The Relationship between Sense of Presence, Emotional Response, and Clinical Outcomes in Virtual Reality-Based Therapy for Treatment-Resistant Schizophrenia: An Exploratory Correlational Study.

Avatar therapy (AT) is a novel virtual reality-based psychotherapy that has been developed to treat auditory verbal hallucinations (AVH) in treatment-resistant schizophrenia. Various psychotherapeutic components, such as emotions and sense of presence, could contribute to clinical outcomes. However, the interplay between sense of presence, emotions, and clinical response has seldom been investigated. This study aimed to explore the relations between sense of presence, emotions, and clinical outcomes in AT. To conduct this investigation, data from previous and ongoing AT trials were used. Sense of presence and emotions were assessed using standardized questionnaires. AVH were evaluated using the Psychotic Symptom Rating Scales. While sense of presence was positively associated with positive emotions such as control and serenity, no significant associations were found for negative emotions. Moreover, a higher level of sense of presence was associated with a bigger decrease in AVH. Overall, positive emotions seem to be associated with sense of presence in AT. Sense of presence also seems to be involved in the therapeutic outcome, thereby suggesting that this could be an important component related to clinical response. More studies are needed to confirm these trends, which could be generalized to other virtual reality-based psychotherapies.

Is There a Dose-Response Relationship Between Cannabis Use and Violence? A Longitudinal Study in Individuals with Severe Mental Disorders.

Introduction: Recent longitudinal studies point toward the existence of a positive relationship between cannabis use and violence in people with severe mental disorders (SMD). However, the existence of a dose-response relationship between the frequency/severity of cannabis use and violence has seldom been investigated. Therefore, this study aims to determine if such a relationship exists in a psychiatric population. Methods: To do so, a total of 98 outpatients (81 males and 17 females, all over 18 years of age) with SMD were recruited at the Institut universitaire de santé mentale de Montréal (Montréal, Canada) and included in the analyses. Clinical evaluations were conducted every 3 months for a year. Substance use, violent behaviors, and potential covariables were assessed through self-reported assessments, urinary testing, as well as clinical, criminal, and police records. Using generalized estimating equations, the association between cannabis use frequency (nonusers, occasional, regular, and frequent users) and violence was investigated, as well as the association between the severity of cannabis use and violent behaviors. Results: It was found that cannabis use frequency and severity were significant predictors of violent behaviors. After adjustment for time, age, sex, ethnicity, diagnoses, impulsivity, and use of alcohol and stimulants, odds ratios were of 1.91 (p<0.001) between each frequency profile and 1.040 (p<0.001) for each increase of one point of the severity of cannabis use score (ranging from 0 to 79). Conclusions: Despite the high attrition rate, these findings may have important implications for clinicians as cannabis use may have serious consequences in psychiatric populations. Nevertheless, the mechanisms underlying this association remain unclear.

Exploration of the role of emotional expression of treatment-resistant schizophrenia patients having followed virtual reality therapy: a content analysis.

BACKGROUND: Emotional responses are an important component of psychotherapeutic processes. Avatar therapy (AT) is a virtual reality-based therapy currently being developed and studied for patients suffering from treatment resistant schizophrenia. Considering the importance of identifying emotions in therapeutical processes and their impact on the therapeutic outcome, an exploration of such emotions is needed. METHODS: The aim of this study is to identify the underlying emotions at the core of the patient-Avatar interaction during AT by content analysis of immersive sessions transcripts and audio recordings. A content analysis of AT transcripts and audio recordings using iterative categorization was conducted for 16 patients suffering from TRS who underwent AT between 2017 and 2022 (128 transcripts and 128 audio recordings). An iterative categorization technique was conducted to identify the different emotions expressed by the patient and the Avatar during the immersive sessions. RESULTS: The following emotions were identified in this study: Anger, Contempt/ Disgust, Fear, Sadness, Shame/ Embarrassment, Interest, Surprise, Joy and Neutral. Patients expressed mostly neutral, joy and anger emotions whereas the Avatar expressed predominantly interest, disgust/contempt, and neutral emotions. CONCLUSIONS: This study portrays a first qualitative insight on the emotions that are expressed in AT and serves as a steppingstone for further investigation in the role of emotions in the therapeutic outcomes of AT.

