From Thoughts to Voices: Understanding
the Development of Auditory
Hallucinations in Schizophrenia
#Springer Science+Business Media Dordrecht 2015
Abstract Drawing upon core phenomenological contributions of the last decades, the
present paper provides an integrated description of the development of auditory
hallucinations in schizophrenia. Specifically, these contributions are (i) the transitional
sequences of development of psychotic symptoms of schizophrenia as envisioned by
Klosterkötter and rooted in the basic symptoms approach, (ii) Conrad’s Gestalt-analysis
of developing psychosis, and (iii) Sass and Parnas’self-disturbance approach.
Klosterkötter’s contribution provides a general descriptive psychopathological ap-
proach to the transitional sequence of the development of auditory hallucinations.
The key concepts in Conrad’s proposal (such as trema, apophany, anastrophy,
Reflexionskrampf [hyperreflexivity] and transparence) are discussed, as their role is
central as driving forces of the process from non-psychotic symptoms to overt hallu-
cinations. Finally, Parnas and Sass link psychiatry to philosophy and psychology, and
provide an in-depth and thorough description of these phenomena in their work on
schizophrenia as a disorder of consciousness and self-experience (disturbed ipseity)
with hyper-reflexivity and diminished self-affection as key aspects.
Mental Health Center Nordsjaelland, Dyrehavevej 48, 3400 Hilleroed, Denmark
Mental Health Center Ballerup, Maglevaenget 2, 2750 Ballerup, Denmark
NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction,
University of Oslo and Diakonhjemmet Hospital, Oslo, Norway
Department of Mental Health, Reggio Emilia, Italy
Department of Psychology: Cogniton and Behaviour, University of Liège, Liège, Belgium
Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
E. Kraepelin - Dementia Praecox and Paraphrenia (1919).
For the most part the origin of the voices is sought for in the external world …At
other times they do not appear to the patients as sense perceptions at all. There is an
Binner feeling in the soul^,anBinward voice in the thoughts^;Bit is thought inwardly in
me^;itBsounded as if thought^;Bit was between hearing and foreboding^.(p.8)
E. Bleuler - Dementia Praecox or the Group of Schizophrenias (1952).
Although auditory hallucinations are a matter of great preoccupation, even intelli-
gent patients are not always sure that they are actually hearing the voices or whether
they are only compelled to think them. There are Bsuch vivid thoughts^which are
called Bvoices^by the patients. At other times they are Baudible thoughts^or
Bsoundless voices^.^(p. 110)
Auditory hallucinations are common in schizophrenia and other psychotic condi-
tions. As observed by Jaspers (1913), such psychopathological phenomena are irre-
ducibly linked to an impression of reality grounded in perception. In schizophrenia, this
is reflected in an overall transformation of subjectivity with a radical change in the
stream of experience, involving the perceptualization of thought. Such emerging
qualitative changes in the content of consciousness were already described by Bleuer
(1952), who observed that some patients Bare not always sure that they are actually
hearing the voices or whether they are only compelled to think them^. There are such
Bvivid thoughts, which are called voices by the patients^.
This descriptive richness is vastly impoverished in mainstream definitions of audi-
tory hallucinations adopted in most of contemporary (neo-kraepelinian and post-DSM-
IIIR) research, by de facto equating them to mere disorders of acoustic perceptions.
Furthermore, such an approach neglects important, phenomenological features of the
psycho-pathogenesis of auditory hallucinations. This is particularly evident in the
prodromal phases of schizophrenia, where non-psychotic experiential precursors de-
velop into psychotic phenomena such as auditory hallucinations through a series of
progressive experiential changes.
Therefore, familiarizing clinicians and researchers with these anomalous experiential
changes in the development of auditory hallucinations is important for at least three
reasons. Firstly, in order to facilitate the early recognition of impending psychosis;
secondly, to provide an understanding of schizophrenic symptoms in view of psycho-
educational and therapeutic support, and thirdly, to orient research in the etiology of
psychosis and thus providing suitable early phenotypic markers of psychosis.
The aim of this paper is to delineate a phenomenologically inspired model of the
development of auditory hallucinations in schizophrenia that could serve both as a clinical
guide (for psychopathological exploration) and as a heuristic framework to characterize
some of the symptom generation pathways that lead to full-blown psychosis. Specifically,
we strive to provide a clinically grounded phenomenological account of the pathogenesis
of auditory hallucinations by building on core, selected phenomenological contributions.
These contributions are: (i) the post-Jasperian notion of basic symptoms and the transi-
tional sequences leading to first rank symptoms, (ii) Conrad’s Gestalt-analysis of the
development of psychosis, and (iii) recent phenomenological research on disorders of
subjectivity in schizophrenia. Most importantly, we wish to remain faithful to the clinical
richness of auditory hallucinations as captured during more than one century of clinical
P. Handest et al.
psychopathologic research on schizophrenia, and epitomized in the quotes from its
founding fathers, Kraepelin and Bleuler (see the quotes above).
There are at least two ways of understanding the term phenomenological psycho-
pathology. One is the descriptive phenomenology that tries to give rich, detailed,
careful and qualitative descriptions of the various symptoms and signs of psychiatric
disorders. It is the basis of psychopathological instruments used to classify and
diagnose, such as the Present State Examination. Another is a psychopathology
inspired by phenomenological philosophy that describes the basic structures of human
consciousness and subjectivity, and the deviations of these structures, with emphasis on
the understanding of the subjective experiences of the individual. This is sometimes
referred to as Bthe continental phenomenological psychiatric tradition^.
