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Johannessen DA, Overå S, Arnevik EA. The role of contextual factors in avenues to recover from gambling disorder: a scoping review. Front Psychol 2024; 15:1247152. [PMID: 38410405 PMCID: PMC10894926 DOI: 10.3389/fpsyg.2024.1247152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Recovery from complex conditions such as gambling disorders (GD) often entail considerable change and require a range of adaptable interventions in the health care system. Outcomes from such avenues to change are influenced by multifarious contextual factors, which are less frequently considered in treatment outcome studies. Accordingly, this scoping review aims to map the level of evidence and explore how contextual factors influence the provision and outcomes of GD interventions. Methods A systematic search in selected health and social science research databases yielded a total of 2.464 unique references. The results were screened in three selection steps-titles (n = 2.464), abstracts (n = 284) and full-text (n = 104). The scoping approach was applied to provide a narrative account of the final included references (n = 34). Results and discussion Findings suggest that the research on GD treatment is in the early stages of development. Additionally, studies on GD interventions are characterized by cultural biases (Region and ethnicity and Gender perspectives), while three key elements are described as successful avenues to recover from GD (Competence, Perception and Utilization). In line with these findings, proposals for future research and treatment designs are made.
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Affiliation(s)
- Dagny Adriaenssen Johannessen
- Department of Social Work, Child Welfare and Social Policy, OsloMet—Oslo Metropolitan University, Oslo, Norway
- Blue Cross East, Oslo, Norway
| | - Stian Overå
- Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brumunddal, Norway
| | - Espen Ajo Arnevik
- Section for Clinical Addiction Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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2
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Quaglieri A, Pizzo A, Cricenti C, Tagliaferri G, Frisari FV, Burrai J, Mari E, Lausi G, Giannini AM, Zivi P. Gambling and virtual reality: unraveling the illusion of near-misses effect. Front Psychiatry 2024; 15:1322631. [PMID: 38362030 PMCID: PMC10867214 DOI: 10.3389/fpsyt.2024.1322631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Studying gambling behavior is a crucial element in reducing the impact of problem gambling. Nevertheless, most current research is carried out in controlled laboratory settings rather than real-life situations, which raises concerns about how applicable the findings are in the broader context. Virtual reality (VR) has proven to be a valuable tool and has been utilized in various experimental scenarios. A limited number of studies have employed VR to investigate gambling behaviors, and few have explored them in an older adolescent context. Methods This study examined the behavioral and physiological effects of gambling behavior, including problem gambling, gaming addiction, and risk-taking decision-making in a sample of 36 high-school students aged between 18 to 20 years using an ad-hoc constructed VR scenario designed to simulate a slot-machine platform. Results The behavioral results highlighted that participants reporting more problem gambling were sensitive to near-misses: i.e., they bet more after near-misses than after losses. This result may reflect the false belief that gamblers, after near-misses, are closer to winning. Physiological data showed that participants exhibited heart rate deceleration during the anticipation of the outcome, which has been suggested to represent a marker of feedback anticipation processing and hyposensitivity to losses. Discussion Overall, this study provides evidence for a new VR tool to assess gambling behaviors and new insights into gambling-related behavioral and physiological factors. Implications for the treatment of problem gambling are discussed.
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Affiliation(s)
| | - Alessandra Pizzo
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | | | | | - Francesca Valeria Frisari
- Department of Psychology of Development and Socialization Processes, Sapienza University of Rome, Rome, Italy
| | - Jessica Burrai
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Emanuela Mari
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | - Giulia Lausi
- Department of Psychology, Sapienza University of Rome, Rome, Italy
| | | | - Pierpaolo Zivi
- Department of Psychology, Sapienza University of Rome, Rome, Italy
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3
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Forner-Ordioni E. Virtual Reality Therapy in France: A Therapeutic Innovation Between Technology and Care. Cult Med Psychiatry 2023; 47:722-742. [PMID: 35771307 DOI: 10.1007/s11013-022-09801-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/26/2022]
Abstract
The latest form of cognitive behavioral therapy, virtual reality therapy has been developing in France since 2012, in both university hospitals and private practices. Patients receiving this therapy are immersed in a digitally created environment, using a virtual reality headset, in order to be exposed to their phobias. How does the introduction of technical objects such as the virtual reality headset affect and transform the care relationship between the patient and the therapist? Based on an ethnographic study conducted between 2012 and 2018 in the psychiatric unit of a French university hospital, this article outlines the emergence of virtual reality therapy, describes how it operates, and analyzes how it shapes the patient-therapist relationship. I argue that this device-namely virtual reality therapy-promotes a new therapeutic style in psychiatry, whose format and therapeutic indications align with the requirements of evidence-based medicine.
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Affiliation(s)
- Elsa Forner-Ordioni
- École des Hautes Études en Sciences Sociales, Centre d'Étude des Mouvements Sociaux, 54, boulevard Raspail, Paris 6e, France.
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4
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Kiyak C, Simonetti ME, Norton S, Deluca P. The efficacy of cue exposure therapy on alcohol use disorders: A quantitative meta-analysis and systematic review. Addict Behav 2023; 139:107578. [PMID: 36563480 DOI: 10.1016/j.addbeh.2022.107578] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/13/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cue exposure therapy (CET) techniques involves repeated and controlled exposures to alcohol stimuli which rest upon the well-established principles of Pavlovian extinction (Byrne et al., 2019). However, the efficacy of CET while treating alcohol use disorders (AUDs) is still a matter of debate. Therefore, we aimed to investigate the efficacy of CET on AUDs by using previous meta-analysis study on the same topic from Mellentin et al. (2017) as a base. METHODS A computer-assisted search of relevant articles identified 879 studies in Medline, PsycInfo and Embase, of which 11 studies (published between 1992 and 2019) were selected. Three outcome measures were extracted: alcohol consumption defined as drinks per day (drinking intensity) and alcohol reduction defined as drinking days and relapse (drinking frequency). This study is registered with PROSPERO (Registration no: #CRD42021259077). RESULTS The present meta-analytical review found small to medium effect on drinks per day (g = -0.35; 95 %CI -0.72 to 0.03), drinking days (g = -0.30; 95 %CI -0.54 to -0.06) and relapse (OR = -0.58; 95 %CI 0.29 to 1.15) while investigating the efficacy of CET on AUDs. GRADE assessment was used to evaluate the overall quality, and it was assessed as low. Regarding Risk of Bias, the studies in this systematic review were evaluated with "some concerns". CONCLUSION The present meta-analysis demonstrated that CET has small to medium effect on drinks per day, drinking days and relapse. Future research should strive to conduct larger scale multi-site CET trials with additional methodological innovations and increase retention.
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Affiliation(s)
- Ceyda Kiyak
- School of Psychology, University of East Anglia, Norwich, United Kingdom.
| | | | - Sam Norton
- Institute of Psychiatry Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Paolo Deluca
- Institute of Psychiatry Psychology & Neuroscience, King's College London, London, United Kingdom
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5
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Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, Blumenthal N, Li M, Asché L, Jonas S, Bey K, Schulze M, Steffens M, Pensel MC, Guth M, Rohlfsen F, Ekhlas M, Lügering H, Fileccia H, Pakos J, Lux S, Philipsen A, Braun N. Virtual reality in the diagnostic and therapy for mental disorders: A systematic review. Clin Psychol Rev 2022; 98:102213. [PMID: 36356351 DOI: 10.1016/j.cpr.2022.102213] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 08/21/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders. OBJECTIVE To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders. DATA SOURCE Systematic literature searches via PubMed (last literature update: 9th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders. ELIGIBILITY CRITERIA To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology. STUDY EVALUATION For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria. RESULTS Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder. CONCLUSION While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application. REVIEW REGISTRATION PROSPERO register CRD42020188436. FUNDING The review was funded by budgets from the University of Bonn. No third party funding was involved.
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Affiliation(s)
- Annika Wiebe
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Kyra Kannen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Benjamin Selaskowski
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Aylin Mehren
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Ann-Kathrin Thöne
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Pramme
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Nike Blumenthal
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mengtong Li
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Laura Asché
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Stephan Jonas
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Katharina Bey
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Marcel Schulze
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Maria Steffens
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Max Christian Pensel
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Matthias Guth
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Felicia Rohlfsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mogda Ekhlas
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Lügering
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Fileccia
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Julian Pakos
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.
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Bergeron PY, Giroux I, Chrétien M, Bouchard S. Exposure Therapy for Gambling Disorder: Systematic Review and Meta-analysis. CURRENT ADDICTION REPORTS 2022. [DOI: 10.1007/s40429-022-00428-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of Review
Cognitive behaviour therapy is the gold standard for the treatment of gambling disorder. Obstacles remain regarding its efficacy, namely relapses and difficulty in implementing cognitive restructuring for some clients. Given these observations, behavioural interventions for gambling disorder, such as exposure therapy, which aims to decrease gambling craving, may be effective as a complementary or alternative intervention to cognitive behaviour therapy. This systematic review and meta-analysis aims to explore how exposure therapy for gambling disorder has been studied and to evaluate its efficacy. To answer these questions, 3406 studies, retrieved using PsycNet, Medline and Google Scholar, were screened.
