A Virtual Reality Mindfulness Application for Aggression in Schizophrenia

Short UPPS-P Impulsive Behavior Scale

The Short UPPS-P is an instrument composed of 20 items rated on a four-point Likert scale: (1) disagree strongly, (2) disagree some, (3) agree some, and (4) agree strongly. Five scales were computed by adding the 4 items corresponding to each scale: (1) negative urgency (NU), the tendency to act impulsively when experiencing negative emotions (e.g., sadness, anger); (2) positive urgency (PU), the tendency to act rashly under extreme positive emotions or excitement; (3) sensation seeking (SS), the tendency to seek out novel and thrilling experiences, often involving risk; (4) lack of perseveration (PE), the inability to stay focused on a task, especially when it becomes difficult or boring; and (5) lack of premeditation (PR), difficulty thinking and reflecting on the consequences of an act before engaging in it. Each scale ranges from 4 to 16.

Impulsive-Premeditated Aggression Scale

The Impulsive-Premeditated Aggression Scale (IPAS; Mathias et al., 2007) will be administered at screening, baseline, after completion of 16 sessions and after completion of 24 sessions. The IPAS is a 30-item self-report questionnaire used to rate aggressive acts occurring over the past six months. Items are scored on a five-point scale (1 = Strongly Disagree; 2 = Disagree; 3 = Neutral; 4 = Agree; 5 = Strongly Agree). The scale differentiates three factors -premeditated aggression, here referred to as 'PM' and impulsive aggression, here referred to as 'IA'-that can be scored either dimensionally or categorically, and Familiarity Items (Stanford MS, Classification procedures, unpublished manual). Discrete categories (impulsive vs premeditated) are obtained by a categorical approach in which only the percentage of the positive items (5 = strongly agree or 4 = agree) for each aggression scale is calculated (Stanford MS, Classification procedures, unpublished manual).

Positive and Negative Syndrome Scale

The PANSS will be used to assess psychopathology. The PANSS is a 30-item, clinician-administered assessment that provides scores for positive, negative, and general psychopathology symptoms. The PANSS Excitement Component (PANSS EC; Lindenmayer et al., 2004a; Faay et al., 2018, Lindenmayer et al., 2004b, Montoya et al., 2011) will be examined to assess change in aggressive behaviors. Each PANSS item is scored from 1 to 7, with a minimum score of 30 and a maximum score of 210.

Overt Aggression Scale - Modified

Our secondary outcome measure is time to aggressive acts as measured by the Overt Aggression Scale - Modified (OAS-M). The OAS-M is a four-part behavior rating scale used to evaluate and document the "frequency and severity" of aggressive episodes: verbal aggression, aggression against objects, aggression against self, and aggression against others. The OAS-M is a widely used measures for violence and aggression (Mattes, 2010). Each category is rated 0-4 based on severity, with the score multiplied by a weight (1, 2, 3, or 4, respectively) to produce a total weighted score.

Clinical Global Impression Aggression Scales

The CGI rating scales are tools used to evaluate both the severity of illness and change from baseline (Guy 1976). The CGI-S Aggression reflects the severity of illness on a 7-point scale ranging from no symptoms (1) to very severe (7). The CGI-I Aggression is used to assess the clinical change as compared to symptoms at baseline using a 7-point scale, ranging from very much improved (1) to very much worse (7).

Point Subtraction Aggression Paradigm

The PSAP is a commonly used behavioral aggression paradigm wherein participants earn points (i.e., money) and can steal points from (i.e., aggressive behavior) or have points stolen by an opponent (i.e., provocation), reflecting a more social/non-violent form of reactive aggression. Aggression is scored by counting the number of button presses (e.g., 40, 50, or 100) on a "provocation" button that removes points from the opponent, or by total point subtractions per trial.

Quality-of-Life Enjoyment and Satisfaction Questionnaire - Short Form

The QLES-Q-SF will be administered at each study visit to measure patient-assessed health and well-being. This brief, self-report measure is made up of 16 items and is scored using a 5-point Likert scale, and the higher the total score, the more satisfied the patient is with life. The Q-LES-Q-SF (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form) is a 16-item self-report tool where the first 14 items are summed to measure life satisfaction (scores 14-70), with higher scores indicating greater enjoyment. Items use a 5-point Likert scale (1=Very Poor, 5=Very Good). It is converted to a 0-100% scale for interpretation.

Oxford Daily Mood Scale (OMS)

The Oxford Daily Mood Scale is a self-assessment tool designed to help individuals quantify their emotional state throughout the day using a simple 10-point scale. This scale allows users to track fluctuations in their mood over time by assigning a score based on how they felt at different points during the day. Scale Description: 1. Very Depressed 2. Depressed 3. Somewhat Low 4. Slightly Low 5. "So-so" 6. Slightly Good 7. Somewhat Happy 8. Happy 9. Very Happy

Columbia-Suicide Severity Rating Scale Baseline

The Columbia-Suicide Severity Rating Scale (C-SSRS) is a clinical tool designed to assess suicide risk, facilitating comprehensive evaluations in both clinical and research settings. Below is an extended description of the scale, its application, and its significance in assessing suicide risk. The C-SSRS aims to: Identify Individuals at Risk: It helps health professionals determine the severity of suicidal ideation and behavior in individuals, enabling timely intervention. Facilitate Management Plans: By quantifying suicide risk, this scale informs treatment planning and follow-up strategies. Standardize Assessments: It provides a structured format for evaluating suicidality, enhancing reliability across different raters and settings.

Columbia-Suicide Severity Rating Scale Since Last Visit

The Columbia-Suicide Severity Rating Scale (C-SSRS) is a clinical tool designed to assess suicide risk, facilitating comprehensive evaluations in both clinical and research settings. Below is an extended description of the scale, its application, and its significance in assessing suicide risk. The C-SSRS aims to: Identify Individuals at Risk: It helps health professionals determine the severity of suicidal ideation and behavior in individuals, enabling timely intervention. Facilitate Management Plans: By quantifying suicide risk, this scale informs treatment planning and follow-up strategies. Standardize Assessments: It provides a structured format for evaluating suicidality, enhancing reliability across different raters and settings.

Simulator Sickness Questionnaire

The Simulator Sickness Questionnaire (SSQ) is a 16-item self-report tool developed by Kennedy et al. (1993) to quantify side effects from virtual environments or flight simulators. It rates symptoms - nausea, oculomotor, and disorientation, on a 0-3 scale, widely used to assess cybersickness in VR. Scores determine overall severity, aiding in identifying problematic simulators. The SSQ measures 16 symptoms (e.g., headache, eyestrain, dizziness, vertigo, nausea) rated by the participant as "None" (0), "Slight" (1), "Moderate" (2), or "Severe" (3). Subscales: Symptoms are grouped into three factors: 1. Nausea (N): General discomfort, increased salivation, sweating, nausea, difficulty concentrating, stomach awareness, burping. 2. Oculomotor (O): General discomfort, fatigue, headache, eyestrain, difficulty focusing, difficulty concentrating, blurred vision. 3\. Disorientation (D): Difficulty focusing, nausea, fullness of head, blurred vision, dizziness, vertigo.