Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

A randomized controlled trial of a self-led, virtual reality-based cognitive behavioral therapy on sick role adaptation in colorectal cancer patients: study protocol

BACKGROUND

Significant concomitants of the sick role maladaptation in colorectal cancer (CRC) patients include inappropriate cognitions, emotional states, and overt conducts associated to disease. This protocol was developed to implement and evaluate the effects of a self-led, virtual reality-based cognitive behavioral therapy (VR-CBT) on the sick role adaptation among working-age CRC patients.

METHODS

This is an assessor-blinded, randomized controlled trail that adheres to the SPIRIT 2013 Statement guidelines. A total of 60 working-age CRC patients will be recruited from the colorectal wards of a cancer center and randomly assigned to the VR-CBT group or attention control (AC) group. The VR-CBT group will receive a 7-sessions VR-CBT targeted to sick role adaptation, while the AC group will receive weekly attention at the same time the VR-CBT group receives the intervention. The sick role adaptation, anxiety and depression, illness perceptions, and quality of life will be measured at baseline, 1, 2 and 3-month after completion of the intervention. Side-effects related to VR in the VR-CBT group will be measured at the end of each session. The participants will receive invitations to participate in semi-structured interviews to explore their experiences with the intervention.

DISCUSSION

The positive outcomes and user experience of VR-CBT will advance researches on the effectiveness of psychosocial interventions that aims to promote adaptation to the unexpected sick role on cancer populations. This protocol can be tested as an accessible and feasible alternative to traditional high-cost treatment in a randomized controlled study to improve the outcomes of younger cancer survivors.

TRIAL REGISTRATION

The protocol was registered on 21 June, 2023 in Chinese Clinical Trial Registry (No.: ChiCTR2300072699) at https://www.chictr.org.cn/ .

Immersive virtual reality in the treatment of auditory hallucinations: A PRISMA scoping review

BACKGROUND

A large group of psychiatric patients suffer from auditory hallucinations (AH) despite relevant treatment regimens. In mental health populations, AH tend to be verbal (AVH) and the content critical or abusive. Trials employing immersive virtual reality (VR) to treat mental health disorders are emerging.

OBJECTIVE

The aim of this scoping review is to provide an overview of clinical trials utilizing VR in the treatment of AH and to document knowledge gaps in the literature.

METHODS

PubMed, Cochrane Library, and Embase were searched for studies reporting on the use of VR to target AH.

RESULTS

16 papers were included in this PRISMA scoping review (ScR). In most studies VR therapy (VRT) was employed to ameliorate treatment resistant AVH in schizophrenia spectrum disorders. Only two studies included patients with a diagnosis of affective disorders. The VRT was carried out with the use of an avatar to represent the patient's most dominant voice.

DISCUSSION

The research field employing VR to treat AH is promising but still in its infancy. Results from larger randomized clinical trials are needed to establish substantial evidence of therapy effectiveness. Additionally, the knowledge base would benefit from more profound qualitative data exploring views of patients and therapists.

Application of Immersive Virtual Reality for Assessment and Intervention in Psychosis: A Systematic Review

Virtual reality (VR) has emerged as a safe and non-invasive technology for the assessment of psychotic symptoms, social and cognitive impairments, and psychosocial intervention in improving outcomes in psychosis. This study systematically reviewed the current state of evidence in applying semi- and fully immersive VR for assessing and treating patients with psychosis. A systematic review was conducted adhering to the PRISMA statement and was conducted in Embase, PsycINFO, and PubMed databases for articles published between January 2013 and April 2022, which identified 28 eligible studies, including 12 for assessment and 16 for intervention. In the assessment studies, not all VR tasks could distinguish the differences between patients and healthy controls regarding their physiological responses, paranoid ideation, and certain aspects of cognitive functioning such as memory bias on the object tasks. Comparatively, VR-based interventions are more promising, especially for improving cognitive impairments, social skills, agoraphobic avoidance, negative and positive affective states, auditory verbal hallucination, paranoid ideation and persecutory delusions, and other psychiatric symptoms in patients. We conclude that more rigorous studies are needed to confirm treatment effectiveness and to understand the underlying mechanism of VR-based intervention for psychotic disorders. Future studies should also improve the reliability and validity of VR-based assessments for psychotic disorders.

