This article was downloaded by: [182.182.14.

223] On: 07 February 2013, At: 06:45 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychosis: Psychological, Social and Integrative Approaches

Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rpsy20

Treatment of hallucinations: A comment

Dirk Corstens , Eleanor Longden , Bertel Rydinger , Richard Bentall & Jim van Os
a b d e a b c

Riagg Maastricht, Maastricht, Netherlands

University of Leeds, Institute of Psychological Sciences, Leeds, UK

c d

Slotsvaenget, Lyngby, Denmark

University of Liverpool, Institute of Psychology, Health and Society, Liverpool, UK

e

Maastricht University Medical Center, Psychiatry and Neuropsychology, Maastricht, Netherlands Version of record first published: 15 Nov 2012.

To cite this article: Dirk Corstens , Eleanor Longden , Bertel Rydinger , Richard Bentall & Jim van Os (2013): Treatment of hallucinations: A comment, Psychosis: Psychological, Social and Integrative Approaches, 5:1, 98-102 To link to this article: http://dx.doi.org/10.1080/17522439.2012.740069

PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-andconditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings,

demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

Downloaded by [182.182.14.223] at 06:45 07 February 2013

Psychosis, 2013, Vol. 5, No. 1, 98102, http://dx.doi.org/10.1080/17522439.2012.740069

OPINION PIECE Treatment of hallucinations: A comment

Dirk Corstensa*, Eleanor Longdenb, Bertel Rydingerc, Richard Bentalld and Jim van Ose
Riagg Maastricht, Maastricht, Netherlands; bUniversity of Leeds, Institute of Psychological Sciences, Leeds, UK; cSlotsvaenget, Lyngby, Denmark; dUniversity of Liverpool, Institute of Psychology, Health and Society, Liverpool, UK; eMaastricht University Medical Center, Psychiatry and Neuropsychology, Maastricht, Netherlands
a

Downloaded by [182.182.14.223] at 06:45 07 February 2013

(Received 30 September 2012; nal version received 11 October 2012) We comment on a recently published article in Schizophrenia Bulletin: The treatment of hallucinations in schizophrenia spectrum disorders (Sommer et al., 2012). Contrary to the recommendations made in this piece, we suggest that, on the basis of available evidence, psychological therapies (including, but not limited to cognitive behavioural therapy) should be proposed as a treatment of choice, medication as a possible augmentation strategy, and electroconvulsive therapy and transcranial magnetic stimulation not recommended at all. Keywords: hallucinations; psychosis; antipychotics; electroconvulsive therapy; cognitive therapy

We wish to comment on a recently published article in Schizophrenia Bulletin: The treatment of hallucinations in schizophrenia spectrum disorders by Sommer, Slotema, Daskalakis, Derks, Blom and van der Gaag (2012). We applaud the authors scholarly endeavour to recommend evidence-based treatments for this specic experience. For example, the proposed recommendations for the treatment of hallucinations in organic disorders such as Parkinsons Disease are particularly important for clinical practice, given the scant attention paid to this issue in existing literature. Nevertheless, the authors make a series of claims in this article that we believe are not robustly evidence-based. Specically, Sommer et al. state that only 8% of rst-episode patients still experience mild to moderate hallucinations after one year of medication usage. They further recommend depot administration for many patients on the basis of high non-adherence rates. These recommendations are derived from only one trial of individuals with a rst-episode of psychosis (n = 498). The original research (Boter, 2009; Kahn et al., 2008) used a single severity item of hallucinations from the positive and negative symptom scale (PANSS) in 362 patients that scored 3 or more on that particular item. Although there are many validated instruments available to monitor various aspects of hallucinations (Ratcliff, Farhall, & Shawyer, 2011), none of these were used here. Half of the subjects under investigation stopped their medication during the course of the study (the assumption of Missing at Random was used to correct for this using unbiased parameter estimates).
*Corresponding author. Email: d.corstens@lavori.nl
2013 Taylor & Francis

