JMIR SERIOUS GAMES Mena-Moreno et al Original Paper Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report Teresa Mena-Moreno1,2,3, PhD; Lucero Munguía1,2,3, PhD; Rosario Granero2,4, PhD; Ignacio Lucas1,3, PhD; Almudena Sánchez-Gómez5,6, MD, PhD; Ana Cámara5,6, BSN, MSN; Yaroslau Compta5,6, MD, PhD; Francesc Valldeoriola5,6, MD, PhD; Fernando Fernandez-Aranda1,2,3,7, PhD, FAED; Anne Sauvaget8, MD, PhD; José M Menchón1,3,7,9, MD, PhD; Susana Jiménez-Murcia1,2,3,7, PhD 1 Department of Psychiatry, Bellvitge University Hospital, Hospitalet de Llobregat, Spain 2 Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y la Nutrición, Instituto de Salud Carlos III, Madrid, Spain 3 Instituto de Investigación Biomédica de Bellvitge, Hospitalet de Llobregat, Spain 4 Department of Psychobiology and Methodology, Autonomous University of Barcelona, Barcelona, Spain 5 Parkinson's Disease and Movement Disorders Unit, Neurology Service, Hospital Clínic, Institut D'Investigacions Biomediques August Pi i Sunyer, Institut de Neurociències Universitat de Barcelona (Maria de Maeztu Excellence Center), Barcelona, Spain 6 Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Instituto de Salud Carlos III, Madrid, Spain 7 Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain 8 Movement, Interactions, Performance, University of Nantes, Nantes, France 9 Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain Corresponding Author: Susana Jiménez-Murcia, PhD Department of Psychiatry Bellvitge University Hospital c/ Feixa Llarga, s/n Hospitalet de Llobregat, 08907 Spain Phone: 34 93 2607988 Fax: 34 93 2607658 Email: sjimenez@bellvitgehospital.cat Abstract Background: Impulse control disorders (ICDs) are commonly developed among patients who take dopamine agonist drugs as a treatment for Parkinson disease (PD). Gambling disorder and hypersexuality are more frequent in male patients with PD, with a prevalence over 4% in dopamine agonists users. Although impulsive-compulsive behaviors are related to antiparkinsonian medication, and even though ICD symptomatology, such as hypersexuality, often subsides when the dopaminergic dose is reduced, sometimes ICD persists in spite of drug adjustment. Consequently, a multidisciplinary approach should be considered to address these comorbidities and to explore new forms of complementary interventions, such as serious games or therapies adapted to PD. Objective: The aim of this study is to present the case of a patient with ICD (ie, hypersexuality) triggered by dopaminergic medication for PD. A combined intervention was carried out using cognitive behavioral therapy (CBT) for ICD adapted to PD, plus an intervention using a serious game—e-Estesia—whose objective is to improve emotion regulation and impulsivity. The aim of the combination of these interventions was to reduce the harm of the disease. Methods: After 20 CBT sessions, the patient received the e-Estesia intervention over 15 sessions. Repeated measures, before and after the combined intervention, were administered to assess emotion regulation, general psychopathology, and emotional distress and impulsivity. Results: After the intervention with CBT techniques and e-Estesia, the patient presented fewer difficulties to regulate emotion, less emotional distress, and lower levels of impulsivity in comparison to before the treatment. Moreover, the frequency and severity of the relapses also decreased. https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 1 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al Conclusions: The combined intervention—CBT and a serious game—showed positive results in terms of treatment outcomes. (JMIR Serious Games 2022;10(3):e33858) doi: 10.2196/33858 KEYWORDS Parkinson disease; impulse control disorder; hypersexuality; multidisciplinary approach; serious game dopamine agonists and almost 2% in patients with PD who do Introduction not take dopamine agonists [22]. Background ICDs are characterized by a failure to resist a temptation, urge, Parkinson disease (PD) is a neurodegenerative disorder or impulse that may harm oneself or others. Patients characterized by a set of motor disturbances, such as rigidity, compulsively pursue certain reward-based activities and make slowness, and tremor [1], mainly caused by the loss of over poorly informed decisions without foreseeing the potential 70% of the dopaminergic neurons in the substantia nigra. PD personal and interpersonal consequences that arise from also leads to nonmotor symptoms, such as hyposmia, sleep repetitive participation in these activities. Impulsivity is a disorders, and constipation; cognitive impairment disorders (eg, fundamental factor in ICD [24,25]. It can be understood as a mild cognitive impairment and dementia) [2]; emotional trait consisting of a stable personality characteristic, which is disorders (eg, anxiety, 60%; apathy, 60%; and depression, 35%) defined as the tendency to perform behaviors without [3-5]; and behavioral symptoms. In this latter regard, there is premeditation and having premature responses to stimuli that growing evidence that patients with PD are at risk of developing often produce adverse consequences. The model by Whiteside one or more of the four major impulse control disorders (ICDs) and Lynam [26] is one of the most accepted theoretical [6]. The Diagnostic and Statistical