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Acceptability of a Plasticity-Focused Serious Game Intervention for Posttraumatic Stress Disorder: User Requirements Analysis

Acceptability of a Plasticity-Focused Serious Game Intervention for Posttraumatic Stress... Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for posttraumatic stress disorder (PTSD). Despite a solid evidence base, TF-CBT response and attrition rates vary considerably. Plasticity-focused interventions, including the use of serious games, have the potential to improve TF-CBT response and treatment retention. Objective: The aim of this study was to assess the acceptability of a mobile phone–delivered plasticity-focused serious game to improve response to TF-CBT for PTSD, and carry out a user requirements analysis should the development of a prototype be warranted. Methods: We conducted 2 one-to-one interviews (n=2), one focus group involving service users who had received a diagnosis of PTSD (n=3) and one focus group involving psychological trauma service clinicians (n=4). Results: We found that the concept of a plasticity-focused mobile phone intervention for PTSD is acceptable to patients and clinicians. Service users and clinicians both believed that the usage should be guided by a therapist, and both contributed useful inputs regarding the audiovisual aspects of the proposed serious game. It was accepted that the game would not be suitable for all patients and that clinicians would need to appropriately prescribe the usage of the game. Conclusions: The findings highlight the acceptability of the proposed serious game and clarify the user requirements for such an intervention. It is the intention of the authors to carry out a user experience evaluation using a prototype serious game in a clinical population. (JMIR Serious Games 2019;7(2):e11909) doi: 10.2196/11909 KEYWORDS PTSD; mobile applications; neuronal plasticity; cognitive behavioral therapy nightmares, and avoidance of event-related stimuli [2]. In the Introduction United Kingdom, trauma-focused cognitive-behavioral therapy (TF-CBT) is the first-line treatment for PTSD [3]. TF-CBT Background refers to a range of evidence-based psychotherapeutic techniques In the absence of UK estimates, lifetime prevalence of for the treatment of psychological trauma. Despite a strong posttraumatic stress disorder (PTSD) in the United States has evidence base and wide implementation of TF-CBT, been estimated to be between 6.8% and 7.8% [1]. This disorder non-response and attrition rates vary widely, in some is characterized by intrusive memories of traumatic events, circumstances exceeding 50% [4,5]. Contributory factors that http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al reduce optimal response to therapy in PTSD are varied, such mechanics such as switching between a first- or third-person as many possible social and behavioral factors [4]. One possible perspective and an aerial map perspective of a virtual contributory variable is neural deficit associated with PTSD. environment have been associated with recruitment of Functional imaging studies suggest that reduced frontomedial frontomedial circuitry [12]. On the basis of these data, it appears neural network connectivity (eg, reduced prefrontal modulation possible that a specifically designed video game (serious game) of the amygdala) and volumetric abnormality of medial limbic could encourage plastic changes in frontomedial neural circuitry structures are associated with PTSD psychopathology [6-8]. by presenting the player with tasks known to recruit this neural network. For example, a video game could present a player with Neural Correlates of Posttraumatic Stress Disorder a two-dimensional aerial map representation of a novel 3D According to the theoretical frameworks underpinning TF-CBT, environment, inside which several objects were placed. The frontomedial neural connectivity is thought to play a critical player could then be asked to memorize the location of each role in regulating computational processes that are integral to object, choose an order to collect the objects, then navigate the processing trauma memories. These processes include pattern environment, and collect each object in the order they have identification, separation, and completion [9], which allow for chosen, aided by salient environmental landmarks. complete retrieval and successful discrimination between This study aimed to find out the following: contextually similar episodic or event memory formations based on familiar stimuli. Difficulty in completing these processes is • If a plasticity-focused serious game intervention designed a characteristic of PTSD. For example, someone who to aid response to TF-CBT in PTSD patients would prove experiences posttraumatic symptoms in relation to the trauma an acceptable concept to service users and providers? of surviving a house fire, may experience involuntary recall of • What would be the user requirements for such an traumatic memory in response to the sight and smell of a bonfire. intervention to be feasible and accessible? There is also evidence of intrinsic medial temporal lobe (MTL) Methods connectivity contributing to the successful processing of fear-related memory [10] and the formation of egocentric The authors conducted a focus group (n=3) and 2 semistructured episodic memory representations [11]. Reduced neural interviews (n=2) with service users and, in addition, conducted connectivity in the MTL, especially in relation to the strong a focus group with psychological trauma service clinicians efferent connections between the retrosplenial cortex and the (n=4). hippocampus, may have negative clinical implications for PTSD patients engaging in TF-CBT. This is because a core component Participants of TF-CBT, known as reliving, is a form of in vitro exposure The recruited number of eligible participants was 9. In total, 5 that involves the guided retrieval of episodic memory of participants were service users and 4 were trauma service traumatic incidents from an egocentric viewpoint in vivid detail. clinicians. Among them, 1 service user participant was a female, and the remaining 4 were males. Mean age for service user Objective participants was 59.8 years with the age range between 53 and Several