The self or the voice? Relative contributions of self-esteem and voice appraisal in persistent auditory hallucinations

Neither saintly nor psychotic: a narrative systematic review of the evolving Western perception of voice hearing

We present a social-historical perspective on the evolution of the voice-hearing phenomenon in Western society. Based upon a systematic search from a selection of nine databases, we trace the way hearing voices has been understood throughout the ages. Originally, hearing voices was considered a gifted talent for accessing the divine, but the progressive influence of monotheistic religion gradually condemned the practice to social marginalization. Later, the medical and psychiatric professions of secular society were instrumental in attaching stigma to both voice hearers and the phenomenon itself, thereby reinforcing social exclusion. More recently, the re-integration of voice hearers into the community by health authorities in various countries appears to have provided a new, socially acceptable setting for the phenomenon.

Increasing access to CBT for psychosis patients: study protocol for a randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE3)

BACKGROUND

The National Institute for Health and Care Excellence (NICE) recommends that cognitive behaviour therapy (CBT) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBT. This is attributable, in part, to the resource-intensive nature of CBT. One response to this problem has been the development of CBT in brief formats that are targeted at a single symptom and are deliverable by briefly trained therapists. We have developed Guided self-help CBT (the GiVE intervention) as a brief form of CBT for distressing voices and reported evidence for the feasibility of a randomised controlled trial (RCT) when the intervention was delivered by briefly trained therapists (assistant psychologists). This study will investigate the clinical and cost-effectiveness of the GiVE intervention when delivered by assistant psychologists following a brief training.

METHODS

This study is a pragmatic, two-arm, parallel group, superiority RCT comparing the GiVE intervention (delivered by assistant psychologists) and treatment as usual to treatment as usual alone, recruiting across three sites, using 1:1 allocation and blind post-treatment and follow-up assessments. A nested qualitative study will develop a model for implementation.

DISCUSSION

If the GiVE intervention is found to be effective when delivered by assistant psychologists, this intervention could significantly contribute to increasing access to evidence-based psychological interventions for psychosis patients. Furthermore, implementation across secondary care services within the UK's National Health Service may pave the way for other symptom-specific and less resource-intensive CBT-informed interventions for psychosis patients to be developed and evaluated.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN registration number: 12748453. Registered on 28 September 2022.

Distress factors of voice-hearing in young people and social relating: Exploring a cognitive-interpersonal voice-hearing model

OBJECTIVES

Little is known about the factors that can maintain the distress related to voice-hearing experiences in youth. Building upon understandings developed with adults, this study aimed to explore the associations between negative relating between hearer and voices, persecutory beliefs about voices and voice-related distress in a clinical sample of adolescents. The study also aimed to investigate associations between relating to voices and wider patterns of social relating.

DESIGN

This was an observational, cross-sectional, survey study.

METHODS

Thirty-four young people (age 14-18 years) who were hearing voices completed measures about voices (characteristics, relating and beliefs) and relating to social others (negative relating styles, social connectedness and belongingness). Participants were patients of NHS mental health services. Bivariate correlations explored associations between relating to voices and distress, beliefs about voices and distress, and between relating to voices and social relating variables.

RESULTS

Perceiving the voices as dominant, intrusive, and persecutory and resisting them was significantly associated with distress. Adjusting for loudness and negative content rendered the association between persecutory beliefs and distress non-significant. Fear of separation and of being alone in relation to social others was associated with distancing from voices. Being suspicious, uncommunicative and self-reliant and/or being sadistic and intimidating towards social others was significantly associated with dependence towards the voices. Greater hearer-to-voice dependence was associated with lower perceived social belongingness and connectedness.

CONCLUSIONS

Beliefs about voices being persecutory, dominant, intrusive and resisting voices seem to be significant contributors of distress in young people. In terms of proximity and power, relating to voices and social others appears to be contrasting.

Measuring the longitudinal course of voice hearing under psychological interventions: A systematic review

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course and impact of voice hearing under these interventions and to evaluate how these variables change over time. Inclusion and exclusion criteria were applied, resulting in a total of 66 articles. Of these, 60 studies (28 RCTs, 23 uncontrolled, 9 non-randomised) were published in peer-reviewed journals, whilst 6 were recently completed or currently ongoing. The findings of this review suggest that a range of variables that are not directly relevant to psychological interventions have been used (e.g., depression, characteristics of voice hearing experience), whilst those directly impacted by psychological interventions (e.g., voice-related distress), broader concepts of outcome (e.g., functioning) and specific associated processes (e.g., self-schema) have received less attention. Findings also showed that the majority of variables demonstrated improvements, but effect sizes varied considerably across trials. This may be attributed to methodological differences such as statistical power, blinding, control groups and different methods of measurement. Our review highlights the importance of determining a set of outcomes that are directly targeted and should change under psychological interventions. Recommendations include the use of voice-related distress as a primary outcome. This can ultimately facilitate comparisons across studies and inform the development of psychological interventions.

