Award Title: Stopping abusive voices from distressing patients with schizophrenia
Funder: Health Education England

Abstract: Background: The majority of patients with a diagnosis of schizophrenia hear voices (70%). Around half report their voice(s) to be persistently abusive or violent.Hence it is unsurprising that voice hearers experience depression, anxiety, low self-esteem, suicidality and, when acute, hospital admission. Current treatments require substantial improvement: antipsychotic medication is only moderately effective and generic CBT results in only small improvements in voices.Evidence suggests that the diagnosis of schizophrenia is comprised of multiple independent psychotic experiences including hearing voices (as well as for example paranoid and grandiose beliefs). The heritability of these individual experiences differs and there are distinct genetic and environmental contributions to each. The most fruitful approach to improving outcomes will be to use a precision medicine paradigm, understanding the unique psychological mechanisms maintaining each psychotic experience and building a treatment which targets them. Within voices alone there are multiple differing presentations. One of the most successful existing treatments targets just one of these voice presentations: command hallucinations. The current application therefore adopts a similarly focused approach to understanding and treating a different voice presentation: engagement with abusive voices.The applicant has developed a cognitive framework for understanding why patients listen to and believe (i.e. engage with) abusive voices. This proposes that key cognitions (thoughts) drive engagement with voices (e.g. 'the voice has important information'), despite the patient knowing that if they engage with the voices, this will leave them feeling distressed. This framework forms the foundations upon which a cognitive model will be developed, based on qualitative analysis of patient experiences. The components of the model will be empirically tested to inform the development of a targeted intervention.Research aims: There are three aims: i) to develop the first model of engagement with abusive voices ii) to refine the model and gather predictive data (ie. how well do key psychological variables in the model predict engagement with abusive voices?) and iii) develop the model into a targeted treatment which enables patients to disengage from abusive voices.Research questions: i)What psychological variables (i.e. cognitions, cognitive styles, attentional styles and affect) are described by people who have experience of engaging with abusive voices? ii) Which psychological variables predict engagement with voices over time? iii)Is it feasible and acceptable to deliver a CBT treatment protocol, based on the above model of engagement, to patients experiencing abusive voices?Plan of investigation: Study one will build a maintenance model of engagement with voices. This will involve a qualitative study with patients to identify psychological factors which promote engagement with abusive voices. From this a cognitive model of voice engagement will be developed. Study two will i) develop and validate a new measure of voice engagement and ii) test the association between model components and engagement with abusive voices over time, using a longitudinal observational design. The model will be refined in light of results and study three will develop a treatment which manipulates key variables to reduce engagement with distressing voices.Potential benefit to patients and the NHS: This programme of translational research will develop a novel targeted treatment, based on a thorough mechanistic understanding of psychological factors which predict engagement with voices. The targeted treatment for abusive voices can be further evaluated in a randomised controlled trial. Patient involvement will ensure that the treatment is highly acceptable to voice hearers.Manual style workbooks and training workshops delivered by the applicant will enable the treatment to be disseminated easily to NHS clinicians. The treatment could be offered as a stand-alone intervention, or added to treatments for other symptoms such as paranoia.

Lay Abstract: The problem: 'Some really evil [voices] came and they were trying to convince me to kill myself  they made themselves out to sound like people were going to break into my house and kick the hell out of me... With the evil voices comes an overwhelming sense of fear.. a fear I've never experienced before.. the darkest thing I wish I never felt... I felt completely helpless and so vulnerable. I was believing it....'. - Domicile'The voices were quite derogatory and it was a hard time to cope with them. I remember feeling so bad about my situation - the bully voice always making me even more depressed -h; that one day I decided to hang myself, but it was the comforting voices that stopped me.' -h; StewartApproximately 70% of people with a diagnosis of schizophrenia hear voices in the absence of someone speaking. There are many ways that these voices manifest, but this research will focus on one common clinical presentation: abusive voices. These are voices which are derogatory or threatening. Depression, anxiety, suicidal thinking, difficulty maintaining friendships, unemployment and hospitalisation are common in this group. Current treatments group all voice presentations together and don't focus on specific sub-types. Anti-psychotic medication and generic cognitive behavioural therapy (CBT, a talking therapy) are the recommended treatments. These require substantial improvement: medication is only moderately effective and associated with marked side-effects, generic CBT results in only small improvements in voices. Only 14-20% of people make a full recovery. This is not as good as CBT for other difficulties, like anxiety. One way to improve effect sizes is to identify factors which maintain specific voice presentations and build treatments which target them. However there has been no sustained research attention investigating factors which cause people to engage with abusive voices, and hence there is no specific treatment.How beliefs about voices promote engagement with them (a cognitive framework):Through clinical experience the applicant has observed a paradox: patients say the voices are trying to upset them, that the voices are doing it on purpose. Whilst patients are aware of this hostile intent, they still listen to and believe (engage with) the voice's derogatory or threatening comments. This results in depression and anxiety. A novel framework for understanding this paradox has been developed by the applicant, drawing on previous literature on i) why people engage in excessive worry, and ii) why patients comply with commands from voices (another specific voice presentation). Whilst most people say that they would prefer not to listen to the voice, there are clear reasons for listening. These are hypothesised to fall into two groups: i) beliefs about listening to voices (reasons for listening) and ii) beliefs about the person's inability to try out alternative approaches. Examples of beliefs about listening to voices include: because the voices threaten to harm them or have important information. Beliefs about the person's inability to try out alternative approaches may include feeling resigned that they have been changed forever by the voices, so there is no point trying. Or, negative predictions about the consequences of disengaging from voices (e.g. 'It'll get so bad that I won't be able to cope'). Next stepsThe framework needs elaborating and testing through the proposed research programme. A comprehensive theory will be developed to explain why people continue to engage with abusive voices. This will be empirically tested and developed into a CBT treatment. Working alongside people with experience of voices will ensure the model and treatment are relevant and acceptable. The research aims to:1) Interview people with experience of hearing abusive voices to identify the psychological factors (e.g. beliefs, thinking styles, attention styles and emotion) that maintain engagement with voices (a qualitative study).2) Monitor patients who hear abusive voices over three months to test which of these psychological factors predict engagement with abusive voices (a quantitative study).3) Translate the theoretical understanding into a CBT treatment (therapeutic development). Feasibility will be examined by offering it to twelve patients. This is important preparatory work before conducting a larger scale effectiveness trial, which would take place at a later point.Potential benefit to patients and the NHS:The programme will produce a potentially much more effective treatment for abusive voices in schizophrenia. A series of workbook style manuals accompanying the CBT will be produced and disseminated to NHS clinicians to ensure that as many people benefit from the research as possible.

Research Activity Codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS;5.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health Categories: MENTAL HEALTH