Indian Journal of Health and Wellbeing 2015 Indian Association of Health,

2015, 6(5), 480-483 Research and Welfare

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Efficacy of cognitive behaviour therapy in management of

delusion, hallucination in patients with schizophrenia
Md. Raqueb Ansari and Masroor Jahan
Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry
and Allied Sciences (RINPAS), Kanke, Ranchi, Jharkhand

Schizophrenia is still considered to be chronic and depilating illness. The aim of the present study is to manage the
delusion and hallucination in patients with schizophrenia. 24 patients diagnosed with schizophrenia according to
ICD-10 DCR were chosen from different inpatient department of RINPAS, kanke using the simple random
sampling technique. After taking informed consent from the patients, socio-demographic and clinical data sheet and
PSYRATS were administered and they were randomly assigned to CBT+TAU and TAU group. Cognitive
behaviour therapy was given to CBT+TAU group, total 17-20 sessions of 45 minutes each with a frequency of thrice
a week. After completion of the therapy sessions, post assessment was done and follow up assessment was done
after six months of post assessment. Data was analyzed with the help of Mann-Whitney U test and Chi-square Test
was used for statistical analysis. The significant reduction was found in delusion and hallucination. Cognitive
behaviour therapy was found to be effective in management of delusion and hallucination.

Keywords: schizophrenia, delusion, hallucination and cognitive behaviour therapy

Schizophrenia and other psychotic disorders are still chronic and disorders do not prohibit effective cognitive-behavioural treatment
debilitating conditions despite the advances in pharmacological of auditory hallucinations.
treatments (Pratt & Mueser, 2002). Research suggests that between
25 to 60 percent of the patients continue to experience psychotic Method
symptoms even after satisfactory drug adherence (Curson et al.,
1998). Despite the effectiveness of anti-psychotic pharmacotherapy,
Participants
residual hallucinations and delusions do not completely resolve in In this study initially 24 schizphrenic patients meeting various
some medicated patients. Additional cognitive behavioral therapy inclusion and exclusion criterions were selected from different
(CBT) seems to improve the management of positive symptoms. inpatient wards of RINPAS, kanke, Ranchi, Jharkhand through
Even with the use of optimal doses of clozapine, 40% of patients with simple random sampling. In due course of study four patients (2
treatment-resistant schizophrenia do not respond. An effective from control and 2 from experimental group) drop out from the
psychological treatment is currently the only option for such patients study as they were prematurely discharged from the hospital on care
to ameliorate disabling symptoms. giver request. Hence, final analysis was done only for 20 patients.
Cognitive behavioural therapy has been established as an effective Both groups were comparable in socio-demographic characteristic
treatment for residual psychotic symptoms but a substantial and clinical variables. Hence, possible effects of these were
proportion of people do not benefit from this treatment. There has controlled prior to the intervention. Patients in the age range of 20-
been little direct study of predictors of outcome, particularly in 40 years. Most of them were educated up to at least 8th std. To
treatment targeting auditory hallucinations. A study done by Thomas control confounding variable patients with history suggesting
et al. (2010) in which Psychotic Symptom Rating Scales mental retardation, general medical condition, substance abuse and
(PSYRATS) and Positive and Negative Syndrome Scale (PANSS) having acute medical conditions or other co-morbid psychiatric
were administered pre- and post-therapy to 33 people with condition at the time of selection were excluded.
schizophrenia-related disorders receiving CBT for auditory Instruments
hallucinations in a specialist clinic. Outcome was compared with
pre-therapy measures of insight, beliefs about the origin of Socio-demographic and Clinical Data Sheet: It consisted of all areas
hallucinations, negative symptoms and cognitive disorganization. of socio-demographic details like age, domicile, education,
Results showed significant improvement was found on post- employment, marital status etc. and question elated to nature of
treatment on the PSYRATS and PANSS Positive and General Scales. illness, substance dependence, and co-morbid psychiatric disorder,
Improvement on the PSYRATS was associated with lower levels of duration of illness and severe physical illness in the near past and
negative symptoms, but was unrelated to overall insight, delusional both group were matched on all above mentioned variables.
conviction regarding the origins of hallucinations, or levels of Psychotic Symptoms Rating Scale: This scale was developed in
cognitive disorganization. Based on their study Thomas et al. (2010) recognition of the complexity of hallucinations and delusions. It also
concluded that Lack of insight and presence of formal thought measures the severity of these symptoms. It is intended to be of use
to practitioners interested in assessing changes in symptoms. There
are two sets of scales, one for hallucinations (AH; 11 items) and the
Correspondence should be sent to Masroor Jahan, Department of other for delusions (AD; 6 items). Severity is rated using a 5-point
Clinical Psychology, RINPAS, Kanke, Ranchi, Jharkhand scale. The hallucinations scale includes frequency, duration,
E-mail: [email protected] intensity of distress, control lability, loudness, location, negative
 Indian Journal of Health and Wellbeing 2015, 6(5), 480-483 481

