Hallucinations in Children and Adolescents: An Updated Review and Practical Recommendations for Clinicians

Children's early signs and developmental trajectories of psychotic-like experiences

INTRODUCTION

Children who experience persistent psychotic-like experiences (PLEs) are at a higher risk of developing psychotic disorder later in life. The developmental trajectories of PLEs are influenced by various factors. Therefore, it is important to identify early characteristics that can distinguish and predict between different developmental trajectories of PLEs.

METHODS

Using PLEs scores from the Adolescent Brain Cognitive Development (ABCD) data across three waves, we categorized participants into five distinct PLEs trajectories groups: persistent group (n = 47), remitting group (n = 185), increasing group (n = 117), remittent group (n = 21), and no PLEs group (n = 4,476). We utilized linear mixed-effect models and generalized linear mixed-effect models to examine the differences in baseline characteristics, including psychological and behavioral problems, suicidality, trauma experiences, developmental milestones, cognitive function, physical health, family income, family history of mental illness, and brain structureamong these PLEs trajectory groups.

RESULTS

We found that psychological and behavioral problems (such as DSM-oriented scales/externalizing/ADHD/social/attention/thought problems) assessed by the Child Behavior Checklist (CBCL) were associated with all PLEs groups. The persistent PLEs group had greater ADHD/social/thought problems and suicidal behavior compared to the remitting PLEs group. Comparing with the no PLEs group, poor cognitive function, abnormal brain structure (such as temporal lobe and supramarginal gyrus), more trauma experiences, and lower family income were found in only one of the PLEs groups, but not all PLEs groups.

CONCLUSION

The development of PLEs is accompanied by changes in many domains, implying a dynamic and complex developmental process. Given that psychological and behavioral problems can predict the emergence of PLEs at any time and can be regarded as risk factors for persistent PLEs, thereby enabling early precisely interventions, it is important to place greater emphasis on assessing psychological and behavioral problems.

Identification and treatment of individuals with childhood-onset and early-onset schizophrenia

Approximately 8 % of patients with schizophrenia are diagnosed before age 18, and 18 % experience their first symptoms before age 18. This narrative review explores the management of patients with early-onset schizophrenia (EOS) and childhood-onset schizophrenia (COS) from diagnosis to their transition to adult care settings. Early diagnosis of schizophrenia in children and adolescents is essential for improving outcomes, but delays are common due to overlapping of symptoms with developmental phenomena and other psychiatric conditions, including substance use, and lack of clinicians' awareness. Once diagnosed, antipsychotic treatment is key, with specific second-generation agents generally being preferred due to better tolerability and their broader efficacy evidence-base in youth. Dosing should be carefully individualized, considering age-related differences in drug metabolism and side effect liability. Clinicians must be vigilant in detecting early non-response and consider switching or dose escalation when appropriate. Since early age of illness onset is a consistent risk factor for treatment-resistant schizophrenia (TRS), clinicians need to be competent in diagnosing TRS and using clozapine. Since COS and EOS are associated with cognitive deficits and impaired functioning, psychosocial interventions should be considered to improve overall functioning and quality of life. Good long-term outcomes depend on continuous treatment engagement, and successful transitioning from pediatric to adult care requires careful planning, early preparation, and collaboration between pediatric and adult clinicians. Targeting functional outcomes and quality of life in addition to symptom remission can improve overall patient well-being. Comprehensive evaluations, age-specific assessments, and targeted interventions are needed to address the unique challenges of EOS and COS.

Multi-modal hallucinations across diagnoses: What relationships do they have with voice-related distress?

BACKGROUND

Research into hallucinatory experiences has focused primarily upon hallucinations within the auditory modality, to the relative neglect of other modalities. Furthermore, the exploration of auditory hallucinations (or 'voices') has focused primarily upon the experiences of people with a diagnosis of psychosis. The presence of multi-modal hallucinations may have implications across diagnoses for levels of distress, formulation and the targeting of psychological interventions.

METHODS

This study presents a cross-sectional analysis of observational data from the PREFER survey (N = 335). Linear regression was used to explore the relationships between voice-related distress and the presence, number, type and timing of multi-modal hallucinations.

RESULTS

Simple relationships were not found between distress and the presence of hallucinations in visual, tactile, olfactory or gustatory modalities, or in the number of modalities experienced. When considering the degree to which another modality hallucination was experienced simultaneously with voices, there was some evidence that the degree of co-occurrence with visual hallucinations was predictive of distress.

CONCLUSIONS

The co-occurrence of voices with visual hallucinations may be associated with relatively greater distress, but not consistently, and the association between multimodal hallucinations and clinical impact appear complex and potentially variable from individual to individual. Further study of associated variables such as perceived voice power may further illuminate these relationships.

Understanding unusual sensory experiences: a randomised experimental study of a school-based intervention for adolescents

BACKGROUND

One in ten young people experience unusual sensory experiences (USE), such as hallucinations. From a cognitive perspective, the appraisal of USE determines the impact of these experiences. Negative appraisal, as well as other psychological processes (e.g. thinking flexibility, maladaptive schemas, anxiety/depression), is associated with more distress. Our aim was to (a) develop a universal single-session school-based intervention on USE for adolescents and (b) evaluate the effect of the intervention on appraisals of and help seeking intentions for USE.

METHODS

A randomised controlled experimental design with a one-month follow-up was used to test the effectiveness of the intervention in one school. Students (n = 223) aged 12-13 were randomised by class to a single-session intervention on USE or a control intervention (generic mental wellbeing). Participants completed measures of appraisals of and help-seeking intentions for USE at pre- and postintervention and at one-month follow-up. They also completed measures of schemas, thinking flexibility and anxiety/depression at preintervention.

RESULTS

Overall, 190 adolescents completed the main outcome measures at all three points. The intervention on USE led to a significant (p < .05) increase of positive appraisals of USE compared with the control, with effects sustained at one-month follow-up. The intervention on USE did not lead to significantly greater help-seeking intentions for USE (p = .26). Adolescents' schemas were associated with appraisals and slow thinking and anxiety/depressive symptoms with help-seeking behaviour for USE.

CONCLUSIONS

A single-session universal school-based intervention shows promise by improving appraisals of USE. Further research is required across different school populations.

