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Characteristics of Auditory Hallucinations

and Associated Factors in Older Adults


with Schizophrenia
Carl I. Cohen, M.D., Ifeanyi Izediuno, M.D., Audra M. Yadack, M.D.,
Biswarup Ghosh, M.D., Michael Garrett, M.D.

Objective: To examine the characteristics of auditory verbal hallucinations and


associated factors in older adults with schizophrenia. Methods: One hundred ninetyeight persons aged 55 and older living in the community who had developed
schizophrenia before age 45 years were assessed for the presence, topography,
content, and subjective qualities of auditory hallucinations. Georges social antecedent model of psychopathology was used to examine 17 predictor variables of
auditory hallucinations. Results: Thirty-two percent experienced auditory verbal
hallucinations. More than half heard voices daily, heard good/pleasant voices, or had
command hallucinations; 25% obeyed bad voices, whereas 87% obeyed good
voices. There were no signicant differences in depression and social functioning
between persons judging their voices to be good versus bad. In logistic regression
analysis, depressive symptoms, Positive and Negative Syndrome Scale delusion score
(>2), and male gender were associated with auditory verbal hallucinations.
Conclusion: Older adults with schizophrenia had a lower rate of auditory verbal
hallucinations than had been reported previously for younger persons with schizophrenia. For most features of auditory verbal hallucinations, older adults had similar
rates to younger persons. However, older adults were more apt to judge their voices as
good and more likely to obey the good voices than those voices perceived as bad.
From a clinical standpoint, this may be construed as a potentially useful coping
strategy. However, subjective judgments about voices did not signicantly affect
mood or functioning, and the presence of auditory verbal hallucinations was associated with more depressive symptoms. (Am J Geriatr Psychiatry 2014; 22:442e449)
Key Words: Schizophrenia, elderly, auditory hallucinations, depression

INTRODUCTION
The presence of auditory hallucinations in persons
with schizophrenia in tandem with positive symptoms
in general is thought to diminish in later life.1

However, little research has specically focused


on the presence and characteristics of auditory hallucinations among older adults. In this article, we
examine the presence, topography (e.g., clarity, loudness, frequency), content, and subjective qualities of

Received March 2, 2013; revised July 1, 2013; accepted July 4, 2013. From the Division of Geriatric Psychiatry (CIC), SUNY Downstate Medical
Center (II, AMY, BG, MG), Brooklyn, NY. Send correspondence and reprint requests to Carl I. Cohen, M.D., Division of Geriatric Psychiatry,
Box 1203, 450 Clarkson Ave., Brooklyn, NY 11203. e-mail: carl.cohen@downstate.edu
2014 American Association for Geriatric Psychiatry
http://dx.doi.org/10.1016/j.jagp.2013.07.001

442

Am J Geriatr Psychiatry 22:5, May 2014

Cohen et al.
auditory verbal hallucinations and associated factors
in older adults with schizophrenia living in the
community.
Auditory verbal hallucinations are among the most
common symptoms of schizophrenia. Pooled data
from 16 studies of younger and mixed-age populations found that, on average, 60% of persons
reported auditory verbal hallucinations,2 and a
review by Laroi et al.3 noted estimates ranging from
40% to 80%. The topography and content of hallucinations have been well described in younger persons
with schizophrenia. For example, the frequency of
daily auditory verbal hallucinations has ranged from
49 to 70%,4e7 and clarity of voices has ranged from
54% to 100%.5e12 The most common identities of
voices were God or the devil (13%e31%), acquaintances or relatives (23%e46%),4,5,13,14 or public
gures (46%).13 Finally, the most common types of
hallucinations were evaluative (27%e37%), directive
or command (42%e84%), informative (46%e80%),
and inquisitive (29%).5,10,13,15,16
Subjective affective aspects of auditory verbal
hallucinations have also been studied in younger
persons with schizophrenia. The percentage of
persons experiencing good or pleasant (benevolent) voices has ranged from 6% to 64%.4,12,14,17e20
The percentage experiencing bad or unpleasant
(malevolent) voices has ranged from 55% to
90%.4e6,12e16,19 Several investigators have speculated
that benevolent voices may be useful and helpful and
may improve mood and outcome.8,18e20
The presence of auditory hallucinations has been
linked to higher rates of depression,21,22 and female
gender has been associated with hallucinations of
any type.23 Persons hearing good or pleasant voices
had lower levels of distress, greater control over
voices, and more illness chronicity than persons
hearing negative or unpleasant voices.18
With respect to older adults, although positive
symptoms on the Positive and Negative Syndrome
Scale (PANSS) have been found to be lower in this
age group,24,25 the presence of hallucinations is only
one of seven positive symptom items on the PANSS,
and no studies have specically examined auditory
verbal hallucinations. One small British study26 of
middle-aged and older inpatients with chronic
schizophrenia (N 92) found a mean of 28% had
hallucinations of any type at two observational
points, although 35% experienced hallucinations at