The impacts of the COVID-19 pandemic on treatment-resistant schizophrenia patients having followed virtual reality therapy or cognitive behavioural therapy: a content analysis

PURPOSE

The COVID-19 pandemic led to exacerbation of mental health symptoms and deterioration in psychological well-being in individuals suffering from schizophrenia. The primary objective of this study is to evaluate the impacts of the COVID-19 pandemic on patients suffering from treatment-resistant schizophrenia (TRS) with auditory verbal hallucinations (AVH) having undergone virtual reality therapy (VRT) or cognitive behavioural therapy (CBT) on their symptomatology. The secondary objective is to identify the differences and similarities in relation to the response to the COVID 19 pandemic between these two groups of patients.

METHODS

Qualitative analysis of semi-structured interviews was conducted with 42 patients suffering from TRS who had previously followed VRT or CBT. All interviews were recorded, transcribed, and analysed.

RESULTS

Four themes emerged in this study: Psychotherapeutic Interventions, Impact of COVID-19 and Public health and safety policies, Substance use and Psychiatric follow-up. Participants from both groups reported that their therapy was beneficial in controlling AVH. Patients having followed CBT reported more depressive symptoms whereas patients having followed VRT reported more anxious symptoms.

CONCLUSIONS

This study offers a first qualitative insight in patients suffering from TRS and the impacts of COVID-19 on them and opens the door to the protective factors of CBT and VRT for this specific population.

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.

Measuring the longitudinal course of voice hearing under psychological interventions: A systematic review

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course and impact of voice hearing under these interventions and to evaluate how these variables change over time. Inclusion and exclusion criteria were applied, resulting in a total of 66 articles. Of these, 60 studies (28 RCTs, 23 uncontrolled, 9 non-randomised) were published in peer-reviewed journals, whilst 6 were recently completed or currently ongoing. The findings of this review suggest that a range of variables that are not directly relevant to psychological interventions have been used (e.g., depression, characteristics of voice hearing experience), whilst those directly impacted by psychological interventions (e.g., voice-related distress), broader concepts of outcome (e.g., functioning) and specific associated processes (e.g., self-schema) have received less attention. Findings also showed that the majority of variables demonstrated improvements, but effect sizes varied considerably across trials. This may be attributed to methodological differences such as statistical power, blinding, control groups and different methods of measurement. Our review highlights the importance of determining a set of outcomes that are directly targeted and should change under psychological interventions. Recommendations include the use of voice-related distress as a primary outcome. This can ultimately facilitate comparisons across studies and inform the development of psychological interventions.

A systematic review of relational-based therapies for the treatment of auditory hallucinations in patients with psychotic disorders

BACKGROUND

Auditory hallucinations in patients with psychotic disorders may be very distressing. Unfortunately, a large proportion of individuals are resistant to pharmacological interventions and the gold-standard cognitive-behavioral therapy for psychosis offers at best modest effects. To improve therapeutic outcomes, several therapies have been created to establish a relationship between voice-hearers and their voices. With increasing literature, we conducted a systematic review of dialogical therapies and examined the evidence behind their efficacy.

METHODS

A systematic search was performed in PubMed, PsycINFO, Web of Science, and Google Scholar. Articles were included if they discussed the effects of dialogical interventions for patients with psychotic disorders.

RESULTS

A total of 17 studies were included within this systematic review. Cumulative evidence from various therapies has shown that entering in a dialog with voices is beneficial to patients, even those who are resistant to current pharmacological treatments. Heightened benefits have been mainly observed with Relating Therapy and Avatar Therapy/Virtual Reality assisted Therapy, with evidence generally of moderate quality. Both these interventions have shown large to very large effects on voices and voice-related distress as well as moderate to large magnitude improvements on affective symptoms. Though, cognitive-behavioral therapy for command hallucinations and making sense of voices noted no improvements on voices.

CONCLUSIONS

Literature on relational-based interventions with a strong emphasis on the relational aspects of voice hearing has shown positive effects. Results suggest that these dialogical therapies might surpass the efficacy of current gold-standard approaches.

