The usefulness of a self-report questionnaire measuring auditory verbal hallucinations

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Abstract

A self-report measure of psychotic symptoms has been considered to be unsuitable due to the possible denial of symptoms in the patients with schizophrenia. However, a self-report questionnaire would be an efficient tool for the evaluation of subjective aspects of auditory verbal hallucination (AVH), which requires further clarification. In this study, a total of 87 patients with schizophrenia took baseline evaluations for Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ), a self-report questionnaire for AVH, and Psychotic Symptom Rating Scales-Auditory Hallucination Subscale (PSYRATS-AH) and an item measuring hallucinations (P3) on Positive and Negative Syndrome Scale for Schizophrenia (PANSS), both interviewer-rated scales for AVH. At 1 week and at 6 months post-baseline, 39 and 68 patients repeated HPSVQ and PSYRATS-AH, respectively. Total scores on HPSVQ showed good agreement with those on PSYRATS-AH and PANSS, Item P3, and HPSVQ showed good test–retest reliability and internal consistency. In addition, the changes in total scores of HPSVQ during 6-month follow-up were also highly correlated to those of PSYRATS-AH. The findings of factor analysis and hierarchical cluster analysis suggested that the items addressing emotional characteristics of AVH constituted one factor and that the remaining items, primarily concerning the physical characteristics, combined to form another factor. Taken together, the HPSVQ, a self-report questionnaire measuring AVH, was characterized by good psychometric properties, which suggests the appropriateness of a self-report scale for examining the internal structure of AVH in patients with schizophrenia.

Introduction

Auditory verbal hallucinations are among the most common positive symptoms of schizophrenia (Ditman and Kuperberg, 2005, Sartorius et al., 1974), and a significant portion of patients have exhibited persistent auditory hallucinations despite antipsychotic treatment, contributing to ongoing disability and morbidity (Meltzer, 1992). A number of studies have attempted to evaluate the phenomenological characteristics of hallucinations (Aleman and Laroi, 2008, Chang et al., 2005, Chang et al., 2009, Laroi and Woodward, 2007, Steel et al., 2007), and several measures have been introduced to evaluate auditory verbal hallucinations in psychotic individuals (Haddock et al., 1999, Kay et al., 1987, Van Lieshout and Goldberg, 2007).

The Psychotic Symptoms Rating Scale (PSYRATS) was developed by Haddock et al. (1999) to provide a quantitative assessment of the severity of both delusions and auditory hallucinations in psychotic patients. In addition to its reportedly excellent psychometric properties, several studies have confirmed that the PSYRATS is easy to use for assessing information relevant to the key symptoms of psychosis and is appropriate for evaluating the clinical characteristics of psychotic symptoms, including auditory hallucinations (Chang et al., 2009, Durham et al., 2003, Lewis et al., 2002, Steel et al., 2007). However, the PSYRATS is an interviewer-administered and -rated scale, which means that the interviewers must have a thorough understanding of the criteria used in the evaluation before making an informed judgment with regard to each item.

The evaluation of auditory verbal hallucinations relies inherently on the subjective descriptions and/or behaviors of the patients who experience these symptoms (Ditman and Kuperberg, 2005). Self-report questionnaires have been suggested as offering several advantages over standard evaluations of psychiatric symptoms, including the absence of skilled interviewers and the consequent lack of interviewer bias (Pinto et al., 2007); these characteristics can enhance the flexibility, adaptability, and cost-effectiveness of evaluations using this approach (Del Boca and Noll, 2000). However, self-report measures of psychotic symptoms are quite scarce (Rabinowitz et al., 2008), possibly due to the claim that self-report questionnaires are unsuitable for evaluating psychotic disorders because of the possible denial of symptoms related to impaired insight (Doyle et al., 1999, Selten et al., 2000).

On the other hand, however, the use of self-report scales to identify psychotic symptoms, including hallucinations, has been suggested, except during the most acute phases, and psychotic patients have been able to self-rate relevant symptoms (Bell et al., 2007, Liraud et al., 2004, Peters et al., 1999, Schwartz, 1998, van Os et al., 1999). It has also been suggested that differences between interviewer-administered rating scales and those relying on self-reports were minimal when the questions were fairly clear (Blazer et al., 1994, Niv et al., 2007, Rabinowitz et al., 2008). Therefore, a self-report questionnaire for the evaluation of auditory verbal hallucinations can be expected to provide an efficient and practical tool for measuring these experiences.

