Daily-life stress reactivity and recovery following virtual-reality-based cognitive behavioral therapy in patients with a psychotic disorder.

Introduction: Studies have consistently demonstrated increased stress sensitivity in individuals with psychosis. Since stress sensitivity may play a role in the onset and maintenance of psychosis, this could potentially be a promising target for treatment. The current study was the first to investigate whether reactivity to and recovery from daily-life stressors in psychosis change in response to treatment, namely virtual-reality-based cognitive behavioral therapy (VR-CBT). Methods: 116 patients were randomized to either VR-CBT or the waiting list control group (WL). Pre-treatment and post-treatment participants completed a diary ten times a day during six to ten days. Multilevel analyses were used to model the time-lagged effects of daily stressful events on negative affect (NA) and paranoia symptoms to examine reactivity and recovery. Results: There was a significant difference in NA reactivity. VR-CBT showed higher NA at post-treatment compared to pre-treatment than WL (bpre=0.14; bpost=0.19 vs bpre=0.18; bpost=0.14). There was a significant difference in NA recovery and paranoia recovery between the groups at lag 1: VR-CBT showed relatively lower negative affect (bpre=0.07; bpost=-0.06) and paranoia (bpre= 0.08; bpost=-0.10) at post-treatment compared to pre-treatment than WL (bpre=0.08; bpost=0.08; bpre=0.04; bpost=0.03). Conclusion: Negative affect and paranoia recovery improved in response to treatment. Increased NA reactivity may be explained by a decrease in safety behavior in the VR-CBT group. The discrepancy between reactivity and recovery findings may be explained by the inhibitory learning theory that suggests that an original threat reaction may not erase but can be inhibited as a consequence of exposure therapy.

VR-assisted aggression treatment in forensic psychiatry: a qualitative study in patients with severe mental disorders.

Introduction: Improvements in virtual reality (VR) have made it possible to create realistic, virtual settings for behavioral assessment and skills training that cannot otherwise be accessed in a safe way in forensic psychiatric settings. VR interventions are under development but little is known how forensic psychiatric patients with severe mental disorders experience VR-assisted assessments or treatments. Methods: The present study aimed to help fill this knowledge gap via qualitative interviews with seven patients with severe mental disorders at a high-security forensic psychiatric clinic who had completed the newly revised Virtual Reality Aggression Prevention Training (VRAPT). All participants were interviewed 12 weeks after the VRAPT intervention, and interview data analyzed with manifest inductive content analysis. Results: Six manifest content categories were identified: 1. Therapeutic process, 2. VRAPT method, 3. VR technology, 4. Previous treatment experiences, 5. Challenges to treatment of aggression, and 6. Unexpected experiences. The participants had diverse experiences related to both the VRAPT intervention and forensic psychiatric care. Participants described a mixture of positive experiences in relation to VR-assisted role-plays, and less positive in relation to motivation for aggression-focused treatment and technological limitations. Discussion: The present findings suggest further studies are needed on how to best implement VR-assisted treatments for aggression in forensic settings, and potentially further modification of treatment content in interventions like VRAPT.

Evaluating changes in functioning and psychological distress in visitors of the @ease youth mental health walk-in centres.

BACKGROUND: Highly accessible youth initiatives worldwide aim to prevent worsening of mental health problems, but research into outcomes over time is scarce. AIMS: This study aimed to evaluate outcomes and support use in 12- to 15-year-old visitors of the @ease mental health walk-in centres, a Dutch initiative offering free counselling by trained and supervised peers. METHOD: Data of 754 visitors, collected 2018-2022, included psychological distress (Clinical Outcomes in Routine Evaluation 10 (CORE-10)), social and occupational functioning (Social and Occupational Functioning Assessment Scale (SOFAS)), school absenteeism and support use, analysed with change indicators (first to last visit), and mixed models (first three visits). RESULTS: Among return visitors, 50.5% were female, 79.4% were in tertiary education and 36.9% were born outside of The Netherlands (one-time visitors: 64.7%, 72.9% and 41.3%, respectively). Moreover, 29.9% of return visitors presented with suicidal ideations, 97.1% had clinical psychological distress levels, and 64.1% of the latter had no support in the previous 3 months (one-time visitors: 27.2%, 90.7% and 71.1%, respectively). From visit 1 to 3, psychological distress decreased (ß = -3.79, 95% CI -5.41 to -2.18; P < 0.001) and social and occupational functioning improved (ß = 3.93, 95% CI 0.51-7.36; P = 0.025). Over an average 3.9 visits, 39.6% improved reliably and 28.0% improved clinically significantly on the SOFAS, which was 28.4% and 8.8%, respectively, on the CORE-10, where 43.2% improved in clinical category. Counselling satisfaction was rated 4.5/5. CONCLUSIONS: Reductions in psychological distress, improvements in functioning and high counselling satisfaction were found among @ease visitors, forming a basis for future research with a control group.

