Auditory verbal hallucinations in persons with and without a need for care

A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT

BACKGROUND

Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution.

OBJECTIVE

The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT).

DESIGN AND SETTING

This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks.

PARTICIPANTS

A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited.

INTERVENTION

REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages.

MAIN OUTCOME MEASURE

The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items.

RESULTS

Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported.

LIMITATIONS

The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random.

CONCLUSIONS

An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only.

FUTURE WORK

Further research in improving the effectiveness of online carer support interventions is required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN72019945.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.

External speech processing and auditory verbal hallucinations: A systematic review of functional neuroimaging studies

It has been documented that individuals who hear auditory verbal hallucinations (AVH) exhibit diminished capabilities in processing external speech. While functional neuroimaging studies have attempted to characterise the cortical regions and networks facilitating these deficits in a bid to understand AVH, considerable methodological heterogeneity has prevented a consensus being reached. The current systematic review investigated the neurobiological underpinnings of external speech processing deficits in voice-hearers in 38 studies published between January 1990 to June 2020. AVH-specific deviations in the activity and lateralisation of the temporal auditory regions were apparent when processing speech sounds, words and sentences. During active or affective listening tasks, functional connectivity changes arose within the language, limbic and default mode networks. However, poor study quality and lack of replicable results plague the field. A detailed list of recommendations has been provided to improve the quality of future research on this topic.

Psychophysiological stress-reactivity in clinical and non-clinical voice-hearers

BACKGROUND

Psychosis is associated with dysregulation of psychophysiological stress-reactivity, including in subjective, autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) parameters.

AIMS

This study investigated whether dysregulated psychophysiological stress-reactivity is specifically associated with auditory verbal hallucinations (AVHs) or psychosis more generally by comparing voice-hearers with and without a need for care.

METHOD

Clinical (n = 20) and non-clinical voice-hearers (n = 23), as well as a healthy control group with no voices (n = 23), were compared on HPA and ANS responses, and subjective reactivity, to a psychophysiological stress paradigm, the socially evaluative cold pressor test.

RESULTS

Measures of HPA function in both clinical and non-clinical voice-hearers diverged from non-voice-hearing controls. Clinical participants showed a blunted peak response compared to both non-clinical groups (p = 0.02), whilst non-clinical voice-hearers showed, at trend-level, reduced cortisol levels during stress exposure compared to both clinical voice-hearers (p = 0.07) and healthy controls (p = 0.07), who unexpectedly did not differ from each other (p = 0.97). Clinical participants showed greater subjective stress levels than both non-clinical groups (p < 0.001), as well as greater anticipatory stress (p = 0.001) and less recovery. There were no differences between groups on parameters of the ANS (all p > 0.05).

CONCLUSIONS

Dysregulated psychophysiological stress-function is present in clinical voice-hearers, and partially discriminates them from non-clinical voice-hearers. Overall, the present findings identified specific potential psychophysiological markers of risk and resilience in auditory verbal hallucinations and need for care.

Managing unusual sensory experiences: A feasibility trial in an At Risk Mental States for psychosis group

OBJECTIVES

To conduct a feasibility study on a new, tablet-delivered treatment for unusual sensory experiences in service-users with an At Risk Mental States for psychosis.

DESIGN

A mixed method design was employed, using content analysis to investigate whether service-users and therapists found the new treatment acceptable and helpful. We also collected data on the impact of treatment, but without a control group could not make any claims about effectiveness.

METHODS

Eligible participants were contacted before starting treatment and offered the chance to participate. Assessments were conducted before and after the treatment, which typically was completed in 4-6 sessions by an accredited CBT therapist. A structured interview was used to collect qualitative feedback.

RESULTS

Qualitative feedback suggested that the treatment was acceptable to service-users and therapists, and the progression criteria were met for recruitment, retention, and adherence to treatment.

CONCLUSIONS

The new treatment targeting subtypes of auditory and visual hallucinations was acceptable to service-users and the benefits of addressing psychological mechanisms thought to contribute to hallucinations was supported by qualitative feedback.

PRACTITIONER POINTS

A novel treatment has been developed for unusual sensory experiences based on subtyping voices and using technology to help explain psychological mechanisms that may be linked to hallucinations. The treatment was acceptable to service users and therapists in At Risk Mental States for psychosis services with qualitative feedback supporting the approach. The treatment may be particularly useful in preventing the progressions of psychosis as people who have not developed fixed ideas about the origin of the experiences may be more open to alternative explanations.

Need for care, adversity exposure and perceived stress in clinical and healthy voice-hearers

OBJECTIVES

Psychosis, and in particular auditory verbal hallucinations (AVHs), are associated with adversity exposure. However, AVHs also occur in populations with no need for care or distress.

AIMS

This study investigated whether adversity exposure would differentiate clinical and healthy voice-hearers within the context of a 'three-hit' model of vulnerability and stress exposure.

METHODS

Samples of 57 clinical and 45 healthy voice-hearers were compared on the three 'hits': familial risk; adversity exposure in childhood and in adolescence/adulthood.

RESULTS

Clinical voice-hearers showed greater familial risk than healthy voice-hearers, with more family members with a history of psychosis, but not with other mental disorders. The two groups did not differ in their exposure to adversity in childhood [sexual and non-sexual, victimisation; discrimination and socio-economic status (SES)]. Contrary to expectations, clinical voice-hearers did not differ from healthy voice-hearers in their exposure to victimisation (sexual/non-sexual) and discrimination in adolescence/adulthood, but reported more cannabis and substance misuse, and lower SES.

CONCLUSIONS

The current study found no evidence that clinical and healthy voice-hearers differ in lifetime victimisation exposure, suggesting victimisation may be linked to the emergence of AVHs generally, rather than need-for-care. Familial risk, substance misuse and lower SES may be additional risk factors involved in the emergence of need-for-care and distress.

Changing Attitudes Towards Voice Hearers: A Literature Review

Auditory verbal hallucinations, or voice hearing, is increasingly understood as a common experience. Despite this, voice hearers still experience a great deal of stigma, which can have serious negative impacts on the person's experience of their voices, and their recovery. Research has demonstrated that healthcare professionals may be a major source of the stigma surrounding voice hearing, with service-level implications for the development and delivery of evidence-based interventions. Therefore, reducing this stigma is a critical intervention target. The purpose of this narrative review is to examine evidence for interventions aimed at reducing stigma towards people who hear voices, in populations of healthcare professionals, students, and the general public. The available evidence supports the use of anti-stigma interventions based around direct contact with voice hearers and education about voice hearing. However, further research is necessary in this area to confirm these findings.

