Online Methods of Managing Auditory Hallucinations: A New Trend to Understand Psychopathology.

Treatment seekers use various coping methods to reduce the distress associated with auditory hallucinations. With the increase use of technology, the technology means are also in use to manage the auditory hallucination. The current report documents the implications of technology means for the management of auditory hallucinations. The user was assessed using clinical interview, internet addiction test, problematic online gaming questionnaire, and screening questions for technology addiction. It showed the use of technology to manage the auditory hallucinations. Psychotherapy work revealed a reduction in their use of technology means at follow-up. It implies to evolve the therapeutic use of technology means and development of alternative therapeutic means to manage the auditory hallucinations.

INTRODUCTION

Auditory hallucinations are the commonly reported symptom among the treatment seeker diagnosed with schizophrenia. 64.3% of Indian psychiatric population had a complaint of auditory hallucination.[1] The experience of auditory hallucinations is often extremely distressing. It has been found to have a negative effect on quality of life, affective state of the person, as well as increase the risk of suicide/self-harm. Hallucinations have been managed more frequently with coping strategies than any other psychotic symptoms. Coping strategies for dealing with hallucinations in schizophrenia have been studied along with other symptoms and also individually.[23] Patients use one or more coping strategies for dealing with hallucinations. Approximately, 60– 90% of patients with schizophrenia who hallucinate can clearly delineate the use of individual coping strategies.[45]

The commonly used strategies to manage hallucinations have been divided into 3 main categories: (a) Behavioral changes (e.g. involving in pleasurable activities), change in posture (lie down or walk) and interpersonal contact (withdrawing or engaging), (b) Physiological changes in physiological arousal (relaxation or increasing arousal by exercising), and cognitive strategies (accepting or suppression).[6] (c) Various themes in the form of rejection, control, resignation, minimization, avoidance, and dependency were also identified as a way of coping with hallucination. These themes were further classified into control helplessness and acknowledgment of threat disavowal of threat. The commonly used strategies in the Indian context are seeking medical help/consulting a doctor.[7] Empirical evidence suggests that coping strategies aimed at reducing stress is more effective than hallucination specific coping strategies.[8] Internet use also has an effect on expression of psychopathology among treatment seeker with obsessions – compulsions.[9]

There is a dearth of reports on implications of technology use for the management of hallucinations. The following case series give us an understanding role of technology use as a way of coping method and its implication for developing an addiction. These patients were referred for the management of excessive use of technology to Service for Healthy Use of Technology Clinic. It is India's first clinic to manage technology addiction.

CASE REPORTS

Case 1

A 23-year-old graduate from urban background sought consultation for the presence of decreased sleep, delusion of reference, delusion of persecution, 2nd and 3rd person hallucinations, and use of game for the last 2 months. He attributed the use of games (especially strategies games) to control/minimize the voices. The other coping methods used were talking to others and playing. On an average, the user was playing games 6–7 h a day. The user attributed the excessive use to the greater feeling of well-being/control over voices in comparison to other coping methods. The excessive use of gaming led to dysfunctions in the form of sleep disturbance, increased financial expenditure on playing paid games, eye strain and fatigue, and interpersonal disturbance secondary to active psychopathology/excessive use of gaming. The caregivers reported the presence of irritable/anger outburst in the users, whenever asked or advised to stop playing games. Premorbid personality indicated the presence of schizoid traits. The internet addiction test yields the score sixty indicated the problematic use of internet use.[10] The user has preoccupation, overuse, and withdrawals on problematic online gaming questionnaire.[11] The user was given intervention in the form of psychoeducation, daily activity scheduling, contingency contracting for the usage of mobile phone, and motivation enhancement therapy to build up lifestyle changes/control use of mobile phone. The user showed changes in usages pattern of mobile phone/activity scheduling during the inpatient stay, as well as at 1-month interval. The finding was corroborated by the presence of gaming as one of the coping methods to manage hallucination.

Case 2

A 25-year-old from urban background was presented with the complains of elementary hallucinations, 2nd and 3rd person hallucinations, paranoid delusions, reduced sleep, inability to concentrate, social withdrawal, and excessive use of smartphone to listen to music excessively for the last 1-year. The patients attributed the excessive listening music to control distressing and fearful auditory hallucinations. User refused to indulge into any other activities except listening music. On an average, user listened to music for 10–15 h/day. User preferred listening to the music with lyrics which overpowered the voices of auditory hallucinations. User reported hallucinations-related distress if she does not listen to the music. User started downloading music tracks every day as user was getting habituated to the old music tracks and gradually they reportedly were not effective. Therefore, the user needed new songs to distract from auditory hallucinations. This excessive music listening was leading to social withdrawal and was contributing to dysfunctions (lack of self-care, irregular food habits, delaying the sleeping time, and eye strain). The user used to get irritable and angry if the phone was taken away. Whenever, user used to indulge in any other activity, user had the desire of getting back and listening to the music. The clinical interview revealed the presence of craving, loss of control, and compulsion and consequences related to smartphone use for downloading songs. The patient was given the intervention in the form of psychoeducation. The user was explained the harmful effects of excessive use and how the problematic use of smartphone was acting as a hurdle in her recovery. The gradual reduction of smartphone use was carried out with the simultaneous substitution of pleasurable activities. The relaxation training was introduced to help the user for the management of anxiety. Alongside, meta-study cognitive therapy was carried out to manage the psychotic features. The user showed positive changes in the pattern of mobile use and social interaction during the inpatient stay. Follow sessions showed the maintenance of changes.

DISCUSSION

The case documents the role of technology in the form of music/game to manage the hallucinations. The patients indulge in both active and avoidant coping strategies to deal with the distress attached to these hallucinations. A similar pattern of overwhelming distress and coping in response to hallucinations was also seen in the above-illustrated cases. Patients also reported the use of strategies such as the use of ear plugs and loud music to drown the intensity of the hallucinations.[4] Use of diversion techniques is more common among patient from urban background.[12] The use of radio or music has been replaced by use of internet. The case report document the need for evolving the therapeutic use of technology. It will also decrease the chance of developing the addictive use among the present psychiatric group. Mental health professionals should be aware of these potential negative consequences of therapeutic strategies and monitor patients for such technology addictions during follow-ups.

Therefore, it is important to replenish the patients’ repertoire of distraction techniques. A variety of distraction techniques needs to be introduced rather than focusing on any one to make distraction an effective method.

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Conflicts of interest

There are no conflicts of interest.