psychosis; schizophrenia; post-traumatic stress disorder; cognitive behavioral therapy; traumatology
There is growing evidence to suggest that delusions associated with schizophrenia arise from altered structural brain connectivity. The present study investigated whether structural changes in three major fasciculi that interconnect the limbic system – the cingulum bundle, uncinate fasciculus and fornix – are associated with delusions in chronic schizophrenia patients.
Free-water corrected Diffusion Tensor Imaging was used to investigate the association between delusions and both microstructural changes within these three fasciculi and extracellular changes in the surrounding free-water. Clinical data and diffusion MRI scans were obtained from 28 healthy controls and 86 schizophrenia patients, of whom 34 had present state delusions, 35 had a lifetime history but currently remitted delusions, and 17 had never experienced delusions.
While present state and remitted delusions were found to be associated with reduced free-water corrected fractional anisotropy (FAT) and increased free-water corrected radial diffusivity (RDT) in the cingulum bundle bilaterally, extracellular free-water (FW) in the left cingulum bundle was found to be specifically associated with present state delusions in chronic schizophrenia. No changes were observed in the remaining tracts.
These findings suggest that state and trait delusions in chronic schizophrenia are associated with microstructural processes, such as myelin abnormalities (as indicated by decreased FAT and increased RDT) in the cingulum bundle and that state delusions are additionally associated with extracellular processes such as neuroinflammation or atrophy (as indicated by increased FW) in the left cingulum bundle.
•Free-water imaging was used to differentiate microstructural and extracellular processes.•Patients with delusions showed increased RDT and FW in the cingulum bundle.•Myelin abnormalities and neuroinflammation may be involved in the manifestation of delusions.
Free-water imaging; Schizophrenia; Delusions; Limbic system; Diffusion Tensor Imaging
In recent years, there has been increasing interest in the potential for alterations to the brain’s resting-state networks (RSNs) to explain various kinds of psychopathology. RSNs provide an intriguing new explanatory framework for hallucinations, which can occur in different modalities and population groups, but which remain poorly understood. This collaboration from the International Consortium on Hallucination Research (ICHR) reports on the evidence linking resting-state alterations to auditory hallucinations (AH) and provides a critical appraisal of the methodological approaches used in this area. In the report, we describe findings from resting connectivity fMRI in AH (in schizophrenia and nonclinical individuals) and compare them with findings from neurophysiological research, structural MRI, and research on visual hallucinations (VH). In AH, various studies show resting connectivity differences in left-hemisphere auditory and language regions, as well as atypical interaction of the default mode network and RSNs linked to cognitive control and salience. As the latter are also evident in studies of VH, this points to a domain-general mechanism for hallucinations alongside modality-specific changes to RSNs in different sensory regions. However, we also observed high methodological heterogeneity in the current literature, affecting the ability to make clear comparisons between studies. To address this, we provide some methodological recommendations and options for future research on the resting state and hallucinations.
psychosis; schizophrenia; fMRI; default mode network; perception
This paper explores the experiences of women who “hear voices” (auditory verbal hallucinations). We begin by examining historical understandings of women hearing voices, showing these have been driven by androcentric theories of how women’s bodies functioned leading to women being viewed as requiring their voices be interpreted by men. We show the twentieth century was associated with recognition that the mental violation of women’s minds (represented by some voice-hearing) was often a consequence of the physical violation of women’s bodies. We next report the results of a qualitative study into voice-hearing women’s experiences (n = 8). This found similarities between women’s relationships with their voices and their relationships with others and the wider social context. Finally, we present results from a quantitative study comparing voice-hearing in women (n = 65) and men (n = 132) in a psychiatric setting. Women were more likely than men to have certain forms of voice-hearing (voices conversing) and to have antecedent events of trauma, physical illness, and relationship problems. Voices identified as female may have more positive affect than male voices. We conclude that women voice-hearers have and continue to face specific challenges necessitating research and activism, and hope this paper will act as a stimulus to such work.
abuse; gender; hallucinations; psychosis; schizophrenia; traumatology; women; women’s health
Cognitive behavioral therapy (CBT) for voice-hearing (i.e., auditory verbal hallucinations; AVH) has, at best, small to moderate effects. One possible reason for this limited efficacy is that current CBT approaches tend to conceptualize voice-hearing as a homogenous experience in terms of the cognitive processes involved in AVH. However, the highly heterogeneous nature of voice-hearing suggests that many different cognitive processes may be involved in the etiology of AVH. These heterogeneous voice-hearing experiences do, however, appear to cluster into a set of subtypes, opening up the possibility of tailoring treatment to the subtype of AVH that a voice-hearer reports. In this paper, we (a) outline our rationale for tailoring CBT to subtypes of voice-hearing, (b) describe CBT for three putative subtypes of AVH (inner speech-based AVH, memory-based AVH, and hypervigilance AVH), and (c) discuss potential limitations and problems with such an approach. We conclude by arguing that tailoring CBT to subtypes of voice-hearing could prove to be a valuable therapeutic development, which may be especially effective when used in early intervention in psychosis services.
