Twenty year multi-follow-up of different types of hallucinations in schizophrenia, schizoaffective disorder, bipolar disorder, and depression
Introduction
Hallucinations are a core feature of psychotic disorders and also present frequently in mood disorders (APA, 2013). Despite the diagnostic value of hallucinations, there is currently limited information on different forms of hallucinations and their prominence in different psychotic and mood disorders. Furthermore, the longitudinal course of different forms of hallucinations is largely unavailable. As hallucinations are one of the most commonly endorsed psychotic symptom and can be reliably assessed, a more fulsome understanding of the presence and persistence of different types of hallucination in common psychotic and mood disorders would provide necessary information on course and differentiation. Given that hallucinations are endorsed by patients with a variety of diagnoses, misdiagnosis is common, which can have serious implications for treatment planning. Also, much of our theoretical knowledge of schizophrenia and the categorization of psychosis and mood disorders comes from the longitudinal understanding of course (Kraepelin, 1907). Therefore, this information has implications for our understanding of diagnostic boundaries, differential diagnosis, and treatment planning. To this end, our goal was to present information on different forms of hallucinations prospectively over 20 years and to relate index hallucinatory status to recovery in patients with schizophrenia, schizoaffective disorder, bipolar disorder, and unipolar depression.
Underscoring the importance of research in this area, the International Consortium on Hallucinations, focusing on auditory hallucinations, in its top 16 goals, listed understanding the phenomenology of hallucinations in different clinical groups as a core goal (Waters et al., 2012). Also, the proliferation of the Hearing Voices Movement and related networks has highlighted the number of patients and nonpatients affected (Corstens et al., 2014). Given that there is even less information on non-auditory forms of hallucinations, we extend the call to better understanding all forms of hallucinations, and also better understanding the relationship between symptom presentation and outcome.
Focusing more broadly on symptoms and functioning in schizophrenia and other disorders, research has shown that schizophrenia is a more chronic disorder that tends to be more severe, as schizophrenia patients have poorer outcomes than schizoaffective, bipolar, and unipolar affective patients (reviewed in Mcglashan, 1988). Furthermore, longitudinal studies have demonstrated that the early phase of schizophrenia (first 5–10 years) is where the greatest loss of recovery takes place (Mcglashan, 1988). Last, studies have demonstrated that outcome is heterogeneous in schizophrenia (Mcglashan, 1988).
More specific examination of symptom dimensions longitudinally over 10 years, by Eaton et al. (1995), demonstrated that positive and negative symptoms decline in the year following first hospitalization and then remained largely stable. This study also showed that the positive and negative symptom clusters were largely independent at baseline and over the 10 year follow-up; however, over time a single factor including both positive and negative symptoms became more prominent. In contrast, Mancevski et al. (2007), focusing on chronically institutionalized schizophrenia patients and following patients from onset to death, found that there were significant decreases in positive symptoms and increases in negative symptoms with time. Research generally has demonstrated that positive symptoms tend to decrease over the lifespan of schizophrenia patients (Goghari et al., 2013, Gur et al., 1996, Harrow and Jobe, 2010, Pfohl and Winokur, 1982, Schultz et al., 1997).
In our previously published study from this dataset (Goghari et al., 2013), we investigated the longitudinal course of all forms of hallucinations collapsed, based on diagnoses at their index hospitalization, for patients with schizophrenia, schizoaffective disorder, bipolar disorder with psychosis, and depression without psychosis prospectively over 20 years. Our data showed that schizophrenia, schizoaffective, and bipolar with psychosis patients all had significantly less hallucinations after the early years. Some of this reduction was due to the high level of psychopathology that was present during the early years for many patients. Of significance, our data highlighted that there were a substantial number of patients who continued to show hallucinations after their index hospitalization. Forty-four percent of schizophrenia patients and 20% of schizoaffective patients showed frequent or chronic hallucinations over the 20 year course of the study. Additionally, we found the longitudinal course of hallucinations differentiated between disorders. The pattern clearly differentiated between schizophrenia and bipolar disorder with psychosis patients, and suggested some diagnostic similarities between schizophrenia and schizoaffective patients, and between bipolar disorder and schizoaffective disorder with depression patients.
