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References

van Heugten-van der Kloet, D., Cosgrave, J., van Rheede, J., & Hicks, S. (2018). Out-of-body experience in virtual reality induces acute

dissociation. Psychology of Consciousness: Theory, Research, and Practice, 5(4), 346–357. https://doi-org.library.capella.edu

/10.1037/cns0000172

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Out-of-Body Experience in Virtual Reality Induces Acute Dissociation

By: Dalena van Heugten–van der Kloet

Department of Clinical Psychological Science, Faculty of Psychology & Neuroscience, Maastricht University, and Nuffield

Department of Clinical Neurosciences, John Radcliffe Hospital, Sleep and Circadian Neuroscience Institute, The Sir William Dunn

School of Pathology, University of Oxford;

Jan Cosgrave

Nuffield Department of Clinical Neurosciences, Sleep and Circadian Neuroscience Institute, The Sir William Dunn School of

Pathology, University of Oxford

Joram van Rheede

Department of Pharmacology, University of Oxford

Stephen Hicks

Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford

Acknowledgement:

Virtual reality (VR) creates novel computer-generated interactive environments that exchange actual real-life sensory perceptions

with synthetic perceptions in a virtual world (Steuer, 1992). VR has been cited as “a technological revolution in mental health

care” (Freeman et al., 2017, p. 1) because of its ability to create sensations or situations that are practically impossible to create

in real life. Indeed, central to all mental health issues is an individual’s struggle to engage or interact with the world (Freeman et

al., 2017), which is why VR offers considerable promise.

Dissociative symptoms refer to disturbances in the integration of thoughts, feelings, and experiences in consciousness and

memory (American Psychiatric Association, 2013) that can produce feelings of disembodiment and disconnectedness with the

self and the environment, as in cases of dissociative identity disorder and depersonalization/derealization syndrome. Dissociative

symptoms are notorious for their complex nature and encompass a wide variety of everyday experiences, including excessive

daydreaming, absorption, and severe absentmindedness. Broadly speaking, dissociative experiences can be described as lapses

in human consciousness, and are closely related to how we perceive ourselves and our surrounding environment. Indeed, part of

a broad definition of dissociation refers to the phenomenon as “a sense of experiential disconnectedness that may include

perceptual distortions about the self or the environment” (Cardeña & Carlson, 2011, p. 252), as well as an impairment in memory,

as in the case of dissociative amnesia.

Although as mental disorders, dissociative disorders such as dissociative identity disorder are considered to be relatively rare,

dissociative experiences are ubiquitous in both the general population and psychiatric samples (i.e., 4% and 29%, respectively,

exhibit severe dissociative pathology; Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006). As many as 80% to 90% of individuals

report at least mild dissociative experiences in their lifetimes (Gershuny & Thayer, 1999). Depersonalization refers to feeling

detached one’s mind or your body, and is often described as being a detached observer of one’s self (Sierra & Berrios, 2001). It

is the third most common psychological symptom, after feelings of depression and anxiety (Simeon, 2004), and can be a

symptom of panic disorder, posttraumatic stress disorder (PTSD), and can accompany sleep deprivation, migraine, and temporal

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lobe epilepsy (Lambert, Sierra, Phillips, & David, 2002). Relatedly, derealization is about an alteration in the perception of

experience of the external world so that it seems unreal, like seeing the world through a fog or feeling like living in a dream (APA,

2013). These symptoms are common, with a lifetime prevalence of around 5% and 31–66% during a traumatic event (Hunter,

Sierra, & David, 2004). Depersonalization/derealization (co-)occurs with a variety of mental disorders (i.e., dissociative disorders,

anxiety, bipolar disorder, borderline personality disorder, schizophrenia; Simeon, Knutelska, Nelson, & Guralnik, 2003), and

patients suffering from both depersonalization/derealization symptoms and a mental disorder such as anxiety or depression

predict a worse clinical picture with earlier age of onset, more functional impairment, and higher rates of current mental health-

care utilization (Michal et al., 2016).

