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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
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
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
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
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
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
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.
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
446
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
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.
447
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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