After we became adept at eliciting open conversations from patients about their hearing voices (Holmes, 1995), we realized that most of the PTSD veterans appeared to hear voices and have a dissociative disorder. Although dissociative symptoms are being reported in PTSD (Marmar, et al, 1994; Hyer, Albrecht, Boudewyns, Woods, and Brandsma, 1993; Bremner, et al, 1992), no one has studied the importance of hallucinations in this condition.
However, Kluft (1987) and others have reported that a majority of patients with dissociative identity disorder (DID) hear voices. Many of our patients revealed that their voices talked to them and that they usually felt an automatic obedience to one voice. Among the veterans who had made suicide attempts, many told us that a voice compelled them to do so. We concluded that the presence of dissociative voices is important. The purpose of this paper is to report data about dissociative hallucinations in PTSD and to discuss some relevant treatment responses.
Psychometric data were obtained for a series of patients (N=85) upon their entry into the outpatient PTSD program. Fifty-eight percent of the patients endorsed the item, "Do you hear voices that others do not hear?," when given a general instruction to "circle how you have felt during the past week" on the Symptom Checklist-45 (SCL-45). Eighty-five percent of the patients hearing voices scored higher than the cut-off score of 29 for dissociative disorders on the Dissociative Experiences Scale (DES) (Bernstein and Putnam, 1986; Ross, et al., 1988). Their mean score was 40.12 (SD=18.27). When data for patients in a recently developed inpatient PTSD program were examined (N=30), it was learned that 87% of the patients endorsed the voice item on the SCL-45 upon entry to the program. Seventy-three percent of those scored 30 or higher on the DES (M=42.58, SD=17.74). This was not a surprise, because prior to seeing the SCL-45 data we had reported to the treatment team that group participants were openly acknowledging and discussing their voices.
The auditory hallucinations reported by our patients have been of a dissociative type rather than a schizophrenic type. This differentiation as applied to DID was made by Steinberg, et al. (1994): ("Auditory hallucinations reflect dialogues between alternate personalities; these voices are perceived as occurring inside their head; often described as similar to thoughts (p. 500).") Historically, distinctions have been made between internal and external voices and among levels of audibility. To illustrate, Bleuler wrote: "These examples are far from exhausting the possible nuances of the projections of auditory hallucinations.
Two main classes in general are differentiated by the patients: the voices which come from the outside like ordinary ones -- and those projected into their own bodies which have hardly any sensory components and are mainly designated as inner voices ...(1911/1950, p.111)."; and, "Although auditory hallucinations are a matter of great preoccupation, even intelligent patients are not always sure that they are actually hearing the voices or whether they are only compelled to think them. They are 'such vivid thoughts' which are called 'voices' by the patients. At other times they are 'audible thoughts' or 'soundless voices.' These are two expressions which may perhaps mean the same thing and certainly signify very closely related phenomena (1911/1950, p. 110)."
A report of similar findings from West Haven VA Medical Center provides evidence that our findings may well be generalizable to combat veterans with PTSD currently in treatment: The PTSD patients frequently reported identity confusion, i.e., feeling confused as to who they were and feeling a struggle within themselves about who they were. They reported dialogues inside their heads, in which different voices argued with each other.... Some patients reported the feeling that one part of them did not want to go on in life, felt that no one really cared about them, and felt that life was meaningless, while another part wanted to go on.... The PTSD patients reported the feeling that there was someone else inside of them, a 'combat person' or 'warrior', who typically did not care about life or death.... (Bremner et al, 1993, p. 1013)." To determine the limits of Generalizability, cross- validational studies applying principles associated with quasi-experimental designs and multi-method, multi-trait approaches to construct validity are suggested.
It should be noted that inherent difficulties in determining whether a patient actually hears "voices" present specific methodological challenges to determining prevalence and incidence of hearing voices. On the one hand, possible secondary gains may lead to a general exaggeration of symptoms, including auditory hallucinations. Social demand characteristics of the clinical or research situation may lead to over-reporting of such symptoms and a therapist's focus on hearing voices conceivably might lead to such phenomena being experienced.
On the other hand, for patients to acknowledge that they hear voices requires that they overcome many societal and personal inhibitions. Under-reporting because of a belief that "hearing voices" equals "being crazy" has long been noted (Bleuler, 1911/1950), despite evidence that many more people hear voices than can be accounted for by the prevalence of schizophrenia (Tien, 1991). First-admission inpatients under-report voices (Fennig, et al., 1994), as do forensically referred individuals (Rogers, Gillis, Turner, and Frise-Smith, 1990) and dissociative patients ("The majority of MPD patients will experience auditory and/or visual hallucinations, although they will seldom admit to these experiences early in therapy (Putnam, 1989, p.61).") On the MMPI, the item, "I commonly hear voices without knowing where they come from," lacked discriminatory power and was included in the F-scale but not Scale 8 (Schizophrenia). Perhaps the item's infrequency of endorsement was related to its "unfavorability" rating, which was higher than for 98% of the 566 items on the MMPI (Dahlstrom & Welsh, 1960).
