ORIGINAL ARTICLE
Brief Psychoeducation for Schizophrenia Primarily Intended to Change the Cognition of Auditory Hallucinations An Exploratory Study Nao Shiraishi, MD,* Norio Watanabe, MD, PhD,* Yoshihiro Kinoshita, MD, PhD,Þ Atsuko Kaneko, OT,þ Shinichi Yoshida, MD, PhD,þ Toshiaki A. Furukawa, MD, PhD,§ and Tatsuo Akechi, MD, PhD* Abstract: Auditory hallucinations and delusions are core symptoms of schizophrenia, which interact with each other. The attribution of auditory hallucinations to other people is considered to lead to secondary delusions. This study examined whether brief psychoeducation can change the cognition of auditory hallucinations, particularly, their attribution, and thus alleviate secondary delusions. Twenty-two schizophrenic patients with auditory hallucinations were recruited in this open study. The intervention consisted of five sessions during the course of 4 weeks. Outcome measures were used to assess delusions, beliefs about auditory hallucinations, and depression. At the end of the intervention, statistically significant reduction was observed in both delusions and depression. Beliefs about hallucinations showed statistically significant improvement in terms of malevolence, omnipotence, and resistance but not in terms of benevolence and engagement. In conclusion, the present study suggests that psychoeducation might be useful in reducing secondary delusions without exacerbating a depressive state. Key Words: Schizophrenia, psychoeducation, normalization, auditory hallucinations, secondary delusions. (J Nerv Ment Dis 2014;202: 35Y39)
BACKGROUND Psychoeducation is a useful method for providing support to persons with a mental disorder and their relatives. Knowledge conveyed with consideration for their psychological states enables them to cope with problems and troubles caused by mental disorders (Katsuki et al., 2011; Pitschel-Walz et al., 2001; Shimazu et al., 2011). Recent evidence has shown that psychoeducation for schizophrenia reduces the frequency of relapse and readmission and improves medication adherence (Xia et al., 2011). Auditory hallucinations and delusions are positive symptoms of schizophrenia, which influence each other. Recent studies in cognitive psychology have revealed that schizophrenic patients have a bias toward attributing their inner experiences to external sources (Baker and Morrison, 1998; Brebion et al., 2000; Moritz et al., 2010). As a consequence of auditory hallucinations attributed to external sources, certain delusions such as thought broadcasting and ideation of persecution and reference can develop as secondary delusions (Harada, 2001). Secondary delusions are defined as delusions that are *Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan; †Department of Psychiatry, Shinshu University School of Medicine, Matsumoto, Japan; ‡Shiseikai Yagoto Hospital, Nagoya, Japan; and §Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan. Dr Watanabe is now at the Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology & Psychiatry, Kodaira, Tokyo, Japan. Send reprint requests to Nao Shiraishi, MD, Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20201Y0035 DOI: 10.1097/NMD.0000000000000064
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understandable in the context of the patient’s background, current situation, and mental state (Jaspers, 1913). There is a relationship between the intrusiveness of hallucinations and the intensity of delusional beliefs (Hustig and Hafner, 1990). The attribution and intrusiveness of auditory hallucinations can cause patients to have the following beliefs about voices: malevolence, benevolence, omnipotence, resistance, and engagement. Of these, resistance and engagement relate to the behavioral response to auditory hallucinations (Chadwick and Birchwood, 1994, 1995). As an intervention to reevaluate their cognitions relating to the target symptoms, cognitive behavioral therapy (CBT) is clinically effective on positive symptoms (Wykes et al., 2008). Some CBT trials targeted auditory hallucinations (Penn et al., 2009; Trower et al., 2004), and psychoeducation was an essential and important component of those interventions. However, it could be practically difficult to provide CBT for all adaptable schizophrenic patients in terms of securing therapists and medical resources (Goldberg, 2006). In such a situation, psychoeducation that targets the cognition of auditory hallucination might be an effective, low-intensity intervention to improve positive symptoms. Despite the existence of various types of psychoeducation for schizophrenia, no study has evaluated the influence that the intervention in the cognition of auditory hallucinations has on secondary delusions. The present article, therefore, aimed to examine whether brief group psychoeducation changes the cognition of auditory hallucinations and alleviates secondary delusions. Our hypotheses are as follows: Psychoeducation (1) eliminates or alleviates secondary delusions and delusional ideations, (2) changes beliefs about voices, and (3) mitigates the severity of depression.
METHODS Participants Participants were recruited from March 2009 to July 2011, at an outpatient department in Shiseikai Yagoto Hospital, Japan. The inclusion criteria were outpatients (1) who were diagnosed with schizophrenia by psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; (2) aged between 18 and 64 years; and (3) with experience of auditory hallucinations. The diagnosis was checked on the medical records by one of the authors (N. S.). We excluded those without auditory hallucinations and those diagnosed with other psychotic disorders, organic mental disorders, or mental disorders due to psychoactive substance use. This study was approved by the Ethics Review Committee of Shiseikai Yagoto Hospital and was conducted in accordance with the principles of the Helsinki Declaration. Written informed consent was obtained from all participants after providing them with a thorough explanation of the purpose and the procedure of this study.
