The metacognitive beliefs account of hallucinatory experiences: a literature review and meta-analysis

Experiencing hallucinations in daily life: The role of metacognition

BACKGROUND

Hallucinations have been linked to failures in metacognitive reflection suggesting an association between hallucinations and overestimation of performance, although the cross-sectional findings are inconsistent. This inconsistency may relate to the fluctuating hallucinatory experiences that are not captured in cross-sectional studies. Ecological Momentary Assessment (EMA) captures in-the-moment experiences over time so can identify causal relationships between variables such as the associations between metacognition and hallucinatory experience in daily life and overcome problems in cross-sectional designs.

METHODS

Participants (N = 41) experiencing daily hallucinations completed baseline questionnaires and smartphone surveys 7 times per day for 14 days. They were prompted to identify a task they would complete in the next 4 h and to make metacognitive predictions around the likelihood of completing the task, the difficulty of the task, and how well they would complete it (standard of completion).

RESULTS

76 % finished the 14-days of assessment with an average of 42.2 % survey completion. Less accurate metacognition was associated with more hallucinations, but less accurate likelihood and standard of completion was associated with fewer hallucinations. Using a cross-lagged analysis, metacognitive predictions around the likelihood of completion (p < .001) and standard of completion (p = .01) predicted hallucination intensity at the following timepoint, and metacognitive predictions regarding likelihood of completion (p = .02) predicted hallucination control at the following timepoint.

DISCUSSION

Interventions that aim to improve metacognitive ability in-the-moment may serve to reduce the intensity and increase the control of hallucinations.

Meta-analysis of the relationship between metacognition and disorganized symptoms in psychosis

OBJECTIVE

Disorganized symptoms show associations with metacognitive deficits in psychosis. However, the magnitude of this relationship is unclear. This meta-analysis aimed to 1) quantify relationships between metacognition and both disorganized symptoms and disorganized speech; and 2) examine moderators of these relationships (e.g., metacognition type, neurocognition).

METHOD

A literature search was conducted using PsycINFO, Web of Science, PubMed, and EMBASE databases. English-language studies measuring disorganized symptoms and metacognition (i.e., introspective accuracy, metacognitive beliefs, or metacognitive capacity) in psychosis were included. Random effects meta-analyses were conducted using Pearson's r.

RESULTS

Meta-analysis of 20 studies (n = 1490) resulted in a significant negative medium correlation between disorganized symptoms and metacognition (r = -0.332, 95 % CI [-0.423, -0.235]). Magnitude was moderated by metacognition type. A significant negative small correlation between disorganized speech and metacognition (r = -0.173, 95 % CI [-0.254, -0.089], n = 1470) was observed, with no significant moderators.

CONCLUSIONS

Results clarify the magnitude of the relationships between metacognition and both disorganized symptoms and disorganized speech. Significant relationships may indicate conceptual links, yet the different magnitudes may reflect a distinction between disorganized symptoms and speech. The moderator finding highlights that metacognitive capacity has an especially strong link to disorganized symptoms and underscores the need for careful distinction between types of metacognition in future work.

Metacognition and psychosis-spectrum experiences: A study of objective and subjective measures

BACKGROUND

Metacognition refers to appraising one's thoughts and behaviours. Deficits in metacognition are associated with psychosis-spectrum experiences, such as hallucinations and delusions, in both clinical and non-clinical populations. Assessments of metacognitive function and abilities in clinical populations often vary in administration duration, and subjectivity of scores. This study investigates associations between different measures of metacognition and their prediction of psychosis spectrum experiences using objective and self-report measures in a cross-sectional study of psychosis-spectrum disorder (PSD) participants and controls.

METHOD

Twenty-three individuals with PSD and forty-four controls were recruited online and completed in-the-moment objective ratings of metacognitive accuracy (meta-Dots Task), and retrospective self-report of metacognitive self-reflection (Beck Cognitive Insight Scale) and abilities (Metacognition Self-Assessment Scale).

RESULTS

There were group differences in self-reported metacognition, with PSD participants having lower scores of metacognitive ability, but no differences in self-reflectiveness or objective metacognitive accuracy. In the PSD group, only self-reported metacognitive ability was associated with and predicted distress about, and conviction in, delusional thoughts.

CONCLUSIONS

The findings demonstrate group differences in some self-reported, but not objective, measures of metacognition, and highlight that prediction of PSD experiences depends on the metacognitive construct being measured, and the type of measurement used.

Cognitive correlates of auditory hallucinations in schizophrenia spectrum disorders

Auditory hallucinations (AHs) are one of the central symptoms of schizophrenia spectrum disorders (SSD). Current cognitive models of AH implicate source monitoring, top-down processes, and inhibitory control. However, research combining these processes is limited. Our study aimed to examine how source monitoring bias, top-down processes, and inhibitory control contribute to AHs in individuals with SSD. Eighty seven patients (aged 18-45 years) with SSD were included in the analyses. Participants completed cognitive tasks assessing source monitoring (Action Memory Task), top-down processes (False Perception Task; FPT), and inhibitory control (Auditory Go/NoGo task). AH was positively associated with response bias on the FPT. Correlations between AH and the other cognitive tasks were nonsignificant. Source monitoring errors correlated positively with response bias measures and negatively with Hits on the FPT. PANSS total score was positively correlated with source monitoring bias and False Alarms on the Go/NoGo task. The severity of disorganized symptoms was related to Source Monitoring Errors and False Alarms in the Go/NoGo task. Negative symptoms were associated with Hits and False Alarms in the Go/NoGo task. Future studies are necessary to further elucidate the relationships between different cognitive processes that may be related to clinical symptoms of psychosis.

Metacognition vulnerabilities in time of crisis: Who to protect from suicidal risk?

INTRODUCTION

During stressful events, we are all trying to cope. We may not be equal depending on our emotional, psychological, and mental states. During the COVID-19 pandemic, we could try to avoid negative information processing and anxiogenics content to prevent unhealthy thinking processes. One of the processes we can observe regarding our way of thinking and its impact on our psychological well-being is Metacognition.

METHODS

We recruited 104 outpatients in 2018. In 2020, during the pandemic, we recruited 216 outpatients and 176 healthy controls. We assessed their level of metacognition with the MCQ30 scale together with Suicidal risk and Hopelessness.

RESULTS

All three groups showed significant differences, with the nonclinical sample having higher scores in MCQ30. Regression revealed the different profiles where Hopelessness was the only predictor for the clinical sample, whereas metacognition was an adjunctive predictor of suicidal risk for the nonclinical sample.

