Role of coping strategies and attitudes in mediating distress due to hallucinations in schizophrenia
address: Dr Gagandeep Singh, Department of Psychiatry, Government Medical College and Hospital, Chandigarh 160030, India.
The purpose of the present study was to determine the role of coping strategies and attitudes in predicting distress due to hallucinations in schizophrenia. Seventy-five chronic stable schizophrenia patients were assessed with respect to sociodemographic profile, clinical variables, general psychopathology, phenomenology (severity) of hallucinations, attitude towards hallucinations, distress due to hallucinations (determined by two measures) and coping strategies used to deal with hallucinations. On multiple stepwise regression analysis, ‘severity of hallucinations’ and ‘problem-solving coping strategies’ contributed significantly to both measures of distress. It can be concluded that distress due to hallucinations in schizophrenia is determined by severity of hallucinations (stressor) and problem-solving coping strategies. Attitudes do not seem to play any role in this respect.
Research on stress in schizophrenia patients has shifted from stressors external to the patients1,2 to symptoms that patients experience.3 Hallucinations have been reported to be a source of continuous stress to patients of schizophrenia. Different attitudes adopted by patients towards hallucination and coping strategies used by them have been demonstrated to affect the distress caused by hallucinations in some studies.4–10
Duration of illness (acute vs chronic)7,9 and various parameters of hallucinations such as persistence despite treatment,8 lack of perceived control over it,7,9 interference in occupation7,9 and content (unpleasant)7 have been reported to be determinants of distress.
Sixty to 90 percent of hallucinating schizophrenia patients use specific coping strategies.4,7,11,12 Strategies vary from 1–2 to 13.4 per patient depending upon the assessment method used to elicit coping responses.10,11 More distressed patients use a greater number of coping strategies.10 Counterintuitively it is observed that patients who stated that they would miss voices (had positive attitudes) employed more coping strategies than those who said they would not.4
Depending upon the method of assessment, 30–90% of patients identified their coping strategies to be useful.4,5,13 Patients reported strategies of singing, humming, playing instruments, praying and meditating and use of alcohol as useful in dealing with hallucinations.4,8,10 Nayani and David reported that patients with a greater number of coping strategies were less distressed.7 This finding was not replicated in other studies.4 Perceived usefulness of coping strategies was not found to be influenced by attitudes towards hallucinations.4
Hallucinatory experience may be described as positive, negative or neutral.14 Investigators have reported that hallucination made patients feel privileged, relieved their boredom, amused them, acted as a guide, provided an outlet for anxiety, relieved unpleasant affect, served a protective or companionship function, helped in integrating trauma, strengthened and stimulated them.15–19 In contrast, some investigators have described voices to be perceived as threatening, accusing, reproving, hurting, freezing, disgracing or intruding.17 Romme and Escher found that 93% of their hallucinating sample reported that hallucinatory voices had a negative impact on their lives.19 Miller et al. found that 52% of patients reported that hallucinations had some positive effect and 12% of patients wanted the hallucinations to continue because they were perceived to be useful, while 98% of hallucinating patients stated that hallucination also had some adverse effects on their lives, consequently 68% wanted these to stop.17 Attitude variables were not influenced by sociodemographic variables or clinical variables such as diagnostic category, duration of illness, length of treatment or hospital stay.
Researchers in this area for the most part have conducted descriptive research. Barring a few studies, most work to date has stopped short of adopting a consistent theoretical paradigm. Such a paradigm is necessary for choosing an appropriate set of relevant variables for study, and also to generate directional hypothesis, which further research can test. The present study is based itself on the stress-coping paradigm.
In accordance with requirements of the paradigm the following variables form the central set: hallucinations (stress), attitudes towards hallucinations, coping strategies used to deal with hallucinations and distress due to hallucinations. Other variables, which may affect the level of distress, namely sociodemographic factors, illness and treatment-related factors (e.g. general psychopathology and dose of psychotropic drugs) were included in the study to characterize the confound that they may introduce in interpretation of results.
All first-contact schizophrenia patients diagnosed according to International Classification of Diseases and Related Health Problems (10th revision; ICD-10) criteria in the outpatient psychiatric clinic of the Department of Psychiatry at Postgraduate Institute of Medical Education and Research were screened and those who fulfilled the inclusion criteria of our research project were taken up for the present study.