Recent Findings
After two screenings, 13 papers were selected for the systematic review and five were statistically combined for the meta-analysis. Quantitative results support exposure therapy’s efficacy to decrease gambling craving at post-intervention (g = − 0.955) and at last follow-up (6 or 12 months; − 1.010). Results also show a large decrease in gambling severity as documented by screening instruments (− 1.087) as well as time spent gambling (− 2.136) at post-intervention. Furthermore, a large decrease in gambling measured via screening instruments (− 1.162) and erroneous beliefs (− 1.308) was found at last follow-up.
Summary
This is the first meta-analysis on behavioural exposure therapy for gambling disorder. Results support that exposure therapy reduces gambling cravings and severity, as well as time spent gambling and erroneous beliefs. These results are discussed in comparison to other therapeutic approaches and are interpreted according to the high risk of bias in included studies.
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7
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Augner C, Vlasak T, Aichhorn W, Barth A. Psychological online interventions for problem gambling and gambling disorder - A meta-analytic approach. J Psychiatr Res 2022; 151:86-94. [PMID: 35472684 DOI: 10.1016/j.jpsychires.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/24/2022] [Accepted: 04/06/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The Covid-19 pandemic has reignited discussions about the prevalence of and treatment options for problem gambling and gambling disorder (PGGD). Since affected persons seldom seek professional help, online interventions can improve accessibility. Thus, this study aimed to investigate the effectiveness of psychological online interventions on PGGD. METHODS We conducted a systematic review and meta-analysis and searched in PubMed, PsycINFO, and Google Scholar for peer-reviewed experimental and quasi-experimental research published between 2010 and 2021. We calculated two meta-anlyses, one for treatment control comparisons (TCC), and one for pre-post-comparisons (PCC). RESULTS We included six studies (ten TCC and n = 2076) in meta-analysis 1 and five studies (six PCC and n = 781) in meta-analysis 2. Online interventions turned out to be effective in both analyses with Hedges g = 0.41, 95% confidence interval = [0.22 to 0.60], p < .001, for meta-anaylsis 1 and Hegdes g = 1.28, 95% confidence interval = [0.85 to 1.71], p < .001, for meta-analysis 2. CONCLUSIONS We identified significant effects of online interventions on PGGD in both analyses, indicating the potential of online applications. We discuss methodological aspects and further research directions.
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Affiliation(s)
- Christoph Augner
- Department of Psychiatry, Psychotherapy & Psychosomatics, Christian-Doppler Medical Centre, University Clinics of the Paracelsus Medical University, Salzburg, Austria; Institute for Human Resources Research in Health Care, University Clinics of the Paracelsus Medical University, Salzburg, Austria.
| | - Thomas Vlasak
- Institute for Psychology, Sigmund Freud University Linz, Austria
| | - Wolfgang Aichhorn
- Department of Psychiatry, Psychotherapy & Psychosomatics, Christian-Doppler Medical Centre, University Clinics of the Paracelsus Medical University, Salzburg, Austria
| | - Alfred Barth
- Institute for Psychology, Sigmund Freud University Linz, Austria
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8
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Giordano R, Donati MA, Zamboni L, Fusina F, Primi C, Lugoboni F. Alter Game: A Study Protocol on a Virtual "Serious Game" for Relapse Prevention in Patients With Gambling Disorder. Front Psychiatry 2022; 13:854088. [PMID: 35432033 PMCID: PMC9010883 DOI: 10.3389/fpsyt.2022.854088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Cognitive behavioral therapy (CBT) is the most successful protocol in gambling disorder (GD) treatment. However, it presents some weaknesses, especially concerning relapse prevention (RP). RP is one of the most important therapeutic steps, aiming at managing cravings and to avoid future relapse increasing perceived self-efficacy. Encouraging results come from the blending of psychotherapy and virtual reality (VR), containing gambling cues. The goal of Alter Game (approved by the Ethical Commission, Prot. No. 69346) is verifying the efficacy of an innovative psychological treatment for GD based on the integration of traditional CBT therapy and an immersive VR cue exposure therapy using a serious virtual game, which is a game designed for purposes other than entertainment. RP in virtual cue-exposure therapy allows pathological gamblers to manage the urge to gamble and to avoid relapse by becoming aware of which internal and external triggers are related to craving. We hypothesize that the integrated intervention will be more effective than simple CBT with regard to self-efficacy, craving, and gambling-related distortions. Four virtual ecological environments were developed, and a virtual app, Exludo, interfaced with a computerized multiparametric acquisition system for biofeedback, was created. A sample of about 60 patients aged between 18 and 65 with GD referring to the Addiction Medicine Unit of Verona (Rossi Hospital) will be recruited. Patients will be randomly assigned to the CBT group (16 CBT sessions) or the CBT + VR group (8 CBT sessions + 8 VR cue-exposure therapy sessions). The MCMI-III, the BIS-11, and the SOGS will be used to evaluate inclusion and exclusion criteria, while the Gambling Related Cognitions Scale and the Multidimensional Gambling Self-Efficacy Scale will be used to verify changes as a function of the treatment. Craving will be evaluated through VAS, and psychophysiological variables will be assessed through biofeedback. A pre-test/post-test experimental design with a 1-month follow-up will be conducted. This study will examine an innovative psychotherapeutic protocol for GD treatment, and it will help in identifying new virtual tools to increase the efficacy of traditional therapeutic approaches that could also be applied to treat other addictions.
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Affiliation(s)
- Rosaria Giordano
- Department of Internal Medicine, Unit of Addiction Medicine, G.B. Rossi Hospital, Verona, Italy
- Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Maria Anna Donati
- Department of Neuroscience, Psychology, Drug, and Child's Health, Section of Psychology, University of Florence, Florence, Italy
| | - Lorenzo Zamboni
- Department of Internal Medicine, Unit of Addiction Medicine, G.B. Rossi Hospital, Verona, Italy
- Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Francesca Fusina
- Department of General Psychology, University of Padova, Padua, Italy
- Padova Neuroscience Center, University of Padova, Padua, Italy
| | - Caterina Primi
- Department of Neuroscience, Psychology, Drug, and Child's Health, Section of Psychology, University of Florence, Florence, Italy
| | - Fabio Lugoboni
- Department of Internal Medicine, Unit of Addiction Medicine, G.B. Rossi Hospital, Verona, Italy
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Client's Experiences Using a Location-Based Technology ICT System during Gambling Treatments' Crucial Components: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073769. [PMID: 35409450 PMCID: PMC8997771 DOI: 10.3390/ijerph19073769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/18/2022] [Accepted: 03/20/2022] [Indexed: 12/18/2022]
Abstract
Cognitive Behavioral Therapy is the treatment of choice for Gambling Disorder (GD), with stimulus control (SC) and exposure with response prevention (ERP) being its two core components. Despite their efficacy, SC and ERP are not easy to deliver, so it is important to explore new ways to enhance patient compliance regarding SC and ERP. The aim of this study is to describe and assess the opinion of two patients diagnosed with problem gambling and GD that used the Symptoms app, a location-based ICT system, during SC and ERP. A consensual qualitative research study was conducted. We used a semi-structured interview, developed ad-hoc based on the Expectation and Satisfaction Scale and System Usability Scale. A total of 20 categories were identified within six domains: usefulness, improvements, recommendation to other people, safety, usability, and opinion regarding the use of the app after completing the intervention. The patients considered the app to be useful during the SC and ERP components and emphasized that feeling observed and supported at any given time helped them avoid lapses. This work can offer a starting point that opens up new research paths regarding psychological interventions for gambling disorder, such as assessing whether location-based ICT tools enhance commitment rates.
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Geraets CNW, Wallinius M, Sygel K. Use of Virtual Reality in Psychiatric Diagnostic Assessments: A Systematic Review. Front Psychiatry 2022; 13:828410. [PMID: 35295778 PMCID: PMC8918631 DOI: 10.3389/fpsyt.2022.828410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/03/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Technological developments such as Virtual reality (VR) provide new opportunities to extend and innovate mental healthcare. VR as a tool for clinical assessment has been described as promising, as it can enable real-time assessment within real-like environments or contexts as opposed to self-report and behavioral tasks in laboratory settings. OBJECTIVE With this systematic review we aimed to provide an overview of recent studies using VR in the assessment of psychiatric disorders. METHODS A systematic search was performed using Pubmed, Embase, PsycInfo, and Web of Science between 2016 and 2020. Studies were included if they used immersive VR, concerned assessment of psychiatric symptoms/disorders, and included adult patients with psychiatric disorders. RESULTS The search resulted in 3,163 potentially eligible articles, from which a total of 27 studies fulfilled inclusion criteria. Most studies considered anxiety (n = 7), addictive, (n = 7), or psychotic disorders (n = 5). Regarding ADHD (n = 3), PTSD (n = 3), and pedophilic disorder (n = 1), a few studies had been performed since 2016. The majority of the included studies compared patient groups to healthy control groups. DISCUSSION Recent studies on VR-assisted psychiatric assessments have been conducted to validate VR environments, to assess symptoms for diagnostics or therapy goals, search for biomarkers, and to gain knowledge on psychiatric disorders. VR tasks were able to detect some difference between patient and healthy control groups, mainly with regard to self-report measures. Despite previous, promising prospects, the use of VR as a tool in clinical assessments must still be considered as a field in need of continued developments and evaluations. SYSTEMATIC REVIEW REGISTRATION www.crd.york.ac.uk/prospero, identifier: CRD42021233772.
