Beyond Trauma: A Multiple Pathways Approach to Auditory Hallucinations in Clinical and Nonclinical Populations

Recorded Rates of Trauma-Exposure in a Retrospective Epidemiologically Complete First-Episode Psychosis Cohort

BACKGROUND

Trauma plays an important role in the development and maintenance of psychosis. However, it is still under-examined in daily clinical practice. The current study investigated the rates of recording of trauma-exposure in the clinical histories of a first-episode psychosis (FEP) cohort attending an early intervention psychosis service.

METHODS

This study used a retrospective chart review methodology in a 6-year epidemiologically complete FEP cohort attending an early intervention psychosis service. The Trauma and Life Events Checklist was used to define the rate and types of trauma-exposure reported in clinical histories. The relationships were examined between recorded trauma-exposure and positive and negative symptoms, depression and duration of untreated psychosis at first assessment.

RESULTS

Trauma-exposure was frequently recorded within clinical histories. Childhood trauma-exposure was recorded in 47.4% of the sample, which is lower than may be expected. No significant relationships between the recorded trauma-exposure and symptom measures were found. A significant relationship was found between interpersonal stressors and positive symptoms, and work-related stress and negative symptoms, highlighting the importance of proximal stressful life events.

DISCUSSION

This study found that clinicians were frequently recording trauma-exposure in daily practice. However, it was unclear whether the recording of trauma-exposure highlighted led to systematic diagnosis, assessment or treatment of trauma for people with psychosis. The importance of treatment and service planning to include information about trauma-exposure is discussed.

Varieties of felt presence? Three surveys of presence phenomena and their relations to psychopathology

BACKGROUND

Experiences of felt presence (FP) are well documented in neurology, neuropsychology and bereavement research, but systematic research in relation to psychopathology is limited. FP is a feature of sensorimotor disruption in psychosis, hypnagogic experiences, solo pursuits and spiritual encounters, but research comparing these phenomena remains rare. A comparative approach to the phenomenology of FP has the potential to identify shared and unique processes underlying the experience across these contexts, with implications for clinical understanding and intervention.

METHODS

We present a mixed-methods analysis from three online surveys comparing FP across three diverse contexts: a population sample which included people with experience of psychosis and voice-hearing (study 1, N = 75), people with spiritual and spiritualist beliefs (study 2, N = 47) and practitioners of endurance/solo pursuits (study 3, N = 84). Participants were asked to provide descriptions of their FP experiences and completed questionnaires on FP frequency, hallucinatory experiences, dissociation, paranoia, social inner speech and sleep. Data and code for the study are available via OSF.

RESULTS

Hierarchical linear regression analysis indicated that FP frequency was predicted by a general tendency to experience hallucinations in all three studies, although paranoia and gender (female > male) were also significant predictors in sample 1. Qualitative analysis highlighted shared and diverging phenomenology of FP experiences across the three studies, including a role for immersive states in FP.

CONCLUSIONS

These data combine to provide the first picture of the potential shared mechanisms underlying different accounts of FP, supporting a unitary model of the experience.

Detecting anomalous experiences in the community: The Transpersonal Experiences Questionnaire (TEQ)

OBJECTIVES

There is growing recognition of the value of researching anomalous experiences in the general population to aid our understanding of the psychosis continuum. There are key differences in aims, foci and epistemologies of existing measures, with varying utility for specific research designs. This study addresses gaps in the literature by developing a measure of anomalous experiences with utility for longitudinal (time-sensitive) research, and with particular reliability for people towards the upper (high scoring) end of the continuum.

METHODS

An online sample was recruited from the general population to provide questionnaire data for two study parts: (A) item selection and (B) psychometric evaluation. For Part A, both classical test theory and item response theory methods were used to select which items to be included from an initial pool of 57, generated from individuals with persistent anomalous experiences. For Part B, psychometric properties of the resulting measure were evaluated using exploratory and confirmatory factor analysis and tests of reliability and validity.

RESULTS

Scores were provided by 532 participants, from which a 19-item scale, the Transpersonal Experiences Questionnaire (TEQ), was developed. The TEQ was found to be a unidimensional scale, with satisfactory internal consistency (0.85), good test-retest reliability and convergent validity.

CONCLUSIONS

The TEQ can be used as a unidimensional scale to detect anomalous experiences in the general population, with particular reliability for people with higher incidence of these experiences.

Studying Healthy Psychosislike Experiences to Improve Illness Prediction

Importance

Distinguishing delusions and hallucinations from unusual beliefs and experiences has proven challenging.

