The intrasubjectivity of self, voices and delusions: A phenomenological analysis

What are delusions? Examining the typology problem

Delusions are a heterogenous transdiagnostic phenomenon with a higher prevalence in schizophrenia. One of the most fundamental debates surrounding the philosophical understanding of delusions concerns the question about the type of mental state in which reports that we label as delusional are grounded, namely, the typology problem. The formulation of potential answers for this problem seems to have important repercussions for experimental research in clinical psychiatry and the development of psychotherapeutic tools for the treatment of delusions in clinical psychology. Problematically, such alternatives are scattered in the literature, making it difficult to follow the current development and state of the target discussion. This paper offers an updated critical examination of the alternatives to the typology problem currently available in the literature. After clarifying the two main philosophical views underlying the dominant formulation of the debate (interpretivism and functionalism), we follow the usual distinction between doxastic (the idea that delusions are a type of belief) and anti-doxastic views. We then introduce two new sub-distinctions; on the doxastic camp, we distinguish between revisionist and non-revisionist proposals; on the anti-doxastic camp, we distinguish between commonsensical and non-commonsensical anti-doxasticisms. After analyzing the main claims of each view, we conclude with some of the most fundamental challenges that remain open within the discussion. This article is categorized under: Philosophy > Foundations of Cognitive Science Philosophy > Consciousness Philosophy > Psychological Capacities Neuroscience > Cognition.

'Are these my thoughts?': A 20-year prospective study of thought insertion, thought withdrawal, thought broadcasting, and their relationship to auditory verbal hallucinations

The co-occurrence of delusions and other symptoms at the onset of psychosis is a challenge for theories about the aetiology of psychosis. This paper explores the relatedness of delusions about the experience of thinking (thought insertion, thought withdrawal, and thought broadcasting) and auditory verbal hallucinations by describing their trajectories over a 20-year period in individuals diagnosed with schizophrenia, affective and other psychosis, and unipolar depression nonpsychosis. The sample consisted of 407 participants who were recruited at index hospitalization and evaluated over six follow-ups over 20 years. The symptom structure associated with thought insertion included auditory verbal hallucinations, somatic hallucinations, other hallucinations, delusions of thought-dissemination, delusions of control, delusion of self-depreciation, depersonalization and anxiety. The symptom constellation of thought withdrawal included somatic hallucinations, other hallucinations, delusions of thought dissemination, delusions of control, sexual delusions, depersonalization, negative symptoms, depression, and anxiety. The symptom constellation of thought broadcasting included auditory verbal hallucinations, somatic hallucinations, delusions of thought-dissemination, delusion of self-depreciation, fantastic delusions, sexual delusions, and depersonalization. Auditory verbal hallucinations and delusions of self-depreciation were significantly associated with both thought insertion and thought broadcasting. Thought insertion and thought withdrawal were significantly associated with other hallucinations, delusions of control, and anxiety; thought withdrawal and thought broadcasting were significantly related to sexual delusions. We hypothesize that specific symptom constellations over time might be explained as the product of pseudo-coherent realities created to give meaning to the experience of the world and the self of individuals in psychosis based on both prior top-down and ongoing bottom-up elements.

Sensed Presence, Attenuated Psychosis, and Transliminality: At the Threshold of Consciousness

INTRODUCTION

The experience of "sensed presence" or "felt presence" in the absence of "other" has been described as a complex multimodal experience to which meaning is given. Sensed presence (SenP) is a transdiagnostic experience that exists along a continuum that can appear during isolation, spirit quests, exposure to extreme elements, bereavement, anxiety, and psychosis. Given the prevalence and vast heterogeneity of SenP, in addition to a surprising lack of targeted research into this phenomenon, this research examined the interrelationship of SenP, attenuated psychosis symptoms (APS), and transliminality. Transliminality is composed of absorption, fantasy proneness, paranormal belief, mystical experiences, increased creativity, and hyperaesthesia.