researchers have found functional and structural plastic 68 years. The duration of PTSD symptoms reported by service changes in neural circuits following the prolonged use of user participants ranged from 3 to 30 years. A total of 3 commercial video games and have queried the potential for participants had experienced combat-related trauma. The nature therapeutic application [12-14]. Neuroimaging and behavioral of trauma experienced by the other service users was unknown. data suggest that frontomedial circuitry is implicated in The clinical roles represented by the trauma service clinicians generating short-term memory representations related to (n=4) were 1 trainee clinical psychologist, 1 assistant way-finding and memory-based decision-making tasks [15,16], psychologist, 1 specialist clinical psychologist, and 1 consultant similar to the use of salient landmarks to aid navigation of novel clinical psychologist. Principal inclusion and exclusion criteria three-dimensional (3D) environments [17]. In addition, are presented in Textbox 1. Textbox 1. Principal inclusion and exclusion criteria. Service users Inclusion criteria: aged 18 years and above; previous or current diagnosis of posttraumatic stress disorder (PTSD); in frequent and regular contact with service clinicians for treatment or other services, eg, mentoring Exclusion criteria: aged under 18 years; inability to provide informed consent to participate Clinicians Inclusion criteria: aged 18 years and above; currently working clinically with patients with PTSD Exclusion criteria: not working directly with patients with PTSD; unqualified or trainee clinicians without ongoing clinical supervision http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al Textbox 2. Topic guide: participants and domains of inquiry. Service users Current mobile phone capabilities Coping strategies employed by service users (and those which involve mobile phone apps or Web-based resources) Acceptability of the proposed intervention (including concerns) Views on game presentation (in terms of graphics and audio) Clinicians Acceptability of the proposed intervention (including concerns) Views on game presentation (in terms of graphics and audio) running Apple’s iOS. Participants’ mobile phones were capable Materials of running software apps, and all reported social media apps A topic guide was developed by the authors and used for both that were their favored and most frequently used apps. These the focus groups and interviews. Open-ended questions with included Facebook, Facebook Messenger, and WhatsApp. prompts addressed a total of 5 broad domains of inquiry (as Existing Coping Strategies Reported by Service Users summarized in Textbox 2). All topics were explored in each interview and focus group. Interviews lasted between 30 and All participating service users reported reliance on particular 60 min, and focus groups lasted between 90 and 120 min. lifestyle-related strategies to cope with PTSD symptoms. The Demographic data, including age and gender, were requested majority of participants reported social support (through either from service user participants only. We sought permission from friends or family or organized support groups) and engagement all participants to make live written notes and audio-record in outdoor activities, including cycling and dog walking. All interviews and focus groups on digital voice recorders placed but one participant reported using mobile apps in seeking on a table, around which participants and researchers sat. All support from others (eg, Facebook, WhatsApp, short message audio and written data were transcribed verbatim on a later date. service text messaging, phone). All participating service users reported that PTSD had adversely Procedure affected their memory. Participants gave examples of impaired To identify and engage members of the target population for episodic and prospective memory capacity, such as frequent recruitment into the study, the authors approached several examples of the doorway effect and forgetting seemingly organizations, including third sector organizations and National meaningful upcoming or past events, particularly when stressed. Health Services. A branch of a national charity offering mental Out of the 5 service users, 3 participants did not use any health mentoring and practical support to military veterans in memory-specific coping strategies, whereas 1 participant South Wales, responded promptly and positively to our queries. reported using mobile phone to create calendar reminders, and One-to-one interviews were carried out at the charity’s premises 1 reported writing things down using a pen and paper. Walking during April 2017. We decided not to include the name and and cycling were reported to be helpful activities by 2 location of this service in the interest of the confidentiality and participants, and 1 reported using Google Maps for planning anonymity of study participants. The psychological trauma cycling routes. All but 1 had previous TF-CBT; all reported service at Springfield University Hospital in Tooting, London, current medication with selective serotonin reuptake inhibitors. also responded positively and promptly to our enquiries. Focus groups involving patients and clinical staff were carried out No participants had used Web-based resources to help them here in June 2017. cope with PTSD symptoms. Only 1 of 5 participants reported having used an app called PTSD Coach [18] released by the Data Analysis United States Department of Veterans Affairs. The app focuses Data were thematically analyzed, summarized, and described on education around PTSD and symptom tracking and is in relation to our domains of inquiry. As the interviews were marketed as a therapeutic tool. They described the app as relatively unstructured and we sought to assess acceptability unhelpful and were no longer using it. No participant reported rather than develop a theory of theoretical framework, we actively using general health or well-being–related apps. Usage attempted to calculate interrater reliability. of relaxation and meditation apps were reported by 2 participants (these were the freely available Stop, Breathe and Think and Results Smiling Mind Android apps) [19,20], which included scripted meditation and