The dimensionality of perceptual anomalies and their relationships with bullying victimization among Chinese adolescents: From a network perspective

Anomalous perceptual experiences in adolescents are common and may predict future psychotic disorders and other psychopathologies. However, the underlying structure and their specific relationships with bullying victimizations, a typical stressor for adolescents, remain unclear. Therefore, the current study aimed to clarify the structure of perceptual anomalies as assessed by the Cardiff Anomalous Perceptions Scale (CAPS) using exploratory graph analysis (EGA), a new factor retention method based on network psychometrics. The second aim was to explore whether specific dimensions of perceptual anomalies are particularly associated with certain forms of bullying victimization. Data from a validated sample of 1199 Chinese adolescents (56.0 % females, age range: 14-20) on perceptual anomalies and bullying victimizations were analyzed using network approaches, including EGA and mixed graphical modeling (mgm). Results showed that each anomalous perception was experienced by 13.8-50.3 % of the participants. EGA identified four dimensions: aberrant bodily perceptions, altered daily experiences, chemosensation (i.e., abnormal gustatory and olfactory experiences), and clinical psychosis (i.e., visual and auditory hallucinatory experiences). Among them, the altered daily experiences dimension possessed the highest centrality. Physical bullying and cyberbullying were directly and positively linked to two of the aberrant bodily experiences. Bootstrap analyses suggest that the results are reliable. The current findings support the existence of multiple contributive factors to perceptual anomalies and underscore the importance of bullying prevention in reducing mental health risks for adolescents, particularly the risk of psychosis.

Sleep disorders predict the 1-year onset, persistence, but not remission of psychotic experiences in preadolescence: a longitudinal analysis of the ABCD cohort data

The relationship between sleep disorder and psychotic experiences in preadolescence has not been extensively studied despite the potential for intervention. The current study addressed this relationship using the Adolescent Brain and Cognitive Development (ABCD) cohort, which provided baseline data from 11,830 10- to 11-year-old; for 4910 of these, 1-year follow-up data were also available. A set of pre-registered multi-level regression models were applied to test whether (a) sleep disorder is associated with psychotic experiences at baseline; (b) baseline sleep disorder predicts psychotic experiences at follow-up; (c) the persistence of sleep disorder predicts persistence of psychotic experiences at follow-up; d) the remission of sleep disorder predicts the remission of psychotic experiences at follow-up. After controlling for potential confounders, sleep disorder was associated with psychotic experiences cross-sectionally (OR = 1.40, 95% CI 1.20-1.63), at 1-year follow-up (OR = 1.32, 95% CI 1.11-1.57), and the persistence of sleep disorder predicted the persistence of psychotic experiences (OR = 1.72, 95% CI 1.44-2.04). However, remission of sleep problems did not predict remission of psychotic experiences (OR = 1.041, 95% CI 0.80-1.35). The results indicate that sleep disorders in preadolescence are common and associated with psychotic experiences, although the lack of co-remission raises questions about the mechanism of association. However, given these findings, and existing evidence in later adolescence and adults, further investigation of sleep as a preventative mental health intervention target in this age group is warranted.

A Psychoeducational Workshop for the Parents of Young Voice Hearers: A Preliminary Investigation into Acceptability and Outcomes in an NHS Child and Adolescent Mental Health Service

BACKGROUND

Hearing voices is a common experience in young people and can be associated with distress, self-harm, and an increased risk of attempting suicide. Many parents lack confidence in supporting young people who are distressed by voices. However, there are currently no evidence-based interventions to support the parents of young voice hearers.

METHOD

This was an uncontrolled study exploring the preliminary acceptability and outcomes of a psychoeducation workshop for the parents of young people experiencing distressing voices within a Child and Adolescent Mental Health Service (CAMHS) in the UK's National Health Service.

RESULTS

A total of 21 parents consented to participate, 15 attended a workshop and 10 provided complete data sets. Five workshops were delivered across a seven-month period. Qualitative feedback was suggestive of acceptability and highlighted possible adaptations in relation to inclusivity, content focus and delivery format. Participants reported increased confidence and improved attitudes and beliefs towards voice hearing.

CONCLUSIONS

The findings from this study suggest that a psychoeducational workshop within a CAMHS context can be acceptable and helpful for parents of young people with distressing voice hearing experiences. Adaptations to the workshop are required to maximise inclusion, engagement, and outcomes.

"Attitudes to voices": a survey exploring the factors influencing clinicians' intention to assess distressing voices and attitudes towards working with young people who hear voices

Introduction

Due to the general psychopathological vulnerability of young people who hear distressing voices, research has stressed the importance for clinicians to assess this experience in youth. Nonetheless, the limited literature on the topic comes from studies with clinicians in adult health services and it primarily reports that clinicians do not feel confident in systematically assessing voice-hearing and doubt the appropriateness of doing so. We applied the Theory of Planned Behavior and identified clinicians' job attitudes, perceived behavioral control, and perceived subjective norms as putative predictors of their intent to assess voice-hearing in youth.

Method

Nine hundred and ninety-six clinicians from adult mental health services, 467 from Child and Adolescent Mental Health (CAMHS) and Early Intervention in Psychosis (EIP) services and 318 primary care clinicians across the UK completed an online survey. The survey gathered data on attitudes toward working with people who hear voices, stigmatizing beliefs, and self-perceived confidence in voice-related practices (screening for, discussing and providing psychoeducation material about voice-hearing). Responses from youth mental health clinicians were compared with professionals working in adult mental health and primary care settings. This study also aimed to identify what youth mental health clinicians believe about assessing distressing voices in adolescents and how beliefs predict assessment intention.

Results

Compared to other clinicians, EIP clinicians reported the most positive job attitudes toward working with young voice-hearers, the highest self-efficacy in voice-hearing practices, and similar levels of stigma. Job attitudes, perceived behavioral control and subjective norms explained a large part of the influences on clinician's intention to assess voice-hearing across all service groups. In both CAMHS and EIP services, specific beliefs relating to the usefulness of assessing voice-hearing, and perceived social pressure from specialist mental health professionals regarding assessment practices predicted clinician intention.

Discussion

Clinicians' intention to assess distressing voices in young people was moderately high, with attitudes, subjective norms and perceived behavioral control explaining a large part of its variance. Specifically in youth mental health services, promoting a working culture that encourages opening and engaging in discussions about voice-hearing between clinicians, and with young people, and introducing supportive assessment and psychoeducation material about voice-hearing could encourage conversations about voices.

