Elsevier

Schizophrenia Research

Volume 192, February 2018, Pages 96-101
Schizophrenia Research

Social environments and interpersonal distance regulation in psychosis: A virtual reality study

https://doi.org/10.1016/j.schres.2017.04.034Get rights and content

Abstract

Background

Experimentally studying the influence of social environments on mental health and behavior is challenging, as social context is difficult to standardize in laboratory settings. Virtual Reality (VR) enables studying social interaction in terms of interpersonal distance in a more ecologically valid manner. Regulation of interpersonal distance may be abnormal in patients with psychotic disorders and influenced by environmental stress, symptoms or distress.

Aims

To investigate interpersonal distance in people with a psychotic disorder and at ultrahigh risk for psychosis (UHR) compared to siblings and controls in virtual social environments, and explore the relationship between clinical characteristics and interpersonal distance.

Methods

Nineteen UHR patients, 52 patients with psychotic disorders, 40 siblings of patients with a psychotic disorder and 47 controls were exposed to virtual cafés. In five virtual café visits, participants were exposed to different levels of social stress, in terms of crowdedness, ethnicity and hostility. Measures on interpersonal distance, distress and state paranoia were obtained. Baseline measures included trait paranoia, social anxiety, depressive, positive and negative symptoms.

Results

Interpersonal distance increased when social stressors were present in the environment. No difference in interpersonal distance regulation was found between the groups. Social anxiety and distress were positively associated with interpersonal distance in the total sample.

Conclusion

This VR paradigm indicates that interpersonal distance regulation in response to environmental social stressors is unaltered in people with psychosis or UHR. Environmental stress, social anxiety and distress trigger both people with and without psychosis to maintain larger interpersonal distances in social situations.

Introduction

Psychotic disorders often involve impaired social functioning (Couture et al., 2006, Van Beilen et al., 2003). Adequate social functioning includes keeping an appropriate physical distance to others. It is difficult to study a dynamic concept such as interpersonal distance, as laboratory settings do not represent real life social contexts and often lack interaction between the subject and environmental characteristics. Using Virtual Reality (VR), the current study investigated the influence of social environments on interpersonal distance in psychosis.

Personal space or interpersonal distance, is the distance we keep to people in our surroundings. Personal space is regulated dynamically and intrusion of personal space boundaries causes discomfort (Hayduk, 1978). Several factors influence which distance is desirable or appropriate at a certain moment. For example, when feeling threatened, people enlarge their distance to others (Hayduk, 1978). In contrast, when accompanied by familiar people, personal space boundaries become smaller (Hall, 1963, Nechamkin et al., 2003). Other factors influencing interpersonal distance are cultural norms, age, gender (Ozdemir, 2008) and psychopathology (Asada et al., 2016, Kim et al., 2009).

People with psychosis were shown to prefer larger distances than controls in dyadic paradigms, that is, relative to a single person or single stimulus (de la Asuncion et al., 2015, Deus and Jokić-Begić, 2006, Duke and Mullens, 1973, Schoretsanitis et al., 2015). Dyadic studies usually use tasks on paper or stop-distance tasks. In stop-distance tasks subjects are approached and have to indicate when they feel the approaching person gets so close that the subject starts to feel uncomfortable (Schoretsanitis et al., 2015).

In the last decade, dyadic interpersonal distance research has been extended with VR. Immersive VR experiments are more ecologically valid than pen and paper tasks but can still be controlled and replicated in a degree that is impossible in real life experiments (Blascovich et al., 2002). Healthy subjects showed a positive relation between subclinical paranoid ideation and interpersonal distance in a dyadic VR setting (Fornells-Ambrojo et al., 2016). Park and others (2009) observed a complex relation between interpersonal distance, facial affect and negative symptoms in patients with psychosis. Interpersonal distances were smaller when more negative symptoms were present, but only if avatars looked angry or neutral and not when looking happy. These findings suggest that interpersonal distance regulation may depend on multiple social and personal characteristics.