RELATE-a randomised controlled feasibility trial of a Relating Therapy module for distressing auditory verbal hallucinations: a study protocol

INTRODUCTION

Auditory verbal hallucinations (AVHs) are associated with distress and reduced functioning. Research suggests that distress is associated with the voice hearer's responding to AVH in a passive and subordinate manner. A novel approach focuses on relating to AVH and teaches assertive responses to AVH using experiential role-plays. A small pilot study found a large effect of this approach on AVH distress but an independent multicentre study is required to ascertain effectiveness across different settings. We aim to estimate the expected effect for a subsequent trial to demonstrate that adding a module of Relating Therapy (RT) to treatment as usual (TAU) is superior to TAU alone in reducing AVH distress. We also test the feasibility of patient recruitment, therapist training, and therapy monitoring in different psychological and psychiatric outpatient facilities in Germany.

METHODS AND ANALYSIS

We will recruit 75 patients diagnosed with a schizophrenia spectrum disorder and persistent distressing AVH across four sites. Patients will be randomised to receive either 16 sessions of RT plus TAU or TAU alone within a 5-month period. Randomisation will be stratified by sites. Single-blind assessments will take place at baseline, at 5 months (T1) and at 9 months (T2). The primary outcome is the distress factor score of the AVH subscale of the Psychotic Symptoms Rating Scale at T2 adjusted for the baseline value. Secondary outcomes are change in depressive symptoms, quality of life, time spent in structured activities as well as negative relating to voices and to other people.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the German Psychological Society Ethics Committee. The trial results will be disseminated through conference presentations, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04578314).

Psychotic-like experiences? Trajectories and typologies of hallucinations and delusions from early adolescence to early adulthood in a population-based sample of Irish youth

OBJECTIVES

Hallucinations and delusions that occur in the absence of a psychotic disorder are common in children and adolescents. Longitudinal phenomenological studies exploring these experiences are notably lacking. The objective of the current paper was to explore the phenomenology and characteristics of hallucinations and delusions from early adolescence to early adulthood.

METHODS

Participants were 17 young people aged 18-21 years from the general population, all of whom had a history of childhood hallucinations and/or delusions. Longitudinal data on the phenomenological characteristics and attributions of reported hallucinatory and delusional phenomena spanning nine years were explored using content analysis.

RESULTS

Hallucinatory and delusional phenomena were transient for two-thirds of the sample. The remaining one-third reported reoccurring hallucinatory and delusional phenomena into early adulthood. In those, two typologies were identified: (1) Paranormal typology and (2) Pathological typology. The former was characterised by hallucinatory and delusional phenomena that were exclusively grounded in subcultural paranormal or spiritual belief systems and not a source of distress. The latter was characterised by delusion-like beliefs that were enmeshed with individuals' mood states and a source of distress. The perceived source, the subcultural context and how young people appraised and integrated their experiences differentiated the Paranormal and Pathological typologies.

CONCLUSIONS

Not all hallucinatory and delusion-like experiences are psychotic-like in nature. To reliably differentiate between pathological and non-pathological hallucinations and delusions, assessments need to explore factors including the phenomenology of individuals' experiences, how people make sense and appraise them, and the subcultural contexts within which they are experienced.

Hearing Voices and Seeing Things: Symptoms of Anxiety Misconstrued as Evidence of Schizophrenia in an Adolescent

A patient's complaint of "hearing voices" or "seeing things" or of similar perceptual abnormalities leaves the clinician with 2 decisions: (1) Is the patient actually experiencing a hallucination, or does the complaint reflect a different mental experience, ranging from outright fabrication to the misinterpretation or mislabeling of vivid thoughts and emotions? (2) How should the experience reported by the patient, whether determined to be a hallucination or not, be understood in the context of the patient's entire history and mental state? We report the case of a 16-year-old whose cartoon-like hallucinations had led to the diagnosis of schizophrenia and had directed attention of the patient, her parents, and her clinicians away from critical issues of anxiety, depression, learning difficulties, and traumatic school experiences. This case illustrates how the diagnosis of schizophrenia can be driven by the prominence and vividness of psychotic-like symptoms reported by a patient, the expectation that patients' chief complaints must be directly and immediately addressed, insufficient attention to collateral information, and the distortions of a "checklist" approach to psychiatric diagnosis driven by the criteria in the Diagnostic and Statistical Manual of Mental Disorders, insurers, and the properties of electronic medical records. Given the consequences of either underdiagnosing or overdiagnosing schizophrenia, and the current lack of validated objective tests to assist with this diagnosis, clinicians are obligated to perform a thorough clinical assessment of such patients, including a probing exploration of the patient's mental state and a systematic collection of collateral information.

The relationship between appraisals of voices (auditory verbal hallucinations) and distress in voice-hearers with schizophrenia-spectrum diagnoses: A meta-analytic review

Cognitive-behavioural models of auditory verbal hallucinations (voices) predict that the interpretation of voices determines the levels of distress experienced by voice-hearers. Examining the contribution of these voice appraisals is central to the delivery of effective psychological interventions for the management of distressing psychotic symptoms. This meta-analysis synthesised evidence from studies that tested the relationship between a range of appraisals and several distress measures (voice-related and emotional distress) in individuals with schizophrenia-spectrum diagnoses. A database search (PsycINFO, PubMed and Web of Science) was conducted for articles published up to August 2020. Twenty-eight eligible studies, comprising of 1497 clinical participants examined the association between eight voice appraisals and distress. Moderate to large summary effects (r ranging between 0.30 and 0.50) were observed in several analyses focusing on 'maladaptive' appraisals and beliefs about voices (malevolence, power, metaphysical beliefs, beliefs about loss of control, voice intrusiveness), with voice dominance having a large summary effect, r = 0.58, 95% CI [0.43, 0.69]. Positive appraisals and beliefs had small negative summary effects on distress. The magnitude of the observed effects was similar across subgroup analyses considering measures of voice-related distress, anxiety and depression. The findings of this evidence synthesis broadly corroborate cognitive-behavioural models of distressing voices, but suggested that factors other than voice appraisals may also predict the distress and impairment caused by hallucinatory experiences in people with schizophrenia-spectrum disorders. Nonetheless, our findings confirm that voice appraisals are an important and meaningful target for treatment in help-seeking voice hearers with psychosis.