Manual of Mental Disorders, approaches for defining impulsivity as a multifactorial construct. Fifth Edition, by the American Psychiatric Association [7] It was originally formed by the following four dimensions, after defines ICDs as a category of behavioral disorders characterized which a fifth was added [27]: (1) lack of premeditation, by recurrent maladaptive disinhibited behavior despite adverse involving acting without thinking; (2) lack of perseverance, personal and relationship consequences. representing the tendency to not finish tasks; (3) sensation seeking, encompassing behavior tendencies of trying new and Dopaminergic medications, particularly dopamine agonists, are exciting activities or sensations; and (4) positive and negative associated with the development of ICDs and are related to urgency, including the tendency to act rashly in response to impulsive-compulsive behaviors in patients with PD [6,8]. The extreme negative or positive emotions. This model has been reported prevalence is 14%, but the estimated prevalence of validated across several age samples, such as children, each subtype of ICD is quite variable, often as a consequence adolescents, and young adults [28], and was the basis for of the variability in diagnostic criteria and assessment [9]. Other development of the UPPS-P (Urgency, Premeditation, types of impulsive-compulsive behaviors include punding and Perseverance, Sensation Seeking, and Positive Urgency) scale compulsive use of dopamine replacement therapy, also known [27,29]. as dopamine dysregulation syndrome, whose prevalence might be over 25% among the idiopathic PD population [10]. On the other hand, the concept of emotion regulation (ER) is closely related to impulsive behaviors and addictive disorders The main risk factors for impulse control behavior in patients [30-33]. Different studies have found that many addictive with PD are young age, the use of dopamine agonists, male behaviors increased during stressful times, such as smoking and gender, drug abuse, depression, smoking, genetic factors, unhealthy eating [34-37] or the use and abuse of alcohol to impulsive personality, and family history of ICDs [9,11-20]. In regulate positive and negative moods [38]. Other research has patients with PD, the most frequent forms of ICD include found that impulsive decision-making may be an attempt to gambling disorder (GD), which is also considered a behavioral change a negative emotional state [39]. This relationship addiction, but in any case a disorder related to impulsivity; between impulsive behaviors and emotional state has been compulsive shopping; hypersexuality; binge eating disorder, studied in previous neuroscience research, indicating that both considered as an eating disorder in terms of diagnostics, but the prefrontal cortex and the amygdala play key roles in ER highly related to impulsivity as well; and other psychiatric [40,41], as well as in impulsive behaviors, reasoning, risk-taking, complications (eg, depressive symptoms or sleep disorders) and decision-making [42-46]. [9,21]. Regarding ICD subtypes, female patients tend to suffer more from compulsive shopping, while hypersexuality is more Beyond its relationship with impulsivity, ER is the ability to frequent among male patients [16,22], especially in those with experience and modulate emotions [47]. ER allows people to an early onset of PD [16]. Hypersexuality is defined as access functional resources in stressful situations and allows compulsive sexual behavior, consisting of excessive and for the use of appropriate coping strategies [48]. Some of the distressing sexual thoughts that persist for more than 1 month strategies used to regulate emotions are adaptive (eg, and interfere with social activity and daily routine [15,16]. It reappraisal), whereas others are maladaptive (eg, suppression) includes excessive preoccupation with sexual thoughts, desire [47,49]. Gratz and Roemer [50] developed the Difficulties in for frequent genital stimulation, internet pornography, Emotion Regulation Scale (DERS), based on their own promiscuity, and telephone sex, among other behaviors [15,23]. theoretical framework that was divided into six dimensions: It has been stated that its prevalence is over 4% in users of nonacceptance, goals or directed behaviors, impulse control, https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 2 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al emotional awareness, regulation strategies, and emotional literature is inconclusive and provides contradictory findings clarity. This scale has been amply validated in different age about the efficacy of game-based rehabilitation programs for groups [51-54] and different ethnic populations [51,52,55]. PD [70]. Some studies indicate that patients with PD can benefit from serious games, as they aim at improving their physical Treatment Approaches health condition, such as their motor skills, via motion-based The treatment of any of the aforementioned ICDs in PD video games [60,71] or as they aim at helping in their represents a challenge, due to the fact that not only is the quality rehabilitation [72]. Serious games are known to increase the of life of patients decreased, but also that of their families or rehabilitation dose by augmenting the intensity and repetition caregivers [56]. of