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The auditory hallucination: A phenomenological survey
Abstract
Synopsis
A comprehensive semi-structured questionnaire was administered to 100 psychotic patients who had experienced auditory hallucinations. The aim was to extend the phenomenology of the hallucination into areas of both form and content and also to guide future theoretical development. All subjects heard ‘voices’ talking to or about them. The location of the voice, its characteristics and the nature of address were described. Precipitants and alleviating factors plus the effect of the hallucinations on the sufferer were identified. Other hallucinatory experiences, thought insertion and insight were examined for their inter-relationships. A pattern emerged of increasing complexity of the auditory–verbal hallucination over time by a process of accretion, with the addition of more voices and extended dialogues, and more intimacy between subject and voice. Such evolution seemed to relate to the lessening of distress and improved coping. These findings should inform both neurological and cognitive accounts of the pathogenesis of auditory hallucinations in psychotic disorders.
... Aunque las alucinaciones son experiencias fenomenológicamente heterogéneas, y en particular las alucinaciones auditivas verbales y las no verbales, éstas pueden involucrar diferentes tipos de sonidos que varían en complejidad; por ejemplo: soplos, crujidos, tarareos, gritos, risas, susurros y oír hablar en voz alta (Nayani y David, 1996;Watkins, 2003). Gauntlett-Gilbert y Kuipers (2003) estudiaron varias características fenomenológicas de alucinaciones visuales en un grupo de pacientes psiquiátricos y encontraron, por ejemplo, que las alucinaciones visuales con contenido humanoide tenían características específicas, como rostros, calaveras o figuras enteras o fragmentadas. ...
... Junginger dice que "pocas personas en nuestra investigación […] reconocieron a la voz alucinada como propia, pero refieren a ellas como si fueran propias" (1986: 527), y sugirió que las alucinaciones pueden variar a lo largo de la dimensión "yo/no yo". Pueden describirlas como proviniendo desde dentro o por fuera, pero también hay casos en los cuales es difícil hacer esta distinción (Nayani y David, 1996;Oulis, Mavreas, Mamounas y Stefanis, 1995;Copolov, Trauer, Mackinnon, 2004;Judkins y Slade, 1981). Por lo tanto, parece que las alucinaciones pueden variar no sólo a lo largo de una dimensión interna/externa, sino también de una dimensión yo/no yo. ...
... La no atribución del discurso interno puede ser el causante más probable, esto sugiere que, en la mayoría de los casos, el contenido de la voz puede ser amenazante o crítico. El contenido de las voces puede ser negativo, positivo, instructivo o neutral (Nayani y David, 1996;Close y Garety, 1998;Leudar, McNally y Glinski, 1997). Incluso, es más negativo en individuos que han estado en los servicios psiquiátricos (Romme y Escher, 2005). ...
Las alucinaciones son percepciones que ocurren en ausencia de estímulos sensoriales correspondientes, pero desde el punto de vista subjetivo del individuo que las experimenta son indistinguibles de la percepción normal. Algo es percibido, pero objetivamente no hay nada para percibir. La alucinación presenta tres características; en primer lugar, existe la convicción de que el fenómeno tiene su origen fuera de uno mismo, hay una falta de control por parte del individuo que in¬tenta distinguir entre las alucinaciones y, por ejemplo, la imaginación; y en tercer lugar, existe una imposibilidad, o por lo menos una dificultad, de alterar o disminuir la experiencia en forma voluntaria.
En buena medida, lo disfuncional de una experiencia alucinatoria dependerá de la respuesta social. Definitivamente, existe diferencia entre una persona que experimenta un delirio místico y una que tiene una experiencia mística. Es diagnóstico psicológico de una persona que dice ver a Jesucristo o a la Virgen María en un santuario mariano no recibe el mismo juicio de integridad mental que una persona que está en un hospital neuropsiquiátrico. Además, individuos que mantienen conversaciones con espíritus son menos propensos a padecer empeoramiento funcional, en tanto y en cuanto, estén rodeados por personas que acepten su experiencia, que si están rodeados por individuos que menosprecian o rechazan sus experiencias.
En conclusión, el autor sostiene que las alucinaciones también pueden ser observadas en personas que no presentan ningún tipo de trastorno psicopatológico. Esta situación lleva a proponer una continuidad del fenómeno alucinatorio entre la normalidad y la patología. Más aún, el modelo de continuidad de la experiencia alucinatoria que se desarrolla en esta obra se basa principalmente en estudios epidemiológicos, y como varía la distribución de estos síntomas en la población general según cómo se mida el fenómeno y explorar otras experiencias perceptuales anómalas. Finalmente, se examina si resulta necesario una nueva palabra para suplir el termino “alucinación” a causa de la clara connotación patológica de la experiencia.
... There are many excellent studies published in this area assessing the different dimensions of AVH. [1][2][3][4] Aims and objectives ...
... 12 In Nayani et al. study the internal or external did not differ on reality score. 2 The neurological literature suggests that experience of unilateral hallucination is associated with contralateral temporal lobe diseases (Almedia et al. 1993) 13 or with ipsilateral ear discharge (Taylor and Fleminger,1981). 14 Loudness has high correlation with all other dimensions (including disruption to life) used in PSYRATS except location and controllability of voices. ...
... 17 Literature shows that about half of patient are able to exert some control over their voices. 2 and two third developed the coping mechanism to deal with them. When various types of auditory input were presented to patient with schizophrenia who experienced hallucinations, it was found that it was not the degree of external stimulation that was required to diminish hallucination but the nature of stimulus and degree of attention it received. ...
Background: Auditory hallucinations are common feature in psychotic disorder and have also given diagnostic importance. These hallucinations can be rated on different dimensions both quantitatively and qualitatively, so here comes phenomenological aspect. Study of phenomenological aspects may lead to more understanding about them and further can help in management of distressing auditory hallucinations. Aims and Objectives: The aims and objectives of the current study was as follows- 1. To explore the phenomenology of auditory hallucination in schizophrenia spectrum disorder. 2. To find out clinical correlation of auditory hallucination with other psychotic symptoms. 3. To find out factor structure of PSYRATS (Psychotic Symptom Rating Scale) and their correlation with PANSS and its subscales. Materials and Methods: One hundred patients, who had schizophrenia spectrum diagnoses attending general hospital psychiatry unit in India having auditory verbal hallucination (AVH) in last seven days were studied. Phenomenology was assessed by using Psychotic Symptoms Rating Scale (PSYRATS) and Positive and Negative Syndrome Scale (PANSS). Pearson correlation for the psychotic symptoms, Dimensions of psychotic symptoms on PSYRATS were explored by principal component analysis. Results: In study 82% patients had schizophrenia. More than one third patients heard voices continuously, in more than two-third patients voices were coming from outside head only, had no control over them, and had same loudness as one’s own voice. One third patients had AVH (Auditory Verbal Hallucinations) with all negative content, 19% had AVH commanding nature. 79% had delusions, 96% had hallucinatory behavior. Bipolar index showed dominance of positive symptoms. 80% reported depression. On principal component analysis three factors found, all three factors were positively correlated with positive subscale and total PANSS score. None of three factors were correlated with negative subscale of PANSS. Conclusion: In this study of AVH phenomenology among schizophrenia spectrum disorders, most dimensions of AVH correlated well with one another. On principal component analysis three factor structure of PSYRATS was found.
... Il peut ainsi s'agir d'ordres, de critiques, d'insultes ou encore de propos menaçants envers le patient lui-même et/ou envers autrui (McCarthy-Jones, Trauer, et al., 2014;Nayani & David, 1996), pouvant conduire au suicide (Franck & Thibaut, 2003;Palmer et al., 2005). Moins souvent, les HAV peuvent aussi être perçues comme des voix positives et agréables. ...
... Les patients peuvent entendre une ou plusieurs voix (en moyenne trois ou quatre), masculines ou féminines (le plus souvent masculines) et familières ou non (McCarthy-Jones, Trauer, et al., 2014;Nayani & David, 1996). Nayani et David rapportent que, dans la plupart des cas, les patients identifient leurs voix comme étant celle de Dieu, du diable ou d'un proche (Nayani & David, 1996). ...
... Les patients peuvent entendre une ou plusieurs voix (en moyenne trois ou quatre), masculines ou féminines (le plus souvent masculines) et familières ou non (McCarthy-Jones, Trauer, et al., 2014;Nayani & David, 1996). Nayani et David rapportent que, dans la plupart des cas, les patients identifient leurs voix comme étant celle de Dieu, du diable ou d'un proche (Nayani & David, 1996). ...
Les hallucinations auditives verbales (HAV) sont sous-tendues par des altérations de la connectivité cérébrale structurelle et fonctionnelle dans le réseau du langage et dans le réseau par défaut (DMN). La Stimulation Magnétique Transcrânienne répétée (rTMS) est une technique non-invasive présentant un potentiel thérapeutique pour le traitement de symptômes issus de perturbations de la connectivité cérébrale comme les HAV. Toutefois, ses bénéfices thérapeutiques sont modérés et hautement variables d’un patient à l’autre. L’objectif de cette thèse était de mieux caractériser la réponse clinique au traitement par rTMS en étudiant les corrélats structurels et fonctionnels au sein du réseau du langage et du DMN chez des patients atteints de schizophrénie.Nos résultats ont montré une connectivité structurelle plus faible dans le faisceau arqué gauche chez les patients Répondeurs comparés aux Non-Répondeurs, corrélée avec l’amélioration des HAV après rTMS. La rTMS à 1 Hz sur l’aire de Wernicke réduisait la sévérité des HAV. Nous observons une augmentation de la connectivité fonctionnelle entre l’aire de Wernicke et le précunéus droit dans le groupe Répondeur et une diminution de connectivité entre ces deux régions dans le groupe Non-Répondeur. La connectivité entre ces deux régions était corrélée avec l’amélioration des HAV. Une analyse de modélisation de l’effet de la TMS n’a pas permis de mieux comprendre l’amélioration des HAV.La connectivité structurelle du faisceau arqué gauche pourrait être un marqueur prédictif de la réponse clinique à la rTMS. Nos travaux suggèrent des pistes de recherche pour développer des protocoles thérapeutiques personnalisés pour chaque individu.
... Furthermore, it is well-known that individuals often hear a number and variety of different voices. Yet phenomenological studies have not provided detailed descriptions of the content and nature of multiple voices experienced by the same person, despite noting and sometimes enquiring about their existence (Carter et al., 1995;McCarthy-Jones et al., 2014b;Nayani and David, 1996;Stephane et al., 2003;Woods et al., 2015). Conclusions about mechanisms, subtypes, or risk factors for hearing voices may not be valid unless this multiplicity is adequately reflected in the data. ...
... Consistent with Nayani and David (1996), the majority of voices were perceived as male. The perceived gender of the voice often differed from that of the respondent, and in a minority of cases the perceived age was substantially greater. ...
... Our data add to previous findings concerning the frequency of voicehearing and the extent to which voices are subjectively believed or a source of distress (e.g., Nayani and David, 1996;Larøi et al., 2012). The confirmation that hearers report a large number and variety of voices has important implications for research and clinical evaluation. ...
Although it is recognized that voice-hearers often report a large number and variety of voices there have been few investigations of this multiplicity. Understanding the phenomenology of voice-hearing can provide a firm foundation for theorizing about its causes. In this international online survey of voice-hearers, details were elicited of the content of up to five utterances associated with up to five voices from each respondent. The contents were independently rated and associated with characteristics of each voice such as its perceived age, whether it had changed over time, and whether it was of a familiar person. We investigated predictors (e.g., diagnoses, voice gender, age first heard) of utterance negativity, length, and whether voices referred to themselves. The average number of voices reported was approximately four. The majority were perceived as male and had negative content. Child-aged voices were significantly less negative than all other voices except those perceived as being elderly. Multilevel analyses indicated that there was significant variability at the level of different utterances within voices but variability was more prominent at the level of different voices within an individual. The data were inconsistent with general cognitive models for hearing voices such as the misattribution of inner speech and were more congruent with a dissociation model of voice-hearing. Our findings support approaches based on subtype or dimensional methods of classifying voices, and additionally indicate that research and clinical assessment may benefit from more systematic assessment of multiplicity.
... From a descriptive point of view, people diagnosed with schizophrenia report hearing voices with multiple characteristics [see (9)(10)(11)(12)(13)(14)(15)]. They report being addressed by the hallucinatory voices from different perspectives (2nd or 3rd person), or by a number of different entities over time (13,(16)(17)(18). For example, an individual with schizophrenia diagnosis reports: "I hear distinct voices. ...
... As mentioned in the introductory section, a number of studies reflect a wide heterogeneity in the descriptions of the patients' voices. While some people report phenomenal clarity similar to a conversation with another person (49), others report them as ideas or "silent sensations" (16,21). Most patients manage to differentiate voices from their own thoughts (30,49) and they usually have normal volume. ...
... Although many patients hear more than one voice, most refer to a middle-aged male voice that commands or insults but may also make positive comments (20). Less frequent are whispers or shouts, and, very importantly for our discussion, voices are referred as both inside and outside the head (16,21,23). ...
In trying to make sense of the extensive phenomenological variation of first-personal reports on auditory verbal hallucinations, the concept of pseudohallucination is originally introduced to designate any hallucinatory-like phenomena not exhibiting some of the paradigmatic features of “genuine” hallucinations. After its introduction, Karl Jaspers locates the notion of pseudohallucinations into the auditory domain, appealing to a distinction between hallucinatory voices heard within the subjective inner space (pseudohallucination) and voices heard in the outer external space (real hallucinations) with differences in their sensory richness. Jaspers' characterization of the term has been the target of a number of phenomenological, conceptual and empirically-based criticisms. From this latter point of view, it has been claimed that the concept cannot capture distinct phenomena at the neurobiological level. Over the last years, the notion of pseudohallucination seems to be falling into disuse as no major diagnostic system seems to refer to it. In this paper, we propose that even if the concept of pseudohallucination is not helpful to differentiate distinct phenomena at the neurobiological level, the inner/outer distinction highlighted by Jaspers' characterization of the term still remains an open explanatory challenge for dominant theories about the neurocognitive origin of auditory verbal hallucinations. We call this, “the challenge from pseudohallucinations”. After exploring this issue in detail, we propose some phenomenological, conceptual, and empirical paths for future research that might help to build up a more contextualized and dynamic view of auditory verbal hallucinatory phenomena.