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Affiliation(s)
- Chris N W Geraets
- Lund Clinical Research on Externalizing and Developmental Psychopathology, Child and Adolescent Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Research and Development Unit, Regional Forensic Psychiatric Clinic, Växjö, Sweden.,Department of Psychiatry, University Medical Center Groningen, Groningen, Netherlands
| | - Märta Wallinius
- Lund Clinical Research on Externalizing and Developmental Psychopathology, Child and Adolescent Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Research and Development Unit, Regional Forensic Psychiatric Clinic, Växjö, Sweden.,Department of Psychiatry and Neurochemistry, Centre for Ethics, Law and Mental Health, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Kristina Sygel
- Research and Development Unit, Regional Forensic Psychiatric Clinic, Växjö, Sweden.,Department of Psychiatry and Neurochemistry, Centre for Ethics, Law and Mental Health, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Forensic Psychiatry, National Board of Forensic Medicine, Stockholm, Sweden
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11
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Virtual reality: a powerful technology to provide novel insight into treatment mechanisms of addiction. Transl Psychiatry 2021; 11:617. [PMID: 34873146 PMCID: PMC8648903 DOI: 10.1038/s41398-021-01739-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 12/31/2022] Open
Abstract
Due to its high ecological validity, virtual reality (VR) technology has emerged as a powerful tool for mental health research. Despite the wide use of VR simulations in research on mental illnesses, the study of addictive processes through the use of VR environments is still at its dawn. In a systematic literature search, we identified 38 reports of research projects using highly immersive head-mounted displays, goggles, or CAVE technologies to provide insight into treatment mechanisms of addictive behaviors. So far, VR research has mainly addressed the roles of craving, psychophysiology, affective states, cognition, and brain activity in addiction. The computer-generated VR environments offer very realistic, dynamic, interactive, and complex real-life simulations requesting active participation. They create a high sense of immersion in users by combining stereoscopic three-dimensional visual, auditory, olfactory, and tactile perceptions, tracking systems responding to user movements, and social interactions. VR is an emerging tool to study how proximal multi-sensorial cues, contextual environmental cues, as well as their interaction (complex cues) modulate addictive behaviors. VR allows for experimental designs under highly standardized, strictly controlled, predictable, and repeatable conditions. Moreover, VR simulations can be personalized. They are currently refined for psychotherapeutic interventions. Embodiment, eye-tracking, and neurobiological factors represent novel future directions. The progress of VR applications has bred auspicious ways to advance the understanding of treatment mechanisms underlying addictions, which researchers have only recently begun to exploit. VR methods promise to yield significant achievements to the addiction field. These are necessary to develop more efficacious and efficient preventive and therapeutic strategies.
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12
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Langener S, Van Der Nagel J, van Manen J, Markus W, Dijkstra B, De Fuentes-Merillas L, Klaassen R, Heitmann J, Heylen D, Schellekens A. Clinical Relevance of Immersive Virtual Reality in the Assessment and Treatment of Addictive Disorders: A Systematic Review and Future Perspective. J Clin Med 2021; 10:3658. [PMID: 34441953 PMCID: PMC8396890 DOI: 10.3390/jcm10163658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/10/2021] [Accepted: 08/14/2021] [Indexed: 02/02/2023] Open
Abstract
(1) Background: Virtual reality (VR) has been investigated in a variety of psychiatric disorders, including addictive disorders (ADs); (2) Objective: This systematic review evaluates the current evidence of immersive VR (using head-mounted displays) in the clinical assessment and treatment of ADs; (3) Method: PubMed and PsycINFO were queried for publications up to November 2020; (4) Results: We screened 4519 titles, 114 abstracts and 85 full-texts, and analyzed 36 articles regarding the clinical assessment (i.e., diagnostic and prognostic value; n = 19) and treatment (i.e., interventions; n = 17) of ADs. Though most VR assessment studies (n = 15/19) showed associations between VR-induced cue-reactivity and clinical parameters, only two studies specified diagnostic value. VR treatment studies based on exposure therapy showed no or negative effects. However, other VR interventions like embodied and aversive learning paradigms demonstrated positive findings. The overall study quality was rather poor; (5) Conclusion: Though VR in ADs provides ecologically valid environments to induce cue-reactivity and provide new treatment paradigms, the added clinical value in assessment and therapy remains to be elucidated before VR can be applied in clinical care. Therefore, future work should investigate VR efficacy in randomized clinical trials using well-defined clinical endpoints.
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Affiliation(s)
- Simon Langener
- Human Media Interaction, University of Twente, 7522 NB Enschede, The Netherlands; (J.V.D.N.); (R.K.); (D.H.)
- Tactus Addiction Centre, 7418 ET Deventer, The Netherlands;
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
| | - Joanne Van Der Nagel
- Human Media Interaction, University of Twente, 7522 NB Enschede, The Netherlands; (J.V.D.N.); (R.K.); (D.H.)
- Tactus Addiction Centre, 7418 ET Deventer, The Netherlands;
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
| | - Jeannette van Manen
- Tactus Addiction Centre, 7418 ET Deventer, The Netherlands;
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
| | - Wiebren Markus
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
- IrisZorg Addiction Care, 6835 HZ Arnhem, The Netherlands
| | - Boukje Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
- Radboud University Medical Centre, 6525 GC Nijmegen, The Netherlands
- Novadic-Kentron, Network for Addiction Treatment Service, 5261 LX Vught, The Netherlands
| | - Laura De Fuentes-Merillas
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
- Novadic-Kentron, Network for Addiction Treatment Service, 5261 LX Vught, The Netherlands
| | - Randy Klaassen
- Human Media Interaction, University of Twente, 7522 NB Enschede, The Netherlands; (J.V.D.N.); (R.K.); (D.H.)
| | - Janika Heitmann
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Dirk Heylen
- Human Media Interaction, University of Twente, 7522 NB Enschede, The Netherlands; (J.V.D.N.); (R.K.); (D.H.)
| | - Arnt Schellekens
- Nijmegen Institute for Scientist-Practitioners in Addiction, 6525 GD Nijmegen, The Netherlands; (W.M.); (B.D.); (L.D.F.-M.); (J.H.); (A.S.)
- Radboud University Medical Centre, 6525 GC Nijmegen, The Netherlands
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Tsamitros N, Sebold M, Gutwinski S, Beck A. Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders. CURRENT ADDICTION REPORTS 2021. [DOI: 10.1007/s40429-021-00377-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Abstract
Purpose
Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches.
Findings
There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances.
Summary
This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required.
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van Deursen M, Reuvers L, Duits JD, de Jong G, van den Hurk M, Henssen D. Virtual reality and annotated radiological data as effective and motivating tools to help Social Sciences students learn neuroanatomy. Sci Rep 2021; 11:12843. [PMID: 34145335 PMCID: PMC8213773 DOI: 10.1038/s41598-021-92109-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/04/2021] [Indexed: 02/07/2023] Open
Abstract
Neuroanatomy as a subject is important to learn, because a good understanding of neuroanatomy supports the establishment of a correct diagnosis in neurological patients. However, rapid changes in curricula reduced time assigned to study (neuro)anatomy. Therefore, it is important to find alternative teaching methods to study the complex three-dimensional structure of the brain. The aim of this manuscript was to explore the effectiveness of Virtual Reality (VR) in comparison with Radiological Data (RaD) as suitable learning methods to build knowledge and increase motivation for learning neuroanatomy. Forty-seven students (mean age of 19.47 ± 0.54 years; 43 females; 4 males) were included; 23 students comprised the VR group. Both methods showed to improve knowledge significantly, the improvement between groups was not different. The RaD group showed to have a significantly higher score on expectancy than students in the VR group. Task value scores regarding finding a task interesting, useful and fun were found to be significantly different in favor of the VR group. Consequently, significant higher Motivation scores were found in the VR group. Motivation and expectancy, however, did not moderate learning results, whereas task value impacted the results in favour of the VR group. This study concludes that VR and RaD are effective and diverting methods to learn neuroanatomy, with VR being more motivating than RaD. Future research should investigate motivation and task value when using VR over a longer period of time.