Procedure The study design was a single-arm clinical investigation. The psychoeducation consisted of five weekly group sessions (two or
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three participants), each lasting 60 minutes. The intervention was performed by two therapists (one psychiatrist and one occupational therapist). Each session was structured by using the detailed manual with checklists, which was developed by the authors and was based on two books (Harada, 2002; Wright et al., 2008). Harada’s book has been widely used for psychoeducation for schizophrenia in Japan. At the first session, we created the case formulations that focused on the situation just before the participants experienced the voices for the first time. The stressful situations were drawn out, accompanied by insomnia, isolation, and fatigue (the triad). At the second session, we explained that people could hear voices in a number of normal situations, for example, an experience of stranded mountain climbers. This was demonstrated by using the normalization approach (Kingdon and Turkington, 1991). Then, it was explained that these were stressful situations that could lead to hearing voices. Subsequently, we had the participants discover such stressful situations in their own formulations to change the attribution of auditory hallucinations. After that, it was pointed out that the voices were derived from their own mind (brain). At the third session, we illustrated that the voices had ‘‘bad influences (secondary delusions)’’ if the participants recognized these auditory hallucinations as voices of real persons. An example of the explanations was, ‘‘In stressful situations, people can be easily influenced by a suggestion, so if you perceived auditory hallucinations as real people’s voices, it was natural that you fell into the error of thinking that people could communicate telepathically.’’ Then, it was shown that believing in these bad influences without questioning leads to the creation of ‘‘the vicious circle’’ (Figure 1). Next, we had the participants apply their experiences to the model. At the fourth session, the participants were taught attitudes toward auditory hallucinations such as not attending to and not talking to them. On the basis of the attitudes taught, coping strategies were discussed for altering behavior that escalated stressful situations; during the fifth session, we suggested antipsychotic drugs as therapy to reduce individual susceptibility to stress. To minimize cointervention, the physicians in charge were asked not to increase the dosage of antipsychotic drugs until the end of the intervention, so long as the patient’s condition did not worsen. If an admission to the hospital occurred during the intervention, the psychoeducation was discontinued but the assessment of outcomes was maintained according to the original schedule.
FIGURE 1. ‘‘The vicious circle’’ caused by bad influences of the voices. 36
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Measures We used self-report questionnaires to evaluate delusions and delusional ideations, beliefs about auditory hallucinations, and the severity of depression at the first and last sessions of the intervention. Our primary outcome was the score of delusional ideations, which was assessed by using the Japanese version of the 21-Item Peters et al. Delusions Inventory (21-Item PDI; Peters et al., 2004). The 21-Item PDI is the short version of the PDI (Peters et al., 1999). The reliability and the validity of its Japanese version have been confirmed (Yamazaki et al., 2004). Significant correlations were found between the score of delusional ideations and positive symptom scores of the Positive and Negative Syndrome Scale (r = 0.41Y0.47, p G 0.05). We evaluated the patient’s status during the week before the assessment. Each item of the 21-Item PDI was answered with yes or no. The sum of yes answers was defined as the score of delusional ideations, which could range from 0 to 21. The 21 items were classified into 11 components: religiosity (items 8 and 11), persecution (items 4 and 5), grandiosity (items 6 and 7), paranormal beliefs (items 9 and 12), thought disturbance (items 18 and 20), suspiciousness (items 1 and 3), catastrophic ideation and thought broadcast (items 17 and 19), negative self (items 14 and 21), paranoid ideation (items 13 and 15), ideation of reference and influence (items 2 and 10), and depersonalization (item 16). Beliefs about auditory hallucinations were measured by the Japanese version of the Beliefs About Voices QuestionnaireYRevised (BAVQ-R; Chadwick et al., 2000). The BAVQ-R is a 35-item questionnaire of beliefs about auditory hallucinations with five subscales of malevolence, benevolence, omnipotence, resistance, and engagement. The reliability and the validity of the Japanese version have been demonstrated (Kaneda, 2008). We evaluated the patient’s status during the week before the assessment. Depression was measured by the Japanese version of the Beck Depression InventoryYII (BDI-II; Beck et al., 1996). The BDI-II is a 21-item questionnaire for assessing the severity of depression. The reliability and the validity of the Japanese version have been confirmed (Kojima et al., 2002). We also assessed the total amount of antipsychotic dose converted to chlorpromazine equivalent at the first and the last session of the intervention (Gardner et al., 2010).
Sample Size and Statistical Analyses Sixteen participants would be needed to detect a decrease of 1.5 points on the score of delusional ideations in the PDI with 80% power using a paired t-test at a 5% significance level, assuming an SD of differences of 1.51, which was based on our pilot study. The sample size was set at 20 to allow for a 20% dropout rate. We examined changes in scores on the 21-Item PDI, the BAVQ-R, the BDI-II, and the total amount of antipsychotic dose from baseline to the end of the intervention. Paired t-tests were used to determine changes in scores. All tests were two tailed, with the significance level set at 5%. We adopted the 5% significance level to avoid false-negative results because of the preliminary nature of this study. We compared the total number of the items to which the participants answered yes in each of the 11 components of the PDI-21 between baseline and the end of the intervention. The purpose of the comparison was to examine which types of delusional ideations were likely to diminish. To detect the change in the cognition about auditory hallucinations that influences the change in delusions and depression, stepwise multiple regression analyses (probability of F to enter, e0.50; to remove, Q0.10) were conducted. The pre-post changes in the score of delusional ideations in the PDI-21 and the BDI-II were used as the dependent variables; and the pre-post changes of the * 2014 Lippincott Williams & Wilkins
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TABLE 1. Patient Characteristics Education Compulsory High school Two-year college University Employment status Unemployed Sheltered Full-time Marriage status Unmarried Married Living status Living with family Living with live-in partner
n
%
2 10 6 4
9.1 45.5 27.3 18.2
20 1 1
90.9 4.5 4.5
19 3
86.4 13.6
20 2
90.9 9.1
five subscales in the BAVQ-R, as independent variables. Data were analyzed using the Statistical Package for the Social Sciences 20.0 for Windows.
