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

Diversity Within the Psychotic Continuum

There has been great interest in the hallucination-like events experienced by the general nonclinical population. Many psychiatric scientists have come to identify these as part of a "psychotic continuum" and have begun to ask what we might learn from these experiences that will enable us to better understand and treat psychosis. While sympathetic to this goal, this paper argues that many of these events in the nonclinical population may be associated with the attention to inner imagery characteristic of much religious practice like unscripted prayer. Many of these hallucination-like events are phenomenologically distinct, culturally salient, and are predicted both by a measure of absorption, which probes for an interest in inner imagery, and by inner sense cultivation practice. These observations suggest that rare, brief, and positive sensory events may not be associated with psychotic vulnerability. They also suggest there may be an absorption-dissociation pathway, with or without trauma, for more frequent hallucinations.

Testing continuum models of psychosis: No reduction in source monitoring ability in healthy individuals prone to auditory hallucinations

People with schizophrenia who hallucinate show impairments in reality monitoring (the ability to distinguish internally generated information from information obtained from external sources) compared to non-hallucinating patients and healthy individuals. While this may be explained at least in part by an increased externalizing bias, it remains unclear whether this impairment is specific to reality monitoring, or whether it also reflects a general deficit in the monitoring of self-generated information (internal source monitoring). Much interest has focused recently on continuum models of psychosis which argue that hallucination-proneness is distributed in clinical and non-clinical groups, but few studies have directly investigated reality monitoring and internal source monitoring abilities in healthy individuals with a proneness to hallucinations. Two experiments are presented here: the first (N = 47, with participants selected for hallucination-proneness from a larger sample of 677 adults) found no evidence of an impairment or externalizing bias on a reality monitoring task in hallucination-prone individuals; the second (N = 124) found no evidence of atypical performance on an internal source monitoring task in hallucination-prone individuals. The significance of these findings is reviewed in light of the clinical evidence and the implications for models of hallucination generation discussed.

Hallucinations, loneliness, and social isolation in Alzheimer's disease

INTRODUCTION

Cognitive and functional compromise, as frequently observed in Alzheimer's disease (AD), hinders communication and social interactions. One consequence of this hindrance may be a feeling of loneliness. Moreover, emptiness and boredom, as observed in social isolation and loneliness, may thus be compensated for by creating imagined stimuli. Conditions of loneliness may be viewed as potentially generating hallucinatory experiences. To assess this assumption, the present study explored the relationship between social isolation, loneliness, and hallucinations in a sample of 22 mild AD participants and 24 elderly, healthy controls.

METHODS

Participants were assessed using the Launay-Slade Hallucination Scale, the UCLA Loneliness Scale, and a scale exploring contact with others and social participation.

RESULTS

More hallucinatory experiences, social isolation, and loneliness were found in the AD group than in the healthy control group. Moreover, significant correlations were observed between hallucinations and loneliness and between hallucinations and social isolation in both groups. Finally, hallucinations were predicted by social isolation.

DISCUSSION

Hallucinations may constitute a compensatory mechanism that aims to fulfil communication needs in lonely, elderly participants. Hallucinations may also be regarded as experiences that allow certain participants to escape the cycle of boredom, emptiness, and affective deprivation caused by social isolation.

Auditory verbal hallucinations and continuum models of psychosis: A systematic review of the healthy voice-hearer literature

Recent decades have seen a surge of research interest in the phenomenon of healthy individuals who experience auditory verbal hallucinations, yet do not exhibit distress or need for care. The aims of the present systematic review are to provide a comprehensive overview of this research and examine how healthy voice-hearers may best be conceptualised in relation to the diagnostic versus ‘quasi-‘ and ‘fully-dimensional’ continuum models of psychosis. A systematic literature search was conducted, resulting in a total of 398 article titles and abstracts that were scrutinised for appropriateness to the present objective. Seventy articles were identified for full-text analysis, of which 36 met criteria for inclusion. Subjective perceptual experience of voices, such as loudness or location (i.e., inside/outside head), is similar in clinical and non-clinical groups, although clinical voice-hearers have more frequent voices, more negative voice content, and an older age of onset. Groups differ significantly in beliefs about voices, control over voices, voice-related distress, and affective difficulties. Cognitive biases, reduced global functioning, and psychiatric symptoms such as delusions, appear more prevalent in healthy voice-hearers than in healthy controls, yet less than in clinical samples. Transition to mental health difficulties is increased in HVHs, yet only occurs in a minority and is predicted by previous mood problems and voice distress. Whilst healthy voice-hearers show similar brain activity during hallucinatory experiences to clinical voice-hearers, other neuroimaging measures, such as mismatch negativity, have been inconclusive. Risk factors such as familial and childhood trauma appear similar between clinical and non-clinical voice-hearers. Overall the results of the present systematic review support a continuum view rather than a diagnostic model, but cannot distinguish between ‘quasi’ and ‘fully’ dimensional models. Healthy voice-hearers may be a key resource in informing transdiagnostic approaches to research of auditory hallucinations.

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Subjective perceptual experiences of voices appear similar in clinical and non-clinical groups.

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Healthy voice-hearers hear voices less frequently, with less negative content, more perceived control and from an earlier age.

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Healthy and clinical voice-hearers differ in beliefs about voices, voice-related distress, and affective difficulties.

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Healthy voice-hearers show more cognitive biases, psychiatric symptoms and functional impairments than healthy controls.

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Risk factors such as familial and childhood trauma appear similar between clinical and non-clinical voice-hearers.