CONCLUSION

Our results showed that the COVID-19 crisis influenced metacognitive levels for the nonclinical sample but not for the clinical population. Moreover, Hopelessness predicted suicide risk for both populations, but Metacognition was also a predictive factor for the nonclinical sample. We conclude with the possible impact of preventive measures based on Metacognitive work that can be created out of these results.

Mediating role for metacognitive processes in the relationship between schizotypy and anxiety and depression symptoms

Introduction: Depression and anxiety symptoms are highly prevalent in schizophrenia-spectrum disorders and are commonly associated with schizotypy in non-clinical samples. However, it remains unclear what factors could be contributing to the relationships between schizotypy and anxiety and depression symptoms. Using path analysis, we explored the complex interplay between schizotypy, metacognitive beliefs, cognitive insight, and symptoms of emotional distress.Methods: Self-report data of schizotypy, metacognitive beliefs, cognitive insight, depression, and anxiety symptoms were collected from 344 participants from a predominantly student sample.Results: Path analysis confirmed unique associations between schizotypy dimensions, metacognitive beliefs, and cognitive insight. Furthermore, negative beliefs about worry mediated the link between the schizotypy dimensions, unusual experiences, cognitive disorganisation, and introvertive anhedonia and both depression and anxiety symptoms. Lack of cognitive confidence also mediated the relationship between cognitive disorganisation and depression symptoms. Finally, the cognitive insight subcomponent self-reflectiveness mediated the relationship between unusual experiences and cognitive disorganisation and anxiety.Conclusions: This study significantly furthers our understanding of the complex relationship between schizotypy, metacognitive processes, and emotional distress. Our findings also provide support for interventions which modify metacognitive beliefs and self-reflectiveness, which may prove beneficial for treatment in clinical settings.

Childhood interpersonal trauma and paranoia in psychosis: The role of disorganised attachment and negative schema

Paranoia is associated with significant distress and is associated with childhood trauma. Understanding the mechanisms responsible for this association is important for informing psychological interventions. Theoretical proposals suggest that negative schema and insecure attachment may be important mechanisms in the development of paranoia. Disorganised attachment may be particularly relevant. The current study is the first to examine whether the relationship between childhood interpersonal trauma and paranoia is mediated by disorganised attachment, and the impact of disorganised attachment on negative self and negative other schema. A large online sample of 242 people with self-reported psychosis completed measures of childhood trauma, attachment, self and other schema, paranoia and psychosis symptomatology. Path analysis indicated that childhood interpersonal trauma was associated with disorganised attachment, which in turn was associated with negative self-schema, negative other schema, and paranoia. Negative schema about others, but not self, was associated with paranoia. Disorganised attachment and negative other schema fully mediated the relationship between trauma and paranoia. Negative other schema partially mediated the association between disorganised attachment and paranoia. Results were found when controlling for depression, hallucinations and age. Results suggest that interventions that aim to modify disorganised attachment patterns and negative schema about others can potentially alleviate the impact of trauma on paranoia. Findings provide justification for longitudinal studies to confirm the direction of effects, and intervention studies that aim to manipulate disorganised attachment and negative schema about others and observe the impact of this on paranoia.

Unusual experiences and their association with metacognition: investigating ASMR and Tulpamancy

BACKGROUND

Unusual experiences in Tulpamancer and Autonomous Sensory Meridian Response (ASMR) communities are generally positive and sought after, unlike hallucinations and delusions in clinical populations. Metacognition, the ability to reflect on self-referential experiences, may aid sense-making around unusual experiences, reducing distress. This study investigated group differences in hallucination-proneness, delusion-proneness, and metacognition in these communities compared to controls, and whether metacognition predicted unusual experiences.

METHODS

243 participants reporting ASMR, Tulpamancy, or neither, with no history of psychosis, took part in an online observational study. Participants completed the Beck Cognitive Insight Scale, Metacognitions Questionnaire-30, and Brief Core Schema Scales to capture metacognition. A Tulpamancer+ (reporting ASMR) group was identified and included in analyses. ANCOVAs highlighted group differences in hallucination-proneness, with Tulpamancer+ scoring higher, and metacognitive beliefs, with Tulpamancers reporting lower metacognitive belief endorsement. There were no group differences in delusion-proneness, self-reflection, or self-schemas. Stepwise regression demonstrated metacognition does influence unusual experiences in the non-clinical population, and this influence varies across groups.

CONCLUSIONS

In non-clinical populations, unusual sensory experiences are not associated with increased metacognitive beliefs, but having multiple unusual experiences is associated with higher hallucination-proneness. Results suggest improving metacognition in clinical groups may help reduce distress related to unusual sensory experiences.

Insight-related beliefs and controllability appraisals contribute little to hallucinated voices: a transdiagnostic network analysis study

Hallucinated voices cause high levels of distress and disability. Current theories suggest that insight-related beliefs, about internal or external origin, perceived source location, and appraisals of controllability are important in mediating the impact of these experiences but previous findings have been mixed. We report two open code and open data network analytic studies of items in the Psychotic Symptoms Ratings Scale for auditory verbal hallucinations (PSYRATS-AH) in a large sample of patients with hallucinated voices to examine the network structure of items at (1) first assessment, and (2) differences over two consecutive assessments during a wait-list period. Networks were generated using least absolute shrinkage and selection operator (LASSO) and extended Bayesian information criterion (EBIC) with node predictability. In Study 1 (N = 386), we report that insight-related items made a negligible contribution to hallucinated voices and the controllability appraisal made at most a modest contribution. Items relating to distress and negative content were the most central and most predicted by the wider network. In Study 2 (N = 204), we tested the longitudinal stability of the structure of hallucinated voices over a period of several months, finding a small change in total hallucination score and global strength but no clear evidence for an alteration in the structural relationship. The insight-related and controllability items remained as least influential over time. Insight-related beliefs and controllability appraisals may contribute less than previously thought to distressing hallucinated voices although we do not discount that other appraisals may remain important.