relaxation exercises. Both participants described Current Service User Mobile Phone Capabilities these as unhelpful, with 1 participant describing the sensation Of the 5 service user participants, 4 owned a mobile phone and of being out of control when using the apps, as they were anxiety 1 owned an older generation mobile phone. Of the 4 participants inducing. who owned a mobile phone, 3 owned a mobile phone running Google’s Android operating system and the other used a phone http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al At the time of the focus groups and interviews, the researcher Service Users’ Reported Acceptability of the Proposed would describe the need for novel landmarks to be located in Serious Game the environment and ask the participants how they would like All participants described themselves as being willing to try the these to be represented. In response to this query, mountains proposed serious game intervention. Only 1 participant was less and trees were described as ideal landmarks by all participants. enthusiastic about using the app along with therapy than before Man-made structures were described by 3 participants, with therapy, and 1 was concerned that using the app would interfere Buddhist temple or similar architecture being the favored choice. with therapy rather than enhance it; however, these concerns could be alleviated if assurance of the game’s efficacy was Clinicians’ Reported Acceptability of the Proposed provided by a clinician. All participants stated that they would Serious Game be more confident about using the app under the guidance of a As with service user participants, clinicians were positively clinician. inquisitive about the concept behind the proposed serious game. Of the 5 participants, 3 stated that they would be unlikely to Clinicians were more likely to inquire about the theoretical basis use the app at times when they were experiencing acute for the intervention. No clinician reported any concerns about symptoms of PTSD, for example, experiencing a flashback or potential adverse effects; however, all participants favored symptoms of panic. Only 1 participant described long periods clinician-guided use of the game as opposed to independent of inactivity alluding to depressive symptoms as potential barrier use. It was the prevailing view that a significant proportion of to using the app. All agreed that the app would have to be easy patients would require coaching in using the game with adequate to use and intuitive in its design. All participants expressed frequency. concern that if the game were too difficult, they may become Clinicians’ Views on the Proposed Serious Game's frustrated and cease using it relatively quickly. Should this not Graphics and Audio Components be the case, 2 participants stated that they would be willing to use the app for 30 min every day over a prolonged period When discussing the sound and graphics content of the game, (defined by the interviewer as between 3 and 6 weeks). The all participants agreed that the game must avoid sound and remaining 3 participants stated they would be willing to use the graphic content likely to trigger symptoms of PTSD. All agreed app for 30 min every other day over the same period. All that the more realistic the environment was, the more difficult participants were enthusiastic about the prospect of patients this task became, and so a cartoon-like or abstract appearance using the serious game while on a waiting list. They described for the environment was favored. It was accepted that creating positive implications for self-efficacy: an environment that guaranteed not to trigger symptoms of PTSD in any player would be infeasible. However, it was ...you’re not just waiting for someone to help you accepted that creating an environment that was unlikely to then, you are doing something [to help] yourself. trigger PTSD symptoms for the majority of users was feasible, All participants were positively inquisitive about the concept especially if the environment was customizable and the game behind the proposed serious game, especially the fact that the was carefully prescribed. game would not include a psychotherapeutic component to Clinicians stated that the game should match the patient’s address PTSD or PTSD-related symptoms directly. No abilities: participant reported any concerns or negative attitudes toward the concept underpinning the proposed serious game when ...if the game is too boring, the patient would prompted, for example: disengage, weakening the effect of the experimental manipulation. What do you think of the serious game concept? Service users, on the other hand, were more concerned with the Do you think this could work for you? amount of concentration required to sustain while playing the Service Users’ Views on the Proposed Serious Game's game; if they had to concentrate too hard, they could get Graphics and Audio Components frustrated and give up. This balance of skill and difficulty is referred to as a component of flow theory and is frequently In terms of graphical and audio design features that would be referenced when designing games for educational and clinical beneficial to the user experience, all participants favored an purposes [21]. expansive outdoor environment. Water, in the form of rivers and lakes, including the sound of naturally running water was Clinicians raised the issue of increasing the numbers of asylum described as desirable by 4 participants. However, beaches were seekers seeking help for PTSD in the United Kingdom in recent described as reminiscent of combat trauma and therefore years. As many of these service users may have difficulty especially undesirable by 2 of the 4 participants. Desert understanding English, the game interface must be intuitive and landscapes were also described as undesirable. Woods and include very little text guidance. Translating the game into many greenery were described as desirable by 4 participants, and 1 different languages would present a less feasible option, given participant described the ideal aesthetic to be that of a garden. the available funding and resources. In addition, in the The need for the player to be able to choose different seasons clinician’s experiences, many patients who had arrived in the for the