A linguistic comparison between auditory verbal hallucinations in patients with a psychotic disorder and in nonpsychotic individuals: Not just what the voices say, but how they say it

BACKGROUND

Auditory verbal hallucinations (AVH) in psychotic patients are associated with activation of right hemisphere language areas, although this hemisphere is non-dominant in most people. Language generated in the right hemisphere can be observed in aphasia patients with left hemisphere damage. It is called "automatic speech", characterized by low syntactic complexity and negative emotional valence. AVH in nonpsychotic individuals, by contrast, predominantly have a neutral or positive emotional content and may be less dependent on right hemisphere activity. We hypothesize that right hemisphere language characteristics can be observed in the language of AVH, differentiating psychotic from nonpsychotic individuals.

METHOD

17 patients with a psychotic disorder and 19 nonpsychotic individuals were instructed to repeat their AVH verbatim directly upon hearing them. Responses were recorded, transcribed and analyzed for total words, mean length of utterance, proportion of grammatical utterances, proportion of negations, literal and thematic perseverations, abuses, type-token ratio, embeddings, verb complexity, noun-verb ratio, and open-closed class ratio.

RESULTS

Linguistic features of AVH overall differed between groups F(13,24)=3.920, p=0.002; Pillai's Trace 0.680. AVH of psychotic patients compared with AVH of nonpsychotic individuals had a shorter mean length of utterance, lower verb complexity, and more verbal abuses and perseverations (all p<0.05). Other features were similar between groups.

CONCLUSION

AVH of psychotic patients showed lower syntactic complexity and higher levels of repetition and abuses than AVH of nonpsychotic individuals. These differences are in line with a stronger involvement of the right hemisphere in the origination of AVH in patients than in nonpsychotic voice hearers.

Associations between nonauditory hallucinations, dissociation, and childhood adversity in first-episode psychosis

Although repeated associations have been found between adversity exposure (particularly exposure to childhood sexual abuse), dissociation, and auditory hallucinations in the context of psychosis, there is little comparable research examining hallucinations in other modalities. This study aimed to determine whether cumulative adversity exposure influences the likelihood of experiencing visual, tactile, olfactory, and gustatory hallucinations among psychosis patients and whether measures of dissociation are significantly associated with nonauditory hallucinations when exposure to childhood adversity and psychological distress are adjusted for. Self-report measures and a retrospective case-control design were applied to assess nonauditory hallucinations, dissociation, psychological distress, and childhood adversity exposure in a sample of first-episode psychosis patients reporting nonauditory hallucinations (n = 36) and controls from the same clinical population without nonauditory hallucinations (n = 31). Case participants reported higher levels of dissociation, psychological distress, and exposure to childhood rape than the control group. Dissociation remained significantly associated with nonauditory hallucinations when we adjusted for childhood sexual abuse, other types of childhood adversity, and a combined measure of emotional distress. Indication of a dose-response relationship was detected, in that total number of adversities was significantly associated with reporting more than one modality of nonauditory hallucination. Observed associations between auditory hallucinations and dissociation in psychosis may extend to other hallucination modalities. It is suggested that more research attention be paid to the etiology and impact of nonauditory hallucinations in psychosis samples.

Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood: Prospective evidence from the MUSP birth cohort study

BACKGROUND

Hallucinations, once equated with serious mental disorders, are common in adolescents. Given the high prevalence of hallucinations, it is important to determine if they are associated with adverse mental health outcomes in adulthood. This study compared the mental health outcomes of participants (aged 30-33years) in the Mater-University of Queensland Study of Pregnancy (MUSP) who reported hallucinations at (a) 14years only and (b) 14 and 21years versus cohort members without hallucinations.

METHOD

Participants (n=333) were aged between 30 and 33years and (a) reported hallucinations on the Youth Self-Report Questionnaire at 14 and/or the Young Adult Self-Report Questionnaire at 21years and (b) controls (n=321) who did not report hallucinations. Lifetime diagnoses of mental disorders were ascertained by the Structured Clinical Interview for DSM Disorders (DSM IV-TR) administered by clinical psychologists. Suicidal behaviour was measured by self report.

RESULTS

Hallucinations at 14years only were not associated with an increased risk of mental disorders in adulthood. Hallucinations reported at both 14 and 21years were associated with lifetime diagnoses of psychotic disorders (OR, 8.84; 95% CI: 1.61-48.43 and substance use disorders (OR, 2.34; 95% CI: 1.36-4.07) and also strongly associated with lifetime suicide attempts (OR, 7.11; 95% CI: 2.68-18.83).

CONCLUSIONS

Most adolescents who experience hallucinations do not have an increased rate of mental disorder in adulthood; however, those with hallucinations that are experienced at more than one point in time are at increased risk of suicidal behaviour and both psychotic and non-psychotic psychopathology.

Impaired Self-Monitoring of Inner Speech in Schizophrenia Patients with Verbal Hallucinations and in Non-clinical Individuals Prone to Hallucinations

BACKGROUND

Previous research has shown that various memory errors reflecting failure in the self-monitoring of speech were associated with auditory/verbal hallucinations in schizophrenia patients and with proneness to hallucinations in non-clinical individuals.

METHOD

We administered to 57 schizophrenia patients and 60 healthy participants a verbal memory task involving free recall and recognition of lists of words with different structures (high-frequency, low-frequency, and semantically organisable words). Extra-list intrusions in free recall were tallied, and the response bias reflecting tendency to make false recognitions of non-presented words was computed for each list.

RESULTS

In the male patient subsample, extra-list intrusions were positively associated with verbal hallucinations and inversely associated with negative symptoms. In the healthy participants the extra-list intrusions were positively associated with proneness to hallucinations. A liberal response bias in the recognition of the high-frequency words was associated with verbal hallucinations in male patients and with proneness to hallucinations in healthy men. Meanwhile, a conservative response bias for these high-frequency words was associated with negative symptoms in male patients and with social anhedonia in healthy men.

CONCLUSION

Misattribution of inner speech to an external source, reflected by false recollection of familiar material, seems to underlie both clinical and non-clinical hallucinations. Further, both clinical and non-clinical negative symptoms may exert on verbal memory errors an effect opposite to that of hallucinations.