Meta-review on the efficacy of psychological therapies for the treatment of substance use disorders.

This meta-review aimed to summarize the current state of knowledge provided by meta-analyzes on the efficacy of psychotherapies for substance use disorders. A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyzes were included if they quantitatively examined the efficacy of a psychotherapy on substance use. Among the 6866 potential articles that were screened for eligibility, 23 meta-analyzes were eligible (78 effect sizes). Each meta-analysis included 2-156 studies, with samples ranging between approximately 130 to over 33,000 individuals. The quality of evidence was evaluated as being globally of low to moderate quality. Substances were categorized as: alcohol (k = 12), cannabis (k = 7), stimulants (k = 4), opioids (k = 3) and benzodiazepines (k = 1). Interventions comprised brief intervention, cognitive-behavioral therapy, contingency management, voucher-based reinforcement therapy, motivational interview, motivational enhancement therapy, significant other people involved in the treatment, and cue-expose therapy. Concerning solely significant results, small benefits were observed for significant other people involved in treatment, motivational interviewing, and the combination of cognitive-behavioral therapy with motivational interviewing for alcohol use disorder. Likewise, small-to-moderate effects were found for motivational approaches, and cognitive-behavioral therapy as well as the combination of cognitive-behavioral therapy and motivational enhancement therapy in the case of cannabis use disorder. Small effects were observed for contingency management as well as cognitive behavioral-therapy for amphetamine-type use disorder. Small effects were similarly found for contingency management for cocaine use disorder. Concerning opioid use disorder, moderate effects were observed for contingency management and voucher-based reinforcement intervention. For benzodiazepine use disorder, small effects were noted for cognitive-behavioral therapy with taper. Results often displayed small to moderate heterogeneity when reported and were generally compared to inactive controls, such as treatment-as-usual. In all, the psychosocial treatments for substance use disorders included in this meta-review have shown to be at best moderately effective over inactive controls in the short term. Nevertheless, further trials are needed as well as meta-analyzes on interventions not included in this meta-review.

Avatar Intervention for Cannabis Use Disorder in Individuals with Severe Mental Disorders: A Pilot Study.

Cannabis use disorder (CUD) is a complex issue, even more so when it is comorbid with a severe mental disorder (SMD). Available interventions are at best slightly effective, and their effects are not maintained over time. Therefore, the integration of virtual reality (VR) may increase efficacy; however, it has not yet been investigated in the treatment of CUD. A novel approach, avatar intervention for CUD, uses existing therapeutic techniques from other recommended therapies (e.g., cognitive behavioral methods, motivational interviewing) and allows participants to practice them in real-time. During immersive sessions, participants are invited to interact with an avatar representing a significant person related to their drug use. This pilot clinical trial aimed to evaluate the short-term efficacity of avatar intervention for CUD on 19 participants with a dual diagnosis of SMD and CUD. Results showed a significant moderate reduction in the quantity of cannabis use (Cohen's d = 0.611, p = 0.004), which was confirmed via urinary quantification of cannabis use. Overall, this unique intervention shows promising results. Longer-term results, as well as comparison with classical interventions in a larger sample, are warranted through a future single-blind randomized controlled trial.

The Potential Paradoxical Neurocognitive Effects of Cannabis Use in Patients with Psychotic Disorders: A Critical Meta-Review of Meta-Analytical Evidence.

Background: The association between cannabis and cognitive functions has been thoroughly studied in psychotic disorders, but conflictual/paradoxical results have emerged. This critical meta-review examined the magnitude of effects of cannabis on neurocognitive functions in patients with psychotic disorders provided by meta-analyses and evaluated the quality of evidence. Methods: A systematic search of meta-analyses was performed in PubMed, PsycINFO, Web of Science, and Google Scholar. Results: The search retrieved six meta-analyses. Quality of evidence varied from very low to moderate quality. No neurocognitive difference was observed between cannabis users and nonusers in first episode of psychosis samples. Limited evidence showed no significant difference in language, psychomotor functioning, and verbal/visual learning/memory, apart from improvements in verbal and visual memory (recognition). Findings showed better neurocognitive performances in cannabis-using patients for planning/reasoning and working memory. There were tendencies toward significance for processing speed and attention. Most effect sizes showed small to moderate degrees of outperformances in cannabis users. Individuals with lifetime use appeared to show better neurocognitive functions. Conclusion: Evidence indicated nonuniform effects of cannabis use across cognitive domains, with some areas suggesting better cognitive performances in cannabis users, entitled the paradoxical effect of the dually diagnosed. Clinical significance of these findings should be interpreted cautiously.