1.1 The Psychopathological Pathway to Schizophrenic Hallucinations
The development of schizophrenic psychosis as a breakdown of the Self (i.e., a
transformation of subjectivity in its structural features) was proposed already at the
turn of the 19th and 20th centuries by several leading psychiatrists such as Bleuler,
Jaspers, Gruhle, Berze, Schneider, Conrad, Minkowski, Binswanger, Ey, Tatossian,
Blankenburg and Laing (see Parnas and Sass 2002 for a review). This breakdown of the
Self and the related development of psychotic psychopathology, including schizophren-
ic hallucinations, has been described in various terms by those authors. Yet, in all
descriptions, a common characteristic is the qualitative change in the medium of
consciousness that accompanies the transition towards psychotic phenomena.
We will specifically describe the contributions of the basic symptom model, devel-
oped by Huber, Gross and Klosterkötter in the context of the post-Schneiderian
tradition in psychopathology, and Conrad’s multiphase model of the onset of schizo-
phrenia. Both of these approaches try to bridge the gap between the diagnostically
relevant changes in experience (i.e., the phenomenological level of symptoms) and
biologically oriented etiological research (i.e., the presumed neurobiological substrate
level). Huber, Gross and Klosterkötter’s model is closer to a descriptive phenomenol-
ogy, whereas Conrad’sBanthropological analysis^tends to have a more philosophical
phenomenological slant. Thus, the combination of these two major contributions can be
extremely illuminative in the context of an understanding of the phenomenological
development of auditory hallucinations.
Huber, Gross and Klosterkötter’s model is based on extensive long-term exploration
and interviewing of a large cohort of patients with schizophrenia. This eventually
underwent sequential refinements that lead to the development of specific assessment
tools (described later in the paper), as well as to the description of specific criteria to
stratify the risk of impending psychosis (Klosterkötter et al. 2001; Schultze-Lutter
2009; Schultze-Lutter et al. 2010). This model provides a structural map of the
transitional sequences leading from non-psychotic anomalies of subjective experience
(basic symptoms) to Schneiderian first rank symptoms (i.e., overt delusions and
auditory hallucinations). Basic symptoms are described in the Bonn Scale for the
Assessment of Basic Symptoms (BSABS) (Gross et al. 1987,2008).
Conrad’s account emphasizes discrete qualitative stages that dynamically shape such
transitions. Conrad developed his stage model of impending schizophrenia on the basis
of in-depth interviews and minute descriptions of a large and uniform sample (n=107)
From Thoughts to Voices: Understanding the Development
of World War II soldiers whom were referred to him in 1941/42 while he was serving as
a psychiatrist in the German army.
Sass and Parnas (2003) have more recently proposed an account of the experiential
genesis of auditory hallucinations that enriches and complements the insight in both the
basic symptom model and Conrad’s account. In particular, Sass and Parnas (2003) situated
previous clinical-descriptive accounts within the framework of Husserlian philosophy,
focusing on structural alterations of self-consciousness as the basis for the development of
psychotic symptoms. They argue that auditory hallucinations (as well as other psychotic
symptoms) arise from progressive experiential changes that include the spatialization of
experience, perceptualization of the stream of consciousness, and objectification of inner
speech. All these phenomena reflect a fundamental disturbance of the basic self (i.e., the
primordial, pre-reflective sense of existing as a unified, embodied subject of experience).
Parnas et al. (2005) have published the Examination of Anomalous Experience scale
(EASE), a thorough and comprehensive description of subjective disturbances within the
schizophrenic spectrum, which gives an excellent overview of these phenomena and
provides a starting point for systematic research study and for clinical work.
Parnas and Sass’approach is concerned with the earliest experiential precursors,
while Conrad emphasizes the late prodromal phase, the development of psychosis and
the subsequent psychotic symptoms. Finally, Huber, Gross and Klosterkötter’sbasic
symptoms approach gives a well-founded analysis of their sequential transitions.
Brought together, these approaches give (1) a description of the development of
typical psychotic symptoms in schizophrenia from the earliest experiential precursors,
(2) precise descriptions and definitions of these phenomena, (3) scales for their assess-
ment (BSABS, EASE), (4) an understanding of these phenomena from a phenomeno-
logical viewpoint with (5) links to philosophy and psychology of past and present.
1.2 Huber, Gross and Klosterkötter’s Basic Symptoms: Transitional Sequences
to Auditory Hallucinations
Basic symptoms are subtle, subjectively experienced subclinical disturbances in drive,
affect, thinking, speech, perception, bodily sensations, motor action, central vegetative
functions, and stress tolerance. They are clearly distinguished from psychotic experi-
ences and are conceived of as the closest phenomenological correlates to the underlying
neurobiological disturbances manifested in schizophrenia (Gross et al. 1987,2008).
Regular transitions from basic symptoms to the typical manifestations of schizo-
phrenic psychoses are described in terms of Btransitional sequences^(Klosterkötter
1992). They are defined as linear, phenomenologically coherent connections from
elementary basic symptoms to Schneiderian first rank symptoms of psychosis. These
transitional sequential patterns involve the following stepwise progression:
1) Basic irritation phase (initial disturbances): unspecific subjective disturbances of
perception, thinking, speech, memory, actions and body sensations.
2) Psychotic externalization phase (intermediate phenomena): non-psychotic symp-
toms more typical (specific) of schizophrenia such as derealisation, depersonali-
zation, delusional mood, thought blocking, pressured thinking, disturbed discrim-
ination between thoughts and perceptions, etc., and Bas if^experiences e.g., of
body and will being influenced. The Bas if^term corresponds to the patient who
P. Handest et al.
often uses this expression to convey to the interviewer that he knows that these
experiences are abnormal. The patient does not believe that that he is being
influenced (delusion), but describes the experience as just like it.