Auditory Hallucinations and the Brain's Resting-State Networks: Findings and Methodological Observations

In recent years, there has been increasing interest in the potential for alterations to the brain's resting-state networks (RSNs) to explain various kinds of psychopathology. RSNs provide an intriguing new explanatory framework for hallucinations, which can occur in different modalities and population groups, but which remain poorly understood. This collaboration from the International Consortium on Hallucination Research (ICHR) reports on the evidence linking resting-state alterations to auditory hallucinations (AH) and provides a critical appraisal of the methodological approaches used in this area. In the report, we describe findings from resting connectivity fMRI in AH (in schizophrenia and nonclinical individuals) and compare them with findings from neurophysiological research, structural MRI, and research on visual hallucinations (VH). In AH, various studies show resting connectivity differences in left-hemisphere auditory and language regions, as well as atypical interaction of the default mode network and RSNs linked to cognitive control and salience. As the latter are also evident in studies of VH, this points to a domain-general mechanism for hallucinations alongside modality-specific changes to RSNs in different sensory regions. However, we also observed high methodological heterogeneity in the current literature, affecting the ability to make clear comparisons between studies. To address this, we provide some methodological recommendations and options for future research on the resting state and hallucinations.

Hallucinations as top-down effects on perception

The problem of whether and how information is integrated across hierarchical brain networks embodies a fundamental tension in contemporary cognitive neuroscience, and by extension, cognitive neuropsychiatry. Indeed, the penetrability of perceptual processes in a 'top-down' manner by higher-level cognition-a natural extension of hierarchical models of perception-may contradict a strictly modular view of mental organization. Furthermore, some in the cognitive science community have challenged cognitive penetration as an unlikely, if not impossible, process. We review the evidence for and against top-down influences in perception, informed by a predictive coding model of perception and drawing heavily upon the literature of computational neuroimaging. We extend these findings to propose a way in which these processes may be altered in mental illness. We propose that hallucinations - perceptions without stimulus - can be understood as top-down effects on perception, mediated by inappropriate perceptual priors.

Using virtual reality to investigate psychological processes and mechanisms associated with the onset and maintenance of psychosis: a systematic review

PURPOSE

In the last decade researchers have embraced virtual reality to explore the psychological processes and mechanisms that are involved in the onset and maintenance of psychosis. A systematic review was conducted to synthesise the evidence of using virtual reality to investigate these mechanisms.

METHODS

Web of Science, PsycINFO, Embase, and Medline were searched. Reference lists of collected papers were also visually inspected to locate any relevant cited journal articles. In total 6001 articles were potentially eligible for inclusion; of these, 16 studies were included in the review.

RESULTS

The review identified studies investigating the effect of interpersonal sensitivity, childhood bullying victimisation, physical assault, perceived ethnic discrimination, social defeat, population density and ethnic density on the real-time appraisal of VR social situations. Further studies demonstrated the potential of VR to investigate paranoid ideation, anomalous experiences, self-confidence, self-comparison, physiological activation and behavioural response.

CONCLUSIONS

The reviewed studies suggest that VR can be used to investigate psychological processes and mechanisms associated with psychosis. Implications for further experimental research, as well as for assessment and clinical practise are discussed. The present review has been registered in the PROSPERO register: CRD42016038085.

Listening to Schneiderian Voices: A Novel Phenomenological Analysis

BACKGROUND/AIMS

This paper reports on analyses designed to elucidate phenomenological characteristics, content and experience specifically targeting participants with Schneiderian voices conversing/commenting (VC) while exploring differences in clinical presentation and quality of life compared to those with voices not conversing (VNC).

METHODS

This mixed-method investigation of Schneiderian voices included standardized clinical metrics and exploratory phenomenological interviews designed to elicit in-depth information about the characteristics, content, meaning, and personification of auditory verbal hallucinations.

RESULTS

The subjective experience shows a striking pattern of VC, as they are experienced as internal at initial onset and during the longer-term course of illness when compared to VNC. Participants in the VC group were more likely to attribute the origin of their voices to an external source such as God, telepathic communication, or mediumistic sources. VC and VNC were described as characterological entities that were distinct from self (I/we vs. you). We also found an association between VC and the positive, cognitive, and depression symptom profile. However, we did not find a significant group difference in overall quality of life.

CONCLUSIONS

The clinical portrait of VC is complex, multisensory, and distinct, and suggests a need for further research into the biopsychosocial interface between subjective experience, socioenvironmental constraints, individual psychology, and the biological architecture of intersecting symptoms.

Auditory Hallucinatory Beliefs in Patients With Schizophrenia: Association of Auditory Hallucinations With Social Interactions, Characteristics and Emotional Behaviors Over 3 Months

The aims of this study were to explore social interactions, characteristics, and emotional behaviors to detect changes in auditory hallucinatory beliefs in patients with schizophrenia over a 3-month period. Participants (n=189) were evaluated using the Auditory Hallucinations Assessment Scale (AHAS) and the Assessment of Communication and Interaction Skills (ACIS). The characteristics and emotional behaviors measured by the AHAS showed improvements, while auditory hallucinatory beliefs became less influential. Social interaction scores increased regardless of changes in auditory hallucinatory beliefs. Psychiatric professionals need to train those who hear voices to react to them with indifference.

