ArticlePDF Available

From Thoughts to Voices: Understanding the Development of Auditory Hallucinations in Schizophrenia

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 approach 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 hallucinations. 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.
From Thoughts to Voices: Understanding
the Development of Auditory
Hallucinations in Schizophrenia
Peter Handest
1
&Christoph Klimpke
2
&
Andrea Raballo
3,4
&Frank Larøi
5,6
#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) Conrads Gestalt-analysis
of developing psychosis, and (iii) Sass and Parnasself-disturbance approach.
Klosterkötters contribution provides a general descriptive psychopathological ap-
proach to the transitional sequence of the development of auditory hallucinations.
The key concepts in Conrads 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.
Rev.Phil.Psych.
DOI 10.1007/s13164-015-0286-8
*Peter Handest
handest@dadlnet.dk
1
Mental Health Center Nordsjaelland, Dyrehavevej 48, 3400 Hilleroed, Denmark
2
Mental Health Center Ballerup, Maglevaenget 2, 2750 Ballerup, Denmark
3
NORMENT, KG Jebsen Centre for Psychosis Research, Division of Mental Health and Addiction,
University of Oslo and Diakonhjemmet Hospital, Oslo, Norway
4
Department of Mental Health, Reggio Emilia, Italy
5
Department of Psychology: Cogniton and Behaviour, University of Liège, Liège, Belgium
6
Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
1 Introduction
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) Conrads 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 Conrads 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 Klosterkötters model is closer to a descriptive phenomenol-
ogy, whereas ConradsBanthropological 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 Klosterkötters 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).
Conrads 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 Conrads 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 Sassapproach 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 Klosterköttersbasic
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 Klosterkötters 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 Klosterkötters(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
Conrads gestalt-analysis of impending schizophrenia. Indeed, Conrads concept cluster
of apophany, Reflexionskrampf (hyperreflexivity) and transparence can further illumi-
nate the experiential change that drives this process.
1.3 Conrads Phase Model of Impending Schizophrenia
Conrads 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
Final phenomena
Intermediate phenomena
Initial disturbances
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
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
consolidation phase.
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 trappedin 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 ones 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.
1.3.1 Trema
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 individuals 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 personsdoubts 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
outer world.
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.
1.3.3 Anastrophy
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 wasnt 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 thats what sound is,
isnt 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
restlessness:
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
common sense.
Case example (from authors). Sasha, (same Sasha as above) describing a changed
way of experiencing herself due to hyperreflexivity:
Its 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
wasnt 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 Im 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 Blankenburgs(1971)BDer Verlust der natürlichen Selbstverständlichkeit^, where
the patient is trying to describe what this loss of common sense is:
Idontknowhow shall I put it Im so low-spirited and crouched. I can never
really be part of things and participate. I dont know - it is always the same really.
I dont know what to call it. I just call itIt is justI dont know, no
knowledge, it is likeEvery 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.
1.3.4 Transparence
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 ones
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 outerand 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 810 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
porch.^
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 innerand
outerspace. 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 patientspre-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
disturbances.
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
anything.
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
Final phenomena
Intermediate phenomena
Initial disturbances
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
Hyperreflexivity
Hyperreflexivity
Hyperreflexivity
Apophany
Fig. 2 The development of auditory hallucinations: the interaction of the Klosterkötter (1992) and Conrad
(1958) concepts
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:
Im 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
chaos.
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 authorsexperience, 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 Im almost starting to get up, and go
P. Handest et al.
andpickupthephone.SosometimesIdont 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:
Ive 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 510 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 SassBasic Disorder of Subjectivity and Auditory Hallucinations
in Schizophrenia
(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 Sassapproach provides
a further description and understanding of the phenomena described above (and of
other phenomena important for the understanding of schizophrenia).
Parnas and Sassipseity-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 patients
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 Conrads 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 onesown
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.
2 Conclusion
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-hearersdistress, 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 patients
sense of self-coherence.
From Thoughts to Voices: Understanding the Development
References
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: 3041.
Klosterkötter, J., M. Hellmich, E.M. Steinmeyer, and F. Schultze-Lutter. 2001. Diagnosing schizophrenia in
the initial prodromal phase. Archives of General Psychiatry 58: 158164.
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: 225240.
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: 217232.
Mundt, C. 2005. Anomalous self-experience: A plea for phenomenology. Psychopathology 38: 231235.
Parnas, J., and P. Handest. 2003. Phenomenology of anomalous self-experience in early schizophrenia.
Comprehensive Psychiatry 44: 121134.