exercises because of their motivational properties and to Even though impulsive-compulsive behaviors are related to improve the follow-up of rehabilitation by the patient [73]. antiparkinsonian medication and ICD symptomatology often However, games conceived to tackle patients’ mental health, subsides when the dopaminergic dose is reduced [57], not all in particular their PD-related ICDs, are also essential. Some patients will decrease their dosage. Consequently, a authors emphasize the importance of the game design and multidisciplinary approach should be considered to address personalization in order to secure better adherence and a more these comorbidities [58]. positive treatment outcome [74]. Jiménez-Murcia et al [59] published a protocol for the adaptation In addition, new therapy using computer-based ER training or of cognitive behavioral therapy (CBT) to treat GD in patients serious video games has emerged [75-81].Tailor-made games suffering from PD. This therapy consists of 16 sessions and that use biosignals to enhance ER have been tested under includes specific interventions in PD, such as psychoeducation laboratory conditions. One study reported that individuals about specific PD conditions (eg, medication checks and increased their emotional awareness and improved their possible side effects) and PD’s relationship with GD, as well decision-making by refining reward processing through the as strategies to cope and accept a chronic illness. game’s biofeedback mechanism [82]. Biofeedback can be defined as a technique in which individuals learn to adapt their Another approach that might be explored is the use of new behaviors based on physiological signals (eg, heart rate technologies, considering that they have been shown to be a variability [HRV]). Thanks to the use of biofeedback, it is coadjuvant tool in the rehabilitation of patients with PD [60] possible to connect the emotional reaction to the media display, and to help in the treatment of ICDs [61,62]. Therefore, the use which helps individuals learn how to regulate their emotions of new technologies to tackle impulsive-compulsive behaviors and visually rewards them when doing so appropriately [83]. in PD is likely to have positive responses. Finally, there are A great advantage of serious games is that they allow real several surgical techniques indicated to reduce the side effects situations to be recreated in virtual scenarios, while generating of antiparkinsonian medication [63]. However, the selection of a series of cognitive, emotional, and behavioral responses in the candidates must be done carefully. Neuropsychological and individuals. This allows for the training of specific skills in a neuropsychiatric factors also constitute important considerations motivating and entertaining way that can be more difficult to in predicting the operative outcomes [64], but the risks and achieve with traditional therapies. Self-training via serious benefits of the intervention must be taken into account. games with biofeedback sensors has been shown to reduce A serious game is understood as “a mental contest, played with general impulsive behaviors and arousal as well as to enhance a computer [and today, with other electronic devices] in self-control [61,76]. A serious game called PlayMancer presents accordance with specific rules, that uses entertainment to further these advantages and has shown positive results from training government or corporate training, education, health, public users in relaxation, self-awareness, and self-regulation policy, and strategic communication objectives” [65]. In the techniques [79]. Regarding biosignals, HRV responds to context of mental health, serious games can be used to autonomic flexibility; therefore, an increased HRV correlates complement traditional psychotherapy, providing additional with greater emotional control [84]. Different studies have tools for therapists, especially in those patients that exhibit shown the results of the use of breathing management and resistance to treatment and might be receptive to new biofeedback with measures of HRV to reduce anxiety; reduce technologies [66,67]. Serious games are becoming widespread psychological stress, as fear of losing control; and make the use resources in personalized medicine approaches, which require of coping strategies more habitual as a form of adaptive ER that treatment be tailored to the specific needs of patients [68]. [85-87]. A number of studies have reported promising results regarding The aim of this study is to present the case of a patient that the efficacy of serious games in treating mental health issues suffers from an ICD—hypersexuality—that is triggered by [69]. In particular, individuals experiencing ICDs seem to dopaminergic medication for PD. As far as we know, this is the respond well to interventions aided by serious games [61,62]. first case study of a patient with PD with a comorbid ICD who In these cases, the gameplay and narrative structure are designed was treated with a serious game as a complementary tool of to favor the ER of participants, training them to delay their CBT. reactions to external and internal stimuli that usually trigger responses in them. There is growing interest in using serious games in rehabilitation programs for neurological diseases, although to date, the