Inclusion criteria were a definite diagnosis of schizophrenia according to ICD diagnostic criteria for research (ICD-DCR) diagnostic guidelines, duration of illness >2 years, clinical stability for at least 3 months prior to assessment (absence of exacerbation of illness requiring increase in drug dosages by ≥50%) and presence of hallucinations (in any modality) reported in the last 3 months. Patients with any other major chronic illness, organic brain disease and substance abuse were excluded. Written informed consent for inclusion in the present study was obtained from the patient or an adult relative in cases where the patient was considered unfit for providing an informed consent.
Sociodemographic and clinical details (i.e. diagnosis, duration of illness, mean daily dose of neuroleptics in chlorpromazine equivalents over the week immediately preceding assessment, change of neuroleptic dose in the last 3 months, modality of hallucination, last hallucination reported, number of hospitalizations and family history of schizophrenia) were recorded. The patients were then assessed with the following instruments: Brief Psychiatric Rating Scale (BPRS),20 Phenomenology of Hallucination,14 Patient's Attitudes towards Hallucinations,17 Distress due to Hallucination Scale, and Instrument for Assessment of Coping Behavior.21
Phenomenology of hallucinations is a semistructured interview consisting of 15 items, each of which is scored from 1 to 3.14 It measures various parameters of hallucinations, namely extent (frequency and duration), location, reality (current and past), sensory intensity, constancy, overt behavior, control, time, causal, experience shared, content/affect. A modified version of the scale was reported to have good interrater reliability.17 The instrument does not yield a total score. For the purpose of present study a total score signifying the overall severity of hallucinations was calculated, based on a restricted set of items (nine in number), which correlated to a significant extent with raw total (15 items) on item-total analysis. The items that contributed to the total (severity of hallucination) score were: frequency, duration, location, reality (current and past), sensory intensity, overt behavior, causal and content (verb).
Patient's Attitudes towards Hallucinations is an 11-item scale.17 Each item is rated as 0, ‘not positive or only negative’; 1, ‘both positive and negative’; or 2, ‘positive only’. The scale was found to have good interrater reliability by the authors.
Distress due to Hallucinations Scale was specially prepared for the present study. This scale was modified from the Postgraduate Institute (PGI) Health Questionnaire N2 (PGI N2).22 The original scale consisted of 60 items and is used as a self-report measure of neuroticism. For the present study 25 items were selected by the three experts (two consultant psychiatrists and one consultant psychologist (clinical)) as capable of rating distress due to hallucinations. Only these items were administered to the patients. To obtain a measure of total distress, these items were subjected to an item–total correlation using the E1/3 method. Twenty-four items contributed significantly to the total score. Crohnbach's α to test reliability of the scale yielded a value of 0.74. Additionally, distress was also measured by a single item (Instrument for Assessment of Coping Behavior), which measures distress on a 0–4 scale.
Instrument for Assessment of Coping Behavior (IKB) is a structured interview that assesses coping strategies in schizophrenic patients for various complaints.21 Degree of perceived stress is rated from 0 (no stress) to 4 (high stress). The instrument is reported to have good interrater reliability. Kumar et al. performed a principal component analysis on coping strategies used by 53 schizophrenic patients.6 It yielded a four-factor solution: problem-solving, diversion, avoidance and help-seeking. This grouping was used for descriptive and analytic purposes in the present study. Each question on coping was asked in relation to hallucination as the stressor.
Pearson's product moment coefficient of correlation was computed to examine the relationship between the two measures of distress and various independent variables (total hallucination severity scores, score on parameters of hallucination that did not contribute significantly to the total score on item total analysis, total attitude score, total coping strategies scores and scores on four factor of coping strategies). Multiple linear stepwise regression was used to identify the truly significant predictors of distress due to hallucinations. All independent variables (duration of illness, dose of neuroleptics, general psychopathology scores, individual parameters of hallucinations, severity of hallucinations score, attitudes scores, total coping strategies scores and scores on four factors of coping strategies) were fed into a multiple linear stepwise regression analysis with two measures of distress as dependent variables.
The study sample consisted of 75 patients of schizophrenia. The majority of the patients were male (65%), married (64%) and Hindu (66%). Most (53%) were from nuclear families and from an urban locality (70.6%). The majority of patients were not earning (60%; unemployed, housewives, retired or students).
