The Indian Journal of Occupational Therapy: Volume: 44 : Issue: 1 (January 2012 - April 2012)

EFFECT OF COPING STRATEGIES ON CHRONIC DRUG RESISTANT

AUDITORY HALLUCINATION IN SCHIZOPHRENIA: A CROSS OVER STUDY.
Author: Dr. Chandrashekhar Bagul, MOTh-3
Co-Aurhors: Dr. (Mrs.) Karuna Nadkarni, Associate Professor,
O.T School & Centre Seth G.S.M.C & K.E.M.H, Mumbai.
Jayanti Yadav, MOTh-3, Ajish K Abraham, BOTh, Sulokshana Pednekar, BOTh

ABSTRACT
OBJECTIVE:
To study the effectiveness of coping strategies (monaural occlusion,auditory localisation and processing activity, humming and reading
aloud) and conventional occupational therapy in chronic drug resistant auditory hallucination in schizophrenia.
METHODOLOGY:
4 patients with mean age of 46 years were randomly selected from Thane MentalHospital, who underwent 7 weeks intervention divided into
3 phases. Each phase lasted for 1 week followed by 2 weeks of wash out period.duration of each session was 1.5 hours per day.
Phase 1-Earmuffs + auditory localization and processing.
Phase 2-Humming + Reading aloud
Phase 3- Conventional Occupational therapy + Earmuffs +Humming
The changes in dimensions of auditory hallucinations were assessed on Auditory Hallucination Rating Scale (AHRS) pre and post each
phase. In phase 3 pre and post work performance scale(WPS) was also done.
RESULTS:
The mean score of AHRS was computed
Phase 1-Pre mean score = 32.5 , (SD 0.568), Post mean score=23.75,
(SD 0.768),Percentage improvement=19.89% .
Phase 2- Pre mean score = 32.5 , (SD 0.568), Post mean score=24.50,
(SD 0.596),Percentage improvement=18.18% .
Phase 3- Pre mean score = 27.00, (SD 0.400), Post mean score=17.75,
(SD 0.465),Percentage improvement=21.02% .
Phase 3 Pre WPS mean score=28.75,(SD 4.0311),Post WPS mean
score=38.75, (SD 2.872), Percentage improvement=23.81%
CONCLUSION:
Auditory hallucinations reduced in phase 3 indicates that coping strategies alongwith conventional Occupational therapy is beneficial than
individual coping strategies.
KEYWORDS: schizophrenia, auditory hallucinations,coping strategies.

INTRODUCTION:
Schizophrenia is characterised by disturbance in thought
and verbal behaviour, perception, affect, motor behaviour
and relationship to the external world. Hallucinations
(perceptions without stimuli) are common in schizophrenia
Auditory hallucinations are by far the most frequent .These
can be
1) Elementary hallucinations(i.e. hearing simple sounds
rather than voices)

Place of Research: O.T School & Centre Seth G.S.M.C

& K.E.M.H, Mumbai
Place of Study: Thane Mental Hospital.
Period of Study: May2009- July 2009
Correspondence:
Dr. Chandrashekhar Panditrao Bagul
Q- Type 9/2, Ordnance Estate Ambernath- 421502.
Phone: 09833458820
e mail: chandrashekharbagul@gmail.com
Award: AIOTA Trophy for Best Paper in Mental Health
at OTICON'12, Goa

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January 2012 - April 2012

2) 'Thought echo' (audible thoughts)

3) Third person hallucination (voices heard arguing),
discussing the patient in third person
4) Voices commenting on one's action

These changes in Broca's area, which is in the dominant

hemisphere, suggest that the 'voices' may emanate from
dysfunction in the language area. Since Broca's area is
interconnected with Wernicke's area (via the arcuate
fasciculus) and with regions of the middle temporal gyrus7 8
and medial temporal gyrus. 9 10

Only the 'third person hallucinations' are believed to be

characteristic of Schizophrenia29

In psychological theories, Slade 11,12 observed that

hallucinations occured during periods of stress .The link
between stress and hallucinations may be that stress itself
impairs the processing of semantic information.13

Auditory hallucinations in mental disorders can be non-verbal

[unorganised] such as cluttering, ringing, mumbling, music,
noises or as in most cases verbal hallucinations [organised]
Characteristics of verbal auditory hallucinations:
One or more voices may be heard. They may originate inside
or outside the head i.e. location of voices. Two or more voices
may speak simultaneously or conduct a conversation
between them. A voice or voices may speak to the patient or
about the patient commenting on his or her thoughts or
actions Voices can be heard speaking (most cases), singing
or shouting at the patient. Voices rarely speak in complete
sentences - usually say a few disjointed words in brief
utterances. Voices may have immediate meaning in some
cases.

