Cognitive behavioural therapy for auditory hallucinations in schizophrenia: A review

Table 1 Randomized clinical trials of cognitive behavioral therapy for auditory hallucinations

Ref.	Sample	Methods	Criteria for diagnosis	Criteria for outcome	Focused treatment	Results	Follow-up
Shawyer et al[14]	n = 44 Mean age: 39	RCT	(1) diagnosis of schizophrenia or related condition based on DSM-IV criteria (2) command hallucinations within the previous 6 mo that caused distress or dysfunction despite treatment with antipsychotic medication at therapeutic doses	Assessor-rated degree of compliance with harmful command hallucinations on a scale of 0-7 Self-rated confidence to resist obeying harmful commands and confidence in coping with general commands on a scale of 0-100 PANSS Modified GAF PSYRATS Quality of Life Enjoyment and Satisfaction Questionnaire Client Satisfaction Questionnaire VAAS BAVQ-R 8-item self-report Insight Scale RSQ	Randomized to 15 sessions of the intervention “TORCH” or the control, Befriending. A sub-sample of 17 participants was randomized to a waitlist control before being allocated to TORCH or Befriending Pharmacological treatment: Chlorpromazine equivalent dose (mg) Mean = 742.9 SD = 388.7	Confidence to resist harmful CHs (P = n.s.) Confidence in coping with CHs (P < 0.01) PANSS total (P < 0.05) Modified GAF (P = n.s.) Distress PSYRATS (P < 0.01) Disruption PSYRATS (P < 0.01) Quality of Life ( P < 0.05) VAAS (P = n.s.) BAVQ-R (P = n.s.)	6-mo
Birchwood et al[15]	n = 197 Mean age: 37.4	RCT	(1) ICD-10 schizophrenia, schizoaffective, or mood disorders, under care of a clinical team (2) history of harmful command hallucinations of at least 6 mo duration with recent (< 9 mo) history of harm to self, others or major social transgressions as a result of the commands (full or partial compliance); or harmful command hallucinations where the individual is distressed and appeasing the powerful voice	VCS VPD Personal knowledge questionnaire/omniscience scale BAVQ-R PSYRATS Calgary Depression Rating Scale for Schizophrenia Beck Hopeleness Scale Beck Scale for Suicidal Ideation PANSS	Randomized to cognitive Therapy for command Hallucinations + treatment as usual or treatment as usual alone Adherence to cognitive therapy was excellent: only 12 (12%) of 98 participants not attending any sessions, and 79 (81%) completing the therapy (all manualised elements) Pharmacological treatment: Olanzapine equivalents dose (mg) 25.79 (SD: 21.73).	RSQ (P = n.s.) VCS experimental group: 41; control group: 49 VPD total, experimental group: 21.31; control group: 23.98 Personal knowledge questionnaire (P = 0.09) BAVQ-R (P = n.s.) PSYRATS total (P = n.s.) Calgary Depression Rating Scale for Schizophrenia (P = n.s.) Beck Scale for Suicidal Ideation (P = n.s.) PANSS total (P = n.s.)	18-mo

AHs: Auditory hallucinations; BAVQ-R: Beliefs about the voices questionnaire-revised; CHs: Command hallucinations; GAF: Global assessment of functioning scale; n.s.: Not significant; PANSS: Positive and negative syndrome scale; RCT: Randomized clinical trial; PSYRATS: Psychotic symptom rating scale; RSQ: Recovery style questionnaire; VAAS: Voices acceptance and action scale; VCS: Voice compliance scale; VPD: Voice power differential scale.

Table 2 Non randomized clinical trials of cognitive behavioral therapy for auditory hallucinations

