| Home | Help | Search | Feedback | Contents | |
| Copyright 1998 by the | Psychology in Spain, Vol . 2. No 1, 3-10 |
| Colegio Oficial de Psicólogos |
|
Behavioural treatment of auditory hallucinations in a schizophrenic outpatient: a case study. In this paper we present a case-study of a behavioural intervention to modify auditory hallucinations in a schizophrenic patient. The results showed a significant decrease of hallucinations and an improvement in his social and personal functioning. The results of the follow-up showed that these benefits remained 5, 12, 21 and 24 months after the end of the treatment.
Se presenta en este trabajo, un estudio de caso en el que se realiza una investigación conductual para modificar las alucinaciones auditivas en un paciente esquizofrénico. Los resultados muestran una disminución significativa de las alucinaciones del paciente, y una mejora tambien de su funcionamiento personal y social. Los resultados del seguimiento muestra que los beneficios se mantienen a los 5, 12, 21 y 24 meses de finalizado el tratamiento.
ince the introduction by Esquirol in 1832 of the term hallucination into medical vocabulary,
perception disorders in which the subject seemingly perceives an event, or a series of
events, in the absence of an appropriate stimulus, have been considered among the most
mysterious and serious examples of psychological disorder. Schneider (1959) considered them as
a first-order symptom of schizophrenia where no cerebral pathology was demonstrated.
Almost all the theories proposed to explain hallucinations share the assumption that
hallucinators confuse "private" or "imagined" events with stimuli from
the "real" world, and attempt to explain this type of erroneous attribution
through a series of cognitive variables. The theories supporting these explanations
include those of classical conditioning; the theory of filtration; the theory of mental
representations in images; the theory of subvocalisation; and the theory of deficit in
metacognitive skills of the discrimination of reality (Slade and Bentall, 1988).
Any theory on the psychological processes responsible for hallucinations should take into
account the following:
1. Hallucinations are more probable during periods of great anxiety or stress (Cooklin, Sturgeon and Leff, 1983).
2. These experiences may be influenced by environmental conditions such as sensorial
deprivation or exposure to white noise or other forms of ambiguous stimulation (Margo,
Hemslaw and Slade, 1981).
3. Some studies have indicated that verbal auditory hallucinations tend to be associated
with the concealed activity of the musculature responsible for speech, or
"subvocalisations" (Green
and Kinsbourne, 1990).
4. There is evidence that verbal auditory hallucinations may be blocked or inhibited by
tasks such as reading or conversation (James, 1983).
On the basis of the theories and data to which we have referred, behavioural treatments
have been designed in which schizophrenic subjects are trained in strategies for coping
with verbal auditory hallucinations (Slade
and Bentall, 1988). Although the first-choice treatment approach for hallucinations is
the use of neuroleptics, behavioural treatment may be applied when the patient continues
to experience hallucinations that do not respond to pharmacological treatments, when
patients are especially sensitive to the side-effects of these, or when they fail
completely or partially to adhere to the pharmacological treatment. For this group of
patients behavioural treatments may constitute a promising alternative.
The present work involves a case study where a multimodal therapeutic procedure is
employed in a case of verbal auditory hallucinations in a subject with a schizophrenic
disorder.
METHOD
Subject
Functional analysis of the auditory hallucinations
The auditory hallucinations, according to the patient, consisted in hearing the voices of
people who were not present at that moment, or who had died. They were short sentences or
words with a content formed generally of insults or comments showing annoyance directed
towards him, for example "get lost", "you're mad", "you're an
idiot", "drop dead", etc.
He attributed the voices to a friend who was killed in a car accident several years
before, or to a neighbour from the flat above. He said that both the dead friend and the
neighbour wanted to make his life unbearable, and that the latter was aware of his every
move.
Resulting from these experiences were other beliefs, such as that they "read his
thoughts" -he said that what the voices said was what he was thinkingand that they
"echoed" him, as very often he would think of a word and immediately afterwards
the voices would repeat what he had thought. He also believed that they "controlled
his thoughts", because he said that when he heard a voice he could not avoid
"thinking" the same automatically.
The hallucinations occurred in various situations. The most frequent were those in which
he could hear the sound of car engines. It was in these situations that the rate was
highest, especially when he was on a street or road where there was a lot of traffic, when
he was walking past queues of cars at traffic lights, or when he was in his room with the
windows open, as these gave onto a busy street. In these situations he felt great anxiety,
and thought that "all the cars wanted to talk to him at the same time."