METHODS

A completely anonymous online survey of unusual experiences and mental health was distributed via social media (i.e., Twitter, Facebook, Reddit, and mass emailing lists) to recruit participants. Demographic data were analyzed using χ2 tests and one-way ANOVAs. A two-step cluster analysis was conducted to identify distinct sub-categories of transliminality followed by ANOVAs with bootstrapping at 1,000 iterations to compare SenP, increased APS, and transliminality. Pearson's bivariate correlations were conducted to determine the association between SenP, APS, and transliminality.

RESULTS

Together with descriptive findings, we show distinct characteristics between clusters. T1 cluster consisted of individuals with few SenP experiences, low APS, and low transliminality. T2 consisted of individuals with a moderate prevalence of SenP, low APS, moderate transliminality, and increased overall feeling of closeness to G-d. There was no significant difference in APS between T1 and T2 or in the level of distress associated with APS. T3 individuals showed a significantly higher prevalence of SenP in all domains (frequency, distress, vividness, and total score), higher APS, and higher transliminality, compared to T1 and T2. The T3 cluster met criteria for high risk to develop psychosis.

CONCLUSION

Thus, our findings demonstrate a strong association and entanglement of these experiences which suggests that the interrelatedness of transliminality/absorption and APS may serve as a potentially provocative underlying structure in the phenomenology of SenP.

'An experience of meaning': A 20-year prospective analysis of delusional realities in schizophrenia and affective psychoses

Delusions are transdiagnostic and heterogeneous phenomena with varying degrees of intensity, stability, and dimensional attributes where the boundaries between everyday beliefs and delusional beliefs can be experienced as clearly demarcated, fuzzy, or indistinguishable. This highlights the difficulty in defining delusional realities. All individuals in the current study were evaluated at index and at least one of six subsequential follow-ups over 20 years in the Chicago Longitudinal Study. We assessed 16 distinct delusions categorized as thought or thematic delusions. We also examined the probability of recurrence and the relationships between delusions and hallucinations, depression, anxiety, and negative symptoms. The sample consisted of 262 individuals with schizophrenia vs. affective psychosis. Thought delusions were significantly different between groups at all follow-up evaluations except the 20-year timepoint. Thematic delusions were more common than thought delusions and show a significant decreasing pattern. In general, delusional content varied over time. Referential, persecutory, and thought dissemination delusions show the highest probability of recurrence. Hallucinations were the strongest indicator for thought, thematic, and overall delusions. The formation and maintenance of delusions were conceptualized as a multimodal construct consisting of sensory, perceptual, emotional, social, and somatic embodiment of an "experience of meanings". Given the significant associations between delusions and hallucinations, future work incorporating participatory research is needed to better define and align subjective and objective perspectives. Our research also points to the need for future clinical interventions that specifically evaluate and target the coexistence and entanglement of delusions and hallucinations.

Investigating the relationship between thought interference, somatic passivity and outcomes in patients with psychosis: a natural language processing approach using a clinical records search platform in south London

OBJECTIVES

We aimed to apply natural language processing algorithms in routine healthcare records to identify reported somatic passivity (external control of sensations, actions and impulses) and thought interference symptoms (thought broadcasting, insertion, withdrawal), first-rank symptoms traditionally central to diagnosing schizophrenia, and determine associations with prognosis by analysing routine outcomes.

DESIGN

Four algorithms were developed on deidentified mental healthcare data and applied to ascertain recorded symptoms over the 3 months following first presentation to a mental healthcare provider in a cohort of patients with a primary schizophreniform disorder (ICD-10 F20-F29) diagnosis.

SETTING AND PARTICIPANTS

From the electronic health records of a large secondary mental healthcare provider in south London, 9323 patients were ascertained from 2007 to the data extraction date (25 February 2020).

OUTCOMES

The primary binary dependent variable for logistic regression analyses was any negative outcome (Mental Health Act section, >2 antipsychotics prescribed, >22 days spent in crisis care) over the subsequent 2 years.

