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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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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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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 (%)|
| Schizophrenia||135 (94)|
| Schizoaffective disorder||9 (6)|
|Duration of auditory hallucination|
| <6 months||20 (14)|
| 6 months−3 years||17 (12)|
| >3 years||84 (58)|
| Unknown||23 (16)|
|Frequency of auditory hallucinations per day|
| <5||38 (26)|
| 5–10||65 (45)|
| >10||41 (29)|
|Use of atypical antipsychotics||43 (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 hospitalizations||4.1 ± 4.0 (0–28)|
|PANSS negative symptom cluster score||16.4 ± 4.4 (6–27) |
|PANSS Positive symptom cluster score||10.7 ± 2.3 (5–16) |
|PANSS Excitement symptom cluster score||6.7 ± 2.1 (3–12)|
|PANSS Anxiety symptom cluster score||5.4 ± 1.8 (2–10)|
|PANSS thought disturbance symptom cluster score||9.4 ± 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
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.