Hong Kong J Psychiatry 2002;12(1):2-5

ORIGINAL ARTICLE

G Singh, P Sharan, P Kulhara

Dr G Singh, MD, Senior Resident, Department of Psychiatry, Post- graduate Institute of Medical Education and Research, Chandigarh, India
Dr P Sharan, MD, Associate Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Dr P Kulhara, MD, Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Address for correspondence: Dr G Singh, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh – 160012, India
Tel: (91 172) 747 585/602, ext. 247
Fax: (91 172) 744 401/745 078/744 503

E-mail: medinst@pgi.chd.nic.in

Submitted: 20 March 2001; Accepted: 28 September 2001

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Introduction

Psychotic patients are known to respond to their illness in different ways during the illness and after recovery. The resultant attitude affects recovery and subsequent outcome.¹

In 1969, Soskis and Bowers found that patients who had a positive integrating attitude (inclusion of illness into a continuous set of life values) towards their illness had better outcomes.²

Auditory hallucinations, like other symptoms, have a powerful impact on the lives of those who experience them.³

Different investigators have reported that hallucinations made patients feel privileged, praised, or amused. They relieved the patients of their boredom, amused them, acted as a guide, helped in integrating trauma, and strengthened and stimulated them.^3-8 In 1981, Falloon and Talbot reported that patients with chronic hallucinations did not want to reject their hallucinations.⁹ Carter et al reported that 36% of their series of hallucinating patients (60% with schizophrenia) said that they would miss their voices.¹⁰ Voices were liked by many patients irrespective of their content.⁶

Nevertheless, in other investigations, voices are perceived as being threatening, accusing, reproving, instructing (usually obscenely), hurting, criticising, disgracing, and intruding.¹¹ Romme et al found that 93% of their sample of hallucinating patients described a negative impact of hallucinating voices on their lives.¹² These authors reported that 24% of hallucinating patients felt that their hallucinations evoked negative responses from others. An equal number of patients felt others’ responses to be positive.

The content of hallucinations and attitudes towards hallucinations have often been discussed without adequate discrimination. Lowe included the following example of content of hallucinations: “They wanted to protect me/they were just passing by”.¹¹ Similarly, Larkin defined the ‘content’ of hallucinations as a patient’s perception of the subject matter of hallucinations, such as loneliness, hopelessness, and anger.¹³ These would reflect the attitudes of patients rather than real content.

Miller et al developed a questionnaire on attitudes towards hallucination based on their analysis of the descriptive literature, which provided a systematic approach to the study of attitudes.⁴ On applying the questionnaire to a group of 50 patients of different diagnostic categories, the authors found that 52% of the sample valued their hallucinations in one way or another. Twelve percent of patients wanted their hallucinations to continue as they were perceived to be helpful. Olfactory hallucinations were the most liked of all the hallucinations. Patients who were able to predict the occurrence of their hallucinations by internal antecedents were also more likely to value these hallucinations.

Researchers reported that 98% of hallucinating patients also felt that the hallucinations were a nuisance or had some adverse effect on their lives. Sixty-eight percent of the patients wanted the hallucinations to stop. Age, sex, occupation, marital relationships or level of education, diag- nostic category, duration of illness, length of hospital stay, or treatment apparently had no effect on attitude variables.

A review of studies aimed at examining attitudes towards hallucinations revealed that only 1 study has provided a systematic description of attitudes towards hallucination.⁴ Further, attitudes have not been studied exclusively in pa- tients with schizophrenia. The present study was designed to explore attitudes of patients with schizophrenia towards their hallucinatory experiences and to examine the socio- demographic, clinical and psychological correlates of these attitudes.

Methods

Seventy five patients were selected from the patient popula- tion attending the Psychiatry Outpatient Department, Nehru Hospital, Postgraduate Institute of Medical Education and Research, in Chandigarh. The inclusion criteria were:

• a definite diagnosis of schizophrenia according to ICD-10 diagnostic criteria¹⁴
• duration of illness of more than 2 years
• clinical stability for at least 3 months prior to assessment (clinical stability was operationally defined as absence of exacerbation of illness requiring increase in drug dosages by 50% or more)
• reported presence of hallucinations (in any modality) during the past 3 months.