Metacognitive Beliefs and Suicidal Ideation: An Experience Sampling Study

The current study aimed to examine the relationship between metacognitive beliefs about suicidal ideation and the content and process of suicidal ideation. This was to examine the potential contribution of the Self-Regulatory Executive Function (S-REF) model (Wells and Matthew, 2015) to suicidal ideation. Twenty-seven participants completed both trait and state-level measures of suicidal ideation, negative affect, defeat, hopelessness, entrapment and metacognitive beliefs. Experience Sampling Methodology (ESM) was adopted to measure state-level measurements with participants invited to complete an online diary up to seven times a day for six days. Multi-level modelling enabled a detailed examination of the relationships between metacognitive beliefs and suicidal ideation. Positive (β = 0.241, p < 0.001) and negative (β = 0.167, p < 0.001) metacognitive beliefs about suicidal ideation were positively associated with concurrent suicidal ideation even when known cognitive correlates of suicide were controlled for. The results have important clinical implications for the assessment, formulation and treatment of suicidal ideation. Novel meta-cognitive treatments targeting beliefs about suicidal ideation are now indicated. A limited range of characteristics reported by participants affects the generalizability of findings. Future research is recommended to advance understanding of metacognition and suicide but results demonstrate an important contribution of the S-REF model.

Correlates of Hallucinatory Experiences in the General Population: An International Multisite Replication Study

Hallucinatory experiences can occur in both clinical and nonclinical groups. However, in previous studies of the general population, investigations of the cognitive mechanisms underlying hallucinatory experiences have yielded inconsistent results. We ran a large-scale preregistered multisite study, in which general-population participants (N = 1,394 across 11 data-collection sites and online) completed assessments of hallucinatory experiences, a measure of adverse childhood experiences, and four tasks: source memory, dichotic listening, backward digit span, and auditory signal detection. We found that hallucinatory experiences were associated with a higher false-alarm rate on the signal detection task and a greater number of reported adverse childhood experiences but not with any of the other cognitive measures employed. These findings are an important step in improving reproducibility in hallucinations research and suggest that the replicability of some findings regarding cognition in clinical samples needs to be investigated.

Experience-based knowledge increases confidence in discriminating our memories

The present study investigated the accuracy of metacognitive judgments in source monitoring with self-report scales engaging either information- or experienced-based knowledge. We expected that the source monitoring abilities may be affected by the origins of meta-knowledge that underlie post-decision wagering (PDW) based on economic categorizations (experience-based scale) and confidence ratings (CR) using a conventional taxonomy of confidence (information-based scale). To examine this hypothesis, healthy participants (N = 50) performed an action memory task, in which simple actions were presented in order to be performed or imagined. In the second phase of the task, participants were required to assess source monitoring by distinguishing whether the presented action was performed or imagined. Then, the participants randomly assigned into the PDW or CR group rated their confidence in responses related to source monitoring performance. It was found that source monitoring ability is resistant to manipulation of the type of knowledge used in the scales. However, measures of metacognition indicated that accuracy of the experienced-based judgments of PDW was higher as compared to the CR scale while source monitoring. These findings suggest the origin of knowledge whose justification rests more on empirical observations generates more accurate knowledge than self-evident direct intuition with respect to discriminations of one’s own memories.

Psychotic Experiences and Hikikomori in a Nationally Representative Sample of Adult Community Residents in Japan: A Cross-Sectional Study

Psychotic experiences (PEs) may be associated with hikikomori. In the present study, we analyzed interview data from a community-based representative sample (N = 1,616) in Japan to know the association of PEs over a life time, as well as the two components, hallucinatory experiences (HEs) and delusional experiences (DEs), with lifetime experience of hikikomori (severe social withdrawal). Logistic regression analysis was used to estimate the association between any PE, any HE, and any DE; and hikikomori, adjusting for socio-demographics and other psychopathologies (mental disorder in the past 12 months or having autistic spectrum disorder trait). Any PE was significantly associated with hikikomori [odds ratio (OR) =3.44, 95% CI = 1.14-10.33] after adjustment for sociodemographic factors, although the association attenuated after adjusting for other psychopathologies. Any DE remained significantly associated with hikikomori, even after adjustment for all the covariates (OR = 10.50, 95% CI = 1.57-70.29). Any HE was not significantly associated with hikikomori. DEs may be associated with hikikomori. However, because the study sample was small and the temporal association between DEs and hikikomori was unclear, a future study is needed to examine a causal relationship between DEs and hikikomori.

Clinical effectiveness of metacognitive training as a transdiagnostic program in routine clinical settings: A prospective, multicenter, single-group study

AIM

To evaluate the clinical effectiveness of metacognitive training (MCT) as a transdiagnostic program, on a diverse population with mental disorders in routine Japanese day-care settings.

METHODS

This study employed a prospective, multicenter, single-group pre-post design. Participants diagnosed with various mental disorders received 10 MCT group sessions. We set transdiagnostic outcomes to assess quality of life, global functioning, cognitive insight, and depressive symptoms. At the end of the MCT, we also evaluated participants' satisfaction with treatment. Assessments were conducted at baseline (Pre), Week 5 (Mid), Week 10 (Post), and Week 14 (follow-up: FU).

RESULTS

Thirty-four participants enrolled in the study and received MCT (schizophrenia = 22, non-schizophrenia = 12). Intent-to-treat analyses revealed significant improvements in quality of life/global functioning during the intervention period, and further improvements were observed during the follow-up (all p < .05). The Pre-FU treatment effect sizes for quality of life and global functioning were small (Hedge's g = 0.44 and 0.47, respectively). Significant improvements were also found in depressive symptoms during both the intervention and follow-up periods (all p < .05), but not in cognitive insight. Overall, participants were highly satisfied with the MCT content and format. Scores on almost all outcomes (except for depression) at each assessment point were not significantly different between the schizophrenic and non-schizophrenic sub-groups.

CONCLUSIONS

Despite several limitations, mainly due to small sample size and having no control conditions, our results suggest that MCT for a diverse population with mental disorders is a potentially effective approach in improving quality of life/global functioning and other clinical outcomes in routine day-care settings.

Effects of age and sex on clinical high-risk for psychosis in the community

BACKGROUND

Recent reports of both heightened prevalence rates and limited clinical relevance of clinical high-risk (CHR) criteria and their relevant symptoms in children and adolescents indicate an important role of neurodevelopment in the early detection of psychoses. Furthermore, sex effects in CHR symptoms have been reported, though studies were inconclusive. As sex also impacts on neurodevelopment, we expected that sex might have an additional contribution to age in the prevalence and clinical relevance of CHR symptoms and criteria.

AIM

To investigate age and sex effects on CHR criteria and symptoms and their association with psychosocial impairment and mental disorder.

