Multi-modal hallucinations across diagnoses: What relationships do they have with voice-related distress?

BACKGROUND: Research into hallucinatory experiences has focused primarily upon hallucinations within the auditory modality, to the relative neglect of other modalities. Furthermore, the exploration of auditory hallucinations (or 'voices') has focused primarily upon the experiences of people with a diagnosis of psychosis. The presence of multi-modal hallucinations may have implications across diagnoses for levels of distress, formulation and the targeting of psychological interventions. METHODS: This study presents a cross-sectional analysis of observational data from the PREFER survey (N = 335). Linear regression was used to explore the relationships between voice-related distress and the presence, number, type and timing of multi-modal hallucinations. RESULTS: Simple relationships were not found between distress and the presence of hallucinations in visual, tactile, olfactory or gustatory modalities, or in the number of modalities experienced. When considering the degree to which another modality hallucination was experienced simultaneously with voices, there was some evidence that the degree of co-occurrence with visual hallucinations was predictive of distress. CONCLUSIONS: The co-occurrence of voices with visual hallucinations may be associated with relatively greater distress, but not consistently, and the association between multimodal hallucinations and clinical impact appear complex and potentially variable from individual to individual. Further study of associated variables such as perceived voice power may further illuminate these relationships.

Self-Reported Pain Treatment Practices Among U.S. and Canadian Adults: Findings From a Population Survey.

Background and Objectives: Pain treatments and their efficacy have been studied extensively. Yet surprisingly little is known about the types of treatments, and combinations of treatments, that community-dwelling adults use to manage pain, as well as how treatment types are associated with individual characteristics and national-level context. To fill this gap, we evaluated self-reported pain treatment types among community-dwelling adults in the United States and Canada. We also assessed how treatment types correlate with individuals' pain levels, sociodemographic characteristics, and country of residence, and identified unique clusters of adults in terms of treatment combinations. Research Design and Methods: We used the 2020 "Recovery and Resilience" United States-Canada general online survey with 2 041 U.S. and 2 072 Canadian community-dwelling adults. Respondents selected up to 10 pain treatment options including medication, physical therapy, exercise, etc., and an open-ended item was available for self-report of any additional treatments. Data were analyzed using descriptive, regression-based, and latent class analyses. Results: Over-the-counter (OTC) medication was reported most frequently (by 55% of respondents, 95% CI 53%-56%), followed by "just living with pain" (41%, 95% CI 40%-43%) and exercise (40%, 95% CI 38%-41%). The modal response (29%) to the open-ended item was cannabis use. Pain was the most salient correlate, predicting a greater frequency of all pain treatments. Country differences were generally small; a notable exception was alcohol use, which was reported twice as often among U.S. versus Canadian adults. Individuals were grouped into 5 distinct clusters: 2 groups relied predominantly on medication (prescription or OTC), another favored exercise and other self-care approaches, one included adults "just living with" pain, and the cluster with the highest pain levels employed all modalities heavily. Discussion and Implications: Our findings provide new insights into recent pain treatment strategies among North American adults and identify population subgroups with potentially unmet need for more adaptive and effective pain management.

Relating Therapy for Distressing Voices in the Context of Anorexia Nervosa: A Case Series.

ABSTRACT: Voice hearing experiences are commonly reported by patients with anorexia nervosa (AN) and are associated with negative outcomes. The "eating disorder voice" (EDV) can be understood within relational frameworks. Relating therapy (RT) has offered encouraging outcomes when targeted at voice hearing experiences transdiagnostically but has not been evaluated in the context of AN. This study aimed to offer a preliminary and mixed methods exploration of RT for the EDV. RT was delivered to three participants with a diagnosis of AN who were distressed by an EDV. Weight, negative impact of voices, and eating disorder cognitions were assessed at baseline, posttherapy and at brief follow-up. Participant experiences were explored through exit interviews. Therapy was completed by all participants. Weight gain was reported by two participants and maintained at brief follow-up. Positive changes were not reported on other measures. Qualitative data were suggestive of positive experiences that facilitated assertive responding.

What's the impact of voice-hearing experiences on the social relating of young people: A comparison between help-seeking young people who did and did not hear voices.

