INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2003; 18: 537–539.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.847

CASE REPORT

Late-onset auditory hallucinations treated with cognitivebehaviour therapy

Philip Wilkinson1 and Stefan Schuller2*

1Oxfordshire Mental Healthcare NHS Trust, Fulbrook Centre, Churchill Hospital, Oxford, UK2Department of Clinical Psychology, Warneford Hospital, Oxford, UK

Despite the increasing interest in the nature andaetiology of late-life psychotic disorders, work inthe field has tended to concentrate on the developmentof biological markers. Interventions with older adultshave not kept pace with the management of psychosisin younger adults where psychological models pro-vide the link between neurobiological explanationsand the patient’s experience (Garety et al., 2001).This is surprising, given that work with older adultsshould provide ample opportunity for integrating thelongitudinal perspective of lifestage tasks with ourunderstanding of personality and vulnerability factors(Hassett, 1997). We report a case in which a cognitivebehavioural formulation and intervention contributedto the treatment of a 73-year-old lady with severeauditory hallucinations and depression.

According to Beck’s cognitive model (Beck, 1976),depression can occur following an incident whichholds a specific negative meaning for the individual.If this fits in with and triggers a depression proneunderlying belief (schema) it can give rise to a streamof ‘negative automatic thoughts’, which may take theform of intrusive memories of earlier losses (Brewinet al., 1996). The patient may not be immediatelyaware of these thoughts, although once aware s/hewill usually recognise them as her/his own. If the con-tent of intrusive thoughts is inconsistent with personalvalues or otherwise threatening, however, vulnerableindividuals may misattribute the thoughts to an exter-nal source and perceive them as auditory hallucina-

tions (Morrison, 2001). It is this ‘externalityappraisal’ that according to Garety et al. (2001) givesthe experience of personally salient, threat-relatedthoughts their psychotic flavour.

Apart from externality, appraisals that hallucina-tions are dangerous and uncontrollable are alsobelieved to mediate the clinical presentation. Thus inauditory command hallucinations, the voice-hearer’sappraisal of whether the voice is malevolent or bene-volent, and how powerful the voice identity is, deter-mine whether the voice is complied with or resisted(Birchwood and Chadwick, 1997). Controllabilityappraisals reflect the extent to which the patient feelsable to bring on or terminate and generally influencethe impact of the hallucinatory experiences. Beliefmaterial that is highly salient in hallucinations isfrequently rooted in previous inter-personal relation-ships, such as negative experiences and marginalisa-tion in childhood (Garety et al., 2001). Rooske andBirchwood (1998) present a prospective studydemonstrating that in younger adult schizophrenia,episodes of depression are triggered when residualpsychotic symptoms are seen by the patient as anentrapment and as humiliating, or in other words, asa permanent obstacle to overcoming the loss of cher-ished personal goals.

A 73-year-old Irish woman was referred for urgentpsychiatric assessment. She had suffered with depres-sion in her thirties but had never had psychotic symp-toms. She had arrived in England from her nativeRepublic of Ireland in her mid-life in order to pursuea life of religious devotion and theological research ina college environment. So that she would fit into hernew environment, she had thought it important to sup-press her Irish identity. Two years before referral she

Received 10 December 2002Copyright # 2003 John Wiley & Sons, Ltd. Accepted 28 January 2003

* Correspondence to: S. Schuller, Consultant Clinical Psychologist,Department of Clinical Psychology, Warneford Hospital, OxfordOX3 7JX, UK. Tel: þ44 (0)1865 223968.E-mail: stefan.schuller@oxmhc-tr.nhs.uk

had begun to experience hallucinations of heavenlymusic with occasional visions which, being spiritualin nature, did not interfere excessively with her work.Following an emotional return trip to Dublin, how-ever, the hallucinations changed to men’s voices sing-ing familiar Irish songs from her childhood. Sheexperienced these as menacing, believing them to bea sinful distraction from her religious contemplationand her academic pursuits. She developed depressedmood, suicidal ideas, anergia and loss of interest.She commenced treatment with venlafaxine 150 mgdaily and olanzapine 10 mg daily. Her overall moodimproved, but her distress and preoccupation tied tothe hallucinations persisted, leaving her exasperatedand unable to work. She therefore received a courseof eight sessions of cognitive behaviour therapy inconjunction with her pharmacotherapy.

