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Year : 2022  |  Volume : 31  |  Issue : 2  |  Page : 376-377  Table of Contents     

Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia

Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India

Date of Submission16-Jan-2021
Date of Acceptance03-Feb-2022
Date of Web Publication08-Aug-2022

Correspondence Address:
Dr. Abhinav Agrawal
Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_137_21

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How to cite this article:
Agrawal A, Kaur RD, Sidana A. Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia. Ind Psychiatry J 2022;31:376-7

How to cite this URL:
Agrawal A, Kaur RD, Sidana A. Cognitive behavioral therapy-based approach for management of persistent hallucinations in treatment-resistant schizophrenia. Ind Psychiatry J [serial online] 2022 [cited 2023 Jan 28];31:376-7. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/376/353549


Auditory hallucinations (AHs) are common psychiatric symptoms occurring across a range of disorders and the most common type of hallucination in schizophrenia.[1] Pharmacological treatment with antipsychotics remains the cornerstone of management, yet at least one-third of patients exhibit persistent psychotic symptoms.[2] The case highlights the effective use of cognitive behavioral therapy (CBT) in an individual diagnosed with treatment-resistant schizophrenia (TRS), having persisting and distressing AHs, despite improvement in other symptoms on treatment with clozapine and pharmacological augmentation.

A young man was brought to the department of psychiatry, accompanied by his family with complaint of uncontrolled aggression. History revealed an illness of 10-year duration, characterized by persistent irritability of mood, delusion of persecution, and AHs. On a few occasions, he even went to neighbor's home, verbally abused them, and threatened physical violence. His social and occupational functioning had declined significantly over the years, and he spent the entire day at home.

There was no significant family history and no past medical, psychiatric history, or substance use reported. He had received adequate doses of haloperidol, chlorpromazine, risperidone, olanzapine, and amisulpride in multiple combinations, but with no sustained improvement. His premorbid personality and developmental history were unremarkable.

His general physical examination was within normal limits. Initial mental status examination revealed irritable affect, delusion of persecution, and second- and third-person AHs (commenting type) with impaired judgment and absent insight.

A diagnosis of paranoid schizophrenia according to International Classification of Diseases-10 was made. Since he fulfilled the criteria of TRS based on modified Kane's criteria,[3] clozapine was initiated and optimized to 350 mg over 6 weeks. The emergence of distressing side effects of daytime sedation and constipation desisted the treating team from increasing the dose further. Oral amisulpride was continued at 800 mg. Initial Positive and Negative Syndrome Scale (PANSS) score was 78 (25/11/42) that decreased to 44 (14/07/23) by 6 weeks of pharmacological treatment.

It was noted that despite the resolution of delusional beliefs and significant improvement in social interaction and self-care, AHs persisted. They remained a source of distress, impaired functioning, and caused disturbed sleep at night.

A CBT-based approach using the AH Interview Guide[4] was initiated. Total 8 sessions of 40-min duration each were taken weekly for next 8 weeks. CBT aimed at teaching the link between perceptions, beliefs, and emotional or behavioral reactions; questioning the apparent evidence supporting abnormal beliefs; encouraging self-monitoring; and teaching effective coping strategies for distressing AHs.[5] The objective PANSS scores showed slight improvement from 44 (14/07/23) to 40 (12/07/21), but the patient and family reported remarkable subjective improvement following these sessions, CGI score[6] decreased from 2 to 1, and he felt confident enough to initiate work. Booster sessions were planned for follow-up.

CBT for schizophrenia is considered a promising intervention for reducing the distress associated with psychotic experiences and controlling the overall severity of positive symptoms that has been seen in index case too.[7] In the Indian context, a case series reported improvement on outcome when combining psychosocial interventions (including CBT-based approach) with pharmacological management in cases of clozapine nonresponders.[8] Only one randomized controlled trial (FOCUS) has evaluated the role of CBT as an effective augmentation strategy in patients with clozapine-resistant schizophrenia, with CBT leading to significant improvement initially.[9] The index case highlights that CBT-based approaches have a role as adjuvant in the holistic management of people with TRS, which currently remains underutilized possibly due to dearth of data and resources.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Mueser KT, Bellack AS, Brady EU. Hallucinations in schizophrenia. Acta Psychiatr Scand 1990;82:26-9.  Back to cited text no. 1
Pantelis C, Barnes TR. Drug strategies and treatment-resistant schizophrenia. Aust N Z J Psychiatry 1996;30:20-37.  Back to cited text no. 2
Kane JM, Marder SR. Psychopharmacologic treatment of schizophrenia. Schizophr Bull 1993;19:287-302.  Back to cited text no. 3
Trygstad LN, Buccheri RK, Buffum MD, Ju DS, Dowling GA. Auditory hallucinations interview guide: Promoting recovery with an interactive assessment tool. J Psychosoc Nurs Ment Health Serv 2015;53:20-8.  Back to cited text no. 4
Morrison AP, Barratt S. What are the components of CBT for psychosis? A delphi study. Schizophr Bull 2010;36:136-42.  Back to cited text no. 5
Busner J, Targum SD. The clinical global impressions scale: Applying a research tool in clinical practice. Psychiatry (Edgmont) 2007;4:28-37.  Back to cited text no. 6
Pontillo M, De Crescenzo F, Vicari S, Pucciarini ML, Averna R, Santonastaso O, et al. Cognitive behavioural therapy for auditory hallucinations in schizophrenia: A review. World J Psychiatry 2016;6:372-80.  Back to cited text no. 7
Valaparla VL, Patidar V, Chakrabarti S. Augmenting Clozapine non-response in schizophrenia with psychosocial interventions: Lessons from a patient series. J Dis Glob Health 2016:146-51.  Back to cited text no. 8
Morrison AP, Pyle M, Gumley A, Schwannauer M, Turkington D, MacLennan G, et al. Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): An assessor-blinded, randomised controlled trial. Lancet Psychiatry 2018;5:633-43.  Back to cited text no. 9


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