content, degree of negative content and belief about voices and delusions and hallucinations. A core set of cognitive behaviour therapy
disruption. The delusion scale includes preoccupation, distress, technique were used. Then on further sessions the patients beliefs were
duration, conviction, intensity of distress, and disruption. challenged by some logical questions. Some effective techniques were
A factor analysis yielded three factors (a) emotional characteristics used as logical questioning and examining the evidence. Cognitive
(b) physical characteristics (c) cognitive interpretation, behaviour therapy technique for hallucinations such as distractions
Interrater reliability of hallucination ranged from 0.79 to 0.90. technique (i.e. reading books, listening song , gardening etc.) were
Reliability for the delusions scale was also high. All six of the items used according to the patients interest and availability in the hospital as
were above 0.88. well as at home. Prior to discharge, participants were evaluated again
on the same measure as it was on baseline.
Procedure
Research design
In this study patients diagnosed with schizophrenia as per ICD-10
(DCR) and meeting the inclusion and exclusion criterions were A pre-test and post test with control design was used in this study.
selected from different units of Ranchi Institute of Neuro-Psychiatry Equal number of patients was randomly assigned to cognitive
and Allied Sciences. Potential and interested candidates were behaviour therapy (CBT+TAU) and treatment as usual group (TAU).
approached. Once patients agreed to participate, informed consent was Statistical analysis
taken and demographic and clinical information was collected by using
socio-demographic and clinical data sheet. Immediately after As sample size in this study was small, hence obtained data was
obtaining consent and collecting socio-demographic and clinical data analyzed by using non-parametric statics, namely, chi-square test,
PSYRATS was administered to collect baseline data. After this they Mann Whitney U test (for between group comparison).
were randomly assigned to TAU+CBT and TAU group. Patients in the
Results
TAU condition received standard treatment on the unit, which includes
psycho-education, supportive therapy and pharmacotherapy. Patients Table 1 is showing the comparison between patients with
in the TAU+CBT conditions received approximately 17-20 one hour schizophrenia in treatment as usual and patients in treatment as usual
long sessions of individual CBT thrice in a week during their stay in the plus cognitive behaviour therapy (TAU+CBT) at baseline and post
hospital. Initially, 2-3 sessions a good rapport was developed with on delusions and hallucinations. To compare both groups at baseline
patients and then the patients were allowed to discuss about their and post assessment scores Mann Whitney 'U' test was calculated.

Table 1: Comparison of delusion of psychotic symptoms rating scale between Experimental and Control Group at Baseline
Area of assessment Experimental group Control group Mann Whitney Test
Mean SD Mean SD Mean Rank
Experimental Control U Value Z Score
Group Group
Preoccupation from delusion 3.600.51 3.300.67 11.70 9.30 38.00 1.02 NS
Duration of preoccupation 3.100.87 3.000.94 10.80 10.20 47.00 0.24 NS
Conviction 3.700.48 3.200.63 12.65 8.35 28.50 1.83 NS
Amount of distress 3.700.48 3.000.47 13.65 7.35 28.50 1.86 NS
Intensity of distress 3.500.52 3.000.66 12.50 8.50 30.00 1.69 NS
Disruption to life 3.800.42 3.200.78 12.70 8.30 28.00 1.91 NS
NS- Not Significant

By observing the Table 1 it is evident that there was no significant p>0.05), duration of preoccupation (U=47, Z=0.24, p>0.05),
difference between both groups in terms of delusion on PSYRATS. conviction (U=28.50, Z=1.83, p>0.05),amount of distress
This suggests that both groups were similar on different elements of (U=28.50, Z=1.86, p>0.05)intensity of distress (U=30, Z=1.91,
delusions. No significant difference was found on any element of p>0.05) and disruption to life (U=28, Z=1.91 ,p>0.05).
delusion such as preoccupation from delusion (U=38, Z=1.02,

