Category Archives: Schizophrenia

How can escaping into virtual reality improve healthcare?

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You slowly creep towards the door while being acutely aware that the slightest sound will get you caught. As you reach for the handle and steadily open the large wooden door you hear a slight creak. Suddenly, the expansive and exposed wall to your right explodes in a flurry of shrapnel, wallpaper and dust. A figure starts to emerge from the wound in the wall and stares directly at you with a terrifying smile. You’ve been found out…

Virtual reality isn’t always quite so terrifying but the above example reminds us that the virtual world has the capacity to make us believe what is thrust directly in front of us. The fear is real and the experience is one which mimics the experience of navigating a trap ridden residence. Besides terrifying us and fuelling visions of humanity being locked in a virtual world to escape the real one, what is the future of virtual reality? Well, one emerging area appears to be concerned with improving mental health.

Use of virtual reality to treat mental health difficulties

Psychosis, a cardinal symptom of schizophrenia, is the presence of delusions and hallucinations which can cause considerable distress. Delusions can take many forms and the nature of these seem to be tied to the diagnosis present (e.g. bipolar disorder, depression or schizophrenia). One delusion common to those diagnosed with schizophrenia is paranoia which can, understandably, cause significant distress and impairment in an individual’s life. However, what if we could challenge the paranoid thoughts of those experiencing psychosis and illustrate their unfounded nature? A real-world setting is likely to be too anxiety-provoking for obvious reasons but what if we could recreate paranoia-inducing environments in the relative safety of virtual reality?

This is exactly what a group at the University of Oxford led by Professor Daniel Freeman has explored in their study for the British Journal of Psychiatry last year. They exposed individuals with persecutory delusions (e.g. paranoid thoughts) to one of two mock real-life setting through virtual reality and asked them to do one of two things. One group was simply exposed to the virtual environment and asked to simply experience the situation. The effect of this on their their paranoia was assessed. The second group, by contrast, was asked to drop their guard, stop using their safety behaviours, and actively put their paranoid thoughts to the test (e.g. Do people in this environment see me as an easy target and do they actually do things to belittle me?). This second condition was known as the cognitive therapy group as they were encouraged to actively re-evaluate their delusions in the safe confines of the virtual environment.

There were 30 participants tested and they were randomised to either an exposure or cognitive therapy condition. They were tested in a real-life setting initially, then gradually introduced to the virtual reality environment, and then finally tested in the real life setting once again. At each point participants were tested before and after their immersion to either real-life or virtual reality on a scale assessing the conviction and distress of paranoid thoughts. As a test of ‘credibility’ the participants were also asked whether they believed the virtual reality setting would help them overcome their paranoid thoughts. Participants were tested in one of two different virtual reality settings. The first setting was a typical one for any Londoner: a tube journey. The second was a lift which the participant walked into and could inspect the other passengers.

So, what did they find? They found that there was a significant and large reduction in conviction and distress of delusions following the cognitive therapy group’s immersion into the virtual environments. Interestingly, these findings also carried over to the real-world setting. On average, they found a reduction in scores of around 20% for the cognitive therapy vs the exposure virtual reality condition. This suggested that getting individuals with paranoid delusions to test out their threat beliefs in a safe environment had the impact of reducing their paranoia. This should be considered in light of the difficulty to achieve this in a real life setting due to considerable anxiety and stress. This suggests that virtual reality is a simple and effective way to combat threat beliefs in paranoia.

However, this was only completed over a single day and the long-term impacts of using virtual reality is this way are currently unknown. Is there a dose-dependent effect of VR on threat beliefs? How long do the therapeutic gains last for? Are there individuals for whom this works better or worse? Are there any unintended side effects of using VR for multiple sessions in a patient population? And many other questions which remain to be answered. Psychosis is not the only field where virtual reality has started to prove its worth in treatment and research but anxiety, depression and eating disorders are also highlighted in the recent review by Professor Freeman earlier this year.