METHODS

In this cross-sectional cohort study, n = 2916 8- to 40-year-olds, randomly drawn from the population register of the Swiss canton Bern, were assessed in semi-structured interviews by phone or face-to-face for CHR symptoms and criteria using the Structured Interview for Psychosis-Risk Syndromes and the Schizophrenia Proneness Instrument in its child and youth, and adult version, respectively. Furthermore, social and occupational functioning and DSM-IV axis I disorders were assessed. Simple and interaction effects of age and sex on CHR symptoms and criteria, and interaction effects of age, sex, and CHR symptoms and criteria on presentation of functional impairment and of non-psychotic disorder were investigated using logistic regression analyses.

RESULTS

Altogether, 542 (18.6%) participants reported any CHR symptom; of these, 261 (9.0%) participants reported any one of the 11 criteria relevant cognitive and perceptual basic symptoms, and 381 (13.1%) any one of the five attenuated or transient psychotic symptoms (attenuated psychotic symptoms/brief intermittent psychotic symptoms). Fewer participants met any one of the CHR criteria (n = 82, 2.8%) or any one of the three recently recommended CHR criteria (n = 38, 1.3%). Both age and sex were significantly (P < 0.05) associated with CHR symptoms and criteria, mostly by younger age and female sex. Though slightly differing between symptom groups, age thresholds were detected around the turn from adolescence to adulthood; they were highest for cognitive basic symptoms and CHR criteria. With the exception of the infrequent speech disorganization attenuated psychotic symptom, the interaction of age with CHR symptoms and criteria predicted functional impairment; whereas, independent of each other, sex and CHR symptoms mostly predicted mental disorders.

CONCLUSION

Age and sex differentially impact on CHR symptoms and criteria; these differences may support better understanding of causal pathways. Thus, future CHR studies should consider effects of sex and age.

Metacognitive approaches to the treatment of psychosis: a comparison of four approaches

In light of increasing interest in metacognition and its role in recovery from psychosis, a range of new treatments focused on addressing metacognitive deficits have emerged. These include Metacognitive Therapy, Metacognitive Training, metacognitive insight and reflection therapy, and metacognitive interpersonal therapy for psychosis. While each of these treatments uses the term metacognitive, each differs in terms of their epistemological underpinnings, their structure, format, presumed mechanisms of action, and primary outcomes. To clarify how these treatments converge and diverge, we first offer a brief history of metacognition as well as its potential role in an individual's response to and recovery from complicated mental health conditions including psychosis. We then review the background, practices, and supporting evidence for each treatment. Finally, we will offer a framework for thinking about how each of these approaches may ultimately complement rather than contradict one another and highlight areas for development. We suggest first that each is concerned with something beyond what people with psychosis think about themselves and their lives. Each of these four approaches is interested in how patients with severe mental illness think about themselves. Each looks at immediate reactions and ideas that frame the meaning of thoughts. Second, each of these approaches is more concerned with why people make dysfunctional decisions and take maladaptive actions rather than what comprised those decisions and actions. Third, despite their differences, each of these treatments is true to the larger construct of metacognition and is focused on person's relationships to their mental experiences, promoting various forms of self-understanding which allow for better self-management. Each can be distinguished from other cognitive and skills-based approaches to the treatment of psychosis in their emphasis on sense-making rather than learning a new specific thing to say, think, or do in a given situation.

The role of cognitive and metacognitive factors in non-clinical paranoia and negative affect

OBJECTIVES

It is increasingly accepted that paranoia lies on a continuum of severity that can be observed in the general population. Several psychological factors have been implicated in the development of more distressing persecutory ideas including negative affect (i.e., anxiety and depression), beliefs about oneself and other people (i.e., schemas), and metacognitive beliefs. This study aimed to explore the combined role of cognition and metacognition in paranoia. Specifically, unhelpful metacognitive beliefs and schematic beliefs were tested as potential moderators of the relationship between non-clinical paranoid ideation and negative affect.

METHODS

Measures from 227 people who took part in a cross-sectional online survey were analysed using structural equation modelling. A series of models grounded in cognitive and metacognitive theory were tested sequentially.

RESULTS

The results demonstrated that unhelpful metacognitive beliefs had a positive moderating effect on the relationship between paranoia and negative affect. Negative beliefs about oneself and other people did not moderate negative affect but positive beliefs about other people had a negative moderating effect. In a final model, negative schematic beliefs predicted paranoid ideation whilst metacognitive beliefs predicted and moderated affect.

CONCLUSIONS

The findings suggest that consideration of metacognitive beliefs, as well as schemas, may be important in understanding non-clinical paranoia.

PRACTITIONER POINTS

Metacognitive beliefs may be an important determinant of negative affect in the context of non-clinical paranoia. The consideration of both cognitive and metacognitive factors may be helpful when working with people with distressing paranoid ideas.

Do people with psychosis engage in unhelpful metacognitive coping strategies? A test of the validity of the Cognitive Attentional Syndrome (CAS) in a clinical sample

The Self-Regulatory Executive Function (S-REF) model assumes that unhelpful metacognitive coping strategies characterised by worry, rumination, threat monitoring and attempts to control thoughts, have a central role in psychological disorders and prolonged negative affect. Collectively, these strategies constitute the Cognitive Attentional Syndrome (CAS). This research aims to test whether a questionnaire designed to capture these responses (the CAS-1: Wells, 2009, p. 268) is a valid assessment tool in clinical psychosis, and to test whether activation of the CAS is associated with positive and negative outcomes. A sample of 60 people with psychosis completed a semi-structured interview about psychotic symptoms, the CAS-1 self-report measure and validated self-report measures of metacognitive beliefs, negative affect, quality of life and recovery. The CAS-1 demonstrated good internal consistency, concurrent validity and predictive validity. Hierarchical multiple regression analyses revealed that negative metacognitive beliefs predict negative affect, perceptions of recovery and quality of life in people with psychosis over and above psychotic symptoms. CAS-1 scores did not contribute additional variance in the final regression models. Implications for theory and clinical practice are discussed.

Metacognitive beliefs mediate the effect of emotional abuse on depressive and psychotic symptoms in severe mental disorders

BACKGROUND

Early trauma is linked to higher symptom levels in bipolar and psychotic disorders, but the translating mechanisms are not well understood. This study examines whether the relationship between early emotional abuse and depressive symptoms is mediated by metacognitive beliefs about thoughts being uncontrollable/dangerous, and whether this pathway extends to influence positive symptoms.

