Hallucinations Respond To Innovative Use of CBT

Antipsychotic medications do not always banish auditory hallucinations from the lives of schizophrenia patients. And when that is the case, how can patients cope with the voices that plague them?

Perhaps by participating in an eclectic therapy being explored by Dutch psychiatrist Durk Wiersma, M.D., a professor of clinical epidemiology in psychiatric disorders at the University of Groningen, and colleagues in the Netherlands.

The therapy, called Hallucination-Focused Integrative Treatment (HIT), appears to improve the quality of life and social functioning of patients who have suffered from auditory hallucinations for a long time, a study conducted by Wiersma and his team suggests.

The HIT therapy offers schizophrenia patients whose auditory hallucinations are not being eliminated by antipsychotic medications some cognitive-behavioral therapy (CBT) techniques for dealing with those hallucinations. The program is directed to the families of schizophrenia patients as well as to the patients themselves; in this way it differs from most CBT interventions.

For instance, in HIT therapy, hallucinations are viewed as a reality for which the patients themselves are held responsible. Patients are asked to monitor the characteristics of their “voices” on a daily basis and to note triggering events. Ideas about “voices” are shared and challenged in therapy. Both patients and their relatives are encouraged to come up with new ideas about and solutions to deal with patients'“ voices.”

HIT therapy is usually offered to patients and their families in 20 one-hour sessions over nine months.

Although Wiersma and his colleagues, as well as other clinicians, have been using HIT to help schizophrenia patients deal with their hallucinations, no study has been conducted to test the therapy's effectiveness.

Thus, the researchers conducted a trial with 63 schizophrenia patients who were similar on sociodemographic, diagnostic, medication, and medical history variables and who had been suffering from auditory hallucinations for an average of 11 years in spite of antipsychotic medications.

Thirty-two of the patients were randomly allocated to receive care as usual— that is, regular medical contacts, home visits, day-care activities, psychosocial education for patients and families, and supportive counseling. The remaining 31 patients received HIT plus routine care. All of the subjects continued to receive antipsychotic medications during the study, and the kind and amount that each subject received during the study were recorded.

The researchers used a 26-item self-report questionnaire, the World Health Organization Quality of Life Schedule, and a semistructured interview, the Groningen Social Disabilities Schedule, to assess quality of life and social functioning of the subjects at the start of the study; at nine months into the study, that is, after HIT therapy had ended; and 18 months after the study began. The World Health Organization Quality of Life Schedule measured factors such as sleep, safety, enjoyment of life, and satisfaction with life; the Groningen Social Disabilities Schedule measured factors such as the quality of relationships with family, partners, or friends and ability to carry out household or work activities.

The investigators then compared the quality of life and social functioning of the HIT subjects with those of the control subjects.

With regard to quality of life, HIT subjects improved steadily in almost every domain throughout the study and significantly so by the 18-month follow-up. The controls, in contrast, did not show such improvement.

On social-functioning measures, HIT subjects improved significantly in five of the eight assessed domains by nine months into the study. In contrast, controls hardly improved at all. What's more, the HIT group maintained their improvements at nine months and at the 18-month assessment.

Finally, the researchers looked to see whether their results might have been distorted by the kinds and amounts of antipsychotic medications subjects had taken during the study or by other variables, but found no such distortion.

These data “suggest a significant improvement of quality of life and in particular in social-role functioning” for HIT subjects, Wiersma and his team concluded in their report, which was published in the March Acta Psychiatrica Scandinavica.

True, Wiersma told Psychiatric News, HIT therapy may not banish auditory hallucinations, but the burden of such hallucinations can be relieved by HIT therapy “better than was initially expected.”

Peter Weiden, M.D., a professor of psychiatry at the State University of New York Downstate Medical Center and a specialist in the use of CBT for schizophrenia, told Psychiatirc News, “This is the kind of rigorous, randomized, controlled clinical trial that is being done in other countries and that looks at the impact of CBT and related psychosocial treatments on active symptoms of schizophrenia. The U.S. is way behind in this.”

The study was financed by the Ziekenfondsraad, a health care advisory body of the Dutch government.

An abstract of the study, “Hallucination-Focused Integrative Treatment Improves Quality of Life in Schizophrenia Patients,” is posted online at<www.blackwellsynergy.com/links/doi/10.1046/j.0001-690X.2003.00237.x/abs/>.▪