Psychosis

99

Furthermore, there was no comparison with a placebo condition, despite the fact that placebo effects in schizophrenia trials may be of comparable magnitude, quality, and impact to those observed in depression trials (Kinon, Potts, & Watson, 2011). Indeed, Sommer et al. themselves concede that there is no available research that monitors the specic effect of antipsychotic medication on hallucinations in a scientically valid way (Sanjuan, Aguilar, & Artigas, 2010). In this respect, McCarthy-Jones (2012) has recently established that the pervasive clinical use of antipsychotic medication for hallucinations is predominantly based on recourse to outdated literature that does not adequately demonstrate efcacy. In addition, the research (Boter, 2009; Kahn et al., 2008) cited by Sommer et al. was designed with discontinuation of medication as a primary outcome measure in order to determine which of the drugs were most efcacious and best tolerated by patients. Furthermore, the group under study was primarily white, male (mainly admitted to University Centres throughout Europe a very specic and probably biased population) with a mean age of 25 years, of whom only 10% lived alone and 2042% of whom had not previously used antipsychotics. Many individuals used co-medications (antidepressants, benzodiazepines, anticholinergics and anticonvulsants), making the specic impact of antipsychotic medication on symptoms unclear. Interestingly, an author in the original study (Boter, 2009, pp. 9798) stated that: Although changes in mean values of the PANSS may be signicant, the clinical relevance of such changes is often less clear. While symptom severity and assessment of global functioning improved, total PANSS scores did not change signicantly after 12 months. To demonstrate the efcacy of antipsychotic medication for hallucinations, Sommer et al. have therefore selected only one item from a study that was not primarily designed to measure the effect of medication on hallucinations, which was conducted with an unrepresentative group of individuals in very specic settings, many of whom used assorted medication, half of whom did not even take the medication for the whole year, and whose hallucinations occurred in the context of a range of other psychopathological changes (motivational impairment, cognitive alterations, affective dysregulations) that are likely to affect perceptual alterations in a range of uncontrolled ways. We dispute that this is adequate grounds on which to recommend pharmacology as a preferred treatment. Most secondary recommendations (e.g. about maintenance, depot medications, drugs of choice) are derived from other, non-specic symptom-directed research. Before recommending interventions for a specic symptom we need valid research and meta-analyses, which to our knowledge are not currently available. Indeed, a recent review of the Cochrane Schizophrenia Group register has reported that: Data are too limited to assess outcomes from initial antipsychotic medication treatment for individuals with an early episode of schizophrenia (Bola, Kao, & Soydan, 2012, p. 25). Reviews in populations with more persistent symptoms have likewise questioned the efcacy of second-generation antipsychotics for instituting clinically signicant improvement (Lepping et al., 2011; Leucht et al., 2009). In effect, antipsychotics should be used more selectively, for shorter durations, and with the lowest possible therapeutic dose with regard to reduced life expectancy and antipsychotic-related structural brain changes (Weinmann & Aderhold, 2010). In contrast to the scant evidence-base for recommending either antipsychotics in general, or depot injections in particular, Sommer et al. state that The effectiveness of CBT [cognitive behavioural therapy] for hallucinations and other psychotic

Downloaded by [182.182.14.223] at 06:45 07 February 2013

100

D. Corstens et al.

symptoms is well documented in several meta-analyses (p. 707). However, they subsequently conclude that CBT should only be applied as an augmentation to antipsychotic medication (p. 704). Electroconvulsive therapy (ECT), which Sommer et al. concede has no evidence-base at all for the treatment of hallucinations, is, nevertheless, also described as an augmentation strategy. That ECT is ineffective in the treatment of schizophrenia, both in the short and the long term, is further conrmed by a recent systematic review by Read and Bentall (2010). Transcranial magnetic stimulation (TMS) is similarly endorsed by Sommer et al. for combined use with pharmacology, despite the acknowledgement that meta-analyses of this treatment are derived from small, exploratory studies in which many extraneous factors may contribute to response. We suggest that until data from a large, welldesigned and well-implemented trial are available, no reasonable case can be made that TMS is of benet for patients with hallucinations. Treatments for psychosis and/or auditory hallucinations need to be able to address the long-term sequelae of adversarial life events (particularly childhood maltreatment), which meta-analytic work shows are strongly associated with the experience of hearing voices (e.g. Read, van Os, Morrison, & Ross, 2005; Varese et al., 2012). It may be argued that psychological treatments represent a better initial choice than chemical interventions. There is increasing evidence that hallucinations are meaningful to the individual and associated with early stress exposure. Psychological approaches may therefore be particularly suitable to engage patients in order to understand, interpret and overcome their distress (Beavan & Read, 2010; Chadwick, 2006; Longden, Corstens, Escher, & Romme, 2011; Longden, Madill, & Waterman, 2012; Meaden, Birchwood, & Trower, 2010; Romme, Escher, Dillon, Corstens, & Morris, 2009). In this respect, initial psychosocial intervention, combined with a time-limited deferment of antipsychotic medications for eligible rst-episode patients, may facilitate reductions in long-term medication dependence (Bola, Lehtinen, Cullberg, & Ciompi, 2009). While antipsychotics can have a role, clinicians should always utilise, where possible, opportunities for patients to make sense of their experiences and reduce distress and impact on behaviour using psychological strategies. In this respect, such interventions should not only be restricted to CBT, given that its evidence-base for psychosis is not wholly robust (Lynch, Laws, & McKenna, 2010; Mawson, Cohen, & Berry, 2010; Wykes, Steel, Everitt, & Tarrier, 2008) and its effects not necessarily better than less complex and less costly treatments (Cormac, Jones, Campbell, & Silveira, 2002). In conclusion, we propose that if the recommendations were derived logically, without preconception, from the evidence provided by Sommer et al. themselves, then psychological therapies (including, but not limited to, CBT) would be proposed as the treatment of choice, medication as an augmentation strategy (but with proper regard to the relative safety of these two approaches), and ECT and TMS not recommended at all. References
Aleman, A., & Laroi, F. (2008). Hallucinations: The idiosyncracy of perception. Washington, DC: American Psychological Association. Beavan, V., & Read, J. (2010). Hearing voices and listening to what they say: The importance of voice content in understanding and working with distressing voices. Journal of Nervous and Mental Disease, 198, 201205.