... Although the frequency of hallucinatory types seen in schizophrenia may vary between cultures, especially at regional levels (Bauer et al., 2011;McLean et al., 2013;Ndetei & Singh, 1983;Ndetei & Vadher, 1984;Thomas, Mathur, Gottesman, Nagpal, Nimgaonkar, & Deshpande, 2007), auditory hallucinations are the most common type of hallucination independent of culture (Geçici, Kuloğlu, Güler, Özbulut, Kurt E, Önen, & Albayrak, 2010;Mueser, Bellack, & Brady, 1990;Nayani & David, 1996;Winokur, Scharfetter, & Angst, 1985;Zarrough, 1975). Visual hallucinations generally are more common in Africa, Asia, the Middle East, and the Caribbean than in Europe and North America, according to the studies included in the systematic review. ...
... -- Winokur et al (1985) Switzerland ( Nayani & David, 1996;Suhail & Cochrane, 2002;Weismann, Lopez, Ventura, & Hwang, 2000). In contrast, religious and cultural themes along with family members and hostile voices were found more prevalent in Africa, Asia, and the Middle East, suggesting that these parameters influence the content of hallucinations (Azhar et al., 1993;Geçici et al., 2010;Kent & Wahass, 1996;Lee, Chong, Chan, & Sathyadevan, 2004;Suhail & Cochrane, 2002;Yip, 2003;Zamir, Javedi, S. A., & Maijidi, 2016). ...
The symptoms of schizophrenia may vary across cultures largely in terms of positive symptoms. Culture-specific symptoms can affect treatment or assessment processes, therefore it is considered crucial to determine these differences in positive symptoms, especially hallucinations. In this study, we aim to systematically examine and understand these cultural differences in hallucinations within the context of schizophrenia. Using the related keywords in different databases, we identified 465 articles. The systematic review included 21 articles published between 1975 and 2016 that met the eligibility criteria. After systematically reviewing the articles, it appears that auditory hallucinations were generally the same across cultures, but visual hallucinations were more common in Africa, Asia, the Middle East, and the Caribbean than in Europe and America. In some cultures, religious and cultural beliefs were influential in terms of the content of hallucinations. While the order of frequency types of hallucinations seen in schizophrenia across cultures seems to be relatively similar, the frequency of hallucination types may differ across cultures suggesting the pathofacilitative effects can partly play. Furthermore, the pathoplastic effect and social kindling hypotheses may explain the content differences by identifying that culture influences the expression of symptoms at the content level. Although studies have limitations, some of which need to be read carefully since they may not fully represent cultural samples, it was expected that this study would contribute to a better understanding of how culture affects hallucinations as well as highlight the treatment and assessment options that might be useful for clinicians.
... A better understanding of self-voice perception is of immediate clinical relevance, as deficits in self-other VD have been related to auditory-verbal hallucinations (AVHs) [19][20][21][22] (i.e. 'hearing voices'), one of the most common [23,24] and most distressing [25,26] hallucinations in a major psychiatric disorder, schizophrenia. Investigating different perceptual factors underlying selfother VD, we here hypothesized that one key contribution would stem from bone conduction and, based on our findings, propose a new experimental paradigm that improves the ecological validity for studying self-voice perception. ...
... Based on these findings, future studies can avoid presenting self-voice stimuli through traditional air-conducting media, especially considering the increasing availability of bone conduction headsets. Finally, this work could serve as a scaffold for clinical investigations of a very common [23,24] and highly distressing [25,26] psychiatric symptom-AVH, i.e. 'hearing voices'-as they have been proposed to arise as a self-other VD deficit [19,22,[87][88][89]. Specifically, characterizing differences in self-other VD curves in voice-hearers compared with controls (e.g. ...
One's own voice is one of the most important and most frequently heard voices. Although it is the sound we associate most with ourselves, it is perceived as strange when played back in a recording. One of the main reasons is the lack of bone conduction that is inevitably present when hearing one's own voice while speaking. The resulting discrepancy between experimental and natural self-voice stimuli has significantly impeded self-voice research, rendering it one of the least investigated aspects of self-consciousness. Accordingly, factors that contribute to self-voice perception remain largely unknown. In a series of three studies, we rectified this ecological discrepancy by augmenting experimental self-voice stimuli with bone-conducted vibrotactile stimulation that is present during natural self-voice perception. Combining voice morphing with psychophysics, we demonstrate that specifically self-other but not familiar-other voice discrimination improved for stimuli presented using bone as compared with air conduction. Furthermore, our data outline independent contributions of familiarity and acoustic processing to separating the own from another's voice: although vocal differences increased general voice discrimination, self-voices were more confused with familiar than unfamiliar voices, regardless of their acoustic similarity. Collectively, our findings show that concomitant vibrotactile stimulation improves auditory self-identification, thereby portraying self-voice as a fundamentally multi-modal construct.
... Whilst hallucinatory experiences vary from person to person, hallucination is, by definition, an experience that is as vividly real as a true perception, is experienced as uncontrollable and seems to have a life of its own (Slade & Bentall, 1988). People usually hear voices saying things related to themselves or what they are doing, typically in the form of voices talking to the hearer, or about them Nayani & David, 1996). Whilst neutral content such as running commentary is characteristic for some people, negatively valanced content is most N. Thomas (*) · K. Morris Swinburne University of Technology, Melbourne, Australia e-mail: neilthomas@swin.edu.au ...
... Whilst neutral content such as running commentary is characteristic for some people, negatively valanced content is most N. Thomas (*) · K. Morris Swinburne University of Technology, Melbourne, Australia e-mail: neilthomas@swin.edu.au typical, with voices very often involving hearing criticism, threats to harm the person or others, or commands often to do harmful things (Larøi et al., 2019;Nayani & David, 1996;McCarthy-Jones et al., 2014). ...
... Nonetheless, extending older reports noting differences between psychedelic-associated psychosis and schizophrenia [117], the same recent review [116] also highlighted various crucial differences. For instance, schizophrenic hallucinations are often characterized by associative network overactivation, are mostly auditory in nature, and are detailed, concrete, and well-anchored in space [118], whereas psychedelic hallucinations are mostly visual, and linked to 5-HT2A and primary visual cortex over-activation [119], varying from simple and mostly geometric hallucinations to complex hallucinations containing ordinary and extraordinary entities [120]. Although psychedelic hallucinations can be very vivid, reality testing normally remains intact [121] and discriminates the hallucinations from everyday perception. ...
... In summary, the enhancing effects of serotonergic psychedelics on neural plasticity [194,195,197], fear extinction [92] and antidepressant effect suggest that psychedelics might prove beneficial in treating the cognitive and negative symptoms of schizophrenia. However, although psychedelics rarely induce prolonged psychosis [198] and their hallucinogenic effect is distinguished from schizophrenic hallucinations [118][119][120], schizophrenic patients are considered at greater risk for adverse effects of serotonergic psychedelics. An approach that might be taken to achieve the possible therapeutic effect of psychedelics in treating negative and cognitive symptoms of schizophrenia (other than using lower, sub-psychedelic, non-hallucinogenic doses) would be to use a full dose of psychedelic in the presence of 5-HT2A antagonists. ...
Schizophrenia is a widespread psychiatric disorder that affects 0.5–1.0% of the world’s population and induces significant, long-term disability that exacts high personal and societal cost. Negative symptoms, which respond poorly to available antipsychotic drugs, are the primary cause of this disability. Association of negative symptoms with cortical atrophy and cell loss is widely reported. Psychedelic drugs are undergoing a significant renaissance in psychiatric disorders with efficacy reported in several conditions including depression, in individuals facing terminal cancer, posttraumatic stress disorder, and addiction. There is considerable evidence from preclinical studies and some support from human studies that psychedelics enhance neuroplasticity. In this Perspective, we consider the possibility that psychedelic drugs could have a role in treating cortical atrophy and cell loss in schizophrenia, and ameliorating the negative symptoms associated with these pathological manifestations. The foremost concern in treating schizophrenia patients with psychedelic drugs is induction or exacerbation of psychosis. We consider several strategies that could be implemented to mitigate the danger of psychotogenic effects and allow treatment of schizophrenia patients with psychedelics to be implemented. These include use of non-hallucinogenic derivatives, which are currently the focus of intense study, implementation of sub-psychedelic or microdosing, harnessing of entourage effects in extracts of psychedelic mushrooms, and blocking 5-HT2A receptor-mediated hallucinogenic effects. Preclinical studies that employ appropriate animal models are a prerequisite and clinical studies will need to be carefully designed on the basis of preclinical and translational data. Careful research in this area could significantly impact the treatment of one of the most severe and socially debilitating psychiatric disorders and open an exciting new frontier in psychopharmacology.
... A central factor that appears to distinguish voice hearers with and without the need for care is negative voice content (Larøi, 2012). Some voice hearers can experience critical voices (e.g., 'you can't do anything right'), which has been linked to increased risk of suicide (Kjelby et al., 2015;Larøi, 2012;Nayani & David, 1996). On some occasions, voices can give instructions which individuals may comply with to minimise distress (Byrne, Birchwood, Trower, & P. E., 2007). ...
... On some occasions, voices can give instructions which individuals may comply with to minimise distress (Byrne, Birchwood, Trower, & P. E., 2007). The severity of these instructions can range from benign orders (e.g., 'get the milk') to commands to harm (e. g., physically injuring one-self or others) (Nayani & David, 1996). ...
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.
... Surveys exploring the phenomenology of voices in large samples have helped to shed light on the degree and nature of negative voice content in psychiatric populations. Nayani and David's (1996) study of 100 voice hearers with schizophrenia-spectrum disorder diagnoses found that the majority reported experiencing voices with negative content, with critical, derogatory, persecutory, threatening but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content. ...
... Interestingly, around 40%-50% of voice hearers in psychiatric populations report hearing voices perceived as benevolent and with positive content in addition to voices with negative content (for example, endorsing hearing voices that were helpful, guiding and affirming; McCarthy-Jones et al., 2014;Nayani & David, 1996). These findings indicate that positive and negative voice content often co-occur. ...
Objective:
People who experience distressing voices frequently report negative (e.g. abusive or threatening) voice content and this is a key driver of distress. There has also been recognition that positive (e.g. reassuring, or guiding) voice content contributes to better outcomes. Despite this, voice content has been neglected as a standalone outcome in evaluations of psychological therapies for distressing voices. We aimed to examine whether a modular cognitive-behavioural therapy (CBT) intervention for voices led to changes in negative and positive voice content.
Design/methods:
In a naturalistic, uncontrolled pre- and post- service evaluation study, 32 clients at an outpatient psychology service for distressing voices received eight sessions of CBT for distressing voices and completed self-report measures of negative and positive voice content at pre-, mid- and post- therapy.
Results:
There was no significant change in positive voice content. There was no significant change in negative voice content from pre- to post-therapy; however, there was a significant change in negative voice content between mid and post-treatment in which the cognitive therapy component was delivered. The CBT treatment was also associated with significant changes in routinely reported outcomes of voice-related distress and voice severity.
Conclusions:
The cognitive component of CBT for distressing voices may be associated with changes in negative, but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content.
... Auditory verbal hallucinations (AVHs) are prevalent, occurring in approximately 70 % of patients with schizophrenia (Zhuo et al., 2019), often described as "like listening to other people's voices" (Zhuo et al., 2019). AVHs are associated with high distress, behavioral dyscontrol, and reduced quality of life (Nayani and David, 1996;Shergill et al., 1998). Hallucinations drain cognitive resources unproductively way (Hugdahl, 2009) and often involve negative emotional valence, distress and an increased suicide risk (Hor and Taylor, 2010;Waters et al., 2006). ...
Background: A scale for self-assessment of auditory verbal hallucinations (SAVH) was developed for patients, and this study aimed to validate the scale by investigating its psychometric properties. Methods: Forty one patients with schizophrenia or schizoaffective disorders (DSM-5) self-assessed their hallucinations using nine SAVH questions. Each question was scored from 0 to 5, indicating the severity of the symptoms. Patients were also evaluated with the Brief Psychiatric Rating Scale (BPRS), Auditory Hallucination Rating Scale (AHRS), and Birchwood Insight Scale (BIS). The psychometric properties of the SAVH were assessed by the face, internal consistency, construct, convergent and discriminant validities. Results: SAVH scores were used to examine the psychometric properties. Cronbach's α and Guttman's Lambda-6 were 0.67 and 0.73 respectively. Significant correlations were observed between SAVH and AHRS total scores, as well as BPRS hallucinatory behavior subscores. No significant correlations were found between total SAVH scores and (i) levels of insight or (ii) negative BPRS subscores. Factor analysis on SAVH revealed three factors accounting for 59.3 % of the variance. Most patients found the questions clear, appropriate, and of adequate length. Conclusions: SAVH demonstrated good psychometric properties, suggesting its utility in assessing auditory verbal hallucinations (AVH). This self-assessment could be valuable in evaluating AVH treatment efficacy, monitoring AVH, and empowering patients.
... Men also dehumanise and use danger-relevant stereotypes about outgroup members all of which support the OIH. Furthermore, persecutory delusions in males were found in one particular study to relate mostly to gangs of male strangers (Zolotova & Brüne, 2006), and the vast majority of auditory hallucinations are of male voices (Nayani & David, 1996). ...
The “Aberrant Salience Hypothesis” (ASH) is arguably the pre-eminent proximate, theoretical model of psychosis in the current literature. As well as its consilience with phenomenological accounts, since its initial proposal, subsequent neuroscientific work has updated its empirical basis by demonstrating a functionally distinct large-scale brain network known as the “salience network” (SN), and crucially, demonstrated SN dysregulation in psychosis. Here, we elaborate upon this hypothesis through the application of evolutionary thinking, structured upon Tinbergen’s 4 questions. After delineating how the mechanism proposed by the ASH has been bolstered by subsequent neuroscientific advances, the ontogeny of psychosis is then considered. A critical aetiological role is attributed to toxic stress resulting from complex interactions between factors including urban living, migrant-status, male-sex, low socioeconomic status, subjective social status, and adverse childhood experiences. Our model, the modified ASH (“MASH”), seeks to provide a crucial bridge to the consideration of the evolutionary roots of psychosis. Environmental mismatch is implicated as the key evolutionary process. The model helps resolve the apparent puzzle of the persistence of psychosis, despite its detrimental effect on fitness. The adaptive significance of what shall be termed the “Salience Evaluation System” in humans is discussed, with particular reference to the uniquely complex human social environment. This provides an explanation for a further puzzle: that psychosis appears to be a human, species-specific phenomenon. Finally, we offer a number of testable predictions for future research.
