• auditory hallucination;
  • coping technique;
  • phenomenology;
  • psychotic symptom


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  2. Abstract

Abstract  Use of coping techniques is of importance in the treatment for patients experiencing auditory hallucinations. Phenomenological features of auditory hallucinations and other psychotic symptoms are assumed to be factors influencing the coping activities. The aim of the present study was to determine psychotic symptoms including auditory hallucination phenomenological features that have effects on coping activities. The authors investigated 17 generally used coping techniques of 144 chronically psychotic patients who were currently experiencing auditory hallucination in DSM-IV schizophrenia or schizoaffective psychosis. Using factor analysis, scales characterizing the styles of coping application and efficacy were constructed. To assess the phenomenological features, the authors used the Matsuzawa Assessment Schedule for Auditory Hallucination (MASAH), which had been devised to assess four basic phenomenological features: intractability, delusion, influence, and externality. The Positive and Negative Syndrome Scale (PANSS) was also applied for the assessment of psychotic symptoms. Regression analyses were conducted to determine the features and symptoms that could have effects on coping activities. Constructed scales were those of distraction and counteraction styles for each of coping application and efficacy. It was found that MASAH influence and externality features had an activating effect on both distraction and counteraction coping application, and counteraction coping application, respectively, and that PANSS negative symptom clusters and MASAH delusion feature had an inhibiting effect on distraction and counteraction coping application, respectively. No salient factor for coping efficacy was recognized. The current study presents information on the relationship between coping activities and the psychotic experience features and symptoms, which can be of help for planning coping training programs.


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  2. Abstract

The use of techniques by patients to cope with their auditory hallucination has been acknowledged to be effective in mitigating distress of their abnormal experience.1 Therefore, it has been intensively studied,2–4 and has become an important focus for psychosocial treatment of auditory hallucinations.5–7 Thus, training of coping techniques has been incorporated as an indispensable part in many cognitive behavioral treatments for patients with psychoses.8 However, the number of investigations into the factors in determining effective coping techniques remains insufficient. If we know which factors work on the coping activities, we will be able to help patients to enhance their effectiveness. Among others, phenomenology of the experience and psychotic symptomatology can be assumed to have some effects on the activities.

The aim of the present study was to explore the ways in which phenomenological features of auditory hallucination and other psychotic symptoms may affect coping activity. The present results may shed light on the relationship between coping techniques and psychotic experience, and be useful in planning coping training programs.


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  2. Abstract

The present subjects were enrolled by asking psychiatrists working at Tokyo Metropolitan Matsuzawa Hospital to list candidate patients for this study. Criteria for inclusion were (i) currently experiencing auditory hallucination; (ii) clinically judged to be stable enough to undergo the assessment; and (iii) giving written informed consent to participate in this study. The present investigation was conducted as part of a research project, the first stage of which we presented elsewhere (along with the procedures for recruiting and obtaining informed consent). A total of 144 patients with schizophrenia or schizoaffective psychosis participated in the present study. Diagnoses were made on the basis of examining case records according to DSM-IV criteria and additional diagnostic inquiries during the investigation. The subject demographic and clinical data are given in Table 1. As indicated in that table, the course of illness and hallucinatory experience was chronic for most of the subjects.

Table 1.  Subject characteristics
 n (%)
  1. PANSS, Positive and Negative Syndrome Scale.

Male64 (44)
Female80 (56)
Inpatient113 (78)
Outpatient31 (22)
 Schizophrenia135 (94)
 Schizoaffective disorder9 (6)
Duration of auditory hallucination
 <6 months20 (14)
 6 months−3 years17 (12)
 >3 years84 (58)
 Unknown23 (16)
Frequency of auditory hallucinations per day
 <538 (26)
 5–1065 (45)
 >1041 (29)
Use of atypical antipsychotics43 (30)
 Mean ± SD (range)
Age at investigation (years) 50.0 ± 14.2 (19–75)
Age at onset (years)27.0 ± 9.9 (10–64)
Duration of illness (years)23.1 ± 14.4 (1–58)
Education (years)11.7 ± 2.3 (6–16)
Lifetime hospitalizations4.1 ± 4.0 (0–28)
PANSS negative symptom cluster score16.4 ± 4.4 (6–27)
PANSS Positive symptom cluster score10.7 ± 2.3 (5–16)
PANSS Excitement symptom cluster score6.7 ± 2.1 (3–12)
PANSS Anxiety symptom cluster score5.4 ± 1.8 (2–10)
PANSS thought disturbance symptom cluster score9.4 ± 3.0 (3–17)

