Cutting-edge Advances Help Mute Voices in Schizophrenia

Liam Davenport

April 12, 2018

FLORENCE, Italy — Schizophrenia patients with auditory verbal hallucinations (AVH) that have not responded to treatment may experience improvement with two cutting-edge techniques, new research shows.

A study by Alexandre Dumais, MD, PhD, Institute Philippe Pinel of Montreal, Canada, included more than 50 schizophrenia patients with treatment-refractory AVH. The patients were randomly assigned either to undergo a computerized therapy in which the patients created an avatar of their tormentor before confronting it, or to standard cognitive-behavioral therapy (CBT).

The patients who underwent the avatar therapy not only experienced significant improvements in AVHs but also in levels of anxiety and schizophrenia symptoms and in quality of life. Both patient groups demonstrated an improvement in depression scores.

The researchers note that although the study involved a small number of patients, their findings nonetheless support the superiority of avatar therapy on AVH.

"The current trial will contribute to the validation of a novel innovative approach answering a fundamental clinical need," they write.

In a second study, Jean-Pierre Lindenmayer, MD, clinical professor, Department of Psychiatry, NYU Langone Health, New York City, randomly assigned almost 30 patients to receive either active or sham transcranial direct-current stimulation (tDCS), a noninvasive neurostimulation technique.

With the active treatment, patients experienced significant improvements in scores on a measure that assesses auditory hallucinations. Improvements included reductions in the number and frequency of voices heard, as well as an increase in working memory.

The researchers observe that their results "indicate that patients who have been ultraresistant to antipsychotic treatments and who received prolonged tDCS treatment presented with significant diminution of their auditory hallucinations and their total psychopathology."

Both studies were presented here at the Schizophrenia International Research Society (SIRS) 2018 Biennial Meeting.

Avatar Therapy

Up to 70% of schizophrenia patients experience AVH. Although pharmacologic therapy reduces such hallucinations in the majority of patients, approximately one third of patients continue to hear distressing voices.

CBT has achieved moderate success in reducing AVH. Computer-based techniques have shown promise for patients with schizophrenia by allowing them to engage in a dialogue with their distressing voices.

After conducting a successful pilot study of an avatar therapy in 15 patients with refractory AVH, Dumais and colleagues started a larger randomized trial of adult patients with treatment-resistant schizophrenia or schizoaffective disorder who were hearing persecutory voices. The patients had not responded to ≥2 trials with antipsychotic medications.

The patients are randomly assigned in a single-blinded fashion to receive either avatar therapy or CBT.

AV therapy consisted of nine weekly sessions. In the first session, patients created an avatar. In the following eight therapeutic sessions, the patients were confronted by a reproduction of their hallucinatory experience and were encouraged to enter in a dialogue with their virtual persecutor.

CBT comprised nine weekly sessions consisting of learning modules and task assignments that were focused on the normalization of hallucinations and on coping mechanisms.

At baseline and post treatment, patients underwent assessment of AVH with the Psychotic Symptoms Rating Scale (PSRC). Secondary outcomes included changes in scores on anxiety, symptom, depression, and quality-of-life scales.

Dumais presented interim results for 52 patients, of whom 30 received avatar therapy and 22 CBT. Eighty-three percent of the patients were diagnosed with schizophrenia. The remainder had schizoaffective disorder.

The majority (67%) of the participants were male; the mean age was 41 years. The patients were typically white (85%), single (75%), and unemployed (77%).

Significant Improvement

The patients who underwent avatar therapy showed significant improvement in scores on the total (P = .001), distress (P < .001), and frequency (P < .029) subscales of the PSRC.

In addition, the patients who received avatar therapy had significant improvements in state (P = .046) and trait (P < .001) scores on the Anxiety State Traits Assessment, as well as improvements in total (P = .002), positive (P = .001), and general (P = .003) scores on the PANSS scale.

Patients who received avatar therapy also showed significant improvement in total quality-of-life scores (P = .002) on the Quality of Life Enjoyment and Satisfaction Questionnaire.

Patients in both the avatar therapy and CBT groups showed significant improvements in total and cognitive scores on the Beck Depression Inventory.

Dumais told Medscape Medical News that the improvements seen with avatar therapy in comparison with CBT may be due to the fact that it feels more like a "real experience."

He noted that with CBT, the patient needs to figure out advanced coping strategies and execute them. On the other hand, avatar therapy is interactive, so patients immediately experience the voice in real time, said Dumais.

He explained that the technique is, in essence, a development of the "empty chair" technique, in which the patient is encouraged to imagine that their tormentor is sitting in an empty chair in front of them.

Dumais noted that avatar therapy is particularly popular with his younger patients.

"Many of them really didn't want to do any psychotherapy because they think it's boring, because you're seeing a therapist, but this is a high-tech thing, so they want to come; they think it's fun," he said.

Brain Stimulation

In the second study, Lindemayer and colleagues enrolled 28 inpatient schizophrenia sufferers who had refractory AVH that had persisted for more than 5 years. The patients were randomly assigned to receive either active or sham tDCS.

tDCS treatment was delivered as 20-min sessions twice daily for 5 consecutive days using the Chattanooga, dual-channel CHA-1335 stimulator. The duration of treatment was 4 weeks, and patients completed a battery of assessments at baseline and after treatment.

The two treatment groups were comparable in terms of baseline characteristics. Twenty-one patients completed the trial; three patients dropped out of the active tDCS treatment group, and four control patients dropped out of the study after being discharged from hospital.

The length of psychiatric admission ranged from 1 to 25 months (mean, 2.9 months). Patients were receiving a range of antipsychotic medications.

Patients who received active tDCS experienced significant reductions in total scores on the Auditory Hallucinations Rating Scale in comparison with the patients who received sham treatment (P = .025), as well as significant reductions in scores on the auditory hallucination frequency (P = .044) and length of hallucination (P = .033) subscales.

Active tDCS was associated with significant improvements in working memory compared with sham treatment (P = .046). No other significant changes were observed.

The team concludeded "that tDCS can be effective not only for ambulatory, higher-functioning patients, but can also be adapted and used for much lower-functioning chronic schizophrenia patients with medication-refractory auditory verbal hallucinations."

No funding for the studies has been disclosed. The investigators have disclosed no relevant financial relationships.

Schizophrenia International Research Society (SIRS) 2018 Biennial Meeting. Poster S58, presented April 7, 2018; and poster T43, presented April 5, 2018.

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