https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 3 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al Description of the Intervention Methods After the assessment, the patient started to receive psychological Case Description attention. To date, he has received 20 individual sessions of The patient is a man in his early 30s who was treated at the CBT adapted for cases of PD [59]. Different aspects were Gambling Disorder Unit of the Department of Psychiatry at incorporated into the patient’s treatment in order to treat his Bellvitge University Hospital, Barcelona, Spain. This is a hypersexuality problem, taking into consideration his PD. A university hospital belonging to the public health care system mood and mental state scan was carried out during the first and and is certified as a highly specialized care center for the second treatment sessions. In these sessions, the patient received treatment of GD and other behavioral addictions. The patient psychoeducation about hypersexuality and the therapeutic was referred from the Department of Neurology at the Hospital process and regarding specific PD conditions (eg, medication Clinic of Barcelona, Spain. checks and possible side effects). In sessions 3 and 4, the objectives were to promote gradual abstinence (ie, stimulus The patient lives with his parents, both early retirees: the father control) and explain the importance of the role of cotherapists worked in the audiovisual sector, and the mother worked in a (ie, his parents). In sessions 5 and 6, difficulties and obstacles banking institution. The patient has no siblings. He studied related to the treatment were explored. In addition, social skills vocational training for the position of Higher Technician in training and productive time management (ie, planning of Audiovisuals and Shows. He is in a heterosexual relationship hobbies, role playing, and behavioral experiments) were of 5 years in length. Regarding recreational activities, he used accomplished. In sessions 7 and 8, alternative behaviors to to go to the cinema and participate in sports (eg, running, prevent relapse were generated, and the clinical psychologist football, and the gym) before the PD diagnosis. In general terms, explained the relationship between cognitions, emotions, and the patient had healthy habits and did not engage in tobacco or behaviors to the patient. Moreover, specific risk situations and alcohol consumption. the development of other impulse control behaviors were Clinical History analyzed, and a medical evaluation was performed in collaboration with a neurologist. From session 9 to 16, the At the age of 30 years, the patient went to the outpatient clinic patient performed cognitive restructuring using daily cognitive of the Movement Disorders Unit of the Hospital Clinic of self-monitoring. Moreover, stimulus control was minimally Barcelona, having experienced a few months of predominant reduced throughout these sessions, due to the enormous bradykinesia and rigidity with a mild rest tremor in his left self-control difficulties presented by the patient. Vulnerability limbs. After clinical assessment, he was diagnosed with factors and similar aspects of thinking were discussed as well. early-onset Parkinson disease in October 2016. He started In these sessions, the patient was trained in positive medical treatment, specifically pramipexol, with good response communication styles and new risk behaviors were explored. but with rapid tolerance, leading to a dose increase of up to 3.15 In the final therapy sessions, several objectives were established: mg per day. Due to high functional requirements, to prevent relapse and conduct future risk factor analysis, to levodopa/carbidopa (Sinemet Plus) was added soon after, discuss future difficulties and the relevance of maintaining full reaching doses of 100 mg/25 mg of levodopa/carbidopa four abstinence, and to analyze the presence of other impulse control times per day. In December 2017, after 1 year of PD evolution, behaviors and learn how to cope with somatic chronic disease. the patient already presented motor fluctuations and dyskinesias Medical evaluation was carried out in collaboration with a as well as hypersexuality, which led to the withdrawal of the neurologist. dopamine agonist and the introduction of quetiapine. Intestinal infusion of levodopa gel was eventually administered to try and The patient attended all the treatment sessions. He was deliver continuous stimulation as a means of reducing collaborative and fully participated in the sessions. His parents dopaminergic stimulation. Due to the lack of control of his ICD, acted as cotherapists throughout the treatment process. he was referred to our unit. The patient was evaluated by a Cotherapist duties included learning about hypersexuality and clinical psychologist using a clinical interview and the PD, handling risk situations, and helping the patient with his Questionnaire for Impulsive-Compulsive Disorders in compliance with the treatment guidelines. Furthermore, his Parkinson’s Disease; he was then diagnosed with a nonspecified parents directly collaborated in some aspects of the treatment, ICD (ie, hypersexuality) in the context of PD. such as stimulus control, and in supporting the patient to find alternative healthy behaviors, such as new distractions and The