Reality-monitoring deficits and visual hallucinations in schizophrenia.

The presence of visual hallucinations in addition to auditory hallucinations (V + AH) is associated with poor prognosis in patients with schizophrenia. However, little consideration has been given to these symptoms and their underlying cognitive bases remain unclear. Based on cognitive models of hallucinations, we hypothesized that V + AH are underpinned by an impairment in reality-monitoring processes. The objective of the present study was to test whether reality-monitoring deficits were associated with V + AH in schizophrenia. This study examined reality-monitoring abilities in two groups of patients with schizophrenia: a group of patients with V + AH (n = 24) and a group of patients with AH only (n = 22). Patients with V + AH were significantly more likely to misremember imagined words as being perceived from an external source, compared to patients with AH only (p = 0.008, d = -0.82). In other words, V + AH patients display a larger externalization bias than patients with AH only. One explanation for these results could be that experiencing hallucinations in two sensory modalities may contribute to increased vividness of mental imagery and, in turn, lead to disruption in reality-monitoring processes. This study helps to refine our understanding of the cognitive processes underlying the presence of both auditory and visual hallucinations in patients with schizophrenia.

Disruption in neural phase synchrony is related to identification of inattentional deafness in real-world setting.

Individuals often have reduced ability to hear alarms in real world situations (e.g., anesthesia monitoring, flying airplanes) when attention is focused on another task, sometimes with devastating consequences. This phenomenon is called inattentional deafness and usually occurs under critical high workload conditions. It is difficult to simulate the critical nature of these tasks in the laboratory. In this study, dry electroencephalography is used to investigate inattentional deafness in real flight while piloting an airplane. The pilots participating in the experiment responded to audio alarms while experiencing critical high workload situations. It was found that missed relative to detected alarms were marked by reduced stimulus evoked phase synchrony in theta and alpha frequencies (6-14 Hz) from 120 to 230 ms poststimulus onset. Correlation of alarm detection performance with intertrial coherence measures of neural phase synchrony showed different frequency and time ranges for detected and missed alarms. These results are consistent with selective attentional processes actively disrupting oscillatory coherence in sensory networks not involved with the primary task (piloting in this case) under critical high load conditions. This hypothesis is corroborated by analyses of flight parameters showing greater maneuvering associated with difficult phases of flight occurring during missed alarms. Our results suggest modulation of neural oscillation is a general mechanism of attention utilizing enhancement of phase synchrony to sharpen alarm perception during successful divided attention, and disruption of phase synchrony in brain networks when attentional demands of the primary task are great, such as in the case of inattentional deafness.

Remembering verbally-presented items as pictures: Brain activity underlying visual mental images in schizophrenia patients with visual hallucinations.

BACKGROUND: Previous research suggests that visual hallucinations in schizophrenia consist of mental images mistaken for percepts due to failure of the reality-monitoring processes. However, the neural substrates that underpin such dysfunction are currently unknown. We conducted a brain imaging study to investigate the role of visual mental imagery in visual hallucinations. METHOD: Twenty-three patients with schizophrenia and 26 healthy participants were administered a reality-monitoring task whilst undergoing an fMRI protocol. At the encoding phase, a mixture of pictures of common items and labels designating common items were presented. On the memory test, participants were requested to remember whether a picture of the item had been presented or merely its label. RESULTS: Visual hallucination scores were associated with a liberal response bias reflecting propensity to erroneously remember pictures of the items that had in fact been presented as words. At encoding, patients with visual hallucinations differentially activated the right fusiform gyrus when processing the words they later remembered as pictures, which suggests the formation of visual mental images. On the memory test, the whole patient group activated the anterior cingulate and medial superior frontal gyrus when falsely remembering pictures. However, no differential activation was observed in patients with visual hallucinations, whereas in the healthy sample, the production of visual mental images at encoding led to greater activation of a fronto-parietal decisional network on the memory test. CONCLUSIONS: Visual hallucinations are associated with enhanced visual imagery and possibly with a failure of the reality-monitoring processes that enable discrimination between imagined and perceived events.

Reality monitoring performance and the role of visual imagery in visual hallucinations.

