Indian Journal of Health and Wellbeing 2015 Indian Association of Health,

2015, 6(5), 480-483 Research and Welfare

http://www.iahrw.com/index.php/home/journal_detail/19#list ISSN-p-2229-5356,e-2321-3698

Efficacy of cognitive behaviour therapy in management of

delusion, hallucination in patients with schizophrenia
Md. Raqueb Ansari and Masroor Jahan
Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry
and Allied Sciences (RINPAS), Kanke, Ranchi, Jharkhand

Schizophrenia is still considered to be chronic and depilating illness. The aim of the present study is to manage the
delusion and hallucination in patients with schizophrenia. 24 patients diagnosed with schizophrenia according to
ICD-10 DCR were chosen from different inpatient department of RINPAS, kanke using the simple random
sampling technique. After taking informed consent from the patients, socio-demographic and clinical data sheet and
PSYRATS were administered and they were randomly assigned to CBT+TAU and TAU group. Cognitive
behaviour therapy was given to CBT+TAU group, total 17-20 sessions of 45 minutes each with a frequency of thrice
a week. After completion of the therapy sessions, post assessment was done and follow up assessment was done
after six months of post assessment. Data was analyzed with the help of Mann-Whitney U test and Chi-square Test
was used for statistical analysis. The significant reduction was found in delusion and hallucination. Cognitive
behaviour therapy was found to be effective in management of delusion and hallucination.

Keywords: schizophrenia, delusion, hallucination and cognitive behaviour therapy

Schizophrenia and other psychotic disorders are still chronic and
debilitating conditions despite the advances in pharmacological
treatments (Pratt & Mueser, 2002). Research suggests that between
25 to 60 percent of the patients continue to experience psychotic
symptoms even after satisfactory drug adherence (Curson et al.,
1998). Despite the effectiveness of anti-psychotic pharmacotherapy,
residual hallucinations and delusions do not completely resolve in
some medicated patients. Additional cognitive behavioral therapy
(CBT) seems to improve the management of positive symptoms.
Even with the use of optimal doses of clozapine, 40% of patients with
treatment-resistant schizophrenia do not respond. An effective
psychological treatment is currently the only option for such patients
to ameliorate disabling symptoms.
Cognitive behavioural therapy has been established as an effective
treatment for residual psychotic symptoms but a substantial
proportion of people do not benefit from this treatment. There has
been little direct study of predictors of outcome, particularly in
treatment targeting auditory hallucinations. A study done by Thomas
et al. (2010) in which Psychotic Symptom Rating Scales
(PSYRATS) and Positive and Negative Syndrome Scale (PANSS)
were administered pre- and post-therapy to 33 people with
schizophrenia-related disorders receiving CBT for auditory
hallucinations in a specialist clinic. Outcome was compared with
pre-therapy measures of insight, beliefs about the origin of
hallucinations, negative symptoms and cognitive disorganization.
Results showed significant improvement was found on post-
treatment on the PSYRATS and PANSS Positive and General Scales.
Improvement on the PSYRATS was associated with lower levels of
negative symptoms, but was unrelated to overall insight, delusional
conviction regarding the origins of hallucinations, or levels of
cognitive disorganization. Based on their study Thomas et al. (2010)
concluded that Lack of insight and presence of formal thought
Correspondence should be sent to Masroor Jahan, Department of
Clinical Psychology, RINPAS, Kanke, Ranchi, Jharkhand
E-mail: masroorjahan@yahoo.com
disorders do not prohibit effective cognitive-behavioural treatment
of auditory hallucinations.
Method
Participants
In this study initially 24 schizphrenic patients meeting various
inclusion and exclusion criterions were selected from different
inpatient wards of RINPAS, kanke, Ranchi, Jharkhand through
simple random sampling. In due course of study four patients (2
from control and 2 from experimental group) drop out from the
study as they were prematurely discharged from the hospital on care
giver request. Hence, final analysis was done only for 20 patients.
Both groups were comparable in socio-demographic characteristic
and clinical variables. Hence, possible effects of these were
controlled prior to the intervention. Patients in the age range of 20-
40 years. Most of them were educated up to at least 8th std. To
control confounding variable patients with history suggesting
mental retardation, general medical condition, substance abuse and
having acute medical conditions or other co-morbid psychiatric
condition at the time of selection were excluded.
Instruments
Socio-demographic and Clinical Data Sheet: It consisted of all areas
of socio-demographic details like age, domicile, education,
employment, marital status etc. and question elated to nature of
illness, substance dependence, and co-morbid psychiatric disorder,
duration of illness and severe physical illness in the near past and
both group were matched on all above mentioned variables.
Psychotic Symptoms Rating Scale: This scale was developed in
recognition of the complexity of hallucinations and delusions. It also
measures the severity of these symptoms. It is intended to be of use
to practitioners interested in assessing changes in symptoms. There
are two sets of scales, one for hallucinations (AH; 11 items) and the
other for delusions (AD; 6 items). Severity is rated using a 5-point
scale. The hallucinations scale includes frequency, duration,
intensity of distress, control lability, loudness, location, negative
 Indian Journal of Health and Wellbeing 2015, 6(5), 480-483 481