Parnas, J., and L.A. Sass. 2002. Self, solipsism, and schizophrenic delusions. Philosophy, Psychiatry &
Psychology 8: 101120.
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: 236258.
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
10: 200204.
Parnas, J., L.A. Sass, and D. Zahavi. 2012. Rediscovering psychopathology: The epistemology and phenom-
enology of the psychiatric object. Schizophrenia Bulletin 39: 270277.
Raballo, A., and F. Larøi. 2011. Murmurs of thought: Phenomenology of hallucinatory consciousness in
impending psychosis. Psychosis 3: 163166.
Sass, L. A. 1992. Madness and Modernism: Insanity in light of modern art, literature, and thought, New York,
Basic Books.
Sass, L.A., and J. Parnas. 2003. Schizophrenia, consciousness, and self. Schizophrenia Bulletin 29: 427444.
Sass, L., J. Parnas, and D. Zahavi. 2011. Philosophy, Psychiatry, & Psychology, 1: 123.
Schultze-Lutter, F. 2009. Subjective symptoms of schizophrenia in research and the clinic: The basic symptom
concept. Schizophrenia Bulletin 35: 58.
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:
182191.
Stanghellini, G., and M. Ballerini. 2004. Autism: Disembodied existence. Philosophy, Psychiatry&
Psychology 11: 259268.
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, 113127. Oxford: Oxford University Press.
P. Handest et al.
... Séglas (1982) referred to hallucinations as thoughts audible only to the person himself. Building on the works of Jaspers (1913), hallucinations have been described as objectification of inner speech, spatialization of experience, or perception of consciousness (Sass and Parnas, 2003), as a cognitive phenomenon (Handest et al., 2016) not exclusively perceptive-sensory. This is the case of a patient who said she recognized her husband's mistress, was completely convinced that she had finally found out who she was, and that she had seen her, and at the same time, mentioned that it was raining at the time and she could not see her face because of the umbrella, and all the while insisted she did not know who the woman was. ...
Article
Full-text available
Hallucinations and delusions, in keeping with the distress accompanying them, are major features in the diagnosis of psychosis in international classifications. In spite of their human and clinical importance, the concepts are unclear. The distinction between hallucinations and delusions in terms of perception-thought is not precise enough, causing problems in analyzing the patient’s words. Nor are the differentiations or variations within each precise enough. Continuing the long clinical tradition discussing the distinction between hallucinations and delusions while assuming their similarities, this study poses a concept integrating the two phenomena as attributions people make about themselves and their settings. Then the elements of any attribution can be used as guides for structuring significant literature on both, and reduce analytical ambiguity. Such attributions make more sense within the structure of two-way relationships with factors in a person’s own framework and setting. This structure is described with its variables and relationships as a guide to assessment, follow-up, and intervention. Two checklists are provided for orientation.
... 83 A series of experiential changes often precede the onset of psychosis, including AH (for a review, see Refs. 84,85 ). The occurrence of these prodromal hallucinations often provokes intense emotions; they may be attributed to a supernatural origin and viewed as a sign of a larger meaning or fate. ...
Article
Full-text available
The recent renaissance of psychedelic science has reignited interest in the similarity of drug-induced experiences to those more commonly observed in psychiatric contexts such as the schizophrenia-spectrum. This report from a multidisciplinary working group of the International Consortium on Hallucinations Research (ICHR) addresses this issue, putting special emphasis on hallucinatory experiences. We review evidence collected at different scales of understanding, from pharmacology to brain-imaging, phenomenology and anthropology, highlighting similarities and differences between hallucinations under psychedelics and in the schizophrenia-spectrum disorders. Finally, we attempt to integrate these findings using computational approaches and conclude with recommendations for future research.
... Furthermore, some theoretical models of hallucination draw links between cognitive dysfunction and thought disorder in the prodromal phase and later development of hallucinations, which may be influenced by these disordered thoughts. For example, as reviewed by [33], Klosterkotter [34] noted that many patients described elements of thought disorder in the prodromal phase and hypothesized that these could transform into audible thoughts. Conrad (reviewed in [35]) described "trema", a state of fear and anxiety as well as cognitive and thought disturbances during the prodromal period, which is succeeded by frank psychosis and the development of hallucinations and delusions; he conceptualized certain thought disturbances, such as pressured thinking or thought interference, as transforming into hallucinations. ...
