Examining the relationships between cognition and auditory hallucinations: A systematic review.

OBJECTIVE: Auditory hallucinations (hearing voices) have been associated with a range of altered cognitive functions, pertaining to signal detection, source-monitoring, memory, inhibition and language processes. Yet, empirical results are inconsistent. Despite this, several theoretical models of auditory hallucinations persist, alongside increasing emphasis on the utility of a multidimensional framework. Thus, clarification of current evidence across the broad scope of proposed mechanisms is warranted. METHOD: A systematic search of the Web of Science, PubMed and Scopus databases was conducted. Records were screened to confirm the use of an objective behavioural cognitive task, and valid measurement of hallucinations specific to the auditory modality. RESULTS: Auditory hallucinations were primarily associated with difficulties in perceptual decision-making (i.e. reduced sensitivity/accuracy for signal-noise discrimination; liberal responding to ambiguity), source-monitoring (i.e. self-other and temporal context confusion), working memory and language function (i.e. reduced verbal fluency). Mixed or limited support was observed for perceptual feature discrimination, imagery vividness/illusion susceptibility, source-monitoring for stimulus form and spatial context, recognition and recall memory, executive functions (e.g. attention, inhibition), emotion processing and language comprehension/hemispheric organisation. CONCLUSIONS: Findings were considered within predictive coding and self-monitoring frameworks. Of concern was the portion of studies which - despite offering auditory-hallucination-specific aims and inferences - employed modality-general measures, and/or diagnostic-based contrasts with psychologically healthy individuals. This review highlights disparities within the literature between theoretical conceptualisations of auditory hallucinations and the body of rigorous empirical evidence supporting such inferences. Future cognitive investigations, beyond the schizophrenia-spectrum, which explicitly define and measure the timeframe and sensory modality of hallucinations, are recommended.

Exploring the cognitive profiles related to unimodal auditory versus multisensory hallucinations in schizophrenia-spectrum disorders.

INTRODUCTION: Hallucinations can be experienced across multiple sensory modalities, but psychiatric studies investigating the cognitive mechanisms of hallucinations have been somewhat restricted to the auditory domain. This study explored the cognitive profiles of individuals experiencing multisensory hallucinations (MH) in schizophrenia-spectrum disorders (SSD) and compared these to those experiencing unimodal auditory hallucinations (AH) or no hallucinations (NH). METHODS: Participants included SSD patients (n = 119) stratified by current hallucination status (NH, AH, MH) and nonclinical controls (NCs; n = 113). Group performance was compared across several cognitive domains: speed of processing, attention, working memory, verbal learning, visual learning, reasoning and problem-solving, social cognition, and inhibition. RESULTS: The clinical groups performed worse than NCs but differences between the clinical groups were not evident across most cognitive domains. Exploratory analyses revealed that the MH group was more impaired on the visual learning task compared to the NH (but not AH) group. CONCLUSIONS: Preliminary results suggest that impaired visual learning may be related to MH. This could be attributed to the presence of visual hallucinations (VH), or greater psychopathology, in this group. However, replication is needed, as well as the investigation of other potential cognitive mechanisms of MH.

A phenomenological comparison of auditory hallucinations between borderline personality disorder and schizophrenia: A systematic review.

OBJECTIVE: Borderline personality disorder (BPD) with auditory hallucinations (AHs) may inadvertently be misdiagnosed with a primary psychotic disorder, such as schizophrenia (SZ). This misidentification can lead to challenges in providing effective psychological treatment. This review therefore aims to identify the phenomenological characteristics of AHs in BPD in comparison to SZ, as well as psychological interventions that explicitly target AHs in BPD. METHODS: A systematic review was conducted to summarise the existing evidence base regarding the phenomenological similarities and differences of AHs in BPD and SZ, along with the identification of psychological interventions for AHs in BPD. RESULTS: Eighteen studies were eligible for inclusion. Compared to the SZ group, BPD clients were characterised by more persistent and repetitive AHs, significantly more voice-related distress and appraisals of omnipotence, and an earlier age of onset of AHs. The BPD group also reported more severe depression and anxiety, a higher incidence of childhood trauma, and more negative self-schema. Cognitive Behaviour Therapy Coping Strategy Enhancement (CBT-CSE) might be a promising intervention to reduce AH-related distress in BPD, although further studies are required to determine its effectiveness. CONCLUSION: In order to prevent misdiagnosis of AHs in BPD, the DSM-5 may need to acknowledge the broader and more frequent occurrence of psychosis symptoms in BPD clients. Such clarification may enhance diagnostic practices and facilitate more timely access to treatment. There is also a need to develop and trial psychological interventions that explicitly target AHs in BPD.