hallucinations; voice-hearing; psychosis; schizophrenia; cognitive behavioral therapy
Hallucinations are common in psychiatric disorders, and are also experienced by many individuals who are not mentally ill. Here, in 153 participants, we investigate brain structural markers that predict the occurrence of hallucinations by comparing patients with schizophrenia who have experienced hallucinations against patients who have not, matched on a number of demographic and clinical variables. Using both newly validated visual classification techniques and automated, data-driven methods, hallucinations were associated with specific brain morphology differences in the paracingulate sulcus, a fold in the medial prefrontal cortex, with a 1 cm reduction in sulcal length increasing the likelihood of hallucinations by 19.9%, regardless of the sensory modality in which they were experienced. The findings suggest a specific morphological basis for a pervasive feature of typical and atypical human experience.
Hallucinations can occur in both healthy individuals and patients with psychiatric disorders. Garrison et al. here report that specific brain morphology differences in the paracingulate sulcus (PCS) can determine the occurrence of hallucinations in schizophrenia, irrespective of sensory modality.
Auditory verbal hallucinations (AVH: ‘hearing voices’) are found in both schizophrenia and post-traumatic stress disorder (PTSD). In this paper we first demonstrate that AVH in these two diagnoses share a qualitatively similar phenomenology. We then show that the presence of AVH in schizophrenia is often associated with earlier exposure to traumatic/emotionally overwhelming events, as it is by definition in PTSD. We next argue that the content of AVH relates to earlier traumatic events in a similar way in both PTSD and schizophrenia, most commonly having direct or indirect thematic links to emotionally overwhelming events, rather than being direct re-experiencing. We then propose, following cognitive models of PTSD, that the reconstructive nature of memory may be able to account for the nature of these associations between trauma and AVH content, as may threat-hypervigilance and the individual’s personal goals. We conclude that a notable subset of people diagnosed with schizophrenia with AVH are having phenomenologically and aetiologically identical experiences to PTSD patients who hear voices. As such we propose that the iron curtain between AVH in PTSD (often termed ‘dissociative AVH’) and AVH in schizophrenia (so-called ‘psychotic AVH’) needs to be torn down, as these are often the same experience. One implication of this is that these trauma-related AVH require a common trans-diagnostic treatment strategy. Whilst antipsychotics are already increasingly being used to treat AVH in PTSD, we argue for the centrality of trauma-based interventions for trauma-based AVH in both PTSD and in people diagnosed with schizophrenia.
abuse; dissociation; hallucinations; hearing voices; memory; PTSD; psychosis; traumatology
Inner speech has been implicated in important aspects of normal and atypical cognition, including the development of auditory hallucinations. Studies to date have focused on covert speech elicited by simple word or sentence repetition, while ignoring richer and arguably more psychologically significant varieties of inner speech. This study compared neural activation for inner speech involving conversations (‘dialogic inner speech’) with single-speaker scenarios (‘monologic inner speech’). Inner speech-related activation differences were then compared with activations relating to Theory-of-Mind (ToM) reasoning and visual perspective-taking in a conjunction design. Generation of dialogic (compared with monologic) scenarios was associated with a widespread bilateral network including left and right superior temporal gyri, precuneus, posterior cingulate and left inferior and medial frontal gyri. Activation associated with dialogic scenarios and ToM reasoning overlapped in areas of right posterior temporal cortex previously linked to mental state representation. Implications for understanding verbal cognition in typical and atypical populations are discussed.
monologue; dialogue; fMRI; auditory verbal hallucinations; covert speech
A comprehensive understanding of the phenomenology of auditory hallucinations (AHs) is essential for developing accurate models of their causes. Yet, only 1 detailed study of the phenomenology of AHs with a sample size of N ≥ 100 has been published. The potential for overreliance on these findings, coupled with a lack of phenomenological research into many aspects of AHs relevant to contemporary neurocognitive models and the proposed (but largely untested) existence of AH subtypes, necessitates further research in this area. We undertook the most comprehensive phenomenological study of AHs to date in a psychiatric population (N = 199; 81% people diagnosed with schizophrenia), using a structured interview schedule. Previous phenomenological findings were only partially replicated. New findings included that 39% of participants reported that their voices seemed in some way to be replays of memories of previous conversations they had experienced; 45% reported that the general theme or content of what the voices said was always the same; and 55% said new voices had the same content/theme as previous voices. Cluster analysis, by variable, suggested the existence of 4 AH subtypes. We propose that there are likely to be different neurocognitive processes underpinning these experiences, necessitating revised AH models.
auditory verbal hallucinations; memory; schizophrenia
•Inner speech, self-esteem, dissociation and hallucination proneness were examined.•Self-esteem was linked to inner speech but not hallucination proneness.•Dissociation mediated links between inner speech and hallucination proneness.