Observations

The advent of neural network and generative modeling approaches to big data offers a challenge and an opportunity; healthy individuals with unusual beliefs and experiences who are not ill may raise false alarms and serve as adversarial examples to such networks.

Conclusions and Relevance

Explicitly training predictive models with adversarial examples should provide clearer focus on the features most relevant to casehood, which will empower clinical research and ultimately diagnosis and treatment.

Associations among psychosis, mood, anxiety, and posttraumatic stress symptoms: A network analysis

The associations among psychotic experiences (i.e., hallucinations and delusions), trauma exposure, and posttraumatic stress symptoms are complex and multidirectional. Using network analysis to understand how psychotic experiences and symptoms of posttraumatic stress disorder (PTSD) relate to one another may identify new interventional targets to treat comorbidity and its underlying pathological processes. This study aimed to use network analysis to examine the associations among psychotic experiences; negative symptoms of psychosis; and symptoms of PTSD, anxiety, and depression. In this population-based cohort study, 4,472 participants (36.7% male) were assessed for psychotic experiences, negative symptoms of psychosis, PTSD, anxiety, and depression at age 23 (M = 23.86 years, SD = 0.520) or 24 years (M = 24.03, SD = 0.848). Associations among symptoms were assessed via network analysis. Exploratory graph analysis identified three clusters of densely connected symptoms within the overall network: psychotic experiences; PTSD symptoms; and depressive and anxiety symptoms and negative symptoms of psychosis. Psychotic experiences had the strongest associations with other symptoms in the network, and symptoms of anxiety played a key role in bridging psychotic experiences, symptoms of PTSD, and depressive symptoms. Consistent with the stress reactivity and affective models for psychotic experiences, the results suggest that symptoms of anxiety and emotional distress (e.g., hyperarousal, panic) may have a key role in the development and maintenance of psychotic experiences and symptoms of PTSD. Targeting these symptoms may ameliorate symptom burden transdiagnostically.

Learning to Discern the Voices of Gods, Spirits, Tulpas, and the Dead

There are communities in which hearing voices frequently is common and expected, and in which participants are not expected to have a need for care. This paper compares the ideas and practices of these communities. We observe that these communities utilize cultural models to identify and to explain voice-like events-and that there are some common features to these models across communities. All communities teach participants to "discern," or identify accurately, the legitimate voice of the spirit or being who speaks. We also observe that there are roughly two methods taught to participants to enable them to experience spirits (or other invisible beings): trained attention to inner experience, and repeated speech to the invisible other. We also observe that all of these communities model a learning process in which the ability to hear spirit (or invisible others) becomes more skilled with practice, and in which what they hear becomes clearer over time. Practice-including the practice of discernment-is presumed to change experience. We also note that despite these shared cultural ideas and practices, there is considerable individual variation in experience-some of which may reflect psychotic process, and some perhaps not. We suggest that voice-like events in this context may be shaped by cognitive expectation and trained practice as well as an experiential pathway. We also suggest that researchers could explore these common features both as a way to help those struggling with psychosis, and to consider the possibility that expectations and practice may affect the voice-hearing experience.

Childhood Trauma in Clozapine-Resistant Schizophrenia: Prevalence, and Relationship With Symptoms

Background and Hypothesis

The role of early adversity and trauma is increasingly recognized in psychosis but treatments for trauma and its consequences are lacking. Psychological treatments need to understand the prevalence of these experiences, the relationship with specific symptoms and identify potentially tractable processes that may be targeted in therapy. It was hypothesized that greater adversity, and specifically abuse rather than neglect, would be associated with positive symptoms and specifically hallucinations. In addition, negative beliefs would mediate the relationship with positive symptoms.

Study Design

292 Patients with treatment resistant psychosis completed measures of early adversity as well as current symptoms of psychosis.

Study Results

Early adversity in the form of abuse and neglect were common in one-third of the sample. Adversity was associated with higher levels of psychotic symptoms generally, and more so with positive rather than negative symptoms. Abuse rather than neglect was associated with positive but not with negative symptoms. Abuse rather than neglect was associated with hallucinations but not delusions. Abuse and neglect were related to negative beliefs about the self and negative beliefs about others. Mediation demonstrated a general relationship with adversity, negative-self, and other views and overall psychotic symptoms but not in relation to the specific experience of abuse and hallucinations. Females were more likely to be abused, but not neglected, than males.

Conclusions

Whilst most relationships were modest, they supported previous work indicating that adversity contributes to people with psychosis experiencing distressing symptoms especially hallucinations. Treatments need to address and target adversity.

The future of hallucination research: Can hallucinogens and psychedelic drugs teach us anything?