Visual P300 as a neurophysiological correlate of symptomatic improvement by a virtual reality-based computer AT system in patients with auditory verbal hallucinations: A Pilot study

Previous comparative trials showed that virtual reality (VR) therapies achieved larger effects than gold-standard cognitive-behavioral therapy (CBT) on overall auditory verbal hallucinations (AVHs). However, no trial has examined the corresponding underlying electrophysiological mechanisms. We performed a pilot randomized comparative trial evaluating the efficacy of a virtual reality-based computer AT system (CATS) over CBT for schizophrenia (SCZ) patients with treatment-resistant AVHs and explored these potential electrophysiological changes via the visual P300 component. Patients (CATS, n = 32; CBT, n = 33) completed the clinical assessments pre- and post-interventions and at 12-week follow-up. The visual P300 were measured before and after both therapies. The analysis of changes in psychiatric symptoms used linear mixed-effects models, and the P300 response in temporal and time-frequency domains was analyzed with repeated-measures analysis of variance. There was no interaction effect between change in clinical symptoms and treatment group. However, several statistically significant within-group improvements were found for CATS and CBT over time. AVH improved significantly after both treatments, as measured with the Psychotic Symptom Rating Scales-Auditory Hallucinations (PSYRATS-AH) sub-scores. Especially for the CATS group, omnipotence beliefs, anxiety symptoms, self-esteem, and quality of life also remained improved at the 12-week follow-up. Moreover, P300 amplitude had a significant interaction effect and correlation with AVH response. Overall, our analysis did not demonstrate general clinical superiority of CATS over CBT, but CATS improved refractory AVH in SCZ patients, likely by increasing P300 amplitude. These findings support the continued development of CATS for persistent AVH and suggest further trials to clarify the neurological effects of CATS.

Feasibility and Efficacy of Virtual Reality Interventions to Improve Psychosocial Functioning in Psychosis: Systematic Review

BACKGROUND

Functional recovery in psychosis remains a challenge despite current evidence-based treatment approaches. To address this problem, innovative interventions using virtual reality (VR) have recently been developed. VR technologies have enabled the development of realistic environments in which individuals with psychosis can receive psychosocial treatment interventions in more ecological settings than traditional clinics. These interventions may therefore increase the transfer of learned psychosocial skills to real-world environments, thereby promoting long-term functional recovery. However, the overall feasibility and efficacy of such interventions within the psychosis population remain unclear.

OBJECTIVE

This systematic review aims to investigate whether VR-based psychosocial interventions are feasible and enjoyable for individuals with psychosis, synthesize current evidence on the efficacy of VR-based psychosocial interventions for psychosis, and identify the limitations in the current literature to guide future research.

METHODS

This research followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches were conducted in PubMed and PsycINFO in May 2021. We searched for peer-reviewed English articles that used a psychosocial intervention with a VR component. Participants in the included studies were diagnosed with schizophrenia, schizoaffective disorder, or another psychotic disorder. The included studies were divided into four categories as follows: cognitive remediation interventions, social skills interventions, vocational skills interventions, and auditory verbal hallucinations and paranoia interventions. The risk of bias assessment was performed for each study.

RESULTS

A total of 18 studies were included in this systematic review. Of these 18 studies, 4 (22%) studies used a cognitive remediation intervention, 4 (22%) studies used a social skills intervention, 3 (17%) studies used a vocational skills intervention, and 7 (39%) studies implemented an intervention aimed at improving auditory verbal hallucinations or paranoia. A total of 745 individuals with psychosis were included in the study. All the studies that evaluated feasibility showed that VR-based psychosocial interventions were feasible and enjoyable for individuals with psychosis. The preliminary evidence on efficacy included in this review suggests that VR-based psychosocial interventions can improve cognitive, social, and vocational skills in individuals with psychosis. VR-based interventions may also improve the symptoms of auditory verbal hallucinations and paranoia. The skills that participants learned through these interventions were durable, transferred into real-world environments, and led to improved functional outcomes, such as autonomy, managing housework, and work performance.

