Disturbances of spontaneous empathic processing relate with the severity of the negative symptoms in patients with schizophrenia: A behavioural pilot-study using virtual reality technology

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Virtual reality-based assessment and treatment of social functioning impairments in psychosis: a systematic review

People with psychosis can experience social functioning impairments. Virtual reality (VR) has been used to assess and treat these difficulties. This systematic review (Prospero CRD42015026288) provides an evaluation of these VR applications. PsycINFO, MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus were searched until May 2020. The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess studies. Database searching identified 3810 titles. Fifty-eight studies (published 2005-2020; N = 2,853), comprising twenty-six head-mounted display studies (20 assessment, 6 treatment) and thirty-two immersive 2D screen studies (23 assessment, 9 treatment), were included. There were forty-eight observational studies and ten randomised controlled trials, with 1570 participants (of which, 185 were at ultra-high risk of psychosis) in VR test groups. Nearly half the studies were published since 2016. Assessments targeted cognitive and behavioural indicators of social functioning, e.g. paranoia, eye gaze, or interpersonal distance. Treatments promoted cognitive-behavioural social skills or job interview training. Studies indicate feasibility, acceptability, and effectiveness of VR for social functioning impairments in psychosis. Limitations of studies include the narrow scope of social functioning, small sample sizes, and limited randomised controlled trials and standardised interventions. Findings suggest VR has potential to be integrated with existing psychological approaches.

The Relation Between Empathy and Insight in Psychiatric Disorders: Phenomenological, Etiological, and Neuro-Functional Mechanisms

Lack of insight, i.e., unawareness of one's mental illness, is frequently encountered in psychiatric conditions. Insight is the capacity to recognize (psychical insight) and accept one's mental illness (emotional insight). Insight growth necessitates developing an objective perspective on one's subjective pathological experiences. Therefore, insight has been posited to require undamaged self-reflexion and cognitive perspective-taking capacities. These enable patients to look objectively at themselves from the imagined perspective of someone else. Preserved theory-of-mind performances have been reported to positively impact insight in psychosis. However, some patients with schizophrenia or obsessive-compulsive disorders, although recognizing their mental disease, are still not convinced of this and do not accept it. Hence, perspective-taking explains psychical insight (recognition) but not emotional insight (acceptance). Here, we propose a new conceptual model. We hypothesize that insight growth relies upon the association of intact self-reflexion and empathic capacities. Empathy (feeling into someone else) integrates heterocentered visuo-spatial perspective (feeling into), embodiment, affective (feeling into) and cognitive processes, leading to internally experience the other's thought. We posit that this subjective experience enables to better understand the other's thought about oneself and to affectively adhere to this. We propose that the process of objectification, resulting from empathic heterocentered, embodiment, and cognitive processes, generates an objective viewpoint on oneself. It enables to recognize one's mental illness and positively impacts psychical insight. The process of subjectification, resulting from empathic affective processes, enables to accept one's illness and positively impacts emotional insight. That is, affectively experiencing the thought of another person about oneself reinforces the adhesion of the emotional system to the objective recognition of the disease. Applying our model to different psychiatric disorders, we predict that the negative effect of impaired self-reflexion and empathic capacities on insight is a transnosographic state and that endophenotypical differences modulate this common state, determining a psychiatric disease as specific.

A Short Empathy Paradigm to Assess Empathic Deficits in Schizophrenia

Empathy is important for successful social interaction and maintaining relationships. Several studies detected impairments in empathic abilities in schizophrenia, with some even indicating a broader deficit in several components, including emotion recognition, perspective taking, and affective responsiveness. The aim of our study was to validate a short version of the previous empathy paradigm as a reliable and easily applicable method to assess empathic deficits in patients with schizophrenia potentially within clinical routine. To do so, we applied the short version to 30 patients (14 females) diagnosed with schizophrenia meeting the DSM-5 criteria and 30 well-matched healthy controls (14 females). The data analysis indicates a significant empathic deficit in patients due to worse performance in all three domains. We managed to replicate most of the findings of our previous study. In contrary to the previous study, significant correlations between performance in the empathy tasks and psychopathology occurred: the severity of negative symptoms was negatively associated with performance in the emotion recognition task and the affective responsiveness task. Gender did not significantly affect performance in the empathy tasks. Regarding the results, our short empathy paradigm appears to be a valid method in assessing empathic impairments in schizophrenia that may be useful in clinical routine.