Am J Geriatr Psychiatry 22:5, May 2014

either of the two observations. Therefore, an examination of an older schizophrenia population with
respect to various features of auditory verbal hallucinations can further the understanding of the pathogenesis and the lifetime course of schizophrenia.
Likewise, from a clinical standpoint, it would be
useful to know what factors are associated with the
presence of auditory verbal hallucinations and
whether the subjective aspects of hallucinations such
as of good and bad voices are associated with any
outcome measures. Therefore, using a sample of
older adults with schizophrenia aged 55 and over
living in New York City, we addressed the following
questions:
1. What percentage of these persons experience
auditory verbal hallucinations?
2. What are the topography, content, and subjective features of the auditory verbal
hallucinations?
3. What factors are associated with the presence of
auditory verbal hallucinations?
4. Are emotionally positive voices associated with
lower levels of distress?

METHODS
The methods used here are described in detail
elsewhere.27 Briey, we recruited persons aged 55
and older who lived in the community and developed a schizophrenia spectrum disorder before the
age of 45. We focused on persons with early-onset
schizophrenia because evidence suggests differences
exist in clinical symptoms (particularly type of
hallucinations), risk factors, pathophysiology, neuropsychological functioning, and etiology from lateonset schizophrenia, especially in those developing
symptoms after age 60. Moreover, about four-fths of
persons develop schizophrenia before age 45.28 We
used a stratied sampling method in which we
attempted to interview approximately half of the
participants from outpatient clinics and day
programs and the other half from supported
community residences, including sites with varying
degrees of on-site supervision. Inclusion was based
on a chart diagnosis of schizophrenia or schizoaffective disorder (Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition criteria) that was
supplemented by a lifetime illness review adapted

443

Auditory Hallucinations in Adults with Schizophrenia

TABLE 1. Comparison of Hallucination Data from Current


Study with Range of Values from Prior Studies in
Younger Populations with Schizophrenia

Age range, y
Auditory verbal hallucinations
Clear auditory hallucinations, %
Daily auditory hallucinations, %
Any pleasant voices, %
Any good voices, %
Identity: God or devil, %
Identity: relatives, %
Identity: unknown or vague, %
Type: directive or command
auditory hallucination, %
Obeys commands, %
Type: evaluative, %
Type: informative, %
Type: mundane, %
Visual hallucinations, %
Olfactory hallucinations, %

Current
Study

Studies with
Younger Samples

55e82
32

18e86
40e80; 60
(pooled)
50e100
43e100
26e40
6e64
13e31

56
55
57
61
31 (God: 24;
devil: 6)
13
34
58
54
24
31
32
13
9

23e43
15e50
42e84
10e51
6e64
46e80
57e60
14e71
9e38

Notes: Comparison data were derived from the following articles:


Slade & Bentall,2 Laroi et al.,3 Copolov et al.,4 Vaughn et al.,5 Kent
et al.,6 Fortuyn et al.,7 Miller,8 Yamada et al.,9 Goodwin et al.,10
Small et al.,11 Lowe,12 Leuder et al.,13 Close et al.,14 Nayani
et al.,15 Oulis et al.,16 OSullivan,17 Sanjuan et al.,18 Jenner et al.,19
Zisook et al.47

from Jeste et al.29 We excluded persons with cognitive impairment too severe for completion of the
questionnaire (i.e., dened as scores < 5 on the
Mental Status Questionnaire).30
Subjects were offered $75 for completing the 21/2 hour interview, and there was a 7% rejection rate.
Our sample consisted of 198 persons, of whom 39%
were living independently in the community and
61% lived in supported community residences; 49%
percent were women. The racial distribution was
African American (35%), white (57%), Latino (7%),
and other (2%). The mean age of our sample was 61.5
years (standard deviation: 5.6), 8% were married or
living with partners, 13% were still working (all parttime), and median income ranged from $7,000 to
$12,999. Although symptoms may have begun earlier
in life, illness was diagnosed at a mean age of 29.3
years (standard deviation: 10.6).
Instruments
In previous work examining factors associated
with other clinical symptoms in schizophrenia,25 we
used an adaptation of Georges social antecedent

