Varieties of felt presence? Three surveys of presence phenomena and their relations to psychopathology.

BACKGROUND: Experiences of felt presence (FP) are well documented in neurology, neuropsychology and bereavement research, but systematic research in relation to psychopathology is limited. FP is a feature of sensorimotor disruption in psychosis, hypnagogic experiences, solo pursuits and spiritual encounters, but research comparing these phenomena remains rare. A comparative approach to the phenomenology of FP has the potential to identify shared and unique processes underlying the experience across these contexts, with implications for clinical understanding and intervention. METHODS: We present a mixed-methods analysis from three online surveys comparing FP across three diverse contexts: a population sample which included people with experience of psychosis and voice-hearing (study 1, N = 75), people with spiritual and spiritualist beliefs (study 2, N = 47) and practitioners of endurance/solo pursuits (study 3, N = 84). Participants were asked to provide descriptions of their FP experiences and completed questionnaires on FP frequency, hallucinatory experiences, dissociation, paranoia, social inner speech and sleep. Data and code for the study are available via OSF. RESULTS: Hierarchical linear regression analysis indicated that FP frequency was predicted by a general tendency to experience hallucinations in all three studies, although paranoia and gender (female > male) were also significant predictors in sample 1. Qualitative analysis highlighted shared and diverging phenomenology of FP experiences across the three studies, including a role for immersive states in FP. CONCLUSIONS: These data combine to provide the first picture of the potential shared mechanisms underlying different accounts of FP, supporting a unitary model of the experience.

Continuities and Discontinuities in the Cognitive Mechanisms Associated With Clinical and Nonclinical Auditory Verbal Hallucinations.

Auditory verbal hallucinations (AVHs) are typically associated with schizophrenia but also occur in individuals without any need for care (nonclinical voice hearers [NCVHs]). Cognitive models of AVHs posit potential biases in source monitoring, top-down processes, or a failure to inhibit intrusive memories. However, research across clinical/nonclinical groups is limited, and the extent to which there may be continuity in cognitive mechanism across groups, as predicted by the psychosis-continuum hypothesis, is unclear. We report two studies in which voice hearers with psychosis (n = 31) and NCVH participants reporting regular spiritual voices (n = 26) completed a battery of cognitive tasks. Compared with non-voice-hearing groups (ns = 33 and 28), voice hearers with psychosis showed atypical performance on signal detection, dichotic listening, and memory-inhibition tasks but intact performance on the source-monitoring task. NCVH participants, however, showed only atypical signal detection, which suggests differences between clinical and nonclinical voice hearers potentially related to attentional control and inhibition. These findings suggest that at the level of cognition, continuum models of hallucinations may need to take into account continuity but also discontinuity between clinical and nonclinical groups.

Tailoring cognitive behavioural therapy to subtypes of voice-hearing using a novel tabletised manual: a feasibility study.

BACKGROUND: Cognitive behavioural therapy for psychosis (CBTp) is a recommended treatment for psychotic experiences, but its effectiveness has been questioned. One way of addressing this may be to tailor therapy materials to the phenomenology of specific psychotic experiences. AIM: In this study, we investigated the acceptability of a novel treatment manual for subtypes of 'voice-hearing' experiences (i.e. auditory verbal hallucinations). An uncontrolled, single-arm design was used to assess feasibility and acceptability of using the manual in routine care for people with frequent voice-hearing experiences. METHOD: The manual was delivered on a smart tablet and incorporated recent research evidence and theory into its psychoeducation materials. In total, 24 participants completed a baseline assessment; 19 started treatment, 15 completed treatment and 12 participants completed a follow-up assessment (after 10 sessions of using the manual). RESULTS: Satisfaction with therapy scores and acceptability ratings were high, while completion rates suggested that the manual may be more appropriate for help with participants from Early Intervention in Psychosis services rather than Community Mental Health Teams. CONCLUSION: Within-group changes in symptom scores suggested that overall symptom severity of hallucinations - but not other psychosis features, or beliefs about voices - are likely to be the most appropriate primary outcome for further evaluation in a full randomised controlled trial.

Managing unusual sensory experiences: A feasibility trial in an At Risk Mental States for psychosis group.