Self-other recognition impairments in individuals with schizophrenia: a new experimental paradigm using a double mirror

Clinical observations suggest early self-consciousness disturbances in schizophrenia. A double mirror combining the images of two individuals sitting on each side of the mirror was used to study self-other differentiation in 12 individuals with early onset schizophrenia (EOS) and 15 individuals with adult onset schizophrenia (AOS) compared to 27 typically developing controls (TDC) matched on age and sex. The effects of intermodal sensory perception (visual-tactile and visual-kinesthetic) on self-other recognition were also studied. The results showed that EOS and AOS individuals, independently of age and schizophrenia severity, were centered on their own image compared to TDC, with both significant earlier self-recognition and delayed other-recognition during the visual recognition task. In addition, there was no significant effect of intermodal sensory stimulation on self-other recognition in EOS and AOS patients, whereas self-centered functioning was significantly increased by visual-tactile stimulation and decreased by visual-kinesthetic stimulation in TDC. The findings suggest that self-other recognition impairments might be a possible endophenotypic trait of schizophrenia.

Behavioral Own-Body-Transformations in Children and Adolescents With Typical Development, Autism Spectrum Disorder, and Developmental Coordination Disorder

Background: In motor imitation, taking a partner's perspective often involves a mental body transformation from an embodied, ego-centered viewpoint to a disembodied, hetero-centered viewpoint. Impairments of both own-body-transformation (OBT) and abnormalities in visual-spatial processing have been reported in patients with neurodevelopmental disorders including autism spectrum disorder (ASD). In the context of a visual-motor interactive task, studying OBT impairments while disentangling the contribution of visual-spatial impairments associated with motor coordination problems has not been investigated. Methods: 85 children and adolescents (39 controls with typical development, TD; 29 patients with ASD; 17 patients with developmental coordination disorder, DCD), aged 6-19 years, participated in a behavioral paradigm in which participants interacted with a virtual tightrope walker (TW) standing and moving with him. The protocol enables to distinguish ego-centered and hetero-centered perspectives. Results: We show that (1) OBT was possible but difficult for children with neurodevelopmental disorders, as well as for TD children, when the task required the participant to perform a mental rotation in order to adopt a hetero-centered perspective. (2) Using multivariate models, hetero-centered perspective score was significantly associated with age, TW orientation, latency, and diagnosis. ASD and TD groups' performances were close and significantly correlated with age. However, it was not the case for DCD, since this group was specifically handicapped by visual-spatial impairments. (3) ASD and DCD did not perform similarly: motor performance as shown by movement amplitude was better in DCD than ASD. ASD motor response was more ambiguous and hardly readable. Conclusion: Changing perspective in a spatial environment is possible for patients with ASD although delayed compared with TD children. In patients with DCD, their visual-spatial impairments negatively modulated their performances in the experiment.

Empathy in schizophrenia: A meta-analysis of the Interpersonal Reactivity Index

Empathy is a complex construct, thought to contain multiple components. One popular measurement paradigm, the Interpersonal Reactivity Index (IRI), has been used extensively to measure empathic tendencies in schizophrenia research across four domains: empathic concern, perspective-taking, personal distress, and fantasy. However, no recent meta-analysis has been conducted for all four factors of this scale. The goal of this meta-analysis was to examine self-reported empathic tendencies for each factor of the IRI in people with schizophrenia as compared to healthy controls. A literature search revealed 32 eligible schizophrenia studies. The Hedges' g standardized difference effect size was calculated for each component using a random effects meta-analytic model. Compared to healthy controls, schizophrenia samples reported significantly reduced tendencies for empathic concern, perspective-taking, and fantasy, but significantly greater tendencies for personal distress. Duration of illness significantly moderated the results for perspective-taking such that those with a longer duration exhibited greater deficits; percent female significantly moderated the results for personal distress such that samples with more females exhibited reduced effect sizes. Future work is needed to examine the impact of heightened personal distress on the empathic tendencies and abilities of those with schizophrenia, including the possible role of emotion regulation.