444

model of psychopathology in older persons.31 This


model examines the social precursors of psychopathology and categorizes them into six different
stages: demographic variables, early events and
achievements, later events and achievements, social
integration, vulnerability and protective factors, and
provoking agents and coping.
For this study, we selected 17 variables based on
their theoretical importance in the model and for
having been identied in the literature as inuencing
the presence of hallucinations (see Table 2). These
variables were derived from the following instruments: Center for Epidemiological StudiesDepression Scale,32 a 20-item scale with scores
ranging from 0 to 60 (most depressed); the Multilevel
Assessment Inventory and the Physical SelfMaintenance Scale,33 which were used to generate
both a physical illness score that represented the
sum of seven healthcare items and 13 illness categories and the Instrumental Activities of Daily Living
Scale, a 9-item scale with scores ranging from 9 to 27
where higher scores indicate better functioning; the
Network Analysis Prole,34 which was used to
determine the number of condantes; the PANSS,35
from which we used the delusion item (scores
range from 1 to 7 [most severe]); the Dementia Rating
Scale,36 which assesses ve areas of cognitive functioning: attention, initiation and perseveration,
construction, conceptualization, and memory, with
scores ranging from 0 to 144 (higher scores indicate
better functioning); Lifetime Trauma and Victimization Scale,37 a 12-item scale based on the number of
times persons experienced trauma or victimization
multiplied by the degree of perceived stress with
possible scores ranging from 0 to 108 (higher scores
indicate more traumatic distress); Religiousness
Scale,38 an 8-item scale with scores ranging from 1 to
27 (higher scores indicate more religiousness);
Cognitive Coping Strategy Scale,39 a 7-item scale that
contains items concerning reframing ones thinking
about various stressors and/or trying to remain
positive (scores range from 0 to 7); and the CAGE,40
with an afrmative lifetime response to any of the 4
items considered to be indicative of current or past
problems with alcohol.
The Structured Clinical Interview-PANSS,41
developed originally to assist in scoring the PANSS,
consists of 28 open-ended and semistructured items
concerning hallucinations and associated delusions.

Am J Geriatr Psychiatry 22:5, May 2014

Cohen et al.

TABLE 2. Bivariate Analysis of Variables in Georges Model for Auditory Hallucinators and Nonhallucinators
Corresponding
Georges
Dimension

Variables

Auditory Hallucinations
Present (N [ 62)

No Auditory Hallucinations
(N [ 136)

Statistical
Test

df

23
31
32
21
34

37
50
53
34
55

74
81
24
45
73

54
60
18
33
54

5.11
1.58
25.98
0.012
0.023

1
1
1
1
1

0.02
0.21
<0.001
0.91
0.88

Female
White
PANSS delusion > 2
CAGE positive (lifetime)
Psychiatric services usage
above median

Demographic
Demographic
Vulnerability
Vulnerability
Coping
N

Mean

SD

Mean

SD

Mann-Whitney U

Z-score

Age
Education
Physical illness score
Religiousness scale
IADL scale
Cognitive coping scale
Lifetime trauma scale
Number of condantes
Dementia Rating Scale
CES-D
Number of psychiatry
medications
PANSS negative symptoms

Demographic
Achievements
Vulnerability
Coping
Vulnerability
Coping
Provoking agents
Social integration
Vulnerability
Vulnerability
Coping

62
60
62
57
62
61
62
62
62
62
62

60.63
12.15
1.40
15.91
21.79
5.31
11.31
3.89
127.94
16.89
2.44

4.98
3.70
1.55
5.51
4.06
2.07
12.51
3.52
13.05
10.94
1.48

133
136
136
128
136
134
135
136
136
136
136

61.87
12.26
1.26
15.14
22.37
5.75
6.62
3.60
127.59
10.79
1.94

5.80
3.36
1.32
5.85
3.78
1.62
9.49
3.80
13.14
8.80
1.29

3,631
3,937
4,115
3,396
3,829
3,676
3,085
3,969
4,099
2,785
3,335

1.35
0.40
0.28
0.75
1.04
1.18
3.01
0.67
0.31
3.83
2.42

0.18
0.69
0.78
0.45
0.30
0.24
0.003
0.50
0.75
<0.001
0.016

Vulnerability

61

12.46

5.46

136

11.86

6.23

3,598

1.50

0.13

Notes: IADL: Instrumental Activities of Daily Living; CES-D: Center for Epidemiological Studies Depression Scale; PANSS: Positive and
Negative Syndrome Scale.