Cognitive and neural models of threat appraisal in psychosis: A theoretical integration

Cognitive models of psychosis propose that maladaptive appraisals of anomalous experiences contribute to distress and disability in psychosis. Attentional, attributional and reasoning biases are hypothesised to drive these threat-based appraisals. Experimental and self-report data have provided support for the presence of these biases in psychosis populations, but recently there have been calls for neurobiological data to be integrated into these findings. Currently, little investigation has been conducted into the neural correlates of maladaptive appraisals. Experimental and neuroimaging research in social cognition employing threatening stimuli provide the closest equivalent of maladaptive appraisal in psychosis. Consequently, a rapprochement of these two literatures was attempted in order to identify neural networks relevant to threat appraisal in psychosis. This revealed overlapping models of aberrant emotion processing in anxiety and schizophrenia, encompassing the amygdala, insula, hippocampus, anterior cingulate cortex, and prefrontal cortex. These models posit that aberrant activity in these systems relates to altered emotional significance detection and affect regulation, providing a conceptual overlap with threat appraisal in psychosis, specifically attentional and attributional biases towards threat. It remains to be seen if direct examination of these biases using neuroimaging paradigms supports the theoretical integration of extant models of emotion processing and maladaptive appraisals in psychosis.

The intrasubjectivity of self, voices and delusions: A phenomenological analysis

To advance the area of phenomenology of voices and their interrelatedness to forms of delusions this study investigated the prevalence and interrelatedness of co-occurring auditory verbal hallucinations (AVHs) and delusions. Additionally we explored the characterization of distinct sub-categories/clusters of AVHs and delusions. Ninety-two participants experiencing psychosis were administered standardized clinical measures. We found a significant diagnostic difference with increased prevalence of co-occurring AVHs and delusions within the schizophrenia group compared to the bipolar with psychosis group. Regardless of diagnosis, there was a significant positive correlation between AVHs and delusions of reference, persecution, control, thought insertion, thought withdrawal and thought broadcasting. However, no significant relationship was found between AVHs and grandiose, somatic, religious, guilty or jealousy-themed delusions. Cluster analysis yielded two distinct cluster groups. Cluster One: Voices and Thought Delusions, and Cluster Two: Voices and Thematic Delusions. Cluster One participants showed elevated disorganized, cognitive and depressive symptoms, but not negative symptoms or excitement. This study underscores the need for expanded clinical and phenomenological research into the intersection of AVHs and delusions, including work that seeks to deconstruct conventional divisions between ostensible symptoms of perception' (hallucinations) and belief' (delusions).

The Representation of Agents in Auditory Verbal Hallucinations

Current models of auditory verbal hallucinations (AVHs) tend to focus on the mechanisms underlying their occurrence, but often fail to address the content of the auditory experience. In other words, they tend to ask why there are AVHs at all, instead of asking why, given that there are AVHs, they have the properties that they have. One such property, which has been largely overlooked and which we will focus on here, is why the voices are often experienced as coming from (or being the voices of) agents, and often specific, individualised agents. In this article, we argue not only that the representation of agents is important in accurately describing many cases of AVH, but also that deeper reflection on what is involved in the representation of agents has potentially vital consequences for our aetiological understanding of AVH, namely, for understanding how and why AVHs come about.

Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a "need for care"

Individuals reporting persistent psychotic experiences (PEs) in the general population, but without a "need for care", are a unique group of particular importance in identifying risk and protective factors for psychosis. We compared people with persistent PEs and no "need for care" (non-clinical, N=92) with patients diagnosed with a psychotic disorder (clinical, N=84) and controls without PEs (N=83), in terms of their phenomenological, socio-demographic and psychological features. The 259 participants were recruited from one urban and one rural area in the UK, as part of the UNIQUE (Unusual Experiences Enquiry) study. Results showed that the non-clinical group experienced hallucinations in all modalities as well as first-rank symptoms, with an earlier age of onset than in the clinical group. Somatic/tactile hallucinations were more frequent than in the clinical group, while commenting and conversing voices were rare. Participants in the non-clinical group were differentiated from their clinical counterparts by being less paranoid and deluded, apart from ideas of reference, and having fewer cognitive difficulties and negative symptoms. Unlike the clinical group, they were characterized neither by low psychosocial functioning nor by social adversity. However, childhood trauma featured in both groups. They were similar to the controls in psychological characteristics: they did not report current emotional problems, had intact self-esteem, displayed healthy schemas about the self and others, showed high life satisfaction and well-being, and high mindfulness. These findings support biopsychosocial models postulating that environmental and psychological factors interact with biological processes in the aetiology of psychosis. While some PEs may be more malign than others, lower levels of social and environmental adversity, combined with protective factors such as intact IQ, spirituality, and psychological and emotional well-being, may reduce the likelihood of persistent PEs leading to pathological outcomes. Future research should focus on protective factors and determinants of well-being in the context of PEs, rather than exclusively on risk factors and biomarkers of disease states.

Non-invasive Brain Stimulation and Auditory Verbal Hallucinations: New Techniques and Future Directions

Auditory verbal hallucinations (AVHs) are the experience of hearing a voice in the absence of any speaker. Results from recent attempts to treat AVHs with neurostimulation (rTMS or tDCS) to the left temporoparietal junction have not been conclusive, but suggest that it may be a promising treatment option for some individuals. Some evidence suggests that the therapeutic effect of neurostimulation on AVHs may result from modulation of cortical areas involved in the ability to monitor the source of self-generated information. Here, we provide a brief overview of cognitive models and neurostimulation paradigms associated with treatment of AVHs, and discuss techniques that could be explored in the future to improve the efficacy of treatment, including alternating current and random noise stimulation. Technical issues surrounding the use of neurostimulation as a treatment option are discussed (including methods to localize the targeted cortical area, and the state-dependent effects of brain stimulation), as are issues surrounding the acceptability of neurostimulation for adolescent populations and individuals who experience qualitatively different types of AVH.

Auditory verbal hallucinations: Social, but how?

Auditory verbal hallucinations (AVH) are experiences of hearing voices in the absence of an external speaker. Standard explanatory models propose that AVH arise from misattributed verbal cognitions (i.e. inner speech), but provide little account of how heard voices often have a distinct persona and agency. Here we review the argument that AVH have important social and agent-like properties and consider how different neurocognitive approaches to AVH can account for these elements, focusing on inner speech, memory, and predictive processing. We then evaluate the possible role of separate social-cognitive processes in the development of AVH, before outlining three ways in which speech and language processes already involve socially important information, such as cues to interact with others. We propose that when these are taken into account, the social characteristics of AVH can be explained without an appeal to separate social-cognitive systems.

