Transforming treatments for schizophrenia: Virtual reality, brain stimulation and social cognition

Initial Requirements for the Prototyping of an App for a Psychosocial Rehabilitation Project: An Integrative Review

The Psychosocial Rehabilitation Project (PRP) is a tool designed to structure and organize mental health care, guided by the theoretical and practical principles of Psychosocial Rehabilitation (PR). This article aims to identify the initial requirements for the prototyping of a "Psychosocial Rehabilitation Project App". To achieve this, an integrative review was conducted with the research question: what initial requirements are important to compose the prototype of the "Psychosocial Rehabilitation Project App" in mental health? In the search process, 834 articles were identified and exported to the online systematic review application Rayyan QCRI, resulting in 36 eligible articles for this study, along with one app. The reading of this material allowed the elicitation of three themes: privacy and data protection policy; design; and software and programming. The prototyping of the "Psychosocial Rehabilitation Project App" should prioritize data security and protection, simplicity in design, and the integration of technological resources that facilitate the management, construction, monitoring, and evaluation of psychosocial rehabilitation projects by mental health professionals.

Is It Possible to Combine Non-Invasive Brain Stimulation and Evidence-Based Psychosocial Interventions in Schizophrenia? A Critical Review

In schizophrenia, it was suggested that an integrated and multimodal approach, combining pharmacological and non-pharmacological interventions, could improve functional outcomes and clinical features in patients living with schizophrenia (PLWS). Among these alternatives, evidence-based psychosocial interventions (EBPIs) and Non-Invasive Brain Stimulation (NIBS) represent feasible treatment options targeting the clinical features that are unmet needs of PLWS (especially negative and cognitive symptoms). As no clear evidence is available on the combination of these non-pharmacological approaches, this review aimed to collect the available literature on the combination of EBPIs and NIBS in the treatment of PLWS. We demonstrated that the field of combining EBPIs and NIBS in schizophrenia is in its infancy, as only 11 studies were reviewed. In fact, only a few trials, with divergent results, combined these non-pharmacological modalities; while emerging evidence is available on the combination of cognitive remediation and rTMS/iTBS, inconclusive results were obtained. Conversely, albeit preliminary, more solid findings are available on the combination of HF-rTMS and family intervention. Moreover, despite the fact that cognitive activation could not be considered an EBPI, promising results are available in combination with tDCS to improve the working memory domain. To overcome these limitations, we considered several methodological issues to promote research in this field.

Effect of tDCS combined with virtual reality for post-stroke cognitive impairment: a randomized controlled trial study protocol

BACKGROUND

Post-stroke cognitive impairment (PSCI) not only increases patient mortality and disability, but also adversely affects motor function and the ability to perform routine daily activities. Current therapeutic approaches for, PSCI lack specificity, primarily relying on and medication and traditional cognitive therapy supplemented by a limited array of tools. Both transcranial direct current stimulation (tDCS) and virtual reality (VR) training have demonstrated efficacy in improving cognitive performance among PSCI patients. Previous findings across various conditions suggest that implementing a therapeutic protocol combining tDCS and VR (tDCS - VR) may yield superior in isolation. Despite this, to our knowledge, no clinical investigation combining tDCS and VR for PSCI rehabilitation has been conducted. Thus, the purpose of this study is to explore the effects of tDCS - VR on PSCI rehabilitation.

METHODS

This 4-week, single-center randomized clinical trial protocol will recruit 200 patients who were randomly assigned to one of four groups: Group A (tDCS + VR), Group B (tDCS + sham VR), Group C (sham tDCS + VR), Group D (sham tDCS + sham VR). All four groups will receive conventional cognitive rehabilitation training. The primary outcome measurement utilizes the Mini-Mental State Examination (MMSE). Secondary outcome measures include the Montreal Cognitive Assessment, Frontal Assessment Battery, Clock Drawing Test, Digital Span Test, Logic Memory Test, and Modified Barthel Index. Additionally, S-YYZ-01 apparatus for diagnosis and treating language disorders assesses subjects' speech function. Pre- and post-four-week intervention assessments are conducted for all outcome measures. Functional near-infrared spectroscopy (fNIRS) is employed to observe changes in oxygenated hemoglobin (HbO), deoxy-hemoglobin (HbR), and total hemoglobin (HbT) in the cerebral cortex.