METHOD

Patients (N = 261) with psychotic or bipolar disorders were assessed for early trauma experiences, metacognitive beliefs, and current depression/anxiety and positive symptoms. Mediation path analyses using ordinary least-squares regressions tested if the effect of early emotional abuse on depression/anxiety was mediated by metacognitive beliefs, and if the effect of early emotional abuse on positive symptoms was mediated by metacognitive beliefs and depression/anxiety.

RESULTS

Metacognitive beliefs about thoughts being uncontrollable/dangerous significantly mediated the relationship between early emotional abuse and depression/anxiety. Metacognitive beliefs and depression/anxiety significantly mediated the relationship between early emotional abuse and positive symptoms. The models explained a moderate amount of the variance in symptoms (R 2 = 0.21-0.29).

CONCLUSION

Our results indicate that early emotional abuse is relevant to depression/anxiety and positive symptoms in bipolar and psychotic disorders, and suggest that metacognitive beliefs could play a role in an affective pathway to psychosis. Metacognitive beliefs could be relevant treatment targets with regards to depression/anxiety and positive symptoms in bipolar and psychotic disorders.

The role of metacognition and obsessive-compulsive symptoms in psychosis: an analogue study

BACKGROUND

Several studies have indicated that obsessive-compulsive disorder (OCD) is a common comorbidity in patients with psychotic disorders, but there is sparse knowledge about the relationship between symptoms of OCD and psychotic symptoms. Metacognitions which guides thinking and coping is theorized to be a transdiagnostic component central for development and maintenance of psychological disorders, OCD and psychosis included. The aim of the study was therefore to explore how symptoms of OCD and metacognitions relate to symptoms of psychosis. Our main hypotheses were that metacognitions would be significantly related to all symptoms of psychological distress, and that there is considerable overlap between symptoms of psychosis and OCD.

METHODS

Community controls (N = 194) completed an internet survey measuring levels of paranoid ideation, predisposition to hallucinations, symptoms of OCD, depression, anxiety, and metacognitions. Correlations and hierarchical multiple linear regression analyses were used to unveil the relationship between symptoms and beliefs.

RESULTS

Symptoms of OCD showed a strong positive correlation with symptoms of psychosis, and the relationships were still significant after controlling for symptoms of anxiety and depression. Metacognitions also showed strong positive correlations with all symptom measures. Metacognition and OCD-symptoms accounted for 53.8% of the variance in paranoid ideation and 43.8% of predisposition to hallucinations. There was a large overlap between symptoms of psychosis, OCD-symptoms, and metacognitions (30.2-37.3%).

CONCLUSIONS

In general, the results suggest considerable overlap between paranoid ideation, predisposition to hallucinations, and OCD and metacognitive beliefs in a non-clinical sample. Further experimental- and clinical studies are needed in order to explore metacognitive models of OCD and psychosis.

Dysfunctional metacognition across psychopathologies: A meta-analytic review

BACKGROUND

Dysfunctions in metacognition have been reported in individuals with anxiety disorders. Although recent studies have examined metacognition in other disorders, how dysfunctional metacognition compares across disorders is not clear. This review aimed to ascertain the importance of dysfunctional metacognition in various psychopathologies, and to identify similarities and differences in metacognitive profiles across disorders.

METHODS

Forty-seven studies were selected from 586 articles published between 1990 and August 2015, including a total sample of 3772 patients and 3376 healthy individuals. Studies that measured metacognition using the Meta-Cognitions Questionnaire (MCQ) and its variants were included. We conducted five meta-analyses including 49 to 55 effect sizes, comparing psychiatric patients to healthy individuals on respective metacognitive dimensions of the MCQ.

RESULTS

We found elevated metacognitive dysfunctions in patients, as a group, on all MCQ dimensions. Group effects were large and robust for the two negative beliefs (i.e., beliefs about the uncontrollability and danger of thoughts, and beliefs about the need to control thoughts), and moderate and unstable for the positive beliefs. Patients showed decreased cognitive confidence and heightened cognitive self-consciousness on moderate to large levels. Moderator analyses revealed that negative beliefs about uncontrollability and danger of thoughts were most prevalent in generalized anxiety disorder, whereas heightened cognitive self-consciousness was more characteristic in obsessive-compulsive disorder. Generalized anxiety disorder, obsessive-compulsive disorder and eating disorders manifested more similar metacognitive profiles than other disorders.

CONCLUSIONS

Our findings supported dysfunctional metacognition as common processes across psychopathologies, with certain dimensions being more prevalent in particular disorders.

A meta-analysis of metacognitive beliefs as implicated in the self-regulatory executive function model in clinical psychosis

This meta-analysis investigated whether the five metacognitive beliefs implicated in the Self-Regulatory Executive Function (S-REF) model (Wells and Matthews, 1994; Wells and Matthews, 1996) are elevated in people with clinical psychosis compared to people with emotional disorder and non-psychiatric controls. The review followed guidance set-out in the PRISMA statement. Primary analyses compared summary effect sizes on each sub-scale of the Metacognitions Questionnaire (MCQ) for people with psychosis and non-psychiatric controls; and people with psychosis and people with emotional disorder. Eleven eligible studies were identified comprised of 568 psychosis participants, 212 emotional disorder participants and 776 non-psychiatric controls. Findings indicated that people with psychosis had higher scores on all sub-scales of the MCQ compared to non-psychiatric controls; and higher scores on the positive beliefs about worry sub-scale compared to people with emotional disorder. This suggests metacognitive beliefs may be associated with the presence of psychological disorder and distress in general, rather than specific diagnoses. Implications for models of psychosis and treatment are discussed.

The role of unhelpful metacognitive beliefs in psychosis: Relationships with positive symptoms and negative affect

The Self-Regulatory Executive Function (s-REF) model assumes that a common set of unhelpful metacognitive beliefs have a central role in predisposition to psychological disorder and the maintenance of symptoms and distress. This research aims to test whether the five unhelpful metacognitive beliefs implicated in the model are associated with positive symptoms of psychosis and whether they are a better predictor of negative affect than topological characteristics of positive symptoms. A sample of people with psychosis completed a semi-structured interview about psychotic symptoms and self-report measures of metacognitive beliefs (MCQ-30), anxiety and depression. Hierarchical multiple regression analyses suggested that unhelpful metacognitive beliefs predict negative affect in people with psychosis over and above symptom frequency and other topological characteristics of symptoms captured by the Psychotic Symptoms Rating Scale (PSYRATS). The findings support the application of the metacognitive model to emotional distress in people with psychosis.