Neither saintly nor psychotic: a narrative systematic review of the evolving Western perception of voice hearing.

We present a social-historical perspective on the evolution of the voice-hearing phenomenon in Western society. Based upon a systematic search from a selection of nine databases, we trace the way hearing voices has been understood throughout the ages. Originally, hearing voices was considered a gifted talent for accessing the divine, but the progressive influence of monotheistic religion gradually condemned the practice to social marginalization. Later, the medical and psychiatric professions of secular society were instrumental in attaching stigma to both voice hearers and the phenomenon itself, thereby reinforcing social exclusion. More recently, the re-integration of voice hearers into the community by health authorities in various countries appears to have provided a new, socially acceptable setting for the phenomenon.

Recovery of auditory evoked response attentional gain modulation following the first psychotic episode indexes improvements in symptom severity.

Attentional control of auditory N100/M100 gain is reduced in individuals with first-episode psychosis (FEP). Persistent problems with executive modulation of auditory sensory activity may impact multiple aspects of psychosis. As a follow-up to our prior work reporting deficits in attentional M100 gain modulation in auditory cortex, we examined changes in M100 gain modulation longitudinally, and further examined relationships between auditory M100 and symptoms of psychosis. We compared auditory M100 in auditory sensory cortex between 21 FEP and 29 matched healthy participants and between timepoints separated by 220 ± 100 days. Magnetoencephalography data were recorded while participants alternately attended or ignored tones in an auditory oddball task. M100 was measured as the average of 80-140 ms post-stimulus in source-localized evoked responses within bilateral auditory cortex. Symptoms were assessed using the PANSS and PSYRATS. M100 amplitudes, attentional modulation of M100 amplitudes, and symptom severity all improved in FEP over time. Further, improvement in M100 modulation correlated with improvements in negative symptoms (PANSS) as well as physical, cognitive, and emotional components of hallucinations (PSYRATS). Conversely, improvements in the overall size of the M100, rather than the difference between active and passive M100 amplitudes, were related to worsening of positive symptoms (PANSS) and physical components of hallucinations. Results indicate a link between symptoms (particularly auditory hallucinations) and auditory cortex neurophysiology in FEP, where auditory attention and auditory sensation have opposed relationships to symptom change. These findings may inform current models of psychosis etiology and could provide nonpharmaceutical avenues for early intervention.

Voice phenomenology as a mirror of the past.

BACKGROUND: Post-traumatic mechanisms are theorised to contribute to voice-hearing in people with psychosis and a history of trauma. Phenomenological links between trauma and voices support this hypothesis, as they suggest post-traumatic processes contribute to the content of, and relationships with, voices. However, research has included small samples and lacked theory-based comprehensive assessments. METHOD: In people with distressing voices (n = 73) who experienced trauma prior to voice-hearing, trauma-voice links were assessed both independently and dependently (descriptions were presented and rated separately and together, respectively) by both participants and researchers. A structured coding frame assessed four types of independent links (i.e. victimisation type, physiological-behavioural, emotional, and cognitive response themes including negative self-beliefs) and three types of dependent links: relational (similar interaction with/response to, voice and trauma); content (voice and trauma content are exactly the same); and identity (voice identity is the same as perpetrator). RESULTS: Independent links were prevalent in participants (51-58%) and low to moderately present in researcher ratings (8-41%) for significant themes. Identification of negative self-beliefs in trauma was associated with a significantly higher likelihood of negative self-beliefs in voices [participants odds ratio (OR) 9.8; researchers OR 4.9]. Participants and researchers also reported many dependent links (80%, 66%, respectively), most frequently relational links (75%, 64%), followed by content (60%, 25%) and identity links (51%, 22%). CONCLUSION: Trauma appears to be a strong shaping force for voice content and its psychological impact. The most common trauma-voice links involved the experience of cognitive-affective psychological threat, embodied in relational experiences. Trauma-induced mechanisms may be important intervention targets.

