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.     

Analysis of the multidimensionality of hallucination-like experiences in clinical and nonclinical Spanish samples and their relation to clinical symptoms: implications for the model of continuity

Numerous studies have found that hallucinatory experiences occur in the general population. But to date, few studies have been conducted to compare clinical and nonclinical groups across a broad array of clinical symptoms that may co-occur with hallucinations. Likewise, hallucination-like experiences are measured as a multidimensional construct, with clinical and subclinical components related to vivid daydreams, intrusive thoughts, perceptual disturbance, and clinical hallucinatory experiences. Nevertheless, these individual subcomponents have not been examined across a broad spectrum of clinically disordered and nonclinical groups. The goal of the present study was to analyze the differences and similarities in the distribution of responses to hallucination-like experience in clinical and nonclinical populations and to determine the relation of these hallucination-like experiences with various clinical symptoms. These groups included patients with schizophrenia, non-psychotic clinically disordered patients, and a group of individuals with no psychiatric diagnoses. The results revealed that hallucination-like experiences are related to various clinical symptoms across diverse groups of individuals. Regression analysis found that the Psychoticism dimension of the Symptom Check List (SCL-90-R) was the most important predictor of hallucination-like experiences. Additionally, increased auditory and visual hallucination was the only subcomponent that differentiated schizophrenic patients from other groups. This distribution of responses in the dimensions of hallucination-like experiences suggests that not all the dimensions are characteristic of people hearing voices. Vivid daydreams, intrusive thoughts, and auditory distortions and visual perceptual distortions may represent a state of general vulnerability that does not denote a specific risk for clinical hallucinations. Overall, these results support the notion that hallucination-like experiences are closer to a quasi-continuum approach and that total scores on these scales explain a state of vulnerability to general perceptual disturbance.     

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.     

Experiencing malevolent voices is associated with attentional dysfunction in psychotic patients

Inattention in people with schizophrenia is common. However, there has been little research on the association between inattention and auditory hallucinations. The aim of the study was to investigate how inattention is affected by beliefs about voices as benevolent and malevolent and perceived control of voices. A total of 31 patients who experienced auditory hallucinations and who met the criteria for schizophrenia or other psychosis completed the attention subscale of the Scale for the Assessment of Negative Symptoms (SANS) and the Connors’ Continuous Performance Test II (CCPT‐II). The revised Beliefs About Voices Questionnaire (BAVQ‐R) was used to assess malevolent and benevolent beliefs about voices, and severity of auditory hallucinations (the Psychotic Symptom Rating Scales; PSYRATS) was used to assess perceived control of voices and frequency of voices. Levels of depression (the Beck Depression Inventory; BDI), anxiety (the Beck Anxiety Inventory; BAI), severity of overall psychiatric symptoms (the Brief Psychiatric Rating Scale; BPRS), and severity of negative symptoms (SANS) were assessed to control for their potential confounding effects. The relations between the variables were explored with correlations and multiple hierarchical regression analyses. The results indicated that more malevolent, but not more benevolent, beliefs about voices predicted lower levels of attention, independently of general psychiatric symptoms and various other psychotic symptoms such as frequency of and perceived control of voices. These findings suggest an important relationship between malevolent beliefs about voices and levels of inattention. The possible impact of changing beliefs about voices to improve attentional functioning is discussed.     

The role of objective versus perceived life threat in the psychological adjustment to cancer