A second group of antecedents where there was a high probability of hallucinations being
elicited involved those social situations that led to nervousness or anxiety. For example,
being in places where there were people he didn't know, and with whom he had to initiate
or maintain a conversation, crowded buses, visiting a place for the first time and having
to interact with those present, etc. The more anxiety he felt in these situations, the
greater were the intensity and frequency of hallucinations.
The third group of antecedents concerned listening to sounds of a "white noise"
type, that is, monotonous and incessant sounds, such as those produced by food mixers,
coffee grinders or vacuum cleaners; hallucinations were also elicited by the background
noise of a badly-tuned radio or television. Such sounds also unnerved him and made him
anxious.
The first group of antecedents (car engine or traffic noise) was that which produced the
highest rate of hallucinations. Next came the stressful social situations, and the lowest
rate was produced by the third group ("white noise"-like sounds).
Situations in which hallucinations did not occur were when he was in his room with the
windows closed, in other places where traffic noise could not be heard, and in familiar
places or with people he knew.
As a result of the hallucinations he would go home or not go out, shut himself away in his
room or sleep for long periods. In this way he escaped from situations in which he heard
the noise of cars, and also from those social situations where he had to converse with
people.
From the described analysis, we established the hypothesis that the hallucinations were
related to the great anxiety experienced by the patient in the three contexts, preventing
him from discriminating between external events and self-generated events (thoughts and
subvocalisations). Behaviours of evasion or escape from these situations were negatively
reinforced through the reduction of anxiety, which helped these contexts to maintain their
capacity for eliciting anxiety, and therefore increased the probability of experiencing
hallucinations in them.
From his attempts to explain these hallucinatory-type experiences, the subject derived
other delusions, such as the belief that his friend or neighbour wanted to make his life a
misery, that they insulted him and that they could read or control his thoughts.
In the case of the stressful social situations the high levels of anxiety provoked were
related to a low level of conversational ability. This inability to master situations of
initiating or maintaining conversations increased the subject's anxiety (see Figure 1). In order to confirm the hypothesis
described above, we carried out a series of tests which allowed us to collect
relevant information through situations designed to generate auditory hallucinations.
Thus, we carried out two tests to confirm, at least partially, our hypothesis. Since one
of the offices of our Rehabilitation Unit gave onto the street, so that traffic noise
could be heard, we took advantage of this fact to carry out a first test to explore the
relationship between car engine noise and increase (or not) in hallucinations described by
the subject.
We trained the patient to snap his fingers every time he heard voices, so that we were
able to count the frequency of auditory hallucinations in each condition.Four trials of
five minutes each were made, as follows:
Trial One: the patient sat on a chair in
the office, and he was told not to speak, and to indicate with a snap of the fingers when
he heard voices. The windows of the office were closed, reducing the amount of traffic
noise that could be heard. Voices were reported to be heard five times in this trial.
Trial Two: the patient sat in the same
office with the windows closed, but he was told to read a newspaper aloud for five
minutes. Only one hallucination was reported in this trial.
Trial Three: in this trial the windows of
the office were opened, so that the noise of cars from the street could be clearly heard.
The patient was told to be silent for five minutes. Nine hallucinations were reported in
this trial.
Trial Four: in this final trial, the
windows stayed open and the patient was once again asked to read the newspaper aloud.
Three hallucinations were reported (see Figure 2).
Although in all these trials the patient was exposed to traffic noise, with the windows
open the exposure was greater, and therefore so was the elicitation of hallucinations, as
can be seen in Figure 2. Also, it was found that
reading aloud was a behaviour incompatible with hearing voices, which suggested that this
may constitute a coping behaviour.
A second test was carried out to confirm our hypothesis. This consisted in going outside
with the patient to some traffic lights on a busy street. Frequency of hallucinations was
recorded in five-minute trials, of which four were carried out:
Trial One: the therapist and the patient
stood by the traffic lights for five minutes, without speaking. As in the previous trials,
the patient snapped his fingers every time he heard a voice. Fourteen hallucinations were
reported.
Trial Two: the patient and the therapist
went into a store which was not very busy at the time, and where the noise of traffic
could not be heard. Again they did not speak. No hallucinations were reported.
Trial Three: they returned to the traffic
lights, where they held a conversation unrelated to the disorder. Again, no hallucinations
were reported.
Trial Four: in the same location, without
speaking. Thirteen hallucinations were reported (see Figure
3).
