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

Therapy: Volume: 44 : Issue: 1 (January 2012 - April 2012) “ EFFECT OF COPING STRATEGIES

“ 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 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%

Hallucination Rating Scale (AHRS) pre and post each

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.

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

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)

2) 'Thought echo' (audible thoughts) 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

4) Voices commenting on one's action interconnected with Wernicke's area (via the arcuate

3) Third

person

hallucination

(voices

heard

arguing),

discussing the patient in third person

Only the 'third person hallucinations' are believed to be characteristic of Schizophrenia

29

fasciculus) and with regions of the middle temporal gyrus and medial temporal gyrus.

9 10

7 8

11,12

In psychological theories, Slade observed that hallucinations occured during periods of stress .The link between stress and hallucinations may be that stress itself

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] impairs the processing of semantic information.

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

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.

about the patient commenting on his or her thoughts

Frith

and output theories of hallucinations.

14 proposed two psychological models , namely input

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 activity in brain.

1

Owen suggested that dopamine receptors in schizophrenic patients are supersensitive to normal amounts of dopamine.

2

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.

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

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 hallucinations 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.

4

5

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

• Anticholinergics

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 Temporal lobe epilepsy

neostriatum.

6

Why to study about auditory hallucinations? frequent auditory hallucinations fail to demonstrate an

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 hallucinations persistent and more severe. In anxiety

hyperacusis auditory hallucination, single earmuff reduce

an environment that is often isolative and prejudicial towards

Stress vulnerability model by Zubin and Spring suggests that anxiety is a precipitating factor which makes auditory

expected right ear advantage. 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:

23

24

persons with mental illness . anxiety by reducing auditory input by 50%. Earmuff helps in

reducing the load on the auditory processing ability by MANAGEMENT OF HALLUCINATIONS: improving the attention span of the patient which would have

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. hallucination? Gould(1948) recorded increased EMG activity

in muscles of the chin and lips of hallucinating subjects as

skills of the patient. compared to normal subjects suggesting that hallucinations

Therapy- various therapies targeted in improving the coping

hallucinations. Does humming help in reducing auditory

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

26

have a psychomotor component.

15

COPING STRATEGIES:

Haddock et al (1996) notes that early

psychosis tend to fit into three main categories:

those which involve distraction techniques for

phenomena, those which involve focusing the patient directly onto the phenomena and those which involve anxiety Reading aloud:

reduction as a target for intervention.

Various coping strategies include Use of personal stereo (Feder 1982; Johnston et al 2002) Monaural occlusion (Birchwood 1986) Humming (Green & Kinsbourne 1989) Sub-vocal counting/naming Relaxation training (one to one) Thought stopping Audio tape therapy

approaches to

psychotic

In a study conducted by Foster Green and Marcel Kisbourne humming a single note silently reduced auditory hallucinations by 59% .

15 16 17 18 19

16

15

Bick and Kisbourne (1987) conducted an experimental study

21 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

20

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

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. 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

22

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. Phase 1-Earmuffs + auditory localization and processing. Phase 2-Humming + Reading aloud Study conducted Phase 3-Conventional Occupational therapy + Earmuffs +

AIM:

To study the effectiveness of coping strategies (monaural

occlusion,

humming and reading aloud) and conventional occupational

therapy in chronic drug resistant auditory hallucination in and post each phase. In phase 3 pre and post work

schizophrenia. performance scale(WPS) was also done.

The changes in dimensions of auditory hallucinations were assessed on Auditory Hallucination Rating Scale (AHRS) pre

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.

Humming

auditory

localisation

and processing activity,

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

auditory localization and processing exercises. Pre AHRS

left sided earmuffs on auditory hallucinations. was done. Monaural occlusion with left sided earmuffs to be

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

Auditory localization of ringing bells with eyes closed from

hallucinations. various regions in space, listening to music and answering to

4) To find out the effect of performance.

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.

Goal: To override subvocalisations and facilitate corollary

Age between 15 to 60 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

patients. Any other mental or physical disorder which can 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

(envelope

making, carrom) and social skills training.

(deep

Work performance scale

Auditory hallucination rating scale(AHRS)

Outcome measures:

interfere with the study eg. Mental Retardation,hearing loss etc. Age above 60 yrs

1) To see the effectiveness of monaural occlusion by using

worn throughout the week.

Activities given like:

auditory hallucination on work

related questions posed by the therapist.