The relationship of depersonalization and absorption to hallucinations in psychotic and non-clinical participants

The purpose of this study was to examine the relationship between dissociative variables and hallucinations, or predisposition to hallucinations, respectively, in patients with psychoses and non-clinical participants, controlling for any possible effect of emotional variables and age. Three groups were formed for this purpose: patients diagnosed with schizophrenia with auditory hallucinations at the time of study, healthy participants prone to hallucinations, and healthy participants not prone to hallucinations. The final sample was 318 participants with a mean age of 21.41 years (SD: 5.78) and a male-to-female ratio of 67:251. All participants were given the Tellegen Absorption Scale, the Cambridge Depersonalization Scale and the Metacognitions Questionnaire. The results showed that patients with psychosis had higher levels of depersonalization than participants prone and not prone to hallucinations. Prone participants showed higher levels of absorption than patients with psychosis and healthy participants with no proneness to hallucinations. Finally, a multinomial logistic regression analysis showed that depersonalization increased the probability of belonging to the group of patients with psychosis and auditory hallucinations, and absorption in the group prone to hallucinations. The conclusions discuss the importance of dissociative variables in understanding the etiology of hallucinations and consider the possibility that different psychological processes may occur in healthy participants prone to hallucinations and in hallucinations in persons with psychoses.

Experiential avoidance and appraisals of voices as predictors of voice-related distress

OBJECTIVES

Research has suggested that the extent to which voices (i.e., auditory verbal hallucinations) are experienced as distressing might be influenced by negative beliefs about voices as well as maladaptive metacognitive styles involving the negative appraisal and maladaptive control of mental experiences. This cross-sectional study examined the contribution of both specific appraisals of voices and a metacognitive factor (i.e., experiential avoidance) to voice-related distress.

METHODS

Self-report measurers of voice characteristics (voice frequency, duration as well as amount and intensity of voice-related distress), experiential avoidance, and appraisals of voices were collected in a sample of 101 voice-hearers.

RESULTS

Experiential avoidance and negative beliefs about voices were associated with higher levels of voice-related distress, but not to measures of voice frequency and duration. Experiential avoidance and negative 'metaphysical' beliefs about voices were significant predictors of voice-related distress even after accounting for the effect of frequency and duration of voices, and explained similar proportions of unique variance in distress.

CONCLUSIONS

These findings suggest that the appraisals of voices and experiential avoidance are predictive of voice-related distress and that cognitive-behavioural interventions targeting both voice-specific appraisals and general maladaptive metacognitive processes could prove useful treatment approaches for clients with distressing voices.

PRACTITIONER POINTS

Experiential avoidance (EA) and negative appraisals predict voice-related distress caused by voices, but not their frequency and duration. Interventions for voices should consider targeting EA and negative appraisals (e.g., cognitive-behavioural therapy, Acceptance and Commitment Therapy) to ameliorate distress.

Unhelpful metacognitive beliefs in early psychosis are associated with affective symptoms and childhood social adjustment

BACKGROUND

Previous studies have shown that individuals with schizophrenia exhibit higher levels of unhelpful metacognitive beliefs than healthy controls, but no studies have explored metacognitive beliefs in early psychosis.

AIMS

We examined i) differences in levels of unhelpful metacognitive beliefs between psychosis spectrum disorders, and healthy controls, and ii) to what extent demographic and clinical characteristics predicted levels of metacognitive beliefs in the early treated phases of psychotic disorders.

METHOD

Patients were included within two years of first treatment for a psychotic disorder (N=92). They were assessed on premorbid adjustment, psychotic symptoms, anxiety/depression, and self-reported metacognitive beliefs (MCQ-30). Ninety-seven controls also completed MCQ-30. Predictors of metacognitive beliefs were explored with multiple linear regression analyses.

RESULTS

Patients scored significantly higher than controls on all metacognitive subscales except positive beliefs about worry. The regression model explained 14-38% of the variance on each metacognitive subscale. Current affective symptoms explained a significant amount of variance on all subscales, except positive beliefs about worry. Childhood (premorbid) social adjustment predicted a significant amount of the variance on all subscales, except cognitive confidence. Duration of untreated psychosis contributed significantly to more unhelpful beliefs about cognitive confidence. Negative symptoms predicted lower scores on cognitive self-consciousness.

CONCLUSION

Affective symptoms and childhood social adjustment could be important predictors of unhelpful metacognitive beliefs in the early treated phases of psychosis, indicating potential psychopathological relationships that warrant further investigation for clinical relevance.

Dysfunctional meta-cognitive beliefs mediate the relation between temperament traits and hallucination-proneness in non-clinical population

We investigated whether dysfunctional metacognitive beliefs (negative beliefs about uncontrollability and danger of thoughts) mediate the relationship between temperamental characteristics of behavior and hallucinatory-like experiences in healthy subjects (n=137). Our analyses showed that four temperamental traits (emotional reactivity, perseveration, endurance and briskness) were mediated by negative beliefs about uncontrollability and danger of thoughts in relation to hallucination proneness. Our research tentatively suggests that temperament affects hallucination proneness via metacognition.

Discrimination of schizophrenia auditory hallucinators by machine learning of resting-state functional MRI

Auditory hallucinations (AH) are a symptom that is most often associated with schizophrenia, but patients with other neuropsychiatric conditions, and even a small percentage of healthy individuals, may also experience AH. Elucidating the neural mechanisms underlying AH in schizophrenia may offer insight into the pathophysiology associated with AH more broadly across multiple neuropsychiatric disease conditions. In this paper, we address the problem of classifying schizophrenia patients with and without a history of AH, and healthy control (HC) subjects. To this end, we performed feature extraction from resting state functional magnetic resonance imaging (rsfMRI) data and applied machine learning classifiers, testing two kinds of neuroimaging features: (a) functional connectivity (FC) measures computed by lattice auto-associative memories (LAAM), and (b) local activity (LA) measures, including regional homogeneity (ReHo) and fractional amplitude of low frequency fluctuations (fALFF). We show that it is possible to perform classification within each pair of subject groups with high accuracy. Discrimination between patients with and without lifetime AH was highest, while discrimination between schizophrenia patients and HC participants was worst, suggesting that classification according to the symptom dimension of AH may be more valid than discrimination on the basis of traditional diagnostic categories. FC measures seeded in right Heschl's gyrus (RHG) consistently showed stronger discriminative power than those seeded in left Heschl's gyrus (LHG), a finding that appears to support AH models focusing on right hemisphere abnormalities. The cortical brain localizations derived from the features with strong classification performance are consistent with proposed AH models, and include left inferior frontal gyrus (IFG), parahippocampal gyri, the cingulate cortex, as well as several temporal and prefrontal cortical brain regions. Overall, the observed findings suggest that computational intelligence approaches can provide robust tools for uncovering subtleties in complex neuroimaging data, and have the potential to advance the search for more neuroscience-based criteria for classifying mental illness in psychiatry research.

