An inter-subjective multi-factorial model of auditory verbal hallucinations in schizophrenia

Auditory verbal hallucinations (AVHs) are perceptive-like experiences happening without appropriate stimuli that in individuals with schizophrenia very often feature distressing contents. AVH frequently interfere with social relationships or result in dangerous behaviours. We hypothesize that in schizophrenia several vulnerability factors, especially when a subject is engaged in real or represented interpersonal transactions, lead to the appearance of AVHs, and favour their self-perpetuation over time. We analyse the different psychological factors that, according to empirical studies and clinical experience with persons with schizophrenia, seem involved in the genesis of AVHs. Several vulnerability factors appear to interact with situational ones to trigger AVHs: a) a facilitation of neural transmission from the premotor regions to the perceptual ones; b) a difficulty attuning with others, c) interpersonal schemas, provoking emotional suffering, intrusive thoughts and rumination; d) metacognitive dysfunctions. Once AVHs have appeared, further factors promote their perpetuation over time: a) cognitive factors like ruminative processing on AVHs, b) metacognitive beliefs about AVHs. An integrated theoretical model of AVHs is described and ideas for its empirical testing are suggested.     

A phenomenological survey of auditory verbal hallucinations in the hypnagogic and hypnopompic states

The phenomenology of auditory verbal hallucinations (AVHs) occurring in hypnagogic and hypnopompic (H&H) states has received little attention. In a sample of healthy participants (N = 325), 108 participants reported H&H AVHs and answered subsequent questions on their phenomenology. AVHs in the H&H state were found (1) to be more likely to only feature the occasional clear word than to be clear, (2) to be more likely to be one-off voices than to be recurrent voices, (3) to be more likely to be voices of people known to the individual than unknown persons, (4) to be more likely to talk directly to the person rather than not, and (5) to only rarely give commands, ask questions, or to result in an interactive conversation. Their phenomenology was similar to normative AVHs in wakefulness (as established by previous research) in that the voice-hearer was usually the target of the voice, and the voice was more likely to be of a recognized person. However, H&H AVHs differed from AVHs in wakefulness in that commands and questions were rare, and there was typically no dialogical engagement with the voice. We conclude by proposing that two distinct types of H&H AVHs may exist (which we term “dialogic” and “monologic”), based on an analysis of the phenomenology of the experience, and suggest avenues for future research.     

Thought as action: inner speech, self-monitoring, and auditory verbal hallucinations

Passivity experiences in schizophrenia are thought to be due to a failure in a neurocognitive action self-monitoring system (NASS). Drawing on the assumption that inner speech is a form of action, a recent model of auditory verbal hallucinations (AVHs) has proposed that AVHs can be explained by a failure in the NASS. In this article, we offer an alternative application of the NASS to AVHs, with separate mechanisms creating the emotion of self-as-agent and other-as-agent. We defend the assumption that inner speech can be considered as a form of action, and show how a number of previous criticisms of applying the NASS to AVHs can be refuted. This is achieved in part through taking a Vygotskian developmental perspective on inner speech. It is suggested that more research into the nature and development of inner speech is needed to further our understanding of AVHs.     

Alien voices and inner dialogue: towards a developmental account of auditory verbal hallucinations

The phenomenon of auditory verbal hallucinations (AVHs) is one of the most intriguing features of the psychiatric literature. Two alternative models of the development of AVHs in both normal and psychotic populations are proposed. In the disruption to internalisation (DI) model, AVHs result from a disruption to the normal processes of internalisation of inner speech. In the re-expansion (RE) model, AVHs result when normal inner speech is re-expanded into inner dialogue under conditions of stress and cognitive challenge. Both models draw on Vygotsky's (The Collected Works Of L.S. Vygotsky, New York, Plenum Press, 1987) ideas about the development of inner speech. On this view, normal inner speech is considerably abbreviated relative to external speech, and also undergoes some important semantic transformations. In both the DI and RE models, AVHs arise when the subject's inner speech involves inappropriately expanded inner dialogue, leading the subject to experience the voices in the dialogue as alien. The two models may prove useful in explaining some of the social-developmental evidence surrounding the phenomenon, and also make a number of testable predictions which are suggested as priorities for future research.     

How anxiety induces verbal hallucinations

Verbal hallucinations are often associated with pronounced feelings of anxiety, and it has also been suggested that anxiety somehow triggers them. In this paper, we offer a phenomenological or ‘personal-level’ account of how it does so. We show how anxious anticipation of one’s own thought contents can generate an experience of their being ‘alien’. It does so by making an experience of thinking more like one of perceiving, resulting in an unfamiliar kind of intentional state. This accounts for a substantial subset of verbal hallucinations, which are experienced as falling within one’s psychological boundaries and lacking in auditory qualities.     

Prevalence of auditory verbal hallucinations in a general population: A group comparison study

The present study was specifically designed to investigate the prevalence of auditory verbal hallucinations (AVH) in the general population, and sought to compare similarities and differences regarding socio‐demographics, mental health and severe life events between individuals who have never experienced AVH with those who had. The study also aimed to compare those who sought professional help for their experience of AVH with those who had not sought help. Through a postal questionnaire, 2,533 participants ages 18 and over from a national survey completed the Launay‐Slade Hallucinations Scale and other measures examining AVH characteristics and other areas related to AVH. In total, 7.3% of the sample reported a life‐time prevalence of AVH. Those with AVH were more likely to be single and unemployed, reported higher levels of depression and anxiety, and experienced a higher number of severe life events compared with those without AVH. Only 16% of those who experienced AVH in the general population sought professional help for these experiences. Compared to those who did not seek professional help, participants that had were more likely to experience AVH with a negative content, experience them on a daily basis, undergo negative reactions when experiencing AVH, and resist AVH. In conclusion, the prevalence of AVH was found to be relatively high. The results also revealed higher levels of reduced mental health for individuals who sought professional help, followed by those who did not, compared with those who had never experienced AVH.     