Limited research has explored the specific impact of voice-hearing experiences upon the social relating of adolescents. This study examined the associations of voice-hearing in youth with social relating, and putative explanatory factors. An observational, cross-sectional design using a clinical comparison group was employed to examine historical and concurrent associations with voice-hearing. Thirty-four young people (age 14-18 years) with voice-hearing experiences and 34 young people who did not hear voices were recruited from NHS mental health services. Participants completed measures about social relating and potential explanatory factors. Analyses of covariance were used to examine between-group differences. Voice-hearers scored higher on negative schematic beliefs (self-beliefs, partial η2 = .163, p = .001; other-beliefs, partial η2 = .152, p =. 002) and depressive and anxiety symptoms (partial η2 = .23 and partial η2 = .24, p-s <. 001 respectively). The two groups did not differ significantly on childhood trauma levels (partial η2 = .02, p = .273), however, the voice-hearing group scored lower on premorbid adjustment (partial η2 = .19, p < .001). Hearing voices in help-seeking youth could be an indicator for social relating issues and holding negative schematic beliefs, and may be an indicator for of increased psychopathological complexity. Although poorer premorbid adjustment might indicate an early vulnerability to social relating difficulties, voice-hearing might be an aggravating factor and one that requires treatment.

Increasing access to CBT for psychosis patients: study protocol for a randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE3).

BACKGROUND: The National Institute for Health and Care Excellence (NICE) recommends that cognitive behaviour therapy (CBT) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBT. This is attributable, in part, to the resource-intensive nature of CBT. One response to this problem has been the development of CBT in brief formats that are targeted at a single symptom and are deliverable by briefly trained therapists. We have developed Guided self-help CBT (the GiVE intervention) as a brief form of CBT for distressing voices and reported evidence for the feasibility of a randomised controlled trial (RCT) when the intervention was delivered by briefly trained therapists (assistant psychologists). This study will investigate the clinical and cost-effectiveness of the GiVE intervention when delivered by assistant psychologists following a brief training. METHODS: This study is a pragmatic, two-arm, parallel group, superiority RCT comparing the GiVE intervention (delivered by assistant psychologists) and treatment as usual to treatment as usual alone, recruiting across three sites, using 1:1 allocation and blind post-treatment and follow-up assessments. A nested qualitative study will develop a model for implementation. DISCUSSION: If the GiVE intervention is found to be effective when delivered by assistant psychologists, this intervention could significantly contribute to increasing access to evidence-based psychological interventions for psychosis patients. Furthermore, implementation across secondary care services within the UK's National Health Service may pave the way for other symptom-specific and less resource-intensive CBT-informed interventions for psychosis patients to be developed and evaluated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN registration number: 12748453. Registered on 28 September 2022.

"Attitudes to voices": a survey exploring the factors influencing clinicians' intention to assess distressing voices and attitudes towards working with young people who hear voices.

Introduction: Due to the general psychopathological vulnerability of young people who hear distressing voices, research has stressed the importance for clinicians to assess this experience in youth. Nonetheless, the limited literature on the topic comes from studies with clinicians in adult health services and it primarily reports that clinicians do not feel confident in systematically assessing voice-hearing and doubt the appropriateness of doing so. We applied the Theory of Planned Behavior and identified clinicians' job attitudes, perceived behavioral control, and perceived subjective norms as putative predictors of their intent to assess voice-hearing in youth. Method: Nine hundred and ninety-six clinicians from adult mental health services, 467 from Child and Adolescent Mental Health (CAMHS) and Early Intervention in Psychosis (EIP) services and 318 primary care clinicians across the UK completed an online survey. The survey gathered data on attitudes toward working with people who hear voices, stigmatizing beliefs, and self-perceived confidence in voice-related practices (screening for, discussing and providing psychoeducation material about voice-hearing). Responses from youth mental health clinicians were compared with professionals working in adult mental health and primary care settings. This study also aimed to identify what youth mental health clinicians believe about assessing distressing voices in adolescents and how beliefs predict assessment intention. Results: Compared to other clinicians, EIP clinicians reported the most positive job attitudes toward working with young voice-hearers, the highest self-efficacy in voice-hearing practices, and similar levels of stigma. Job attitudes, perceived behavioral control and subjective norms explained a large part of the influences on clinician's intention to assess voice-hearing across all service groups. In both CAMHS and EIP services, specific beliefs relating to the usefulness of assessing voice-hearing, and perceived social pressure from specialist mental health professionals regarding assessment practices predicted clinician intention. Discussion: Clinicians' intention to assess distressing voices in young people was moderately high, with attitudes, subjective norms and perceived behavioral control explaining a large part of its variance. Specifically in youth mental health services, promoting a working culture that encourages opening and engaging in discussions about voice-hearing between clinicians, and with young people, and introducing supportive assessment and psychoeducation material about voice-hearing could encourage conversations about voices.

