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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 168-178

Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients


Department of Psychiatric Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt

Date of Submission03-May-2017
Date of Acceptance30-May-2017
Date of Web Publication12-Jan-2018

Correspondence Address:
Zamzam A Ahmed
Lecturer of Psychiatric Nursing, Department of Psychiatric Nursing, Faculty of Nursing, Assiut University, Assiut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_25_17

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  Abstract 

The study aimed to evaluate the effectiveness of teaching self-management strategies on auditory hallucinations among schizophrenic patients. A quasiexperimental design (pre–post test design) was utilized in this study. The study was carried out at Inpatient Unit at Neuropsychiatry and Neurosurgical Hospital at Assiut University. The study consisted of 30 patients with chronic schizophrenia. Three tools were used to collect data from this study: tool 1, a structured interview tool for the sociodemographic and clinical data of patients with schizophrenia who are suffering from auditory hallucinations; tool 2, phenomenology scale of hallucinations, which is a semistructured interview and was a modified version; and tool 3 structured interviewing tool of self-management strategies to control auditory hallucinations. The study results revealed that there was a statistically significant difference as regards hallucination and coping strategies of self-management to control auditory hallucination before and after intervention. On the basis of the present study it can be concluded that patients can use self-management strategies to reduce the severity of auditory hallucination and help them to cope and succeed in dealing with their own illness. In the light of the result of the present study it is recommended that the psychiatric healthcare provider (psychiatric nurse and/or psychiatrist) provides accurate information to schizophrenic patients who have auditory hallucinations about different self-management techniques. Schizophrenic patients with auditory hallucination should be trained on self-management coping strategies to control their hallucination.

Keywords: auditory hallucinations, schizophrenia, self-management


How to cite this article:
Sayied NE, Ahmed ZA. Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients. Egypt Nurs J 2017;14:168-78

How to cite this URL:
Sayied NE, Ahmed ZA. Efficacy of teaching self-management strategies on auditory hallucinations among schizophrenic patients. Egypt Nurs J [serial online] 2017 [cited 2018 Nov 18];14:168-78. Available from: http://www.enj.eg.net/text.asp?2017/14/2/168/223101


  Introduction Top


Auditory hallucinations experienced in psychotic illness contribute significantly to distress and disability. Many patients with schizophrenia in inpatient psychiatric units experience painful auditory hallucinations. Substantial individual differences in specific characteristics and impact of hallucinations have been shown, and thus require careful exploration. Hearing voices is an internal experience, and it cannot be directly observed (Nayani and David, 1996; Copolov et al., 2004).

These auditory hallucinations often give ‘bad advice’, including commanding patients to harm themselves or others. If patients have a lack of effective self-management skills, these voices are especially dangerous, and the only way they can manage them is by obeying them. Buccheri et al. (2007) stated that hearing voices is an internal experience; it cannot be directly observed. Even though from time to time it is accompanied by observable behaviors such as addressing a hidden speaker, investigation of auditory hallucinations essentially relies on the voice hearer’s reports.

Hallucination is the most common symptom of schizophrenia (Uhlhass and Mishara, 2006) and auditory hallucination is the most common form of hallucination in schizophrenia (Waters, 2010). It is estimated that the prevalence of auditory hallucinations among people living with schizophrenia ranges from 64.3 to 83.4% (Thomas et al., 2007).

Copolov et al. (2004) stated that a number of studies were located concerning the impact of auditory hallucinations on the lives of individuals. An Australian study on 199 people with a psychotic disorder reported that people who experience auditory hallucinations frequently feel depressed. In addition, Suryani (2006) found that most of the participants (60% of 150 participants) were disturbed by the sound of voices to the point of becoming angry, depressed, and unable to attend to activities of daily living. Similarly, a systematic review by Waters (2010) confirmed that people who experience auditory hallucinations were stressed by the intrusive and personal nature of the voices.

A study by Beavan and Read (2010) in New Zealand explored the effects of the content of hallucinations on emotional well-being in 154 people. The findings of the study indicated that there was a correlation between the content of the voices and participants’ emotional response. For example, participants who heard negative content such as being criticized experienced negative emotions such as feeling distressed.

