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The Significance of Hallucinations
A 20-Year Multi-follow-up of Hallucinations in Schizophrenia, Other Psychotic, and Mood Disorders
Goghari VM, Harrow M, Grossman LS, Rosen C
Psychol Med. 2013;43:1151-1160
Goghari and colleagues report on a prospective study of 150 individuals who were enrolled in the Chicago Follow-up study. The 20-year trajectory of hallucinations was assessed in 51 patients with schizophrenia, 25 with schizoaffective disorder, 25 with bipolar disorder with psychotic features, and 49 with unipolar depression without psychosis (the latter was included as a comparison group). The investigators found that the longitudinal course of hallucinations clearly differentiated between schizophrenia and bipolar disorder with psychosis and suggested some diagnostic similarities between schizophrenia and schizoaffective disorder, and between bipolar disorder and schizoaffective disorder and depression.
Of note, frequent or persistent hallucinatory activity over the 20-year period was a feature of 40%-45% of patients with schizophrenia, and the early presence of hallucinations predicted the lack of future periods of recovery in all patients. In this study, recovery was defined as the absence of positive or negative symptoms and no rehospitalizations during the follow-up year, as well as partially adequate (or better) work and social functioning as assessed by scores of “2 — employed half-time or greater” on the Strauss/Carpenter scale. Increased hallucinatory activity was associated with reduced work attainment in all patients.
On cross-sectional mental status examination, a person with psychotic symptoms, including hallucinations, is often a diagnostic dilemma. Psychotic symptoms are a hallmark of schizophrenia and schizoaffective disorder, but these may also be present in a person with bipolar disorder or major depressive disorder. The Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria instruct clinicians to first rule out a mood disorder (or a toxic or medical cause), before considering a diagnosis of schizophrenia. A longitudinal history is necessary to arrive at the correct diagnosis, and the usual focus has been on interepisodic functioning and the presence of characteristic mood symptoms when ill.
Hallucinations have usually been considered nonspecific enough to be of little use when determining diagnosis. This study provides evidence suggesting that clinicians can use the presence and course of hallucinations as an aid in determining diagnosis and prognosis, and to help in better tailoring individual treatment plans.