2.1 Introduction

Obsessive compulsive disorder (OCD) is a neuropsychiatric disorder that affects 2–3% of people globally, and one which can have serious and deleterious effects on the wellbeing of those living with it. Research reflects that a substantial number of people living with OCD experience suicidal ideation (Chaudhary et al. 2016), and that those living with OCD have a higher risk of attempting or dying by suicide (Fernández de la Cruz et al. 2016). It is crucial that those living with OCD therefore receive the best possible treatment. To provide this, medical practitioners require a full understanding of the underlying pathophysiology of OCD. However, OCD is an extremely complex disorder.

The cortico-striato-thalamo-cortical (CSTC) circuit, a circuit in the brain, has been implicated in OCD. This circuit is involved in regulating complex behaviours such as decision making (Robertson et al. 2017), and so disorder in this circuit can result in such functions becoming impaired. As Fig. 2.1 suggests, the CSTC circuit is not easily understood. It involves a variety of different areas of the brain, as well as different connections and neurotransmitters. There are two pathways through the CSTC circuit, direct and indirect. Certain behaviours are encouraged by direct pathway activation, while activation of the indirect pathway discourages them. It has been suggested that OCD is related to excessive activation of the former, and insufficient activation of the latter (Richter et al. 2012; Parmar and Sarkar 2016; Zhang et al. 2016). Communication from brain area to brain area in both these pathways occurs via neurotransmitters. Glutamate, gamma aminobutyric acid (GABA), serotonin, and dopamine are the four neurotransmitters principally associated with OCD.

The complexity of OCD means that it is both challenging to teach and difficult to learn. In addition to this, many medical students report experiencing “neurophobia” (Jozefowicz 1994), meaning they struggle to learn topics connected with neuroscience, neurology, or the nervous system (McCarron et al. 2014; Santos-Lobato et al. 2018). These are obstacles to achieving the best possible treatment for individuals living with OCD. The pathophysiology of OCD must therefore be taught to medical students in the most effective way possible.

There is an abundance of evidence indicating that interactive 3D visualisations can improve education. Anatomy education has benefited from the use of such visualisations, as summarised in reviews of the literature (Yammine and Violato 2015; Hackett and Proctor 2016). These reviews have found that using 3D models in anatomy education improves student performance and reduces the cognitive load on students. 3D visualisations also expedite the acquisition of improved knowledge and understanding of spatial relationships between anatomical structures (Azer and Azer 2016). Students receiving both conventional and interactive 3D methods of anatomy education have been shown to have improved results in examinations than students who only had conventional methods of teaching (Allen et al. 2016). Neurology education has also been shown to benefit from using such methods, with students using virtual reality applications to train in neurosurgery benefiting from the experience (Henn et al. 2002). As of yet however, there is scant research into the use of interactive 3D visualisations to educate on neuropsychiatric disorders, and no research into using such visualisations to educate on the topic of the pathophysiology of OCD.

This paper presents a study which aimed to design an application for Android tablets, which combined referenced information from the scientific literature with interactive 3D visualisations illustrating the pathophysiology of OCD in order to improve medical students’ education on this topic. Additionally, this study aimed to assess the user experience and the educational effect of the application by carrying out an evaluation with a cohort of students that resembled the target group as closely as possible.

2.2 “The Pathophysiology of OCD”

A pre-production phase was the first stage of development. The functional design of the application, which describes what the system must do and how it should do it, was performed using standardised software engineering methodologies. Then, storyboards were drawn out to determine how the final application ought to look (Fig. 2.2).

Fig. 2.2
figure 2

Storyboards for the application drawn up during the conceptual development stage

Full size image

The 3D models in the application were constructed using both 3DSMax and Mudbox. Once these were made, they were imported into the Unity game engine, which was used to build the final application.

The final application, “The Pathophysiology of OCD”, is launched by clicking the thumbnail icon. On launch, a splash screen loads (Fig. 2.3), discouraging users from basing medical treatments on the contents of this application.

