Dissociative and metacognitive factors in hallucination-proneness when controlling for comorbid symptoms

A Mixture Modeling of the Behavioral Activation System and Problematic Internet Use in Adolescents: The Role of Metacognition, Online Dissociation, and Insomnia

Due to the rapidly developing technological advancements, the overuse of the Internet has led to the emergence of problematic Internet use, which has become a part of our daily lives. This study aims to investigate the relationships between problematic Internet use, Behavioral Activation System (BAS), metacognition, online dissociative experiences, and insomnia. Participants were 341 Turkish adolescents aged between 15 and 19 years (Mean = 15.49, SD = 1.03), of whom 63% were female. Participants responded to the Behavioral Inhibition/Behavioral Activation System Scale, Metacognition Questionnaire, Van Online Dissociative Experiences Schedule, Insomnia Severity Index, and Chen Internet Addiction Scale. The mixture structural equation modeling approach was used to analyze the data. We found a positive relationship between BAS and metacognition, as well as insomnia, and a negative relationship with online dissociation. Furthermore, BAS was indirectly related to problematic Internet use via metacognition, online dissociation, and insomnia. The mixture analysis grouped participants into two latent classes. The first class (76%) had low levels of metacognition, online dissociation, insomnia, and problematic Internet use and high levels of behavioral activation while the second class (24%) had low levels of behavioral activation and high levels of metacognition, online dissociation, insomnia, and problematic Internet use. These findings indicate that individuals with high impulsivity, a tendency toward fun-seeking, and reward sensitivity are predisposed to excessively use the Internet and that metacognition, online dissociative experiences, and insomnia play a determining role in this behavior.

Intolerance of uncertainty and psychosis: A systematic review

OBJECTIVES

Intolerance of uncertainty, the tendency to interpret and react negatively to uncertainty, is a transdiagnostic risk factor for anxiety, depression and eating-related disorders. Given the high comorbidity between anxiety, depression and schizophrenia-spectrum diagnoses (SSDs), there is potential for intolerance of uncertainty to play a role in modulating psychosis symptoms. To address this gap in our understanding, we conducted the first prospectively registered systematic review on intolerance of uncertainty and psychotic symptoms in both people with SSDs and in the general population.

METHODS

Four databases were searched (PsycINFO, Medline, Web of Science and PubMed), which identified ten studies with a total of 1503 participants that measured intolerance of uncertainty and psychosis symptoms.

RESULTS

Key findings suggest the following: (1) Intolerance of uncertainty was associated with total negative psychotic symptoms with small-medium effect sizes; (2) intolerance of uncertainty was higher in individuals with an 'at-risk' mental state for psychosis compared to controls; (3) higher intolerance of uncertainty was associated with more individual psychotic symptoms related to delusions and paranoia within clinical and nonclinical samples; and (4) there was mixed evidence for a relationship between intolerance of uncertainty and auditory hallucinations and intolerance of uncertainty and total positive symptoms in clinical samples.

CONCLUSIONS

Overall, these findings highlight that intolerance of uncertainty may be an important transdiagnostic dimension and potential treatment target for psychotic symptoms such as delusions and paranoia in people with SSDs.

Relations between psychosis and emotion regulation in daily life: A systematic review and meta-analyses of studies using experience sampling methods

Research has shown that heightened emotionality often precedes psychotic experiences. Understanding how individuals cope with these emotions is crucial for psychosis. While prior studies on emotion regulation (ER) and psychosis have mainly relied on self-report questionnaires, recent research has increasingly utilised daily life methods. This systematic review and meta-analysis seek to examine the relationship between daily ER and psychotic experiences. In total, 15 studies were included in the meta-analysis (21 in the systematic review). The results of Experience Sampling Methods (ESM) studies indicated that ER strategies of avoidance, reappraisal, repetitive thinking, and emotional suppression are not associated with psychotic experiences in daily life. The effect was not moderated by type of sample (clinical vs non-clinical), symptom (hallucination vs delusions), relation (contemporaneous vs perspective), or other methodological variables. Acceptance was found to be negatively associated with psychotic experiences, but the effect was small. These results indicate that ER in daily life might not impact directly on psychotic experiences. The results are discussed in light of conceptual and methodological limitations in the field.

The Relationships Between Multidimensional Schizotypy and Metacognitive Beliefs

There has been a recent surge in schizotypy and metacognition research. Metacognition is an umbrella term for higher-order thought processes. Here, we focussed on maladaptive metacognitive beliefs, which are beliefs related to one's thought processes and often play an important role in the preponderance of psychological disorders. Despite the extensive literature, relatively less is known about metacognitive beliefs in the context of multidimensional schizotypy, which consists of positive, negative, and disorganised dimensions and represents the milder forms of schizophrenia symptoms and vulnerability to developing schizophrenia. This is the first study that examined the links not only with positive schizotypy, but also with negative and disorganised schizotypy. We also attempted to circumvent the limitations related to schizotypy assessment in the previous studies by using a newly developed measure, the Multidimensional Schizotypy Scale (MSS), which was based on the current operationalisations of the construct. We examined the links in a non-clinical sample, including first-year psychology students and members of the wider community of an Australian university (N = 68). Self-report data was collected by administering the Metacognitions Questionnaire-30, MSS, and Marlowe-Crowne Social Desirability Scale to control the self-report measures' social desirability biases. Results revealed positive correlations of maladaptive metacognitive beliefs not only with positive schizotypy, but also with negative and disorganised schizotypy. Our findings support the importance of examining schizotypy as a multidimensional construct. Further, our findings have implications for research and practice, including treatment modalities focusing on the modification of metacognitive beliefs for the prevention of schizophrenia and related conditions.