Exploration of the role of emotional expression of treatment-resistant schizophrenia patients having followed virtual reality therapy: a content analysis.

BACKGROUND: Emotional responses are an important component of psychotherapeutic processes. Avatar therapy (AT) is a virtual reality-based therapy currently being developed and studied for patients suffering from treatment resistant schizophrenia. Considering the importance of identifying emotions in therapeutical processes and their impact on the therapeutic outcome, an exploration of such emotions is needed. METHODS: The aim of this study is to identify the underlying emotions at the core of the patient-Avatar interaction during AT by content analysis of immersive sessions transcripts and audio recordings. A content analysis of AT transcripts and audio recordings using iterative categorization was conducted for 16 patients suffering from TRS who underwent AT between 2017 and 2022 (128 transcripts and 128 audio recordings). An iterative categorization technique was conducted to identify the different emotions expressed by the patient and the Avatar during the immersive sessions. RESULTS: The following emotions were identified in this study: Anger, Contempt/ Disgust, Fear, Sadness, Shame/ Embarrassment, Interest, Surprise, Joy and Neutral. Patients expressed mostly neutral, joy and anger emotions whereas the Avatar expressed predominantly interest, disgust/contempt, and neutral emotions. CONCLUSIONS: This study portrays a first qualitative insight on the emotions that are expressed in AT and serves as a steppingstone for further investigation in the role of emotions in the therapeutic outcomes of AT.

Decreased insight, but not self-stigma or belief about medicine, is associated with greater severity of delusions in a sample of long-stay patients with schizophrenia: a cross-sectional study.

BACKGROUND: There are, to date, limited and inconsistent findings concerning the relationship between insight and psychotic symptoms, despite some evidence in favor of the clinical and therapeutic relevance of the insight construct. We aimed to add to the pool of the available data in this area, by examining the correlations between the severity of insight and positive psychotic symptoms (delusions and auditory hallucinations), while accounting for self-stigma and attitudes towards medication, in a sample of long-stay inpatients with schizophrenia. METHODS: A cross-sectional study was conducted at the Psychiatric Hospital of the Cross, between July and October 2021. A total of 82 patients diagnosed with schizophrenia (aged 55.55 ± 10.21 years, 54.9% males) were enrolled. The semi-structured psychotic symptom rating scales, the Birchwood Insight Scale, the Belief About Medicine Questionnaire, and the Internalized Stigma of Mental Illness were used. RESULTS: The mean duration of illness in years was 30.15 ± 11.73, and the mean duration of hospitalization in years was 17.56 ± 9.24. Sixteen out of the 82 patients (19.5%) were considered as having poor insight. Bivariate analyses showed that higher chlorpromazine equivalent dose was significantly associated with more delusions, whereas higher insight was significantly associated with lower delusions. Multivariable analyses revealed that Higher chlorpromazine equivalent dose (Beta = 0.004) was significantly associated with more delusions, whereas higher insight (Beta = - 0.89) was significantly associated with less delusions. No significant associations were found between insight, self-stigma and hallucinations. CONCLUSION: Our results imply that more impaired insight is associated with greater severity of delusions, above and beyond the effects of self-stigma and medication doses. These findings are valuable to aid clinicians and researchers improve their understanding of the relationship insight-psychotic symptoms, and could help personalize prevention and early intervention strategies in schizophrenia.

A case series study of compassion-focused therapy for distressing experiences in psychosis.

OBJECTIVES: Compassion-focused therapy (CFT) is an evolution-informed biopsychosocial approach that seeks to cultivate attachment and care motivational systems and their psychophysiological regulators. These can counteract some of the harmful effects of social threat, inferiority, shame, self-criticism and depression, which are common in people with psychosis and undermine their well-being, social trust and ability to feel safe. This study aimed to test the acceptability of a novel manualized individual CFT intervention for psychosis (CFTp). DESIGN: A non-concurrent, multiple-baseline, case series design, with three phases: baseline, intervention and follow-up. METHODS: The 26-session CFTp intervention was provided for a sample of eight people with distressing psychotic experiences and a psychosis-related diagnosis. The study aimed to assess acceptability of CFTp and to test clinically reliable improvements while receiving the intervention, compared to a baseline period. RESULTS: Seven of eight participants completed the therapy, and clinically reliable improvements were found at both the single-case and group level of analysis. At the single-case level, over half the participants showed improvements in depression (5/7), stress (5/7), distress (5/7), anxiety (4/7) and voices (3/5). One participant showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level (n = 7), there were significant improvements in depression, stress, distress, voices and delusions. The improvements in voices, delusions and distress were sustained at 6- to 8-week follow-up, but depression and stress dropped slightly to trend-level improvements. CONCLUSIONS: CFTp is a feasible and acceptable intervention for psychosis, and further investigation is warranted with a randomized controlled trial.