Frith 14 proposed two psychological models , namely input

and output theories of hallucinations.
Input theory:
The input theory proposes that hallucinations arise through
the misperception of external stimuli. A stimulus is most likely
misperceived when it is complex and ambiguous and when
the target sound is weak and the irrelevant surrounding noise
is loud. People who misperceive stimuli may have a difficulty
with discrimination, which presumably would be harder when
the noise associated with the stimuli was increased.

Patho-physiology of auditory hallucinations:

It was postulated by Randrup and Munkward in 1972 that
auditory hallucinations are due to excess dopaminergic
1
activity in brain.

Output theory:
The output theory implies that the patient is talking to himself
but perceives the voices as coming from somewhere
else.Frith suggests that the problem may be failure to
recognize that the production of inner speech is self initiated.
The patients misperceive self-generated actions as those
arising externally i.e. there is a defect in self-monitoring.

Owen suggested that dopamine receptors in schizophrenic

patients are supersensitive to normal amounts of dopamine.2
Barta et al. demonstrated with MRI that the volume of the
superior temporal gyrus was lower in schizophrenics than in
controls and the shrinkage in this region correlated strongly
with severity of auditory hallucinations.3

AUDITORY HALLUCINATIONS ARE SEEN IN:

Schizoaffective disorder
Bipolar disorder
Obsessive compulsive disorder
Stress
Sleep deprivation
Depression
Alcohol withdrawal
Dementia
Alcohol withdrawal
Dementia
Delirium
Amphetamines
Ketamine
Narcolepsy
Temporal lobe epilepsy
Anticholinergics

Recent studies by Penfield and Perot using PET scan shows

that auditory hallucinations can be elicited by electrical
stimulation of the superior temporal gyrus raising the
possibility that neural activity in this region is responsible for
these hallucinations4 Mcguire et.al. using SPET showed that
there is increased cerebral blood flow in Broca's area during
auditory hallucinations than in the non-hallucinating state.5
Schizophrenic hallucinations have also been associated with
decreased metabolism in the superior temporal gyrus, and
their frequency has been positively correlated with
metabolism in the anterior cingulate cortex and the
neostriatum.6

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Why to study about auditory hallucinations?

Auditory hallucinations are among the most common
symptoms in schizophrenia. About 70% of schizophrenics
have auditory hallucinations termed as Schneider's first rank
symptoms. Persistent auditory hallucination interferes with a
person's ability to engage in work, leisure and self-care tasks
thereby making it difficult to engage in meaningful tasks or
relationships. For some patients, hallucinations are
problematic only in certain situations or at specific times,
such as when they are alone or in a stressful situation.
For others, hallucinations can have a positive effect in that the
hallucinations may provide companionship and guidance in
an environment that is often isolative and prejudicial towards
persons with mental illness26.

frequent auditory hallucinations fail to demonstrate an

expected right ear advantage.23 24 Absence of a right ear
advantage(REA) is indicative of a functional deficit in the left
peri-Sylvian region. Lateralistion of brain is lost. REA which is
so essential for focusing attention for long duration on a task
comprehending when auditory stimulus is shifting between
one ear to other.(Kimura 1967, Kinsbourne 1970)
Modern view for effectiveness of earmuffs:
Stress vulnerability model by Zubin and Spring suggests that
anxiety is a precipitating factor which makes auditory
hallucinations persistent and more severe. In anxiety
hyperacusis auditory hallucination, single earmuff reduce
anxiety by reducing auditory input by 50%. Earmuff helps in
reducing the load on the auditory processing ability by
improving the attention span of the patient which would have
shifted between both ears unnaturally. Earmuff can act as a
placebo helping suggestibility by a therapist. Earmuffs can
act as an aid for distinguishing real sounds from auditory
hallucinations. Does humming help in reducing auditory
hallucination? Gould(1948) recorded increased EMG activity
in muscles of the chin and lips of hallucinating subjects as
compared to normal subjects suggesting that hallucinations
have a psychomotor component.15

MANAGEMENT OF HALLUCINATIONS:
Medications - most of the hallucinations are managed with
medications (antipsychotics-but about 20% to 40 % of
patients continue to experience persistent hallucinations
known as chronic drug resistant hallucinating patients.)27
Transcranial magnetic stimulation is also given.
Therapy- various therapies targeted in improving the coping
skills of the patient.
COPING STRATEGIES:
Haddock et al (1996) notes that early approaches to
psychosis tend to fit into three main categories:
those which involve distraction techniques for psychotic
phenomena, those which involve focusing the patient directly
onto the phenomena and those which involve anxiety
reduction as a target for intervention.
Various coping strategies include 15 16 17 18 19
Use of personal stereo (Feder 1982; Johnston et al 2002) 21
Monaural occlusion (Birchwood 1986)16
Humming (Green & Kinsbourne 1989)15
Sub-vocal counting/naming 20
Relaxation training (one to one)
Thought stopping
Audio tape therapy