Family members' experiences of seeking help for a young person with symptoms associated with the psychosis spectrum: A narrative review and synthesis

Young people often rely on family carers to access support for their mental health. However, stigma can be a barrier to help seeking for young people and families. Little research has been undertaken with young people who experience highly stigmatised symptoms, such as psychosis spectrum symptoms, and even less research has been conducted with parents and carers, meaning barriers to help go unchallenged. Therefore, this narrative review aimed to explore stories of family experiences of seeking help for young people with symptoms associated with the psychosis spectrum. Sources searched were PsycINFO and PubMed. Reference lists of the selected papers were also cross-checked to ensure the search had not missed potential papers for inclusion. Searches returned 139 results, of which 12 were identified for inclusion. A narrative analytic approach was adopted to synthesise qualitative findings to provide a nuanced interpretation of help-seeking experiences. The narrative synthesis provided an opportunity to identify differences, similarities, and patterns across the studies to tell a cumulative emancipatory narrative of family experiences of seeking help for psychosis spectrum symptoms. Help-seeking experiences had a relational impact on families, with stress adding to conflict and anxieties inhibiting hopefulness, although families could emerge stronger and assertively with compassionate support.

Association between suicidal behaviors and auditory and visual hallucinations in Japanese adolescent psychiatric outpatients at first visit: a cross-sectional study

BACKGROUND

Suicide remains one of the leading causes of death among adolescents. Although recent studies have suggested a strong association between auditory hallucinations and suicidal behaviors, little is known regarding the association between suicidal behaviors and visual hallucinations, which are also common among adolescent psychiatric patients.

METHOD

A cross-sectional study of all first-time patients aged 10-15 years was conducted at three child and adolescent psychiatric outpatient facilities in Kanagawa Prefecture, Japan, from April 2015 to March 2018. Self-reported questionnaires were administered to evaluate auditory and visual hallucinations, suicide planning, and suicide attempts within the two weeks prior to the first visit. Our logistic regression model included three covariates (sex, age, and presence of major depressive episode) for adjustments. Among the 1285 respondents, 37 who had moderate or severe intellectual disability were excluded, leaving 1248 for analysis.

RESULTS

Among the 1069 patients who completed questionnaire items on hallucinations, 230 (21.5%) experienced auditory or visual hallucinations. After controlling for all confounders, visual hallucinations, but not auditory hallucinations, were significantly associated with increased odds of suicide planning (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.5-4.1). In contrast, auditory hallucinations, but not visual hallucinations, were significantly associated with increased odds of suicide attempts (OR 2.8, 95% CI 1.3-6.1). No interaction effects were observed between suicidal behaviors and auditory or visual hallucinations.

CONCLUSIONS

Clinicians should consider the prevalence of both auditory and visual hallucinations among young adolescent patients, with emphasis on auditory hallucinations, given their association with suicide attempts.

Coping strategy enhancement for the treatment of distressing voices in young people: A service evaluation within routine clinical practice

BACKGROUND

Hearing voices is a common experience in young people, irrespective of diagnosis. This experience can be associated with distress, self-harm and an increased risk of attempting suicide. However, there are currently no evidence-based interventions which specifically target distressing voice hearing experiences in young people.

METHOD

This was a service evaluation exploring the engagement, outcomes and experiences of young people who were offered a brief 4-session intervention for distressing voices within a Child and Adolescent Mental Health Service (CAMHS) in the UK's National Health Service. The intervention was based on the principles of Coping Strategy Enhancement (CSE).

RESULTS

A total of 24 young people were offered the CSE intervention over a 20-month period. The intervention was completed by 15 young people. Pre-post outcomes suggested clinically meaningful reductions in the negative impact of voices for the majority of the young people. Qualitative feedback was positive and highlighted the value of both a space to talk about voice hearing experiences and a focus upon coping strategies.

CONCLUSIONS

The findings from this service evaluation suggest that CSE can be a brief, acceptable and helpful way for young people within a CAMHS context to start a therapeutic conversation about their distressing voice hearing experiences.

Psychotic experiences in the general population, a review; definition, risk factors, outcomes and interventions

Psychotic experiences (PE) are common in the general population, in particular in childhood, adolescence and young adulthood. PE have been shown to be associated with an increased risk for later psychotic disorders, mental disorders, and poorer functioning. Recent findings have highlighted the relevance of PE to many fields of healthcare, including treatment response in clinical services for anxiety & depression treatment, healthcare costs and service use. Despite PE relevance to many areas of mental health, and healthcare research, there remains a gap of information between PE researchers and experts in other fields. With this review, we aim to bridge this gap by providing a broad overview of the current state of PE research, and future directions. This narrative review aims to provide an broad overview of the literature on psychotic experiences, under the following headings: (1) Definition and Measurement of PE; (2) Risk Factors for PE; (3) PE and Health; (4) PE and Psychosocial Functioning; (5) Interventions for PE, (6) Future Directions.

"Figuring out how to be normal": Exploring how young people and parents make sense of voice-hearing in the family context

OBJECTIVES

Making sense of voice-hearing-exploring the purpose, cause, and relationship with voices-is seen as therapeutically valuable for adults, but there is a paucity of research with adolescents. Family intervention is recommended for young people, yet little is known about families' perspectives on, or role in, a child's voice-hearing. This study therefore aimed to explore how both young people and parents had made sense of voice-hearing in the family context.

METHOD

Semi-structured interviews were conducted with seven young people who hear voices (six females, one male, age M = 17 years) and six parents of young people who hear voices (five females, one male). Data were analysed using interpretative phenomenological analysis.

RESULTS

The young people struggled to reconcile their voice-hearing experiences within themselves, wanted control, 'normality', and not to let their mental health hold them back. Parents saw the voices as separate to their child, who they were protective of, and came to an acceptance and hope for the future amidst continued uncertainty. Pragmatism, and shame, ran through parents' and young people's accounts. Tensions between them, such as autonomy versus involvement, were also apparent.

CONCLUSIONS

Few participants had made sense of their experiences in any concrete form, yet hope, control, and getting on with their lives were not conditional on having done so. Young people valued the family as a safe, non-enquiring space to be 'normal' and not to talk about their experiences. While all had been challenged by their experiences, an energy and strength ran through their accounts.

Editorial: Can At-Risk Mental State (ARMS) Diagnosis in Children and Adolescents Predict Transition to a Psychotic Disorder? We Are Not There Yet

Psychosis is one of the most extreme and feared forms of psychopathology. Because early intervention leads to better outcomes for psychotic disorders, our field is highly motivated to identify this problem in its earliest stages. Ideally, early intervention during childhood and adolescence would be optimal to help restore healthy brain development and prevent the onset of a psychotic disorder. Structural clinical interviews have been developed to identify youth who are at high risk for psychosis, based largely on the presence of attenuated and/or transient psychotic symptoms. However, these evaluations are challenging because of vast developmental differences among children, adolescents, and adults in how these experiences are understood and expressed. In the wake of a growing body of literature examining the utility of assessments for At Risk Mental States (ARMS) for predicting later transition to a psychotic disorder, the time is ripe for a systematic review to assess the state of this emerging field.

