Psychiatry Research 228 (2015) 462467

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Evaluation of auditory hallucinations in patients with schizophrenia: A

validation study of the Malay version of Psychotic Symptom Rating
Scales (PSYRATS)
Suzaily Wahab a, Mohd Normani Zakaria b, Dinsuhaimi Sidek c,
Abdul Hamid Abdul Rahman a, Shamsul Azhar Shah d, Noor Alaudin Abdul Wahab b,e,n
a
Department of Psychiatry, Universiti Kebangsaan Malaysia Medical Center, 56000 Cheras, Malaysia
b
Audiology Programme, School of Health Sciences, Universiti Sains Malaysia, 16150 Kubang Krian, Malaysia
c
Department of Otorhinolaryngology, Medical Faculty, Universiti Sains Malaysia, 16150 Kubang Krian, Malaysia
d
Department of Public Health, Universiti Kebangsaan Malaysia Medical Center, 56000 Cheras, Malaysia
e
Audiology Programme, School of Rehabilitation Sciences, Faculty of Health Sciences, 53200 Kuala Lumpur, Malaysia

art ic l e i nf o a b s t r a c t

Article history: The Psychotic Symptom Rating Scales (PSYRATS) is the most widely used validated scale to measure the
Received 23 September 2014 specic symptoms of auditory hallucination and delusion. The aim of this study was to validate and to
Received in revised form examine the psychometric properties of the auditory hallucination component of the Malay PSYRATS
24 June 2015
(MyPSYRATS). The research was done in the Universiti Kebangsaan Malaysia Medical Center (UKMMC)
Accepted 25 June 2015
Available online 26 June 2015
among 51 schizophrenia inpatients and outpatients who had experienced or reported verbal auditory
hallucination. The psychometric properties of MyPSYRATS (auditory hallucination) were studied and a
Keywords: comparison was made between the psychometric properties obtained and the Positive and Negative
Schizophrenia Syndrome Scale (PANSS). The internal consistency of MyPSYRATS was good as revealed by Cronbachs
Translation
alpha value. Factor analysis replicated three components (emotional, cognitive, and physical) similar to
Psychometric
the factorial structure of the original auditory hallucination scale. However, two items were regrouped
Validity
Reliability under the emotional component. Spearmans rank-order correlation showed a signicant positive re-
lationship between the total score of auditory hallucinations and PANSS auditory hallucinations item
(P3). In conclusion, the auditory hallucination domain of MyPSYRATS is a reliable and valid assessment
tool for further clinical applications.
& 2015 Published by Elsevier Ireland Ltd.

1. Introduction
Verbal auditory hallucination (VAH; as the experience of per-
ceiving speech in the auditory modality without corresponding
external stimuli) is one of the common symptom identied in
patients with schizophrenia (Lari, 2012). The symptom, based on
phenomenological studies, is shown to have diverse characteristics
which include but not limited to its content and linguistic com-
plexity (Stephane, 2013). In addition, while VAH may be associated
with intrusive commentaries (Johns et al., 2002), it also interferes
with the social (Favrod et al., 2004) and professional functioning
(Goghari et al., 2013) of the affected individuals. Nevertheless,
there have also been reports where patients felt that the voices
had a positive impact on them (Badcock and Hugdahl, 2012;
n
Corresponding author at: Audiology Programme, School of Health Sciences,
Universiti Sains Malaysia, 16150 Kubang Krian, Malaysia.
E-mail address: alaudin.phd@gmail.com (N.A. Abdul Wahab).
Jenner et al., 2008). To date, the Psychotic Symptom Rating Scales
(PSYRATS) is the most widely used psychometrically validated
multi-dimensional questionnaire to assess the severity of auditory
hallucination.
The advantage of PSYRATS, unlike other psychometric scales,
lies in its assessment of the detailed characteristics of hallucina-
tions and delusions (Favrod et al., 2012). The tool, which was
originally developed by Haddock et al. (1999), is an easily ad-
ministered semi-structured interviewer-rated questionnaire that
contains two major domains: auditory hallucinations and delu-
sions. The domains can be used either separately or mutually
when evaluating psychotic patients with symptoms representing
the said domains. More importantly, PSYRATS either in its original
or translated versions has been reported to have high reliability
and validity when applied to the target population (Favrod et al.,
2012; Gonzalez et al., 2003; Haddock et al., 1999; Hatton et al.,
2005; Jung et al., 2007; Kronmller et al., 2011). Nevertheless,
PSYRATS has neither been translated into, nor validated in the
Malay language.