OBJECTIVES: To conduct a feasibility study on a new, tablet-delivered treatment for unusual sensory experiences in service-users with an At Risk Mental States for psychosis. DESIGN: A mixed method design was employed, using content analysis to investigate whether service-users and therapists found the new treatment acceptable and helpful. We also collected data on the impact of treatment, but without a control group could not make any claims about effectiveness. METHODS: Eligible participants were contacted before starting treatment and offered the chance to participate. Assessments were conducted before and after the treatment, which typically was completed in 4-6 sessions by an accredited CBT therapist. A structured interview was used to collect qualitative feedback. RESULTS: Qualitative feedback suggested that the treatment was acceptable to service-users and therapists, and the progression criteria were met for recruitment, retention, and adherence to treatment. CONCLUSIONS: The new treatment targeting subtypes of auditory and visual hallucinations was acceptable to service-users and the benefits of addressing psychological mechanisms thought to contribute to hallucinations was supported by qualitative feedback. PRACTITIONER POINTS: A novel treatment has been developed for unusual sensory experiences based on subtyping voices and using technology to help explain psychological mechanisms that may be linked to hallucinations. The treatment was acceptable to service users and therapists in At Risk Mental States for psychosis services with qualitative feedback supporting the approach. The treatment may be particularly useful in preventing the progressions of psychosis as people who have not developed fixed ideas about the origin of the experiences may be more open to alternative explanations.

Inner experience differs in rumination and distraction without a change in electromyographical correlates of inner speech.

Ruminative thought is a style of thinking which involves repetitively focusing upon one's own negative mood, its causes and its consequences. The negative effects of rumination are well-documented, but comparatively little is known about how rumination is experienced. The evaluative nature of rumination suggests that it could involve more inner speech than non-ruminative states. The present study (N = 31) combined facial electromyography and self-report questionnaires to determine the type of inner experience that occurs in rumination. The results showed that induced rumination involved similar levels of muscle activity related to inner speech as periods of induced distraction. However, experience sampling and questionnaire responses showed that rumination involved more verbal thought, and also involved more evaluative and dialogic inner speech than distraction. These findings contribute to the understanding of inner speech as a flexible phenomenon and confirms the importance of employing multiple methods to investigate inner speech. Future research should clarify the link between inner speech in rumination and its negative effects on wellbeing.

Processing Speech and Thoughts during Silent Reading: Direct Reference Effects for Speech by Fictional Characters in Voice-Selective Auditory Cortex and a Theory-of-Mind Network.

Stories transport readers into vivid imaginative worlds, but understanding how readers create such worlds-populating them with characters, objects, and events-presents serious challenges across disciplines. Auditory imagery is thought to play a prominent role in this process, especially when representing characters' voices. Previous research has shown that direct reference to speech in stories (e.g., He said, "I'm over here") may prompt spontaneous activation of voice-selective auditory cortex more than indirect speech [Yao, B., Belin, P., & Scheepers, C. Silent reading of direct versus indirect speech activates voice-selective areas in the auditory cortex. Journal of Cognitive Neuroscience, 23, 3146-3152, 2011]. However, it is unclear whether this effect reflects differential processing of speech or differences in linguistic content, source memory, or grammar. One way to test this is to compare direct reference effects for characters speaking and thinking in a story. Here, we present a multidisciplinary fMRI study of 21 readers' responses to characters' speech and thoughts during silent reading of short fictional stories. Activations relating to direct and indirect references were compared for both speaking and thinking. Eye-tracking and independent localizer tasks (auditory cortex and theory of mind [ToM]) established ROIs in which responses to stories could be tracked for individuals. Evidence of elevated auditory cortex responses to direct speech over indirect speech was observed, replicating previously reported effects; no reference effect was observed for thoughts. Moreover, a direct reference effect specific to speech was also evident in regions previously associated with inferring intentions from communication. Implications are discussed for the spontaneous representation of fictional characters and the potential roles of inner speech and ToM in this process.

Reading characters in voices: Ratings of personality characteristics from voices predict proneness to auditory verbal hallucinations.

