Immersive Virtual Reality Cognitive Treatment (VRCT) for persecutory delusions.

The issue: Persecutory delusions are a key problem for patients with severe mental disorders such as schizophrenia. Examples include: 'People are trying to cause me physical, mental, and emotional harm'; 'When I go out the devil and other people persecute me'; 'People see me as an easy target and do things to get at me'; 'People know what I'm thinking and want to kill me'. These strongly held, unfounded beliefs are associated with many negative outcomes, including isolation, depression, disrupted education and employment, and hospital admission. The main treatment is medication but this is inadequate for too many patients. Patients want psychological help, but rarely get such help, and the effectiveness of standard intervention needs significant improvement. A treatment is needed, targeted for this problem, that is much more effective, and that can be accessed by a greater number of patients.

A potential solution: Our approach is to combine the best theoretical understanding of persecutory delusions with developments in technology. We want to tackle the fundamental fear that underlies paranoia: the sense of danger from other people. The most effective way to do that is to help individuals learn from experience that others will not attack them. As the feeling of safety increases, so the delusion diminishes. Patients need to drop their defences, go into the situations that they fear, and relearn that they are safe. But this is very difficult for patients to do because of the severe anxiety generated. Virtual reality (VR) provides a powerful means to make the new learning. VR provides interactive, three-dimensional worlds. Although you know what you're seeing isn't real, your mind and body behave as if it were. So it is much easier to enter feared situations, but you still make important learning that transfers to everyday life. The fact that patients can try the same situation many times, and be instantly transported from one challenging situation to another, means that progress can be fast. VR has successfully been used to treat the fears in anxiety disorders - we believe it can do the same for persecutory delusions. VR is emerging into the mainstream, with affordable equipment that can take it from specialist labs into clinics and homes.

Our pilot study: In the first VR treatment study for delusions, 30 patients took part, all of whom were experiencing persecutory delusions (despite medication). We compared two different VR therapies (lasting just 30 minutes), with half the patients undergoing virtual reality cognitive therapy (VRCT) and the other participants undergoing exposure therapy (VRET). The VRCT group, like the VRET patients, took several virtual train and lift rides. But they were helped to do so without using defensive behaviours, such as avoiding eye contact or looking for escape routes. The results paint a very striking picture of the power of VRCT. Immediately after the VR therapy session, eight of the 15 patients who had VRCT no longer met the criteria for persecutory delusions. VR cognitive therapy very clearly outperformed VR exposure therapy in all the statistical testing.

The research: We want to develop an extended VRCT, use the latest consumer equipment, and test it in a clinical trial. Based on patient feedback, VRCT scenarios for four treatment sessions will be developed, each scenario having different levels of difficulty, and with a virtual coach present to help encourage the patient. A shared manual for patients and mental health staff will be written. All this development work will occur with patients who have had such difficulties. We will then go on to test VRCT in a clinical trial. 90 patients with persecutory delusions will either have VRCT or spend identical time in relaxing VR environments. Patients will be assessed over six months. We predict substantial benefits for patients with this new treatment that will help to transform the mental health services of the future.

Problem: Persecutory delusions are a major psychiatric problem, associated with a wide range of adverse outcomes, for which current treatments do not work at all for over 50% of patients.

Solution: Our theoretical model views these delusions as unfounded threat beliefs, which persist due to defence behaviours (e.g. avoidance, enhanced vigilance) that prevent disconfirmatory evidence being processed. The treatment implications are that patients: 1. need to go into feared situations and 2. not use defence behaviours. This enables relearning of safety and hence paranoia diminution. However this is very difficult for patients due to severe anxiety. A solution is to use virtual reality (VR) social situations, which are engaging, graded in difficulty, and that patients find much easier to enter.

Pilot work: In a randomised controlled study with 30 patients with persecutory delusions, we showed that a single session of our VR cognitive treatment (going into VR feared situations with dropping of defence behaviours) led to a large reduction in the delusions (d=1.3) directly compared to an alternative active treatment (VR exposure treatment). Benefits transferred to the real world.

Objective: To produce an affordable, portable, efficacious 'plug and play' VR treatment for delusions.

Design: We will develop additional VR situations, obtain patient feedback, and finalise the treatment manual. Treatment effect sizes will be re-established in an internal pilot with 30 patients with delusions randomised to four sessions of VRCT or VR mental relaxation treatment (rated as equally credible). If effect sizes are as expected, then we will continue the trial, testing 90 patients in total in a Phase IIa trial, assessed at 0, 2, 4 (post treatment), 8, 16, and 24 weeks. The primary outcome is level of delusional conviction. Secondary outcomes are real world distress, activity levels, suicidal ideation, and quality of life. Mediation will also be tested.

Patients with severe mental health problems will benefit from this research. The research project has been devised with a very clear aim to produce direct practical benefits for patients. The potential beneficiaries of the research are patients with severe mental illnesses such as schizophrenia, schizo-affective disorder, delusional disorder, bipolar disorder, or psychotic depression. These are conditions in which severe paranoid fears are common despite existing treatment.

First, the proposed research is likely to produce a treatment that has much higher efficacy for the major clinical problem of persistent persecutory delusions (i.e. severe paranoia that has not responded to standard treatments). Second, the proposed research is likely to produce a treatment that helps to address the substantial problem of lack of accessibility of psychological treatments for patients with severe mental health problems. The treatment is relatively brief, requires little staff input, and is largely self-administered. This means that a far greater number of patients could have access to a powerful psychological treatment. It is also a type of intervention that would be very suitable for use on psychiatric wards, which is a time when patients really need help but currently receive all too little. Patients typically have less than one hour of activity a day on a psychiatric ward. When used in this setting, the VR treatment could speed time to recovery and mean that patients are better prepared for a return to the community.