A cross-sectional study of auditory verbal hallucinations experienced by people with a diagnosis of borderline personality disorder

BACKGROUND

The presence of auditory verbal hallucinations (AVHs) does not currently feature in the main diagnostic criteria for borderline personality disorder (BPD). However, there is accumulating evidence that a high proportion of BPD patients report longstanding and frequent AVHs which constitute a significant risk factor for suicide plans and attempts, and hospitalization.

AIM

This study addressed questions about the validity and phenomenology of AVHs in the context of BPD. The longer-term aim is to facilitate the development and translation of treatment approaches to address the unmet need of this population.

METHOD

This was a cross-sectional study, combining phenomenological and psychological assessments administered in person and online. We explored the experiences of 48 patients with a diagnosis of BPD who were hearing AVHs.

RESULTS

Participants gave 'consistent' reports on the measure of AVH phenomenology, suggesting that these experiences were legitimate. Similar to AVHs in a psychosis context, AVHs were experienced as distressing and appraised as persecutory. AVHs were found to be weakly associated with BPD symptoms. AVHs were also rated highly as a treatment priority by the majority of participants.

CONCLUSION

The findings suggest that AVH is a legitimate and distressing symptom of BPD and a treatment priority for some patients. The relative independence of AVHs from other BPD symptoms and emotional states suggests that psychological treatment may need to be targeted specifically at the symptom of AVHs. This treatment could be adapted from cognitive behaviour therapy, the psychological intervention that is recommended for the treatment of AVHs in the context of psychosis.

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.

Young people's narratives of hearing voices: Systemic influences and conceptual challenges

Despite the prevalence of voice hearing in childhood and adolescence, little qualitative research has been undertaken with young people directly to advance phenomenological and aetiological insights into their experiences and interpretations. Consequently, the researchers sought demographic, contextual, and qualitative data from 74 young people from eleven countries, aged 13-18 years (28% = male; 61% = female; 21% = Transgender and Gender Non-Binary [TGNB]), who self-identified as hearing voices. A Foucauldian-informed narrative analysis yielded four analytic chapters, offering novel perspectives into individual, relational, systemic, and cultural interpretative narratives surrounding multisensory and multi-self voice hearing. Overall, young people reported heterogenous experiences of voice hearing and associated sensory experiences, and most participants reported voice hearing beginning between ages 8 and 11. Further, the emotions felt by the child, as well as reactions displayed by people around the child in relation to the voices, influenced voice-related distress and the nature of the voices in a triadic relationship. A continuum of multisensory features of voice content, nature, and relational significance is tentatively proposed to capture the breadth and depth of voice hearing for adolescents to offer a possible framework for future study and intervention design. Specifically, participants described that voice-related distress could be exacerbated by observed anxiety or internalized stigma about voice hearing, social isolation, and attribution to illness. These findings suggest that we may need to reconsider how the experience of hearing voices in childhood influences their relationships and how relationships influence the voice hearing experience. Further, young people seem to have a broad understanding of what the term "hearing voices" means, which could inform how researchers and practitioners work with this group of young people. Finally, participants described benefitting from multisensory coping strategies, such as imagery and meditation, which could offer important considerations for tailoring therapeutic interventions for adolescent voice hearers.

Reducing distress and improving social functioning in daily life in people with auditory verbal hallucinations: study protocol for the 'Temstem' randomised controlled trial

INTRODUCTION

Auditory verbal hallucinations (AVH) are prevalent experiences that can induce distress and impede social functioning. While most voice hearers benefit from antipsychotic medication or cognitive-behavioural therapy, additional effective interventions are needed to reduce the burden of experiencing AVH. 'Temstem' is an easily accessible and useable smartphone application that was developed by designers in close cooperation with voice hearers and experts. By using language games, Temstem aims to reduce distress and improve social functioning.

METHODS

This is a single-blind multicentre randomised controlled trial with two arms: 'Temstem+AVH monitoring' versus 'AVH monitoring' (total n=100). Participants are adult patients who suffer daily from AVH and will be recruited in outpatient units. Primary assessment in daily life is made by the Experience Sampling Method (ESM) and daily monitoring with the PsyMate app. During an ESM period of 6 days, participants assess their mental state (including AVH and context) several times a day by filling in short questionnaires. There are three 6-day ESM periods: at baseline (week 0-1), post-treatment (weeks 5-6) and follow-up (weeks 9-10). In addition, during the entire 10-week study period, all participants monitor their AVH two times a day with a short assessment via the PsyMate app. Participants in the Temstem+AVH monitoring condition are provided with the Temstem app from week 1 to 6. Other assessments made at baseline, post-treatment and follow-up are based on questionnaires and a clinical interview.

