Cognitive and Metacognitive Evaluation in VR-Based Avatar Therapy for Psychosis

Evaluation of Cognitive, Metacognitive, Social Cognition and Trauma Related-Variables in Patients With Psychosis Receiving VR-Based Avatar Therapy

This study aims to evaluate the relationship between cognitive, metacognitive and social cognition variables in patients with psychosis undergoing VR-based Avatar Therapy for the treatment of auditory hallucinations. In addition to the primary intervention, participants will be assessed using validated tools for emotion recognition, attributional style, theory of mind, neurocognition, and metacognition. The study also explores the potential role of trauma as a predisposing factor. Assessments will be conducted at four time points: screening (week 0), baseline (week 12), intervention period (weeks 12-24), and post-therapy follow-up (week 24). By investigating these variables, this study seeks to better understand their impact on treatment outcomes and contribute to the development of personalized therapeutic approaches.

This interventional study investigates the impact of cognitive, metacognitive, and social cognition variables on the outcomes of VR-based Avatar Therapy for auditory hallucinations in patients with psychosis. Participants will be assessed at four key time points: screening (week 0), baseline (week 12), during the intervention (weeks 12-24), and post-therapy (week 24).

The intervention consists of 7 individual VR-based Avatar Therapy sessions delivered over 12 weeks. The therapy uses virtual reality to externalize and reframe distressing auditory hallucinations, helping participants develop more adaptive responses.

In addition to evaluating the therapy's effectiveness, the study incorporates validated tools to measure:

Social Cognition: Emotional recognition (Test de Reconocimiento Emocional), attributional style (AIHQ), theory of mind (Hinting Task), and social perception (SFRT-2).

Metacognition: Insight and cognitive monitoring using the BCIS and CBQ. Cognition: Neuropsychological functions, including attention, flexibility, and memory (SCIP, Stroop, TMT, and Vocabulary WAIS).

Trauma as a predisposing factor: Using the Childhood Trauma Questionnaire (CTQ).

By examining these variables, the study aims to deepen the understanding of their influence on treatment outcomes and inform the development of personalized therapeutic approaches for psychosis.

**Inclusion Criteria:**

• Adults aged 18 years or older.
• Diagnosis of schizophrenia spectrum disorder according to DSM-5 criteria.
• Experience of persistent auditory hallucinations for at least 3 months (PANSS hallucination score ≥ 3).
• Stable medication dosage for at least 4 weeks prior to recruitment.
• Fluent in the spoken language of the study site (Spanish).
• Able to provide informed consent.
• Regular psychiatric follow-up care.

**Exclusion Criteria:**

• Inability to identify a dominant voice for Avatar Therapy intervention.
• Intellectual disability based on medical history.
• Active substance abuse.
• Central nervous system injury or neurological disorders affecting cognitive performance.
• Severe visual impairment that precludes the use of VR technology.
• Aversion to virtual reality or prior experience of simulator sickness.
• Current suicidal ideation or risk.
• Lack of cooperation or inability to comply with study procedures.