An unexplored aspect of interpersonal distance is the influence of social environments. Especially in patients with psychosis, the environment may be of importance for social functioning. Social stimuli in the surrounding which are meaningless to most people, can be threatening or over-arousing to people with psychotic disorders (Collip et al., 2011, Haralanova et al., 2012, Kapur, 2003) and may increase interpersonal distance as a form of safety behavior. Moreover, increased stress reactivity (Myin-Germeys and van Os, 2007) and cognitive biases are common in psychosis (Van der Gaag et al., 2013). Together, this could result in elevated distress levels or paranoia in response to social environments. Primary results of the current study showed that patients with psychosis and at ultrahigh risk for psychosis (UHR) were indeed more sensitive to virtual social environmental stress than controls (Veling et al., 2016). Higher levels of social environmental stressors were related to increased paranoia and psychological distress.

Abnormal interpersonal distances can cause problems in social interactions (Hall, 1966). When distances become larger it might be more difficult to see and interpret facial affect. Also, people could respond differently if someone does not follow the social norms of personal space, which can contribute to paranoia, misinterpretations and social isolation in psychosis. A safety and feasibility pilot study on social environmental VR designs by our research group unexpectedly found that, compared to controls, psychosis patients kept smaller rather than larger interpersonal distances in virtual social environments (Veling et al., 2014), but the sample was too small to draw conclusions.

In this study we investigated interpersonal distance regulation in response to social environments in people with different psychosis liability; patients with a psychotic disorder, individuals at UHR, siblings of patients and controls. Participants were exposed to virtual surroundings differing in social stress in terms of crowdedness, ethnicity and hostility. To explore mechanisms by which environmental stress might influence interpersonal distance, the relation with symptoms and mental states was examined.

We hypothesised that (a) interpersonal distance increases with the number of VR social stressors in the environment, (b) independent of psychosis liability, interpersonal distance is positively related to baseline levels of (subclinical) social anxiety and paranoia, and state paranoia and distress during VR experiments, (c) people with psychotic disorders and UHR keep larger interpersonal distances compared to healthy controls and siblings, and (d) there is an interaction between level of virtual social stressors and psychosis liability on interpersonal distance, that is, the effect of social stressors on interpersonal distance is larger in people with psychotic disorders and UHR than in siblings and controls.

Section snippets

Subjects

Four groups of participants aged 18–35 were enrolled: people with a psychotic disorder (psychosis), people with an UHR status (UHR), siblings of people with a psychotic disorder (siblings) and healthy controls (HC).

Psychosis participants were in treatment for first episode psychosis (unrelated to substance use or medical conditions), diagnosed in the preceding five years. The diagnosis was verified with a Schedules for Clinical Assessment in Neuropsychiatry (Wing et al., 1990) or Comprehensive

Participant characteristics

156 participants were included for data analyses. Inclusion criteria were met by 170 people. Two participants were excluded because of missing baseline data. Twelve were excluded because less than two experiments were completed correctly due to cybersickness (n = 10) and failures in the experimental set-up (n = 2). Baseline characteristics and exploration indices are shown in Table 2. Exploration indices did not differ between groups, indicating that people covered a similar area of the café.

Interpersonal distance

The

Main findings

Larger distances were kept to others in the café when one or more stressors (i.e. crowdedness, hostility and ethnic minority) were present compared to no stressors. Interpersonal distance was positively related to the level of reported distress, and individuals with higher pre-existent levels of social anxiety kept larger distances to others, regardless of psychosis liability. All psychosis liability groups responded similarly to different social environments; no difference in regulation of

Author's contributions

Geraets and van Beilen wrote the first draft of the manuscript. Geraets managed the literature searches and statistical analysis. Veling, and Van der Gaag supervised and designed the study. Pot-Kolder and Counotte contributed with acquisition, administrative and technical support. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare no conflicts of interest.

Funding and support

This study was supported by a Veni laureate to Veling from the Netherlands Organization for Health Research and Development (916.12.013), and by EU-GEI (HEALTH-F2-2009-241909).

Acknowledgements

None.

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