Digital health technologies in the psychosocial treatment of core symptoms of psychotic disorders - literature review and practical aspects

Peer reviewe

Chapter 4 AVATAR Therapy for Refractory Auditory Hallucinations

AVATAR therapy is part of a new and exciting wave of therapies which adopt an explicitly relational and dialogic approach to working with the distressing voices. To understand the AVATAR approach, it is important to consider its position in the evolution of psychological interventions for distressing voices

Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta‐analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty‐two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post‐traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross‐sectional research. Our findings suggest that there may be distinct psy­chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis

Childhood trauma, negative schemas, and trust: an exploration using virtual reality

This thesis explores the impact of childhood trauma. Part one presents a systematic review and meta-analysis of the association between childhood sexual abuse and auditory hallucinations. The results suggest that sexual abuse increases the likelihood of auditory hallucination development. A dose-response relationship was also observed, whereby sexual abuse of greater severity was associated with increased symptom severity. The results are discussed in the context of current theoretical understandings of childhood risk factors and auditory hallucinations. Part two reports on an empirical study that used virtual reality to explore the impact of childhood interpersonal trauma and negative schemas on trust. Seventy participants from the general population interacted with a virtual avatar. Lower ratings of this avatar’s trustworthiness, as well as a preference for greater interpersonal distance, were shown to be associated with increased experiences of particular forms of childhood trauma. The majority of these associations were found to be mediated by negative beliefs about the self and others. The potential mechanisms underlying these specific associations and the clinical implications are discussed. This study was a joint research project completed with Emilie Bourke, a fellow D.Clin.Psy Trainee at University College London. The findings of this researcher’s thesis are presented separately. Part three is a critical appraisal, providing thoughts and personal reflections regarding the research process as a whole. It discusses the difficulties of recruiting a clinical sample, considers the complexities of the study of trauma, and remarks upon the bi-directional relationship between research and clinical practice

A first step toward cognitive remediation of voices: a case study.

Several studies have shown that source-monitoring errors are related to verbal hallucinations in schizophrenia. An exploratory pilot study has been carried out to investigate the possibility of training patients in how to avoid errors in source-monitoring. One patient with paranoid schizophrenia and persistent thought insertions was trained for 6 hours to use mnemonic techniques to compensate specific deficits in source-monitoring. Results show that the patient was able to improve his performance and maintain the acquired progress at a 1-month follow-up assessment. These preliminary results are interesting for developing a larger controlled study of cognitive remediation of source-monitoring deficits

Cognitive mechanisms associated with clinical and non-clinical psychotic experiences