patient also reported visiting websites with pornographic hobbies. content with the purpose of having telephone sex, as well as frequent visits to prostitutes. The frequency of the dysfunctional Although a significant improvement was observed in terms of behavior was daily during the periods of disease activity and harm reduction with CBT (ie, fewer behaviors related to seeking only decreased when the parents exercised strict external control. sexual stimulation and fewer intense and risky consequences), The patient used to run away from home, if the door was left the relapses were still frequent: the maximum time of abstinence unlocked, and disappear from his parents’ sight when they went from the behavior was 2 weeks. He also showed high levels of for a walk. He even used to jump out of the window of his impulsivity and deficits of ER, so a complementary treatment home—it was a mezzanine—if his parents were not careful was implemented: intervention with a serious game. Thus, the enough. In other words, the impact and interference of this patient received adjunctive treatment with a serious game called behavior on his life and his family members’ lives were severe. e-Estesia. This treatment aimed at improving ER and reducing impulsivity levels through the training of diaphragmatic https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 4 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al respiration, which might help reduce physiological activation The Serious Game e-Estesia in stressful situations. e-Estesia is a serious game that integrates e-Estesia is a serious game that was developed by our research the biofeedback mechanism, through heart rate and HRV team at Bellvitge University Hospital. It was inspired by biosignals, and the diaphragmatic breathing technique to induce PlayMancer, a previous serious game that emerged during a a state of well-being in the patient. This combination is possible European project at the same hospital, whose application was because cardiac fluctuations are conditioned by the respiratory very successful [61,76,79,90-92]. The PlayMancer app was processes of inspiration and expiration. Heart rate increases tested in a significant sample of patients with diagnoses of GD during inhalation of air and decreases with exhalation, which and eating disorders. This evaluation led to the conclusion that is known as respiratory sinus arrhythmia [88,89]. a future serious game should be developed using a similar The e-Estesia intervention consisted of 15 sessions, each 10 strategy, but with a simpler configuration. It was also apparent minutes in length. Some questionnaires were administered on to the research team that the app had to be usable at any time the day of the first session: the DERS; the Emotion Regulation and in any situation, allowing the patients to bring the tablet Questionnaire (ERQ); the Symptom Checklist-90-Revised home to self-administer the intervention as they wish. More (SCL-90-R), which measures general psychopathology; and the information about the description of e-Estesia and the usability UPPS-P scale, which measures impulsivity. These results can be found in the paper by Mena-Moreno et al [93]. questionnaires were administered at the end of the 15 sessions. The serious game e-Estesia is an app that can be used on mobile The first session lasted 30 minutes. The patient was taught how devices. It consists of a virtual marine landscape that contains to use the device (ie, an Android tablet), how to place the chest a series of animations, from a radiant sun to a tropical storm. band with the biosensor, and how to use the serious game. He The patient must visualize the images while breathing deeply was also taught how to breathe (ie, deeply and slowly) in order and slowly; the diaphragmatic breathing technique would have to interact with the app. The benefits of this relaxation technique been previously taught. A physiological signal that is registered were also explained. The following 14 sessions with e-Estesia by the app is HRV, which is detected by a biosensor placed at took place at the patient’s home, without the supervision of any the thoracic level (Figure 1) and is connected through Bluetooth. professional. The patient used the device at home once a day, It allows the patient to interact with the app through the following the instructions given in the first session. He usually biofeedback technique while he is using the serious game played the serious game around noon, a time that coincided (Figure 2). with the on-period of the pharmacological medication. Figure 1. Biosensor placed at the thoracic level to record heart rate variability. Figure 2. Use of the serious game app e-Estesia. https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 5 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al Each session with e-Estesia lasts 10 minutes and is divided into deeply and the situation agitates him or her, the storm will three periods of time. During the first and last 3 minutes, the increase in intensity (ie, a signal that the behavior is not patient should try to relax while visualizing the landscape and appropriate), the rain will be heavier, and the sound of falling breathe deeply. During the middle 4 minutes, gray clouds and water will increase. These 4 minutes allow patients to be trained rain appear