Hallucinations are one of the most interesting and least understood of all human experiences. This commentary addresses the ideas which most influenced my thinking in the past 20 years and what I believe to be the most currently promising area of enquiry. Interest in hallucinations reaches far back into antiquity and across cultures. The similarity of hallucinations in mental illness with the perceptual experiences reported by individuals who not mentally unwell has long been recognized. Early scientific research on hallucinogen drugs such as lysergic acid diethylamide (LSD) was criticized and then withdrawn, but its recent revival offers new opportunities to examine the mechanism and 'process' of hallucinating. Many psychedelic compounds can elicit intense and realistic hallucinations. The study of hallucinogens conducted in carefully controlled and supervised settings and with individuals who are not mentally unwell opens exciting new possibilities. For example, it may be possible to study the temporal shifts in perceptual awareness, decode what influences the contents, affect, meaning, and appraisals of hallucinations and guide novel psychotherapy techniques and drug therapy.

Hearing spiritually significant voices: A phenomenological survey and taxonomy

Whereas previous research in the medical humanities has tended to neglect theology and religious studies, these disciplines sometimes have a very important contribution to make. The hearing of spiritually significant voices provides a case in point. The context, content and identity of these voices, all of which have typically not been seen as important in the assessment of auditory-verbal hallucinations (AVHs) within psychiatry, are key to understanding their spiritual significance. A taxonomy of spiritually significant voices is proposed, which takes into account frequency, context, affect and identity of the voice. In a predominantly Christian sample of 58 people who reported having heard spiritually significant voices, most began in adult life and were infrequent experiences. Almost 90% reported that the voice was divine in identity and approximately one-third were heard in the context of prayer. The phenomenological characteristics of these voices were different from those in previous studies of voice hearing (AVHs). Most comprised a single voice; half were auditory; and a quarter were more thought-like (the rest being a mixture). Only half were characterful, and one-third included commands or prompts. The voices were experienced positively and as meaningful. The survey has implications for both clinical and pastoral work. The phenomenology of spiritually significant voices may be confused with that of psychopathology, thus potentially leading to misdiagnosis of normal religious experiences. The finding of meaning in content and context may be important in voice hearing more widely, and especially in coping with negative or distressing voices.

"Figuring out how to be normal": Exploring how young people and parents make sense of voice-hearing in the family context

OBJECTIVES

Making sense of voice-hearing-exploring the purpose, cause, and relationship with voices-is seen as therapeutically valuable for adults, but there is a paucity of research with adolescents. Family intervention is recommended for young people, yet little is known about families' perspectives on, or role in, a child's voice-hearing. This study therefore aimed to explore how both young people and parents had made sense of voice-hearing in the family context.

METHOD

Semi-structured interviews were conducted with seven young people who hear voices (six females, one male, age M = 17 years) and six parents of young people who hear voices (five females, one male). Data were analysed using interpretative phenomenological analysis.

RESULTS

The young people struggled to reconcile their voice-hearing experiences within themselves, wanted control, 'normality', and not to let their mental health hold them back. Parents saw the voices as separate to their child, who they were protective of, and came to an acceptance and hope for the future amidst continued uncertainty. Pragmatism, and shame, ran through parents' and young people's accounts. Tensions between them, such as autonomy versus involvement, were also apparent.

CONCLUSIONS

Few participants had made sense of their experiences in any concrete form, yet hope, control, and getting on with their lives were not conditional on having done so. Young people valued the family as a safe, non-enquiring space to be 'normal' and not to talk about their experiences. While all had been challenged by their experiences, an energy and strength ran through their accounts.

Thinking about hallucinations: why philosophy matters

Introduction: Hallucinations research is increasingly incorporating philosophy or the work of philosophically trained individuals. We present three different ways in which this is successfully implemented to the enhancement of knowledge and understanding of hallucinations and related phenomena.Method: We review contributions from phenomenology, philosophy of cognitive science, and philosophy of science and psychiatry.Results: We demonstrate that these areas of philosophy make significant contributions to hallucinations research. Phenomenology gives us a sophisticated and critical understanding of the lived experience of hallucinations. Philosophy of cognitive science enables big-picture theorising and synthesis of ideas, as well as a critical engagement with new paradigms. Philosophy of science and psychiatry raises valuable and theoretically informed questions about diagnosis and categorisation.Conclusions: These contributions reflect both the methodological variety within philosophy and its relevance to the hallucinations researcher.

