A Preliminary Study to Determine Comprehensive Research and Development Plans for Promoting Mental Health Services.

OBJECTIVES: The aim of this study was to analyze research and development projects in mental health services in Korea, using priority evaluation of mental health promotion policies to determine direction of the service. METHODS: An online survey was conducted that targeted experts in the mental health service regarding promotion of mental health in Korea in 2016. The survey was based on 32 policy projects that resulted from 12 strategies according to 4 policy objectives. RESULTS: Analysis of 32 mental health projects were assessed regarding the possibility of technology development success, magnitude of the ripple effect, and necessity of a national response. It was observed that 3 policy projects relevant to suicide, had a high relative priority. This was followed by policies for improvement of health insurance and the medical benefit cost system, and policies for reinforcement of crisis psychological support such as those for disaster victims. CONCLUSION: The prioritization of mental health services should place an emphasis on promotion of a healthy mental lifestyle, rehabilitation support for patients with serious mental illness, and reinforcement of social safety networks for suicide prevention.

Aversive eye gaze during a speech in virtual environment in patients with social anxiety disorder.

OBJECTIVE: One of the main characteristics of social anxiety disorder is excessive fear of social evaluation. In such situations, anxiety can influence gaze behaviour. Thus, the current study adopted virtual reality to examine eye gaze pattern of social anxiety disorder patients while presenting different types of speeches. METHODS: A total of 79 social anxiety disorder patients and 51 healthy controls presented prepared speeches on general topics and impromptu speeches on self-related topics to a virtual audience while their eye gaze was recorded. Their presentation performance was also evaluated. RESULTS: Overall, social anxiety disorder patients showed less eye gaze towards the audience than healthy controls. Types of speech did not influence social anxiety disorder patients' gaze allocation towards the audience. However, patients with social anxiety disorder showed significant correlations between the amount of eye gaze towards the audience while presenting self-related speeches and social anxiety cognitions. CONCLUSION: The current study confirms that eye gaze behaviour of social anxiety disorder patients is aversive and that their anxiety symptoms are more dependent on the nature of topic.

Altered Functional Connectivity of the Default Mode Network in Low-Empathy Subjects.

Empathy is the ability to identify with or make a vicariously experience of another person's feelings or thoughts based on memory and/or self-referential mental simulation. The default mode network in particular is related to self-referential empathy. In order to elucidate the possible neural mechanisms underlying empathy, we investigated the functional connectivity of the default mode network in subjects from a general population. Resting state functional magnetic resonance imaging data were acquired from 19 low-empathy subjects and 18 medium-empathy subjects. An independent component analysis was used to identify the default mode network, and differences in functional connectivity strength were compared between the two groups. The low-empathy group showed lower functional connectivity of the medial prefrontal cortex and anterior cingulate cortex (Brodmann areas 9 and 32) within the default mode network, compared to the medium-empathy group. The results of the present study suggest that empathy is related to functional connectivity of the medial prefrontal cortex/anterior cingulate cortex within the default mode network. Functional decreases in connectivity among low-empathy subjects may reflect an impairment of self-referential mental simulation.

Effect of perceived intimacy on social decision-making in patients with schizophrenia.

Social dysfunctions including emotional perception and social decision-making are common in patients with schizophrenia. The aim of this study was to determine the level of intimacy formation and the effect of intimacy on social decision in patients with schizophrenia using virtual reality tasks, which simulate complicated social situations. Twenty-seven patients with schizophrenia and 30 healthy controls performed the 2 virtual social tasks: the intimacy task and the social decision task. The first one was to estimate repeatedly how intimate participants felt with each avatar after listening to what avatars said. The second one was to decide whether or not participants accepted the requests of easy, medium, or hard difficulty by the intimate or distant avatars. During the intimacy task, the intimacy rating scores for intimate avatars were not significantly different between groups, but those for distant avatars were significantly higher in patients than in controls. During the social decision task, the difference in the acceptance rate between intimate and distant avatars was significantly smaller in patients than in controls. In detail, a significant group difference in the acceptance rate was found only for the hard requests, but not for the easy and medium difficulty requests. These results suggest that patients with schizophrenia have a deficit in emotional perception and social decision-making. Various factors such as a peculiarity of emotional deficits, motivational deficits, concreteness, and paranoid tendency may contribute to these abnormalities.