Average duration of illness was >10 years (mean: 128.73 ± 70.31 months). Patients had sought treatment on average approximately 28 months after onset of illness and were receiving approximately 500 mg of neuroleptics in chlorpromazine equivalents per day at the time of assessment (mean 483.33 ± 321.56 mg). Sixty-four percent of patients were diagnosed to have paranoid schizophrenia. Medication dosage had not been changed by more than 25% of the initial dose in 80% of the patients in 3 months prior to the assessment. The majority of patients (76%) had experienced hallucinations on the day of assessment. Auditory hallucinations alone were reported by 84% of patients. Both auditory and visual hallucinations were reported by 11% of patients. A majority of patients had never been hospitalized in the course of their illness. Eighty percent of the patients had no family history of any psychiatric illness.
The mean scores on various psychological tests obtained by the patients were: BPRS, 44.66 (SD 7.09); severity of hallucination, 19.77 (SD 3.77); Attitude Scale Score, 3.20 (SD 3.66); distress score on single item rating obtained from IKB, 2.41 (SD 0.81); and distress score on Distress due to Hallucination Scale, 12.35 (SD 4.04).
On the average, each patient used four coping strategies to deal with hallucinations. Help-seeking coping strategies were used most frequently (mean 1.36 ± 0.61). Diversion coping strategies were the next most common (mean 1.20 ± 0.66). On average, each patient used one problem-solving coping strategy. Avoidance coping strategies were least commonly used (mean 0.21 ± 0.36).
Table 1 shows the results of correlational analyses between Hallucination Distress Scale score and BPRS score, hallucination severity score, attitude score, total coping strategies score and various factors of coping strategies.
Table 1. . Correlation (Pearson's r) between Hallucinations Distress Scale score and various psychological test scores
|Brief Psychiatric Rating Scale score||−0.0513|
|Hallucination severity score|| 0.3278**|
|Coping strategies score|| 0.2593*|
|Problem-solving coping strategies score|| 0.3112*|
|Diversion coping strategies score|| 0.1274|
|Avoidance coping strategies score|| 0.1462|
|Help-seeking coping strategies score|| 0.1750|
|Other coping strategies score||−0.0930|
It revealed that only hallucination severity score (r = 0.32, P < 0.01), total coping strategies score (r = 0.25, P < 0.05) and problem-solving coping strategies (r = 0.31, P < 0.05) correlated significantly with Hallucination Distress Scale score
Among parameters of hallucination not included in the ‘total hallucination severity score’ only the parameter of affect/reaction correlated significantly with the Hallucination Distress Scale score (r = 0.25, P < 0.05).
When the single item distress score (IKB) was correlated with independent variables (Table 2), significant correlations were seen with hallucination severity score (r = 0.43, P < 0.01), coping strategies score (r = 0.42, P < 0.01), problem-solving coping strategies (r = 0.43, P < 0.001) and diversion coping strategies (r = 0.13, P < 0.05).
Table 2. . Correlation (Pearson's r) of single item rating distress score (IKB) with various psychological test scores
|Brief Psychiatric Rating Scale score|| 0.0131|
|Hallucination severity score|| 0.4267**|
|Coping strategies score|| 0.4155**|
|Problem-olving coping strategies score|| 0.4282**|
|Diversion coping strategies score|| 0.2997*|
|Avoidance coping strategies score|| 0.2272|
|Help-eeking coping strategies score|| 0.2246|
|Other coping strategies score||−0.0348|
As with Hallucination Distress Scale score, parameter of affect/reaction correlated significantly with distress score (r = 0.27, P < 0.05) when various parameters of hallucination not included in the ‘total hallucination severity score’ were correlated.
Various sociodemographic and other clinical variables (duration of illness, mean dose of neuroleptics, diagnosis, dose change, type of hallucinations, family history of psychiatric disorders) did not correlate with either measure of distress.
Independent variables that had correlated with distress scores on bivariate analysis were fed into stepwise (forward) multiple linear regression separately for each distress score (Hallucination Distress Scales score and single item distress score (IKB)). Coping strategies scores and specific clusters of coping strategies were correlated with distress scores on bivariate analysis. Only specific coping strategies cluster scores were used in the regression analysis to avoid duplication.
Hallucination severity and problem-solving coping strategies contributed 10% and 9% to the variance in the Hallucination Distress Scale score (Table 3). Total variance explained was 19%.
Table 3. . (Statistical) effect of various independent variables on Hallucination Distress Scale score
|1.||Hallucination severity score||0.233||0.3278||8.695*||0.102||10.0|
|2.||Problem-solving coping strategies||0.835||0.3112||8.429*||0.190|| 9.0|
| ||Total|| || || || ||19.0|
On single item rating (IKB) (Table 4), hallucination severity and problem-solving coping strategies contributed 18% and 13%, respectively, to the variance in distress score. Total variance explained was 31%.
