Self-focused attention in schizophrenic patients with and without auditory hallucinations and normal subjects: A comparative study

Self-focused attention has been implicated in a number of psychiatric disorders, but little research has examined this in schizophrenic subjects. In this study, a sample of schizophrenic patients experiencing auditory hallucinations, schizophrenic patients not experiencing auditory hallucinations and normal controls were asked to complete the private self-consciousness subscale of the Self Consciousness Scale. It was found that patients experiencing auditory hallucinations exhibited significantly higher levels of self-focus than those not experiencing hallucinations, although they did not differ from normal subjects. It was also shown that level of self-focus predicted whether or not subjects experienced hallucinations. These results, and their implications, are discussed with reference to the literature.     

The role of metacognitive beliefs in auditory hallucinations

The mechanisms contributing to the occurrence of auditory hallucinations have not been fully described, although many researchers agree that they may result from some type of misattributed cognitive event. A number of authors have shown that this misattribution may be influenced by ‘top down' processes such as beliefs and expectations. This type of cognitive bias has also been implicated in other psychological disorders. One area of focus, particularly within the anxiety disorders, has been on metacognitive beliefs and their role in the occurrence and maintenance of symptoms. Metacognitive beliefs have not been widely investigated in psychosis and tools to investigate them have not been developed. In this study, a metacognitions questionnaire [MCQ; Cartwright-Hatton, S., & Wells, A. (1997). Journal of Anxiety Disorders, 11(3),279–296.] (previously used with anxiety disorders) was modified and used to assess metacognitive beliefs with schizophrenic patients. Metacognitive beliefs were compared between schizophrenic patients who were currently experiencing auditory hallucinations and schizophrenic patients who had never had hallucinations. A group of patients with anxiety disorders and a group of non-patients were used as controls. Hallucinating and non-hallucinating schizophrenics scored significantly higher than both the non-patient group and the anxiety patient group on the amount to which they believed their thoughts should be consistent with each other. Hallucinators and anxiety controls had significantly lower confidence in their cognitive processes than non-hallucinating schizophrenics and normal controls. The significance of these findings are discussed in relation to the literature on cognitive processes in hallucinations.     

Interpretations of voices in patients with hallucinations and non-patient controls: a comparison and predictors of distress in patients

BACKGROUND: This study tested the hypotheses that interpretations of voices will be associated with distress linked to auditory hallucinations, and that patients experiencing hallucinations will exhibit higher levels of negative interpretations in comparison with non-patients. METHOD: The Interpretation of Voices Inventory (British Journal of Clinical Psychology 41 (2002) 259) was administered to patients who met DSM-IV criteria for schizophrenia spectrum disorders with auditory hallucinations and non-patients. Patients were also assessed using a semi-structured interview to asses clinical dimensions of their voices. RESULTS: The results showed that people with psychosis who experience auditory hallucinations did exhibit higher levels of positive and negative interpretations of voices, in comparison to non-patients. Correlational analyses revealed that interpretations of voices were significantly associated with emotional, physical and cognitive characteristics of voices. Regression analyses demonstrated that physical characteristics of voices and metaphysical beliefs were significant predictors of emotional characteristics of voices. CONCLUSIONS: The theoretical and clinical implications of these findings are discussed.     

A verbal behavior analysis of auditory hallucinations

A review of recent research on the non-medical control of auditory hallucinations is presented. It is suggested that the decreases in hallucinatory behavior obtained in studies using aversive contingencies may be attributable to the disruption of the chains of behavior involved. The results of several additional studies are interpreted as indicating that methods of stimulus control and the use of incompatible behaviors may be effective in reducing the rate of auditory hallucinations. Research relating auditory hallucinations to subvocalizations is presented in support of the view that hallucinatory phenomena are sometimes related to the subject's own vocal productions. Skinner's views (1934, 1936, 1953, 1957, 1980) are then presented as possible explanations of some hallucinatory behavior. It is suggested that some auditory hallucinations consit of the mishearing of environmental and physiological stimuli as voices in a fashion similar to that which Skinner observed in his work with the verbal summator. The maintenance of long chains of such responses may be largely attributable to self-intraverbal influences (such as are present during automatic writing). With some auditory hallucinations, this progression involves first mishearing ambiguous stimuli as voices and then attributing the voices to some cause (e.g., insanity, the television, radio, or God). Later, the frequent and ongoing chains of such behavior may contaminate other verbal responses. Such verbal behavior may be parasitic on "normal verbal behavior" (and hence, not directly dependent on consquences for maintenance), may be cued by various stimuli (including respiration), and may interfere with other covert and overt behavior. Several studies to investigate this view are presented. It is hoped that such research will lead to a better understanding of the major issues involved in the etiology and treatment of auditory hallucinations in particular and perhaps of psychosis in general.     