Altered structural connectivity and trait anhedonia in patients with schizophrenia.

This study tested association between anhedonia scores and white matter integrity in order to investigate the neural basis of trait anhedonia in schizophrenia. A total of 31 patients with schizophrenia and 33 healthy controls underwent diffusion weighted imaging and scoring of trait anhedonia using the Physical Anhedonia Scale. Using tract-based spatial statistics, we found that fractional anisotropy values of some white matter regions were differently correlated with Physical Anhedonia Scale scores between the two groups. The white matter regions that were more significantly correlated with trait anhedonia in patients than in controls included the left side of the cingulum, splenium of the corpus callosum, inferior longitudinal fasciculus, superior longitudinal fasciculus I and II, anterior thalamic radiation, and optic radiation. Of these regions, fractional anisotropy values in the cingulum and superior longitudinal fasciculus II were positively correlated with trait anhedonia in patients with schizophrenia. These findings suggest that alterations in structural connectivity within large-scale brain networks, including the default mode and central executive networks, may contribute to the development of trait anhedonia in patients with schizophrenia.

Deficient gaze pattern during virtual multiparty conversation in patients with schizophrenia.

Virtual reality has been used to measure abnormal social characteristics, particularly in one-to-one situations. In real life, however, conversations with multiple companions are common and more complicated than two-party conversations. In this study, we explored the features of social behaviors in patients with schizophrenia during virtual multiparty conversations. Twenty-three patients with schizophrenia and 22 healthy controls performed the virtual three-party conversation task, which included leading and aiding avatars, positive- and negative-emotion-laden situations, and listening and speaking phases. Patients showed a significant negative correlation in the listening phase between the amount of gaze on the between-avatar space and reasoning ability, and demonstrated increased gaze on the between-avatar space in the speaking phase that was uncorrelated with attentional ability. These results suggest that patients with schizophrenia have active avoidance of eye contact during three-party conversations. Virtual reality may provide a useful way to measure abnormal social characteristics during multiparty conversations in schizophrenia.

rTMS over bilateral inferior parietal cortex induces decrement of spatial sustained attention.

Sustained attention is an essential brain function that enables a subject to maintain attention level over the time of a task. In previous work, the right inferior parietal lobe (IPL) has been reported as one of the main brain regions related to sustained attention, however, the right lateralization of vigilance/sustained attention is unclear because information about the network for sustained attention is traditionally provided by neglect patients who typically have right brain damage. Here, we investigated sustained attention by applying a virtual lesion technique, transcranial magnetic stimulation (TMS), over the left and right superior parietal lobe (SPL) and IPL. We used two different types of visual sustained attention tasks: spatial (location based) and non-spatial (feature based). When the participants performed the spatial task, repetitive TMS (rTMS) over either the right or left IPL induced a significant decrement of sustained attention causing a progressive increment of errors and response time. In contrast, participants' performance was not changed by rTMS on the non-spatial task. Also, omission errors (true negative) gradually increased with time on right and left IPL rTMS conditions, while commission errors (false positive) were relatively stable. These findings suggest that the maintenance of attention, especially in tasks regarding spatial location, is not uniquely lateralized to the right IPL, but may also involve participation of the left IPL.

The effect of simulated auditory hallucinations on daily activities in schizophrenia patients.

BACKGROUND: Auditory hallucinations often influence schizophrenia patients in many aspects. In order to develop effective behavioral interventions for overcoming enduring auditory hallucinations, it is necessary to understand how the annoying symptom affects the daily lives of the patients. This study evaluated the effect of hearing unusual voices on performing the activities of daily life in schizophrenia patients. METHODS: Eighteen hallucinating patients, 18 nonhallucinating patients and 20 normal controls performed the virtual daily-life task of packing 8 items for travel under 3 conditions: (1) without unusual voices and without avatars, (2) with unusual voices and without avatars and (3) with unusual voices and with avatars. Task completion time and the number of times the packing list was checked were recorded as a measure of the task performance. RESULTS: When exposed to unusual voices without avatars, hallucinating patients checked the packing list fewer times than nonhallucinating patients, and they required longer to complete the task, as positive and negative symptoms were worse. Subjective responses to unusual voices were stronger in hallucinating patients than in nonhallucinating patients. CONCLUSIONS: Daily-life activities of hallucinating patients may be less easily influenced by odd auditory stimuli in a nonsocial situation than those of nonhallucinating patients; however, hallucinating patients may feel more strongly affected by unusual voices. To better evaluate and thereby understand the difficulties faced by hallucinating patients in their daily life, the discrepancies between objective and subjective measures as well as social situations should be taken into consideration.

