Healthy gaming

Whether it’s one or one million people, changing behaviour  - it seems - is no easy thing. And adding mental health problems into the mix presents further challenges. Barbara Sahakian is a cognitive neuroscientist at Cambridge university, who’s interested in improving cognition and motivation in people with neuropsychiatric disorders and brain injuries. Katie Haylor spoke with Barbara, asking firstly about cognition, and how this relates to behaviour...

Barbara - Cognition is really all about the way that you think, of course, and your thinking affects your behaviour because what you decide to do or not do will affect what you actually act on, and do and choose in different situations. So cognition is extremely important, and we need to keep our cognition and also our wellbeing at very high levels throughout our whole life course. So part of what I'm very interested in is how can we promote good cognition and wellbeing? So from a neuroscience perspective, behaviour change requires motivation and top down cognitive control by prefrontal cortex, which stops you engaging in maladaptive or harmful behaviours.

Katie - OK, so the prefrontal cortex is a specific, quite special part of the brain right? There's a lot that goes on there.

Barbara - And it's very well developed in humans and that helps us with our decision making. It also helps us to deal with novel situations.

Katie - And this top down processing that you mentioned, what is that?

Barbara - The motivation is kind of the reward when you want behaviour change. It's helpful to motivate people you know rewards and things like that actually get people interested in doing something. And we know that very well with children but also with adults, different rewards make you want to engage in different activities and promote good health and things like that. And that's part of what I call our hot cognition. But we also sometimes have a sort of stop. We all know that when you go out with your friends and you’re drinking if you're going to drive you decide “oh I'll have a non-alcoholic drink”. That is really your dorsal lateral prefrontal cortex and other areas of your frontal cortex helping you to make a good decision for that behaviour that “I'm not going to take that drink of alcohol because I know I'm going to drive later on”.

Katie - It's like you've got the accelerator pedal and then the brake pedal. And it's a constant kind of switching between the two. Is that an accurate analogy?

Barbara - Quite a good one actually. It's not quite so simple because there are all these individual differences that people have in terms of their genetics for instance for risky behaviour and things like that. But basically the brain often works in that way, that we have the promotion mechanisms and then we have the stopping mechanisms, and they're really to get us at the optimal level of our behaviour so that we can function as best as possible in an environment that's changing all the time.

And so that's why it's so important that we have both the motivation to pay attention to the relevant things and do the right behaviour, but also that we have stopping mechanisms that will make us reflect on “well is this really a good idea?” and “how will I feel about this tomorrow?” and that kind of thing. Looking ahead, planning and things like that, we also have to think about that when we're making decisions.

Katie - How does this relate to conditions that you study?

Barbara - Well the easiest way to explain it probably is in terms of substance abuse. So frequently people may impulsively try substances of abuse, they find it very pleasurable perhaps, and they start using them recreationally, and then eventually they start using it habitually. So they are really driven to use these substances, but the brake isn't working so well so the top down cognitive control to stop them doing this behaviour is not really as strong as it should be. That's why it's very good to intervene very early when people are able to modify their behaviour so they don't get addicted or they don't end up in a compulsive mode of trying to seek drugs of abuse.

Katie - And does this same system work for other public health challenges like obesity or smoking cessation?

Barbara - Some people actually call these behavioural addictions, a lot of these things do fall into the compulsivity range. Not all forms of obesity do, but there are some people who are more or less compulsive eaters and that would sort of fall under the behavioural addictions. It's still an area of controversy whether behavioural addictions really are addictions or not. But the same form of compulsivity may happen.

And so gambling is another one of these things where people start to do it and it might be you know harmless and they're enjoying it and so forth, but later they feel compelled to do it. And actually it's causing a lot of harm but they can't stop. So it's that type of thing you need the stopping mechanism and it's good to have a good reward system because we do need to be motivated to go do our jobs and other things like that, to do difficult things that we may need to do, we need to feel motivation, so it's good to keep our motivation up and we know that in certain patient groups, say for instance, people with schizophrenia who have problems in motivation, it's very hard for them to want to do things. So that system is very important too. But we have to keep it under control so that we're enjoying ourselves but we're not causing ourselves any harm or other people any harm and disadvantage.

Katie - So bearing in mind the motivation and control, what does your research suggest we can do to help people who might be suffering from psychiatric disorders?

Barbara - At the moment what I'm doing is a lot of work on cognitive training. Now cognitive training has been shown to improve cognition, as you train you can see that it's strengthening certain neural networks in the brain. But the problem is that at the moment usually you have to come into a hospital. So it might be expensive, you might need a specialist to help you train, and a lot of the patients who are training, say patients with schizophrenia, or patients with mild cognitive impairment (which is a very early stage of Alzheimer's disease) find it rather tedious so they don't really want to do it.

And some of the studies with cognitive training unfortunately dropout rates can be as high as 40 percent. So what I've done in my work is to think about well how can we cognitively train people and get them to do this work but really enjoy it and have it engaging? And also I want to individualize it because people have different levels of cognitive ability and we want to make sure that they're progressing in their own program, a bit like a brain gym where you have your own personal trainer.

So what I've done is to work with a games developer and my laboratory, Tom Piercy, we've developed these games which are based around neuropsychological and neuro-evidenced, and we've tested them in people with mild cognitive impairment. These are elderly people in their 70s and we've also used a different game called Wizard which is for people with schizophrenia, but also for healthy people at the more challenging levels.

And we find that these games, they really enjoy doing them and they improve their cognitive function, they improve their episodic memory which is the everyday memory that we use. So when we're, you know, trying to remember where we left our mobile phone in the house or we're trying to remember where we left our car in amulti-storey car park. That's episodic memory. It's the first memory to go in Alzheimer's disease and in both Alzheimer's disease and schizophrenia, episodic memory has been shown to link to functional outcome, you know how well can you do your job, how well can you function around your house, how well do you engage in different activities. So it's how you behave as your activities of daily living which is how you're behaving in your normal environment. So that's a really good way to get this generalized behaviour change because this kind of cognition is so closely linked to our everyday activities.

Katie - What about going beyond the groups of people who specifically suffer with psychiatric disorders? Can this gamification of brain training, can it be used for the average Jo?

Barbara - Absolutely. So we've just been working on a game called Decoder. A lot of people have come to me and they've said “I'm having trouble, I'm getting distracted all the time at work”. The way that we work these days where we're checking our texts, we're checking our emails, we've got multitasking to do. Sometimes you come home at the end of the day and people say to themselves “well I've been busy all day but I don't seem to have achieved my goals, I haven't got any one thing completely done”. So this is really to help you focus your attention, stay with a big challenging job and then you'll have your goal completed.

Katie - With these games that you've designed, is the prescription as it were for long term use or can you work really hard with your game, your cognition improves and then you're all set?

Barbara - I think it will have some carryover, that's really what you're saying, like how long does it last? And we haven't really studied that very carefully so I can't really say for sure. But it's really meant to be something that you do all the time. You wouldn't stop going to the gym and expect your physical health and all the gains that you got from working in the gym to carry on forever. It's something that you have to keep doing on a regular basis, and that's really what the games are meant for. They strengthen a neurocircuitry in the brain and it's a kind of use it or lose it. And the idea is that you should be boosting it every now and then and trying to get even better. Cognitive enhancement is something we should be trying to do, the more we can do it, the better we can boost our cognition and boost our wellbeing, the better off we'll be.