The temporal association between social isolation, distress, and psychotic experiences in individuals at clinical high-risk for psychosis.

BACKGROUND: Psychotic experiences (PEs) and social isolation (SI) seem related during early stages of psychosis, but the temporal dynamics between the two are not clear. Literature so far suggests a self-perpetuating cycle wherein momentary increases in PEs lead to social withdrawal, which, subsequently, triggers PEs at a next point in time, especially when SI is associated with increased distress. The current study investigated the daily-life temporal associations between SI and PEs, as well as the role of SI-related and general affective distress in individuals at clinical high risk (CHR) for psychosis. METHODS: We used experience sampling methodology in a sample of 137 CHR participants. We analyzed the association between SI, PEs, and distress using time-lagged linear mixed-effects models. RESULTS: SI did not predict next-moment fluctuations in PEs, or vice versa. Furthermore, although SI-related distress was not predictive of subsequent PEs, general affective distress during SI was a robust predictor of next-moment PEs. CONCLUSIONS: Our results suggest that SI and PEs are not directly related on a moment-to-moment level, but a negative emotional state when alone does contribute to the risk of PEs. These findings highlight the role of affective wellbeing during early-stage psychosis development.

Virtual food exposure with positive mood induction or social support to reduce food anxiety in anorexia nervosa: A feasibility study.

OBJECTIVE: Aversive emotions toward food and the consequences of eating are at the core of anorexia nervosa. Exposure therapy is effective to reduce anxiety and avoidance toward feared stimuli. Based on the inhibitory learning framework, this study examined the feasibility to induce social support or positive mood to enhance the impact of a single session virtual food exposure on food-related anxiety in anorexia nervosa. METHOD: One hundred and forty-five patients were randomized to: (1) virtual food exposure (i.e., baseline condition), (2) virtual food exposure plus positive mood induction (i.e., positive mood condition), or (3) virtual food exposure plus social support (i.e., social support condition). They completed self-report assessments of anxiety toward virtual foods, general anxiety, positive mood, social support, and hunger, before and after virtual food exposure. Number of eye gazes and touches toward foods were recorded during the virtual reality exposure. RESULTS: Patients had lower levels of anxiety toward virtual foods in the positive mood condition, compared to the baseline condition [F(2,141) = 4.36, p = .015; medium effect size]. They also touched food items more often in the baseline condition. No other significant changes were found. DISCUSSION: Virtual food exposure enhanced by positive mood induction seems a feasible approach to strengthen the impact of food exposure in anorexia nervosa. PUBLIC SIGNIFICANCE: This research contributes to the understanding of how patients with anorexia nervosa can be supported to overcome fear and anxiety around food. Virtual reality enables patients to expose themselves to difficult situations (e.g., kitchen with foods of various calorie contents) while experiencing positive stimuli, such as a loving and kind pet or a supportive avatar.

Immersive virtual reality as a novel approach to investigate the association between adverse events and adolescent paranoid ideation.

PURPOSE: Paranoid ideation is common among adolescents, yet little is known about the precursors. Using a novel immersive virtual reality (VR) paradigm, we tested whether experiences of bullying, and other interpersonal/threatening events, are associated with paranoid ideation to a greater degree than other types of (i) non-interpersonal events or (ii) adverse childhood experiences. METHODS: Self-reported exposure to adverse life events and bullying was collected on 481 adolescents, aged 11-15. We used mixed effects (multilevel) linear regression to estimate the magnitude of associations between risk factors and paranoid ideation, assessed by means of adolescents' reactions to ambiguously behaving avatars in a VR school canteen, adjusting for putative confounders (gender, year group, ethnicity, free school meal status, place of birth, family mental health problems). RESULTS: Lifetime exposure to interpersonal/threatening events, but not non-interpersonal events or adverse circumstances, was associated with higher levels of state paranoid ideation, with further evidence that the effect was cumulative (1 type: ϐadj 0.07, 95% CI -0.01-0.14; 2 types: ϐadj 0.14, 95% CI 0.05-0.24; 3 + types: ϐadj 0.24, 95% CI 0.12-0.36). More tentatively, for girls, but not boys, recent bullying was associated with heightened paranoid ideation with effect estimates ranging from ϐadj 0.06 (95% CI -0.02-0.15) for physical bullying to ϐadj 0.21 (95% CI 0.10-0.32) for cyber bullying. CONCLUSIONS: Our data suggest a degree of specificity for adversities involving interpersonal threat or hostility, i.e. those that involve unwanted interference and/or attempted control of an individual's personal boundaries being associated with heightened levels of state paranoid ideation among adolescents.