Assessment of cognitive flexibility in real life using virtual reality: a comparison of healthy individuals and schizophrenia patients.

To date, cognitive flexibility has been measured only using neuropsychological tasks, and has not been tested using more ecologically valid task due to methodological limitations. In this study, a virtual reality task was developed to evaluate cognitive flexibility in a real life situation and performance on this task was compared between 30 healthy individuals and 30 schizophrenia patients. Compared to healthy controls, a greater number of schizophrenia patients made concrete decisions, and their decision-making times were negatively correlated with the severity of their negative symptoms. These findings indicate that virtual reality can be an ecologically valid measurement of cognitive flexibility.

Deficits in eye gaze during negative social interactions in patients with schizophrenia.

Impaired social functioning has been reported in patients with schizophrenia. This study aimed to examine characteristics of interpersonal behaviors in patients with schizophrenia during various social interactions using the virtual reality system. Twenty-six patients and 26 controls engaged in the virtual conversation tasks, including 3 positive and 3 negative emotion-laden conversations. Eye gaze and other behavioral parameters were recorded during the listening and answering phases. The amount of eye gaze was assessed as smaller in the patients than in the controls. A significant interaction effect of group status and emotional type was found for the listening phase. The amount of eye gaze in the patients inversely correlated with self-rated scores of assertiveness for the listening phase. These results suggest that the patients displayed inadequate levels of augmentations in eye gaze during negative emotional situations. These deficits should be considered in the treatment and social skills training for patients with schizophrenia.

Development of a computer-based behavioral assessment of checking behavior in obsessive-compulsive disorder.

OBJECTIVE: The goal of the current study was to develop and obtain preliminary psychometric data for a computer-based behavioral measure of compulsive checking behavior in a sample of patients with obsessive-compulsive disorder (OCD). METHOD: We examined performance on a novel behavioral measure in 30 patients with OCD and 27 matched healthy controls. In the computerized assessment, participants navigated through two virtual environments (home and office) using a joystick and head-mounted display. The experiment consisted of three phases: training, distraction, and the main task. After the training and distraction phases, participants were instructed to check the virtual environments freely as if they were in their natural environment. Primary dependent variables in the current study included several indices of frequency and duration of checking behaviors. We examined construct validity for the task by comparing the novel behavioral measures with standardized self-report and interviewer-rated measures. RESULTS: Results indicated that (1) OCD patients demonstrated significantly greater problems with compulsive checking compared to controls, and (2) performance on the task was positively correlated with both self-reported symptoms and interviewer-rated measures associated with OCD. CONCLUSIONS: This study provides preliminary data to support the use of this task as a new possible behavioral measure of compulsive checking behavior in OCD. If we merge the traditional behavioral research with this novel and ecologically valid method, it could improve the assessment of OCD in both clinical and research setting.

Validity and reliability of cognitive assessment using virtual environment technology in patients with stroke.

OBJECTIVES: We assessed the validity and reliability of a virtual environment technology (VET)-based cognitive assessment program that was developed as a measurement tool of cognitive abilities in patients after a stroke. DESIGN: Twenty participants diagnosed with stroke caused by unilateral brain lesions were enrolled to assess the VET program's validity and test-retest reliability. Participants underwent evaluation by paper-based neuropsychological tests including the Korean Mini-Mental Status Examination, the Korean-Wechsler Adult Intelligence Scale, the Motor Free Visual Perception Test, Rey-Kim Memory Test, and Kim's Frontal-Executive Neuropsychologic Test as well as the VET-based cognitive assessment. Major variables and indices of the VET program were calculated. The VET program validity was evaluated using a simple correlation analysis between variables from the VET program and conventional paper-based neuropsychological measurements, and the reliability was evaluated by investigating the test-retest correlation coefficients. RESULTS: Major variables and indices of the VET program in patients with stroke correlated significantly with the related scores of paper-based neuropsychological tests. In addition, the test-retest reliability analysis revealed that the correlation coefficients ranged from 0.528 to 0.926. CONCLUSION: The VET-based cognitive assessment program showed adequate reliability and validity as a method of cognitive assessment in patients after stroke.