BACKGROUND: Auditory Hallucinations may arise from people confusing their own inner speech with external spoken speech. People with visual hallucinations (VH) may similarly confuse vivid mental imagery with external events. This paper reports two experiments exploring confusion between internal and external visual material. METHOD: Experiment 1 examined reality monitoring in people with psychosis; those with visual hallucinations (n = 16) and those without (n = 15). Experiment 2 used two non-clinical groups of people with high or low predisposition to VH (HVH, n = 26, LVH, n = 21). All participants completed the same reality monitoring task. Participants in Experiment 2 also completed measures of imagery. RESULTS: Psychosis patients with VH demonstrated biased reality monitoring, where they misremembered items that had been presented as words as having been presented as pictures. Patients without VH did not show this bias. In Experiment 2, the HVH group demonstrated the same bias in reality monitoring that psychosis patients with VH had shown. The LVH group did not show this bias. In addition, the HVH group reported more vivid imagery and particularly more negative imagery. CONCLUSIONS: Both studies found that people with visual hallucinations or prone-ness to such experiences confused their inner visual experiences with external images. Vivid imagery was also related to proneness to VH. Hence, vivid imagery and reality monitoring confusion could be contributory factors to understanding VH.

Cognitive-behavioural therapy and recovery of a delusional dysmorphophobia case.

BACKGROUND: We present the application of cognitive-behavioural therapy in a clinical case diagnosed with delusional dysmorphophobia. METHOD: The psychometric scales used for evaluation were the Positive and Negative Syndrome Scale for Schizophrenia, Beck Anxiety and Depression inventories, the Rosenberg Self-Esteem Scale along with the degree of conviction in the delusional belief and in alternative explanations, and social functioning measured by patient reporting. The therapy included cognitive and behavioural techniques: evidence analysis, search for alternative explanations, logical and functional analysis, reality testing, progressive relaxation techniques, in vivo and imaginal exposure therapy. Evaluations were performed before and after the treatment and then at follow-up after 12 and 24 months. RESULTS: Progressively, the delusional conviction disappeared. There were significant improvements at an emotional level and the patient recovered social and work  functioning. CONCLUSIONS: The need to use psychological treatments for people with delusional disorder as first choice treatment must be considered.

[Magical and physical reality].

In the postmodern countries the computer generated virtual reality provides new perceptual domains wherein the evaluation of real and unreal contents generates an essential challenge for both children and adults. The expectances to perceive unreal content which is contradictory with the common sense experiences become seductive for most of people. The time in front of the screen that emits the magic reality gradually rises. The sudden advance in generation of alternative realities demands that we have to recall the basic principles of psychological reality testing and the involving mechanism that produces a distinction between phantasy and reality for both healthy and pathological mind. Frame of reference usually restrains the thinking. This review contains two parts, the first is focuses on the historical aspect of magical and physical reality and the second one, that will be published in a next issue, will present an evaluation of the boundary between self and another person in point of view of the psychopathological phenomenon. This analysis will focus on how the boundary of the self behaves in physically real and magic computer generated environment.

["What I don't Appreciate in Real Life": Online Role Playing Game Addiction of an Adolescent--Case Study]. / ¼Was ich am richtigen Leben nicht so schätze« Online-Rollenspielsucht eines Jugendlichen--Fallstudie.

The present article aims to provide an insight into the life story of a computer-game addicted adolescent. Here, the relationship between the symptom game addiction, the family as a reference framework, the game's characteristics, as well as the subjective emotional state of the adolescent are of particular interest. An emphasis is also laid on the psychodynamically approached question of the impact of infantile and current relationship experiences (both within a family environment as well as with peers) on personal development. Last, still within a psychodynamic framework, we hope to provide a better understanding of the role of online computer-game addiction in the process of experiences potentially dominated by conflicts.

The impact of negative affect on reality discrimination.

BACKGROUND AND OBJECTIVES: People who experience auditory hallucinations tend to show weak reality discrimination skills, so that they misattribute internal, self-generated events to an external, non-self source. We examined whether inducing negative affect in healthy young adults would increase their tendency to make external misattributions on a reality discrimination task. METHODS: Participants (N = 54) received one of three mood inductions (one positive, two negative) and then performed an auditory signal detection task to assess reality discrimination. RESULTS: Participants who received either of the two negative inductions made more false alarms, but not more hits, than participants who received the neutral induction, indicating that negative affect makes participants more likely to misattribute internal, self-generated events to an external, non-self source. LIMITATIONS: These findings are drawn from an analogue sample, and research that examines whether negative affect also impairs reality discrimination in patients who experience auditory hallucinations is required. CONCLUSIONS: These findings show that negative affect disrupts reality discrimination and suggest one way in which negative affect may lead to hallucinatory experiences.

The Analysis of a Phobic Child: Some Problems of Theory and Technique in Child Analysis.