In a study conducted by Foster Green and Marcel Kisbourne

humming a single note silently reduced auditory
hallucinations by 59% .
Reading aloud:
Bick and Kisbourne (1987) conducted an experimental study
which showed that keeping mouth open reduced auditory
hallucination.
Opening the mouth interferes with subvocal activity and
minute muscular twitches responsible for maintaining
auditory hallucination.28
Occupational Therapist also work with schizophrenics.
Although the topic of hallucinations has been widely
addressed in the psychological and psychiatric literature, it is
virtually ignored in the occupational therapy literature. This
lack of discussion is probably because the occupational
therapy is more likely to focus on the disruption of
occupational performance areas of work, leisure and self
care rather than on specific symptoms.22 Occupational
Therapy often minimize the importance of symptomatology,
believing symptoms to be separate from their main concern
of functional ability. Usually Occupational Therapists working
with clients having psychosocial dysfunctions evaluate the

Monaural occlusion/single earmuffs:

M.F. Green in 1989 conducted random trials with earmuffs
and found out that majority of the subjects given left sided
earmuffs showed considerable reduction in auditory
hallucinations. Birchwood 1986 also emphasises use of
monaural occlusion.16
Explanation given were earmuffs facilitate the use of the
same pathways responsible for neural activation during the
development of foetus. According to the results of dichot
listening test patients with schizophrenia who experience

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January 2012 - April 2012

hallucinations as a part of routine assessment, and provide a

general intervention for the patient; i.e. we do not employ any
special intervention strategies for hallucinations per se. So in
this study we have tried to use some of the coping strategies
as an adjunct to conventional Occupational Therapy to see if
it has an effect on the auditory hallucinations and functionality
of chronic schizophrenic patients.

age of 46 years were randomly selected from Thane Mental

Hospital, who underwent 7 weeks intervention divided into 3
phases. Each phase lasted for 1 week followed by 2 weeks of
wash out period. Duration of each session was 1.5 hours per
day.
Phase 1-Earmuffs + auditory localization and processing.
Phase 2-Humming + Reading aloud
Phase 3-Conventional Occupational therapy + Earmuffs +
Humming

Study conducted
AIM:
To study the effectiveness of coping strategies (monaural
occlusion, auditory localisation and processing activity,
humming and reading aloud) and conventional occupational
therapy in chronic drug resistant auditory hallucination in
schizophrenia.

The changes in dimensions of auditory hallucinations were

assessed on Auditory Hallucination Rating Scale (AHRS) pre
and post each phase. In phase 3 pre and post work
performance scale(WPS) was also done.

OBJECTIVES:
1) To see the effectiveness of monaural occlusion by using
left sided earmuffs on auditory hallucinations.
2) To see the effectiveness of humming and reading aloud
on auditory hallucinations.
3) To see the effect of conventional occupational therapy
alongwith earmuffs and humming on auditory
hallucinations.
4) To find out the effect of auditory hallucination on work
performance.

Phase 1 protocol: for 1 week patients were given earmuffs +

auditory localization and processing exercises. Pre AHRS
was done. Monaural occlusion with left sided earmuffs to be
worn throughout the week.
Activities given like:
Auditory localization of ringing bells with eyes closed from
various regions in space, listening to music and answering to
related questions posed by the therapist.
Goal: To develop auditory localization and processing skills.
At the end of the week post AHRS was done. After this 2
weeks washout period was given to all 4 patients.

METHODOLOGY:
Inclusion criteria:
Patient should be chronic drug resistant
auditory
hallucination for more than a year. Patient should have an
insight about his hallucination Should be co-operative and
ready to follow the strategies taught during therapy session.
Should be kept off ECT before and during therapy sessions.
Age between 15 to 60

Activity given: Reading a paragraph loudly and with

understanding.
Goal: To override subvocalisations and facilitate corollary
discharge through vibration. Post AHRS done at the end of
one week. After this again 2 weeks of washout period was
given.

Exclusion criteria:
Catatonic schizophrenic
or grossly mentally affected
patients. Any other mental or physical disorder which can
interfere with the study eg. Mental Retardation,hearing loss
etc.
Age above 60 yrs

Phase 3 protocol: For 1 week patients were given

Conventional Occupational therapy + Earmuffs +Humming
Pre AHRS and Pre Work performance scale were assessed.
Conventional occupational therapy given along with earmuffs
and humming was given. In conventional occupational
therapy activities given were: movement therapy, table top
activities(Puzzles, simple table games), relaxation therapy
(deep breathing exercises),group activities (envelope
making, carrom) and social skills training.