Article
Full-text available
Hallucinations, including auditory verbal hallucinations (AVH), occur in both the healthy population and in psychotic conditions such as schizophrenia (often developing after a prodromal period). In addition, hallucinations can be in-context (they can be consistent with the environment, such as when one hallucinates the end of a sentence that has been repeated many times), or out-of-context (such as the bizarre hallucinations associated with schizophrenia). In previous work, we introduced a model of hallucinations as false (positive) inferences based on a (Markov decision process) formulation of active inference. In this work, we extend this model to include content-to disclose the computational mechanisms behind in- and out-of-context hallucinations. In active inference, sensory information is used to disambiguate alternative hypotheses about the causes of sensations. Sensory information is balanced against prior beliefs, and when this balance is tipped in the favor of prior beliefs, hallucinations can occur. We show that in-context hallucinations arise when (simulated) subjects cannot use sensory information to correct prior beliefs about hearing a voice, but beliefs about content (i.e. the sequential order of a sentence) remain accurate. When hallucinating subjects also have inaccurate beliefs about state transitions, out-of-context hallucinations occur; i.e. their hallucinated speech content is disordered. Note that out-of-context hallucinations in this setting does not refer to inference about context, but rather to false perceptual inference that emerges when the confidence in-or precision of-sensory evidence is reduced. Furthermore, subjects with inaccurate beliefs about state transitions but an intact ability to use sensory information do not hallucinate and are reminiscent of prodromal patients. This work demonstrates the different computational mechanisms that may underlie the spectrum of hallucinatory experience-from the healthy population to psychotic states.
... Furthermore, some theoretical models of hallucination draw links between cognitive dysfunction and thought disorder in the prodromal phase and later development of hallucinations, which may be influenced by these disordered thoughts. For example, as reviewed by Handest et al., 2016, Klosterkotter (1992 noted that many patients described elements of thought disorder in the prodromal phase and hypothesized that these could transform into audible thoughts. Conrad (reviewed in Sass and Parnas 2003) described "trema", a state of fear and anxiety as well as cognitive and thought disturbances during the prodromal period, which is succeeded by frank psychosis and the development of hallucinations and delusions; he conceptualized certain thought disturbances, such as pressured thinking or thought interference, as transforming into hallucinations. ...
Preprint
Full-text available
Hallucinations, including auditory verbal hallucinations (AVH), occur in both the healthy population and in psychotic conditions such as schizophrenia (often developing after a prodromal period). In addition, hallucinations can be in-context (they can be consistent with the environment, such as when one hallucinates the end of a sentence that has been repeated many times), or out-of-context (such as the bizarre hallucinations associated with schizophrenia). In previous work, we introduced a model of hallucinations as false (positive) inferences based on a (Markov decision process) formulation of active inference. In this work, we extend this model to include content – to disclose the computational mechanisms behind in- and out-of-context hallucinations. In active inference, sensory information is used to disambiguate alternative hypotheses about the causes of sensations. Sensory information is balanced against prior beliefs, and when this balance is tipped in the favor of prior beliefs, hallucinations can occur. We show that in-context hallucinations arise when (simulated) subjects cannot use sensory information to correct prior beliefs about hearing a voice, but beliefs about content (i.e. the sequential order of a sentence) remain accurate. When hallucinating subjects also have inaccurate beliefs about state transitions, out-of-context hallucinations occur; i.e. their hallucinated speech content is disordered. Furthermore, subjects with inaccurate beliefs about state transitions but an intact ability to use sensory information do not hallucinate and are reminiscent of prodromal patients. This work demonstrates the different computational mechanisms that may underlie the spectrum of hallucinatory experience – from the healthy population to psychotic states.
... Their seemingly straightforward characterization belies an experiential complexity that, while not new to literature on these phenomena, is currently borne out by many strands of contemporary research. [11][12][13][14] Indeed, as Berrios and Marková 15 note, the conceptual history of hallucinations is a long and complex one, and includes debates about the representational vs nonrepresentational nature of hallucinations, their equivalency with sensory perception, and the distinction (if any) between hallucinations found in psychiatric vs neurological or other organic conditions. This article aims to broaden this lens by examining key areas of experience that could contextualize hallucinations within the larger realm of mental or experiential states associated with psychosis or psychotic vulnerability: cognitive experience, perceptual experience, selfhood and sense of reality, temporality, interpersonal experience, and embodiment (supplementary material note i). ...