Inner speech is a commonly experienced but poorly understood phenomenon. The Varieties of Inner Speech Questionnaire (VISQ; McCarthy-Jones & Fernyhough, 2011) assesses four characteristics of inner speech: dialogicality, evaluative/motivational content, condensation, and the presence of other people. Prior findings have linked anxiety and proneness to auditory hallucinations (AH) to these types of inner speech. This study extends that work by examining how inner speech relates to self-esteem and dissociation, and their combined impact upon AH-proneness. 156 students completed the VISQ and measures of self-esteem, dissociation and AH-proneness. Correlational analyses indicated that evaluative inner speech and other people in inner speech were associated with lower self-esteem and greater frequency of dissociative experiences. Dissociation and VISQ scores, but not self-esteem, predicted AH-proneness. Structural equation modelling supported a mediating role for dissociation between specific components of inner speech (evaluative and other people) and AH-proneness. Implications for the development of “hearing voices” are discussed.
Inner speech; Dissociation; Self-esteem; Hallucination; Psychosis; Dialogicality
The phenomenological diversity of auditory verbal hallucinations (AVH) is not currently accounted for by any model based around a single mechanism. This has led to the proposal that there may be distinct AVH subtypes, which each possess unique (as well as shared) underpinning mechanisms. This could have important implications both for research design and clinical interventions because different subtypes may be responsive to different types of treatment. This article explores how AVH subtypes may be identified at the levels of phenomenology, cognition, neurology, etiology, treatment response, diagnosis, and voice hearer’s own interpretations. Five subtypes are proposed; hypervigilance, autobiographical memory (subdivided into dissociative and nondissociative), inner speech (subdivided into obsessional, own thought, and novel), epileptic and deafferentation. We suggest other facets of AVH, including negative content and form (eg, commands), may be best treated as dimensional constructs that vary across subtypes. After considering the limitations and challenges of AVH subtyping, we highlight future research directions, including the need for a subtype assessment tool.
AVH; hearing voices; phenomenology; schizophrenia; symptom classification; trauma
The international Hearing Voices Movement (HVM) is a prominent mental health service-user/survivor movement that promotes the needs and perspectives of experts by experience in the phenomenon of hearing voices (auditory verbal hallucinations). The main tenet of the HVM is the notion that hearing voices is a meaningful human experience, and in this article, we discuss the historical growth and influence of the HVM before considering the implications of its values for research and practice in relation to voice-hearing. Among other recommendations, we suggest that the involvement of voice-hearers in research and a greater use of narrative and qualitative approaches are essential. Challenges for implementing user-led research are identified, and avenues for future developments are discussed.
auditory hallucinations; service-user involvement; social psychiatry
Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research.
nonclinical; need for care; psychosis; prevalence
This report from the International Consortium on Hallucinations Research considers the current status and future directions in research on psychological therapies targeting auditory hallucinations (hearing voices). Therapy approaches have evolved from behavioral and coping-focused interventions, through formulation-driven interventions using methods from cognitive therapy, to a number of contemporary developments. Recent developments include the application of acceptance- and mindfulness-based approaches, and consolidation of methods for working with connections between voices and views of self, others, relationships and personal history. In this article, we discuss the development of therapies for voices and review the empirical findings. This review shows that psychological therapies are broadly effective for people with positive symptoms, but that more research is required to understand the specific application of therapies to voices. Six key research directions are identified: (1) moving beyond the focus on overall efficacy to understand specific therapeutic processes targeting voices, (2) better targeting psychological processes associated with voices such as trauma, cognitive mechanisms, and personal recovery, (3) more focused measurement of the intended outcomes of therapy, (4) understanding individual differences among voice hearers, (5) extending beyond a focus on voices and schizophrenia into other populations and sensory modalities, and (6) shaping interventions for service implementation.
auditory hallucinations; psychosocial intervention; psychological therapy; cognitive behavioral therapy; psychosis
Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) “front-loading” research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.