Fig. 2.3
figure 3

The splash screen, which loads when the application is first launched

Full size image

The next scene to open is the main menu scene (Fig. 2.4a). Through the main menu, users can choose to navigate to any of the other scenes contained within the application. They may also choose to view the references consulted during the making of the application (Fig. 2.4b), or they can view an informative “help” page (Fig. 2.4c). Lastly, they can quit the application.

Fig. 2.4
figure 4

The main menu screen (a), through which users can choose to navigate to any other scene. The references panel (b), that lists the sources consulted while making the application. The help panel (c), which offers advice on how to use the application

Full size image

The user can navigate to the “Introduction to OCD” scene (Fig. 2.5a), which explains the nature of the CSTC circuit and how it is affected in OCD, or choose instead to view a scene showing how different neurotransmitters are affected in OCD (Fig. 2.5b), or choose to learn more about how different treatments for OCD work (Fig. 2.5c). The user may also view the “Explore the Circuitry” scene (Fig. 2.5d), which gives complete control over the brain, allowing it to be rotated in any direction. They may also zoom in and out.

Fig. 2.5
figure 5

The “Introduction to OCD” scene (a), the “Glutamate – Neurotransmitter in OCD” scene (b), the “Anti-Glutamatergics – Treating OCD” scene (c), and the “Explore the Circuitry” scene (d)

Full size image

Finally, there is a quiz (Fig. 2.6). There are ten questions in the quiz, with three possible answers to each. Only one is correct. The questions progress sequentially, and whether the user selects the correct answer or not, a brief explanation of the correct answer is given after each question.

Fig. 2.6
figure 6

An example of a question (a) and answer screen (b) in the quiz scene

Full size image

2.3 Evaluation

2.3.1 Participants

To assess the user experience and educational potential of the application, a pilot evaluation was conducted with five postgraduate students aged 30–49 (3 males, 2 females) from the College of Medical, Veterinary, and Life Sciences at the University of Glasgow. All participants were undertaking a PhD at the University of Glasgow.

Information obtained through a pre-screener questionnaire indicated that only one participant did not regularly use tablet devices. Each of the participants who did regularly use such devices used them for entertainment purposes. Two of these participants also used them for communication, and one of those participants also used such devices for education and work.

2.3.2 Experimental Procedure

Participants were given an information sheet to read and sign before taking part in the study. They then completed a pre-screener, designed to gather some demographic information and to determine the participant’s technical literacy. Before using the application, participants also completed a pre-test comprising of six questions with three possible answers to each, shown in Table 2.1.

Table 2.1 Questions asked in the pre-test and post-test, and the answers available. Correct answers are shown in bold
Full size table

Participants were provided a Samsung Galaxy Tab S2, with “The Pathophysiology of OCD” installed and open. The researcher remained in the room throughout to answer questions or troubleshoot problems. Applicants were advised to complete the application in their own time. Once they were finished using the application, they completed a survey, designed to assess the usability and visual design of “The Pathophysiology of OCD”. The questions in this survey are shown in Table 2.2. They also completed another test. This asked the same questions as the previous test, but the order the questions and answers appeared in was altered. The results of the pre-test and post-test were compared to assess the educational impact of the application.

Table 2.2 A list of the questions asked in the post-app survey, and the response options available
Full size table
Fig. 2.7
figure 7

Breakdown of answers given to the question “How useful did you find “The Pathophysiology of Obsessive Compulsive Disorder application?”

Full size image

2.3.3 Data Analysis

In the pre-screener, participants simply had to circle demographic answers. In the post-survey, there were three Likert scale questions. The first of these presented five possible options, while the other two presented three options. The latter two also provided space for participants to provide more details. The results of these Likert scale questions were assembled into pie charts, as presented below (Figs. 2.7 and 2.8). The post-survey also contained three open ended questions. With regard to the pre- and post-test, the percentage of correct answers to each question before and after using the app were compared, and this information was used to construct a bar chart, shown below (Fig. 2.8).

Fig. 2.8
figure 8

Breakdown of the answers given to the question “Did you experience any problems/issues while using the application?”

