Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

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

Identifying Triggers of Alcohol Craving to Develop Effective Virtual Environments for Cue Exposure Therapy

Background: Many studies have indicated that alcohol craving is a core mechanism in the acquisition, maintenance, and precipitation of relapse in alcohol use disorder (AUD). A common treatment approach in AUD is cue exposure therapy (CET). New technologies like virtual reality (VR) have the potential to enhance the effectiveness of CET by creating realistic scenarios in naturalistic environments. In this study, we aimed to determine relevant triggers of alcohol craving in patients with AUD. Methods: We enrolled 75 outpatients diagnosed with AUD according to the DSM-5 criteria Participants completed the Alcohol Use Disorder Identification Test and a self-administered questionnaire to assess alcohol craving. The variables included in the craving questionnaire were as follows: presence of others, situations, time of the day, day of the week, mood, and type of alcoholic beverage. Results: Greater levels of alcohol craving were seen in many situations, including being at a party, in a restaurant, in a bar or pub, and at home. Drinking alone and drinking with two or more friends were equally associated with higher levels of craving. Drinking at night and drinking at weekends also emerged as triggers for alcohol craving. Emotional states like anxiety or tension, sadness, stress, frustration, or irritability were highly associated with urges to drink alcohol. The alcoholic drinks most highly associated with increased levels of craving were beer, wine, and whisky. Gender and age implications were discussed. Conclusion: This study is part of a larger project aiming to develop and validate CET based on VR technology for patients with AUD who are resistant to classical treatment. The identified triggers have been used to develop relevant VR environments for CET, and further research is ongoing to implement our findings

Assessing attentional bias for alcohol-related cues using eye tracking in a virtual reality environment

peer reviewedSeveral experimental paradigms were developed to measure attentional biases towards alcohol-related cues. However, most of them are based on reaction times to two-dimensional stimuli displayed on a computer screen, such that their ecological validity has been questioned. To address this, we integrated an eye tracking system into a virtual reality headset (ET-VR) and measured attentional biases in a subclinical population of alcohol users. In this exploratory study, forty social drinkers were recruited and immersed in a virtual bar including alcohol-related stimuli. Attentional focus was assessed using dwell time and number of fixations for these alcohol-related stimuli as well as for neutral stimuli unrelated to alcohol consumption. The results show that the number of fixations and, to a lesser extent, the dwell time for alcohol- related cues were positively correlated with the drinking motivation of the participants. In contrast, no significant correlation was found for neutral stimuli. In conclusion, the present study shows that alcohol-induced attentional biases can be studied using an ET-VR device in a subclinical population of alcohol users.3. Good health and well-bein

The Efficacy of Cue Exposure Therapy on Alcohol Use Disorders: A Quantitative Meta-Analysis and Systematic Review

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=-.35; 95%CI -.72 to .03), drinking days (g=-.30; 95%CI -.54 to -.06) and relapse (OR=-.58; 95%CI .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

L’intervention Avatar pour le trouble de l’usage de cannabis chez des individus ayant un trouble mental sévère