Both tests provide us with valuable information which, at least provisionally, allows us
to maintain the hypothesis that a relationship exists between traffic noise and the
increase of auditory hallucinations in this patient. It also allows us to confirm the
hypothesis that if this patient, during the auditory hallucination episodes, is able to
carry out behaviours of a verbal nature (such as speaking or reading), he can,
voluntarily, decrease the rate of hallucinations (Slade and Bentall, 1988).
With regard to social situations as a condition for hallucinations, this was affirmed in
the initial interviews with the patient from the non-systematic information provided by
the personnel of the Rehabilitation Unit. At that time, the Unit was a new place where
there were people unfamiliar to him. In the first two interviews, the patient said that he
was very nervous, as he didn't know anyone, and he heard voices. In fact, at one of the
interviews, when he was in the waiting room, he left the Unit suddenly and took a taxi
home. As he began to visit the Unit more often (thanks to the support of his parents) his
anxiety responses started to disappear, and the frequency of hallucinations to decrease,
allowing him to spend longer periods receiving our attention.
The Unit's staff informed us that in the waiting-room situations he remained quiet, and
did not maintain conversations with the other people present; this information coincided
with what the patient himself said during the interviews. Thus, in order to test whether
social anxiety was related to a possible deficit in conversational skills, these were
assessed. The assessment process was that which we normally used (Cuevas and Perona, 1992). The
results show that the patient's language was hesitant, that he exhibited a suitable facial
expression and body posture, that he did not ask open questions, that frequent silences
occurred, that he did not handle conversation well, frequently changing the subject, and
that he presented physiological responses of anxiety, such as sweating profusely during
the conversations. His abilities were equally deficient with speakers of either sex. No
test was carried out for the third group of antecedents (sounds like "white
noise"). From the hypothesis previously described, the following objectives were set:
1. To decrease the patient's anxiety in situations that evoked auditory hallucinations. 2.
To teach him to attribute the hallucinations to himself, and not to external agents. 3. To
teach him to use, in those situations, behaviours incompatible with auditory
hallucinations. 4. To increase the patient's social activities.
Procedure
On the basis of the objectives described, the treatment was carried out in the following
way:
Coping with auditory hallucinations in situations where the patient could hear traffic
noise.
a) Training phase. The training phase was
carried out over a period of five months, with weekly sessions of approximately 60 to 70
minutes. There was a total of 19 sessions. In the first session we explained to the
patient the functional analysis made and the hypothesis resulting from that analysis. The
working hypothesis was presented as a form of explanation for his symptoms that we were to
test. We began by training him to cope with the auditory hallucinations experienced in the
presence of traffic noise, since that was the condition with the highest rate of
elicitation of hallucinations, and also the easiest to approach in the training sessions.
The technique used was the direct exposure to these stimuli.
We recorded onto cassette tape the traffic noise from a very busy street, and once we had
confirmed that this recording was a good elicitor of voices, it was used as an exposure
stimulus. The sessions commenced with an explanation of the working hypothesis and 10
minutes of relaxation. When the subject was relaxed the treatment of exposure to the
voices began. The subject placed the headset of a personal cassette player (Walkman) on
his head. The cassette player was operated by the therapist, so that he could control time
of exposure to the recording of traffic noise. In the initial sessions each exposure trial
lasted 5 minutes, and during this time the subject had to indicate with a snap of the
fingers whenever he heard voices. Between trials there were two minutes of relaxation. The
final 15 minutes of the session were used for analysing, through the technique of Socratic
dialogue, the working hypothesis and any others the patient might suggest based on the
experience of the session. The object of this analysis was to teach him to reattribute the
source of the hallucinations to himself, rather than to external agents. From the fourth
session onwards a modification was introduced into the procedure, whereby the subject was
exposed for 30 minutes to sounds on the tape, but alternating five-minute periods of being
silent with fiveminute periods in which he conversed with the therapist. Throughout this
30 minutes the number of times voices were heard continued to be recorded. At the end of
the exposure time it was confirmed that in the periods of silence the patient always heard
more voices than during the periods of conversation. These results were used as proof of
the reality of the situation and as material to be discussed in the final 10 or 15 minutes
of the session. In the final sessions there was alternation of sessions in which the
training was carried out using the cassette as exposure stimulus and sessions (six in
total) in which the same procedure was used, but with direct exposure to traffic noise in
a busy street.
b) Monitoring phase.
The training phase having concluded, the 12-month monitoring phase began. This consisted
of fortnightly or monthly sessions in which the patient's psychopathological state was
reviewed, what had been learned was put into practice, and specific examples of hearing
voices were analysed. The technique of reattribution of the source of hallucinations was
continued. It was sometimes necessary to have recall sessions.