Singh et al. (2003) reported that people diagnosed with schizophrenia who experience auditory hallucinations feel significant stress and discomfort. The often unabating presence of the voices has led individuals to develop their own coping strategies. An exploratory descriptive study in Taiwan by Tsai et al. (2003) asked 200 participants to describe their coping strategies in managing auditory hallucinations. They found that most of the participants developed their own distraction techniques such as ignoring the voices, engaging in activities, and accepting or arguing with the voices.

Significance

A lot of patients with schizophrenia in inpatient psychiatric units experience painful auditory hallucinations. These auditory hallucinations often include ‘bad advice’ such as commanding patients to harm themselves or others. These voices are dangerous if patients lack successful self-management skills and the only way they can manage them is by obeying them. Self-management strategies allow individuals to cope with disease and help them to succeed in dealing with their own illness. Therefore, we designed and implemented evidence-based program to teach those patients how to cope with auditory hallucinations.


  Aim Top


The study was aimed to evaluate the effectiveness of teaching self-management strategies on auditory hallucinations among those patients.

Hypothesis

At the end of study we expected the following:

Schizophrenic patient who receive teaching on self-management strategies will have lower hallucination and show improvement in coping with hallucination than that before intervention.


  Patients and methods Top


Research design

First, screening of chronic schizophrenic patients with complaints of auditory hallucination was carried out.

Thereafter, a quasiexperimental design (pre–post test design) was utilized in this study through the application of self-management strategies to cope with auditory hallucinations.

Research setting

The study was carried out at the Inpatient Unit at Neuropsychiatry and Neurosurgical Hospital at Assiut University.

Patients

The study sample included 30 patients with chronic schizophrenia diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, 5th ed. 60% of the studied sample was male, with a mean±SD age of 36.2±10.9 years (range: 18–65 years); 36.7% were illiterate, 36.7% did not have work, and 70% were married.

Inclusion criteria

  • Diagnosis of chronic schizophrenia.
  • Both sexes.
  • Age from 18 to 65 years.


Exclusion criteria

  • Mental retardation.
  • Age less than 18 years or more than 65 years.


Tools of data collection

Tool 1

A structured interview tool was used for the sociodemographic and clinical data of patients with schizophrenia suffering from auditory hallucinations. This tool includes two parts:
  1. Sociodemographic characteristics: It includes age, sex, marital status, education, and occupation.
  2. This part included clinical data of psychiatric inpatients, such as diagnosis, length of time experiencing voices, and hallucination in other modalities − visual/olfactory/gustatory/tactile.


Tool 2

Phenomenology scale of hallucinations: It is a semistructured interview. It was developed by Lowe (1973) and modified by Miller et al. (1993). The scale measures various parameters of hallucination. It consists of 11 items, each of which is scored on a four-point Likert scale from 0 to 4, with zero indicating the lowest severity and four indicating the highest severity. It measures various parameters of hallucinations − namely, extent (frequency, duration, loudness, and beliefs), reorigin of voices, amount of negative content of voices, degree of negative content of voices, amount of distress, intensity of distress, disruption, and control. The hallucination severity score therefore ranged from 0 to 44. This scale was tested for content validity. A jury of five experts in the psychiatric nursing and medicine field examined the content and tested for its validity. Cronbach’s α reliability coefficient of the tool was reported (r=0.95).

Tool 3

Structured interviewing sheet of self-management strategies to control auditory hallucinations: It was developed by Abd El-Hay (2008) and Gaber, (2013). It consists of three categories:
  1. Physiological category: It includes seven items to reduce patient’s arousal, such as sleeping, taking extra medication, lying down, and resting, and strategies to increase patient’s arousal, such as listening to music, exercising, smoking cigarettes, etc.
  2. Cognitive category: It includes eleven items of acceptance of voices, such as arguing with voices, accepting and staying with voices peacefully, doing as the voices say, talking to voices, asking self to calm down, and reduced attention to voices, such as ignoring them, verifying voices, etc.
  3. Behavioral category: It includes seventeen items of blocking ears, such as watching television, seeking help from nurse and doctor, talking to others, praying, singing, going to crowded place, isolating self, eating, crying, leaving the place, etc. The participants respond on a four-point Likert scale (not used=0, did not help=1, helped to some extent=2, or helped a lot=3). This scale was tested for content validity by a jury of five experts in the psychiatric nursing and medicine field. Categories of this tool proved to be strongly reliable, physiological strategy (r=0.88), cognitive strategy (r=0.97), and behavioral strategy (r=0.86).