Nonverbal social behaviors of patients with bipolar mania during interactions with virtual humans.

It has been proposed that positive emotional biases could make bipolar manic (BM) patients maintain abnormally approaching behaviors during social interactions. To test this hypothesis, we measured interpersonal distance (IPD) and gaze angle of BM patients and normal controls (NCs) during social interaction in immersive virtual environment. Overall, IPDs of BM patients (n = 20) were greater than those of normal controls (n = 20). The IPD difference was even greater between NCs and BM patients with psychotic features (n = 11) than those without psychotic features (n = 9). Regardless of the presence of psychotic features, BM patients averted their gazes more than NCs, and even more while speaking than while listening. Our results might suggest negativistic social cognition of bipolar patients, as was previously found even during a manic phase, or the role of paranoid symptoms in avoidant social behaviors, in agreement with prior studies with schizophrenic patients. Use of proper space and gaze might have psychotherapeutic implication in developing secure, two-person relationship with bipolar patients regardless of the presence of disrupting manic symptoms.

Virtual reality prototype for measurement of expression characteristics in emotional situations.

Expressions are a basic necessity for daily living, as they are required for managing relationships with other people. Conventional expression training has difficulty achieving an objective measurement, because their assessment depends on the therapist's ability to assess a patient's state or training effectiveness. In addition, it is difficult to provide emotional and social situations in the same manner for each training or assessment session. Virtual reality techniques can overcome shortcomings occurring in conventional studies by providing exact and objective measurements and emotional and social situations. In this study, we developed a virtual reality prototype that could present emotional situation and measure expression characteristics. Although this is a preliminary study, it could be considered that this study shows the potential of virtual reality as an assessment tool.

Anxiety provocation and measurement using virtual reality in patients with obsessive-compulsive disorder.

The current study is a preliminary test of a virtual reality (VR) anxiety-provoking tool using a sample of participants with obsessive-compulsive disorder (OCD). The tasks were administrated to 33 participants with OCD and 30 healthy control participants. In the VR task, participants navigated through a virtual environment using a joystick and head-mounted display. The virtual environment consisted of three phases: training, distraction, and the main task. After the training and distraction phases, participants were allowed to check (a common OCD behavior) freely, as they would in the real world, and a visual analogy scale of anxiety was recorded during VR. Participants' anxiety in the virtual environment was measured with a validated measure of psychiatric symptoms and functions and analyzed with a VR questionnaire. Results revealed that those with OCD had significantly higher anxiety in the virtual environment than did healthy controls, and the decreased ratio of anxiety in participants with OCD was also higher than that of healthy controls. Moreover, the degree of anxiety of an individual with OCD was positively correlated with a his or her symptom score and immersive tendency score. These results suggest the possibility that VR technology has a value as an anxiety-provoking or treatment tool for OCD.

Brain mechanisms involved in processing unreal perceptions.

Individuals sometimes experience an illusory or hallucinatory perception. This unreal perception is usually resolved after the individual recognizes that the perception was not real. In this study, we investigated the brain mechanisms involved in the process to an illusory or hallucinatory perception through 'obtaining insight into unreality'. We used a novel and intuitive paradigm designed by combining functional magnetic resonance imaging and augmented reality technology to simulate visual illusory stimuli that mimic hallucinations during brain scanning. The results showed various brain activations, predominantly in the amygdala in the early phase, the medial frontal cortex and the occipitotemporal junction in the middle phase, and the thalamus in the late phase, which correlated with a subject's proneness to hallucinating. These activations may correspond to a 'responding stage' for a perception-based immediate emotional reaction, a 'monitoring stage' for integration and recalibration to ascertain that the perception was not real, and a 'resolving stage' for controlling the information and finally settling it, respectively. Our paradigm and findings may be useful in understanding the mechanisms for discriminating and coping with hallucinatory perceptions.

Development and verification of an alcohol craving-induction tool using virtual reality: craving characteristics in social pressure situation.