RESULTS Participant Characteristics Twenty-five patients were approached; of these, 22 provided written informed consent to participate in the psychoeducation group. The proportion of male patients was 50%. The median age, duration of the disorder, and number of hospitalizations were 32.0 years (range, 18Y60), 57.5 months (range, 4Y336), and 1.0 (range, 0Y8), respectively. Table 1 presents the other baseline demographic characteristics of the participants. All participants attended all five sessions.
Outcomes Table 2 presents the main scores of the outcome variables. The score of delusional ideations in the 21-Item PDI showed statistically significant improvement from baseline to postintervention (baseline, 7.1 T 6.4; postintervention, 3.9 T 6.1; paired t = 3.7; p = 0.001). Table 3 reports the differences in the total number of the items to which the participants responded with yes in each of the 11 delusional components of the 21-Item PDI. The components were ranked in descending order of reduction rate: ideation of reference and influence (65%), persecution (63%), grandiosity (58%), suspiciousness (58%), catastrophic ideation and thought broadcast (50%), thought disturbance
Psychoeducation for Schizophrenia
(47%), negative self (40%), religiosity (33%), paranormal beliefs (25%), depersonalization (20%), and paranoid ideation (j11%). Among the five subscales of the BAVQ-R, malevolence, omnipotence, and resistance showed statistically significant improvements (baseline, 8.4 T 5.1; postintervention, 4.1 T 4.2; paired t = 4.5; p G 0.001; baseline, 7.8 T 5.0; postintervention, 4.7 T 4.1; paired t = 3.9; p = 0.001; and baseline, 15.3 T 7.2; postintervention, 11.3 T 6.2; paired t = 2.8; p = 0.012, respectively). The BDI-II also showed significant improvement (baseline, 20.6 T 13.3; after intervention, 16.0 T 11.9; paired t = 2.3; p G 0.034). The pre-post change for engagement in the BAVQ-R was significantly associated with the pre-post change in the score of delusional ideations in the 21-Item PDI: F(1,20) = 5.679, p = 0.027. The model explained 18.2% of the variance (adjusted R2 = 0.182). On the other hand, the pre-post change for malevolence in the BAVQ-R was significantly associated with the pre-post change in the severity of depression in the BDI-II: F(1,20) = 8.717, p = 0.008. The model explained 26.9% of the variance (adjusted R2 = 0.269). The total amount of the antipsychotic doses did not show significant increase from baseline to postintervention (baseline, 621 T 333 mg; after intervention, 603 T 327 mg, paired t = 1.6; p = 0.117).
DISCUSSION To our knowledge, this is the first study to evaluate the influence that intervening in the cognition of auditory hallucinations has on secondary delusions. The main finding can be summarized as follows. Brief psychoeducation targeting the cognition of auditory hallucinations might be useful in reducing secondary delusions and delusional ideations. It might be particularly effective for delusional experiences that are more susceptible to auditory hallucinations, such as ideation of reference and persecution. This study showed the association between the score of delusional ideations and the engagement in auditory hallucinations. From the standpoint of coping strategies related to beliefs about auditory hallucinations, resistance is related to the counteraction coping application, whereas engagement is related to the distraction coping application. Patients are unlikely to use distraction coping techniques against hallucinations with delusional features (Hayashi et al., 2007). This fact might mean that the development of secondary delusions is related to the intensity of the engagement. In the present study, the severity of depression also reduced, although psychoeducation had been indicated to have a risk for aggravating self-stigma and the depressive state of patients with schizophrenia by improving insight (Carroll et al., 1999; Cunningham Owens et al., 2001). Improvement of the beliefs about malevolent voices might attenuate their impact and mitigate the severity of depression. This speculation came from the fact that the severity of
TABLE 2. Differences in the Main Outcomes Between Baseline and Postintervention Baseline
21-Item PDI BAVQ-R Malevolence Benevolence Omnipotence Resistance Engagement BDI-II
Postintervention
Baseline to Postintervention Change
Mean
SD
Mean
SD
Mean
7.1
6.4
3.9
6.1
3.3
8.4 2.9 7.8 15.3 4.6 20.6
5.1 3.4 5.0 7.2 4.9 13.3
4.1 1.8 4.7 11.3 2.9 16.0
4.2 2.9 4.1 6.2 3.4 11.9
4.4 1.0 3.1 4.0 1.6 4.6
95% CI
1.4 to 5.1** 2.3 j0.3 1.5 1.0 j0.1 0.4
to to to to to to
6.4** 2.4 4.7** 7.1* 3.4 8.9*
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CI indicates confidence interval. *p G 0.05. **p G 0.01.