Activity given: Reading a paragraph loudly and with understanding.

or grossly mentally affected

(Appendix A)

(Appendix B)

(WPS)

breathing

exercises),group

activities

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

Goal: To improve work performance and maintain or lower auditory hallucinations. Post AHRS and post WPS was done at the end of week.

RESULTS and TABLES:

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

1

week

of

Ear

muff

+

auditory

localization

and

processing.

   

Sr

Component

 

Pre

 

Post

 

No.

   
   

1

2

3

4

Mean

1

2

3

4

Mean

1

Frequency

4

2

3

2

2.75

2

1

2

1

1.5

2

Duration

4

2

3

4

3.25

2

1

2

1

1.5

3

Location

3

2

1

4

2.5

3

2

1

4

2.5

4

Loudness

2

1

3

3

2.25

2

1

3

2

2

5

Beliefs of re- origin

4

1

4

4

3.25

4

1

4

4

3.25

6

Amt of-

2

3

4

4

3.25

2

2

2

2

2

ve content

7

Degree of

4

1

2

4

2.75

3

1

2

2

2

ve content

8

Amt of

4

4

4

4

4

4

3

4

3

3.5

distress

9

Intensity of

4

3

3

3

3.25

2

3

3

3

2.75

distress

10

Disruption

2

2

1

3

2

1

1

1

1

1

11

Control

4

4

4

1

3.25

1

2

3

1

1.75

Graph 1: Showing Pre and Post mean score graph of AHRS after 1 week of Ear muff therapy and auditory localisation.

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Pre AHRS score Post AHRS
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Pre AHRS score
Post AHRS score
Frequency
Duration
Location
Belief of reorigin of voices
Loudness
of - ve of cnt
Amt
voice
Degree
of
- ve of Amt Intensity nt
of voice
distress
of distress
Disruption
Control

Table 2: Showing Pre and Post mean score of AHRS after 1 week of Humming and reading aloud.

Sr

Component

 

Pre

 

Post

 

No.

   
   

1

2

3

4

Mean

1

2

3

4

Mean

1

Frequency

4

2

3

2

2.75

3

1

2

1

1.75

2

Duration

4

2

3

4

3.25

3

1

2

2

2

3

Location

3

2

1

4

2.5

3

2

1

4

2.5

4

Loudness

2

1

3

3

2.25

2

1

3

3

2.25

5

Beliefs of re-

4

1

4

4

3.25

4

1

4

4

3.25

origin

6

Amt of-

2

3

4

4

3.25

2

2

2

2

2

ve content

7

Degree of

4

1

2

4

2.75

3

2

2

2

2.25

ve content

8

Amt of

4

4

4

4

4

3

3

3

2

2.75

distress

9

Intensity of

4

3

3

3

3.25

3

3

3

2

2.75

distress

10

Disruption

2

2

1

3

2

1

1

1

1

1

11

Control

4

4

4

1

3.25

2

2

3

1

2

Graph 2: Showing Pre and Post mean score graph of

AHRS after 1 week of Humming and reading aloud therapy

as

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Pre AHRS score Post AHRS
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Pre AHRS score
Post AHRS score
Frequency
Duration
Location
Belief of reorigin of voices
of Loudness
- ve of cnt
Amt
voice
Degree
of
- ve of Amt Intensity nt
of voice
distress
of distress
Disruption
Control

Table 3: Showing Pre and Post mean score of AHRS after 1 week of Conventional Occupational therapy + Ear muff + Humming

Sr

Component

 

Pre

 

Post

 

No.

   
   

1

2

3

4

Mean

1

2

3

4

Mean

1

Frequency

3

2

3

1

2.25

2

1

1

0

1

2

Duration

3

1

3

1

2

2

1

1

0

1

 

3 Location

3

2

1

4

2.5

3

2

1

0

1.5

 

4 Loudness

2

1

3

2

2

2

1

1

0

1

5

Beliefs of re- origin

4

1

4

4

3.25

4

1

4

0

2.25

6

Amt of-

2

3

4

2

2.75

2

3

4

0

2.25

ve content

7

Degree of

3

2

3

2

2.5

2

2

3

0

1.75

ve content

 

8 Amt of

3

3

4

1

2.75

3

2

3

0

2

distress

 

Intensity of

9 3

 

3

3

2

2.75

3

2

2

0

1.75

distress

 

Disruption

10 2

 

2

2

2

2

2

2

2

0

1.5

 

Control

11 2

 