Le trouble de l’usage de cannabis (TLUC) est une problématique complexe particulièrement lorsqu’il est comorbide à un trouble mental sévère (TMS). D’une part, aucune pharmacothérapie n’a été approuvée pour son traitement et d’une autre part, les psychothérapies existantes offrent au mieux une efficacité faible et non maintenue dans le temps. L’émergence de la réalité virtuelle (RV) en psychiatrie pourrait augmenter l’efficacité considérant le potentiel qu’elle a démontré pour une variété de conditions psychiatriques. Actuellement, aucune intervention ayant incorporé la RV visant le traitement du TLUC n’a fait l'objet de recherche. L’intervention Avatar pour le TLUC se veut une approche innovante utilisant la RV en tant qu’outil thérapeutique afin de faire des apprentissages et les pratiquer au moment où les cravings et les émotions sont d’intensité similaire à celle de leur quotidien. Cette intervention comprenant huit séances utilise des techniques provenant de thérapie recommandée (ex., thérapie cognitivo-comportementale, entrevue motivationnelle). Durant les périodes d’immersion, les participants ont interagi avec un avatar représentant une personne significative en lien avec leur consommation dont le thérapeute joue le rôle. Cet essai clinique pilote a visé l’évaluation de l’efficacité ainsi que la faisabilité et l’acceptabilité à court terme chez 19 participants ayant un double diagnostic de TMS et TLUC. Les résultats ont montré une réduction significative modérée de la quantité de cannabis consommée (d=0,545; p=0,017), laquelle a été confirmée par quantification du THC-COOH dans les urines. Une tendance a été observée pour la fréquence de l’usage (d=0,313; p=0,052). Concernant la sévérité du TLUC et la motivation aux changements, une petite (d=0,474; p=0,046) et modérée (d=0,523; p=0,046) taille d’effet ont été obtenues respectivement. Aucun effet significatif n’a été observé pour la qualité de vie et les symptômes psychiatriques sont restés stables. Les résultats à moyen et long terme seront évalués lorsque les participants auront terminé les suivis à 3, 6 et 12 mois. Un essai randomisé contrôlé à simple insu comparant l’intervention Avatar pour TLUC à une intervention classique en toxicomanie est en cours.Cannabis use disorder (CUD) is a complex issue, particularly when it is comorbid with a severe mental disorder (SMD). On one hand, no pharmacotherapy has been approved for its treatment. On the other hand, existing psychotherapies offer, at best, low efficacy that is not sustained over time. The emergence of virtual reality (VR) in psychiatry could increase efficacy, given the potential it has demonstrated for a variety of psychiatric conditions. To date, no intervention incorporating VR for the treatment of CUD has been developed. The Avatar intervention for CUD is an innovative approach using VR as a therapeutic tool to learn and practice in real-time when cravings and emotions are of similar intensity to their everyday lives. This eight-session intervention uses techniques from commonly used therapeutic approaches (e.g., cognitive-behavioral therapy, motivational interviewing). During immersive sessions, participants interacted with an avatar played by the therapist, representing a significant person intrinsically linked with their consumption. This pilot clinical trial was designed to assess efficacy at short-term, feasibility, and acceptability in 19 participants with a dual diagnosis of SMD and CUD. Results showed a significant moderate reduction in the amount of cannabis consumed (d=0.545, p=0.017), which was confirmed by the quantification of THC-COOH in urine. Regarding the severity of TLUC and motivation to change, a small (d=0.474; p=0.046) and moderate (d=0.523; p=0.046) effect size were obtained, respectively. No significant effect was obtained for quality of life, and psychiatric symptoms remained stable. Once participants have completed the 3-, 6- and 12-month follow-ups, medium- and long-term results will also be assessed. A single-blind randomized controlled trial is currently underway to compare the Avatar intervention for CUD with a conventional addiction intervention

Cue reactivity to self-harm cues: the development of a systematic treatment intervention for deliberate self-harm

There is increasing awareness of the prevalence of deliberate self-harm (DSH) although the phenomenon is still poorly understood. Those who self-harm often have a poor long-term prognosis, yet systematic focused treatment interventions are scarce. DSH appears to share fundamental characteristics with addictive behaviour, including; impulsive or compulsive urges to act in the presence of triggers, positive and negative reinforcing consequences and endorsement of the diagnostic criteria for clinical dependence. Given this fact, a behavioural mode of DSH may be appropriate. A range of events are anecdotally reported to trigger DSH. This thesis was designed to identify these cues, to develop an understanding of how those who self-harm respond to these cues and the processes by which these cues may operate to maintain DSH. An intervention based on the management of urges to self-harm in the presence of these cues was developed.Study I identified that triggers for DSH (interpersonal, intrapersonal and environmental) were similar to those that reliably predict addictive behaviour. Respondents endorsed the diagnostic criteria for dependency and reported that the act of DSH reduced negative emotions. The second two studies identified self-reported cue reactivity, and generalised hyperarousal to both DSH and neutral stimuli in those who self-harm but no evidence of psychophysiological cue reactivity. Study IV used ERP methodology to evaluate cue reactivity at the CNS level and to evaluate two mechanisms by which cues might operate to maintain DSH. There was some preliminary support for enhanced preconscious attentional bias towards emotional, but not environmental DSH cues, and no support for emotional interference. Study V identified that those who self-harm exhibited enhanced tolerance to physical and psychological stressors, and that priming with interpersonal distress did not impact on this tolerance. Finally, a single case intervention study identified a reduction in DSH, reduced psychophysiological arousal and urges to self-harm and improved clinical symptomatology. However, clinical improvements were not time-locked to targeted exposure intervention phases. The clinical and theoretical implications for these findings are discussed