... Sometimes he touched her whilst she lay in the dark. Nayani and David (1996), analysing the reports of patients over time, suggest there is a process of 'elaboration' of what or who a voice represents. ...
... Authors further postulated that these 'visual' experiences were the result of an involuntary exercise of imagination (Baillarger, 2016), with the specific features to be perceived as 'forced' (Kandinskiĭ, 1885), alien to themselves (Petit, 2017), or 'automatic' (Petit, 2017). From this perspective, this phenomenon exhibits a striking analogy to the loss of a sense of agency seen in thinking, which forms the basis of auditory verbal hallucinations in schizophrenia (Nayani & David, 1996;Stephane, 2019;Stephane et al., 2001). ...
Pseudohallucinations are subjective experiences closely resembling hallucinations but
lacking any objective basis. These experiences blur the line between what is perceived
as real and what is a product of imagination. Visual pseudohallucinations and auditory
verbal hallucinations may share a common origin. This commonality may lie in the
disruption of the sense of agency and the breakdown of self-embodiment processing.
This loss of control can lead to the perception of vivid and sensory-like experiences
that seem as real as the external world.
Various factors come into play in shaping the prevalence and characteristics of visual
pseudohallucinations. Individual differences in imagination, cultural influences, and
developmental phases can influence the propensity for these experiences. The
significance of understanding visual pseudohallucinations extends beyond theoretical
exploration. It provides valuable insights into the complex landscape of psychotic
experiences and may have practical implications for clinical practice.
... Among all the SZ symptoms, auditory verbal hallucinations (AVH), i.e., selfother distinction impairments, which might result in the common and distressing subjective experiences of hearing voices in the absence of corresponding external auditory stimulation, are one of the most common and distressing symptoms of SZ. AVHs affect about 60%-90% of SZ patients 14 and induce discomfort, functional impairment and behavioral alterations 15 . AVH plays a key role in Crow's 16,17 hypothesis on the pathogenesis of SZ, as AVH have been associated with decreased functional left hemispheric dominance, specifically affecting speech perception areas in the left temporal lobe 18 . ...
Although schizophrenia (SZ) represents a complex multiform psychiatric disorder, one of its most striking symptoms are auditory verbal hallucinations (AVH). While the neurophysiological origin of this pervasive symptom has been extensively studied, there is so far no consensus conclusion on the neural correlates of the vulnerability to hallucinate. With a network-based fMRI approach, following the hypothesis of altered hemispheric dominance (Crow, 1997), we expected that LN alterations might result in self-other distinction impairments in SZ patients, and lead to the distressing subjective experiences of hearing voices. We used the independent component analysis of resting-state fMRI data, to first analyze LN connectivity in three groups of participants: SZ patients with and without hallucinations (AVH/D+ and AVH/D–, respectively), and a matched healthy control (HC) group. Then, we assessed the fMRI fluctuations using additional analyses based on fractional Amplitude of Low Frequency-Fluctuations (fALFF), both at the network- and region of interest (ROI)-level. Specific LN nodes were recruited in the right hemisphere (insula and Broca homologous area) for AVH/D+ , but not for HC and AVH/D–, consistent with a left hemisphere deficit in AVH patients. The fALFF analysis at the ROI level showed a negative correlation between fALFF Slow-4 and P1 Delusions PANSS subscale and a positive correlation between the fALFF Slow-5 and P3 Hallucination PANSS subscale for AVH/D+ only. These effects were not a consequence of structural differences between groups, as morphometric analysis did not evidence any group differences. Given the role of language as an emerging property resulting from the integration of many high-level cognitive processes and the underlying cortical areas, our results suggest that LN features from fMRI connectivity and fluctuations can be a marker of neurophysiological features characterizing SZ patients depending on their vulnerability to hallucinate.
... It is prevalent in the texts and customs of most ancient and contemporary faith traditions (Cook, 2019). And it affects around 75% of people with schizophrenia (Nayani & David, 1996). Still, while schizophrenia affects around 1% of the population (Johns & van Os, 2001), estimations of the prevalence of voice-hearing put it at around 10-15% (Tien, 1991;Pechey & Halligan, 2012). ...
In this paper, I identify a unique form of hermeneutical injustice that occurs when individuals are denied the opportunity to interpret their own experiences within their own religious framework. Specifically, I argue that this injustice can be observed in cases where the possibility of a genuine religious experience in a patient is dismissed solely based on a medical diagnosis. The issue is not solely the absence of a valid interpretation; it's the dominance and exclusivity of a particular perspective that creates a significant power imbalance. To begin, I introduce the concept of hermeneutical injustice and its applications in psychiatry, discussing the developments in this field. I highlight how voice-hearers are often victims of such injustices but also draw attention to the literature's oversight regarding the harm caused when someone's personal interpretation of their experiences is completely disregarded due to the overwhelming influence of medical views. To illustrate this, I present a case that exemplifies the negative impact on patients diagnosed with psychotic symptoms containing religious content. I argue that depriving individuals of the ability to find meaning in their experiences constitutes a profound form of hermeneutical injustice. I reference studies exploring how anomalous experiences can be reframed through a religious lens and integrated into a more normalized framework. Finally, I draw insights from a successful case, emphasizing the importance of hermeneutical justice by promoting respect for first-person authority and embracing hermeneutical flexibility. These attitudes can contribute to a more equitable and just understanding of diverse human experiences.
... Voice-hearing understanding and assistance provided to VHs throughout their rehabilitation are caught in conflicting circumstances, specifically because of the ongoing friction between the person-centred Post Psychiatric Movement and the Medical Model. Older research on AHs presents a high level of individual suffering, with limited coping strategies and control over the voices (Nayani & David, 1996). In fact, before the turn of the century, individuals who heard voices had no realistic prospects for recovery, and the only available strategic type of care was found in asylums (Chow & Priebe, 2013). ...
Auditory hallucinations or hearing voices are often associated with schizophrenia and other psychotic disorders. However, several voice-hearers do not have any mental health issues or diagnoses. The study presented in this paper aimed to explore how voice-hearers understand and react to their concerns by reflecting on and exploring their experiences and interpretations of these experiences. The participants were nine individuals - three females, four males and two others, all experiencing auditory hallucinations for at least five years, residing either at their home or at one of the Hostels run by Richmond Foundation (Malta). A qualitative approach following the principles of Interpretative Phenomenological Analysis was used. In-depth interviews were conducted to explore how the participants perceive their voices, what coping strategies are used, and how their experiences affect their lives. Four super-ordinate themes related to the participants' perceptions and their interpretation of the experience of hearing voices were identified: 'A tough experience', 'Methods used to cope with voices', 'Factors linked to recovery' and 'Relationships'. Furthermore, the study elicited the voice-hearers' recommendations (both for other voice-hearers and mental health professionals).
... Particularly, auditory hallucinations were regarded as a hallmark positive symptom of schizophrenia 9,10 . ...
Gamma oscillations are essential for communication between brain regions, and 40Hz neural oscillation defects in schizophrenia. Due to the impaired functional connectivity of the left frontotemporal region, the information communication and integration between the frontal lobe and the temporo-parietal region of schizophrenia are faulty, thus produce auditory hallucinations. Homophasic transcranial alternating current stimulation is thought to enhance connectivity between different brain regions by modulating brain oscillations. In this work, we applied a frontal-temporal-parietal 40Hz-tACS stimulation strategy for treating auditory hallucinations and further explored the effect of tACS on functional connectivity of brain networks. 32 schizophrenia patients with refractory auditory hallucinations received 20 daily 20-min, 40Hz, 1-mA sessions of active or sham tACS on weekdays for 4 consecutive weeks, followed by a 2-week follow-up period without stimulation.Auditory hallucination symptom scores and 64-channel electroencephalograms were measured at baseline, week2, week4 and follow-up. For clinical symptom score, we observed a significant interaction between group and time for auditory hallucinations symptoms (F(3,90) = 26.964, p༜0.001), and subsequent analysis showed that the 40Hz-tACS group had a higher symptom reduction rate than the sham group at week4 (p = 0.036) and follow-up (p = 0.047). EEG results showed that, the 40Hz-tACS group had higher functional connectivity in the right and left frontal (F (1, 30) = 4.15, p = 0.051), right frontal to parietal (F (1, 30) = 7.24, p = 0.012), right frontal to occipital (F (1, 30) = 7.98, p = 0.008) and right intrafrontal (F (1, 30) = 4.13, p = 0.051) than the sham group at week4. Further, functional brain network controllability outcomes showed that the 40Hz-tACS group had increased average controllability (F (1, 30) = 6.26, p = 0.018) and decreased modality controllability (F (1, 30) = 6.50, p = 0.016) in the right frontal lobe compared to the sham group. Our study indicates that 40Hz-tACS may be an effective treatment for targeting symptoms specific to auditory hallucinations and altering functional connectivity and controllability at the network level.
... 25 Yet, some studies have had different results in that the perceptual quality of the voices is sometimes almost as real and loud as true perceptions. 24,[27][28][29] In one of these phenomenological studies, 24 most of the voice-hearers heard their voices at normal (35%) or loud (25%) volume (whispering softly: 31%). Moreover, 70% of voice-hearers reported that the sound of the voice was clear (46%) or sharp (24%). ...
Kurt Schneider has played a leading role in shaping our current view of schizophrenia, placing certain manifestations of delusions and hallucinations at the center of the disorder, especially ideas of persecution and voice-hearing. The first part of this review summarizes Schneider’s original ideas and then traces how the different editions of the DSM merged aspects of Kraepelin’s, Bleuler’s, and Schneider’s historical concepts. Special attention is given to the transition from the DSM-IV to the DSM-5, which eliminated much of Schneider’s original concept. In the second part of the article, we contrast the current definition of hallucination in the DSM-5 with that of Schneider. We present empirically derived arguments that favor a redefinition of hallucinations, much in accordance with Schneider’s original ideas. We plea for a two-dimensional model of hallucinations that represents the degree of insight and perceptuality, ranging from thoughts with full “mineness” via perception-laden thoughts and intrusions (including “as if” experiences”) to hallucinations. While we concur with the DSM-5 that cognitions that are indistinguishable from perceptions should be labeled as hallucinations, we suggest expanding the definition to internally generated sensory phenomena, including those with only partial resemblance to external perceptions, that the individual considers real and that may lie at the heart of a subsequent delusional superstructure.
... Voices are often described in terms of an experience of communication with a personified other (6, 7), and there has been longstanding interest in this aspect of voice phenomenology (8,9). Personification or characterisation of voices (terms we view as essentially equivalent) is common, and around 70% of voice-hearers associate their voice(s) with 'characterful qualities' (10); that is, people or person-like entities with distinct characteristics, such as gender, age, patterned emotional responses, or intentions. ...
Aim
There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses degree of voice characterisation, identified as relevant to a new wave of relational approaches.
Methods
The sample comprised participants experiencing distressing voices, recruited at baseline on the AVATAR2 trial between January 2021 and July 2022 (n = 170). Inter-rater reliability (IRR) and internal consistency analyses (Cronbach’s alpha) were conducted.
Results
The majority of participants reported some degree of voice personification (94%) with high endorsement of voices as distinct auditory experiences (87%) with basic attributes of gender and age (82%). While most identified a voice intention (75%) and personality (76%), attribution of mental states (35%) to the voice (‘What are they thinking?’) and a known historical relationship (36%) were less common. The internal consistency of the VoCC was acceptable (10 items, α = 0.71). IRR analysis indicated acceptable to excellent reliability at the item-level for 9/10 items and moderate agreement between raters’ global (binary) classification of more vs. less highly characterised voices, κ = 0.549 (95% CI, 0.240–0.859), p < 0.05.
Conclusion
The VoCC is a reliable and internally consistent tool for assessing voice characterisation and will be used to test whether voice characterisation moderates treatment outcome to AVATAR therapy. There is potential wider utility within clinical trials of other relational therapies as well as routine clinical practice.
... Authors suggested that, it is not the hallucination itself but rather its persistence which is related to insight; and that "getting used" to the hallucination could lead to ''believing'' in its real existence [47]. Other research has shown that insight is differently associated with external (heard outside the head) vs. internal (heard inside) auditory hallucinations [48]; albeit, here again, mixed results have been reported [49]. A review by Waters et al. [50] suggested that the presence of insight appears to influence individuals' views, interpretation and response to auditory hallucinations; and therefore contributes to determining the meaning of these experiences. ...
Background: There are, to date, limited and inconsistent findings concerning the relationship between insight and psychotic symptoms, despite some evidence in favor of the clinical and therapeutic relevance of the insight construct. We aimed to add to the pool of the available data in this area, by examining the correlations between the severity of insight and positive psychotic symptoms (delusions and auditory hallucinations), while accounting for self-stigma and attitudes towards medication, in a sample of long-stay inpatients with schizophrenia.
Methods: A cross-sectional study was conducted at the Psychiatric Hospital of the Cross, between July and October 2021. A total of 82 patients diagnosed with schizophrenia (aged 55.55 ± 10.21 years, 54.9% males) were enrolled. The semi-structured psychotic symptom rating scales, the Birchwood Insight Scale, the Belief About Medicine Questionnaire, and the Internalized Stigma of Mental Illness were used.
Results: The mean duration of illness in years was 30.15 ± 11.73, and the mean duration of hospitalization in years was 17.56 ± 9.24. Sixteen out of the 82 patients (19.5%) were considered as having poor insight. Bivariate analyses showed that higher chlorpromazine equivalent dose was significantly associated with more delusions, whereas higher insight was significantly associated with lower delusions. Multivariable analyses revealed that Higher chlorpromazine equivalent dose (Beta= .004) was significantly associated with more delusions, whereas higher insight (Beta= -.89) was significantly associated with less delusions.
No significant associations were found between insight, self-stigma and hallucinations.
Conclusion: Our results imply that more impaired insight is associated with greater severity of delusions, above and beyond the effects of self-stigma and medication doses. These findings are valuable to aid clinicians and researchers improve their understanding of the relationship insight-psychotic symptoms, and could help personalize prevention and early intervention strategies in schizophrenia.
... Auditory verbal hallucinations (AVHs) refer to one's sensory experience of hearing voices even in the absence of any external auditory stimuli, which is a core positive symptom of schizophrenia and usually affects 70-75% of schizophrenic patients (Nayani and David, 1996). As seen in previous studies (Ohtani et al., 2014;Wagner et al., 2015), AVH patients show structural abnormalities and functional dysfunction mainly concentrated in brain regions including the bilateral temporal lobe, prefrontal lobe and parietal cortex (Hugdahl et. ...