The modification of auditory hallucinations

The ABAB withdrawal design was used to document the effectiveness of a behavioral treatment package in reducing the duration of auditory hallucinations of a chronically mentally ill inpatient. Results revealed clear functional control of the treatment package over the occurrence of the subject's auditory hallucinations during a 2-hr time period.     

Coping strategies for auditory hallucinations: A review

This article reviews the literature on the strategies which psychiatric patients spontaneously use in order to cope with their auditory hallucinations. The common strategies found between studies are described and these are grouped according to four categories: (i) social contact; (ii) sensory stimulation; (iii) physiological arousal; and (iv) cognitive strategies. An attempt is made to relate these strategies to the theoretical and experimental literature on auditory hallucinations and, finally, the role of the counselling psychologist in fostering the development of effective coping strategies is outlined.     

When soft voices die: auditory verbal hallucinations and a four letter word (love)

Understandings of auditory verbal hallucinations (also referred to as “hearing voices”), and help for people distressed by them, are dominated by a biomedical framework. Yet, many people who have sought help for the distress and/or impairment caused by hearing voices express dissatisfaction with treatment solely within this framework, highlighting the need for a more rounded, biopsychosocial-spiritual approach. This paper examines the neglected role of a fundamental part of human experience, love, in the experience of hearing voices. First, we argue a lack of love is likely to play a causal role in voice-hearing experiences. Second, we demonstrate that a lack of love is central to the distress and dysfunction often caused by hearing voices. Finally, we show that love plays a core role in recovery. Given this centrality of love, we argue that an interdisciplinary approach to hearing voices involving the mind sciences and theology/religion may be fruitful. The relevance of this for psychotherapeutic interventions for people who hear voices is discussed.     

Some verbal behavior about verbal behavior

Beginning with behavior analysts' tendency to characterize verbal behavior as "mere" verbal behavior, the author reviews his own attempt to employ it to influence both his staff and policies of our government. He then describes its role in psychopathology, its effect on speakers in healing themselves and on engendering creativity. The paper ends by calling to our attention the role of verbal behavior in the construction of behavior analysis.     

The roles of thought suppression and metacognitive beliefs in proneness to auditory verbal hallucinations in a non-clinical sample

In a non-clinical sample (N = 751), we investigated relations among two subscales (self-reported intrusiveness of unwanted thoughts and thought suppression) of the White Bear Suppression Inventory (WBSI), metacognitive beliefs, and proneness to auditory verbal hallucinations (AVHs). Both subscales of the WBSI were found to be related to AVH-proneness and strongly positively related to metacognitive beliefs about the uncontrollability and danger of thoughts. Regression analyses were used to test models of the relations among AVH-proneness and a range of metacognitive beliefs. When the WBSI subscale relating to the self-reported intrusiveness of unwanted thoughts was controlled for, the metacognitive style that was the strongest predictor of AVH-proneness was cognitive self-consciousness. Cognitive confidence and beliefs about the uncontrollability of thoughts were also significant predictors of AVH-proneness. These findings are used to revise existing models of the relations between metacognitive beliefs and AVHs. Implications for the management of AVHs are discussed.     

The roles of thought suppression and metacognitive beliefs in proneness to auditory verbal hallucinations in a non-clinical sample

In a non-clinical sample (N = 751), we investigated relations among two subscales (self-reported intrusiveness of unwanted thoughts and thought suppression) of the White Bear Suppression Inventory (WBSI), metacognitive beliefs, and proneness to auditory verbal hallucinations (AVHs). Both subscales of the WBSI were found to be related to AVH-proneness and strongly positively related to metacognitive beliefs about the uncontrollability and danger of thoughts. Regression analyses were used to test models of the relations among AVH-proneness and a range of metacognitive beliefs. When the WBSI subscale relating to the self-reported intrusiveness of unwanted thoughts was controlled for, the metacognitive style that was the strongest predictor of AVH-proneness was cognitive self-consciousness. Cognitive confidence and beliefs about the uncontrollability of thoughts were also significant predictors of AVH-proneness. These findings are used to revise existing models of the relations between metacognitive beliefs and AVHs. Implications for the management of AVHs are discussed.     

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.     

Functioning of the phonological loop in auditory hallucinations

Two experiments designed to assess the functioning of the phonological store and loop were carried out with schizophrenic patients experiencing auditory hallucinations, schizophrenic patients not experiencing hallucinations and normal subjects. In the first experiment, phonological encoding was assessed. Although both groups of psychiatric patients performed more poorly overall than the normal subjects, there were no significant differences between the performances of the hallucinating and nonhallucinating patients. In the second experiment, the unattended speech effect (a phenomenon thought to reflect the functioning of the phonological store in normal subjects) was assessed in hallucinating schizophrenic patients, non-hallucinating schizophrenic patients and normal controls. The psychiatric patients performed more poorly overall than the normal subjects, but there was no evidence of abnormal functioning of the phonological store or loop in either patient group. Overall, the findings indicate that phonological store and loop abnormalities are not implicated in the experience of auditory hallucinations.