A Psychoeducational Workshop for the Parents of Young Voice Hearers: A Preliminary Investigation into Acceptability and Outcomes in an NHS Child and Adolescent Mental Health Service.

BACKGROUND: Hearing voices is a common experience in young people and can be associated with distress, self-harm, and an increased risk of attempting suicide. Many parents lack confidence in supporting young people who are distressed by voices. However, there are currently no evidence-based interventions to support the parents of young voice hearers. METHOD: This was an uncontrolled study exploring the preliminary acceptability and outcomes of a psychoeducation workshop for the parents of young people experiencing distressing voices within a Child and Adolescent Mental Health Service (CAMHS) in the UK's National Health Service. RESULTS: A total of 21 parents consented to participate, 15 attended a workshop and 10 provided complete data sets. Five workshops were delivered across a seven-month period. Qualitative feedback was suggestive of acceptability and highlighted possible adaptations in relation to inclusivity, content focus and delivery format. Participants reported increased confidence and improved attitudes and beliefs towards voice hearing. CONCLUSIONS: The findings from this study suggest that a psychoeducational workshop within a CAMHS context can be acceptable and helpful for parents of young people with distressing voice hearing experiences. Adaptations to the workshop are required to maximise inclusion, engagement, and outcomes.

Black-White Differences in Offspring Educational Attainment and Older Parents' Dementia.

Emerging research documents the health benefits of having highly educated adult offspring. Yet less is known about whether those advantages vary across racial groups. This study examines how offspring education is tied to parents' dementia risk for Black and White parents in the United States. Using data from the Health and Retirement Study, findings suggest that children's education does not account for the Black-White gap in dementia risk. However, results confirm that parental race moderates the relationship between children's education and dementia risk and that the association between children's education and parents' dementia risk is strongest among less-educated parents. Among less-educated parents, higher levels of children's attainment prevent the risk of dementia onset for Black parents, but low levels of offspring schooling increase dementia risk among White parents. The study highlights how offspring education shapes the cognitive health of social groups differently and points to new avenues for future research.

Dynamic Changes in the Association Between Education and Health in the United States.

Policy Points We reviewed some of the recent advances in education and health, arguing that attention to social contextual factors and the dynamics of social and institutional change provide critical insights into the ways in which the association is embedded in institutional contexts. Based on our findings, we believe incorporating this perspective is fundamentally important to ameliorate current negative trends and inequality in Americans' health and longevity.

Coping Strategy Enhancement for Auditory Verbal Hallucinations Within Routine Clinical Practice.

ABSTRACT: Auditory verbal hallucinations (AVH) are often multiple distressing experiences. Emerging evidence suggests that interventions informed by the principles of cognitive behavioral therapy, such as brief Cognitive Strategy Enhancement (brief-CSE), can reduce the distress related to AVH. The benefits of brief-CSE have been demonstrated for English-speaking patients. This uncontrolled pilot study, conducted in routine clinical practice, evaluated the benefits of brief-CSE within a group of French-speaking AVH hearers. Thirty-two patients were offered the brief-CSE intervention. Self-administered questionnaires were completed pre-post intervention. A significant reduction was observed in AVH distress, with a large effect size, and for more than half of the patients, this reduction was clinically meaningful. AVH severity and anxiety also decreased significantly. This study demonstrates that brief-CSE can be implemented in non-English-speaking routine clinical practice and can reduce several aspects of AVH subjective experience. There is a need to confirm these findings in a larger sample.

A systematic review and thematic synthesis of qualitative literature on personal recovery and voice hearing.

BACKGROUND: Personal recovery literature has been influential in the conceptualization of emotional distress and service provision. While personal recovery in psychosis has been well-studied, voice hearing literature has not been reviewed to elucidate recovery processes. METHOD: Five databases were systematically searched to identify relevant qualitative recovery literature. Twelve eligible studies were included in this review, and an appraisal tool was applied to assess quality. Thematic synthesis was used to examine the results. RESULTS: Three superordinate themes were found relating to 'Recovery Phases', 'Recovery Facilitators' and 'Barriers to Recovery'. Papers included descriptions of finding voices distressing initially yet moving towards integrating and accepting voices. Searching for meaning versus seeking distance from voices were pivotal processes to recovery pathways. Enabling and disrupting recovery experiences are discussed within a proposed model. CONCLUSIONS: Recovery in voice hearing is an individual and potentially ongoing process. Future research should seek to examine recovery factors in voice hearing longitudinally and add further evidence to the supportive role services can play in recovery and voice hearing.