Auditory verbal hallucinations (AVH) are a core positive symptom of schizophrenia and are regarded as a consequence of the functional breakdown in the related sensory process. Yet, the potential mechanism of AVH is still lacking. In the present study, we explored the difference between AVHs (n = 23) and non-AVHs (n = 19) in schizophrenia and healthy controls (n = 29) by using multidimensional electroencephalograms data during an auditory oddball task. Compared to healthy controls, both AVH and non-AVH groups showed reduced P300 amplitudes. Additionally, the results from brain networks analysis revealed that AVH patients showed reduced left frontal to posterior parietal/temporal connectivity compared to non-AVH patients. Moreover, using the fused network properties of both delta and theta bands as features for in-depth learning made it possible to identify the AVH from non-AVH patients at an accuracy of 80.95%. The left frontal-parietal/temporal networks seen in the auditory oddball paradigm might be underlying biomarkers of AVH in schizophrenia. This study demonstrated for the first time the functional breakdown of the auditory processing pathway in the AVH patients, leading to a better understanding of the atypical brain network of the AVH patients.
... 4 Yet, clinicians in our sample do not seem to see this in their clinical settings. As the perception of voices has historically been associated with psychiatric and neurological disorders, [30][31][32] differentiating between AHs due to HI and other causes might be harder than initially thought. Comparisons between AHs in neurodegenerative disorders and HI showed no differences regarding their phenomenological features, aside from insight into their nature. ...
Background and Hypothesis
Patients with hearing impairment (HI) may experience hearing sounds without external sources, ranging from random meaningless noises (tinnitus) to music and other auditory hallucinations (AHs) with meaningful qualities. To ensure appropriate assessment and management, clinicians need to be aware of these phenomena. However, sensory impairment studies have shown that such clinical awareness is low.
Study Design
An online survey was conducted investigating awareness of AHs among clinicians and their opinions about these hallucinations.
Study Results
In total, 125 clinicians (68.8% audiologists; 18.4% Ear-Nose-Throat [ENT] specialists) across 10 countries participated in the survey. The majority (96.8%) was at least slightly aware of AHs in HI. About 69.6% of participants reported encountering patients with AHs less than once every 6 months in their clinic. Awareness was significantly associated with clinicians’ belief that patients feel anxious about their hallucinations (β = .018, t(118) = 2.47, P < .01), their belief that clinicians should be more aware of these hallucinations (β =.018, t(118) = 2.60, P < .01), and with confidence of clinicians in their skills to assess them (β = .017, t(118) = 2.63, P < .01). Clinicians felt underequipped to treat AHs (Median = 31; U = 1838; PFDRadj < .01).
Conclusions
Awareness of AHs among the surveyed clinicians was high. Yet, the low frequency of encounters with hallucinating patients and their belief in music as the most commonly perceived sound suggest unreported cases. Clinicians in this study expressed a lack of confidence regarding the assessment and treatment of AHs and welcome more information.
... Other findings suggest a positive correlation between increased frequency of hallucinations and low frequency oscillations (i.e., delta and theta; Gattaz et al., 1992;Juszczak, 2011), which might also play a role in the generation of the emotionally charged hallucinations of abusive voices expressing personal insults (Nayani & David, 1996). More specifically, recent research has demonstrated the link between fronto-central theta power abnormalities and sensory processing deficits (Roa Romero et al., 2016), also proposing a role for fronto-temporal delta connectivity (Ford et al., 2002) and frontal/central/temporal theta power/coherence dysfunctions in patients with paranoid schizophrenia experiencing auditory hallucinations (Zheng et al., 2015). ...
Introduction: The incomplete effectiveness of interventions demands new ways to help people diagnosed with schizophrenia who experience auditory verbal hallucinations (SZ-AVH). We aimed to perform a feasibility study of low-resolution electromagnetic tomography analysis (LORETA) neurofeedback with people exhibiting treatment-resistant SZ-AVH. Methods: We examined changes in resting-state quantitative electroencephalogram (qEEG) in four people with SZ-AVH (three male, one female) after LORETA Z-score neurofeedback training. Results: The study design had to be amended due to a national COVID-19 lockdown. Neurofeedback was well tolerated and no participants dropped out. Recruitment was the main feasibility issue. Barriers included a lack of knowledge of neurofeedback by patients and mental health teams, as well as the travel and time commitment involved. For the only patient who completed all 20 sessions, elevated frontal, central, and temporal theta absolute power measured at baseline normalized after treatment, but decreased temporal delta and an increase in coherence for all frequency bands were also found. Conclusions: Two key lessons were drawn for the feasibility of trials of EEG neurofeedback in this population. First, significant effort is needed to educate mental health professionals and patients about neurofeedback. Second, the equipment employed for neurofeedback training needs to be physically based at a site where patients routinely attend.
... The underlying neural mechanisms involve both distributed functional connectivity deficits and more circumscribed hyper/hypoactivity 6 , implicating abnormal oscillatory dynamics at both low frequencies (alpha, theta) and high frequencies (gamma) 7,8 . In particular, auditory hallucinations represent a prevailing positive symptom of schizophrenia 9,10 . They are often associated with hyperactivity in the auditory cortex near the left temporoparietal junction (TPJ) and are thought to reflect abnormal bottom-up activity in the auditory pathway [11][12][13][14][15] . ...
People with schizophrenia exhibit reduced alpha oscillations and frontotemporal coordination of brain activity. Alpha oscillations are associated with top-down inhibition. Reduced alpha oscillations may fail to censor spurious endogenous activity, leading to auditory hallucinations. Transcranial alternating current stimulation (tACS) at the alpha frequency was shown to enhance alpha oscillations in people with schizophrenia and may thus be a network-based treatment for auditory hallucinations. We conducted a double-blind, randomized, placebo-controlled pilot clinical trial to examine the efficacy of 10-Hz tACS in treating auditory hallucinations in people with schizophrenia. 10-Hz tACS was administered in phase at the dorsolateral prefrontal cortex and the temporoparietal junction with a return current at Cz. Patients were randomized to receive tACS or sham for five consecutive days during the treatment week (40 min/day), followed by a maintenance period, during which participants received weekly tACS (40 min/visit) or sham. tACS treatment reduced general psychopathology (p < 0.05, Cohen’s d = −0.690), especially depression (p < 0.005, Cohen’s d = −0.806), but not auditory hallucinations. tACS treatment increased alpha power in the target region (p < 0.05), increased the frequency of peak global functional connectivity towards 10 Hz (p < 0.05), and reduced left-right frontal functional connectivity (p < 0.005). Importantly, changes in brain functional connectivity significantly correlated with symptom improvement (p < 0.05). Daily 10 Hz-tACS increased alpha power and altered alpha-band functional connectivity. Successful target engagement reduced depression and other general psychopathology symptoms, but not auditory hallucinations. Considering existing research of 10Hz tACS as a treatment for major depressive disorder, our study demonstrates its transdiagnostic potential for treating depression.
... Auditory verbal hallucinations (AVH) are a core, often distressing, symptom of schizophrenia which are estimated to occur in around 70% of patients [1]. Their clinical features are well established: they may be single or multiple, are often derogatory but less commonly neutral or praising, and they can be experienced as originating inside and outside the head (or both) [1,2]. Nevertheless, despite research stretching back over more than half a century [3,4], their underlying basis or bases remain uncertain. ...
The experience of auditory verbal hallucinations (AVH, "hearing voices") in schizophrenia has been found to be associated with reduced auditory cortex activation during perception of real auditory stimuli like tones and speech. We re-examined this finding using 46 patients with schizophrenia (23 with frequent AVH and 23 hallucination-free), who underwent fMRI scanning while they heard words, sentences and reversed speech. Twenty-five matched healthy controls were also examined. Perception of words, sentences and reversed speech all elicited activation of the bilateral superior temporal cortex, the inferior and lateral prefrontal cortex, the inferior parietal cortex and the supplementary motor area in the patients and the healthy controls. During the sentence and reversed speech conditions, the schizophrenia patients as a group showed reduced activation in the left primary auditory cortex (Heschl's gyrus) relative to the healthy controls. No differences were found between the patients with and without hallucinations in any condition. This study therefore fails to support previous findings that experience of AVH attenuates speech-perception-related brain activations in the auditory cortex. At the same time, it suggests that schizophrenia patients, regardless of presence of AVH, show reduced activation in the primary auditory cortex during speech perception, a finding which could reflect an early information processing deficit in the disorder.
... Fear has been noted as a feature of voice-hearing in prior phenomenological work, but perhaps not to the same degree. Nayani and David (1996), for example, observed that only 16% of their participants reported fear in association with, or prompting the onset of, their voices. For the VIP participants, fear can be elicited in different ways. ...
Voices in Psychosis: Interdisciplinary Perspectives deepens and extends the understanding of hearing voices in psychosis in a striking way. For the first time, this collection brings multiple disciplinary, clinical, and experiential perspectives to bear on an original and extraordinarily rich body of testimony: transcripts of forty in-depth phenomenological interviews conducted with people who hear voices and who have accessed Early Intervention in Psychosis services. Voice-hearing experiences associated with psychosis are highly varied, frequently distressing, poorly understood, and deeply stigmatized, even within mental health services. Voices in Psychosis responds to the urgent need for new ways of listening to, and making sense of, these experiences. The book addresses the social, clinical, and research contexts in which the interviews took place, thoroughly investigating the embodied, multisensory, affective, linguistic, spatial, and relational qualities of voice-hearing experiences. The nature, politics, and consequences of these analytic endeavours is a focus of critical reflection throughout. This volume presents a collection of essays by members and associates of the Hearing the Voice project that were written in response to the transcripts. Each chapter gives a multifaceted insight into the experiences of voice-hearers in the North East of England and to their wider resonance in contexts ranging from medieval mysticism to Amazonian shamanism, from the nineteenth-century novel to the twenty-first-century survivor movement.
... Fear has been noted as a feature of voice-hearing in prior phenomenological work, but perhaps not to the same degree. Nayani and David (1996), for example, observed that only 16% of their participants reported fear in association with, or prompting the onset of, their voices. For the VIP participants, fear can be elicited in different ways. ...
Voices in Psychosis: Interdisciplinary Perspectives deepens and extends the understanding of hearing voices in psychosis in a striking way. For the first time, this collection brings multiple disciplinary, clinical, and experiential perspectives to bear on an original and extraordinarily rich body of testimony: transcripts of forty in-depth phenomenological interviews conducted with people who hear voices and who have accessed Early Intervention in Psychosis services. Voice-hearing experiences associated with psychosis are highly varied, frequently distressing, poorly understood, and deeply stigmatized, even within mental health services. Voices in Psychosis responds to the urgent need for new ways of listening to, and making sense of, these experiences. The book addresses the social, clinical, and research contexts in which the interviews took place, thoroughly investigating the embodied, multisensory, affective, linguistic, spatial, and relational qualities of voice-hearing experiences. The nature, politics, and consequences of these analytic endeavours is a focus of critical reflection throughout. This volume presents a collection of essays by members and associates of the Hearing the Voice project that were written in response to the transcripts. Each chapter gives a multifaceted insight into the experiences of voice-hearers in the North East of England and to their wider resonance in contexts ranging from medieval mysticism to Amazonian shamanism, from the nineteenth-century novel to the twenty-first-century survivor movement.
... Moreover, past studies found that inner voices are thought to be precursors to full-blown auditory hallucinations that are attributed to the external space and so may be more common in the otherwise healthy population than in clinical populations. (21). ...
Background and aims
Psychotic-like experiences (PLEs) are hallucinatory or delusional experiences that fall below the threshold of a diagnosable psychotic disorder. Although PLEs are common across the spectrum of psychiatric disorders, they also have been commonly reported in the general population. In this study, we aimed to describe the types of PLEs experienced by university students in Qatar. Furthermore, we aimed to examine how students frame, explain, and deal with these experiences as well as understand how culture and religion may shape the way students attribute and respond to these experiences.
Method
This study used a qualitative phenomenological approach. For collecting the data, we conducted semi-structured interviews using the Questionnaire for Psychotic Experiences (QPE). The QPE is a valid and reliable tool to assess the phenomenology of psychotic-like experiences. The questionnaire was translated into Arabic and tested and validated in Qatar (a fast-developing Muslim country in the Arabian Peninsula). We conducted interviews in Arabic with 12 undergraduate female students at Qatar University (the only national university in Qatar). The interviewees were of different Arab nationalities. Interviews were transcribed verbatim and two authors conducted the content-thematic analysis separately, as a strategy to validate the findings. The study was part of a larger nationally funded project that was approved by the Qatar University Institutional Review Board. The approvals were granted before any interview was conducted.
Results
The PLEs were prevalent in our non-clinical sample. The content-thematic analysis revealed the following main themes about these experiences: type, impact on daily function, frequency, immediate reaction, attribution style, assumptions about the root cause of these experiences, other associations, and religious links to experiences. The results also highlighted that religion and culture play a role in shaping the types of hallucinations and some delusions.
Conclusion
Our findings support the importance of culture and religion in relation to the types and explanations that students provided when describing PLEs. Notably, it was common among those who reported having these experiences to normalize and link PLEs to real-life events. This may be a defense mechanism to protect the self against the stigma of mental illness and from being labeled as “abnormal”.
... SZ patients may also exhibit cognitive deficits, including impaired working memory, attention, and executive functions. Among all symptoms, auditory verbal hallucinations (AVH), defined as the experience of "hearing voices" in the absence of external stimuli that cause them, are one of the most common and distressing symptoms of SZ, affecting about 60%-90% of patients (Alderson-Day et al., 2015), and inducing discomfort, functional impairment and behavioral alterations (Nayani and David, 1996). Since AVH is directly associated with a disruption of language-related functional areas and networks (Ćurčić-Blake et al., 2017;Hugdahl, 2009;Jardri et al., 2011;Kompus et al., 2011), inter-and intra-hemispheric connectivity might show different dysfunctional patterns in SZ patients suffering from hallucinations (AVH-SZ), as opposed to patients without hallucinations (nAVH-SZ). ...