Ref.	Sample	Methods	Criteria for diagnosis	Criteria for outcome	Focused treatment	Results	Follow-up
Zanello et al[21]	n = 41 age-range: 18-65	Naturalistic Study	(1) Diagnosis of a schizophrenia or schizoaffective disorder (2) Current AHs in the form of voices, occurring at least once per week	Reduction of AHs: BPRS Total symptom severity without AHs: BPRS	7 sessions of CBT based upon the program “Voice Group” of Wikes et al 1999 Pharmacological treatment: New antipsychotic Combined antipsychotic Anxiolytic, mood stabilizer, hypnotic or antidepressant medication Dosage: Changed when clinically required	Decrease in the hallucinations item score of Bprs (P < 0.05) Decrease in the total symptoms severity score of BPRS (P < 0.01)	6-mo
Thomas et al[16]	n = 33 Mean age: 36.4	Non-RCT Open trial	1) Diagnosis of a schizophrenia or schizoaffective disorder (2) Current AHs in the form of voices, occurring at least once per week (3) Voices associated with significant subjective distress (4) History of voices for at least one year; and (5) currently prescribed antipsychotic medication	Correlation between PSYRATS, PANSS, SAI and Outcome Main Outcome measure: Improvement of five points of more on the PSYSTRATS	24 sessions of CBT based upon the manual of Fowler et al (1995) Pharmacological treatment: Chlorpromazine-equivalent pre-treatment: M = 793.1 mg, SD = 468.6 mg; post–treatment: M = 768.1 mg, SD = 473.8 mg	Only negative symptoms showed a statistically correlation with outcome (rpb = -0.60; P ≤ 0.001)	None
Mortan et al[17]	n = 12 age range: 18-55	Pilot study	(1) Criteria for schizophrenia or schizoaffective based on DSM-IV-R (SCID I) (2) At least 1 psychotic attack with hospitalization (3) Ongoing AHs (4) Use of oral and injectable antipsychotic	Presence of Positive Symptoms: SAPS Presence of Negative Symptoms: SANS Comorbid symptoms: BDI HDI	9-10 sessions of CBT upon the manual of Morrison, 2002, Goldberg, 2007) Pharmacological treatment: Oral and injectable antipsychotic medication	Difference between pre-treatment and post-treatment Treatment goup: SAPS hallucination subscale score (P = 0.027) SAPS delusion sub-scale score (P = 0.028) SANS total scored (P = 0.046) KSQ (P = n.s.) BDI (P = n.s.) Control group: SAPS hallucination subscale score (P = n.s.) SAPS delusion sub-scale score (P = n.s.) SANS total scored (P = n.s.) BDI (P = 0.043) HDI (P = n.s.)	1-yr post-treatment follow-up
Hutton et al[18]	Single case, An 18-year-old man	Case report	Criteria for schizophrenia spectrum disorder based on DSM-IV Symptoms and psychosocial functioning: GAF; BPRS; Clinical questionnaire	Positive Symptoms: PSYRATS/CAARMS Beliefs about control of AHs: IVI	Brief CBT upon the mindfulness approach Pharmacological treatment: None	Pre-treatment: IVI score: 62 Post treatment: IVI score 2 The frequency and duration of AHs had reduced to zero	1, 3, 4, 9 mo post therapy
Dannahy et al[19]	n = 62 divided in nine groups Mean age: 41.1 SD: 9.2	Pilot study	The individual had been experiencing treatment-resistant and subjectively distressing voices for at least the preceding 2 yr, with the voice-distress rated at 3 or greater on at least one of the two PSYRATS voice-distress items	Primary outcome measure: Improve general psychosocial well-being (CORE-OM); Secondary measures: Reduce distress and perceived voice-control; Evaluate the relationship with voice (VAY)	Group person-based cognitive Therapy (PBCT) conducted over 8-12 sessions based upon the manual of Chadwick et al (2006) Pharmacological treatment: Standard psychiatric care Group person-based cognitive Therapy (PBCT) conducted over 8-12 sessions based upon the manual of Chadwick et al (2006) Pharmacological treatment: Standard psychiatric care	CORE-OM Total score: Post-group: 1.90b (0.70) VOICE-DISTRESS Total score: Post-group: 3.57b (0.83) VOICE-CONTROL total score: Post-group: 53.47b (23.59) VAY Voice Dependence total score: Post group: 6.76 (5.69) VAY Voice Intrusiveness total score: Post group: 9.03 (4.32) VAY Voice Dominance total score: - Post group: 14.46 (6.37) VAY Hearer distance total score: Post group: 12.93 (5.93)	1 mo
Gottlieb et al[20]	n = 17 Mean age: 40.10 SD: 13.63	Pilot study	(1) Criteria for schizophrenia, schizoaffective disorder, or psychosis, NOS based on DSM-IV (2) At least “moderate” level of AHs severity over the past week (BPRS Hallucinations item 4 or higher); (3) Between the ages of 18-65; (4) No exposure to CBTp within the past 3 yr (5) No current suicidal ideation or hospitalization within the past month (6) Taking a stable dose of an antipsychotic medication for at least one month; (7) No active substance abuse/dependence (8) MMSE score ≥ 24)	Primary outcomes: Reduce the frequency, intensity, loudness, associated distress, perceived degree of controllability of, and interference from AHs (PSYRATS) Secondary outcomes: Evaluate beliefs about AHs (BAVQ-R); Evaluate overall psychopathology (BPRS), and depression (BDI-II)	Web-based cognitive-behavioral therapy for AHs: - 10 session: - psychoeducational video tutorials - games - interactive exercises - social network to examine the coping strategies of other users. Pharmacological treatment: stable dose of antipsychotic medication for at least one month	Significant reductions from baseline to post-treatment in several measures of AHs and in overall psychopathology on the BPRS: PSYRATS AHs subscale total: P = 0.007 PSYRATS AHs Subscale: Voices location: P = 0.029 Voices intensity of negative statements: P = 0.049 PSYRATS delusions subscale total: P = 0.101 BPRS total score: P = 0.001 BPRS Subscale: BPRS Psychosis: P = 0.002 - BPRS Depression: P = 0.004 BPRS Activation: P = 0.001 BAVQ-R total score: P = 0.902 (n.s.) BDI-II-total score: P = 0.085 (n.s.)	None

^bP < 0.001. BPRS: Brief psychiatric rating scale; PSYRATS: Psychotic symptom rating scale; PANSS: The positive and negative syndrome scale for schizophrenia; SAI: The Schedule for the Assessment of Insight; SCID-I: Structured Clinical Interview for DSM; SAPS: Scale for the assessment of positive symptoms; SANS: Scale for the assessment of negative symptoms; BDI-II: The Back Depression Inventory II; HDI: Hamilton depression inventory; CAARMS: Comprehensive Assessment of At-Risk Mental States; GAF: Global Assessment of functioning; IVI: Interpretation Voices of Inventory; CORE-OM: Clinical outcomes in routine evaluation-outcome measure; VAY: Voice and You; BAVQ-R: The Belief about Voices Questionnaire-Revised; MMSE: Mini Mental State Examination; AHs: Auditory hallucinations.