Crazy'App: A web survey on representations and attitudes toward mental disorders using video testimonies

In the international context of efforts to combat the stigmatization of people with mental health problems, representations and attitudes about these illnesses have not to date been widely investigated in France. However, new technologies offer an unprecedented opportunity to collect such information on a large scale and to deploy more efficient action against stigma.

OBJECTIVES

The Crazy'App survey was designed as an instrument for studying potentially stigmatizing representations and attitudes towards mental disorders. It asks respondents to react, rather than to standard diagnostic labels or case vignettes, to video testimonies by people with different mental disorders talking about their experiences.

METHODS

The web survey was made available on smartphone or computer and advertised on various media and during a French exhibition about mental disorders, mental health and well-being ("Mental Désordre", Cité des sciences, Paris, 2016). It consisted of short (<2min) video testimonials by four people presenting respectively anorexia, bipolar disorder, obsessive-compulsive disorder and addiction to alcohol. Each testimony was immediately followed by series of questions to which participants were to respond using visual analog scales. The questionnaires investigated different domains, such as the causes of each of these mental disorders, the possible treatments and the respondent's personal attitudes in hypothetical situations (e.g. working with the person seen in the video). After having completed the survey, respondents were offered an opportunity to compare their own responses to those of the other respondents, and watch expert psychiatrists interviews delivering clinical and scientific knowledge and sharing their own attitudes.

RESULTS

The respondents (n=2600) were young, mostly women, educated and concerned about the subject. They exhibited good knowledge of the disorders. They reported a multi-causal view of the etiologies, where psychological causes were rated higher than neurobiological causes (although less so for respondents reporting having had a mental disorder themselves), while other types of causes (environmental, spiritual, and nutritional) received much lower ratings. Respondents also expressed high potential social proximity, but this result varied according to the type of disorder, in particular, the social distance and the perception of dangerousness were greater for addiction and bipolar disorder.

CONCLUSIONS

Crazy'App operationalizes emerging strategies in the efforts to combat stigma, implementing what is known as a "contact based intervention" in English-speaking countries. While it does not erase the differences in attitudes observed from one pathology to another, this type of survey-intervention based on video testimonies could help to reduce the desire for social distancing from people with mental disorders, even in a particularly sensitized and informed population. Multimedia technologies are an efficient way to offer rich, potentially interactive content better able to embody people and their actual experiences than clinical descriptions or even life narratives. However the use of videos could put the focus on the individual characteristics (physical, gestural, verbal, nonverbal…), and this should be cautiously taken into account according to the anti-stigma objectives. Connected technologies also make it possible to enhance the more classic de-stigmatization actions focused on the deconstruction of preconceived ideas, making the action more participatory, while simultaneously assessing their efficacy. By mediating contact with individuals and behaviors perceived as deviant, the aim would be to develop psycho-social skills and concrete abilities for action in the general population, to include people with mental disorders in the community.

[Can the efficacy of behavioral and cognitive therapy for obsessive compulsive disorder be augmented by innovative computerized adjuvant?]

AIM

Cognitive behavioral therapy (CBT) is recognized as an effective treatment for obsessive-compulsive disorder (OCD). To maximize its effectiveness, we designed an "experimental" CBT defined by the addition of a computerized psychoeducative tool.

METHOD

In a participative process involving patients through meetings of the French OCD association (AFTOC) and therapists through methodological workshops, we built a therapeutic tool from an experimental checking task. This task, which had been published in an earlier work, was adapted for its psychoeducative dimension. We here report on a randomized double-blind trial which included 35 patients with a moderate to severe OCD (Yale-Brown obsessive-compulsive scale, YBOCS between 16 and 25) predominant checking symptoms, no comorbidities, and 2-month stabilized or no treatment. Patients were randomly assigned to either "standard" versus "experimental" CBT. Both therapies were conducted by four CBT-experienced therapists specialized in OCD through weekly individualized sessions over 3 months. Therapy sessions of the experimental CBT were conducted as the standard CBT except for a short exercise with the computerized psychoeducative tool performed by the patient and debriefed with the therapist at the end of the sessions. Patients were assessed before, during, after therapy and again 6 months later using standard clinical tools and a neurobehavioral assessment based on an original symptom-provocation task with anxiety ratings including three types of photographs: neutral, generic inducing obsessions (e.g., doorknobs, electric wires…) and personalized (taken by the patients in their own environment).

RESULTS

Clinically, "standard" and "experimental" CBT resulted in a significant but equivalent improvement (48% vs 45% reduction of the Y-BOCS score; P=0.36; d=0.12). Therapists were satisfied with the psychoeducative dimension of the computerized psychoeducative tool but reported variable acceptance across patients. Patients appreciated its usability. The clinical improvement was associated with a reduction of the task-induced anxiety (r=0.42, P<0.05), especially towards personalized items (-28,2% vs -20.41% for generic and -6.24% for neutral photographs, P<0.001). Mid-therapy response level was predictive of the final improvement (r=0.82, P<0.001).

CONCLUSION

The computerized tool may provide a well-accepted therapeutic adjuvant even though it doesn't improve the therapeutic effect. Using a personalized symptom-provocation task reveals the parallel evolution of symptoms and neurobehavioral markers through CBT. Despite the difficulty of improving an evidence-based therapy, mid-therapy results call for investigating the possible adjustments of treatment strategies at an early stage.

Dynamics of psychotherapy-related cerebral haemodynamic changes in obsessive compulsive disorder using a personalized exposure task in functional magnetic resonance imaging

BACKGROUND

Cognitive behavioural therapy (CBT) is a successful treatment of obsessive compulsive disorder (OCD). It is known to induce changes in cerebral metabolism; however, the dynamics of these changes and their relation to clinical change remain largely unknown, precluding the identification of individualized response biomarkers.

METHOD

In order to study the dynamics of treatment response, we performed systematic clinical and functional magnetic resonance imaging (fMRI) evaluation of 35 OCD patients immediately before a 3-month course of CBT, halfway through and at its end, as well as 6 months after. To sensitize fMRI probing, we used an original exposure task using neutral, generic and personalized obsession-inducing images.

RESULTS

As expected, CBT produced a significant improvement in OCD. This improvement was continuous over the course of the therapy; therefore, outcome could be predicted by response at mid-therapy (r 2 = 0.67, p < 0.001). Haemodynamic response to the task was located in the anterior cingulate and orbitofrontal cortices and was stronger during exposure to personalized obsession-inducing images. In addition, both the anxiety ratings and the haemodynamic response to the obsession-inducing images in the anterior cingulate and the left but not the right orbitofrontal clusters decreased with symptom improvement. Interestingly, haemodynamic activity continued to decrease after stabilization of clinical symptoms.

CONCLUSIONS

Using an innovative and highly sensitive exposure paradigm in fMRI, we showed that clinical and haemodynamic phenotypes have similar time courses during CBT. Our results, which suggest that the initial CBT sessions are crucial, prompt us to investigate the anatomo-functional modifications underlying the very first weeks of the therapy.