on the screen, simulating an intense storm; if the to face stressful or emotionally negative situations using patient remains relaxed (ie, low activation level) and breathes breathing as a complementary therapeutic strategy. These deeply (ie, diaphragmatic breathing), these clouds will dissipate, techniques are the ones learned during their standard treatment which is the reward element (ie, reinforcement of the behavior (Figure 3). to be implemented). However, if the patient stops breathing Figure 3. Animation sequence of the serous game app e-Estesia. The patient plays an active role throughout the session with investigator. Both the patient and his parents accepted, and the e-Estesia. He or she must manage their breathing (ie, breathing patient himself signed the informed consent document. deeply and slowly), and the app reports feedback through the animations that appear on the tablet screen. The patient is in Results continuous interaction with the serious game, receiving information about whether or not he or she is performing the Physiological Activity Registered in e-Estesia task adequately, reinforcing learning, while at the same time Figure 4 shows the results of the heart rate and HRV modifying his or her behavior and physiological responses to measurements during 15 days of using e-Estesia. These achieve the marked objective. physiological measures show two clearly different periods Ethics Approval throughout the treatment with this system: the first half versus the second half of the treatment period. The first period included This study was conducted according to the guidelines of the the first 7 days of practice, while the second period comprised Declaration of Helsinki of 1975 (revised in 2013) and was the last 8 days. When comparing the two periods, we found that approved by the Research Ethics Committee of the Bellvitge the mean heart rate decreased from the first period (92 bpm) to University Hospital (reference No. PR208/22). Signed informed the second period (86.38 bpm). Regarding HRV, we also found consent was obtained from the patient involved in the study. changes between these two periods. During the first half of the Since the patient was of legal age, it was not necessary for his treatment period (mean HRV 38.86 ms), the patient displayed parents to sign the consent form, although they were also lower HRV than in the second period (mean HRV 41.38 ms). informed verbally about the study by the group’s principal Figure 4. Mean heart rate and heart rate variability over 15 days of using the serious game app e-Estesia. https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 6 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al Psychopathological and Clinical Indices For the SCL-90-R scales, decreasing standardized t scores from Figure 5 shows the pre- to posttreatment changes in the pre- to posttreatment were also observed: the highest change psychometric scales of the study measuring the dysregulation was for global severity index (22 points, from t=75 to t=53) and of emotional state, psychopathology, and impulsivity levels. the lowest change was for paranoia (19 points, from t=60 to Decreasing standardized t scores from pre- to posttreatment t=41). All the standardized t scores for the SCL-90-R scales at were observed for the DERS: the highest change was observed posttreatment were in the normal range (t<63) [95]. for impulse control (17 points, from t=73 to t=56) and the lowest Regarding the UPPS-P scales, decreasing standardized t scores change was observed for emotional awareness (2 points, from from pre- to posttreatment were also observed for lack of t=59 to t=57). All the standardized t scores for the DERS at perseverance (5 points, from t=50 to t=45), positive urgency (2 posttreatment were in the normal range (t<60) [94]. Increasing points, from t=59 to t=57), and negative urgency (2 points, from standardized t scores were observed from pre- to posttreatment t=50 to t=48). No pre- to posttreatment change was observed for both strategies measured using the ERQ: reappraisal (20 for the total score, while lack of premeditation minimally points, from t=41 to t=61) and suppression (3 points, from t=64 increased (2 points, from t=35 to t=37) and sensation seeking to t=67). increased (9 points, from t=39 to t=48). Figure 5. Pre- and posttest changes in the psychometric measures. DERS: Difficulties in Emotion Regulation Scale; ERQ: Emotion Regulation Questionnaire; GSI: gait symmetry index; Obs. compuls.: obsessive compulsion; premeditat.: premeditation; SCL-90-R: Symptom Checklist-90-Revised; UPPS-P: Urgency, Premeditation, Perseverance, Sensation Seeking, and Positive Urgency. CBT (ie, fewer behaviors related to seeking sexual stimulation, Discussion with less intensity and fewer risky consequences). Principal Findings After the intervention with e-Estesia, as expected, the patient As far as we know, this is the first case study of a patient with presented a change in the collected psychophysiological PD with a comorbid ICD treated with a serious game as a measures (ie, heart rate and HRV). Regarding complementary tool to CBT. e-Estesia was employed with psychophysiological variables, a decrease in heart rate response partial but clinically significant success, with amelioration of was seen during the last sessions in comparison with the