It should be noted that virtual reality is by no means only being realised within mental health but it is starting to be used extensively within physical healthcare too. VR provides an optimal way to train new surgeons, doctors, and nurses in medical procedures. This is what current research is exploring and virtual reality is only one avenue. Augmented reality is becoming more common and apps such as VR in the OR allow us to witness surgical procedures in an interactive manner from the comfort of your own home.

Basic Science and Mechanisms Research

So, there appears to be promise for using virtual reality as a way to deliver therapy but what about research more basic, mechanistic, research (e.g. what causes paranoid thinking in the first place)? Surely if we can create a convincing setting then we could start to study how threat beliefs are generated, in the case of psychosis, or understand what might reduce of exacerbate mental health difficulties in general. In an earlier study conducted in 2003, Prof. Freeman showed that paranoid thoughts could be seen in a virtual reality setting with healthy individuals. In their early foray into the use of VR they found that a small number of participants in their sample attributed hostility towards the avatars present in the environment. The researchers argued that this showed that VR could be used to study paranoia and provide a more realistic environment to test predictors of paranoia in a social setting.

Finally, because we can treat these virtual realities as realistic and convincing, they provide a great landscape in which to explore situations which might prove difficult for those at risk for certain mental illnesses. This allows researchers to test out hypotheses without unnecessarily exposing participants to a threatening situation, and with the ease of removing the headset instantly if the situation becomes distressing. For example, it would be possible to further probe the effect of sleep on mood and how this might contribute to mental health difficulties through the use of virtual reality. Now, as with any science, the worth of the study is not dependent on how flashy the toys are which are used but the strength of the research question and design. Although VR may strike some as flashy, it is useful in that it provides a way to recreate reality but in the controlled and safe confines of the lab. VR may currently be synonymous with jump scares and large price tags it is also being used to improve the health of the public. The widespread use of VR across healthcare settings is still a while off. For now, we shall just have to be content with scaring ourselves senseless with Resident Evil and other horror games.

References

Freeman, D., Bradley, J., Antley, A., Bourke, E., DeWeever, N., Evans, N., … & Slater, M. (2016). Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction. The British Journal of Psychiatry, 209 (1), 62-67.

Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 1-8.

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Virtual Reality (Header)

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BBC’s ‘In the Mind’ Series

Television

I haven’t written anything in a little while but hopefully that should be fixed over the next week (workload depending). Anyway, this brief post is a slight departure from the normal foray in sleep and everything related to it. I wanted to bring people’s attention to the series of mental health documentaries, short films and portrayals of serious mental illnesses been shown on the BBC over this month. You can find a summary of all of the programs which have already been aired, and are yet to be aired here: http://www.bbc.co.uk/mediacentre/latestnews/2016/in-the-mind

The hour long documentaries / films follow people who have suffered from mental illness in some form of another and create a narrative for the viewer to follow. The aim is to educate and through this hopefully reduce the stigma surrounding in general.

It’s great to see that these documentaries have tackled issues which receive less attention in the media such as postpartum psychosis and bipolar disorder. The former is a disorder which I frequently come across in my reading but which I had no real understanding of. Although an hour is hardly enough to really get to grips with how these disease manifest and impact on a wide variety of different peoples’ lives, the documentaries on biplolar disorder and postpartum psychosis do provide us a privileged window into the lives of people, and their loved ones, fighting with mental illness. Admittedly, it is hard to watch certain scenes and it personally brings back familiar experiences from my own family, both as a child and as an adult.