This paper attempts to clarify some theoretical and technical aspects of child analysis by correlating the course of treatment, the structure of the neurosis, and the technique employed in the case of a phobic boy who was in analysis over a period of three years. The case was chosen for presentation: (1) because of the discrepancy between the clinical simplicity of the symptom and the complicated ego structure behind it; (2) because of the unusual clearness with which the patient brought to the fore the variegated patterns of his libidinal demands; (3) because of the patient's attempts at transitory solutions, oscillations between perversions and symptoms, and processes of new symptom formation; (4) because the vicissitudes and stabilization of character traits could be clearly traced; (5) and finally, because of the rare opportunity to witness during treatment the change from grappling with reality by means of pathological mechanisms, to dealing with reality in a relatively conflict-free fashion.

[Between faith and delusion]. / Zwischen Glauben und Wahn.

Religious beliefs can lead to difficulties in psychiatric diagnosis, when it comes to distinguishing between faith and delusion. Delusion is defined as a false assessment of reality combined with subjective certainty, which is in contrast with the reality of the social environment. The problem with this definition is that reality cannot be examined with scientific methods/criteria and that the assessment of reality itself underlies historical and cultural fluctuations. The current diagnostic manuals for psychiatric disorders DSM 5 and ICD-10 require, that the content of the belief has to be inadequate even in the subculture of the patient (ICD-10) and that the cultural and socioeconomic background of the patient has to be taken into account (DSM 5). On the basis of this case-report and of selected publications on this topic we want to discuss this diagnostic problem. After that we present a diagnostic model for delusion, which is easy to handle in the daily routine of psychiatrists.

Shifting self, shifting memory: testing the self-memory system model with hypnotic identity delusions.

According to Conway's self-memory system (SMS) model, autobiographical memories may be facilitated, inhibited, or misremembered to be consistent with current self. In 3 experiments, the authors tested this by hypnotically suggesting an identity delusion and indexing whether this shift in self produced a corresponding shift in autobiographical memory. High hypnotizable participants displayed a compelling identity delusion and elicited specific autobiographical events that they could justify when challenged. These memories were reinterpretations of previous experiences that supported the suggested identity. Importantly, autobiographical memories that were no longer consistent with the hypnotically deluded self were less accessible than other memories. The authors discuss these findings in the context of Conway's SMS model and propose 2 accounts of autobiographical remembering during hypnotic and clinical delusions.

Ethnic syndromes as disguise for protest against colonialism: three ethnographic examples.

Historical connections are suggested between the domination of 1 culture by another and dissociative spiritual and religious responses to that oppression. Connections are drawn between colonial oppression, trauma, and 3 examples of dissociation and spirit possession: the Zar cult of Southern Sudan, "Puerto Rican syndrome" or ataque, and the Balinese trance dance. Discussed by means of these examples are the role and functions of spirit possession as a means of escape from unbearable reality, where it becomes a form of the expression of needs and desires forbidden by authorities, a way of entering an identity not subject to traditional authorities, and reenactment of traumatic experience.

The function of suffering as portrayed in the Scarlet Letter and reflected in clinical work.

Suffering is commonly seen as an unconscious effort to alleviate painful feelings of guilt. However, suffering also aims at averting loss of ego functions and hence loss of mental stability. This second function of suffering is discussed in the light of Freud's observations of characters wrecked by success and Weiss's ideas about mutual love as a threat to mental stability. Hawthorne's portrayal of Arthur Dimmesdale in The Scarlet Letter (1850), biographical material about the author, material from his diaries, and material from a psychotherapy case and an analysis illustrate the function of suffering to preserve mental stability in the face of heightened success and happiness. Hawthorne, it is argued, intuitively grasped this function of suffering in his novel.

Building false memories without suggestions.

People can come to remember doing things they have never done. The question we asked in this study is whether people can systematically come to remember performing actions they never really did, in the absence of any suggestion from the experimenter. People built LEGO vehicles, performing some steps but not others. For half the people, all the pieces needed to assemble each vehicle were laid out in order in front of them while they did the building; for the other half, the pieces were hidden from view. The next day, everyone returned for a surprise recognition test. People falsely and confidently remembered having carried out steps they did not; those who saw all the pieces while they built each vehicle were more likely to correctly remember performing steps they did perform but equally likely to falsely remember performing steps they did not. We explain our results using the source monitoring framework: People used the relationships between actions to internally generate the missing, related actions, later mistaking that information for genuine experience.

Susceptibility to misleading information under social pressure in schizophrenia.