Patients with concomitant chronic medical illness, organic brain disease, and substance abuse were excluded from the study. None of the patients had received psychological treatment of any nature (e.g. coping skill training, cognitive behaviour therapy) to deal with the hallucinations. After obtaining written informed consent from the patient or an adult relative in case the patient was considered to be in- competent of providing such consent, sociodemographic data was recorded.

Then, the patient and a relative were interviewed to elicit information regarding the diagnosis, duration of illness, duration of drug treatment, mean daily dose of neuroleptics (in chlorpromazine equivalents) during the past week, change of drug dosages during the past 3 months, type of hallucinations, insight about the illness, and family history of schizophrenia.

Insight was clinically assessed by asking the patient about his/her awareness of the illness. Insight was classified as ‘absent’ (patient denying that he/she is ill and requires treatment), ‘present’ (patient admitting that he/ she suffers from a mental illness which requires medical management) and ‘partial’ (patient being aware that he/ she is ill, but does not know what the illness is or how it should be managed).

All patients were also assessed according to the follow- ing parameters:

• Brief Psychiatric Rating Scale (BPRS)¹⁵
• phenomenology of hallucinations¹¹
• attitude towards hallucinations.⁴

Phenomenology of hallucinations is assessed by a semistructured interview consisting of 15 items, each of which is scored from 1 to 3.¹¹ The scale measures various parameters of hallucinations, namely extent (frequency and duration), location, reality (current and past), sensory intensity, constancy, overt behaviour, control, time, ‘causal’, experience shared, and content/affect. A modified version of the scale has been reported to have good inter-rater reliability.⁴ The scale does not yield a total score. For the purpose of this study, the scale was administered as recom- mended but a total score signifying the overall severity of hallucination was also calculated, based on a restricted set of 9 items, which correlated to a significant extent with the raw total (15 items) on item-total analysis. The items, which contributed to the severity of hallucination score, were: frequency, duration, location, reality (current and past), sensory intensity, overt behaviour, ‘causal’, and content. The hallucination severity score therefore ranged from 9 to 27. Patient’s attitudes towards hallucinations⁴ are assessed by an 11-item scale. Each item is rated as 0 (not positive or only negative), 1 (both positive and negative), or 2 (positive only). A total score can be obtained by adding up item scores. The scores on attitudes towards hallucinations ranged from 0 to 22.

Student’s t test and analysis of variance (ANOVA) were used for group comparison. Pearson’s product moment coefficient of correlation was computed to examine the relationship between attitude score and other variables.

Results

Forty nine patients (65%) were male and 26 (35%) were female. Forty eight patients (64%) had married at some point in their lives and 27 (36%) were single. Six patients (8%) were professional or semi-professional. Thirteen patients (17%) belonged to the category of shop-owner/clerical/ farmer/skilled worker. Eleven patients (15%) were semi- skilled or unskilled workers. Forty five patients (60%) belonged to the category of unemployed/housewife/retired/ student.

Seventeen patients (23%) were educated up to primary level. Twenty six patients (35%) had completed 10 years of education, while 32 patients (43%) had completed 12 or more years of education.

Hindus formed a majority of the study group (66%). Fifty three percent of the patients lived in nuclear families and the majority of the patients (70%) lived in urban areas.

Sixty four percent of patients had the ‘paranoid’ sub- type of schizophrenia, while 28% had the ‘undifferentiated’ subtype. One patient (1.3%) each belonged to the categories of ‘hebephrenic’, ‘residual’, and ‘other’. Three patients (4.0%) were labelled as having ‘schizophrenia — not otherwise specified’.

The average duration of illness was just over 10 years (mean, 128.7 months; SD, 90.3 months). Mean BPRS score at the time of assessment was 44.7 (SD, 7.1). Patients had sought treatment approximately 28 months after the onset of illness and were receiving approximately 500 mg of neuro- leptics in chlorpromazine equivalents per day at the time of assessment (mean, 483.3 mg/day; SD, 312. 6 mg/day). The majority of patients had not been admitted to hospital during the course of their illness. Eighty percent had no family history of schizophrenia.

The majority of patients (76%) were hallucinating at the time of the study (last hallucination on the day of assessment). Auditory hallucinations alone were reported by 84% of patients. Auditory and visual hallucinations were reported by another 11% of patients. The mean score of hallucination severity was 19.8 (SD, 3.7). The mean attitude score was 3.20 (SD, 3.66).