3) Psychotic concretization phase (final phenomena): the specific, Bas if^phenomena
have developed into hallucinations and concrete delusions of influence, thought
withdrawal, broadcasting, etc.
Highly relevant in respect to this paper is Klosterkötter’s(1992) description of the
transitional sequences, which showed that the majority of patients with schizophrenia,
who later developed auditory hallucinations, reported self-perceived, non-psychotic
changes in the prodromal phase that correspond to specific cognitive basic symptoms,
including thought interference, thought perseveration and pressured thinking.
According to the transitional sequences, the development of hallucinations (Fig. 1)
starts with unspecific cognitive subjective disturbances of memory, thinking and
concentration. This starts by first turning into thought interference, pressured thinking
and obsessive-like perseveration of mental content, which then intensify into higher-
order phenomena such as audible thoughts, and disturbed discrimination between
thoughts and auditory images. Thereafter, audible thoughts and disturbed discrimina-
tion of auditory images and actual acoustic perception become more and more prom-
inent. Finally, commenting and discussing voices emerge.
This, and the other sequences, offers a precise description of the symptomatological
progression (mostly on a descriptive level) that can be enriched by resorting to
Conrad’s gestalt-analysis of impending schizophrenia. Indeed, Conrad’s concept cluster
of apophany, Reflexionskrampf (hyperreflexivity) and transparence can further illumi-
nate the experiential change that drives this process.
1.3 Conrad’s Phase Model of Impending Schizophrenia
Conrad’s model (Conrad 1958) depicts four developmental stages related to the
formation of psychotic symptoms: trema (i.e., the initial phase), apophany (i.e., the
phase in which an incipient delusion becomes Bvisible and apparent^, with the quality
Imperative, commenting and
Audible thoughts, disturbed
discrimination between auditive
images and perceptions
Thought interference, pressured
thinking, thought block, obsessive-like
Disturbance of memory, concentration
and other subjective cognitive
Fig. 1 The development of auditory hallucinations, modified after Klosterkötter (1992)
From Thoughts to Voices: Understanding the Development
of a revelatory experience), apocalypse (i.e., the true eruptive phase) and, finally, the
During these phases, the individual suffers from an immediate and profound worry
due to his inability to surmount the autocentric (Ptolemaic) frame of experience (which
Conrad describes as being ‘trapped’in a reflective mode). In the writings of Conrad and
Huber, Gross and Klosterkötter (and other European continental psychiatrists), there is
often a reference to the Ptolemaic versus the Copernican view of the world in
schizophrenia. Therefore, a short description of this way of describing a crucial element
in the development of schizophrenic psychosis is provided.
The Ptolemaic view is that the sun and planet orbit around the Earth. This is equivalent
to the patient view in psychosis. Reality, or the Copernican view, is that the earth (and the
other planets) orbit around the sun. This is the view of others. In the development of
psychosis, the patient loses the ability to take the Copernican view on himself. He loses the
ability to look at himself with the eyes of another person and thereby loses the ability see
his symptoms as symptoms, but instead experiences them as reality. In this process - i.e.,
the subjective dynamic oscillation between allocentric (Copernican) and autocentric
(Ptolemaic) viewpoints - the phenomena in the field of experience change significantly,
into a mode that is strictly self-referential. The ability to shift between the two ontological
standpoints is lost in the schizophrenic psychosis. Conrad called loss of
BÜberstiegsfähigkeit^or loss of the ability to evaluate one’s own experience correctly
when in contradiction with agreed laws and rules of the world. A typical example is the
patient with schizophrenia who is convinced that others share his thoughts.
The prodromal phase, the trema, is characterized by a certain experiential atmosphere.
Trema (stage fright or BLampenfieber^, literally Blamp-fever^) is a term that Conrad
borrowed from the world of theatre and that refers to the specific kind of excitement or
tension before a performance. Lamp-fever addressestwoaspectsofthisexperience:the
feverish, anticipatory excitement, and the sense of being exposed in the spotlight. A
person during a prodromal phase often has an overwhelming feeling (bordering on
certainty) that something important is going to happen and often feels over-exposed to
such an impending transformation. The trema is often, but not necessarily, characterized
by such symptoms as fear and a feeling of detachment from other people. The character-
istic aspect of the trema is a restriction or narrowing of the entire field of existence, which
can only be resolved by passing through the Bsituation^, that is the performance on stage.
Passing through the Bsituation^refers to the fact that the trema has developed into
psychosis, that the individual has found a Bsolution^to the experienced tension. In the
context of auditory hallucinations, this could involve going from the annoying experience
of experiencing thought interference, pressured thinking,audible thoughts etc., to (more or
less suddenly) having the knowledge that voices are talking to you. Such psychotic
actualization would contribute to a significant decrease in the individual’s level of anxiety
and thereby decreasing tension. As trema resolves, delusional ideation unfolds and marks
a transformation of the entire experiential structure, covering all modes of intentionality
from perception, imagination, and thinking –which Conrad saw as the cornerstone of the
early phases of schizophrenia. This transformation is characterized by the concept-cluster
of apophany, anastrophy and transparence.
P. Handest et al.
1.3.2 Apophany of Outer and Inner Space (World)
Apophany of outer and inner space comes from the Greek Bapo^[away from] and
Bphaenein^[to show]. It refers to the experience of seeing meaningful patterns or
connections within random or meaningless data. It is a state of arousal, where the
original agreed upon meaning of signs and symbols of the world change, subjectively
akin to a revelatory experience (i.e., private, unescapable and self-evident). Conrad
coined the term in order to refine, expand upon, and make more practical the German
concepts of Babnormes Bedeutungsbewusstsein^(abnormal awareness of meaning) and
BBeziehungssetzung ohne Anlass^(making connections without a cause –delusions of
reference). Apophany thus bears a certain semantic resemblance to the terms
Brevelation^and Bepiphany^. Conrad characterized the apophanous mode of experi-
ence like this: BThe afflicted behaves like the man in the Revelations^. The meaning of
events is evident and characterized by a total absence of doubt for the afflicted and,
furthermore, other persons’doubts are met with disbelief (loss of Überstiegfähigkeit).