Also, if anyone is interested, Prof. Richard Bentall has given his own opinion on the BBC’s depiction of bipolar disorder as primarily a biological disorder (https://blogs.canterbury.ac.uk/discursive/all-in-the-brain/#.VscA52Zud_U.twitter) He acknowledges the role of drugs in the recovery of very ill individuals but argues that a focus on the biological aspect of mental illness does very little to help with stigma (e.g. it creates a dichotomy of the sick and the healthy). I agree in the sense that the documentaries I have managed to watch so far focus on the severe stages of mental illness and neglect the broad spectrum of mental illness from health to hospitalisation. They give people a glimpse into mental health but perhaps see it as if through a window into the ‘other side’. However, I would also argue that these documentaries give understanding of what it means to be given a diagnosis of a mental illness and how individuals and their families deal with this. In this sense, they help to break down boundaries between stigmatised terms, such as ‘psychosis’, with no human experience to attach to them. It is because of this I would suggest people watch at least one of the documentaries being shown and currently on iPlayer.

Anyway, I just wanted this to be brief and not a matter of me typing lots of stuff into the ether of wordpress. One last thing, I also want to give a link to a really useful link about the role of drawing in talking and dealing with mental health (here http://www.bbc.co.uk/newsbeat/article/35564616/mental-health-week-how-drawings-on-social-media-are-changing-the-conversation?ocid=socialflow_facebook&ns_mchannel=social&ns_campaign=bbcnews&ns_source=facebook) Although her work isn’t included here but I personally found the drawings of Allie Brosh particularly helpful and a good explanation of what it is to live with depression (http://hyperboleandahalf.blogspot.co.uk/2011/10/adventures-in-depression.html). Please check some of these out, and share them with people who might find them helpful, educational, or simply interesting.

Inquisitive Tortoise

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What Causes Sleepwalking?

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“Jack… Jack? Jack…!” A flash of lights and the whizz of cars speeding past suddenly assault my senses. In the background, I’m dimly aware of my name being called. In a few more seconds I have woken more fully and, as if suddenly coming up from underwater, I hear the shouts and then realise why my name being called out in increasingly frantic tones. “Close the door! Jack…! Close it!”

The car door was halfway open and I had just taken off my seat-belt. I was, as I began to realise, a mere second or two from stepping out of the family car hurtling along the M6. Suffice to say, I wasn’t trusted with the privilege of a child-lock-free place in the car after that.

Sleepwalking can be considered to be one of a number of different but related disorders which come under the global title of ‘disorders of arousal’. Confusional arousal, sleep-related eating disorder and sleep-related abnormal sexual behaviours are all considered to be forms of, or to be related to, sleepwalking. These are behaviours of differing complexity, all of which are performed while an individual is asleep and of which they typically have little to no memory afterwards. Sleepwalking is typically classified by seemingly automated behaviours which may appear to serve some purpose.

It is not uncommon in childhood and, unlike my own experience, may cause a little distress and embarrassment but hardly have the potential for injury or death. In fact, sleepwalking during childhood occurs in as many as 17% of children at its peak age of 11 years old, and it is generally accepted that we grow out of this behaviour. Indeed, only around 1-4% of the adult population report sleepwalking episodes. Given that the brain and our sleep and bodily rhythms go through major changes during adolescence, this shift from a common phenomenon to relative rarity is far from surprising. Incidentally, as we will later see, the changes in the structure of sleep from childhood to adulthood may explain why we may remember the odd embarrassing sleepwalking episode as a child but not as an adult.

However, it is considered less than benign if sleepwalking becomes common in our adult lives. In both childhood and adult sleepwalkers, there is a relationship between sleepwalking and anxiety, psychosis and other parasomnias, such as night terrors. The main concern in adulthood is the risk of physical harm to the sleepwalker or others. All of us have probably been exposed to what sleepwalking is and what forms it can take. This can range from simply walking around the house to preparing food, having a conversation or even, in rare instances, driving. Given the range of complex behaviours which can occur during a period of sleepwalking, it should come as no surprise that some consider its occurrence in adults far from benign. Instances of murder, sexual assault and personal injury are purported to have taken place during a sleepwalking episode.

It should be stressed that this is far from the norm among adult sleepwalkers. These concerns are rare and although the sleepwalker may harm themselves or their bed-partner, it is typically the loss of sleep and subsequent daytime sleepiness which are of primary concern to doctors.