Article
Full-text available
Recent psychiatric research and treatment initiatives have tended to move away from traditional diagnostic categories and have focused instead on transdiagnostic phenomena, such as hallucinations. However, this emphasis on isolated experiences may artificially limit the definition of such phenomena and ignore the rich, complex, and dynamic changes occurring simultaneously in other domains of experience. This article reviews the literature on a range of experien-tial features associated with psychosis, with a focus on their relevance for hallucinations. Phenomenological research on changes in cognition, perception, selfhood and reality, temporality, interpersonal experience, and embodiment are discussed, along with their implications for traditional conceptualizations of hallucinations. We then discuss several phenomenological and neurocognitive theories, as well as the potential impact of trauma on these phenomena. Hallucinations are suggested to be an equifinal outcome of multiple genetic, neurocognitive, subjective, and social processes; by grouping them together under a single, opera-tionalizable definition, meaningful differences in etiology and phenomenology may be ignored. It is suggested that future research efforts strive to incorporate a broader range of experiential alterations, potentially expanding on traditional definitions of hallucinations. Relevance for clinical practice, including emphasizing phenomenologically responsive techniques and developing targeted new therapies , is discussed.
... Although they are usually allocated into separate descriptive silos (ie, according to the conventional dichotomy between aberrant perception and cognition, respectively), AVH and delusional thoughts share important phenomenological features, such as an autocentric, self-referential architecture and profound alterations of lived space, time, and intersubjectivity. [7][8][9][10][11][12] This is particularly manifest in prototypical "voices" (eg, commenting and imperative voices) and transitivistic delusions or thought interference (eg, delusions of control, thought insertion, thought withdrawal, and thought broadcasting), and also in delusions of reference and persecution. Recent empirical analyses 13 indicate indeed that AVH articulate themselves in an experiential realm that is in-between the phenomenology of cognition and perception, retaining features of both an altered stream of thought and quasi-material aspects of sensorial givenness. ...
Article
Full-text available
Schizophrenia-spectrum psychoses are highly complex and heterogeneous disorders that necessitate multiple lines of scientific inquiry and levels of explanation. In recent years, both computational and phenomenological approaches to the understanding of mental illness have received much interest , and significant progress has been made in both fields. However, there has been relatively little progress bridging investigations in these seemingly disparate fields. In this conceptual review and collaborative project from the 4th Meeting of the International Consortium on Hallucination Research, we aim to facilitate the beginning of such dialogue between fields and put forward the argument that computational psychiatry and phenomenology can in fact inform each other, rather than being viewed as isolated or even incompatible approaches. We begin with an overview of phenomenological observations on the interrelationships between auditory-verbal hallucinations (AVH) and delusional thoughts in general, before moving on to review several theoretical frameworks and empirical findings in the computational modeling of AVH. We then relate the computational models to the phe-nomenological accounts, with a special focus on AVH and delusions that involve the senses of agency and ownership of thought (delusions of thought interference). Finally, we offer some tentative directions for future research, emphasizing the importance of a mutual understanding between separate lines of inquiry.
... The central tenet is that while psychotic developments within affective disorders are positively associated with profound changes in mood, as well as with psychomotricity and temporalization, this is not the case in schizophrenia. Positive symptoms in schizophrenia spectrum disorders often appear to be psychotic end products of longitudinal, developmental psychopathological pathways typically associated with profound changes in the structure of self-experience (see, e.g., the transitional sequences from basic symptoms to first-rank symptoms (e.g., [66]) and the emergence of AVHs from self-disorders (e.g., [9,10,67]). It is the nature and temporal articulation of such underlying, trait-like changes in the structure of experiencing that entails the highest degree of diagnostic specificity, rather than the "surface-level" state-like features of hallucinatory phenomena. ...
Chapter
Albeit endowed with clinical and semeiologic commonalities and often addressed as a broad index of severity and poor prognostic outcome in severe mental disorders, productive symptoms (i.e., delusions, hallucinations, disorganization) present different colorings within major psychoses. While this may be rather intuitive for delusions (see Stanghellini and Raballo 2015) and disorganized symptoms (see [1]), the nosographic specificity of hallucinatory phenomena remains more elusive [2, 3], particularly in developmental years [4] and in at-risk mental states [5].
