Position paper - CFT for psychosis

PURPOSE

This paper outlines the theoretical and empirical basis for compassion focused therapy (CFT) for psychosis, the gaps in the current knowledge and research, as well as some of the challenges for addressing gaps. It will guide the direction of future work and the steps needed to develop and advance this approach.

METHOD

This paper reviews evidence of how evolutionary models such as social rank theory and attachment theory have greatly contributed to our understanding of psychosis and provide a clear rationale and evidence base for the mechanisms of change in CFT for psychosis. It reviews the evidence for outcomes of compassion training more generally, and early feasibility evaluations of CFT for psychosis.

RESULTS

The process evidence shows that people with psychosis have highly active social rank and threat systems, and the benefits of switching into attachment and care systems, which can support emotion regulation and integrative mind states. The outcomes evidence shows that compassion training impacts not only psychological outcomes, but also physiological outcomes such as neural circuits, immune system, and the autonomic nervous system. Within the psychosis field, outcomes research is still in the early days, but there are good indications of feasibility and a clear path forward for the next steps.

CONCLUSIONS

CFT for psychosis is an approach that integrates biopsychosocial processes, an integration that's evidenced across each aspect of the model, from theoretical foundations (evolution-informed) to interventions (e.g., body/breath training and relational techniques), to evaluation. Future RCTs are required to understand the effects on biopsychosocial outcomes for people with psychosis.

Left-handed voices? Examining the perceptual learning of novel person characteristics from the voice

We regularly form impressions of who a person is from their voice, such that we can readily categorise people as being female or male, child or adult, trustworthy or not, and can furthermore recognise who specifically is speaking. How we establish mental representations for such categories of person characteristics has, however, only been explored in detail for voice identity learning. In a series of experiments, we therefore set out to examine whether and how listeners can learn to recognise a novel person characteristic. We specifically asked how diagnostic acoustic properties underpinning category distinctions inform perceptual judgements. We manipulated recordings of voices to create acoustic signatures for a person's handedness (left-handed vs. right-handed) in their voice. After training, we found that listeners were able to successfully learn to recognise handedness from voices with above-chance accuracy, although no significant differences in accuracy between the different types of manipulation emerged. Listeners were, furthermore, sensitive to the specific distributions of acoustic properties that underpinned the category distinctions. We, however, also find evidence for perceptual biases that may reflect long-term prior exposure to how voices vary in naturalistic settings. These biases shape how listeners use acoustic information in the voices when forming representations for distinguishing handedness from voices. This study is thus a first step to examine how representations for novel person characteristics are established, outside of voice identity perception. We discuss our findings in light of theoretical accounts of voice perception and speculate about potential mechanisms that may underpin our results.

A narrative journey into the borderland of patient safety: Toward an expanded, relational concept of safety

"Patient safety" is routinely defined in health services globally as "safety for patients against harm and risk of injury in health care." (Danish Board of Quality in Health Care, 2022, p. 28; translated by the author). This is a standardized, broad, and general definition of what counts as safety. In this article, I argue for an expanded, relational concept of patient safety revolving around experienced patient safety. Recognizing safety as vital for all groups of patients, I follow a dialogical, critical-reflexive approach to focus on safety in a somatic hospital setting in Denmark as it is experienced by people with lived experience of mental distress. Safety in this context is often compromised, contributing to inequity in health for people with mental distress. I present and analyze the narratives of two experts by experience about their somatic hospital stay. As an analytical approach, I draw on Frank's dialogical narrative analysis together with elements from Bakhtin's theory of dialogue and Foucault's theory of power/knowledge. Forefronting voices of those rarely asked and seldom heard, dialogical narrative analysis provides insight into how "patient safety" is enacted through situated negotiations of meaning in the narratives of people with lived experience. The storytellers are continuously struggling to fit in and to be seen as human beings, trying to resist public narratives on mental distress that threaten to limit their scope of action and who they can become. The discussion highlights how unintended emotional and psychosocial harm limit the benefits of patient safety for certain groups in society. In particular, shame, individualized responsibility, and internalized inferiority hinder equity in health. Building on my analysis, I suggest a collaborative, participatory approach for coproducing further knowledge through joint analysis with people with lived experience and nurses from somatic hospital wards.

Voice hearers' explanations of trauma-related voices and processes of change throughout imagery rescripting: A qualitative exploration

OBJECTIVES

Post-traumatic stress is common among people who hear voices (auditory verbal hallucinations), many of whom hear trauma-related voices, whereby voice content is related to past trauma. Preliminary evidence suggests that imagery rescripting (ImRs) may more effectively reduce post-traumatic stress and voices compared to treatments that are based on existing models of PTSD or positive symptoms. No known studies have explored the potential maintaining factors of trauma-related voices in relation to ImRs. We aimed to uncover insights into the factors that maintain trauma-related voices and how ImRs may influence such factors by exploring voice hearers' explanations of voices and experiences of change throughout ImRs.