When words and pictures come alive: Relating the modality of intrusive thoughts to modalities of hypnagogic/hypnopompic hallucinations

Hypnagogic and hypnopompic (H&H) hallucinations are those experienced on the borders of sleep and waking. Intrusive thoughts have been proposed to relate to the occurrence of such experiences. In a sample of students (N = 299), the present study investigated the relation between auditory and felt-presence H&H experiences, and specific modalities of intrusive thought (auditory and visual) whilst controlling for age, gender, depression, anxiety and thought suppression. The psychometric properties of the Durham Hypnagogic and Hypnopompic Hallucinations Questionnaire (DHQ) were also examined. Exploratory (N = 299) and, in a second sample, confirmatory (N = 502) factor analyses showed good internal and test-retest reliability for the auditory and felt-presence subscales of the DHQ, but not for the visual subscale. Regression analyses indicated that the sole predictor of auditory H&H hallucinations was intrusive auditory imagery, and the sole predictor of felt-presence H&H experiences was intrusive visual imagery. Explanations for these findings are considered and implications for future research are discussed.     

Auditory and visual hallucinations in a sample of severely mentally ill Puerto Rican women: an examination of the cultural context

The content, interpretation, and structure of hallucinations experienced by individuals with severe mental illness are influenced by the culture of the individuals who experience them. We analyzed the content of visual and auditory hallucinations of 53 Puerto Rican women in northeastern Ohio with a diagnosis of a severe mental illness (SMI) who were participating in a study of HIV risk among Hispanic women with SMI. Compared to non-hallucinators, hallucinators had lower global assessment of functioning scores and greater suicidality. Hallucinations reflected three themes: religious themes, command hallucinations, and unidentifiable voices. Hallucinators’ subjective experience of their hallucinations ranged from a sense of security to significant distress. Participants developed a wide range of strategies to deal with threatening hallucinations. Provider response to individuals’ experience appeared to impact the quality of the patient–provider relationship. We recommend the inclusion of religious history in the initial assessment of individuals. This will assist the provider in making an accurate diagnosis, distinguishing between religious beliefs and those that reflect underlying pathology, and in increasing the level of cultural competence of the care provided. Religious and spiritual beliefs that provide a source of hope and strength for the patient can be utilized to expand and enhance the patient's coping strategies.     

Intrusive thoughts and auditory hallucinations: a comparative study of intrusions in psychosis

Several theories of auditory hallucinations implicate the involvement of intrusive thoughts and other theories suggest that the interpretation of voices determines the distress associated with them. This study tested the hypotheses that patients who experience auditory hallucinations will experience more intrusive thoughts and be more distressed by them and interpret them as more uncontrollable and unacceptable than the control groups. It also examines whether the interpretation of hallucinations is associated with the distress caused by them and whether there are differences in the way that patients respond to and interpret their thoughts and voices. A questionnaire examining the frequency of intrusive thoughts and the reactions to them was administered to a group of patients with a diagnosis of schizophrenia who experienced auditory hallucinations, a psychiatric control group and a non-patient control group. In addition, the patients in the first group completed a similar questionnaire in relation to their voices. Analyses of covariance showed that patients who experienced auditory hallucinations had more intrusive thoughts than the control groups and that they found their intrusive thoughts more distressing, uncontrollable and unacceptable than the control groups. Correlational analyses revealed that patients' interpretations of their voices were associated with the measures of distress in relation to them. Repeated measures analyses of covariance found no differences between thoughts and voices on the dimensions assessed. The theoretical and clinical implications of these findings are discussed.     