Table 1 shows the distribution of responses to attitude variables concerning hallucinations. ‘Positive only’ res- ponses meant that patients expressed only positive attitudes. Nineteen percent of the patients found hallucinations to be useful as they provided company. None of patients felt that halluvAnations improved their relationships or financial conditions, or evoked positive reactions from others.

‘Negative only’ responses meant that patients expressed only negative attitudes towards their experiences. Impaired financial conditions were perceived to be the commonest adverse effects (95%). Ninety one percent of patients perceived that their hallucinations elicited unfavourable reactions from others. Decreased sexual interest/performance (87%), impaired relationships (81%), decreased (general) performance (77%), and poor self-concept (76%) were other adverse effects attributed to hallucinations. Sixty eight percent of patients expressed that hallucinations made them feel unprotected and tense.

‘Both positive and negative’ responses meant that patients were ambivalent about their feelings. Patients were ambi- valent regarding the utility of hallucination in providing com- panionship (36%), self-soothing (28%), and defensiveness (27%). Three percent of patients wanted the hallucinations to continue. Sixteen percent of patients were ambivalent about whether they wanted the hallucination to continue or stop. Eighty one percent of the patients wanted the hallucinations to stop. Two thirds of patients wanted them to stop even if they could control them.

When comparing the attitude scores of various socio- demographic subgroups, it was found that attitude score did not differ significantly amongst subgroups defined by gen- der, marital status, occupation, monthly income, educational status, family type, religion, and locality. Comparison of attitude scores among the groups subdivided according to various clinical characteristics revealed that attitude score did not differ significantly in the subgroup defined by diagnostic categories of schizophrenia, dose change during the past 3 months, number of admissions to hospital, family history of schizophrenia, time of last reported hallucination, and form of hallucination.

The majority of patients (85%) had ‘partial’ insight. Ten and five percent of patients were in ‘absent’ and ‘present’ insight categories, respectively. On correlating attitude scores with age and other clinical characteristics, it was seen that age, duration of illness, duration of treatment, mean dose of antipsychotic drugs (in chlorpromazine equivalents mg/day), total psychopathology (BPRS score), and individual para- meters of hallucinations (frequency, duration, location, reality [current and past], sensory intensity, constancy, overt behav- iour, control, time, ‘causal’, experience shared, content [noun], content [verb], reaction/affect) did not significantly correlate with total attitude score. Hallucination severity score also did not significantly correlate with attitude scores.

Discussion

The results indicate that patients with stable chronic schizo- phrenia whose continuing psychopathology included hallucinations held a largely negative attitude towards hallucinations (negative, 45 to 94%; positive, 0 to 14%). Our results differ from those of Miller et al, who had found a more favourable attitude towards hallucinations in patients from different diagnostic groups (negative, 48%; positive, 52%).⁴

A more positive attitude was elicited in the area of companionship (“Hallucinations provided them company”) for 19% of patients, which was similar to the report of Miller et al, who also reported most positive attitude in this area (28%).⁴ Reporting a high rate of positive attitude in the area of companionship poignantly highlights how even psychopathology may be preferable to the social isolation that a patient with chronic schizophrenia faces. Only 3% of patients definitely wanted their hallucinations to continue. Another 16% were ambivalent about it. However, a greater percentage may have wanted them to continue if they could control them (controlling attitude – positive, 9%; ambivalent, 24%). This reflects patients’ desire to manipulate the experience so that they could extract the desired benefit out of them.

Patients reported that hallucinations led to financial difficulties (95%), provoked bad reactions from others (91%), decreased their sexual performance (87%), and impaired their relationships (81%). Miller et al had reported negative attitudes in financial areas (94%), soothing effect (82%), performance (68%), and reaction of others (66%).⁴ The importance of negative reactions of significant others in the lives of hallucinating patients has also been emphasised by others¹².

Attitude scores did not correlate with any sociodemo- graphic or clinical factors, including total psychopathology. Attitude scores also did not correlate with any of the parameters of hallucinations or severity of hallucinations.

This perhaps means that attitude towards a particular experience is not determined by the experience itself or its strength per se.

In summary, this report highlights the preponderance of negative over positive attitudes towards hallucinations in chronic stable schizophrenia. Attitudes do not seem to be influenced by sociodemographic or clinical variables.

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