(Attenuated) hallucinations join basic symptoms in a transdiagnostic network cluster analysis

Hallucinations are considered characteristic symptoms of psychosis and part of the 'psychosis superspectrum' of the Hierarchical Taxonomy Of Psychopathology (HiTOP) initiative. To gain insight into their psychopathological relevance, we studied their dimensional placement within a single dense transdiagnostic network constituting of basic symptoms as well as of attenuated and frank psychotic, and related symptoms. Newman's modularity analysis was used to detect symptom clusters in an earlier generated network (Jimeno, N., et al., 2020. Main symptomatic treatment targets in suspected and early psychosis: New insights from network analysis. Schizophr. Bull. 46, 884-895. https://doi.org/10.1093/schbul/sbz140). The constituting 86 symptoms were assessed with the Schizophrenia Proneness Instrument, Adult version (SPI-A), the Structured Interview for Psychosis-Risk Syndromes (SIPS), and the Positive And Negative Syndrome Scale (PANSS) in three adult samples of an early detection service: clinical high-risk (n = 203), first-episode psychosis (n = 153), and major depression (n = 104). Three clusters were detected: "subjective disturbances", "positive symptoms and behaviors", and "negative and anxious-depressive symptoms". The predominately attenuated hallucinations of both SIPS and PANSS joined the basic symptoms in "subjective disturbances", whereas other positive symptoms entered "positive symptoms and behaviors". Our results underline the importance of insight in separating true psychotic hallucinations from other hallucinatory experiences that, albeit phenomenologically similar are still experienced with some insight, i.e., are present in an attenuated form. We conclude that, strictly, hallucinations held with any degree of insight should not be used to diagnose transition to or presence of frank psychoses and, relatedly, to justify antipsychotic medication.

Arts-based methods for hallucination research

INTRODUCTION

Neurocognitive models of hallucinations posit theories of misattribution and deficits in the monitoring of mental or perceptual phenomena but cannot yet account for the subjective experience of hallucinations across individuals and diagnostic categories. Arts-based research methods (ABRM) have potential for advancing research, as art depicts experiences which cognitive neuropsychiatry seeks to explain.

METHODS

To examine how incorporating ABRM may advance hallucination research and theories, we explore data on the lived experiences of hallucinations in psychiatric and neurological populations. We present a multiple case study of two empirical ABRM studies, which used participant-generated artwork and artist collaborations alongside interviews.

RESULTS

ABRM combined with interviews illustrated that hallucinations were infused with sensory features, characterised by embodiment, and situated within lived circumstances. These findings advance neurocognitive models of hallucinations by nuancing their multimodal nature, illustrating their embodied feelings, and exploring their content and themes. The process of generating artworks aided in disclosing difficult to discuss hallucinations, promoted participant self-reflection, and clarified multimodal details that may have been misconstrued through interview alone. ABRM were relevant and acceptable for participants and researchers.

CONCLUSION

ABRM may contribute to the development of neurocognitive models of hallucinations by making hallucination experiences more visible, tangible, and accessible.

Susceptibility to auditory hallucinations is associated with spontaneous but not directed modulation of top-down expectations for speech

Auditory verbal hallucinations (AVHs)-or hearing voices-occur in clinical and non-clinical populations, but their mechanisms remain unclear. Predictive processing models of psychosis have proposed that hallucinations arise from an over-weighting of prior expectations in perception. It is unknown, however, whether this reflects (i) a sensitivity to explicit modulation of prior knowledge or (ii) a pre-existing tendency to spontaneously use such knowledge in ambiguous contexts. Four experiments were conducted to examine this question in healthy participants listening to ambiguous speech stimuli. In experiments 1a (n = 60) and 1b (n = 60), participants discriminated intelligible and unintelligible sine-wave speech before and after exposure to the original language templates (i.e. a modulation of expectation). No relationship was observed between top-down modulation and two common measures of hallucination-proneness. Experiment 2 (n = 99) confirmed this pattern with a different stimulus-sine-vocoded speech (SVS)-that was designed to minimize ceiling effects in discrimination and more closely model previous top-down effects reported in psychosis. In Experiment 3 (n = 134), participants were exposed to SVS without prior knowledge that it contained speech (i.e. naïve listening). AVH-proneness significantly predicted both pre-exposure identification of speech and successful recall for words hidden in SVS, indicating that participants could actually decode the hidden signal spontaneously. Altogether, these findings support a pre-existing tendency to spontaneously draw upon prior knowledge in healthy people prone to AVH, rather than a sensitivity to temporary modulations of expectation. We propose a model of clinical and non-clinical hallucinations, across auditory and visual modalities, with testable predictions for future research.

Predicting persistence of hallucinations from childhood to adolescence

BACKGROUND

Psychotic experiences predict adverse health outcomes, particularly if they are persistent. However, it is unclear what distinguishes persistent from transient psychotic experiences.

AIMS

In a large population-based cohort, we aimed to (a) describe the course of hallucinatory experiences from childhood to adolescence, (b) compare characteristics of youth with persistent and remittent hallucinatory experiences, and (c) examine prediction models for persistence.

METHOD

Youth were assessed longitudinally for hallucinatory experiences at mean ages of 10 and 14 years (n = 3473). Multi-informant-rated mental health problems, stressful life events, self-esteem, non-verbal IQ and parental psychopathology were examined in relation to absent, persistent, remittent and incident hallucinatory experiences. We evaluated two prediction models for persistence with logistic regression and assessed discrimination using the area under the curve (AUC).

RESULTS

The persistence rate of hallucinatory experiences was 20.5%. Adolescents with persistent hallucinatory experiences had higher baseline levels of hallucinatory experiences, emotional and behavioural problems, as well as lower self-esteem and non-verbal IQ scores than youth with remittent hallucinatory experiences. Although the prediction model for persistence versus absence of hallucinatory experiences demonstrated excellent discriminatory power (AUC-corrected = 0.80), the prediction model for persistence versus remittance demonstrated poor accuracy (AUC-corrected = 0.61).