Multimodal versus unimodal auditory hallucinations in clinical practice: Clinical characteristics and treatment outcomes

Psychological treatments for hallucinations typically target auditory verbal hallucinations (AVH) but neglect the influence of hallucinations in other sensory modalities. This study compared the baseline clinical characteristics and therapeutic outcomes (following brief Coping Strategy Enhancement) of adult clients (N = 100) with multimodal or unimodal (auditory) hallucinations attending an outpatient service for distressing AVH. The results showed that 72.1% of clients reported multimodal hallucinations in the past month. Group comparisons of most baseline clinical characteristics (AVH features, beliefs about AVH, number of traumatic events, personal and social functioning, negative affect) were non-significant. However, in the subgroup (N = 65) reporting ongoing effects of traumatic events, those with multimodal hallucinations reported significantly higher posttraumatic stress symptoms (d = 0.62). Notably, both multimodal and unimodal hallucination groups showed improvement in AVH distress and frequency post-treatment, but group differences in treatment outcomes were not significant. These findings, in a naturalistic service setting, confirm that multimodal hallucinations are common in people seeking help for distressing AVH and may be associated with higher levels of posttraumatic stress symptoms. Importantly, they also suggest that psychological therapy may be suitable and effective for clients experiencing AVH - irrespective of the presence of hallucinations in other sensory modalities.

The Centroid Cannot Hold: Comparing Sequential and Global Estimates of Coherence as Indicators of Formal Thought Disorder

Thought disorder (TD) as reflected in incoherent speech is a cardinal symptom of schizophrenia and related disorders. Quantification of the degree ofTD can inform diagnosis, monitoring, and timely intervention. Consequently, there has been an interest in applying methods ofdistributional semantics to quantify incoherence ofspoken language. Prior studies have generally involved few participants and utilized speech data collected in on-site structured interviews. In this paper we conduct a comprehensive evaluation ofapproaches to quantify incoherence using distributional semantics, including a novel variant that measures the global coherence oftext. This evaluation is conducted in the context of "audio diaries" collected from participants experiencing auditory verbal hallucinations using a smartphone application. Results reveal our novel global coherence metric using the centroid (weighted vector average) outperforms established approaches in their agreement with human annotators, supporting their preferential use in the context of short recordings ofunstructured and largely spontaneous speech.

Cognitive and phenomenological characteristics of hallucination-proneness across the lifespan

INTRODUCTION

The impact of age on hallucination-proneness within healthy adult cohorts and its relation to underlying cognitive mechanisms is underexplored. Based on previously researched trends in relation to cognitive ageing, we hypothesised that older and younger adults, when compared to a middle adult age group, would show differential relations between hallucination-proneness and cognitive performance.

METHODS

A mixed methods, between-groups study was conducted with 30 young adults, 26 older adults, and 27 from a "middle adulthood" group. Participants completed a source memory task, jumbled speech task, Launay-Slade hallucination scale, unusual experiences schedule, and control measures of delusion-proneness and attitudes to mental health.

RESULTS

Compared to older age-groups, younger participants demonstrated better scores on the source memory task, and reported hearing more words in jumbled speech. Additionally, younger cohorts rated higher on hallucination-proneness and disclosed more unusual experiences on a customised schedule designed to gather further qualitative data. Jumbled speech scores positively correlated with hallucination-proneness scores, particularly for the "middle" age group. Source memory performance unexpectedly correlated positively with hallucination-proneness, although this may be the product of age differences in task performance.

CONCLUSIONS

Age differences in hallucination-proneness are evident on self-report and cognitive measures. Implications are discussed for potentially non-overlapping cognitive mechanisms underlying hallucination-proneness in non-clinical groups.

Hallucination, imagery, dreaming: reassembling stimulus-independent perceptions based on Edmund Parish's classic misperception framework

Within the broad field of human perception lies the category of stimulus-independent perceptions, which draws together experiences such as hallucinations, mental imagery and dreams. Traditional divisions between medical and psychological sciences have contributed to these experiences being investigated separately. This review aims to examine their similarities and differences at the levels of phenomenology and underlying brain function and thus reassemble them within a common framework. Using Edmund Parish's historical work as a guiding tool and the latest research findings in the cognitive, clinical and computational sciences, we consider how different perspectives may be reconciled and help generate novel hypotheses for future research. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Mobile RDoC: Using Smartphones to Understand the Relationship Between Auditory Verbal Hallucinations and Need for Care

Objective

Auditory verbal hallucinations (AVH) are common in multiple clinical populations but also occur in individuals who are otherwise considered healthy. Adopting the National Institute of Mental Health's Research Domain Criteria (RDoC) framework, the aim of the current study was to integrate a variety of measures to evaluate whether AVH experience varies across clinical and nonclinical individuals.

Methods

A total of 384 people with AVH from 41 US states participated in the study; 295 participants (77%) who received inpatient, outpatient, or combination treatments for AVH and 89 participants (23%) who never received care. Participants used a multi-modal smartphone data collection system to report on their AVH experiences and co-occurring psychological states multiple times daily, over 30 days. In parallel, smartphone sensors recorded their physical activity, geolocation, and calling and texting behavior continuously.

Results

The clinical sample experienced AVH more frequently than the nonclinical group and rated their AVH as significantly louder and more powerful. They experienced more co-occurring negative affect and were more socially withdrawn, spending significantly more time at home and significantly less time near other people. Participants with a history of inpatient care also rated their AVH as infused with significantly more negative content. The groups did not differ in their physical activity or use of their smartphones for digital communication.

Conclusion

Smartphone-assisted remote data collection revealed real-time/real-place phenomenological, affective, and behavioral differences between clinical and nonclinical samples of people who experience AVH. The study provided strong support for the application of RDoC-informed approaches in psychosis research.

Hallucinations and source monitoring in Alzheimer's disease

INTRODUCTION

the source monitoring account has been widely investigated for hallucinations in schizophrenia. According to this account, hallucinations are inner events that are misattributed to another source. Our paper investigated this account for Alzheimer's disease.

METHOD

we investigated hallucination experiences in participants with Alzheimer's disease and age-matched healthy controls, as well as their source monitoring ability. The assessment of source monitoring included three conditions. In the first condition, participants had to remember whether objects were previously manipulated by themselves or by the experimenter (i.e. reality monitoring). In the second condition, they had to remember whether objects were previously manipulated by a black or white experimenter-gloved hand (i.e. external monitoring). In the third condition, participants had to remember whether they had previously manipulated objects or had imagined having done so (i.e. internal monitoring).

RESULTS

relative to healthy control participants, participants with Alzheimer's disease experienced hallucinations more often and lower hits on source monitoring. Interestingly, significant correlations were only observed between hallucinations and the internal monitoring condition in participants with Alzheimer's disease.

DISCUSSION

hallucinations in Alzheimer's disease seem to be related to the processes of making judgments about the (internal) context in which an event has occurred.