Breaking the cycle: Exploring the relationship of metacognition beliefs, obsessive-compulsive symptoms, and psychosocial performance among individuals diagnosed with schizophrenia

THE RELEVANCE TO MENTAL HEALTH NURSING

This research paper explores the intricate relationship between metacognitive dysfunctional beliefs, obsessive-compulsive symptoms, and psychosocial performance in patients diagnosed with schizophrenia. Understanding these dynamics can help mental health nurses identify and address each patient's needs more effectively. It can guide them in devising personalized care plans that not only manage the symptoms but also improve the underlying mechanism that exacerbates the psychotic symptoms and social functioning and the overall quality of life. Moreover, the findings of this research can contribute to developing training programs for mental health nurses, equipping them with the necessary skills and knowledge to provide optimal care. What the paper adds to existing knowledge? • This study provides empirical evidence of the significant positive correlation between OCS and metacognitive dimensions in individuals with schizophrenia. • It highlights the role of certain demographic factors, such as younger age and single marital status, in increasing the likelihood of elevated OCS. • It underscores the inverse relationship between higher metacognitive dysfunctional beliefs and lower levels of psychosocial functioning. • It identifies age and metacognitive scores as crucial predictors of psychosocial functioning across various domains. What are the implications for practice? • The findings suggest that therapeutic nursing interventions for individuals diagnosed with schizophrenia should address metacognitive dysfunctional beliefs to improve overall functioning and well-being. • Clinicians, including psychiatrists and psychiatric nurses, should consider the patient's age, marital status, and metacognitive scores when assessing the risk of elevated OCS and devising treatment plans. • The study emphasizes the need for comprehensive psychiatric nursing assessment, including metacognitive dysfunction and OCS evaluation. What are the implications for future research? • Future research could explore the causal relationships between metacognitive dysfunctional beliefs, OCS, and psychosocial functioning in schizophrenia. • Longitudinal studies could provide insights into the progression of these relationships over time and the impact of therapeutic interventions. • Further research could also investigate the effectiveness of specific therapeutic strategies such as Metacognitive Therapy (MCT), Schema Therapy (ST), Cognitive Enhancement Therapy (CET), and Cognitive Behaviour Therapy (CBT) to address this population's metacognitive dysfunctional beliefs.

ABSTRACT

BACKGROUND: Schizophrenia is a chronic mental health disorder that significantly impacts an individual's cognitive, emotional and social functioning. Recent research has highlighted the role of metacognitive beliefs and obsessive-compulsive symptoms (OCS) in the psychosocial performance of individuals diagnosed with schizophrenia. Understanding these relationships could provide valuable insights for developing more effective nursing interventions. This study aimed to investigate the relationship between metacognitive beliefs, OCS and psychosocial performance among individuals diagnosed with schizophrenia.

DESIGN

A cross-sectional survey was conducted involving 174 purposively selected participants diagnosed with schizophrenia.

TOOLS

The Meta-Cognitions Questionnaire-30, Young Adult Self-Report Scale for OCS and Specific Level of Functioning Scale were used to gather the necessary data.

RESULTS

The study found a significant positive correlation between OCS and metacognitive dimensions. Age was a significant predictor with an Oddis Ratio of 2.471. The metacognitive dysfunction was a highly significant predictor in univariate and multivariate analyses, with Oddis Ratios of 1.087 and 1.106, respectively. The study also discovered that higher levels of metacognitive dysfunctional beliefs were associated with lower levels of psychosocial functioning. Age and the metacognitive dysfunction score were significant predictors of psychosocial functioning scores, accounting for 26.8% of the variance in these scores.

CONCLUSION

The study reveals a compelling inverse relationship between higher metacognitive dysfunctional beliefs and lower levels of psychosocial functioning in individuals diagnosed with schizophrenia. It also identifies certain demographic factors, such as younger age, as significant contributors to elevated OCS. Importantly, metacognitive dysfunction emerged as a critical predictor of psychosocial functioning across various domains. These findings underscore the potential of incorporating metacognitive-focused interventions in the treatment plans for schizophrenia patients. By addressing these cognitive patterns, healthcare professionals can enhance overall functioning and well-being in individuals diagnosed with schizophrenia.

Cross-validation of the ego dissolution scale: implications for studying psychedelics

Introduction

Ego dissolution, variously called Ego-Loss, self-loss, and ego disintegration, is a hallmark of psychedelic drug use. We cross-validated the 10-item Ego Dissolution Scale, which we developed to assess ego dissolution in everyday life, and we included comparator variables that expanded our original assessment of construct validity.

Methods

Undergraduate college student volunteers (N = 527) completed the measures online.

Results

We replicated the original two factor structure (i.e., subfactors: Ego-Loss and Unity/connectedness with others, the world, universe), and we determined that the total score (Cronbach's α = 0.79) and subfactors (Ego-Loss = 78; Unity = 0.83) possessed adequate-to-good reliability and strong convergent validity (e.g., mindfulness, hallucination-predisposition, sleep variables, personality variables, positive/negative affect transliminality, dissociation/depersonalization), while neuroticism, social desirability did not correlate highly with ego dissolution. We identified distinct patterns of relations of measures associated with the Ego-Loss vs. Unity subfactors.

Discussion

We discuss the implications of the use of the EDS for studying everyday aspects of ego dissolution, the long-term effects of psychedelic use, and the value of using the scale in conjunction with measures of the acute effects of psychedelics.

Neurocognitive bases of self-monitoring of inner speech in hallucination prone individuals

Verbal hallucinations in schizophrenia patients might be seen as internal verbal productions mistaken for perceptions as a result of over-salient inner speech and/or defective self-monitoring processes. Similar cognitive mechanisms might underpin verbal hallucination proneness in the general population. We investigated, in a non-clinical sample, the cerebral activity associated with verbal hallucinatory predisposition during false recognition of familiar words -assumed to stem from poor monitoring of inner speech-vs. uncommon words. Thirty-seven healthy participants underwent a verbal recognition task. High- and low-frequency words were presented outside the scanner. In the scanner, the participants were then required to recognize the target words among equivalent distractors. Results showed that verbal hallucination proneness was associated with higher rates of false recognition of high-frequency words. It was further associated with activation of language and decisional brain areas during false recognitions of low-, but not high-, frequency words, and with activation of a recollective brain area during correct recognitions of low-, but not high-, frequency words. The increased tendency to report familiar words as targets, along with a lack of activation of the language, recollective, and decisional brain areas necessary for their judgement, suggests failure in the self-monitoring of inner speech in verbal hallucination-prone individuals.

A Systematic Review of the experimental induction of auditory perceptual experiences

BACKGROUND AND OBJECTIVES

Voice-hearing exists on a continuum and research studies have utilised experimental paradigms in an attempt to induce unusual auditory experiences in clinical and non-clinical samples. The aim of the current review was to systematically identify, review and appraise voice-hearing induction paradigms in order to guide researchers.

METHODS

Five databases were searched for studies in which an experimental manipulation was used with the aim of inducing an auditory experience akin to voice-hearing. Papers were assessed for quality and the voice-hearing paradigms critically appraised.

RESULTS

Forty-nine studies, included in 41 papers, were reviewed. Studies were organised into five groups based on the type of voice-hearing paradigm used: sensory deprivation/limitation; hallucination suggestion; combined suggestion and ambiguous stimulus; signal detection and voice detection tasks; and auditory discrimination/transformation. Signal and voice detection tasks were found to be the most robust paradigms. The quality of paradigms was assessed, and their strengths and limitations evaluated, including evidence in relation to their utility, ecological validity and usability.