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Affiliation(s)
- Margot van Deursen
- Department of Educational Sciences, Faculty of Social Sciences, Radboud University, Nijmegen, The Netherlands
| | - Laura Reuvers
- Department of Educational Sciences, Faculty of Social Sciences, Radboud University, Nijmegen, The Netherlands
| | - Jacobus Dylan Duits
- Radboudumc 3D Lab, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Guido de Jong
- Radboudumc 3D Lab, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marianne van den Hurk
- Department of Educational Sciences, Faculty of Social Sciences, Radboud University, Nijmegen, The Netherlands
| | - Dylan Henssen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
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Hernández-Serrano O, Ghiţă A, Fernández-Ruiz J, Monràs M, Gual A, Gacto M, Porras-García B, Ferrer-García M, Gutiérrez-Maldonado J. Determinants of Cue-Elicited Alcohol Craving and Perceived Realism in Virtual Reality Environments among Patients with Alcohol Use Disorder. J Clin Med 2021; 10:2241. [PMID: 34064120 PMCID: PMC8196721 DOI: 10.3390/jcm10112241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/31/2022] Open
Abstract
The identification of variables that can modulate the efficacy of cue exposure using virtual reality (VR) is crucial. This study aimed to explore determinant variables of cue-elicited alcohol craving and perceived realism (PR) of environments and alcoholic beverages during a VR cue-exposure session among alcohol use disorder (AUD) outpatients. A prospective cohort study was conducted amongst 72 outpatients with AUD from a clinical setting. Alcohol craving experienced during VR exposure and PR of virtual environments and alcoholic drinks were evaluated after a VR session of exposure to alcohol-related contexts and cues. Sociodemographic, psychological and consumption characteristics were examined as possible predicting variables. Multiple linear regression analyses showed that the AUD severity and PR of beverages were predictors of cue-elicited alcohol craving. Educational level, PR of beverages and age were predictors of the PR of VR environments. In relation to the PR of VR beverages, cue-elicited alcohol craving and the PR of environments were predictors. A simple mediational model was also performed to analyze the influence of the PR of beverages on the relationship between the AUD severity and alcohol craving experienced during VR exposure: an indirect or mediational effect was found. PR of alcoholic beverages was (1) a key predictor of the PR of VR environments (and vice versa) and the alcohol craving (and vice versa) experienced during VR cue-exposure sessions using ALCO-VR software among AUD patients and (2) a mediator between AUD severity and cue-elicited alcohol craving.
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Affiliation(s)
- Olga Hernández-Serrano
- Department of Psychology, Catholic University of Saint Anthony, Av. de los Jerónimos, 135, Guadalupe de Maciascoque, 30107 Murcia, Spain;
| | - Alexandra Ghiţă
- Department of Psychology, Health and Technology, University of Twente, Drienerlolaan, 5, 7522 NB Enschede, The Netherlands;
| | - Jolanda Fernández-Ruiz
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Passeig de Vall d’Hebron 175, 08035 Barcelona, Spain; (J.F.-R.); (B.P.-G.); (M.F.-G.)
| | - Miquel Monràs
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, Carrer de Villarroel, 170, 08036 Barcelona, Spain; (M.M.); (A.G.)
| | - Antoni Gual
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, Carrer de Villarroel, 170, 08036 Barcelona, Spain; (M.M.); (A.G.)
| | - Mariano Gacto
- Department of Physical Therapy, Faculty of Medicine, Campus Espinardo, University of Murcia, 30100 Murcia, Spain;
| | - Bruno Porras-García
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Passeig de Vall d’Hebron 175, 08035 Barcelona, Spain; (J.F.-R.); (B.P.-G.); (M.F.-G.)
| | - Marta Ferrer-García
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Passeig de Vall d’Hebron 175, 08035 Barcelona, Spain; (J.F.-R.); (B.P.-G.); (M.F.-G.)
| | - José Gutiérrez-Maldonado
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Passeig de Vall d’Hebron 175, 08035 Barcelona, Spain; (J.F.-R.); (B.P.-G.); (M.F.-G.)
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Reliability assessment of temporal discounting measures in virtual reality environments. Sci Rep 2021; 11:7015. [PMID: 33782424 PMCID: PMC8007609 DOI: 10.1038/s41598-021-86388-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/15/2021] [Indexed: 02/01/2023] Open
Abstract
In recent years the emergence of high-performance virtual reality (VR) technology has opened up new possibilities for the examination of context effects in psychological studies. The opportunity to create ecologically valid stimulation in a highly controlled lab environment is especially relevant for studies of psychiatric disorders, where it can be problematic to confront participants with certain stimuli in real life. However, before VR can be confidently applied widely it is important to establish that commonly used behavioral tasks generate reliable data within a VR surrounding. One field of research that could benefit greatly from VR-applications are studies assessing the reactivity to addiction related cues (cue-reactivity) in participants suffering from gambling disorder. Here we tested the reliability of a commonly used temporal discounting task in a novel VR set-up designed for the concurrent assessment of behavioral and psychophysiological cue-reactivity in gambling disorder. On 2 days, thirty-four healthy non-gambling participants explored two rich and navigable VR-environments (neutral: café vs. gambling-related: casino and sports-betting facility), while their electrodermal activity was measured using remote sensors. In addition, participants completed the temporal discounting task implemented in each VR environment. On a third day, participants performed the task in a standard lab testing context. We then used comprehensive computational modeling using both standard softmax and drift diffusion model (DDM) choice rules to assess the reliability of discounting model parameters assessed in VR. Test-retest reliability estimates were good to excellent for the discount rate log(k), whereas they were poor to moderate for additional DDM parameters. Differences in model parameters between standard lab testing and VR, reflecting reactivity to the different environments, were mostly numerically small and of inconclusive directionality. Finally, while exposure to VR generally increased tonic skin conductance, this effect was not modulated by the neutral versus gambling-related VR-environment. Taken together this proof-of-concept study in non-gambling participants demonstrates that temporal discounting measures obtained in VR are reliable, suggesting that VR is a promising tool for applications in computational psychiatry, including studies on cue-reactivity in addiction.
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Hawker CO, Merkouris SS, Youssef GJ, Dowling NA. A Smartphone-Delivered Ecological Momentary Intervention for Problem Gambling (GamblingLess: Curb Your Urge): Single-Arm Acceptability and Feasibility Trial. J Med Internet Res 2021; 23:e25786. [PMID: 33769294 PMCID: PMC8088874 DOI: 10.2196/25786] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/31/2020] [Accepted: 01/31/2021] [Indexed: 01/26/2023] Open
Abstract
Background Low uptake rates of traditional gambling treatments highlight the need for innovative treatment modalities. Smartphone apps can provide unprecedented access to real-time ecological momentary interventions (EMIs) delivered in people’s everyday lives. Objective This study aims to examine the acceptability, feasibility, and preliminary effectiveness of GamblingLess: Curb Your Urge, the first smartphone app–delivered EMI that aims to prevent gambling episodes by reducing craving intensity in people seeking help for gambling problems. Methods This study was a single-arm, 5-week acceptability and feasibility trial (1-week baseline and 4-week intervention periods) involving ecological momentary assessments (EMAs) delivered 3 times daily. The EMAs measured gambling episodes, cravings, and self-efficacy. Web-based evaluations at baseline, postintervention, and 1-month follow-up measured gambling outcomes (severity, cravings, frequency, expenditure, and self-efficacy) and the intervention’s perceived helpfulness, relevance, burden, satisfaction, and impact in relation to gambling cravings. Results A total of 36 participants, of whom 22/36 (61%) were male and 34/36 (94%) were problem gamblers, completed the baseline measures, with 61% (22/36) completing the postintervention evaluation and 58% (21/36) completing the follow-up evaluation. The intervention was considered acceptable, as participants perceived all intervention content to be above average in helpfulness and the EMA to be highly relevant but somewhat burdensome. Participants reported that they were satisfied with the intervention and that the intervention improved their knowledge, attitudes, awareness, behavior change, intention to change, and help-seeking behavior for gambling cravings. Regarding the intervention’s feasibility, compliance rates for the EMA (51%) and EMI (15%) were low; however, the intervention was used 166 times, including 59 uses within 60 minutes of EMA completion and 107 on-demand uses. Regarding the intervention’s preliminary effectiveness, descriptive EMA data showed that, compared with the baseline period, 71% and 72% reductions in the average number of gambling episodes and craving occurrences were reported in the intervention period, respectively. In addition, clustered paired-sample two-tailed t tests revealed a significant 5.4% reduction in real-time craving intensity (P=.01) immediately after intervention use, which increased to 10.5% (P=.01), where use was recommended based on craving occurrence. At the group level, significant medium-to-large reductions were observed in mean gambling symptom severity (P=.01 and .003), cravings (P=.03 and .02), frequency (P=.01 and .004), and expenditure (P=.04 and .003) at postintervention and follow-up; moreover, increased mean gambling self-efficacy and craving self-efficacy (P=.01 and .01) were observed at postintervention and increased gambling self-efficacy (P=.04) was observed at follow-up. At the individual level, over a quarter of participants (6/22, 27% to 10/21, 48%) could be categorized as recovered or improved regarding their gambling symptom severity and cravings. Conclusions The results support the acceptability, feasibility, and preliminary effectiveness of this app-delivered EMI for preventing gambling episodes through craving management in people with gambling problems, which has implications for extending the reach of evidence-based treatment to moments of vulnerability in people’s everyday lives.
