Simulating real world functioning in schizophrenia using a naturalistic city environment and single-trial, goal-directed navigation

Maladaptive explore/exploit trade-offs in schizophrenia

Schizophrenia is a complex disorder that remains poorly understood, particularly at the systems level. In this opinion article we argue that the explore/exploit trade-off concept provides a holistic and ecologically valid framework to resolve some of the apparent paradoxes that have emerged within schizophrenia research. We review recent evidence suggesting that fundamental explore/exploit behaviors may be maladaptive in schizophrenia during physical, visual, and cognitive foraging. We also describe how theories from the broader optimal foraging literature, such as the marginal value theorem (MVT), could provide valuable insight into how aberrant processing of reward, context, and cost/effort evaluations interact to produce maladaptive responses.

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.

Therapeutic Use of VR Serious Games in the Treatment of Negative Schizophrenia Symptoms: A Systematic Review

Schizophrenia is a chronic brain disorder that affects 1 in every 300 people worldwide. This study intended to perform a systematic review to describe the state-of-the-art of interventions involving patients with negative symptoms of schizophrenia that use Virtual Reality (VR) games as a complement to therapy, and to analyze the key features of such games. Literature research was conducted in three databases, namely, the Institute of Electrical and Electronics Engineers (IEEE), Scopus, and PubMed, to identify relevant publications dated from 2010 to 2021. Of the initial 74 publications found, only 11 satisfied the eligibility requirements and were included in this study. The results were then organized and displayed in a flow diagram. Overall, the results from the studies suggest that the use of VR in therapies enables an increase in social skills and a decrease in anxiety symptoms. The use of such technology in therapy has proven to be effective, although it still lacks features to provide better long-term results.

Mapping Personal Geographies in Psychosis: From Space to Place

Recently, there has been a growing interest in the interaction between the urban milieu and the development of psychosis. While growing up in an urban environment constitutes a risk factor for developing psychosis, patients who develop a first episode of psychosis tend to avoid city centers and suffer from isolation. These observations have fostered emerging interest in ways of developing contexts in cities that are favorable to mental health and that may help service users in their paths to recovery. Building on work on place attachment as well as systemic therapy, we present a new approach to map the urban spaces experienced by service users. We propose two tools, the "place attachment diagram" and "life space network," to situate emotional bond and spatial dimension respectively at their center and help service users to map meaningful places in the city. We also suggest that different facets of the illness such as epidemiological risk factors (residential mobility, migration, urban living, trauma), early place attachment and abnormal space experience, may shape individual space and place experience in psychosis. Psychotherapeutic process with patients should aim at turning urban "spaces" into "places" characterized by a sense of familiarity, security and opportunity. Finally, we argue that the "spatial" is a forgotten dimension in psychotherapy and should be taken into account when treating individuals with psychosis.

Urban remediation: a new recovery-oriented strategy to manage urban stress after first-episode psychosis

PURPOSE

Urban living is a major risk factor for psychosis. Considering worldwide increasing rates of urbanization, new approaches are needed to enhance patients' wellbeing in cities. Recent data suggest that once psychosis has emerged, patients struggle to adapt to urban milieu and that they lose access to city centers, which contributes to isolation and reduced social contacts. While it is acknowledged that there are promising initiatives to improve mental health in cities, concrete therapeutic strategies to help patients with psychosis to better handle urban stress are lacking. We believe that we should no longer wait to develop and test new therapeutic approaches.

METHOD

In this review, we first focus on the role of urban planning, policies, and design, and second on possible novel therapeutic strategies at the individual level. We review how patients with psychosis may experience stress in the urban environment. We then review and describe a set of possible strategies, which could be proposed to patients with the first-episode psychosis.

RESULTS

We propose to group these strategies under the umbrella term of 'urban remediation' and discuss how this novel approach could help patients to recover from their first psychotic episode.

CONCLUSION

The concepts developed in this paper are speculative and a lot of work remains to be done before it can be usefully proposed to patients. However, considering the high prevalence of social withdrawal and its detrimental impact on the recovery process, we strongly believe that researchers should invest this new domain to help patients regain access to city centers.