Identifying Oneself with the Face of Someone Else Impairs the Egocentered Visuo-spatial Mechanisms: A New Double Mirror Paradigm to Study Self-other Distinction and Interaction

Looking at our face in a mirror is one of the strongest phenomenological experiences of the Self in which we need to identify the face as reflected in the mirror as belonging to us. Recent behavioral and neuroimaging studies reported that self-face identification not only relies upon visual-mnemonic representation of one’s own face but also upon continuous updating and integration of visuo-tactile signals. Therefore, bodily self-consciousness plays a major role in self-face identification, with respect to interplay between unisensory and multisensory processing. However, if previous studies demonstrated that the integration of multisensory body-related signals contributes to the visual processing of one’s own face, there is so far no data regarding how self-face identification, inversely, contributes to bodily self-consciousness. In the present study, we tested whether self–other face identification impacts either the egocentered or heterocentered visuo-spatial mechanisms that are core processes of bodily self-consciousness and sustain self–other distinction. For that, we developed a new paradigm, named “Double Mirror.” This paradigm, consisting of a semi-transparent double mirror and computer-controlled Light Emitting Diodes, elicits self–other face merging illusory effect in ecologically more valid conditions, i.e., when participants are physically facing each other and interacting. Self-face identification was manipulated by exposing pairs of participants to an Interpersonal Visual Stimulation in which the reflection of their faces merged in the mirror. Participants simultaneously performed visuo-spatial and mental own-body transformation tasks centered on their own face (egocentered) or the face of their partner (heterocentered) in the pre- and post-stimulation phase. We show that self–other face identification altered the egocentered visuo-spatial mechanisms. Heterocentered coding was preserved. Our data suggest that changes in self-face identification induced a bottom-up conflict between the current visual representation and the stored mnemonic representation of one’s own face which, in turn, top-down impacted bodily self-consciousness.

Affective empathy in schizophrenia: a meta-analysis

BACKGROUND

Affective empathy, or the emotional response one has to the experiences or emotional states of others, contributes to relationship-maintaining behaviors and is key in fostering social connections, yet no work has synthesized the body of literature for people with schizophrenia. The aim of the present meta-analysis was to determine the extent to which those diagnosed with schizophrenia experience deficits in affective empathy.

METHODS

A literature search was conducted of studies examining empathy. Data were analyzed using a random effects meta-analytic model with Hedges' g standardized mean difference effect size.

RESULTS

Individuals with schizophrenia exhibited significant, medium deficits in affective empathy (k=37). Measurement type moderated the affective empathy deficit such that performance-based measures showed larger schizophrenia group deficits than self-report measures.

CONCLUSION

Consistent, significant deficits in affective empathy were found comparing people with schizophrenia to healthy controls, especially when using performance-based assessments. The medium effect suggests an important role for empathy in the realm of social cognitive research, and points to the need for further investigation of measurement techniques and associations with functional outcomes.