Auditory verbal hallucinations and childhood trauma subtypes across the psychosis continuum: a cluster analysis

Introduction: A strong link between voice-hearing experience and childhood trauma has been established. The aim of this study was to identify whether there were unique clusters of childhood trauma subtypes in a sample across the clinical spectrum of auditory verbal hallucinations (AVH) and to examine clinical and phenomenological features across these clusters.Methods: Combining two independent international datasets (the Netherlands and Australia), childhood trauma subtypes were examined using hierarchical cluster analysis. Clinical and phenomenological characteristics were compared across emerging clusters using MANOVA and chi-squared analyses.Results: The total sample (n = 413) included 166 clinical individuals with a psychotic disorder and AVH, 122 non-clinical individuals with AVH and 125 non-clinical individuals without AVH. Three clusters emerged: (1) low trauma (n = 299); (2) emotion-focused trauma (n = 71); (3) multi-trauma (n = 43). The three clusters differed significantly on their AVH ratings of amount of negative content, with trend-level effects for loudness, degree of negative content and degree of experienced distress. Furthermore, perceptions of voices being malevolent, benevolent and resistance towards voices differed significantly.Conclusion: The data revealed different types of childhood trauma had different relationships between clinical and phenomenological features of voice-hearing experiences. Thus, implicating different mechanistic pathways and a need for tailored treatment approaches.

Sensory experiences of one's deceased spouse in older adults: An analysis of predisposing factors

Objectives This study focuses on pre-disposing factors associated with sensory experiences of the deceased (SED), also called bereavement hallucinations. Even though SED are common among older widowed adults, our knowledge of these experiences is still limited.Method Survey responses were obtained from 310 older widowed participants (M = 70.05 ± 8.39), complemented with data from Danish national registers.Results Hierarchical logistic regression analysis revealed four significant pre-disposing factors: prior experiences of SED in the context of previous significant bereavements (OR = 4.72), a history of interpersonal trauma (OR = 5.8), high pre-death relationship closeness (OR = 2.76) and stronger religious/spiritual worldview (OR = 1.12). No association to registered mental health diagnosis was identified.Conclusion: SED may be considered an interpersonal experience, which may be more likely to occur if the pre-death relationship is described as very close and if the bereaved has previously experienced interpersonal trauma. We argue that SED should not necessarily be considered an indication of neurodegenerative or psychiatric diseases.

Auditory Hallucination Among Traumatized Cambodian Refugees: PTSD Association and Biocultural Shaping

At a psychiatric refugee clinic for survivors of the Khmer Rouge genocide, a survey revealed that 42% (38/90) had auditory hallucinations (AHs) in the last month. Of those with AHs, 87% (33/38) had PTSD, whereas of those without AHs, 31% (16/52) had PTSD, giving a chi square of 27.8, p < .001, odds ratio 14.8 (4.8-45). Most AHs were of a "ghost summoning" (khmaoch hao), considered an exhortation to go with a ghost (e.g., hearing "Please come with me, younger sister"), experienced by 73% percent of patients with AHs. The voices were always exterior and usually loud and clear. AHs were heard most often during hypnagogia (i.e., upon falling asleep or awakening), experienced by 72% of patients with AHs, whereas 42% of patients with AHs experienced AHs when fully awake. AHs were almost always attributed to a ghost, giving rise to great fear: of having the "soul" called away or of being frightened to death. AH episodes almost always triggered trauma recall. AHs caused patients to undertake certain actions to address acute episodes and to prevent further ones. To illustrate these processes, cases are provided. AH appears to be a key part of the Cambodian bioculturally shaped trauma subjectivity.

A network analysis of post-traumatic stress and psychosis symptoms

BACKGROUND

Understanding the interplay between trauma-related psychological mechanisms and psychotic symptoms may improve the effectiveness of interventions for post-traumatic stress reactions in psychosis. Network theory assumes that mental health problems persist not because of a common latent variable, but from dynamic feedback loops between symptoms, thereby addressing the heterogeneous and overlapping nature of traumagenic and psychotic diagnoses. This is a proof-of-concept study examining interactions between post-traumatic stress symptoms, which were hypothesized to reflect trauma-related psychological mechanisms, and auditory hallucinations and delusions.

METHOD

Baseline data from two randomised controlled trials (N = 216) of trauma-focused therapy in people with post-traumatic stress symptoms (87.5% met diagnostic criteria for PTSD) and psychotic disorder were analysed. Reexperiencing, hyperarousal, avoidance, trauma-related beliefs, auditory hallucinations and delusional beliefs were used to estimate a Gaussian graphical model along with expected node influence and predictability (proportion of explained variance).

RESULTS

Trauma-related beliefs had the largest direct influence on the network and, together with hypervigilance, were implicated in the shortest paths from flashbacks to delusions and auditory hallucinations.

