Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations

Service User Representation in Qualitative Research on Cognitive Health and Related Interventions for Psychosis: A Scoping Review

BACKGROUND AND HYPOTHESIS

Cognitive health in schizophrenia spectrum psychosis has received substantial empirical attention in recent decades, coinciding with the development and implementation of interventions including cognitive remediation. Subjective experience in psychosis, including qualitative explorations of service user perspectives, has also proliferated; however, there is no available synthesis of service user representation in the psychosis cognitive health literature. This scoping review investigated prevalence and characteristics of qualitative research reporting service user perspectives across the extant research on cognitive health and related interventions in psychosis.

STUDY DESIGN

We conducted a literature search on qualitative methods in cognitive health and/or related interventions across PubMed, Web of Science, and PsycInfo databases. The review followed the PRISMA-ScR guidelines for scoping reviews and identified 23 papers. Data extraction included study design and sample characteristics, qualitative methodology, and reporting.

STUDY RESULTS

Of 23 articles, 18 reported on user experiences of interventions, most often in the context of feasibility/acceptability for otherwise quantitative trials. Five studies described service user experiences of cognitive health separately from interventions. Only 3 included any service user involvement or participatory methods. Twenty articles reported any demographic characteristics, and fewer than half (11) reported any racial or ethnic sample characteristics. There was substantial variability in qualitative methodology and reporting across studies.

CONCLUSIONS

Qualitative methodology is lacking in its representation and rigor across the cognitive health literature for schizophrenia spectrum psychosis. Additional inclusion of service user lived experience is critical for future research to better characterize cognitive health and inform interventions to promote recovery.

Anomalies of imagination and development of psychosis: A phenomenological account

In 20th century psychiatry, various disturbances of imagination were discussed in the context of schizophrenia. Today, these notions have almost completely vanished from mainstream psychopathology. However, recent work has suggested that specific phenomena within this area have a relevance for differential diagnosis and early detection of psychosis. This paper first provides an overview of 20th century psychopathological literature, as well as more recent neurocognitive studies, addressing disturbances of imagination and their role for symptom formation in schizophrenia. It then discusses recent empirical investigations of subjective anomalies of imagination in schizophrenia-spectrum disorders and suggests a clinical-phenomenological account of their role in the development of psychotic symptoms. Empirically and conceptually, these subjective anomalies are linked with disturbances of basic self. Patients' descriptions of the development of their anomalous experiences and symptoms indicate that increased spatial (object-like) articulation and instability of the first-personal manifestation of imaginative experience can be involved in the emergence of delusions and hallucinatory phenomena. Finally, a potential link between subjective anomalies of imagination and the neurocognitive construct of source monitoring deficits is discussed.

Corpus linguistics and clinical psychology: Investigating personification in first-person accounts of voice-hearing

Triangulating corpus linguistic approaches with other (linguistic and non-linguistic) approaches enhances "both the rigour of corpus linguistics and its incorporation into all kinds of research" (McEnery & Hardie, 2012:227). Our study investigates an important area of mental health research: the experiences of those who hear voices that others cannot hear, and particularly the ways in which those voices are described as person-like. We apply corpus methods to augment the findings of a qualitative approach to 40 interviews with voice-hearers, whereby each interview was coded as involving 'minimal' or 'complex' personification of voices. Our analysis provides linguistic evidence in support of the qualitative coding of the interviews, but also goes beyond a binary approach by revealing different types and degrees of personification of voices, based on how they are referred to and described by voice-hearers. We relate these findings to concepts that inform therapeutic interventions in clinical psychology.

Occurrence and phenomenology of hallucinations in the general population: A large online survey

Although epidemiological studies report that hallucinations occur in 6–15% of the general population, little is known about their phenomenology. To overcome this paucity, this study investigates the phenomenological characteristics of hallucinations in the general population, by using a nationally promoted online survey to assess hallucination phenomenology in four sensory modalities, through a self-report version of the Questionnaire for Psychotic Experiences (QPE), in 10,448 participants (aged 14–88 years). The phenomenology of hallucinations was assessed if hallucinations reportedly occurred in the past month. In the past month, auditory hallucinations were reported most frequently (29.5%), followed by visual (21.5%), tactile (19.9%), and olfactory hallucinations (17.3%); hallucinations in two or more modalities were reported by 47.6%. Substantial numbers of participants rated their hallucinations as severe, due to negative content (16.0–31.6%), previous bothersome experiences (14.8–20.2%), ensuing distress (10.5–16.8%), and/or ensuing disfunctioning (12.7–17.3%). Decreased insight was found in 10.2–11.4%. Hypnagogia was reported by 9.0–10.6%, and bereavement hallucinations by 2.8%. Despite a low prevalence of delusions (7.0%), these phenomena were significantly associated with recent hallucinations, observed in up to 13.4% of the participants with hallucinations during the past week (p < 0.001). Our results indicate a wide variety of the phenomenology of hallucinations in the general population and support the existence of a phenomenological continuum.