environment before the play was expressed by 3 country seeking asylum had come from Middle Eastern and participants. No participant desired the inclusion of human North African countries and had experienced trauma not only characters in the environment; however, 3 enthusiastically in the countries from which they were escaping but also during favored the inclusion of wildlife such as dogs, birds, and horses. http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al their perilous journeys to the United Kingdom. For this reason, a medium-specification Android device. We will measure graphics of beaches, large expanses of open water, boats, lorries, readiness to use a digital intervention such as Hippocampal and and desert landscapes were deemed undesirable. Prefrontal Plasticity Inducement Application (HAPPIA), using a previously validated method of assessment such as the eHealth Discussion Readiness Scale [22], and include a user satisfaction questionnaire to supplement our qualitative data collection. We Principal Findings will also formally measure aspects of participant’s individual pathology using validated tools. For example, we will measure We captured qualitative data regarding the acceptability of a engagement in existing coping strategies for trauma symptoms plasticity-focused serious game to aid response to TF-CBT for using the Trauma Coping Self-Efficacy scale [23]; the Life PTSD from a small sample of service users and clinicians. These Events Checklist will be used to assess the nature of experienced data suggest that the concept of such an intervention is trauma events [24]; and the Posttraumatic Stress Disorder acceptable to both groups and can be made accessible to the Checklist for the Diagnostic and Statistical Manual of Mental target population who mostly have access to capable hardware. Disorders, fifth edition will be used to measure symptom Care must be taken in terms of graphical and audio content to severity [25]. Data from this testing will be used to refine the ensure that the game does not elicit trauma symptoms in service design of the software and further inform the choice of hardware users and is accessible and easy to use. This represents a used to deliver the intervention before clinical evaluation. significant design challenge given the highly varied clinical Screenshots from the in-development prototype informed by population in question. It was the view of the service users and the qualitative data reported here are presented below. The clinicians that the game usage should be guided by a therapist. prototype dubbed “HAPPIA” has begun development using the The issue of negative affect influencing motivation and poor Unity software engine developed by Unity Technologies and prospective memory in PTSD patients reinforced the need for is optimized to run on medium-spec Android devices including therapist involvement. It was also accepted that the game would mobile phones and tablet personal computers. not be suitable for all patients, and so the clinicians would have to use their knowledge and expertise to appropriately prescribe Following further refinement and development of the HAPPIA usage of the game. app by way of user-experience testing, we will seek to evaluate HAPPIA as a clinical intervention by carrying out a randomized Limitations controlled trial. Patients awaiting a course of TF-CBT will be This study was limited by a small and opportunistic sample, randomly assigned to HAPPIA plus treatment as usual (TAU) most notably missing asylum-seeking representatives. or TAU alone. Symptom severity at the outset of treatment, at Participants had received a diagnosis of PTSD by specialist cessation of treatment, and at follow-up will be measured using trauma clinicians. Details of individual’s diagnosis, including validated psychometric measures and compared among groups. the nature of the trauma or traumas, or the symptom severity at Attrition rates and changes in psychotropic medication (eg, the time of participation, were not available to the researchers. anxiolytics) dosage will also be compared among groups. We In addition, we did not collect data related to spiritual or will capture demographic data, including age and gender, for religious beliefs, which could have helped put in to context the clinical participants. HAPPIA will record game-related data, preference for Buddhist style structures in the virtual including time spent playing the game, time taken to complete environment. tasks, and efficiency of task completion for within-group analysis. Future Steps We propose to complete user-experience testing with service users and clinicians using a prototype video game running on Acknowledgments The authors would like to express their warm thanks and gratitude to the service users and staff members who helped with this study. Ethical approval for this research was granted by the College of Science at Swansea University, United Kingdom. SM’s involvement in this study contributed toward a MSc in Computer Science under the tutelage of TO. CHERISH-DE escalator funding was used to support the study. Conflicts of Interest None declared. References 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. 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[doi: 10.1002/jts.22059] [Medline: 26606250] Abbreviations 3D: three-dimensional HAPPIA: Hippocampal and Prefrontal Plasticity Inducement Application MTL: medial temporal lobe http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al PTSD: posttraumatic stress disorder TF-CBT: trauma-focused cognitive-behavioral therapy Edited by G Eysenbach; submitted 10.08.18; peer-reviewed by C Yeager, A Antoniades; comments to author 27.10.18; revised version received 01.11.18; accepted 09.12.18; published 16.04.19 Please cite as: Jones M, Denisova A, Mitchell S, Owen T JMIR Serious Games 2019;7(2):e11909 URL: http://games.jmir.org/2019/2/e11909/ doi: 10.2196/11909 PMID: 30990461 ©Matthew Jones, Alena Denisova, Stephen Mitchell, Tom Owen. Originally published in JMIR Serious Games (http://games.jmir.org), 16.04.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 7 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Acceptability of a Plasticity-Focused Serious Game Intervention for Posttraumatic Stress Disorder: User Requirements Analysis

