A Virtual Reality Mindfulness Application for Aggression in Schizophrenia - PROJECT SUMMARY While most people with psychosis are not dangerous and most violence is committed by non-psychotic people, people with psychotic disorders are at increased risk for violence, and violence is associated with worse outcomes and increased stigma. Therefore, decreasing violence risk in psychosis is clinically relevant and has important public health implications. Studies from our group and others show that mindfulness interventions can decrease incidents of aggression, specifically impulsive aggression, in various indications. The mechanism of mindfulness-related improvements has yet to be determined, and the use of mindfulness via virtual reality (VR) has not been tested in inpatients with schizophrenia. Further, there are no VR mindfulness (MBI VR) studies that measure neuroimaging target engagement, limiting advances in understanding mechanisms and the ability for treatment-target development. The dmPFC acts as a conduit between cognitive control areas and affect- triggering regions, it plays a role in both generating and regulating emotion, and it shows reduced volume and abnormal activation in impulsive aggressive patients relative to non-aggressive patients. Additionally, increased dmPFC activation during the expectation of ‘unknown’ and negative stimuli in mindfulness studies is in line with findings on cognitive emotion regulation. This suggests that neuronal activity of the dmPFC may be associated with MBI and may be an important mediating mechanism in reduction of aggression. Our goal is to determine whether MBI VR may decrease impulsive aggressive behavior in patients with schizophrenia and whether this decrease is accompanied by a change in dmPFC activity. The R61 objective is to determine the optimal dosing paradigm for increased activation in the dmPFC and will test in the R33 phase the effect of MBI VR vs a control condition on dmPFC activation at the determined dose together with correlations with clinical outcome (changes in impulsive aggression) in individuals with schizophrenia and schizoaffective disorder (R33 phase). The R61 aim will be assessed by enrolling 48 participants randomized to 2 groups. Participants will be scanned at baseline and after 16 sessions, then after 24 sessions for the R61 phase. Go/no-go criteria: 1) dose-dependent increase in dmPFC activation during task-related fMRI, 2) a change across the MBI VR group and TAU (Cohen’s d ≥ 0.4) at one of the two doses. The R33 phase (n = 68) will confirm the effect of the optimal MBI VR dose identified in the R61 (n = 48) to engage the dmPFC in a larger sample and to examine its relationship to reduction in impulsive aggression. If successful, the project will provide evidence of positive effects of MBI VR as a novel treatment for impulsive aggression in schizophrenia and schizoaffective disorder and provide information as to the neural mechanisms underlying impulsive aggression and of response to MBI VR.