Goal-directed planning and action impairments in schizophrenia evaluated in a virtual environment

Planning and executing goal-directed behaviours are critical final steps in translating motivation into action. Amotivation is a key feature of schizophrenia, but its impact on goal-directed functioning has not been extensively studied in an objective and ecologically valid manner. To address this, we investigated goal-directed planning and action in schizophrenia using a virtual reality task, the Multitasking in the City Test (MCT). The MCT was administered to 49 outpatients with schizophrenia and 55 healthy controls, and required participants to complete a series of errands in a virtual city. Ability to complete the task as directed was assessed by a performance score based on errands completed and errors committed. Task efficiency was evaluated by the total distance travelled, and an index of path efficiency comparing an optimal route with the traversed route. Schizophrenia participants had lower performance scores, travelled farther, and had reduced path efficiency compared to healthy controls. Greater distance travelled and lower path efficiency in schizophrenia were related to amotivation. Path efficiency in schizophrenia was also related to neurocognition, including planning ability; notably, this relationship appeared to be independent of the relationship with amotivation. Individuals with schizophrenia demonstrated impaired goal-directed planning and action in the context of a simulated everyday errands task, both in terms of reduced capacity to complete errands and reduced efficiency in doing so. The latter may manifest as diminished real-world motivated and functional behaviour in patients with schizophrenia and indicates a specific deficit in the execution of planned behaviour.

Virtual Reality Objectifies the Diagnosis of Psychiatric Disorders: A Literature Review

BACKGROUND

To date, a diagnosis in psychiatry is largely based on a clinical interview and questionnaires. The retrospective and subjective nature of these methods leads to recall and interviewer biases. Therefore, there is a clear need for more objective and standardized assessment methods to support the diagnostic process. The introduction of virtual reality (VR) creates the possibility to simultaneously provoke and measure psychiatric symptoms. Therefore, VR could contribute to the objectivity and reliability in the assessment of psychiatric disorders.

OBJECTIVE

In this literature review, we will evaluate the assessment of psychiatric disorders by means of VR environments. First, we investigate if these VR environments are capable of simultaneously provoking and measuring psychiatric symptoms. Next, we compare these measures with traditional diagnostic measures.

METHODS

We performed a systematic search using PubMed, Embase, and Psycinfo; references of selected articles were checked for eligibility. We identified studies from 1990 to 2016 on VR used in the assessment of psychiatric disorders. Studies were excluded if VR was used for therapeutic purposes, if a different technique was used, or in case of limitation to a non-clinical sample.

RESULTS

A total of 39 studies were included for further analysis. The disorders most frequently studied included schizophrenia (n = 15), developmental disorders (n = 12), eating disorders (n = 3), and anxiety disorders (n = 6). In attention-deficit hyperactivity disorder, the most comprehensive measurement was used including several key symptoms of the disorder. Most of the studies, however, concerned the use of VR to assess a single aspect of a psychiatric disorder.

DISCUSSION

In general, nearly all VR environments studied were able to simultaneously provoke and measure psychiatric symptoms. Furthermore, in 14 studies, significant correlations were found between VR measures and traditional diagnostic measures. Relatively small clinical sample sizes were used, impeding definite conclusions. Based on this review, the innovative technique of VR shows potential to contribute to objectivity and reliability in the psychiatric diagnostic process.

A Serious Game to Improve Cognitive Functions in Schizophrenia: A Pilot Study

Cognitive deficits in schizophrenia impair everyday functioning and instrumental daily living activities. These disabilities can be partly responsible for chronicity and institutionalization. We present here a virtual reality (VR) tool in which patients with schizophrenia performed a virtual game in an imaginary town during a 3-month program. In a pilot study, seven patients with schizophrenia (DSM-5), institutionalized for many years, attended weekly 1-h-and-a-half sessions organized by two clinicians. During the first sessions, they listed together the difficulties they experienced in everyday organization and planning. After being familiarized with the joystick and the VR environment, they navigated in the town, and planned actions that were difficult for them to carry out in their usual life (e.g., shopping, memorizing the way to the supermarket or being on time at a meeting point). They had to look for alternative routes and practice a switch from a 2D Map to the 3D Map. They also gathered their efforts to share strategies for each action, or discussed the action plan they could generate to solve concrete problems. The pre/post-neuropsychological evaluations showed attention, working memory, prospective, and retrospective memory benefits, but no improvement in planning as assessed by the Zoo map test and the action program subtest of Behavioral Assessment of the Dysexecutive Syndrome. Patients also clinically and functionally improved, gaining autonomy. Pragmatically, they reported a strong energy to elaborate concrete plans to search for jobs, or return to activities in the community. Qualitative assessments showed a benefit in sparing time, planning better, enriched relatedness, and better management of their housework. This VR game opens avenue to rehabilitation for patients with schizophrenia experiencing chronicity in their life, less attendance in daycare units, and a better community living. This program might reduce neurocognitive difficulties and might evolve into a true method for cognitive remediation (trial n° 2011-A00988-33).