I Hear My Voice; Therefore I Spoke: The Sense of Agency Over Speech Is Enhanced by Hearing One's Own Voice.

The subjective experience of causing an action is known as the sense of agency. Dysfunctional sense of agency over speech has been suggested as a cause of auditory hallucinations. However, agency over speech has not been extensively characterized in previous empirical studies. Here, we manipulated self-voice identity, an indicator of self, embedded in the acoustic quality of voice and examined implicit and explicit measures of the sense of agency. Experiment 1 (N = 29 adults) demonstrated more compression of a perceived interval between action and outcome when participants heard their undistorted voices than their pitch-distorted voices. Experiment 2 (N = 28 adults) revealed a strong top-down effect of self-voice identity: Specifically, the judgment of agency over speech was more resistant than the judgment of agency over hand/limb movement to low-level sensorimotor inconsistency. Our findings provide new insight into the sense of agency over speech and an informative perspective for understanding aberrant experience in auditory hallucinations.

A systematic review of relational-based therapies for the treatment of auditory hallucinations in patients with psychotic disorders.

BACKGROUND: Auditory hallucinations in patients with psychotic disorders may be very distressing. Unfortunately, a large proportion of individuals are resistant to pharmacological interventions and the gold-standard cognitive-behavioral therapy for psychosis offers at best modest effects. To improve therapeutic outcomes, several therapies have been created to establish a relationship between voice-hearers and their voices. With increasing literature, we conducted a systematic review of dialogical therapies and examined the evidence behind their efficacy. METHODS: A systematic search was performed in PubMed, PsycINFO, Web of Science, and Google Scholar. Articles were included if they discussed the effects of dialogical interventions for patients with psychotic disorders. RESULTS: A total of 17 studies were included within this systematic review. Cumulative evidence from various therapies has shown that entering in a dialog with voices is beneficial to patients, even those who are resistant to current pharmacological treatments. Heightened benefits have been mainly observed with Relating Therapy and Avatar Therapy/Virtual Reality assisted Therapy, with evidence generally of moderate quality. Both these interventions have shown large to very large effects on voices and voice-related distress as well as moderate to large magnitude improvements on affective symptoms. Though, cognitive-behavioral therapy for command hallucinations and making sense of voices noted no improvements on voices. CONCLUSIONS: Literature on relational-based interventions with a strong emphasis on the relational aspects of voice hearing has shown positive effects. Results suggest that these dialogical therapies might surpass the efficacy of current gold-standard approaches.

Participants' experiences of AVATAR therapy for distressing voices: a thematic qualitative evaluation.

BACKGROUND: AVATAR therapy is an innovative therapy designed to support people with distressing voices. Voice hearers co-create a digital representation of their voice and engage in dialogue with it. Although it has been successfully tested in a powered randomised controlled trial (ISRCTN65314790), the participants' experience of this therapy has not been yet evaluated. We aimed to explore enablers and barriers to engagement with the therapy and potential for real-world impact on distressing voices. METHODS: Thirty per cent of those who completed AVATAR therapy (15 people in total) and 5 who dropped out from therapy within the main AVATAR RCT were invited to participate in a semi-structured interview, which was audio-recorded and subsequently transcribed. RESULTS: Fourteen therapy completers (28% of the full sample) and one person who dropped out of therapy after 1 active session, were interviewed. Thematic analysis was used to explore the interviews. A total of 1276 references were coded, and five overarching themes identified: AVATAR therapy set-up; voice embodiment and associated emotions; working in a safe space (supported by the therapist); learning new ways of relating to the voices; impact of therapy on everyday life. Overall, the therapy set-up, with its digital components and its distinctive features as compared with common face-to-face talking therapies, was satisfactory. The inclusion of technology was well accepted as both a means to deliver the therapy and a tool to create a digital representation of the person's distressing voice. The co-creation of the avatar and the enactment of the relationship between the person and the voice were perceived as a very helpful process to promote the therapeutical dialogue. Participants reported engaging well with the therapist and feeling supported and identified specific learnt strategies to deal with the voices and how they have had an impact on everyday life. CONCLUSIONS: AVATAR therapy is acceptable and provides benefit for participants with psychosis. Our results highlighted the enablers and challenges of working dialogically with distressing voices using a digital representation and dealing with highly demanding emotional, cognitive, and relational processes linked to the experience. Our analysis also identified the core strategies learnt by participants and how these were generalised to their daily life resulting into a positive change in different domains, and in particular broader social relationships.