We inquired into the subjects' auditory hallucination and application and efficacy of techniques for coping with the experience in the previous 2 weeks. The auditory hallucinations were assessed by means of the Matsuzawa Assessment Schedule for Auditory Hallucinations (MASAH).9 Using MASAH, perceptual characteristics, and patients' responses and beliefs were investigated, and scores for the four phenomenological feature subscales were calculated: F1, intractability of auditory hallucination experience; F2, delusion (level of delusional elements in the experience); F3, influence (level of influence and control in the experience, e.g. ‘made’ experience by imperative hallucinatory voices); and F4, externality (level of external experience localization).

The investigated coping technique items were (1) posture change (sit, lie down, stand etc.), (2) hobbies, (3) listening to music, (4) watching TV, (5) listening to the radio (except for music alone), (6) relaxation, (7) body movement (walk, run, exercise etc.), (8) making noises (tap, clap, tick etc.), (9) conversation with others, (10) thinking of other things, (11) retorting or dissuading, (12) falling asleep, (13) using ear plugs, (14) talking to oneself, (15) echoing voices, (16) reading aloud and (17) ignoring. The item set were determined in the preliminary stage of the present study. The selection of this item set was conducted as follows. Originally a set of 35 coping technique items that were thought to be generally applicable was created from the techniques pooled from the previous studies.2,4,10–12 Subsequently, they were tested with 15 patient subjects, and techniques not selected by the subjects in this stage and those of seeking treatment or substance were excluded.

Application of the coping techniques was scored on a 2-point scale (yes, 1; no, 0), and efficacy of the applied coping techniques, on a 3-point scale (unsuccessful, 0; partially successful, 1; completely successful, 2).

Prior to administration of the aforementioned assessments, we conducted an assessment using the Positive and Negative Syndrome Scale (PANSS), and produced scores of its symptom cluster scales: negative, positive, excitement, anxiety, thought disturbance, which are defined in the recent PANSS rating manual.13 Formerly, our study group reported favorable reliability of our research groups' PANSS assessment.14

Data analysis

First, principal components analysis with varimax rotation was performed to examine the factor structures of the application and efficacy items of the coping techniques and to reduce the set of coping technique variables to a smaller and more manageable number. On the basis of the extracted factors, we constructed scales for application and efficacy of the coping techniques. Subsequently, to explore the effects of auditory hallucination features and psychotic symptoms on the coping technique application and efficacy, multiple regression analysis with forward stepwise procedure (P to enter = 0.05 and P to remove = 0.10) was done using the coping application and efficacy scales as dependent variables, and MASAH scales and PANSS symptom clusters as initially contained independent variables. SPSS (version 10.0.5, Chicago, IL, USA) was used for the entire data analysis.


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  2. Abstract

Frequency and effectiveness of coping techniques

Frequency of application and efficacy of the studied coping techniques are presented in Table 2. The trend of efficacy of coping techniques was similar to those of the Carter et al. study.2 Conversation with others, and hobbies had relatively high efficacy rates (corresponding items in the Carter et al. study were talk to someone; and play an instrument or game,2 respectively), and retorting or dissuading; and reading aloud, had low efficacy (yell or talk back to voices; and read aloud, in the Carter et al. study,2 respectively). In some previous studies, as well as the present study, listening to music was more effective than watching TV.2,11,14 The trend of coping technique application was also in line with that shown in previous studies. For example, as was shown in the present study, listening to music and body movement (exercise) were preferred coping techniques in some previous studies.2,12