LIMITATIONS

The current review excluded case studies, grey literature and studies which were not written in the English language, and as such voice-hearing paradigms may have been missed.

CONCLUSIONS

Voice-hearing paradigms vary in their ecological validity and experimental robustness. A challenge for future research is to develop a paradigm in which internally generated material can be attributed externally in a way that more closely represents inner speech and the experience of voice-hearing.

The revised Psychosis Attachment Measure: Measuring disorganized attachment

Objectives

The Psychosis Attachment Measure (PAM) is currently the most widely used and validated measure of attachment in psychosis. However, the PAM does not assess disorganized attachment, the type of attachment that has been most closely linked with vulnerability to psychosis. This study aimed to expand the PAM to capture the concept of disorganized attachment and to examine its psychometric properties in a psychosis sample.

Methods

Clinical and academic experts in the field of psychosis and service user representatives were asked to assess the comprehensiveness and comprehensibility of the pool of disorganized items. This process resulted in 12 items hypothesized to capture disorganized attachment that were included with the original items of the PAM. A sample of 144 individuals with either a self‐reported diagnosis of, or treatment for, a psychosis‐related condition completed a battery of online measures comprising the revised PAM, existing measures of adult disorganized attachment and constructs hypothesized to be conceptually related to disorganized attachment.

Results

An exploratory factor analysis was conducted with three factors retained; these were labelled anxious, avoidant and disorganized attachment. The factors displayed good internal consistency and test–retest reliability and the disorganized factor displayed good construct validity with related measures and constructs.

Conclusions

These results provide preliminary evidence that the revised PAM captures the concept of disorganized attachment. However, confirmatory psychometric evaluation of the revised PAM is required, within a separate psychosis sample, to confirm its factor structure. The relationship between these results and the current literature, in addition to the clinical and research implications, are discussed.

Practitioner points

We present an expanded version of the Psychosis Attachment Measure (PAM), revised to capture the concept of disorganised attachment in adulthood. This expanded measure showed good reliability and the new disorganized subscale demonstrated construct validity.

These results provide preliminary evidence that disorganized attachment can be measured using a simple self‐report measure with individuals with psychosis.

Further research is required to confirm the structural dimensionality of the revised PAM within a new sample using confirmatory factor analysis.

Following further psychometric validation the use of this measure has the potential to be expanded to other mental health conditions in which disorganized attachment has been implicated in the development and maintenance of difficulties, for example, trauma‐related conditions and borderline personality disorder.

Pareidolia-proneness, reality discrimination errors, and visual hallucination-like experiences in a non-clinical sample

Introduction: It has been proposed that hallucinations occur because of problems with reality discrimination (when internal, self-generated cognitions are misattributed to an external, non-self source) and because of elevated levels of top-down processing. In this study, we examined whether visual reality discrimination abilities and elevated top-down processing (assessed via face pareidolia-proneness) were associated with how often non-clinical participants report visual hallucination-like experiences.Methods: Participants (N = 82, mean age = 23.12 years) completed a visual reality discrimination task and a face pareidolia task, as well as self-report measures of schizotypy and of the frequency of visual hallucination-like experiences.Results: Regression analysis demonstrated that the number of false alarms made on the visual reality discrimination task and the number of hits made on the face pareidolia task were independent predictors of the frequency of visual hallucination-like experiences. Correlations between performance on the tasks and levels of schizotypy were not statistically significant.Conclusions: These findings suggest that weaker visual reality discrimination abilities and elevated levels of top-down processing are associated with visual hallucination-proneness and are discussed in terms of the idea that clinical visual hallucinations and non-clinical visual hallucination-like experiences share similar cognitive mechanisms.

Assessing Voice Hearing in Trauma Spectrum Disorders: A Comparison of Two Measures and a Review of the Literature

Voice hearing (VH) can occur in trauma spectrum disorders (TSD) such as posttraumatic stress disorder (PTSD) and dissociative disorders. However, previous estimates of VH among individuals with TSD vary widely. In this study, we sought to better characterize the rate and phenomenology of VH in a sample of 70 women with TSD related to childhood abuse who were receiving care in a specialized trauma program. We compared the rate of VH within our sample using two different measures: 1) the auditory hallucination (AH) item in the Structured Clinical Interview for DSM-IV-TR (SCID), and 2) the thirteen questions involving VH in the Multidimensional Inventory of Dissociation (MID), a self-report questionnaire that comprehensively assesses pathological dissociation. We found that 45.7% of our sample met threshold for SCID AH, while 91.4% met criteria for MID VH. Receiver operating characteristics (ROC) analyses showed that while SCID AH and MID VH items have greater than chance agreement, the strength of agreement is only moderate, suggesting that SCID and MID VH items measure related but not identical constructs. Thirty-two patients met criteria for both SCID AH and at least one MID VH item ("unequivocal VH"), 32 for at least one MID VH item but not SCID AH ("ambiguous VH"), and 6 met criteria for neither ("unequivocal non-VH"). Relative to the ambiguous VH group, the unequivocal VH group had higher dissociation scores for child voices, and higher mean frequencies for child voices and Schneiderian voices. Our findings suggest that VH in women with TSD related to childhood abuse is common, but that the rate of VH depends on how the question is asked. We review prior studies examining AH and/or VH in TSD, focusing on the measures used to ascertain these experiences, and conclude that our two estimates are consistent with previous studies that used comparable instruments and patient samples. Our results add to growing evidence that VH-an experience typically considered psychotic or psychotic-like-is not equivalent to having a psychotic disorder. Instruments that assess VH apart from psychotic disorders and that capture their multidimensional nature may improve identification of VH, especially among patients with non-psychotic disorders.

Clinical and non-clinical hallucinations are similarly associated with source memory errors in a visual memory task

Hallucinations have been found to be associated with various types of source memory failure in both schizophrenia patients and hallucination-prone healthy individuals. We investigated the associations of clinical and non-clinical hallucinations with source memory errors in a visual memory task that involved the remembering of picture presentation context. 59 schizophrenia patients and 61 healthy individuals took part in the study. Pictures were presented either at different locations or in association with different visual stimuli. The participants were required afterwards to recognize the target pictures among distractors, and then to remember their spatial location or the visual stimulus that was associated with them. Liberal response bias in picture recognition was associated with hallucination proneness and auditory-verbal hallucinations in subsamples of participants with significant non-clinical or clinical hallucinations. After controlling for overall memory performance, failure to remember the spatial location of the pictures was associated with visual hallucinations in male patients; failure to remember the associated visual stimulus was related to auditory-verbal hallucinations in female patients and to hallucination proneness in healthy women. The findings suggest that both clinical and non-clinical hallucinations are associated with loss of contextual information relative to the acquisition of events.