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Affiliation(s)
| | | | - George J Youssef
- Deakin University, Geelong, Australia.,Royal Children's Hospital, Centre for Adolescent Health, Murdoch Children's Research Institute, Melbourne, Australia
| | - Nicki A Dowling
- Deakin University, Geelong, Australia.,Melbourne Graduate School of Education, University of Melbourne, Parkville, Australia
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Ribeiro EO, Afonso NH, Morgado P. Non-pharmacological treatment of gambling disorder: a systematic review of randomized controlled trials. BMC Psychiatry 2021; 21:105. [PMID: 33596853 PMCID: PMC7888125 DOI: 10.1186/s12888-021-03097-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The main focus of the non-pharmacological treatment of Gambling Disorder (GD) is the behaviour, cognition and motivation of the patient, addressing the psychological determinants of gambling. Although there is not a gold standard non-pharmacological treatment yet, many studies already had promising results, and the outcomes were even better when pharmacotherapies were combined with psychotherapies. This review intended to synthesise the efficacy of various available non-pharmacological therapies for GD evaluated in randomized controlled trials. METHODS A systematic search was conducted in PubMed and in Cochrane Library for randomized controlled trials. Studies were included if participants had GD as their primary diagnosis and excluded if patients had other comorbidities. RESULTS From 320 records identified, 22 studies were included in the critical appraisal. They included a total of 1694 patients, with a mean age of 42.94 years, and a 62.31% of males. Seven trials revealed the efficacy of cognitive behaviour therapy in improving significantly the outcomes. Three studies assessing cognitive therapy showed significant improvements in gambling symptoms, while one study showed improvements in gambling behaviour using exposure therapy. Combined or separate motivational interviewing and imaginal desensitization had significant results in 4 trials. Four other studies also showed efficacy for: couples therapy, node-link mapping therapy, 12-step facilitated and personalized feedback intervention. Physical exercise had promising results but did not reach significance. CONCLUSION The literature included in this review showed the heterogeneity of available psychotherapies. The majority of studies supported the efficacy of the tested therapies, while some of them, due to limitations such as small sample sizes or inadequate control groups, failed to reach significance.
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Affiliation(s)
| | - Nuno H. Afonso
- School of Medicine, University of Minho, Braga, Portugal
| | - Pedro Morgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS-3Bs PT Government Associate Laboratory, School of Medicine, University of Minho, 4710-057 Braga, Guimarães Portugal
- Hospital de Braga, Sete Fontes — São Victor, 4710-243 Braga, Portugal
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Gómez-Busto FJ, Ortiz MI. Virtual Reality and Psychedelics for the Treatment of Psychiatric Disease: A Systematic Literature Review. CLINICAL NEUROPSYCHIATRY 2020; 17:365-380. [PMID: 34909015 PMCID: PMC8629068 DOI: 10.36131/cnfioritieditore20200606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hallucinogenic substances or psychedelic drugs have been historically used by humans worldwide for centuries, and interest grows around them because of the therapeutic potential that they pose for mental disease. Virtual Reality (VR), has been highly developed and improved in the last decade, and it is also gaining importance due to their potential as therapeutic tools. In this article, the most recent and relevant information regarding the medical applications of both VR and psychedelics was highlighted, and diverse potential therapeutic uses were explored in hope to set the ground for further research on this topic. METHOD A systematic literature review using the PRISMA methods was conducted in PubMed, Medline, Embase, Cochrane Library, Scopus and Web of Science, including only peer-reviewed clinical trials or case studies written in English, that address the use of psychedelics and/or VR for the treatment of psychiatric disorders and that measure the success of the therapies. A final selection of 23 manuscripts were used in this systematic review. RESULTS VR showed security and significant efficacy in the management of special cases of phobias (social, motion pain and spiders), eating disorder, post-traumatic stress disorder (PTSD), gambling disorder, preoperative anxiety and schizophrenia. CONCLUSIONS The hallucinogenic drugs evaluated exhibited positive effects in treatment of depressive and anxiety disorders, alcohol dependence and PTSD. More research is needed in order to test the effectiveness of these therapies (alone or together) in different mental illnesses and different populations.
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Affiliation(s)
- Federico J. Gómez-Busto
- Department of Pharmacology, Academic Area of Medicine, Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico., Eliseo Ramírez Ulloa 400, Col. Doctores, 42090, Pachuca, Hidalgo, MEXICO
| | - Mario I. Ortiz
- Department of Pharmacology, Academic Area of Medicine, Institute of Health Sciences, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico., Eliseo Ramírez Ulloa 400, Col. Doctores, 42090, Pachuca, Hidalgo, MEXICO,Corresponding author Mario I. Ortiz, Ph.D. Department of Pharmacology, Academic Area of Medicine, Institute of Health Sciences Universidad Autónoma del Estado de Hidalgo Eliseo Ramírez Ulloa 400, Col. Doctores Pachuca, Hgo. - 42090, MEXICO Phone: +52-77-1717-2000 Ext. 2361 E-mail:
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Abstract
AbstractVirtual reality (VR) is an immersive technology capable of creating a powerful, perceptual illusion of being present in a virtual environment. VR technology has been used in cognitive behavior therapy since the 1990s and accumulated an impressive evidence base, yet with the recent release of consumer VR platforms came a true paradigm shift in the capabilities and scalability of VR for mental health. This narrative review summarizes the past, present, and future of the field, including milestone studies and discussions on the clinical potential of alternative embodiment, gamification, avatar therapists, virtual gatherings, immersive storytelling, and more. Although the future is hard to predict, clinical VR has and will continue to be inherently intertwined with what are now rapid developments in technology, presenting both challenges and exciting opportunities to do what is not possible in the real world.
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21
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Ede MO, Omeje JC, Ncheke DC, Agah JJ, Chinweuba NH, Amoke CV. Assessment of the Effectiveness of Group Cognitive Behavioural Therapy in Reducing Pathological Gambling. J Gambl Stud 2020; 36:1325-1339. [PMID: 33037961 DOI: 10.1007/s10899-020-09981-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/17/2022]
Abstract
Pathological gambling is a developmental disorder usually associated with a continuous loss of control over gambling; it also involves a preoccupation with gambling and with obtaining money for the same purpose of gambling, irrational thinking, and a continuation of the behaviour despite being aware of its adverse consequences. This study examined the effectiveness of group cognitive-behavioural therapy (GCBT) on pathological gambling among Nigerian students. The study used a group randomised controlled trial design to assign participants to intervention and control groups. A total of 40 undergraduate students, aged 18-30, were classified as pathological gamblers (participants) in this study. Participants completed self-report scales titled South oaks gambling screen and Gambling Symptom Assessment Scale at three-time points. The intervention lasted for 8 weeks. The data collected were statistically analysed using repeated-measures ANOVA. Results revealed that GCBT has a significant effect in decreasing the symptoms of pathological gambling among the participants in GCBT compared to those in the control group and that the improvements were maintained at follow-up. The study concluded that group cognitive-behavioural therapy is impactful therapy in reducing pathological gambling among students. It has also validated the effectiveness of cognitive-behavioural therapy in altering erroneous thoughts and replacing it with a better alternative realistic way of thinking.
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Affiliation(s)
- Moses Onyemaechi Ede
- Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, Enugu State, Nigeria.
| | - Joachim C Omeje
- Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Damian Chijioke Ncheke
- Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, Enugu State, Nigeria.
| | - John J Agah
- Department of Science Education, Faculty of Education, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Ngozi H Chinweuba
- Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, Enugu State, Nigeria
| | - Chijioke Virgilus Amoke
- Department of Educational Foundations, Faculty of Education, University of Nigeria, Nsukka, Enugu State, Nigeria
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Dellazizzo L, Potvin S, Luigi M, Dumais A. Evidence on Virtual Reality-Based Therapies for Psychiatric Disorders: Meta-Review of Meta-Analyses. J Med Internet Res 2020; 22:e20889. [PMID: 32812889 PMCID: PMC7468638 DOI: 10.2196/20889] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/12/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Among all diseases globally, mental illnesses are one of the major causes of burden. As many people are resistant to conventional evidence-based treatments, there is an unmet need for the implementation of novel mental health treatments. Efforts to increase the effectiveness and benefits of evidence-based psychotherapy in psychiatry have led to the emergence of virtual reality (VR)–based interventions. These interventions have shown a wide range of advantages over conventional psychotherapies. Currently, VR-based interventions have been developed mainly for anxiety-related disorders; however, they are also used for developmental disorders, severe mental disorders, and neurocognitive disorders. Objective This meta-review aims to summarize the current state of evidence on the efficacy of VR-based interventions for various psychiatric disorders by evaluating the quality of evidence provided by meta-analytical studies. Methods A systematic search was performed using the following electronic databases: PubMed, PsycINFO, Web of Science, and Google Scholar (any time until February 2020). Meta-analyses were included as long as they quantitatively examined the efficacy of VR-based interventions for symptoms of a psychiatric disorder. To avoid overlap among meta-analyses, for each subanalysis included within this meta-review, only one analysis provided from one meta-analysis was selected based on the best quality of evidence. Results The search retrieved 11 eligible meta-analyses. The quality of evidence varied from very low to moderate quality. Several reasons account for the lower quality evidence, such as a limited number of randomized controlled trials, lack of follow-up analysis or control group, and the presence of heterogeneity and publication bias. Nonetheless, evidence has shown that VR-based interventions for anxiety-related disorders display overall medium-to-large effects when compared with inactive controls but no significant difference when compared with standard evidence-based approaches. Preliminary data have highlighted that such effects appear to be sustained in time, and subjects may fare better than active controls. Neurocognitive disorders also appear to improve with VR-based approaches, with small effects being found for various clinical outcomes (eg, cognition, emotion). Finally, there are insufficient data to classify VR-based interventions as an evidence-based practice for social skills training in neurodevelopmental disorders and compliance among patients with schizophrenia. Conclusions VR provides unlimited opportunities by tailoring approaches to specific complex problems and individualizing the intervention. However, VR-based interventions have not shown superiority compared with usual evidence-based treatments. Future VR-based interventions should focus on developing innovative approaches for complex and treatment-resistant symptoms that are difficult to address with traditional treatments. Future research should also aim to gain a better understanding of the potential factors that may mediate VR outcomes to improve treatment.