ETHICS AND DISSEMINATION

The results from this study will provide an evaluation of the effectiveness of Temstem, a non-invasive and easily accessible app for voice hearers, and insight into the determinants of optimal use. Results will be disseminated unreservedly, irrespective of the magnitude or direction of the effects. This study protocol was approved by the Medical Ethics Committee of the VU University Medical Centre (METC number: 2015.435/NL53684.029.15).

TRIAL REGISTRATION NUMBER

ISRCTN75717636; Pre-results.

Brief Coping Strategy Enhancement for Distressing Voices: an Evaluation in Routine Clinical Practice

Background: Hearing voices can be a common and distressing experience. Psychological treatment in the form of cognitive behavioural therapy for psychosis (CBTp) is effective, but is rarely available to patients. The barriers to increasing access include a lack of time for clinicians to deliver therapy. Emerging evidence suggests that CBTp delivered in brief forms can be effective and offer one solution to increasing access. Aims: We adapted an existing form of CBTp, coping strategy enhancement (CSE), to focus specifically on distressing voices in a brief format. This intervention was evaluated within an uncontrolled study conducted in routine clinical practice. Method: This was a service evaluation comparing pre–post outcomes in patients who had completed CSE over four sessions within a specialist out-patient service within NHS Mental Health Services. The primary outcome was the distress scale of the Psychotic Symptoms Rating Scale – Auditory Hallucinations (PSYRATS-AH). Results: Data were available from 101 patients who had completed therapy. A reduction approaching clinical importance was found on the PSYRATS distress scale post-therapy when compared with the baseline. Conclusions: The findings from this study suggest that CSE, as a focused and brief form of CBTp, can be effective in the treatment of distressing voices within routine clinical practice. Within the context of the limitations of this study, brief CSE may best be viewed as the beginning of a therapeutic conversation and a low-intensity intervention in a stepped approach to the treatment of distressing voices.

Elucidating the role of Early Maladaptive Schemas for psychotic symptomatology

Although cognitive accounts postulate negative self-concepts as a causal factor in the emergence of psychotic symptoms, little is known about the role of specific self-schemas for psychotic symptomatology. Building on a differentiated and treatment-informed schema model, we aimed to elucidate the role of Early Maladaptive Schemas (EMS) for psychotic symptomatology, particularly their specificity to patients with psychosis and their association with positive versus negative symptoms. We assessed EMS with the Young Schema Questionnaire in patients with psychosis (n=81), patients with depression (n=28) as well as healthy participants (n=60). In the psychosis sample symptoms were rated using the Positive and Negative Syndrome Scale. In comparison to healthy participants, patients with either psychosis or depression showed a higher overall number and intensity of EMS whereas the psychosis and the depression sample did not significantly differ. The overall number and intensity of EMS were significantly associated with positive but not with negative symptoms. Contrary to previous findings, patients with psychosis and patients with depression did not differ in the EMS subscale Mistrust/Abuse. The results suggest that EMS are particularly relevant to positive symptoms. Our findings imply that addressing maladaptive schemas in patients with psychosis by making use of the schema-concept holds potential.

Bringing the "self" into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of "self" (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

What Are the Primary Goals of Cognitive Behavior Therapy for Psychosis? A Theoretical and Empirical Review

Despite a rise in the popularity of cognitive behavior therapy for psychosis (CBTp) over the past 15 years, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over other psychosocial treatments is poor (Jones, Hacker, Meaden, Cormac, & Irving, 2012; Wykes, Steel, Everitt, & Tarrier, 2008). However, for some time now, some authors prominent in the development of CBTp have argued the primary goals of CBTp not to be global syndrome reduction but the amelioration of emotional distress and behavioral disturbance in relation to individual psychotic symptoms (Birchwood & Trower, 2006). A review of the theoretical and empirical literature related to CBTp reveals broad support for this position. Implications and recommendations for research into the efficacy of CBTp are discussed.

The Relationship Between Cognitive Behavioral Therapy Maintenance Processes, Emotional Distress, and Positive Psychotic Symptoms: Evidence That CBT Is “Not a Quasi-Neuroleptic”

Cognitive behavioral therapy for psychosis (CBTp) has enjoyed a steep rise in popularity over the past 15 years; however, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over other psychosocial treatments is poor. And although it has been argued by some prominent authors that CBTp is not designed to alleviate the “psychotic syndrome,” there is little empirical evidence linking CBTp change mechanisms with syndrome versus single-symptom outcome measures. This study investigated the relationship between CBTp change processes, beliefs about voices, and thought control strategies, with a range of outcome measures including global positive psychotic symptoms in a sample of 40 voice hearers with established diagnosis of psychotic disorder. Consistent with the assertions of Birchwood and Trower (2006), global positive symptoms were found to be generally poorly related to CBTp change processes. Conversely, these CBTp change processes were found to be generally strongly related to measures of emotional distress and some measures of single psychotic symptoms. The implications for past and future CBTp treatment outcome studies are discussed.