People rapidly make first impressions of others, often based on very little information-minimal exposure to faces or voices is sufficient for humans to make up their mind about personality of others. While there has been considerable research on voice personality perception, much less is known about its relevance to hallucination-proneness, despite auditory hallucinations being frequently perceived as personified social agents. The present paper reports two studies investigating the relation between voice personality perception and hallucination-proneness in non-clinical samples. A voice personality perception task was created, in which participants rated short voice recordings on four personality characteristics, relating to dimensions of the voice's perceived Valence and Dominance. Hierarchical regression was used to assess contributions of Valence and Dominance voice personality ratings to hallucination-proneness scores, controlling for paranoia-proneness and vividness of mental imagery. Results from Study 1 suggested that high ratings of voices as dominant might be related to high hallucination-proneness; however, this relation seemed to be dependent on reported levels of paranoid thinking. In Study 2, we show that hallucination-proneness was associated with high ratings of voice dominance, and this was independent of paranoia and imagery abilities scores, both of which were found to be significant predictors of hallucination-proneness. Results from Study 2 suggest an interaction between gender of participants and the gender of the voice actor, where only ratings of own gender voices on Dominance characteristics are related to hallucination-proneness scores. These results are important for understanding the perception of characterful features of voices and its significance for psychopathology.

Intentional inhibition but not source memory is related to hallucination-proneness and intrusive thoughts in a university sample.

Proneness to unusual perceptual states - such as auditory or visual hallucinations - has been proposed to exist on a continuum in the general population, but whether there is a cognitive basis for such a continuum remains unclear. Intentional cognitive inhibition (the ability to wilfully control thoughts and memories) is one mechanism that has been linked to auditory hallucination susceptibility, but most evidence to date has been drawn from clinical samples only. Moreover, such a link has yet to be demonstrated over and above relations to other cognitive skills (source monitoring) and cognitive states (intrusive thoughts) that often correlate with both inhibition and hallucinations. The present study deployed two tests of intentional inhibition ability - the Inhibition of Currently Irrelevant Memories (ICIM) task and Directed Forgetting (DF) task - and one test of source monitoring (a source memory task) to examine how cognitive task performance relates to self-reported i) auditory hallucination-proneness and ii) susceptibility to intrusive thoughts in a non-clinical student sample (N = 76). Hierarchical regression analyses were used to assess the independent and combined contributions of task performance to proneness scores. ICIM performance but not DF or source memory scores were significantly related to both hallucination-proneness and intrusive thoughts. Further analysis suggested that intrusive thoughts may mediate the link between intentional inhibition skills and auditory hallucination-proneness, suggesting a potential pathway from inhibition to perception via intrusions in cognition. The implications for studying cognitive mechanisms of hallucination and their role in "continuum" views of psychosis-like experiences are discussed.

Investigating the roles of medial prefrontal and superior temporal cortex in source monitoring.

Source monitoring, or the ability to recall the origin of information, is a crucial aspect of remembering past experience. One facet of this, reality monitoring, refers to the ability to distinguish between internally generated and externally generated information, biases in which have previously been associated with auditory verbal hallucinations in schizophrenia. Neuroimaging evidence suggests that medial prefrontal and superior temporal (STG) regions may play a role in reality monitoring for auditory verbal information, with evidence from a previous neurostimulation experiment also suggesting that modulation of excitability in STG may affect reality monitoring task performance. Here, two experiments are reported that used transcranial direct current stimulation (tDCS) to modulate excitability in medial prefrontal and superior temporal cortex, to further investigate the role of these brain regions in reality monitoring. In the first experiment (N = 36), tDCS was applied during the encoding stage of the task, while in the second experiment, in a separate sample (N = 36), it was applied during the test stage. There was no effect of tDCS compared to a sham condition in either experiment, with Bayesian analysis providing evidence for the null hypothesis in both cases. This suggests that tDCS applied to superior temporal or medial prefrontal regions may not affect reality monitoring performance, and has implications for theoretical models that link reality monitoring to the therapeutic effect of tDCS on auditory verbal hallucinations.

The varieties of inner speech questionnaire - Revised (VISQ-R): Replicating and refining links between inner speech and psychopathology.

Inner speech is a common experience for many but hard to measure empirically. The Varieties of Inner Speech Questionnaire (VISQ) has been used to link everyday phenomenology of inner speech - such as inner dialogue - to various psychopathological traits. However, positive and supportive aspects of inner speech have not always been captured. This study presents a revised version of the scale - the VISQ-R - based on factor analyses in two large samples: respondents to a survey on inner speech and reading (N = 1412) and a sample of university students (N = 377). Exploratory factor analysis indicated a five-factor structure including three previous subscales (dialogic, condensed, and other people in inner speech), an evaluative/critical factor, and a new positive/regulatory factor. Confirmatory factor analysis then replicated this structure in sample 2. Hierarchical regression analyses also replicated a number of relations between inner speech, hallucination-proneness, anxiety, depression, self-esteem, and dissociation.