In that study, we also investigated the relationship between hallucinations and outcome (Goghari et al., 2013). We found the early presence of hallucinations predicted the lack of a future period of recovery in all patients, and increased hallucinatory activity was associated with reduced work attainment in all patients. Previous reviews have proposed recovery is most predicted by cognition, and to a lesser degree, by negative symptoms, with positive symptoms playing a modest role (Green, 1996, Green et al., 2000). However, other studies from our group have provided supports that positive symptoms, such as delusions, are associated with lower work recovery (Harrow et al., 2004, Harrow and Jobe, 2010, Racenstein et al., 2002). These results advocate for further study of the association between different forms of hallucinations and recovery.
Most studies have focused on hallucinations or positive symptoms in general. However, the prevalence and trajectory of individual forms of hallucinations has not received substantial attention, and less is known about the association with different forms of hallucinations and recovery. Knowing the longitudinal trajectory of the frequency of different forms of hallucination in common psychotic and mood disorders is necessary to increase our clinical knowledge. To further advance the area of phenomenology of different forms of hallucinations, including visual, auditory, and olfactory, in psychiatric disorders, our objectives were to document (1) the longitudinal course of different forms of hallucinations, (2) determine whether hallucinations differentiated patients with different psychotic and mood disorders, and (3) determine whether the presence of hallucinations during the early years was associated with the presence or absence of a later period of recovery.
Section snippets
Participants and measures
As described in detail previously (Goghari et al., 2013, Harrow et al., 2004, Harrow and Jobe, 2005), the current investigation is based on data from the Chicago Follow-up Study, a prospectively designed, longitudinal, multi–follow-up research program studying psychopathology and recovery in psychiatric disorders. Institutional Review Board approval was obtained from the University of Chicago and University of Illinois-Chicago. Signed informed consent was obtained from all participants. All
Participant characteristics
Table 1 summarizes participant characteristics. There was no overall significant difference between groups for age (F(3, 179) = 1.77, p = 0.16) at the index hospitalization; however, bipolar patients were older than schizoaffective (p = 0.04) and depression patients (p = 0.05), and marginally older than schizophrenia patients (p = 0.09). There was also a significant difference in sex distribution between groups (X2(3) = 12.68, p = 0.005), with the depression patients having the greatest number of female
Discussion
Hallucinations are one of the most commonly reported symptoms of schizophrenia and schizoaffective patients, and are also frequently reported by some patients with a primary mood disorder. However, limited information is available on the prevalence and course of different forms of hallucinations. Knowledge about the course of symptoms has been considered core to understanding disorders since the time of Kraepelin, and plays a prominent role in the diagnostic process (Bleuler, 1950, Kraepelin,
Conflict of interest
No authors report any potential conflicts of interest.
Contributors
Martin Harrow designed the study and wrote the protocol. Vina Goghari managed the literature searches and analyses. Vina Goghari undertook the statistical analysis, and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Role of funding source
This work was supported by National Institute of Mental Health (M.H.; grant numbers MH-26341, MH-068688) and the Foundation for Excellent Mental Health Care (M.H.) and a Canadian Institutes of Health Research New Investigator Award (V.M.G.). The funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Acknowledgements
We thank Bob Faull for his role in data management.
References (41)
- et al.
Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences
Eur. Psychiatry
(2001) - et al.
Neurocognition in schizophrenia: a 20-year multi-follow-up of the course of processing speed and stored knowledge
Compr. Psychiatry
(2010) - et al.
Schizophrenia throughout life: sex differences in severity and profile of symptoms
Schizophr. Res.
(1996) - et al.
The continuity of psychotic experiences in the general population
Clin. Psychol. Rev.
(2001) - et al.