Associations of self-esteem, dysfunctional beliefs and coping style with depression in patients with schizophrenia: a preliminary survey

Psychological models of depression in schizophrenia have proposed that cognitive structures (e.g., self-esteem, dysfunctional beliefs) may have a role in the development and maintenance of depression. However, it has not been clear what the characteristics of these cognitive structures were in people with schizophrenia and whether they have an independent association with depression, especially in those from a Chinese cultural background. The present investigation examined 133 people with schizophrenia and 50 healthy controls and indicated that compared to the controls people with schizophrenia showed lower self-esteem, higher levels of dysfunctional beliefs and negative coping styles. Multiple linear regression analysis revealed that only low frustration tolerance, problem solving and self-blame were found to be the independent correlates of depression in schizophrenia. Results are discussed with the view of clinical implications of cognitive formulation and therapy for schizophrenia in China.

The neural correlates of positive self-evaluation and self-related memory

Humans tend to have a positive self-evaluation (PSE). To what extent positive self-perception is interacting with valenced self-related memories is debated. The underlying neural substrates are not adequately explained yet. To explore the cerebral correlates of PSE and its influence on memory, 24 healthy subjects were asked during fMRI to decide in two conditions whether presented positive and negative personality traits characterized their own selves (self-evaluation) or an intimate other (other-evaluation). A lexical condition served as control task. In a subsequent unannounced recognition task, trait adjectives had to be classified as old or new. Activation during positive self- vs positive other-evaluation was found in the medial ventral and dorsolateral prefrontal gyri, the parahippocampus and the supplementary motor area. Memory increased for positive personality traits and traits that had been referred to oneself or the other. In contrast to adjectives of the other-evaluation or lexical condition, recollection of negative vs positive traits of the self-evaluation condition specifically induced increased activation in the hippocampus and several prefrontal and temporal areas. Our data imply a specific network for PSE (although intimate others are perceived similarly). Moreover, memory for traits contradicting PSE resulted in activation increases indicating greater cognitive effort and emotional involvement.

Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: a randomized controlled trial

OBJECTIVES

This study investigates whether depression can be ameliorated by weakening the associations between auditory verbal hallucinations and easily activated networks with negative self-evaluations, by strengthening the access to competing memories of positive self-esteem. Design.  A randomized controlled clinical trial comparing competitive memory training (COMET) with treatment as usual (TAU) in schizophrenia patients with persistent auditory hallucinations.

METHODS

Patients with schizophrenia-spectrum disorders were randomized into COMET (n = 39) versus TAU (n = 38). COMET consisted of seven sessions with four stages: (1) identification of aspects of negative self-esteem reinforced by the voice; (2) retrieval and re-living of memories associated with positive self-esteem; (3) positive self-esteem is brought in to compete with the content of the voices to weaken the association between voice content and negative self-evaluation; and (4) learning to disengage from the voices and to accept the voices as psychic phenomena.

RESULTS

Compared to TAU the COMET group improved on depression but there were no significant effects on auditory hallucinations. The effect of COMET on depression was fully mediated by self-esteem and acceptance of voices, and partially mediated by social rank and attributed power to the voices.

CONCLUSIONS

COMET can be helpful in reappraising the meaning and changing the emotional impact of auditory hallucinations. These findings are consistent with the results of comparable COMET protocols applied in other psychiatric diagnoses. The technique can be used within regular cognitive behavioural therapy.

A review of hearing voices groups: evidence and mechanisms of change

As a heavily stigmatized group, voice hearers often value the chance to meet others with similar experiences. As a result, Hearing Voices Groups (HVGs) are becoming increasingly common in both inpatient and outpatient settings. Where resources are constrained, HVGs are frequently viewed as a desirable alternative to individual therapy and are often preferred by service users themselves. HVGs often vary in their content and structure, with four common approaches: CBT, skills-training, mindfulness and unstructured support groups. This review evaluates the evidence for HVGs and the mechanisms of change for successful interventions. CBT was the only approach with evidence from well-controlled studies. However, several evidence-based treatments share 'key ingredients' which evidence suggests help reduce distress. Successful groups supply a safe context for participants to share experiences, and enable dissemination of strategies for coping with voices as well as considering alternative beliefs about voices. Future research should focus on isolating mechanisms of change and predictors of outcome in order to refine HVG approaches, rather than polarizing them and setting them against one another in efficacy trials.