Long-term Changes in Personal Recovery and Quality of Life Among Patients With Schizophrenia Spectrum Disorders and Different Durations of Illness: A Meta-analysis.

BACKGROUND AND HYPOTHESIS: In schizophrenia spectrum disorders (SSD) personal recovery and subjective quality of life (S-QOL) are crucial and show conceptual overlap. There is limited knowledge about how these outcomes change over time. Therefore, we investigated changes in personal recovery or S-QOL for patients with SSD. We specifically focused on the influence of the patients' durations of illness (DOI) on changes in personal recovery and S-QOL. STUDY DESIGN: We included 46 studies investigating longitudinal changes in quantitative assessments of personal recovery or S-QOL for patients with SSD. Outcomes were categorized in overall personal recovery, overall S-QOL connectedness, hope and optimism, identity, meaning in life, and empowerment. We evaluated effect sizes of change between baseline and follow-up assessments. We also evaluated potential moderating effects, including DOI on these changes in outcomes. STUDY RESULTS: We found small improvements of overall personal recovery and S-QOL, but marginal or no improvement over time in the other more specific outcome domains. Patients without a schizophrenia diagnosis, a younger age, and more recent publications positively influenced these changes. We found no significant influence of DOI on the changes in any outcome domain. CONCLUSIONS: Improvement in personal recovery or S-QOL of people with SSD is modest at best. However, these studies did not fully capture the personal narratives or nonlinear process of recovery of an individual. Future research should focus on how to shift from a clinical to more person-oriented approach in clinical practice to support patients in improving their personal process of recovery. REVIEW PROTOCOL REGISTRATION: CRD42022377100.

The associations between daily reports of loneliness and psychotic experiences in the early risk stages for psychosis.

AIM: Bi-directional associations between loneliness and psychotic experiences (PEs) have been reported, but the mechanisms underlying these associations are unknown. This study aims to explore associations between daily reports of loneliness and PEs, and test differences in this association across young adult individuals at different levels of risk for psychosis. METHODS: We analysed 90-day diary data on loneliness and PEs from N = 96 participants (mean age 24.7, range 18-35, 77% female) divided into 4 subgroups, each indexing increased levels of risk for psychosis according to the clinical staging model: 'psychometric' (n = 25), 'low' (n = 27), 'mild' (n = 24), and 'ultra-high'(n = 20) risk. Multilevel vector autoregressive models examined within-day (contemporaneous) and between-day (temporal) associations between loneliness and PEs for the total sample. Next, these associations were compared across subgroups. RESULTS: Loneliness and PEs were significantly associated contemporaneously (partial correlation B = 0.14) but not temporally. Subgroup membership moderated both contemporaneous and temporal associations. The contemporaneous association between loneliness and PEs was stronger in the low-risk subgroup compared to the mild-risk (B = -0.35, p < .01) and ultra-high-risk (B = -0.36, p < .01) subgroups. The temporal association between loneliness on the previous day and PEs on the current day was stronger in mild-risk subgroup compared to the ultra-high-risk subgroup (B = -0.03, p = .03). After adjusting for multiple testing, only the contemporaneous-but not the temporal-associations remained statistically significant. CONCLUSIONS: Loneliness is associated with PEs in individuals at risk for psychosis, particularly in those with low to mild symptoms. Our findings tentatively suggest that especially individuals with low expressions of PEs may be more sensitive to social context, but future studies are needed to replicate and further unravel the potentially stage-specific interplay between social context and PEs.

