Elsevier

Psychiatry Research

Volume 188, Issue 1, 30 June 2011, Pages 13-17
Psychiatry Research

What happened to the voices? A fine-grained analysis of how hallucinations and delusions change under psychiatric treatment

https://doi.org/10.1016/j.psychres.2010.12.013Get rights and content

Abstract

The Psychiatric Symptom Rating Scales (PSYRATS) have demonstrated their usefulness for the dimensional assessment of hallucinations and delusions. However, there is no evaluated German version of the PSYRATS to date. Also, in spite of theoretical conceptions about “detaching” effects of antipsychotics, there are few consolidated findings about how core symptomatic aspects of schizophrenia change during antipsychotic treatment. The present study aimed to fill this gap. A total of 40 schizophrenic voice-hearers were interviewed three times during the course of six months using a newly developed German version of the PSYRATS with very good psychometric properties. At the same time, psychopathology was assessed with the Positive and Negative Syndrome Scale (PANSS). In the longitudinal course, a general symptomatic decrease became apparent only for auditory hallucinations but not for delusions. Specifically, the loudness of the hallucinated voices as well as the associated distress decreased early, while other aspects of the hallucinations took more time to fade. In this study, the PSYRATS proved to be a valuable tool for measuring the change of specific symptom dimensions. However, our results only partially supported the notion of a general detachment from symptoms due to psychiatric treatment.

Introduction

During the last decades, multiple instruments aimed at capturing psychotic symptoms have been developed (Kay et al., 1987, Haddock et al., 1999, Liddle et al., 2002). To determine the severity of psychotic disorders as well as specific syndromes, the Positive and Negative Syndrome Scale (PANSS, Kay et al., 1987) is considered the “gold standard” (Rabinowitz et al., 2006). Instruments like the PANSS mirror the psychotic symptomatology in more detail than general clinical-diagnostic interviews. Furthermore, the PANSS is especially useful as a measure of global treatment outcome because it measures the severity of psychotic symptoms in a comprehensive way. Yet, core symptoms such as hallucinations or delusions are assessed rather globally and important qualitative aspects such as sensory features of the hallucinations, conviction and distress are lumped together in one score (Moritz et al., 2001). A fine-grained analysis is important for elucidating the specific action mechanisms of different therapeutic strategies, especially cognitive-behavioral therapy (CBT) or antipsychotic treatment in psychosis. This is especially crucial as the prescription of antipsychotic drugs has largely increased during the last decade (Verdoux et al., 2010). For example, Kapur and colleagues (Kapur, 2003, Kapur et al., 2005, Kapur et al., 2006) proposed that antipsychotic treatment affects delusions and hallucinations primarily by making them less important and less “salient”, not by changing their appearance and contents. There is some research supporting this notion by showing that patients experience the effects of antipsychotic medication as a “detachment” rather than as an elimination of symptoms (Mizrahi et al., 2005, Mizrahi et al., 2006) but these studies were cross-sectional, relying heavily on retrospective memory. Furthermore, they did not measure dimensions of specific symptoms but dimensions of the general psychotic experience (i.e., cognitive preoccupation or behavioral impact). However, a dimensional investigation of symptoms is necessary to analyze whether these effects differ across individual symptoms or not. For example, the specific effects of psychiatric treatment on hallucinations are currently not elucidated. It might be that voices disappear, are less loud or are re-appraised as self-generated.

The Psychotic Symptom Rating Scales (PSYRATS, Haddock et al., 1999) meet the demands for a dimensional investigation of symptoms. In two independent subscales, eleven characteristics of hallucinations and six characteristics of delusions are assessed using an item-specific anchored five-point rating system. In the auditory hallucinations subscale (PSYRATS-AH) hallucinations are rated for example in regard to their frequency, location, loudness, and disruption to life. The delusions subscale (PSYRATS-DS) includes for example items concerning the amount and duration of preoccupation with delusions or amount and intensity of distress. The ratings are based on the patients' experiences during the previous week. In particular, the separate assessment of the dimension of the personal distress linked to symptoms is a major advantage of the PSYRATS in comparison to the more general measures, such as the PANSS. The aspect of distress is of particular relevance, as distress has been demonstrated a hallmark feature discriminating between clinical and subclinical delusional beliefs (Lincoln, 2007) and the reduction of distress is the primary aim of many psychotherapeutic treatment attempts.

