Recent social stress and severity of auditory hallucinations.

BACKGROUND AND HYPOTHESIS: Hearing voices is a common and often distressing experience for people with psychosis, and many individuals experience medication-resistant auditory verbal hallucinations (AVH). Psychosocial interventions are often employed to address distress over hearing voices. However, although links have been made between adverse social experiences and psychosis broadly, no work has yet delineated the relationship between day-to-day social stress and hallucination severity. We aimed to define that relationship in both clinical and non-clinical voice-hearers. STUDY DESIGN: A sample of 278 participants with a history of hearing voices was selected from the Yale Control Over Perceptual Experiences (COPE) Project. They were administered self-report measures of recent stress and recent auditory experiences within a cross-sectional design. Regression models were used to evaluate whether self-reported aspects of recent stress-and social stress in particular-were related to recent frequency of and distress over hearing voices. Related demographics and clinical characteristics were included as covariates. STUDY RESULTS: A significant relationship was observed between recent social stress and both recent frequency of and distress over hearing voices. While other aspects of recent stress were also related to recent distress over voices, social stressors uniquely predicted distress over voice-hearing, beyond the influence of other stressors. Depressive symptom severity was also related to distress over voices. CONCLUSIONS: Results suggest that daily social stress may be an important consideration and a potential treatment target for individuals experiencing clinical distress over auditory hallucinations.

Evidence for Reduced Sensory Precision and Increased Reliance on Priors in Hallucination-Prone Individuals in a General Population Sample.

BACKGROUND: There is increasing evidence that people with hallucinations overweight perceptual beliefs relative to incoming sensory evidence. Past work demonstrating prior overweighting has used simple, nonlinguistic stimuli. However, auditory hallucinations in psychosis are often complex and linguistic. There may be an interaction between the type of auditory information being processed and its perceived quality in engendering hallucinations. STUDY DESIGN: We administered a linguistic version of the conditioned hallucinations (CH) task to an online sample of 88 general population participants. Metrics related to hallucination-proneness, hallucination severity, stimulus thresholds, and stimulus detection rates were collected. Data were used to fit parameters of a Hierarchical Gaussian Filter (HGF) model of perceptual inference to determine how latent perceptual states influenced task behavior. STUDY RESULTS: Replicating past results, higher CH rates were observed both in those with recent hallucinatory experiences as well as participants with high hallucination-proneness; CH rates were positively correlated with increased prior weighting; and increased prior weighting was related to hallucination severity. Unlike past results, participants with recent hallucinatory experiences as well as those with higher hallucination-proneness had higher stimulus thresholds, lower sensitivity to stimuli presented at the highest threshold, and had lower response confidence, consistent with lower precision of sensory evidence. CONCLUSIONS: We replicate the finding that increased CH rates and recent hallucinations correlate with increased prior weighting using a linguistic version of the CH task. Results support a role for reduced sensory precision in the interplay between prior weighting and hallucination-proneness.

Conditioned Hallucinations and Prior Overweighting Are State-Sensitive Markers of Hallucination Susceptibility.

BACKGROUND: Recent advances in computational psychiatry have identified latent cognitive and perceptual states that predispose to psychotic symptoms. Behavioral data fit to Bayesian models have demonstrated an overreliance on priors (i.e., prior overweighting) during perception in select samples of individuals with hallucinations, corresponding to increased precision of prior expectations over incoming sensory evidence. However, the clinical utility of this observation depends on the extent to which it reflects static symptom risk or current symptom state. METHODS: To determine whether task performance and estimated prior weighting relate to specific elements of symptom expression, a large, heterogeneous, and deeply phenotyped sample of hallucinators (n = 249) and nonhallucinators (n = 209) performed the conditioned hallucination (CH) task. RESULTS: We found that CH rates predicted stable measures of hallucination status (i.e., peak frequency). However, CH rates were more sensitive to hallucination state (i.e., recent frequency), significantly correlating with recent hallucination severity and driven by heightened reliance on past experiences (priors). To further test the sensitivity of CH rate and prior weighting to symptom severity, a subset of participants with hallucinations (n = 40) performed a repeated-measures version of the CH task. Changes in both CH frequency and prior weighting varied with changes in auditory hallucination frequency on follow-up. CONCLUSIONS: These results indicate that CH rate and prior overweighting are state markers of hallucination status, potentially useful in tracking disease development and treatment response.

Measuring Voluntary Control Over Hallucinations: The Yale Control Over Perceptual Experiences (COPE) Scales.