Table 2.  Application and efficacy of coping techniques
 No. subjects who applied technique, n (%)Outcome of technique, n (%)
UnsuccessfulPartially successfulCompletely successful
Conversation with others (9)52 (36)0 (0)34 (65)18 (35)
Hobbies (2)44 (31)7 (16)22 (50)15 (34)
Falling asleep (12)57 (40)9 (16)24 (42)24 (42)
Listening to music (3)62 (43)11 (18)29 (47)22 (35)
Listening to the radio (5)39 (27)7 (18)21 (54)11 (28)
Relaxation (6)47 (33)9 (19)29 (62)9 (19)
Body movement (7)58 (40)12 (21)33 (57)13 (22)
Watching TV (4)50 (35)5 (10)28 (56)17 (34)
Making noises (8)20 (14)5 (25)10 (50)5 (25)
Reading aloud (16)20 (14)5 (25)10 (50)5 (25)
Thinking of other things (10)53 (37)14 (26)31 (58)8 (15)
Echoing voices (15)31 (22)9 (29)15 (48)7 (23)
Using ear plugs (13)14 (10)4 (29)7 (50)3 (21)
Talking to oneself (14)49 (34)16 (33)23 (47)10 (20)
Ignoring (17)75 (52)26 (35)26 (35)23 (31)
Posture change (1)46 (32)17 (37)23 (50)6 (13)
Retorting or dissuading (11)56 (39)21 (38)22 (39)13 (23)

Construction of coping application and efficacy scales

The factor structures obtained in principal component analysis of application and efficacy coping technique items are shown in Table 3. The two-factor solution for both factor analyses was determined by scree plot inspection, and was found to be clinically interpretable. The variances explained by prerotational factors for coping technique application and efficacy were 33.2%, 9.0%, 7.4% and 6.0%, and 38.3%, 10.1%, 7.0% and 6.0% in order of extraction, respectively.

Table 3.  Varimax rotation principal components analysis of application and efficacy of coping techniques Thumbnail image of

The principal components of the factors, that is, the items that loaded ≥0.5, are indicated by bold font in Table 3, and were mostly common across the two analyses. The differences found between the two-factor structures of the application and the efficacy of coping techniques were that the principal component items of talking to oneself (item 14) and ignoring (item 17) in the factor structure of the coping efficacy items were not principal components in the coping application items, and that making noises (item 8) was a principal component in the first factor analysis but not in the second (factor loading 0.482). Other than these few differences, the results were very similar to each other. Therefore, we used the principal component items in the factor analysis of application items indicated by the boxes in Table 3 for constructing the composite scales of both coping application and efficacy. The composite scale scores were calculated by adding item scores of corresponding factor principal components.

Distraction application and efficacy scales are composed of the items of distractive coping technique: relaxation; watching tv; conversation with others; listening to music; listening to the radio; body movement; hobbies; and thinking of other things. The items composing the counteraction application and efficacy scales were techniques in which the patients took a more active role than in distraction ones. The counteraction techniques were echoing voices; retorting or dissuading the voices; falling asleep; posture change; and making noises. The four coping application and efficacy scales had permissible internal consistency (Cronbach's alpha > 0.7), as indicated in Table 3. The means ± SD (range) of the constructed scales of distraction and counteraction application scales, and distraction and counteraction efficacy scales were 2.81 ± 2.67 (0–8), 1.83 ± 1.76 (0–6), 20.87 ± 3.96 (8–24) and 16.25 ± 2.32 (6–18), respectively. Pearson's correlation coefficient between distraction and counteraction application scales was 0.625 (P < 0.001), and that between distraction and counteraction efficacy scales, 0.626 (P < 0.001).

Multiple regression

Regression analysis of the coping application and efficacy scales is given in Table 4. The MASAH influence feature of auditory hallucination had an effect of arousing the coping technique application. MASAH delusion feature and the negative symptom had a mild effect to reduce the distraction coping application. MASAH externality feature had a mild effect to arouse the use of counteraction coping techniques.

Table 4.  Stepwise multiple regression of coping technique application and efficacy
 BSE BβMultiple R, d.f.
  • *

     P < 0.05,

  • **

     P < 0.01,

  • ***

     P < 0.001.