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TABLE 3. Differences in Each Delusional Component of the 21-Item PDI Between Baseline and Postintervention Components
Religiosity Persecution Grandiosity Paranormal beliefs Thought disturbance Suspiciousness Catastrophic ideation and thought broadcast Negative self Paranoid ideation Ideation of reference and influence Depersonalization
Items
Baseline
Postintervention
8 and 11 4 and 5 6 and 7 9 and 12 18 and 20 1 and 3 17 and 19
9 (5 + 4) 16 (7 + 9) 19 (10 + 9) 16 (9 + 7) 15 (9 + 6) 19 (12 + 7) 14 (6 + 8)
6 (3 + 3) 6 (3 + 3) 8 (4 + 4) 12 (7 + 5) 8 (5 + 3) 8 (3 + 5) 7 (3 + 4)
14 and 21 13 and 15 2 and 10
15 (9 + 6) 9 (4 + 5) 20 (11 + 9)
9 (5 + 4) 10 (4 + 6) 7 (3 + 4)
16
5
4
Numbers in parentheses note the sum of each item to which the participants responded with yes.
depression was associated with the malevolence of voices. Indeed, negative voice contents are related to an increase in the severity of depression (Beavan and Read, 2010). Moreover, the appraisal of the voice contents, particularly malevolent belief, is linked to the severity of depression (van der Gaag et al., 2003). We must note several limitations in the present study. First, the performance by the dependent therapists in the study did not guarantee general feasibility or the same results. However, external validity and fidelity of the intervention could be maximized by structuring each session by using the detailed manual. Second, although we had a choice to adopt blinded assessment by independent raters, we used self-report questionnaires for the assessment. There are known limitations of self-report questionnaires such as the acquiescence set and reactivity. Nevertheless, we prioritized such questionnaires for our purpose because these were more effective for assessing comprehensive categories of delusions than were objective scales. Third, this study has obvious limitations due to its preliminary nature. There was no control group, and the sample size was small. In addition, we evaluated the outcomes immediately after the end of the intervention. Long-term consequences should be assessed in future studies.
CONCLUSIONS The present study suggests that brief psychoeducation for schizophrenia might be useful in reducing the intensity of secondary delusions caused by auditory hallucinations without exacerbating a depressive state. DISCLOSURES This study was supported by Shiseikai Yagoto Hospital and the Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences. Nao Shiraishi has received research fund from Aichi Health Promotion Foundation. He has also received a speaking fee from Eli Lilly and a royalty from Seiwa-Shoten. Norio Watanabe has received research funds (no. 10103220) from the Japanese Ministry of Health Labor and Welfare and the Japanese Ministry of Education, Science and Technology. He has also received speaking fees and research funds from Asahi Kasei, Dai-Nippon Sumitomo, Eli Lilly, GlaxoSimthKline, Janssen, Otsuka, Pfizer, and Schering-Plough. Yoshihiro Kinoshita, Atsuko Kaneko, and Shinichi Yoshida have no conflicts of interest to declare. Tatsuo Akechi has received research funds from the Japanese Ministry of Health Labor and Welfare and the Japanese Ministry of 38
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Education, Science and Technology. He has also received research funds and speaking fees from Astellas, AstraZeneca, Dai-Nippon Sumitomo, GlaxoSmithKline, Meiji, Otsuka, Pfizer, SanofiAventis, Shionogi, and Takeda. He has received royalties from Igaku-Shoin, Nanzando, Chugai-igakusya, Iyaku-Journal, Seiwa-Shoten, Sozo-Shuppan, Nippon Hoso Kyokai, and Health Publishing. Toshiaki A. Furukawa has received honoraria for speaking at CME meetings sponsored by Asahi Kasei, Eli Lilly, GlaxoSmithKline, Kyorin, Meiji, Mochida, MSD, Otsuka, Pfizer, Shionogi, and Tanabe-Mitsubishi. He has received royalties from Igaku-Shoin, Seiwa-Shoten, and Nihon Bunka Kagaku-sha. He is on the advisory board for Sekisui Chemicals and Takeda Science Foundation. The Japanese Ministry of Education, Science, and Technology; the Japanese Ministry of Health, Labor and Welfare; and the Japan Foundation for Neuroscience and Mental Health have funded his research projects.
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Penn DL, Meyer PS, Evans E, Wirth RJ, Cai K, Burchinal M (2009) A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations. Schizophr Res. 109:52Y59. Peters E, Joseph S, Day S, Garety P (2004) Measuring delusional ideation: The 21-item Peters et al. Delusions Inventory (PDI). Schizophr Bull. 30: 1005Y1022. Peters ER, Joseph SA, Garety PA (1999) Measurement of delusional ideation in the normal population: Introducing the PDI (Peters et al. Delusions Inventory). Schizophr Bull. 25:553Y576. Pitschel-Walz G, Leucht S, Bauml J, Kissling W, Engel RR (2001) The effect of family interventions on relapse and rehospitalization in schizophreniaVA meta-analysis. Schizophr Bull. 27:73Y92. Shimazu K, Shimodera S, Mino Y, Nishida A, Kamimura N, Sawada K, Fujita H, Furukawa TA, Inoue S (2011) Family psychoeducation for major depression: randomised controlled trial. Br J Psychiatry. 198:385Y390.