Coping with hallucinations in stressful social situations
Other situations in which the probability of the subject
reporting having heard voices increased were those where he had to interact with other
people. As pointed out earlier, in the assessment carried out it was observed that he
spent most of his time at home -more specifically, in his bedroom-, avoiding or evading
invitations to go out with friends. It was also confirmed that his level of conversational
skills was low, and that, although he had three or four friends with whom he could go out,
he had not done so for several months, due to the great anxiety and high frequency of
hallucinations he experienced when he went with them to discos, cinema, etc. In view of
the above, he began participating in a conversational skills training group. The duration
of the programme was 7 months, and the content of the training was similar to that
normally used by our Unit (Cuevas
and Perona, 1992). The "homework" tasks consisted of the programming of
visits to the cinema or discos, excursions, visits to museums, etc, with fellow group
members or friends from his neighbourhood. The training in conversational skills and the
training and monitoring of coping with traffic noise concluded at the same time, and it
was at this point that the follow-up phase began.
Measurement instruments
In order to assess the results of our treatment, the following measurements were made:
* Brief Psychiatric Rating Scale, BPRS (version
adapted by Lukoff, Nuechterlein and Ventura, 1986). Three measurements were taken before
the beginning of the treatment, at monthly intervals. During the treatment eight
measurements were carried out, at approximately two-monthly intervals. In the follow-up
phase four measurements were made, 5, 12, 21 and 24 months after the conclusion of the
treatment.
* The LSP Scale (Life Skills Profile, Spanish
adaptation by Bulbena, Fernández and Domínguez, 1992). This scale was applied before
and immediately after the treatment, and again after 24 months.
RESULTS AND DISCUSSION
Figure 4 shows the results of our treatment,
measured by means of the hallucination scale and psychosis index of the BPRS. With regard
to the first scale it was found that in the baseline period the subject obtained the
highest scores possible for hallucinations, that is, between 5 and 7 points. This
indicated that, before the treatment, the patient experienced auditory hallucinations with
a high daily frequency, and, as shown by the functional analysis, this seriously
affected his personal and social functioning. The scores obtained on the psychosis index
in the baseline period were also high, ranging between 11 and 13 points.
Immediately after the commencement of the treatment, we observed an increase both in the
scores for hallucinations and in those of the psychosis index, probably as a consequence
of the exposure treatment carried out, with scores being obtained of 7 points on the
former scale and 13 points on the latter. However, having reached this maximum, there was
a gradual and steady decrease of the symptoms, so that by the end of the treatment
non-pathological levels were attained in both measures.
The more the patient was exposed to the different situations in which it was most probable
that auditory hallucinations would occur, the more anxiety towards them decreased, and the
characteristics of the voices altered. At first, as mentioned earlier, what was heard were
frequent short phrases or words, high in tone and easily identified by the patient. Later,
the frequency, clarity and tone level began to decrease, and an interesting phenomenon
relating to the content of the voices was produced. Originally, they were quite upsetting
for the patient, but as he confessed to becoming calmer, they became less offensive and of
a more neutral character, being described by the end of the treatment as murmurs or noises
of very low intensity that did not affect his life. For example, he described to us, at an
advanced stage of the treatment, that, as he was taking a shower, the voices he heard were
simply giving instructions about what he had to do at that moment: "turn on the
tap", "get the soap", etc.
The treatment of exposure to traffic noise was quite effective within a short time of its
commencement. However, although the use of conversation as a coping strategy was also
quite effective, this behaviour was not generalised to situations other than those of the
training. It was very unlikely that the patient exposed himself to social situations on
his own initiative, and that he used the strategy of conversation to deal with his
hallucinations. Thus, it became necessary to improve his conversational skills. By the end
of the conversational skills training, the patient admitted to feeling less anxiety in
social situations, and had improved significantly his abilities to initiate and maintain
conversations.
The improvement in this type of ability clearly helped the patient to decrease the rate of
hallucinations, since the "homework" tasks encouraged him to expose himself to
social situations that were stressful for him, and which he had been unable to deal with
successfully.