Hearing spiritually significant voices: A phenomenological survey and taxonomy

Whereas previous research in the medical humanities has tended to neglect theology and religious studies, these disciplines sometimes have a very important contribution to make. The hearing of spiritually significant voices provides a case in point. The context, content and identity of these voices, all of which have typically not been seen as important in the assessment of auditory-verbal hallucinations (AVHs) within psychiatry, are key to understanding their spiritual significance. A taxonomy of spiritually significant voices is proposed, which takes into account frequency, context, affect and identity of the voice. In a predominantly Christian sample of 58 people who reported having heard spiritually significant voices, most began in adult life and were infrequent experiences. Almost 90% reported that the voice was divine in identity and approximately one-third were heard in the context of prayer. The phenomenological characteristics of these voices were different from those in previous studies of voice hearing (AVHs). Most comprised a single voice; half were auditory; and a quarter were more thought-like (the rest being a mixture). Only half were characterful, and one-third included commands or prompts. The voices were experienced positively and as meaningful. The survey has implications for both clinical and pastoral work. The phenomenology of spiritually significant voices may be confused with that of psychopathology, thus potentially leading to misdiagnosis of normal religious experiences. The finding of meaning in content and context may be important in voice hearing more widely, and especially in coping with negative or distressing voices.

Auditory Verbal Hallucinations in Schizophrenia, Part II: Phenomenological Qualities and Evolution

ABSTRACT

Hallucination is defined in the diagnostic systems as an experience resembling true perception without causal stimulus. In this second report from an in-depth phenomenological study of schizophrenia patients experiencing auditory verbal hallucinations (AVHs), we focused on the phenomenological qualities of AVHs. We found that a substantial proportion of patients could not clearly distinguish between thinking and hallucinating. The emotional tone of the voices increased in negativity. AVHs became more complex. Spatial localization was ambiguous and only 10% experienced only external hallucinations. There was an overlap with passivity phenomena in one third of the cases. The patients occasionally acted upon the content of AVHs. In the discussion section, we criticize the perceptual model of AVHs. We conclude that the definition of AVH in schizophrenia is misleading and exerts negative consequences on the clinical work and empirical research.

An Introduction to Engaged Phenomenology

In this article, I introduce engaged phenomenology as an approach through which phenomenologists can more explicitly and critically consider the generative conditions and implications of their research. I make an explicit link between philosophical insights from critical and generative phenomenology and the ethical and methodological insights offered by engaged research methods-a community-oriented approach to the generation of shared understanding for the mutual benefit of all stakeholders in research. The article consists of (a) a review of these respective strands of inquiry, (b) an overview and critique of mainstream qualitative methodologies in phenomenology, and (c) suggestions for those interested in working through engaged phenomenology as an approach to both theory and research praxis.

Voice-Hearing Across The Continuum: A Phenomenology of Spiritual Voices

BACKGROUND AND HYPOTHESIS

Voice-hearing in clinical and nonclinical groups has previously been compared using standardized assessments of psychotic experiences. Findings from several studies suggest that nonclinical voice-hearing is distinguished by reduced distress and increased control. However, symptom-rating scales developed for clinical populations may be limited in their ability to elucidate subtle aspects of nonclinical voices. Moreover, such experiences often occur within specific contexts and belief systems, such as spiritualism. We investigated similarities and differences in the phenomenology of clinical voice-hearing and nonclinical voice-hearer (NCVH).

STUDY DESIGN

We conducted a comparative interdisciplinary study which administered a semi-structured interview to NCVH individuals (N = 26) and psychosis patients (N = 40). The nonclinical group was recruited from spiritualist communities. We used content analysis and inductive thematic analysis to create a coding frame which was used across both spiritual and patient groups to compare phenomenological features of voice-hearing.

STUDY RESULTS

The findings were consistent with previous results regarding distress and control. Additionally, in the NCVH group, multiple modalities were often integrated into 1 entity, and there were high levels of associated visual imagery, and subtle differences in the location of voices relating to perceptual boundaries. Most NCVHs reported voices before encountering spiritualism, suggesting that their onset was not solely due to deliberate practice.

CONCLUSIONS

Nonclinical spiritual voice-hearing has important similarities and differences to voices in psychosis. Future research should aim to understand how spiritual voice-hearers cultivate and control voice-hearing after its onset, which may inform interventions for people with psychosis with distressing voices.

Thinking about hallucinations: why philosophy matters

Introduction: Hallucinations research is increasingly incorporating philosophy or the work of philosophically trained individuals. We present three different ways in which this is successfully implemented to the enhancement of knowledge and understanding of hallucinations and related phenomena.Method: We review contributions from phenomenology, philosophy of cognitive science, and philosophy of science and psychiatry.Results: We demonstrate that these areas of philosophy make significant contributions to hallucinations research. Phenomenology gives us a sophisticated and critical understanding of the lived experience of hallucinations. Philosophy of cognitive science enables big-picture theorising and synthesis of ideas, as well as a critical engagement with new paradigms. Philosophy of science and psychiatry raises valuable and theoretically informed questions about diagnosis and categorisation.Conclusions: These contributions reflect both the methodological variety within philosophy and its relevance to the hallucinations researcher.

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.

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.