DESIGN

Thematic analytical methodology was used due to the study's critical epistemological framework.

METHODS

Semi-structured interviews explored relationships between trauma and voices, and experiences of change and stability throughout ImRs in a transdiagnostic sample (N = 10) who underwent 10-18 weekly ImRs sessions. Thematic analysis was used to develop themes.

RESULTS

Two themes captured explanations of voices, which suggested voices may have counterproductive protective functions. Three themes captured psychological experiences during ImRs, which reflected concepts such as freedom to experience emotions, and experiences of justice, closure and grieving. Three themes described the outcomes of ImRs, reflecting concepts such as increased confidence, coping, perceived safety and voices becoming less powerful.

CONCLUSIONS

Trauma-related voices may have underlying protective functions and ImRs may support emotional expression, adaptive trauma re-appraisals and improve self-worth and coping self-efficacy. These change processes may have clinical implications in ImRs and other treatments for trauma-affected voice hearers.

Report on Proceedings of the Fifteenth Annual European CME Forum, Barcelona, Spain, November 2022

In a welcome return to a live, in person, same space meeting, albeit with some participants joining virtually, the Fifteenth Annual European Continuing Medical Education (CME) Forum (#15ECF) was hosted in Barcelona, Spain,2-4 November 2022. The meeting began with sessions conducted by three special interest groups affiliated with the European CME Forum, but open to all registrants. The main part of the meeting comprised interactive discussion sessions conducted by presenters from North and South America, Europe, India, and Australia, which were interspersed with breakout workshops that tackled three themes, Innovation and Impact, Attitudes and Culture, and Environment and Community. A featured topic was the patient voice in education and insights were provided by the international delegates on their local frameworks for CME/CPD. Updates were also provided on harmonisation among international accreditors, and an important change to the Journal of European CME, that is closely linked to the European CME Forum, was announced. An oral presentation was made by one of the poster authors, and the perennial favourites "Lunch with the Learners" and the "CME Unsession" werealso included. The level of engagement displayed by the participants would seem to suggest that much of the recent fatigue associated with virtual meetings was mitigated by this live event.

A case series study of compassion-focused therapy for distressing experiences in psychosis

OBJECTIVES

Compassion-focused therapy (CFT) is an evolution-informed biopsychosocial approach that seeks to cultivate attachment and care motivational systems and their psychophysiological regulators. These can counteract some of the harmful effects of social threat, inferiority, shame, self-criticism and depression, which are common in people with psychosis and undermine their well-being, social trust and ability to feel safe. This study aimed to test the acceptability of a novel manualized individual CFT intervention for psychosis (CFTp).

DESIGN

A non-concurrent, multiple-baseline, case series design, with three phases: baseline, intervention and follow-up.

METHODS

The 26-session CFTp intervention was provided for a sample of eight people with distressing psychotic experiences and a psychosis-related diagnosis. The study aimed to assess acceptability of CFTp and to test clinically reliable improvements while receiving the intervention, compared to a baseline period.

RESULTS

Seven of eight participants completed the therapy, and clinically reliable improvements were found at both the single-case and group level of analysis. At the single-case level, over half the participants showed improvements in depression (5/7), stress (5/7), distress (5/7), anxiety (4/7) and voices (3/5). One participant showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level (n = 7), there were significant improvements in depression, stress, distress, voices and delusions. The improvements in voices, delusions and distress were sustained at 6- to 8-week follow-up, but depression and stress dropped slightly to trend-level improvements.

CONCLUSIONS

CFTp is a feasible and acceptable intervention for psychosis, and further investigation is warranted with a randomized controlled trial.

Modality-specific brain representations during automatic processing of face, voice and body expressions