auditory verbal hallucinations; phenomenology; interdisciplinarity; research collaboration; psychosis
We explore how hallucinations might be studied within the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) framework, which asks investigators to step back from diagnoses based on symptoms and focus on basic dimensions of functioning. We start with a description of the objectives of the RDoC project and its domains and constructs. Because the RDoC initiative asks investigators to study phenomena across the wellness spectrum and different diagnoses, we address whether hallucinations experienced in nonclinical populations are the same as those experienced by people with psychotic diagnoses, and whether hallucinations studied in one clinical group can inform our understanding of the same phenomenon in another. We then discuss the phenomenology of hallucinations and how different RDoC domains might be relevant to their study. We end with a discussion of various challenges and potential next steps to advance the application of the RDoC approach to this area of research.
hallucinations; Research; Domain; Criteria; RDoC
Despite a growing interest in auditory verbal hallucinations (AVHs) in different clinical and nonclinical groups, the phenomenological characteristics of such experiences have not yet been reviewed and contrasted, limiting our understanding of these phenomena on multiple empirical, theoretical, and clinical levels. We look at some of the most prominent descriptive features of AVHs in schizophrenia (SZ). These are then examined in clinical conditions including substance abuse, Parkinson’s disease, epilepsy, dementia, late-onset SZ, mood disorders, borderline personality disorder, hearing impairment, and dissociative disorders. The phenomenological changes linked to AVHs in prepsychotic stages are also outlined, together with a review of AVHs in healthy persons. A discussion of key issues and future research directions concludes the review.
hallucinations; hallucinosis; hearing voices; psychosis; transdiagnostic
Progress in identifying the neural correlates of auditory verbal hallucinations (AVHs) experienced by patients with schizophrenia has not fulfilled its promise to lead to new methods of treatments. Given the existence of a large number of such patients who have AVHs that are refractory to traditional treatments, there is the urgent need for the development of new effective interventions. This article proposes that the technique of neurofeedback may be an appropriate method to allow the translation of pure research findings from AVH-research into a clinical intervention. Neurofeedback is a method through which individuals can self-regulate their neural activity in specific neural regions/frequencies, following operant conditioning of their intentional manipulation of visually presented real-time feedback of their neural activity. Four empirically testable hypotheses are proposed as to how neurofeedback may be employed to therapeutic effect in patients with AVHs.
psychosis; brain-computer interface; hearing voices
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.
hallucination; phenomenology; psychosis; schizophrenia; interdisciplinary
The Cognitive Style Questionnaire (CSQ) is a frequently employed measure of negative cognitive style, associated with vulnerability to anxiety and depression. However, the CSQ's length can limit its utility in research. We describe the development of a Short-Form version of the CSQ. After evaluation and modification of two pilot versions, the 8-item CSQ Short Form (CSQ-SF) was administered to a convenience sample of adults (N = 278). The CSQ-SF was found to have satisfactory internal reliability and test-retest reliability. It also exhibited construct validity by demonstrating predicted correlations with measures of depression and anxiety. Results suggest that the CSQ-SF is suitable for administration via the Internet.
Cognitive style; Depression; Anxiety
► We developed a Short-Form version of the Cognitive Style Questionnaire (CSQ). ► The CSQ Short Form (CSQ-SF) demonstrated satisfactory internal reliability. ► Test–retest reliability was also satisfactory. ► Scores demonstrated predicted correlations with measures of depression and anxiety. ► The CSQ-SF may be a useful research tool in assessing vulnerability to depression.
The Cognitive Style Questionnaire (CSQ) is a frequently employed measure of negative cognitive style, associated with vulnerability to anxiety and depression. However, the CSQ’s length can limit its utility in research. We describe the development of a Short-Form version of the CSQ. After evaluation and modification of two pilot versions, the 8-item CSQ Short Form (CSQ-SF) was administered to a convenience sample of adults (N = 278). The CSQ-SF was found to have satisfactory internal reliability and test–retest reliability. It also exhibited construct validity by demonstrating predicted correlations with measures of depression and anxiety. Results suggest that the CSQ-SF is suitable for administration via the Internet.
Cognitive style; Depression; Anxiety
For millennia, some people have heard voices that others cannot hear. These have been variously understood as medical, psychological and spiritual phenomena. In this article we consider the specific role of spirituality in voice-hearing in two ways. First, we examine how spirituality may help or hinder people who hear voices. Benefits are suggested to include offering an alternative meaning to the experience which can give more control and comfort, enabling the development of specific coping strategies, increasing social support, and encouraging forgiveness. Potential drawbacks are noted to include increased distress and reduced control resulting from placing frightening or coercive constructions on voices, social isolation, the development of dysfunctional beliefs, and missed/delayed opportunities for successful mental health interventions. After examining problems surrounding classifying voices as either spiritual or psychotic, we move beyond an essentialist position to examine how such a classification is likely to be fluid, and how a given voice may move between these designations. We also highlight tensions between modernist and postmodernist approaches to voice-hearing.
Psychosis; auditory verbal hallucinations; schizophrenia