A linguistic approach to the psychosis continuum: (dis)similarities and (dis)continuities in how clinical and non-clinical voice-hearers talk about their voices

Introduction: "Continuum" approaches to psychosis have generated reports of similarities and differences in voice-hearing in clinical and non-clinical populations at the cohort level, but not typically examined overlap or degrees of difference between groups. Methods: We used a computer-aided linguistic approach to explore reports of voice-hearing by a clinical group (Early Intervention in Psychosis service-users; N = 40) and a non-clinical group (spiritualists; N = 27). We identify semantic categories of terms statistically overused by one group compared with the other, and by each group compared to a control sample of non-voice-hearing interview data (log likelihood (LL) value 6.63+=p < .01; effect size measure: log ratio 1.0+). We consider whether individual values support a continuum model. Results: Notwithstanding significant cohort-level differences, there was considerable continuity in language use. Reports of negative affect were prominent in both groups (p < .01, log ratio: 1.12+). Challenges of cognitive control were also evident in both cohorts, with references to "disengagement" accentuated in service-users (p < .01, log ratio: 1.14+). Conclusion: A corpus linguistic approach to voice-hearing provides new evidence of differences between clinical and non-clinical groups. Variability at the individual level provides substantial evidence of continuity with implications for cognitive mechanisms underlying voice-hearing.

The Role of Inner Speech in Executive Functioning Tasks: Schizophrenia With Auditory Verbal Hallucinations and Autistic Spectrum Conditions as Case Studies

Several theories propose that one of the core functions of inner speech (IS) is to support subjects in the completion of cognitively effortful tasks, especially those involving executive functions (EF). In this paper we focus on two populations who notoriously encounter difficulties in performing EF tasks, namely, people diagnosed with schizophrenia who experience auditory verbal hallucinations (Sz-AVH) and people with autism spectrum conditions (ASC). We focus on these two populations because they represent two different ways in which IS can fail to help in EF tasks, which can be illustrative for other mental conditions. First, we review the main components of EF (see section "Executive Functions"). Then we explain the functions that IS is taken to perform in the domain of EF (see section "Inner Speech and Executive Functions") and review the evidence concerning problems about EF in the two populations of our study: Sz-AVH (see section "Executive Functions and Inner Speech in Sz-AVH") and ASC (see section "Executive Function and Inner Speech in ASC"). After this we further detail our account about what a properly functioning IS can do for both populations and how different IS profiles may impact EF performance: in the case of Sz-AVH, the uncontrolled and intrusive character of IS negatively affects EF performance, whereas in ASC, EF is not sufficiently supported by IS, given the tendency in this population to present a diminished use of IS (see section "IS in ASC and Sz-AVH: How It Relates to EF"). We finally briefly discuss Attention Deficit/Hyperactivity Disorder (ADHD) and Developmental Language Disorders (DLD) (see section "Further Considerations").

Voluntary control of auditory hallucinations: phenomenology to therapeutic implications

Auditory verbal hallucinations (AVH) have traditionally been thought to be outside the influence of conscious control. However, recent work with voice hearers makes clear that both treatment-seeking and non-treatment-seeking voice hearers may exert varying degrees of control over their voices. Evidence suggests that this ability may be a key factor in determining health status, but little systematic examination of control in AVH has been carried out. This review provides an overview of the research examining control over AVH in both treatment-seeking and non-treatment-seeking populations. We first examine the relationship between control over AVH and health status as well as the psychosocial factors that may influence control and functioning. We then link control to various cognitive constructs that appear to be important for voice hearing. Finally, we reconcile the possibility of control with the field’s current understanding of the proposed cognitive, computational, and neural underpinnings of hallucinations and perception more broadly. Established relationships between control, health status, and functioning suggest that the development of control over AVH could increase functioning and reduce distress. A more detailed understanding of the discrete types of control, their development, and their neural underpinnings is essential for translating this knowledge into new therapeutic approaches.

Real-Time Functional Magnetic Resonance Imaging Neurofeedback for the Relief of Distressing Auditory-Verbal Hallucinations: Methodological and Empirical Advances

Auditory-verbal hallucinations (AVH) are often associated with high levels of distress and disability in individuals with schizophrenia-spectrum disorders. In around 30% of individuals with distressing AVH and diagnosed with schizophrenia, traditional antipsychotic drugs have little or no effect. Thus, it is important to develop mechanistic models of AVH to inform new treatments. Recently a small number of studies have begun to explore the use of real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) for the treatment of AVH in individuals with schizophrenia. rtfMRI-NF protocols have been developed to provide feedback about brain activation in real time to enable participants to progressively achieve voluntary control over their brain activity. We offer a conceptual review of the background and general features of neurofeedback procedures before summarizing and evaluating existing mechanistic models of AVH to identify feasible neural targets for the application of rtfMRI-NF as a potential treatment. We consider methodological issues, including the choice of localizers and practicalities in logistics when setting up neurofeedback procedures in a clinical setting. We discuss clinical considerations relating to the use of rtfMRI-NF for AVH in individuals distressed by their experiences and put forward a number of questions and recommendations about best practice. Lastly, we conclude by offering suggestions for new avenues for neurofeedback methodology and mechanistic targets in relation to the research and treatment of AVH.

On the phenomenology of auditory verbal hallucinations in affective and non-affective psychosis

Phenomenological comparisons of auditory verbal hallucinations (AVHs) in affective versus non-affective psychosis have not been adequately documented. The current study aimed to: a) comprehensively describe AVH phenomenology by diagnosis and mood state, b) investigate significant predictors of voice-related distress and functional impairment, and c) conduct qualitative thematic analysis of participants' experiences. Participants were diagnosed with: a) bipolar disorder (n = 31), b) major depressive disorder (n = 34), c) schizophrenia (n = 50), or d) schizoaffective disorder (n = 26). Current voice-hearers were also subdivided into prevailing mood states: a) euthymic (n = 23), b) depressed (n = 51), or c) mania-mixed (n = 12). An in-depth, semi-structured interview was conducted, accompanied by mixed-methods analyses. Of the 34 AVH characteristics, significant group differences across diagnoses were identified only for frequency, number of voices, form of address, perceived location, level of conviction, beliefs regarding origin, and functional interference. Random forests modelling (RFM) showed experienced distress and functional interference were best predicted by discrete AVH variables. Qualitative thematic analysis revealed first-order themes: a) content, b) form, c) function, and d) non-voice. There were more similarities than differences in the phenomenology of AVHs across diagnoses, yet significant predictors of voice-related distress and functional impairment differed across affective and non-affective psychosis. This has important nosological and therapeutic applications.