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.

Do paranoid delusions exist on a continuum with subclinical paranoia? A multi-method taxometric study

BACKGROUND

There is widespread interest in whether psychosis exists on a continuum with healthy functioning. Previous research has implied that paranoia, a common symptom of psychosis, exists on a continuum but this has not been investigated using samples including both patients and non-patients and up-to-date taxometric methods.

AIM

To assess the latent structure of paranoia in a diverse sample using taxometric methods.

METHOD

We obtained data from 2836 participants, including the general population as well as at-risk mental state and psychotic patients using the P-scale of the Paranoia and Deservedness Scale. Data were analysed using three taxometric procedures, MAMBAC, MAXEIG and L-MODE (Ruscio, 2016), and two sets of paranoia indicators (subscales and selected items from the P scale), including and excluding the patient groups.

RESULTS

Eleven of the twelve analyses supported a dimensional model. Using the full sample and subscales as indicators, the MAMBAC analysis was ambiguous. Overall, the findings converged on a dimensional latent structure.

CONCLUSIONS

A dimensional latent structure of paranoia implies that the processes involved in sub-clinical paranoia may be similar to those in clinical paranoia.

Metacognitive profiles in schizophrenia and bipolar disorder: Comparisons with healthy controls and correlations with negative symptoms

While deficits in metacognition, or the ability to notice and reflect upon mental states has been observed in schizophrenia and linked with poorer concurrent and future function, it is unknown whether these deficits are unique to schizophrenia. Accordingly, this study assessed metacognition using the Metacognitive Assessment Scale-Abbreviated (MAS-A) and the Metacognitions Questionnaire- 30 (MCQ-30) among 26 adults with schizophrenia, 23 with bipolar disorder and 23 healthy controls. Symptom levels of the psychiatric groups were assessed with the Brief Psychiatric Rating Scale. ANCOVA controlling for age and education revealed that the schizophrenia group had lower scores on the MAS-A total and its subscales compared to the bipolar group and healthy controls. The bipolar disorder group also had lower MAS-A scores than the healthy control group. No group differences were found for the MCQ-30. Examination of symptom correlates revealed MAS-A scores were most commonly related to negative symptoms in both clinical groups. The total score and need for control subscale of MCQ-30 was related to total symptomatology and positive symptoms in patients with bipolar disorder. Correlations between the two measures of metacognition revealed that higher MAS-A scores were significantly related to lower scores on the Need to Control Thoughts MCQ-30 subscale.

Hearing voices, dissociation, and the self: A functional-analytic perspective

In the current article, we review existing models of the etiology of voice hearing. We summarize the argument and evidence that voice hearing is primarily a dissociative process involving critical aspects of self. We propose a complementary perspective on these phenomena that is based on a modern behavioral account of complex behavior known as relational frame theory. This type of approach to voice hearing concerns itself with the functions served for the individual by this voice hearing; the necessary history, such as trauma, that establishes these functions; and the relevant dissociative processes involving self and others. In short, we propose a trauma-dissociation developmental trajectory in which trauma impacts negatively on the development of self through the process of dissociation. Using the relational frame theory concept of relations of perspective taking, our dissociation model purports that trauma gives rise to more coordination than distinction relations between self and others, thus weakening an individual's sense of a distinct self. Voice hearing experiences, therefore, reflect an individual's perceptions of self and others and may indicate impairments in the natural psychological boundaries between these critical related concepts. One clinical implication suggested by this model is that therapeutic intervention should understand the behaviors associated with a sense of self that is fragile and threatened by others. Relations with self and others should be a key focus of therapy as well as interventions designed to enhance a coherent distinct sense of self.

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.

Suggestibility and signal detection performance in hallucination-prone students

INTRODUCTION

Auditory hallucinations are associated with signal detection biases. We examine the extent to which suggestions influence performance on a signal detection task (SDT) in highly hallucination-prone and low hallucination-prone students. We also explore the relationship between trait suggestibility, dissociation and hallucination proneness.

METHOD

In two experiments, students completed on-line measures of hallucination proneness (the revised Launay-Slade Hallucination Scale; LSHS-R), trait suggestibility (Inventory of Suggestibility) and dissociation (Dissociative Experiences Scale-II). Students in the upper and lower tertiles of the LSHS-R performed an auditory SDT. Prior to the task, suggestions were made pertaining to the number of expected targets (Experiment 1, N = 60: high vs. low suggestions; Experiment 2, N = 62, no suggestion vs. high suggestion vs. no voice suggestion).

RESULTS

Correlational and regression analyses indicated that trait suggestibility and dissociation predicted hallucination proneness. Highly hallucination-prone students showed a higher SDT bias in both studies. In Experiment 1, both bias scores were significantly affected by suggestions to the same degree. In Experiment 2, highly hallucination-prone students were more reactive to the high suggestion condition than the controls.

CONCLUSION

Suggestions may affect source-monitoring judgments, and this effect may be greater in those who have a predisposition towards hallucinatory experiences.

The Beliefs about Paranoia Scale: Confirmatory factor analysis and tests of a metacognitive model of paranoia in a clinical sample

This study aimed to confirm the factor structure of the Beliefs about Paranoia Scale (BaPS), a self-report measure to assess metacognitive beliefs about paranoia, and to test hypotheses of a metacognitive model. We hypothesised that positive and negative beliefs about paranoia would be associated with severity of suspiciousness, and that the co-occurrence of positive and negative beliefs would be associated with increased suspiciousness. A total of 335 patients meeting criteria for a schizophrenia spectrum disorder completed the BaPS, the Positive and Negative Syndromes Scale (PANSS), and the Psychotic Symptom Rating Scales (PSYRATS). Confirmatory factor analysis verified that the three BaPS subscales (negative beliefs about paranoia, paranoia as a survival strategy, and normalizing beliefs) were an adequate fit of the data. Ordinal regression showed that positive beliefs about paranoia as a survival strategy and negative beliefs were both associated with severity of suspiciousness. This was the first study to show that the co-occurrence of positive and negative beliefs was associated with increased suspiciousness. All hypotheses were confirmed, suggesting that a metacognitive approach has utility for the conceptualization of paranoia. Clinical implications suggest a role for metacognitive therapy, including strategies such as detached mindfulness and worry postponement.

