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Successful systematic desensitization in a chronic schizophrenic patient
3". Behav. Ther. & Exp. Psychiat. Vol. 6, pp. 345-346. Pergamon Press, 1975. Printed in Great Britain.
SUCCESSFUL SYSTEMATIC DESENSITIZATION IN A CHRONIC SCHIZOPHRENIC PATIENT JEROME M . SIEGEL* Hahnemann Medical College and Hospital
Summary--This case study presents the successful systematic desensitization of anxiety engendered by auditory hallucinations in a chronic schizophrenic patient. A 21-month term follow-up indicated that the effects of the treatment persisted.
THE suitability of psychotic patients for treatment by systematic desensitization has been somewhat controversial in the behavior therapy literature. Cowden and Ford (1962) treated two schizophrenic patients by this method. Success was reported in the first case, a 27-yr-old ex-marine with strong fears of talking to other people. However, the second patient, a middle-aged man with an obsessional fear of leaving things behind, became able to leave things behind only when the therapist was present. Weidner (1970) reported the successful in vivo desensitization of a chronic paranoid schizophrenic patient who feared that C.I.A. agents were out to get him. Alumbaugh (1971) employed the technique in a schizophrenic female patient suffering from auditory hallucinations. Accepting the validity of the patient's own hypothesis that the hallucinations were caused by her cigarette smoking, desensitization involved a hierarchy of stressful situations related to smoking. Both hallucinations and cigarette smoking had been completely in abeyance 1 yr following treatment. By contrast, Serber and Nelson (1971), however, reported no success with 16 hospitalized schizophrenic patients. The present study examined the use of systematic desensitization for anxiety engendered by auditory hallucinations in a chronic schizophrenic patient.
CASE
HISTORY
The subject was a 39-yr-old male outpatient whose diagnosis was chronic undifferentiated schizophrenia. His main complaint was hearing voices, some of which had been disturbing him for the past 8 yr by engendering anxiety. They communicated a range of specific commands from the benign " G o get a cup of coffee", to the threatening--"Jump out of the window". The voices were
most frequent when the patient was alone, and anxiety was highest at bedtime, when they communicated the " J u m p out of the window" command. The patient's response to the voice at bedtime was to get out of bed and pace the floor for 10 or 15 min and then return to bed less anxious. The frequency of this bedtime pacing had been two or three times a week for a period of 2 yr. Pacing during the day also occurred. The patient estimated that at the height of his anxiety over the voices about 3 yr previously, he had been pacing about 6 hr a day. He was looking for employment at the time of treatment, and was concerned that the voices would tell him to quit his job if he found one. TREATMENT Accepting the patient's report that the anxiety accompanying certain of the voices was disturbing, and that the voices unaccompanied by anxiety were not a problem, it was decided to treat the anxiety by systematic desensitization. Relaxation training was begun with the patient listening to taped relaxation exercises. He seemed to understand the procedure, followed the instructions, and reported that he was relaxed at the end of the session. He was given a homework assignment to practice relaxation. At the next session, he reported that he had practiced twice. The exercises were repeated, and the patient reported complete relaxation. A hierarchy was constructed with the patient's cooperation at the next session. This hierarchy had as its subjectmatter a day in the life of the patient, progressing from a non-anxiety-provoking scene early in the day, to bedtime and the " J u m p out of the window" voice. He advanced successfully through the hierarchy in two sessions. After the first desensitization session, he reported that he heard no more voices telling him to jump out of the window, and did no pacing after getting into bed. He was
*Requests for reprints should be sent to : Jerome M. Siegel, Division of Research and Evaluation, Hahnemann Community Mental Health/Mental Retardation Center, 314 N o r t h Broad Street, Philadelphia, Pennsylvania 19102. 345
346
JEROME M. SIEGEL
asked to come in for a series of follow-up interviews for a period of 15 weeks. During this period there was no recurrence of the bedtime behaviors. He reported practicing the relaxation exercises on his own and that their use had enabled him to cut down on his pacing during the day. He was more relaxed generally and more optimistic about his life. He felt that the relaxation exercises enabled him to control the anxiety over the voices, whereas previously the anxiety had controlled him. He still heard the voices at bedtime, but they had become completely benign, telling him to "Go to sleep" or "Get a cup of coffee, but you can do it tomorrow". Apparentlyremoving the anxiety associated with the hallucinations had changed the character of the hallucinations themselves. At a follow-up 21 months after treatment, he again reported no voices at bedtime and no pacing. He still paced during the evening once or twice a week but felt that this had become more of a "habit" than the result of anxiety. During evenings, he was happier and much less anxious, and was able to concentrate on television better. He still heard the voices during the evening but
they were friendly rather than hostile. He was doing the relaxation exercises whenever he felt anxious. He was still a psychiatric patient and had worked very infrequently at odd jobs during the 21 months. REFERENCES ALUMBAUGHR. V. (1971) Use of Behavior Modification Techniques Toward Reduction of Hallucinatory Behavior: A Case Study. Psychol. Rec. 21,415-417. COWDEN R. C. and FORD L. I. (1962) Systematic Desensitization with Phobic Schizophrenics, Am. J. Psychiat. 119, 241-245. SERBER M. and NELSON P. (1971) The Ineffectiveness of Systematic Desensitization and Assertive Training in Hospitalized Schizophrenics. J. Behav. Ther. & Exp. Psychiat. 2, 107-109. WEIDNER F. (1970) In vivo Desensitization of a Paranoid Schizophrenic, J. Behav. Ther. Exper. Psychiatry 1, 79-81.