content, degree of negative content and belief about voices and
disruption. The delusion scale includes preoccupation, distress,
duration, conviction, intensity of distress, and disruption.
A factor analysis yielded three factors (a) emotional characteristics
(b) physical characteristics (c) cognitive interpretation,
Interrater reliability of hallucination ranged from 0.79 to 0.90.
Reliability for the delusions scale was also high. All six of the items
were above 0.88.
Procedure
In this study patients diagnosed with schizophrenia as per ICD-10
(DCR) and meeting the inclusion and exclusion criterions were
selected from different units of Ranchi Institute of Neuro-Psychiatry
and Allied Sciences. Potential and interested candidates were
approached. Once patients agreed to participate, informed consent was
taken and demographic and clinical information was collected by using
socio-demographic and clinical data sheet. Immediately after
obtaining consent and collecting socio-demographic and clinical data
PSYRATS was administered to collect baseline data. After this they
were randomly assigned to TAU+CBT and TAU group. Patients in the
TAU condition received standard treatment on the unit, which includes
psycho-education, supportive therapy and pharmacotherapy. Patients
in the TAU+CBT conditions received approximately 17-20 one hour
long sessions of individual CBT thrice in a week during their stay in the
hospital. Initially, 2-3 sessions a good rapport was developed with
patients and then the patients were allowed to discuss about their
delusions and hallucinations. A core set of cognitive behaviour therapy
technique were used. Then on further sessions the patients beliefs were
challenged by some logical questions. Some effective techniques were
used as logical questioning and examining the evidence. Cognitive
behaviour therapy technique for hallucinations such as distractions
technique (i.e. reading books, listening song , gardening etc.) were
used according to the patients interest and availability in the hospital as
well as at home. Prior to discharge, participants were evaluated again
on the same measure as it was on baseline.
Research design
A pre-test and post test with control design was used in this study.
Equal number of patients was randomly assigned to cognitive
behaviour therapy (CBT+TAU) and treatment as usual group (TAU).
Statistical analysis
As sample size in this study was small, hence obtained data was
analyzed by using non-parametric statics, namely, chi-square test,
Mann Whitney U test (for between group comparison).
Results
Table 1 is showing the comparison between patients with
schizophrenia in treatment as usual and patients in treatment as usual
plus cognitive behaviour therapy (TAU+CBT) at baseline and post
on delusions and hallucinations. To compare both groups at baseline
and post assessment scores Mann Whitney 'U' test was calculated.

Table 1: Comparison of delusion of psychotic symptoms rating scale between Experimental and Control Group at Baseline
Area of assessment Experimental group Control group Mann Whitney Test
Mean SD Mean SD Mean Rank
Experimental Control U Value Z Score
Group Group
Preoccupation from delusion 3.600.51 3.300.67 11.70 9.30 38.00 1.02 NS
Duration of preoccupation 3.100.87 3.000.94 10.80 10.20 47.00 0.24 NS
Conviction 3.700.48 3.200.63 12.65 8.35 28.50 1.83 NS
Amount of distress 3.700.48 3.000.47 13.65 7.35 28.50 1.86 NS
Intensity of distress 3.500.52 3.000.66 12.50 8.50 30.00 1.69 NS
Disruption to life 3.800.42 3.200.78 12.70 8.30 28.00 1.91 NS
NS- Not Significant

By observing the Table 1 it is evident that there was no significant
difference between both groups in terms of delusion on PSYRATS.
This suggests that both groups were similar on different elements of
delusions. No significant difference was found on any element of
delusion such as preoccupation from delusion (U=38, Z=1.02,
p>0.05), duration of preoccupation (U=47, Z=0.24, p>0.05),
conviction (U=28.50, Z=1.83, p>0.05),amount of distress
(U=28.50, Z=1.86, p>0.05)intensity of distress (U=30, Z=1.91,
p>0.05) and disruption to life (U=28, Z=1.91 ,p>0.05).