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Affiliation(s)
- Laura Dellazizzo
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,University of Montreal, Montreal, QC, Canada
| | - Stéphane Potvin
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,University of Montreal, Montreal, QC, Canada
| | - Mimosa Luigi
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,University of Montreal, Montreal, QC, Canada
| | - Alexandre Dumais
- Research Center of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.,University of Montreal, Montreal, QC, Canada.,Institut national de psychiatrie légale Philippe-Pinel, Montreal, QC, Canada
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Dickinson P, Gerling K, Wilson L, Parke A. Virtual reality as a platform for research in gambling behaviour. COMPUTERS IN HUMAN BEHAVIOR 2020. [DOI: 10.1016/j.chb.2020.106293] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Segawa T, Baudry T, Bourla A, Blanc JV, Peretti CS, Mouchabac S, Ferreri F. Virtual Reality (VR) in Assessment and Treatment of Addictive Disorders: A Systematic Review. Front Neurosci 2020; 13:1409. [PMID: 31998066 PMCID: PMC6965009 DOI: 10.3389/fnins.2019.01409] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Substance Use Disorder (SUD) and behavioral addictions are common and require a multidisciplinary approach. New technologies like Virtual Reality could have the potential to improve assessment and treatment of these disorders. Objective: In the present paper, we therefore present an overview of Virtual Reality (Head Mounted Devices) in the field of addiction medicine for craving assessment and treatment. Method: We conducted a systematic review by querying PubMed database for the titles of articles published up to March 2019 with the terms [virtual] AND [addictive] OR [addiction] OR [substance] OR [alcohol] OR [cocaine] OR [cannabis] OR [opioid] OR [tobacco] OR [nicotine] OR [methamphetamine] OR [gaming] OR [gambling]. Results: We screened 319 abstracts and analyzed 37 articles, dividing them into two categories, the first for assessment of cue reactivity (craving, psychophysiological response and attention to cue) and the second for intervention, each drug (nicotine, cocaine, alcohol, cannabis, gambling) being detailed within each category. Conclusions: This overview suggest that VR provide benefits in the assessment and treatment of substance use disorders and behavior addictions and achieve high levels of ecological validity. While, craving provocation in VR is effective across addiction disorders, treatments based exclusively on virtual exposure to drug related cues as shown heterogenous results.
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Affiliation(s)
- Tomoyuki Segawa
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Thomas Baudry
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Alexis Bourla
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France.,Jeanne d'Arc Hospital, INICEA Group, Saint-Mandé, France
| | - Jean-Victor Blanc
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | | | - Stephane Mouchabac
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Florian Ferreri
- Department of Psychiatry, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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25
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Rémond JJ, Hernández-Mora M, Marseille C, Mesure G, Romo L. [Feasibility study of therapeutic exposure in virtual reality for pathological gamblers]. Encephale 2019; 46:23-29. [PMID: 31761313 DOI: 10.1016/j.encep.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/27/2019] [Accepted: 09/02/2019] [Indexed: 11/27/2022]
Abstract
The experiment presented is the result of a partnership between the Paris-Nanterre University (CLIPSYD laboratory, EA 4430) and the CSAPA Imagine (Simone Veil Hospital, GH Eaubonne-Montmorency). Virtual reality immersion exposure for pathological gamblers is beneficial in the context of cognitive and behavioral interventions. It can be used to evoke the desire to play and to have access to automatic thoughts and mistaken beliefs of the players when they find themselves in a gambling context. Exposure is used until the urge to play diminishes and disappears which is the process of desensitization or extinction. OBJECTIVE The objective of the study was to investigate the possibilities implemented by virtual reality in the case of an exhibition for pathological gamers to create a desire to play and work with the patient in an environment identical to the ecological one. Two hypotheses were proposed. On the one hand, the virtual reality exhibition will help to change the desire to play in relation to the game. On the other hand, virtual exhibition sessions associated with cognitive restructuring will have a greater impact on the perception of reality. METHOD After a diagnosis was made, participation in the study was offered to patients (n=10) in routine care and able to participate (exclusion criteria). It consisted of four virtual reality exposure sessions integrated with traditional care. Exposure did not exceed 20minutes. To carry out this study we used the virtual reality headset "Oculus Rift CV1" and the headphones measuring EEG waves, "Emotiv Epoc". A battery of questionnaires were proposed to evaluate gambling-related behaviors (ICJP, GRCS, UPPS), to analyze the interest of the virtual reality exhibition (SIS, CGI, TEI, EVA), and to glimpse the immersion abilities (QEP and QPI). RESULTS Ten participants aged 25 to 60 agreed to participate in the study. The results of this study demonstrated the viability of RV gamers' exposure as a tool that can help reduce pathological gambling symptoms and the severity perceived by therapists (CPI: t=1.6, P=0.001; CGI: t=4.87, P=0.001) between the beginning of the care and the end of the care and at D+1. We were also able to observe significant results (P<0.05) concerning a decrease in cognitive distortions (GRCS tot, Illusion of control, Power of prediction, Favorable interpretation). CONCLUSION The feasibility study shows that the desire to play is very present during the virtual reality exhibition in accordance with literature studies. The results also demonstrate the utility of virtual reality to allow the patient to elaborate on the cognitive distortions associated with the practice of pathological gambling. From a therapeutic point of view, the results suggest that virtual reality can increase the effectiveness of cognitive restructuring and increase understanding of the urge to play related to stimuli in the environment of play.
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Affiliation(s)
- J-J Rémond
- CLIPSYD 4430 EA 4430, université Paris Nanterre, 92, 92000 Nanterre, France.
| | - M Hernández-Mora
- CSAPA Imagine, hospitalier Eaubonne-Montmorency, Ermont, 95, 14, rue de Saint-Prix, 95600 Eaubonne, France
| | - C Marseille
- CSAPA Imagine, hospitalier Eaubonne-Montmorency, Ermont, 95, 14, rue de Saint-Prix, 95600 Eaubonne, France
| | - G Mesure
- CSAPA Imagine, hospitalier Eaubonne-Montmorency, Ermont, 95, 14, rue de Saint-Prix, 95600 Eaubonne, France
| | - L Romo
- CLIPSYD 4430 EA 4430, université Paris Nanterre, 92, 92000 Nanterre, France; Inserm U494 centre hospitalier Sainte-Anne (CMME), 75014 Paris, France
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A Psychophysiological and Behavioural Study of Slot Machine Near-Misses Using Immersive Virtual Reality. J Gambl Stud 2019; 35:929-944. [PMID: 30684139 DOI: 10.1007/s10899-018-09822-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
During slot machine gambling, near-miss outcomes occur when the final winning icon lands one position off the pay-line. To understand how near-misses promote gambling behaviour in healthy populations, autonomic arousal is often used to index outcome response valence. Findings remain equivocal, possibly owing to the limited ecological validity of computer simulations. Relevant psychological traits, such as impulsivity, which increase the risk of problem gambling, are often not examined. Here, we used immersive virtual reality (VR) to investigate near-miss-induced changes in physiological arousal and VR gambling behaviour. Sixty adult participants with no history of problem gambling were immersed in a VR casino-bar where they engaged with a self-selected slot machine. Real-time heart rate (HR) data were acquired during immersion. Within-subjects analyses were conducted on HR and post-reinforcement pauses (PRPs; i.e., time taken to initiate next-spin) across wins, losses and near-misses. Significant HR acceleration occurred for both near-misses and losses compared to wins, indexing an initial orientation response. Both types of losses were associated with faster next-spin responses. Near-misses did not apparently have unique HR or PRP profiles from losses, although this may reflect our loss control condition, which in itself may have been a subtler near-miss outcome. Impulsivity measured by the SUPPS-P was not associated with near-miss responses. Losses may encourage gambling as participants experience more immediate HR acceleration (indexing arousal unique to losing) and initiate faster responses. Future studies should clarify this effect by investigating problem gambling cohorts and develop VR paradigms taking into consideration the current findings and limitations.