DISCUSSION

Our hypothesis posits that the tDCS - VR therapy, in opposed to individual tDCS or VR interventions, could enhance cognitive function, speech ability and daily living skills in PSCI patients while concurrently augmenting frontal cortical activity. This randomized study aims to provide a robust theoretical foundation supported by scientific evidence for the practical implementation of the tDCS - VR combination as a secure and efficient PSCI rehabilitation approach.

TRIAL REGISTRATION

Chictr.org.cn Identifier: ChiCTR2300070580. Registered on 17th April 2023.

Aberrant brain functional connectivity mediates the effects of negative symptoms on cognitive function in schizophrenia: A structural equation model

BACKGROUND

Schizophrenia is a severe psychiatric disorder, characterized by positive symptoms, negative symptoms, and cognitive deficits. Elucidating the mechanism of negative symptom and cognitive deficits could contribute to the treatment and prognosis of schizophrenia. We hypothesized that abnormal functional connectivity would be involved in the indirect effects of negative symptoms on cognitive function.

METHODS

A total of 150 schizophrenia male patients and 108 healthy controls matched for age, education and gender were enrolled in the study. The scores of Brief Negative Symptom Scale were divided into two factors: motivation and pleasure deficits (MAP) and diminished expression (EXP). Subsequently, a series of classic neurocognitive tests were used to evaluate cognitive functions. Resting-state fMRI data was collected from all participants. The Anatomical Automatic Labeling template was employed to establish regions of interest, thereby constructing the functional connectivity network across the entire brain. Eventually, scores of patients' negative symptoms scale, cognitive function, and strengths of abnormal functional connectivity were incorporated into a structural equation model to explore the interactions among variables.

RESULTS

MAP exhibited a distinctly and significantly negative impact on cognitive function. The functional connectivity between the left insula and left precuneus, along with that between the left precuneus and right angular gyrus, collectively served as intermediaries, contributing to the indirect effects of MAP and EXP on cognitive function.

CONCLUSIONS

Our findings demonstrated the moderating role of aberrant brain functional connectivity between negative symptoms and cognitive function, providing clues about the neural correlates of negative symptoms and cognitive deficits in schizophrenia.

Navigating Social Cognitive Impairments in Schizophrenia Spectrum Disorders: Protocol for a Pilot Pre-Post Quasi-Experimental Study for Remote Avatar-Assisted Cognitive Remediation Therapy

BACKGROUND

Social cognitive impairments are prevalent in schizophrenia spectrum disorder (SSD) and have detrimental effects on functioning. Cognitive remediation (CR) has shown its efficacy in improving social cognitive impairments, although the transfer of these skills to daily life and the personalization of these interventions remain challenging. RC2S (Remédiation Cognitive de la Cognition Sociale dans la Schizophrénie; Cognitive remediation of social cognition in Schizophrenia) is a French CR that combines the learning of strategies and practice using paper-and-pencil exercises and digital relational simulations. This French program was designed as an in-person intervention.

OBJECTIVE

This project aims to culturally adapt the RC2S program, in French-Canadian and North American English and to assess the feasibility, acceptability, safety, and implementation of a remote version in people with SSD. An exploratory objective is to assess the preliminary effect of remote RC2S on goal attainment, social cognition, and psychosocial outcomes.

METHODS

We will use a pre-post quasi-experimental design. First, the translation and cultural adaptation in North American English and French-Canadian of RC2S is presented. Then, 20 participants aged ≥18 years with a diagnosis of SSD, presenting with a subjective or an objective impairment in social cognition, will be included to receive RC2S. In addition, 5 therapists will be included as research participants to assess their perspective on RC2S. Participants with SSD will undergo a baseline remote assessment of their social cognition, clinical symptoms, and functioning. They will then start remote RC2S for 24 biweekly individual 1-hour sessions with a therapist. Following the case formulation and goal setting, participants will complete personalized paper-and-pencil exercises to develop strategies and integrative digital relational simulations, during which they will help an avatar navigate through a variety of social contexts and relationships. The last 2 sessions are dedicated to the transfer to daily life. All participants will complete in-session questionnaires assessing therapeutic alliance, motivation, acceptability, feasibility, and implementation. Following RC2S, the participants with SSD will repeat the same assessment as the baseline. Descriptive statistics will be used to summarize the data about acceptability, feasibility, safety, and implementation. To assess the preliminary effect of RC2S, an intention-to-treat approach will be used with linear mixed models for repeated measures with fixed effects of time.