CONCLUSIONS

These findings are in contrast to previous research suggesting a central role for re-experiencing, emotional numbing and interpersonal avoidance in psychosis. Trauma-related beliefs were the psychological mechanism most associated with psychotic symptoms, although not all relevant mechanisms were measured. This work demonstrates that investigating multiple putative mediators may clarify which processes are most relevant to trauma-related psychosis. Further research should use network modelling to investigate how the spectrum of traumatic stress reactions play a role in psychotic symptoms.

Towards Deciphering the Fetal Foundation of Normal Cognition and Cognitive Symptoms From Sulcation of the Cortex

Growing evidence supports that prenatal processes play an important role for cognitive ability in normal and clinical conditions. In this context, several neuroimaging studies searched for features in postnatal life that could serve as a proxy for earlier developmental events. A very interesting candidate is the sulcal, or sulco-gyral, patterns, macroscopic features of the cortex anatomy related to the fold topology-e.g., continuous vs. interrupted/broken fold, present vs. absent fold-or their spatial organization. Indeed, as opposed to quantitative features of the cortical sheet (e.g., thickness, surface area or curvature) taking decades to reach the levels measured in adult, the qualitative sulcal patterns are mainly determined before birth and stable across the lifespan. The sulcal patterns therefore offer a window on the fetal constraints on specific brain areas on cognitive abilities and clinical symptoms that manifest later in life. After a global review of the cerebral cortex sulcation, its mechanisms, its ontogenesis along with methodological issues on how to measure the sulcal patterns, we present a selection of studies illustrating that analysis of the sulcal patterns can provide information on prenatal dispositions to cognition (with a focus on cognitive control and academic abilities) and cognitive symptoms (with a focus on schizophrenia and bipolar disorders). Finally, perspectives of sulcal studies are discussed.

Whispers, echoes, friends and fears: forms and functions of voice-hearing in adolescence

BACKGROUND

Despite the high prevalence of voice-hearing in childhood, research with adolescents aged under 16 years is scarce. Theoretical connections between clinical and developmental conceptualizations of voice-hearing are limited, resulting in missed opportunities to explore unusual sensory experiences with young people.

METHODS

Demographic, contextual and qualitative data were collected through a web-based survey with 68 adolescents (M = 14.91; SD = 2.77) from Australia, Canada, Ireland, New Zealand, Spain, the United Kingdom and United States of America. A Foucauldian-informed narrative analysis captured phenomenologically meaningful individual accounts and systemically informed narratives. Analytic layers attended specifically to the form and function of voices, including relational, protective, distressing and nuanced experiences, offering new insights into individual, systemic and cultural interpretative narratives surrounding voice-hearing to inform research, policy and tailored support.

RESULTS

The average self-reported age of onset of voices was 9 years, 5 months. Reciprocal relationships with pleasant voices were evidenced through the narratives and characterization of voices, while distressing voices were described without reciprocity and the voices held greater power over the young person. Positive aspects of negative voices were discussed and are illustrated with a continuum matrix reflecting interpretation and related affect.

CONCLUSIONS

Voice-hearing is a heterogeneous and often complex relational experience for young people, with structural inequalities, relational traumas and social isolation attributed causes of voice-hearing. Developing personal meaning-making mitigated voice-related distress through contextualizing the origin of the voices in past experiences, without attribution to mental illness. Recommendations are proposed for assessment, formulation and relational interventions that recognize the potential impact of the voice-child-other relationship upon psychosocial functioning and wellbeing.

rs1344706 polymorphism of zinc finger protein 804a (ZNF804a) gene related to the integrity of white matter fiber bundle in schizophrenics

Genetic factors play an important role in the pathogenesis of schizophrenia (SZ), and the zinc finger protein 804a (ZNF804a) gene has been considered to be a risk gene for schizophrenia. In the present study, the correlation between rs1344706 polymorphism of ZNF804a gene and the integrity of white matter in schizophrenic cases was explored. A total of 60 SZ patients and 100 healthy controls (HC) were included to undergo head MRI. According to the genotyping of rs1344706 in ZNF804a, the subjects in each group were divided into a normal allele and risk allele-carrying group. The imaging data were preprocessed by PANDA software, and thefractional anisotropy (FA) of each subject was calculated. With SPM8 software, age and years of education were considered as covariates, and diagnosis as well as genotype (AA, GG/AG) were considered as intergroup factors. Four groups of FA images were analyzed by two-factor analysis of variance. The FA value of the right posterior radiocrown in the patient group was lower than that in the control group, and the difference was statistically significant. The FA value of the right lower frontal occipital tract and the right upper radiocrown in the G allele carrier group was lower than that in the A allele homozygous group. There was detection of an interaction between the FA value of the splenium of corpus callosum, the body part of the corpus callosum and the right cingulate tract. In the present study, it was demonstrated that the rs1344706 GG/AG genotype of the ZNF804a gene locus in SZ patients suffered from abnormal structure in a specific region of the brain. This finding indicated that the rs1344706 single nucleotide polymorphism of the ZNF804a gene may affect the integrity of the white matter of the brain in SZ patients and may be involved in the pathophysiological mechanism of SZ.