2

3

2

2.25

2

2

3

0

1.75

Graph 3: Pre and Post mean score graph of AHRS after 1 week of Conventional Occupational therapy + Ear muff + Humming

3.5 3 2.5 2 1.5 1 0.5 0 Pre AHRS score Post AHRS score Frequency
3.5
3
2.5
2
1.5
1
0.5
0
Pre AHRS score
Post AHRS score
Frequency
Belief Duration
Location
Loudness
reorigin
of Amt
- ve of of cnt
of
- voices
voice
Degree
ve
of
of Amt Intensity nt
of voice
distress
of distress
Disruption
Control

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

Table : 4.1

SUBJECT 1

COMPONENTS OF WPS

PRE

POST

Interest in activities

Fair

Fair

Interest in completion

Fair

Good

Initial learning

Fair

Fair

Complexity and organization of tasks

Poor

Fair

Problem solving

Fair

Fair

Conc entration

Fair

Good

Retention and recall

Poor

Fair

Speed of performance

Poor

Fair

Activity neatness

Fair

Fair

Frustration tolerance

Fair

Good

Work Tolerance

Fair

Good

Reaction to authority

Good

Good

Sociability with Therapist

Fair

Good

Sociability with patients

Fair

Good

TOTAL

24

35

Table : 4.2

SUBJECT 2

COMPONENTS OF WPS

PRE

POST

Interest in activities

Good

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

SUBJECT 3

COMPONENTS OF WPS

PRE

POST

Interest in activities

Fair

Good

Interest in completion

Fair

Good

Initial learning

Fair

Fair

Complexity and organization of tasks

Fair

Good

Problem solving

Fair

Fair

Concentration

Fair

Good

Retention and recall

Poor

Fair

Speed of performance

Poor

Fair

Activity neatness

Fair

Good

Frustration tolerance

Fair

Good

Work Tolerance

Fair

Good

Reaction to authority

Good

Good

Sociability with Therapist

Fair

Good

Sociability with patients

Fair

Good

TOTAL

27

38

Table : 4.4

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

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,(SD±0.768), Percentage improvement=19.89% .

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 content, amount of distress and controllability of voices. The

mean score of AHRS was computed Pre mean score = 32.5 ,

Conventional Occupational Therapy + Ear muffs and

There is a observable decline in duration, amount of negative

auditory localization a processing + Humming and (SD± 0.568), Post mean score=24.50, (SD± 0.596),

reading aloud in phase 3

Percentage improvement=18.18%

45 40 35 30 25 20 15 10 5 0 Subject 1 Subject 2 Subject
45
40
35
30
25
20
15
10
5
0
Subject 1
Subject 2
Subject 3
Subject 4
Pre WPS score
Post WPS score

RESULTS:

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

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.

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% .

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.

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%

Graph 4 shows changes in pre and post scores of WPS

DISCUSSION:

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

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 auditory hallucinations. They had better insight into their

condition which helped them understand the beliefs of re- origin of voices, which did not change when coping strategies were used individually. As the hallucinations decreased their work performance also improved markedly.

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

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

23 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. 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.

have right ear advantage

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.

16

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

25 Humming single note involved the

subjects in actively using the subvocal musculature for some

time which improved self awareness and they knew this

voices are self produced.

sound is self produced and is not alien. By

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.

25

reading

O.T. probably helped subjects to be actively engaged in purposeful activities for longer duration of time and thus

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.

6.

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

minutes, hours, all day long?

auditory hallucinations. Am J Psychiat 1992; 149: 1062 4.

0.

Voices not present.

7. Demonet J-F, Chollet F, Ramsay S, et al. The anatomy of phonological

1.

Voices last for a few seconds, fleeting voices.

and semantic processing in normal subjects. Brain 1992;115: 1753-68.

2.

Voices last for several minutes.

8. Howard D,Patterson K,Wise R,et al. The cortical localization of the

9. Price C,Wise R, Howard D, et al. The brain regions involed in the

3.

Voices last for at least one hour.

lexicons. Brain 1992;115:1769-82.

4.

Voices last for hours at a time.

recognition of visually presented words.J Cerb Blood Flow Metab

3.

LOCATION:

1993;13 (suppl 1):s501.

When you hear your voices where do they sound like they're coming from?

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.

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?

11.

Slade PD. The effects of systematic desensitisation on auditory

0.

No voices present.

hallucinations. Behav Res Ther 1972;10:85-91.

1.

Voices originate inside head only.