http://dx.doi.org/10.1016/j.psychres.2015.06.014
0165-1781/& 2015 Published by Elsevier Ireland Ltd.
 S. Wahab et al. / Psychiatry Research 228 (2015) 462467 463

PSYRATS is a useful tool in helping researchers to evaluate the hallucinations within a week prior to the MyPSYRATS interview.
effectiveness of medication or treatment method. For instance, the Patients with a primary diagnosis of alcohol or substance depen-
effectiveness of cognitive behavioral therapy (CBT) on schizo- dence were not included in the current study. All patients were on
phrenia patients with auditory hallucinations was evidenced by second generation of anti-psychotic medications.
the improvement in their PSYRATS score (Thomas et al., 2011).
PSYRATS has also been used in assessing the severity of auditory 2.2. Materials
hallucinations and central auditory function in patients with
schizophrenia (Fisher et al., 2011). Thus, with the limited number 2.2.1. Psychotic Symptom Rating Scales (PSYRATS)
of validated Malay version questionnaires available in the local The PSYRATS is a ve-point scale, multi-dimensional measure
mental health care system, a Malay version of PSYRATS (MyP- of auditory hallucinations and delusions (Haddock et al., 1999). It
SYRATS) is denitely necessary in Malaysia. A standardized and consists of 11 items and 6 items for auditory hallucinations and
validated Malay version could minimize biases arising from mis- delusion, respectively. Depending on the clinicians objectives,
interpretation by either raters or patients due to differences in each domain can either be used separately or together when as-
language backgrounds. Therefore, the current study aims were to sessing patients with schizophrenia. The permission to translate
translate and validate the auditory hallucinations domain of the the original PSYRATS into Malay and to validate the Malay version
original PSYRATS into the Malay language. of the questionnaire was obtained from the corresponding author.
Only the auditory hallucinations domain was applied to the schi-
zophrenia patients in this study.
2. Method
2.2.2. Positive and negative syndrome scale (PANSS)
The PANSS (Kay et al., 1988) is a rating instrument used by
In the present study, a series of validation and reliability tasks
mental health physicians to assess symptoms associated with
was performed on the MyPSYRATS. The data were analyzed using
schizophrenia. In this particular study, only the hallucination
descriptive and inferential statistics as appropriate. This study was
component (P3), that is, the positive scale, was applied to the
approved by Universiti Kebangsaan Malaysia Medical Center
schizophrenia patients.
(UKMMC) ethics committee.
2.2.3. Mini-international neuropsychiatric interview (MINI)
2.1. Participants The M.I.N.I (Sheehan et al., 1998) is a structured clinical inter-
view that has been widely used by researchers to diagnose psy-
Written informed consent was obtained from 51 in schizo- chiatric disorders in accordance to DSM IV or ICD 10. In this re-
phrenia patients who attended psychiatric clinic UKMMC for search M.I.N.I was used to further conrm the diagnosis of
participation in the study. Of these, 23 (45.1%) were males and 28 schizophrenia.
(54.9%) were females. Majority, 31 (60.8%) were Malays while the
rest were Chinese 18 (35.3%) and Indians 2 (3.9%). Overall, their 2.3. Forward and backward translations
mean age was 38.51 years (SD 10.26) and the mean duration of
illness was 9.22 years (SD 6.25). The patients were selected from Two psychiatrists and a clinician with sufcient MalayEnglish