Outcome measures:
Auditory hallucination rating scale(AHRS) ..(Appendix A)
Work performance scale (WPS).....................(Appendix B)
Procedure :
Study was conducted at Thane Mental Hospital for a period
of 7 wks. 4 patients were selected fitting the inclusion criteria
Each therapy session lasted for 1.5 hrs 4 patients with mean

IJOT: Volume: 44 : Issue: 1

Goal: To improve work performance and maintain or lower

auditory hallucinations. Post AHRS and post WPS was done
at the end of week.

23

January 2012 - April 2012

RESULTS and TABLES:

Table 2: Showing Pre and Post mean score of AHRS after

1 week of Humming and reading aloud.

Table 1: Showing Pre and Post mean score of AHRS after

1 week of Ear muff + auditory localization and
processing.
Sr

Component

Pre

Sr

Frequency

Post

Mean

Mean

2.75

1.75

Duration

3.25

Location

2.5

2.5

Mean

Mean

2.75

1.5

Loudness

2.25

2.25

Beliefs of re-

3.25

3.25

3.25

2.75

2.25

2.75

3.25

2.75

3.25

1.5

2.5

2.5

Loudness

2.25

3.25

origin
6

Amt ofve content

3.25
7

origin
Amt of-

3.25

Degree of
ve content

2
8

ve content
Degree of

2.75

Amt of
distress

2
9

Intensity of

distress

10

Disruption

Intensity of

11

Control

3.25

ve content
8

Amt of

Duration

Frequency

Location

1
1

1
2

Beliefs of re-

Post

3
5

Pre

No.

No.
1

Component

distress

3.5

3.25

2.75

distress
10

Disruption

11

Control

3.25

1.75

Graph 2: Showing Pre and Post mean score graph of

AHRS after 1 week of Humming and reading aloud as
therapy

Graph 1: Showing Pre and Post mean score graph of

AHRS after 1 week of Ear muff therapy and auditory
localisation.

4.5

4
4.5

3.5

4
3.5

2.5

2.5

1.5
1.5

1
1

0.5
0.5

24

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IJOT: Volume: 44 : Issue: 1

Pre AHRS score

nt
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Pre AHRS score

Post AHRS score

January 2012 - April 2012

Table 3: Showing Pre and Post mean score of AHRS after

1 week of Conventional Occupational therapy + Ear muff
+ Humming
Sr

Component

Pre

Changes in Work Performance Scale after 1 week of O.T

+ Ear muffs + auditory localization and processing and
Humming + reading aloud in phase 3.
Table 4.1

Post

No.
1

Mean

Mean

Frequency

2.25

Duration

1
1.5

Location

2.5

Loudness

Beliefs of re-

3.25

2.25

Amt of-

2.75

2.25

2.5

1.75

2.75

2.75

1.75

origin
ve content
7

Degree of
ve content

Amt of
distress

Intensity of

10

Disruption

1.5

11

Control

2.25

1.75

distress

Graph 3: Pre and Post mean score graph of AHRS after 1

week of Conventional Occupational therapy + Ear muff +
Humming
3.5

2.5

1.5

0.5

Fr
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IJOT: Volume: 44 : Issue: 1

Post AHRS score

25

Table : 4.1
COMPONENTS OF WPS
Interest in activities
Interest in completion
Initial learning
Complexity and organization of tasks
Problem solving
Conc entration
Retention and recall
Speed of performance
Activity neatness
Frustration tolerance
Work Tolerance
Reaction to authority
Sociability with Therapist
Sociability with patients
TOTAL

SUBJECT 1
PRE
Fair
Fair
Fair
Poor
Fair
Fair
Poor
Poor
Fair
Fair
Fair
Good
Fair
Fair
24

Table : 4.2

SUBJECT 2

POST
Fair
Good
Fair
Fair
Fair
Good
Fair
Fair
Fair
Good
Good
Good
Good
Good
35

COMPONENTS OF WPS

PRE

Interest in activities

Good

POST
Good

Interest in completion

Good

Good

Initial learning

Fair

Good

Complexity and organization of tasks

Fair

Good

Problem solving

Fair

Good

Concentration

Fair

Good

Retention and recall

Poor

Fair

Speed of performance

Fair

Good

Activity neatness

Fair

Good

Frustration tolerance

Good

Good

Work Tolerance

Fair

Good

Reaction to authority

Good

Good

Sociability with Therapist

Fair

Good

Sociability with patients

Fair

Good

TOTAL

31

41

Table : 4.3
COMPONENTS OF WPS
Interest in activities
Interest in completion
Initial learning
Complexity and organization of tasks
Problem solving
Concentration
Retention and recall
Speed of performance
Activity neatness
Frustration tolerance
Work Tolerance
Reaction to authority
Sociability with Therapist
Sociability with patients
TOTAL