CONCLUSIONS

VR-based interventions may represent a novel and efficacious approach for improving psychosocial functioning in psychosis. Therefore, VR-based psychosocial interventions represent a promising adjunctive therapy for the treatment of psychosis, which may be used to improve psychosocial skills, community functioning, and quality of life.

The use of virtual reality and augmented reality in psychosocial rehabilitation for adults with neurodevelopmental disorders: A systematic review

OBJECTIVES

Virtual reality and augmented reality have been used in psychosocial rehabilitation for adults with neurodevelopmental disorders in recent years, to provide functional training in a scaffolded and appealing manner. This systematic review attempted to evaluate (1) how virtual reality or augmented reality technology was deployed, when used as an intervention for adults with neurodevelopmental disorders; and (2) how virtual or augmented reality-assisted psychosocial rehabilitation programs impacted on the functional domains of community living, employment and social participation.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was adopted and a search of publications between June 2012 and June 2022 was carried out. The target groups were adults with schizophrenia/schizoaffective disorders, autism spectrum disorder, intellectual disabilities and attention deficit hyperactivity disorder. Interventions that targeted at least one functional domain were included.

RESULTS

The database search generated 1,267 records and 38 studies met the inclusion criteria. Three studies utilized augmented reality while the rest utilized virtual reality. The virtual scenarios were displayed in various ways, such as head-mounted displays, computer screens, mobile devices and cave rooms. A few studies also used features such as speech recognition, eye tracking and motion-capture device to provide real-time feedback to participants during rehabilitation. Eleven studies reported interventions that addressed community living, 15 studies addressed vocational skills and nine studies trained participants in social skills or social cognition. Three studies sought to improve quality of life using virtual scenarios to expose participants to various situations. Majority of these studies reported preliminary promising results, with improvement in the functional domains addressed. However, several studies had small sample sizes and many single-arm pretest-posttest studies were assessed to be of serious or critical risk of bias.

CONCLUSION

Virtual reality and augmented reality are deployed in various ways to augment psychosocial rehabilitation for adults with neurodevelopmental disorders. Most interventions target skills training or strategy learning in the areas of community living, work and social participation. Preliminary positive findings of their effects on functional performance were reported. Larger and robust studies using ecologically valid outcome measures will be needed to establish their effects on real-world functional outcomes.

SYSTEMATIC REVIEW REGISTRATION

identifier: CRD42022335443.

L’amélioration de la qualité de vie chez les patients atteints d’une schizophrénie réfractaire ayant suivi la Thérapie assistée par la Réalité Virtuelle : une analyse de contenu

Objectifs La schizophrénie, en particulier la schizophrénie résistante aux traitements (SRT), est considérée comme l’un des troubles psychiatriques les plus invalidants en termes d’effets indésirables sur la qualité de vie (QV) des patients. La QV subjective est devenue une cible particulièrement cruciale qui devrait être améliorée avec le traitement, car une QV améliorée peut entraîner le rétablissement chez les patients atteints de schizophrénie. Il existe cependant peu de preuves des effets des interventions psychosociales recommandées sur les mesures non symptomatiques comme la QV. À cet égard, le traitement de la schizophrénie peut être renforcé si, en plus du traitement des symptômes, l’accent thérapeutique est mis sur d’autres sphères importantes pour les patients. Avec les progrès technologiques, la Thérapie assistée par la Réalité Virtuelle (TRV) permet aux entendeurs de voix d’entrer en dialogue direct avec un avatar, animé entièrement par le thérapeute, qui représente leur voix la plus persécutrice. Ceci dans le but de leur permettre d’acquérir un meilleur contrôle sur leurs voix et de travailler sur leur estime de soi. Au-delà de la symptomatologie, les résultats des projets pilotes sur cette thérapie innovante ont montré des résultats significatifs sur la QV.

Méthode Afin de peaufiner les résultats quantitatifs trouvés, cet article a exploré les thèmes émergents d’une analyse de contenu découlant du discours spontané de 10 patients ayant bien répondu à la TRV.