Psychosocial and behavioural interventions for the negative symptoms of schizophrenia: a systematic review of efficacy meta-analyses.

BACKGROUND: Currently there is no first-line treatment recommended for the negative symptoms of schizophrenia. Psychosocial and behavioural interventions are widely used to reduce the burden of negative symptoms. Meta-analytic studies have summarised the evidence for specific approaches but not compared evidence quality and benefit. AIM: To review and evaluate the evidence from meta-analytic studies of psychosocial and behavioural interventions for the negative symptoms of schizophrenia. METHOD: A systematic literature search was undertaken to identify all meta-analyses evaluating psychosocial and behavioural interventions reporting on negative symptom outcomes in people with schizophrenia. Data on intervention, study characteristics, acceptability and outcome were extracted. Risk of bias was evaluated. Results were summarised descriptively, and evidence ranked on methodological quality. RESULTS: In total, 31 systematic reviews met the inclusion criteria evaluating the efficacy of negative symptom interventions on 33 141 participants. Exercise interventions showed effect sizes (reduction in negative symptoms) ranging from -0.59 to -0.24 and psychological interventions ranging from -0.65 to -0.04. Attrition ranged between 12% to 32%. Across the studies considered heterogeneity varied substantially (range 0-100). Most of the reviews were of very low to low methodological quality. Methodological quality ranking suggested that the effect size for cognitive remediation and exercise therapy may be more robust compared with other approaches. CONCLUSIONS: Most of the interventions considered had a small-to-moderate effect size, good acceptability levels but very few had negative symptoms as the primary intervention target. To improve the confidence of these effect sizes being replicated in clinical settings future studies should minimise risk of bias.

Serum immune markers and transition to psychosis in individuals at clinical high risk.

Individuals at clinical high risk (CHR) for psychosis have been found to have altered cytokine levels, but whether these changes are related to clinical outcomes remains unclear. We addressed this issue by measuring serum levels of 20 immune markers in 325 participants (n = 269 CHR, n = 56 healthy controls) using multiplex immunoassays, and then followed up the CHR sample to determine their clinical outcomes. Among 269 CHR individuals, 50 (18.6 %) developed psychosis by two years. Univariate and machine learning techniques were used to compare levels of inflammatory markers in CHR subjects and healthy controls, and in CHR subjects who had (CHR-t), or had not (CHR-nt) transitioned to psychosis. An ANCOVA identified significant group differences (CHR-t, CHR-nt and controls) and post-hoc tests indicated that VEGF levels and the IL-10/IL-6 ratio were significantly higher in CHR-t than CHR-nt, after adjusting for multiple comparisons. Using a penalised logistic regression classifier, CHR participants were distinguished from controls with an area-under the curve (AUC) of 0.82, with IL-6 and IL-4 levels the most important discriminating features. Transition to psychosis was predicted with an AUC of 0.57, with higher VEGF level and IL-10/IL-6 ratio the most important discriminating features. These data suggest that alterations in the levels of peripheral immune markers are associated with the subsequent onset of psychosis. The association with increased VEGF levels could reflect altered blood-brain-barrier (BBB) permeability, while the link with an elevated IL-10/IL-6 ratio points to an imbalance between anti- and pro-inflammatory cytokines.

The incidence of non-affective psychotic disorders in low and middle-income countries: a systematic review and meta-analysis.

PURPOSE: Global understanding of the epidemiological landscape of non-affective psychotic disorders (NAPD) is predominantly based on studies from high-income countries. We sought to systematically review and meta-analyse all incidence studies conducted in low and middle-income countries (LMICs). METHODS: We systematically searched four databases using terms for NAPD, incidence and LMICs. Citations were eligible for inclusion if: published between 1 January 1960 and 31 May 2022; wholly or partially conducted in an LMIC, and; containing data on NAPD incidence in the general adult population. Two independent raters assessed study quality according to previously published criteria. We conducted a narrative synthesis and random-effects meta-analyses where sufficient studies were available (N ≥ 5). RESULTS: We retrieved 11 421 records, of which 23 citations met inclusion criteria from 18 unique studies across 19 settings in 10 LMICs. Median study quality was 4 out of 7 (interquartile range: 3-6). The crude incidence of NAPD varied around 4.2 times, from 10.0 per 100,000 person-years (95% confidence interval [CI] 8.7-11.4) in Brazil to 42.0 (95%CI 32.2-54.8) in India, with marked heterogeneity in methodologies and rates. Our 60-year review highlights the dearth of robust evidence on the incidence of psychotic disorders in LMICs. CONCLUSION: Without reliable, contemporary estimates of this fundamental cornerstone of population health, it is impossible to understand the true burden, distribution or causes of psychotic disorders in over 87% of the world's population. A new, more equitable global mental health evidence base for NAPD is now urgently required.