Van Lieshout and Goldberg (2007) developed a brief self-report measure, the Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ), to quantify the self-reports of auditory verbal hallucinations in persons with psychosis. The HPSVQ consists of nine items with 5-point rating scales that are used to produce a quantitative assessment of auditory verbal hallucinations, and four items that are used to produce a qualitative assessment of auditory verbal hallucinations. Adequate stability, internal consistency, and concurrent validity for the HPSVQ compared to the interviewer-rated PSYRATS auditory hallucinations subscale (PSYRATS-AH) were reported. It has been suggested that the HPSVQ offers several advantages compared with examiner-rated instruments, including requiring less time to administer, the absence of inter-rater differences, and the absence of influence attributable to factors associated with an interviewer (Van Lieshout and Goldberg, 2007).

Self-reports might be influenced by cultural factors that affect their validity and reliability (National Institutes of Health, 1998). Indeed, cultural differences have been suggested to characterize the experience of hallucinations (Aleman and Laroi, 2008, Kulhara and Chakrabarti, 2001, Maslowski and Oosthuizen, 1993). Moreover, Van Lieshout and Goldberg's report (2007) was limited by its small sample, rendering further research with larger samples necessary to ensure the generalizability of the findings and to enable additional analyses of the characteristics of the scale, including factor structure of HPSVQ. Therefore, additional studies with larger samples drawn from different cultures are needed to evaluate the usefulness of the HPSVQ, a self-report questionnaire for assessing auditory verbal hallucinations.

This study examined the psychometric properties of the self-report questionnaire measuring auditory verbal hallucinations, the Korean version of the HPSVQ, in Korea, a non-Western Asian country; the compatibility of this self-report questionnaire with the interviewer-rated scale of auditory verbal hallucinations, the PSYRATS-AH, for evaluating auditory verbal hallucinations in patients with schizophrenia; and the longer-term changes in the phenomenological characteristics of auditory verbal hallucinations obtained with the self-report questionnaire over a period of 6 months.

Section snippets

Subjects

Patients diagnosed with schizophrenia and reporting active auditory verbal hallucinations were recruited from Seoul National University Hospital and Boramae Medical Center in Seoul, Republic of Korea. Active auditory verbal hallucinations (AVH) were operationally defined as including both the experience of hearing “voices” and a minimum score of 3 on the hallucination item (P3) of the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987). The inclusion criteria were the Diagnostic and

Demographic and clinical characteristics

A total of 87 patients (44 men and 43 women) meeting DSM-IV criteria for schizophrenia completed evaluations at baseline, and 39 and 68 patients with schizophrenia completed follow-up evaluations at 1 week and 6 months, respectively. As the study was performed in naturalistic follow-up condition, the assessment at 1 week post-baseline was performed only with the subjects who required earlier follow-up. The baseline demographic and clinical characteristics of the subjects, including age, age of

Discussion

In this study, the HPSVQ, a self-report questionnaire measuring auditory verbal hallucinations, demonstrated good psychometric properties in Korean patients with schizophrenia using a relatively larger sample than that used in the original study reported by Van Lieshout and Goldberg (2007). Moreover, changes in auditory verbal hallucinations under antipsychotic treatments were appropriately reflected with self-report scale HPSVQ compared to the interviewer-rated scale PSYRATS, and the stability

Conclusion

This study suggested that the HPVSQ is qualified to measure auditory verbal hallucinations in patients with schizophrenia. We demonstrated that this instrument was characterized by good psychometric properties, accurately reflected the phenomenology of auditory verbal hallucinations, and was compatible with the PSYRATS, an interviewer-rated validated scale for auditory verbal hallucinations. Due to its advantages as a self-report measure, including convenience and acceptability to patients, and

Acknowledgements

This study was supported by a grant from the Korea Healthcare Technology R&D Project, Ministry for Health, Welfare, and Family Affairs (03-PJ10-PG13-GD01-0002), Republic of Korea. All the authors declare that they do not have any commercial associations that might pose a conflict of interest in connection with this manuscript. We greatly appreciate Drs. Van Lieshout and Goldberg, authors of the HPSVQ, for kindly permitting development of the Korean version of the scale.

Copies of the HPSVQ are

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