Article
Full-text available
Представлен авторский взгляд на проблему осмысления терроризма. Внимание ак-центируется на джихадистском типе. Обосновывается актуальность прогрессивной эвристики, работающей на подкрепление знания об объекте исследования. Предлага-ется рассматривать его, основываясь на коммуникативно-сетевой концепции М. Кастельса. Правомерность подхода аргументируется путем обращения к соот-ветствующей практике, отраженной в отчетах международных организаций, ана-литических центров, материалах СМИ. Ключевые слова: контрвласть, террористические сети, насилие, дискурс. Abstract. Taking into account the risk potential and the destructiveness of terrorism, as well as the factor of its progressive development, the task of an intellectual reflection on enhancing knowledge about the phenomenon acquires scientific significance. The issue is especially relevant for terrorism of a jihadist type, demonstrating a transition from a regime of dispersed local and sporadically manifested cases of dictate of will to a level of permanent geopolitical influence. The aim of the article is to verify the hypothesis of the possibility of explication of jihadist terrorism as a counter-power. The methodologi-cal guideline for the study was the provisions of Manuel Castells’s communication network concept resonating with the network and digital dynamics of the present. To substantiate the assumptions and conclusions, the author of the article appeals to sources of information concerning the most important aspects of terrorism: reports and accounts of the UN, the Collective Security Treaty Organization, analytical data of foreign and Russian expert communities, research centers and institutions, and media materials. Valuable material was also received from research articles on the topics under study. The article includes several logically interconnected parts. At the beginning of the text, the need for the evolution of a heuristic that works to reinforce the existing theoretical ideas about the object of study is problematized. Attention is focused on Castells’s views relevant in terms of their applicability to the present analysis. Further, the essential manifestations of jihadist terrorism are indicated that show that this type of terrorism acquired the status of a counter-power. Based on the factual material, the idea is proved that the terrorist community is building a meta-capital and becoming a political counteragent that influences the global and regional processes, forms networks and acts as a trans-communicative center for radical consolidation and integration. By organically complementing the tactics of direct violence with discourse practices, terrorists reprogram the consciousness of recipients, which deter-mines the multiplication of the nongovernmental component in different societies. Finally, a conclu-sion is drawn on the transformation of jihadist terrorism toward asserting itself as a force challenging the dominance of the institutionally organized order. Keywords: counter-power; terrorist networks; violence, discourse
Chapter
Abnormalities in brain connectivity are associated with hallucinations. Several networks including sensory and resting-state networks have been pointed out as crucial in various hallucination modalities. Here we review the literature on brain connectivity relevant to auditory verbal and visual hallucinations with an emphasis on the most recent studies. Most recent literature investigates this issue in first-episode patients who are mainly medication naive. This enables the investigation of “true” abnormalities in brain connections, how they change with medication, and how they develop with illness progression. The literature that includes neural correlates of hallucinations in mood disorder is deficient. Both visual and auditory verbal hallucinations are associated with abnormal connections of perception areas, specific to that particular hallucination modality.
Article
Full-text available
We propose that typical schizophrenic delusions develop on the background of preexisting anomalies of self-experience. We argue that disorders of the Self represent the experiential core clinical phenomena of schizophrenia, as was already suggested by the founders of the concept of schizophrenia and elaborated in the phenomenological psychiatric tradition. The article provides detailed descriptions of the pre-psychotic or schizotypal anomalies of self-experience, often illustrated through clinical vignettes. We argue that delusional transformation in the evolution of schizophrenic psychosis reflects a global reorganization of consciousness and existential reorientation, both of which radiate from a fundamental alteration of the Self. We critically address the contemporary cognitive approaches to delusion formation, often finding them inconsistent with the clinical features of schizophrenia or implausible from a phenomenological point of view.
Article
Full-text available
The present paper clarifies key issues in phenomenology and phenomenological psychopathology (especially of schizophrenia) through a critique of a recent article that addresses these topics. Topics include (1) Phenomenology's role in clarifying issues not amenable to purely empirical methods; (2) The relationship between a phenomenological approach (focusing on the subjective life of the patient) and empirical science, including neuroscience; (3) The nature of self-experience, especially in its pre-reflective form ("ipseity"—involving "operative intentionality"), and its possible disturbance in schizophrenia ("hyper-reflexivity" and "diminished self-affection"); (4) The relationship between self-disturbance in schizophrenia and disorders of both temporality and (what Husserl termed) "passive syntheses"; (5) The role of intentional or quasi-volitional processes in the perceptual (and other) disorders in schizophrenia; (6) The nature and diversity of phenomenology's potential contribution to the enterprise of "explanation"; and (7) The meaning of several concepts: "hermeneutic" or "existential" approach, phenomenological "reflection," and "negative symptoms."