RESULTS

So far, 45% (9/20) of participants with SSD (mean age 37.9, SD 9.3 years) have completed the project. They received a mean of 20.5 out of 24 (SD 3.5) sessions of RC2S. A total of 5 therapists also completed the project.

CONCLUSIONS

Improving social cognitive impairments is an important target in SSD to promote functional recovery. Using digital technologies to address these impairments and deliver the intervention is a promising approach to increase the ecological validity of CR and access to the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05017532; https://classic.clinicaltrials.gov/ct2/show/NCT05017532.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54251.

Combining transcranial magnetic stimulation with training to improve social cognition impairment in schizophrenia: a pilot randomized controlled trial

Schizophrenia is a severe, chronic mental disorder that profoundly impacts patients' everyday lives. The illness's core features include positive and negative symptoms and cognitive impairments. In particular, deficits in the social cognition domain showed a tighter connection to patients' everyday functioning than the other symptoms. Social remediation interventions have been developed, providing heterogeneous results considering the possibility of generalizing the acquired improvements in patients' daily activities. In this pilot randomized controlled trial, we investigated the feasibility of combining fifteen daily cognitive and social training sessions with non-invasive brain stimulation to boost the effectiveness of the two interventions. We delivered intermittent theta burst stimulation (iTBS) over the left dorsolateral prefrontal cortex (DLPFC). Twenty-one patients were randomized into four groups, varying for the assigned stimulation condition (real vs. sham iTBS) and the type of cognitive intervention (training vs. no training). Clinical symptoms and social cognition tests were administered at five time points, i.e., before and after the treatment, and at three follow-ups at one, three, and six months after the treatments' end. Preliminary data show a trend in improving the competence in managing emotion in participants performing the training. Conversely, no differences were found in pre and post-treatment scores for emotion recognition, theory of mind, and attribution of intentions scores. The iTBS intervention did not induce additional effects on individuals' performance. The methodological approach's novelty and limitations of the present study are discussed.

Non-invasive brain stimulation for patients and healthy subjects: Current challenges and future perspectives

Non-invasive brain stimulation (NIBS) techniques have a rich historical background, yet their utilization has witnessed significant growth only recently. These techniques encompass transcranial electrical stimulation and transcranial magnetic stimulation, which were initially employed in neuroscience to explore the intricate relationship between the brain and behaviour. However, they are increasingly finding application in research contexts as a means to address various neurological, psychiatric, and neurodegenerative disorders. This article aims to fulfill two primary objectives. Firstly, it seeks to showcase the current state of the art in the clinical application of NIBS, highlighting how it can improve and complement existing treatments. Secondly, it provides a comprehensive overview of the utilization of NIBS in augmenting the brain function of healthy individuals, thereby enhancing their performance. Furthermore, the article delves into the points of convergence and divergence between these two techniques. It also addresses the existing challenges and future prospects associated with NIBS from ethical and research standpoints.

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.

Self-Regulatory Neuronal Mechanisms and Long-Term Challenges in Schizophrenia Treatment

Schizophrenia is a chronic and relapsing disorder that is characterized not only by delusions and hallucinations but also mainly by the progressive development of cognitive and social deficits. These deficits are related to impaired synaptic plasticity and impaired neurotransmission in the nervous system. Currently, technological innovations and medical advances make it possible to use various self-regulatory methods to improve impaired synaptic plasticity. To evaluate the therapeutic effect of various rehabilitation methods, we reviewed methods that modify synaptic plasticity and improve the cognitive and executive processes of patients with a diagnosis of schizophrenia. PubMed, Scopus, and Google Scholar bibliographic databases were searched with the keywords mentioned below. A total of 555 records were identified. Modern methods of schizophrenia therapy with neuroplastic potential, including neurofeedback, transcranial magnetic stimulation, transcranial direct current stimulation, vagus nerve stimulation, virtual reality therapy, and cognitive remediation therapy, were reviewed and analyzed. Since randomized controlled studies of long-term schizophrenia treatment do not exceed 2-3 years, and the pharmacological treatment itself has an incompletely estimated benefit-risk ratio, treatment methods based on other paradigms, including neuronal self-regulatory and neural plasticity mechanisms, should be considered. Methods available for monitoring neuroplastic effects in vivo (e.g., fMRI, neuropeptides in serum), as well as unfavorable parameters (e.g., features of the metabolic syndrome), enable individualized monitoring of the effectiveness of long-term treatment of schizophrenia.