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Santiago A, Carré A, Miranda R, Benyamina A, Luquiens A. La santé à l’ère du numérique. Med Sci (Paris) 2019; 35:787-791. [DOI: 10.1051/medsci/2019151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Les technologies de l’information et de la communication ont profondément marqué le champ de la santé. De nouvelles pratiques médicales utilisant ces technologies tentent de promouvoir une meilleure égalité d’accès aux soins, en particulier dans le champ de la santé mentale et des addictions où le recours aux professionnels de santé demeure faible. L’addiction aux jeux de hasard et d’argent en ligne, que nous désignerons sous le terme de jeu problématique, semble représenter un modèle pertinent de mesures de prévention et de soin fondé sur l’exploitation des données numériques issues du Big data et sur l’utilisation des nouvelles technologies. Ens effet, les données issues des comptes des joueurs offrent la possibilité d’une lecture directe de leur comportement de jeu. Parallèlement, le recours à l’internet offre un cadre de soin auquel les joueurs en ligne pourraient être particulièrement sensibles.
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28
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Ghiţă A, Hernández-Serrano O, Fernández-Ruiz Y, Monras M, Ortega L, Mondon S, Teixidor L, Gual A, Porras-García B, Ferrer-García M, Gutiérrez-Maldonado J. Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study. J Clin Med 2019; 8:E1153. [PMID: 31382353 PMCID: PMC6723764 DOI: 10.3390/jcm8081153] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/30/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND This study is part of a larger project aiming to develop a virtual reality (VR) software to be implemented as a clinical tool for patients diagnosed with alcohol use disorder (AUD). The study is based on previous research in which we identified factors that elicit craving for alcohol in a sample of AUD patients, and which led to the development of a virtual reality software to be used in cue exposure treatments of alcohol use disorder (ALCO-VR). The main objective of this study was to test the effectiveness of ALCO-VR to elicit cue-induced craving and anxiety responses among social drinkers (SD) and AUD patients. Our secondary objective was to explore which responses (cue-induced craving or anxiety) can best differentiate between AUD patients and the SD group. METHOD Twenty-seven individuals (13 AUD patients and 14 SD) participated in this study after giving written informed consent. Their anxiety and alcohol craving levels were measured by different instruments at different stages of the procedure. The VR equipment consisted of Oculus Rift technology, and the software consisted of the ALCO-VR platform. RESULTS Our data indicate that the ALCO-VR software can elicit responses of anxiety and alcohol craving, especially in the group of AUD patients. The cue-induced anxiety response differentiated AUD patients and the SD group better than the cue-induced craving response. CONCLUSIONS The general interest in applying new technologies to the assessment and treatment of mental health disorders has led to the development of immersive real-life simulations based on the advantages of VR technology. Our study concluded that the ALCO-VR software can elicit anxiety and craving responses and that cue-induced anxiety responses can distinguish between AUD and SD groups better than cue-induced craving. The data on craving and anxiety were assessed consistently by different instruments. In addition, we consider that ALCO-VR is able to ecologically assess cue-induced anxiety and alcohol craving levels during exposure to VR alcohol-related environments.
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Affiliation(s)
- Alexandra Ghiţă
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Passeig de la Vall d' Hebron 171, 08035 Barcelona, Spain
| | | | - Yolanda Fernández-Ruiz
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Passeig de la Vall d' Hebron 171, 08035 Barcelona, Spain
| | - Miquel Monras
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Lluisa Ortega
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Silvia Mondon
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Lidia Teixidor
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Antoni Gual
- Addictive Behaviors Unit, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Bruno Porras-García
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Passeig de la Vall d' Hebron 171, 08035 Barcelona, Spain
| | - Marta Ferrer-García
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Passeig de la Vall d' Hebron 171, 08035 Barcelona, Spain
| | - José Gutiérrez-Maldonado
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Passeig de la Vall d' Hebron 171, 08035 Barcelona, Spain.
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Abstract
PURPOSE OF REVIEW To assess recent developments in professionally delivered interventions for gambling disorder. RECENT FINDINGS During the past 24 months a number of reviews and individual studies have been published. Collectively they assess the efficacy and effectiveness of a range of interventions and identify methodological and other shortcomings. These studies advance knowledge with respect to pharmacological and psychological treatments including brief interventions delivered face-to-face and in other ways. Increased attention has been given to patient diversity, comorbidity, relapse, and nongambling outcomes. A variety of novel interventions have been developed and assessed. SUMMARY CBT and brief interventions remain well supported and appear to be similarly effective across varied patient groups. A range of promising new and combination treatments have been developed that require further evaluation. Larger, more robust pragmatic trials are required with diverse populations. Increased attention needs to be given to mechanisms of change, therapy mediators, patient retention, comorbidities, long-term treatment outcome, and relapse prevention.
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Matheson FI, Hamilton-Wright S, Kryszajtys DT, Wiese JL, Cadel L, Ziegler C, Hwang SW, Guilcher SJT. The use of self-management strategies for problem gambling: a scoping review. BMC Public Health 2019; 19:445. [PMID: 31035978 PMCID: PMC6489359 DOI: 10.1186/s12889-019-6755-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/08/2019] [Indexed: 12/18/2022] Open
Abstract
Background Problem gambling (PG) is a serious public health concern that disproportionately affects people experiencing poverty, homelessness, and multimorbidity including mental health and substance use concerns. Little research has focused on self-help and self-management in gambling recovery, despite evidence that a substantial number of people do not seek formal treatment. This study explored the literature on PG self-management strategies. Self-management was defined as the capacity to manage symptoms, the intervention, health consequences and altered lifestyle that accompanies a chronic health concern. Methods We searched 10 databases to identity interdisciplinary articles from the social sciences, allied health professions, nursing and psychology, between 2000 and June 28, 2017. We reviewed records for eligibility and extracted data from relevant articles. Studies were included in the review if they examined PG self-management strategies used by adults (18+) in at least a subset of the sample, and in which PG was confirmed using a validated diagnostic or screening tool. Results We conducted a scoping review of studies from 2000 to 2017, identifying 31 articles that met the criteria for full text review from a search strategy that yielded 2662 potential articles. The majority of studies examined self-exclusion (39%), followed by use of workbooks (35%), and money or time limiting strategies (17%). The remaining 8% focused on cognitive, behavioural and coping strategies, stress management, and mindfulness. Conclusions Given that a minority of people with gambling concerns seek treatment, that stigma is an enormous barrier to care, and that PG services are scarce and most do not address multimorbidity, it is important to examine the personal self-management of gambling as an alternative to formalized treatment. Electronic supplementary material The online version of this article (10.1186/s12889-019-6755-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flora I Matheson
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Sarah Hamilton-Wright
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - David T Kryszajtys
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Jessica L Wiese
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Carolyn Ziegler
- Health Information Sciences Library, University of Toronto, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Sara J T Guilcher
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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Lindner P, Miloff A, Zetterlund E, Reuterskiöld L, Andersson G, Carlbring P. Attitudes Toward and Familiarity With Virtual Reality Therapy Among Practicing Cognitive Behavior Therapists: A Cross-Sectional Survey Study in the Era of Consumer VR Platforms. Front Psychol 2019; 10:176. [PMID: 30800086 PMCID: PMC6376952 DOI: 10.3389/fpsyg.2019.00176] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/18/2019] [Indexed: 12/12/2022] Open
Abstract
Virtual reality exposure therapy (VRET) is an efficacious treatment for fear and anxiety and has the potential to solve both logistic issues for therapists and be used for scalable self-help interventions. However, VRET has yet to see large-scale implementation in clinical settings or as a consumer product, and past research suggests that while therapists may acknowledge the many advantages of VRET, they view the technology as technically inaccessible and expensive. We reasoned that after the 2016 release of several consumer virtual reality (VR) platforms and associated public acquaintance with VR, therapists' concerns about VRET may have evolved. The present study surveyed attitudes toward and familiarity with VR and VRET among practicing cognitive behavior therapists (n = 185) attending a conference. Results showed that therapists had an overall positive attitude toward VRET (pros rated higher than cons) and viewed VR as applicable to conditions other than anxiety. Unlike in earlier research, high financial costs and technical difficulties were no longer top-rated negative aspects. Average negative attitude was a larger negative predictor of self-rated likelihood of future use than positive attitude was a positive predictor and partially mediated the positive association between VRET knowledge and likelihood of future use, suggesting that promotional efforts should focus on addressing concerns. We conclude that therapist's attitudes toward VRET appear to have evolved in recent years, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.