Moreover, dissociative symptoms in general are considered an important (and often negative) feature in several mental health

diagnoses, including substance abuse (van Heugten-van der Kloet, Giesbrecht, van Wel, et al., 2015), PTSD (Stein et al., 2013),

psychosis (Pilton, Varese, Berry, & Bucci, 2015), and anxiety and depression (Mula, Pini, & Cassano, 2007). Dissociative

symptoms are also an important predictor of poorer treatment outcomes and prognoses in several disorders, including borderline

personality disorder (Kleindienst et al., 2011), obsessive–compulsive disorder (Rufer et al., 2006), PTSD (Rufer et al., 2006),

schizophrenia (Yu et al., 2010), and anxiety and depression (Prasko et al., 2016). Thus, developing a better understanding of

causes and predictors of dissociative experiences is of great relevance to the field of psychopathology.

Feeling a sense of connectedness within ourselves and our bodies is fundamental to being conscious of the self, that is, the

experience and behavior of being someone. An important term in this area is minimal phenomenal selfhood (MPS), which can be

defined as the simplest form of self-consciousness and forms the basis of contemporary studies on body perception and self-

consciousness (Blanke & Metzinger, 2009). There has been a recent flood of research on the topic of self-consciousness, with a

particular interest in the body. The self can be conceptualized as the “experience of being a distinct, holistic entity capable of

global self-control and attention, possessing a body and a location in time and space” (Blanke & Metzinger, 2009, p. 7). This

sense of embodiment can be experimentally researched using illusory own-body perceptions. These can entail manipulations for

parts of the body, such as the famous “rubber hand illusion” (Botvinick & Cohen, 1998), in which tactile sensations were referred

to an alien limb. They can also include full-body illusions in which conflicting visual and somatosensory input in a virtual reality

setting creates a disruption of the spatial unity between the self and the body (Lenggenhager, Tadi, Metzinger, & Blanke, 2007).

These body-ownership illusions are important in understanding MPS because they manipulate our sense of having a body, which

forms a core component of MPS.

One such method of a body-ownership illusion involves creating an out-of-body experience (OBE). An OBE can be defined as,

while awake, seeing the body from a location outside of the physical body (Blanke, Landis, Spinelli, & Seeck, 2004). OBEs are

associated with a sense of disembodiment; that is, the subject of conscious experience is located outside the person’s bodily

borders (Blanke & Metzinger, 2009). OBEs have been successfully experimentally induced in the laboratory. For example,

Ehrsson (2007) manipulated participants to experience the location of their body to be at the location of a camera placed behind

their back, which was connected to a head-mounted display. He simultaneously touched the participant’s actual chest and the

chest of the “illusory body”(a location just below the camera) with two plastic rods. The combination of the visual perspective and

the multisensory information created the illusion that the participant was located behind his or her physical body.

An established challenge in studying dissociation is developing effective methodologies to induce dissociative symptomatology in

the laboratory. Previous attempts to induce dissociative states include sleep deprivation, which is time-consuming, invasive, and

expensive (van Heugten-van der Kloet, Giesbrecht, & Merckelbach, 2015) and by means of dot-staring or mirror-gazing (Dorahy,

Peck, & Huntjens, 2016), which has been shown to be limited in its effect size (Leonard, Telch, & Harrington, 1999). Nash, Lynn,

and Stanley (1984) and others (Cardeña, 2005; Tart, 1998; Tressoldi & Del Prete, 2007) have succeeded in either inducing OBEs

with hypnotic suggestions or studying them during hypnosis, but the ability to experience such a realistic and complex perceptual

hallucination has been examined only with highly suggestible individuals and may be very difficult to produce in less highly

suggestible participants.

Thus, the primary aim of our study was to pilot the efficacy of VR to induce acute dissociative symptomatology in a group of

healthy participants. Using VR equipment, participants experienced viewing themselves in the third person. Given that this

perspective is closely aligned with the core dissociative experience of depersonalization, we hypothesized that this perceptual

experience would induce dissociative experiences in healthy participants. Because of previous findings linking dissociation with

sleep, that is, chronic poor sleep quality relates to higher levels of dissociation, and experimentally induced sleep loss leads to an

acute increase in dissociative symptoms (van Heugten-van der Kloet, Cosgrave, et al., 2015), we also predicted that participants

with poorer sleep quality would be more vulnerable to experiencing dissociation than participants who report good sleep quality.