Full size image
Fig. 2.9
figure 9

The percentage of correct answers to each question before and after using the application. There was a general trend to an increased knowledge of OCD after using the application

Full size image

2.3.4 Ethics

This study was reviewed and approved in accordance with the Glasgow School of Art Ethics policy.

2.4 Results

Every participant reported they found the application useful or very useful (Fig. 2.7). None identified any major usability issues with the application, although some did indicate they had minor issues (Fig. 2.8). When asked to clarify, they advised that they did not realise that models were interactive to begin with, and that the way the user had to return to the main menu was bothersome. Most participants did not report any issues, however.

Participants were then asked to advise if they had learned anything from the application. All five users reported that they had, with three opting to provide further details. One learned “how OCD occurs”, while another found the “overview of transmitters and circuits” helpful, and another cited “up to date details on treatments” as something they had gained an insight into through using the application.

The next two questions asked participants to advise what they liked about the application, and what they felt could be improved. All participants were able to identify specific features they liked. Participants advised that they liked “the 3D models and the wee animations”, while others advised they appreciated the “clear images” and “interactive images”. Two participants also indicated that they found the application “easy to use”.

When asked to suggest improvements, four participants gave feedback. One participant felt that the application could benefit from “clearer instructions and menu navigation”. Another suggested a feature that could be incorporated to enhance interactivity. Lastly, two different participants identified issues with the text, with one saying that “some text a bit harder to read”, and another saying that the “justification in text boxes sometimes results in distorted spacing”.

The percentage of correct answers to each of the test questions before and after using the application is shown in Fig. 2.9. There was a general increase in knowledge among participants after using the application, with some exceptions. All participants answered question 2 correctly without using the application, so there was no opportunity for improvement here. Only one participant answered question 5 correctly in both the pre-test and post-test. Interestingly however it was not the same individual on both occasions.

2.5 Discussion

In this pilot evaluation of “The Pathophysiology of OCD”, feedback was positive. The evaluation revealed that there were no major usability issues with the application. Minor criticisms of usability features were identified through the evaluation; these challenges have since been addressed.

Promisingly, the results of the pre-test and post-test indicate an educational benefit to using the application. For the most part the number of correct responses to each question increased after using the application. Question 2 and 5 were the exception. All participants answered question 2 correctly in the first instance, therefore this could not be improved upon. The fact that there was no improvement in the number of correct answers to question 5, and that the person who answered correctly in the pre-test was not the same person who answered correctly in the post-test, is interesting. Question 5 was a question about Riluzole, a pharmaceutical treatment that has been suggested to have beneficial effects in OCD. These results therefore suggest that the content of the application concerning Riluzole was not as effective as initially hoped. With positive results being seen elsewhere in the application, work should be done to determine precisely how this section differs from others, and to bring this section to the same standard as the others.

Being a pilot study over a limited period of time, a small number of participants were recruited, and a short, simple survey was used. Therefore, broad all-encompassing conclusions cannot be drawn from this research, nor is statistical analysis of the results possible. This pilot study is not without value however. Usability issues were identified as a consequence of this evaluation, and the visual design of the application was assessed as part of this application, and the feedback given was positive. In future work, efforts will be made to recruit a larger number of participants, and to provide more expansive surveys to participants, to gain a thorough understanding of the strengths and weaknesses of the application so that improvements can be made.

The data from the pre-test and post-test suggests a general increased knowledge of OCD after using the application. This suggests that there is a benefit to using interactive 3D visualisations in education on the topic of OCD, and supports further investigation into using such visualisations more broadly in neuropsychiatric education.

2.6 Conclusion

The final product of this project was an application for tablet devices containing both fully referenced information on OCD and interactive 3D visualisations to illustrate the information. The first of its kind, this application has been shown to be an effective tool for educating on the topic of the pathophysiology of OCD, and the results of this study support a role for similar applications in future education. More effort should be made to improve the application based on the feedback collected from participants in this study, and to broaden the scope of the application so that it encompasses a greater number of neuropsychiatric disorders.