As can be seen in Figure 4, the patterns of change
in the hallucinations scale and the psychosis index are quite similar, both in the
baseline period and during the treatment. This leads us to think that the treatment for
hallucinations is in some way influencing (or rather, is related to) the other behaviours
assessed through the psychosis index. However, the data provided by this work do not
permit us to offer a conclusive explanation of this result. All we can say is that our
results can be understood from the perspective of Maher's (1988) hypothesis, which affirms that the delirious person
presents primary perceptive problems that cause anomalous experiences. This author
maintains that these anomalous experiences (for example, hearing voices in the absence of
an obvious source) produce a sense of bewilderment, which in turn results in the search
for an explanation, which will therefore be an abnormal or irrational one, since the
experience from which it is derived is also abnormal (or delirious). This hypothesis
basically coincides with that derived from the functional analysis carried out here, which
maintains the idea that our subject, starting out from his hallucinatory experiences,
arrived at other beliefs of an irrational nature. Thus, it could be proposed from this
hypothesis that the modification of the hallucinations may in turn have an effect on this
subject's irrational ideas. In the follow-up phase it is observed not only that what was
achieved during the treatment is maintained, but also that the voices disappeared totally
for a period of 24 months. Very similar results are observed for the psychosis index.
The explanation for these results during the follow-up period can probably be found in the
fact that, although the treatment for the hallucinations had formally ended, the
patient continued to participate in other rehabilitation programmes of an occupational
nature. The focus of the treatment was no longer on the hallucinatory behaviours, but
rather on the training and stimulation of his participation in work training activities,
which indirectly influenced the problem behaviours, facilitating an overlearning of the
skills acquired over the previous months. Together with the decrease in auditory
hallucinations, an improvement was observed in the patient's general functioning. In Figure 5 we can observe the results obtained in this
aspect on the LSP.
Before treatment the patient demonstrated adequate functioning in two of the five
sub-scales of the LSP (those of Self-care and Non-personal
social behaviour). However, in the other
three sub-scales (Social-interpersonal
behaviour, Social communication-contact and Life independence), he presented deficient functioning in the pretest, which improved
significantly in the post-test and follow-up. As it can be seen, the subject's general
functioning, though not particularly deficient in some areas, improved significantly,
where there were deficiencies, with respect to the pretest, these results being maintained
over the 24 months following the end of the treatment. All of this may be explained taking
into account certain factors: firstly, the patient started out with an acceptable
pre-illness level of social adaptation, which was altered by the appearance of the
disorder; secondly, the decrease in auditory hallucinations allowed him to go out, and
help provide the conditions for the recovery of a normal lifestyle; thirdly, the training
in conversational skills helped him to recover and foment social contacts, and to be able
to be reinforced by these.
During the follow-up it has been observed that this improvement in the subject's social
functioning has been maintained; he has started going out once more with some of his
friends from before the onset of the disorder, and he has made new friends in our
Rehabilitation Unit, with whom he goes out frequently to discos, to the cinema, or simply
to walk around the city. Also, for the last seven months, he has been on a work training
programme, to which he has adapted quite satisfactorily. Lastly, we should mention that on
this programme he has met a female patient from our Unit with whom, for some four months,
he has maintained an affective relationship.
CONCLUSIONS
Any conclusions drawn from this case study, given its design characteristics, should be
treated with caution, and should be tested in studies with greater experimental control.
Nevertheless, some ideas are suggested which may be interesting for future research.
Firstly, pharmacological treatment is not the only strategy available for the treatment of
psychotic symptoms: it is possible to design, as demonstrated in the present work,
psychological strategies of a behavioural type to teach schizophrenic subjects to cope
with auditory hallucinations.
Recently a new direction is developing in the treatment of subjects diagnosed with
schizophrenic disorders, based on symptom-orientation. Authors such as Bentall, Jackson and Pilgrim (1988)
argue for the possibility of studying symptoms
as psychological phenomena in their own
right, as opposed to the traditional emphasis on psychiatric syndromes.
These authors are making an important contribution to psychopathological research, and
fomenting the appearance of new approaches to treatment, not only of hallucinations, but
also of other psychotic symptoms, such as delusions.
Secondly, it is difficult, in the current state of research in this area, to conclude
which variables have contributed to the behavioural change in this patient. In a review of
the literature, Slade and Bentall
(1988) stress that treatment for hallucinations can be classified in three main groups
according to the mechanisms responsible for therapeutic change: 1) those techniques,
referred to as counterstimulation, which place the emphasis on distracting the
hallucinating patient from his/her voices; 2) techniques that encourage the patient to
focus his/her attention on the voices. 3) techniques whose objective is the reduction of
anxiety. These authors affirm that techniques based on counterstimulation (for example,
listening to music through a Walkman or reading aloud), though useful in some patients,
fail to produce lasting benefits because they do not address the basic cognitive disorder
involved in hallucination (the erroneous attribution of the hallucinations to external
agents and not to the subject him/herself). According to these authors, attention-focusing
techniques (e.g. self-monitoring, blocking out of thoughts, etc.), in which the patient
must identify the voices as being related to him/herself, are more likely to produce more
lasting therapeutic changes. However, anxiety-reducing techniques (such as that of
systematic desensitisation) with which positive results have been obtained cannot be
easily explained through the principle of attention-focusing. Slade and Bentall suggest
that the mechanism of change should probably be looked for elsewhere, and refer to studies
that have found a connection between hallucinations and the increase of physiological
arousal (Cooklin, Sturgeon and Leff,
1983).