Several studies in the oncology literature have used disease stage as a measure of life threat. According to the transactional model of stress (Lazarus and Folkman, ), however, the individual's perception of a threatening situation is more strongly related to distress than the objective event itself. Thus, the present study examined whether cancer patients’ perceived life threat (PLT) is more strongly associated with psychological adjustment than a more objective index of disease prognosis (i.e., cancer stage). In addition, based on cognitive processing theories, this study examined whether intrusive thoughts and avoidance, cognitive characteristics of posttraumatic stress disorder (PTSD), mediate the relationship between PLT and distress. Patients diagnosed with various types of cancer (N = 97) completed questionnaires assessing PLT, cancer-related intrusive thoughts and avoidance, distress, and quality of life. Consistent with theoretical predictions, regression analyses showed that PLT, but not disease stage, was significantly related to psychological distress and quality of life. In addition, intrusive thoughts and avoidance mediated the relationship between PLT and distress. Taken together, these findings suggest that cancer patients’ PLT is more strongly related to distress than is cancer stage and that this association is partly due to cognitive symptoms that are part of PTSD symptomatology. Thus, patients who appraise their illness as life threatening may benefit from cognitive interventions aimed at reducing distress associated with intrusive thoughts.     

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.     

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.     

A comparison of thought suppression to an acceptance-based technique in the management of personal intrusive thoughts: a controlled evaluation

Research suggests that suppressing unwanted thoughts is not possible, leads to a subsequent increase in frequency of the suppressed thoughts, and results in higher levels of distress. Because thought suppression may have negative effects, an alternative, acceptance-based approach has been proposed. The current paper reports the outcomes of two studies. Study I examined the relationships between two naturally occurring strategies of thought management (thought suppression and acceptance), symptoms of psychopathology, and experiences with personally relevant intrusive thoughts. Results showed that those who naturally suppress personally relevant intrusive thoughts have more, are more distressed by, and have a greater "urge to do something" about the thoughts, while those who are naturally more accepting of their intrusive thoughts are less obsessional, have lower levels of depression, and are less anxious. Study II compared three groups (thought suppression, acceptance, and monitor-only groups) on the frequency and distress associated with experiencing personally relevant intrusive thoughts. Results revealed that those instructed to suppress their personal intrusive thoughts were unable to do so and experienced an increased level of distress after suppression, whereas those instructed to use an acceptance-based strategy experienced a decrease in discomfort level (but not thought frequency) after having used such a strategy. These data offer initial evidence that acceptance may be a useful alternative to the suppression of personally relevant intrusive thoughts.     

Distress and recurrence of intrusive thoughts in younger and older adults

The current study incorporated a life span perspective into existing theories of intrusive thoughts to examine age-related differences in the difficulty controlling intrusive thoughts, the distress following intrusive thought recurrences, and the meanings assigned to these recurrences. Younger (N = 51) and older (N = 49) community adults were randomly assigned to suppress (i.e., keep out of mind) or monitor an intrusive thought. Participants rated their positive and negative affect throughout engagement with the intrusive thought, and they also rated the meanings they gave to recurrences of their everyday intrusive thoughts. The results demonstrated that older adults tended to perceive greater difficulty with controlling the intrusive thought than younger adults despite the fact that they did not differ in the actual recurrence of the intrusive thought. With regard to distress, older adults experienced steadier levels of positive affect than younger adults throughout engagement with the intrusive thought. However, older adults also reported greater residual negative affect after engaging with the intrusive thought than younger adults. Finally, older and younger adults appeared to assign meanings to recurrences of intrusive thoughts in line with age-relevant concerns. Specifically, older adults were prone to interpret the recurrence of intrusive thoughts as a sign of cognitive decline, but they were less likely than younger adults to see intrusive thoughts as a sign of moral failure. Together, these results highlight a range of potential risk and protective factors in older adults for experiencing emotion dysregulation after intrusive thoughts.     

Appraisals of obsessional thoughts in normal samples

Cognitive theories of obsessive-compulsive disorder (OCD) posit that appraisals about the significance of thoughts are critical in the development and persistence of obsessions. Rachman [(1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793-802.] proposes that appraisals of unwanted thoughts distinguish clinical obsessions from normal intrusive thoughts; thoughts appraised as important and personally significant are expected to be upsetting and recur. Appraisals are also expected to be related to symptoms of OCD. To explore the features of normal appraisals of obsession-like thoughts, nonclinical participants in two studies rated the personal significance of intrusive thoughts portrayed in vignettes containing prototypical themes associated with primary obsessions: aggressive, sexual, and blasphemous thoughts. Unwanted intrusive thoughts that were described as occurring more frequently were appraised as more personally significant, but participants appraised these socially unacceptable thoughts similarly whether they imagined having personally experienced them or a friend confiding about having experienced them. Appraisals in both studies were related to subclinical OC symptoms and OC beliefs.     