AFPBN – Insight et empathie en psychiatrie

L’insight et l’empathie sont deux notions fondamentales en psychiatrie. Fondamentales, certes, mais difficiles à étudier lorsqu’on tente de les interroger de façon conjointe. En effet, à première vue, l’empathie et l’insight semblent s’opposer au point de vue phénoménologique mais aussi différer au point de vue neurofonctionnel. L’insight et l’empathie renvoient tout d’abord à des phénomènes, sinon contraires, du moins inverses. L’insight est un terme anglais sans équivalence en français, traduit par le terme d’« introvision » ou « voir à l’intérieur de » (« insight into »). En psychiatrie, il renvoie à la conscience qu’a le patient de son trouble, c’est-à-dire à la conscience qu’a le patient de lui-même comme sujet malade et de cette maladie comme étant la sienne. L’objet intentionnel de l’insight est, donc, le Soi en relation à sa pathologie. L’empathie est la traduction de l’allemand « Einfu - hlung » qui signifie « sentir [fu - hlen] dans [ein] ». L’empathie consiste en un processus mental de décentrement ou de transposition de soi dans autrui par lequel nous pouvons vivre et éprouver ce que l’autre vit et éprouve, comprendre le contenu de son expérience mais tout en maintenant la distinction entre soi et autrui. L’objet intentionnel de l’empathie est, par conséquent, autrui. Ainsi, l’insight et l’empathie semblent-ils renvoyer à deux phénomènes dont le mouvement intentionnel est inverse : « voir à l’intérieur de soi » et « sentir dans autrui ». De la même manière, du point de vue psychobiologique et neurofonctionnel, leurs bases neurales sont aussi distinctes : l’insight ferait plutôt intervenir l’insula alors que l’empathie mettrait en jeu un réseau cérébral très largement distribué au sein duquel la jonction temporopariétale aurait un rôle prépondérant. Mais l’empathie et l’insight sont-ils autant exclusifs l’un de l’autre que ce qu’une première approche pourrait laisser penser ? En effet, si l’empathie repose sur un décentrement de soi dans autrui qui permet d’adopter la perspective d’autrui, l’insight semble aussi reposer sur une forme de décentrement de soi par rapport à soi, permettant de prendre une perspective objective sur soi-même. C’est-à-dire de se voir soi-même comme autrui nous verrait de son point de vue. L’insight, dans sa dimension métacognitive, serait-il possible sans le développement des capacités empathiques de décentrement ? Inversement, comment le décentrement de soi dans autrui dans l’empathie qui repose sur des codages complexes du corps propre dans l’espace serait-il possible sans l’insight somesthésique ? En outre, certaines données de neuro-imagerie récentes montrent l’implication de l’insula dans l’empathie. Et on connaît l’implication de la jonction temporopariétale dans la conscience du Soi corporel. Sommes-nous alors face à des paradoxes ? Comment peut-on aller plus loin dans la compréhension de ces deux concepts ? Ces phénomènes peuvent-ils être étudiés en recherche translationnelle et être modélisés chez l’animal en vue d’une meilleure étude physiopathologique ? Quel serait le comportement empathique d’un animal par rapport à un autre en difficulté ? Que nous disent les premiers résultats en neuroscience psychiatrique (issus d’études réalisées dans le cadre d’un travail collaboratif entre l’unité de recherche clinique au centre hospitalier Henri-Laborit à Poitiers et l’équipe du Pr Alain Berthoz au Collège de France ? Nous espérons que ce symposium et les différents échanges formels et informels que nous y aurons nous permettront de clarifier l’interrelation de ces deux concepts.

New paradigms and tests for evaluating and remediating visuospatial deficits in children

This review suggests several hypotheses about the cognitive developmental mechanisms involved in the motor deficits of children with cerebral palsy. We suggest a new theory that visuospatial deficits involving the manipulation of multiple spatial reference frames are crucial components of the disorder in spatial orientation, manipulation, locomotion, navigation, and even social interactions. We review basic knowledge about the brain networks involved in spatial memory and cognition. We then present several potential paradigms for studying specific deficits. We consider first the use of vestibular signals for egocentric spatial orientation in children and the 'locomotor trajectory paradigm' for studying gaze anticipation and perceptual components of walking. We then describe new paradigms for studying egocentric and allocentric strategies in spatial tasks: the 'virtual path length', the 'virtual palace' and the 'virtual star maze'. We also consider paradigms involving the use of other persons and perspective change from a first person's to a third person's viewpoint as reference in spatial tasks or social interactions: the 'designation' paradigm, the 'harlequin', and the 'tightrope walker'. Finally, we briefly present a new experimental set up involving a 'virtual carpet', which follows previous studies of cognitive strategies for generating locomotor trajectories using the 'magic carpet' and which will allow a large variety of studies involving executive functions and inhibition of the first-appearing strategies during development. Several of these new paradigms could be used for remediation.