Use of Technologies in the Therapy of Social Cognition Deficits in Neurological and Mental Diseases: A Systematic Review

Objective: This article systematically reviews the effects of technology-based (TB) treatments on impaired social cognition (SC) in neurological and mental disorders. Methods: Strictly adhering to the PRISMA guidelines, a systematic search was carried out in PsycINFO, PubMed, and Web of Science (last search: April 22, 2021) to identify studies that, implementing a control group design, evaluated TB treatments targeting deficits in emotion recognition, Theory of Mind (ToM) and social behavior in adult patients with nondevelopmental and nonprogressive neurological or mental disorders. Risk of bias was assessed using the PEDro Scale, certainty assessment followed the GRADE approach. Results: Sixteen studies involving 857 patients, all focusing on psychotic disorders, were retrieved. The most pronounced effects were observed concerning emotion recognition with all studies revealing overall improvements. Regarding ToM and social behavior, results were mixed. However, the number of studies including outcome measures for these domains, is significantly lower compared to the domain of emotion recognition, limiting the validity of the results. Risk of bias and certainty assessment revealed further limitations of evidence. Conclusion: TB treatment achieves positive effects especially with regard to emotion recognition impairments, at least for patients with schizophrenia. Future research should expand the evaluation of TB training of other SC domains, ought to be carried out in more diverse patient populations, rely on different devices, and include follow-up measurements.

Altered Surface Area Covariance in the Mentalizing Network in Schizophrenia: Insight Into Theory of Mind Processing

BACKGROUND

Theory of mind (ToM), the cognitive capacity to attribute mental states to self and others, is robustly affected in schizophrenia. The neural substrates of ToM impairment have been largely studied with functional imaging, but little is known about structural abnormalities. We compared structural covariance (between-subjects correlations of brain regional measures) of magnetic resonance imaging-based cortical surface area between patients with schizophrenia and healthy control subjects and between schizophrenia subgroups based on the patients' ToM ability to examine ToM-specific effects on structural covariance in schizophrenia.

METHODS

T1-weighted structural images were acquired on a 3T magnetic resonance imaging scanner, and ToM was assessed with the Hinting Task for 104 patients with schizophrenia and 69 healthy control subjects. The sum of surface area was computed for 12 regions of interest selected and compared between groups to examine structural covariance within the often reported mentalizing network: rostral and caudal middle frontal gyrus, inferior parietal lobule, precuneus, and middle and superior temporal gyrus. High and low ToM groups were defined using a median split on the Hinting Task.

RESULTS

Cortical surface contraction was observed in the schizophrenia group, predominantly in temporoparietal regions. Patients with schizophrenia also exhibited significantly stronger covariance between the right rostral middle frontal gyrus and the right superior temporal gyrus than control subjects (r = 4.015; p < .001). Direct comparisons between high and low ToM subgroups revealed stronger contralateral frontotemporal covariances in the low ToM group.

CONCLUSIONS

Our results provide evidence for structural changes underlying ToM impairments in schizophrenia that need to be confirmed to develop new therapeutic perspectives.

Modelling neural entrainment and its persistence: influence of frequency of stimulation and phase at the stimulus offset

Neural entrainment, the synchronization of brain oscillations to the frequency of an external stimuli, is a key mechanism that shapes perceptual and cognitive processes.Objective.Using simulations, we investigated the dynamics of neural entrainment, particularly the period following the end of the stimulation, since the persistence (reverberation) of neural entrainment may condition future sensory representations based on predictions about stimulus rhythmicity.Methods.Neural entrainment was assessed using a modified Jansen-Rit neural mass model (NMM) of coupled cortical columns, in which the spectral features of the output resembled that of the electroencephalogram (EEG). We evaluated spectro-temporal features of entrainment as a function of the stimulation frequency, the resonant frequency of the neural populations comprising the NMM, and the coupling strength between cortical columns. Furthermore, we tested if the entrainment persistence depended on the phase of the EEG-like oscillation at the time the stimulus ended.Main Results.The entrainment of the column that received the stimulation was maximum when the frequency of the entrainer was within a narrow range around the resonant frequency of the column. When this occurred, entrainment persisted for several cycles after the stimulus terminated, and the propagation of the entrainment to other columns was facilitated. Propagation also depended on the resonant frequency of the second column, and the coupling strength between columns. The duration of the persistence of the entrainment depended on the phase of the neural oscillation at the time the entrainer terminated, such that falling phases (fromπ/2 to 3π/2 in a sine function) led to longer persistence than rising phases (from 0 toπ/2 and 3π/2 to 2π).Significance.The study bridges between models of neural oscillations and empirical electrophysiology, providing insights to the mechanisms underlying neural entrainment and the use of rhythmic sensory stimulation for neuroenhancement.

Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review

BACKGROUND

The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions.

OBJECTIVE

To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions.

METHODS

We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care.

RESULTS

Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence.

CONCLUSIONS

Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions.

From the Group to the Individual in Schizophrenia Spectrum Disorders: Biomarkers of Social Cognitive Impairments and Therapeutic Translation

People with schizophrenia spectrum disorders (SSDs) often experience persistent social cognitive impairments, associated with poor functional outcome. There are currently no approved treatment options for these debilitating symptoms, highlighting the need for novel therapeutic strategies. Work to date has elucidated differential social processes and underlying neural circuitry affected in SSDs, which may be amenable to modulation using neurostimulation. Further, advances in functional connectivity mapping and electric field modeling may be used to identify individualized treatment targets to maximize the impact of brain stimulation on social cognitive networks. Here, we review literature supporting a roadmap for translating functional connectivity biomarker discovery to individualized treatment development for social cognitive impairments in SSDs. First, we outline the relevance of social cognitive impairments in SSDs. We review machine learning approaches for dimensional brain-behavior biomarker discovery, emphasizing the importance of individual differences. We synthesize research showing that brain stimulation techniques, such as repetitive transcranial magnetic stimulation, can be used to target relevant networks. Further, functional connectivity-based individualized targeting may enhance treatment response. We then outline recent approaches to account for neuroanatomical variability and optimize coil positioning to individually maximize target engagement. Overall, the synthesized literature provides support for the utility and feasibility of this translational approach to precision treatment. The proposed roadmap to translate biomarkers of social cognitive impairments to individualized treatment is currently under evaluation in precision-guided trials. Such a translational approach may also be applicable across conditions and generalizable for the development of individualized neurostimulation targeting other behavioral deficits.

Virtual Reality Rehabilitation's Impact on Negative Symptoms and Psychosocial Rehabilitation in Schizophrenia Spectrum Disorder: A Systematic Review

Background: Schizophrenia is a chronic psychiatric disorder with symptoms that can severely affect patients’ quality of life. While drug administration inhibits most of the positive symptoms, it fails to effectively treat the negative symptoms and in turn relies on rehabilitation therapies. With technological progress, virtual reality (VR) has been the target of recent studies in terms of mental health rehabilitation and has been shown to be a tool with ecological validity in order to introduce the individual to situations similar to their daily life. Methods: From July to August 2021, we conducted a systematic review with the purpose of understanding the impact of virtual reality rehabilitation on negative symptoms and psychosocial rehabilitation in the schizophrenia spectrum. The searches were performed in the databases Web of Science, Scopus, and PubMed. Results: In our search, we identified 201 results, where 108 duplicates were excluded, resulting in a final balance of 93. After reading and assessing the titles and abstracts, 66 studies were excluded. Of the remaining 27 reports, 23 were excluded for not meeting the previously defined eligibility criteria, resulting in the inclusion of four studies in this systematic review. Conclusions: The available data on the specific topic was limited and could have been more complete. However, in our review, we were able to identify statistically relevant results demonstrating the effectiveness of intervention. We could find medium to large effects, allowing VR to be an ally for rehabilitation of symptoms related to schizophrenia.

Executive Dysfunctions in Schizophrenia: A Critical Review of Traditional, Ecological, and Virtual Reality Assessments

In recent years, interest has grown in measuring executive function in schizophrenia with ecological and virtual reality (VR) tools. However, there is a lack of critical analysis comparing those tools with traditional ones. This paper aims to characterize executive dysfunction in schizophrenia by comparing ecological and virtual reality assessments with traditional tools, and to describe the neurobiological and psychopathological correlates. The analysis revealed that ecological and VR tests have higher levels of verisimilitude and similar levels of veridicality compared to traditional tools. Both negative symptoms and disorganization correlate significantly with executive dysfunction as measured by traditional tools, but their relationships with measures based on ecological and VR methods are still unclear. Although there is much research on brain correlates of executive impairments in schizophrenia with traditional tools, it is uncertain if these results will be confirmed with the use of ecological and VR tools. In the diagnosis of executive dysfunction, it is important to use a variety of neuropsychological methods—especially those with confirmed ecological validity—to properly recognize the underlying characteristics of the observed deficits and to implement effective forms of therapy.