Links between inflammation and immune functioning with cognitive status among older Americans in the Health and Retirement Study.

Elevated inflammation and poor immune functioning are tied to worse cognitive health. Both processes are fundamental to aging and are strongly implicated in the development of age-related health outcomes, including cognitive status. However, results from prior studies evaluating links between indicators of inflammation and immune function and cognitive impairment have been inconsistent due to biomarker selection, sample selection, and cognitive outcome. Using the Health and Retirement Study (HRS), a nationally representative study of older adults in the United States, we assessed how indicators of inflammation (neutrophil-lymphocyte ratio (NLR), albumin, CRP, IL6, IL10, IL-1Ra, sTNFR1, and TGFß1) and immune functioning (CMV, CD4+ TN/TM, and CD8+ TN/TM) are associated with cognitive status. First, to examine the association between each biomarker and cognitive status, we tested whether markers of inflammation and immune functioning varied across cognitive status categories. We found that dementia and cognitive impairment without dementia (CIND) were associated with elevated inflammation and poorer immune functioning across biomarkers except for CD4+ TN/TM. Next, we estimated multinomial logistic regression models to assess which biomarkers would continue to be associated with dementia and CIND, net of each other. In these models, albumin, cytokines, CMV, CD4+ TN/TM, and CD8+ TN/TM are associated with cognitive status. Because poor immune functioning and increased inflammation are associated with cognitive impairment, improving immune functioning and reducing inflammation may provide a mechanism for reducing ADRD risk in the population.

Caring for Carers (C4C): Results from a feasibility randomised controlled trial of positive written disclosure for older adult carers of people with psychosis.

BACKGROUND: Older adult carers of people who experience psychosis are at increased risk of developing physical and mental health problems due to the compounding factors of supporting their care-recipient and the health changes associated with ageing. Effective interventions exist but can be difficult to access and maintain prolonged engagement. Self-directed writing therapies, frequently referred to as Written Emotional Disclosure (WED), might be a suitable alternative intervention to improve the wellbeing of carers. METHODS: This study aimed to determine the feasibility (recruitment, retention and primary outcome completion) and acceptability of a specific WED intervention known as Positive Written Disclosure (PWD). Informal carers of people with psychosis were randomised to PWD, neutral writing or no writing. Quantitative outcomes including positive and negative affect, carer wellbeing, quality of life, depression, anxiety, stress, self-efficacy, leisure time satisfaction as well as health care utilisation were collected at baseline, 1-, 3-, and 6-month assessments. Qualitative feedback was also collected via questionnaire and semi-structured interviews from those randomised to either writing group. RESULTS: We successfully met our progression criteria, recruiting to target and within timeframes whilst attaining 97% retention and 84% primary outcome data completed at 6 months. Carers randomised to the positive writing group described the intervention as enabling them to have a more positive attitude and focus on activities for themselves. Both writing groups described their tasks as providing distraction from caring responsibilities. However, some carers found the narrow positive emotion focus challenging. CONCLUSIONS: PWD is a feasible and acceptable intervention for older adult carers of people with psychosis within a community setting. Further refinement of the writing protocol to include choice in type of emotion disclosed in addition to screening for some level of need may be required in future trials to reduce floor/ceiling effects of outcomes which may explain the lack of change observed.

U.S. state policy contexts and mortality of working-age adults.

The rise in working-age mortality rates in the United States in recent decades largely reflects stalled declines in cardiovascular disease (CVD) mortality alongside rising mortality from alcohol-induced causes, suicide, and drug poisoning; and it has been especially severe in some U.S. states. Building on recent work, this study examined whether U.S. state policy contexts may be a central explanation. We modeled the associations between working-age mortality rates and state policies during 1999 to 2019. We used annual data from the 1999-2019 National Vital Statistics System to calculate state-level age-adjusted mortality rates for deaths from all causes and from CVD, alcohol-induced causes, suicide, and drug poisoning among adults ages 25-64 years. We merged that data with annual state-level data on eight policy domains, such as labor and taxes, where each domain was scored on a 0-1 conservative-to-liberal continuum. Results show that the policy domains were associated with working-age mortality. More conservative marijuana policies and more liberal policies on the environment, gun safety, labor, economic taxes, and tobacco taxes in a state were associated with lower mortality in that state. Especially strong associations were observed between certain domains and specific causes of death: between the gun safety domain and suicide mortality among men, between the labor domain and alcohol-induced mortality, and between both the economic tax and tobacco tax domains and CVD mortality. Simulations indicate that changing all policy domains in all states to a fully liberal orientation might have saved 171,030 lives in 2019, while changing them to a fully conservative orientation might have cost 217,635 lives.