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Abstract

Background: Trauma-focused cognitive behavioral therapy (TF-CBT) is a first-line treatment for posttraumatic stress disorder (PTSD). Despite a solid evidence base, TF-CBT response and attrition rates vary considerably. Plasticity-focused interventions, including the use of serious games, have the potential to improve TF-CBT response and treatment retention. Objective: The aim of this study was to assess the acceptability of a mobile phone–delivered plasticity-focused serious game to improve response to TF-CBT for PTSD, and carry out a user requirements analysis should the development of a prototype be warranted. Methods: We conducted 2 one-to-one interviews (n=2), one focus group involving service users who had received a diagnosis of PTSD (n=3) and one focus group involving psychological trauma service clinicians (n=4). Results: We found that the concept of a plasticity-focused mobile phone intervention for PTSD is acceptable to patients and clinicians. Service users and clinicians both believed that the usage should be guided by a therapist, and both contributed useful inputs regarding the audiovisual aspects of the proposed serious game. It was accepted that the game would not be suitable for all patients and that clinicians would need to appropriately prescribe the usage of the game. Conclusions: The findings highlight the acceptability of the proposed serious game and clarify the user requirements for such an intervention. It is the intention of the authors to carry out a user experience evaluation using a prototype serious game in a clinical population. (JMIR Serious Games 2019;7(2):e11909) doi: 10.2196/11909 KEYWORDS PTSD; mobile applications; neuronal plasticity; cognitive behavioral therapy nightmares, and avoidance of event-related stimuli [2]. In the Introduction United Kingdom, trauma-focused cognitive-behavioral therapy (TF-CBT) is the first-line treatment for PTSD [3]. TF-CBT Background refers to a range of evidence-based psychotherapeutic techniques In the absence of UK estimates, lifetime prevalence of for the treatment of psychological trauma. Despite a strong posttraumatic stress disorder (PTSD) in the United States has evidence base and wide implementation of TF-CBT, been estimated to be between 6.8% and 7.8% [1]. This disorder non-response and attrition rates vary widely, in some is characterized by intrusive memories of traumatic events, circumstances exceeding 50% [4,5]. Contributory factors that http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al reduce optimal response to therapy in PTSD are varied, such mechanics such as switching between a first- or third-person as many possible social and behavioral factors [4]. One possible perspective and an aerial map perspective of a virtual contributory variable is neural deficit associated with PTSD. environment have been associated with recruitment of Functional imaging studies suggest that reduced frontomedial frontomedial circuitry [12]. On the basis of these data, it appears neural network connectivity (eg, reduced prefrontal modulation possible that a specifically designed video game (serious game) of the amygdala) and volumetric abnormality of medial limbic could encourage plastic changes in frontomedial neural circuitry structures are associated with PTSD psychopathology [6-8]. by presenting the player with tasks known to recruit this neural network. For example, a video game could present a player with Neural Correlates of Posttraumatic Stress Disorder a two-dimensional aerial map representation of a novel 3D According to the theoretical frameworks underpinning TF-CBT, environment, inside which several objects were placed. The frontomedial neural connectivity is thought to play a critical player could then be asked to memorize the location of each role in regulating computational processes that are integral to object, choose an order to collect the objects, then navigate the processing trauma memories. These processes include pattern environment, and collect each object in the order they have identification, separation, and completion [9], which allow for chosen, aided by salient environmental landmarks. complete retrieval and successful discrimination between This study aimed to find out the following: contextually similar episodic or event memory formations based on familiar stimuli. Difficulty in completing these processes is • If a plasticity-focused serious game intervention designed a characteristic of PTSD. For example, someone who to aid response to TF-CBT in PTSD patients would prove experiences posttraumatic symptoms in relation to the trauma an acceptable concept to service users and providers? of surviving a house fire, may experience involuntary recall of • What would be the user requirements for such an traumatic memory in response to the sight and smell of a bonfire. intervention to be feasible and accessible? There is also evidence of intrinsic medial temporal lobe (MTL) Methods connectivity contributing to the successful processing of fear-related memory [10] and the formation of egocentric The authors conducted a focus group (n=3) and 2 semistructured episodic memory representations [11]. Reduced neural interviews (n=2) with service users and, in addition, conducted connectivity in the MTL, especially in relation to the strong a focus group with psychological trauma service clinicians efferent connections between the retrosplenial cortex and the (n=4). hippocampus, may have negative clinical implications for PTSD patients engaging in TF-CBT. This is because a core component Participants of TF-CBT, known as reliving, is a form of in vitro exposure The recruited number of eligible participants was 9. In total, 5 that involves the guided retrieval of episodic memory of participants were service users and 4 were trauma service traumatic incidents from an egocentric viewpoint in vivid detail. clinicians. Among them, 1 service user participant was a female, and the remaining 4 were males. Mean age for service user Objective participants was 59.8 years with the age range between 53 and Several researchers have found functional and structural plastic 68 years. The duration of PTSD symptoms reported by service changes in neural circuits following the prolonged