SELF-FOCUSED VERSUS OTHER-FOCUSED COGNITIVE STRATEGIES FOR COPING WITH SMOKING CUE EXPOSURE: A FUNCTIONAL MAGNETIC RESONANCE IMAGING STUDY

The ability to cope effectively during high-risk situations (e.g., exposure to drug-related stimuli during acute withdrawal) is essential for forestalling relapse during attempts to quit problematic substance use. Attempting to exert executive cognitive control over affective reactions is a frequently employed strategy for managing temptation and sustaining cessation. Such attempts are not failsafe, however, with many individuals succumbing to temptation despite reporting the use of cognitive coping strategies. The reasons for such failure, as well as for the observation that the efficacy of coping varies significantly both within and between individuals, remain largely unknown. The goal of the present study was to address this important knowledge gap by investigating the mechanisms underlying cognitive coping in cigarette smokers, with two specific aims. The first aim was to examine the neural correlates of the use of two different forms of cognitive coping during drug cue exposure, with the prediction that the use of a non-self-referential strategy would be associated with relatively greater activation of the DLPFC than a strategy that entails the use of self-referential information. In contrast, it was hypothesized that a strategy that involves the generation and maintenance of self-relevant information would be associated with comparatively greater activation of portions of the anterior medial prefrontal cortex than a strategy in which the focus is on non-self-referential information. The second aim of the study was to examine whether non-self-referential and self-referential coping strategies are differentially moderated by individual differences in working memory capacity, with the hypothesis that working memory ability would more strongly predict the magnitude of cue-elicited activation of the DLPFC during the use of a non-self-referential coping strategy than during the use of a self-referential coping strategy. Findings suggest non-self-referential and self-referential coping indeed are associated with different patterns of neural activation during cue exposure, although the specific relationships that were observed proved to be more complex than initially hypothesized. In contrast to expectations, however, working memory capacity did not differentially moderate the activation of the DLPFC and measures of cue-reactivity. Potential implications and extensions of these findings are discussed

Psychological mechanisms contributing to alcohol-induced increases in energy intake

Consumption of alcohol is a significant risk factor for undesirable weight. Previous investigations have demonstrated that acute alcohol consumption reliably increases caloric intake relative to consumption of an alcohol-free comparator, however a complete understanding of the mechanisms contributing to this effect is lacking. Therefore, this thesis investigated the psychological mechanisms underpinning alcohol consumption’s effects on eating behaviour. Specifically, it investigated the role of alcohol-induced changes to cognitive control of eating as well as food reward. The thesis also explored whether alcohol-induced changes to food intake and BMI can be explained by a dual-process account of appetite control - an interaction of top-down and bottom-up processes. Chapter 3 (Studies 1 and 2) investigated whether acute alcohol consumption can impair recall of memories related to a recently consumed meal and whether this affects subsequent food intake. Findings revealed that acute alcohol consumption prior to a lunch meal impaired meal memory recall relative to an alcohol-free drink in Study 2 but not in Study 1. Both studies failed to provide evidence that meal memory recall affects subsequent food intake. Chapter 4 (Studies 3 and 4) investigated whether acute alcohol consumption can enhance food reward, relative to a placebo-alcohol. Study 3 found that an alcohol dose of 0.3 g/kg (grams of alcohol per kilogram of bodyweight) did not enhance food reward (measured using self-report scales and an attentional bias task) or increase food intake. However, Study 4 showed that a dose of 0.6 g/kg, acute alcohol consumption enhanced food reward and food intake relative to the placebo. Contrary to predictions of the dual-process account, the interaction between trait motor impulsivity and change in food-related attentional bias between drink conditions did not significantly predict change in food intake. Finally, Chapter 5 (Study 5) examined whether change in BMI over a 12-month period is predicted by change in drinking behaviour, and whether trait motor impulsivity moderates this effect. Findings did not support these predictions. Overall, the findings of this thesis demonstrate that acute alcohol consumption does affect important cognitive factors implicated in appetite control, however there is no evidence to suggest that this contributes to alcohol-induced increase in food intake. Results also indicate that alcohol-induced enhanced food reward and increases in food intake may be dose-dependent, whereby lower doses of iv alcohol may be insufficient at increasing food intake. The dual-process model of eating behaviour did not appear to explain alcohol-induced change to food intake or BMI in these studies. Further research regarding the importance of cognitive and reward-based mechanisms within the context of alcohol-induced food intake and BMI is now warranted