Characteristics of non-clinical hallucinations: A mixed-methods analysis of auditory, visual, tactile and olfactory hallucinations in a primary voice-hearing cohort

Phenomenological studies involving hallucinations in non-clinical populations have been relatively neglected, especially within the non-auditory realm. Relevant knowledge would help further a more nuanced understanding of the psychosis continuum. Participants (N=33) were non-clinical voice-hearers, who have experienced auditory verbal hallucinations, but with no known mental health diagnosis and not taking any prescribed psychiatric medications. A comprehensive hallucinations phenomenology interview was conducted to assess physical, cognitive and emotional characteristics of hallucinatory experiences across sensory domains. Mixed methods analysis was employed. Characteristics of reported AVHs were mostly in agreement with existing knowledge, though some deviations did exist (e.g. controllability). In addition, 50%, 24% and 29% of our voice-hearing sample experienced hallucinations in the visual, tactile and olfactory domains at least once a week. In contrast, delusions and disordered thinking were rare. Qualitative thematic analysis yielded added phenomenological insights into contextual triggers as well as the content and perceived purpose(s) of multisensory hallucinations. Our findings highlight lesser-reported data that hallucinations in non-auditory domains are relatively frequent in non-clinical voice-hearers. However, other psychotic-like symptoms (i.e. delusions and thought disorder) seem less common. These insights should be considered in the context of the psychosis continuum argument.

Changes in motor preparation affect the sensory consequences of voice production in voice hearers

BACKGROUND

Auditory verbal hallucinations (AVH) are a cardinal symptom of psychosis but are also present in 6-13% of the general population. Alterations in sensory feedback processing are a likely cause of AVH, indicative of changes in the forward model. However, it is unknown whether such alterations are related to anomalies in forming an efference copy during action preparation, selective for voices, and similar along the psychosis continuum. By directly comparing psychotic and nonclinical voice hearers (NCVH), the current study specifies whether and how AVH proneness modulates both the efference copy (Readiness Potential) and sensory feedback processing for voices and tones (N1, P2) with event-related brain potentials (ERPs).

METHODS

Controls with low AVH proneness (n = 15), NCVH (n = 16) and first-episode psychotic patients with AVH (n = 16) engaged in a button-press task with two types of stimuli: self-initiated and externally generated self-voices or tones during EEG recordings.

RESULTS

Groups differed in sensory feedback processing of expected and actual feedback: NCVH displayed an atypically enhanced N1 to self-initiated voices, while N1 suppression was reduced in psychotic patients. P2 suppression for voices and tones was strongest in NCVH, but absent for voices in patients. Motor activity preceding the button press was reduced in NCVH and patients, specifically for sensory feedback to self-voice in NCVH.

CONCLUSIONS

These findings suggest that selective changes in sensory feedback to voice are core to AVH. These changes already show in preparatory motor activity, potentially reflecting changes in forming an efference copy. The results provide partial support for continuum models of psychosis.

World/self ambivalence: A shared mechanism in different subsets of psychotic experiences? Linking symptoms with resting-state fMRI

The psychosis spectrum comprises heterogeneous disorders characterized by both world-related and self-related symptoms. How these symptoms may arise with similar features in spite of the different aetiologies is yet an unsolved question. In behavior narrative review, we compare three conditions characterized by psychotic experiences (schizophrenia, substance-use disorder and sensory-deprivation) searching for links between their phenomenological features and the mechanisms underlying their onset. Clinically, psychotic experiences are characterized by the reciprocal contamination of world- and self-related contents, termed 'world/self ambivalence'. Neuroimaging evidence suggests that the imbalance between stimuli-, self-, and attention-related functional networks (visual/auditory, default-mode, and salience network respectively) assumes central relevance in all the conditions considered. Phenomenology and neurobiology were thus interrelated in light of the reviewed literature, identifying two key neuronal mechanisms which may lead to world/self ambivalence. First, psychotic experiences are associated with the relative dominance of one network over the other (default-mode over auditory/visual networks, or vice-versa), prompting an excess of internal or external pressure to the experienced ambivalence between world and self. Second, an altered salience network resting-state functional connectivity could generate a dysregulation of the attentive fluctuations from self- to world-related activity, thus blurring the boundary between the environment and oneself, labelled the 'world/self boundary'.

A typical antipsychotic treatment induced gradually expanding white matter alterations in healthy individuals with persistent auditory verbal hallucinations-an artificially controlled pilot study

OBJECTIVE

The aim of this study was to explore the effects of atypical antipsychotics (AaPs) on brain white matter (WM) tracts in healthy individuals with auditory verbal hallucinations (Hi-AVHs).

METHODS

We analyzed neuroimaging, AVH symptoms, and cognitive assessment data obtained from 39 Hi-AVHs who reported being distressed by persistent AVHs and volunteered to receive AaP treatment. We used tract-based spatial statistics (TBSS) and t tests to explore AaP pharmacotherapy effects on AVH symptoms and brain WM alterations in Hi-AVH subjects.

RESULTS

TBSS and t tests revealed WM alterations after AaP treatment, relative to pretreatment observations. Although AaPs alleviated AVH symptoms, WM alterations in these subjects expanded over 8 months of AaP treatment, encompassing most major WM tracts by the end of the observation period, including the corpus callosum, arcuate fasciculus, cortico-spinal tracts, anterior commissure, and posterior commissure.

CONCLUSIONS

The worsening of AaP-associated WM alterations observed in this study suggest that AaPs may not be a good choice for the treatment of Hi-AVHs despite their ability to alleviate AVHs.

Clinical and theoretical relevance of responses to analogues of psychotic experiences in people with psychotic experiences with and without a need-for-care: an experimental study

BACKGROUND

Certain ways of responding to psychotic experiences (PEs) appear more commonly associated with clinical distress (e.g. avoidance) and other ways with benign or positive outcomes (e.g. reappraisal and acceptance). Past research has largely been limited to retrospective self-report. We aimed to compare clinical and non-clinical individuals on experimental analogues of anomalous experiences.

METHOD

Response styles of two groups with persistent PEs (clinical n = 84; non-clinical n = 92) and a control group without PEs (n = 83) were compared following experimental analogues of thought interference (Cards Task, Telepath) and hearing voices (Virtual Acoustic Space Paradigm).

RESULTS

The non-clinical group with PEs were less likely to endorse unhelpful response styles, such as passive responding or attempts to avoid, suppress, worry about or control mental experiences, compared with the clinical group on all three tasks. The clinical group were more likely to endorse unhelpful response styles compared with controls on two out of three tasks (Cards Task and Telepath). The non-clinical group performed similarly to controls on unhelpful responding across all tasks. There were no group differences for helpful response styles, such as cognitive reappraisal or mindful acceptance of experiences.

CONCLUSIONS

In line with cognitive models of psychosis, the findings suggest that the way in which individuals respond to unusual experiences may be an important factor in understanding clinical distress, supporting the therapeutic rationale of targeting potentially unhelpful patterns of response.