Image Processing for mHealth-Based Approach to Detect the Local Tissue Inflammation in Cutaneous Leishmaniasis: A Proof of Concept Study

Skin lesions are a feature of many diseases including cutaneous leishmaniasis (CL). Ulcerative lesions are a common manifestation of CL. Response to treatment in such lesions is judged through the assessment of the healing process by regular clinical observations, which remains a challenge for the clinician, health system, and the patient in leishmaniasis endemic countries. In this study, image processing was initially done using 40 CL lesion color images that were captured using a mobile phone camera, to establish a technique to extract features from the image which could be related to the clinical status of the lesion. The identified techniques were further developed, and ten ulcer images were analyzed to detect the extent of inflammatory response and/or signs of healing using pattern recognition of inflammatory tissue captured in the image. The images were preprocessed at the outset, and the quality was improved using the CIE L∗a∗b color space technique. Furthermore, features were extracted using the principal component analysis and profiled using the signal spectrogram technique. This study has established an adaptive thresholding technique ranging between 35 and 200 to profile the skin lesion images using signal spectrogram plotted using Signal Analyzer in MATLAB. The outcome indicates its potential utility in visualizing and assessing inflammatory tissue response in a CL ulcer. This approach is expected to be developed further to a mHealth-based prediction algorithm to enable remote monitoring of treatment response of cutaneous leishmaniasis.

Person-ness of voices in lived experience accounts of psychosis: combining literary linguistics and clinical psychology

In this paper, we use concepts and insights from the literary linguistic study of story-world characters to shed new light on the nature of voices as social agents in the context of lived experience accounts of voice-hearing. We demonstrate a considerable overlap between approaches to voices as social agents in clinical psychology and the perception of characters in the linguistic study of fiction, but argue that the literary linguistic approach facilitates a much more nuanced account of the different degrees of person-ness voices might be perceived to possess. We propose a scalar Characterisation Model of Voices and demonstrate its explanatory potential by comparing two lived experience descriptions of voices in interviews with voice-hearers in a psychosis intervention. The new insights into the phenomenology of voice-hearing achieved by applying the model are relevant to the understanding of voice-hearing as well as to therapeutic interventions.

Hallucinations Under Psychedelics and in the Schizophrenia Spectrum: An Interdisciplinary and Multiscale Comparison

The recent renaissance of psychedelic science has reignited interest in the similarity of drug-induced experiences to those more commonly observed in psychiatric contexts such as the schizophrenia-spectrum. This report from a multidisciplinary working group of the International Consortium on Hallucinations Research (ICHR) addresses this issue, putting special emphasis on hallucinatory experiences. We review evidence collected at different scales of understanding, from pharmacology to brain-imaging, phenomenology and anthropology, highlighting similarities and differences between hallucinations under psychedelics and in the schizophrenia-spectrum disorders. Finally, we attempt to integrate these findings using computational approaches and conclude with recommendations for future research.

Auditory Verbal Hallucinations in Schizophrenia: Mode of Onset and Disclosure

Recent reviews on auditory verbal hallucinations (AVHs) advocate a qualitative and interdisciplinary research that not only is limited to single descriptive features, but also involves contextual issues and co-occurring psychopathology. In this study of mainly readmitted patients with the International Classification of Diseases, Tenth Revision, diagnosis of paranoid schizophrenia and experiencing AVH, we performed a qualitative, phenomenologically oriented interview study. The focus was on the beginning of hallucinatory experiences, time to disclosure of the symptom, and the context surrounding the disclosure. We found that on average the patients experiencing AVH for 6.5 years before disclosing the symptom to a psychiatrist. Moreover, the term "voices" was typically appropriated by the patient during his contact with a psychiatric treatment facility. None of the patients considered themselves as being psychotic or severely mentally ill. The AVH in the majority of the patients was associated with other pathological subjective experiences. The significance of these findings is briefly discussed in relation to the concept of insight, diagnosis of psychosis, and early detection.

The Role of Sense of Voice Presence and Anxiety Reduction in AVATAR Therapy

AVATAR therapy offers a unique therapeutic context that uses virtual reality technology to create a virtual embodiment of the voice-hearing experience, enabling the person to visualize their persecutory voice and engage in real-time "face-to-face" dialogue. The present study explores, for the first time, the contribution of sense of voice presence, together with session-by-session reduction of anxiety and paranoid attributions about the avatar, to changes in primary outcomes following AVATAR therapy. Data from 39 participants, who completed AVATAR therapy and attended a 12-week follow-up assessment, were analysed. Mid- to high-levels of sense of voice presence were reported across the therapy sessions, along with significant reductions of anxiety levels and paranoid attributions about the avatar. The interaction of sense of voice presence and reduction of anxiety was associated with two of the significant therapy outcomes: PSYRATS total and frequency of voices. The findings suggest that improvements in voice severity and frequency at post AVATAR therapy may be influenced by the combination of feeling less anxious in the context of a realistic simulation of the voice, while voice-related distress may involve additional cognitive and relational processes.

The phenomenology of auditory verbal hallucinations in emotionally unstable personality disorder and post-traumatic stress disorder

Objective:

To explore the phenomenology of auditory verbal hallucinations (AVHs) in a clinical sample of young people who have a ‘non-psychotic’ diagnosis.

Methods:

Ten participants aged 17–31 years with presentation of emotionally unstable personality disorder or post-traumatic stress disorder and frequent AVHs were recruited and participated in a qualitative study exploring their subjective experience of hearing voices. Photo-elicitation and ethnographic diaries were used to stimulate discussion in an otherwise unstructured walking interview.