Cognitive Attachment Model of Voices: Evidence Base and Future Implications

There is a robust association between hearing voices and exposure to traumatic events. Identifying mediating mechanisms for this relationship is key to theories of voice hearing and the development of therapies for distressing voices. This paper outlines the Cognitive Attachment model of Voices (CAV), a theoretical model to understand the relationship between earlier interpersonal trauma and distressing voice hearing. The model builds on attachment theory and well-established cognitive models of voices and argues that attachment and dissociative processes are key psychological mechanisms that explain how trauma influences voice hearing. Following the presentation of the model, the paper will review the current state of evidence regarding the proposed mechanisms of vulnerability to voice hearing and maintenance of voice-related distress. This review will include evidence from studies supporting associations between dissociation and voices, followed by details of our own research supporting the role of dissociation in mediating the relationship between trauma and voices and evidence supporting the role of adult attachment in influencing beliefs and relationships that voice hearers can develop with voices. The paper concludes by outlining the key questions that future research needs to address to fully test the model and the clinical implications that arise from the work.

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.

Auditory false perception in schizophrenia: Development and validation of auditory signal detection task

Auditory hallucinations constitute an important symptom component in 70-80% of schizophrenia patients. These hallucinations are proposed to occur due to an imbalance between perceptual expectation and external input, resulting in attachment of meaning to abstract noises; signal detection theory has been proposed to explain these phenomena. In this study, we describe the development of an auditory signal detection task using a carefully chosen set of English words that could be tested successfully in schizophrenia patients coming from varying linguistic, cultural and social backgrounds. Schizophrenia patients with significant auditory hallucinations (N=15) and healthy controls (N=15) performed the auditory signal detection task wherein they were instructed to differentiate between a 5-s burst of plain white noise and voiced-noise. The analysis showed that false alarms (p=0.02), discriminability index (p=0.001) and decision bias (p=0.004) were significantly different between the two groups. There was a significant negative correlation between false alarm rate and decision bias. These findings extend further support for impaired perceptual expectation system in schizophrenia patients.

Is this my voice or yours? The role of emotion and acoustic quality in self-other voice discrimination in schizophrenia

INTRODUCTION

Impairments in self-other voice discrimination have been consistently reported in schizophrenia, and associated with the severity of auditory verbal hallucinations (AVHs). This study probed the interactions between voice identity, voice acoustic quality, and semantic valence in a self-other voice discrimination task in schizophrenia patients compared with healthy subjects. The relationship between voice identity discrimination and AVH severity was also explored.

METHODS

Seventeen chronic schizophrenia patients and 19 healthy controls were asked to read aloud a list of adjectives characterised by emotional or neutral content. Participants' voice was recorded in the first session. In the behavioural task, 840 spoken words differing in identity (self/non-self), acoustic quality (undistorted/distorted), and semantic valence (negative/positive/neutral) were presented. Participants indicated if the words were spoken in their own voice, another person's voice, or were unsure.

RESULTS

Patients were less accurate than controls in the recognition of self-generated speech with negative content only. Impaired recognition of negative self-generated speech was associated with AVH severity ("voices conversing").

CONCLUSIONS

These results suggest that abnormalities in higher order processes (evaluation of the salience of a speech stimulus) modulate impaired self-other voice discrimination in schizophrenia. Abnormal processing of negative self-generated speech may play a role in the experience of AVH.

Dissociation and mindfulness in patients with auditory verbal hallucinations

The very few studies relating mindfulness and dissociation have found a negative association between them (depersonalization and absorption). However, all of these studies have been done in nonclinical populations, and there are no data on the relationship between these variables in psychiatric patients with auditory hallucinations. This study was designed to study the relationship between mindfulness and the two dissociative variables, absorption and depersonalization, as well as their predictive power for the severity of auditory hallucinations and the distress they cause in a clinical population. A total of 55 psychiatric patients with hallucinations were given the following tests: the Mindful Attention Awareness Scale (K. Brown & R. Ryan, 2003), the Tellegen Absorption Scale (A. Tellegen & G. Atkinson, 1974), the Cambridge Depersonalization Scale (M. Sierra & G. E. Berrios, 2000), the Psychotic Symptom Rating Scales (G. Haddock, J. McCarron, N. Tarrier, & E. B. Faragher, 1999), and the Positive and Negative Syndrome Scale (S. R. Kay, L. A. Opler, & J.-P. Lindenmayer, 1988). A significant negative correlation was found between mindfulness and the dissociative variables and between mindfulness and the distress caused by the hallucinations. A positive correlation was found between absorption and distress caused by hallucinations and between depersonalization and the severity of hallucinations. Finally, the variable with the most predictive power for severity of the voices was depersonalization, and the variable with the most predictive power for distress caused by the voices was mindfulness. Interventions addressing training in mindfulness techniques could diminish the distress associated with hearing voices.

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.

The effect of auditory verbal imagery on signal detection in hallucination-prone individuals

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Investigated relation between hallucinations, mental imagery and signal detection.

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Individuals prone to hallucinations showed a lower SDT response bias with imagery.

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Finding held for both instructed and self-reported use of auditory verbal imagery.

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Atypical auditory imagery may lead to the generation of auditory hallucinations.

Cognitive models have suggested that auditory hallucinations occur when internal mental events, such as inner speech or auditory verbal imagery (AVI), are misattributed to an external source. This has been supported by numerous studies indicating that individuals who experience hallucinations tend to perform in a biased manner on tasks that require them to distinguish self-generated from non-self-generated perceptions. However, these tasks have typically been of limited relevance to inner speech models of hallucinations, because they have not manipulated the AVI that participants used during the task. Here, a new paradigm was employed to investigate the interaction between imagery and perception, in which a healthy, non-clinical sample of participants were instructed to use AVI whilst completing an auditory signal detection task. It was hypothesized that AVI-usage would cause participants to perform in a biased manner, therefore falsely detecting more voices in bursts of noise. In Experiment 1, when cued to generate AVI, highly hallucination-prone participants showed a lower response bias than when performing a standard signal detection task, being more willing to report the presence of a voice in the noise. Participants not prone to hallucinations performed no differently between the two conditions. In Experiment 2, participants were not specifically instructed to use AVI, but retrospectively reported how often they engaged in AVI during the task. Highly hallucination-prone participants who retrospectively reported using imagery showed a lower response bias than did participants with lower proneness who also reported using AVI. Results are discussed in relation to prominent inner speech models of hallucinations.