first the symptoms related to ER and impulsivity. A significant ones. Regarding cardiac activity, HRV was found to be higher improvement in harm reduction had already been observed with at the end of the e-Estesia treatment in comparison with the first https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 7 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al part of treatment. HRV is a measure that responds to autonomic result is in concordance with the literature, indicating that the flexibility and, therefore, an increased HRV correlates with use of serious games could be of benefit to increase attention greater emotional control [84]. Previous studies have shown in order to develop abilities and competencies [104,105]. that cardiac activity can be modulated by respiratory training Therefore, the use of e-Estesia could not only improve ER or using biofeedback applications [96-98]. Diaphragmatic breathing impulsivity but other neurocognitive processes as well, such as increases the vagal tone, activating the relaxation response of attention and learning, which seem to be disturbed in PD. the parasympathetic nervous system [99]. Hence, the diminished However, the level of sensation seeking continues increasing heart rate response after the intervention could point toward an despite the treatment. This result could be related to the typical attenuated emotional response due to the treatment with course of the disease. Higher levels of this impulsivity e-Estesia. Similarly, the increase in HRV could be related to dimension have been found in patients with PD who have ICD the skills learned by the patient when using e-Estesia, which [103,106,107]. probably improved ER processes. Both variables support the Clinical symptoms measured with the SCL-90-R also showed idea of a more adaptive affective response, probably related to a significant overall reduction, indicating a better better ER processes. Therefore, the treatment with e-Estesia psychopathological state and lower distress level at the end of may have produced a diminished emotional response to negative the treatment [108]. events as well as better affect regulation skills. Due to the severity and complexity of the case, absolute The results from the psychophysiological measures correspond abstinence was not achieved—although, it was not the goal of to the changes at the clinical level collected by the psychometric the therapy—but the combined intervention (ie, CBT plus the measures. After the intervention with e-Estesia, an improvement serious game) resulted in a significant improvement in harm was observed in general psychopathology, such as better ER reduction, impulsivity, ER, and mood. It also increased the and lower scores in some of the impulsivity scales. awareness and self-control of the problem behavior. In addition, Decreased standardized t scores for the DERS and the higher the impact of this behavior on the patient’s life and environment use of reappraisal strategies as observed by the ERQ indicated was reduced. a better ER after the intervention with e-Estesia [49,50]. Reappraisal is a strategy that results in positive emotional and Limitations physical responses to emotion-eliciting stimuli, whereas various Although the use of e-Estesia has been effective, due to the forms of suppression and avoidance have been implicated in complexity involved in dealing with this type of comorbid psychopathology [47,49]. problem, it is difficult to attribute the success of the intervention to the serious game only, since other factors, such as the effect After the intervention with the serious game, the patient showed of the medication, may have come into play regarding the fewer difficulties in ER [50,94]. The impulse control subscale therapeutic outcome. showed the greatest change, reflecting fewer difficulties in controlling impulses and behaviors in the presence of negative Conclusions emotions. Also, a notable difference in the directed behaviors In the clinical case presented, different interventions from a scale was also observed after the intervention with e-Estesia, multidisciplinary perspective were carried out in order to treat indicating fewer difficulties in adopting goal-oriented behaviors ICD (ie, hypersexuality) triggered by dopaminergic medication and performing a task in the presence of negative emotions [50]. for PD. The result of the different interventions has been According to the impulsivity measures, there was a decrease in positive: a combination of a manualized CBT approach plus an the scores for the positive and negative urgency UPPS-P intervention with a serious game (e-Estesia). subscales, which represent emotion-related aspects of Due to the different symptoms developed in this type of patient, impulsivity, with the negative urgency subscale score being in which the lack of impulse control itself is encouraged by the even higher. These personality traits are defined as the tendency treatment (ie, usually dopaminergic medications) [6,8,9,109] to act rashly when experiencing extreme emotional states for the first medical condition (ie, PD), the need arises to apply [26,27,100], for which it is possible to hypothesize that this a multidisciplinary perspective. Although impulsive-compulsive result might be associated with the improvements in ER behaviors are related to antiparkinsonian