Discontinuation of psychotropic medication: a synthesis of evidence across medication classes.

Pharmacotherapy is an effective treatment modality across psychiatric disorders. Nevertheless, many patients discontinue their medication at some point. Evidence-based guidance for patients, clinicians, and policymakers on rational discontinuation strategies is vital to enable the best, personalized treatment for any given patient. Nonetheless, there is a scarcity of guidelines on discontinuation strategies. In this perspective, we therefore summarize and critically appraise the evidence on discontinuation of six major psychotropic medication classes: antidepressants, antipsychotics, benzodiazepines, mood stabilizers, opioids, and stimulants. For each medication class, a wide range of topics pertaining to each of the following questions are discussed: (1) Who can discontinue (e.g., what are risk factors for relapse?); (2) When to discontinue (e.g., after 1 year or several years of antidepressant use?); and (3) How to discontinue (e.g., what's the efficacy of dose reduction compared to full cessation and interventions to mitigate relapse risk?). We thus highlight how comparing the evidence across medication classes can identify knowledge gaps, which may pave the way for more integrated research on discontinuation.

Personal recovery in first-episode psychosis: Beyond clinical and functional recovery.

BACKGROUND: The concept of personal recovery after psychotic illness focuses more on patients' social and existential needs compared to traditional outcome measures including clinical and functional recovery. This research aims to contribute to a broad framework on (personal) recovery and associated factors. METHODS: Data from 203 persons with symptomatic remission of their first-episode psychosis from the ongoing HAMLETT study were analyzed. To determine the relative importance of several biological, clinical, psychological, and social factors in explaining personal recovery as measured by the Recovery Assessment Scale (RAS), partial Spearman correlations (controlling for clinical recovery (PANSS) and functional recovery (WHODAS 2.0)) and a bootstrapped multiple regression were performed. Indirect effects on personal recovery within these factors, clinical recovery, and functional recovery were explored using a regularized partial correlation network. RESULTS: Of the factors that explained personal recovery beyond the effects of clinical and functional recovery, social support was the strongest predictor, followed by self-esteem, internalized stigma, and insecure attachment, collectively explaining 48.2 % of the variance. Anhedonia/apathy showed a trend towards a negative correlation. Age at onset, sex, early trauma/neglect, cognition, and being married/cohabiting did not significantly correlate with personal recovery. The network (n = 143) was consistent with these findings and indicated possible mediation pathways for early trauma/neglect, insecure attachment, cognition, and being married/cohabiting. CONCLUSIONS: Personal recovery is an important addition to traditional measures of outcome after psychosis. Various quality of life indicators, such as self-esteem and social support, explain variance in personal recovery over clinical and functional recovery.

A single-session VR intervention addressing self-compassion and self-criticism with and without perspective change: Results of a randomized controlled experiment.

Excessive self-criticism is an important transdiagnostic psychological factor. In contrast, self-compassion can contribute to the resilience and recovery of clinical populations, making this an important target for treatment. Virtual Reality (VR) has the potential to improve existing interventions as it allows for personalized roleplays that can be experienced from different perspectives, by using the novel VR technique of perspective change. We investigated the effects of a VR intervention on self-criticism and self-compassion, and the added value of changing perspectives. In total, 68 undergraduate students with high levels of self-criticism were randomized to either the perspective change condition or the control condition. Participants played two roleplays in which they had to react compassionately toward a virtual character that expressed the participants' own self-critical thoughts. In the perspective change condition, after each roleplay perspective change was used to receive one's own compassionate words. Results showed that self-compassion increased and self-criticism decreased significantly in both conditions. No significant differences were found for negative and positive affect. Furthermore, no differences were found between the conditions. Thus, receiving compassionate words through perspective change had no additional effect. Expressing compassion to someone with similar self-criticism showed to be sufficient to reduce self-criticism and increase self-compassion.

Virtual reality aggression prevention treatment in a Dutch prison-based population: a pilot study.