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Method

Participants

Twenty-five naïve volunteers (10 men, 15 women) took part in the study. Their mean age was 31 years (SD = 12.2; range =

18–60 years). Inclusion criteria included being 18 years or older and normal or corrected-to-normal vision, with the ability to give

informed consent. Exclusion criteria included a history of severe motion sickness or epilepsy, or having experienced

unpleasantness in a virtual reality scenario. The study was approved by the Medical Sciences Interdivisional Research Ethics

Committee, University of Oxford (MS-IDREC–C1-2015–039).

Design

Given the primary aim of this study was to pilot the efficacy of VR in inducing a dissociative state, we employed a within-subjects

design, with the baseline measurement of dissociative experiences for each participant acting as the comparison condition.

Participants were seated at all times. They were asked to wear an Oculus Rift (Menlo Park, CA) head-mounted virtual reality

display that filled the wearer’s view up to 100 degrees. The Oculus Rift is padded and comfortable and was connected by a cable

over the shoulder to a laptop computer. A camera stand was placed approximately three meters in front of the participant with a

wide-angle GoPro (San Mateo, CA) video camera. The camera was positioned at standing eye level p (approx. 1.70 m) so that

the participants were able to see themselves, the experimenter, and the surrounding environment (see Figure 1). Participants

were asked to partake in a number of simple exercises that lasted for a maximum of 5 min while wearing the Oculus Rift (see

Procedure section). Furthermore, participants completed a questionnaire on sleep quality (the Sleep Condition Indicator) and the

Clinician-Administered Dissociative States Scale (CADSS) before and after the perceptual experience (see Measures).

Figure 1. Oculus Rift and Go-Pro camera set-up.

Measures

SCI

The SCI (Espie et al., 2014) measures insomnia disorder with eight items. Scores range from 0–32, with lower scores indicating

poorer sleep quality. The scale has good psychometric properties including good internal consistency, Cronbach’s α = .86 (Espie

et al., 2014). Internal consistency for the current sample was strong as well, with Cronbach’s α = .87.

Clinician-Administered Dissociative States Scale (CADSS)

The CADSS (Bremner et al., 1998; Cronbach’s α pre = .84; post = .93) is a 27-item scale with 19 participant-rated items, and

eight observer-scored items, which are scored on a 5-point scale (0 = not at all, 4 = extremely). The CADSS has three subscales:

Amnesia (Items 14, 15), Depersonalization (Items 3–7), and Derealization (Items 1, 2, 8–13, 16–19). The items are presented in

Table 2. Bremner and colleagues (1998) found the CADSS to be a highly reliable and valid instrument for measuring present-

state dissociative symptoms. We administered only the self-report items.

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Main Endorsement of CADSS Items and Partial Correlations With the SCI, Controlling for Age and Gender

Procedure

Participants were asked to participate in the study during a science open day (during Brain Awareness Week) at the Museum of

the History of Science, which was conducted by Dalena van Heugten–van der Kloet and Stephen Hicks. They were invited to

experience virtual reality and were informed about completing questionnaires before and after the experience. They all provided

written informed consent. Participants were placed on a swivel chair directly in front of the camera, making it possible for them to

see themselves from the position of the GoPro camera, that is, in the third person (see Figure 1–1). We then carried out the

following protocol. First, we swiveled the participant slowly from left to right while keeping the base of the chair stationary (see

Figure 1–2), which allowed participants to adjust to the new visual perspective. Participants were then asked if this experience

induced any experiences of nausea; all answered no.

Second, the experimenter moved the swivel chair, that is, the actual participant, to the side of the angle and then outside the

angle of the camera, rendering the virtual participant no longer visible to the actual one (see Figure 1–3). Third, the experimenter

began talking directly into the camera, which gave the participant the illusion that the experimenter was looking directly into the

participant’s eyes, which was designed to induce the experience of being present at the position of the camera (the virtual

participant) rather than in his or her own physical body (depersonalization). Fourth, participants were instructed to conduct three

exercises to strengthen the illusion of depersonalization. First, the experimenter asked if he could touch the shoulder of the virtual

participant a number of times. During this exercise, one experimenter touched a point beneath the camera that corresponded to

the location of the participant’s shoulder, while a second experimenter standing behind and out of sight of the participant touched

the actual participant’s shoulder simultaneously. This methodology is based on a previous finding in VR research that, if a

person’s chest is stroked during a VR condition, this person would not feel the touch as strongly as if an area below the camera

were stroked (Blanke & Metzinger, 2009). Second, participants were instructed to slowly raise their right arms while the second

experimenter stood behind the camera and mimicked the exact movements to induce a feeling of control over the experimenter’s

arm, that is, the illusion that the experimenter’s arm was their own. Third, the experimenter surprised the participant by throwing a

ball to the camera and asking her or him to catch it. These exercises were considered an enjoyable experience, having provided

no discomfort.