Table2: Comparison of hallucinations of Psychotic Symptoms Rating Scale between Experimental and Control Group at Baseline
Area of assessment Experimental group Control group Mann Whitney Test
Mean SD Mean SD Mean Rank
Experimental Control U Value Z Score
Group Group
Frequency of auditory hallucination 3.300.67 3.500.70 9.60 11.40 41.00 0.75 NS
Duration of auditory hallucination 2.700.67 2.400.51 11.70 9.30 38.00 1.02 NS
Location of auditory hallucination 3.600.51 3.500.70 10.70 10.30 48.00 0.17 NS
482 ANSARI AND JAHAN/ EFFICACY OF COGNITIVE BEHAVIOUR THERAPY

Loudness of auditory hallucination 2.900.73 2.900.56 10.45 10.55 49.50 0.04 NS

Re -Origin of voices 3.500.52 3.600.69 9.75 11.25 42.50 0.65 NS
Amount of negative content 2.800.63 2.500.52 11.75 9.25 37.50 1.07 NS
Degree of negative content 2.500.52 2.700.67 9.75 11.25 42.50 0.64 NS
Amount of distress 3.100.56 3.100.31 10.55 10.45 49.50 0.05 NS
Intensity of distress 2.700.48 2.700.48 10.50 10.50 50.00 0.00 NS
Disruption to life 2.500.52 2.500.52 10.50 10.50 50.00 0.00 NS
Controllability 3.400.69 3.700.48 9.35 11.65 38.50 1.00 NS
NS- Not Significant

By observing the Table no 2 it is evident that there was no significant elements of hallucinations such as frequency of auditory
difference between both groups in terms of different elements of hallucination (U=41, Z=0.75, p>0.05), frequency of auditory
hallucinations on PSYRATS at baseline level. It means that both hallucination (U=38, Z=1.02, p>0.05), location of auditory
groups were similar at baseline level. The Mann Whitney U value hallucination (U=48, Z=0.17, p>0.05) and etc.
indicates that there was no significant difference was found on any

Table : 3 Showing after Intervention Status of Clinical Symptoms of the Experimental Group and Control Group on Psychotic Symptom
Rating Scale (SAPS)'s Dimension of Delusion.
Area of assessment Experimental Group Control Group Mann Whitney Test
MSD MSD
Pre Post Difference Pre Post Difference Mean rank U value Z Score
(Pre-Post) (Pre-Post)
Experimental Control
Group Group
Preoccupation from delusion 3.600.51 1.400.84 2.201.03 3.300.67 2.900.73 0.400.69 14.80 6.20 7.00 3.41**
Duration of preoccupation 3.100.87 1.400.51 1.700.67 3.000.94 2.800.63 0.201.13 14.05 6.95 14.50 2.82**
Conviction 3.700.48 1.000.81 2.700.82 3.200.63 2.800.63 0.401.07 15.00 6.00 5.00 3.49**
Amount of distress 3.700.48 0.700.48 3.000.66 3.000.47 2.800.78 0.200.78 15.50 5.50 0.00 3.86**
Intensity of distress 3.500.52 1.600.51 1.900.73 3.000.66 2.800.78 0.200.63 15.05 5.95 4.50 3.56**
Disruption to life 3.800.42 2.700.48 1.100.73 3.200.78 3.000.47 0.200.63 13.55 7.45 19.50 2.47*
* - Significant at 0.05 level, ** - Significant at 0.01 level

Table 3 shows the comparison between both groups on post assess Z=3.86, p<0.01) and disruption to life (U=19.50, Z=2.47, p<0.05).
ment after intervention and it was found that there were significant Table 4 shows the comparison of both groups on post assessment
differences were found on all elements of delusions of PSYRATS. after intervention and it was found that there were significant
The significant differences were found on preoccupation from delusion difference was found on all elements of hallucination such as freque-
(U=7.00, Z=3.41, p<0.01),duration of preoccupation (U=14.50, ncy of auditory hallucination (U=1.50, Z=3.83, p<0.01), duration
Z=2.82, p<0.01),conviction (U=5.00, Z=3.49, p<0.01), amount of (U=7.50, Z=3.30, p<0.01), location (U=2.00, Z=3.72, p<0.01),
distress (U=0.00, Z=3.86, p<0.01), intensity of distress (U=4.50, loudness of auditory hallucination (U=9.50, Z=3.18, p<0.01) etc.