Results:

‘Non-psychotic’ voices comprised auditory qualities such as volume and clarity. Participants commonly personified their voices, viewing them as distinct characters with which they could interact and form relationships. There appeared to be an intimate and unstable relationship between participant and voice, whereby voices changed according to the participants’ mood, insecurities, distress and circumstance. Equally, participants reacted to provocation by the voice, leading to changes in mood and circumstance through emotional and physical disturbances. In contrast to our previous qualitative work in psychosis, voice hearing was not experienced with a sense of imposition or control.

Conclusions:

This phenomenological research yielded in-depth and novel accounts of ‘non-psychotic’ voices which were intimately linked to emotional experience. In contrast to standard reports of voices in disorders such as schizophrenia, participants described a complex and bi-directional relationship with their voices. Many other features were in common with voice hearing in psychosis. Knowledge of the phenomenology of hallucinations in non-psychotic disorders has the potential to inform future more successful management strategies. This report gives preliminary evidence for future research.

Voice-Hearing and Personification: Characterizing Social Qualities of Auditory Verbal Hallucinations in Early Psychosis

Recent therapeutic approaches to auditory verbal hallucinations (AVH) exploit the person-like qualities of voices. Little is known, however, about how, why, and when AVH become personified. We aimed to investigate personification in individuals' early voice-hearing experiences. We invited Early Intervention in Psychosis (EIP) service users aged 16-65 to participate in a semistructured interview on AVH phenomenology. Forty voice-hearers (M = 114.13 days in EIP) were recruited through 2 National Health Service trusts in northern England. We used content and thematic analysis to code the interviews and then statistically examined key associations with personification. Some participants had heard voices intermittently for multiple years prior to clinical involvement (M = 74.38 months), although distressing voice onset was typically more recent (median = 12 months). Participants reported a range of negative emotions (predominantly fear, 60%, 24/40, and anxiety, 62.5%, 26/40), visual hallucinations (75%, 30/40), bodily states (65%, 25/40), and "felt presences" (52.5%, 21/40) in relation to voices. Complex personification, reported by a sizeable minority (16/40, 40%), was associated with experiencing voices as conversational (odds ratio [OR] = 2.56) and companionable (OR = 3.19) but not as commanding or trauma-related. Neither age of AVH onset nor time since onset related to personification. Our findings highlight significant personification of AVH even at first clinical presentation. Personified voices appear to be distinguished less by their intrinsic properties, commanding qualities, or connection with trauma than by their affordances for conversation and companionship.

Does hallucination perceptual modality impact psychosis risk?

OBJECTIVE

Subthreshold perceptual abnormalities are commonly used to identify individuals at clinical high risk (CHR) for developing a psychotic disorder. Predictive validity for modality-specific perceptual abnormality severity on psychosis risk is unknown.

METHODS

We examined prospectively collected data from 164 individuals age 12-35 meeting criteria for CHR followed for 6-24 months or until conversion to psychosis. Using intake interview notes, baseline perceptual abnormality scores were split into auditory, visual, somatic/tactile, and olfactory/gustatory components, and auditory scores were further split into those for verbal vs non-verbal content. Relationships between perceptual abnormality characteristics and conversion were assessed with Cox proportional hazards regression and logistic regression.

RESULTS

Unusual thought content and paranoia were predictive of conversion, but no modality-specific perceptual abnormality score predicted conversion status or days to conversion. However, when auditory perceptual abnormalities were further categorized as verbal vs non-verbal, the severity of verbal experiences was predictive of conversion to psychosis (P = 0.007).

CONCLUSIONS

Perceptual abnormality scores failed to meaningfully predict conversion to psychosis in either direction in this CHR sample. However, verbal auditory experiences may identify a group of CHR individuals at elevated risk of conversion. Further exploration of the relationship between phenomenological aspects of perceptual abnormalities and conversion risk is warranted.

Beliefs about voices and their relation to severity of psychosis in chronic schizophrenia patients

BACKGROUND

Auditory hallucinations may persist in a subset of chronic psychotic patients in spite of treatment. It is important to understand the personal meaning and significance of voices in these patients. In spite of its relevance, only a limited literature is available.

AIM

This exploratory study aimed to assess the beliefs regarding voices in treatment-seeking patients with chronic schizophrenia having persistent auditory verbal hallucinations (AVHs) and assess their relation to the severity of psychosis.

MATERIALS AND METHODS

We recruited thirty adult patients with chronic schizophrenia as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with both lifetime and current significant AVHs (≥50% days/month). Co-occurring psychiatric disorders were ruled out using the Mini International Neuropsychiatric Interview-7.0.0. Patients were assessed using a semi-structured proforma, Beliefs about Voices Questionnaire-Revised (BAVQ-R), Psychotic Symptom Rating Scale (PSYRATS), Scale for the Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative Symptoms (SANS), and Clinical Global Impression-Schizophrenia (CGI-SCH)-severity.

RESULTS

The median age of the patients was 32 years (interquartile range [IQR]: 23.8-40.5). The median duration of illness and treatment was 7 years (IQR: 3.4-15.0) and 3 years (IQR: 1.9-10.5), respectively. Higher BAVQ-R scores were found on "malevolence," "omnipotence," and "emotional and behavioral resistance." These beliefs had a significant positive correlation with PSYRATS hallucination subscale, but not with the severity of psychosis (SAPS, SANS, and CGI-SCH). The sample had lower scores for "benevolence" and "engagement" subscales of BAV-Q.