The effects of focus of attention on attributional bias in patients experiencing auditory hallucinations

Cognitive models suggest that auditory hallucinations occur as the result of internal events attributed to an external source. The present study represents an attempt to evaluate the source monitoring performance of people who experience auditory hallucinations, specifically in terms of the suggested links between source monitoring, emotionality of stimuli and self-focused attention. The source monitoring performance of a group of 30 patients with a diagnosis of a schizophrenia spectrum disorder who experience auditory hallucinations was compared following successful experimental manipulation of their attention, designed to increase and decrease their levels of self-focused attention. The inclusion of words previously rated as emotionally salient by schizophrenic patients assessed the effect of emotionality on source monitoring performance. This study demonstrated that participants' ratings of both internality and control of their responses to the word association task were lower in the external focus condition than the internal focus condition. Furthermore, it was found that ratings of internality and control were lower for responses to both positive and negative stimuli compared to responses to neutral stimuli, and the magnitude of these differences was amplified in the internal focus condition relative to the external focus condition. Focus of attention has a significant effect on source monitoring performance in people experiencing auditory hallucinations. The theoretical and clinical implications of these findings are discussed.     

Punishment vs negative reinforcement in the aversive conditioning of auditory hallucinations1

The behavioural treatment of auditory hallucinations in three chronic schizophrenic patients is reported. Two treatment conditions, one in which white noise followed hallucinations and a second in which white noise was presented during reported hallucinations, were contrasted in a crossover design with a control condition where white noise was presented randomly. All three patients improved, although reported reductions in hallucinations were more marked in two cases than in the third. Some generalization of treatment effects was observed in all three patients. White noise presented concurrently with hallucinatory reports appeared to be the most effective. The implication of these findings for a theory of auditory hallucinations is discussed.     

Sleep deprivation and hallucinations. A qualitative study of military personnel

Much anecdotal evidence suggests that sleep deprivation not only impairs performance, but also brings about other extraordinary effects like hallucinations. However, knowledge about how sleep deprivation may trigger hallucinations is limited. To qualitatively describe hallucinatory experiences during sleep deprivation 12 male military officers from the Norwegian Armed Forces who all had experienced at least one sleep loss-induced hallucinatory experience were recruited. Data were collected and analyzed by semi-structured interviews and thematic analysis. This resulted in the identification of three distinct main themes: (1) Modalities, (2) circumstances/triggers and (3) reactions to hallucinations. Hallucinations were experienced in several modalities (visual, auditory and multi-modality), although visual hallucinations seemed to dominate. Typical reported circumstances/triggers were sleep loss, physical exhaustion, time-of-day, low calorie intake, mental exhaustion and lack of external stimuli (low sensory and social input, boring situations, and monotonous activity). Negative emotions were dominant during the hallucinatory episodes. Often some reasoning and checking on behalf of the officers were necessary to differentiate between real percepts and hallucinations. In some cases the hallucinations caused erroneous actions. Retrospectively, most officers viewed their hallucinatory experiences in light of positive emotions and several emphasized having learned something from them. The results are discussed in relation to the existing literature and suggestions for future studies are outlined.     

Influence of metacognitive variables and thought suppression on number of thoughts, discomfort they produce and number and quality of auditory illusions

Based on the model proposed by Morrison, Haddock & Tarrier (1995) on auditory hallucinations, this study explores the relationships between certain metacognitive variables and number of thoughts, the discomfort they produce, number of auditory illusions and the quality with which they are perceived in a sample from a non-clinical population. After group administration of the Metacognitions Questionnaire, 61 participants were randomly assigned to a suppression group (n = 31) or a focalization group (n = 30) in relation to thoughts with different degrees of self-discrepancy. Forty-eight hours after the set task, a non-vocal auditory stimulus was presented, and subjects were required to say whether they heard any words and, if so, how clearly. The results show how the metacognitive factors studied are useful for predicting our findings only for the suppression group and not for that of focalization. These data are discussed in the light of Morrison et al.'s model of auditory hallucinations.     

Book Review: Acceptance and Commitment Therapy

Based on the model proposed by Morrison, Haddock &; Tarrier (1995) on auditory hallucinations, this study explores the relationships between certain metacognitive variables and number of thoughts, the discomfort they produce, number of auditory illusions and the quality with which they are perceived in a sample from a non-clinical population. After group administration of the Metacognitions Questionnaire, 61 participants were randomly assigned to a suppression group (n?=?31) or a focalization group (n?=?30) in relation to thoughts with different degrees of self-discrepancy. Forty-eight hours after the set task, a non-vocal auditory stimulus was presented, and subjects were required to say whether they heard any words and, if so, how clearly. The results show how the metacognitive factors studied are useful for predicting our findings only for the suppression group and not for that of focalization. These data are discussed in the light of Morrison et al.'s model of auditory hallucinations.     