These experiences can be of a delusional degree (delusional perception, i.e., a normal
sensory perception, to which a person attributes a delusional meaning) or may involve
more subtle, non-psychotic changes in the perception and experiencing of the inner and
There are three stages of apophany:
1. Pure apophany: The experienced object ineffably Breveals^itself as having a
particular meaning for the person, who is still uncertain about what that particular
meaning might be.
Case example (from authors). An excerpt from an inpatient diagnosed with
schizotypal disorder, ICD-10 (schizotypal personality disorder, DSM-5) describing
his changed experience of the surrounding world prior to his hospitalization:
…and then being in the subway, I was able to calm down a little bit. However,
after a short while the billboards - you know, they have these advertising
billboards hanging on the walls - the text on the billboards began to speak in
an important way to me. Well, I cannot remember what it was, but the text on the
billboards were like aimed at me. That is, they had this deeper meaning - a deeper
meaning specifically to me.
2. Feeling of stagedness: The experienced object Breveals^itself as having a partic-
ular meaning for the afflicted, and the afflicted immediately knows the meaning
(e.g., the object having been placed there to test him).
Conrad gives us this example: BA patient is asked to choose the most
beautiful postcard among 16 different postcards, but declines the task. It is
impossible in his current state of mind, which he maintains despite numer-
ous and extensive invitations. Nor reframing it, i.e., that he is in a book-
store and has to find a postcard for a friend, can persuade him. When asked
why not, he answers that it would be quite hopeless, that he would not be
able to describe it. The patient became more and more confused by this
request. He apparently has the feeling of being in an extremely important
test situation, as if his life depended on the card selection.^
From Thoughts to Voices: Understanding the Development
3. Delusions of reference: The experienced object Breveals^itself as having an
exceptional and specific meaning for the afflicted.
The main case (Rainer) described in Conrad (1958) has the persecutory delusion
that his superiors constantly follow everything he is doing to test him to find out
whether or not he is suited for becoming an officer. In his narrative, there are
several examples of objects, situations, etc. revealing an exceptional and
specific meaning just for the patient. For instance that Bthe bed creaking^at
night in the occupancy room meant that his fellow soldiers were Bsneaking
up on him^. A group of soldiers handling their rifles meant Bpull yourself
together!^A damaged car engine meant that things would go wrong. A big
BN^on a railway sign meant that his wish to become an officer would not
be fulfilled. A Bgreen truck tarpaulin^meant Bnew hope^.Animalsroaring
meant that he was going to be slaughtered like an animal. Drops of water
on cheese lying on a table meant that he once and for all should get his act
together, and so on.
During the anastrophy stage, the person experiences himself as the passive centre of the
world. BI have a feeling that everything revolves around me.^The passive element is of
special importance. Conrad describes this as Reflexionskrampf –equivalent to
hyperreflexivity as defined by Parnas et al. (2005), or a state of affliction where the
delusional person becomes a prisoner of his own ego. While reflection is normally
conceived of as a voluntary operation of the mind, or a Bliberation from the uncon-
scious darkness of unreflecting (animal) life^, the afflicted is trapped in this operation,
making the possibility ofsurmounting it impossible. The Bstepping over^(BÜberstieg^)
into a frame of reference other than the reflexive one is not possible, and thus
effectively suppressing the conduct of everyday life.
Case example (from authors). Sasha diagnosed with schizotypal personality disor-
der, describing hyperreflexivity:
I wasn’t able to listen to the radio because I was thinking that what I heard was
just sound waves going into my ears, forming a certain frequency that made me
hear something. That it actually was just an illusion. And that’s what sound is,
isn’t it! The same thing may well occur when I watch television. That I then think
way too much about it.
While apophany describes the changes of the world and its objects in relation to the
subject, anastrophy denounces the way that the BI^appears to itself –that is, as the
centre of the world. The interdependence of the two (apophany and anastrophy) is
crucial to Conrad, thus: Bwhenever there is an apophanous experience, the I has to
undergo an anastrophic change^. That is, when in the apophanous mode, the person
inevitably also experiences (suffers from) hyperreflexivity. According to Conrad,
hyperreflexivity has an immediate influence on the way mental content is experienced.
This can be experienced even in an everyday-like way. When intensively focusing on a
certain word or concept and thinking of all its meanings, and/or repeating the word or
P. Handest et al.
concept in your head, it can be experienced that the word or concept looses its
significance and meaning.
Some case examples (from authors) of changed experience due to hyperreflexivity:
Female patient diagnosed with paranoid schizophrenia describing an inner feeling of
What is restless? It is a combination of rest and less. What is rest and what is less?
How are they connected? Rest, rest, rest, less, less, less, restless, restless, restless.
Those words continue to go on in my head. Rest means certain differing things
and less likewise. What is actually the meaning of restless?
Here, the patient is Ba prisoner of her own reflection^and her knowledge of restless
is disappearing. In her apophanous state of Babnormal awareness of meaning^,the
normal meaning of being restless disappears leading to an alienation from linguistic
Case example (from authors). Sasha, (same Sasha as above) describing a changed
way of experiencing herself due to hyperreflexivity:
It’s that thing, all the time feeling outside yourself; like you can hear yourself
talking - that you can see yourself doing things. I have had a very unpleasant
experience, as if I was looking out through my own eyes, because I was aware of
myself looking. I experienced that I was placed somewhat behind myself. That I
wasn’t actually a part of my movements, my voice, my eyes. I was kind of
retracted. As if, I have a kind of superior consciousness that I did not have before.