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.

Evidence on the acute and residual neurocognitive effects of cannabis use in adolescents and adults: a systematic meta-review of meta-analyses.

BACKGROUND: Cannabis is among the most consumed psychoactive substances world-wide. Considering changing policy trends regarding the substance, it is crucial to understand more clearly its potential acute and residual adverse effects from a public health viewpoint. Cognitive function is one of the targeted areas with conflicting findings. This meta-review measured the magnitude of acute and residual effects of cannabis on cognition in adolescents and adults provided by meta-analyses and evaluated quality of evidence. METHODS: A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyses were included if they quantitatively examined the performances of users from the general population on cognitive tasks. RESULTS: The search retrieved 10 eligible meta-analyses (71 effects sizes, n = 43 761) with evidence ranging from low to moderate quality, which were categorized into domains of cognitive functions: executive functions (k = 7), learning and memory (k = 5), attention (k = 4), processing speed (k = 5), perceptual motor function (k = 2) and language (k = 2). Verbal learning and memory displayed the most robust evidence and were most impaired by acute cannabis intoxication that persisted after intoxication passed. Small-to-moderate acute and residual adverse effects were reported for executive functioning. Cannabis use led to small deficits in inhibitory processes and flexibility, whereas small-to-moderate deficits were reported for working memory and decision-making. Evidence regarding processing speed and attention has shown that cannabis administration induced small-to-moderate adverse effects and residual neurocognitive deficits were observed in heavy cannabis-using youths. Results showed no significant difference between cannabis users and non-users on language, and small-to-moderate effects for simple motor skills. CONCLUSION: Meta-analytical data on the acute effects of cannabis use on neurocognitive function have shown that cannabis intoxication leads to small to moderate deficits in several cognitive domains. These acute impairments accord with documented residual effects, suggesting that the detrimental effects of cannabis persist beyond acute intake.

[Improving Quality of Life in Patients with Refractory Schizophrenia After Virtual Reality-assisted Therapy: A Content Analysis]. / 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.

Objectives Schizophrenia, particularly treatment-resistant schizophrenia (TRS), is one of the most disabling psychiatric disorders in terms of adverse effects on the quality of life (QOL) of patients. Subjective QOL has become a particularly crucial target that should be improved with treatment, since improved QOL may lead to recovery in patients with schizophrenia. However, there is little evidence on the efficacy of recommended psychosocial interventions on non-symptomatic measures such as QOL. In this regard, the treatment of schizophrenia can be enhanced if, in addition to the treatment of symptoms, therapeutic emphasis is placed on other areas of importance to patients. With advancements in technology, Virtual Reality assisted Therapy (VRT) allows voice hearers to enter in a direct dialogue with an avatar, fully animated by the therapist, who represents their most persecuting voice. This is in the aim to allow them to gain better control over their voices and to work on their self-esteem. Beyond symptomatology, the results of the pilot projects on this innovative therapy have shown significant results on QOL. Method To refine the observed quantitative results, this article will explore emerging themes from a content analysis arising from the spontaneous discourse of 10 patients who responded well to TRV. Results Four general themes emerged: (i) impact of therapy on voices, (ii) interpersonal relationships, (iii) psychological well-being, and (iv) lifestyle. This content analysis has identified several spheres of life that are further improved in patients with TRS using TRV. Conclusion TRV highlights the future of patient-oriented approaches that integrate several relevant processes to potentially improve QOL. TRV can have potentially immense implications for the health and quality of life of patients. This study was a first step towards exploring the subjective effects of TRV on the lives of patients beyond the symptoms.