Virtual reality relaxation for people with mental health conditions: a systematic review.

PURPOSE: Vulnerability to stress is linked to poor mental health. Stress management interventions for people with mental health conditions are numerous but they are difficult to implement and have limited effectiveness in this population. Virtual reality (VR) relaxation is an innovative intervention that aims to reduce stress. This review aimed to synthesize evidence of VR relaxation for people with mental health conditions (PROSPERO 269405). METHODS: Embase, Medline, PsycInfo, and Web of Science were searched until 17th September 2021. The review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The Effective Public Health Practice Project (EPHPP) tool assessed methodological quality of studies. RESULTS: Searching identified 4550 studies. Eighteen studies (N = 848) were included in the review. Studies were published between 2008 and 2021. Eleven were conducted in Europe. Thirteen studies were controlled trials. Participants were mostly working-age adult outpatients experiencing anxiety or stress-related conditions. Other conditions included eating disorders, depression, bipolar disorder, and psychosis. Five studies tested inpatients. All studies used a range of nature-based virtual environments, such as forests, islands, mountains, lakes, waterfalls, and most commonly, beaches to promote relaxation. Studies provided evidence of the feasibility, acceptability, and short-term effectiveness of VR relaxation to increase relaxation and reduce stress. EPHPP ratings were 'strong' (N = 11), 'moderate' (N = 4), and 'weak' (N = 3). CONCLUSIONS: VR relaxation has potential as a low-intensity intervention to promote relaxation and reduce stress for adults with mental health conditions, especially anxiety and stress-related problems. Further research is warranted on this promising intervention.

Food-related aversion in a female sample of people with anorexia nervosa: Cognitive-behavioural correlates, somatic and subjective anxiety, and early experiences.

OBJECTIVE: Food-related anxiety and avoidance are key features of anorexia nervosa, and among the most arduous maintaining processes to address in treatment. This study gathered information on the behavioural and cognitive correlates of food-related anxiety, including their associations with early experiences of aversive learning related to food, and more general anxiety. METHODS: One-hundred and forty-four patients with anorexia nervosa were recruited from clinical services in Italy. They completed online questionnaires to assess food-related anxiety, eating disorder psychopathology, eating disorder safety behaviours and threat cognitions, early experience of aversive learning related to food, and somatic anxiety. RESULTS: Experiences of food-related aversive learning were recalled by the majority of the sample (87.86%), with negative psychological consequences following eating being the most often reported (75%). Safety behaviours and threat cognitions related to the consequences of eating were also reported (14.29%-87.86%, and 36.43-90% respectively, depending on the behaviour/cognition). Eating disorder psychopathology was predicted by both somatic anxiety and negative psychological consequences following eating, whereas self-reported food anxiety was only predicted by somatic anxiety. CONCLUSION: Findings validate an anxiety-based model of anorexia nervosa which establishes the role of safety behaviours, threat cognitions, early aversive learning experiences, and anxiety in the psychopathology of the illness. Exposure-based interventions have the potential to target these factors, and inhibit food-related fear.

Influence of cannabis use on incidence of psychosis in people at clinical high risk.