Tailoring Cognitive Behavioral Therapy to Subtypes of Voice-Hearing

Cognitive behavioral therapy (CBT) for voice-hearing (i.e., auditory verbal hallucinations; AVH) has, at best, small to moderate effects. One possible reason for this limited efficacy is that current CBT approaches tend to conceptualize voice-hearing as a homogenous experience in terms of the cognitive processes involved in AVH. However, the highly heterogeneous nature of voice-hearing suggests that many different cognitive processes may be involved in the etiology of AVH. These heterogeneous voice-hearing experiences do, however, appear to cluster into a set of subtypes, opening up the possibility of tailoring treatment to the subtype of AVH that a voice-hearer reports. In this paper, we (a) outline our rationale for tailoring CBT to subtypes of voice-hearing, (b) describe CBT for three putative subtypes of AVH (inner speech-based AVH, memory-based AVH, and hypervigilance AVH), and (c) discuss potential limitations and problems with such an approach. We conclude by arguing that tailoring CBT to subtypes of voice-hearing could prove to be a valuable therapeutic development, which may be especially effective when used in early intervention in psychosis services.

How anxiety induces verbal hallucinations

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Anxiety both triggers verbal hallucinations (VHs) and shapes their content.

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A current model that accounts for this in terms of failed anticipation is critiqued.

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An important subset of VHs arise from a particular anxious style of anticipation.

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This anxious anticipation makes an experience of thinking more like one of perceiving.

Verbal hallucinations are often associated with pronounced feelings of anxiety, and it has also been suggested that anxiety somehow triggers them. In this paper, we offer a phenomenological or ‘personal-level’ account of how it does so. We show how anxious anticipation of one’s own thought contents can generate an experience of their being ‘alien’. It does so by making an experience of thinking more like one of perceiving, resulting in an unfamiliar kind of intentional state. This accounts for a substantial subset of verbal hallucinations, which are experienced as falling within one’s psychological boundaries and lacking in auditory qualities.

Empirical evidence about recovery and mental health

BACKGROUND

Two discourses exist in mental health research and practice. The first focuses on the limitations associated with disability arising from mental disorder. The second focuses on the possibilities for living well with mental health problems.

DISCUSSION

This article was prompted by a review to inform disability policy. We identify seven findings from this review: recovery is best judged by experts or using standardised assessment; few people with mental health problems recover; if a person no longer meets criteria for a mental illness, they are in remission; diagnosis is a robust basis for characterising groups and predicting need; treatment and other supports are important factors for improving outcome; the barriers to receiving effective treatment are availability, financing and client awareness; and the impact of mental illness, in particular schizophrenia, is entirely negative. We selectively review a wider range of evidence which challenge these findings, including the changing understanding of recovery, national mental health policies, systematic review methodology and undertainty, epidemiological evidence about recovery rates, reasoning biased due to assumptions about mental illness being an illness like any other, the contested nature of schizophrenia, the social construction of diagnoses, alternative explanations for psychosis experiences including the role of trauma, diagnostic over-shadowing, stigma, the technological paradigm, the treatment gap, social determinants of mental ill-health, the prevalence of voice-hearing in the general population, and the sometimes positive impact of psychosis experience in relation to perspective and purpose.

CONCLUSION

We propose an alternative seven messages which are both empirically defensible and more helpful to mental health stakeholders: Recovery is best judged by the person living with the experience; Many people with mental health problems recover; If a person no longer meets criteria for a mental illness, they are not ill; Diagnosis is not a robust foundation; Treatment is one route among many to recovery; Some people choose not to use mental health services; and the impact of mental health problems is mixed.

Voices and Thoughts in Psychosis: An Introduction

In this introduction we present the orthodox account of auditory verbal hallucinations (AVHs), a number of worries for this account, and some potential responses open to its proponents. With some problems still remaining, we then introduce the problems presented by the phenomenon of thought insertion, in particular the question of how different it is supposed to be from AVHs. We then mention two ways in which theorists have adopted different approaches to voices and thoughts in psychosis, and then present the motivation and composition of this special issue.

The effect of auditory verbal imagery on signal detection in hallucination-prone individuals

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Investigated relation between hallucinations, mental imagery and signal detection.

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Individuals prone to hallucinations showed a lower SDT response bias with imagery.

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Finding held for both instructed and self-reported use of auditory verbal imagery.

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Atypical auditory imagery may lead to the generation of auditory hallucinations.

Cognitive models have suggested that auditory hallucinations occur when internal mental events, such as inner speech or auditory verbal imagery (AVI), are misattributed to an external source. This has been supported by numerous studies indicating that individuals who experience hallucinations tend to perform in a biased manner on tasks that require them to distinguish self-generated from non-self-generated perceptions. However, these tasks have typically been of limited relevance to inner speech models of hallucinations, because they have not manipulated the AVI that participants used during the task. Here, a new paradigm was employed to investigate the interaction between imagery and perception, in which a healthy, non-clinical sample of participants were instructed to use AVI whilst completing an auditory signal detection task. It was hypothesized that AVI-usage would cause participants to perform in a biased manner, therefore falsely detecting more voices in bursts of noise. In Experiment 1, when cued to generate AVI, highly hallucination-prone participants showed a lower response bias than when performing a standard signal detection task, being more willing to report the presence of a voice in the noise. Participants not prone to hallucinations performed no differently between the two conditions. In Experiment 2, participants were not specifically instructed to use AVI, but retrospectively reported how often they engaged in AVI during the task. Highly hallucination-prone participants who retrospectively reported using imagery showed a lower response bias than did participants with lower proneness who also reported using AVI. Results are discussed in relation to prominent inner speech models of hallucinations.