Table: 4Showing after Intervention Status of Clinical Symptoms of the Experimental and Control Group on Psychotic Symptom Rating
Scale (PSYRATS)'s Dimension on Hallucination.
Area of assessment Experimental Group Control Group Mann Whitney Test
MSD MSD
Pre Post Difference Pre Post Difference Mean rank U value Z Score
(Pre-Post) (Pre-Post)
Experimental Control
Group Group
Frequency of auditory 3.300.67 0.400.51 2.900.73 3.500.70 2.500.84 1.000.47 15.35 5.65 1.50 3.83**
hallucination
Duration of auditory 2.700.67 0.500.51 2.200.82 2.400.51 1.900.56 0.500.84 14.75 6.25 7.50 3.30**
hallucination
Location of auditory 3.600.51 0.450.51 3.150.78 3.500.70 2.500.52 1.000.66 15.30 5.70 2.00 3.72**
hallucination
 Indian Journal of Health and Wellbeing 2015, 6(5), 480-483 483

Loudness of auditory 2.900.73 0.500.51 2.400.84 2.900.56 2.000.47 0.900.73 14.55 6.45 9.50 3.18**
hallucination
Re -Origin of voices 3.500.52 0.300.51 3.200.73 3.600.69 2.500.70 1.101.28 15.00 6.00 5.00 3.51**
Amount of negative content 2.800.63 0.400.51 2.400.84 2.500.52 2.701.05 0.201.03 15.35 5.65 1.50 3.72**
Degree of negative content 2.500.52 0.600.51 1.900.56 2.700.67 2.000.94 0.701.15 14.35 6.65 11.50 3.09**
Amount of distress 3.100.56 0.400.51 2.700.48 3.100.31 2.601.07 0.500.97 15.35 5.65 1.50 3.79**
Intensity of distress 2.700.48 0.600.51 2.100.67 2.700.48 2.000.47 0.700.48 15.15 5.85 3.50 3.68**
Disruption to life 2.500.52 0.500.51 2.000.56 2.500.52 2.000.66 0.500.70 14.90 6.10 6.00 3.50**
Controllability 3.400.69 0.400.51 3.000.81 3.700.48 2.100.31 1.600.51 14.60 6.40 9.00 3.28**
**-Significant at 0.01 level

Discussion (2009). The therapy program was considered effective in increasing

the ability to cope with auditory hallucinations and delusions. It also
Present study was conducted to evaluate the significance of cognitive increases the level of insight and ability to cope with stressed caused
behaviour therapy in reducing the delusion and hallucination in by delusion, which ultimately reduce the severity of psychotic
persons with schizophrenia. symptoms like hallucination, and delusions (Oya et al., 2011).
In this study it was found that CBT group improved significantly Comparison between both groups on difference (baseline -post)
on most of the elements of delusions and hallucinations such as scores suggests that on post assessment CBT group showed
delusion of persecution, jealous, sin or guilt, reference and global significantly sharp decline in delusions and hallucinations as
rating of delusion and frequency, duration, location and loudness etc. compared to TAU group.
of auditory hallucination. Similarly the delusion and hallucinations
There are various studies have been conducted and it was found
of PSYRATS scale the significant improvement was seen in all
that CBT is effective in reducing hallucinations and delusions when
elements of delusions and hallucinations after completion of therapy
it is given with pharmacotherapy.
at post assessment. They showed significant improvement on all
Findings of present study support the use of cognitive behaviour
elements of delusions. This proves that CBT is effective in reducing
therapy in reducing the delusion and hallucinations in patients with
the delusion and hallucinations of the patients. Significant difference
schizophrenia; however, the study has certain limitations. The
was found between both groups on all elements of delusion and
sample was small due to which parametric analysis was not done
hallucination at post assessment where, CBT group score
despite randomized control design and only male patients were
significantly lower in comparison to TAU group. This finding again
selected which limits its generalization for female group. Further
supports the significance of CBT in reducing delusion and
research is required on larger sample so that generalization could be
hallucination in patient with schizophrenia. The severity of
done and to see the durability of the cognitive behaviour therapy the
hallucination and delusion in general did not change significantly on
follow up is required.
post treatment in the control group, whereas they did in the treatment
group. But the findings of the present study shows that total positive References
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