both inpatients and outpatients. Only patients who experienced language background independently translated the original PSY-
auditory hallucination within one week prior to the administration RATS into the Malay language. Subsequently, the three translations
of PSYRATS were included in the study and were assessed using were evaluated by a qualied linguist to verify the suitability of
the hallucination scale and the PANSS (P3) hallucination item. The words and grammar used, prior to the production of an early
specic demographic data were presented in Table 1. Diagnosis of version of MyPSYRATS. The early version of MyPSYRATS was then
schizophrenia was made in accordance to the DSM-IV diagnosis of distributed to three qualied independent translators for back-
mental disorders and was conrmed using M.I.N.I structured in- ward translation. Finally, the translations were compared with the
terview. All patients reported experiencing verbal auditory original PSYRATS and the early version of MyPSYRATS to assess
accuracy. In all, six translations were produced by six translators
Table 1 involved in the entire process. In relation to direct translations, a
The demographic data and the mean scores of MyPSYRATS and PANSS (P3). of
few words were amended to avoid misinterpretation. The direct
male and female patients with schizophrenia.
translation of your voices, in Malay, would be suarasuara awak
Item Male (n 23) Female (n28) which refers to the persons own voice. However, this is not the
Mean (SD) Mean (SD) intention of original PSYRATS that refers your voices to the
hallucination. Hence, the word awak was removed. Secondly, in
Age (years) 37.87 (9.84) 39.04 (10.73)
the Malay language, suarasuara refers to the plural form which
Duration of illness (years) 9.61 (5.45) 8.89 (6.93)
does not exist in Malay. Hence the term your voices in PSYRATS
was just translated to suara.
MyPSYRATS scores
Frequency 2.39 (1.37) 2.39 (1.19)
Duration 2.74 (1.05) 2.75 (1.18) 2.4. Internal consistency
Location 2.57 (1.03) 2.57 (1.03)
Loudness 1.96 (0.97) 1.75 (0.75) A total of 51 schizophrenia patients (as diagnosed by DSM-IV)
Origin of voice 3.00 (1.21) 3.04 (1.04)
were interviewed by two psychiatrists using MyPSYRATS. All pa-
Amount of negative content 2.61 (1.50) 2.25 (1.35)
Degree of negative content 2.17 (1.64) 1.68 (1.42) tients included had experienced or currently reported verbal au-
Amount of distress 1.78 (1.78) 1.82 (1.49) ditory hallucinations. The results were then analyzed to determine
Intensity of distress 1.52 (1.68) 1.75 (1.53) the Cronbachs alpha value.
Disruption to life 1.87 (1.52) 1.79 (1.37)
Controllability 3.39 (1.27) 3.43 (1.14) 2.5. Concurrent validity
Total 26.00 (10.4) 25.21 (8.13)
PANNS (P3) 4.78 (1.51) 4.82 (1.09)
Concurrent validity, a measure of criterion-related validity,
464 S. Wahab et al. / Psychiatry Research 228 (2015) 462467

Table 2
The comparison among current and previous studies on PSYRATS hallucination scale factor loadings.

Studies Item Factor

Emotion Physical Cognitive Disruption Control

Current study (n 51) Frequency 0.197 0.886 0.195

Duration 0.132 0.928 0.044
Location 0.114 0.133 0.645
Loudness 0.472 0.104 0.159
Origin of voice 0.138 0.177 0.809
Amount of negative content 0.704 0.266 0.142
Degree of negative content 0.756 0.269 0.306
Amount of distress 0.913 0.095 0.092
Intensity of distress 0.918 0.021 0.072
Disruption to life 0.774 0.016 0.162
Controllability 0.187  0.051 0.642
Eigenvalues 4.53 1.55 1.18
Cumulative percentage of variance 41.19 55.26 65.94