CONCLUSION

Overall, the study sample believed AVH to be more malicious and omnipotent rather than benevolent, and resisted the voices, engaging only minimally with them. These beliefs were not related to the severity of psychosis, but were related to the severity of hallucinations. Assessing the beliefs regarding AVH in larger, diverse samples may help to plan behavioral interventions.

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

Hallucinations in children and adolescents are now known to occur on a continuum from healthy to psychopathology-related phenomena. Although hallucinations in young populations are mostly transient, they can cause substantial distress. Despite hallucinations being widely investigated, research so far has had limited implications for clinical practice. The present article has 3 main aims: (1) to review research findings since 2014 (when the last major review of the area was published); (2) to present assessment tools validated to measure hallucinations in children and adolescents; and (3) to discuss therapeutic strategies and clinical issues. We conclude by presenting a tailored care model for clinicians and outline future challenges for research.

Fast and slow thinking in distressing delusions: A review of the literature and implications for targeted therapy

The recent literature on reasoning biases in psychosis and delusions is reviewed. The state-of-the-art knowledge from systematic reviews and meta-analyses on the evidence for jumping to conclusions is briefly summarised, before a fuller discussion of the more recent empirical literature on belief flexibility as applied to delusions. The methodology and evidence in relation to studies of belief flexibility and the Bias Against Disconfirmatory Evidence (BADE) across the delusional continuum will be critically appraised, and implications drawn for improving cognitive therapy. It will be proposed that dual process models of reasoning, which Kahneman (Kahneman, 2011) popularised as 'fast and slow thinking', provide a useful theoretical framework for integrating further research and informing clinical practice. The emergence of therapies which specifically target fast and slow thinking in people with distressing delusions will be described.

Musical hallucinations, musical imagery, and earworms: A new phenomenological survey

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We conducted a phenomenological survey comparing musical hallucinations to other inner music.

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MH were more likely to be reported as externally located than other experiences.

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MH were less controllable and less familiar than imagery or earworms.

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MH were less likely to include lyrical content than other forms of inner music.

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Individuals with higher levels of musical expertise were less likely to report MH.

Musical hallucinations (MH) account for a significant proportion of auditory hallucinations, but there is a relative lack of research into their phenomenology. In contrast, much research has focused on other forms of internally generated musical experience, such as earworms (involuntary and repetitive inner music), showing that they can vary in perceived control, repetitiveness, and in their effect on mood. We conducted a large online survey (N = 270), including 44 participants with MH, asking participants to rate imagery, earworms, or MH on several variables. MH were reported as occurring less frequently, with less controllability, less lyrical content, and lower familiarity, than other forms of inner music. MH were also less likely to be reported by participants with higher levels of musical expertise. The findings are outlined in relation to other forms of hallucinatory experience and inner music, and their implications for psychological models of hallucinations discussed.

Brief assessment of schizotypal traits: A multinational study

The Schizotypal Personality Questionnaire-Brief (SPQ-B) was developed with the aim of examining variations in healthy trait schizotypy, as well as latent vulnerability to psychotic-spectrum disorders. No previous study has studied the cross-cultural validity of the SPQ-B in a large cross-national sample. The main goal of the present study was to analyze the reliability and the internal structure of SPQ-B scores in a multinational sample of 28,426 participants recruited from 14 countries. The mean age was 22.63years (SD=7.08; range 16-68years), 37.7% (n=10,711) were men. The omega coefficients were high, ranging from 0.86 to 0.92 for the total sample. Confirmatory factor analysis revealed that SPQ-B items were grouped either in a theoretical structure of three first-order factors (Cognitive-Perceptual, Interpersonal, and Disorganized) or in a bifactor model (three first-order factors plus a general factor of schizotypal personality). In addition, the results supported configural but not strong measurement invariance of SPQ-B scores across samples. These findings provide new information about the factor structure of schizotypal personality, and support the validity and utility of the SPQ-B, a brief and easy tool for assessing self-reported schizotypal traits, in cross-national research. Theoretical and clinical implications for diagnostic systems, psychosis models, and cross-national mental health strategies are derived from these results.

Standards and Guidelines for the Development of Diagnostic Nomenclatures and Alternatives in Mental Health Research and Practice

Diagnostic nomenclatures have been central to mental health research and practice since the turn of the 20th century. In recent years, an increasing number of mental health professionals have proposed that a paradigm shift in diagnosis is inevitable. The Standards and Guidelines for the Development of Diagnostic Nomenclatures and Alternatives in Mental Health Research and Practice are intended to serve as a reference for the development of scientifically sound and ethically principled diagnostic nomenclatures and descriptive alternatives. The Standards and Guidelines are divided into four sections that address the purposes; development; type, content, and structure; and scientific grounding of nomenclatures and alternative systems. They are intended to represent best practice in the classification and description of emotional distress for multidisciplinary mental health professionals.