 

What Causes Sleepwalking?

 

So, what actually causes sleepwalking and why do some people seem to be prone to it whereas others don’t? First we need to have an idea of what happens as we fall asleep and what our brain is doing as we drift off.

The brain does not go to sleep in a unitary manner. Although we may feel ourselves start to drift into sleep as we steadily lose consciousness, the brain enters a sleep state in a progressive, region-specific manner. That is, brain regions which have been active over the course of the day or prior to sleep take longer to enter a sleep-like rhythm. As a result of this facet of sleep physiology, it is possible to observe certain regions of the brain as awake while others are technically asleep. Among those prone to sleepwalking, it is observed that motor regions of the brain may exhibit ‘wakefulness’ while areas responsible for higher cortical functions such as the prefrontal cortex are ‘asleep’. This may explain why someone can seemingly carry out complex actions but yet still be asleep, but it does not tell us how this occurs in the first place. Why is it that this pattern of localised wakefulness only results in sleepwalking in a small subset of adults and a larger subset of children? It seems the pattern of sleep in sleepwalkers sheds some light on this question.

During a typical night’s sleep, we progress through cycles which see us move from light sleep to deep sleep and back again about 4-5 times. Each of these cycles lasts about 90-110 minutes and marks our shift from non-rapid eye-movement (NREM) sleep to rapid eye-movement (REM) sleep. NREM sleep consists of 4 separable stages and dominates the first half of the night, whereas REM sleep is where we typically dream and dominates the latter half of the night. These stages can be tracked using a technique called polysomnography, whereby electrodes are placed on an individual’s head and the underlying neural activity is recorded while they sleep.

Researchers are interested in the function of these different stages of sleep (NREM is made up of four distinct stages) and how they might serve memory consolidation, daytime functioning and even mental health. How does sleepwalking fit into all of this then? Well, research seems to point to the deepest stage of NREM sleep, known as slow wave sleep (SWS), as a potential culprit.

When you compare individuals with a history of sleepwalking against those without in the sleep laboratory, you find some interesting differences. Namely, those with the history of sleepwalking episodes tend to show a fragmentation of their slow-wave sleep compared to the controls. It seems that sleepwalkers are more prone to waking up, albeit very briefly, during SWS sleep, and it is this occurrence which may precede a sleepwalking episode. Moreover, sleep deprivation over 24 hours and experimentally induced awakenings during NREM sleep can induce sleepwalking. However, there’s an important caveat to this: these findings are only found in those already prone to sleepwalking episodes (i.e. a recorded history of adult sleepwalking). Individuals who did not report sleepwalking did not start sleepwalking purely because they were deprived of sleep, or woken up at just the right time.

Problems during SWS fits with our earlier identification of sleepwalking as being commonly found in childhood. The percentage of the sleep cycle taken up by SWS is increased in childhood and decreases as we grow older. As we have already identified, sleepwalking can occur during any stage of NREM sleep but it is during SWS that it is most commonly ‘found’. The next question we’re presented with then is what might lead an individual to be prone to these ‘micro-arousals’ during SWS? The short answer is that we’re still not quite sure. The evidence available suggests that genetic factors play an important role in leading someone to be prone to sleepwalking episodes. For example, you are more likely to have a disorder of arousal such as sleepwalking if another relative also suffers from it.

Other factors beyond genetics have been identified as being linked to sleepwalking. A review last year identified sleep deprivation (which we have covered), stress, forced arousal during sleep (such as needing to go the toilet or a loud noise nearby), an unfamiliar sleep environment and medications (such as those used to treat schizophrenia) as potential triggers for an episode of sleepwalking and other arousal disorders. Interestingly, what all of these factors seem to have in common is that they influence SWS –by either deepening or fragmenting this stage of sleep. This seems to fit with the neural activity characterisation of sleepwalking. Other research groups have identified alcohol as a trigger for sleepwalking, but the evidence is less convincing here. It should be noted that the above factors, bar sleep deprivation, have not been studied in any detail in the sleep laboratory. Anecdote does not science equal but, hopefully, it will provide a springy launch-pad for future research.