Responses to these items were coded and used to


determine the presence, content (e.g., What do they
say?, Do they give orders or instructions?, Where
do they come from?, Why do you have these
experiences?), topography (e.g., frequency, loudness, clarity), and subjective qualities (e.g., good,
bad, pleasant, unpleasant) of auditory verbal
hallucinations. The internal reliability (Cronbachs
alpha) scores of the scales ranged from 0.67 to 0.97.
Interviewers were trained with the assistance of
audiotapes and videotapes, and they were periodically monitored using audiotapes of their interviews.
Intraclass correlations ranged from 0.79 to 0.99 on the
various scales.
Statistical Analyses
In bivariate analyses, we used c2 analysis for
categorical variables and the Mann-Whitney U Test
for continuous variables. All data were not available
for all respondents. We used a logistic regression
analysis to examine the 17 predictors of the presence
of auditory verbal hallucinations in the past 6
months. These were organized according to the
categories of Georges model. There was no evidence

Am J Geriatr Psychiatry 22:5, May 2014

of collinearity among the predictor variables.


Responses as to whether voices were good, bad,
or both were dichotomized so that persons having
both types were combined within the bad group.

RESULTS
Thirty-six percent of the sample (N 72) reported
any hallucinations in the past 6 months, which was
used as the criterion for designation as a hallucinator. Thirty-two percent of the sample (N 62)
experienced auditory verbal hallucinations (Table 1).
No person reported auditory hallucinations that did
not include voices on some occasions, although some
were mufed or indistinct. Visual and olfactory
hallucinations were reported in 13% and 9% of the
sample, respectively; 23%, 10%, and 4% reported one,
two, or three types of hallucinations.
With respect to the topography and the content of
hallucinations (Table 1), among those hearing voices,
55% had daily auditory hallucinations, 56% (N 31)
reported voices that were clear, and the most
common identities of voices were God (24%; N 15),

445

Auditory Hallucinations in Adults with Schizophrenia


the devil (6%; N 4), relatives (13%; N 8), or
unknown or vague (34%, N 21). The most common
types of hallucinations were evaluative (34%; N
15), informative (31%; N 19), and mundane
comments (32%; N 20); 58% (N 35) reported that
the voices gave commands or directions, and 54%
(N 19) obeyed these commands.
With respect to subjective features, about half of
auditory hallucinators responding to these items
experienced good (N 28) or pleasant voices (N
27), roughly two-fths reported bad (N 22) or
unpleasant voices (N 24), and the rest reported
both mixed voices (i.e., good/bad [N 6] or
pleasant/unpleasant [N 5]). Among those hearing
commands or directions, 45% reported that the voices
were good and 55% reported that they were bad or
mixed. Moreover, for those obeying these voices,
only 25% obeyed if the voices were bad or mixed,
whereas 87% obeyed the voices if they were good
(c2 11.89, df 1, p 0.001). Among those hearing
voices, 68% of persons who heard only good voices
were depressed (based on Center for Epidemiological
Studies-Depression Scale > 7 for subclinical depression or greater)42 and 82% of persons who heard
bad or both types of voices were depressed; these
differences were not signicant (c2 1.52, df 1,
p 0.22). On the other hand, 76% of all auditory
hallucinators were depressed versus 54% of
non-hallucinators (c2 8.20, df 1, p 0.004). There
were no signicant differences between persons
hearing good voices and hearing bad/mixed voices
with respect to Instrumental Activities of Daily
Living Scale scores (Mann-Whitney U 365, p
0.66), number of condantes (Mann-Whitney U
359, p 0.58), or total network members (MannWhitney U 338, p 0.37). With respect to the
etiology of the voices, 26% believed they were
supernatural or from God in origin, 26% thought
they were biologically based, 29% reported miscellaneous origins, and 18% would not speculate on
their etiology.
In bivariate analysis (Table 2), we found ve variables associated with the presence of auditory verbal
hallucinations: more depressive symptoms, PANSS
delusion score > 2 (moderate symptoms or
greater), higher lifetime trauma, number of psychiatric medications, and male gender (Table 2). In the
logistic regression analysis (Table 3), although the
overall model was signicant (c2 46.79, df 17,

446

p <0.001), we found only three variables retained


signicance: depressive symptoms, PANSS delusion
score > 2, and male gender. There was no signicant
difference in the mean scores of the PANSS hallucination item between men (2.1  1.5) and women (1.8
 1.4) (Mann-Whitney U 4,358, p 0.20).