Smartphone-assisted guided self-help cognitive behavioral therapy for young people with distressing voices (SmartVoices): study protocol for a randomized controlled trial.

BACKGROUND: The long-standing view that auditory verbal hallucinations (AVH) or hearing voices is a sign of schizophrenia has been challenged by research demonstrating that they lie on a continuum ranging from normal to pathological experience related to distress and need for care. Hearing voices is more prevalent in adolescence than in later life, and hearing voices during adolescence indicates a risk for severe psychopathology, functional impairments, and suicide later in life. While there is increasing evidence for the efficacy of cognitive behavioral therapy for voices (CBTv) in adults with schizophrenia, research on psychological treatments for youth with distressing voices has been scarce. The aim of the current study is to examine the efficacy of CBTv, delivered using smartphone-based Ecological Momentary Assessment Intervention (EMI) in a transdiagnostic sample of youth. METHODS: This is a superiority randomized controlled trial comparing 8 weeks of CBTv-based EMI in addition to treatment as usual (TAU) versus TAU only. TAU covers both no treatment and any form of psychiatric/psychological treatment. In the EMI condition, participants will be prompted twice a day to complete an EMA survey, and receive one intervention proposal per assessment. One-hundred fifty-four youth aged 14-25 years with distressing voices will be recruited from psychiatric clinics, local private practices, internet forums, and advertisements in print and social media. Before and after the intervention phase, participants will undergo a 9-day EMA. Single-blinded assessments will be conducted at baseline (T0) and at 3-month (T1) and 6-month (T2) follow-up. The primary outcome is the distress dimension of the Auditory Hallucinations subscale of the Psychotic Symptom Rating Scales at T1. Secondary outcomes include perceived hostile intention, power, and dominance of voices, passive, aggressive, and assertive relating to voices, and negative core beliefs about the self. DISCUSSION: Adolescence provides a crucial window of opportunity for early intervention for hearing voices. However, youth are notoriously reluctant help-seekers. This study offers a low-intensity psychological intervention for youth with distressing voices beyond diagnostic boundaries that, using a mobile technology approach, may match the treatment preferences of the generation of "digital natives." TRIAL REGISTRATION: German Clinical Trials Register DRKS00026243. Registered on 2 September 2021.

Measuring the longitudinal course of voice hearing under psychological interventions: A systematic review.

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course and impact of voice hearing under these interventions and to evaluate how these variables change over time. Inclusion and exclusion criteria were applied, resulting in a total of 66 articles. Of these, 60 studies (28 RCTs, 23 uncontrolled, 9 non-randomised) were published in peer-reviewed journals, whilst 6 were recently completed or currently ongoing. The findings of this review suggest that a range of variables that are not directly relevant to psychological interventions have been used (e.g., depression, characteristics of voice hearing experience), whilst those directly impacted by psychological interventions (e.g., voice-related distress), broader concepts of outcome (e.g., functioning) and specific associated processes (e.g., self-schema) have received less attention. Findings also showed that the majority of variables demonstrated improvements, but effect sizes varied considerably across trials. This may be attributed to methodological differences such as statistical power, blinding, control groups and different methods of measurement. Our review highlights the importance of determining a set of outcomes that are directly targeted and should change under psychological interventions. Recommendations include the use of voice-related distress as a primary outcome. This can ultimately facilitate comparisons across studies and inform the development of psychological interventions.

Distress factors of voice-hearing in young people and social relating: Exploring a cognitive-interpersonal voice-hearing model.

OBJECTIVES: Little is known about the factors that can maintain the distress related to voice-hearing experiences in youth. Building upon understandings developed with adults, this study aimed to explore the associations between negative relating between hearer and voices, persecutory beliefs about voices and voice-related distress in a clinical sample of adolescents. The study also aimed to investigate associations between relating to voices and wider patterns of social relating. DESIGN: This was an observational, cross-sectional, survey study. METHODS: Thirty-four young people (age 14-18 years) who were hearing voices completed measures about voices (characteristics, relating and beliefs) and relating to social others (negative relating styles, social connectedness and belongingness). Participants were patients of NHS mental health services. Bivariate correlations explored associations between relating to voices and distress, beliefs about voices and distress, and between relating to voices and social relating variables. RESULTS: Perceiving the voices as dominant, intrusive, and persecutory and resisting them was significantly associated with distress. Adjusting for loudness and negative content rendered the association between persecutory beliefs and distress non-significant. Fear of separation and of being alone in relation to social others was associated with distancing from voices. Being suspicious, uncommunicative and self-reliant and/or being sadistic and intimidating towards social others was significantly associated with dependence towards the voices. Greater hearer-to-voice dependence was associated with lower perceived social belongingness and connectedness. CONCLUSIONS: Beliefs about voices being persecutory, dominant, intrusive and resisting voices seem to be significant contributors of distress in young people. In terms of proximity and power, relating to voices and social others appears to be contrasting.