12. Slade PD. The psychological investigation and treatment of auditory hallucinations: A second case report. BrJ Med Psychol 1973;46:293-6.

2.

Voices outside the head, but close to ears or head. Voices inside head may also be present.

13. Schwartz S. Individual differences in cognition: Some relationships between personality and memory. J Res Person 1975;9:217-25.

3.

Voices originate inside or close to ears and outside head away from ears.

14. Frith CD. The Cognitive Neuropsychology of Schizophrenia. Hove, Sussex: Lawrence Erlbaum Associates, 1993:68-73.

4.

Voices originate from outside space, away from head only.

15. Green M.F., & Kinsbourne M. Auditory hallucinations in schizophrenia:

4.

LOUDNESS:

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.

Hemsley A.M. & Slade P. D. The effects of varying auditory input on schizophrenic hallucination. British Journal of Psychiatry1981;

139:122-127.

Feder R. Auditory hallucinations treaed by radio headphones. American Journal of Psychiatry1982; 139 (9):1188-1190.

20.

19.

18.

Louis N. Gould Verbal hallucinations and activity of vocal musculature.:An Electromygraphic Study. Am J Psychiatry

1948;105:367-372.

Rogers J. Order and disorder in medicine and occupational therapy. American Journal of Occupational therapy 1982;36:29-35.

Kimura D. The right and left differences in perception of

22.

23.

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?

25.

26.

melodies

Quart.

J.Exp.psychol. 16,355-358 24. Green MF, Hugdahl K,

0.

Voices not present.

Mitchell S. Dichotic listening during auditory hallucinations in patients

David AS. The neuropsychological origin of auditory hallucinations.

1.

Believes voices to be solely internally generated and related to self.

with schizophrenia. Am J Psychiatry. 1994 Mar;151(3):357-62.

2.

Holds a less than 50% conviction that voices originate from external causes.

David A, Cutting J, eds. Neuropsychology of Schizophrenia. Hove, Sussex: Lawrence Erlbaum Associates, 1994:269-313.

3.

Holds 50% or more conviction (but less than 100%) that voices originate from external cause.

Mac Rae A. Coping with hallucinations : A phenomenological study of the everyday lived experience of people with hallucinatory psychosis.

4.

Believes voices are solely due to external causes (100% conviction)

(Doctoral dissertation, Saybrook Institute, San Francisco,. Ann Arbor,

7.

DEGREE OF NEGATIVE CONTENT:

MI: University Microfilms, 1993.

[Rate using criteria on scale, asking patient for more detail if necessary]

27.

28.

29.

Arana G., & Hyman S. Handbook of psychiatric drug therapy 2nd edn, Little, Brown, 1991.

The neuropsychology of schizophrenia: By Anthony.S.David, John C Cutting

A Short Textbook of psychiatry. Niraj Ahuja 7 edition.

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

3.

that, or say that”. Personal verbal abuse relating to self-concept e.g. “You're lazy, ugly,

4.

mad, perverted. 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).

th

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).

Voices occur for at least once a week 8. AMOUNT OF DISTRESS:

Voices occur at least once a day. Are your voices distressing?

Voices occur at least once an hour. How much of the time?

Voices occur continuously or almost continually i.e. stop only for a few seconds or minutes.

1.

2.

3.

4.

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.

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

DURATION:

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.

 

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, self- care 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.

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.

3.

Subject believes they can have some control over their voices but only

4.

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 =

FORM OF VOICES

1 ST

2 nd

Person

Person

Person Single words or phrases Without pronouns

3

rd

Yes/No

(n=

)

Yes/No

(n=

)

Yes/No

(n=

)

Yes/No

(n=

)

APPENDIX-B

Work performance scale:

Sr. No.

SUBJECT

1.

COMPONENTS OF WPS

PRE

POST

2.

Interest in activities

Good

Good

3.

Interest in completion

Good

Good

4.

Initial learning

Fair

Good

5.

Complexity and organization of tasks

Fair

Good

6.

Problem solving

Fair

Good

7.

Concentration

Fair

Good

8.

Retention and recall

Poor

Fair

9.

Speed of performance

Fair

Good

10.

Activity neatness

Fair

Good

11.

Frustration tolerance

Good

Good

12.

Work Tolerance

Fair

Good

13.

Reaction to authority

Good

Good

14.

Sociability with Therapist

Fair

Good

15.

Sociability with patients

Fair

Good

 

TOTAL

   

***

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