AIMS: Evidence for case-control studies suggests that cannabis use is a risk factor for the development of psychosis. However, there have been limited prospective studies and the direction of this association remains controversial. The primary aim of the present study was to examine the association between cannabis use and the incidence of psychotic disorders in people at clinical high risk of psychosis. Secondary aims were to assess associations between cannabis use and the persistence of psychotic symptoms, and with functional outcome. METHODS: Current and previous cannabis use were assessed in individuals at clinical high risk of psychosis (n = 334) and healthy controls (n = 67), using a modified version of the Cannabis Experience Questionnaire. Participants were assessed at baseline and followed up for 2 years. Transition to psychosis and persistence of psychotic symptoms were assessed using the Comprehensive Assessment of At-Risk Mental States criteria. Level of functioning at follow up was assessed using the Global Assessment of Functioning disability scale. RESULTS: During follow up, 16.2% of the clinical high-risk sample developed psychosis. Of those who did not become psychotic, 51.4% had persistent symptoms and 48.6% were in remission. There was no significant association between any measure of cannabis use at baseline and either transition to psychosis, the persistence of symptoms, or functional outcome. CONCLUSIONS: These findings contrast with epidemiological data that suggest that cannabis use increases the risk of psychotic disorder.

Virtual reality and immersive technologies to promote workplace wellbeing: a systematic review.

BACKGROUND: Work-related stress negatively impacts employee wellbeing. Stress-management interventions that reduce workplace stress can be challenging. Immersive technologies, such as virtual reality (VR), may provide an alternative. AIMS: This systematic review aimed to evaluate feasibility, acceptability, and effectiveness of immersive technologies to promote workplace wellbeing (PROSPERO 268460). METHODS: Databases MEDLINE, Web of Science, PsycINFO and Embase were searched until 22nd July 2021. Studies were included if they tested a workforce or were designed for a workplace. Effective Public Health Practice Project quality assessment tool (EPHPP) was used for quality ratings. RESULTS: There were 17 studies (N = 1270), published 2011-2021. Over half were conducted in Europe. Eight studies were controlled trials. Most studies involved brief, single sessions of immersive VR and provided evidence of feasibility, acceptability, and effectiveness when measuring wellbeing-related variables such as stress, relaxation, and restoration. VR environments included relaxation tasks such as meditation or breathing exercises, and nature-based stimuli, such as forests, beaches, and water. Studies tested office workers, healthcare professionals, social workers, teachers, and military personnel. EPHPP ratings were "strong" (N = 1), "moderate" (N = 13), and "weak" (N = 3). CONCLUSIONS: VR relaxation appears helpful for workplaces. However, limited longer-term data, controlled trials, and naturalistic studies mean conclusions must be drawn cautiously.

Relationship between jumping to conclusions and clinical outcomes in people at clinical high-risk for psychosis.

BACKGROUND: Psychosis is associated with a reasoning bias, which manifests as a tendency to 'jump to conclusions'. We examined this bias in people at clinical high-risk for psychosis (CHR) and investigated its relationship with their clinical outcomes. METHODS: In total, 303 CHR subjects and 57 healthy controls (HC) were included. Both groups were assessed at baseline, and after 1 and 2 years. A 'beads' task was used to assess reasoning bias. Symptoms and level of functioning were assessed using the Comprehensive Assessment of At-Risk Mental States scale (CAARMS) and the Global Assessment of Functioning (GAF), respectively. During follow up, 58 (16.1%) of the CHR group developed psychosis (CHR-T), and 245 did not (CHR-NT). Logistic regressions, multilevel mixed models, and Cox regression were used to analyse the relationship between reasoning bias and transition to psychosis and level of functioning, at each time point. RESULTS: There was no association between reasoning bias at baseline and the subsequent onset of psychosis. However, when assessed after the transition to psychosis, CHR-T participants showed a greater tendency to jump to conclusions than CHR-NT and HC participants (55, 17, 17%; χ2 = 8.13, p = 0.012). There was a significant association between jumping to conclusions (JTC) at baseline and a reduced level of functioning at 2-year follow-up in the CHR group after adjusting for transition, gender, ethnicity, age, and IQ. CONCLUSIONS: In CHR participants, JTC at baseline was associated with adverse functioning at the follow-up. Interventions designed to improve JTC could be beneficial in the CHR population.

The incidence of non-affective psychotic disorders in Chile between 2005 and 2018: results from a national register of over 30 000 cases.