Pilot study

A pilot study was carried out before starting data collection. It was carried out on 10 patients to test clarity and applicability of the study tools and to estimate the time needed to collect data. These 10 patients were excluded from the study.

Development of the interaction program

The following steps were carried out to develop the program.

First stage

  1. Assessment phase:
    • First, the assessment phase included initiation of trustful nurse–patient relationship, maintaining patient safety, and providing supportive teaching methods for the patients.
    • Thereafter, the patients were assessed for auditory hallucination using the Phenomenology scale of hallucinations and structured interviewing sheet of self-management strategies to control auditory hallucinations. On the basis of the assessment phase, a simple booklet and audiovisual material were prepared by the investigators. The program content was revised by a group of experts for content validity and relevancy based on the opinion of the experts and results of the pilot study.
  2. Planning phase:
    • The planning phase included the program strategy (time and number of sessions and interaction methods). The number of sessions was five sessions per week for 1 h for 2 weeks for each patient and for the caregiver the number of sessions was one. The interaction sessions of the program were conducted at the Inpatient Unit at Neuropsychiatry and Neurosurgical Hospital at Assiut University.


Second stage (training stage): content of the program

  • Session 1: Assessment of voice hearer’s experience and assessment of patients’ awareness of these symptoms.
  • Session 2: Teaching the patient and the caregiver techniques that will help in controlling auditory hallucinations, such as talking to someone.
  • Session 3: Teaching the patients to listen to music to distract themselves from hallucination.
  • Session 4: Teaching the patients to watch TV or watch something that moves during hallucination.
  • Session 5: Teaching the patients and the caregivers the technique to control hallucination, such as saying stop and you are not real.
  • Session 6: Teaching the patients and the caregivers the technique to control hallucination, such as changing his or her position and going away.
  • Session 7: Training the patients to use earplugs to control hallucination.
  • Session 8: Teaching the patients relaxation techniques, such as rest, exercise, or engage in activity.
  • Session 9: Teaching the patients to doing something they like to do.
  • Session 10: Teaching the patients to take prescribed medication and not stop it abruptly.


Evaluation phase: Patients with auditory hallucination were assessed immediately after the program implementation using the phenomenology scale of hallucinations and structured interviewing sheet of self-management strategies to control auditory hallucinations.

Third stage: Implementation phase

A total of 10 interaction sessions were conducted for each group in addition to the preassessment session (initial interview).

Methods

The program included teaching the patients self-management strategies to control auditory hallucinations. The sample was divided into subgroups for program implementation; each session included 5–6 patients and their caregivers.

The questionnaire was filled by the investigator on each occasion as follows:

Before commencing the programs an assessment was carried out for patients with auditory hallucination. Thereafter, the questionnaire was administered immediately after complete implementation of programs.

Procedure

The program included the following steps:
  1. An official permission was granted from responsible personnel to carry out the study after explaining the purpose of the study.
  2. A sociodemographic data sheet was developed by the researcher.
  3. The researcher assured voluntary participation and confidentiality to each patient and caregivers who agreed to participate.
  4. The aim and strategy of the study was explained to the patients and their caregivers before data collection.
  5. Patients were assessed before application of the program using the study tools. The interview was carried out in a special room in inpatient unit.
  6. The patients were chosen after final assessment by the researchers.
  7. The program was applied for patients and their caregivers who met the inclusion criteria of the study. The duration of the program was 5 months from October to February.
  8. Application of the program included teaching strategies to control auditory hallucination.
  9. Patients were assessed before and immediately after the program implementation using the Phenomenology scale of hallucinations and Structured interviewing sheet of self-management strategies to control auditory hallucinations.


Statistical analysis

The data were tested for normality using the Anderson–Darling test and for homogeneity variances before further statistical analysis. Categorical variables were described using number and percent, whereas continuous variables were described as mean±SD. The χ2 and Fisher exact tests were used to compare categorical variables, whereas to compare between continuous variables the Paired t-test and analysis of variance were used. A two-tailed P value less than 0.05 was considered statistically significant. All analyses were performed with the IBM SPSS 20.0 software (IBM Corp., Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.).