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Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Ross K (2004) Cognitive therapy for command hallucinations: Randomised controlled trial. Br J Psychiatry. 184:312Y320. van der Gaag M, Hageman MC, Birchwood M (2003) Evidence for a cognitive model of auditory hallucinations. J Nerv Ment Dis. 191:542Y545. Wright JH, Turkington D, Kingdon DG, Basco MR (2008) Cognitive-behavior therapy for severe mental illness: An illustrated guide. Washington, DC: American Psychiatric Publishing. Wykes T, Steel C, Everitt B, Tarrier N (2008) Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophr Bull. 34:523Y537. Xia J, Merinder LB, Belgamwar MR (2011) Psychoeducation for schizophrenia. Cochrane Database Syst Rev. 15:CD002831. Yamazaki S, Tanaka S, Morimoto S (2004) Raliability and validity of the Japanese version of PDI (Peters et al Delusions Inventory). Rinsho Shinkeigaku. 33:911Y918.
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Brief Psychoeducation for Schizophrenia Primarily Intended to Change the Cognition of Auditory Hallucinations An Exploratory Study Nao Shiraishi, MD,* Norio Watanabe, MD, PhD,* Yoshihiro Kinoshita, MD, PhD,Þ Atsuko Kaneko, OT,þ Shinichi Yoshida, MD, PhD,þ Toshiaki A. Furukawa, MD, PhD,§ and Tatsuo Akechi, MD, PhD* Abstract: Auditory hallucinations and delusions are core symptoms of schizophrenia, which interact with each other. The attribution of auditory hallucinations to other people is considered to lead to secondary delusions. This study examined whether brief psychoeducation can change the cognition of auditory hallucinations, particularly, their attribution, and thus alleviate secondary delusions. Twenty-two schizophrenic patients with auditory hallucinations were recruited in this open study. The intervention consisted of five sessions during the course of 4 weeks. Outcome measures were used to assess delusions, beliefs about auditory hallucinations, and depression. At the end of the intervention, statistically significant reduction was observed in both delusions and depression. Beliefs about hallucinations showed statistically significant improvement in terms of malevolence, omnipotence, and resistance but not in terms of benevolence and engagement. In conclusion, the present study suggests that psychoeducation might be useful in reducing secondary delusions without exacerbating a depressive state. Key Words: Schizophrenia, psychoeducation, normalization, auditory hallucinations, secondary delusions. (J Nerv Ment Dis 2014;202: 35Y39)
BACKGROUND Psychoeducation is a useful method for providing support to persons with a mental disorder and their relatives. Knowledge conveyed with consideration for their psychological states enables them to cope with problems and troubles caused by mental disorders (Katsuki et al., 2011; Pitschel-Walz et al., 2001; Shimazu et al., 2011). Recent evidence has shown that psychoeducation for schizophrenia reduces the frequency of relapse and readmission and improves medication adherence (Xia et al., 2011). Auditory hallucinations and delusions are positive symptoms of schizophrenia, which influence each other. Recent studies in cognitive psychology have revealed that schizophrenic patients have a bias toward attributing their inner experiences to external sources (Baker and Morrison, 1998; Brebion et al., 2000; Moritz et al., 2010). As a consequence of auditory hallucinations attributed to external sources, certain delusions such as thought broadcasting and ideation of persecution and reference can develop as secondary delusions (Harada, 2001). Secondary delusions are defined as delusions that are *Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan; †Department of Psychiatry, Shinshu University School of Medicine, Matsumoto, Japan; ‡Shiseikai Yagoto Hospital, Nagoya, Japan; and §Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan. Dr Watanabe is now at the Department of Clinical Epidemiology, Translational Medical Center, National Center of Neurology & Psychiatry, Kodaira, Tokyo, Japan. Send reprint requests to Nao Shiraishi, MD, Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601 Japan. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20201Y0035 DOI: 10.1097/NMD.0000000000000064
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understandable in the context of the patient’s background, current situation, and mental state (Jaspers, 1913). There is a relationship between the intrusiveness of hallucinations and the intensity of delusional beliefs (Hustig and Hafner, 1990). The attribution and intrusiveness of auditory hallucinations can cause patients to have the following beliefs about voices: malevolence, benevolence, omnipotence, resistance, and engagement. Of these, resistance and engagement relate to the behavioral response to auditory hallucinations (Chadwick and Birchwood, 1994, 1995). As an intervention to reevaluate their cognitions relating to the target symptoms, cognitive behavioral therapy (CBT) is clinically effective on positive symptoms (Wykes et al., 2008). Some CBT trials targeted auditory hallucinations (Penn et al., 2009; Trower et al., 2004), and psychoeducation was an essential and important component of those interventions. However, it could be practically difficult to provide CBT for all adaptable schizophrenic patients in terms of securing therapists and medical resources (Goldberg, 2006). In such a situation, psychoeducation that targets the cognition of auditory hallucination might be an effective, low-intensity intervention to improve positive symptoms. Despite the existence of various types of psychoeducation for schizophrenia, no study has evaluated the influence that the intervention in the cognition of auditory hallucinations has on secondary delusions. The present article, therefore, aimed to examine whether brief group psychoeducation changes the cognition of auditory hallucinations and alleviates secondary delusions. Our hypotheses are as follows: Psychoeducation (1) eliminates or alleviates secondary delusions and delusional ideations, (2) changes beliefs about voices, and (3) mitigates the severity of depression.