medication, and even observed after the intervention; as it has been mentioned in the though ICD symptomatology often subsides when the literature, important associations between impulsivity and ER dopaminergic dose is reduced [57], not all patients could have been found in addictive disorders [30-33]. Therefore, the decrease the dosage. Hence, there is a need to apply a use of e-Estesia could be of benefit in the reduction of multidisciplinary approach to address these comorbidities [58]. impulsivity reactions through the training of self-ER. As previous studies have shown, improvements in ER have a In this regard, the implications of this first approximation of positive impact on the reduction of the performance of the use of a serious game as a coadjuvant tool in the treatment characteristic impulsive behaviors in other ICDs [101,102]. of patients with PD who have ICD are important, since positive results were found regarding the reduction of impulsivity and Another important improvement was found in the lack of improvements in ER. This first approximation highlights the perseverance UPPS-P subscale. Lack of perseverance is related importance of developing multidisciplinary interventions for to poor concentration on boring or difficult tasks [26,27], and the treatment of complex conditions, such as comorbid PD and it has been found in patients with PD who have ICD [103]. This ICD. https://games.jmir.org/2022/3/e33858 JMIR Serious Games 2022 | vol. 10 | iss. 3 | e33858 | p. 8 (page number not for citation purposes) XSL• FO RenderX JMIR SERIOUS GAMES Mena-Moreno et al Acknowledgments This research was supported by grants from the CERCA (Centres de Recerca de Catalunya) Programme/Generalitat de Catalunya for institutional support. It was additionally supported by grants from the Ministerio de Economía y Competitividad (grant PSI2015-68701-R) and from the Ministerio de Ciencia, Innovación y Universidades (grant RTI2018-101837-B-100). The research was funded by the Delegación del Gobierno para el Plan Nacional sobre Drogas (grants 2019I47 and 2021I031), Instituto de Salud Carlos III (ISCIII; grant PI17/01167), and cofunded by the FEDER (Federacion Espanola de Enfermedades Raras) funds/European Regional Development Fund, a way to build Europe. CIBERObn (Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y la Nutrición) and CIBERSAM (Centro de Investigación Biomédica en Red de Salud Mental) are both initiatives of ISCIII. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. TMM is supported by a predoctoral grant from the Ministerio de Educación, Cultura y Deporte (grant FPU16/02087). LM is supported by a postdoctoral grant from the Mexican institution Consejo Nacional de Ciencia y Tecnología. RG is supported by the Catalan Institution for Research and Advanced Studies (ICREA-2021 Academia Program). Authors' Contributions SJM, FFA, and TMM contributed to the development of the study concept and design. SJM, FFA, RG, and JMM had previous experience in the design and use of serious games for the treatment of impulsive spectrum disorders, and their experience and advice were decisive in the design of the device in this study. RG performed the statistical analysis, wrote the results, and created the figures. SJM, TMM, LM, IL, and YC aided with interpretation of the data and writing of the manuscript. TMM and LM collected the data. JMM, ASG, AC, FV, and AS revised the manuscript and provided substantive comments. SJM, FFA, and JMM obtained funding. Conflicts of Interest FFA received consultancy honoraria from Novo Nordisk and editorial honoraria as editor-in-chief from Wiley. The rest of the authors declare no conflict of interest. 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[doi: 10.1136/jnnp-2013-306787] [Medline: 24434037] Abbreviations CBT: cognitive behavioral therapy CERCA: Centres de Recerca de Catalunya CIBERObn: Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y la Nutrición CIBERSAM: Centro de Investigación Biomédica en Red de Salud Mental DERS: Difficulties in Emotion Regulation Scale ER: emotion regulation ERQ: Emotion Regulation Questionnaire FEDER: Federacion Espanola de Enfermedades Raras GD: gambling disorder HRV: heart rate variability ICD: impulse control disorder ISCIII: Instituto de Salud Carlos III PD: Parkinson disease SCL-90-R: Symptom Checklist-90-Revised UPPS-P: Urgency, Premeditation, Perseverance, Sensation Seeking, and Positive Urgency Edited by N Zary; submitted 28.09.21; peer-reviewed by E Rahmani, Z Aghaei, N Chalghaf, V Verma; comments to author 25.03.22; revised version received 03.04.22; accepted 22.04.22; published 09.09.22 Please cite as: Mena-Moreno T, Munguía L, Granero R, Lucas I, Sánchez-Gómez A, Cámara A, Compta Y, Valldeoriola F, Fernandez-Aranda F, Sauvaget A, Menchón JM, Jiménez-Murcia S Cognitive Behavioral Therapy Plus a Serious Game as a Complementary Tool for a Patient With Parkinson Disease and Impulse Control Disorder: Case Report JMIR Serious Games 2022;10(3):e33858 URL: https://games.jmir.org/2022/3/e33858 doi: 10.2196/33858 PMID: ©Teresa Mena-Moreno, Lucero Munguía, Rosario Granero, Ignacio Lucas, Almudena Sánchez-Gómez, Ana Cámara, Yaroslau Compta, Francesc Valldeoriola, Fernando Fernandez-Aranda, Anne Sauvaget, José M Menchón, Susana Jiménez-Murcia. 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