CONCLUSIONS

This study provides support for the dynamic expression of childhood hallucinatory experiences and suggests increased neurodevelopmental vulnerability in youth with persistent hallucinatory experiences. Despite the inclusion of a wide array of psychosocial parameters, a prediction model discriminated poorly between youth with persistent versus remittent hallucinatory experiences, confirming that persistent hallucinatory experiences are a complex multifactorial trait.

[Identifying cognitive and emotional markers in relation to auditory-verbal hallucinations in pediatric population: Physalis study]

OBJECTIVES

Auditory-verbal hallucinatory experiences (AVH) represent a prevalence of 12% in the general pediatric population. They are most often considered as a transient and benign developmental phenomenon, associated with mood and anxiety disorders. The persistence of AVHs for several years and into adolescence would represent a poor prognosis of progression into a psychiatric disorder, and more particularly psychotic disorder. The alteration of social and emotional cognitive markers are described as prodromal of this unfavorable progression which should be considered within the continuum between subclinical and clinical signs of the "psychosis phenotype". The objective of this study was to assess these markers in children and adolescents with AVH and their correlation with the presence and persistence of hallucinations.

METHODS

Multicenter prospective case-control study, longitudinal over 6months. Patients were included based on the presence of HAV on clinical examination. Forty subjects aged 8 to 16years from a clinical pediatric population were included. They were divided into two groups according to the Diagnostic Interview Schedule for Children-Child version (DISC-C): a group with AVH ("AVH+"), and a group without HAV ("AVH-"). A diagnosis of schizophrenia spectrum disorder was a non-inclusion criterion according to the criteria of DSM-5 (K-SADS-PL). This group was matched to the control group without AVH (AVH-) according to sex, age (±6months) and associated psychiatric diagnoses assessed by the MINI-Kid. The marker of social cognition was assessed with the NEPSY II test. The emotional marker was assessed with the self-questionnaires: EED IV, which highlights the emotions currently being felt by the subject, and the BAVQ-R, which categorizes the child's emotions in reaction to AVH.

RESULTS

No significant link was found between the social and emotional cognition markers and the presence of AVH at T0. At 6months, 50% of subjects in the AVH+ group suffered from persistent AVH and 18% progressed to a diagnosis of schizophrenia spectrum disorder. The persistence of AVH was not significantly correlated with the marker of social cognition, but it was significantly correlated with the presence of negative emotions (sadness, fear, hostility and anger) and inversely correlated with emotions of joy.

CONCLUSION

In this study, AVH experiences in the pediatric population are not linked to markers of social cognition, but negative emotions appear as early markers of AVH persistence. CLINICALTRIALS.

GOV IDENTIFIER

NCT02567500.

Olfactory hallucinations in a population-based sample

Olfactory hallucinations referring to olfactory perceptions in the absence of chemical stimuli, occur in non-clinical and clinical populations. Few studies have investigated their prevalence in the general population and little is known about factors triggering and maintaining them such as substance use, severe life events, and mood. We analyzed self-report data from 2500 community dwelling Norwegians, aged 18-96 years, for occurrence of olfactory hallucinations and co-occurring hallucinations in other modalities (auditory, visual, tactile). Analyses included age, sex, self-reported symptoms of depression and anxiety, mental health status, and experience of severe life-events. The results show that 4.2% (95% CI 3.5-5.1%) reported having experienced olfactory hallucinations, and 56% of individuals experiencing olfactory hallucinations also reported these in combination with hallucinations in other modalities. Prevalence varied significantly in terms of age and sex, in that olfactory hallucinations were most frequently reported by young individuals and females. Self-reported symptoms of anxiety and experience of stressful life events were significantly associated with olfactory hallucinations, suggesting that experiencing olfactory hallucinations may negatively affect functioning and may increase the likelihood of developing psychopathology. Findings underline the need to continue to examine olfactory hallucinations albeit with a more comprehensive assessment in order to increase knowledge on this experience.

Whispers, echoes, friends and fears: forms and functions of voice-hearing in adolescence

BACKGROUND

Despite the high prevalence of voice-hearing in childhood, research with adolescents aged under 16 years is scarce. Theoretical connections between clinical and developmental conceptualizations of voice-hearing are limited, resulting in missed opportunities to explore unusual sensory experiences with young people.

METHODS

Demographic, contextual and qualitative data were collected through a web-based survey with 68 adolescents (M = 14.91; SD = 2.77) from Australia, Canada, Ireland, New Zealand, Spain, the United Kingdom and United States of America. A Foucauldian-informed narrative analysis captured phenomenologically meaningful individual accounts and systemically informed narratives. Analytic layers attended specifically to the form and function of voices, including relational, protective, distressing and nuanced experiences, offering new insights into individual, systemic and cultural interpretative narratives surrounding voice-hearing to inform research, policy and tailored support.

RESULTS

The average self-reported age of onset of voices was 9 years, 5 months. Reciprocal relationships with pleasant voices were evidenced through the narratives and characterization of voices, while distressing voices were described without reciprocity and the voices held greater power over the young person. Positive aspects of negative voices were discussed and are illustrated with a continuum matrix reflecting interpretation and related affect.

CONCLUSIONS

Voice-hearing is a heterogeneous and often complex relational experience for young people, with structural inequalities, relational traumas and social isolation attributed causes of voice-hearing. Developing personal meaning-making mitigated voice-related distress through contextualizing the origin of the voices in past experiences, without attribution to mental illness. Recommendations are proposed for assessment, formulation and relational interventions that recognize the potential impact of the voice-child-other relationship upon psychosocial functioning and wellbeing.

Experiential avoidance mediates the association between paranoid ideation and depressive symptoms in a sample from the general population

Psychotic experiences are prevalent in the general population and are associated with negative outcomes, including depressive symptoms. The mechanisms underlying this relationship remain unclear, but new insights could be obtained by exploring the role of transdiagnostic processes such as experiential avoidance, defined as a person's attempts or desires to suppress unwanted internal experiences like thoughts, emotions, memories, or bodily sensations. Studies analyzing the link between negative emotional states and psychotic experiences are scant. We explored the association between a specific kind of psychotic experience (paranoid ideation), experiential avoidance, and depressive, anxiety, and stress symptoms in a sample from the general population. We found that experiential avoidance partially mediates the associations between paranoid ideation and stress and anxiety symptoms and that it fully mediates the association between paranoid ideation and depressive symptoms. Our results suggest that the presence of paranoid ideation and the usage of experiential avoidance to cope with it are vulnerability factors associated with psychological distress.