A time-series network approach to auditory verbal hallucinations: Examining dynamic interactions using experience sampling methodology

BACKGROUND

Identifying variables that influence daily-life fluctuations in auditory verbal hallucinations (AVHs) provides insight into potential mechanisms and targets for intervention. Network analysis, that uses time-series data collected by Experience Sampling Method (ESM), could be used to examine relations between multiple variables over time.

METHODS

95 daily voice-hearing individuals filled in a short questionnaire ten times a day for six consecutive days at pseudo-random moments. Using multilevel vector auto-regression, relations between voice-hearing and negative affect, positive affect, uncontrollable thoughts, dissociation, and paranoia were analysed in three types of networks: between-subjects (between persons, undirected), contemporaneous (within persons, undirected), and temporal (within persons, directed) networks. Strength centrality was measured to identify the most interconnected variables in the models.

RESULTS

Voice-hearing co-occurred with all variables, while on a 6-day period voice-hearing was only related to uncontrollable thoughts. Voice-hearing was not predicted by any of the factors, but it did predict uncontrollable thoughts and paranoia. All variables showed large autoregressions, i.e. mainly predicted themselves in this severe voice-hearing sample. Uncontrollable thoughts was the most interconnected factor, though relatively uninfluential.

DISCUSSION

Severe voice-hearing might be mainly related to mental state factors on the short-term. Once activated, voice-hearing appears to maintain itself. It is important to assess possible reactivity of AVH to triggers at the start of therapy; if reactive, therapy should focus on the triggering factor. If not reactive, Cognitive Behavioural interventions could be used first to reduce the negative effects of the voices. Limitations are discussed.

Functional brain alterations in auditory hallucination subtypes in individuals with auditory hallucinations without the diagnosis of specific neurological diseases and mental disorders at the current stage

BACKGROUND

We explored common and distinct pathological features of different subtypes of auditory hallucinations (AHs) to elucidate the underlying pathological mechanisms.

METHODS

We recruited 39 individuals with constant commanding and commenting auditory verbal hallucinations (CCCAVHs), 49 with own thought auditory verbal hallucinations (OTAVHs), 46 with nonverbal AHs (NVAHs), 32 with replay AVHs (RAVHs), and 50 healthy controls. Functional connectivity density mapping was used to investigate global functional connectivity density (gFCD) alterations in these AH groups relative to the control group.

RESULTS

We observed common brain functional alterations among four subtypes of AHs, such as increased gFCD in the bilateral superior temporal gyrus and mesial frontal lobe, and decreased gFCD in the bilateral medial prefrontal cortex. Increased gFCD was detected in the bilateral insula in CCCAVH individuals, bilateral thalamus in OTAVH individuals, bilateral precuneus in NVAH individuals, and bilateral hippocampus in RAVH individuals. The common and distinct gFCD alterations among four AH subtypes were located in main components of the frontoparietal, default mode, salience, central executive, and memory networks. Different AH subtypes exhibited specific aberrant patterns.

CONCLUSIONS

Our findings suggest that aberrant functional activity and metabolism in the abovementioned networks play key roles in the occurrence of AHs. Our findings provide evidence for distinct gFCD alterations in specific AH subtypes.

Testing the Interpersonal-Cognitive Model of Auditory Verbal Hallucinations in Youths with Either Early-Stage Borderline Personality Disorder or First-Episode Schizophrenia Spectrum Disorder

This is the first study to explore interpersonal schemata in outpatient youths (age 15-25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a transdiagnostic youth sample, the finding from studies of adults with AVH that negative beliefs about the self and others lead to negative appraisals of voices, which in turn elicits depression. The following 3 groups were compared: youth with BPD+AVH (n = 23), youth with schizophrenia spectrum disorder (SZ) with AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported more negative and fewer positive self schemata than the SZ+AVH group. They also saw themselves as being more socially inferior to others than did the SZ+AVH group, but they did not differ in appraisals of self or others, compared with the BPD no AVH group. In youths with AVH (BPD+AVH, SZ+AVH combined), the indirect effect of beliefs about self or others, via negative appraisals of voices on depression, was not significant. Instead, a significant indirect effect of negative appraisals of voices on depression, via negative beliefs about self, was found. The experience of AVH during adolescence and young adulthood, when the identity is still being formed, might have a more profound effect on the developing self than during later adulthood, when the self is more stable and resilient. Negative self-appraisals might constitute a treatment target for early intervention for youths with distressing voices, including those with BPD.

Treatment of auditory verbal hallucinations with atypical antipsychotics in healthy individuals: an artificially controlled post-treatment report

OBJECTIVE

This study was performed to investigate the effects and associated global functional connectivity density (gFCD) alterations associated with the use of atypical antipsychotics in healthy individuals with auditory verbal hallucinations (Hi-AVHs) using gFCD mapping techniques.

METHODS

A magnetic resonance imaging database of 38 Hi-AVHs with chronic or severe AVH symptoms was generated. The Hi-AVHs were administered an atypical antipsychotic (risperidone) for 24 weeks and monitored for a treatment response. All patients underwent functional magnetic resonance imaging pre- and post-treatment.

RESULTS

gFCD alterations were found in the auditory-memory-language and visual circuit regions pre- and post-treatment. However, gFCD alterations differed between patients with strong and weak treatment responses.

CONCLUSION

This is the first report to show that atypical antipsychotics can improve the symptoms of AVHs and that the treatment effects are associated with gFCD alterations in the auditory-memory-language circuit. These findings provide a foundation for future exploration of new treatment strategies for Hi-AVHs.

The link between self-compassion and psychotic-like experiences: A matter of distress?

OBJECTIVES

Self-shaming and self-criticism have been shown to contribute to the emergence of distressing psychotic symptoms and psychotic-like experiences (PLEs). In contrast, a self-compassionate mindset may protect against negative evaluations in response to PLEs leading to less distress. This study explores the association between self-compassion, the frequency of PLEs, and their associated distress.

DESIGN

The study used a correlational, cross-sectional design on a German community sample.

METHODS

A total of 234 participants completed the self-compassion scale (SCS), the Peters' Delusions Inventory, and a modified version of the Launay-Slade Hallucination Scale that measures frequency and distress of hallucinatory experiences. Pearson correlations between SCS and frequency of PLEs as well as between SCS and PLE-distress were compared. Additionally, network analyses of SCS and PLE-measures were calculated.

RESULTS

Self-compassion was associated with less-frequent PLEs and with less PLE-distress, with stronger correlations between self-compassion and PLE-distress. The network analysis showed the self-compassion facets isolation and overidentification to be the closest links to PLE-distress.

CONCLUSIONS

Self-compassion is associated with less PLE related distress. Prevention programmes and interventions that target the negative facets associated with lack of self-compassion may be promising. However, future studies need to explore the causal role of self-compassion facets in the formation of PLE-distress.