Inner Speech: Development, Cognitive Functions, Phenomenology, and Neurobiology

Inner speech-also known as covert speech or verbal thinking-has been implicated in theories of cognitive development, speech monitoring, executive function, and psychopathology. Despite a growing body of knowledge on its phenomenology, development, and function, approaches to the scientific study of inner speech have remained diffuse and largely unintegrated. This review examines prominent theoretical approaches to inner speech and methodological challenges in its study, before reviewing current evidence on inner speech in children and adults from both typical and atypical populations. We conclude by considering prospects for an integrated cognitive science of inner speech, and present a multicomponent model of the phenomenon informed by developmental, cognitive, and psycholinguistic considerations. Despite its variability among individuals and across the life span, inner speech appears to perform significant functions in human cognition, which in some cases reflect its developmental origins and its sharing of resources with other cognitive processes.

The prevalence and correlates of childhood trauma in patients with early psychosis

OBJECTIVE

To describe the prevalence and demographic, clinical and functional correlates of childhood trauma in patients attending early psychosis clinics.

METHOD

Participants were recruited from outpatients attending four early psychosis services. Exposure to childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Psychopathology was measured using the Positive and Negative Syndrome Scale and the Depression, Anxiety and Stress Scale. Social and vocational functioning and substance use were also assessed.

RESULTS

Over three-quarters of the 100 patients reported exposure to any childhood trauma. Emotional, physical and sexual abuse were reported by 54%, 23% and 28% of patients, respectively, while 49% and 42% of patients reported emotional and physical neglect, respectively. Female participants were significantly more likely to be exposed to emotional and sexual abuse. Exposure to childhood trauma was correlated with positive psychotic symptoms and higher levels of depressive, anxiety and stress symptoms; however, it had no impact on social or vocational functioning or recent substance use.

CONCLUSION

Exposure to childhood trauma was common in patients with early psychosis, and associated with increased symptomatology. Existing recommendations that standard clinical assessment of patients with early psychosis should include inquiry into exposure to childhood trauma are supported.

Auditory hallucinations: A review of the ERC “VOICE” project

In this invited review I provide a selective overview of recent research on brain mechanisms and cognitive processes involved in auditory hallucinations. The review is focused on research carried out in the “VOICE” ERC Advanced Grant Project, funded by the European Research Council, but I also review and discuss the literature in general. Auditory hallucinations are suggested to be perceptual phenomena, with a neuronal origin in the speech perception areas in the temporal lobe. The phenomenology of auditory hallucinations is conceptualized along three domains, or dimensions; a perceptual dimension, experienced as someone speaking to the patient; a cognitive dimension, experienced as an inability to inhibit, or ignore the voices, and an emotional dimension, experienced as the “voices” having primarily a negative, or sinister, emotional tone. I will review cognitive, imaging, and neurochemistry data related to these dimensions, primarily the first two. The reviewed data are summarized in a model that sees auditory hallucinations as initiated from temporal lobe neuronal hyper-activation that draws attentional focus inward, and which is not inhibited due to frontal lobe hypo-activation. It is further suggested that this is maintained through abnormal glutamate and possibly gamma-amino-butyric-acid transmitter mediation, which could point towards new pathways for pharmacological treatment. A final section discusses new methods of acquiring quantitative data on the phenomenology and subjective experience of auditory hallucination that goes beyond standard interview questionnaires, by suggesting an iPhone/iPod app.

Prevalence of auditory verbal hallucinations in a general population: A group comparison study

The present study was specifically designed to investigate the prevalence of auditory verbal hallucinations (AVH) in the general population, and sought to compare similarities and differences regarding socio-demographics, mental health and severe life events between individuals who have never experienced AVH with those who had. The study also aimed to compare those who sought professional help for their experience of AVH with those who had not sought help. Through a postal questionnaire, 2,533 participants ages 18 and over from a national survey completed the Launay-Slade Hallucinations Scale and other measures examining AVH characteristics and other areas related to AVH. In total, 7.3% of the sample reported a life-time prevalence of AVH. Those with AVH were more likely to be single and unemployed, reported higher levels of depression and anxiety, and experienced a higher number of severe life events compared with those without AVH. Only 16% of those who experienced AVH in the general population sought professional help for these experiences. Compared to those who did not seek professional help, participants that had were more likely to experience AVH with a negative content, experience them on a daily basis, undergo negative reactions when experiencing AVH, and resist AVH. In conclusion, the prevalence of AVH was found to be relatively high. The results also revealed higher levels of reduced mental health for individuals who sought professional help, followed by those who did not, compared with those who had never experienced AVH.

Prevalence of auditory hallucinations in Norwegian adolescents: results from a population-based study

Knowing the prevalence and characteristics of auditory verbal hallucinations (AVH) in adolescents is important for estimations of need for mental health care and assessment of psychosis risk. In this report we assess the prevalence of AVH in a population-based sample of 16-19 years old Norwegian adolescents (n = 9,646, 46.4% male) using two items assessing AVH (from the extended Launay-Slade Hallucination Scale). The prevalence of hearing a voice speaking thoughts aloud was 10.6%. The prevalence of being troubled by voices was 5.3%, showing that negative emotionality about AVH is less frequent than the experience of hearing voices. Female respondents had slightly increased risk for being troubled by voices than males (odds ratio = 1.3), while age did not modulate prevalence. This AVH prevalence is in line with earlier reports in smaller samples of adolescents and indicates that AVH are not uncommon in this period of life. Further longitudinal studies are needed to investigate the value of AVH in predicting psychiatric disorder.