RESULTS

Final adjusted models indicated significant associations of this composite outcome with baseline somatic passivity (prevalence 4.9%; adjusted OR 1.61, 95% CI 1.37 to 1.88), thought insertion (10.7%; 1.24, 95% CI 1.15 to 1.55) and thought withdrawal (4.9%; 1.36, 95% CI 1.10 to 1.69), but not independently with thought broadcast (10.3%; 1.05, 95% CI 0.91 to 1.22).

CONCLUSIONS

Symptoms traditionally central to the diagnosis of schizophrenia, but under-represented in current diagnostic frameworks, were thus identified as important predictors of short-term to medium-term prognosis in schizophreniform disorders.

Relationships among subclinical psychotic symptoms in young adults over time

BACKGROUND

Subclinical psychotic symptoms are common in the general population and are often benign. However, those that become distressing or persistent may increase risk for the development of a psychotic disorder. Cognitive models have proposed that certain appraisals of hallucinatory experiences can lead to delusional beliefs, particularly if an individual is experiencing negative mood. However, the dynamic relationships among these symptoms are poorly understood. This study examined the longitudinal relationships among subclincal hallucinations, delusional ideation, and depression in a sample of young adults.

METHODS

677 college students completed baseline questionnaires to assess: delusional ideation (Peters Delusions Inventory), hallucinations (Launay-Slade Hallucinations Scale-Extended), and depression (Beck Depression Inventory). These measures were repeated 7, 13, 19, and 25 months later.

RESULTS

Higher baseline severity of hallucinations was strongly predictive of severity of delusions across all future follow-up timepoints, specifically when baseline depression was high. However, the severity of hallucinations did not change over time, nor were they predicted by baseline delusional ideation.

CONCLUSIONS

These findings support the proposal that hallucinations frequently precede more severe delusional ideation, rather than the reverse sequence, particularly when depressive symptoms are present. Such longitudinal relationships provide clues to the underlying mechanisms of psychosis, highlighting one pathway for intervention.

Social Perception Deficit as a Factor of Vulnerability to Psychosis: A Brief Proposal for a Definition

Disturbances in social cognition are a core feature of schizophrenia. While most research in the field has focused on emotion perception, social knowledge, theory of mind, and attribution styles, the domain of social perception has received little specific attention. In this paper, we suggest that this issue can be explained by the lack of a precise and unitary definition of the concept, this leads to the existence of different competing uses of the concept and their conflation with other domains of social cognition. Relying on resources coming from the ecological approach to psychology and the phenomenological tradition in psychiatry, we propose that the concept of Social Perception should be used to refer to low-level pre-reflective processes underlying the awareness of interpersonal interactions with and between others. Clinical data suggests that people with schizophrenia have problems perceiving social situations as opportunities for social engagement, so, in order to fulfil this explanatory need, we propose that the term should be used to capture this important-yet neglected-domain of social cognition. We conclude with the discussion of some future directions for research derived from our proposal.

The phenomenology of auditory verbal hallucinations in schizophrenia and the challenge from pseudohallucinations

In trying to make sense of the extensive phenomenological variation of first-personal reports on auditory verbal hallucinations, the concept of pseudohallucination is originally introduced to designate any hallucinatory-like phenomena not exhibiting some of the paradigmatic features of "genuine" hallucinations. After its introduction, Karl Jaspers locates the notion of pseudohallucinations into the auditory domain, appealing to a distinction between hallucinatory voices heard within the subjective inner space (pseudohallucination) and voices heard in the outer external space (real hallucinations) with differences in their sensory richness. Jaspers' characterization of the term has been the target of a number of phenomenological, conceptual and empirically-based criticisms. From this latter point of view, it has been claimed that the concept cannot capture distinct phenomena at the neurobiological level. Over the last years, the notion of pseudohallucination seems to be falling into disuse as no major diagnostic system seems to refer to it. In this paper, we propose that even if the concept of pseudohallucination is not helpful to differentiate distinct phenomena at the neurobiological level, the inner/outer distinction highlighted by Jaspers' characterization of the term still remains an open explanatory challenge for dominant theories about the neurocognitive origin of auditory verbal hallucinations. We call this, "the challenge from pseudohallucinations". After exploring this issue in detail, we propose some phenomenological, conceptual, and empirical paths for future research that might help to build up a more contextualized and dynamic view of auditory verbal hallucinatory phenomena.