Résultats Quatre thèmes généraux ont émergé : 1) impact de la thérapie sur les voix ; 2) relations interpersonnelles ; 3) bien-être psychologique ; et 4) mode de vie. Cette analyse de contenu a permis d’identifier plusieurs sphères de vie qui sont davantage améliorées chez les patients ayant une SRT à l’aide de la TRV.

Conclusion : La TRV met en évidence l’avenir des approches adaptées aux objectifs des patients qui intègrent plusieurs processus pertinents pour potentiellement améliorer leur QV. La TRV peut avoir des implications potentiellement immenses sur la santé et la qualité de vie des patients. Cette étude fut une première étape vers l’exploration des effets subjectifs de la TRV sur la vie des patients au-delà des symptômes.

Extended Reality for Enhanced Telehealth During and Beyond COVID-19: Viewpoint

The COVID-19 pandemic caused widespread challenges and revealed vulnerabilities across global health care systems. In response, many health care providers turned to telehealth solutions, which have been widely embraced and are likely to become standard for modern care. Immersive extended reality (XR) technologies have the potential to enhance telehealth with greater acceptability, engagement, and presence. However, numerous technical, logistic, and clinical barriers remain to the incorporation of XR technology into telehealth practice. COVID-19 may accelerate the union of XR and telehealth as researchers explore novel solutions to close social distances. In this viewpoint, we highlight research demonstrations of XR telehealth during the COVID-19 pandemic and discuss future directions to make XR the next evolution of remote health care.

Facial Affect Recognition by Patients with Schizophrenia Using Human Avatars

People with schizophrenia have difficulty recognizing the emotions in the facial expressions of others, which affects their social interaction and functioning in the community. Static stimuli such as photographs have been used traditionally to examine deficiencies in the recognition of emotions in patients with schizophrenia, which has been criticized by some authors for lacking the dynamism that real facial stimuli have. With the aim of overcoming these drawbacks, in recent years, the creation and validation of virtual humans has been developed. This work presents the results of a study that evaluated facial recognition of emotions through a new set of dynamic virtual humans previously designed by the research team, in patients diagnosed of schizophrenia. The study included 56 stable patients, compared with 56 healthy controls. Our results showed that patients with schizophrenia present a deficit in facial affect recognition, compared to healthy controls (average hit rate 71.6% for patients vs 90.0% for controls). Facial expressions with greater dynamism (compared to less dynamic ones), as well as those presented from frontal view (compared to profile view) were better recognized in both groups. Regarding clinical and sociodemographic variables, the number of hospitalizations throughout life did not correlate with recognition rates. There was also no correlation between functioning or quality of life and recognition. A trend showed a reduction in the emotional recognition rate as a result of increases in Positive and Negative Syndrome Scale (PANSS), being statistically significant for negative PANSS. Patients presented a learning effect during the progression of the task, slightly greater in comparison to the control group. This finding is relevant when designing training interventions for people with schizophrenia. Maintaining the attention of patients and getting them to improve in the proposed tasks is a challenge for today’s psychiatry.

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

BACKGROUND

Combining cognitive behavioral therapy (CBT) for psychosis with another psychosocial intervention comprising virtual reality (VR)-assisted therapy (VRT) may improve targeted outcomes in treatment-resistant schizophrenia patients.

METHODS

Ten participants having followed CBT were part of our comparative clinical trial comparing VRT to CBT and were selected at the end of the study as they desired to continue to achieve improvements with VRT (CBT + VRT). Clinical assessments were administered before/after treatments and at follow-ups. Changes in outcomes were examined using linear mixed-effects models. To gain a more in depth understanding on CBT + VRT, therapists' notes, and open interviews on a sub-group of patients were qualitatively analyzed.

RESULTS

Findings showed that the sequence of both interventions was appreciated by all patients. Several significant improvements were found throughout time points on auditory verbal hallucinations, beliefs about voices, depressive symptoms, symptoms of schizophrenia and quality of life. Although most of these improvements were in similar range to those observed in our comparative trial, effects of CBT + VRT on depressive symptoms and symptoms of schizophrenia were larger than those found for either intervention alone.

CONCLUSION

This proof of concept is the first to merge gold-standard CBT with VRT for treatment refractory voices and to suggest a certain synergistic effect.