Abortion as stigma: cognitive and emotional implications of concealment.

This study examined the stigma of abortion and psychological implications of concealment among 442 women followed for 2 years from the day of their abortion. As predicted, women who felt stigmatized by abortion were more likely to feel a need to keep it a secret from family and friends. Secrecy was related positively to suppressing thoughts of the abortion and negatively to disclosing abortion-related emotions to others. Greater thought suppression was associated with experiencing more intrusive thoughts of the abortion. Both suppression and intrusive thoughts, in turn, were positively related to increases in psychological distress over time. Emotional disclosure moderated the association between intrusive thoughts and distress. Disclosure was associated with decreases in distress among women experiencing intrusive thoughts of their abortion, but was unrelated to distress among women not experiencing intrusive thoughts.     

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.     

Managing unwanted intrusive thoughts in obsessive-compulsive disorder: Relative effectiveness of suppression, focused distraction, and acceptance

Suppression is one of various mental control techniques that people may use to manage unwanted thoughts. Evidence suggests that it is at best unsustainable and at worst counterproductive. This leads to the question: If suppression is a futile way to respond to unwanted, intrusive thoughts, what is a more effective alternative? In the current study, we evaluated the relative effectiveness of suppression and two alternative mental control techniques—focused distraction and acceptance—on the frequency of intrusions and distress associated with them. Results support the claim that suppression is a counterproductive technique for dealing with unwanted, intrusive thoughts in OCD. However, the harmfulness of suppression was reflected primarily in the magnitude of distress and not in intrusion frequency. Focused distraction and acceptance were the more effective techniques for managing clinically significant intrusive thoughts. We discuss implications for the cognitive treatment for OCD.     

Personally relevant intrusions outside the laboratory: Long-term suppression increases intrusion

It has been suggested that the suppression of unwanted thoughts may increase their frequency and that this effect may contribute to some psychological problems. Previous studies have examined this over a period of minutes, in an artificial setting. Suppression over a four day period was evaluated in the present study. Each S was asked to identify a negative intrusive thought which he or she experienced and to record each occurrence of it in conditions designed to maximise the similarity to those experienced by obsessional patients. Ss were randomly allocated to one of three groups. One group was asked to suppress their thoughts whenever they occurred, another group was asked to think about their thoughts whenever they occurred and the third group just recorded the thoughts whenever they occurred. This design allowed experimental control of both attention to and manipulation of the target thoughts in contrast to attention and active suppression. It was found that Ss who suppressed their thoughts experienced more thoughts and found them more uncomfortable than Ss in the other two groups. This is consistent with the theory that suppression increases thought frequency and may be important in the development and maintenance of some disorders.     

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.     

“Hearing voices”: Auditory hallucinations as failure of top‐down control of bottom‐up perceptual processes

Auditory hallucination is a key characteristic of schizophrenia that seriously debilitates the patient, with consequences for social engagement with others. Hallucinatory experiences are also observed in healthy individuals in the general population who report “hearing voices” in the absence of an external acoustic input. A view on auditory hallucinations and “hearing voices” is presented that regards such phenomena as perceptual processes, originating from speech perception areas in the left temporal lobe. Healthy individuals “hearing voices” are, however, often aware that the experience comes from inner thought processes, which is not reported by hallucinating patients. A perceptual model can therefore, not alone explain the difference in the phenomenology of how the “voices heard” are attributed to either an inner or outer cause. An expanded model is thus presented which takes into account top‐down cognitive control, localized to prefrontal cortical areas, to inhibit and re‐attribute the perceptual mis‐representations. The expanded model is suggested to be empirically validated using a dichotic listening speech perception paradigm with instructions for top‐down control of attention focus to either the right or left side in auditory space. It is furthermore suggested to use fMRI to validate the temporal and frontal lobe neuronal correlates of the cognitive processes involved in auditory hallucinations.     