METHODS Participants Participants were recruited from March 2009 to July 2011, at an outpatient department in Shiseikai Yagoto Hospital, Japan. The inclusion criteria were outpatients (1) who were diagnosed with schizophrenia by psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; (2) aged between 18 and 64 years; and (3) with experience of auditory hallucinations. The diagnosis was checked on the medical records by one of the authors (N. S.). We excluded those without auditory hallucinations and those diagnosed with other psychotic disorders, organic mental disorders, or mental disorders due to psychoactive substance use. This study was approved by the Ethics Review Committee of Shiseikai Yagoto Hospital and was conducted in accordance with the principles of the Helsinki Declaration. Written informed consent was obtained from all participants after providing them with a thorough explanation of the purpose and the procedure of this study.
Procedure The study design was a single-arm clinical investigation. The psychoeducation consisted of five weekly group sessions (two or
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three participants), each lasting 60 minutes. The intervention was performed by two therapists (one psychiatrist and one occupational therapist). Each session was structured by using the detailed manual with checklists, which was developed by the authors and was based on two books (Harada, 2002; Wright et al., 2008). Harada’s book has been widely used for psychoeducation for schizophrenia in Japan. At the first session, we created the case formulations that focused on the situation just before the participants experienced the voices for the first time. The stressful situations were drawn out, accompanied by insomnia, isolation, and fatigue (the triad). At the second session, we explained that people could hear voices in a number of normal situations, for example, an experience of stranded mountain climbers. This was demonstrated by using the normalization approach (Kingdon and Turkington, 1991). Then, it was explained that these were stressful situations that could lead to hearing voices. Subsequently, we had the participants discover such stressful situations in their own formulations to change the attribution of auditory hallucinations. After that, it was pointed out that the voices were derived from their own mind (brain). At the third session, we illustrated that the voices had ‘‘bad influences (secondary delusions)’’ if the participants recognized these auditory hallucinations as voices of real persons. An example of the explanations was, ‘‘In stressful situations, people can be easily influenced by a suggestion, so if you perceived auditory hallucinations as real people’s voices, it was natural that you fell into the error of thinking that people could communicate telepathically.’’ Then, it was shown that believing in these bad influences without questioning leads to the creation of ‘‘the vicious circle’’ (Figure 1). Next, we had the participants apply their experiences to the model. At the fourth session, the participants were taught attitudes toward auditory hallucinations such as not attending to and not talking to them. On the basis of the attitudes taught, coping strategies were discussed for altering behavior that escalated stressful situations; during the fifth session, we suggested antipsychotic drugs as therapy to reduce individual susceptibility to stress. To minimize cointervention, the physicians in charge were asked not to increase the dosage of antipsychotic drugs until the end of the intervention, so long as the patient’s condition did not worsen. If an admission to the hospital occurred during the intervention, the psychoeducation was discontinued but the assessment of outcomes was maintained according to the original schedule.
FIGURE 1. ‘‘The vicious circle’’ caused by bad influences of the voices. 36
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Measures We used self-report questionnaires to evaluate delusions and delusional ideations, beliefs about auditory hallucinations, and the severity of depression at the first and last sessions of the intervention. Our primary outcome was the score of delusional ideations, which was assessed by using the Japanese version of the 21-Item Peters et al. Delusions Inventory (21-Item PDI; Peters et al., 2004). The 21-Item PDI is the short version of the PDI (Peters et al., 1999). The reliability and the validity of its Japanese version have been confirmed (Yamazaki et al., 2004). Significant correlations were found between the score of delusional ideations and positive symptom scores of the Positive and Negative Syndrome Scale (r = 0.41Y0.47, p G 0.05). We evaluated the patient’s status during the week before the assessment. Each item of the 21-Item PDI was answered with yes or no. The sum of yes answers was defined as the score of delusional ideations, which could range from 0 to 21. The 21 items were classified into 11 components: religiosity (items 8 and 11), persecution (items 4 and 5), grandiosity (items 6 and 7), paranormal beliefs (items 9 and 12), thought disturbance (items 18 and 20), suspiciousness (items 1 and 3), catastrophic ideation and thought broadcast (items 17 and 19), negative self (items 14 and 21), paranoid ideation (items 13 and 15), ideation of reference and influence (items 2 and 10), and depersonalization (item 16). Beliefs about auditory hallucinations were measured by the Japanese version of the Beliefs About Voices QuestionnaireYRevised (BAVQ-R; Chadwick et al., 2000). The BAVQ-R is a 35-item questionnaire of beliefs about auditory hallucinations with five subscales of malevolence, benevolence, omnipotence, resistance, and engagement. The reliability and the validity of the Japanese version have been demonstrated (Kaneda, 2008). We evaluated the patient’s status during the week before the assessment. Depression was measured by the Japanese version of the Beck Depression InventoryYII (BDI-II; Beck et al., 1996). The BDI-II is a 21-item questionnaire for assessing the severity of depression. The reliability and the validity of the Japanese version have been confirmed (Kojima et al., 2002). We also assessed the total amount of antipsychotic dose converted to chlorpromazine equivalent at the first and the last session of the intervention (Gardner et al., 2010).