Downloaded by [182.182.14.223] at 06:45 07 February 2013

Psychosis

101

Bola, J.R., Lehtinen, K., Cullberg, J., & Ciompi, L. (2009). Psychosocial treatment, antipsychotic postponement, and low-dose medication strategies in rst-episode psychosis: A review of the literature. Psychosis: Psychological, Social and Integrative Approaches, 1, 418. Bola, J.R., Kao, D.T., & Soydan, H. (2012). Antipsychotic medication for early-episode schizophrenia. Schizophrenia Bulletin, 38, 2325. Boter, H. (2009). Effectiveness of antipsychotics in rst-episode schizophrenia and schizophreniform disorder on response and remission: An open randomized clinical trial (EUFEST). Schizophrenia Research, 115, 97103. Chadwick, P. (2006). Person-based cognitive therapy for distressing psychosis. Oxford: Wiley-Blackwell. Cormac, I., Jones, C., Campbell, C., & Silveira, D.M.N.J. (2002). Cognitive behaviour therapy for schizophrenia. Cochrane Data Systematic Review, 1, Art. No.:CD000524. Kahn, R.S., Fleischhacker, W.W., Boter, H., Davidson, M., Vergouwe, Y., Keet, I.P., et al. (2008). Effectiveness of antipsychotic drugs in rst-episode schizophrenia and schizophreniform disorder: An open randomised clinical trial. Lancet, 371, 10851097. Kinon, B.J., Potts, A.J., & Watson, S.B. (2011). Placebo response in clinical trials with schizophrenia patients. Current Opinions in Psychiatry, 24, 107113. Lepping, P., Sambhi, R.S., Whittington, R., Lane, S., & Poole, R. (2011). Clinical relevance of ndings in trials of antipsychotics: Systematic review. British Journal of Psychiatry, 198, 341345. Leucht, S., Arbter, D., Engel, R.R., Kissling, W., & Davis, J.M. (2009). How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials. Molecular Psychiatry, 14, 429427. Longden, E., Corstens, D., Escher, S., & Romme, M. (2012). Voice hearing in biographical context: A model for formulating the relationship between voices and life history. Psychosis: Psychological, Social and Integrative Approaches, 4, 224234. Longden, E., Madill, A., & Waterman, M.G. (2012). Dissociation, trauma, and the role of lived experience. Toward a new conceptualization of voice hearing. Psychological Bulletin, 138, 2876. Lynch, D., Laws, K.R., & McKenna, P.J. (2010). Cognitive behavioural therapy for major psychiatric disorder: Does it really work? A meta-analytical review of well-controlled trials Psychological Medicine, 40, 924. Mawson, A., Cohen, K., & Berry, K. (2010). Reviewing evidence for the cognitive model of auditory hallucinations: The relationship between cognitive voice appraisals and distress during psychosis. Clinical Psychology Review, 30, 248258. McCarthy-Jones, S. (2012). Hearing voices: The histories, causes and meanings of auditory verbal hallucinations (pp. 375383). Cambridge: Cambridge University Press. Meaden, A., Birchwood, M., & Trower, P. (2010). Cognitive therapy for command hallucinations. In F. Lari & A. Aleman (Eds.), Hallucinations: A guide to treatment and management (pp. 103121). Oxford: Oxford University Press. Ratcliff, K., Farhall, J., & Shawyer, F. (2011). Auditory hallucinations: A review of assessment tools. Clinical Psychology and Psychotherapy, 18, 524534. Read, J., van Os, J., Morrison, A.P., & Ross, C. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112(5), 330350. Read, J., & Bentall, R. (2010). The effectiveness of electroconvulsive therapy: A literature review. Epidemiologia e Psichiatria Sociale, 19, 333347. Romme, M., Escher, S., Dillon, J., Corstens, D., & Morris, M. (Eds.). (2009). Living with voices: Fifty stories of recovery. Ross-on-Wye: PCCS Books. Sanjuan, J., Aguilar, E.J., & Artigas, F. (2010). Pharmacological treatment of hallucinations. In F. Laroi & A. Aleman (Eds.), Hallucinations: A guide to treatment and management (pp. 928). Oxford: Oxford University Press. Sommer, I.E., Slotema, C.W., Daskalakis, Z.J., Derks, E.M., Blom, J.D., & van der Gaag, M. (2012). The treatment of hallucinations in schizophrenia spectrum disorders. Schizophrenia Bulletin, 38(4), 704714.

Downloaded by [182.182.14.223] at 06:45 07 February 2013

102

D. Corstens et al.

Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W., et al. (2012). Childhood trauma increases the risk of psychosis: A meta-analysis of patient-control, prospective and cross-sectional cohort studies. Schizophrenia Bulletin, 38, 661671. Weinmann, S., & Aderhold, V. (2010). Antipsychotic medication, mortality and neurodegeneration: The need for more selective use and lower doses. Psychosis: Psychological, Social and Integrative Approaches, 2, 5069. Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523537.

Downloaded by [182.182.14.223] at 06:45 07 February 2013