Background: Treating violent behavior in prisons comes with challenges, such as the inability to practice safely with triggering situations and motivational issues. A solution may be the use of Virtual Reality (VR). With VR, specific conditions or needs can be tailored for individual practice, it can enhance motivation and VR has proven to be a safe and effective tool in mental health treatment. Objective: A pilot study was conducted to test the acceptability, feasibility, and preliminary effects of VR Aggression Prevention Treatment (VRAPT) in a prison-based population. Methods: In total 17 detainees with aggressive behavior were included in this single-group pilot study. Acceptability and feasibility were assessed using qualitative measures for participants and therapists. Preliminary treatment effects were measured with self-report and observational measures on aggression, anger, emotion regulation, and impulsiveness. Results: Participants and therapists were predominantly positive about VRAPT. Participants rated the sessions with an average satisfaction score of 9.2 out of 10 (SD = 0.3). Qualitative data showed that participants reported having learned to respond more adequately to aggressive behavior and gained insights into their own and others' triggers and tension. The combination of VR and theory was experienced as a strength of the treatment, as well as the ability to trigger aggression in VR which provided insights into aggression. However, the theoretical framework was found to be too complex, and more aggressive and personal scenarios should be incorporated into the sessions. Self-reported aggression, anger, provocation, emotion regulation, and observed verbal aggression decreased and seemed to stabilize after the treatment ended, with small to medium effect sizes. Conclusion: VRAPT proved feasible and acceptable for most participants and therapists. An adapted treatment protocol called Virtual Reality Treatment for Aggression Control (VR-TrAC), will be used in a future RCT to investigate the effects of the treatment in a prison-based population.

Integrating a virtual reality relaxation clinic within acute psychiatric services: A pilot study.

People with acute psychiatric conditions experience heightened stress, which is associated with worsened symptoms and increased violence on psychiatric wards. Traditional stress management techniques can be challenging for patients. Virtual reality (VR) relaxation appears promising to reduce stress; however, research on VR for psychiatric wards is limited. This mixed-methods study investigated feasibility and acceptability of integrating a VR relaxation clinic within acute psychiatric services. The study evaluated a VR relaxation session for inpatients and outpatients with acute psychiatric conditions (N = 42) and therapists' (N = 6) experience facilitating VR sessions for patients. Self-report assessments of psychological wellbeing were completed by patients pre- and post-VR. Patients and therapists provided qualitative feedback. The number of violent incidents and restrictive practices on the wards in the 12 weeks before VR implementation was compared to the first 12 weeks of VR. Post-VR, there were statistically significant increases in patients' relaxation, happiness, and connectedness to nature, and decreases in stress, anxiety, and sadness. Qualitative findings indicate patients found sessions enjoyable, relaxing, and helpful. Therapists provided positive feedback but highlighted practical challenges. Violent incidents and restrictive practices halved during VR implementation. VR relaxation appears feasible and acceptable in acute services. Larger studies should evaluate potential impact on psychiatric wards.

How to quit cannabis when you have a mental illness: study from the perspective of patients who have successfully quit.

AIMS AND METHOD: Research regarding quitting cannabis use often excludes patients with severe mental illness (SMI). We investigated facilitating and impeding factors in SMI patients and their advice to others, using semi-structured interviews with 12 SMI-patients, who were daily cannabis users for ≥12 months and had fully stopped using for ≥6 months. RESULTS: Seeking distraction, social contacts in personal environment, avoiding temptation and support from professionals were facilitating factors in stopping. Impeding factors were withdrawal symptoms, user environment, experiencing stress and user's routine. Advice to other patients included to just do it, seek support from others, quit 'cold turkey' and acknowledge that cannabis use is a problem. Advice to mental health professionals is to discuss cannabis use from the start of treatment. CLINICAL IMPLICATIONS: It is important to inform patients that cannabis use has negative consequences and limits the effects of treatment. Do not judge cannabis use or force the patient to stop.

Risk factors for suicidality across psychosis vulnerability spectrum.