DISCUSSION
In addressing the rst question, we found that
roughly one-third of the respondents reported the
presence of hallucinations in the prior 6 months, that
is, 36% and 32% experienced any type and auditory
verbal hallucinations, respectively. The latter rate
was lower than the pooled rate and the range of
auditory verbal hallucinations reported in younger
and mixed-age populations,2,3 whereas the rates of
visual (13%) and olfactory (9%) hallucinations in our
sample were roughly within the range reported in the
literature for younger samples, although they tended
to be on the lower end (Table 1).7e11,43e46 The trend
toward lower rates is consistent with the literature
that has indicated a decline of positive symptoms in
general with age24,25 and with a small British study26
of middle-age and older adults that found 28% had
hallucinations of any type. However, these differences may also reect the fact that many of the
younger samples comprised persons who had
currently or recently experienced a psychiatric
hospitalization.
In addressing the second question, the ndings
provide some preliminary data with respect to the
extent that the phenomenologic characteristics of
auditory verbal hallucinations may change over
a lifetime.3 We found that the rates for the topography, content, and subjective features of auditory
hallucinations fell within the range reported in the
literature for younger samples (Table 1). However,
the percentage of persons hearing pleasant voices
was higher than the rates reported in younger
samples, hearing good voices was on the higher end
of the range in younger samples, and obeying voices
was higher than the range reported in younger
groups. Although the percentage of hallucinators
hearing command-type voices (58%) was roughly the
same as in younger samples5,10,13,15,16,47 and the
proportion reporting that these commands or directions were benevolent (45%) was similar to the

Am J Geriatr Psychiatry 22:5, May 2014

Cohen et al.

TABLE 3. Logistic Regression Analysis of Variables in Georges Model Predicting Presence of Auditory Hallucinations
95% Condence Interval
a

Age
Female
White
Education
Physical illness score
IADL
Dementia Rating Scale
CAGE positive (lifetime)
CES-D score
PANSS negative symptoms
PANSS delusion > 2
Number of condantes
Lifetime trauma scale
Religiousness scale
Cognitive coping scale
Number of psychiatry medications
Psychiatric services usage above median

Wald

Odds Ratio

Lower

Upper

0.08
6.37
0.15
1.35
1.29
2.28
0.03
1.23
7.85
0.16
14.08
0.08
0.61
0.82
0.25
0.42
0.24

0.99
0.34
0.84
0.93
0.83
0.92
1.00
0.62
1.06
0.99
6.50
1.02
1.02
1.04
0.94
1.10
1.22

0.92
0.14
0.36
0.82
0.61
0.82
0.97
0.26
1.02
0.90
2.45
0.90
0.98
0.96
0.72
0.82
0.55

1.07
0.78
2.00
1.05
1.14
1.03
1.04
1.45
1.10
1.07
17.30
1.15
1.06
1.12
1.22
1.48
2.73

0.78
0.01
0.70
0.25
0.26
0.13
0.86
0.27
0.005
0.69
<0.001
0.77
0.43
0.37
0.62
0.52
0.63

Notes: Model: N 177, c2 46.79, df 17, p <0.001. IADL: Instrumental Activities of Daily Living; CES-D: Center for Epidemiological
Studies Depression Scale.
a
df 1.

proportion reported in younger outpatients with


schizophrenia,47 older adults were more apt to obey
their hallucinations. Notably, if persons heard good
voices, they were 31/2 times more likely to obey
orders than if they heard bad voices. This nding is
consistent with previous research that found that
a persons response to a command is generally not to
impulsively comply. In other words, voice hearers
typically make a decision as to whether to act on the
voices directives, and acting impulsively to voices is
rare.13,15 The high levels of benevolent voices in
general and the increased willingness of older adults
to obey commands associated with benevolent voices
suggest a potentially healthy coping strategy to deal
with the persistence of voices in later life. For
example, Sanjuan et al.18 contended that for those
persons with persistent voices, having emotionally
positive voices is an adaptive process for dampening the effects of the voices. However, in the
absence of longitudinal outcome data, this hypothesis
cannot be conrmed.
In addressing the third question, we found that
auditory hallucinations were signicantly associated
with three variables: depressive symptoms, presence
of delusions, and male gender. Our ndings were
consistent with several studies of older adults with
schizophrenia in which depression was associated
with positive symptoms.48,49 However, the earlier

Am J Geriatr Psychiatry 22:5, May 2014

studies had not looked specically at hallucinations.