A word is worth a thousand pictures: A 20-year comparative analysis of aberrant abstraction in schizophrenia, affective psychosis, and non-psychotic depression

thinking is a cognitive process that involves the assimilation of concepts reduced from diffuse sensory input, organized, and interpreted in a manner beyond the obvious. There are multiple facets by which abstraction is measured that include semantic, visual-spatial and social comprehension. This study examined the prevalence and course of abstract and concrete responses to semantic proverbs and aberrant abstraction (composite score of semantic, visual-spatial, and social comprehension) over 20 years in 352 participants diagnosed with schizophrenia, affective psychosis, and unipolar non-psychotic depression. We utilized linear models, two-way ANOVA and contrasts to compare groups and change over time. Linear models with Generalized Estimation Equation (GEE) to determine association. Our findings show that regardless of diagnosis, semantic proverb interpretation improves over time. Participants with schizophrenia give more concrete responses to proverbs when compared to affective psychosis and unipolar depressed without psychosis. We also show that the underlying structure of concretism encompasses increased conceptual overinclusion at index hospitalization and idiosyncratic associations at follow-up; whereas, abstract thinking overtime encompasses increased visual-spatial abstraction at index and rich associations with increased social comprehension scores at follow-up. Regardless of diagnosis, premorbid functioning, descriptive characteristics, and IQ were not associated with aberrant abstraction. Delusions are highly and positively related to aberrant abstraction scores, while hallucinations are mildly and positively related to this score. Lastly, our data point to the importance of examining the underlying interconnected structures of 'established' constructs vis-à-vis mixed methods to provide a description of the rich interior world that may not always map onto current quantitative measures.

Neural Correlates of Aberrant Salience and Source Monitoring in Schizophrenia and At-Risk Mental States-A Systematic Review of fMRI Studies

Cognitive biases are an important factor contributing to the development and symptom severity of psychosis. Despite the fact that various cognitive biases are contributing to psychosis, they are rarely investigated together. In the current systematic review, we aimed at investigating specific and shared functional neural correlates of two important cognitive biases: aberrant salience and source monitoring. We conducted a systematic search of fMRI studies of said cognitive biases. Eight studies on aberrant salience and eleven studies on source monitoring were included in the review. We critically discussed behavioural and neuroimaging findings concerning cognitive biases. Various brain regions are associated with aberrant salience and source monitoring in individuals with schizophrenia and the risk of psychosis. The ventral striatum and insula contribute to aberrant salience. The medial prefrontal cortex, superior and middle temporal gyrus contribute to source monitoring. The anterior cingulate cortex and hippocampus contribute to both cognitive biases, constituting a neural overlap. Our review indicates that aberrant salience and source monitoring may share neural mechanisms, suggesting their joint role in producing disrupted external attributions of perceptual and cognitive experiences, thus elucidating their role in positive symptoms of psychosis. Account bridging mechanisms of these two biases is discussed. Further studies are warranted.

The Sensory and Perceptual Scaffolding of Absorption, Inner Speech, and Self in Psychosis