Although alterations of the default mode network (DMN) in schizophrenia (SZ) have been largely investigated, less research has been carried out on DMN alterations in different sub-phenotypes of this disorder. The aim of this pilot study was to compare DMN features among SZ patients with and without auditory verbal hallucinations (AVH). Three groups of 17 participants each were recruited: patients with hallucinations (AVH-SZ), patients without hallucinations (nAVH-SZ) and age-matched healthy controls (HC). The DMN spatial pattern was similar between the nAVH-SZ and HC, but the comparison between these two groups and the AVH-SZ group revealed alteration in the left Angular Gyrus (lAG) node of the DMN. Using a novel approach based on normalized fractional Amplitude of Low-Frequency Fluctuations (fALFF), the AVH-SZ subgroup showed altered spectral activity in the DMN compared with the other two groups, especially in the lower-frequency bands (0.017–0.04 Hz). Significant positive correlations were found for both SZ groups collapsed, and for the nAVH-SZ group alone between delusional scores (PANSS-P1) and slow fALFF bands of the DMN. Narrowing the analysis to ROI centered on the lAG, significant correlations were found in the AVH-SZ group for hallucination scores (PANSS-P3) and Slow-5 and Slow-4 (both positive), and Slow-3 (negative) fALFF bands. Our results reveal the central role of the left AG in relation with hallucinations, an important cortical area connecting auditory cortex with several hubs (including frontal linguistic centers) and involved in auditory process monitoring.
... For instance, the extent to which self-voice perception differs from that of other familiar voices remains poorly understood; as does the extent to which acoustic properties that enable discriminating voices of other people 18 are involved in self-other voice discrimination (VD). A better understanding of self-voice perception is of immediate clinical relevance, as deficits in self-other VD have been related to auditory-verbal hallucinations [19][20][21][22] (i.e., "hearing voices"), one of the most common 23,24 and most distressing 25,26 hallucinations in a major psychiatric disorder, schizophrenia. Investigating different perceptual factors underlying self-other VD, we here hypothesized that one key contribution would stem from bone-conduction and, based on our findings, propose a new experimental paradigm that improves the ecological validity for studying self-voice perception. ...
One’s own voice is one of the most important and most frequently heard voices and the sound we associate most with ourselves, and yet, it is perceived as strange when played back in a recording. One of the main reasons is the lack of bone conduction that is inevitably present when hearing own voice while speaking. The resulting discrepancy between experimental and natural self-voice stimuli has significantly impeded self-voice research, rendering it one of the least investigated aspects of self-consciousness. Accordingly, factors that contribute to self-voice perception remain largely unknown. In a series of three studies, we rectified this ecological discrepancy by augmenting experimental self-voice stimuli with bone-conducted vibrotactile stimulation that is present during natural self-voice perception. Combining voice-morphing with psychophysics, we demonstrate that specifically self-other but not familiar-other voice discrimination improved for stimuli presented using bone as compared to air conduction. Furthermore, our data outline independent contributions of familiarity and acoustic processing to separating the own from another’s voice: although vocal differences increased general voice discrimination, self-voices were more confused with familiar than unfamiliar voices, regardless of their acoustic similarity. Collectively, our findings show that concomitant vibrotactile stimulation improves auditory self-identification, thereby portraying self-voice as a fundamentally multimodal construct.
... For instance, the extent to which self-voice perception differs from that of other familiar voices remains poorly understood; as does the extent to which acoustic properties that enable discriminating voices of other people 18 are involved in self-other voice discrimination (VD). A better understanding of self-voice perception is of immediate clinical relevance, as deficits in self-other VD have been related to auditory-verbal hallucinations [19][20][21][22] (i.e., "hearing voices"), one of the most common 23,24 and most distressing 25,26 hallucinations in a major psychiatric disorder, schizophrenia. Investigating different perceptual factors underlying self-other VD, we here hypothesized that one key contribution would stem from bone-conduction and, based on our findings, propose a new experimental paradigm that improves the ecological validity for studying self-voice perception. ...
One’s own voice is one of the most important and most frequently heard voices and the sound we associate most with ourselves, and yet, it is perceived as strange when played back in a recording. One of the main reasons is the lack of bone conduction that is inevitably present when hearing own voice while speaking. The resulting discrepancy between experimental and natural self-voice stimuli has significantly impeded self-voice research, rendering it one of the least investigated aspects of self-consciousness. Accordingly, factors that contribute to self-voice perception remain largely unknown. In a series of three studies, we rectified this ecological discrepancy by augmenting experimental self-voice stimuli with bone-conducted vibrotactile stimulation that is present during natural self-voice perception. Combining voice-morphing with psychophysics, we demonstrate that specifically self-other but not familiar-other voice discrimination improved for stimuli presented using bone as compared to air conduction. Furthermore, our data outline independent contributions of familiarity and acoustic processing to separating the own from another’s voice: although vocal differences increased general voice discrimination, self-voices were more confused with familiar than unfamiliar voices, regardless of their acoustic similarity. Collectively, our findings show that concomitant vibrotactile stimulation improves auditory self-identification, thereby portraying self-voice as a fundamentally multimodal construct.
... της κακοποίησης , ενώ ο τρόπος που τα θύματα αντιμετωπίζουν τις φωνές αντανακλά τη σχέση ισχύος (Birchwood et al., 2000). Οι κακοποιητικές και εκφοβιστικές επιθέσεις, καθώς υποβάλλουν το παιδί στις απόψεις των θυτών, το καθιστούν ανήμπορο να διαχωρίσει τι είναι πραγματικό και τι είναι φανταστικό. Η κοινωνική απομόνωση τις επιδεινώνει (Bentall, 1990. Nayani & David, 1996 και η ενότητα που ακολουθεί συζητά τον ρόλο της. ...
Η Μονογραφία αυτή συνεισφέρει στη βιβλιογραφία για την ανάπτυξη ενός κοινοτικά και κοινωνικά προσανατολισμένου συστήματος ψυχικής υγείας. Οι δεκαετίες της ψυχιατρικής μεταρρύθμισης στην Ελλάδα συνέβαλαν ουσιαστικά στην προαγωγή και την προστασία των ανθρωπίνων δικαιωμάτων των ατόμων με ψυχικές διαταραχές, και στην ποιότητα ζωής τους. Τα τελευταία χρόνια, το κοινοτικό μοντέλο φροντίδας ενισχύεται από νέες προσεγγίσεις, όπως το μοντέλο της ανάρρωσης που δίνει έμφαση στην ενδυνάμωση των ατόμων με ακραίες ψυχικές εμπειρίες αναγνωρίζοντας τις προσωπικές τους εμπειρίες ως πηγή γνώσης και νοηματοδότησης. Η Μονογραφία υπηρετεί τις σύγχρονες αυτές προσεγγίσεις, κομίζοντας τη διεθνή βιβλιογραφία αιχμής στο συγκεκριμένο πεδίο. Στο πρώτο μέρος, αναπτύσσεται μια επιστημονικά τεκμηριωμένη ανασκόπηση της σύγχρονης βιβλιογραφίας αναφορικά με την κατανόηση και αντιμετώπιση της ψύχωσης. Στο δεύτερο μέρος, παρουσιάζονται ευρήματα μιας πρωτότυπης, πρωτογενούς έρευνας που εφάρμοσε αφηγηματική βιογραφική προσέγγιση για την ανάδειξη των μαρτυριών των ανθρώπων με ψύχωση. Μέσα από τις μαρτυρίες των συμμετεχόντων, αναδεικνύονται οι εμπειρίες της ζωής πριν την εμφάνιση της ψύχωσης και οι κοινωνικοί παράγοντες που πιθανόν συντέλεσαν σ’ αυτήν. Χαρτογραφούνται, επίσης, οι τρόποι με τους οποίους βίωσαν, νοηματοδότησαν και διαχειρίστηκαν τις ψυχωτικές τους εμπειρίες. Με δεδομένη τη δυναμική ενσωμάτωση νέων επιστημονικών πεδίων, όπως της κοινοτικής κλινικής ψυχολογίας και της κοινωνιολογίας της υγείας και της ασθένειας, στα Προπτυχιακά και στα Μεταπτυχιακά Προγράμματα Σπουδών, η Μονογραφία αναμένεται να αποτελέσει έναν χρήσιμο βιβλιογραφικό πόρο σε φοιτητές/-τριες, ερευνητές/-τριες και επαγγελματίες που επιθυμούν να εργαστούν προς μια ανθρωπιστική κατεύθυνση κατανόησης και αντιμετώπισης του ψυχικού πόνου και να αναπτύξουν επαγγελματικές πρακτικές υποστήριξης της ανάρρωσης, κάτι το οποίο αποτελεί εκπεφρασμένο στόχο και ζητούμενο για τους σύγχρονους επαγγελματίες ψυχικής υγείας.
... schizophrenia (Nayani & David, 1996). The phenomenology of voice-hearing is diverse, involving single or multiple voices, which may be known or unknown, speaking sequentially or simultaneously, in the first, second, or third person, and which may give orders, comments, insults, or encouragement (Jones, 2010). ...
In this paper, I draw on phenomenological analyses of religious voice-hearing and related experiences to elucidate the role of phenomenology in discerning benign from pathological religious experience. First, I present phenomenological discontinuities between cases of benign and pathological voice-hearing by drawing on a study of first-person accounts of voice-hearers within the Pentecostal movement which evinces that voice-hearing is not inherently pathological. Second, I introduce the epidemiological continuity of psychotic-like phenomena by drawing on a study of the contextual and responsive differences between clinical and non-clinical voice-hearers which point to the contexts wherein voice-hearing does not lead to pathology. Third, I present a successful case where the meaning of the anomalous experiences is validated and normalized by drawing on studies of mediumistic experience which illuminate its therapeutic benefits. Finally, I argue that failing to take the voice-hearer's lived experience into account in the diagnostic moment can result in the pathologization of benign experiences.
... Social cognitive approaches to voice-hearing within clinical psychology posit voices as "hallucinated social identities" or "internalised social actors", rather than simply "hallucinated words or sounds" that are not attributed to a clear person-like internal or external source (Bell, 2013: 1). Several studies have documented a range of complexities in terms of how 'person-like' voices are reported to be (Nayani & David, 1996;Wilkinson & Bell, 2016). Voices may be attributed attitudes, intentions, and different kinds of identities, including proper names. ...
Triangulating corpus linguistic approaches with other (linguistic and non-linguistic) approaches enhances “both the rigour of corpus linguistics and its incorporation into all kinds of research” ( McEnery & Hardie, 2012 : 227). Our study investigates an important area of mental health research: the experiences of those who hear voices that others cannot hear, and particularly the ways in which those voices are described as person-like. We apply corpus methods to augment the findings of a qualitative approach to 40 interviews with voice-hearers, whereby each interview was coded as involving ‘minimal’ or ‘complex’ personification of voices. Our analysis provides linguistic evidence in support of the qualitative coding of the interviews, but also goes beyond a binary approach by revealing different types and degrees of personification of voices, based on how they are referred to and described by voice-hearers. We relate these findings to concepts that inform therapeutic interventions in clinical psychology.
... They can be complimentary and pleasant, but usually they are unpleasant and insulting (Laroi et al., 2012). These voices can be distressing and threatening towards the individuals that hear them (Nayani & David, 1996), causing disruption in all aspects of their life; socially, occupationally and psychologically (Hayward et al., 2017;Ruddle et al., 2011). It has been reported by Larøi et al. (2019) that a significant cohort of people reports hearing voices with a negative content. ...
Accessible Summary
What is known on the subject?
There is no qualitative systematic review of nurses' perceptions of their interactions with people hearing voices. There are some studies exploring the interventions provided by community psychiatric nurses to people hearing voices; these give a sense of what interactions may contain.
What the paper adds to the existing knowledge?
Nurses across both community and inpatient mental healthcare settings feel uncertain about how to interact with people hearing voices, sometimes feeling like they can do little to help. Their interactions are affected by the workplace culture, education and training and concern for their own safety. Nurses rely on a therapeutic relationship for all interactions.
What are the implications for practice?
This is an under investigated area of mental healthcare. None the less this qualitative systematic review highlights that nurses are unclear about how to interact with service users hearing voices with the resultant outcome that service users in great distress may only be receiving minimal benefit from their interactions with the nurses caring for them.
Abstract
Aims and Objectives
The aim of this qualitative systematic review and thematic analysis was to identify and synthesize results from studies that explored psychiatric nurses' perceptions of their interactions with service users experiencing auditory hallucinations (hearing voices).
Method
Qualitative systematic review and thematic analysis.
Results
Five studies that met the inclusion criteria were identified. Nurses reported that they felt uncertain about what to do for service users hearing voices, struggled to have interactions with voice hearers, but greatly valued the therapeutic relationship with service users. Nurses also reported that they required more education and training on how to interact effectively with people hearing voices. Finally, various workplace challenges were identified as an important factor mediating nurse interaction with service users hearing voices.
Discussion
Existing evidence shows that nurses lack clarity about how they can interact effectively and in a way that helps service users who are hearing voices. Significant barriers that they must overcome in order to be more certain of their role in caring for people hearing voices are difficult to engage service users and workplace challenges that were not conducive to helpful interactions and conversations.
Implications for Practice
Nurses caring for people hearing voices require more and better education and training with a view to them becoming more confident and competent when interacting with this service user group. Furthermore, healthy workplace cultures and maintaining a safe environment are necessary for effective caring interactions with people hearing voices.
... 40 Forty percent of patients with schizophrenia described their voices as familiar or recognisable voices. 41 A positive correlation has been found between loneliness and psychotic disorders. 42,43 In the Australian National Psychosis Survey (n = 1825), up to 80% of individuals with a psychotic disorder reported feeling lonely. ...
Background:
Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory.
Aim:
This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD.
Methods:
The PubMed database was used with the following key terms: "borderline personality disorder" and 'hallucinations' and "psychotic symptoms". Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic.
Results:
Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking.
Conclusion:
Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed.
Objective:
Auditory verbal hallucination (AVH) is a prominent symptom of schizophrenia causing profound distress. The influence of AVHs on insight appears to be intricate and contingent on other accompanying symptoms. This study investigated the relationship and possible mediators between AVHs and the degree of insight.
Methods:
One hundred patients with schizophrenia participated in the study. Scales were used to evaluate the hallucinatory experience, the level of insight and other psychopathology. Complex relationships between variables were envisaged as a path model, whose initial structure was constructed via Gaussian Graphical Model. The validity of the final model was verified by Structural Equation Modeling. Separate analyses were performed for self-reported and clinician-rated data to enhance the model's robustness.