BACKGROUND: Evidence suggests the incidence of non-affective psychotic disorders (NAPDs) varies across persons and places, but data from the Global South is scarce. We aimed to estimate the treated incidence of NAPD in Chile, and variance by person, place and time. METHODS: We used national register data from Chile including all people, 10-65 years, with the first episode of NAPD (International Classification of Diseases, Tenth Revision: F20-F29) between 1 January 2005 and 29 August 2018. Denominators were estimated from Chilean National Census data. Our main outcome was treated incidence of NAPD and age group, sex, calendar year and regional-level population density, multidimensional poverty and latitude were exposures of interest. RESULTS: We identified 32 358 NAPD cases [12 136 (39.5%) women; median age-at-first-contact: 24 years (interquartile range 18-39 years)] during 171.1 million person-years [crude incidence: 18.9 per 100 000 person-years; 95% confidence interval (CI) 18.7-19.1]. Multilevel Poisson regression identified a strong age-sex interaction in incidence, with rates peaking in men (57.6 per 100 000 person-years; 95% CI 56.0-59.2) and women (29.5 per 100 000 person-years; 95% CI 28.4-30.7) between 15 and 19 years old. Rates also decreased (non-linearly) over time for women, but not men. We observed a non-linear association with multidimensional poverty and latitude, with the highest rates in the poorest regions and those immediately south of Santiago; no association with regional population density was observed. CONCLUSION: Our findings inform the aetiology of NAPDs, replicating typical associations with age, sex and multidimensional poverty in a Global South context. The absence of association with population density suggests this risk may be context-dependent.

Clinical, cognitive and neuroanatomical associations of serum NMDAR autoantibodies in people at clinical high risk for psychosis.

Serum neuronal autoantibodies, such as those to the NMDA receptor (NMDAR), are detectable in a subgroup of patients with psychotic disorders. It is not known if they are present before the onset of psychosis or whether they are associated with particular clinical features or outcomes. In a case-control study, sera from 254 subjects at clinical high risk (CHR) for psychosis and 116 healthy volunteers were tested for antibodies against multiple neuronal antigens implicated in CNS autoimmune disorders, using fixed and live cell-based assays (CBAs). Within the CHR group, the relationship between NMDAR antibodies and symptoms, cognitive function and clinical outcomes over 24 month follow-up was examined. CHR subjects were not more frequently seropositive for neuronal autoantibodies than controls (8.3% vs. 5.2%; OR = 1.50; 95% CI: 0.58-3.90). The NMDAR was the most common target antigen and NMDAR IgGs were more sensitively detected with live versus fixed CBAs (p < 0.001). Preliminary phenotypic analyses revealed that within the CHR sample, the NMDAR antibody seropositive subjects had higher levels of current depression, performed worse on the Rey Auditory Verbal Learning Task (p < 0.05), and had a markedly lower IQ (p < 0.01). NMDAR IgGs were not more frequent in subjects who later became psychotic than those who did not. NMDAR antibody serostatus and titre was associated with poorer levels of functioning at follow-up (p < 0.05) and the presence of a neuronal autoantibody was associated with larger amygdala volumes (p < 0.05). Altogether, these findings demonstrate that NMDAR autoantibodies are detectable in a subgroup of CHR subjects at equal rates to controls. In the CHR group, they are associated with affective psychopathology, impairments in verbal memory, and overall cognitive function: these findings are qualitatively and individually similar to core features of autoimmune encephalitis and/or animal models of NMDAR antibody-mediated CNS disease. Overall the current work supports further evaluation of NMDAR autoantibodies as a possible prognostic biomarker and aetiological factor in a subset of people already meeting CHR criteria.

Altered relationship between cortisol response to social stress and mediotemporal function during fear processing in people at clinical high risk for psychosis: a preliminary report.

Evidence suggests that people at Clinical High Risk for Psychosis (CHR) have a blunted cortisol response to stress and altered mediotemporal activation during fear processing, which may be neuroendocrine-neuronal signatures of maladaptive threat responses. However, whether these facets are associated with each other and how this relationship is affected by cannabidiol treatment is unknown. We examined the relationship between cortisol response to social stress and mediotemporal function during fear processing in healthy people and in CHR patients. In exploratory analyses, we investigated whether treatment with cannabidiol in CHR individuals could normalise any putative alterations in cortisol-mediotemporal coupling. 33 CHR patients were randomised to 600 mg cannabidiol or placebo treatment. Healthy controls (n = 19) did not receive any drug. Mediotemporal function was assessed using a fearful face-processing functional magnetic resonance imaging paradigm. Serum cortisol and anxiety were measured immediately following the Trier Social Stress Test. The relationship between cortisol and mediotemporal blood-oxygen-level-dependent haemodynamic response was investigated using linear regression. In healthy controls, there was a significant negative relationship between cortisol and parahippocampal activation (p = 0.023), such that the higher the cortisol levels induced by social stress, the lower the parahippocampal activation (greater deactivation) during fear processing. This relationship differed significantly between the control and placebo groups (p = 0.033), but not between the placebo and cannabidiol groups (p = 0.67). Our preliminary findings suggest that the parahippocampal response to fear processing may be associated with the neuroendocrine (cortisol) response to experimentally induced social stress, and that this relationship may be altered in patients at clinical high risk for psychosis.