  Result Top


[Table 1] shows the sociodemographic data of the studied sample. It was revealed that 60% of the studied sample were male with a mean±SD age of 36.2±10.9 years (range: 18–65 years); 36.7% were illiterate, 36.7% did not have work, and 70% were married.
Table 1 Sociodemographic characteristics of the studied schizophrenic patients (N=30)

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[Table 2] presents the clinical data of the studied sample. This table shows the duration of illness. There were 40% of patients with auditory hallucination for more than 4 years.
Table 2 Clinical characteristics of the studied schizophrenic patients

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[Table 3] presents auditory hallucination as reported by schizophrenic patients before and after teaching self-management strategies. It was found that there were statistically significant differences before and after intervention in most items of auditory hallucination rating scale (P=0.001). Before intervention, as regards frequency of the voices, in the majority of the sample (53.3%) voices were heard continuously, but after intervention the voices were heard only once a week (53.3%). In relation to duration of the voices, 60% of the studied sample revealed that voices lasted for several minutes, but after intervention 76.7% of the studied sample said that voices lasted for a few seconds. According to the location of voices, 40% of the studied sample said that the voice came from inside the head; similarly, 40% of them said that the voice came from outside. In relation to negative content in the majority of the sample (63.3%) the content of the voices were unpleasant or negative before intervention but after intervention 56.7% of them reported occasional unpleasant content. As regards control of voices, 76.7% of them had no control over the voices, but after intervention 50% of them believe they can have some control over the voices.
Table 3 Auditory hallucination as reported by schizophrenic patients at pre and post-teaching self-management strategies according to (frequency and duration of hallucination) (N=30)

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[Table 4] presents comparison between pretest and post-test self-management strategies in the studied sample. It was found that there were statistically significant differences between preprogram and postprogram cognitive, behavioral, and physiological strategies in the studied sample (P=0.001). The studied sample showed improvement and used some coping mechanism for stopping hallucination effectively. The studied sample used behavioral techniques for coping and stopping hallucination in relation to physiological techniques: before program 76.7% did not use sleep but after program it helped 50% to some extent; and before program 86.7% did not use the technique of listening to music to cope but after program 60% of them listened to music, which helped them to cope to some extent. As regards cognitive techniques, 86.7% did not use the technique of talking with voices after intervention. 100% of patients did not shout to the voice but after intervention 50% of them shouted to the voice. In relation to behavioral techniques such as covering the ear or placing cotton, 100% of the studied sample did not use this technique but after intervention 66.7% of them covered their ear and reported that it helped a lot. As regards watching TV with loud voices 100% of them did not use, but after program it helped a lot. As regards leaving the place, 100% of patients did not use but after program 53.3% of patients adopted it and reported that it helped a lot.
Table 4 Self-management strategies (physiological coping according to (sleep, ask for medication, listening to music and rest) as reported by schizophrenic patients before and after intervention (N=30)

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[Figure 1] presents comparison between total score of coping mechanism before and after intervention using self-management strategies to control auditory hallucinations. This figure revealed that the patients showed improvement in controlling auditory hallucination after program than that before program. These results indicate that this program helps the patient’s to cope and succeed in dealing with their own illness and used self-management strategies as a way for managing voices.
Figure 1 The comparison between pre and postprogram in relation to self-management strategies as a total score of coping mechanism.

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  Discussion Top


Auditory hallucinations have traditionally been associated with a diagnosis of schizophrenia and are one of the most debilitating symptoms of schizophrenia. Despite the development of new psychotropic medications, a significant number of people with schizophrenia continue to suffer from auditory hallucinations. Auditory hallucinations experienced in psychotic illness contribute significantly to distress and disability. People with schizophrenia not only have the ability to make decisions about taking medicine but also have a great capacity to manage psychotic symptoms [Frederick, 2000; Marks et al. (2005)]. The present study was conducted to identify self-management strategies to control auditory hallucinations among patients with chronic schizophrenia.

