Abstract
Background
Social impairment is a core feature of schizophrenia presenting a major barrier to recovery. Although antipsychotic medications can reduce psychotic symptoms, social impairments often persist, contributing to poor outcome. Validated interventions, such as Social Skills Training (Bellack et al., 2004), target a broad range of social domains but they yield only modest effect sizes for social outcome (Pfammatter et al, 2006). Moreover, conventional social interventions suffer from high burden on the clients and therapists, low adherence, lack of personalization, and low generalizability. Importantly, social interventions are not widely available. Virtual reality (VR) offers a viable alternative to conventional therapies with several advantages including high acceptability, an extensive repertoire of stimuli, low-burden, low-cost and safety (Strickland, 1997). Importantly, VR allows for a precise targeting of social cognitive mechanisms. Social attention, the fast orientation and allocation of resources to social stimuli can be indexed by tracking eye movements. Abnormal eye scanning behavior during social interactions has been linked to poor social functioning in schizophrenia (Brunet-Gouet & Decety, 2006). We designed a VR-based social skills training game to directly target social attention in schizophrenia.
Methods
Eighteen individuals with schizophrenia (SZ) participated in the VR training game twice a week for 5 weeks. Eye movement patterns were recorded throughout the training. Subjects were required to solve social “missions” (e.g., obtain personal information through conversations with avatars) in different naturalistic scenarios. To start a mission, participants had to fixate on the chosen avatar. The latency to engage in a social interaction was indexed by the fixation time (social engagement latency). Each session consisted of 12 missions. We compared social engagement latency and eye gaze patterns pre- and post-training to assess the efficacy of the VR social skills training program.
Results
Social engagement latency significantly decreased after 10 sessions (d=0.78). This result suggests that prosocial attention benefitted from VR training. We also found that the standard deviation of dwell time (i.e., proportion of time spent looking at the avatar’s face during a conversation) significantly increased across training sessions (d=0.56). This result suggests an increased modulation of interpersonal engagement during social interaction. Additionally, participants’ emotion recognition ability significantly increased (η2 = 0.27), and negative symptoms significantly decreased (η2=0.34) from pre- to post- training. Importantly, these changes in social attention correlated with improvement in negative symptoms.
Discussion
Simulated and targeted social interactions with avatars in VR significantly improved social attention in individuals with schizophrenia. Importantly, improvements in negative symptoms and emotion perception after training suggest that this training protocol has an impact on a broad range of social functions. VR training is a promising alternative to traditional psychosocial interventions to target specific mechanisms underlying social functioning in schizophrenia.
Social Skills Training for Negative Symptoms of Schizophrenia