On shame and voice-hearing

Hearing voices in the absence of another speaker-what psychiatry terms an auditory verbal hallucination-is often associated with a wide range of negative emotions. Mainstream clinical research addressing the emotional dimensions of voice-hearing has tended to treat these as self-evident, undifferentiated and so effectively interchangeable. But what happens when a richer, more nuanced understanding of specific emotions is brought to bear on the analysis of distressing voices? This article draws findings from the 'What is it like to hear voices' study conducted as part of the interdisciplinary Hearing the Voice project into conversation with philosopher Dan Zahavi's Self and Other: Exploring Subjectivity, Empathy and Shame to consider how a focus on shame can open up new questions about the experience of hearing voices. A higher-order emotion of social cognition, shame directs our attention to aspects of voice-hearing which are understudied and elusive, particularly as they concern the status of voices as other and the constitution and conceptualisation of the self.

Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review

OBJECTIVES

The aim of the current study was to inform ongoing attempts to identify clinically meaningful subcategories of auditory verbal hallucination (AVH), and to evaluate evidence that might pertain to the suitability of current psychological interventions for people with bipolar disorder (BD) who experience psychotic symptoms.

METHODS

A comprehensive synthesis of findings on the phenomenology of AVH and delusions in BD is included, alongside a critical review of clinical and cognitive correlates. Studies published in the previous 20 years, until December 2016, were retrieved from the following databases: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. Thirty-two articles were reviewed after applying a set of predetermined inclusion criteria.

RESULTS

Psychotic symptoms were common in both manic and depressive phases, although higher frequencies were indicated in mania. Few detailed characterizations of AVH phenomenology were identified. Delusions with persecutory, grandiose and referential themes were the most common in BD. AVHs were associated with delusions and there was evidence to suggest that delusion subtype may vary according to mood state and type of AVH. Data on clinical correlates of AVH in BD were sparse. However, the results indicated that cognitive appraisals or interpretations of voices might be different in BD from those established to be predictive of clinical outcomes in schizophrenia spectrum disorders.

CONCLUSIONS

Clear gaps exist in our current understanding of the first-person experience of AVH in BD and the potential relationship to co-occurring symptoms, including delusions. Further research into cognitive interpretations of AVH in BD might inform adapted psychological interventions for psychotic symptoms in this population.

Diversity Within the Psychotic Continuum

There has been great interest in the hallucination-like events experienced by the general nonclinical population. Many psychiatric scientists have come to identify these as part of a "psychotic continuum" and have begun to ask what we might learn from these experiences that will enable us to better understand and treat psychosis. While sympathetic to this goal, this paper argues that many of these events in the nonclinical population may be associated with the attention to inner imagery characteristic of much religious practice like unscripted prayer. Many of these hallucination-like events are phenomenologically distinct, culturally salient, and are predicted both by a measure of absorption, which probes for an interest in inner imagery, and by inner sense cultivation practice. These observations suggest that rare, brief, and positive sensory events may not be associated with psychotic vulnerability. They also suggest there may be an absorption-dissociation pathway, with or without trauma, for more frequent hallucinations.

Developing schizophrenia

Neuroscience and schizophrenia are densely entangled and mutually supporting, such that a critical evaluation of schizophrenia is, effectively, an evaluation of applied aspects of contemporary neuroscience. A critical historical account of the development of schizophrenia is therefore followed by an overview of current issues and debates. A summary of possible future research directions then identifies a range of extant research strategies which already undercut or exceed this diagnosis. It is concluded that the example of schizophrenia functions more generally to illustrate how neuroscience need not rely upon poorly supported psychiatric concepts of mental illness.

[Multidimensionality of inner speech and its relationship with abnormal perceptions]

BACKGROUND

Inner speech is a common human experience. Recently, there have been studies linking this experience with cognitive functions, such as problem solving, reading, writing, autobiographical memory, and some disorders, such as anxiety and depression. In addition, inner speech is recognised as the main source of auditory hallucinations.

OBJECTIVES

The main purpose of this study is to establish the factor structure of Varieties of Inner Speech Questionnaire (VISQ) in a sample of the Colombian population. Furthermore, it aims at establishing a link between VISQ and abnormal perceptions.

METHOD

This was a cross-sectional study in which 232 college students were assessed using the VISQ and the Cardiff Anomalous Perceptions Scale (CAPS).

RESULTS

Through an exploratory factor analysis, a structure of three factors was found: Other Voices in the Internal Speech, Condensed Inner speech, and Dialogical/Evaluative Inner speech, all of them with acceptable levels of reliability. Gender differences were found in the second and third factor, with higher averages for women. Positive correlations were found among the three VISQ and the two CAPS factors: Multimodal Perceptual Alterations and Experiences Associated with the Temporal Lobe.

CONCLUSIONS

The results are consistent with previous findings linking the factors of inner speech with the propensity to auditory hallucination, a phenomenon widely associated with temporal lobe abnormalities. The hallucinations associated with other perceptual systems, however, are still weakly explained.

Embedding a Recovery Orientation into Neuroscience Research: Involving People with a Lived Experience in Research Activity

This paper highlights the importance and value of involving people with a lived experience of mental ill health and recovery in neuroscience research activity. In this era of recovery oriented service delivery, involving people with the lived experience of mental illness in neuroscience research extends beyond their participation as "subjects". The recovery paradigm reconceptualises people with the lived experience of mental ill health as experts by experience. To support this contribution, local policies and procedures, recovery-oriented training for neuroscience researchers, and dialogue about the practical applications of neuroscience research, are required.