We have attempted to develop brief treatments for traumatized patients and for patients who hear voices. Our endeavors fall within a commonly understood framework of clinical standards implicitly established by the professional community working with dissociative disorders (Braun, 1986; Gabbard, 1994; Kluft, 1991; Putnam, 1989; Ross, 1989). Our areas of interest can be encompassed by Putnam's description of the three major tasks involved in working psychotherapeutically with DID or related dissociative patients (1989, pp. 135-138): (a) establishing a therapeutic alliance; (b) promoting change in the patient's life through resolving traumatic experiences and developing coping skills; and replacing division with unity through developing communication and cooperation among personalities or personality fragments. However, the problem with this standard psychotherapeutic approach is that it takes a long time (frequently one or two sessions per week for three to five years). Our challenge has been to develop more cost-effective interventions.
To establish a therapeutic alliance, we start with a voice-exploration approach during which we inquire about and interact with the voices. Our inquiry, which includes mention of frequent but unfounded apprehensions that lead to withholding information about hearing voices, serves to normalize the phenomenon of hearing voices. When we ask questions of the voices and the person hears the answers and repeats them (or simply speaks them) there dawns the possibility of dealing with the voices. This method was developed for use during the mental status examination and is grounded in the literature related to auditory hallucinations (Holmes, 1995). It is an alternative to, but compatible with, some of the cognitive-behavioral approaches to working with voices (e.g., Chadwick and Birchwood, 1994; Kingdon, Turkington, and John, 1994).
To help the patient resolve traumatic experiences, we use the principles of "time-limited trauma therapy," developed by Tinnin and colleagues (Tinnin, 1994; Tinnin and Bills, 1994). This is a video-assisted exposure therapy involving non-abreactive memory processing and recursive videotape reviews.
These principles are grounded in the literature on traumatology (Everly and Lating, 1995). The Tinnin approach, unlike Eye Movement Desensitization and Reprocessing (EMDR) (Shapiro, 1995), is suitable for routine use with severely dissociated patients.
Finally, to foster a sense of psychological unity, we employ a voice-externalization procedure called Video dialogue. It sets up an observable dialogue between the patient talking to the voice while looking at the eye of a video camera and then talking for the voice responding to the patient's comments in an identical fashion while being recorded. After each recording of comments (by the patient, or by the voice), the videotape is reviewed prior to the next recorded segment. The completed videotape of a session depicts a negotiating sequence between and among voices and the patient, and usually consists of three rounds of comments. The process of negotiation seems to diminish the patient's feeling of automatic obedience to the voice, while the outcome of negotiations usually includes an agreement to try and implement some plan that minimizes the likelihood of voice-interference during stressful situations.
When used together, these three processes provide an alternative to longer-term psychotherapy to diminish the frequency and potency of dissociative hallucinations. Each of the interventions is videotaped and replayed in subsequent sessions and during homework assignments.
Our approach seems to derive much of its apparent impact from this feedback. It appears that when patients are persuaded to adopt an objective, informed perspective toward their voices; to involve themselves in externalizing and cooperatively problem-solving with their voices; and, as needed, to reconstruct dissociation-producing memories of traumatic episodes and their sequelae without abreaction, then dissociative barriers (amnesias) are reduced. With the apparently more successful cases, patients appear to achieve a reorganized, homeostatic balance among internal states, which has lasting adaptive value.
A fourth intervention we are now developing, that of group psychotherapy focused on voices, seems to be valuable in educating patients and overcoming their resistance to internal exploration. The group support helps them withstand the seeming irrationality and multiplicity of internal states and provides a source of social reality for their hearing of voices.
If the findings reported above are accurate, then currently there are likely to be many PTSD patients in treatment who have not acknowledged hearing voices to treatment personnel. Especially with combat veterans, we suggest that the DES be administered, that the "hearing voices" item be examined, and that the veteran be interviewed about hearing voices. Specifically, tell the veteran that hearing voices does not mean one is "crazy," that many more veterans than was realized may hear voices (this article), and that there are treatments for hearing voices. If sufficient interview time is allowed; if an atmosphere permitting disclosure of personally intimate and anxiety-arousing experiences is present; if indirect avenues to learning about voices, such as asking about arguing with oneself, and about lost time are used; in addition to following up on noteworthy DES items, then we would expect many cases to be discovered.
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Authors' Note: We wish to express our appreciation to Edward J. Mortell, M.D., and to Ralph E. Van Atta, Ph.D., of the Louis A. Johnson V.A. Medical Center for their support of this work. Correspondence concerning this article should be addressed to Louis Tinnin, M.D., WVU School of Medicine, 930 Chestnut Ridge Road, Morgantown, WV 26505, e-mail : tinnin.louis@consult.hsc.wvu.edu
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