Rate and predictors of psychotic symptoms after Kashmir earthquake

Psychotic symptoms are more common in general population than validated diagnosis of psychosis. There is evidence to suggest that these symptoms, hallucinations, paranoia, elated mood, thought insertion, are part of a spectrum of psychosis and may have association with the same risk factors that determine development of psychosis. These symptoms have an association with exposure to psychological trauma, post-traumatic stress disorder, anxiety and depression. The aim of this study was to explore the prevalence of psychotic symptoms in the population affected by a natural disaster, earthquake in this case and possible correlates of these symptoms. We conducted a cross-sectional survey of a population sample affected by the disaster, comprising of 1,291 individuals, 18 months after 2005 earthquake in Northern Pakistan and Kashmir to look at the prevalence of these symptoms and their correlates. Screening Instrument for Traumatic Stress in Earthquake Survivors and Self-Reporting Questionnaire and Psychosis Screening Questionnaire were used as tools. We examined association between the symptoms of anxiety, depression, PTSD and psychotic symptoms. We performed logistic regression analysis where hallucinations and delusions were dependent variables and demographic and trauma exposure variables were independent variables. The prevalence of psychotic symptoms ranged between 16.8 and 30.4 %. They were directly correlated with symptoms of post-traumatic stress disorder as well as concurrent symptoms of anxiety and depression. Lower level of education had a strong association in all the regression models. For hallucinations, living in a joint family had a negative association and participation in rescue, history of exposure to previous trauma and past psychiatric history had positive association. Paranoia was associated with female gender. Any psychiatric symptom was associated death of a family member, history of past psychiatric illness and living in a tent at the time of interview. Pattern of association of psychotic symptoms is consistent with prior literature and can be understood in the light of stress vulnerability model.

A Neuropsychological Approach to Auditory Verbal Hallucinations and Thought Insertion - Grounded in Normal Voice Perception

A neuropsychological perspective on auditory verbal hallucinations (AVH) links key phenomenological features of the experience, such as voice location and identity, to functionally separable pathways in normal human audition. Although this auditory processing stream (APS) framework has proven valuable for integrating research on phenomenology with cognitive and neural accounts of hallucinatory experiences, it has not yet been applied to other symptoms presumed to be closely related to AVH – such as thought insertion (TI). In this paper, I propose that an APS framework offers a useful way of thinking about the experience of TI as well as AVH, providing a common conceptual framework for both. I argue that previous self-monitoring theories struggle to account for both the differences and similarities in the characteristic features of AVH and TI, which can be readily accommodated within an APS framework. Furthermore, the APS framework can be integrated with predictive processing accounts of psychotic symptoms; makes predictions about potential sites of prediction error signals; and may offer a template for understanding a range of other symptoms beyond AVH and TI.

Auditory false perceptions are mediated by psychosis risk factors

INTRODUCTION

Auditory hallucinations exist in psychotic disorders as well as the general population. Proneness to hallucinations, as measured by positive schizotypy, predicts false perceptions during an auditory signal detection task (Barkus, Stirling, Hopkins, McKie, & Lewis, 2007). Our aim was to replicate this result and extend it by examining effects of age and sex, both important demographic predictors of psychosis.

METHOD

A sample of 76 healthy volunteers split into 15-17 years (n=46) and 19 years plus (n=30) underwent a signal detection task designed to detect propensity towards false perceptions under ambiguous auditory conditions. Scores on the Unusual Experiences subscale (UE) of the O-LIFE schizotypy scale, IQ, and a measure of working memory were also assessed.

RESULTS

We replicated our initial finding (Barkus et al., 2007): High scores on positive schizotypy were associated with false perceptions. Younger participants who scored highly on positive schizotypy reported significantly more false perceptions compared to other groups (p=.04). Older participants who had had an imaginary friend reported more false perceptions during the signal detection task (p<.01).

CONCLUSIONS

Younger participants seem most vulnerable to the effects of positive schizotypal traits in terms of a signal detection deficit that underlies auditory hallucinations. Schizotypy may have greatest impact closer to the risk period for development of psychotic disorders.

The impact of negative affect on reality discrimination

BACKGROUND AND OBJECTIVES

People who experience auditory hallucinations tend to show weak reality discrimination skills, so that they misattribute internal, self-generated events to an external, non-self source. We examined whether inducing negative affect in healthy young adults would increase their tendency to make external misattributions on a reality discrimination task.

METHODS

Participants (N = 54) received one of three mood inductions (one positive, two negative) and then performed an auditory signal detection task to assess reality discrimination.

RESULTS

Participants who received either of the two negative inductions made more false alarms, but not more hits, than participants who received the neutral induction, indicating that negative affect makes participants more likely to misattribute internal, self-generated events to an external, non-self source.

LIMITATIONS

These findings are drawn from an analogue sample, and research that examines whether negative affect also impairs reality discrimination in patients who experience auditory hallucinations is required.

CONCLUSIONS

These findings show that negative affect disrupts reality discrimination and suggest one way in which negative affect may lead to hallucinatory experiences.

The role of the superior temporal lobe in auditory false perceptions: a transcranial direct current stimulation study

Neuroimaging has shown that a network of cortical areas, which includes the superior temporal gyrus, is active during auditory verbal hallucinations (AVHs). In the present study, healthy, non-hallucinating participants (N=30) completed an auditory signal detection task, in which participants were required to detect a voice in short bursts of white noise, with the variable of interest being the rate of false auditory verbal perceptions. This paradigm was coupled with transcranial direct current stimulation, a noninvasive brain stimulation technique, to test the involvement of the left posterior superior temporal gyrus in the creation of auditory false perceptions. The results showed that increasing the levels of excitability in this region led to a higher rate of ‘false alarm’ responses than when levels of excitability were decreased, with false alarm responses under a sham stimulation condition lying at a mid-point between anodal and cathodal stimulation conditions. There were also corresponding changes in signal detection parameters. These results are discussed in terms of prominent cognitive neuroscientific theories of AVHs, and potential future directions for research are outlined.

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Investigated role of left STG in false perceptions of voices in white noise.

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Used noninvasive brain stimulation whilst participants listened to white noise.

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Tested whether number of false perceptions was affected by stimulation of STG.

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Higher false alarm rate when excitability increased than when decreased.

Relationship of absorption, depersonalisation, and self-focused attention in subjects with and without hallucination proneness

INTRODUCTION

The purpose of this work was to study the relationship of absorption, depersonalisation, and self-focused attention in subjects prone to hallucination.