Unusual perceptions at the end of life: limitations to the diagnosis of hallucinations in palliative medicine

The diagnosis of hallucination for unusual perceptions such as deathbed visions, near-death experiences, or visions of the bereaved, is unhelpful in palliative medicine both academically and clinically. This paper reviews the broad prevalence data about unusual perceptions in the general population as background to identifying the more narrow epidemiological source from which the much smaller focus on hallucinations seem to emerge. Major debates and limitations of current hallucination research are reviewed to show that current academic and clinical certainties are largely confined to unusual perceptions that can be readily linked to psychopathology, quite specific organic disease states and psychoactive drug use. Current state-of-the-art in hallucination studies does not warrant broad or uncritical use of this type of diagnosis in end-of-life care. Conclusions from interdisciplinary (as opposed to single discipline) hallucination studies suggest that the way forward for clinical and research work in palliative medicine may lie in a more biographical and cultural approach to unusual perceptions at the end of life.

Auditory verbal hallucinations in first-episode psychosis: a phenomenological investigation

BACKGROUND

In dimensional understanding of psychosis, auditory verbal hallucinations (AVH) are unitary phenomena present on a continuum from non-clinical voice hearing to severe mental illness. There is mixed evidence for this approach and a relative absence of research into subjective experience of AVH in early psychosis.

AIMS

To conduct primary research into the nature of subjective experience of AVH in first-episode psychosis.

METHOD

A phenomenological study using diary and photo-elicitation qualitative techniques investigating the subjective experience of AVH in 25 young people with first-episode psychosis.

RESULTS

AVH are characterised by: (a) entity, as though from a living being with complex social interchange; and (b) control, exerting authority with ability to influence. AVH are also received with passivity, often accompanied by sensation in other modalities.

CONCLUSIONS

A modern detailed phenomenological investigation, without presupposition, gives results that echo known descriptive psychopathology. However, novel findings also emerge that may be features of AVH in psychosis not currently captured with standardised measures.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

The effects of an Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR therapy): study protocol for a randomised controlled trial

BACKGROUND

Psychological interventions which adopt an explicitly interpersonal approach are a recent development in the treatment of distressing voices. AVATAR therapy is one such approach which creates a direct dialogue between a voice-hearer and a computerised representation of their persecutory voice (the avatar) through which the person may be supported to gain a sense of greater power and control. The main objective of the trial is to test the clinical efficacy of this therapy to reduce the frequency and severity of auditory verbal hallucinations (AVH). Secondary objectives of the study are to explore explanatory mechanisms of action and potential moderators, to carry out a qualitative evaluation of participants' experience and to conduct an economic evaluation.

METHODS/DESIGN

The AVATAR randomised clinical trial will independently randomise 142 participants to receive either 7 sessions of AVATAR therapy or supportive counselling (SC). The study population will be individuals with schizophrenia spectrum and other psychotic disorders who report hearing persistent distressing voices, for more than 12 months, which are unresponsive or only partially responsive to antipsychotic medication. The main hypotheses are that, compared to SC, AVATAR therapy will reduce the frequency and severity of AVH and will also reduce the reported omnipotence and malevolence of these voices. Assessments will occur at 0 weeks (baseline), 12 weeks (post-intervention) and 24 weeks (follow-up), and will be carried out by blinded assessors. Both interventions will be delivered in a community-based mental health centre. Therapy competence and adherence will be monitored in both groups. Statistical analysis will follow the intention-to-treat principle and data will be analysed using a mixed (random) effects model at each post treatment time point separately. A formal mediation and moderator analysis using contemporary causal inference methods will be conducted as a secondary analysis. The trial is funded by the Welcome Trust (WT).

DISCUSSION

AVATAR therapy showed promising effects in a pilot study, but the efficacy of the approach needs to be examined in a larger randomised clinical trial before wider dissemination and implementation in mental health services.

TRIAL REGISTRATION

Current Controlled Trials

ISRCTN

65314790 , registration date: 27 March 2013.

Interdisciplinary collaboration in action: tracking the signal, tracing the noise

Interdisciplinarity is often framed as an unquestioned good within and beyond the academy, one to be encouraged by funders and research institutions alike. And yet there is little research on how interdisciplinary projects actually work-and do not work-in practice, particularly within and across the social sciences and humanities. This article centres on "Hubbub", the first interdisciplinary 2-year research residency of The Hub at Wellcome Collection, which is investigating rest and its opposites in neuroscience, mental health, the arts and the everyday. The article describes how Hubbub is tracing, capturing and reflecting on practices of interdisciplinarity across its large, dispersed team of collaborators, who work across the social sciences, humanities, arts, mind and brain sciences, and public engagement. We first describe the distinctiveness of Hubbub (a project designed for a particular space, and one in which the arts are not positioned as simply illustrating or disseminating the research of the scientists), and then outline three techniques Hubbub has developed to map interdisciplinary collaboration in the making: (1) ethnographic analysis; (2) "In the Diary Room", an aesthetics of collaboration designed to harness and capture affective dynamics within a large, complex project; and (3) the Hubbub Collaboration Questionnaire, which yields quantitative and qualitative data, as well as a social network analysis of collaborators. We conclude by considering some themes that other inter-disciplinary projects might draw on for their own logics of tracking and tracing. This article forms part of an ongoing thematic collection dedicated to interdisciplinary research.