Results

Mean scores and Pearson product–moment correlations between sleep quality and acute dissociation before and after the OBE

are displayed in Table 1. Given the skewed distribution of the CADSS (Bremner et al., 1998) and CADSS change scores, we

performed a nonparametric Wilcoxon signed-ranks test with continuity correction. Acute dissociation was found to increase

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significantly following VR exposure, W = 297.5, p < .001 (see Figure 2a). No gender differences in dissociative states (pre- or

post-VR) were observed in this sample (see Figure 2b). We examined the individual items of the CADSS (see Table 2) to

determine which dissociative experiences were most influenced by VR. Items 1, 3–7, and 17 evidenced the greatest levels of

change (see Figure 2c). These are the items that pertain to Depersonalization (3–7) and Derealization (1, 17). Finally, we

explored which items were most frequently newly endorsed after VR exposure (see Figure 2d). We found that the greatest

changes from pre- to postexposure were in Items 1 (“Do things seem to be moving in slow motion?”), 4 (“Do you feel as if you are

looking at things from outside of your body?”), 6 (“Do you feel disconnected from your own body?”), and 7 (“Does your sense of

your own body feel changed? For instance, does your own body feel unusually large or unusually small?”). Pertaining to the

subscales of the CADSS, increases in acute dissociation therefore seemed specifically expressed in feelings of

Depersonalization (Items 4, 6, 7) and Derealization (Item 1).

Mean Scores and Pearson Product–Moment Correlations Between Subjective Sleep Quality and Acute Dissociation Before and

After the Out-of-Body Experience (N = 25)

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Figure 2. Endorsement of acute dissociation before and after virtual reality (VR) exposure. (1a) Mean Clinician-Administered

Dissociative States Scale (CADSS) scores pre–post VR exposure; (1b) gender differences in CADSS scores pre–post VR

exposure; (1c) CADSS items endorsement pre–post VR exposure; (1d) changes in endorsement of CADSS items pre–post VR

exposure.

Table 2 also displays the exploratory partial correlations with the SCI (Espie et al., 2014) after controlling for gender and age. We

found significant correlations between SCI and three items that assess Derealization on the CADSS (Bremner et al., 1998; Items

8, 17, and 18), revealing a tentative inverse relation between sleep quality and acute Derealization.

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Discussion

The primary aim of our study was to pilot the efficacy of VR (via simulating out-of-body experiences in 25 participants) to induce

dissociative states in healthy subjects. Our findings highlight a significant increase in acute dissociation after VR exposure,

particularly with respect to the endorsement of depersonalization on the CADSS (Bremner et al., 1998). Our study is, to the best

of our knowledge, the first to offer preliminary support that the application of VR offers a viable method to induce dissociative

states in healthy participants.

Further applications of this work would include exploring three of the seven core uses of VR, as described by Freeman (2008).

First, establishing causal factors, that is, manipulating the factor of interest (in this case, dissociation) and understanding the

ramifications or short-term impact of inducing dissociative states in both healthy participants and psychiatric populations. A

second, but related, application is establishing the correlates of the symptom of interest (i.e., dissociation). These could be state,

or in the moment experiences (e.g., fatigue) or baseline traits/demographics (i.e., trait neuroticism or anxiety). Finally, following

from this, is it then possible to identify what are referred to as “differential predictors” (Freeman, 2008, p. 607), that is, predictors

that have alternate effects based on how they interact with different states or traits. For example, high trait anxiety may be more

likely to induce paranoia in highly dissociative states, whereas low trait anxiety may be more related to nonpsychopathological

outcomes, such as mind-wandering or amnesia.