use of user participants ranged from 3 to 30 years. A total of 3 commercial video games and have queried the potential for participants had experienced combat-related trauma. The nature therapeutic application [12-14]. Neuroimaging and behavioral of trauma experienced by the other service users was unknown. data suggest that frontomedial circuitry is implicated in The clinical roles represented by the trauma service clinicians generating short-term memory representations related to (n=4) were 1 trainee clinical psychologist, 1 assistant way-finding and memory-based decision-making tasks [15,16], psychologist, 1 specialist clinical psychologist, and 1 consultant similar to the use of salient landmarks to aid navigation of novel clinical psychologist. Principal inclusion and exclusion criteria three-dimensional (3D) environments [17]. In addition, are presented in Textbox 1. Textbox 1. Principal inclusion and exclusion criteria. Service users Inclusion criteria: aged 18 years and above; previous or current diagnosis of posttraumatic stress disorder (PTSD); in frequent and regular contact with service clinicians for treatment or other services, eg, mentoring Exclusion criteria: aged under 18 years; inability to provide informed consent to participate Clinicians Inclusion criteria: aged 18 years and above; currently working clinically with patients with PTSD Exclusion criteria: not working directly with patients with PTSD; unqualified or trainee clinicians without ongoing clinical supervision http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al Textbox 2. Topic guide: participants and domains of inquiry. Service users Current mobile phone capabilities Coping strategies employed by service users (and those which involve mobile phone apps or Web-based resources) Acceptability of the proposed intervention (including concerns) Views on game presentation (in terms of graphics and audio) Clinicians Acceptability of the proposed intervention (including concerns) Views on game presentation (in terms of graphics and audio) running Apple’s iOS. Participants’ mobile phones were capable Materials of running software apps, and all reported social media apps A topic guide was developed by the authors and used for both that were their favored and most frequently used apps. These the focus groups and interviews. Open-ended questions with included Facebook, Facebook Messenger, and WhatsApp. prompts addressed a total of 5 broad domains of inquiry (as Existing Coping Strategies Reported by Service Users summarized in Textbox 2). All topics were explored in each interview and focus group. Interviews lasted between 30 and All participating service users reported reliance on particular 60 min, and focus groups lasted between 90 and 120 min. lifestyle-related strategies to cope with PTSD symptoms. The Demographic data, including age and gender, were requested majority of participants reported social support (through either from service user participants only. We sought permission from friends or family or organized support groups) and engagement all participants to make live written notes and audio-record in outdoor activities, including cycling and dog walking. All interviews and focus groups on digital voice recorders placed but one participant reported using mobile apps in seeking on a table, around which participants and researchers sat. All support from others (eg, Facebook, WhatsApp, short message audio and written data were transcribed verbatim on a later date. service text messaging, phone). All participating service users reported that PTSD had adversely Procedure affected their memory. Participants gave examples of impaired To identify and engage members of the target population for episodic and prospective memory capacity, such as frequent recruitment into the study, the authors approached several examples of the doorway effect and forgetting seemingly organizations, including third sector organizations and National meaningful upcoming or past events, particularly when stressed. Health Services. A branch of a national charity offering mental Out of the 5 service users, 3 participants did not use any health mentoring and practical support to military veterans in memory-specific coping strategies, whereas 1 participant South Wales, responded promptly and positively to our queries. reported using mobile phone to create calendar reminders, and One-to-one interviews were carried out at the charity’s premises 1 reported writing things down using a pen and paper. Walking during April 2017. We decided not to include the name and and cycling were reported to be helpful activities by 2 location of this service in the interest of the confidentiality and participants, and 1 reported using Google Maps for planning anonymity of study participants. The psychological trauma cycling routes. All but 1 had previous TF-CBT; all reported service at Springfield University Hospital in Tooting, London, current medication with selective serotonin reuptake inhibitors. also responded positively and promptly to our enquiries. Focus groups involving patients and clinical staff were carried out No participants had used Web-based resources to help them here in June 2017. cope with PTSD symptoms. Only 1 of 5 participants reported having used an app called PTSD Coach [18] released by the Data Analysis United States Department of Veterans Affairs. The app focuses Data were thematically analyzed, summarized, and described on education around PTSD and symptom tracking and is in relation to our domains of inquiry. As the interviews were marketed as a therapeutic tool. They described the app as relatively unstructured and we sought to assess acceptability unhelpful and were no longer using it. No participant reported rather than develop a theory of theoretical framework, we actively using general health or well-being–related apps. Usage attempted to calculate interrater reliability. of relaxation and meditation apps were reported by 2 participants (these were the freely available Stop, Breathe and Think and Results Smiling Mind Android apps) [19,20], which included scripted meditation and relaxation exercises. Both participants described Current Service User Mobile Phone Capabilities these as unhelpful, with 1 participant describing the sensation Of the 5 