Further insight into the role of metacognitive beliefs in schizophrenia and OCD patients: testing a mediation model

This study explored the mediation effect of metacognitive beliefs on the relationship between intrusive thoughts and emotional distress in schizophrenia (N=49) and obsessive-compulsive disorder (OCD) (N=35). Intrusive thoughts impact on anxiety and depression through beliefs about uncontrollability and danger of thoughts in schizophrenia. Negative beliefs in general mediated the effect of intrusive thoughts on anxiety in obsessive-compulsive disorder. The results suggest that metacognitive beliefs may be a vulnerability factor for emotional and psychological disorder.

Intérêt de l’analyse textuelle d’entretiens cliniques de sujets schizophrènes souffrant d’hallucinations auditives résistantes

Introduction

Les hallucinations auditives sont un des symptômes fréquent et invalidants demeurant persistantes dans 20 à 30 % des cas et ce malgré les traitements antipsychotiques. Certaines théories suggèrent que les caractéristiques des hallucinations seraient liées à des dimensions psychologiques et émotionnelles pouvant expliquer le phénomène hallucinatoire, mais aussi à la croyance que le sujet halluciné accorde à ces voix [1,2].

Objectif

L’objectif de cette étude est de mettre en évidence l’intérêt clinique des méthodes d’analyse de discours à travers des entretiens menés auprès de patients schizophrènes souffrant d’hallucinations auditives résistantes.

Méthode

Des entretiens semi-dirigés ont été menés auprès de 10 sujets schizophrènes souffrant d’hallucinations résistantes. L’entretien a été construit autour de 10 thèmes principaux se rapportant aux croyances du sujet en rapport à son vécu hallucinatoire, tels que les intentions des voix, le pouvoir qui leur est attribué ou encore les stratégies de contrôle mis en œuvre. L’analyse des données s’est faite à l’aide du logiciel Alceste [3] permettant d’effectuer de manière systématisée et automatisée l’analyse d’entretiens ou de textes. Elle repose sur une classification descendante hiérarchique conduisant à la mise en évidence de mondes lexicaux par la construction de classes de discours mettant en évidence les mots les plus récurrents et significatifs dans le discours du sujet.

Résultats

Les résultats de l’analyse sur 10 sujets ont permis de mettre en évidence des classes de discours renvoyant à des processus psychologiques particuliers, concernant le vécu et les relations qu’entretient le sujet avec ses voix. Nous pensons que ces processus, jusque-là sous-estimés et donc peu analysés pourraient constituer une piste d’exploration du caractère résistant des hallucinations.

The search for elusive structure: a promiscuous realist case for researching specific psychotic experiences such as hallucinations

Problems in psychiatric classification have impeded research into psychopathology for more than a century. Here, I briefly review several new approaches to solving this problem, including the internalizing-externalizing-psychosis spectra, the 5-factor model of psychotic symptoms, and the more recent network approach. Researchers and clinicians should probably adopt an attitude of promiscuous realism and assume that a single classification system is unlikely to be effective for all purposes, and that different systems will need to be chosen for research into etiology, public mental health research, and clinical activities. Progress in understanding the risk factors and mechanisms that lead to psychopathology is most likely to be achieved by focusing on specific types of experience or symptoms such as hallucinations.

Do depression and anxiety mediate the relationship between meta-cognitive beliefs and psychological dimensions of auditory hallucinations and delusions in schizophrenia?

We investigated if depression and anxiety mediate the relationship between meta-cognitive beliefs and psychological dimensions of delusions and hallucinations in schizophrenia subjects (n=74). Depression, but not anxiety, mediated the relationship between certain dysfunctional meta-cognitive beliefs and psychological dimensions of delusions. Although direct effects between hallucination dimensions and certain meta-cognitive beliefs were found, anxiety and depression did not serve as mediators in this relationship. The results suggest a significant pathway from meta-cognition to delusions through depression.

Externalizing biases and hallucinations in source-monitoring, self-monitoring and signal detection studies: a meta-analytic review

BACKGROUND

Cognitive models have postulated that auditory hallucinations arise from the misattribution of internally generated cognitive events to external sources. Several experimental paradigms have been developed to assess this externalizing bias in clinical and non-clinical hallucination-prone samples, including source-monitoring, verbal self-monitoring and auditory signal detection tasks. This meta-analysis aims to synthesize the wealth of empirical findings from these experimental studies.

METHOD

A database search was carried out for reports between January 1985 and March 2012. Additional studies were retrieved by contacting authors and screening references of eligible reports. Studies were considered eligible if they compared either (i) hallucinating and non-hallucinating patients with comparable diagnoses, or (ii) non-clinical hallucination-prone and non-prone participants using source-monitoring, verbal self-monitoring or signal detection tasks, or used correlational analyses to estimate comparable effects.

RESULTS

The analysis included 15 clinical (240 hallucinating patients and 249 non-hallucinating patients) and nine non-clinical studies (171 hallucination-prone and 177 non-prone participants; 57 participants in a correlation study). Moderate-to-large summary effects were observed in both the clinical and analogue samples. Robust and significant effects were observed in source-monitoring and signal detection studies, but not in self-monitoring studies, possibly due to the small numbers of eligible studies in this subgroup. The use of emotionally valenced stimuli led to effects of similar magnitude to the use of neutral stimuli.

CONCLUSIONS

The findings suggest that externalizing biases are important cognitive underpinnings of hallucinatory experiences. Clinical interventions targeting these biases should be explored as possible treatments for clients with distressing voices.

A relationship between hallucination proneness and character and temperament: a mediating role of meta-cognitive beliefs in a non-clinical sample

We investigated a mediating role of meta-cognitions in the relationship between Cloninger's temperament and character dimensions and hallucination proneness among healthy subjects (n=135). Two character dimensions-self-directedness and self-transcendence-were related to hallucination proneness. Negative beliefs about uncontrollability of thoughts partially mediated the relationship between these two character dimensions and hallucination proneness.