Alcoholism is a disease that affects parts of the brain that control emotion, decisions, and behavior. Therapy for people with alcoholism must address coping skills for facing high-risk situations. Therefore, it is important to develop tools to mimic such conditions. Cue exposure therapy (CET) provides high-risk situations during treatment, which raises the individual's ability to recognize that alcohol craving is being induced. Using CET, it is hard to simulate situations that induce alcohol craving. By contrast, virtual reality (VR) approaches can present realistic situations that cannot be experienced directly in CET. Therefore, we hypothesized that is possible to model social pressure situations using VR. We developed a VR system for inducing alcohol craving under social pressure situations and measured both the induced alcohol craving and head gaze of participants. A 2 x 2 experimental model (alcohol-related locality vs. social pressure) was designed. In situations without an avatar (no social pressure), more alcohol craving was induced if alcohol was present than if it was not. And more alcohol craving was induced in situations with an avatar (social pressure) than in situations without an avatar (no social pressure). The difference of angle between the direction of head gazing and the direction of alcohol or avatar was smaller in situations with an avatar alone (social pressure) than in situations with alcohol alone. In situations with both alcohol and an avatar, the angle between the direction of head gaze and the direction of the avatar was smaller than between the direction of head gaze and the direction of the alcohol. Considering the results, this VR system induces alcohol craving using an avatar that can express various social pressure situations.

Development and clinical trial of virtual reality-based cognitive assessment in people with stroke: preliminary study.

Stroke and traumatic brain injury affect an increasing number of people, many of whom retain permanent damage in cognitive functions. Conventionally, cognitive function has been assessed by a paper-based neuropsychological evaluation. However these test environments differ substantially from everyday life. This problem can be overcome by using virtual reality (VR) to objectively evaluate behaviors and cognitive function in simulated daily activities. With our virtual shopping simulation, we compared people who had undergone a stroke with control participants in an immersive VR program that used a head-mounted display (HMD). We evaluated user satisfaction with the tests, complications, and the user interface. Significant differences were consistently found between the stroke group and the control group for the following tasks: stage 1 performance index, interaction error; stage 2 delayed recognition memory score, attention index; and stage 3 executive index (p < 0.001). Perceptive dysfunction, visuospatial dysfunction, level of computer experience, and level of education affected the performance of the stroke group. The frequency of complications in the stroke group, calculated using the cut-off score for the Simulator Sickness Questionnaire, was 9.6% for nausea, 41.9% for oculomotor complications, and 25.8% for disorientation. The frequency of complications between the stroke and control groups was not significantly different. Thirty-five percent of participants in the stroke group and 13% in the control group reported difficulties with using the joystick. This computer-generated VR-based cognitive test shows promise in assessing cognitive function in patients with stroke. More refinements are needed in the user interface and the projection methods.

VR-based conversation training program for patients with schizophrenia: a preliminary clinical trial.

Schizophrenia is a devastating mental illness and is characterized by hallucinations and delusions as well as social skills deficits. Generally, social skills training designed to help patients develop social skills includes role-playing, but this form of training has typical shortcomings, which are largely due to a trainer's difficulties to project emotion. Virtual reality (VR)-based techniques have the potential to solve these difficulties, because they provide a computer-generated but realistic three-dimensional world and humanlike avatars that can provide emotional stimuli. In this paper, we report on a method of implementing virtual environments (VEs) in order to train people with schizophrenia to develop conversational skills in specific situations, which could overcome the shortcomings of or complement conventional role-playing techniques. The paper reports the efficacy of the proposed approach in a preliminary clinical trial with 10 patients with schizophrenia.

Virtual environment training system for rehabilitation of stroke patients with unilateral neglect: crossing the virtual street.

In this paper, we propose a system for training of stroke patients with unilateral neglect by using technology of virtual reality (VR). The proposed system is designed to compensate for unilateral neglect. This system contains the calibration of unilateral neglect and the training of this disease. The calibration procedure is implemented by aligning the virtual object at a subjective middle line. The training procedure is implemented by completing the missions that are used to keep the virtual avatar safe during crossing the street in a virtual environment. The results of this study show that the proposed system is effective to train unilateral neglect. The left to right ratio scores extracted from this system gradually decrease as the sessions of training are repeated. To validate the VR system parameters, the parameters are analyzed by correlation with those of traditional unilateral neglect assessment methods (such as the line bisection test and the cancellation test).