A prospective longitudinal 10-year study of schizophrenia's three major factors and depression
Psychiatry Res.
(2000) - et al.
The relationship between positive symptoms and instrumental work functioning in schizophrenia: a 10 year follow-up study
Schizophr. Res.
(2002) - et al.
Diagnostic and prognostic significance of Schneiderian first-rank symptoms: a 20-year longitudinal study of schizophrenia and bipolar disorder
Compr. Psychiatry
(2011) - et al.
Examining the course of hallucinatory experiences in children and adolescents: a systematic review
Schizophr. Res.
(2012) - et al.
The life course of schizophrenia: age and symptom dimensions
Schizophr. Res.
(1997) - et al.
Remission and recovery during the first outpatient year of the early course of schizophrenia
Schizophr. Res.
(2011)
Diagnostic and Statistical Manual of Mental Disorders: DSM-5
A longitudinal study of symptom dimensions in schizophrenia. Prediction and patterns of change
Arch. Gen. Psychiatry
Dementia Praecox or the Group of Schizophrenias
Emerging perspectives from the hearing voices movement: implications for research and practice
Schizophr. Bull.
Structure and course of positive and negative symptoms in schizophrenia
Arch. Gen. Psychiatry
A diagnostic interview: the schedule for affective disorders and schizophrenia
Arch. Gen. Psychiatry
Sustained remission in drug-free schizophrenic-patients
Am. J. Psychiatr.
A 20-year multi-follow-up of hallucinations in schizophrenia, other psychotic, and mood disorders
Psychol. Med.
What are the functional consequences of neurocognitive deficits in schizophrenia?
Am. J. Psychiatr.
Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the “right stuff”?
Schizophr. Bull.
Cited by (26)
Guidelines for the management of psychosis in the context of mood disorders
2022, Schizophrenia ResearchCitation Excerpt :Interestingly, Schneiderian first rank delusions occur in all forms of psychotic bipolar disorders but their prognostic significance remains uncertain (Burton et al., 2017; Carlson et al., 2012; Keck et al., 2003a). Auditory and visual hallucinations occur in many patients with psychotic mania or psychotic bipolar depression (circa 50–70%) (Carlson et al., 2012; Goghari and Harrow, 2016; Keck et al., 2003a; Van Bergen et al., 2018). Auditory hallucinations are most common and visual hallucinations less frequent.
“Apples and pears are similar, but still different things.” Bipolar disorder and schizophrenia- discrete disorders or just dimensions ?
2021, Journal of Affective DisordersDifferences between self-reported and clinician-rated evaluations of 1-year changes in auditory verbal hallucinations among schizophrenia patients
2019, Progress in Neuro-Psychopharmacology and Biological PsychiatryCitation Excerpt :Many reductions in the scores on the PSYRATS-AH and HPSVQ items were evident over the first 6 months, and significant reductions were apparent at 1 year compared to baseline, whereas no changes developed between 6 months and 1 year. Overall AVH reductions were thus slow but progressive, as described in previous studies (Chang et al., 2009; Goghari and Harrow, 2016; Schneider et al., 2011; Sommer et al., 2012). Although AVHs persist even during antipsychotic treatment, they become less intense, less frequent, less emotionally harmful, less likely to prompt overt behavioral responses, quieter, more controllable, and more frequently identified as such (Miller, 1996; Schneider et al., 2011).
Meta-analytic Evidence for the Plurality of Mechanisms in Transdiagnostic Structural MRI Studies of Hallucination Status
2019, EClinicalMedicineCitation Excerpt :The psychiatric and neurodegenerative meta-analyses illustrate cross-sectional neuroanatomical differences between patients with and without hallucinations. However, the prevalence of hallucinations increases with the duration of illness for PD [116], but generally decrease over time for schizoaffective disorder, schizophrenia, bipolar disorder, and depression [8], whilst the content may equally change over the trajectory of the disorder [116]. Future analyses of longitudinal neuroimaging data may clarify illness category separation in the temporal evolution of hallucinations.