This study examines the interconnectedness between absorption, inner speech, self, and psychopathology. Absorption involves an intense focus and immersion in mental imagery, sensory/perceptual stimuli, or vivid imagination that involves decreased self-awareness and alterations in consciousness. In psychosis, the dissolution and permeability in the demarcation between self and one's sensory experiences and perceptions, and also between self-other and/or inter-object boundaries alter one's sense of self. Thus, as the individual integrates these changes new "meaning making" or understanding evolves as part of an ongoing inner dialogue and dialogue with others. This study consisted of 117 participants: 81 participants with psychosis and 36 controls. We first conducted a bivariate correlation to elucidate the relationship between absorption and inner speech. We next conducted hierarchical multiple regressions to examine the effect of absorption and inner speech to predict psychopathology. Lastly, we conducted a network analysis and applied extended Bayesian Information Criterion to select the best model. We showed that in both the control and psychosis group dialogic and emotional/motivational types of inner speech were strongly associated with absorption subscales, apart from the aesthetic subscale in the control group which was not significant, while in psychosis, condensed inner speech was uniquely associated with increased imaginative involvement. In psychosis, we also demonstrated that altered consciousness, dialogic, and emotional/motivational inner speech all predicted positive symptoms. In terms of network associations, imaginative involvement was the most central, influential, and most highly predictive node in the model from which all other nodes related to inner speech and psychopathology are connected. This study shows a strong interrelatedness between absorption, inner speech and psychosis thus identifying potentially fertile ground for future research and directions, particularly in the exploration into the underlying construct of imaginative involvement in psychotic symptoms.

The role of inner speech on the association between childhood adversity and 'hearing voices'

Adverse childhood experiences are associated with later development of psychosis, particularly auditory verbal hallucinations and delusions. Although auditory hallucinations have been proposed to be misattributed inner speech, the relation between childhood adversity and inner speech has not been previously investigated. The first aim was to test whether childhood adversity is associated with inner speech in persons with psychosis. The second aim was to test for the influence of inner speech on the association between childhood adversity and auditory hallucinations. Our final aim was to test for evidence that would falsify the null hypothesis that inner speech does not impact the relationship between childhood adversity and delusions. In persons with psychosis, we found a positive association between childhood adversity and dialogic inner speech. There was a significant total effect of childhood adversity on auditory hallucinations, including an indirect effect of childhood adversity on auditory hallucinations via dialogic inner speech. There was also a significant total effect of childhood adversity on delusions, but no evidence of any indirect effect via inner speech. These findings suggest that childhood adversities are associated with inner speech and psychosis. The relation between childhood adversity and auditory hallucination severity could be partially influenced by dialogic inner speech.

Hallucinations Beyond Voices: A Conceptual Review of the Phenomenology of Altered Perception in Psychosis

Recent psychiatric research and treatment initiatives have tended to move away from traditional diagnostic categories and have focused instead on transdiagnostic phenomena, such as hallucinations. However, this emphasis on isolated experiences may artificially limit the definition of such phenomena and ignore the rich, complex, and dynamic changes occurring simultaneously in other domains of experience. This article reviews the literature on a range of experiential features associated with psychosis, with a focus on their relevance for hallucinations. Phenomenological research on changes in cognition, perception, selfhood and reality, temporality, interpersonal experience, and embodiment are discussed, along with their implications for traditional conceptualizations of hallucinations. We then discuss several phenomenological and neurocognitive theories, as well as the potential impact of trauma on these phenomena. Hallucinations are suggested to be an equifinal outcome of multiple genetic, neurocognitive, subjective, and social processes; by grouping them together under a single, operationalizable definition, meaningful differences in etiology and phenomenology may be ignored. It is suggested that future research efforts strive to incorporate a broader range of experiential alterations, potentially expanding on traditional definitions of hallucinations. Relevance for clinical practice, including emphasizing phenomenologically responsive techniques and developing targeted new therapies, is discussed.