Sample Size and Statistical Analyses Sixteen participants would be needed to detect a decrease of 1.5 points on the score of delusional ideations in the PDI with 80% power using a paired t-test at a 5% significance level, assuming an SD of differences of 1.51, which was based on our pilot study. The sample size was set at 20 to allow for a 20% dropout rate. We examined changes in scores on the 21-Item PDI, the BAVQ-R, the BDI-II, and the total amount of antipsychotic dose from baseline to the end of the intervention. Paired t-tests were used to determine changes in scores. All tests were two tailed, with the significance level set at 5%. We adopted the 5% significance level to avoid false-negative results because of the preliminary nature of this study. We compared the total number of the items to which the participants answered yes in each of the 11 components of the PDI-21 between baseline and the end of the intervention. The purpose of the comparison was to examine which types of delusional ideations were likely to diminish. To detect the change in the cognition about auditory hallucinations that influences the change in delusions and depression, stepwise multiple regression analyses (probability of F to enter, e0.50; to remove, Q0.10) were conducted. The pre-post changes in the score of delusional ideations in the PDI-21 and the BDI-II were used as the dependent variables; and the pre-post changes of the * 2014 Lippincott Williams & Wilkins
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TABLE 1. Patient Characteristics Education Compulsory High school Two-year college University Employment status Unemployed Sheltered Full-time Marriage status Unmarried Married Living status Living with family Living with live-in partner
n
%
2 10 6 4
9.1 45.5 27.3 18.2
20 1 1
90.9 4.5 4.5
19 3
86.4 13.6
20 2
90.9 9.1
five subscales in the BAVQ-R, as independent variables. Data were analyzed using the Statistical Package for the Social Sciences 20.0 for Windows.
RESULTS Participant Characteristics Twenty-five patients were approached; of these, 22 provided written informed consent to participate in the psychoeducation group. The proportion of male patients was 50%. The median age, duration of the disorder, and number of hospitalizations were 32.0 years (range, 18Y60), 57.5 months (range, 4Y336), and 1.0 (range, 0Y8), respectively. Table 1 presents the other baseline demographic characteristics of the participants. All participants attended all five sessions.
Outcomes Table 2 presents the main scores of the outcome variables. The score of delusional ideations in the 21-Item PDI showed statistically significant improvement from baseline to postintervention (baseline, 7.1 T 6.4; postintervention, 3.9 T 6.1; paired t = 3.7; p = 0.001). Table 3 reports the differences in the total number of the items to which the participants responded with yes in each of the 11 delusional components of the 21-Item PDI. The components were ranked in descending order of reduction rate: ideation of reference and influence (65%), persecution (63%), grandiosity (58%), suspiciousness (58%), catastrophic ideation and thought broadcast (50%), thought disturbance
Psychoeducation for Schizophrenia
(47%), negative self (40%), religiosity (33%), paranormal beliefs (25%), depersonalization (20%), and paranoid ideation (j11%). Among the five subscales of the BAVQ-R, malevolence, omnipotence, and resistance showed statistically significant improvements (baseline, 8.4 T 5.1; postintervention, 4.1 T 4.2; paired t = 4.5; p G 0.001; baseline, 7.8 T 5.0; postintervention, 4.7 T 4.1; paired t = 3.9; p = 0.001; and baseline, 15.3 T 7.2; postintervention, 11.3 T 6.2; paired t = 2.8; p = 0.012, respectively). The BDI-II also showed significant improvement (baseline, 20.6 T 13.3; after intervention, 16.0 T 11.9; paired t = 2.3; p G 0.034). The pre-post change for engagement in the BAVQ-R was significantly associated with the pre-post change in the score of delusional ideations in the 21-Item PDI: F(1,20) = 5.679, p = 0.027. The model explained 18.2% of the variance (adjusted R2 = 0.182). On the other hand, the pre-post change for malevolence in the BAVQ-R was significantly associated with the pre-post change in the severity of depression in the BDI-II: F(1,20) = 8.717, p = 0.008. The model explained 26.9% of the variance (adjusted R2 = 0.269). The total amount of the antipsychotic doses did not show significant increase from baseline to postintervention (baseline, 621 T 333 mg; after intervention, 603 T 327 mg, paired t = 1.6; p = 0.117).
DISCUSSION To our knowledge, this is the first study to evaluate the influence that intervening in the cognition of auditory hallucinations has on secondary delusions. The main finding can be summarized as follows. Brief psychoeducation targeting the cognition of auditory hallucinations might be useful in reducing secondary delusions and delusional ideations. It might be particularly effective for delusional experiences that are more susceptible to auditory hallucinations, such as ideation of reference and persecution. This study showed the association between the score of delusional ideations and the engagement in auditory hallucinations. From the standpoint of coping strategies related to beliefs about auditory hallucinations, resistance is related to the counteraction coping application, whereas engagement is related to the distraction coping application. Patients are unlikely to use distraction coping techniques against hallucinations with delusional features (Hayashi et al., 2007). This fact might mean that the development of secondary delusions is related to the intensity of the engagement. In the present study, the severity of depression also reduced, although psychoeducation had been indicated to have a risk for aggravating self-stigma and the depressive state of patients with schizophrenia by improving insight (Carroll et al., 1999; Cunningham Owens et al., 2001). Improvement of the beliefs about malevolent voices might attenuate their impact and mitigate the severity of depression. This speculation came from the fact that the severity of
TABLE 2. Differences in the Main Outcomes Between Baseline and Postintervention Baseline
21-Item PDI BAVQ-R Malevolence Benevolence Omnipotence Resistance Engagement BDI-II
Postintervention
Baseline to Postintervention Change
Mean
SD
Mean
SD
Mean
7.1
6.4
3.9
6.1
3.3
8.4 2.9 7.8 15.3 4.6 20.6
5.1 3.4 5.0 7.2 4.9 13.3
4.1 1.8 4.7 11.3 2.9 16.0
4.2 2.9 4.1 6.2 3.4 11.9
4.4 1.0 3.1 4.0 1.6 4.6
95% CI
1.4 to 5.1** 2.3 j0.3 1.5 1.0 j0.1 0.4
to to to to to to
6.4** 2.4 4.7** 7.1* 3.4 8.9*
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CI indicates confidence interval. *p G 0.05. **p G 0.01.