METHODS

A sample of 218 healthy subjects was given the LSHS-R Hallucination Scale (Bentall & Slade, 1985). Three groups, subjects with high, medium, and low hallucination proneness, were formed from this sample. The Tellegen Absorption Scale (TAS; Tellegen & Atkinson, 1974), Cambridge Depersonalisation Scale (CDS; Sierra & Berrios, 2000), and Self-Absorption Scale (SAS; McKenzie & Hoyle, 2008) were also given to all the participants. The Metacognitions Questionnaire (MCQ-30; Wells & Cartwright-Hatton, 2004) was used as a covariant to control for the effects of emotional vulnerability on the dependent variables studied.

RESULTS

The results showed that subjects highly prone to hallucinations had significantly higher absorption, depersonalisation, and self-focused attention than the subjects in the other two groups. A hierarchical regression analysis showed that absorption and depersonalisation predict hallucination proneness.

CONCLUSIONS

The importance of the absorption, depersonalisation, and self-focused attention variables for understanding the aetiology of hallucinations is discussed in the Conclusions, where some approaches to its treatment are also suggested.

Relationship between Self-Focused Attention and Mindfulness in People with and without Hallucination Proneness

The purpose of this work was to study the relationship between self-focused attention and mindfulness in participants prone to hallucinations and others who were not. A sample of 318 healthy participants, students at the universities of Sevilla and Almería, was given the Launay-Slade Hallucinations Scale-revised (LSHS-R, Bentall & Slade, 1985). Based on this sample, two groups were formed: participants with high (n = 55) and low proneness (n = 28) to hallucinations. Participants with a score higher than a standard deviation from the mean in the LSHS-R were included in the high proneness group, participants with a score lower than a standard deviation from the mean in the LSHR-R were included in the second one. All participants were also given the Self-Absorption Scale (SAS, McKenzie & Hoyle, 2008) and the Southampton Mindfulness Questionnaire (SMQ, Chadwick et al., 2008). The results showed that participants with high hallucination proneness had significantly higher levels of public (t(80) = 6.81, p < .001) and private (t(77) = 7.39, p < .001) self-focused attention and lower levels of mindfulness (t(81) = -4.56, p < .001) than participants in the group with low hallucination proneness. A correlational analysis showed a negative association between self-focused attention (private and public) and mindfulness (r = -0.23, p < .001; r = -0.38, p < .001 respectively). Finally, mindfulness was found to partly mediate between self-focused attention and hallucination proneness. The importance of self-focused attention and mindfulness in understanding the etiology of hallucinations discussed and suggest some approaches to their treatment.

Relationship between childhood trauma, mindfulness, and dissociation in subjects with and without hallucination proneness

The purpose of this study was to examine the relationship between childhood traumas, mindfulness, and dissociation (more specifically, absorption and depersonalization) in healthy subjects with and without hallucination proneness. A sample of 318 subjects was given the Launay-Slade Hallucination Scale-Revised (R. P. Bentall & P. Slade, 1985). From this sample, 2 groups were formed: one with high and the other with low hallucination proneness. Furthermore, all participants were given the Tellegen Absorption Scale (A. Tellegen & G. Atkinson, 1974), the Cambridge Depersonalization Scale (M. Sierra & G. E. Berrios, 2000), the Southampton Mindfulness Questionnaire (P. D. J. Chadwick et al., 2008), and the Trauma Questionnaire (J. R. E. Davidson, D. Hughes, & D. G. Blazer, 1990). The results showed that in the group with high hallucination proneness, there were significantly more subjects with traumatic experiences than in the group with low predisposition, although no significant difference in the mean number of traumatic experiences undergone in childhood was found between the 2 groups, although there was a trend toward significance. A correlation analysis showed a significant negative association between mindfulness on the one hand and absorption and depersonalization on the other. A positive relationship was also found between childhood traumas and absorption and depersonalization. Finally, multiple mediation analysis showed that the absorption and depersonalization variables acted as mediators between childhood traumas and hallucination proneness. We discuss the importance of the relationship between the variables studied and hallucination proneness and suggest some approaches for their treatment.

A model of memory impairment in schizophrenia: cognitive and clinical factors associated with memory efficiency and memory errors

BACKGROUND

Memory impairments in patients with schizophrenia have been associated with various cognitive and clinical factors. Hallucinations have been more specifically associated with errors stemming from source monitoring failure.

METHODS

We conducted a broad investigation of verbal memory and visual memory as well as source memory functioning in a sample of patients with schizophrenia. Various memory measures were tallied, and we studied their associations with processing speed, working memory span, and positive, negative, and depressive symptoms.

RESULTS

Superficial and deep memory processes were differentially associated with processing speed, working memory span, avolition, depression, and attention disorders. Auditory/verbal and visual hallucinations were differentially associated with specific types of source memory error.

CONCLUSIONS

We integrated all the results into a revised version of a previously published model of memory functioning in schizophrenia. The model describes the factors that affect memory efficiency, as well as the cognitive underpinnings of hallucinations within the source monitoring framework.

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 comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals

Over the years, the prevalence of auditory verbal hallucinations (AVHs) have been documented across the lifespan in varied contexts, and with a range of potential long-term outcomes. Initially the emphasis focused on whether AVHs conferred risk for psychosis. However, recent research has identified significant differences in the presentation and outcomes of AVH in patients compared to those in non-clinical populations. For this reason, it has been suggested that auditory hallucinations are an entity by themselves and not necessarily indicative of transition along the psychosis continuum. This review will examine the presentation of auditory hallucinations across the life span, as well as in various clinical groups. The stages described include childhood, adolescence, adult non-clinical populations, hypnagogic/hypnopompic experiences, high schizotypal traits, schizophrenia, substance induced AVH, AVH in epilepsy, and AVH in the elderly. In children, need for care depends upon whether the child associates the voice with negative beliefs, appraisals and other symptoms of psychosis. This theme appears to carry right through to healthy voice hearers in adulthood, in which a negative impact of the voice usually only exists if the individual has negative experiences as a result of their voice(s). This includes features of the voices such as the negative content, frequency, and emotional valence as well as anxiety and depression, independently or caused by voices presence. It seems possible that the mechanisms which maintain AVH in non-clinical populations are different from those which are behind AVH presentations in psychotic illness. For example, the existence of maladaptive coping strategies in patient populations is one significant difference between clinical and non-clinical groups which is associated with a need for care. Whether or not these mechanisms start out the same and have differential trajectories is not yet evidenced. Future research needs to focus on the comparison of underlying factors and mechanisms that lead to the onset of AVH in both patient and non-clinical populations.