A central question in affective science and one that is relevant for its clinical applications is how emotions provided by different stimuli are experienced and represented in the brain. Following the traditional view emotional signals are recognized with the help of emotion concepts that are typically used in descriptions of mental states and emotional experiences, irrespective of the sensory modality. This perspective motivated the search for abstract representations of emotions in the brain, shared across variations in stimulus type (face, body, voice) and sensory origin (visual, auditory). On the other hand, emotion signals like for example an aggressive gesture, trigger rapid automatic behavioral responses and this may take place before or independently of full abstract representation of the emotion. This pleads in favor specific emotion signals that may trigger rapid adaptative behavior only by mobilizing modality and stimulus specific brain representations without relying on higher order abstract emotion categories. To test this hypothesis, we presented participants with naturalistic dynamic emotion expressions of the face, the whole body, or the voice in a functional magnetic resonance (fMRI) study. To focus on automatic emotion processing and sidestep explicit concept-based emotion recognition, participants performed an unrelated target detection task presented in a different sensory modality than the stimulus. By using multivariate analyses to assess neural activity patterns in response to the different stimulus types, we reveal a stimulus category and modality specific brain organization of affective signals. Our findings are consistent with the notion that under ecological conditions emotion expressions of the face, body and voice may have different functional roles in triggering rapid adaptive behavior, even if when viewed from an abstract conceptual vantage point, they may all exemplify the same emotion. This has implications for a neuroethologically grounded emotion research program that should start from detailed behavioral observations of how face, body, and voice expressions function in naturalistic contexts.

Gender Role Attitudes Influence Vocal Masculine Preferences Among Gay Men in China

Gender role attitudes refer to attitudes toward the appropriate roles, rights, and responsibilities of men and women in society. Evidence indicates that individuals with traditional gender role attitudes tend to prefer mates with sex-typical opposite-sex characteristics in heterosexual men and women. This study examined whether gender role attitudes were associated with vocal masculinity preference in gay men in China. Five hundred and sixty-seven participants aged between 16 and 49 years completed the vocal masculinity preference (voice pitch and vocal tract length; VTLs) and gender role attitudes scale. The results indicated that gay men generally preferred masculine voices (lower voice pitch and longer VTLs) and gender role attitudes were positively correlated with preferences for masculine cues in the voices of men. While individuals indicating an affinity with traditional gender roles exhibited stronger preferences for feminine voices, which were inconsistent with the present hypotheses. The results help us understand the role of traditional gender beliefs in the mate preferences of gay men in China. Furthermore, based on the results, understanding one's gender-role attitudes can help cultivate more diversified criteria for mate selection and facilitate gay men in better choosing suitable mates. Future longitudinal studies should examine the relationship between gender role attitudes and masculine preference changes over time. Whether this relationship differs in the different sexual roles of gay men should also be explored.

Hearing voices among Russian patients with schizophrenia

There has been relatively little work which systematically examines whether the content of hallucinations in individuals diagnosed with schizophrenia varies by cultural context. The work that exists finds that it does. The present project explores the way auditory hallucinations, or "voices," manifest in a Russian cultural context. A total of 28 individuals, diagnosed with schizophrenia, who reported hearing voices at the Republican Clinical Psychiatric Hospitals in Kazan, Russia, were interviewed about their experience of auditory hallucinations. The voices reported by our Russian participants did appear to have culturally specific content. Commands tended to be non-violent and focused on chores or other activities associated with daily life (byt). Many patients also reported sensory hallucinations involving other visions, sounds, and smells which sometimes reflected Russian folklore themes. For the most part, religious themes did not appear in patients' auditory vocal hallucinations, though nearly all patients expressed adherence to a religion. These findings support research that finds that the content, and perhaps the form, of auditory hallucinations may be shaped by local culture.

Undiagnosing St Joan: She Does Not Need a Medical or Psychiatric Diagnosis

ABSTRACT

This article traces the history of Joan of Arc through her brief life that includes leading an army in defense of France at the age of 17 and ending with her death at the stake at the age of 19. In her activities, St Joan reported that she was guided by voices and visions in which she communicated with venerated spiritual figures such as St Michael and St Margaret. Questions have arisen about the nature of these experiences, and various medical and psychiatric diagnoses have been offered by contemporary experts. In our effort to evaluate the diagnostic proposals, we have examined the incidence of voices and visions in the Middle Ages, and we have followed that with a review of nonpathologic voice-hearing in our own era. We then move on to an analysis of some proposed medical and psychiatric diagnoses, all of which we find unconvincing. With this background, we argue that St Joan does not warrant a medical or psychiatric diagnosis. Such a conclusion, however, leaves us with another issue, that of Joan's achievements. How do we understand an adolescent being able to lead an army? Addressing this question proves more difficult than deciding whether St Joan warrants a diagnosis. In addition to her achievements in the war against Britain, Joan of Arc stands out as both the most documented person in Western civilization up until her era, and as the only person who has been both condemned and canonized by the Catholic Church.