When experiences of presence go awry: A survey on psychotherapy practice with the ambivalent-to-distressing 'hallucination' of the deceased

OBJECTIVES

Experiences of presence, involving the sensory perception or felt presence of the deceased, are common amongst the bereaved (30-60%). Despite them being predominantly comforting and reassuring, a minority (approximately 25%) report ambivalent or distressing experiences. The study's aim was to explore how psychotherapy is practised with this subset.

METHOD

A mixed-method approach, involving both quantitative analysis and thematic analysis, was used to analyse data from an online survey, conducted in English and Spanish, amongst mental health therapists (i.e., psychologists, psychotherapists, and counsellors). Seventy responded to the survey and four of them were further interviewed.

RESULTS

The participants primarily framed interventions for ambivalent-to-distressing experiences of presence as grief therapy, with the severity of the presentation as the main factor influencing their clinical decision-making, but several perspectives co-existed regarding how to intervene. These discourses were categorized into two themes: 'A normalising and exploratory psychotherapy' and 'A grief stages psychotherapy'. The main sources of patient's distress, as understood by the sample, were located in the bereaved-departed relationship, in pre-existing mental health issues, and in a societal taboo or stigma.

CONCLUSION

After comparing and contrasting the participants' working hypotheses with existing knowledge on experiences of presence, and contemporary theories in the research area, guidelines are presented on how to intervene with people disturbed by their experiences of presence.

PRACTITIONER POINTS

Perceiving the deceased person, or feeling their presence, is common and normal amongst bereaved people. When these experiences are distressing or ambivalent, therapists' share that psychological suffering may originate from the departed-bereaved relationship, pre-existing mental health issues, or the effect of societal taboo or stigma. Psychotherapy is frequently aimed at normalizing, accepting, supporting, and exploring patient's experience.

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.

Development and Validation of an Instrument for the Detection of Early Traumatic Experiences (ExpTra-S) in Patients With Psychosis

The risk of the appearance of psychosis may reflect the existence of an underlying vulnerability, which may be influenced by environmental factors such as early traumatic experiences. This means that in clinical practice, the assessment of and approach to previous traumatic events is important in persons with psychotic disorders. The psychometric assessment of trauma has advanced considerably in recent years; however, there is no instrument that has been constructed and validated specifically for the evaluation of early traumatic experiences in the clinical population with psychosis. The main goal of this study was to present the construction and validation process of the Screening of Early Traumatic Experiences in Patients with Severe Mental Illness (ExpTra-S). The sample consisted of 114 patients who had experienced at least one psychotic episode (M = 35.5 years of age; SD = 9.26) and a comparison group of 153 young adults (M = 20.8 years of age; SD = 1.8). The factor analysis revealed an essentially one-dimensional structure. The ExpTra-S was associated with the positive dimension of the psychosis phenotype but not with the negative or affective dimensions, or subjective experiences. No items displayed differential functioning for sex and age. The ordinal alpha for the total score was 0.96. The patients with psychosis had a higher score for early traumatic experiences in comparison with the non-clinical group. The results obtained showed that the measuring instrument developed, the ExpTra-S, is a brief, simple, and useful measuring instrument for assessing the presence of early traumatic experiences in patients with severe mental illness.

Evidence in cortical folding patterns for prenatal predispositions to hallucinations in schizophrenia

All perception is a construction of the brain from sensory input. Our first perceptions begin during gestation, making fetal brain development fundamental to how we experience a diverse world. Hallucinations are percepts without origin in physical reality that occur in health and disease. Despite longstanding research on the brain structures supporting hallucinations and on perinatal contributions to the pathophysiology of schizophrenia, what links these two distinct lines of research remains unclear. Sulcal patterns derived from structural magnetic resonance (MR) images can provide a proxy in adulthood for early brain development. We studied two independent datasets of patients with schizophrenia who underwent clinical assessment and 3T MR imaging from the United Kingdom and Shanghai, China (n = 181 combined) and 63 healthy controls from Shanghai. Participants were stratified into those with (n = 79 UK; n = 22 Shanghai) and without (n = 43 UK; n = 37 Shanghai) hallucinations from the PANSS P3 scores for hallucinatory behaviour. We quantified the length, depth, and asymmetry indices of the paracingulate and superior temporal sulci (PCS, STS), which have previously been associated with hallucinations in schizophrenia, and constructed cortical folding covariance matrices organized by large-scale functional networks. In both ethnic groups, we demonstrated a significantly shorter left PCS in patients with hallucinations compared to those without, and to healthy controls. Reduced PCS length and STS depth corresponded to focal deviations in their geometry and to significantly increased covariance within and between areas of the salience and auditory networks. The discovery of neurodevelopmental alterations contributing to hallucinations establishes testable models for these enigmatic, sometimes highly distressing, perceptions and provides mechanistic insight into the pathological consequences of prenatal origins.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Culture and the plasticity of perception