Then I was embedded directly in myself, now I’m so out of myself.
Asked to clarify the meaning of Bsuperior consciousness^,thepatientanswered:
It is that I reflect upon myself, my own impressions, on myself. Whereas a dog, a
Labrador retriever, would just be in its own self, and would never think upon
itself. It would instinctly do just what it wanted to do. I think of all the things I do,
because I observe myself from the outside.
The patient describes an experience of alienation toward herself. Even looking at the
world is experienced as something she does from a distance. In this way,
hyperreflexivity changes the way the patient experiences herself and the world.
The way the patient describes her fundamental problem resembles the patient Anne
from Blankenburg’s(1971)BDer Verlust der natürlichen Selbstverständlichkeit^, where
the patient is trying to describe what this loss of common sense is:
Idon’tknow–how shall I put it –I’m so low-spirited and crouched. I can never
really be part of things and participate. I don’t know - it is always the same really.
I don’t know what to call it. I just call it…It is just…I don’t know, no
knowledge, it is like…Every child knows this!
The similarity of metaphors is striking. Anne experienced lacking something that
even a child possessed, our patient was lacking in something even a dog has. Both a
From Thoughts to Voices: Understanding the Development
child and a dog are commonly perceived of as behaving straight forward, spontane-
ously and instinctively, and without excessive thinking prior to actions.
Apophany and hyperreflexivity entail a mode of experience that influences the content
of consciousness (of the inner and outer world/space). To begin with, apophany often
spares the inner space, while the outer world starts to be experienced in an apophanic
light. This leads to what Conrad calls Bdedifferentiation^(Entdifferenzierung), where
certain characteristics (Wesenseigenschaften) of the outer world gain primacy over the
whole. As things progress, however, the Blocalization^of experience changes: BThe
inner and outer world begin to communicate^, and the inner space becomes progres-
sively transparent. As a consequence of the apophanous mode of experience and
hyperreflexivity, the person experiences a distance to contents of his own conscious-
ness, e.g., thoughts. Initially, the person describes an experience of strangeness towards
his own thoughts (auto-psychic depersonalization), further on, the experiential distance
is accentuated, and a quality of alienation of thoughts emerges, and in the end, there is a
complete lack of ownership of thoughts. Thoughts may thus first be identified as one’s
own, then as Bafflatus^(i.e., the staggering and stunning blow that ensues at the
appearance of a new idea, an idea that the person may not be able to explain) where
there is a primacy of the ‘outer’and where thoughts may be experienced as inserted or
even forced upon the subject, and finally take the form of commanding or threatening
voices. This can be seen in the form of symptoms such as thought insertion, thought
broadcast, audible thoughts and auditory hallucinations.
Case 61 (from Conrad) constantly complains about the reading of his thoughts. Even
when he writes and reads, what he reads is simultaneously read aloud by someone else.
He received a text to read. After looking at it for a moment, he looks up and says: BDid
you hear that?^
Case 11 (from Conrad) comments: BAs soon as I think about something, somebody
else says the thoughts out loud. About 8–10 people can do that.^[…]BWhen I wrote a
letter, he (another patient) prompted every word. I heard every sentence beforehand.^
[…]BEverything I read is repeated, I hear it exactly, it gets repeated outside on the
Case 60 (from Conrad) reports that he has been hearing commenting voices for a
number of years. When he was about to eat or light a cigarette, he heard: BNow he is
about to eat^or Bnow he is going to light a cigarette^. These remarks were always
made in another room than the one the patient was in.
According to Conrad: BPhenomenologically, the differences between the experience
of thought-broadcast and audible thoughts are merely differences of degree^,even
though these symptoms are normally categorized in two different diagnostic domains –
as thought disorders (Denkstörungen) and perceptual disorders
(Wahrnehmungsstörungen), respectively. Conrad contests this view and argues that
these hallucinations genetically and directly originate and develop in thinking, and thus
represent a higher degree of transparence and communication between ‘inner’and
‘outer’space. From this perspective, (commenting) voices are another expression of
hyperreflexivity where everyday life is subjected to a constant monitoring by the ego.
The myriad manifestations of these phenomena are, according to Conrad, dependent
P. Handest et al.
upon the patients’pre-morbid differences in styles of thinking and internal dialogue.
People may, for example, address themselves in the first or second person while others
employ different forms of word play.
1.4 The Development of Auditory Hallucinations: Combining the Concepts
of Klosterkötter and Conrad
The development of auditory hallucinations from the view of Klosterkötter
(1992) starts with unspecific disturbances of memory and concentration, the
basic irritation phase (Fig. 1). Our main case, Erik, describes the symptoms in
the following way:
Case example (from authors). Erik describing unspecific subjective, cognitive
…I was unable to do anything. I found it hard to attend to my studies. It was
difficult to concentrate when reading my books, and difficult to understand what I
read, and remember what I read. I was pretty desperate, because there were all
these exams I had to pass. During this time, I was lying on the bed and looked up
at the ceiling, and smoked cigarettes, and drank coffee and did not think of
In this stage, the patient is already in the experiential state of apophany and
hyperreflexivity, which changes the way the patient experiences himself and the world
as described above. Due to the Baction^of hyperreflexivity and apophany, a loss of
control of his own thoughts appears and the unspecific cognitive disturbances are
transformed into pressured thinking, thought interference, and obsessive-like persever-
ation of mental content (Fig. 2).