The "common" experience of voice-hearing and its relationship with shame and guilt: a systematic review.

BACKGROUND: Despite Auditory Verbal Hallucinations (AVHs) having been long associated with mental illness, they represent a common experience also in the non-clinical population, yet do not exhibit distress or need for care. Shame and guilt are emotions related to one's perception of oneself and one's responsibility. As such, they direct our attention to aspects of AVHs that are under-researched and elusive, particularly about the status of voices as others, their social implications and the constitution and conceptualisation of the self. OBJECTIVES: This paper aims to provide a systematic review of studies that investigated the relationship between auditory hallucinations, shame, and guilt in people without relevant signs of psychiatric issues. METHODS: We searched studies reporting information about voices characteristics, the relationship between voices and hearers, hearer's reactions, and beliefs, paying peculiar attention to shame and guilt issues. Included papers were evaluated for risk of bias. RESULTS: Eleven studies that explored the relationship between AVHs, shame and guilt, were extracted. Phenomenological, pragmatic, as well as neuropsychological features of hearing voices in non-clinical populations, allowed us to note a dynamic relationship and the constellation of subjective experiences that can occur. The role of guilt was characterized by few studies and mixed results, while shame was mainly common. CONCLUSIONS: Due to the high heterogeneity detected and the scarce sources available, further studies should focus on both the aetiology and the bidirectional relationship between hearing voices, shame, and guilt in non-clinical people. This can be helpful in therapies for non-clinical populations who are distressed by their voices (e.g., psychotherapy), and for whom shame, and guilt may contribute to negative consequences such as isolation, anxiety or future depression. Moreover, it might favour the development and implication of different treatments considering emotion regulation, distress tolerance and interpersonal sensitivity on the clinical populations.

Metabolomics and Cytokine Analysis for Identification of Schizophrenia with Auditory Hallucination.

PURPOSE: To investigate the metabolic profile and biomarkers of schizophrenia with auditory hallucinations (AHs). METHODS: A total of 18 schizophrenic patients with the symptom of pure AHs (pAHs), 28 without AH (nAHs) and 43 age-matched healthy persons (Con) were enrolled in this study. Participants in pAHs and nAHs groups had relapsed into exacerbations of psychosis after self-discontinuing antipsychotics for at least one month; blood samples were drawn prior to restarting anti-psychotic treatment. Participants with history of recreational substance use were excluded. Positive and Negative Syndrome Scale (PANSS) and Auditory Hallucinations Rating Scale (AHRS) were used to assess the clinical mental state of all samples. Enzyme-linked immunosorbent assay (ELISA) was used to estimate the level of cytokines, and metabolomics analysis to identify potential biomarkers and pathways in the three groups. Graphpad 8.0 software was used to calculate the area under the receiver operating characteristic (ROC) curve. The relationship between metabolites and cytokines were determined using correlation analysis. RESULTS: Questionnaire scores showed significant differences in the positive symptom scale and PANSS total between nAHs and pAHs groups. Four cytokines (BDNF, IL-2, NGF-ß and TNF-α) differed significantly among the three groups. Six molecules in the nAHs group (phenylalanine, hippurate, serine, glutamate, valine and cystine) and four in the pAHs group (phenylalanine, serine, glutamate and cystine) were identified as potential biomarkers. In addition, phenylalanine was shown as a potential independent diagnostic biomarker for pAHs. Correlation analysis revealed that cystine and serine were significantly negatively correlated with IL-2 in the pAHs group. CONCLUSIONS: This study revealed the metabolic profile of patients with schizophrenia with AHs and provided new information to support the diagnosis. The identification of unique biomarkers would contribute to objective and reliable diagnoses of patients with schizophrenia with AH.