Heterogeneity of auditory verbal working memory in schizophrenia

The heterogeneity of schizophrenia remains an obstacle for understanding its pathophysiology. Studies using a tone discrimination screening test to classify patients have found evidence for 2 subgroups having either a specific deficit in verbal working memory (WM) or deficits in both verbal and nonverbal memory. This study aimed to (a) replicate in larger samples differences between these subgroups in auditory verbal WM; (b) evaluate their performance on tests of explicit memory and sustained attention; (c) determine the relation of verbal WM deficits to auditory hallucinations and other symptoms; and (d) examine medication effects. The verbal WM and tone discrimination performance did not differ between medicated (n = 45) and unmedicated (n = 38) patients. Patients with schizophrenia who passed the tone screening test (discriminators; n = 60) were compared with those who did not (nondiscriminators; n = 23) and healthy controls (n = 47). The discriminator subgroup showed poorer verbal WM than did controls and a deficit in verbal but not visual memory on the Wechsler Memory Scale-Revised (Wechsler, 1987), whereas the nondiscriminator subgroup showed overall poorer performance on both verbal and nonverbal tests and a marked deficit in sustained attention. Verbal WM deficits in discriminators were correlated with auditory hallucinations but not with negative symptoms. The results are consistent with a verbal memory deficit in a subgroup of schizophrenia having intact auditory perception, which may stem from dysfunction of language-related cortical regions, and a more generalized cognitive deficit in a subgroup having auditory perceptual and attentional dysfunction.     

Wegner on hallucinations,inconsistency, and the illusion of free will. Some critical remarks

Wegner’s argument on the illusory nature of conscious will, as developed in The Illusion of Conscious Will (2002) and other publications, has had major impact. Based on empirical data, he develops a theory of apparent mental causation in order to explain the occurrence of the illusion of conscious will. Part of the evidence for his argument is derived from a specific interpretation of the phenomenon of auditory verbal hallucinations as they may occur in schizophrenia. The aim of this paper is to evaluate the validity of the evidence on auditory verbal hallucinations as employed by Wegner. I conclude that auditory hallucinations do not provide solid evidence for Wegner’s theory. Moreover, the phenomena in schizophrenia provide, in fact, an argument against part of Wegner’s theory of apparent mental causation.     

A comparison of metacognitions in patients with hallucinations,delusions, panic disorder,and non-patient controls

This study tested the hypothesis that metacognitions are a general vulnerability factor for psychological disorder. It was predicted that patients with psychosis (hallucinations or delusions), and patients with panic disorder would score higher than non-patients on measures of metacognition. Moreover, it was hypothesised that patients showing most dysregulation of thinking (voice-hearers) would endorse significantly higher metacognition scores than individuals in the other groups. The Meta-Cognitions Questionnaire (MCQ: ) was administered to patients who met DSM-IV criteria for schizophrenia spectrum disorders with auditory hallucinations, patients who met DSM-IV criteria for schizophrenia spectrum disorders with persecutory delusions, patients who met DSM-IV criteria for panic disorder and non-patients. The results showed that psychotic patients who experience auditory hallucinations tended to exhibit higher levels of dysfunctional metacognitive beliefs than other patient groups, scoring significantly higher than at least two of the three control groups on positive beliefs about worry, negative beliefs about uncontrollability and danger, cognitive confidence and negative beliefs including superstition, punishment and responsibility. It was also found that the metacognitive beliefs of patients with persecutory delusions and panic patients were often similar to each other, and elevated in comparison to non-patients, suggesting that such beliefs are generic vulnerability factors. The theoretical and clinical implications of these findings are discussed.     

Auditory Verbal Experience and Agency in Waking,Sleep Onset,REM, and Non‐REM Sleep

We present one of the first quantitative studies on auditory verbal experiences (“hearing voices”) and auditory verbal agency (inner speech, and specifically “talking to (imaginary) voices or characters”) in healthy participants across states of consciousness. Tools of quantitative linguistic analysis were used to measure participants’ implicit knowledge of auditory verbal experiences (VE) and auditory verbal agencies (VA), displayed in mentation reports from four different states. Analysis was conducted on a total of 569 mentation reports from rapid eye movement (REM) sleep, non‐REM sleep, sleep onset, and waking. Physiology was controlled with the nightcap sleep–wake mentation monitoring system. Sleep‐onset hallucinations, traditionally at the focus of scientific attention on auditory verbal hallucinations, showed the lowest degree of VE and VA, whereas REM sleep showed the highest degrees. Degrees of different linguistic‐pragmatic aspects of VE and VA likewise depend on the physiological states. The quantity and pragmatics of VE and VA are a function of the physiologically distinct state of consciousness in which they are conceived.     