Pressured thinking refers to having the impression that many thoughts (or
images) with different, unrelated or remotely related meaning/content pop-up
and disappear in quick sequences without the patient being able to suppress or
Imperative, commenting and conversing voices
Audible thoughts, disturbed discrimination
between auditive images and perceptions
Thought interference, pressured thinking,
thought block, obsessive-like perseveration
Disturbance of memory, concentration and
other subjective cognitive disturbances
Tran spa ren ce
Tran spa ren ce
Fig. 2 The development of auditory hallucinations: the interaction of the Klosterkötter (1992) and Conrad
From Thoughts to Voices: Understanding the Development
control the appearance and disappearance of contents of consciousness. Thought
interference is the sudden appearance of thoughts without the patient having the
intention of initiating these thoughts. Obsessive-like perseveration is ruminating
on all kinds of things from urgent matters to insignificant trivialities, which is
differentiated from pressured thinking, as thoughts are not chaotic, but sequen-
tial. The patient has entered the intermediary phase.
Case example (from authors). Erik describing pressured thinking:
I’m very familiar with the experience of thinking or trying to think many thoughts
at the same time. But they pile up, as if they were originating from many different
places in the brain, so that I have no control over them - and it ends up in total
Thoughts come and go with the patient being able to control the appearance and
disappearance of thoughts. As the contents lack a common theme and are at times
irrelevant to the patient, this enhances the feeling of loss of control. The patient
experiences a change in both content and form of thoughts, which causes a loss of
coherence or meaning for the patient. The lack of control, coherence and meaning
amplifies the effect of the driving forces - apophany and hyperreflexivity. Patients often
use variations of Bdistance^or Bnot genuine^to describe the changed experiences of
thoughts (and the world).
This amplifies the generators of auditory hallucinations, i.e., apophany and
hyperreflexivity that push thoughts into the next phase. During this transfor-
mation, transparence also starts functioning as a generator. The experiencing
of mental content as distant and/or not quite genuine contributes to the
formation of transparence, which in turn further changes the way mental
content is experienced. In the next stage, the patient experiences
perceptualization of thought (Gedankenlautwerden), that is, thoughts that be-
come audible to him, but not to others, and the development of transparence
is clearly visible as the patient becomes uncertain as to the place of origin of
his own thoughts, ideas, etc.
Case example (from authors). Erik describing audible thoughts:
I often hear my thoughts inside my head, and at the same time, I see them written
down. It is as if I read aloud from a piece of paper, on which my thoughts have
been written down.
The patient also experiences visible thoughts. Which is another example of change
in the form of thoughts. In the authors’experience, these two experiences –audible and
visible thought, are often reported as occurring together.
Case example (from authors). Erik describing disturbed discrimination of audible
images and perceptions:
It has been a recurring thing, that I heard phones ringing, or that the
phone rang, and I hear it in my head, and I know perfectly well that the
phone is not ringing. But it keeps ringing inside my head anyway. And
every time I feel a jerk in me and I’m almost starting to get up, and go
P. Handest et al.
andpickupthephone.SosometimesIdon’t know if the phone is ringing
or if I am imagining it.
The development of intermediary phenomena into actual voices highly depends on
transparence created by the mode of apophanous experience and hyperreflexivity. As
the process ofapophany, hyperreflexivity, transparenceand alienation of mental content
continues, the mental content is experienced as more distant and possessing a clear
quality of strangeness or a sentiment of Bnot really mine^. Along with this process,
perceptualization of thoughts also increases. Finally, the patient experiences thoughts as
alien, Bdefinitely not mine^and so distant that they are perceived as either internal
voices or, if the transparence has gone even further, as external voices.
Case example (from authors). Erik describing his voices:
I’ve had experiences, where at the same time I saw cobblestones, darkness, and a
dark street and heard rain in front of me. I was able to recognize this as the place I
lived at the time. It was as if I was standing on the fourth floor and looking into
the rain and down on the dark street, the cobblestones and at the street lamps, and
there was something with that window up on the fourth floor, which was very
appealing to me, and very dangerous. I heard the rain and voices from the
window, which both encouraged and ordered me to get over to the window and
jump out to commit suicide. It lasted about 5–10 min and while I was watching
and hearing it, it was actually real, but afterwards I knew very well that it was a
hallucination of some kind.
1.5 Parnas and Sass’Basic Disorder of Subjectivity and Auditory Hallucinations
(Parnas and Sass 2002;Parnasetal.2012;Parnasetal.2011)approachbuildsonboth
previous clinical-psychopathological insights into the experiential level of the devel-
opment of psychotic experiences, and philosophical-phenomenological descriptions of
the structure of human consciousness. Their approach offers a strong linkage to
philosophy and psychology and an expansion of the description of schizophrenic
psychopathology based on concepts from these two fields. The link to phenomenolog-
ical philosophy and psychology is stronger or at least more explicitly formulated than
with Conrad and Huber, Gross and Klosterklötter. Parnas and Sass’approach provides
a further description and understanding of the phenomena described above (and of
other phenomena important for the understanding of schizophrenia).
Parnas and Sass’ipseity-hyperreflexivity model claims that instability of pre-
reflective self-awareness is a core, generative feature of schizophrenia that affects the
minimal or core self (Parnas and Sass 2002;Parnasetal.2012). Ipseity (Latin for self or
it-self) refers to an experiential sense of being a vital, self-coinciding embodied subject
of experience endowed with a unique first personal access to the world. In non-
technical language, that I know without thinking that I am me, myself, and every
gesture, action, utterance, feeling, emotion, etc. is mine or me. In that this experience is
so self-evident to me, I never think about it. Only when forced to do it, however, will I
become aware that this is actually a unique experience.