BACKGROUND: Suicide is a leading cause of death in individuals with psychotic disorders. Risk factors for suicidality across the psychosis vulnerability spectrum are insufficiently known. METHODS: For patients (n = 830), siblings (n = 664) and controls (n = 444), suicidality was assessed by the use of a clinical interview. Multilevel modelling was used to investigate risk factors of suicidality. Lastly, risk factor × familial risk interaction effects were examined. RESULTS: Multivariable models revealed a significant relation between suicidality and depressive symptoms across all three groups, and childhood trauma in patients and siblings. The association between suicidality and psychotic-like experiences is more pronounced in siblings compared to controls. CONCLUSION: Across the psychosis vulnerability spectrum, depressive symptoms and childhood trauma have been associated with suicidality. Clinicians should pay attention to suicidality in individuals at high familial risk for psychosis with psychotic-like experiences.

The association of childhood trauma with depressive and negative symptoms in recent onset psychosis: a sex-specific analysis.

BACKGROUND: Childhood trauma may impact the course of schizophrenia spectrum disorders (SSD), specifically in relation to the increased severity of depressive or negative symptoms. The type and impact of trauma may differ between sexes. In a large sample of recent-onset patients, we investigated the associations of depressive and negative symptoms with childhood trauma and whether these are sex-specific. METHODS: A total of 187 first-episode psychosis patients in remission (Handling Antipsychotic Medication: Long-term Evaluation of Targeted Treatment study) and 115 recent-onset SSD patients (Simvastatin study) were included in this cross-sectional study (men: n = 218; women: n = 84). Total trauma score and trauma subtypes were assessed using the Childhood Trauma Questionnaire Short Form; depressive and negative symptoms were rated using the Positive And Negative Symptoms Scale. Sex-specific regression analyses were performed. RESULTS: Women reported higher rates of sexual abuse than men (23.5% v. 7.8%). Depressive symptoms were associated with total trauma scores and emotional abuse ratings in men (ß: 0.219-0.295; p ≤ 0.001). In women, depressive symptoms were associated with sexual abuse ratings (ß: 0.271; p = 0.011). Negative symptoms were associated with total trauma score and emotional neglect ratings in men (ß: 0.166-0.232; p ≤ 0.001). Negative symptoms in women were not linked to childhood trauma, potentially due to lack of statistical power. CONCLUSIONS: Depressive symptom severity was associated with different types of trauma in men and women with recent-onset SSD. Specifically, in women, depressive symptom severity was associated with childhood sexual abuse, which was reported three times as often as in men. Our results emphasize the importance of sex-specific analyses in SSD research.

Short- and long-term changes in symptom dimensions among patients with schizophrenia spectrum disorders and different durations of illness: A meta-analysis.

In schizophrenia spectrum disorders, improvement in symptoms varies between patients with short and long durations of illness. In this meta-analysis we provided an overview of both short- and long-term symptomatic improvement for patients with schizophrenia spectrum disorders with distinct durations of illness. We included 82 longitudinal studies assessing the course of positive, negative, depressive and disorganization symptoms. We analyzed effect sizes of change in four subgroups based on durations of illness at baseline: <2 years, 2-5 years, 5-10 years, >10 years. Potential moderators were explored using meta-regression and sensitivity analyses. Overall, we found large improvements of positive symptoms and small improvements of negative, depressive, and disorganization symptoms. Positive and disorganization symptoms improved relatively stronger for patients earlier in the course of illness, whereas negative and depressive symptoms showed modest improvement regardless of duration of illness. Improvement of symptoms was associated with higher baseline severity of positive symptoms, a younger age, a smaller subsample with schizophrenia, and, specifically for negative symptoms, higher baseline severity of depressive symptoms. Future research should focus on exploring ways to optimize improvement in negative and depressive symptoms for patients with schizophrenia spectrum disorders.

Traditional and faith-based healthcare in the management of psychotic disorders in Africa: in search for synergy.