Exploring concomitant neuroimaging and genetic alterations in patients with and patients without auditory verbal hallucinations: A pilot study and mini review

Objective

To explore concomitant neuroimaging and genetic alterations in patients with schizophrenia with or without auditory verbal hallucinations (AVHs), and to discuss the use of pattern recognition techniques in the development of an objective index that may improve diagnostic accuracy and treatment outcomes for schizophrenia.

Methods

The pilot study included patients with schizophrenia with AVHs (SCH-AVH group) and without AVHs (SCH-no AVH group). High throughput sequencing (HTS) was performed to explore RNA networks. Global functional connectivity density (gFCD) analysis was performed to assess functional connectivity (FC) alterations of the default mode network (DMN). Quantitative long noncoding (lnc) RNA and mRNA expression data were related to peak T values of gFCDs using Pearson’s correlation coefficient analysis.

Results

Compared with the SCH-no AVH group (n = 5), patients in the SCH-AVH group (n = 5) exhibited differences in RNA expression in RNA networks that were related to AVH severity, and displayed alterations in FC (reflected by gFCD differences) within the DMN (posterior cingulate and dorsal-medial prefrontal cortex), and in the right parietal lobe, left occipital lobe, and left temporal lobe. Peak lncRNA expression values were significantly related to peak gFCD T values within the DMN.

Conclusion

Among patients with schizophrenia, there are concomitant FC and genetic expression alterations associated with AVHs. Data from pattern recognition studies may inform the development of an objective index aimed at improving early diagnostic accuracy and treatment planning for patients with schizophrenia with and without AVHs.

Psychotic-like experiences? Trajectories and typologies of hallucinations and delusions from early adolescence to early adulthood in a population-based sample of Irish youth

OBJECTIVES

Hallucinations and delusions that occur in the absence of a psychotic disorder are common in children and adolescents. Longitudinal phenomenological studies exploring these experiences are notably lacking. The objective of the current paper was to explore the phenomenology and characteristics of hallucinations and delusions from early adolescence to early adulthood.

METHODS

Participants were 17 young people aged 18-21 years from the general population, all of whom had a history of childhood hallucinations and/or delusions. Longitudinal data on the phenomenological characteristics and attributions of reported hallucinatory and delusional phenomena spanning nine years were explored using content analysis.

RESULTS

Hallucinatory and delusional phenomena were transient for two-thirds of the sample. The remaining one-third reported reoccurring hallucinatory and delusional phenomena into early adulthood. In those, two typologies were identified: (1) Paranormal typology and (2) Pathological typology. The former was characterised by hallucinatory and delusional phenomena that were exclusively grounded in subcultural paranormal or spiritual belief systems and not a source of distress. The latter was characterised by delusion-like beliefs that were enmeshed with individuals' mood states and a source of distress. The perceived source, the subcultural context and how young people appraised and integrated their experiences differentiated the Paranormal and Pathological typologies.

CONCLUSIONS

Not all hallucinatory and delusion-like experiences are psychotic-like in nature. To reliably differentiate between pathological and non-pathological hallucinations and delusions, assessments need to explore factors including the phenomenology of individuals' experiences, how people make sense and appraise them, and the subcultural contexts within which they are experienced.

Hearing Voices and Seeing Things: Symptoms of Anxiety Misconstrued as Evidence of Schizophrenia in an Adolescent

A patient's complaint of "hearing voices" or "seeing things" or of similar perceptual abnormalities leaves the clinician with 2 decisions: (1) Is the patient actually experiencing a hallucination, or does the complaint reflect a different mental experience, ranging from outright fabrication to the misinterpretation or mislabeling of vivid thoughts and emotions? (2) How should the experience reported by the patient, whether determined to be a hallucination or not, be understood in the context of the patient's entire history and mental state? We report the case of a 16-year-old whose cartoon-like hallucinations had led to the diagnosis of schizophrenia and had directed attention of the patient, her parents, and her clinicians away from critical issues of anxiety, depression, learning difficulties, and traumatic school experiences. This case illustrates how the diagnosis of schizophrenia can be driven by the prominence and vividness of psychotic-like symptoms reported by a patient, the expectation that patients' chief complaints must be directly and immediately addressed, insufficient attention to collateral information, and the distortions of a "checklist" approach to psychiatric diagnosis driven by the criteria in the Diagnostic and Statistical Manual of Mental Disorders, insurers, and the properties of electronic medical records. Given the consequences of either underdiagnosing or overdiagnosing schizophrenia, and the current lack of validated objective tests to assist with this diagnosis, clinicians are obligated to perform a thorough clinical assessment of such patients, including a probing exploration of the patient's mental state and a systematic collection of collateral information.

Commentary: Diagnostic Challenges in Evaluating Adolescents

Three cases presented in this issue highlight diagnostic challenges in evaluating adolescents, in particular those with a constellation of symptoms that includes hallucinations. These cases raise the question of the accuracy of patient reports and the importance of further exploring symptoms before rushing to a diagnosis or treatment. The first case involved an 18-year-old female patient with Cotard syndrome. She had the syndrome's typical delusions and hallucinations, but her case was unusual because this syndrome is more common in adults and usually involves prominent mood symptoms. The second case involved a 14-year-old girl with depressive symptoms, suicidal ideas, and auditory and visual hallucinations, as well as sexually predatory behavior. This case was unusual in that girls and women are less commonly sexual predators although such behavior is more common among survivors of sexual abuse, as was the case with this patient. The authors believe that the patient's "hallucinations" were more likely related to posttraumatic stress disorder and dissociation. The third case involved a 16-year-old girl diagnosed with schizophrenia and treated with antipsychotics based merely on her report of "visions" of demons but absent any auditory hallucinations, delusions, or thought disorder. The authors, consulting on the case, identified more prominent depression, anxiety, and trauma-related symptoms as a result of school bullying and concluded that the patient did not have schizophrenia. Only the patient in the first of these 3 cases actually met the criteria for a psychotic disorder and warranted medication treatment. These cases highlight the importance of a full differential diagnosis in evaluating adolescent patients presenting with what appear to be psychotic symptoms to avoid the harm that can occur in terms of stigma and unnecessary treatment with the risk of side effects from antipsychotic medications when an incorrect diagnosis is made.