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TABLE 3. Differences in Each Delusional Component of the 21-Item PDI Between Baseline and Postintervention Components
Religiosity Persecution Grandiosity Paranormal beliefs Thought disturbance Suspiciousness Catastrophic ideation and thought broadcast Negative self Paranoid ideation Ideation of reference and influence Depersonalization
Items
Baseline
Postintervention
8 and 11 4 and 5 6 and 7 9 and 12 18 and 20 1 and 3 17 and 19
9 (5 + 4) 16 (7 + 9) 19 (10 + 9) 16 (9 + 7) 15 (9 + 6) 19 (12 + 7) 14 (6 + 8)
6 (3 + 3) 6 (3 + 3) 8 (4 + 4) 12 (7 + 5) 8 (5 + 3) 8 (3 + 5) 7 (3 + 4)
14 and 21 13 and 15 2 and 10
15 (9 + 6) 9 (4 + 5) 20 (11 + 9)
9 (5 + 4) 10 (4 + 6) 7 (3 + 4)
16
5
4
Numbers in parentheses note the sum of each item to which the participants responded with yes.
depression was associated with the malevolence of voices. Indeed, negative voice contents are related to an increase in the severity of depression (Beavan and Read, 2010). Moreover, the appraisal of the voice contents, particularly malevolent belief, is linked to the severity of depression (van der Gaag et al., 2003). We must note several limitations in the present study. First, the performance by the dependent therapists in the study did not guarantee general feasibility or the same results. However, external validity and fidelity of the intervention could be maximized by structuring each session by using the detailed manual. Second, although we had a choice to adopt blinded assessment by independent raters, we used self-report questionnaires for the assessment. There are known limitations of self-report questionnaires such as the acquiescence set and reactivity. Nevertheless, we prioritized such questionnaires for our purpose because these were more effective for assessing comprehensive categories of delusions than were objective scales. Third, this study has obvious limitations due to its preliminary nature. There was no control group, and the sample size was small. In addition, we evaluated the outcomes immediately after the end of the intervention. Long-term consequences should be assessed in future studies.
CONCLUSIONS The present study suggests that brief psychoeducation for schizophrenia might be useful in reducing the intensity of secondary delusions caused by auditory hallucinations without exacerbating a depressive state. DISCLOSURES This study was supported by Shiseikai Yagoto Hospital and the Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences. Nao Shiraishi has received research fund from Aichi Health Promotion Foundation. He has also received a speaking fee from Eli Lilly and a royalty from Seiwa-Shoten. Norio Watanabe has received research funds (no. 10103220) from the Japanese Ministry of Health Labor and Welfare and the Japanese Ministry of Education, Science and Technology. He has also received speaking fees and research funds from Asahi Kasei, Dai-Nippon Sumitomo, Eli Lilly, GlaxoSimthKline, Janssen, Otsuka, Pfizer, and Schering-Plough. Yoshihiro Kinoshita, Atsuko Kaneko, and Shinichi Yoshida have no conflicts of interest to declare. Tatsuo Akechi has received research funds from the Japanese Ministry of Health Labor and Welfare and the Japanese Ministry of 38
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Education, Science and Technology. He has also received research funds and speaking fees from Astellas, AstraZeneca, Dai-Nippon Sumitomo, GlaxoSmithKline, Meiji, Otsuka, Pfizer, SanofiAventis, Shionogi, and Takeda. He has received royalties from Igaku-Shoin, Nanzando, Chugai-igakusya, Iyaku-Journal, Seiwa-Shoten, Sozo-Shuppan, Nippon Hoso Kyokai, and Health Publishing. Toshiaki A. Furukawa has received honoraria for speaking at CME meetings sponsored by Asahi Kasei, Eli Lilly, GlaxoSmithKline, Kyorin, Meiji, Mochida, MSD, Otsuka, Pfizer, Shionogi, and Tanabe-Mitsubishi. He has received royalties from Igaku-Shoin, Seiwa-Shoten, and Nihon Bunka Kagaku-sha. He is on the advisory board for Sekisui Chemicals and Takeda Science Foundation. The Japanese Ministry of Education, Science, and Technology; the Japanese Ministry of Health, Labor and Welfare; and the Japan Foundation for Neuroscience and Mental Health have funded his research projects.
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