SUBJECT 3
PRE
Fair
Fair
Fair
Fair
Fair
Fair
Poor
Poor
Fair
Fair
Fair
Good
Fair
Fair
27

POST
Good
Good
Fair
Good
Fair
Good
Fair
Fair
Good
Good
Good
Good
Good
Good
38

January 2012 - April 2012

Table : 4.4

after 1 week of ear muffs and auditory localization and from

table 1 and graph 1 it is evident that there is a decline in 9
components of AHRS. 2 components - location and beliefs of
re origin remained unchanged. There is a observable decline
in controllability,duration, amount of negative content and
loudness of voices. The mean score of AHRS was computed
Pre mean score = 32.5 (SD 0.568),
Post mean score=23.75,(SD0.768),
Percentage improvement=19.89% .

SUBJECT 4

COMPONENTS OF WPS

PRE

POST

Interest in activities

Good

Good

Interest in completion

Fair

Good

Initial learning

Fair

Good

Complexity and organization of tasks

Fair

Fair

Problem solving

Fair

Good

Concentration

Fair

Good

Retention and recall

Fair

Good

Speed of performance

Fair

Good

Activity neatness

Good

Good

Frustration tolerance

Good

Good

Work Tolerance

Good

Good

Reaction to authority

Good

Good

Sociability with Therapist

Fair

Good

Sociability with patients

Fair

Good

TOTAL

33

41

PHASE 2: Humming and reading aloud.

Table 2 shows changes in pre and post mean scores of AHRS
after 1 week of humming and reading aloud in phase 2. From
table 2 and graph 2 it is evident that there is a decline in 8
components of AHRS.
3 components - location, loudness, and beliefs of re-origin
remained unchanged.

Graph 4: Work performance scale By considering

Poor = 1, Fair =2, Good =3 showing changes in Pre and
Post Work Performance Scale after 1 week of
Conventional Occupational Therapy + Ear muffs and
auditory localization a processing + Humming and
reading aloud in phase 3

There is a observable decline in duration, amount of negative

content, amount of distress and controllability of voices. The
mean score of AHRS was computed Pre mean score = 32.5 ,
(SD 0.568), Post mean score=24.50, (SD 0.596),
Percentage improvement=18.18%
PHASE 3 : conventional occupational therapy +earmuff +
humming Table 3 shows changes in pre and post mean
scores of AHRS after 1week of conventional O.T.+ earmuffs+
humming in phase 3 From table 3 and graph 3 it is evident
that there is a decline in all the 11 components of AHRS.

45
40
35
30

The mean score of AHRS was computed Pre mean score =

27.00, (SD 0.400), Post mean score=17.75, (SD 0.465),
Percentage improvement=21.02% .

25
20

Table 4.1, 4.2, 4.3 and 4.4 show changes in work

performance scale after 1 week conventional occupational
therapy+earmuffs and auditory localisation and
processing+humming and reading aloud in phase 3 in
subject 1, 2, 3 and 4 respectively.

15
10
5

Graph 4 shows changes in pre and post scores of WPS of all

4 subjects in phase 3. In subject 1 WPS improved from 24 to
35, in subject 2 from 31 to 41 , in subject 3 from 27 to 38 and
in subject 4 from 33 to 41. The mean score of WPS was
computed Phase 3 - Pre WPS mean score=28.75,(SD
4.0311), Post WPS mean score=38.75, (SD 2.872),
Percentage improvement=23.81%

0
Subject 1

Subject 2

Subject 3

Pre WPS score

Subject 4

Post WPS score

RESULTS:
Phase 1: Earmuffs + auditory localization and processing.
Table 1 shows changes in pre and post AHRS mean scores

IJOT: Volume: 44 : Issue: 1

DISCUSSION:
In phase 1 all the four subjects were given earmuffs in left ear

26

January 2012 - April 2012

to be worn throughout the day and everyday they were given

auditory localization and proccessing exercises like paying
attention to ringing bell with eyes closed from various regions
in space, listening to music and answering to related
questions asked by the therapist.

sustain contact with reality,this also improved their self

awareness, self esteem and self worth. The cumulative effect
of O.T. and other coping stategies helped them reduce
auditory hallucinations. They had better insight into their
condition which helped them understand the beliefs of reorigin of voices, which did not change when coping strategies
were used individually. As the hallucinations decreased their
work performance also improved markedly.

