Chadwick P, Birchwood M
University of Birmingham.
Br J Psychiatry. 1994 Feb;164(2):190-201. doi: 10.1192/bjp.164.2.190.
We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations.
我们为一种新的认知方法提供初步支持，该方法用于理解和治疗被诊断为精神分裂症患者的耐药性幻听。研究1通过详细阐述26名患者对持续幻听的行为、认知和情感反应，强调了认知模型的相关性，表明与幻听——恐惧、安心、参与和抵抗——的高度不同关系反映了对幻听信念的重要差异。所有患者都认为他们的幻听无所不能、无所不知。然而，对幻听身份和意义的信念导致幻听被解释为“善意的”或“恶意的”。患者为这些信念提供了有说服力的理由（证据），这些理由并不总是与幻听内容相关；事实上，在31%的案例中，信念与内容不一致，这正如认知模型所预期的那样。毫无疑问，被认为是恶意的幻听会引发恐惧并遭到抵抗，而那些被视为善意的幻听则会被迎合。然而，对于命令性幻听，对命令是否被服从的主要影响因素是命令的严重程度。研究2说明了这些关于幻听的核心信念如何可能成为治疗的新靶点。我们描述了一种改编版认知疗法（CT）在治疗4名患者耐药性幻听中的应用。在患者正在服药的情况下，药物治疗保持不变，同时系统地质疑和检验关于幻听无所不能、身份和目的的信念。据报告，这些信念的确信度大幅且稳定地降低，并且这些与痛苦减轻、适应性行为增加相关，出乎意料的是，幻听活动也有所下降。这些变化得到了负责的精神科医生的证实。总体而言，这些案例证明了CT作为治疗幻听的前景。