From Computation to the First-Person: Auditory-Verbal Hallucinations and Delusions of Thought Interference in Schizophrenia-Spectrum Psychoses

Schizophrenia-spectrum psychoses are highly complex and heterogeneous disorders that necessitate multiple lines of scientific inquiry and levels of explanation. In recent years, both computational and phenomenological approaches to the understanding of mental illness have received much interest, and significant progress has been made in both fields. However, there has been relatively little progress bridging investigations in these seemingly disparate fields. In this conceptual review and collaborative project from the 4th Meeting of the International Consortium on Hallucination Research, we aim to facilitate the beginning of such dialogue between fields and put forward the argument that computational psychiatry and phenomenology can in fact inform each other, rather than being viewed as isolated or even incompatible approaches. We begin with an overview of phenomenological observations on the interrelationships between auditory-verbal hallucinations (AVH) and delusional thoughts in general, before moving on to review several theoretical frameworks and empirical findings in the computational modeling of AVH. We then relate the computational models to the phenomenological accounts, with a special focus on AVH and delusions that involve the senses of agency and ownership of thought (delusions of thought interference). Finally, we offer some tentative directions for future research, emphasizing the importance of a mutual understanding between separate lines of inquiry.

The tangled roots of inner speech, voices and delusions

The role of inner speech in the experience of auditory verbal hallucinations (AVH) and delusions remains unclear. This exploratory study tested for differences in inner speech (assessed via self-report questionnaire) between 89 participants with psychosis and 37 non-clinical controls. We also tested for associations of inner speech with, i) state/trait AVH, ii) AVH-severity; iii) patients' relations with their voices, and; iv) delusion-severity. Persons with psychosis had greater levels of dialogic inner speech, other people in inner speech, and evaluative/motivational inner speech than non-clinical controls. Those with state, but not trait AVH had greater levels of dialogic and evaluative/motivational inner speech than non-clinical controls. After controlling for delusions, there was a positive relation between AVH-severity and both evaluative/motivational inner speech and other people in inner speech. Participants with greater levels of dialogic inner speech reported better relations both with and between their voices. There was no association between delusion-severity and inner speech. These results highlight the importance of better understanding relations between inner speech and AVH, provide avenues for future research, and underscore the need for research into the interrelatedness of inner speech, voices and delusions, and the complexities involved in disentangling these experiences.

Immersion in altered experience: An investigation of the relationship between absorption and psychopathology

Understanding alterations in perceptual experiences as a component of the basic symptom structure of psychosis may improve early detection and the identification of subtle shifts that can precede symptom onset or exacerbation. We explored the phenomenological construct of absorption and psychotic experiences in both clinical (bipolar psychosis and schizophrenia spectrum) and non-clinical participants. Participants with psychosis endorsed significantly higher absorption compared to the non-clinical group. Absorption was positively correlated with all types of hallucinations and multiple types of delusions. The analysis yielded two distinct cluster groups that demarcated a distinction along the continuum of self-disturbance: on characterized by attenuated ego boundaries and the other stable ego boundaries. The study suggests that absorption is a potentially important but under-researched component of psychosis that overlaps with, but is not identical to the more heavily theorized constructs of aberrant salience and hyperreflexivity.

Listening to Schneiderian Voices: A Novel Phenomenological Analysis

BACKGROUND/AIMS

This paper reports on analyses designed to elucidate phenomenological characteristics, content and experience specifically targeting participants with Schneiderian voices conversing/commenting (VC) while exploring differences in clinical presentation and quality of life compared to those with voices not conversing (VNC).

METHODS

This mixed-method investigation of Schneiderian voices included standardized clinical metrics and exploratory phenomenological interviews designed to elicit in-depth information about the characteristics, content, meaning, and personification of auditory verbal hallucinations.

RESULTS

The subjective experience shows a striking pattern of VC, as they are experienced as internal at initial onset and during the longer-term course of illness when compared to VNC. Participants in the VC group were more likely to attribute the origin of their voices to an external source such as God, telepathic communication, or mediumistic sources. VC and VNC were described as characterological entities that were distinct from self (I/we vs. you). We also found an association between VC and the positive, cognitive, and depression symptom profile. However, we did not find a significant group difference in overall quality of life.

CONCLUSIONS

The clinical portrait of VC is complex, multisensory, and distinct, and suggests a need for further research into the biopsychosocial interface between subjective experience, socioenvironmental constraints, individual psychology, and the biological architecture of intersecting symptoms.