So, returning to the beginning and my story of my own sleepwalking episodes as a child. Sleepwalking, like sleep itself, is a puzzling but fascinating phenomenon. It may be that children are more likely to experience sleepwalking briefly as a facet of normal sleep architecture development. This likely explains my own, admittedly hair-raising, experience. However, a definite answer for what may cause sleepwalking in adults is less certain. Further research of known triggers and improvements in eliciting somnambulism in the sleep lab will help clarify these issues. Regardless, we already have some useful clues and it is likely that slow wave sleep problems will lead us in the right direction.

No doubt sleepwalking will remain of interest to scientists, playwrights, artists and anyone who has had even a brief brush with embarrassing or benign breaks in sleep. FYI, the story I decided to share with you is the least embarrassing sleepwalking episode I could think of.

Inquisitive Tortoise

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What is it like to Hear Voices? A questionnaire study

A research study looking into the experience of hearing voices. Click the link below to find out more:

What is it like to Hear Voices? A questionnaire study.

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Second Meeting of the International Consortium on Hallucination Research: Durham University 12 / 13th September

Last week I was lucky enough to be invited along to attend the ‘Second Meeting of the International Consortium on Hallucination Research’ at Durham University where researchers from all over the world discussed hallucinations of all modalities. Through this I was able to meet some rather interesting and inspiring individuals connected to the Hearing the Voice movement (HtV) (more of this in my next post). Although I felt quite out of my depth speaking to experts in the field it was really exciting to get a chance to talk to those people who, up until this point, I could only refer to as citations in one of my essays. As a psychology geek I was truly in my element, even if my courage to talk to the more eminent researchers failed me several times before success started to set in… Admittedly it was ‘slightly’ overwhelming to be surrounded by so many experts in the field, but as a student I was able to learn so much about not just hallucination research but the scientific process in action.

My interest in the work of the ‘Hearing the Voice Network Durham’ has existed since its genesis nearly two years ago in 2011, and the conference reinforced many of the ideas the Durham network had already advocated. The ‘HtV’ movement in Durham is a multidisciplinary group that aims to consider auditory hallucinations (voice-hearing) from different perspectives and to understand these complex phenomena as more than a symptom of schizophrenia and other psychiatric and neurological disorders. Through a volunteering with this group, I have become influenced by their work and gained some hands-on experience with some rather cool equipment (fMRI is oddly cosy when you get used to the noise…). It has sparked the notion that hearing voices need not be considered pathological or tied to psychosis.

My first introduction to hallucinations being so much more than a symptom of schizophrenia came through a talk by Marius Romme and Sandra Escher. These two social psychiatrists from the Netherlands who have worked with voice-hearers and been instrumental in changing the way we look at auditory verbal hallucinations (AVHs). The aspect of their talk back in 2011 that caught me and still intrigues me the most today is that ‘hearing voices’ is not by itself a sign of mental disturbance. On the contrary, it can have a beneficial impact on an individual’s life and almost as many as 10-15% of the population experience the perception of hallucinatory voices while still being regarded ‘healthy’. Admittedly, this is by no means the majority, but the fact that this classic symptom of madness could be seen as a positive force in a sizeable number of people fascinated me.

Ultimately, the conference captured this ethos, and although there was considerable talk about alleviating distress in clinical voice hearers, there was also the prevailing opinion that an individual and their voices can reach harmony. This point is clearly shown in the case of Eleanor Longden, a voice-hearer who suffered with voices and face institutionalisation only to gain full control of her life again. Her recently published TedTalk describes this better than I could attempt to:

I realise I have touched on quite a few issues in very brief detail (and I haven’t touched on about the part students can play in this arena yet), but that shall be a job for my next few posts.

InquisitiveTortoise

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