Metacognitions in patients with hallucinations and obsessive-compulsive disorder: the superstition factor

On the basis of the analogy between intrusive thoughts and auditory hallucinations established by Morrison et al. [(1995). Intrusive thoughts and auditory hallucinations: a cognitive approach. Behavioural and Cognitive Psychotherapy, 23, 265-280], the present work compares the metacognitive beliefs and processes of five groups of patients (current hallucinators, never-hallucinated people with a diagnosis of schizophrenia, recovered hallucinators, obsessive-compulsive disorder (OCD) patients, and a clinical control group) and a non-clinical group. The results show that of the five metacognitive factors considered in this study, two were found to be different in the current hallucinators group in comparison to any other group in the design. Likewise, it is found that the metacognitive beliefs of the current hallucinators coincide with those of the OCD patients in various factors, particularly that relating to superstition, and this is interpreted as lending support to the model of Morrison et al. (1995). Furthermore, the results are discussed in the light of existing research on Thought-Action Fusion, stressing the role that may be played by superstitious beliefs and magical thinking in auditory hallucinations and OCD.     

Auditory, visual, tactile, olfactory, and bodily hallucinations in patients with obsessive-compulsive disorder

Although much attention has been paid to patients who lack insight into their obsessional beliefs, less importance has been given to individuals with obsessive-compulsive disorder (OCD) who display perceptual disturbances typically found in psychotic disorders, including schizophrenia, schizoaffective disorders, or mood disorders with psychotic features. We would like to call the attention to a phenomenon that has been neglected in the psychiatric literature: the occurrence of hallucinations and related phenomena in patients with OCD. In this case report, we describe five clinical vignettes of patients with OCD with hallucinations in several different sensory modalities, including the auditory, the visual, the tactile, the olfactory, and the cenesthetic ones. Further psychopathological research should clarify the clinical significance of hallucinations among patients with OCD.     

Attention Training With Auditory Hallucinations: A Case Study

The case presented in this paper illustrates how Attention Training (ATT; [Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273–280.]) can be applied in an outpatient setting in the treatment of auditory hallucinations. The 25-year-old male patient presented had a 4-year history of schizophrenia and treatment-refractory auditory hallucinations. He had received cognitive behavior therapy (CBT) before starting ATT. CBT had changed his attribution of the voices, and when he started with ATT the patient no longer held the belief that “voices are dangerous,” but his processing configuration was still acting “as if” the voices were a source of threat: He would listen to them, ruminate about them, and was easily distracted by them. Eight sessions of ATT resulted in a reduction of symptoms and in a dramatic change in the perceived control and mastery of the auditory hallucinations. It is concluded that ATT may be a helpful adjunct strategy in the treatment of specific psychotic symptoms.     

Twice daily low frequency rTMS for treatment-resistant auditory hallucinations

BackgroundRepetitive transcranial magnetic stimulation (rTMS) has emerged as a therapeutic solution in patients with treatment-resistant auditory verbal hallucinations. However, the optimal stimulation parameters remain unclear, especially for patients with clozapine-resistant symptoms.MethodIn an open label retrospective study, we investigated whether parameters of stimulation that were useful in patients with major depressive disorder would help schizophrenia patients with treatment-resistant auditory verbal hallucinations. Fourteen participants, including 9 under clozapine, received 30 sessions of 1 Hz rTMS over 3 weeks (360 pulses per sessions delivered with 60 s ‘on’ and 30 s ‘off’ at 110% of the resting motor threshold, 2 sessions per day). Stimulations were applied over the left temporoparietal junction (T3-P3 according to 10/20 system).ResultsAfter rTMS, a significant decrease of auditory verbal hallucinations was observed (?38.7% ± 31.8, p = 0.003) on the Auditory Hallucination Rating Scale. The beneficial effects were also significant in the 9 patients who were also receiving clozapine (?34.9% ± 28.4, p = 0.01).ConclusionsLow frequency rTMS, 30 sessions over 3 weeks, appears to be a suitable approach to decrease treatment-resistant auditory verbal hallucinations, including in patients with clozapine-resistant symptoms. Results from the current retrospective study in the clinical settings need to be confirmed by large-scale randomized sham-controlled trials.