Auditory verbal hallucinations (AVH) frequently cause significant distress and dysfunction, and may be unresponsive to conventional treatments. Some voice-hearers report an ability to fully control the onset and offset of their AVH, making them significantly less disruptive. Measuring and understanding these abilities may lead to novel interventions to enhance control over AVH. Fifty-two voice-hearers participated in the pilot study. 318 participants with frequent AVH participated in the validation study. A pool of 59 items was developed by a diverse team including voice-hearers and clinicians. After the pilot study, 35 items were retained. Factorial structure was assessed with exploratory (EFA, n = 148) and confirmatory (CFA, n = 170) factor analyses. Reliability and convergent validity were assessed using a comprehensive battery of validated phenomenological and clinical scales. CFA on the final 18 items supported two factors for a Methods of Control Scale (5 items each, average ω = .87), and one factor for a Degree of Control Scale (8 items, average ω = .95). Correlation with clinical measures supported convergent validity. Degree of control was associated with positive clinical outcomes in voice-hearers both with and without a psychosis-spectrum diagnosis. Degree of control also varied with quality of life independently of symptom severity and AVH content. The Yale control over perceptual experiences (COPE) Scales robustly measure voice-hearers' control over AVH and exhibit sound psychometric properties. Results demonstrate that the capacity to voluntarily control AVH is independently associated with positive clinical outcomes. Reliable measurement of control over AVH will enable future development of interventions meant to bolster that control.

Computational Mechanism for the Effect of Psychosis Community Treatment: A Conceptual Review From Neurobiology to Social Interaction.

The computational underpinnings of positive psychotic symptoms have recently received significant attention. Candidate mechanisms include some combination of maladaptive priors and reduced updating of these priors during perception. A potential benefit of models with such mechanisms is their ability to link multiple levels of explanation, from the neurobiological to the social, allowing us to provide an information processing-based account of how specific alterations in self-self and self-environment interactions result in the experience of positive symptoms. This is key to improving how we understand the experience of psychosis. Moreover, it points us toward more comprehensive avenues for therapeutic research by providing a putative mechanism that could allow for the generation of new treatments from first principles. In order to demonstrate this, our conceptual paper will discuss the application of the insights from previous computational models to an important and complex set of evidence-based clinical interventions with strong social elements, such as coordinated specialty care clinics (CSC) in early psychosis and assertive community treatment (ACT). These interventions may include but also go beyond psychopharmacology, providing, we argue, structure and predictability for patients experiencing psychosis. We develop the argument that this structure and predictability directly counteract the relatively low precision afforded to sensory information in psychosis, while also providing the patient more access to external cognitive resources in the form of providers and the structure of the programs themselves. We discuss how computational models explain the resulting reduction in symptoms, as well as the predictions these models make about potential responses of patients to modifications or to different variations of these interventions. We also link, via the framework of computational models, the patient's experiences and response to interventions to putative neurobiology.

A Clinical Program for Transgender and Gender-Diverse Neurodiverse/Autistic Adolescents Developed through Community-Based Participatory Design.

Objective: A series of studies report elevated rates of autism and autistic characteristics among gender-diverse youth seeking gender services. Although youth with the co-occurrence present with complex care needs, existing studies have focused on co-occurrence rates. Further, clinical commentaries have emphasized provider-centered interpretations of clinical needs rather than key stakeholder-driven clinical approaches. This study aimed to employ community-based participatory research methodologies to develop a key stakeholder-driven clinical group program.Method: Autistic/neurodiverse gender-diverse (A/ND-GD) youth (N = 31), parents of A/ND-GD youth (N = 46), A/ND-GD self-advocates (N = 10), and expert clinical providers (N = 10) participated in a multi-stage community-based participatory procedure. Needs assessment data were collected repeatedly over time from A/ND-GD youth and their parents as the youth interacted with one another through ongoing clinical groups, the curriculum of which was developed progressively through the iterative needs assessments.Results: Separate adolescent and parent needs assessments revealed key priorities for youth (e.g., the importance of connecting with other A/ND-GD youth and the benefit of experiencing a range of gender-diverse role models to make gender exploration and/or gender affirmation more concrete) and parents (e.g., the need for A/ND-related supports for their children as well as provision of an A/ND-friendly environment that fosters exploration of a range of gender expressions/options). Integration and translation of youth and parent priorities resulted in 11 novel clinical techniques for this population.Conclusions: With generally high acceptability ratings for each component of the group program, this study presents a community-driven clinical model to support broad care needs and preferences of A/ND-GD adolescents.

"They Thought It Was an Obsession": Trajectories and Perspectives of Autistic Transgender and Gender-Diverse Adolescents.

Despite research exploring autism in gender-diverse adolescents, no studies have elicited these individuals' perspectives. In-depth interviews with 22 well-characterized autistic gender-diverse adolescents revealed critical themes, including: recollections of pre-pubertal gender nonconformity; vivid experiences of gender dysphoria; a fear of social gender expression due to perceived animosity toward transgender people; and specific challenges that result from the interplay of gender diversity and neurodiversity. During the ~ 22 month study social gender affirmation increased in six participants and gender dysphoria attenuated in four participants. Given the ethical imperative to understand and prioritize the voiced perspectives and needs of autistic gender minority adolescents as well as the discovery of shared themes and experiences in this population, results should inform clinical research approaches and priorities.