The present study illustrated that more than half of the studied sample had a frequency of auditory hallucinations of once/day or more continuously. These findings are consistent with El Ashry and Hassan Abdel Al (2015), who reported that more than two-thirds of the studied sample (65.0%) had a frequency of auditory hallucinations once/day or more. Moreover, Kelkar (2002) noted that hallucinations are directly responsible for profound dysfunction in all aspects of daily life. In addition, Brown (2008) indicated that a large majority of individuals experiencing auditory hallucinations reported the frequency as several times per day. Concerning the location of voices, David (2004) also reported that hallucination was defined as sensory experience that occurs in the absence of corresponding external stimulation of the relevant sensory organ and has a sufficient sense of reality to resemble a veridical perception, over which the one does not feel one has direct and voluntary control. This may be due to, one is that nurses are still afraid to talk openly to people about hearing voices. A second reason may be that nurses do not know about the strategies that could be used to help those patients to control auditory hallucination.

The current study results revealed that less than half of the studied sample had voices coming from outside the patient’s body. Similarly, less than half of the patients in the studied sample had voice inside the head that was real to them. This result is partially supported by Cottam et al. (2011) and Gaber (2013), who reported that patients hear voices in the head. This finding was supported by El Ashry and Hassan Abdel Al (2015), who found that, as regards location of voices, 53.3% of the studied patients had voices coming from outside the patient’s body. This may be due to patient’s conviction of the reality of heard voices, or it may be due to patients beliefs about the origin of the voices − that is, if a person believes that the voices come from existing independent beings of some type (e.g. God, devils, evil spirits, invisible people, or dead relatives). This is in agreement with Shepherd et al. (2010), who concluded that patients with schizophrenia often perceive hallucinated voices/sounds as being located in the external auditory space. In this respect, Duffy (2006) reported that some patients reported that when voices start they take specific posture and speak with voices. This may probably be attributed to the fact that all voices were perceived to be omnipotent by the hearer.

The finding of the present study illustrated that the majority of patients in the studied sample showed improvement and used some self-management strategies for stopping hallucination effectively (physiological, cognitive, and behavioral techniques). This result is in agreement with Abd El-Hay (2008), who reported that the majority of the studied sample used behavioral and physiological strategies as coping strategies. In addition, El Ashry and Hassan Abdel Al (2015) reported that the studied patients used different forms of self-management strategies (e.g. physiological, cognitive, and/or behavioral) to deal with auditory hallucinations, such as ‘sleep’ as a way for managing voices. Moreover, Hayashi et al. (2007) and Wong (2008) indicated that a large number of patients use ‘falling asleep’ as a way for managing voices and they reported that it is a completely successful technique.

Moreover, Zou et al. (2013) reported that the most commonly used strategy to deal with persistent symptoms by Chinese patients was ignoring them. However, this finding is contradictory to the study by Beck and Rector (2003), who stated that more than half of the people who experience voices are not successful in their efforts to escape or ignore the voices. The present study revealed that there were statistically significant differences between behavioral, cognitive, and physiological strategies and hallucination rating scale, which means that increased use of behavioral self-management techniques is associated with increased use of cognitive physiological self-management strategies. The greater the use of self-management strategies the better the control of auditory hallucination. This result is congruent with El Ashry and Hassan Abdel Al (2015), who found that there was statistically significant difference between behavioral self-management strategies and a cognitive self-management strategies, which means that, when there is increased use of behavioral self-management strategies, it is accompanied by increased use of cognitive self-management strategies and vice versa.


  Conclusion Top


On the basis of the results of the present study it can be concluded that patients can use self-management strategies to reduce the severity of auditory hallucination and help them to cope and succeed in dealing with their own illness.

Recommendation

In the light of the result of the present study, the following were recommended:
  1. Psychiatric healthcare provider (psychiatric nurse and/or psychiatrist) should provide accurate information to schizophrenic patients who have auditory hallucinations about different self-management techniques.
  2. Schizophrenic patients with auditory hallucination should be trained on self-management coping strategies to help them in controlling their hallucination.


Limitation

Decreased chronic schizophrenic patients flow.

Some patients were aggressive due to response to auditory hallucinations.

Strength

Most of the patients responded to teaching self-management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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