A number of applications for the treatment of psychiatric disorders using VR have already been established (for a review, see

Freeman et al., 2017). Thus far, this research has been heavily dominated by treatment programs in anxiety disorders

(particularly phobias), psychosis (specifically persecutory ideation), and eating and substance-abuse disorders to a lesser extent

(Freeman et al., 2017). Further investigations of dissociative symptomatology in mental health disorders could be of real benefit

to the field, given their prevalence on a transdiagnostic basis. Indeed, a long-term goal of research in this area may be the ability

to work more effectively with patient groups for whom dissociative symptomatology is a known cause of significant impairment.

More specifically, the induction of dissociation could facilitate the ability of patients to recognize the onset of the experience, and,

in turn, learn to avoid or manage their symptoms (Leonard et al., 1999).

Another promising avenue for future research using VR is in the assessment of psychological symptoms in diagnosing mental

health disorders. Recent studies point to the possibilities of inducing symptoms in an artificial setting to measure them more

directly and objectively, instead of relying on patients’ self-reports (Veling, Moritz, & van der Gaag, 2014). The use of these

techniques in diagnostic assessment still remains in its infancy, yet holds great potential for the field (Krijn, Emmelkamp,

Olafsson, & Biemond, 2004; Veling et al., 2014). For example, it would be interesting to examine similarities and differences

between “natural” OBEs and laboratory or induced OBEs and determine which stimuli and personality characteristics are

conducive to or moderate OBEs in the laboratory, as well as in more naturalistic (i.e., not experimentally induced) situations.

Our study also yields interesting speculations with regard to the induction of dissociative experiences and their relation to self-

consciousness. When studying these links, two important brain networks need to be considered: the default mode network

(DMN) and the central executive network (CEN), which are continuously active during waking cognition and sleep (de la Salle et

al., 2016). The DMN is active during passive rest and mind-wandering—a state in which we find ourselves most of the time.

Accordingly, the constant presence of subpersonal and automatically generated mental activity might be the most functional core

of human self-consciousness (Mantini & Vanduffel, 2013). DMN activity is negatively correlated with the CEN, which is geared

toward externally oriented processes such as attention. Rather, the DMN reflects internal processes, such as self-reference and

emotional states of one’s self and others. When our minds are not wandering, spatial self-location, temporal self-location, and

self-identification coincide; however, during mind-wandering, these aspects of consciousness become functionally dissociated

(Blanke & Metzinger, 2009). One might speculate that an OBE via VR might thus be a suitable technique to interfere with or

manipulate the DMN, and therefore serve as a method to study self-consciousness and dissociation.

Imbalance between these networks may underlie clinical and cognitive features of various psychiatric disorders (Menon, 2011).

Specifically, a reduced negative correlation between DMN and CEN is thought to confuse internal and external mental contents,

producing “self-environment blurring” (Vollenweider et al., 1997). Experiencing less clear distinctions between the self and the

environment, because the DMN and CEN are not acting as separate agents, potentially provides a mechanistic pathway to

explain dissociative symptoms.

Relatedly, Simeon (2004) provided preliminary physiological evidence linking dissociation to dysfunction in brain areas connected

to the DMN, including alterations in metabolic activity in the sensory association cortex and prefrontal hyperactivation and limbic

inhibition in response to aversive stimuli. Furthermore, a recent study using fMRI in 21 patients with PTSD (Tursich et al., 2015)

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showed that dissociation was associated with reduced DMN connectivity and altered synchrony between DMN and CEN.

Accordingly, the dynamic relationship between the DMN and the CEN is worthy of study in terms of shifts in the sense of self and

the environment generally, and in particular, as it relates to depersonalization/derealization.

A secondary goal of this experiment was to understand whether poor sleep quality was a symptom correlate of the level of

dissociation induced, which is why we had each participant rate his or her sleep quality before the experiment. We found that

poorer sleep quality was related to qualitatively higher initial scores of acute dissociation before the VR. This correlation is

consistent with earlier studies, although not statistically significant because of weak power (Aviram & Soffer-Dudek, 2018;

Giesbrecht, Smeets, Leppink, Jelicic, & Merckelbach, 2007; Soffer-Dudek et al., 2017; van Heugten-van der Kloet, Cosgrave, et

al., 2015). This association demonstrated remarkable specificity to Items 7, 17 and 18 on the CADSS, that is, the three items

responsible for assessing derealization. This finding fits well with research by Picchioni, Duyn, and Horovitz, (2013), who studied

sleep as a modulator of DMN and identified how sleep stages are linked to various connectivity levels between DMN and CEN.