From Thoughts to Voices: Understanding the Development
The two main features of the ipseity disturbance are hyperreflexivity and diminished
self-affection. According to Parnas et al. (2005), hyperreflexivity is a tendency to take
oneself or aspects of the world as objects of intense reflection. This increase in the
reflection on own thinking, feelings and behavior, causes an inability to react and
behave spontaneously and in a carefree manner. Hyperreflexivity refers to forms of
exaggerated automatic self-consciousness in which Bsomething normally tacit becomes
focal and explicit^. This disrupts awareness and action because of the popping-up and
popping-out of the normally tacit processes and phenomena. Sass and Parnas distin-
guish between hyperreflexivity and hyperreflectivity. The latter being a part of
hyperreflexivity, but with Bfairly volitional, quasi-volitional or intellectual processes^,
BaBreflective^kind of self-consciousness^. Hyperreflexivity has a distinct component
of being outside the range of will.
Clinically, hyperreflexivity emerges in phenomena such as the feeling of losing the
automaticity of normally tacit, habitual sensorimotor processes animating everyday
behavior (e.g., getting dressed, drinking coffee, interacting with others, etc.). Instead,
the proprioceptive and kinesthetic background moves to the foreground of the patient’s
focal attention. The person becomes overly aware of the effort required to produce each
gesture or movement, to such an extent that his body is eventually experienced as a
mechanical object, resulting in an experience of disembodiment or Bself-alienation^
(Sass and Parnas 2003,Sassetal.2011). Actions are dislodged from the gestalt of the
situational context and thus appear strange or uncanny (Wiggins and Schwartz 2007).
This concept of hyperreflexivity is equivalent to the description of Reflexionskrampf
by Conrad (1958). As hyperreflexivity is English and probably more understandable,
the authors have chosen to use this expression instead of a translation of
Reflexionskrampf into English.
Diminished self-affection involves a decreased sense of existing as a vital and self-
possessed subject of awareness. The patient has a decreased sense of existing as an
experiencing subject, of experiencing himself as the vital center-point of subjective life
(Sass and Parnas 2003,Sassetal.2011). In schizophrenia spectrum disorders, the
subject undergoes subtle but pervasive and persistent qualitative changes of subjective
experience due to the ipseity disturbance and hyperreflexivity. These include an
extensive variety of non-psychotic phenomena, such as subtle feelings of alienation,
depersonalization, perplexity, changes in bodily experiences, loss of the automatic
attunement to intersubjectively shared meanings, as well as distortion of the primordial
sense of self-presence and stream of consciousness. These anomalous subjective
experiences, which are systematically described in the Examination of Anomalous
Self-Experience (EASE; Parnas et al. 2005), are indicative of a disturbance affecting
the very structure of experiencing, that is, ipseity. Even the perceptual act itself may rise
to the level of focal awareness, e.g., BI became aware of my eye watching an object,^
(Stanghellini and Ballerini 2004, p. 113).
In sum, hyperreflexivity tends to objectify normally tacit, pre-reflective processes of
agency and perception, thus triggering the second, complementary component of
ipseity disturbance, that is, the diminishment of self-affection. This description of
objectifying and diminished self-affection resembles Conrad’s concepts of developing
schizophrenia, i.e., apophany and transparence. Experiences of diminished self-
affection are, for example, the feeling of a growing inner distance from one’sown
stream of consciousness (BI saw everything I did like a film-camera^(Sass 1992)), or of
P. Handest et al.
Ban inner void^or Black of inner nucleus^where the self would normally be (Parnas
and Handest 2003a, b). The joint effect of hyperreflexivity and diminished self-
affection is a progressive and enduring erosion of the basic sense of self-presence with
a contextual loss of the perspectival coherence that enables us to maintain an experi-
ential grip on the world. This can also affect the development of auditory hallucinations
that, according to Sass and Parnas (2003), might be viewed as an autochthonous
transformation of inner speech (i.e., a constitutive phenomenon of our stream of
thought) in the context of a diminished self-presence that no longer fills the field of
consciousness. (Parnas et al. 2012) state that this phenomenology helps to understand
how one form of experience leads into another, or worded differently, can inspire or
motivate the transformation of subjectivity.
In the introduction, we advocated three aims for this paper: to facilitate the early
recognition of impending psychosis; to provide an understanding of schizophrenic
symptoms in view of psycho-educational and therapeutic support, and finally to offer
a foundation for research in the etiology of the pathogenetic pathways to psychosis. A
phenomenologically (in both understandings of this concept) inspired approach to the
experiential development of auditory hallucinations that can be used in clinical explo-
ration is, however, still largely lacking in the contemporary scientific literature (cf.
McCarthy-Jones et al. 2013; Raballo and Larøi 2011; Larøi et al. 2010).
Such an approach, mapping the pathways from early, non-psychotic experiential
changes to full-blown auditory hallucinations, has both clear clinical advantages and
research implications. This approach captures the developmental nature of these expe-
riences, and therefore can play a role in etiologic research, in that early pre-
hallucinatory experiences are a closer index of vulnerability than overt symptoms of
impending schizophrenia. Being aware of the psychopathological phenomena de-
scribed in this paper helps both the clinician and researcher to identify patients with
prodromal schizophrenia. In this respect, it is important to note that validated assess-
ment instruments exist, such as the Bonn Scale for the Assessment of Basic Symptoms
(Gross et al. 1987,2008), the Schizophrenia Proneness Instrument (Schultze-Lutter
et al. 2007) and the Examination of Anomalous Self Experience (Parnas et al. 2005).