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Affiliation(s)
- Philip Lindner
- Department of Psychology, Stockholm University, Stockholm, Sweden.,Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Miloff
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Elin Zetterlund
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | | | - Gerhard Andersson
- Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.,Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden.,Department of Psychology, University of Southern Denmark, Odense, Denmark
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Tabri N, Hollingshead SJ, Wohl MJA. A limit approaching pop-up message reduces gambling expenditures, except among players with a financially focused self-concept. INTERNATIONAL GAMBLING STUDIES 2019. [DOI: 10.1080/14459795.2019.1567806] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Nassim Tabri
- Department of Psychology, Carleton University, Ottawa, Canada
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Luquiens A, Miranda R, Benyamina A, Carré A, Aubin HJ. Cognitive training: A new avenue in gambling disorder management? Neurosci Biobehav Rev 2018; 106:227-233. [PMID: 30359663 DOI: 10.1016/j.neubiorev.2018.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 09/10/2018] [Accepted: 10/18/2018] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cognitive deficits are being robustly documented in gambling disorder. Cognitive training has been increasingly investigated as a treatment of substance use disorders. Four training components have been listed to date: cognitive bias, response inhibition, working memory, and goal-directed. This review aimed at the identification of use and efficacy findings in cognitive training in gambling disorder. METHODS We conducted a systematic search to identify use and efficacy data of cognitive training in gambling disorder. No use or efficacy data was available. DISCUSSION AND PERSPECTIVES Studies assessing cognitive training in gambling disorder are being conducted and first results should be upcoming. Methodological challenges have been identified. Several candidate target cognitive functions of training programs are being investigated, relying on the most documented impairments in gambling disorder, inhibition, reward sensitivity and decision making. Gambling-specific or neutral environments are to be distinguished clearly and do not rely on similar assumptions, i.e. general vulnerability or vulnerability expressed only in the specific context of gambling. Proper control groups with placebo conditions should be implemented. Assessment of efficacy should include clinical and neuropsychological assessments to give information of underlying mechanisms of action.
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Affiliation(s)
- Amandine Luquiens
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France.
| | - Ruben Miranda
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
| | - Amine Benyamina
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
| | - Arnaud Carré
- Univ. Grenoble Alpes, Univ. Savoie Mont Blanc, LIP/PC2S, 38000, Grenoble, France
| | - Henri-Jean Aubin
- Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France
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Jerdan SW, Grindle M, van Woerden HC, Kamel Boulos MN. Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research. JMIR Serious Games 2018; 6:e14. [PMID: 29980500 PMCID: PMC6054705 DOI: 10.2196/games.9226] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 02/11/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. OBJECTIVE In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. METHODS We compiled a table of 82 studies that made use of head-mounted devices in their interventions. RESULTS Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. CONCLUSIONS Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment.
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Affiliation(s)
- Shaun W Jerdan
- Department of Digital Health, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Mark Grindle
- Department of Digital Health, Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Hugo C van Woerden
- Public Health Directorate, NHS Highland, Inverness, United Kingdom.,Centre for Health Science, University of the Highlands and Islands, Inverness, United Kingdom
| | - Maged N Kamel Boulos
- The Alexander Graham Bell Centre for Digital Health, Moray College UHI, University of the Highlands and Islands, Elgin, United Kingdom
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Clark L, Goudriaan AE. The neuroscience and neuropsychology of gambling and gambling addiction: an introduction to the special issue. INTERNATIONAL GAMBLING STUDIES 2018. [DOI: 10.1080/14459795.2018.1467946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Luke Clark
- Centre for Gambling Research at UBC, Department of Psychology, University of British Columbia , Vancouver, Canada
| | - Anna E. Goudriaan
- Department of Psychiatry, Amsterdam Institute for Addiction Research, Academic Medical Center, University of Amsterdam , Amsterdam, The Netherlands
- Arkin Mental Health , The Netherlands
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Shin YB, Kim JJ, Kim MK, Kyeong S, Jung YH, Eom H, Kim E. Development of an effective virtual environment in eliciting craving in adolescents and young adults with internet gaming disorder. PLoS One 2018; 13:e0195677. [PMID: 29672530 PMCID: PMC5908156 DOI: 10.1371/journal.pone.0195677] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 03/27/2018] [Indexed: 12/13/2022] Open
Abstract
Internet gaming disorder (IGD) is a new disorder that warrants further investigation, as recently noted in the research criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Offering controlled environments that increase cue-induced craving, virtual reality cue-exposure therapy has been shown to be effective for some addiction disorders. To assess the feasibility of virtual reality for patients with IGD, this study aimed to develop virtual environments that represent risk situations for inducing craving, and assess the effect of virtual reality in cue reactivity. A total of 64 male adolescents and young adults (34 with IGD and 30 without) were recruited for participation. We developed a virtual internet café environment and the participants were exposed to four different tasks. As the primary feasibility outcome, cravings were measured with a visual analogue scale measuring current urge to play a game after exposure to each task. The virtual internet café induced significantly greater cravings in patients with IGD compared to controls. Additionally, patients exhibited a significantly higher acceptance rate of an avatar's invitation to play a game together than that of controls. In IGD, craving response to the tasks was positively associated with the symptom severity score as measured by Young's Internet Addiction Test. These findings reveal that virtual reality laden with complex game-related cues could evoke game craving in patients with IGD and could be used in the treatment of IGD as a cue-exposure therapy tool for eliciting craving.
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Affiliation(s)
- Yu-Bin Shin
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Republic of Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Jin Kim
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Republic of Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Psychiatry, Yonsei University Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Min-Kyeong Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Psychiatry, Yonsei University Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Sunghyon Kyeong
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Hoon Jung
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Republic of Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyojung Eom
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Republic of Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eunjoo Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Psychiatry, Yonsei University Gangnam Severance Hospital, Seoul, Republic of Korea
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Menchon JM, Mestre-Bach G, Steward T, Fernández-Aranda F, Jiménez-Murcia S. An overview of gambling disorder: from treatment approaches to risk factors. F1000Res 2018; 7:434. [PMID: 30090625 PMCID: PMC5893944 DOI: 10.12688/f1000research.12784.1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2018] [Indexed: 12/26/2022] Open
Abstract
Gambling disorder (GD) has been reclassified recently into the "Substance-Related and Addictive Disorders" category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a landmark occurrence for a behavioral addiction. GD is characterized by recurrent, maladaptive gambling behavior that results in clinically significant distress. Although the number of randomized controlled trials assessing the effectiveness of pharmacological treatments is limited, some pharmacological treatments, notably opiate antagonists, have been employed in the treatment of GD. Patients with GD often present cognitive distortions and specific personality traits, making treatment more difficult. Cognitive behavioral therapy has become the most common psychological intervention for treating gambling problems, and it is effective in reducing gambling behavior. In this brief overview, we provide a report on the state of pharmacological and psychological treatments for gambling disorder. Risk factors and potential future lines of research are addressed.
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Affiliation(s)
- José M Menchon
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain.,Departament of Clinical Sciences, School of Medicine, University of Barcelona , Barcelona, Spain.,CIBER Salud Mental (CIBERSAM), Instituto Carlos III, Barcelona, Spain
| | - Gemma Mestre-Bach
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain.,Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Barcelona, Spain
| | - Trevor Steward
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain.,Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Barcelona, Spain
| | - Fernando Fernández-Aranda
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain.,Departament of Clinical Sciences, School of Medicine, University of Barcelona , Barcelona, Spain.,Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Barcelona, Spain
| | - Susana Jiménez-Murcia
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain.,Departament of Clinical Sciences, School of Medicine, University of Barcelona , Barcelona, Spain.,Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Barcelona, Spain
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Chrétien M, Giroux I, Goulet A, Jacques C, Bouchard S. Cognitive restructuring of gambling-related thoughts: A systematic review. Addict Behav 2017; 75:108-121. [PMID: 28728039 DOI: 10.1016/j.addbeh.2017.07.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/27/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
Gamblers' thoughts have a fundamental influence on their gambling problem. Cognitive restructuring is the intervention of choice to correct those thoughts. However, certain difficulties are noted in the application of cognitive restructuring techniques and the comprehension of their guidelines. Furthermore, the increase of skill game players (e.g. poker) entering treatment creates a challenge for therapists, as these gamblers present with different thoughts than those of the gamblers usually encountered in treatment (e.g. chance-only games like electronic gambling machines). This systematic review aims to describe how cognitive restructuring is carried out with gamblers based on the evidence available in empirical studies that include cognitive interventions for gambling. Of the 2607 studies collected, 39 were retained. The results highlight exposure as the most frequently used technique to facilitate identification of gambling-related thoughts (imaginal=28.2%; in vivo=10.3%). More than half of the studies (69.2%) clearly reported therapeutic techniques aimed to correct gamblers' thoughts, of which 37% involved visual support to challenge those thoughts (e.g. ABC log). Of the 39 studies retained, 48.7% included skill game players (i.e., poker, blackjack, sports betting) in their sample. However, none of these studies mentioned whether cognitive restructuring had been adapted for these gamblers. Several terms referring to gamblers' thoughts were used interchangeably (e.g. erroneous, dysfunctional or inadequate thoughts), although each of these terms could refer to specific content. Clinical implications of the results are discussed with regard to the needs of therapists. This review also suggests recommendations for future research.
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Abstract
PURPOSE OF REVIEW This review provides an overview of the current evidence base for and clinical applications of the use of virtual reality (VR) in psychiatric practice, in context of recent technological developments. RECENT FINDINGS The use of VR in psychiatric practice shows promise with much of the research demonstrating clinical effectiveness for conditions including post-traumatic stress disorder, anxiety and phobias, chronic pain, rehabilitation, and addictions. However, more research is needed before the use of VR is considered a clinical standard of practice in some areas. The recent release of first generation consumer VR products signals a change in the viability of further developing VR systems and applications. As applications increase so will the need for good quality research to best understand what makes VR effective, and when VR is not appropriate for clinical services. As the field progresses, it is hopeful that the flexibility afforded by this technology will yield superior outcomes and a better understanding of the underlying mechanisms impacting those outcomes.
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