Results:
The greater the severity of the physical aspects of AVHs, the lower the level of insight observed. Conversely, higher emotional distress was associated with increased insight. These relationships were only evident in the self-reported results and were not reflected in the clinician-rated results. The path model suggested that the Positive and Negative Syndrome Scale (PANSS) anxiety/depression factor was an important mediator that linked the found association. Notably, the PANSS negative symptom had the opposite effect on the PANSS anxiety/depression factor and insight, making it difficult to define its overall effect.
Conclusion:
The findings of this study provided one possible route for the positive influence of AVH experience in gaining insight. The mediating role of anxiety/depression modified by negative symptoms emerged as a valuable concept for clarifying this intricate relationship.
Purpose
Insecure attachment may constitute a vulnerability factor for psychosis, and dissociation may be a key mechanism in the development of auditory hallucinations specifically. While there is good evidence for the role of these processes in isolation, it is unclear whether dissociation accounts for the association between insecure attachment and psychosis. This systematic review takes a theory‐driven approach to examine proposed causal relationships across the clinical and nonclinical literature.
Methods
We searched five databases (PubMeD, Web of Science, PsycINFO, CINAHL and ETHOS) for published and unpublished research examining attachment, dissociation and psychosis. Two independent reviewers extracted the data and assessed the quality of all included studies.
Results
We identified 242 potential articles and included 13 in the final review (2096 participants). We found that (1) disorganised attachment was consistently associated with dissociation and inconsistently associated with voices and paranoia, (2) dissociation was associated with voices and paranoia, and these links were stronger in clinical samples, and (3) dissociation played a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups.
Conclusions
This is the first review to synthesise the research examining attachment, dissociation, and psychosis. The evidence is consistent with proposed causal hypotheses and raises conceptual and measurement issues, for example, the need to clarify the relative contributions of different insecure attachment styles, and utilise behavioural/observational measures to strengthen study designs. Most importantly, we need experimental and longitudinal studies to confirm causal links and targets for treatment.
Schizophrenia is a severe psychological disorder in which reality is interpreted abnormally by the patient. The symptoms of the disease include delusions and hallucinations, associated with extremely disordered behavior and thinking, which may affect the daily lives of the patients. Advancements in technology have led to understanding the dynamics of the disease and the identification of the underlying causes. Multiple investigations prove that it is regulated genetically, and epigenetically, and is affected by environmental factors. The molecular and neural pathways linked to the regulation of schizophrenia have been extensively studied. Over 180 Schizophrenic risk loci have now been recognized due to several genome‐wide association studies (GWAS). It has been observed that multiple transcription factors (TF) binding‐disrupting single nucleotide polymorphisms (SNPs) have been related to gene expression responsible for the disease in cerebral complexes. Copy number variation, SNP defects, and epigenetic changes in chromosomes may cause overexpression or underexpression of certain genes responsible for the disease. Nowadays, gene therapy is being implemented for its treatment as several of these genetic defects have been identified. Scientists are trying to use viral vectors, miRNA, siRNA, and CRISPR technology. In addition, nanotechnology is also being applied to target such genes. The primary aim of such targeting was to either delete or silence such hyperactive genes or induce certain genes that inhibit the expression of these genes. There are challenges in delivering the gene/DNA to the site of action in the brain, and scientists are working to resolve the same. The present article describes the basics regarding the disease, its causes and factors responsible, and the gene therapy solutions available to treat this disease.
The comparative study of voice hearing is in its early stages. This approach is important due to the observation that the content of voices differs across different settings, which suggests that voice hearing may respond to cultural invitation and, ultimately, to learning. Our interview-based study found that persons diagnosed with schizophrenia in China (Shanghai), compared to those diagnosed with schizophrenia in the United States, Ghana, and India, reported voices that were strikingly concerned with politics. Compared to participants in the United States in particular, voices seemed to be experienced more relationally: Shanghai participants reported voices notable for a sense of benevolent persuasion rather than harsh command, and knew the identities of their voices more so than in the United States. The voices were striking as well for their religious content, despite the previous prohibition of religion in China. Our findings further support the hypothesis that voice hearing seems to be shaped by context, and we observe that this shaping may affect not only conceptual content but the emotional valence of the experience.
There has been relatively little work which systematically examines whether the content of hallucinations in individuals diagnosed with schizophrenia varies by cultural context. The work that exists finds that it does. The present project explores the way auditory hallucinations, or "voices," manifest in a Russian cultural context. A total of 28 individuals, diagnosed with schizophrenia, who reported hearing voices at the Republican Clinical Psychiatric Hospitals in Kazan, Russia, were interviewed about their experience of auditory hallucinations. The voices reported by our Russian participants did appear to have culturally specific content. Commands tended to be non-violent and focused on chores or other activities associated with daily life (byt). Many patients also reported sensory hallucinations involving other visions, sounds, and smells which sometimes reflected Russian folklore themes. For the most part, religious themes did not appear in patients' auditory vocal hallucinations, though nearly all patients expressed adherence to a religion. These findings support research that finds that the content, and perhaps the form, of auditory hallucinations may be shaped by local culture.
Persisting distressing experiences of hearing voices (auditory hallucinations) are a common target for psychological therapies in psychosis. Whilst cognitive behavioural therapy for psychosis has emerged as the standard treatment approach in practice guidelines, a range of further therapeutic approaches have been applied to people with this experience. To meet the challenge of combining best-evidenced therapy with innovations that may meet individualised needs, our specialist Voices Clinic in Melbourne uses a framework we call Functional Analysis Informed Therapy for Hallucinations (FAITH) to tailor therapeutic methods to the individual. This involves using a collaborative formulation of antecedents and maintaining factors for voices and voice-related distress to guide alternate responses and targeted therapeutic strategies. We present a case study of the incorporation of acceptance and commitment therapy (ACT) methods within this approach, describing a client for whom initial work focused on enhancing coping strategies elicited increasingly critical voice content and attempts to suppress the experience. The case illustrates how an overall behavioural formulation can provide a coherent framework for incorporating third-wave therapeutic methods into therapy.KeywordsHallucinationsPsychosisFunctional analysisAcceptance and commitment therapyCognitive behavioural therapy
Auditory verbal hallucinations (AVH) are frequently associated with psychotic disorders, yet also occur in non-clinical voice-hearers. AVH in this group are similar to those within clinical voice-hearers in terms of several phenomenological aspects, but non-clinical voice-hearers report to have more control over their AVH and attribute less emotional valence to them. These dissimilarities may stem from differences on the neurobiological level, as it is still under debate whether the mechanisms involved in AVH are the same in clinical and non-clinical voice-hearers. In this study, 21 clinical and 21 non-clinical voice-hearers indicated the onset and offsets of AVH during an fMRI scan. Using a method called leading eigenvector dynamics analysis (LEiDA), we examined time-varying dynamics of functional connectivity involved in AVH with a sub-second temporal resolution. We assessed differences between groups, and between hallucination and rest periods in dwell time, switching frequency, probability of occurrence, and transition probabilities of nine recurrent states of functional connectivity with a permutation ANOVA. Deviations in dwell times, switching frequencies, and switch probabilities in the hallucination period indicated more erratic dynamics during this condition regardless of their clinical status. Post-hoc analyses of the dwell times exhibited the most distinct differences between the rest and hallucination condition for the non-clinical sample, suggesting stronger differences between the two conditions in this group. Overall, these findings suggest that the neurobiological mechanisms involved in AVH are similar in clinical and non-clinical individuals.
Background
Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) diminishes auditory hallucinations (AHs). The aims of our study were a) to assess the efficacy of LF-rTMS in a randomized, sham-controlled double-blind alignment, b) to identify the electrophysiological changes accompanying the LF-rTMS, and c) to identify the influence of LF-rTMS on brain functional connectivity (FC). Methods: Nineteen schizophrenia patients with antipsychotic-resistant AHs were randomized to either active (n=10) or sham (n=9) LF-rTMS administered over the left temporo-parietal region for ten days. The clinical effect was assessed by the Auditory Hallucination Rating Scale (AHRS). The localization of the differences in electrical activity was identified by standardized low resolution brain electromagnetic tomography (sLORETA) and FC was measured by lagged phase synchronization. Results: AHRS scores were significantly improved for patients receiving active rTMS compared to the sham (median reduction: 40% vs. 12%; p=0.01). sLORETA revealed a decrease of alpha-2, beta-1,-2 bands in the left hemisphere in the active group. Active rTMS led to a decrease of the lagged phase connectivity in beta bands originating in areas close to the site of stimulation, and to a prevailing increase of alpha-2 FC. No significant differences in current density or FC were observed in the sham group. Limitations: Limitations to our study included the small group sizes, and the disability of LORETA to assess subcortical neuronal activity. Conclusions: LF-rTMS attenuated AHs and induced a decrease of higher frequency bands on the left hemisphere. The FC changes support the assumption that LF-rTMS is linked to the modulation of cortico-cortical coupling.
Islamic religious education is an effort to educate humans in accordance with the teachings of Islam as a guide for one's life. Islamic Religious Education in reality only focuses on education organized by educational institutions or institutions from elementary to tertiary levels, but it has not touched the empirical areas faced by society such as Schizophrenia. This article uses Library Research Design. The results of the study is the number of cases that occur due to psychotic disorders has made a number of mental hospitals implement the forms of activities with the nuances of Islamic Religious Education in dealing with schizophrenia psychotic patients, such as Islamic counseling therapy, Islamic adab, Miliu therapy, interacting politely and kindly, and Islamic studies. These forms of handling have proven that Islamic Religious Education actually covers areas of medicine and health sciences, which in reality many consider Islamic Religious Education cannot touch these areas. A more in-depth study of the role of Islamic Religious Education is needed in order to make a real contribution to the problems faced by society.Keywords: Islamic Religious Education, Schizophrenia, Spiritual Development. AbstrakPendidikan Agama Islam merupakan upaya mendidik manusia sesuai dengan ajaran agama Islam sebagai petunjuk dan pedoman hidup seseorang. Pendidikan Agama Islam pada kenyataannya hanya berkutat pada pendidikan yang diselenggarakan oleh institusi atau lembaga pendidikan dari jenjang dasar sampai perguruan tinggi, namun belum menyentuh wilayah-wilayah empirik yang dihadapi oleh masyarakat seperti Skizofrenia. Artikel ini menggunakan design penelitian kepustakaan. Hasil yang diperoleh yakni banyaknya kasus yang terjadi akibat gangguan psikotik ini membuat sejumlah rumah sakit jiwa menerapkan bentuk kegiatan yang bernuansa Pendidikan Agama Islam dalam menangani pasien psikotik skizofrenia, seperti Terapi konseling Islami, Adab Islami, Miliu terapi, berinteraksi dengan sopan dan ramah, serta Pengkajian Islami. Bentuk-bentuk penanganan tersebut telah membuktikan bahwa sebenarnya Pendidikan Agama Islam mencakup wilayah-wilayah kedokteran dan ilmu-ilmu kesehatan yang dalam kenyataannya banyak yang menilai Pendidikan Agama Islam tidak dapat menyentuh wilayah tersebut. Dibutuhkan kajian yang lebih mendalam mengenai peran Pendidikan Agama Islam agar dapat memberikan sumbangsih nyata pada problem-problem yang dihadapi oleh masyarakat. Kata Kunci: Pendidikan Agama Islam, Skizofrenia, Pembinaan Spiritual.
35 symptom formations were isolated through an analysis of the case histories of 793 psychiatric patients with functional disorders. Percentage of patients in 1 of 4 groups (manic-depressive, schizophrenic, psychoneurotic, character disorder) characterized by each symptom was tabulated. The results indicated that there are no particular symptoms which are specific to 1 of the 4 psychiatric groupings, and that these groupings are not described by any unique clustering of symptoms. A symptom classification system (by Phillips & Rabinovitch, 1958) was seen to have a positive, though small, statistical relationship with psychiatric grouping. From Psyc Abstracts 36:04:4HI69Z. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Reviews clinical and anthropological studies, and indicates that social and cultural factors affect both the definition of, and the sensory systems involved in, hallucinations. It appears that the pejorative labeling of certain reported experiences as hallucinatory is dependent on linguistic factors as well as social and cultural beliefs (e.g., the consideration of hallucinations as an index of social maturity, social competence, and social conformity). It is noted that the degree of rationality in the culture is associated with attitudes, emotional response, and the attribution of pathology to hallucinatory experiences. The implications of social and cultural factors for the behavioral and psychoanalytical approaches to hallucinations are discussed. (3½ p ref)
Hallucinations are often manifestations of severe psychiatric conditions seen clinically. However, little is known about the distribution of incident hallucinations in the community, nor whether there has been a change over the past century. Data from the NIMH Epidemiologic Catchment Area Program is used here to provide descriptive information on the community distribution, and data from the Sidgewick study from a century earlier provides comparative information. In the ECA data, the incidence of visual hallucinations was slightly higher in males (about 20 per 1000 per year) than females (about 13 per 1000 per year) across the age span from 18 to 80 years old, with a subsequent increase in the rate for females (up to about 40 per 1000 per year) after age 80. For auditory hallucinations there was an age 25-30 peak in males with a trough for females, and a later age 40-50 peak for females. Overall, there were substantial gender differences, and the effect of aging to increase the incidence of hallucinations was the most consistent and prominent. The Sidgewick study showed a much higher proportion of visual hallucinations than the ECA program. This might be due to factors affecting brain function as well as social and psychological changes over time, although methodological weaknesses in both studies might also be responsible.
Schizophrenic patients tend to demonstrate reduced cerebral metabolism in frontal areas. Studies of human brain development reveal that synapses in the cerebral cortex are progressively reduced throughout childhood and adolescence, with parallel reductions in cerebral metabolism. This relationship is not surprising, since synaptic density is a primary factor determining regional metabolic requirements. The elimination of synapses in prefrontal cortex continues for a particularly long period of time, extending well into adolescence. Thus, reduced frontal metabolism in schizophrenic patients could be due to a developmental process--namely, elimination of synapses--gone too far. Animal studies indicate that developmentally induced reductions in synaptic density are due to the pruning of axonal collaterals rather than the death of neurons, which raises a critical question: Does excessive axonal pruning have specific pathological effects on cortical information processing? To answer this question, computer simulations of neural information processing systems were subjected to axonal pruning which reduced synaptic density. If pruning was conducted overzealously, cognitive pathology was induced that could, in humans, lead to the conscious experience of hallucinations, delusions, and Schneiderian symptoms.