The Effects of Video Games on Cognition and Brain Structure: Potential Implications for Neuropsychiatric Disorders

Video games are now a ubiquitous form of entertainment that has occasionally attracted negative attention. Video games have also been used to test cognitive function, as therapeutic interventions for neuropsychiatric disorders, and to explore mechanisms of experience-dependent structural brain changes. Here, we review current research on video games published from January 2011 to April 2014 with a focus on studies relating to mental health, cognition, and brain imaging. Overall, there is evidence that specific types of video games can alter brain structure or improve certain aspects of cognitive functioning. Video games can also be useful as neuropsychological assessment tools. While research in this area is still at a very early stage, there are interesting results that encourage further work in this field, and hold promise for utilizing this technology as a powerful therapeutic and experimental tool.

Virtual Reality Job Interview Training for Veterans with Posttraumatic Stress Disorder

BACKGROUND

Veterans with posttraumatic stress disorder (PTSD) have low employment rates and the job interview presents a critical barrier for them to obtain competitive employment.

OBJECTIVE

To evaluate the acceptability and efficacy of virtual reality job interview training (VR-JIT) among veterans with PTSD via a small randomized controlled trial (n=23 VR-JIT trainees, n=10 waitlist treatment-as-usual (TAU) controls).

METHODS

VR-JIT trainees completed up to 10 hours of simulated job interviews and reviewed information and tips about job interviewing, while wait-list TAU controls received services as usual. Primary outcome measures included two pre-test and two post-test video-recorded role-play interviews scored by blinded human resource experts and self-reported interviewing self-confidence.

RESULTS

Trainees attended 95% of lab-based VR-JIT sessions and found the intervention easy-to-use, helpful, and prepared them for future interviews. VR-JIT trainees demonstrated significantly greater improvement on role-play interviews compared with wait-list TAU controls (p=0.04) and demonstrated a large effect for within-subject change (Cohen's d=0.76). VR-JIT performance scores increased significantly over time (R-Squared=0.76). Although VR-JIT trainees showed a moderate effect for within-subject change on self-confidence (Cohen's d=0.58), the observed difference between conditions did not reach significance (p=0.09).

CONCLUSIONS

Results provide preliminary support that VR-JIT is acceptable to trainees and may be efficacious for improving job interview skills and self-confidence in veterans with PTSD.

Virtual reality in assessment and treatment of schizophrenia: a systematic review

Objective To conduct a systematic review about the use of virtual reality (VR) for evaluation, treatment and/or rehabilitation of patients with schizophrenia, focused on: areas, fields and objectives; methodological issues; features of the VR used; viability and efficiency of this resource. Methods Searches were performed about schizophrenia and virtual reality in PsycINFO, Academic Search Complete, MEDLINE Complete, CINAHL with Full Text, Web of Science and Business Source Premier databases, using the following keywords: [“schizophrenia”] AND [“virtual reality” OR “serious game”] AND [“treatment” OR “therapy” OR “rehabilitation”]. The search was carried out between November 2013 and June 2014 without using any search limiters. Results A total of 101 papers were identified, and after the application of exclusion criteria, 33 papers remained. The studies analysed focused on the use of VR for the evaluation of cognitive, social, perceptual and sensory skills, and the vast majority were experimental studies, with virtual reality specifically created for them. All the reviewed papers point towards a reliable and safe use of VR for evaluating and treating cognitive and social deficits in patients with schizophrenia, with different results in terms of generalisation, motivation, assertiveness and task participation rate. Some problems were highlighted, such as its high cost and a constant need for software maintenance. Conclusion The studies show that using the virtual reality may streamline traditional evaluation/rehabilitation programmes, allowing to enhance the results achieved, both in the cognitive and in the social field, helping for the legitimisation of this population’s psycho-social inclusion.

Prefrontal cortical GABA modulation of spatial reference and working memory

BACKGROUND

Dysfunction in prefrontal cortex (PFC) GABA transmission has been proposed to contribute to cognitive dysfunction in schizophrenia, yet how this system regulates different cognitive and mnemonic functions remains unclear.

METHODS

We assessed the effects of pharmacological reduction of GABAA signaling in the medial PFC of rats on spatial reference/working memory using different versions of the radial-arm maze task. We used a massed-trials procedure to probe how PFC GABA regulates susceptibility to proactive interference. Male rats were well-trained to retrieve food from the same 4 arms of an 8-arm maze, receiving 5 trials/day (1-2 min intervals).