The early sessions of therapy were used to concep-tualise her symptoms based both on her early experi-ences and her current ways of thinking and behavingin response to the hallucinations. She recounted that,as a child, she had felt criticised and discouraged byher mother but had enjoyed positive relationshipswith her father and brother; sadly, however, theyhad both died while she was in her teens. In fact,the songs that she now heard as hallucinations werethose she had enjoyed singing with her father andbrother. She reported that throughout her life, hardwork and religious devoutness had been central toher sense of self-worth. Assessment and therapeuticengagement blended into one another when she cameto see that the hallucinations, which represented sali-ent personal memories, were a product of her ownmind and not actually from a sinister external source.

Ongoing assessment revealed that her responses tothe hallucinations were based on threat appraisalssuch as ‘I won’t be able to work’ or ‘I shouldn’t bedwelling on my past’, inducing feelings of frustrationand guilt, respectively. This led to her trying to sup-press the hallucinations, which is consistent with herpresumed underlying beliefs about always needing towork hard on her religious studies in order to feelworthwhile. It was hypothesised that as with obses-sional thoughts, such attempts at thought suppressionwould actually tend to maintain and intensify theexperience of the distressing symptoms. Based on thisconceptualisation, a range of therapeutic strategieswas implemented to help her to manage her hallucina-tions differently. Firstly, she was encouraged toacknowledge and express her grief for her father,brother and native Ireland. She identified other signif-icant losses including a relationship with an Australianman, at which point her hallucinations changed to

‘Waltzing Matilda’! She gradually came to terms withthese losses and, importantly, was able to draw on thesupport of her college community, beginning toexpress her Irish identity in the process. She beganto regard her hallucinations as an understandable partof this grieving process and, therefore, not a sign ofdanger. Secondly, through behavioural experimentsand monitoring she was helped to realise that attemptsto suppress the hallucinations actually intensifiedthem. She was thus encouraged not to resist the hallu-cinations, but to allow them to happen and when theydid occur, to challenge her thoughts that they were anexternal threat or a reason to be guilty.

In summary, cognitive behavioural treatmenthelped this patient to modify her appraisal of thevoices from one of threat to one of an opportunityto deal with unprocessed grief towards the end ofher life. By the end of therapy she was feeling lesshopeless and brighter in mood. The hallucinationswere still present for part of the day but were signifi-cantly reduced in intensity and duration and did notinterfere with her lifestyle. This was reflected in areduction in her score on the auditory hallucinationssubscale of the Psychotic Symptom Rating Scales(PSYRATS; Haddock et al., 1999) from 30/44 beforetreatment to 6/44 at the end of treatment. At one-yearfollow-up her improvement was maintained. Sheoccasionally heard feint music that would subside assoon as she reminded herself that it was not from anexternal source.

This case report illustrates the effectiveness of apromising adjunctive treatment for late-onset psycho-tic symptoms. Single case methodology with ade-quate baseline periods needs to be employed next toadvance this area of inquiry (Townend, 2002).

REFERENCES

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Brewin CR, Hunter E, Carroll F, Tata P. 1996. Intrusive memories indepression: an index of schema activation? Psychol Med 26:1271–1276.

Garety PA, Kuipers E, Fowler D, et al. 2001. A cognitive modelof the positive symptoms of psychosis. Psychol Med 31:189–195.

Haddock G, McCarron J, Tarrier N, Faragher EB. 1999. Scales tomeasure dimensions of hallucinations and delusions: the psycho-tic symptom rating scales (PSYRATS). Psychol Med 29: 879–889.

Hassett A. 1997. The case for a psychological perspective on late-onset psychosis. Aust NZ J Psychiatry 31(1): 68–75.

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Copyright # 2003 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2003; 18: 537–539.

Morrison AP. 2001. The interpretation of intrusions in psychosis: anintegrative cognitive approach to hallucinations and delusions.Behavioural Cog Psychother 29: 257–279.

Rooske O, Birchwood M. 1998. Loss, humiliation and entrapmentas appraisals of schizophrenic illness: a prospective study of

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Townend M. 2002. Individual exposure therapy for delusional dis-order in the elderly: a case study of a 71-year-old man. Beha-vioural Cog Psychother 30: 103–109.

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Copyright # 2003 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2003; 18: 537–539.