PRACTITIONER POINTS

Low levels of self-compassion are associated with being more distressed by psychotic experiences. As the self-compassion facets isolation and overidentification are most strongly related to distress, prevention and intervention programmes may benefit from focusing on these negative facets.

Does hallucination perceptual modality impact psychosis risk?

OBJECTIVE

Subthreshold perceptual abnormalities are commonly used to identify individuals at clinical high risk (CHR) for developing a psychotic disorder. Predictive validity for modality-specific perceptual abnormality severity on psychosis risk is unknown.

METHODS

We examined prospectively collected data from 164 individuals age 12-35 meeting criteria for CHR followed for 6-24 months or until conversion to psychosis. Using intake interview notes, baseline perceptual abnormality scores were split into auditory, visual, somatic/tactile, and olfactory/gustatory components, and auditory scores were further split into those for verbal vs non-verbal content. Relationships between perceptual abnormality characteristics and conversion were assessed with Cox proportional hazards regression and logistic regression.

RESULTS

Unusual thought content and paranoia were predictive of conversion, but no modality-specific perceptual abnormality score predicted conversion status or days to conversion. However, when auditory perceptual abnormalities were further categorized as verbal vs non-verbal, the severity of verbal experiences was predictive of conversion to psychosis (P = 0.007).

CONCLUSIONS

Perceptual abnormality scores failed to meaningfully predict conversion to psychosis in either direction in this CHR sample. However, verbal auditory experiences may identify a group of CHR individuals at elevated risk of conversion. Further exploration of the relationship between phenomenological aspects of perceptual abnormalities and conversion risk is warranted.

Psychosocial characteristics differentiate non-distressing and distressing voices in 10,346 adolescents

Adolescents hearing non-existent voices may be at risk for psychosis, but the prevalence of voice-hearing (VH) in the general population complicates clinical interpretations. Differentiating between VH with and without distress may aid treatment decisions in psychosis services, but understanding the differences between these two phenomena as they present in the normal adolescent population is necessary to validate this differentiation. The present study compared VH with and without distress in 10,346 adolescents in relation to clinical characteristics, known risk factors, predictors and psychosocial moderators of psychosis. A population-based cohort of Norwegian 16-19 years old adolescents completed a comprehensive web-based questionnaire, including two questions from the extended Launay-Slade Hallucinations Scale: (1) I often hear a voice speaking my thoughts aloud and (2) I have been troubled by hearing voices in my head. Adolescents reporting no VH, non-distressing VH or distressing VH were compared on 14 psychosocial and clinical variables. A multinomial regression model showed that non-disturbing voices were predicted by better school grades, social dysfunction, distractibility, affective symptoms and experience of trauma, while the disturbing voices were predicted by the experience of bullying and trauma, perceived negative self-worth and self-efficacy, less family support, dysregulation of activation, distractibility, self-harm and anxiety. Hearing voices without distress versus being distressed by the voices is related to different constellations of psychosocial variables, suggesting that they represent two separate groups of adolescents. The findings validate the emphasis on distress in clinical practice.

The comments of voices on the appearance of patients with psychosis: 'the voices tell me that I am ugly'

BACKGROUND

There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal.

AIMS

To systematically assess the occurrence of voice content regarding appearance and identify correlates.

METHOD

Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being.

RESULTS

Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was 'the voices tell me that I am ugly' (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was 'I look as nice as other people' (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia.

CONCLUSIONS

Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect - and subsequently reinforce - negative beliefs about one's appearance, low self-esteem, worry and paranoia.

DECLARATION OF INTEREST

None.

Reading characters in voices: Ratings of personality characteristics from voices predict proneness to auditory verbal hallucinations

People rapidly make first impressions of others, often based on very little information–minimal exposure to faces or voices is sufficient for humans to make up their mind about personality of others. While there has been considerable research on voice personality perception, much less is known about its relevance to hallucination-proneness, despite auditory hallucinations being frequently perceived as personified social agents. The present paper reports two studies investigating the relation between voice personality perception and hallucination-proneness in non-clinical samples. A voice personality perception task was created, in which participants rated short voice recordings on four personality characteristics, relating to dimensions of the voice’s perceived Valence and Dominance. Hierarchical regression was used to assess contributions of Valence and Dominance voice personality ratings to hallucination-proneness scores, controlling for paranoia-proneness and vividness of mental imagery. Results from Study 1 suggested that high ratings of voices as dominant might be related to high hallucination-proneness; however, this relation seemed to be dependent on reported levels of paranoid thinking. In Study 2, we show that hallucination-proneness was associated with high ratings of voice dominance, and this was independent of paranoia and imagery abilities scores, both of which were found to be significant predictors of hallucination-proneness. Results from Study 2 suggest an interaction between gender of participants and the gender of the voice actor, where only ratings of own gender voices on Dominance characteristics are related to hallucination-proneness scores. These results are important for understanding the perception of characterful features of voices and its significance for psychopathology.

The Phenomenon of "Hearing Voices": Not Just Psychotic Hallucinations-A Psychological Literature Review and a Reflection on Clinical and Social Health

The phenomenon of hearing voices is currently a much-discussed topic, both in the field of research and in the field of care services. The majority of people who report "hearing voices" do not subsequently receive services or receive a diagnosis of psychopathology. This topic raises questions for professionals in the health field about the lack of tools that can help illuminate the phenomenon. The purposes of this work are (a) to highlight the psychological studies that approach the phenomenon in a non-psychopathological way and (b) to determine which concepts could aid the comprehension of the phenomenon. The method consists of a systematic review of the literature that characterizes the phenomenon of hearing voices from a non-pathological perspective. The literature offers different theoretical approaches to interpret the phenomenon in a way that is not necessarily pathological and presents new tools for examining the phenomenon. For example, a few studies state that it is possible to coexist with voices, while others indicate that it is necessary to know how to manage voices. We highlighted and discussed several concepts that can support doctors, psychiatrists and practitioners in understanding "hearer" patients, particularly attention to the context of belonging, attention to language, and the role of the sense-making process.

Paracingulate Sulcus Morphology and Hallucinations in Clinical and Nonclinical Groups

Hallucinations are a characteristic symptom of psychotic mental health conditions that are also experienced by many individuals without a clinical diagnosis. Hallucinations in schizophrenia have been linked to differences in the length of the paracingulate sulcus (PCS), a structure in the medial prefrontal cortex which has previously been associated with the ability to differentiate perceived and imagined information. We investigated whether this putative morphological basis for hallucinations extends to individuals without a clinical diagnosis, by examining whether nonclinical individuals with hallucinations have shorter PCS than nonclinical individuals without hallucinations. Structural MRI scans were examined from 3 demographically matched groups of individuals: 50 patients with psychotic diagnoses who experienced auditory verbal hallucinations (AVHs), 50 nonclinical individuals with AVHs, and 50 healthy control subjects with no life-time history of hallucinations. Results were verified using automated data-driven gyrification analyses. Patients with hallucinations had shorter PCS than both healthy controls and nonclinical individuals with hallucinations, with no difference between nonclinical individuals with hallucinations and healthy controls. These findings suggest that the association of shorter PCS length with hallucinations is specific to patients with a psychotic disorder. This presents challenges for full-continuum models of psychosis and suggests possible differences in the mechanisms underlying hallucinations in clinical and nonclinical groups.