Cingulum bundle integrity in schizophrenia with auditory verbal hallucinations: A diffusion tensor imaging tractographic study.

Background & objectives: Cingulum bundle (CB) is frequently implicated in schizophrenia; however, its role in specific symptoms of schizophrenia such as auditory verbal hallucinations (AVHs) is less explored. Few studies have reported association between reduced integrity of CB and severity of AVH. Using a symptom-based approach, this diffusion tensor imaging (DTI) tractographic study was aimed to assess and compare the integrity of CB in schizophrenia with AVH, schizophrenia without AVH and healthy controls. Methods: A total of 92 right-handed adult individuals (aged 18-50 yr) were recruited across three study groups. Those with Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) diagnosis of schizophrenia with AVH (group I; n=30) were compared to those with DSM-5 schizophrenia without lifetime AVH (group II; n=32) and healthy controls (group III; n=30; screened using Mini International Neuropsychiatric Interview version-7.0.0. and negative family history). Clinical assessments (groups I and II) included scale for assessment of positive symptoms, scale for assessment of negative symptoms, clinical global impression-schizophrenia and psychotic symptom rating scale. All participants underwent DTI, and quantitative tract-based measurements of fractional anisotropy (FA) were obtained for images using DTI studio version-3.0. Results: All groups were comparable for age, gender, education and severity of illness. Group I had significantly lower FA values in the cingulate gyrus (CG) part of the left CB compared to groups II and III. No significant difference was found between groups II and III. Interpretation & conclusions: The findings of this study suggest that the disruption in the left CB appears to be specific for AVH-positive schizophrenia. The finding is, however, preliminary subject to replication in future studies. Further investigations are needed to understand its relevance in the context of AVH-positive schizophrenia.

A narrative review of psychological theories of post-traumatic stress disorder, voice hearing, and other psychotic symptoms.

BACKGROUND: Most voice hearers report childhood trauma. Many voice hearers report comorbid post-traumatic stress symptoms and that the content of their voices (auditory verbal hallucinations) is directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma is thematically similar) related to their trauma. The factors that maintain trauma-related voices are unknown, and there is limited research in this area. This study aimed to identify potential maintaining factors of trauma-related voices by reviewing models of post-traumatic stress disorder (PTSD) and positive symptoms of psychosis. METHOD: Models of PTSD and positive symptoms were reviewed to identify potential factors that are unique and common to both sets of symptoms. RESULTS: We reviewed 10 models of PTSD, 4 models of positive symptoms, and 2 trauma-informed models of voice hearing. One model provided a theoretical explanation of different types of trauma-related voices. Twenty-one factors were extracted from 16 theoretical models. No existing model incorporated all these factors. DISCUSSION: Existing PTSD and positive symptom models present a range of common and unique factors. There may be value in extending existing integrative models to include a broader range of potential factors that could explain different pathways to, and expressions of, trauma-related voices. A future research agenda is presented to investigate how such an extension could lead to more complete individualized case formulations and targeted treatments.

Brief coping strategy enhancement for the treatment of distressing voices in the context of borderline personality disorder: A comparison with outcomes in the context of psychosis.

BACKGROUND: Voice hearing in the context of Borderline Personality Disorder (BPD) has traditionally been regarded as transient and an experience that lacks legitimacy. Consequently, there are no evidence-based treatments for the voices reported by BPD patients. Contrary to the traditional view, there is a growing literature suggesting that voice hearing in the context of BPD can be an enduring and distressing experience which shares similarities with voice hearing in the context of psychosis. Given these similarities, the aim of this study was to explore whether brief Coping Strategy Enhancement developed in the context of psychosis can be used to treat distressing voice hearing in the context of BPD. METHOD: This was a service evaluation carried out in a specialist NHS service delivering psychological therapies for distressing voices. Patients with either a BPD (n = 46) or a psychosis diagnosis (n = 125) received four sessions of Coping Strategy Enhancement (CSE). The primary outcome was voice-related distress. The pre-post outcomes for BPD patients were explored and compared with those achieved by the psychosis patients. RESULTS: Both the BPD and psychosis groups experienced a significant reduction in voice-related distress after CSE compared with baseline. The interaction between diagnosis group and time was small and statistically non-significant. CONCLUSION: These findings suggest a brief CSE intervention developed in the context of psychosis can be an effective starting point in the treatment of distressing voice hearing in the context of BPD. Such interventions have the potential to be integrated into broader BPD treatment programmes for those who hear voices.

