What happened to the voices? A fine-grained analysis of how hallucinations and delusions change under 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.
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Differences between self-reported and clinician-rated evaluations of 1-year changes in auditory verbal hallucinations among schizophrenia patients
2019, Progress in Neuro-Psychopharmacology and Biological PsychiatryCitation Excerpt :Many reductions in the scores on the PSYRATS-AH and HPSVQ items were evident over the first 6 months, and significant reductions were apparent at 1 year compared to baseline, whereas no changes developed between 6 months and 1 year. Overall AVH reductions were thus slow but progressive, as described in previous studies (Chang et al., 2009; Goghari and Harrow, 2016; Schneider et al., 2011; Sommer et al., 2012). Although AVHs persist even during antipsychotic treatment, they become less intense, less frequent, less emotionally harmful, less likely to prompt overt behavioral responses, quieter, more controllable, and more frequently identified as such (Miller, 1996; Schneider et al., 2011).
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2015, Psychiatry ResearchCitation Excerpt :Good inter-rater reliability, test–retest reliability, internal consistency and validity have been reported (Haddock et al., 1999; Drake et al., 2007). The authorized German version of the PSYRATS was translated and back-translated with satisfactory psychometric properties (Schneider et al., 2011). The Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1989) and the Calgary Depression Scale for Schizophrenia (CDSS; Addington et al., 1993) were, in addition to the PANSS, applied to assess negative and depressive symptoms.
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2014, Progress in Neuro-Psychopharmacology and Biological PsychiatryCitation Excerpt :We are however aware that the latter variable does not sufficiently mirror symptom dynamics over time. AVH are often transient in their content, frequency, loudness, affective quality or degree of control, and some of these dimensions also show different responses to treatment (Schneider et al., 2011). Thus, inference derived from a cross-sectional correlation approach should be cautiously interpreted.
Voxel-based gray and white matter morphometry correlates of hallucinations in schizophrenia: The superior temporal gyrus does not stand alone
2014, NeuroImage: ClinicalCitation Excerpt :Because AVHs and delusions could both be considered symptoms of reality distortion and we aimed to specifically test for effects of AVH presence, we controlled post-hoc for delusion severity. Item P1 (positive subscale, item 1, delusions) has shown high correlations (r = .88) with the Delusions Severity subscale of the PSYRATS (Schneider et al., 2011) and was used to objectify delusion severity. Imaging data were acquired using a Philips 3-tesla Intera Magnetic Resonance system (Best, The Netherlands), equipped with a standard SENSE-8 channel head coil.