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

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

Critical medical humanities: embracing entanglement, taking risks

What can the medical humanities achieve? This paper does not seek to define what is meant by the medical humanities, nor to adjudicate the exact disciplinary or interdisciplinary knowledges it should offer, but rather to consider what it might be capable of doing. Exploring the many valences of the word 'critical', we argue here for a critical medical humanities characterised by: (i) a widening of the sites and scales of 'the medical' beyond the primal scene of the clinical encounter; (ii) greater attention not simply to the context and experience of health and illness, but to their constitution at multiple levels; (iii) closer engagement with critical theory, queer and disability studies, activist politics and other allied fields; (iv) recognition that the arts, humanities and social sciences are best viewed not as in service or in opposition to the clinical and life sciences, but as productively entangled with a 'biomedical culture'; and, following on from this, (v) robust commitment to new forms of interdisciplinary and cross-sector collaboration. We go on to introduce the five other articles published in this special issue of the journal, reflecting on the ways in which collaboration and critique are articulated in their analyses of immunology, critical neuroscience, toxicity, global clinical labour, and psychological coercion and workfare. As these articles demonstrate, embracing the complex role of critical collaborator--one based on notions of entanglement, rather than servility or antagonism--will, we suggest, develop the imaginative and creative heterodox qualities and practices which have long been recognised as core strengths of the medical humanities.

Interdisciplinarity as cognitive integration: auditory verbal hallucinations as a case study

In this article, we advocate a bottom-up direction for the methodological modeling of interdisciplinary research based on concrete interactions among individuals within interdisciplinary projects. Drawing on our experience in Hearing the Voice (a cross-disciplinary project on auditory verbal hallucinations running at Durham University), we focus on the dynamic if also problematic integration of cognitive science (neuroscience, cognitive psychology, and of mind), phenomenology, and humanistic disciplines (literature, narratology, history, and theology). We propose a new model for disciplinary integration which brings to the fore an under-investigated dynamic of interdisciplinary projects, namely their being processes of distributed cognition and cognitive integration.

Studying hallucinations within the NIMH RDoC framework

We explore how hallucinations might be studied within the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) framework, which asks investigators to step back from diagnoses based on symptoms and focus on basic dimensions of functioning. We start with a description of the objectives of the RDoC project and its domains and constructs. Because the RDoC initiative asks investigators to study phenomena across the wellness spectrum and different diagnoses, we address whether hallucinations experienced in nonclinical populations are the same as those experienced by people with psychotic diagnoses, and whether hallucinations studied in one clinical group can inform our understanding of the same phenomenon in another. We then discuss the phenomenology of hallucinations and how different RDoC domains might be relevant to their study. We end with a discussion of various challenges and potential next steps to advance the application of the RDoC approach to this area of research.

Special supplement introduction: hallucinations

This Special Supplement presents reports from 11 working groups of the interdisciplinary International Consortium on Hallucination Research meeting in Durham, UK, September 2013. Topics include psychological therapies for auditory hallucinations, culture and hallucinations, hallucinations in children and adolescents, visual hallucinations, interdisciplinary approaches to the phenomenology of auditory verbal hallucinations (AVHs), AVHs in persons without need for care, a multisite study of the PSYRATS instrument, subtypes of AVHs, the Hearing Voices Movement, Research Domain Criteria for hallucinations, and cortical specialization as a route to understanding hallucinations.

Better than mermaids and stray dogs? Subtyping auditory verbal hallucinations and its implications for research and practice

The phenomenological diversity of auditory verbal hallucinations (AVH) is not currently accounted for by any model based around a single mechanism. This has led to the proposal that there may be distinct AVH subtypes, which each possess unique (as well as shared) underpinning mechanisms. This could have important implications both for research design and clinical interventions because different subtypes may be responsive to different types of treatment. This article explores how AVH subtypes may be identified at the levels of phenomenology, cognition, neurology, etiology, treatment response, diagnosis, and voice hearer's own interpretations. Five subtypes are proposed; hypervigilance, autobiographical memory (subdivided into dissociative and nondissociative), inner speech (subdivided into obsessional, own thought, and novel), epileptic and deafferentation. We suggest other facets of AVH, including negative content and form (eg, commands), may be best treated as dimensional constructs that vary across subtypes. After considering the limitations and challenges of AVH subtyping, we highlight future research directions, including the need for a subtype assessment tool.

Culture and hallucinations: overview and future directions

A number of studies have explored hallucinations as complex experiences involving interactions between psychological, biological, and environmental factors and mechanisms. Nevertheless, relatively little attention has focused on the role of culture in shaping hallucinations. This article reviews the published research, drawing on the expertise of both anthropologists and psychologists. We argue that the extant body of work suggests that culture does indeed have a significant impact on the experience, understanding, and labeling of hallucinations and that there may be important theoretical and clinical consequences of that observation. We find that culture can affect what is identified as a hallucination, that there are different patterns of hallucination among the clinical and nonclinical populations, that hallucinations are often culturally meaningful, that hallucinations occur at different rates in different settings; that culture affects the meaning and characteristics of hallucinations associated with psychosis, and that the cultural variations of psychotic hallucinations may have implications for the clinical outcome of those who struggle with psychosis. We conclude that a clinician should never assume that the mere report of what seems to be a hallucination is necessarily a symptom of pathology and that the patient's cultural background needs to be taken into account when assessing and treating hallucinations.

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

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