Our data suggest that auditory hallucinations may
play a key role in this relationship between positive
symptoms and depression in older adults. Whether
depression induces higher levels of hallucinations or
whether hallucinations cause depression cannot be
determined from our cross-sectional data. Interestingly, in younger persons with schizophrenia,
a feeling of sadness or loneliness is a frequent antecedent to voices.15 Patients may develop an interpersonally coherent relationship with their voices.50
Thus, a novel interpretation of the association of
depression and auditory hallucination is that voices
appear when a person is lonely, in effect providing
a kind of intrapsychic companionship when a person
is wishing for company.
The presence of delusions is consistent with the wellestablished relationship between hallucinations and
delusions found in younger populations.51 Harrow
and Jobe51 postulated that persons with hallucinations
use delusional ideation to explain these perceptions,
although they suggested alternative explanations, such
as persons with delusional thinking being apt to regard
hallucinations more seriously than normal individuals
or that both hallucinations and delusions emerge
because of a general predisposition to reality distortion. Finally, the association between male gender and
hallucinations differs from earlier studies that found

447

Auditory Hallucinations in Adults with Schizophrenia


higher rates in women52 or no appreciable gender
associations with hallucinations.53 It is not clear
whether this reects a true age difference in the presence of auditory hallucinations or a greater willingness
to divulge the presence of voices among older men or
whether this is unique to our sample. Notably, there
were no gender differences in the overall severity of
the general hallucination item of the PANSS.
In addressing whether the subjective content of the
voices is linked to emotional distress, we found that
persons judging their voices to be good had modestly
lower levels of depression than those who rated their
voices as bad (68% versus 82%), but these differences
were not statistically signicant. This nding differed
from earlier research in younger age samples that
found that malevolent and derogatory voices were
linked to depression22 and that emotionally positive
voices were associated with lower levels of distress.18
Moreover, our ndings that the subjective emotional
content of the voices was not associated with any
social and adaptive functioning variables did not
support Favrod et al.s54 more pessimistic observations in a mixed-age sample that hearing benevolent
voices was associated with increased engagement of
these voices, which in turn interfered with social
functioning.
To our knowledge, this is the rst large-scale study
of auditory verbal hallucinations in older adults with
schizophrenia living in the community. The strengths
of the study include its use of a large, multiracial
sample living in various levels of support in the
community and the utilization of a multivariable
theoretical model to assess the predictors of auditory
hallucinations. The use of such models can enhance
the likelihood of the generalizability of the results
and can reduce the confounding effects of multiple
predictor variables. Nevertheless, the ndings must

be viewed as provisional in light of several limitations of the data. First, the data are cross-sectional so
that causal relations cannot be determined. Second,
the sample is drawn from an urban population living
within one geographic area. Third, the study did not
include older adults with late-onset schizophrenia
who, compared with early-onset persons, have
higher levels of visual, olfactory, or tactile hallucinations as well as auditory hallucinations that may be
more accusatory, abusive, and provide running
commentaries.28 Fourth, we did not have a younger
comparison group so that any comparisons with
younger samples should be viewed as illustrative
and provisional. Finally, we conducted multiple
comparisons so the possibility of Type I errors must
be considered, although given the exploratory nature
of this study, we were concerned that Type II errors
could miss potentially important ndings.
In summary, older adults with schizophrenia had
lower rates of auditory verbal hallucinations than
had been reported in most studies of younger
persons. For many features of auditory verbal
hallucinations, older adults had similar rates to
younger persons. However, older adults were more
apt to judge their voices as good and were more
likely to obey good voices. From a clinical standpoint,
this may be construed as a potentially useful coping
strategy. However, subjective judgments about their
voices did not signicantly affect mood or social
functioning, and the presence of auditory verbal
hallucinations was associated with more depressive
symptoms.
The authors thank Dr. Paul M. Ramirez for his
assistance. This study was funded by National Institute
of General Medical Sciences SO6GM54650 and
SO6GM74923.

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