Haddock et al. (1999) (n 71) Frequency 0.532

Duration 0.777
Location 0.476 0.477
Loudness 0.754
Origin of voice 0.750
Amount of negative content 0.870
Degree of negative content 0.725
Amount of distress 0.885
Intensity of distress 0.770
Disruption to life 0.529
Controllability 0.669
Eigenvalues 2.825 2.002 1.486
Cumulative percentage of variance 25.7 43.9 57.4

Steel et al. (2007) (n 276) Frequency 0.854

Duration 0.856
Location 0.778
Loudness 0.757
Origin of voice 0.774
Amount of negative content 0.850
Degree of negative content 0.817
Amount of distress 0.830
Intensity of distress 0.825
Disruption to life 0.441 0.440
Controllability 0.604
Eigenvalues
Cumulative percentage of variance 30.7 44.2 55.7 65.8

Kronmller et al. (2011) (n 200) Frequency 0.75

Duration 0.79
Location 0.69
Loudness 0.46
Origin of voice 0.85
Amount of negative content 0.94
Degree of negative content 0.93
Amount of distress 0.94
Intensity of distress 0.90
Disruption to life 0.66
Controllability 0.79
Eigenvalues
Cumulative percentage of variance 42.13 11.80 11.53 10.18

Favrod et al. (2012) (n 103) Frequency 0.93

Duration 0.44
Location 0.78
Loudness 0.78
Origin of voice 0.81
Amount of negative content 0.86
Degree of negative content 0.76
Amount of distress 0.93
Intensity of distress 0.79
Disruption to life 0.72
Controllability 0.54
Eigenvalues 4.1 1.0 1.6 1.2
Cumulative percentage of variance 37.6 71.9 52.0 62.5
 S. Wahab et al. / Psychiatry Research 228 (2015) 462467
aims to determine the capacity of the questionnaire under devel-
opment to measure its intended constructs (Burton and Mazerolle,
2011). This was achieved by administering, on the same subjects
and point of time, a different questionnaire that also evaluates the
same construct. Specically, the current study administered PANSS
(P3) hallucination item on the schizophrenia patients who parti-
cipated in the current study.
2.6. Statistical analysis
All analyzes were performed using IBM SPSS Statistics version
21. The factor structure of the scales was evaluated by principal
component factor analysis with a varimax rotation with Kaiser
Normalization. Inter-rater reliability was computed by using intra-
class correlations (ICCs). The results of the signicance tests are
quoted as two-tailed probabilities. Associations between the total
scores of PSYRATS and PANSS were examined using Spearman
rank-based correlation test.
3. Results
3.1. Socio-demographic data
The demographic data and the mean scores of MyPSYRATS and
PANSS (P3) of patients with schizophrenia are shown in Table 1.
3.2. Internal consistency
All 51 schizophrenia subjects were successfully interviewed.
The Cronbachs alpha value for MyPSYRATS was high (r 0.85),
suggesting a good internal consistency (DeVellis, 2003; Pallant,
2010).
3.3. Factor analysis
The construct validity of auditory hallucination items was tes-
ted by using principal component factor analyzes with varimax
rotation. The KaiserMayerOlkin (KMO) value of 0.72 and the
Bartletts test of sphericity of less than 0.05 indicate that factor
analysis in the study was appropriate (Leech et al., 2005). In de-
termining the number of factors, only factors with an eigenvalue of
1 or greater (Kaiser criterion) were retained. Based on the factor
analysis table (Table 2), the rst three components showed ei-
genvalues more than 1 (4.531, 1.548, and 1.175). These three
components explained a total of 65.94% of the variance. The Scree
test also suggested a three-factor solution as the optimal re-
presentation of the data. Using the Kaiser criterion, a change in the
Scree plot was observed. The rst change was observed between
components 3 and 4. Therefore, only the rst three components
were retained.
The rotated component matrix (Table 3) showed the loadings of
each of the item on the three components. Most of the items load
quite strongly ( 40.4) (Leech et al., 2005) on the rst component.
After using the varimax rotation, we noted that component
1 consists of items 4, 6, 7, 8, 9 and 10. Items 1 and 2 were in
component 2 while component 3 included item 3, 5, and 11. The
factor for item 7 was determined based on its higher matrix value.