Synopsis
The CNS maintains a fundamental distinction between actions elicited by external stimuli and actions elicited by internal goals (acts of will). As a result the intact organism can monitor centrally three aspects of its own actions: (1) the action appropriate to current external stimulation (stimulus intention or meaning); (2) the action appropriate to current goals (willed intention); and (3) the action which was actually selected (corollary discharge). In Type I (acute) schizophrenic patients, intentions of will lead to actions, but these willed intentions are not monitored correctly. This apparent discrepancy between will and action gives rise to experiential (1st rank) positive symptoms (e.g. delusions of control and passivity). In Type II (chronic) patients, intentions of will are no longer properly formed and so actions are rarely elicited via this route. This gives rise to behavioural negative signs (e.g. poverty of speech).
The behaviour of Type II schizophrenics has surface similarities to that shown by patients with Parkinson's disease and patients with frontal lobe lesions in that all three types of patient show a relative deficit of actions elicited by willed intentions. Dopamine blocking drugs reduce positive symptoms in Type I patients precisely because they induce Parkinsonism, i.e. reduce the likelihood of actions being initiated by willed intentions. This in turn reduces the likelihood that actions will occur for which the patient had no awareness of his intention to act.
Fourteen of 18 hallucinating schizophrenic patients reported that the voices they heard went away when they undertook a maneuver that precluded subvocalization. The same applied to 18 of 21 normal subjects who hallucinated under the influence of hypnotic suggestion. Control maneuvers had no such effect. The authors suggest that auditory hallucinations may be projections of schizophrenic patients' verbal thoughts, subvocalized due to deficient cerebral cortical inhibition.
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Two lines of evidence suggest that the visual field distribution of visual hallucinations in schizophrenia may be of interest. First, visual hallucinations are more frequently perceived in the visual hemifield contralateral to the side of the headache in migraine (Haas 1982) and contralateral to the seizure focus in epilepsy having an occipital (Lishman 1978) or parietal (Lance 1976) lobe focus. Second, stimulation of the visual association cortex produces contralateral visual field hallucinations in neurosurgical patients (Penfield and Perot 1963). We now report a study of the spatial location of visual hallucinations in patients with chronic schizophrenia.
The present report is of the effect of variations of auditory input on hallucinatory experiences in seven schizophrenic patients. Nine experimental conditions, each of two minutes' duration were compared with a control condition. At the end of each period subjects were required to rate the duration, loudness, and clarity of hallucinations during that time. Experimental conditions varied according to the amount of structure present in the material and in its attention-commanding properties. One condition required the active monitoring of material presented and resulted in the greatest decrease in hallucinatory experiences. For the passive conditions, findings were broadly consistent with predictions, indicating that it is not stimulation per se, but rather the extent to which structure is present and attended to, that is important in determining the occurrence of hallucinatory phenomena.
Tested the hypothesis that psychiatric patients with a history of auditory hallucinations would show impaired recognition of their own thoughts relative to nonhallucinating patients; given the need to discriminate between one's own lexical thought and a voice from another source, the person less familiar with the properties of his or her thinking would more likely mislabel the source. 12 hallucinators and 8 nonhallucinators on a short-term psychiatric inpatient unit were asked to identify lexical, semantic, and syntactic properties of their own thoughts expressed 1 wk earlier. As hypothesized, hallucinators were less capable of doing so. Control measures of verbal memory, opinion stability, and communication skill showed no differences between the groups. Analysis of process and reactive premorbid status revealed possible links of impaired thought recognition to excessive internal and external deployment of attention. (23 ref)
Verbal auditory hallucinations are common in schizophrenia but little is known about how they arise. We have used single photon emission tomography (SPET) to measure regional cerebral blood flow with the aim of identifying brain areas that are especially active during auditory hallucinations. We scanned twelve men with schizophrenia while they were experiencing hallucinations. The subjects were rescanned under identical conditions when their hallucinations had resolved (mean 19 weeks later). Blood flow was significantly greater during hallucinations than in the non-hallucinating state in Broca's area (mean count density on SPET 1.18 [SD 0.04] vs 1.13 [0.06]; p < 0.001); flow was also higher during hallucinations in the left anterior cingulate cortex and regions in the left temporal lobe, but these differences did not achieve significance. The increased flow in Broca's area was not accounted for by changes in other clinical variables nor by changes in the dose of neuroleptic drugs. These findings suggest that the production of auditory hallucinations in schizophrenia is associated with increased activity in a network of cortical areas specialised for language.
By repeating words 'in our head', verbal material (such as telephone numbers) can be kept in working memory almost indefinitely. This 'articulatory loop' includes a subvocal rehearsal system and a phonological store. Little is known about neural correlates of this model of verbal short-term memory. We therefore measured regional cerebral blood flow, an index of neuronal activity, in volunteers performing a task engaging both components of the articulatory loop (short-term memory for letters) and a task which engages only the subvocal rehearsal system (rhyming judgement for letters). Stimuli were presented visually and the subjects did not speak. We report here that comparisons of distribution of cerebral blood flow in these conditions localized the phonological store to the left supramarginal gyrus whereas the subvocal rehearsal system was associated with Broca's area. This is, to our knowledge, the first demonstration of the normal anatomy of the components of the 'articulatory loop'.
Introduction
IN both religious and secular literature there are many reports from people who have seen visions or heard voices. At times these phenomena have been considered as manifestations of the supernatural, and the actions, beliefs, and faith of many people have been influenced by them. The course of Western European history was changed by the simple faith of Joan D' Arc in her private percepts that others did not share. In our own time conservative and fundamental religious faiths have placed credence in the testimony of those who have heard voices or seen visions of a religious nature. Clinical psychiatrists tell of patients or their relatives who have described significant sensory perceptual aberrations, yet who do not appear to be mentally disturbed.3,4,16,18 Standard interviews done on relatives of indigent psychiatric patients and on unselected medical students too have shown an evidence of hallucinations of
Of a consecutive series of 117 psychiatric inpatients with hallucinations, all had primary affective disorder, schizophrenia, alcoholism, organic brain syndromes, or hysteria. Hallucinations were found to be nonspecific. Most patients who had hallucinations involving one sensory modality had experienced in the past hallucinations involving other sensory modalities. The hallucinations accompanying acute schizophrenia more closely resembled those seen in affective disorder than in chronic schizophrenia, but no type of hallucination was diagnostic in the sense of occurring significantly more often in one illness than in another. Auditory hallucinations occurred almost as often in affective disorder as in schizophrenia; visual hallucinations were common in all five disorders; and derogatory voices, widely believed to signify depression, occurred most often in schizophrenia.
The experience of hearing a “voice” or “loud thoughts” within the head or some other part of the body is not infrequently reported by psychiatric patients. Schneider (1959) has stipulated that “certain modes of hearing voices are of special diagnostic importance for assuming a schizophrenia: hearing one's own thoughts (or thoughts being audible), voices conversing with one another, and voices that keep up a running commentary on the patient's behaviour”. This paper is primarily concerned with the phenomena of “loud” or “audible” thoughts, “inner voices” and similar experiences. It attempts to show that various phenomena superficially resemble the schizophrenic experience of “thoughts becoming audible”, but that distinction is possible on phenomenological grounds.
This paper will consider the identity of an inner voice that is experienced by everyone, but in very different ways. However, when working in the transference with psychotic patients the boundaries of personal identity and the question of choice and volition are so compromised by the illness that the phenomena are so to speak ‘writ large’. This allows the issues to be brought out with great vividness and intensity and it is the struggle with this that has led me to reconsider the identity of the inner voice in a way which I have found useful for the rest of my clinical work.Prior to 1985, my clinical work with patients with psychotic illnesses was undertaken in the in-patient psychotherapy ward at Shenley Hospital that I was responsible for. With the movement of psychotherapy resources out of Shenley to set up the Willesden Centre, our ability to continue with this work was very compromised because the Centre is entirely an out-patient resource. However, a number of us persevered and gradually worked out ways to be able to continue to offer treatment to patients who had psychotic illnesses. This involved the establishment of a case-manager system to enable the therapist to work in the transference. This evolution has occurred in a specialist workshop that I have been running at the Willesden Centre since 1986.
Compared 20 hallucinating psychiatric patients, 16 patients with delusions but without a history of hallucinations, and 22 normal controls on a reality-monitoring task in which they were 1st required to generate answers to easy or difficult clues and to listen to low-probability or high-probability paired associates. After 1 wk, Ss were presented with a list in which their answers to the clues were mixed with the associates and with words not previously presented, and they were required to identify the source of each item (self-generated, presented by the experimenter, or new). Hallucinators more often misattributed high cognitive effort self-generated items (answers to difficult clues) to the experimenter than either the psychiatric or the normal controls. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Reports in the medical literature of hallucinations of music are reviewed and additional cases described. The phenomenon is categorized under three headings according to possible etiological factors: (a) hearing loss, (b) coarse brain disease, and (c) psychiatric disorder. An association with female sex is seen across all three groups. The relevance of other factors, such as age and lateralized cerebral dysfunction, is discussed. Proposed mechanisms and management strategies are also reviewed, although there is little conclusive information in this area.
(C) Lippincott-Raven Publishers.
How is it that many schizophrenics identify certain instances of verbal imagery as hallucinatory? Most investigators have assumed that alterations in sensory features of imagery explain this. This approach, however, has not yielded a definitive picture of the nature of verbal hallucinations. An alternative perspective suggests itself if one allows the possibility that the nonself quality of hallucinations is inferred on the basis of the experience of unintendedness that accompanies imagery production. Information-processing models of “intentional” cognitive processes call for abstract planning representations that are linked to goals and beliefs. Unintended actions - and imagery - can reflect planning disruptions whereby cognitive products do not cohere with concurrent goals. A model of schizophrenic speech disorganization is presented that postulates a disturbance of discourse planning. Insofar as verbal imagery can be viewed as inwardly directed speech, a consequence of such planning disturbances could be the production of unintended imagery. This link between the outward disorganization of schizophrenic speech and unintended verbal imagery is statistically supported by comparing the speech behavior of hallucinating and nonhallucinating schizophrenics. Studies of “borderline” hallucinations during normal, “goal-less” relaxation and drowsiness suggest that experiential unintendedness leads to a nonpathological variant of hallucinatory otherness that is correctable upon emerging from such passive cognitive states. This contrasts with the schizophrenic case, where nonconcordance with cognitive goals reinforces the unintendedness of verbal images and sustains the conviction of an external source. This model compares favorably with earlier models of verbal hallucinations and provides further evidence for a language production disorder in many schizophrenics. Short Abstract: How is it that many schizophrenics identify certain instances of verbal imagery as hallucinatory? This paper proposes that the critical feature identifying hallucinations is the experience of unintendedness. This experience is nonpathological during passive conscious states but pathological if occurring during goal-directed cognitive processing. A model of schizophrenic speech disorganization is presented that postulates a disturbance of discourse planning that specifies communicative intentions. These alterations could generate unintended verbal imagery as well. Statistical data are offered to support the model, and relevant empirical studies are reviewed.
This paper concerns the discourse features of verbal hallucinations and negative symptoms of schizophrenia. A total of 46 schizophrenics, varying in verbal hallucination and in negative symptoms status, and 22 controls were tested on the Reporter Test. The frequency with which they issued inadequate instructions, attempted to repair the inadequacies, and the success of repairs were compared. We observed that schizophrenics, on the whole, issued more wrong and incomplete instructions. This was in part related to their worse working memory, but it was not affected by verbal hallucinations or negative symptoms. We observed, further, that schizophrenics had no particular problems monitoring messages for inadequacies. We did find, however, that schizophrenics with verbal hallucinations had a specific problem with self-repairing wrong instructions. We interpret these results in the framework of Hoffman's (1986b) plan disruption-based model of verbal hallucinations; the Frith (1987) and Frith and Done (1988) internal monitoring model of positive and negative symptoms; and finally Frith and Frith's (1990) model of negative and positive schizophrenia and we use the results to specify the models.
To evaluate changes in the hallucinatory experience, the author analyzed the form and content of the hallucinations of 10 schizophrenic patients during two phases of their illness, the acute phase and remission. In both test periods the patients experienced auditory hallucinations as objectively real and as directing their thoughts and behavior. Nonauditory hallucinations appeared more common than cursory examination would suggest. The patients were able to stop auditory hallucinations during remission but not during the acute phase of their illness. Hallucinatory content was threatening and isolating during the acute phase but supportive and socially focused during remissions.
This study asks whether auditory hallucinations are reflected in a distinctive metabolic map of the brain.
Regional brain metabolism was measured by positron emission tomography with [18F]-fluorodeoxyglucose in 12 DSM-III schizophrenic patients who experienced auditory hallucinations during glucose uptake and 10 who did not. All patients were free of neuroleptics and 19 had never been treated with neuroleptics. Nine patients were reexamined after 1 year to assess effects of neuroleptic treatment.
Compared with the patients who did not experience hallucinations, the patients who did experience hallucinations had significantly lower relative metabolism in auditory and Wernicke's regions and a trend toward higher metabolism in the right hemisphere homologue of Broca's region. Hallucination scores correlated positively and significantly with relative metabolism in the striatum and anterior cingulate regions. Neuroleptic treatment resulted in a significant increase in striatal metabolism and a reduced frontal-parietal ratio, which was significantly correlated with a decrease in hallucination scores.
Auditory hallucinations involve language regions of the cortex in a pattern similar to that seen in normal subjects listening to their own voices but different in that left prefrontal regions are not activated. The striatum plays a critical role in auditory hallucinations.
An assessment schedule was used to determine the nature of insight in 91 mixed psychotic patients, and to examine its distribution and associations. While all the components of the schedule intercorrelated significantly, scores for compliance were only weakly related to those for ability to label psychotic phenomena as abnormal. Compliance and illness recognition were related to IQ. Total insight score was inversely correlated, moderately, with a global measure of psychopathology derived from the PSE, and was less in patients involuntarily committed. Age, sex, diagnosis, and the number of previous hospital admissions had little effect. The results support the notion that insight is not a unitary concept.
In a recent article, Andreasen and Flaum (Schizophrenia Bulletin, Vol. 17, No. 1, 1991) argued that greater emphasis should be placed on negative symptoms in the diagnosis of schizophrenia,
leading to a less important role for positive symptoms. This article presents a counter-argument to this view. Positive symptoms
are common and reliable and therefore highly useful diagnostically. First-rank symptoms, although not specific to schizophrenia,
show good discriminability. No other type of symptom or investigative method can make such claims to usefulness. Although
positive symptoms do not predict outcome, this is not a necessary function of diagnostic criteria. The predictive power of
negative symptoms is, in any case, based largely on studies of patients with chronic disorder. Premorbidly impaired social
development may interact with schizophrenia, worsening the prognosis. We believe positive symptoms have always been the essence
of psychiatric disorder and should remain so. Increasing the diagnostic weight given to negative symptoms risks restricting
the definition of schizophrenia excessively.