Culture shapes our basic sensory experience of the world. This is particularly striking in the study of religion and psychosis, where we and others have shown that cultural context determines both the structure and content of hallucination-like events. The cultural shaping of hallucinations may provide a rich case-study for linking cultural learning with emerging prediction-based models of perception.

Exploring the relationship between auditory hallucinations, trauma and dissociation

BACKGROUND

It is clinically imperative to better understand the relationship between trauma, auditory hallucinations and dissociation. The personal narrative of trauma has enormous significance for each individual and is also important for the clinician, who must use this information to decide on a diagnosis and treatment approach.

AIMS

To better understand whether dissociation contributes in a significant way to hallucinations in individuals with and without trauma histories.

METHOD

Three groups of participants with auditory hallucinations were recruited, with diagnoses of: schizophrenia (without trauma) (n = 18), post-traumatic stress disorder (PTSD, n = 27) and comorbid schizophrenia and PTSD (SCZ+PTSD), n = 26). Clinician-administered measures included the PTSD Symptoms Scale Interview (PSSI-5), the Clinician-Administered Dissociative States Scale (CADSS) and the Psychotic Symptom Rating Scales (PSYRATS).

RESULTS

Dissociative symptoms were significantly higher in participants with trauma histories (PTSD and SCZ+PTSD groups) and significantly correlated with hallucinations in trauma-exposed participants, but not in participants with schizophrenia (without trauma history). Hallucination severity was correlated with the CADSS amnesia subscale score, but depersonalisation and derealisation were not.

CONCLUSIONS

Dissociation may be a mechanism in trauma-exposed individuals who hear voices, but it does not explain all hallucinatory experiences. The SCZ+PTSD group were in an intermediary position between schizophrenia and PTSD on dissociative and hallucination measures. The PTSD and SCZ+PTSD groups experienced dissociative phenomena much more frequently than the schizophrenia group, with a significant trend towards the amnesia subtype of dissociation.

Anomalous experiences are more prevalent among highly suggestible individuals who are also highly dissociative

Introduction: Predictive coding models propose that high hypnotic suggestibility confers a predisposition to hallucinate due to an elevated propensity to weight perceptual beliefs (priors) over sensory evidence. Multiple lines of research corroborate this prediction and demonstrate a link between hypnotic suggestibility and proneness to anomalous perceptual states. However, such effects might be moderated by dissociative tendencies, which seem to account for heterogeneity in high hypnotic suggestibility. We tested the prediction that the prevalence of anomalous experiences would be greater among highly suggestible individuals who are also highly dissociative.Methods: We compared high and low dissociative highly suggestible participants and low suggestible controls on multiple psychometric measures of anomalous experiences.Results: High dissociative highly suggestible participants reliably reported greater anomalous experiences than low dissociative highly suggestible participants and low suggestible controls, who did not significantly differ from each other.Conclusions: These results suggest a greater predisposition to experience anomalous perceptual states among high dissociative highly suggestible individuals.

Moment-to-moment associations between posttraumatic stress symptoms and auditory hallucinations in the flow of daily life

Traumatic events are associated with increased risk of auditory hallucinations (AHs) and posttraumatic stress symptoms have been implicated in this relationship. We aimed to explore the moment-to-moment relationship between posttraumatic stress symptoms and AHs in daily-life. Twenty-eight people with persistent AHs and a history of traumatic events completed six-days of ecological momentary assessment. We assessed AHs, trauma memory intrusions, avoidance, and hyperarousal at ten time points each day. Multi-level modelling showed that the severity of trauma memory intrusions (but not avoidance or hyperarousal) within the preceding hour was associated with the occurrence of AHs. This relationship was significantly stronger for people with a direct link between the content of their AHs and trauma history. In time-lagged analyses, main effects of trauma memory intrusions, avoidance, and hyperarousal on AHs were not significant. Trauma memory intrusions have momentary associations with AHs and this relationship is stronger and more enduring for those with a direct link between their AH and the trauma. Our findings are in keeping with the proposal that intrusive trauma memories are associated with the occurrence of (some) AHs.