Through the looking glass: self-reassuring meta-cognitive capacity and its relationship with the thematic content of voices

AIMS

To examine the self-critical thoughts and self-reassuring meta-cognitive capacity of those who hear voices and explore whether they are associated with the theme of voice content and appraisals of voice power and voice expressed emotion.

METHOD

A cross-sectional design was used, combining semi-structured interviews and self-report measures. Data on symptomatology, self-critical thoughts and self-reassuring meta-cognitive capacity, thematic voice content, and appraisals of voice power and expressed emotion were collected from 74 voice-hearers in Birmingham, UK.

RESULTS

Common themes of voice content reflected issues of shame, control, and affiliation. Controlling content was the most prevalent theme, however, no significant predictor of this theme was found; shaming thematic voice content linked with reduced capacity to self-reassure following self-critical thoughts. Voice-hearers with the greatest level of self-critical thoughts appraised their voices as powerful and high in voice expressed emotion.

CONCLUSIONS

Findings suggest that voice-hearers self-critical thoughts are reflected in the type of relationship they have with their voice. However, access to self-reassuring meta-cognitive capacity may serve as a protective factor for those who hear voices, resulting in more benign voice content. These findings highlight the importance of this specific meta-cognitive capacity and will inform future therapeutic interventions for the management of voices in this vulnerable group.

Mechanisms Underlying Auditory Hallucinations-Understanding Perception without Stimulus

Auditory verbal hallucinations (AVH) are a common phenomenon, occurring in the “healthy” population as well as in several mental illnesses, most notably schizophrenia. Current thinking supports a spectrum conceptualisation of AVH: several neurocognitive hypotheses of AVH have been proposed, including the “feed-forward” model of failure to provide appropriate information to somatosensory cortices so that stimuli appear unbidden, and an “aberrant memory model” implicating deficient memory processes. Neuroimaging and connectivity studies are in broad agreement with these with a general dysconnectivity between frontotemporal regions involved in language, memory and salience properties. Disappointingly many AVH remain resistant to standard treatments and persist for many years. There is a need to develop novel therapies to augment existing pharmacological and psychological therapies: transcranial magnetic stimulation has emerged as a potential treatment, though more recent clinical data has been less encouraging. Our understanding of AVH remains incomplete though much progress has been made in recent years. We herein provide a broad overview and review of this.

Stop, look, listen: the need for philosophical phenomenological perspectives on auditory verbal hallucinations

One of the leading cognitive models of auditory verbal hallucinations (AVHs) proposes such experiences result from a disturbance in the process by which inner speech is attributed to the self. Research in this area has, however, proceeded in the absence of thorough cognitive and phenomenological investigations of the nature of inner speech, against which AVHs are implicitly or explicitly defined. In this paper we begin by introducing philosophical phenomenology and highlighting its relevance to AVHs, before briefly examining the evolving literature on the relation between inner experiences and AVHs. We then argue for the need for philosophical phenomenology (Phenomenology) and the traditional empirical methods of psychology for studying inner experience (phenomenology) to mutually inform each other to provide a richer and more nuanced picture of both inner experience and AVHs than either could on its own. A critical examination is undertaken of the leading model of AVHs derived from phenomenological philosophy, the ipseity disturbance model. From this we suggest issues that future work in this vein will need to consider, and examine how interdisciplinary methodologies may contribute to advances in our understanding of AVHs. Detailed suggestions are made for the direction and methodology of future work into AVHs, which we suggest should be undertaken in a context where phenomenology and physiology are both necessary, but neither sufficient.

Metacognitive therapy in treatment-resistant psychosis: a multiple-baseline study

BACKGROUND

More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated.

AIMS

Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis.

METHOD

Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up.

RESULTS

Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant.

CONCLUSIONS

Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.

Cognitive-self consciousness and metacognitive beliefs: Stress sensitization in individuals at ultra-high risk of developing psychosis

OBJECTIVE

Metacognitive beliefs (MCB) may guide information and attention processes, increasing affective and symptomatic reactions to stressful events. Cognitive self-consciousness (CSC; i.e., a preoccupation with one's thoughts) may increase awareness of MCB, potentially triggering the onset of psychotic symptoms. This study tested the hypotheses that (1), MCB would moderate affective and symptomatic reactions to stress in individuals at ultra-high risk (UHR) of developing psychosis, and (2), greater CSC would precede worsening in psychotic symptoms in individuals with strong MCB.

METHOD

Twenty-seven individuals at UHR of developing psychosis completed a self-report diary when prompted by an electronic wristwatch several times each day for 6 days (experience sampling).

RESULTS

MCB moderated the association between affective, but not symptomatic, responses to social stress. CSC preceded the subsequent occurrence of hallucinations in individuals who reported strong beliefs about the need to control their thoughts.

CONCLUSIONS

The data suggest that MCB sensitize an individual to social stressors. CSC may represent times where an individual is aware that their thoughts are uncontrollable, and therefore contradicting their MCB, motivating them to make an external attribution. The findings have implications for improving the effectiveness of interventions for people experiencing hallucinations.

Auditory hallucinations in schizophrenia and nonschizophrenia populations: a review and integrated model of cognitive mechanisms

While the majority of cognitive studies on auditory hallucinations (AHs) have been conducted in schizophrenia (SZ), an increasing number of researchers are turning their attention to different clinical and nonclinical populations, often using SZ findings as a model for research. Recent advances derived from SZ studies can therefore be utilized to make substantial progress on AH research in other groups. The objectives of this article were to (1) present an up-to-date review regarding the cognitive mechanisms of AHs in SZ, (2) review findings from cognitive research conducted in other clinical and nonclinical groups, and (3) integrate these recent findings into a cohesive framework. First, SZ studies show that the cognitive underpinnings of AHs include self-source-monitoring deficits and executive and inhibitory control dysfunctions as well as distortions in top-down mechanisms, perceptual and linguistic processes, and emotional factors. Second, consistent with SZ studies, findings in other population groups point to the role of top-down processing, abnormalities in executive inhibition, and negative emotions. Finally, we put forward an integrated model of AHs that incorporates the above findings. We suggest that AHs arise from an interaction between abnormal neural activation patterns that produce salient auditory signals and top-down mechanisms that include signal detection errors, executive and inhibition deficits, a tapestry of expectations and memories, and state characteristics that influence how these experiences are interpreted. Emotional factors play a particular prominent role at all levels of this hierarchy. Our model is distinctively powerful in explaining a range of phenomenological characteristics of AH across a spectrum of disorders.