The PSYRATS yielded very good inter-rater reliability, test–retest-reliability, internal consistency and validity in both chronic and first-episode patients, respectively, (Haddock et al., 1999, Drake et al., 2007). However, the studies cited above administered the original English version of the PSYRATS. A Spanish translation of the hallucination subscale also yielded good results concerning psychometric properties (Gonzalez et al., 2003). Although German versions of other relevant psychotic symptom-scales have been validated and are frequently used (Lincoln et al., 2009), an evaluation of the German version of the PSYRATS is lacking up to this point.

Another issue of interest is the long-term assessment of individual symptoms. Several studies have investigated the severity of hallucinations longitudinally (Arndt et al., 1995, Mancevski et al., 2007). Using the PSYRATS, a recent study examined the structure of hallucination characteristics over six months of antipsychotic treatment (Chang et al., 2009). Yet, the authors limited their description to the course of syndrome clusters and did not report the course of the individual characteristics themselves. As the PSYRATS contain both items concerning hallucinations and delusions, they can help to elucidate the temporal relationship between these two core psychotic symptoms, especially with regard to treatment. As Gunduz-Bruce et al. (2005) demonstrated, delusions usually respond later to antipsychotic treatment than hallucinations. This corresponds to earlier views that conceptualize delusions as an explanation for abnormal and disturbing perceptions, particularly hallucinations (e.g., Maher, 1974). Using the PSYRATS in a longitudinal design, we wanted to investigate the relationship between hallucinations and delusions in more depth.

In addition to the validation of the German PSYRATS version, the major aim of this study was to explore the temporal course of hallucinations and delusions under the influence of psychiatric treatment.

Section snippets

Subjects

Patients were recruited in the psychiatric departments of two university medical centers in Germany, the Department of Psychiatry and Psychotherapy of the University Medical Center Hamburg-Eppendorf, Germany, and the Department for General Psychiatry of the University Medical Center Heidelberg, Germany. To yield comparable results for the hallucinations and the delusions subscale, only patients experiencing auditory hallucinations were investigated. A total of 40 voice-hearers (25 male, 15

Characteristics of the sample

The mean age of the patients was 33.30 years (S.D. = 10.03), their mean premorbid IQ according to the MWT-B was 100.26 (S.D. = 13.07) and they had 10.86 years (S.D. = 1.71) of formal education. Among this sample, 16 were first-treatment patients, while the remaining 24 had had several admissions. A total of 23 patients had a comorbid substance abuse disorder. The mean PANSS total score of the voice-hearers was 82.95 (S.D. = 23.61). For the medications prescribed and their dose for the different

Discussion

The present study sought to elucidate the temporal course of hallucinations and delusions under psychiatric treatment. This goal was pursued by using the rather novel PSYRATS, which the authors have translated into German. The study was based on a sample of 40 voice hearers identified from a pool of 133 schizophrenic patients.

Both subscales of the German PSYRATS version showed very good internal consistency, comparable to the original version (Hatton et al., 2005). The fact that the change

Acknowledgments

We would like to thank Gillian Haddock and Katy Silverman for their help with the verification of the back translation of the German Version of the PSYRATS. The authors would like to thank the anonymous reviewers for their helpful comments.

References (28)

  • S. Arndt et al.

    A longitudinal study of symptom dimensions in schizophrenia. Prediction and patterns of change

    Archives of General Psychiatry

    (1995)
  • J.S. Chang et al.

    Stabilization of the internal structure of persistent auditory verbal hallucinations in schizophrenia

    Australian and New Zealand Journal of Psychiatry

    (2009)
  • J.C. Gonzalez et al.

    Evaluation of auditory hallucinations: the PSYRATS scale

    Actas Españolas de Psiquiatría

    (2003)
  • H. Gunduz-Bruce et al.

    Duration of untreated psychosis and time to treatment response for delusions and hallucinations

    American Journal of Psychiatry

    (2005)
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