Background: Temstem is a mobile application developed in cooperation with voice-hearing persons to help them cope with distressing voices. After psychoeducation about voice hearing, Temstem offers two functions: Silencing is a mode designed to inhibit voice activity through the processing of incompatible language; the Challenging mode introduces dual tasking (as used in eye movement desensitisation and reprocessing) designed to reduce the emotionality and vividness of a voice memory. Two different language games, Lingo Tapper and Word Link, are provided, containing both functions. This study aimed to explore the momentary effects of Temstem on voice-hearing distress, emotionality and vividness in a naturalistic sample of voice-hearing app users. Method: Temstem is freely available in the Netherlands. We collected data through the app from 1048 individual users who had given informed consent for the study. We assessed changes in pre- and post-session scores on distress, emotionality and vividness, and we evaluated differences in outcomes between the games and whether effects remained stable over multiple sessions. Results: Users had been hearing voices for an average of 4.95 years; 79 % had been informed about Temstem by a mental health therapist or coach. After a Silencing session, voice-hearing distress was reduced, t(958) = 27.12, p < .001, d = 0.49; the degree of reduction remained stable after repeated use, F(1, 7905.57) = 1.91, p = .167. After a Challenging session, emotionality, t(651) = 23.16, p < .001, d = 0.74, and the vividness of voice memories were reduced, t(651) = 22.20, p < .001, d = 0.71; both diminished slightly with frequent use, F(1, 2222.86) = 7.21, p < .05; F(1, 2289.92) = 4.25, p < .05. In comparison with Lingo Tapper, larger reductions were seen for a Word Link game: emotionality t(226) = 2.88, p < .005, d = 0.21; vividness t(226) = 2.29, p < .05, d = 0.17. Discussion: In this heterogeneous sample of voice-hearing individuals, Temstem appeared to be a promising coping tool; momentary voice-hearing distress and the emotionality and vividness of voice statements were reduced after a Temstem session. Despite important limitations and the need for more research, naturalistic studies of user app data may yield interesting and generalisable findings.

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In the early years of virtual reality in mental healthcare several reviews were published (Gregg and Tarrier 2007; G. Riva 2002; 2003; 2005). None of them mentions work done on virtual reality with psychotic disorders yet, though some early work was starting to get published around the same time. There are different psychotic disorders with each their own specified combination of symptom domains, symptom intensity and duration. Wood et al. (2011) suggest a dimensional staging of psychosis, ranging from psychotic-like experiences to severe persistent psychotic episodes. A large body of research is accumulating showing psychotic symptoms can be seen as a transdiagnostic and extended phenotype found in the general population (J. van Os and Reininghaus 2016). When psychotic experiences persist, transition to a psychotic disorder becomes a possibility. The main recognizable symptom domains of psychotic disorders are hallucinations and delusions. Hallucinations are perceptions a person experiences without a corresponding external stimulus. Hallucinations can occur for all five senses. Patients with a psychotic disorder for example often experience auditory hallucinations such as hearing voices. These voices can be commentary, give orders to the patient or call them names. Delusions are beliefs people have about the external reality which are strongly maintained despite strong evidence to the contrary or despite what almost everybody else (of a person’s culture or subculture) believes. The most common delusion found in psychotic disorders is the persecutory delusion (paranoia). People with a persecutory delusion feel others (known or unknown) spy on them, pursue them and threaten their safety (van der Gaag et al. 2012; Beck et al. 2009). Hallucinations and delusions often cause anxiety and make the patient avoid (social) situations, which can be treated with exposure therapy. Other symptom domains of psychotic disorders are negative symptoms and impaired cognition. Patients with negative symptoms experience an diminished emotional expression and avolition. Impaired cognition is about learning deficiencies, whether insufficiently thought or thwarted by deficits. For both negative symptoms and impaired cognition training can help patients learn to master new skills. There are some additional symptom domains in psychotic disorders, but these don’t play a part in virtual reality (yet). See Box 13.1 for an overview.@en

Introduction Auditory verbal hallucinations (AVH) are prevalent experiences that can induce distress and impede social functioning. While most voice hearers benefit from antipsychotic medication or cognitive-behavioural therapy, additional effective interventions are needed to reduce the burden of experiencing AVH. Temstem' is an easily accessible and useable smartphone application that was developed by designers in close cooperation with voice hearers and experts. By using language games, Temstem aims to reduce distress and improve social functioning. Methods This is a single-blind multicentre randomised controlled trial with two arms: Temstem+AVH monitoring' versus AVH monitoring' (total n=100). Participants are adult patients who suffer daily from AVH and will be recruited in outpatient units. Primary assessment in daily life is made by the Experience Sampling Method (ESM) and daily monitoring with the PsyMate app. During an ESM period of 6 days, participants assess their mental state (including AVH and context) several times a day by filling in short questionnaires. There are three 6-day ESM periods: at baseline (week 0-1), post-treatment (weeks 5-6) and follow-up (weeks 9-10). In addition, during the entire 10-week study period, all participants monitor their AVH two times a day with a short assessment via the PsyMate app. Participants in the Temstem+AVH monitoring condition are provided with the Temstem app from week 1 to 6. Other assessments made at baseline, post-treatment and follow-up are based on questionnaires and a clinical interview. Ethics and dissemination The results from this study will provide an evaluation of the effectiveness of Temstem, a non-invasive and easily accessible app for voice hearers, and insight into the determinants of optimal use. Results will be disseminated unreservedly, irrespective of the magnitude or direction of the effects. This study protocol was approved by the Medical Ethics Committee of the VU University Medical Centre (METC number: 2015.435/NL53684.029.15). Trial registration number ISRCTN75717636; Pre-results.

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While most voice hearers benefit from antipsychotic medication or cognitive behavior therapy, additional effective interventions are needed to reduce the burden of experiencing AVH, especially in everyday life. ‘Temstem’ is an easily accessible and usable smartphone application that was developed by designers in close cooperation with voice hearers and experts. By using language games, Temstem aims to reduce distress and improve social functioning. Methods: A single-blind multicenter RCT with two arms: ‘Temstem + AVH monitoring’ versus ‘AVH monitoring’. Participants are adult patients with AVH and are recruited in outpatient units. Primary assessment in daily life is made by experience sampling method (ESM) and daily monitoring with the PsyMate app. There are three 6-day ESM periods: at baseline (week 0-1), post-treatment (week 5-6) and follow-up (week 9-10). In addition, during the entire 10-week study period, all participants monitor their AVH two times a day with a short assessment via the PsyMate app. Participants in the Temstem + AVH monitoring condition are provided with the Temstem app from weeks 1-6. Other assessments made at baseline, post-treatment and follow-up are based on questionnaires and a clinical interview. Results: The preliminary results of this study (the study is scheduled to be completed in July 2018) will provide an evaluation of the effectiveness of Temstem, a non-invasive and easily accessible app for voice hearers, and insight into the determinants of optimal use. Conclusions: If Temstem is found to be effective, many voice hearers can be reached at low costs.@en