Thus, component 1, component 2, and component 3 are identied
as the emotional, physical, and cognitive characteristics for audi-
tory hallucinations, respectively.
3.4. Concurrent validity
KolmogorovSmirnov test was conducted as a test of data
normality. As MyPSYRATS is the main questionnaire validated and
465
Table 3
Correlations between items of the PSYRATS hallucination scale and PANSS P3 hallu-
cination item.
PANSS P3 hallucination (n51)
Frequency 0.628nn
Duration 0.352n
Location 0.153
Loudness 0.392nn
Origin of voice 0.336n
Amount of negative content 0.364nn
Degree of negative content 0.419nn
Amount of distress 0.455nn
Intensity of distress 0.463nn
Disruption to life 0.691nn
Controllability 0.224
Total AH 0.631nn
nn
Correlation is signicant at the 0.01 level (2-tailed).
n
Correlation is signicant at the 0.05 level (2-tailed).
its data were normally distributed (p 0.19), the sample size col-
lected in the current study was sufcient. In contrast, data dis-
tribution for PANSS was not normal (p 0.06). Hence, Spearman
based-rank correlation test was performed to analyze the corre-
lation between the questionnaires. The coefcient value was cal-
culated between the MyPSYRATS auditory hallucinations and the
P3 item of the PANSS. The frequency, loudness, amount of negative
content, degree of negative content, amount of distress, level of
distress, disruption-to-life items and the total score of the MyP-
SYRATS hallucinations scale were correlated at the 0.01 level with
the P3 hallucination item of the PANSS. The duration and origin-
of-voice items were correlated at the 0.05 level with the P3 hal-
lucination item of the PANSS (Table 3).
4. Discussion
Obtaining the internal consistency for questionnaires using
Likert scale as in MyPSYRATS is highly recommended (Drnyei,
2010). For a measurement to be considered reliable, the Cron-
bachs alpha value should be at least 0.7 (Pallant, 2010). In this
study, the Cronbachs alpha value was high, indicating a good in-
ternal consistency and agreement with Cronbachs alpha values
obtained from previous studies (Favrod et al., 2012; Gonzalez et al.,
2003; Jung et al., 2007; Kronmller et al., 2011). Therefore, the
outcomes of this reliability study were acceptable.
Our study replicates those by Steel et al. (2007) and Favrod
et al. (2012) who found signicant correlation between the total
auditory hallucination score of MyPSYRATS and the hallucination
item (P3) of the PANSS. As for factor analysis, this study identied
a three-factor solution: emotional, physical, and cognitive. The
items loaded on the factors replicated those reported in the ori-
ginal study (Haddock et al., 1999). Nevertheless, while Haddock
et al. (1999) found disruption and loudness loaded under cognitive
and physical factors, respectively, we found the two items grouped
under the emotional factor. In other studies, both items were
grouped under the distraction factor (Favrod et al., 2012). We also
note that the loudness item had the lowest loading on all three
components, similar to ndings by Woodward et al. (2014). Al-
though we included loudness under emotional factor, there is a
possibility that due to its lowest factor loadings, the loudness item
may also load on its own as argued by Woodward et al. (2014). The
remaining items under the emotional factor of MyPSYRATS re-
plicated previous studies (Favrod et al., 2012; Haddock et al., 1999;
Kronmller et al., 2011; Steel et al., 2007). The location and con-
trollability items were loaded under the cognitive factor, which
replicated the original study (Haddock et al., 1999). Woodward
466 S. Wahab et al. / Psychiatry Research 228 (2015) 462467
et al. (2014), however, have re-labeled the dimensions where
emotional, physical and cognitive were renamed as distress, fre-
quency and attribution respectively. The renaming was based on
two reasons (1) to highlight the equivalent between auditory
hallucination and delusion dimensions and (2) to enhance the
concepts of the dimensional structure.
The dissimilarities in the factor loadings and item locations
among studies could be attributed to a number of factors including