Therapeutically, having a phenomenological background provides the clinician with
the insight to understand and discuss deeper issues regarding the meaning of auditory
hallucinations with the person hearing them and examine how this relates to his present
situation. This is of benefit for the development of cognitive behavioral techniques
aimed at relieving voice-hearers’distress, particularly with regard to being able to
create meaningful formulations (McCarthy-Jones et al. 2013). Similarly, as has been
previously suggested (Møller and Husby 2000;Mundt2005;RaballoandLarøi2011),
the phenomenologically trained clinician will be uniquely qualified in accom-
panying the patient in the appraisal of such experiences thereby resulting in a
substantial tension-relieving effect. This approach gives the patient the oppor-
tunity and space for therapeutic interaction where their subjective perception of
self-alteration can undergo a narrative integration, thus empowering the patient’s
sense of self-coherence.
From Thoughts to Voices: Understanding the Development
Blankenburg, W. 1971. Der Verlust der natürlichen Selbstverständlichkeit: Ein Beitrag zur Psychopathologie
symptomarmer Schizophrenien. Stuttgart: Ferdinand Enke Verlag.
Bleuer, E. 1952. Dementia Praecox or the group of schizophrenias.
Conrad, K. 1958. Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns. Georg Thieme
Verlag. Stuttgart, Germany.
Gross, G., G. Huber, J. Klosterkötter, and M. Linz. 1987. BSABS Bonner Skala für die Beurteilung von
Basissymptomen. Manual, Kommentar, Dokumentationsbogen.. Berlin: Springer.
Gross, G., G. Huber, J. Klosterkötter, and M. Linz. 2008. BSABS - Bonn Scale for the Assessment of Basic
Symptoms: 1st english edition: Manual, commentary, references, index, documentation sheet (Berichte
aus der Medizin). Aachen: Shaker Verlag.
Jaspers, K. 1913. Allgemeine Psychopathologie. Ein Leitfaden für Studierende, Ärzte und Psychologen. Berlin
Springer Verlag. Translated from the German 7th edition by Hoenig J and Hamilton MW in 1959.
Klosterkötter, J. 1992. The meaning of basic symptoms for the development of schizophrenic psychoses.
Neurology Psychiatry and Brain Research 1: 30–41.
Klosterkötter, J., M. Hellmich, E.M. Steinmeyer, and F. Schultze-Lutter. 2001. Diagnosing schizophrenia in
the initial prodromal phase. Archives of General Psychiatry 58: 158–164.
Larøi, F., S. de Haan, S. Jones, and A. Raballo. 2010. Auditory verbal hallucinations: Dialoguing between the
cognitive sciences and phenomenology. Phenomenology and the Cognitive Sciences 9: 225–240.
McCarthy-Jones, S., J. Krueger, F. Larøi, M.R. Broome, and C. Fernyhough. 2013. Stop, look and listen: The
need for philosophical phenomenological perspectives on auditory verbal hallucinations. Frontiers in
Human Neuroscience 7: 127.
Møller, P., and R. Husby. 2000. The initial prodrome in schizophrenia: Searching for naturalistic core
dimensions of experience and behavior. Schizophrenia Bulletin 26: 217–232.
Mundt, C. 2005. Anomalous self-experience: A plea for phenomenology. Psychopathology 38: 231–235.
Parnas, J., and P. Handest. 2003. Phenomenology of anomalous self-experience in early schizophrenia.
Comprehensive Psychiatry 44: 121–134.
Parnas, J., and L.A. Sass. 2002. Self, solipsism, and schizophrenic delusions. Philosophy, Psychiatry &
Psychology 8: 101–120.
Parnas, J., P. Møller, T. Kircher, J. Thalbitzer, L. Jansson, P. Handest, and D. Zahavi. 2005. EASE-scale
(Examination of Anomalous Self-Experience). Psychopathology 38: 236–258.
Parnas, J., A. Raballo, P. Handest, L. Jansson, A. Vollmer-Larsen, and D. Saebye. 2011. Self-experience in the
early phases of schizophrenia: 5-year follow-up of the Copenhagen Prodromal Study. Wor ld Psy chia t r y
Parnas, J., L.A. Sass, and D. Zahavi. 2012. Rediscovering psychopathology: The epistemology and phenom-
enology of the psychiatric object. Schizophrenia Bulletin 39: 270–277.
Raballo, A., and F. Larøi. 2011. Murmurs of thought: Phenomenology of hallucinatory consciousness in
impending psychosis. Psychosis 3: 163–166.
Sass, L. A. 1992. Madness and Modernism: Insanity in light of modern art, literature, and thought, New York,
Sass, L.A., and J. Parnas. 2003. Schizophrenia, consciousness, and self. Schizophrenia Bulletin 29: 427–444.
Sass, L., J. Parnas, and D. Zahavi. 2011. Philosophy, Psychiatry, & Psychology, 1: 1–23.
Schultze-Lutter, F. 2009. Subjective symptoms of schizophrenia in research and the clinic: The basic symptom
concept. Schizophrenia Bulletin 35: 5–8.
Schultze-Lutter, F., J. Addington, S. Ruhrmann, and J. Klosterkötter. 2007. The Schizophrenia Proneness
Instrument –Adult version (SPI-A). Rome: Giovanni Fioriti Editore s.r.l.
Schultze-Lutter, F., S. Ruhrmann, J. Berning, W. Maier, and J. Klosterkötter. 2010. Basic symptoms and
ultrahigh risk criteria: Symptom development in the initial prodromal state. Schizophrenia Bulletin 36:
Stanghellini, G., and M. Ballerini. 2004. Autism: Disembodied existence. Philosophy, Psychiatry&
Psychology 11: 259–268.
Wiggins, O.P., and M.A. Schwartz. 2007. Schizophrenia: a phenomenological-anthropological approach. In
International perspectives in philosophy and psychiatry, Reconceiving schizophrenia, ed. M.C. Chung,
K.W.M. Fulford, and G. Graham, 113–127. Oxford: Oxford University Press.
P. Handest et al.