Social interaction skills and depressive symptoms in people diagnosed with schizophrenia: The mediating role of auditory hallucinations

Past studies have presented evidence that depressive symptoms are affected in different ways by social interaction skills and auditory hallucinatory symptoms in people with schizophrenia. However, few studies have focused on examining the relationship among auditory hallucinatory severity, social interaction skills, and depressive symptoms. This study aimed to explore the mediating effect of auditory hallucinatory severity on social interaction skills and depressive symptoms in people with long-term schizophrenia. We propose that auditory hallucination severity functions as a mechanism through which impaired social interaction skills increase depressive symptoms. In this study, a convenience sample of 186 people with schizophrenia was obtained from hospital-based rehabilitation wards. Four instruments were used: A demographic data questionnaire, the Assessment of Communication and Interaction Skills-Chinese version, the Characteristics of Auditory Hallucinations Questionnaire, and the Beck Depression Inventory II. To investigate the mediating effect of auditory hallucinatory severity after controlling for six covariates, we tested an indirect effect in a simple mediation model using the SPSS macro PROCESS, which is a regression-based approach. The indirect effect and the results of Sobel's test were significant (Z = -2.824, P = 0.005), which confirms that auditory hallucination severity mediates social interaction skills and depressive symptoms. This finding suggests that psychiatric nurses must teach people with schizophrenia to use auditory hallucination management strategies to prevent them from becoming immersed in auditory hallucinations and reducing their social interaction with the real world, so that depressive symptoms can be improved.

Affective and cognitive factors associated with hallucination proneness in the general population: the role of shame and trauma-related intrusions

Introduction: Feelings of shame may be an important factor implicated in the onset and maintenance of hallucination (or hearing voices). Shame has been shown to increase trauma-related intrusions and avoidance and may reinforce negative beliefs about the self, which in turn may contribute to hallucinations in clinical and non-clinical populations. To our knowledge, no study has so far explored the role of shame in hallucination-proneness. Therefore, the main goal of the present study is to explore the mediation role of shame, trauma-related intrusions and avoidance in the association between childhood trauma and hallucination-proneness.Methods: Self-report questionnaires were used to assess past traumatic experiences, trauma-related symptoms, shame, and hallucination proneness in 175 participants from the general population.Results: Mediation analyses (joint-significance test and Monte Carlo test) showed that both shame and intrusions mediated the association between childhood trauma and hallucination-proneness.Conclusions: Our results reinforce the importance of considering previous experiences of trauma and trauma-related symptoms, including feelings of shame in individuals experiencing hallucinations. Moreover, this study reinforces previous studies showing some preliminary evidence that compassion-focused therapy, whose primary goal is to reduce shame by increasing self-compassion, could have a significant effect on voices whose content is hostile.

Imaginary Companions, Inner Speech, and Auditory Verbal Hallucinations: What Are the Relations?

Interacting with imaginary companions (ICs) is now considered a natural part of childhood for many children, and has been associated with a range of positive developmental outcomes. Recent research has explored how the phenomenon of ICs in childhood and adulthood relates to the more unusual experience of hearing voices (or auditory verbal hallucinations, AVH). Specifically, parallels have been drawn between the varied phenomenology of the two kinds of experience, including the issues of quasi-perceptual vividness and autonomy/control. One line of research has explored how ICs might arise through the internalization of linguistically mediated social exchanges to form dialogic inner speech. We present data from two studies on the relation between ICs in childhood and adulthood and the experience of inner speech. In the first, a large community sample of adults (N = 1,472) completed online the new Varieties of Inner Speech – Revised (VISQ-R) questionnaire (Alderson-Day et al., 2018) on the phenomenology of inner speech, in addition to providing data on ICs and AVH. The results showed differences in inner speech phenomenology in individuals with a history of ICs, with higher scores on the Dialogic, Evaluative, and Other Voices subscales of the VISQ-R. In the second study, a smaller community sample of adults (N = 48) completed an auditory signal detection task as well as providing data on ICs and AVH. In addition to scoring higher on AVH proneness, individuals with a history of ICs showed reduced sensitivity to detecting speech in white noise as well as a bias toward detecting it. The latter finding mirrored a pattern previously found in both clinical and nonclinical individuals with AVH. These findings are consistent with the view that ICs represent a hallucination-like experience in childhood and adulthood which shows meaningful developmental relations with the experience of inner speech.