  • F2–4, subscales of MASAH; MASAH, Matsuzawa Assessment Schedule for Auditory Hallucinations;9 PANSS, Positive and Negative Syndrome Scale.13

Distraction coping application
 MASAH Influence (F3)0.1460.0300.375*** 
 PANSS Negative symptom cluster−0.1480.047−0.243** 
 MASAH Delusion (F2)−0.0850.033−0.197*0.438 (3, 140)
Counteraction coping application
 MASAH Influence (F3)0.1100.0190.429*** 
 MASAH Externality (F4)0.0640.0290.166*0.469 (2, 141)
Counteraction coping efficacy
 MASAH Influence (F3)0.0780.0280.232**0.232 (1, 142)

In the regression analysis of the coping efficacy scales, only MASAH influence feature seemed to have an effect to increase counteraction coping efficacy. However, the result must be questioned because it appeared to be only a secondary effect of influence feature on the counteracting coping application that was a strong determinant of its efficacy.


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  2. Abstract

Classification and assessment of coping techniques

On the basis of factors found in factor analysis of coping technique items, the present study proposed a classification of coping techniques: distraction and counteraction. Although it is difficult to compare this classification with those of previous studies based on empiric data analysis due to different data gathering and analytic techniques, corresponding categorizations were able to be determined: passive coping and resistance coping in the factor analytic study of Farhall and Gehrke,3 and two major groups of distraction and competing (or distraction in which a patient takes a more active role) in the classification using a multidimensional scaling technique of Carter et al.2 These previous studies appeared to support some generality of the present classification.

Coping techniques, and phenomenological features and psychotic symptoms

Some previous studies indicated that phenomenological features and psychotic symptoms were possible factors in determining coping activities. The Singh et al. study showed that the severity of and distress caused by auditory hallucinations were associated with use of active coping strategy.15 O'Sullivan also found that unpleasant hallucinatory experience activated use of coping techniques.11 The Birchwood and Chadwick study highlighted the finding that experience with influencing and controlling power tended to induce resisting coping behavior.16 Although the present result is in line with those of the previous studies, there are subtle differences, such as the present findings that the experience of influencing nature had a coping inducing effect while Singh et al. and O'Sullivan suggested that of distressing nature instead,11,15 and that coping techniques activated by the influencing experience were the resisting coping ones in the Birchwood and Chadwick study,16 but a wide range of those in the present study. Further studies are needed to determine the interrelationship.

Furthermore, the present study produced novel findings. It indicated that counteraction coping techniques were more often used when the voices were externally experienced phenomena. An explanation for this may be that counteraction coping is more easily applied to take a stand against externally located experiences. The present study also suggested that patients did not prefer using distraction coping techniques against hallucinations with delusional features. This finding appears to be consistent with that of Carr,10 that patients with delusion did not prefer passive coping techniques, but active ones such as problem solving.

In accordance with the Middelboe and Mortensen study that reported an inverse correlation between negative symptoms and the total number of coping techniques used by patients with psychoses,17 the present study found a small but significant effect of negative symptoms on use of distraction coping techniques. The findings indicate that negative symptoms, damaging many areas of patients' functioning, affect distraction type of coping activity.

As for the efficacy of coping techniques, there were no phenomenological features or psychotic symptoms that had a substantial influence on it. This result is in contrast with that of coping technique application that appeared to be affected by the features and symptoms. This is hopeful because it indicates the possibility of improving effectiveness of coping techniques by means of psychosocial interventions irrespective of the features and psychotic symptoms.

It is necessary to mention limitations of the present study. First, the findings were from a cross-sectional investigation into experience in unintervened conditions. Therefore, they should be tested in actual treatment settings. Next, the classification and the measures for assessing coping techniques proposed in the present study are still hypothetical and deal with only a small number of techniques, and therefore, require more refinement and extension in future studies.

Despite these limitations, the results of the present study are encouraging. The current study presents information on the relationship between coping techniques and auditory hallucination phenomenological features. It can be used to predict what kind of techniques may be preferred and used by patients, and thus may contribute to the therapeutic task of educating and training in use of the techniques.


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  2. Abstract

This study was supported by Grant-in-aid for exploratory Research no. 11877164 of the Japan Society for the Promotion of Science. We appreciate the cooperation in the present study of Drs Ryosuke Nakamura, Naoko Ishige, Yukiyo Inoue, Hirohiko Harima, Hidemasa Onai, Shusuke Yoneda, Taiki Tao and Yuichi Yamashita at Tokyo Metropolitan Matsuzawa Hospital.


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