Can't get you out of my head: Persistence and remission of psychotic experiences in adolescents and its association with self-injury and suicide attempts

BACKGROUND

Persistent psychotic experiences (PEs) may increase risk for mental disorders, non-suicidal self-injury (NSSI), and suicide attempts, relative to PEs that are more transient and remitting in nature. Most investigations of PE persistence have incorporated only two waves of data, and have not investigated the persistence of different PE subtypes and their association with future NSSI and suicide attempts. This study aimed to investigate the association between PE persistence, NSSI, and suicide attempts using three waves of prospective data. A secondary aim was to investigate potential reverse pathways where self-injurious behaviour (and its persistence) instead precedes subsequent PE occurrence.

METHOD

Participants were 1100 adolescents (12-17 years) from an Australian prospective cohort study; with three time points over two years. The Self-Harm Behaviour Questionnaire was used to assess NSSI and suicide attempts. Four PE subtypes (auditory hallucinatory experiences [HEs], and three delusional experiences) were assessed using the Diagnostic Interview Schedule for Children. Logistic regression analyses were conducted where PEs was grouped into five categories according to their persistence across the three waves of data. Analyses were adjusted for sociodemographics and substance use.

RESULTS

Overall, persistence of PEs (with endorsement of PE across two or three waves) was associated with the highest risk of incident NSSI and suicide attempts at 1- and 2-year follow-up (OR range: 2.57-12.25), whereas remitted PEs (with endorsement of PE at baseline only) were not associated with increased risk of future NSSI or suicide attempts. This pattern of association was evident for auditory HEs but not for most other PE subtypes; although some estimates had wide confidence intervals. There was no support for reverse temporality.

CONCLUSION

Our findings support and extend the two-wave cohort literature demonstrating that PEs which persist over time are more robust predictors of future NSSI and suicidal behaviour. Auditory HEs that are persisting in nature are an important but under-recognised risk factor for NSSI and suicide attempts during adolescence, and current findings should inform clinical guidelines into the predictors of self-harm and suicide risk at this life stage.

Young people's narratives of hearing voices: Systemic influences and conceptual challenges

Despite the prevalence of voice hearing in childhood and adolescence, little qualitative research has been undertaken with young people directly to advance phenomenological and aetiological insights into their experiences and interpretations. Consequently, the researchers sought demographic, contextual, and qualitative data from 74 young people from eleven countries, aged 13-18 years (28% = male; 61% = female; 21% = Transgender and Gender Non-Binary [TGNB]), who self-identified as hearing voices. A Foucauldian-informed narrative analysis yielded four analytic chapters, offering novel perspectives into individual, relational, systemic, and cultural interpretative narratives surrounding multisensory and multi-self voice hearing. Overall, young people reported heterogenous experiences of voice hearing and associated sensory experiences, and most participants reported voice hearing beginning between ages 8 and 11. Further, the emotions felt by the child, as well as reactions displayed by people around the child in relation to the voices, influenced voice-related distress and the nature of the voices in a triadic relationship. A continuum of multisensory features of voice content, nature, and relational significance is tentatively proposed to capture the breadth and depth of voice hearing for adolescents to offer a possible framework for future study and intervention design. Specifically, participants described that voice-related distress could be exacerbated by observed anxiety or internalized stigma about voice hearing, social isolation, and attribution to illness. These findings suggest that we may need to reconsider how the experience of hearing voices in childhood influences their relationships and how relationships influence the voice hearing experience. Further, young people seem to have a broad understanding of what the term "hearing voices" means, which could inform how researchers and practitioners work with this group of young people. Finally, participants described benefitting from multisensory coping strategies, such as imagery and meditation, which could offer important considerations for tailoring therapeutic interventions for adolescent voice hearers.

Hallucinations: diagnosis, neurobiology and clinical management

Hallucinations are important diagnostic symptoms in schizophrenia, but also occur in other medical and neuropsychiatric conditions. Not all patients with hallucinations are psychotic. There has been a surge of interest in the topic of hallucinations, as new research data have begun to reveal their neurobiology. Hallucinogenic molecules may also serve as new scaffolds for the development of new psychotropic drugs. We searched and reviewed recent literature, focusing on the refinement of clinical management, which was inspired by new data regarding the neurobiology of hallucination subtypes. We concluded that the successful management of hallucinations depends on accurate differential diagnosis to identify subtypes, which would then determine the most appropriate treatment.

A Review of Multimodal Hallucinations: Categorization, Assessment, Theoretical Perspectives, and Clinical Recommendations

Hallucinations can occur in different sensory modalities, both simultaneously and serially in time. They have typically been studied in clinical populations as phenomena occurring in a single sensory modality. Hallucinatory experiences occurring in multiple sensory systems-multimodal hallucinations (MMHs)-are more prevalent than previously thought and may have greater adverse impact than unimodal ones, but they remain relatively underresearched. Here, we review and discuss: (1) the definition and categorization of both serial and simultaneous MMHs, (2) available assessment tools and how they can be improved, and (3) the explanatory power that current hallucination theories have for MMHs. Overall, we suggest that current models need to be updated or developed to account for MMHs and to inform research into the underlying processes of such hallucinatory phenomena. We make recommendations for future research and for clinical practice, including the need for service user involvement and for better assessment tools that can reliably measure MMHs and distinguish them from other related phenomena.

Hallucinations in Older Adults: A Practical Review

Older adults experience hallucinations in a variety of social, physical, and mental health contexts. Not everyone is open about these experiences, as hallucinations are surrounded with stigma. Hence, hallucinatory experiences in older individuals are often under-recognized. They are also commonly misunderstood by service providers, suggesting that there is significant scope for improvement in the training and practice of professionals working with this age group. The aim of the present article is to increase knowledge about hallucinations in older adults and provide a practical resource for the health and aged-care workforce. Specifically, we provide a concise narrative review and critique of (1) workforce competency and training issues, (2) assessment tools, and (3) current treatments and management guidelines. We conclude with a brief summary including suggestions for service and training providers and future research.

Stronger than your voices: A cognitive behavioral therapy for youth suffering from auditory verbal hallucinations

OBJECTIVE

Auditory verbal hallucinations (AVHs) are a common feature in youth and mostly transient. Nevertheless, while present, AVH can cause considerable distress. Children and adolescents seeking help for distressing AVH represent a heterogeneous group in terms of underlying factors, yet they consistently suffer from their AVH. Until now, a youth-specific psychotherapeutic intervention for AVH was lacking. Experts in the field of treating AVH in both adults and youngsters collaborated with service users to develop the cognitive behavioral therapy (CBT) "Stronger Than Your Voices" (STYV). We investigated feasibility and clinical outcomes of the STYV therapy.