SUCCESSFUL SYSTEMATIC DESENSITIZATION IN A CHRONIC SCHIZOPHRENIC PATIENT JEROME M . SIEGEL* Hahnemann Medical College and Hospital
Summary--This case study presents the successful systematic desensitization of anxiety engendered by auditory hallucinations in a chronic schizophrenic patient. A 21-month term follow-up indicated that the effects of the treatment persisted.
THE suitability of psychotic patients for treatment by systematic desensitization has been somewhat controversial in the behavior therapy literature. Cowden and Ford (1962) treated two schizophrenic patients by this method. Success was reported in the first case, a 27-yr-old ex-marine with strong fears of talking to other people. However, the second patient, a middle-aged man with an obsessional fear of leaving things behind, became able to leave things behind only when the therapist was present. Weidner (1970) reported the successful in vivo desensitization of a chronic paranoid schizophrenic patient who feared that C.I.A. agents were out to get him. Alumbaugh (1971) employed the technique in a schizophrenic female patient suffering from auditory hallucinations. Accepting the validity of the patient's own hypothesis that the hallucinations were caused by her cigarette smoking, desensitization involved a hierarchy of stressful situations related to smoking. Both hallucinations and cigarette smoking had been completely in abeyance 1 yr following treatment. By contrast, Serber and Nelson (1971), however, reported no success with 16 hospitalized schizophrenic patients. The present study examined the use of systematic desensitization for anxiety engendered by auditory hallucinations in a chronic schizophrenic patient.
CASE
HISTORY
The subject was a 39-yr-old male outpatient whose diagnosis was chronic undifferentiated schizophrenia. His main complaint was hearing voices, some of which had been disturbing him for the past 8 yr by engendering anxiety. They communicated a range of specific commands from the benign " G o get a cup of coffee", to the threatening--"Jump out of the window". The voices were
most frequent when the patient was alone, and anxiety was highest at bedtime, when they communicated the " J u m p out of the window" command. The patient's response to the voice at bedtime was to get out of bed and pace the floor for 10 or 15 min and then return to bed less anxious. The frequency of this bedtime pacing had been two or three times a week for a period of 2 yr. Pacing during the day also occurred. The patient estimated that at the height of his anxiety over the voices about 3 yr previously, he had been pacing about 6 hr a day. He was looking for employment at the time of treatment, and was concerned that the voices would tell him to quit his job if he found one. TREATMENT Accepting the patient's report that the anxiety accompanying certain of the voices was disturbing, and that the voices unaccompanied by anxiety were not a problem, it was decided to treat the anxiety by systematic desensitization. Relaxation training was begun with the patient listening to taped relaxation exercises. He seemed to understand the procedure, followed the instructions, and reported that he was relaxed at the end of the session. He was given a homework assignment to practice relaxation. At the next session, he reported that he had practiced twice. The exercises were repeated, and the patient reported complete relaxation. A hierarchy was constructed with the patient's cooperation at the next session. This hierarchy had as its subjectmatter a day in the life of the patient, progressing from a non-anxiety-provoking scene early in the day, to bedtime and the " J u m p out of the window" voice. He advanced successfully through the hierarchy in two sessions. After the first desensitization session, he reported that he heard no more voices telling him to jump out of the window, and did no pacing after getting into bed. He was
*Requests for reprints should be sent to : Jerome M. Siegel, Division of Research and Evaluation, Hahnemann Community Mental Health/Mental Retardation Center, 314 N o r t h Broad Street, Philadelphia, Pennsylvania 19102. 345
346
JEROME M. SIEGEL
asked to come in for a series of follow-up interviews for a period of 15 weeks. During this period there was no recurrence of the bedtime behaviors. He reported practicing the relaxation exercises on his own and that their use had enabled him to cut down on his pacing during the day. He was more relaxed generally and more optimistic about his life. He felt that the relaxation exercises enabled him to control the anxiety over the voices, whereas previously the anxiety had controlled him. He still heard the voices at bedtime, but they had become completely benign, telling him to "Go to sleep" or "Get a cup of coffee, but you can do it tomorrow". Apparentlyremoving the anxiety associated with the hallucinations had changed the character of the hallucinations themselves. At a follow-up 21 months after treatment, he again reported no voices at bedtime and no pacing. He still paced during the evening once or twice a week but felt that this had become more of a "habit" than the result of anxiety. During evenings, he was happier and much less anxious, and was able to concentrate on television better. He still heard the voices during the evening but
they were friendly rather than hostile. He was doing the relaxation exercises whenever he felt anxious. He was still a psychiatric patient and had worked very infrequently at odd jobs during the 21 months. REFERENCES ALUMBAUGHR. V. (1971) Use of Behavior Modification Techniques Toward Reduction of Hallucinatory Behavior: A Case Study. Psychol. Rec. 21,415-417. COWDEN R. C. and FORD L. I. (1962) Systematic Desensitization with Phobic Schizophrenics, Am. J. Psychiat. 119, 241-245. SERBER M. and NELSON P. (1971) The Ineffectiveness of Systematic Desensitization and Assertive Training in Hospitalized Schizophrenics. J. Behav. Ther. & Exp. Psychiat. 2, 107-109. WEIDNER F. (1970) In vivo Desensitization of a Paranoid Schizophrenic, J. Behav. Ther. Exper. Psychiatry 1, 79-81.