In our study, the situation is more complex than that considered by these authors, and it
is difficult to accept the hypothetical mechanism of therapeutic change they propose. In
reality, our treatment is a package that includes: anxiety-reducing techniques, such
as relaxation and exposure in vivo to the hallucination-provoking stimuli; counterstimulation
techniques, such as the use of conversation as a behaviour incompatible with
hallucinating; and focusing techniques, such as the patient counting the voices himself,
the reattribution of the voices to himself through Socratic dialogue, and reality tests.
The choice of techniques was not made using a summed approach of "the more the
better", nor from a simplistic and molecular perspective, where the treatment is
"chosen" solely according to the topography of the response, but rather was
guided by a working hypothesis derived from a functional analysis of the hallucinatory
behaviour of this patient. In that analysis, in contrast to biological or intrapsychical
conceptions, we attempted to determine the molar psychological field formed by the
interrelation of the subject with the different physical, social and verbal factors making
up his immediate environment. We can thus consider that the fundamental element of our
work was the direction of our therapeutic efforts, not towards "curing" a
particular disorder or correcting a specific cognitive bias, but towards the construction
(or reconstruction) of the subject's field of interrelations with his social and verbal
context. In order to do this, it was necessary that the patient were able to decrease his
anxiety in the face of hallucination-provoking physical and social situations, that he
learned behaviours incompatible with the problem behaviour, that he widened his social
network, that he found alternative social environments, that he carried out activities
that increased his sources of reinforcement, and that he considered new hypotheses about
himself and his behaviour. However, and to insist once more, always guided by a working
hypothesis derived from a functional analysis of the subject's behaviour.
REFERENCES
American Psychiatric Association. (1987). Manual diagnóstico y estadístico de los trastornos mentales (Diagnostic and statistical manual of mental disorders) (3rd edition revised). Barcelona: Masson.
Bentall, R. P., Jackson, H. F. and Pilgrim, D. (1988). Abandoning the concept of "schizophrenia". British Journal of Clinical Psychology, 27, 303-324.
Bulbena, A., Fernández, P. and Domínguez, A. I. (1992). Adaptación castellana de la escala LSP (Life Skills Profile scale, Spanish adaptation). Actas LusoEspanola de Neurología, Psiquiatría y Ciencias afines, 20 (2), 51-60.
Cooklin, R, Sturgeon, D. and Leff, J. (1983). The relationship between auditory hallucinations and spontaneous fluctuations of skin conductance in schizophrenia. British Journal of Psychiatry, 142, 47-52.
Cuevas, C. and Perona, S. (1992). Entrenamiento en habilidades sociales en una Unidad de Rehabilitación psicosocial (Training in social skills in a psychosocial rehabilitation unit). In F. Gil, J. M. León and L. Jarana (eds.), Habilidades Sociales y Salud (pp. 101-110). Madrid: Eudema.
Green, P. and Kinsbourne, M. (1990). Subvocal activity and auditory hallucinations: Clues for behavioral treatments? Schizophrenia Bulletin, 16(4), 617-625.
James, D. A. E. (1983). The experimental treatment of two cases of auditory hallucinations. British Journal of Psychiatry, 143, 515-516.
Lukoff, D., Liberman, R. P. and Nuechterlein, K. H. (1986). Symptom monitoring in the rehabilitation of schizophrenic patients. Schizophrenia bulletin, 12(4), 578-593.
Maher, B. A. (1988). Anomalous experience and delusional thinking. In T. F. Oltmanns and B. A.
Maher (Eds.). Delusional Beliefs (pp. 15-33). New York: Wiley.
Schneider, K. (1959). Clinical psychopathology. New York: Grune and Stratton.
Slade, P. D. and Bentall, R. P. (1988). Sensory deception: A scientific analysis of hallucination. London: Croom Helm.
|
|
|
|
|
| Home | Help | Search | Feedback | Contents | |
Full text of this article