Table2: Comparison of hallucinations of Psychotic Symptoms Rating Scale between Experimental and Control Group at Baseline
Area of assessment Experimental group Control group Mann Whitney Test
Mean SD Mean SD Mean Rank
Experimental Control U Value Z Score
Group Group
Frequency of auditory hallucination 3.300.67 3.500.70 9.60 11.40 41.00 0.75 NS
Duration of auditory hallucination 2.700.67 2.400.51 11.70 9.30 38.00 1.02 NS
Location of auditory hallucination 3.600.51 3.500.70 10.70 10.30 48.00 0.17 NS
482 ANSARI AND JAHAN/ EFFICACY OF COGNITIVE BEHAVIOUR THERAPY

Loudness of auditory hallucination 2.900.73 2.900.56 10.45 10.55 49.50 0.04 NS

Re -Origin of voices 3.500.52 3.600.69 9.75 11.25 42.50 0.65 NS
Amount of negative content 2.800.63 2.500.52 11.75 9.25 37.50 1.07 NS
Degree of negative content 2.500.52 2.700.67 9.75 11.25 42.50 0.64 NS
Amount of distress 3.100.56 3.100.31 10.55 10.45 49.50 0.05 NS
Intensity of distress 2.700.48 2.700.48 10.50 10.50 50.00 0.00 NS
Disruption to life 2.500.52 2.500.52 10.50 10.50 50.00 0.00 NS
Controllability 3.400.69 3.700.48 9.35 11.65 38.50 1.00 NS
NS- Not Significant

By observing the Table no 2 it is evident that there was no significant
difference between both groups in terms of different elements of
hallucinations on PSYRATS at baseline level. It means that both
groups were similar at baseline level. The Mann Whitney U value
indicates that there was no significant difference was found on any
elements of hallucinations such as frequency of auditory
hallucination (U=41, Z=0.75, p>0.05), frequency of auditory
hallucination (U=38, Z=1.02, p>0.05), location of auditory
hallucination (U=48, Z=0.17, p>0.05) and etc.

Table : 3 Showing after Intervention Status of Clinical Symptoms of the Experimental Group and Control Group on Psychotic Symptom
Rating Scale (SAPS)'s Dimension of Delusion.
Area of assessment Experimental Group Control Group Mann Whitney Test
MSD MSD
Pre Post Difference Pre Post Difference Mean rank U value Z Score
(Pre-Post) (Pre-Post)
Experimental Control
Group Group
Preoccupation from delusion 3.600.51 1.400.84 2.201.03 3.300.67 2.900.73 0.400.69 14.80 6.20 7.00 3.41**
Duration of preoccupation 3.100.87 1.400.51 1.700.67 3.000.94 2.800.63 0.201.13 14.05 6.95 14.50 2.82**
Conviction 3.700.48 1.000.81 2.700.82 3.200.63 2.800.63 0.401.07 15.00 6.00 5.00 3.49**
Amount of distress 3.700.48 0.700.48 3.000.66 3.000.47 2.800.78 0.200.78 15.50 5.50 0.00 3.86**
Intensity of distress 3.500.52 1.600.51 1.900.73 3.000.66 2.800.78 0.200.63 15.05 5.95 4.50 3.56**
Disruption to life 3.800.42 2.700.48 1.100.73 3.200.78 3.000.47 0.200.63 13.55 7.45 19.50 2.47*
* - Significant at 0.05 level, ** - Significant at 0.01 level

Table 3 shows the comparison between both groups on post assess
ment after intervention and it was found that there were significant
differences were found on all elements of delusions of PSYRATS.
The significant differences were found on preoccupation from delusion
(U=7.00, Z=3.41, p<0.01),duration of preoccupation (U=14.50,
Z=2.82, p<0.01),conviction (U=5.00, Z=3.49, p<0.01), amount of
distress (U=0.00, Z=3.86, p<0.01), intensity of distress (U=4.50,
Z=3.86, p<0.01) and disruption to life (U=19.50, Z=2.47, p<0.05).
Table 4 shows the comparison of both groups on post assessment
after intervention and it was found that there were significant
difference was found on all elements of hallucination such as freque-
ncy of auditory hallucination (U=1.50, Z=3.83, p<0.01), duration
(U=7.50, Z=3.30, p<0.01), location (U=2.00, Z=3.72, p<0.01),
loudness of auditory hallucination (U=9.50, Z=3.18, p<0.01) etc.

