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Auditory verbal hallucinations (AVH) - hearing voices that others cannot hear - are common in psychotic disorders (40-80%) and other mental illnesses such as PTSD (50%), anxiety disorders (27%), bipolar disorder (11-63%), and depression (5-51%) 1,2. For many people AVH are distressing, disabling and persistent, despite medication. Current psychological interventions, mostly focussing on cognitive behavioral therapy (CBT), show low to medium effects 3. Preliminary studies suggest that an innovative empowering psychological therapy using computer simulations representing the AVH (avatars) can be effective for reducing AVH distress and frequency (effect size d=0.8 4). This personalized, targeted therapy enables a “face-to-face” dialogue between the patient and an avatar matching the voice and appearance of their persecutory voice. However, further research and development are needed. Virtual reality (VR) has a real potential to improve this treatment and foster implementation.



o To develop a VR avatar therapy for AVH – called VR-VOICES – which can be implemented in existing VR systems that are currently used in Dutch mental health care. The treatment manual and a therapist training course will be made available by the end of the project.

o To test whether VR-VOICES is effective in reducing the distress and frequency of AVH in patients with a psychiatric disorder in comparison with treatment as usual (TAU).

o To test the efficacy of VR-VOICES on other clinical symptoms and quality of life compared to TAU.

o To explore the working mechanisms of the therapy by testing potential mediators and moderators of VR-VOICES. Mechanisms which may be anxiety-related or mediated by an increase in control or reduced perceived omnipotence.

o To determine the cost-effectiveness of VR-VOICES compared to TAU.



The project consists of three different work packages:

o Work package 1 – Developing VR -VOICES software, protocol and manual in co-creation with patients and professionals

o Work package 2 – Testing VR-VOICES in single-blind multi-center RCT comparing VR-VOICES with TAU (n=117)

o Work package 3 – Dissemination and implementation



Patients with a DSM-5 diagnosis who have experienced distressing AVH for at least the past 3 months, 18 years or older (N=117).



o VR-VOICES intervention: 8 sessions of 45-60 minutes of individual VR assisted therapy during 8 weeks in addition to TAU. Participants allocated to VR-VOICES create together with their therapist a VR digital representation (avatar with face, body and voice) of the voice that bothers them most. Patients have dialogues with the avatar, voiced by the therapist. As indicated in the treatment protocol, over the sessions the avatar will become less hostile and the participant will gain more power and resilience over the avatar, and thus the voices they hear.

o Control: TAU as described in the current Dutch guidelines, which generally exists of pharmacological treatment, supportive counseling, and psychological interventions such as CBT and coping strategies.



Assessments will be obtained at baseline, within VR-VOICES sessions, posttreatment (2 months after baseline), and at 6-month follow-up. Primary outcome: PSYRATS severity of AVH (distress & frequency) at post-treatment. Secondary outcomes: in-depth characteristics of AVH such as the frequency, voice impact, beliefs about voices, power relative to voices, levels of anxiety, distress and impact on daily life as measured with questionnaires and diary assessments in the flow of daily life. Other secondary outcomes include clinical symptoms, cost-effectiveness and quality of life.



We hypothesize that VR-VOICES reduces the distress and frequency of AVH and clinical symptoms and improves quality of life more compared to TAU only.


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