After 1 week their control on hallucinations as perceived by

them was better. The duration, loudness and amount of
negative content also declined. The rationale for giving
earmuffs in left ear is that normally non hallucinating humans
have right ear advantage23 i.e we hear more through right ear
and understand better. This is because right ear is
contrallaterally connected to language dominant left
hemisphere. It is believed that hallucinating patients show no
specific ear advantage. So by occluding left ear we forced
them to use right ear which activated their left hemisphere
which is also the centre for production of hallucinations. Thus
involving left hemisphere actively in purposeful activity and
making more use of it throughout the day probably helped in
self awareness and declining the components of AHRS at the
end of 1 week.16
After phase -1 two weeks of washout period was given to
nullify the effect of earmuffs. Then in phase 2 humming and
reading aloud was given, in which each subject was asked to
hum a single note for 10 seconds and was asked to read
aloud some paragraph with understanding.

CONCLUSION:
Occupational therapy helps patients with auditory
hallucination to be in contact with reality and have a better
insight about self. In this study chronic patients with drug
resistant auditory hallucinations have reported that use of
coping stategies like ear muffs and humming with
occupational therapy led to better control of hallucinations.
As the hallucinations declined patients occupational
perfomance also improved. As the auditory hallucinations in
phase 3 reduced and the work performance improved it
indicates that conventional occupational therapy alongwith
coping strategies is beneficial than individual coping
strategies.
LIMITATIONS:
The study was conducted on a very small sample size. The
study duration for each individual coping strategy was also
less.

The post AHRS score declined in 8 components at the end of

the week. It is known that subvocal activity is increased in
hallucinating patients and they fail to understand that these
voices are self produced.25 Humming single note involved the
subjects in actively using the subvocal musculature for some
time which improved self awareness and they knew this
sound is self produced and is not alien.25 By reading
paragraph aloud with understanding the subjects again
engaged in active subvocal activity and by explaining what
they just read required them to be attentive and in contact
with reality which improved self awareness. All of these
factors probably helped in declining the scores of AHRS.
Again after phase-2 two weeks of washout period was given
to nullify the effects of humming and reading aloud. In phase
3 all 4 subjects were given Occupational therapy alongwith
earmuffs and humming. In O.T. they were given movement
therapy, table top activities,group activities and social skill
training activities. Pre and post AHRS and WPS was done.
After 1 week there was a decline in all the components of
AHRS and WPS also improved markedly.

ACKNOWLEDGEMENTS:
I would like to thank Dr.Sanjay Oak, Director, M.E & M.H,
Dean, Seth.G.S.Medical College & K.E.M.Hospital and
Dr.Jayshree Kale, Head of the Department, Occupational
Therapy School and Centre, Seth.G.S.Medical College &
K.E.M.Hospital. I would like to thank Dr. Zareen D ferzandi for
permitting us to go to thane mental hospital. I would like to
thank the director of Thane mental hospital for allowing us to
conduct the study. And my sincere thanks to Dr. Karuna
Nadkarni for being my guide throughout the study.
REFERENCES:
1. Randrup A, Munkvad I. Evidence indicating an association between
schizophrenia and dopaminergic hyperactivity in the brain. Orthomolec
Psychiatry 1972; 1:2-7.
2. Owen F, Cross AJ, Crow TJ, Longden A, Poulter M, Riley GJ. Increased
dopamine-receptor sensitivity in schizophrenia. Lancet 1978;ii:223-6.
3. Barta PE, Pearlson GD, Powers RE, Richards SS, Tune LE. Auditory
hallucinations and smaller superior temporal gyral volume in
schizophrenia. Am J Psychiat 1990; 147: 1457-62.
4. Penfield W, Perot P. The brain's record of auditory and visual
experience. Brain 1963;86:595-705.
5. McGuire PK, Shah GMS, Murray RM. Increased blood flow in Broca's
area during auditory hallucinations in schizophrenia. Lancet 1993;
342:703-6.

O.T. probably helped subjects to be actively engaged in

purposeful activities for longer duration of time and thus

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minutes, hours, all day long?

0. Voices not present.
1. Voices last for a few seconds, fleeting voices.
2. Voices last for several minutes.
3. Voices last for at least one hour.
4. Voices last for hours at a time.