Pilot evaluation of a brief training video aimed at reducing mental health stigma amongst emergency first responders (the ENHANcE II study).

BACKGROUND: First responders (i.e. police and ambulance staff) have increasingly become part of the mental health care system, often being the first port of call for those experiencing a crisis. Despite their frequent involvement in supporting those with mental health problems, there is evidence that mental health stigma is high amongst first responders. AIMS: The aim of the present study was to evaluate a brief training video aimed at reducing mental health stigma amongst first responders. METHODS: First responders watched a training video based on the cognitive behavioural model of mental health stigma, and involved contributions from people with lived experience, and first responders. Measures of mental health stigma were collected before and after viewing the training. RESULTS: The training video produced small but significant improvements in mental health stigma, and these effects did not differ between police and ambulance staff. We were unable to determine what psychological constructs mediated this change in stigma. The feedback on the training video was generally positive, but also indicated some key areas for future development. CONCLUSIONS: The present study provides encouraging evidence that levels of mental health stigma can be improved using a resource-light training intervention.

Coping strategy enhancement for the treatment of distressing voices in young people: A service evaluation within routine clinical practice.

BACKGROUND: Hearing voices is a common experience in young people, irrespective of diagnosis. This experience can be associated with distress, self-harm and an increased risk of attempting suicide. However, there are currently no evidence-based interventions which specifically target distressing voice hearing experiences in young people. METHOD: This was a service evaluation exploring the engagement, outcomes and experiences of young people who were offered a brief 4-session intervention for distressing voices within a Child and Adolescent Mental Health Service (CAMHS) in the UK's National Health Service. The intervention was based on the principles of Coping Strategy Enhancement (CSE). RESULTS: A total of 24 young people were offered the CSE intervention over a 20-month period. The intervention was completed by 15 young people. Pre-post outcomes suggested clinically meaningful reductions in the negative impact of voices for the majority of the young people. Qualitative feedback was positive and highlighted the value of both a space to talk about voice hearing experiences and a focus upon coping strategies. CONCLUSIONS: The findings from this service evaluation suggest that CSE can be a brief, acceptable and helpful way for young people within a CAMHS context to start a therapeutic conversation about their distressing voice hearing experiences.

Associations between responses to voices, distress and appraisals during daily life: an ecological validation of the cognitive behavioural model.

BACKGROUND: Cognitive models propose that behavioural responses to voices maintain distress by preventing disconfirmation of negative beliefs about voices. We used Experience Sampling Methodology (ESM) to examine the hypothesized maintenance role of behavioural responses during daily life. METHOD: Thirty-one outpatients with frequent voices completed a smartphone-based ESM questionnaire 10 times a day over 9 days, assessing voice-related distress; resistance and compliance responses to voices; voice characteristics (intensity and negative content); appraisals of voice dominance, uncontrollability and intrusiveness. RESULTS: In line with predictions, behavioural responses were associated with voice appraisals (dominance and uncontrollability), but not voice characteristics. Greater resistance and compliance were reported in moments of increased voice distress, but these associations did not persist after controlling for concurrent voice appraisals and characteristics. Voice distress was predicted by appraisals, and, unexpectedly, also by voice characteristics. As predicted, compliance and resistance were related to increases in distress at subsequent timepoints, whilst antecedent voice appraisals and characteristics had no such effect. Compliance, but not resistance, additionally predicted subsequent increases in voice uncontrollability. In both cases, the reverse models showed no association, indicating directional effects of responses on subsequent distress, and of compliance on uncontrollability appraisals. CONCLUSIONS: These results provide support for the cognitive model by suggesting that momentary behavioural and emotional responses to voices are associated with concurrent negative voice appraisals. Findings suggest that behavioural responses may be driven by voice appraisals, rather than directly by distress, and may in turn maintain voice appraisals and associated distress during the course of daily life.