service user participants, 4 owned a mobile phone and of being out of control when using the apps, as they were anxiety 1 owned an older generation mobile phone. Of the 4 participants inducing. who owned a mobile phone, 3 owned a mobile phone running Google’s Android operating system and the other used a phone http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al At the time of the focus groups and interviews, the researcher Service Users’ Reported Acceptability of the Proposed would describe the need for novel landmarks to be located in Serious Game the environment and ask the participants how they would like All participants described themselves as being willing to try the these to be represented. In response to this query, mountains proposed serious game intervention. Only 1 participant was less and trees were described as ideal landmarks by all participants. enthusiastic about using the app along with therapy than before Man-made structures were described by 3 participants, with therapy, and 1 was concerned that using the app would interfere Buddhist temple or similar architecture being the favored choice. with therapy rather than enhance it; however, these concerns could be alleviated if assurance of the game’s efficacy was Clinicians’ Reported Acceptability of the Proposed provided by a clinician. All participants stated that they would Serious Game be more confident about using the app under the guidance of a As with service user participants, clinicians were positively clinician. inquisitive about the concept behind the proposed serious game. Of the 5 participants, 3 stated that they would be unlikely to Clinicians were more likely to inquire about the theoretical basis use the app at times when they were experiencing acute for the intervention. No clinician reported any concerns about symptoms of PTSD, for example, experiencing a flashback or potential adverse effects; however, all participants favored symptoms of panic. Only 1 participant described long periods clinician-guided use of the game as opposed to independent of inactivity alluding to depressive symptoms as potential barrier use. It was the prevailing view that a significant proportion of to using the app. All agreed that the app would have to be easy patients would require coaching in using the game with adequate to use and intuitive in its design. All participants expressed frequency. concern that if the game were too difficult, they may become Clinicians’ Views on the Proposed Serious Game's frustrated and cease using it relatively quickly. Should this not Graphics and Audio Components be the case, 2 participants stated that they would be willing to use the app for 30 min every day over a prolonged period When discussing the sound and graphics content of the game, (defined by the interviewer as between 3 and 6 weeks). The all participants agreed that the game must avoid sound and remaining 3 participants stated they would be willing to use the graphic content likely to trigger symptoms of PTSD. All agreed app for 30 min every other day over the same period. All that the more realistic the environment was, the more difficult participants were enthusiastic about the prospect of patients this task became, and so a cartoon-like or abstract appearance using the serious game while on a waiting list. They described for the environment was favored. It was accepted that creating positive implications for self-efficacy: an environment that guaranteed not to trigger symptoms of PTSD in any player would be infeasible. However, it was ...you’re not just waiting for someone to help you accepted that creating an environment that was unlikely to then, you are doing something [to help] yourself. trigger PTSD symptoms for the majority of users was feasible, All participants were positively inquisitive about the concept especially if the environment was customizable and the game behind the proposed serious game, especially the fact that the was carefully prescribed. game would not include a psychotherapeutic component to Clinicians stated that the game should match the patient’s address PTSD or PTSD-related symptoms directly. No abilities: participant reported any concerns or negative attitudes toward the concept underpinning the proposed serious game when ...if the game is too boring, the patient would prompted, for example: disengage, weakening the effect of the experimental manipulation. What do you think of the serious game concept? Service users, on the other hand, were more concerned with the Do you think this could work for you? amount of concentration required to sustain while playing the Service Users’ Views on the Proposed Serious Game's game; if they had to concentrate too hard, they could get Graphics and Audio Components frustrated and give up. This balance of skill and difficulty is referred to as a component of flow theory and is frequently In terms of graphical and audio design features that would be referenced when designing games for educational and clinical beneficial to the user experience, all participants favored an purposes [21]. expansive outdoor environment. Water, in the form of rivers and lakes, including the sound of naturally running water was Clinicians raised the issue of increasing the numbers of asylum described as desirable by 4 participants. However, beaches were seekers seeking help for PTSD in the United Kingdom in recent described as reminiscent of combat trauma and therefore years. As many of these service users may have difficulty especially undesirable by 2 of the 4 participants. Desert understanding English, the game interface must be intuitive and landscapes were also described as undesirable. Woods and include very little text guidance. Translating the game into many greenery were described as desirable by 4 participants, and 1 different languages would present a less feasible option, given participant described the ideal aesthetic to be that of a garden. the available funding and resources. In addition, in the The need for the player to be able to choose different seasons clinician’s experiences, many patients who had arrived in the for the environment before the play was expressed by 3 country seeking asylum had come from Middle Eastern and participants. No participant desired the inclusion of human North African