Elucidating negative symptoms in the daily life of individuals in the early stages of psychosis.

BACKGROUND: It remains poorly understood how negative symptoms are experienced in the daily lives of individuals in the early stages of psychosis. We aimed to investigate whether altered affective experience, anhedonia, social anhedonia, and asociality were more pronounced in individuals with an at-risk mental state for psychosis (ARMS) and individuals with first-episode psychosis (FEP) than in controls. METHODS: We used the experience sampling methodology (ESM) to assess negative symptoms, as they occurred in the daily life of 51 individuals with FEP and 46 ARMS, compared with 53 controls. RESULTS: Multilevel linear regression analyses showed no overall evidence for a blunting of affective experience. There was some evidence for anhedonia in FEP but not in ARMS, as shown by a smaller increase of positive affect (BΔat-risk v. FEP = 0.08, p = 0.006) as the pleasantness of activities increased. Against our expectations, no evidence was found for greater social anhedonia in any group. FEP were more often alone (57%) than ARMS (38%) and controls (35%) but appraisals of the social situation did not point to asociality. CONCLUSIONS: Overall, altered affective experience, anhedonia, social anhedonia and asociality seem to play less of a role in the daily life of individuals in the early stages of psychosis than previously assumed. With the experience of affect and pleasure in daily life being largely intact, changing social situations and appraisals thereof should be further investigated to prevent development or deterioration of negative symptoms.

Editorial Perspective: Rethinking child and adolescent mental health care after COVID-19.

While COVID-19 pandemic has allegedly passed its first peak in most western countries, health systems are progressively adapting to the 'new normality'. In child and adolescent mental health services (CAMHS), such organizational envisioning is needed to cope with the foreseeable psychological effects of prolonged social isolation induced by nation-wide public health measures such as school closure. CAMHS need to ensure flexible responses to the psychopathological consequences of evolving societal dynamics, as dramatically actualized by the unexpected COVID-19 pandemic. This would imply (a) shifting the focus of intervention from symptom reduction and containment of acute crises in a comparatively small number of severe cases to a broader preventive strategy, guided by a gradient of increasing intensity and specificity of treatment; (b) promoting smooth access pathways into services and encouraging participation of families; (c) adopting a transdiagnostic staging model to capture the developmental fluctuations from subsyndromal to syndromal states and back, with related changes in the intensity of the need of care; and (d) implementing digital tools to encourage help-seeking and compliance by digitally native youth.

Virtual reality-based assessment and treatment of social functioning impairments in psychosis: a systematic review.

People with psychosis can experience social functioning impairments. Virtual reality (VR) has been used to assess and treat these difficulties. This systematic review (Prospero CRD42015026288) provides an evaluation of these VR applications. PsycINFO, MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus were searched until May 2020. The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to assess studies. Database searching identified 3810 titles. Fifty-eight studies (published 2005-2020; N = 2,853), comprising twenty-six head-mounted display studies (20 assessment, 6 treatment) and thirty-two immersive 2D screen studies (23 assessment, 9 treatment), were included. There were forty-eight observational studies and ten randomised controlled trials, with 1570 participants (of which, 185 were at ultra-high risk of psychosis) in VR test groups. Nearly half the studies were published since 2016. Assessments targeted cognitive and behavioural indicators of social functioning, e.g. paranoia, eye gaze, or interpersonal distance. Treatments promoted cognitive-behavioural social skills or job interview training. Studies indicate feasibility, acceptability, and effectiveness of VR for social functioning impairments in psychosis. Limitations of studies include the narrow scope of social functioning, small sample sizes, and limited randomised controlled trials and standardised interventions. Findings suggest VR has potential to be integrated with existing psychological approaches.

Virtual reality relaxation for the general population: a systematic review.