PURPOSE OF REVIEW: This review summarizes the current literature on the role of traditional and faith-based healthcare in the management of psychotic disorders in Africa. RECENT FINDINGS: In contemporary Africa, individuals with psychosis and traditional and faith healers (TFH) are pluralistic towards their understanding of psychosis and their help-seeking behaviour. Traditional healing is perceived to be helpful to patients with psychotic disorders and their family members and may have a positive influence on the course of psychosis in some selected individuals. Studies show that potentially harmful practices are commonly used by African TFH, but that these are associated with a lack of resources and are susceptible to training. Although various TFH and biomedical practitioners are open to collaboration, the many identified obstacles hinder actual partnerships. However, the few studies that have been conducted on collaborative care for patients with psychotic disorders on the continent, show positive outcomes. SUMMARY: Rather than harmonizing the two healing paradigms, synergistic collaboration between traditional/faith-based and biomedical mental healthcare in the management of individuals with psychosis seems to be possible within certain limits. Synergistic collaboration is more culturally syntonic and may actually contribute to bridging the treatment gap for mental disorders in present-day Africa.

Associations between learning principles of cognitive remediation and cognitive and vocational outcomes in early psychosis-an exploratory analysis of RCT data.

Background: Most cognitive remediation (CR) programs are based on multiple scientific learning principles. The role of those learning principles in the beneficial effects of CR is poorly understood. A better understanding of such underlying mechanisms is important to further tailor the intervention and to learn about optimal contexts.Method: An explorative secondary analysis was conducted of data from a randomized controlled trial (RCT) comparing the effects of Individual Placement and Support (IPS) with and without CR. The present study evaluated how CR learning principles of "massed practice," "errorless learning," "strategy use" and "therapist contribution" (therapist fidelity) were associated with cognitive and vocational outcomes within 26 participants in this RCT who were treatment exposed.Results: Cognitive gains after CR were positively associated with "massed practice" and "errorless learning." Negative associations were found with "strategy use" and "therapist fidelity." No direct relationship was found between CR principles and vocational outcomes.Conclusions: Results tentatively suggest that CR is most effective and efficient with a good balance between sufficient intensity, of more than 200 tasks, and a limited duration of the training up to 20 h, using tasks that remain both challenging and rewarding, being applied in a context that facilitates real-life practice.

VR-SOAP, a modular virtual reality treatment for improving social activities and participation of young people with psychosis: a study protocol for a single-blind multi-centre randomized controlled trial.

BACKGROUND: Young people with a psychotic disorder have the same social goals as their healthy peers, but their social networks are smaller, they participate less often in leisure activities and are less successful in work and education. Causes of these problems are multifaceted, but culminate in difficulties with interacting in daily life social situations. Current treatments have only moderate effects on social functioning and often target one specific domain. Virtual reality (VR) has the potential to improve the treatment of social interaction difficulties. We developed a modular VR treatment for social functioning and participation (VR-SOAP). In this study, the effect of this intervention will be investigated in a randomized controlled trial (RCT). METHODS: A total of 116 participants (age 18-40) with a DSM-5 diagnosis of schizophrenia spectrum or other psychotic disorder and problems with social functioning will be recruited from mental healthcare institutes in the Netherlands. Participants will be randomized to the experimental condition (VR-SOAP) or active VR control condition (VRelax). VR-SOAP consists of 14 sessions and 5 modules addressing causes of impaired social functioning: four optional modules (1-4) and one fixed module (5). Vrelax consists of 14 sessions that entail psychoeducation, stress management, relaxation techniques, and the exploration of relaxing environments in VR. Primary outcomes are quantity and quality of social contacts, leisure activities and social participation, measured with the experience sampling method (ESM). Secondary outcomes are psychiatric symptoms, social behaviour, social cognition, self-esteem, self-stigma and paranoid thoughts. Treatment effects will be compared at pre-treatment (baseline), post-treatment and at 6-month follow-up. DISCUSSION: If VR-SOAP proves to be effective, it provides therapists with a much-needed tool to improve social functioning of young adults with a psychotic disorder. Additionally, since the treatment consists of multiple modules targeting different transdiagnostic factors, this trial might provide input for new treatments to improve social functioning in a range of symptoms and disorders, e.g. mood, autism spectrum and anxiety disorders. TRIAL REGISTRATION: On the 10th of November 2021, this trial was registered prospectively in the Dutch Trial Register as NL9784 .