Traylor AC, Bordnick PS, Day SX, Armsworth MW, & Cinciripini PM. Cue reactivity in virtual reality: The role of context. Addictive Behaviors.2011; 36:696-699. http://www.ncbi.nlm.nih.gov/pubmed?term=Cue%20reactivity%20in%20virtual%20reality%3A%20The%20role%20of%20context. Accessed on: 2/5/2013.
- Garcia-Rodriguez O, Pericot-Valverde I, Gutiérrez-Maldonado J, Ferrer-García M, & Secades-Villa R. Validation of smoking-related virtual environments for cue exposure therapy. Addictive Behaviors.2012; 37:703-708. http://www.ncbi.nlm.nih.gov/pubmed/22385732. Accessed on: 2/5/2013.
- Bordnick PS, Traylor A, Copp HL, Graap KM, Carter B, Ferrer M, & Walton, AP. Assessing reactivity to virtual reality alcohol based cues. Addictive Behaviors. 2008; (33):743-756. http://www.ncbi.nlm.nih.gov/pubmed/18282663. Accessed on: 2/5/2013.
- Kaplan GB, Heinrichs SC, Carey RJ. Treatment of addiction and anxiety using extinction approaches: neural mechanisms and their treatment implications. Pharmacol Biochem Behav. 2011; (97):619-25. http://www.ncbi.nlm.nih.gov/pubmed/20723558. Accessed on: 3/15/13.
- Romano DM. Virtual Reality Therapy. Developmental Medicine & Child Neurology. 2005; (47):580. https://www.cambridge.org/core/journals/developmental-medicine-and-child-neurology/article/virtual-reality-therapy/C8AD25FBE37D67292949D34610D3855D. Accessed on: 3/15/13.
- O’Brien CP, Childress AR, McLellan T, Ehrman R. Integrating systemic cue exposure with standard treatment in recovering drug dependent patients. Addict Behav. 1990; (15):355-65. http://www.ncbi.nlm.nih.gov/pubmed/2248109. Accessed on: 3/15/13.
- Lee JH, Kwon H, Choi J, Yang BH. Cue-exposure therapy to decrease alcohol craving in virtual environment. Cyberpsychol Behav.2007; (5):617-23. http://www.ncbi.nlm.nih.gov/pubmed/17927528. Accessed on: 11/1/11.
- Dinska VG, Frank B, Vansteenwegen D, Hermans D, & Beckers T. Counterconditioning reduces cue-induced craving and actual cue-elicited consumption. Journal of Psychology.2010; (10):1528-3542. http://www.academia.edu/588931/Counterconditioning_reduces_cue-induced_craving_and_actual_cue-elicited_consumption. Accessed on: 4/1/2013.
Prior, we discussed similarities between addiction and obesity (See Obesity and Addiction: How They Are Similar). An understanding of addiction theory may offer further insights into potential ways to help people suffering from addictive aspects of overeating.
The cyclical nature of addiction is widely recognized. To facilitate thinking about the possibility of obesity being caused by an addiction-like process, let’s look at the addiction cycle that is widely recognized for substance abuse and substitute food-related words for drug-related terms.
The addiction cycle starts with physical and emotional triggers leading to an urge to use the substance / unhealthy food / amount of food. The urge is characterized by preoccupation with thinking about the food, obtaining the food, anticipating eating it, and craving it. These feelings build until the afflicted person eats the food, sometimes to excess, and experiences pleasure from the experience and temporary relief from the urge. The period of relief is soon replaced by a growing physical urge to eat the food again. The individual may suffer a bad mood, with guilt and/or depression as a consequence of the last unhealthy food eaten or last eating binge. The growing urge to eat unhealthily is then relieved temporarily again.
Imaging studies in animals and humans have shown that different areas of the brain are centers for the three stages of the addiction cycle (Koob & Volkow, 2010):
- Ventral tegmental area and ventral striatum for binge/intoxication
- Amygdala for withdrawal/negative affect stage
- Orbitofrontal cortex-dorsal striatum, prefrontal cortex, basolateral amygdala, hippocampus, and insula for craving
- Cingulate gyrus, dorsolateral prefrontal, and inferior frontal cortices for interruption of inhibitory control
The brain undergoes physical changes over time in substance use disorders. Interventions that target the cognitive/emotional aspects of addiction need to be powerful enough to counteract these changes.
Therapies aim to interrupt addiction at various points in the cycle. Adjunctive supports might also interrupt progression from encountering a food cue, to experiencing an urge to eat it, to actually eating the food or too much food.
Inhibitory control is an executive function that involves controlling one’s thoughts, attention, and emotions and one’s behaviors in response to them. Inhibitory control is thus important in recovering from addiction. Research has shown that training can improve executive functions across the lifespan (Best et al., 2010; Best et al., 2014). Working memory is an important component of inhibitory control. It involves short-term storage and manipulation (Malenka et al., 2015). Thus, it plays a role in decision-making and is important in changing behavior. The prefrontal cortex is an important part of the brain in executive functioning (Malenka et al., 2015). Engaging the prefrontal cortex exerts control over more automatic responses occurring in other cortical regions, such as the association cortex, and subcortical structures responsible for emotion and motivation, including the amygdala and ventral striatum or nucleus accumbens.
Next, we’ll look at Therapeutic Approaches Commonly Used for Treating Addiction for further insights into possible ways to interrupt addictive aspects of overeating.
- Best JR, Miller PH. A developmental perspective on executive function. Child Dev. 2010; 81(6): 1641-1660. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058827/. Accessed, 2/19/2016.
- Best JR, Nagamatsu LS, Liu-Ambrose T. Improvements to executive function during exercise training predict maintenance of physical activity over the following year. Front Hum Neurosci. 2014; 8: 353.
- Koob GF, Volkow ND. Neurocircuitry of addiction. Neuropsychopharmacology. 2010. 35, 217-238. Available at: http://www.nature.com/npp/journal/v35/n1/abs/npp2009110a.html. Accessed 2/23/2016.
- Malenka RC, Nestler EJ, Hyman SE. Chapter 13: Higher Cognitive Function and Behavioral Control. Chapter 14 & 15. In Sydor A, Brown Ry. Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.) New York: McGraw-Hill Medical. pp. 313-321. 2015 ISBN 9780071481274.
Bradley Tanner, MD, ME is a psychiatrist and Studio Head of HealthImpact.studio. In this role, he guides the development and evaluation of novel technological solutions to address health challenges including burnout, stress, and depression seen in medical students, residents, and practicing physicians in their early and later careers. You can reach Dr. Tanner at firstname.lastname@example.org. Personal health concerns and concerns related to suicidality should be addressed with your health professional.