A questionnaire comprising 30 open-ended questions was sent to 450 people with chronic hallucinations of hearing voices who had responded to a request on television. Of the 254 replies, 186 could be used for analysis. It was doubtful whether 13 of these respondents were experiencing true hallucinations. Of the remaining 173 subjects, 115 reported an inability to cope with the voices. Ninety-seven respondents were in psychiatric care, and copers were significantly less often in psychiatric care (24%) than non-copers (49%). Four coping strategies were apparent: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.
A sample of 46 subjects experiencing musical hallucinations was analysed - 10 new cases in addition to 36 culled from the literature. When compared with controls, it was found that musical hallucinations are far more common in females, and that age, deafness, and brain disease affecting the non-dominant hemisphere play an important role in their development. Psychiatric illness and personality factors were found to be unimportant.
The concept of insight into psychosis has received scant attention in the psychiatric literature. Drawing on sources such as phenomenology, clinical research and experimental psychology, it is proposed that insight is not an 'all-or-none' phenomenon but is composed of three distinct, overlapping dimensions, namely, the recognition that one has a mental illness, compliance with treatment, and the ability to relabel unusual mental events (delusions and hallucinations) as pathological. A scheme is proposed to standardise the assessment of insights to assist further research.
In 50 schizophrenic patients, semistructured interviews were carried out concerning disease consciousness, occupation with the disease and behaviour and coping in case of psychotic experiences; 72% of the patients occupied themselves with their disease. In 84% a disease consciousness was present; 38% gave a multifactorial explanation for their psychosis. In 94% the occasional appearance of psychotic experiences was acknowledged. In 86% specific changes of the individual behaviour for coping with these experiences were described. These changes included withdrawal, increasing of interpersonal contact, cognitive control, symptomatic behaviour and adjustment of the neuroleptic medication. The study shows that schizophrenic patients are not passive victims of their disease. In the majority of cases a disease consciousness is present. The patients try to cope with their psychotic experiences in individually different ways. It is assumed that a better knowledge of these strategies might enable the clinician to use these phenomena as an adjunct to pharmacotherapy.
48 patients with episodic psychosis (18 schizophrenia, 30 MDP) were studied to examine whether they had similar hallucinations in consecutive episodes. 34 cases reported hallucinations, 23 of whom had hallucinations in consecutive episodes. In 22 of these 23 cases, the same type of hallucination (in the same sense organ modality) recurred. A recurrence of similar content was found in nearly half of the cases. In cases in whom the hallucinatory content persisted, however, there was no persistence of delusional content. Similar neurophysiological disturbances in similar neuroanatomical regions may result in the persistence of the same hallucinations.
Twelve patients who met DSM-III-R criteria for schizophrenia and had persistent auditory hallucinations completed a diary three times daily for 2 to 3 weeks. Using 5-point equal interval rating scales, nearly all patients were able to record consistently the nature of their hallucinations, the intensity of their delusional beliefs, and the mood and clarity of their thinking. For at least half the patients, there was a statistically significant relationship between the loudness and intrusiveness of hallucinations and the intensity of delusional beliefs; the more intrusive and distressing were the hallucinations, the more anxious and depressed were the patients. The findings suggested that more emphasis might be placed on altering patients' mood in the treatment of persistent hallucinations. The diary approach to research into auditory hallucinations appears promising.
Thirty psychiatric inpatients each rated their relationship with their auditory hallucination using the Structural Analysis
of Social Behavior questionnaires which assess partnerships in terms of interpersonal focus, love-hate, and enmeshment-differentiation.
Results showed that all subjects had integrated, interpersonally coherent relationships with their voice. Qualitative differences
in the nature of the relationships related meaningfully to diagnosis. Selected clinical excerpts suggested that the relationship
with the hallucination may serve an adaptive function. Chronicity may be dependent on the nature of that adaptation.
An experiment is described in which people with each other. On an evening television talk show, a patient—diagnosed several
times as having schizophrenia—talked about her voices. Four hundred and fifty people who also were hearing voices readed to
the program by telephone. A questionnaire was sent to those who responded to the television program in order to get more information
about their way of coping with the vocies. From those who filled out the questionnaire, 20 people were selected who explained
their experiences in a clear way. A meeting for people hearing voices was organized, and the 20 persons were invited to become
the speakers. In this article the experiences described by the participants are reported as well as the many ways in which
they coped with these experiences.
Delusions and hallucinations reported in the social histories of 150 patients admitted to an East Texas state hospital during the 1930s and of 150 patients admitted during the 1980s were examined for content that would characterize and contrast the patient subcultural milieu of the two time periods. Patients admitted during the 1930s tended to reflect the material deprivation and personal powerlessness of the great depression in delusions of great wealth and positive "special powers." The hallucinatory visions and voices of the 1980s patients reflected a more threatening and negative subcultural milieu, with more visions of blood, snakes, and dead people or animals. Command hallucinations to hurt, to kill, or to do "perverse things" would also suggest that the subculture milieu of the 1980s had become more dangerous.
This study was an assessment of several parameters of verbal hallucinations ("voices") based on the self-report of 52 hallucinating psychiatric patients. These subjects were asked to estimate the frequency of their hallucinations and to rate phenomenological aspects (loudness, clarity, location, reality) of their most recent hallucination. Each parameter was assessed with two visual analogue scales which differed in their wording of the dimension. Results showed that the reliability of the subjects' estimates on the parameters differed greatly. Clarity was most reliably reported and reality was least reliably reported. Historical notions that schizophrenics characteristically perceive external "voices" and that such "voices" are perceived as more real were not supported. There was a significant negative correlation between the perceived location and the perceived clarity of hallucinations. No significant differences in mean parameter scores were found between two groups of subjects, schizophrenics and affective psychotics.
A recent examination paper for the Membership of the Royal College of Psychiatrists contained a compulsory question on pseudo-hallucinations. As is proper in a higher examination, the question was difficult, and at least one examiner (the present writer) had no idea what the answer should have been. While it is probably true that an examiner does not need to know a great deal about a question in order to assess a candidate's worth, yet if he is conscientious he will feel that he ought to know something about it. A rapid search through several textbooks proved curiously unhelpful; so this particular examiner awarded marks as best he could, and as soon as time permitted set out to discover what he should have known about pseudo-hallucinations. The present communication reports his findings and reflections. The findings are in no sense an exhaustive enquiry into the subject; they are the outcome of a search through those current textbooks and journals which may be taken to constitute as broad and as authoritative a background of study as can reasonably be expected of an examination candidate faced with a compulsory question.
This phenomenological study systematically compares the characteristics of 202 hallucinations as reported by 60 mental hospital patients, subdivided by diagnosis into manic depressives, organics, paranoids, and schizophrenics. The phenomenological characteristics of these hallucinations were compared in terms of: clinical descriptions of extreme frequencies; multiple rank ordering of frequencies to obtain weighted discriminatory indicators; discriminant function analysis. The findings suggest that phenomenological characteristics of hallucinations may be used as discriminatory indicators for differential diagnosis among psychotics; that some parameters are better than others for discriminating diagnostic groups; and that the best general discriminators are, in descending order, the number of hallucinations, their duration, the import of their content for the patient, the extent to which the patient believes that others share his hallucinatory experience, and the extent to which the hallucination affects his observable behaviour.
An association analysis was made of the responses of young adults to a hand-preference questionnaire. Many patterns of preference were distinguished and there were no marked differences between adjacent classes. These findings are believed to demonstrate that hand preference is distributed continuously and not discretely. When it is necessary to classify handedness, the preference continuum can be divided at several levels of discrimination. A second study of hand preference and manual speed showed that it is possible to order the main preference groups for asymmetry of manual skill. Some of the problems of studies of laterality are examined as possible consequences of the treatment of a continuous distribution as if it were discrete.
Synopsis
The term ‘pseudo-hallucination’ has received two incompatible definitions. It can refer either to self-recognized hallucinations (exterocepted or interocepted) or to introspected images of great vividness and spontaneity. It is argued that the phenomena to which the two definitions refer might best be distinguished as perceived and imaged pseudo-hallucinations.
Kurt Schneider asserted that certain symptoms which he termed ‘first-rank’ invariably distinguished between schizophrenia and manic-depressive psychosis. This assertion, which has attracted considerable critical attention during the past ten years, will be examined in the light of these recent investigations.
Volitional auditory imagery and spontaneous imagery/fantasy are examined in schizophrenic vs. nonschizophrenic psychiatric inpatients. Imaginal aspects of schizophrenia are also studied with regard to concurrent presence or absence of hallucination. Comparisons of imaginal function between diagnostic groups and among hallucinatory subgroups turned up few significant differences. Findings do not support the Mintz and Alpert (Mintz, S., and Alpert, M. Imagery vividness, reality testing, and schizophrenic hallucinations. J. Abnorm. Psychol., 79: 310-316, 1972) enhanced vividness model of schizophrenic hallucination but do provide some support for an imagery deficit model.
An awareness of symptoms being lateralized was established in almost half of a series of 60 acutely ll schizophrenics and is reported in a further series of 16 patients with this disorder. Case illustrations are given. The symptoms most commonly showing this phenomenon were hypochondriacal delusions and hallucinations, usually of an auditory kind. Possible mechanisms underlying the phenomenon are discussed. Some evidence was found for a difference between the sexes in the direction of lateralization symptoms.
SYNOPSIS
Electrodermal activity was measured bilaterally at rest and during stimulation in 22 schizophrenic, 11 depressed and 12 anxiety state patients, and in 32 normal volunteers. No group showed a distinctive pattern of lateral asymmetry. The frequency of spontaneous fluctuations in electrodermal activity was greater in the anxiety state and schizophrenic groups and in those patients who reported auditory hallucinations during recording. Few schizophrenic subjects failed to respond to visual stimulation but a substantial minority failed to habituate. The implications of these findings are discussed.
Synopsis
The strategies used by 40 chronic schizophrenic out-patients with persistent auditory hallucinations to cope with the intrusive phenomena were explored. Frequent coping mechanisms included changes in activity, interpersonal contact, manipulations of physiological arousal, and attentional control. A high risk of suicide was noted.
Coping behaviour appeared somewhat independent of clinical and sociodemographic variables. Successful coping appeared to result from systematic application of widely used coping strategies. The implications for the clinical management of patients with persistent auditory hallucinations are discussed.
We offer provisional support for a new cognitive approach to understanding and treating drug-resistant auditory hallucinations in people with a diagnosis of schizophrenia. Study 1 emphasises the relevance of the cognitive model by detailing the behavioural, cognitive and affective responses to persistent voices in 26 patients, demonstrating that highly disparate relationships with voices-fear, reassurance, engagement and resistance-reflect vital differences in beliefs about the voices. All patients viewed their voices as omnipotent and omniscient. However, beliefs about the voice's identity and meaning led to voices being construed as either 'benevolent' or 'malevolent'. Patients provided cogent reasons (evidence) for these beliefs which were not always linked to voice content; indeed in 31% of cases beliefs were incongruous with content, as would be anticipated by a cognitive model. Without fail, voices believed to be malevolent provoked fear and were resisted and those perceived as benevolent were courted. However, in the case of imperative voices, the primary influence on whether commands were obeyed was the severity of the command. Study 2 illustrates how these core beliefs about voices may become a new target for treatment. We describe the application of an adapted version of cognitive therapy (CT) to the treatment of four patients' drug-resistant voices. Where patients were on medication, this was held constant while beliefs about the voices' omnipotence, identity, and purpose were systematically disputed and tested. Large and stable reductions in conviction in these beliefs were reported, and these were associated with reduced distress, increased adaptive behaviour, and unexpectedly, a fall in voice activity. These changes were corroborated by the responsible psychiatrists. Collectively, the cases attest to the promise of CT as a treatment for auditory hallucinations.
A patient with continuous auditory-verbal hallucinations was studied, in comparison with two cases with a past history of similar hallucinations, from a cognitive neuropsychological perspective. This attempts to place hallucinations in the context of a normal cognitive process which has become disordered. The process in question is the phonological loop, equivalent to inner speech, derived from a model of short-term or working memory. A series of short-term memory tests, assumed to rely on the adequate functioning of the phonological loop, was administered, the results of which broadly conformed to a normal pattern of performance. It is concluded that verbal hallucinations cannot be regarded as involving the phonological loop directly. Other points in the short-term memory/language system at which verbal hallucinations could arise are discussed, as are suggestions for further research of this kind.
One of us has hypothesised that the 'voices' of schizophrenic patients reflect altered preconscious planning of discourse that can produce involuntary 'inner speech' as well as incoherent overt speech. Some schizophrenic patients reporting voices do not, however, have disorganised speech. We hypothesise that these 'counterexample' patients compensate for impairments of discourse planning by reducing language complexity and relying on highly rehearsed topics. A 'language therapy' designed to challenge and enhance novel discourse planning was administered to four such patients; three had significant albeit temporary reductions in the severity of their voices. These clinical findings provide further evidence that alterations of discourse planning may underlie hallucinated voices.
We report a patient with unilateral right auditory hallucinations in association with prominent right-sided hearing impairment and poor performance in neuropsychological tests sensitive to frontal-lobe damage.
This study examined patients' attitudes toward their hallucinations by assessing their beliefs about the purposes served by hallucinations and the adverse effects of hallucinations. It also investigated whether these attitudes were related to characteristics of the hallucinations or of the patients, whether the attitudes changed after treatment, and whether attitudes before treatment predicted the presence or absence of hallucinations after treatment.
Fifty hallucinating psychiatric inpatients were given semistructured interviews shortly after admission to the hospital and again shortly before discharge. The interviews elicited detailed descriptions of 12 phenomenologic characteristics of hallucinations and 11 attitude variables.
The majority of subjects reported some positive effects of hallucinations. The presence of olfactory hallucinations and the ability to predict hallucinations were significantly related to valuing hallucinations. Attitudes usually did not change with treatment; when they did change they usually became more positive. Subjects who valued hallucinations more before treatment were significantly more likely to be hallucinating after treatment.
The findings are consistent with the idea that psychological factors contribute to the expression of hallucinations. Assessing adaptive functions of hallucinations may predict whether hallucinations will respond to treatment and identify fruitful areas for psychosocial intervention.