Article
Full-text available
One of the leading cognitive models of auditory verbal hallucinations (AVHs) proposes such experiences result from a disturbance in the process by which inner speech is attributed to the self. Research in this area has, however, proceeded in the absence of thorough cognitive and phenomenological investigations of the nature of inner speech, against which AVHs are implicitly or explicitly defined. In this paper we begin by introducing philosophical phenomenology and highlighting its relevance to AVHs, before briefly examining the evolving literature on the relation between inner experiences and AVHs. We then argue for the need for philosophical phenomenology (Phenomenology) and the traditional empirical methods of psychology for studying inner experience (phenomenology) to mutually inform each other to provide a richer and more nuanced picture of both inner experience and AVHs than either could on its own. A critical examination is undertaken of the leading model of AVHs derived from phenomenological philosophy, the ipseity disturbance model. From this we suggest issues that future work in this vein will need to consider, and examine how interdisciplinary methodologies may contribute to advances in our understanding of AVHs. Detailed suggestions are made for the direction and methodology of future work into AVHs, which we suggest should be undertaken in a context where phenomenology and physiology are both necessary, but neither sufficient.
Article
Full-text available
This paper considers the nature of schizo- phrenic autism and urges its importance for under- standing the phenomenological core of schizophrenia. Different clinical manifestations of schizophrenic au- tism are demonstrated, and it is asked whether these might reflect different aspects of one underlying phe- nomenologically intelligible phenomenon. Four phe- nomenological hypotheses are put forward: that autism is a function of semantic drifting, emotional drifting, ontological incompleteness, or a particular ethic re- jecting common sense. By way of conclusion an inte- grative hypothesis is considered: that autism is intelli- gible in terms of the experience of disembodiment. Serious aberrations in the use of the concept "autism" have brought much confusion into psychiatric discus- sion. (Stroemgren 1969).
Article
Full-text available
Questions concerning both the ontology and epistemology of the “psychiatric object” (symptoms and signs) should be at the forefront of current concerns of psychiatry as a clinical neuroscience. We argue that neglect of these issues is a crucial source of the stagnation of psychiatric research. In honor of the centenary of Karl Jaspers’ book, General Psychopathology, we offer a critique of the contemporary “operationalist” epistemology, a critique that is consistent with Jaspers’ views. Symptoms and signs cannot be properly understood or identified apart from an appreciation of the nature of consciousness or subjectivity, which in turn cannot be treated as a collection of thing-like, mutually independent objects, accessible to context-free, “atheoretical” definitions or unproblematic forms of measurement (as is often assumed in structured interviewing). Adequate and faithful distinctions in the phenomenal or experiential realm are therefore a fundamental prerequisite for classification, treatment, and research. This requires a multidisciplinary approach, incorporating (among other things) insights provided by psychology, phenomenological philosophy, and the philosophy of mind.
Article
Full-text available
First‐person accounts and detailed phenomenological descriptions are decisive to improve our understanding of auditory verbal hallucinations (AVHs). This is crucial in order to adequately appreciate the biographical–existential complexity of the “voices” and to increase the communication and share‐ability of such experiences. Besides the clear normalizing/de‐stigmatizing value, such an approach has an eminent therapeutic value since it offers a non‐reifying way to approach the broad, gestaltic metamorphosis of consciousness which precedes fully formed, florid AVHs. However, an important feature – namely, the very experiential genesis of the voices before their manifestation as full‐blown AVHs – has up to now not received sufficient attention. “Voices” indeed are often anticipated by subtle pre‐psychotic distortions of the stream of consciousness – such as abnormal sonorization of the inner dialogue and/or perceptualization of thought – which could emerge at the beginning of the prodromal phase. We suggest that a careful attention to these not‐yet psychotic precursors in their experiential continuity with AVHs could have important therapeutic implications.
Article
In the Bonn transition sequences study, the development of the Schneiderian first-rank symptoms in their exact chronological order was studied from the first symptomatological precursors up to the complete forms of the respective psychotic final phenomena. At their onset, subjective experiences of pre-existing disorders of perception, thinking, speech, and memory, of cognitive control of action, and of proprioception were found. These four groups of initial deficiencies, each following always the same pattern, developed via certain intermediate phenomena as derealization or depersonalization and thought hearing into the various first-rank symptoms. The analysis of these transition sequences revealed three phases - basal irritation, psychotic externalization, and content concretization -, each with different generating factors. Altogether, the results showed how the gap between the deficiency findings of the biologically oriented research in schizophrenia and the diagnostically relevant changes in experience can be bridged. In addition, we expect to profit greatly as far as diagnosis and therapy are concerned, for the uncovering of the initial deficiencies will possibly allow an early recognition and a primary prevention of schizophrenia.