Hearing voices in the resting brain: A review of intrinsic functional connectivity research on auditory verbal hallucinations

Resting state networks (RSNs) are thought to reflect the intrinsic functional connectivity of brain regions. Alterations to RSNs have been proposed to underpin various kinds of psychopathology, including the occurrence of auditory verbal hallucinations (AVH). This review outlines the main hypotheses linking AVH and the resting state, and assesses the evidence for alterations to intrinsic connectivity provided by studies of resting fMRI in AVH. The influence of hallucinations during data acquisition, medication confounds, and movement are also considered. Despite a large variety of analytic methods and designs being deployed, it is possible to conclude that resting connectivity in the left temporal lobe in general and left superior temporal gyrus in particular are disrupted in AVH. There is also preliminary evidence of atypical connectivity in the default mode network and its interaction with other RSNs. Recommendations for future research include the adoption of a common analysis protocol to allow for more overlapping datasets and replication of intrinsic functional connectivity alterations.

Examining the Psychosis Continuum

The notion that psychosis may exist on a continuum with normal experience has been proposed in multiple forms throughout the history of psychiatry. However, in recent years there has been an exponential increase in efforts aimed at elucidating what has been termed the 'psychosis continuum'. The present review seeks to summarize some of the more basic characteristics of this continuum and to present some of the recent findings that provide support for its validity. While there is still considerable work to be done, the emerging data holds considerable promise for advancing our understanding of both risk and resilience to psychiatric disorders characterized by psychosis.

Self, Voices and Embodiment: A Phenomenological Analysis

OBJECTIVE

The primary aim of this study was to examine first-person phenomenological descriptions of the relationship between the self and Auditory Verbal Hallucinations (AVHs). Complex AVHs are frequently described as entities with clear interpersonal characteristics. Strikingly, investigations of first-person (subjective) descriptions of the phenomenology of the relationship are virtually absent from the literature.

METHOD

Twenty participants with psychosis and actively experiencing AVHs were recruited from the University of Illinois at Chicago. A mixed-methods design involving qualitative and quantitative components was utilized. Following a priority-sequence model of complementarity, quantitative analyses were used to test elements of emergent qualitative themes.

RESULTS

The qualitative analysis identified three foundational constructs in the relationship between self and voices: 'understanding of origin,' 'distinct interpersonal identities,' and 'locus of control.' Quantitative analyses further supported identified links of these constructs. Subjects experienced their AVHs as having identities distinct from self and actively engaged with their AVHs experienced a greater sense of autonomy and control over AVHs.

DISCUSSION

Given the clinical importance of AVHs and emerging strategies targeting the relationship between the hearer and voices, our findings highlight the importance of these relational constructs in improvement and innovation of clinical interventions. Our analyses also underscore the value of detailed voice assessments such as those provided by the Maastricht Interview are needed in the evaluation process. Subjects narratives shows that the relational phenomena between hearer and AVH(s) is dynamic, and can be influenced and changed through the hearers' engagement, conversation, and negotiation with their voices.

Experiences of hearing voices: analysis of a novel phenomenological survey

BACKGROUND

Auditory hallucinations--or voices--are a common feature of many psychiatric disorders and are also experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the people who hear voices themselves.

METHODS

We made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged 16-84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks, hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used inductive thematic analysis to code the data and χ(2) tests to test additional associations of selected codes.

FINDINGS

Between Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the participants reported hearing literally auditory voices--70 (46%) individuals reported either thought-like or mixed experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were significantly associated with experiences of abusive or violent voices (p=0·024). Although fear, anxiety, depression, and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time (p=0·030), be internally located (p=0·010), and be conversational in nature (p=0·010).

INTERPRETATION

This study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities.

FUNDING

Wellcome Trust.

Differences in the internal structure of hallucinatory experiences between clinical and nonclinical populations

We investigated differential patterns of hallucinatory experiences between nonclinical and clinical samples. A total of 223 nonclinical individuals (108 females) and 111 subjects with schizophrenia (54 females) completed the Launay-Slade Hallucination Scale-Revised (LSHS-R) and Perceptual Aberration Scale (PAS). The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) was used for the nonclinical group, and the Positive and Negative Syndrome Scale (PANSS) hallucination item was used for the clinical group. Cronbach's alpha values showed good internal consistency for the LSHS-R. In the two groups, significant associations were found between LSHS-R and PAS scores. Two factors were extracted through a principal component analysis (PCA) in the nonclinical group, and three factors were identified in the clinical group. The results of a hierarchical cluster analysis (HCA) revealed that a perception-cognition dimension was clear cluster discriminating element for the nonclinical group, whereas alterations in perception-cognition dimension were characteristic in cluster structure of the clinical group. Our findings suggest that the nature of hallucinatory experiences may differ qualitatively between a nonclinical population and subjects with schizophrenia. Perceptual or cognitive aberrations may add a psychopathologic dimension to hallucinatory experiences. Exploring the internal structure of hallucinatory experiences may provide explanatory insight into these experiences in the general population.

Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) "front-loading" research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.

Studying hallucinations within the NIMH RDoC framework

We explore how hallucinations might be studied within the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) framework, which asks investigators to step back from diagnoses based on symptoms and focus on basic dimensions of functioning. We start with a description of the objectives of the RDoC project and its domains and constructs. Because the RDoC initiative asks investigators to study phenomena across the wellness spectrum and different diagnoses, we address whether hallucinations experienced in nonclinical populations are the same as those experienced by people with psychotic diagnoses, and whether hallucinations studied in one clinical group can inform our understanding of the same phenomenon in another. We then discuss the phenomenology of hallucinations and how different RDoC domains might be relevant to their study. We end with a discussion of various challenges and potential next steps to advance the application of the RDoC approach to this area of research.

Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease

Much of the research on visual hallucinations (VHs) has been conducted in the context of eye disease and neurodegenerative conditions, but little is known about these phenomena in psychiatric and nonclinical populations. The purpose of this article is to bring together current knowledge regarding VHs in the psychosis phenotype and contrast this data with the literature drawn from neurodegenerative disorders and eye disease. The evidence challenges the traditional views that VHs are atypical or uncommon in psychosis. The weighted mean for VHs is 27% in schizophrenia, 15% in affective psychosis, and 7.3% in the general community. VHs are linked to a more severe psychopathological profile and less favorable outcome in psychosis and neurodegenerative conditions. VHs typically co-occur with auditory hallucinations, suggesting a common etiological cause. VHs in psychosis are also remarkably complex, negative in content, and are interpreted to have personal relevance. The cognitive mechanisms of VHs in psychosis have rarely been investigated, but existing studies point to source-monitoring deficits and distortions in top-down mechanisms, although evidence for visual processing deficits, which feature strongly in the organic literature, is lacking. Brain imaging studies point to the activation of visual cortex during hallucinations on a background of structural and connectivity changes within wider brain networks. The relationship between VHs in psychosis, eye disease, and neurodegeneration remains unclear, although the pattern of similarities and differences described in this review suggests that comparative studies may have potentially important clinical and theoretical implications.

Special supplement introduction: hallucinations

This Special Supplement presents reports from 11 working groups of the interdisciplinary International Consortium on Hallucination Research meeting in Durham, UK, September 2013. Topics include psychological therapies for auditory hallucinations, culture and hallucinations, hallucinations in children and adolescents, visual hallucinations, interdisciplinary approaches to the phenomenology of auditory verbal hallucinations (AVHs), AVHs in persons without need for care, a multisite study of the PSYRATS instrument, subtypes of AVHs, the Hearing Voices Movement, Research Domain Criteria for hallucinations, and cortical specialization as a route to understanding hallucinations.

Better than mermaids and stray dogs? Subtyping auditory verbal hallucinations and its implications for research and practice

The phenomenological diversity of auditory verbal hallucinations (AVH) is not currently accounted for by any model based around a single mechanism. This has led to the proposal that there may be distinct AVH subtypes, which each possess unique (as well as shared) underpinning mechanisms. This could have important implications both for research design and clinical interventions because different subtypes may be responsive to different types of treatment. This article explores how AVH subtypes may be identified at the levels of phenomenology, cognition, neurology, etiology, treatment response, diagnosis, and voice hearer's own interpretations. Five subtypes are proposed; hypervigilance, autobiographical memory (subdivided into dissociative and nondissociative), inner speech (subdivided into obsessional, own thought, and novel), epileptic and deafferentation. We suggest other facets of AVH, including negative content and form (eg, commands), may be best treated as dimensional constructs that vary across subtypes. After considering the limitations and challenges of AVH subtyping, we highlight future research directions, including the need for a subtype assessment tool.

Culture and hallucinations: overview and future directions

A number of studies have explored hallucinations as complex experiences involving interactions between psychological, biological, and environmental factors and mechanisms. Nevertheless, relatively little attention has focused on the role of culture in shaping hallucinations. This article reviews the published research, drawing on the expertise of both anthropologists and psychologists. We argue that the extant body of work suggests that culture does indeed have a significant impact on the experience, understanding, and labeling of hallucinations and that there may be important theoretical and clinical consequences of that observation. We find that culture can affect what is identified as a hallucination, that there are different patterns of hallucination among the clinical and nonclinical populations, that hallucinations are often culturally meaningful, that hallucinations occur at different rates in different settings; that culture affects the meaning and characteristics of hallucinations associated with psychosis, and that the cultural variations of psychotic hallucinations may have implications for the clinical outcome of those who struggle with psychosis. We conclude that a clinician should never assume that the mere report of what seems to be a hallucination is necessarily a symptom of pathology and that the patient's cultural background needs to be taken into account when assessing and treating hallucinations.

The search for elusive structure: a promiscuous realist case for researching specific psychotic experiences such as hallucinations

Problems in psychiatric classification have impeded research into psychopathology for more than a century. Here, I briefly review several new approaches to solving this problem, including the internalizing-externalizing-psychosis spectra, the 5-factor model of psychotic symptoms, and the more recent network approach. Researchers and clinicians should probably adopt an attitude of promiscuous realism and assume that a single classification system is unlikely to be effective for all purposes, and that different systems will need to be chosen for research into etiology, public mental health research, and clinical activities. Progress in understanding the risk factors and mechanisms that lead to psychopathology is most likely to be achieved by focusing on specific types of experience or symptoms such as hallucinations.

Symptom dimensions of the psychotic symptom rating scales in psychosis: a multisite study

The Psychotic Symptom Rating Scales (PSYRATS) is an instrument designed to quantify the severity of delusions and hallucinations and is typically used in research studies and clinical settings focusing on people with psychosis and schizophrenia. It is comprised of the auditory hallucinations (AHS) and delusions subscales (DS), but these subscales do not necessarily reflect the psychological constructs causing intercorrelation between clusters of scale items. Identification of these constructs is important in some clinical and research contexts because item clustering may be caused by underlying etiological processes of interest. Previous attempts to identify these constructs have produced conflicting results. In this study, we compiled PSYRATS data from 12 sites in 7 countries, comprising 711 participants for AHS and 520 for DS. We compared previously proposed and novel models of underlying constructs using structural equation modeling. For the AHS, a novel 4-dimensional model provided the best fit, with latent variables labeled Distress (negative content, distress, and control), Frequency (frequency, duration, and disruption), Attribution (location and origin of voices), and Loudness (loudness item only). For the DS, a 2-dimensional solution was confirmed, with latent variables labeled Distress (amount/intensity) and Frequency (preoccupation, conviction, and disruption). The within-AHS and within-DS dimension intercorrelations were higher than those between subscales, with the exception of the AHS and DS Distress dimensions, which produced a correlation that approached the range of the within-scale correlations. Recommendations are provided for integrating these underlying constructs into research and clinical applications of the PSYRATS.