Dissociation as a Mediator Between Childhood Abuse and Hallucinations: An Exploratory Investigation Using Dissociative Identity Disorder and Schizophrenia Spectrum Disorders.

Previous research has shown that the relationship between childhood abuse and the presence of auditory hallucinations is mediated by dissociation, specifically depersonalization and absorption. The current study assessed dissociation as a mediator of the relationship between childhood abuse and auditory hallucination frequency, characteristics and associated distress in those with dissociative identity disorder (DID; n = 50) and schizophrenia spectrum disorders (SSD; n = 49). It also tested whether dissociation mediated the relationship between childhood abuse and the presence of non-auditory hallucinations. Participants completed measures of childhood abuse, dissociation, auditory hallucination frequency, characteristics, distress, and non-auditory hallucinations. With distress associated with auditory hallucinations as the outcome, depersonalization was a mediator in the DID group. For non-auditory hallucinations, in the DID group depersonalization and amnesia were mediators between childhood abuse and the presence of visual, tactile and olfactory hallucinations. In the SSD group absorption mediated between childhood abuse and visual, olfactory and gustatory hallucinations. Results suggest that the presence of non-auditory hallucinations in DID and SSD are associated with different dissociative experiences.

'Is hearing believing?': A study of voices and beliefs in psychosis and trauma.

OBJECTIVE: This study compared voice characteristics and beliefs in participants diagnosed with post-traumatic stress disorder (PTSD) with dissociation, schizophrenia (SCZ) and both diagnoses of SCZ and PTSD. The relationship between dissociation and voice beliefs was also assessed. METHOD: We identified 56 participants meeting the diagnostic criteria for PTSD with dissociation, SCZ or both diagnoses (PTSD + SCZ) who also experienced auditory hallucinations. Measures included PTSD Symptoms Scales Interview (PSSI-5), Psychotic Symptoms Rating Scale (PSYRAT), Clinician Administered Dissociative States Scale (CADSS), Beliefs about Voices Questionnaire (BAVQ) and Positive and Negative Syndrome Scale (PANSS). RESULTS: Beliefs about voices were similar across diagnostic groups. Participants with SCZ were more likely to attribute their voices to an external origin, and participants with dual diagnosis were less able to control their voices. The PTSD-only group scored higher in dissociation scores than either the SCZ-only or dual diagnosis group. Malevolent voice appraisals correlated with dissociation scores only in the dual diagnosis group. CONCLUSIONS: This research supports the hypothesis that voice beliefs are similar across diagnoses of PTSD and SCZ. However, differences in voice characteristics, emotional responses and relationship to dissociation may need to be considered in the psychological management of voices.

Need for care, adversity exposure and perceived stress in clinical and healthy voice-hearers.

OBJECTIVES: Psychosis, and in particular auditory verbal hallucinations (AVHs), are associated with adversity exposure. However, AVHs also occur in populations with no need for care or distress. AIMS: This study investigated whether adversity exposure would differentiate clinical and healthy voice-hearers within the context of a 'three-hit' model of vulnerability and stress exposure. METHODS: Samples of 57 clinical and 45 healthy voice-hearers were compared on the three 'hits': familial risk; adversity exposure in childhood and in adolescence/adulthood. RESULTS: Clinical voice-hearers showed greater familial risk than healthy voice-hearers, with more family members with a history of psychosis, but not with other mental disorders. The two groups did not differ in their exposure to adversity in childhood [sexual and non-sexual, victimisation; discrimination and socio-economic status (SES)]. Contrary to expectations, clinical voice-hearers did not differ from healthy voice-hearers in their exposure to victimisation (sexual/non-sexual) and discrimination in adolescence/adulthood, but reported more cannabis and substance misuse, and lower SES. CONCLUSIONS: The current study found no evidence that clinical and healthy voice-hearers differ in lifetime victimisation exposure, suggesting victimisation may be linked to the emergence of AVHs generally, rather than need-for-care. Familial risk, substance misuse and lower SES may be additional risk factors involved in the emergence of need-for-care and distress.