Personalized Virtual Reality Human-Computer Interaction for Psychiatric and Neurological Illnesses: A Dynamically Adaptive Virtual Reality Environment That Changes According to Real-Time Feedback From Electrophysiological Signal Responses

Virtual reality (VR) constitutes an alternative, effective, and increasingly utilized treatment option for people suffering from psychiatric and neurological illnesses. However, the currently available VR simulations provide a predetermined simulative framework that does not take into account the unique personality traits of each individual; this could result in inaccurate, extreme, or unpredictable responses driven by patients who may be overly exposed and in an abrupt manner to the predetermined stimuli, or result in indifferent, almost non-existing, reactions when the stimuli do not affect the patients adequately and thus stronger stimuli are recommended. In this study, we present a VR system that can recognize the individual differences and readjust the VR scenarios during the simulation according to the treatment aims. To investigate and present this dynamically adaptive VR system we employ an Anxiety Disorder condition as a case study, namely arachnophobia. This system consists of distinct anxiety states, aiming to dynamically modify the VR environment in such a way that it can keep the individual within a controlled, and appropriate for the therapy needs, anxiety state, which will be called "desired states" for the study. This happens by adjusting the VR stimulus, in real-time, according to the electrophysiological responses of each individual. These electrophysiological responses are collected by an external electrodermal activity biosensor that serves as a tracker of physiological changes. Thirty-six diagnosed arachnophobic individuals participated in a one-session trial. Participants were divided into two groups, the Experimental Group which was exposed to the proposed real-time adaptive virtual simulation, and the Control Group which was exposed to a pre-recorded static virtual simulation as proposed in the literature. These results demonstrate the proposed system's ability to continuously construct an updated and adapted virtual environment that keeps the users within the appropriately chosen state (higher or lower intensity) for approximately twice the time compared to the pre-recorded static virtual simulation. Thus, such a system can increase the efficiency of VR stimulations for the treatment of central nervous system dysfunctions, as it provides numerically more controlled sessions without unexpected variations.

Using Virtual Reality as a Tool in the Rehabilitation of Movement Abnormalities in Schizophrenia

Movement abnormalities are prevalent across all stages of schizophrenia contributing to poor social functioning and reduced quality of life. To date, treatments are scarce, often involving pharmacological agents, but none have been shown to improve movement abnormalities effectively. Virtual reality (VR) is a tool used to simulate virtual environments where behavioral performance can be quantified safely across different tasks while exerting control over stimulus delivery, feedback and measurement in real time. Sensory information is transmitted via a head mounted display allowing users to directly interact with virtual objects and bodies using gestures and body movements in the real world to perform different actions, permitting a sense of immersion in the simulated virtual environment. Although, VR has been widely used for successful motor rehabilitation in a variety of different neurological domains, none have been exploited for motor rehabilitation in schizophrenia. The objectives of this article are to review movement abnormalities specific to schizophrenia, and how VR can be utilized to restore and improve motor functioning in patients with schizophrenia. Constructing VR-mediated motor-cognitive interventions that can help in retaining and transferring the learned outcomes to real life are also discussed.

Regulation of Reactive Oxygen Species-Mediated Damage in the Pathogenesis of Schizophrenia

The biochemical integrity of the brain is paramount to the function of the central nervous system, and oxidative stress is a key contributor to cerebral biochemical impairment. Oxidative stress, which occurs when an imbalance arises between the production of reactive oxygen species (ROS) and the efficacy of the antioxidant defense mechanism, is believed to play a role in the pathophysiology of various brain disorders. One such disorder, schizophrenia, not only causes lifelong disability but also induces severe emotional distress; however, because of its onset in early adolescence or adulthood and its progressive development, consuming natural antioxidant products may help regulate the pathogenesis of schizophrenia. Therefore, elucidating the functions of ROS and dietary antioxidants in the pathogenesis of schizophrenia could help formulate improved therapeutic strategies for its prevention and treatment. This review focuses specifically on the roles of ROS and oxidative damage in the pathophysiology of schizophrenia, as well as the effects of nutrition, antipsychotic use, cognitive therapies, and quality of life on patients with schizophrenia. By improving our understanding of the effects of various nutrients on schizophrenia, it may become possible to develop nutritional strategies and supplements to treat the disorder, alleviate its symptoms, and facilitate long-term recovery.