Specifically, sleep loss results in both a decreased connectivity within the DMN and between the DMN and the CEN. However,

these results should be interpreted with caution, as we found no association between the overall scores on either measure, nor

did we find a relation between sleep quality and the change in dissociation pre- to postexperiment, most likely because of power

issues.

Recent studies have focused on the link between sleep quality and dissociation, in an attempt to explore the possibilities of

normalizing sleep and reducing dissociation as a consequence (van der Kloet, Lynn, Giesbrecht, Merckelbach, & de Zutter,

2012). These findings therefore warrant further study, as they might point in a direction of specifying outcome measures for future

studies (i.e., focusing more specifically on connecting derealization to sleep-quality measures). A treatment focused on sleep

normalization might specifically target and reduce derealization experiences.

Several caveats merit mention. The exploratory design, small sample size, absence of psychopathology measures, and lack of a

comparison group direct us to interpret our findings with caution. All participants were recruited during a public engagement event

in Oxford, England, which inevitably would have influenced the sampling of the study and the demographics of the participants.

Because of the location, we were not able to reduce ambient noise. Potentially, participants might have had better insight into

their bodies’ location as a result of directional hearing.

Another limitation relates to exploring the induction of depersonalization by way of an OBE, which is a core feature of

dissociation. The mere fact that these illusions isolate specific components of dissociation, focusing on depersonalization rather

than studying dissociation as a whole, is a fundamental caveat in itself. Earlier studies have already identified the paradox of how

we perceive our bodies both as objective “things” that are part of the world, and as subjective forms that comprise our means of

interacting with the world. It is the absence of experiencing the objective body that gives us the feeling of interacting with the

world (Gallagher, 1986; Metzinger, 2004). Thus, it is through ignoring the objective sense of our bodies that we create the mental

space to function within our environment. To illustrate, consider the common feeling of nervousness about giving a presentation

to an audience. Acute awareness of our bodies, for instance, raised heart rate, blushing, or sweating might prevent us from

connecting with the audience and delivering the speech.

However, in body-illusion experiments, when we manipulate such perceptual features as body location, we might only target this

one objective part of our experience, thus making links with dissociation and MPS difficult (Limanowski, 2014). Admittedly, to feel

as if we are interacting with our environment, we need to disconnect from our objective sense of body, rather than focus on it, as

in body-illusion experiments. As dissociation causes us to feel disconnected from ourselves and our environment, it would be

preferable to study both subjective and objective senses of ourselves as a whole. Conversely, Metzinger (2013) proposed that

the “currently active conscious content that generates the subjective experience of ‘I am this’” may change during mind-

wandering and out-of-body experiences, and thus potentially also when experiencing acute dissociative symptoms. Therefore,

the claim that we need an objective body representation for MPS may be incorrect. For example, when we sleep and we are

disconnected from exteroceptive sensory input, we still experience the presence of a core self. Therefore, the study of self-

consciousness and its relations with acute dissociation and sleep quality should be considered important.

A final caveat entails the possible influence of demand characteristics, as the hypotheses of the study were quite transparent:

Participants may well have expected an increase in dissociative experiences as a consequence of the procedures implemented.

These caveats notwithstanding, we believe that our study represents an important contribution and paves the way for

investigating and using VR in the induction, assessment, and treatment of dissociative symptomatology. Dissociative experiences

and symptoms are very common in both general and patient populations, and dissociative disorders remain recalcitrant to

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treatment. Thus, recent technological developments in VR could provide a valuable and fruitful path to understanding dissociative

symptomatology in the future.

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Submitted: October 16, 2017 Revised: July 3, 2018 Accepted: August 5, 2018

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Source: Psychology of Consciousness: Theory, Research, and Practice. Vol. 5. (4), Dec, 2018 pp. 346-357)

Accession Number: 2018-53491-001

Digital Object Identifier: 10.1037/cns0000172

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