6. Cleghorn JM, Franco S, Szechtman B, et a). Towards a brain map of

auditory hallucinations. Am J Psychiat 1992; 149: 1062 4.
7. Demonet J-F, Chollet F, Ramsay S, et al. The anatomy of phonological
and semantic processing in normal subjects. Brain 1992;115: 1753-68.
8. Howard D,Patterson K,Wise R,et al. The cortical localization of the
lexicons. Brain 1992;115:1769-82.
9. Price C,Wise R, Howard D, et al. The brain regions involed in the
recognition of visually presented words.J Cerb Blood Flow Metab
1993;13 (suppl 1):s501.
10. Grossman M, Reivich XS ,Ding D, et al.A cerebral network for sentence
comprehension examine with a PET activation paradiram. J Cereb
Blood Flow Metab 1993;13 (suppl 1) :s525.
11. Slade PD. The effects of systematic desensitisation on auditory
hallucinations. Behav Res Ther 1972;10:85-91.
12. Slade PD. The psychological investigation and treatment of auditory
hallucinations: A second case report. BrJ Med Psychol 1973;46:293-6.
13. Schwartz S. Individual differences in cognition: Some relationships
between personality and memory. J Res Person 1975;9:217-25.
14. Frith CD. The Cognitive Neuropsychology of Schizophrenia. Hove,
Sussex: Lawrence Erlbaum Associates, 1993:68-73.
15. Green M.F., & Kinsbourne M. Auditory hallucinations in schizophrenia:
does Humming help? Biological Psychiatry,1989;25:630-633.
16. Birchwood M. Control of auditory hallucinations through occlusion of
monaural auditory input. British journal of psychiatry:1986;
149:104-107.
17. James D. The experimental treatment of two cases of auditory
hallucinations. British Journal of Psychiatry 1983;143:515-516.
18. Hemsley A.M. & Slade P. D. The effects of varying auditory input on
schizophrenic hallucination. British Journal of Psychiatry1981;
139:122-127.
19. Feder R. Auditory hallucinations treaed by radio headphones. American
Journal of Psychiatry1982; 139 (9):1188-1190.
20. Louis N. Gould Verbal hallucinations and activity of vocal
musculature.:An Electromygraphic Study. Am J Psychiatry
1948;105:367-372.
22. Rogers J. Order and disorder in medicine and occupational therapy.
American Journal of Occupational therapy 1982;36:29-35.
23. Kimura D. The right and left differences in perception of
melodies..Quart. J.Exp.psychol. 16,355-358 24. Green MF, Hugdahl K,
Mitchell S. Dichotic listening during auditory hallucinations in patients
with schizophrenia.
Am J Psychiatry. 1994 Mar;151(3):357-62.
25. David AS. The neuropsychological origin of auditory hallucinations.
David A, Cutting J, eds. Neuropsychology of Schizophrenia. Hove,
Sussex: Lawrence Erlbaum Associates, 1994:269-313.
26. Mac Rae A. Coping with hallucinations : A phenomenological study of
the everyday lived experience of people with hallucinatory psychosis.
(Doctoral dissertation, Saybrook Institute, San Francisco,. Ann Arbor,
MI: University Microfilms, 1993.
27. Arana G., & Hyman S. Handbook of psychiatric drug therapy 2nd edn,
Little, Brown, 1991.
28. The neuropsychology of schizophrenia: By Anthony.S.David, John C
Cutting
29. A Short Textbook of psychiatry. Niraj Ahuja 7th edition.

3. LOCATION:
When you hear your voices where do they sound like they're coming from?
Inside your head and/or outside your head?
If voices sound like they are outside your head, whereabouts do they sound
like they're coming from?
0. No voices present.
1. Voices originate inside head only.
2. Voices outside the head, but close to ears or head. Voices inside head
may also be present.
3. Voices originate inside or close to ears and outside head away from
ears.
4. Voices originate from outside space, away from head only.
4. LOUDNESS:
How loud are your voices? Are they louder than your voice, about the same
loudness, quieter or just a whisper?
0. Voices not present.
1. Quieter than own voice, whisper.
2. About the same loudness as own voice.
3. Louder than own voice.
4. Extremely loud, shouting.
5. BELIEFS RE-ORIGIN OF VOICES:
What do you think has caused your voices?
Are the voices caused by factors related to yourself or solely due to
other people or factors?
If patient expresses an external origin:
How much do you believe that your voices are caused by -------------------(add
patient's attribution) on a scale from 0-100 with 100 being that you are totally
convinced, have no doubts and 0 being that it is completely untrue?
0. Voices not present.
1. Believes voices to be solely internally generated and related to self.
2. Holds a less than 50% conviction that voices originate from external
causes.
3. Holds 50% or more conviction (but less than 100%) that voices originate
from external cause.
4. Believes voices are solely due to external causes (100% conviction)
7.
DEGREE OF NEGATIVE CONTENT:
[Rate using criteria on scale, asking patient for more detail if necessary]
0.
Not unpleasant or negative.
1.
Some degree of negative content, but not personal comments relating
to self or family e.g. swear words or comments not directed to self, e.g.
The milk man is ugly.
2.
Personal verbal abuse, comments on behaviour e.g. Shouldn't do
that, or say that.
3.
Personal verbal abuse relating to self-concept e.g. You're lazy, ugly,
mad, perverted.
4.
Personal threats to self e.g. threats to harm to self or family, extreme
instructions or commands to harm self or others and personal verbal
abuse as in (3).