Table: 4Showing after Intervention Status of Clinical Symptoms of the Experimental and Control Group on Psychotic Symptom Rating
Scale (PSYRATS)'s Dimension on Hallucination.
Area of assessment Experimental Group Control Group Mann Whitney Test
MSD MSD
Pre Post Difference Pre Post Difference Mean rank U value Z Score
(Pre-Post) (Pre-Post)
Experimental Control
Group Group
Frequency of auditory 3.300.67 0.400.51 2.900.73 3.500.70 2.500.84 1.000.47 15.35 5.65 1.50 3.83**
hallucination
Duration of auditory 2.700.67 0.500.51 2.200.82 2.400.51 1.900.56 0.500.84 14.75 6.25 7.50 3.30**
hallucination
Location of auditory 3.600.51 0.450.51 3.150.78 3.500.70 2.500.52 1.000.66 15.30 5.70 2.00 3.72**
hallucination
 Indian Journal of Health and Wellbeing 2015, 6(5), 480-483 483

Loudness of auditory 2.900.73 0.500.51 2.400.84 2.900.56 2.000.47 0.900.73 14.55 6.45 9.50 3.18**
hallucination
Re -Origin of voices 3.500.52 0.300.51 3.200.73 3.600.69 2.500.70 1.101.28 15.00 6.00 5.00 3.51**
Amount of negative content 2.800.63 0.400.51 2.400.84 2.500.52 2.701.05 0.201.03 15.35 5.65 1.50 3.72**
Degree of negative content 2.500.52 0.600.51 1.900.56 2.700.67 2.000.94 0.701.15 14.35 6.65 11.50 3.09**
Amount of distress 3.100.56 0.400.51 2.700.48 3.100.31 2.601.07 0.500.97 15.35 5.65 1.50 3.79**
Intensity of distress 2.700.48 0.600.51 2.100.67 2.700.48 2.000.47 0.700.48 15.15 5.85 3.50 3.68**
Disruption to life 2.500.52 0.500.51 2.000.56 2.500.52 2.000.66 0.500.70 14.90 6.10 6.00 3.50**
Controllability 3.400.69 0.400.51 3.000.81 3.700.48 2.100.31 1.600.51 14.60 6.40 9.00 3.28**
**-Significant at 0.01 level

Discussion (2009). The therapy program was considered effective in increasing

Present study was conducted to evaluate the significance of cognitive
behaviour therapy in reducing the delusion and hallucination in
persons with schizophrenia.
In this study it was found that CBT group improved significantly
on most of the elements of delusions and hallucinations such as
delusion of persecution, jealous, sin or guilt, reference and global
rating of delusion and frequency, duration, location and loudness etc.
of auditory hallucination. Similarly the delusion and hallucinations
of PSYRATS scale the significant improvement was seen in all
elements of delusions and hallucinations after completion of therapy
at post assessment. They showed significant improvement on all
elements of delusions. This proves that CBT is effective in reducing
the delusion and hallucinations of the patients. Significant difference
was found between both groups on all elements of delusion and
hallucination at post assessment where, CBT group score
significantly lower in comparison to TAU group. This finding again
supports the significance of CBT in reducing delusion and
hallucination in patient with schizophrenia. The severity of
hallucination and delusion in general did not change significantly on
post treatment in the control group, whereas they did in the treatment
group. But the findings of the present study shows that total positive
symptoms scores was significantly decreased in both the groups in
preoccupation of delusion but it decreased greater in the
experimental group.
However, in other above-mentioned areas the symptoms were
reduced significantly in the experimental group only. The literature
suggests that drug plus CBT combine treatment is more effective
than drug treatment alone in decreasing positive symptoms
(England, 2007, 2008). However, two studies reported that both
treatment modalities are similarly effective in treating schizophrenia
(Barrowclough et al., 2006; Samarasekera et al., 2007). On the
findings of the present study, it can be concluded that in the
management of hallucination, antipsychotic drugs singly effective
but in the management of delusion, additional psychological
management with pharmacological treatment is more satisfactory in
comparison of only pharmacological management. On the
dimension of delusion, it shows that the severity of clinical
symptoms of the experimental group, after intervention it was
significantly less than the control group. This shows that the
cognitive-behavioral intervention program used in this study was
effective for reducing the clinical symptoms of the experimental
group. The findings of present study are supported by Penn et al.
the ability to cope with auditory hallucinations and delusions. It also
increases the level of insight and ability to cope with stressed caused
by delusion, which ultimately reduce the severity of psychotic
symptoms like hallucination, and delusions (Oya et al., 2011).
Comparison between both groups on difference (baseline -post)
scores suggests that on post assessment CBT group showed
significantly sharp decline in delusions and hallucinations as
compared to TAU group.
There are various studies have been conducted and it was found
that CBT is effective in reducing hallucinations and delusions when
it is given with pharmacotherapy.
Findings of present study support the use of cognitive behaviour
therapy in reducing the delusion and hallucinations in patients with
schizophrenia; however, the study has certain limitations. The
sample was small due to which parametric analysis was not done
despite randomized control design and only male patients were
selected which limits its generalization for female group. Further
research is required on larger sample so that generalization could be
done and to see the durability of the cognitive behaviour therapy the
follow up is required.
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