Feasibility and Acceptability of Using a Mobile Phone App for Characterizing Auditory Verbal Hallucinations in Adolescents With Early-Onset Psychosis: Exploratory Study

Background

Auditory verbal hallucinations (AVH) are the most frequent symptom in early-onset psychosis (EOP) and a risk factor for increased suicide attempts in adolescents. Increased knowledge of AVH characteristics can lead to better prediction of risk and precision of diagnosis and help identify individuals with AVH who need care. As 98% of Norwegian adolescents aged 12 to 16 years own a mobile phone, the use of mobile phone apps in symptom assessment and patient communication is a promising new tool. However, when introducing new technology to patients, their subjective experiences are crucial in identifying risks, further development, and potential integration into clinical care.

Objective

The objective was to explore the feasibility and acceptability of a newly developed mobile phone app in adolescents with EOP by examining compliance with the app and user experiences. Indication of validity was explored by examining associations between AVH dimensions, which were correlated and analyzed.

Methods

Three adolescents with EOP and active AVH were enrolled. Real-time AVH were logged on an iPod touch using the experience sampling method (ESM), for seven or more consecutive days. The app included five dimensions of AVH characteristics and was programmed with five daily notifications. Feasibility and acceptability were examined using the mean response rate of data sampling and by interviewing the participants. Validity was assessed by examining associations between the AVH dimensions using nonparametric correlation analysis and by visual inspection of temporal fluctuations of the AVH dimensions.

Results

One participant was excluded from the statistical analyses but completed the interview and was included in the examination of acceptability. The sampling period of the two participants was mean 12 (SD 6) days with overall completed sampling rate of 74% (SD 30%), indicating adequate to high compliance with the procedure. The user experiences from the interviews clustered into four categories: (1) increased awareness, (2) personal privacy, (3) design and procedure, and (4) usefulness and clinical care. One participant experienced more commenting voices during the sampling period, and all three participants had concerns regarding personal privacy when using electronic devices in symptom assessment. The AVH dimensions of content, control, and influence showed moderate to strong significant correlations with all dimensions (P<.001). Days of data sampling showed weak to moderate correlations with localization (P<.001) and influence (P=.03). Visual inspection indicated that the app was able to capture fluctuations within and across days for all AVH dimensions.

Conclusions

This study demonstrates the value of including patients’ experiences in the development and pilot-testing of new technology. Based on the small sample size, the use of mobile phones with ESM seems feasible for patients with EOP, but the acceptability of using apps should be considered. Further investigation with larger samples is warranted before definitive conclusions are made.

Towards a Mechanistic-Driven Precision Medicine Approach for Tinnitus

In this position review, we propose to establish a path for replacing the empirical classification of tinnitus with a taxonomy from precision medicine. The goal of a classification system is to understand the inherent heterogeneity of individuals experiencing and suffering from tinnitus and to identify what differentiates potential subgroups. Identification of different patient subgroups with distinct audiological, psychophysical, and neurophysiological characteristics will facilitate the management of patients with tinnitus as well as the design and execution of drug development and clinical trials, which, for the most part, have not yielded conclusive results. An alternative outcome of a precision medicine approach in tinnitus would be that additional mechanistic phenotyping might not lead to the identification of distinct drivers in each individual, but instead, it might reveal that each individual may display a quantitative blend of causal factors. Therefore, a precision medicine approach towards identifying these causal factors might not lead to subtyping these patients but may instead highlight causal pathways that can be manipulated for therapeutic gain. These two outcomes are not mutually exclusive, and no matter what the final outcome is, a mechanistic-driven precision medicine approach is a win-win approach for advancing tinnitus research and treatment. Although there are several controversies and inconsistencies in the tinnitus field, which will not be discussed here, we will give a few examples, as to how the field can move forward by exploring the major neurophysiological tinnitus models, mostly by taking advantage of the common features supported by all of the models. Our position stems from the central concept that, as a field, we can and must do more to bring studies of mechanisms into the realm of neuroscience.

A comparison of hallucinatory experiences and their appraisals in those with and without mental illness

Few studies have compared the content and appraisal of hallucinatory experiences (HE) by people with psychosis and those without. This study compared the characteristics of HE, and their appraisals, in individuals with psychotic disorder, non-psychotic mental disorder and no disorder in the general population. Participants (n = 253) aged between 30-33 years who reported HE were recruited from a birth cohort and assessed for lifetime diagnoses of mental disorders. They were allocated to groups based on their diagnosis and their HE were rated to assess their form, content and associated appraisals. Compared to those with no mental disorder, participants with a psychotic disorder had almost twelve times the odds of appraising their HE as distressing and dangerous and nine times the odds of experiencing recurrent HE. Those with a non-psychotic disorder had more than twice the odds of recurrent HE compared to those with no disorder. Overall, HE showed more similarities than differences across the diagnostic groups. Negative appraisals of HE and their recurrence differentiated clinical from non-clinical populations. Screening for HE and assessment of their associated appraisals is essential in those seeking care for mental health difficulties. Interventions aimed at modifying maladaptive appraisals can assist in reducing hallucination related distress.

Adding Cognition to the Semanticscience Integrated Ontology

The goal of the NIMH RDoC initiative is to establish a biological basis for mental illness that includes linking cognition to molecular biology. A key challenge lies in how to represent such large, complex, and multi-scale knowledge in a manner that can support computational analysis, including query answering. Formal ontologies, such as the Semanticscience Integrated Ontology (SIO), offer a scaffold in which complex domain knowledge such as neurological and cognitive functions can be represented and linked to knowledge of molecular biology. In this article, we explore the use of SIO to represent concepts in molecular biology and in cognition. We extend SIO to traditional cognitive topics by illustrating axioms for both an information-processing and a neuroscience perspective on reading. We next discuss the NIMH RDoC taxonomy and include SIO axioms for the units-of-analysis and functions-of-behavior dimensions. An example demonstrates its use of deductive reasoning to establish causal relations across RDoC dimensions. From a broader perspective this article demonstrates how informatics can assist in integrating work in clinical psychology, cognitive psychology, cognitive neuroscience, computer science, molecular biology, and philosophy.