Research looking at specific memory aberrations in the schizophrenia has primarily focused on their phenomenology using standardized semantic laboratory tasks. However, no study has investigated to what extent such aberrations have consequences for everyday episodic memories using more realistic false memory paradigms. Using a false memory paradigm where participants are presented with misleading suggestive information (Gudjonsson Suggestibility Scale), we investigated the susceptibility of patients with schizophrenia (n = 21) and healthy controls (n = 18) to post hoc misleading information acceptance and compliance. Patients with schizophrenia exhibited an increased susceptibility to go along with misleading suggestive items. Furthermore, they showed an increased tendency to change answers under conditions of social pressure. Underscoring previous findings on memory aberrations in schizophrenia, patients with schizophrenia had reduced levels of correct recognition (ie, true memory) relative to healthy controls. The effects remained stable when controlling for specific mediating variables such as symptom severity and intelligence in patients with schizophrenia. These findings are a first indication that social pressure and misleading information may impair source memory for everyday episodic memories in schizophrenia, and such impairment has clear consequences for treatment issues and forensic practice.

A theoretical framework for understanding recovered memory experiences.

If recovered memory experiences appear counter-intuitive, this is in part due to misconceptions about trauma and memory, and to a failure to adopt a comprehensive model of memory that distinguishes personal semantic memory, autobiographical event memory, and memory appraisal. Memory performance is generally superior when events, including traumas, are central to identity. Prolonged trauma in childhood, however, can produce severe identity disturbances that may interfere with the encoding and later retrieval of personal semantic and autobiographical event information. High levels of emotion either at encoding or recall can also interfere with the creation of coherent narrative memories. For example, high levels of shock and fear when memories are recovered unexpectedly may lead to the experience of vivid flashbacks. Memory appraisals may also influence the sense that an event has been forgotten for a long time. Recovered memories, although unusual, do not contradict what we know about how memory works.

Brief cognitive behavioural therapy for hallucinations: can it help people who decide not to take antipsychotic medication? A case report.

BACKGROUND: Cognitive behavioural therapy (CBT) can be helpful for many people who experience psychosis; however most research trials have been conducted with people also taking antipsychotic medication. There is little evidence to know whether CBT can help people who choose not to take this medication, despite this being a very frequent event. Developing effective alternatives to antipsychotics would offer service users real choice. AIMS: To report a case study illustrating how brief CBT may be of value to a young person experiencing psychosis and not wishing to take antipsychotic medication. METHOD: We describe the progress of brief CBT for a young man reporting auditory and visual hallucinations in the form of a controlling and dominating invisible companion. We describe the formulation process and discuss the impact of key interventions such as normalising and detached mindfulness. RESULTS: Seven sessions of CBT resulted in complete disappearance of the invisible companion. The reduction in frequency and duration followed reduction in conviction in key appraisals concerning uncontrollability and unacceptability. CONCLUSIONS: This case adds to the existing evidence base by suggesting that even short-term CBT might lead to valued outcomes for service users experiencing psychosis but not wishing to take antipsychotic medication.

The use of virtual reality in the study, assessment, and treatment of body image in eating disorders and nonclinical samples: a review of the literature.

This article reviews research into the use of virtual reality in the study, assessment, and treatment of body image disturbances in eating disorders and nonclinical samples. During the last decade, virtual reality has emerged as a technology that is especially suitable not only for the assessment of body image disturbances but also for its treatment. Indeed, several virtual environment-based software systems have been developed for this purpose. Furthermore, virtual reality seems to be a good alternative to guided imagery and in vivo exposure, and is therefore very useful for studies that require exposure to life-like situations but which are difficult to conduct in the real world. Nevertheless, review highlights the lack of published controlled studies and the presence of methodological drawbacks that should be considered in future studies. This article also discusses the implications of the results obtained and proposes directions for future research.

Children's discrimination of fantastic vs. realistic visual displays after watching a film with magical content.

Six- and nine-yr.-old children (n=28 of each) were divided into equal experimental and control groups. The experimental groups were shown a film with a magical theme, and the control groups were shown a film with a nonmagical theme. All groups then were presented with a choice task requiring them to discriminate between ordinary and fantastic visual displays on a computer screen. Statistical analyses indicated that mean scores for correctly identifying the ordinary and fantastic displays were significantly different between experimental and control groups. The children in the experimental groups who watched the magical film had significantly higher scores on correct identifications than children in the control groups who watched the nonmagical film for both age groups. The results suggest that watching films with a magical theme might enhance children's sensitivity toward the fantasy/reality distinction.