countries and had experienced trauma not only characters in the environment; however, 3 enthusiastically in the countries from which they were escaping but also during favored the inclusion of wildlife such as dogs, birds, and horses. http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al their perilous journeys to the United Kingdom. For this reason, a medium-specification Android device. We will measure graphics of beaches, large expanses of open water, boats, lorries, readiness to use a digital intervention such as Hippocampal and and desert landscapes were deemed undesirable. Prefrontal Plasticity Inducement Application (HAPPIA), using a previously validated method of assessment such as the eHealth Discussion Readiness Scale [22], and include a user satisfaction questionnaire to supplement our qualitative data collection. We Principal Findings will also formally measure aspects of participant’s individual pathology using validated tools. For example, we will measure We captured qualitative data regarding the acceptability of a engagement in existing coping strategies for trauma symptoms plasticity-focused serious game to aid response to TF-CBT for using the Trauma Coping Self-Efficacy scale [23]; the Life PTSD from a small sample of service users and clinicians. These Events Checklist will be used to assess the nature of experienced data suggest that the concept of such an intervention is trauma events [24]; and the Posttraumatic Stress Disorder acceptable to both groups and can be made accessible to the Checklist for the Diagnostic and Statistical Manual of Mental target population who mostly have access to capable hardware. Disorders, fifth edition will be used to measure symptom Care must be taken in terms of graphical and audio content to severity [25]. Data from this testing will be used to refine the ensure that the game does not elicit trauma symptoms in service design of the software and further inform the choice of hardware users and is accessible and easy to use. This represents a used to deliver the intervention before clinical evaluation. significant design challenge given the highly varied clinical Screenshots from the in-development prototype informed by population in question. It was the view of the service users and the qualitative data reported here are presented below. The clinicians that the game usage should be guided by a therapist. prototype dubbed “HAPPIA” has begun development using the The issue of negative affect influencing motivation and poor Unity software engine developed by Unity Technologies and prospective memory in PTSD patients reinforced the need for is optimized to run on medium-spec Android devices including therapist involvement. It was also accepted that the game would mobile phones and tablet personal computers. not be suitable for all patients, and so the clinicians would have to use their knowledge and expertise to appropriately prescribe Following further refinement and development of the HAPPIA usage of the game. app by way of user-experience testing, we will seek to evaluate HAPPIA as a clinical intervention by carrying out a randomized Limitations controlled trial. Patients awaiting a course of TF-CBT will be This study was limited by a small and opportunistic sample, randomly assigned to HAPPIA plus treatment as usual (TAU) most notably missing asylum-seeking representatives. or TAU alone. Symptom severity at the outset of treatment, at Participants had received a diagnosis of PTSD by specialist cessation of treatment, and at follow-up will be measured using trauma clinicians. Details of individual’s diagnosis, including validated psychometric measures and compared among groups. the nature of the trauma or traumas, or the symptom severity at Attrition rates and changes in psychotropic medication (eg, the time of participation, were not available to the researchers. anxiolytics) dosage will also be compared among groups. We In addition, we did not collect data related to spiritual or will capture demographic data, including age and gender, for religious beliefs, which could have helped put in to context the clinical participants. HAPPIA will record game-related data, preference for Buddhist style structures in the virtual including time spent playing the game, time taken to complete environment. tasks, and efficiency of task completion for within-group analysis. Future Steps We propose to complete user-experience testing with service users and clinicians using a prototype video game running on Acknowledgments The authors would like to express their warm thanks and gratitude to the service users and staff members who helped with this study. Ethical approval for this research was granted by the College of Science at Swansea University, United Kingdom. SM’s involvement in this study contributed toward a MSc in Computer Science under the tutelage of TO. CHERISH-DE escalator funding was used to support the study. Conflicts of Interest None declared. References 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. 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[doi: 10.1002/jts.22059] [Medline: 26606250] Abbreviations 3D: three-dimensional HAPPIA: Hippocampal and Prefrontal Plasticity Inducement Application MTL: medial temporal lobe http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jones et al PTSD: posttraumatic stress disorder TF-CBT: trauma-focused cognitive-behavioral therapy Edited by G Eysenbach; submitted 10.08.18; peer-reviewed by C Yeager, A Antoniades; comments to author 27.10.18; revised version received 01.11.18; accepted 09.12.18; published 16.04.19 Please cite as: Jones M, Denisova A, Mitchell S, Owen T JMIR Serious Games 2019;7(2):e11909 URL: http://games.jmir.org/2019/2/e11909/ doi: 10.2196/11909 PMID: 30990461 ©Matthew Jones, Alena Denisova, Stephen Mitchell, Tom Owen. Originally published in JMIR Serious Games (http://games.jmir.org), 16.04.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2019/2/e11909/ JMIR Serious Games 2019 | vol. 7 | iss. 2 | e11909 | p. 7 (page number not for citation purposes) XSL FO RenderX

Journal

JMIR Serious Games – JMIR Publications

Published: Apr 16, 2019

Keywords: PTSD; mobile applications; neuronal plasticity; cognitive behavioral therapy

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