the different clinical characteristics of study populations, the
duration or chronicity of illness, the diagnosis used (e.g., schizo-
phrenia vs. schizo-affective population), responses to treatment,
and the complex nature of auditory hallucination itself. Dissim-
ilarities among studies may also reect a lack of clear under-
standing of the dimensions of auditory hallucinations as men-
tioned by Steel et al. (2007).
Another point that is discussing is the role of culture as another
possible factor that may lead to the dissimilarities in the factor
loadings. Arguments on the association between cultural and re-
ligious beliefs with emotion had been documented by previous
studies. Thagard (2005), for instance, had argued on the sig-
nicance of emotional factor in an individual when adopting re-
ligious belief that t their emotion. He noted that religion is a
matter of emotional attitudes and different religions have different
balances between positive and negative emotions. Prinz (2011)
discussed on how emotion is affected cross-culturally. Different
cultures have different inuence on what arouses the emotions
and also on the expressions of emotions. The discussion argues on
how the beliefs inuence emotion. Azhar et al. (1993) studied the
effect of religion and cultural beliefs on the symptomatology of
auditory hallucination between two ethnics, i.e Malays and Chi-
nese in the Malaysian population. They found higher percentage of
Malays, especially in rural region, attributed the voices to God,
spirit and demons. The study concluded that religion and culture
might inuence the symptomatology of auditory hallucination. As
such, we speculate that emotion may also have some signicant
contribution to the symptomatology of verbal auditory hallucina-
tion experienced by schizophrenia patients. A current local study
conducted on three major ethnics in Malaysia; i.e Malay, Chinese
and Indian, found that the Chinese, as compared to Malays, were
more vocal in sharing their emotions (Wong and co-workers, un-
published results). The differences in sharing emotions could be
contributed by communication styles, where the Chinese were
more direct than Malays (David and Kuang, 1999). It is therefore
worth noting that the signicant number of Chinese participants
in our study may also contribute to the current factor loading of
emotional components. Future studies to investigate the effect of
cultural and ethnic diversities on psychometric evaluation of
PYSRATS may be necessary. On the other hand, as documented by
Asutay and Vstfjll (2012) emotion may inuence loudness per-
ception. They noted that subjects with disturbed emotion would
perceive voice louder compared to those with stable emotion.
Their study infer how emotional status inuence loudness per-
ception. Hence, to relate with the above facts, the relocation of
loudness into emotional factor in our analysis is also acceptable.
It is worth noting that our study is not without limitations.
Apart from the limited sample size, the focus on one tertiary
center in the urban area for collection of data was also not ideal as
differences do exist with regards to patients characteristics and
medication regime (e.g. the use of conventional versus newer
antipsychotics) between each treatment centre. The ethnic di-
versity of our study population, uneven distribution of the three
ethnic groups and over representation of the Malay compared to
non-Malays might have brought along cultural differences that
could affect our ndings. Despite these limitations, our study
however, had managed to show that the series of validation and
reliability analyzes on MyPSYRATS (auditory hallucination
subscale) had given good results, hence ready to be used clinically
by the local medical professionals.
Acknowledgments
We thank Dr. Gillian Haddock for giving us permission to
translate PSYRATS into the Malay language and to validate the
same. We also acknowledge the Center for Research and In-
strumentation Management (CRIM), Universiti Kebangsaan Ma-
laysia (UKM) for providing funding to this research project
(GGPM-2012-090).
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