The studies reported in this thesis were designed to address several important issues in symptom-specific cognitive models of psychosis. The design of these studies was guided by a commitment to the continuity hypothesis of psychosis, which holds that psychotic experiences exist on a continuum stretching into the healthy population. The thesis firstly examines a two-factor cognitive model of persecutory ideation, focusing primarily on the roles of thought suppression, intrusive thoughts, anxiety, social rank, and the jumping to conclusions bias. The thesis then turns to an examination of cognitive factors involved in hallucinations and, in particular, auditory verbal hallucinations. Chapters in this section describe a series of experimental and theoretical studies of the relations between intrusive thoughts and hallucinations, agency and hallucinations, and the role of inner speech in auditory verbal hallucinations. Two-factor models of persecutory delusion (PD) formation propose that in the first stage of PD formation an initial implausible idea is triggered. The second stage of Deformation is then the uncritical adoption of such a thought as a belief, which may be due to cognitive biases such as the jumping to conclusions (JTC) bias often present in those with PDs. The first study (Chapter 1) investigated whether thought suppression, and its interaction with anxiety, was associated with levels of non-clinical persecutory delusion like beliefs (PDLBs). It was hypothesised that thought suppression could play a role in the formation and maintenance of PDLBs through its tendency to lead to intrusive thoughts, and to trigger initial implausible ideas. Consistent with this proposal, thought suppression was positively associated with PDLBs only when anxiety was high. The second study (Chapter 2) examined a prediction of the two-factor model, namely that a second-stage factor, the jumping to conclusions (JTC) bias, should interact with first-stage factors, specifically social anxiety, social rank, anomalous experiences and thought suppression. Consistent with the two-factor model, the JTC bias was found not to be an independent predictor of PDLB levels, but its interaction with social rank was a significant predictor of PDLBs. It was concluded that although evidence was found for the two-factor model, the presence of the JTC bias was neither a sufficient nor necessary condition for PDLB formation. In addition to being postulated to play a role in persecutory delusion formation, intrusive thoughts have been implicated in the formation of hallucinations, and particularly auditory verbal hallucinations (AVHs). The third study (Chapter 3) created a new tool for assessing hypnagogic and hypnopompic (H&H) hallucinations, and showed that the presence of auditory H&H hallucinations, but not visual or felt-presence H&H hallucinations, was associated with a greater tendency to experience intrusions. The fourth study (Chapter 4) developed an extended model of AVHs in which rumination, as well as thought suppression, were proposed to be involved in the formation of AVHs, through their creation of intrusive thoughts. This model was tested in a healthy sample of individuals using structural equation modelling, and the proposed model was found to be a good fit to the data. The study on rumination and AVHs highlighted that agency disruption factors are likely to be involved in leading these self-generated cognitions to be experienced as alien. A theoretical analysis (Chapter 5) was made of the mechanisms likely to be involved in this disruption of agency, involving the concept of a neurocognitive action self-monitoring system (NASS) and a breakdown in the processes leading to the illusion of conscious will. A consideration was also given to how a Vygotskian conception of inner speech could contribute to inner speech models of AVHs. The next study (Chapter 6) then performed an empirical test of the proposal that the disruption of agency in AVHs is associated with a faulty NASS. Subliminal primes were used as a proxy for the predicted state proposed to exist in the NASS, which leads to the experience of agency. It was proposed that those prone to hallucinations would be less able to use primes to enhance their experience of agency, due to deficits in their NASS. A statistically significant trend was found for the more hallucination-prone to be less able to use subliminal primes, but this effect was only found in women. It was concluded that although this was a promising finding, the effect was too small and gender-specific to be practical to test in a clinical sample of patients with AVHs. The proposal that AVHs result from a breakdown in the NASS, specifically a corollary discharge deficit between speech production and reception areas, has been claimed to be supported by electrophysiological event-related potential (ERP) studies. However, only a simplistic conception of inner speech has thus far been investigated in ERP studies, and the potential confounding effects of attention have not been considered. The Nl ERP component response to auditory stimuli during inner speech was studied in as ample of healthy volunteers (Chapter 7). Although dampening of the Nl response was found during all types of inner speech, as compared to a silent baseline condition, dampening was also found during a mental rotation task. It was concluded that dampening of the Nl ERP component during inner speech is due to attention factors, and is not indicative of a corollary discharge mechanism. Finally, a theoretical analysis considers whether inner speech models of AVHs are able to satisfactorily account for the phenomenology of the experience (Chapter 8). It is concluded that subcategorisation of auditory hallucinations may be necessary, with memory-based, inner speech-based, and ictal-based models each accounting for a subcategory of auditory hallucinations. The concept of the dynamic developmental progression of AVHs is introduced and avenues for future research in this area highlighte

The Virtual University and Avatar Technology: E-learning Through Future Technology

E-learning gains increasingly importance in academic education. Beyond present distance learning technologies a new opportunity emerges by the use of advanced avatar technology. Virtual robots acting in an environment of a virtual campus offer opportunities of advanced learning experiences. Human Machine Interaction (HMI) and Artificial Intelligence (AI) can bridge time zones and ease professional constraints of mature students. Undergraduate students may use such technology to build up topics of their studies beyond taught lectures. Objectives of the paper are to research the options, extent and limitations of avatar technology for academic studies in under- and postgraduate courses and to discuss students' potential acceptance or rejection of interaction with AI. The research method is a case study based on Sir Tony Dyson's avatar technology iBot2000. Sir Tony is a worldwide acknowledged robot specialist, creator of Star Wars' R2D2, who developed in recent years the iBot2000 technology, intelligent avatars adaptable to different environments with the availability to speak up to eight different languages and capable to provide logic answers to questions asked. This technology underwent many prototypes with the latest specific goal to offer blended E-learning entering the field of the virtual 3-D university extending Web2.0 to Web3.0 (Dyson. 2009). Sir Tony included his vast experiences gained in his personal (teaching) work with children for which he received his knighthood. The data was mainly collected through interviews with Sir Tony Dyson, which helps discover the inventor’s view on why such technology is of advantage for academic studies. Based on interviews with Sir Tony, this research critically analyses the options, richness and restrictions, which avatar (iBot2000) technology may add to academic studies. The conclusion will discuss the opportunities, which avatar technology may be able to bring to learning and teaching activities, and the foreseeable limitations – the amount of resources required and the complexity to build a fully integrated virtual 3-D campus. Key Words: virtual learning, avatar technology, iBot2000, virtual universit