Source memory errors in schizophrenia, hallucinations and negative symptoms: a synthesis of research findings

BACKGROUND

Previous research has shown associations between source memory errors and hallucinations in patients with schizophrenia. We bring together here findings from a broad memory investigation to specify better the type of source memory failure that is associated with auditory and visual hallucinations.

METHOD

Forty-one patients with schizophrenia and 43 healthy participants underwent a memory task involving recall and recognition of lists of words, recognition of pictures, memory for temporal and spatial context of presentation of the stimuli, and remembering whether target items were presented as words or pictures.

RESULTS

False recognition of words and pictures was associated with hallucination scores. The extra-list intrusions in free recall were associated with verbal hallucinations whereas the intra-list intrusions were associated with a global hallucination score. Errors in discriminating the temporal context of word presentation and the spatial context of picture presentation were associated with auditory hallucinations. The tendency to remember verbal labels of items as pictures of these items was associated with visual hallucinations. Several memory errors were also inversely associated with affective flattening and anhedonia.

CONCLUSIONS

Verbal and visual hallucinations are associated with confusion between internal verbal thoughts or internal visual images and perception. In addition, auditory hallucinations are associated with failure to process or remember the context of presentation of the events. Certain negative symptoms have an opposite effect on memory errors.

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.

Modelling the emergence of hallucinations: early acquired vulnerabilities, proximal life stressors and maladaptive psychological processes

BACKGROUND

The study aimed to expand upon existing findings on the vulnerability to psychosis by examining synergistic models of hallucination emergence. Hypothesised vulnerability factors were separated into three stages of vulnerability; early acquired and enduring vulnerabilities (heredity, childhood trauma, early cannabis use), proximal life stressors (life hassles) and psychological appraisals/coping (metacognitions/experiential avoidance).

METHODS

Participants were recruited to a non-clinical sample (N = 133) and a clinical sample of psychosis patients (N = 100).

RESULTS

Path analyses in the non-clinical sample indicated that experiences of childhood emotional trauma, in combination with subsequent experiences of life hassles, best predicted vulnerability to both hallucinations in general and auditory hallucinations specifically. This pathway was partially mediated by negative metacognitions. The models were then replicated in the clinical sample, with two notable differences: (1) childhood sexual trauma replaced childhood emotional trauma as the best enduring predictor in the clinical model. (2) Experiential avoidance replaced metacognitions as the best cognitive predictor of hallucinations.

CONCLUSIONS

The study's findings highlighted how vulnerability to hallucinations can occur developmentally across time, with early acquired vulnerability factors, combining additively with more proximal day-to-day factors and cognitive style, to propel a person further towards the formation of hallucinations.

Do specific early-life adversities lead to specific symptoms of psychosis? A study from the 2007 the Adult Psychiatric Morbidity Survey

Previous studies have reported associations between childhood adversities, eg, loss of a parent, being raised in institutional care, sexual and other kinds of abuse by adults and bullying by peers, and psychosis in adulthood. However, the mechanisms by which these adversities lead to psychotic experiences are poorly understood. From models of the psychological processes involved in positive symptoms, it was predicted that childhood sexual abuse would be specifically associated with auditory hallucinations in adulthood, and that disruption of early attachment relations and more chronic forms of victimization such as bullying would be specifically associated with paranoid ideation. We therefore examined the associations between sexual trauma, physical abuse, bullying, and being brought up in institutional or local authority care and reports of auditory hallucinations and paranoid beliefs in the 2007 Adult Psychiatric Morbidity Survey. All simple associations between childhood adversities and the two symptom types were significant. Childhood rape was associated only with hallucinations (OR 8.9, CI = 1.86-42.44) once co-occurring paranoia was controlled for. Being brought up in institutional care (OR = 11.08, CI = 3.26-37.62) was specifically associated with paranoia once comorbid hallucinations had been controlled for. For each symptom, dose-response relationships were observed between the number of childhood traumas and the risk of the symptom. The specific associations observed are consistent with current psychological theories about the origins of hallucinations and paranoia. Further research is required to study the psychological and biological mediators of these associations.

Dissociation mediates the relationship between childhood trauma and hallucination-proneness

BACKGROUND

It has been proposed that the relationship between childhood trauma and hallucinations can be explained by dissociative processes. The present study examined whether the effect of childhood trauma on hallucination-proneness is mediated by dissociative tendencies. In addition, the influence of dissociative symptoms on a cognitive process believed to underlie hallucinatory experiences (i.e. reality discrimination; the capacity to discriminate between internal and external cognitive events) was also investigated.

METHOD

Patients with schizophrenia spectrum disorders (n=45) and healthy controls (with no history of hallucinations; n=20) completed questionnaire measures of hallucination-proneness, dissociative tendencies and childhood trauma, as well as performing an auditory signal detection task.

RESULTS

Compared to both healthy and non-hallucinating clinical controls, hallucinating patients reported both significantly higher dissociative tendencies and childhood sexual abuse. Dissociation positively mediated the effect of childhood trauma on hallucination-proneness. This mediational role was particularly robust for sexual abuse over other types of trauma. Signal detection abnormalities were evident in hallucinating patients and patients with a history of hallucinations, but were not associated with pathological dissociative symptoms.

CONCLUSIONS

These results are consistent with dissociative accounts of the trauma-hallucinations link. Dissociation, however, does not affect reality discrimination. Future research should examine whether other cognitive processes associated with both dissociative states and hallucinations (e.g. deficits in cognitive inhibition) may explain the relationship between dissociation and hallucinatory experiences.

The role of metacognitive beliefs in stress sensitisation, self-esteem variability, and the generation of paranoia

INTRODUCTION. Stress sensitisation may play a key role in the formation of psychosis. The authors examined whether metacognitive beliefs and self-esteem moderate affective response to stress, and whether subtle fluctuations in self-esteem act as a mediator between stress and attenuated psychotic phenomena. METHOD. 70 healthy volunteers completed two conditions of the same experimental tasks, which were designed to be either neutral or stress inducing. Ambulant assessments of negative affect, self-esteem, and suspicious thoughts were taken before and after each task, and standardised questionnaires were completed at the beginning or end of each session. RESULTS. Metacognitive belief subscales, but not self-esteem, moderated the association between stress and resultant negative affect, and negative affect and suspicious thinking. Individuals who placed greater emphasis on controlling their thoughts had greater variability in their self-esteem during the stress condition, which in turn predicted the severity of their attenuated psychotic phenomena. DISCUSSION. Metacognitive beliefs may sensitise an individual to minor stressors, by increasing affective reactivity and causing subtle shifts in appraisals of self-worth. Psychosocial intervention may wish to target these beliefs in order to desensitise an individual to negative events.