METHODS

Patients were derived from children and adolescents seeking help for AVH at the UMC Utrecht outpatient clinic with an indication for STYV therapy. Therapists preferably originated from referring health care facilities and were required to have sufficient general knowledge and experience with CBT. They received a short individual training to apply STYV. After, patients and their therapists could participate this naturalistic pilot study, assessing feasibility, tolerability, and clinical change when applying the STYV therapy.

RESULTS

Six participants (10-16 years old), all suffering from comorbid psychopathology, provided pre and post measures, all completing STYV therapy without experiencing an aggravation of symptoms. AVH total impact decreased 40% with Cohen's d within-group effect size (1.28) also suggesting clinically meaningful change. Therapists were positive about STYV therapy and manual.

CONCLUSION

The STYV therapy is feasible for youth with distressing AVH. First results indicate that STYV may be clinically effective. A trial to further test effectiveness in a larger sample is needed.

The subjective perception of the association between psychotic experiences and suicidal behavior among young adults

OBJECTIVES

Psychotic experiences such as hallucinations and delusions are reported by approximately 7.2% of the general population, even in the absence of a psychotic disorder. Individuals who report such psychotic experiences are significantly more likely to endorse suicidal ideation and behavior across several large epidemiological samples. This study aimed to determine whether individuals who reported psychotic experiences and suicidal behavior would subjectively endorse a causal relationship between these two clinical phenomena.

METHODS

Five open-ended questions were asked via online survey to 12 college students who had previously reported both hallucination-like experiences and suicidal behavior in a quantitative survey. Thematic analysis was used to analyze open-ended responses.

RESULTS

The majority of respondents, n (%) = 11 (91.6), did not endorse a notable subjective relationship between psychosis and suicidal ideation or suicide attempts. However, respondents did spontaneously report that stigma and fear may drive suicidal ideation among people who report psychotic experiences and other symptoms of psychological distress.

CONCLUSIONS

These findings are generally inconsistent with the hypothesis that psychotic experiences are directly related to suicidal behavior, and are consistent with the alternative hypothesis that both psychotic experiences and suicidal behavior are indicators of common underlying factors such as general psychological distress, potentially exacerbated by stigma.

Assessing Youth with Psychotic Experiences: A Phenomenological Approach

Psychotic experiences may be part of normal development or indicate a wide range of mental disorders. This article shows how a systematic, domain-based, phenomenological approach to assessing psychotic symptoms in youth facilitates the gathering of the nuanced clinical information necessary to understand a child's specific experience. Mapping this information onto a narrative timeline, while understanding the evolution and developmental context of psychotic experiences, is essential in making an accurate diagnostic formulation and appropriate treatment plan for youth presenting with psychotic experiences.

Evidence for Specific Associations Between Depressive Symptoms, Psychotic Experiences, and Suicidal Ideation in Chilean Adolescents From the General Population

Associations between psychotic experiences and suicidal ideation are not yet fully understood, and the potential role of depressive symptoms in this relationship remains unclear. The current study examined relationships between depressive symptoms (DS), psychotic experiences (PE) and suicidal ideation (SI) using two complementary approaches on cross-sectional data from a community sample of adolescents aged 13-19 years (N = 1,591). First, we investigated the association between the three domains using mediation analysis, showing that depressive symptoms partly mediate the relationship between psychotic experiences and suicidal ideation. Second, we looked at associations between the three domains at item level using network analysis. Specific associations between symptoms of the three domains were found, indicating depressive symptoms of sadness, avolition, pessimism, and self-criticalness/worthlessness as the most central symptoms in the network. Suicidal ideation was associated with the depressive symptoms pessimism and worthlessness, to social anxiety, and to perceptual anomalies. Our results show that the mediating effect of depressive symptoms between psychotic experiences and suicidal ideation may be due to associations between specific aspects of SI, depressive symptoms and psychotic experiences. These findings can contribute to the planning of health services and programs aimed at the timely detection of psychopathology and suicidal risk in young people.

Feasibility and Acceptability of Using a Mobile Phone App for Characterizing Auditory Verbal Hallucinations in Adolescents With Early-Onset Psychosis: Exploratory Study

Background

Auditory verbal hallucinations (AVH) are the most frequent symptom in early-onset psychosis (EOP) and a risk factor for increased suicide attempts in adolescents. Increased knowledge of AVH characteristics can lead to better prediction of risk and precision of diagnosis and help identify individuals with AVH who need care. As 98% of Norwegian adolescents aged 12 to 16 years own a mobile phone, the use of mobile phone apps in symptom assessment and patient communication is a promising new tool. However, when introducing new technology to patients, their subjective experiences are crucial in identifying risks, further development, and potential integration into clinical care.

Objective

The objective was to explore the feasibility and acceptability of a newly developed mobile phone app in adolescents with EOP by examining compliance with the app and user experiences. Indication of validity was explored by examining associations between AVH dimensions, which were correlated and analyzed.

Methods

Three adolescents with EOP and active AVH were enrolled. Real-time AVH were logged on an iPod touch using the experience sampling method (ESM), for seven or more consecutive days. The app included five dimensions of AVH characteristics and was programmed with five daily notifications. Feasibility and acceptability were examined using the mean response rate of data sampling and by interviewing the participants. Validity was assessed by examining associations between the AVH dimensions using nonparametric correlation analysis and by visual inspection of temporal fluctuations of the AVH dimensions.

Results

One participant was excluded from the statistical analyses but completed the interview and was included in the examination of acceptability. The sampling period of the two participants was mean 12 (SD 6) days with overall completed sampling rate of 74% (SD 30%), indicating adequate to high compliance with the procedure. The user experiences from the interviews clustered into four categories: (1) increased awareness, (2) personal privacy, (3) design and procedure, and (4) usefulness and clinical care. One participant experienced more commenting voices during the sampling period, and all three participants had concerns regarding personal privacy when using electronic devices in symptom assessment. The AVH dimensions of content, control, and influence showed moderate to strong significant correlations with all dimensions (P<.001). Days of data sampling showed weak to moderate correlations with localization (P<.001) and influence (P=.03). Visual inspection indicated that the app was able to capture fluctuations within and across days for all AVH dimensions.

Conclusions

This study demonstrates the value of including patients’ experiences in the development and pilot-testing of new technology. Based on the small sample size, the use of mobile phones with ESM seems feasible for patients with EOP, but the acceptability of using apps should be considered. Further investigation with larger samples is warranted before definitive conclusions are made.