Avatars Ease Voices For Schizophrenia Patients
By Lorna Stewart BBC Health Check May 29, 2013
Use of an avatar can help treat patients with schizophrenia who hear voices, a UK study suggests.
The trial, published in the British Journal of Psychiatry, focused on patients who had not responded to medication.
Using customised computer software, the patients created avatars to match the voices they had been hearing.
After up to six therapy sessions most patients said their voice had improved. Three said it had stopped entirely.
The study was led by psychiatrist emeritus professor Julian Leff, who spoke to patients through their on-screen avatars in therapy sessions. Gradually he coached patients to stand up to their voices.
"I encourage the patient saying, 'you mustn't put up with this, you must tell the avatar that what he or she is saying is nonsense, you don't believe these things, he or she must go away, leave you alone, you don't need this kind of torment'," said Prof Leff.
"The avatar gradually changes to saying, 'all right I'll leave you alone, I can see I've made your life a misery, how can I help you?' And then begins to encourage them to do things that would actually improve their life."
By the end of their treatment, patients reported that they heard the voices less often and that they were less distressed by them. Levels of depression and suicidal thoughts also decreased, a particularly relevant outcome-measure in a patient group where one in 10 will attempt suicide.
Treatment as usual
The trial, conducted by Prof Leff and his team from University College London, compared 14 patients who underwent avatar therapy with 12 patients receiving standard antipsychotic medication and occasional visits to professionals.
Later the patients in the second group were also offered avatar therapy.
Only 16 of the 26 patients completed the therapy. Researchers attributed the high drop-out rate to fear instilled in patients by their voices, some of which "threatened" or "bullied" them into withdrawing from the study.
New treatment options have been welcomed for the one in four patients with schizophrenia who does not respond to medication. Cognitive behaviour therapy can help them to cope but does not usually ease the voices.
Paul Jenkins, of the charity Rethink Mental Illness, said: "We welcome any research which could improve the lives of people living with psychosis.
"As our Schizophrenia Commission reported last year, people with the illness are currently being let down by the limited treatments available.
"While antipsychotic medication is crucial for many people, it comes with some very severe side effects. Our members would be extremely interested in the development of any alternative treatments."
A larger trial featuring 142 patients is planned to start next month in collaboration with the King's College London Institute of Psychiatry.
Prof Thomas Craig, who will lead the larger study, said: "The beauty of the therapy is its simplicity and brevity. Most other therapies for these conditions are costly and take many months to deliver.
"If we show that this treatment is effective, we expect it would be widely available in the UK within just a couple of years as the basic technology is well developed and many mental health professionals already have the basic therapy skills that are needed to deliver it."
Study finds avatar therapy helps silence schizophrenia's voices
The computer software uses gaming technology to enable patients to create a face and voice representing their tormentor.
By Andrea Gerlin / Bloomberg News May 29, 2013
LONDON - People with schizophrenia who didn't respond to medication learned to control hallucinatory voices with the aid of a computer program that used an avatar of their imagined persecutor in a study by British researchers.
The Wellcome Trust, the world's second-largest biomedical charity, said Wednesday it is giving scientists at University College London and King's College London $2 million to test the avatar therapy in more patients.
Schizophrenia is a condition that affects thinking, feeling and behavior in about one in every 100 people. A quarter of them aren't helped by drugs. The avatar therapy reduced the frequency and intensity of auditory hallucinations in patients in the British study. It also diminished the disruption to patients' lives and the delusions they developed about the voices. Three patients stopped hearing voices altogether.
"Many of the patients did learn to stand up to their voices and tell them to go away," Julian Leff, an emeritus professor at University College London who led the study published in the British Journal of Psychiatry in February, said in a telephone interview.
The computer software uses gaming technology. One of Leff's colleagues combined FaceGen, three-dimensional facial construction software from Toronto-based Singular Inversions, and animation software from Annosoft of Richardson, Texas, to enable the patients to create a face and voice representing their tormentor. Leff then spoke to them through the modified voice until the patient gained control.
The researchers also recorded the sessions on MP3 players so that the patients could replay them as reminders of their capacity to overcome the bullying voices.
Twenty-six patients between the ages of 14 and 74 who hadn't been helped by anti-psychotic drugs such as AstraZeneca's Seroquel and Bristol-Myers Squibb's Abilify participated in the trial. They received either treatment as usual or as many as seven sessions of therapy lasting as long as 30 minutes.
"It's short and it's very easy to implement," said Tom Craig, a professor of social psychiatry at King's College London's Institute of Psychiatry, whom Leff has trained to provide the therapy.
Those in the control group were offered the treatment at the end. After the therapy, patients were evaluated by a psychiatrist with commonly used rating scales for psychotic symptoms, their beliefs about the voices, and depression.
Avatar therapy's overall effect was at least twice that of the only other non-pharmaceutical treatment for schizophrenia, cognitive behavioral therapy, Leff said. The approach probably worked for the disabling mental illness because the avatar and its voice were the patient's creation and the image of the persecuting voice validated their experience, according to Leff.
"One patient after two sessions said the voice was gone," Leff said. "He'd been hearing this voice for 3½ years all the time. It woke him up at 5 a.m. and went all day long. He said, '' 'It's as if she left the room.' "
Another patient had been a successful property developer until he began hearing the voice of the devil 16 years earlier, took its advice and lost all his money, Leff said. The voice ceased as the patient was walking away from the hospital after his second session of treatment.
"He came back to see me on the third session and said 'he's gone, he's stopped talking to me,' " Leff said. "He said 'thank you for giving me my life back.' "
The treatment didn't initially affect symptoms of depression in the patients, though in follow-up evaluations three months later they reported their depression symptoms had significantly improved, according to the study. Thoughts of killing themselves also declined, important in patients who face a 10 percent risk of suicide, Leff said.
"Quite often a voice is telling them to jump off a bridge or run under a train," he said.
Leff and his colleagues had difficulty recruiting enough people for the 55,000-pound pilot study because he said other doctors were reluctant to refer patients for an unproven treatment. Only 16 of the 26 participants completed the trial, he said. Some were deterred by voices they heard threatening to harm them if they participated.
"The voices, which can be terribly brutal, end up saying to patients, 'if you try this therapy, I'm going to kill you,' " Leff said.
The therapy isn't the answer for everyone with schizophrenia, Leff said. Those who heard more than one voice had difficulty concentrating when other voices interrupted. Some patients enjoy their auditory hallucinations, such as a young man Leff didn't treat in the trial because the voice he heard was of a broadcaster commenting on his favorite soccer team.
The Wellcome Trust is interested in the research because mental illnesses such as schizophrenia and depression remain a significant health burden, said John Williams, head of neuroscience and mental health at the charity.
"One of our major challenges is understanding the brain," Williams said.
The pilot study was funded by the National Institute of Health Research and Camden and Islington NHS Foundation Trust. The trial funded by Wellcome will enroll as many as 140 patients at least 18 years old at centers in Britain, Vienna and Bologna, Italy. It will primarily measure the reduction in stress from voices, Craig said.