The Effect of State and Trait Self-Critical Rumination on Acute Distress: An Exploratory Experimental Investigation

Self-critical rumination is a process whereby individuals focus attention on past failures and inadequacies without consideration for improvement or problem-solving. Past research has demonstrated that self-critical rumination is a separate process from the experience of having intrusive self-critical thoughts and that engaging in self-critical rumination is strongly correlated with beliefs that it is uncontrollable or represents a weakness of character. What is less clear at this time, however, is the impact that self-critical rumination has on levels of distress when faced with failure. Thirty volunteers who were not experiencing significant levels of depression were randomly assigned across three groups: one rumination and two controls. Acute distress was measured prior to and immediately following a task, as well as upon debrief. Individuals expected to complete an impossible task, who experienced simulated self-critical rumination experienced greater levels of acute distress than controls immediately following the task. There was also a significant correlation between reported levels of trait self-critical rumination, negative metacognitive beliefs and self-esteem with levels of distress following debrief when controlling for initial levels of distress and group membership. The use of subjective self-reports and small sample size limits the findings of this exploratory study. Engaging in self-critical rumination, and associated negative metacognitive beliefs, may have a significant impact on levels of acute distress following a recent failure.

     

Intrusive images in PTSD and in traumatised and non-traumatised depressed patients: a cross-sectional clinical study

Although intrusive images are a hallmark of post-traumatic stress disorder (PTSD) and also occur in depression, little is known about the differences and similarities of such images in these conditions. Our study focuses on the qualities and triggers of intrusive images and responses to them in three groups--patients with PTSD, and depressed patients with and without trauma (n=65)-to highlight the diagnostic specificity of intrusive images for PTSD and depression. We distinguished intrusive images from verbal intrusive cognitions such as rumination and intrusive (brief) lexical thoughts. Consistent with the literature, the intrusive images of PTSD patients had a more "here-and-now quality" and were perceived more visually compared to those of both depressed groups. The groups showed a good deal of similarity concerning other image qualities. Most importantly, the intrusive images in PTSD and depressed patients with and without trauma were perceived as similarly distressing. Rumination and intrusive (brief) lexical thoughts were two of the five most named triggers of intrusive images. Limitations, such as the lack of a control group, and the clinical implications of these results are discussed, demonstrating the need to help non-PTSD patients with and without trauma to deal with intrusive images.     

Laterality effects in perceived spatial location of hallucination-like voices

Aydin and colleagues reported a reversal of physiological 'right-ear advantage' in a group of right-handed patients with schizophrenia, using an auditory acuity test. In schizophrenia, auditory hallucinations may appear to be spatially located inside or outside the patient's head. Here we show, using virtual acoustic space techniques, that normal right-handed subjects have a right-ear advantage for correctly locating the 'source' of hallucination-like voices as from either inside or outside the head. We propose a model for understanding lateralised, external hallucinations in schizophrenia based upon reversal of normal cortical asymmetry for auditory spatial processing.     

Challenging the omnipotence of voices: group cognitive behavior therapy for voices

The present study examines the impact of group based cognitive behavior therapy (CBT) for drug resistant auditory hallucinations, or voices. In particular it assesses treatment effect on beliefs in a voice's omnipotence and control. Twenty-two participants entered one of five 8-session CBT groups. Measures of omnipotence, control, process measures, and symptoms of anxiety and depression were completed at assessment, and first and last group sessions. The groups achieved a significant reduction in conviction in beliefs about omnipotence (df 2, P = 0.002) and control (df 2, P = 0.001). There were no affective changes. Certain participants showed important spontaneous changes in behavior. Process measures suggested that participants valued the groups and benefited from them. These results are promising and the treatment may prove a useful addition to existing psychological interventions.