PURPOSE: Relaxation has significant restorative properties and implications for public health. However, modern, busy lives leave limiting time for relaxation. Virtual reality (VR) experiences of pleasant and calming virtual environments, accessed with a head-mounted display (HMD), appear to promote relaxation. This study aimed to provide a systematic review of feasibility, acceptability, and effectiveness of studies that use VR to promote relaxation in the general population (PROSPERO 195,804). METHODS: Web of Science, PsycINFO, Embase, and MEDLINE were searched until 29th June 2020. Studies were included in the review if they used HMD technology to present virtual environments that aimed to promote or measure relaxation, or relaxation-related variables. The Effective Public Health Practice Project (EPHPP) quality assessment tool was used to assess methodological quality of studies. RESULTS: 6403 articles were identified through database searching. Nineteen studies published between 2007 and 2020, with 1278 participants, were included in the review. Of these, thirteen were controlled studies. Studies predominantly used natural audio-visual stimuli to promote relaxation. Findings indicate feasibility, acceptability, and short-term effectiveness of VR to increase relaxation and reduce stress. Six studies received an EPHPP rating of 'strong', seven were 'moderate', and six were 'weak'. CONCLUSIONS: VR may be a useful tool to promote relaxation in the general population, especially during the COVID-19 pandemic, when stress is increasing worldwide. However, methodological limitations, such as limited randomised controlled trials and longer-term evidence, mean that these conclusions should be drawn with caution. More robust studies are needed to support this promising area of VR relaxation.

Subjective experience of paranoid ideation in a virtual reality social environment: A mixed methods cross-sectional study.

Virtual reality-assisted cognitive-behavioural therapy (VR-CBT) has potential to support people who experience paranoid ideation in social settings. However, virtual reality (VR) research using overt social environments is limited, and lack of qualitative studies on paranoid ideation in VR restricts understanding. This study aimed to use predominantly qualitative methods to investigate subjective experience of paranoia in VR and identify target domains for VR-CBT. Participants (N = 36) were non-clinical adults with high trait paranoia, who entered an interactive VR bar-room environment. After VR, they participated in brief audiotaped semi-structured interviews designed for measuring persecutory ideation in virtual environments. Researchers scored transcripts on the Comprehensive Assessment of At-Risk Mental States Non-Bizarre Ideas Global Rating Scale to rate the state paranoia represented by interview content. Thematic analysis of interviews employed superordinate themes of Social Evaluative Concerns, Ideas of Reference, and Ideas of Persecution to investigate participants' experience of paranoia. Mean score on the Non-Bizarre Ideas scale was 3.06 (standard deviation 1.24, range 1-6), indicating "moderate" attenuated-paranoid experiences. Nearly all participants reported Social Evaluative Concerns (N = 35) and Ideas of Reference (N = 32); half reported Ideas of Persecution (N = 19). Twelve subthemes were identified. Notably, participants believed they did not belong in the environment (N = 31), that they were the object of discussion (N = 20), and that they felt avatars were unfriendly (N = 27) and intentionally rejected them (N = 13). Subthemes reflect interpersonal and social processes that may constitute target areas for VR-CBT, for example, cognitive appraisals and social skills. Identification of these domains indicates how personalized VR-CBT may be operationalized.

Pediatric traumatic brain injury and antisocial behavior: are they linked? A systematic review.

Purpose: Despite growing evidence supporting a link between pediatric traumatic brain injury (TBI) and antisocial behavior, little work has rigorously evaluated this. This review aimed to explore systematically previous literature on the association between TBI before the age of 19 and severe behavioral problems such as violence, aggression and assault. Methods: All articles published from 1990 to 2018 were searched using four major databases, alongside manual searching and cross-referencing. Results: Sixteen articles met the eligibility criteria. Overall, they supported an association between pediatric TBI and antisocial behavior. Factors were identified that might influence this link, such as, for example, TBI severity and substance use. Conclusions: The review identified several issues in the current literature, highlighting key areas for improvement. It is imperative that more attention is paid to gathering detailed information regarding the temporal sequencing of events and TBI severity; evaluating the contribution of biopsychosocial variables co-occurring with TBI and antisocial behavior; disentangling which outcomes are specific to TBI versus any injury. The review has implications for the health and justice systems; regardless of whether TBI is the cause versus a contributing factor to antisocial behavior, increased awareness of their association could lead to more comprehensive assessments, tailored interventions and effective sentencing.