APPENDIX A
AUDITORY HALLUCINATIONS: SCORING CRITERIA
1. FREQUENCY:
How often do you experience voices? e.g. every day, all day long etc.
0. Voices not present or present less than once a week (specify frequency
if present).
1. Voices occur for at least once a week
2. Voices occur at least once a day.
3. Voices occur at least once an hour.
4. Voices occur continuously or almost continually i.e. stop only for a few
seconds or minutes.

8.
AMOUNT OF DISTRESS:
Are your voices distressing?
How much of the time?
0.
Voices not distressing at all.
1.
Voices occasionally distressing, majority not distressing.
2.
Equal amounts of distressing and non-distressing voices.
3.
Majority of voices distressing, minority not distressing.
4.
Voices always distressing.

2. DURATION:
When you hear your voices, how long do they last e.g. a few seconds,

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9. INTENSITY OF DISTRESS:
When voices are distressing, how distressing are they?
Do they cause you minimal, moderate, severe distress?
Are they the most distressing they have ever been?
0.
Voices not distressing at al.
1.
Voices slightly distressing.
2.
Voices are distressing to a moderate degree.
3.
Voices are very distressing, although subject could feel worse.
4.
Voices are extremely distressing, feel the worst he/she could
possibly feel.

3.

4.

Subject believes they can have some control over their voices but only
occasionally. The majority of time the subject experiences voices which
are uncontrollable.
Subject has no control over when the voices occur and cannot dismiss
or bring them on at all.

NUMBER OF VOICES
How many different voices have you heard over the last week?
No. of voices =

10. DISRUPTION TO LIFE CAUSED BY VOICES:

How much disruption do the voices cause to your life?
Do the voices stop you from working or other daytime activity?
Do they interfere with your relationships with friends and/or family?
Do they prevent you from looking after yourself, e.g. bathing changing
clothes etc.
0.
No disruption to life, able to maintain independent living with no
problems in daily living skills. Able to maintain social and family
relationships (if present).
1.
Voices cause minimal amount of disruption to life e.g. interferes with
concentration although able to maintain daytime activity and social and
family relationships and be able to maintain independent living without
support.
2.
Voices cause moderate amount of disruption to life causing some
disturbance to daytime activity and/or family or social activities. The
patient is not in hospital although may live in supported
accommodation or receive additional help with daily living skills.
3.
Voices cause severe disruption to life so that hospitalisation is usually
necessary. The patient is able to maintain some daily activities, selfcare and relationships whilst in hospital. The patient may also be in
supported accommodation but experiencing severe disruption of life in
terms of activities daily living skills and/or relationships.
4.
Voices cause complete disruption of daily life requiring hospitalisation.
The patient in unable to maintain any daily activities and social
relationships. Self-care is also severely disrupted.

FORM OF VOICES
1ST Person
2nd Person
3rd Person
Single words or phrases
Without pronouns

Yes/No
Yes/No
Yes/No
Yes/No

(n=
(n=
(n=
(n=

)
)
)
)

APPENDIX-B
Work performance scale:
Sr. No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

11. CONTROLLABILITY OF VOICES:

Do you think you have any control over when your voices happen?
Can you dismiss or bring on your voices?
0.
Subject believes they can have control over their voices and can
always bring on or dismiss them at will.
1.
Subject believes they can have some control over the voices on the
majority of occasions.
2.
Subject believes they can have some control over their voices
approximately half of the time.

SUBJECT
COMPONENTS OF WPS
Interest in activities
Interest in completion
Initial learning
Complexity and organization of tasks
Problem solving
Concentration
Retention and recall
Speed of performance
Activity neatness
Frustration tolerance
Work Tolerance
Reaction to authority
Sociability with Therapist
Sociability with patients
TOTAL

PRE
Good
Good
Fair
Fair
Fair
Fair
Poor
Fair
Fair
Good
Fair
Good
Fair
Fair

POST
Good
Good
Good
Good
Good
Good
Fair
Good
Good
Good
Good
Good
Good
Good

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