AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial

A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecuto...

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Published in:	The Lancet. Psychiatry Vol. 5; no. 1; p. 31
Main Authors:	Craig, Tom Kj, Rus-Calafell, Mar, Ward, Thomas, Leff, Julian P, Huckvale, Mark, Howarth, Elizabeth, Emsley, Richard, Garety, Philippa A
Format:	Journal Article
Language:	English
Published:	England 01.01.2018
Subjects:	Adult Affective Disorders, Psychotic - diagnosis Affective Disorders, Psychotic - psychology Affective Disorders, Psychotic - therapy Computers Female Hallucinations - therapy Humans Male Middle Aged Pattern Recognition, Physiological Psychiatric Status Rating Scales Psychological Techniques - instrumentation Recognition, Psychology Schizophrenia - diagnosis Schizophrenia - therapy Schizophrenic Psychology Single-Blind Method Treatment Outcome
ISSN:	2215-0374, 2215-0374
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Abstract	A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition. We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790. Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy. To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations. Wellcome Trust.
AbstractList	A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition. We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790. Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy. To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations. Wellcome Trust. A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.BACKGROUNDA quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790.METHODSWe did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790.Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy.FINDINGSBetween Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy.To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.INTERPRETATIONTo our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.Wellcome Trust.FUNDINGWellcome Trust.
Author	Ward, Thomas Rus-Calafell, Mar Craig, Tom Kj Emsley, Richard Garety, Philippa A Howarth, Elizabeth Leff, Julian P Huckvale, Mark
Author_xml	– sequence: 1 givenname: Tom Kj surname: Craig fullname: Craig, Tom Kj email: thomas.craig@kcl.ac.uk organization: Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. Electronic address: thomas.craig@kcl.ac.uk – sequence: 2 givenname: Mar surname: Rus-Calafell fullname: Rus-Calafell, Mar organization: Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK – sequence: 3 givenname: Thomas surname: Ward fullname: Ward, Thomas organization: Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK – sequence: 4 givenname: Julian P surname: Leff fullname: Leff, Julian P organization: Department of Mental Health Sciences, Royal Free and University College Medical School, London, UK – sequence: 5 givenname: Mark surname: Huckvale fullname: Huckvale, Mark organization: Department of Speech, Hearing and Phonetic Sciences, University College London, London, UK – sequence: 6 givenname: Elizabeth surname: Howarth fullname: Howarth, Elizabeth organization: Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK – sequence: 7 givenname: Richard surname: Emsley fullname: Emsley, Richard organization: Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK – sequence: 8 givenname: Philippa A surname: Garety fullname: Garety, Philippa A organization: Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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PublicationTitleAlternate	Lancet Psychiatry
PublicationYear	2018
References	29175275 - Lancet Psychiatry. 2018 Jan;5(1):2-3. doi: 10.1016/S2215-0366(17)30471-6. 29198384 - Lancet Psychiatry. 2018 Jan;5(1):e1. doi: 10.1016/S2215-0366(17)30473-X.
References_xml	– reference: 29175275 - Lancet Psychiatry. 2018 Jan;5(1):2-3. doi: 10.1016/S2215-0366(17)30471-6. – reference: 29198384 - Lancet Psychiatry. 2018 Jan;5(1):e1. doi: 10.1016/S2215-0366(17)30473-X.
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Snippet	A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff...
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SubjectTerms	Adult Affective Disorders, Psychotic - diagnosis Affective Disorders, Psychotic - psychology Affective Disorders, Psychotic - therapy Computers Female Hallucinations - therapy Humans Male Middle Aged Pattern Recognition, Physiological Psychiatric Status Rating Scales Psychological Techniques - instrumentation Recognition, Psychology Schizophrenia - diagnosis Schizophrenia - therapy Schizophrenic Psychology Single-Blind Method Treatment Outcome
Title	AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial
URI	https://www.ncbi.nlm.nih.gov/pubmed/29175276 https://www.proquest.com/docview/1969928885
Volume	5
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