RESULTS

Infusions of the GABAA receptor antagonist bicuculline (12.5-50 ng) markedly increased working and reference memory errors and response latencies. Similar treatments also impaired short-term memory on an 8-baited arm task. These effects did not appear to be due to increased susceptibility to proactive interference. In contrast, PFC inactivation via infusion of GABA agonists baclofen/muscimol did not affect reference/working memory. In comparison to the pronounced effects on the 8-arm maze tasks, PFC GABAA antagonism only causes a slight and transient decrease in accuracy on a 2-arm spatial discrimination.

CONCLUSIONS

These findings demonstrate that prefrontal GABA hypofunction severely disrupts spatial reference and short-term memory and that disinhibition of the PFC can, in some instances, perturb memory processes not normally dependent on the frontal lobes. Moreover, these impairments closely resemble those observed in schizophrenic patients, suggesting that perturbation in PFC GABA signaling may contribute to these types of cognitive deficits associated with the disorder.

Effects of enactment in episodic memory: a pilot virtual reality study with young and elderly adults

None of the previous studies on aging have tested the influence of action with respect to the degree of interaction with the environment (active or passive navigation) and the source of itinerary choice (self or externally imposed), on episodic memory (EM) encoding. The aim of this pilot study was to explore the influence of these factors on feature binding (the association between what, where, and when) in EM and on the subjective sense of remembering. Navigation in a virtual city was performed by 64 young and 64 older adults in one of four modes of exploration: (1) passive condition where participants were immersed as passengers of a virtual car [no interaction, no itinerary control (IC)], (2) IC (the subject chose the itinerary, but did not drive the car), (3) low, or (4) high navigation control (the subject just moved the car on rails or drove the car with a steering-wheel and a gas pedal on a fixed itinerary, respectively). The task was to memorize as many events encountered in the virtual environment as possible along with their factual (what), spatial (where), and temporal (when) details, and then to perform immediate and delayed memory tests. An age-related decline was evidenced for immediate and delayed feature binding. Compared to passive and high navigation conditions, and regardless of age-groups, feature binding was enhanced by low navigation and IC conditions. The subjective sense of remembering was boosted by the IC in older adults. Memory performance following high navigation was specifically linked to variability in executive functions. The present findings suggest that the decision of the itinerary is beneficial to boost EM in aging, although it does not eliminate age-related deficits. Active navigation can also enhance EM when it is not too demanding for subjects' cognitive resources.

Brave new worlds--review and update on virtual reality assessment and treatment in psychosis

In recent years, virtual reality (VR) research on psychotic disorders has been initiated. Several studies showed that VR can elicit paranoid thoughts about virtual characters (avatars), both in patients with psychotic disorders and healthy individuals. Real life symptoms and VR experiences were correlated, lending further support to its validity. Neurocognitive deficits and difficulties in social behavior were found in schizophrenia patients, not only in abstract tasks but also using naturalistic virtual environments that are more relevant to daily life, such as a city or encounters with avatars. VR treatments are conceivable for most dimensions of psychotic disorders. There is a small but expanding literature on interventions for delusions, hallucinations, neurocognition, social cognition, and social skills; preliminary results are promising. VR applications for assessment and treatment of psychotic disorders are in their infancy, but appear to have a great potential for increasing our understanding of psychosis and expanding the therapeutic toolbox.

Virtual reality job interview training for individuals with psychiatric disabilities

Services are available to help support existing employment for individuals with psychiatric disabilities; however, there is a gap in services targeting job interview skills that can help obtain employment. We assessed the feasibility and efficacy of Virtual Reality Job Interview Training (VR-JIT) in a randomized controlled trial. Participants were randomized to VR-JIT (n = 25) or treatment-as-usual (TAU) (n = 12) groups. VR-JIT consisted of 10 hours of simulated job interviews with a virtual character and didactic online training. The participants attended 95% of laboratory-based training sessions and found VR-JIT easy to use and felt prepared for future interviews. The VR-JIT group improved their job interview role-play performance (p ≤ 0.05) and self-confidence (p ≤ 0.05) between baseline and follow-up as compared with the TAU group. VR-JIT performance scores increased over time (R = 0.65). VR-JIT demonstrated initial feasibility and efficacy at improving job interview skills and self-confidence. Future research may help clarify whether this intervention is efficacious in community-based settings.