Table 4. . (Statistical) effect of various independent variables single item distress score (IKB)
|1.||Hallucination severity score||0.080||0.4267||26.493*||0.18||18|
|2.||Problem-solving coping strategies||0.279||0.4282||23.215*||0.31||13|
|4.||Diversion coping strategies||0.043||0.2997||0.277||–||–|
| ||Total|| || || || ||31|
The present study examined the role of attitudes and coping strategies in mediating distress caused by hallucinations in schizophrenia, based on a ‘stress and coping’ paradigm. Here, an attempt was made to define severity of hallucinations and to consider it as a source of stress. Distress caused by this ‘stressor’ was assessed in two ways: a multi-item distress scale score and a subjectively reported single item distress score.
On multiple regression, various independent variables accounted for 19% of variance on ‘distress due to hallucination scale’ and 31% of variance on ‘single item’ rating of distress, respectively. With both forms of distress, ‘severity of hallucinations’ and ‘problem-solving coping strategies’ correlated significantly with distress. But their contribution in explaining variance were higher for the ‘single item’ measure of distress. The differences in the statistical prediction of ‘single-item’ and ‘multi-item’ distress scores point toward the need for employing multiple methods of assessing distress. The ‘multi-item’ measure may be relatively less specific but it is likely to be more reliable.
Severity of hallucinations was presumed to be a stressor in the present study. It has been stated that a stressor cannot be a stressor in absence of strain or distress or vice versa23. The assumption that hallucinations are ‘stressors’ appears to be validated by the results of multiple regression analysis.
While examining the neuroticism score in 30 schizophrenic patients with hallucinations, Ramanathan found that parameters of hallucinations such as frequency, duration, reality and content were not a source of stress to the patients.9 He also reported that patients who perceived hallucinations as externally located and as out of their control were more likely to be distressed. Ramanathan did not use a summary hallucination severity score.9 Reaction (affect), a parameter of phenomenology of hallucination scale was positively correlated with distress scores but it did not contribute to the severity of hallucination. This supports the view that ‘reaction’ should be better conceptualized as a measure of distress (as it appears from its definition) rather than an integral part of the hallucination experience. However, a low correlation (r = 0.22, P < 0.05) with distress suggests that it should be considered as an independent measure of distress or as an important item in a distress scale. Its position as a measure of distress needs to be clarified further.
Problem-solving coping strategies are employed by persons to alter a situation so that it is no longer considered problematic. Positive association between distress and problem-solving coping strategies may indicate that trying out active coping strategies in situations that are not responsive to these efforts may lead to increase in distress.24,25
Patients employing a greater number of coping strategies are expected to be less distressed.7 In the present study, patients with greater distress utilized a greater number of total coping strategies and specifically problem-solving strategies. Others have reported similar findings.10 These findings can be understood in two ways. It is possible that patients may be using a greater number of coping strategies when faced with greater distress; or use of a higher number of coping strategies might indicate the ineffectiveness of previously employed coping strategies. Thus, depending upon the effectiveness/ineffectiveness of coping strategies and severity of stressor, the relationship between cross-section measures of distress and coping strategies might yield positive as well as negative correlations.
Further research is needed to determine how effective coping strategies are in decreasing distress. Such research would have to include measure of perceived helpfulness in controlling hallucinations and of perceived helpfulness in diminishing distress. Accurate phenomenological recording may be more useful than questionnaire-based methods in achieving this end.
There was no correlation between distress and attitudes towards hallucination. It may be possible that a single attitude score may not be capturing the complexity of attitudes, which are often multifaceted, adequately. Further research with subgroups of attitudes is indicated before it is assumed that attitudes do not contribute to distress.
A large proportion of variance in distress score, which remained unexplained, could be due to social support, personality and quality of/meaning in life. Biological factors particularly those that might underpin ‘schizotype’, could also be thought of as contributory variables.
The study suggests that methods to modify stressor (severity of hallucinations) by pharmacological means can reduce distress due to hallucinations. Second, teaching patients hallucination-specific coping strategies may be helpful in reducing distress.
The study also carries some important limitations. First, in the IKB used for the present study there is no inquiry into hallucination-specific coping strategies. Second, while inquiring into coping strategies, no attempt was made to know their reported usefulness/ineffectiveness in decreasing distress due to hallucinations. Third, assessment of severity of hallucinations and distress (multi-item scale) was made on the basis of some items derived from existing scales.