The Time Course of Person Perception From Voices: A Behavioral Study

Listeners spontaneously form impressions of a person from their voice: Is someone old or young? Trustworthy or untrustworthy? Some studies suggest that these impressions emerge rapidly (e.g., < 400 ms for traits), but it is unclear just how rapidly different impressions can emerge and whether the time courses differ across characteristics. I presented 618 adult listeners with voice recordings ranging from 25 ms to 800 ms in duration and asked them to rate physical (age, sex, health), trait (trustworthiness, dominance, attractiveness), and social (educatedness, poshness, professionalism) characteristics. I then used interrater agreement as an index for impression formation. Impressions of physical characteristics and dominance emerged fastest, showing high agreement after only 25 ms of exposure. In contrast, agreement for trait and social characteristics was initially low to moderate and gradually increased. Such a staggered time course suggests that there could be a temporo-perceptual hierarchy for person perception in which faster impressions could influence later ones.

Learning to Discern the Voices of Gods, Spirits, Tulpas, and the Dead

There are communities in which hearing voices frequently is common and expected, and in which participants are not expected to have a need for care. This paper compares the ideas and practices of these communities. We observe that these communities utilize cultural models to identify and to explain voice-like events-and that there are some common features to these models across communities. All communities teach participants to "discern," or identify accurately, the legitimate voice of the spirit or being who speaks. We also observe that there are roughly two methods taught to participants to enable them to experience spirits (or other invisible beings): trained attention to inner experience, and repeated speech to the invisible other. We also observe that all of these communities model a learning process in which the ability to hear spirit (or invisible others) becomes more skilled with practice, and in which what they hear becomes clearer over time. Practice-including the practice of discernment-is presumed to change experience. We also note that despite these shared cultural ideas and practices, there is considerable individual variation in experience-some of which may reflect psychotic process, and some perhaps not. We suggest that voice-like events in this context may be shaped by cognitive expectation and trained practice as well as an experiential pathway. We also suggest that researchers could explore these common features both as a way to help those struggling with psychosis, and to consider the possibility that expectations and practice may affect the voice-hearing experience.

Listening to and Believing Derogatory and Threatening Voices

BACKGROUND AND HYPOTHESIS

A plausible cause of distress for voice hearers is listening to and believing the threats and criticisms heard. Qualitative research indicates that patients have understandable reasons to listen. This study aimed to develop the understanding of distress using this listening and believing framework. Measures were developed of listening and believing voices and the reasons, and associations with distress tested.

STUDY DESIGN

A cross-sectional study of patients hearing derogatory and threatening voices (N = 591). Listening and Believing-Assessment and Listening and Believing-Reasons item pools were completed, and assessments of distress. Exploratory and confirmatory factor analyses and structural equation modeling (SEM) were conducted.

STUDY RESULTS

52% (n = 307) of participants believed their voices most or all the time. Listening and believing had 4 factors: active listening, passive listening, believing, and disregarding. Higher levels of believing, active listening, and particularly passive listening were associated with higher levels of anxiety, depression, and voice distress. Reasons for listening and believing formed 7 factors: to better understand the threat; being too worn down to resist; to learn something insightful; being alone with time to listen; voices trying to capture attention; voices sounding like real people; and voices sounding like known people. Each type of reason was associated with active listening, passive listening, and believing. SEM showed that feeling worn down in particular accounted for listening and believing. Test-retest reliability of measures was excellent.

CONCLUSIONS

A framework of listening and believing negative voices has the potential to inform the understanding and treatment of voice distress.

How Is It to Live with Diabetes Mellitus? The Voices of the Diabetes Mellitus Clients

Background: Diabetes mellitus is described as a chronic disease resulting from failure of the pancreas to generate enough insulin or inability of the body to efficiently utilize the insulin it generates. Diabetes clients must adjust their lives to live healthy with the diseases for the rest of their lives. Optimizing diabetic knowledge and awareness among people living with diabetes will yield better health outcomes. This study seeks to investigate the knowledge, practices, and challenges of diabetes mellitus clients regarding management of the disease at selected clinics in the Capricorn District of Limpopo Province, South Africa. Methods: This study used a qualitative research approach and a phenomenological research design. A purposive sampling method was used to acquire the 18 participants for this study. Semi-structured interviews with a guide were used to collect data. Tesch's coding method was employed for data analysis. Results: The study findings revealed that there are comparable explanations of what it means to follow medication instructions by diabetes mellitus clients, and challenges living with DM. The findings also indicate that there are problems related to conceptualization of medication instructions among diabetes clients. Conclusion: This study indicated that diabetes mellitus clients have poor knowledge regarding management of the disease and its process, and problems related to medication instructions. Therefore, proper teaching of clients and guidance regarding diabetes and its management are required to improve compliance and delay of long-term complications.

Comparison of the Phenomenology of Hallucination and Delusion Characteristics in People Diagnosed With Borderline Personality Disorder and Schizophrenia

Hallucinations and delusions in borderline personality disorder (BPD) are understudied. The authors explore the phenomenology of multisensory hallucinations and delusions in individuals with BPD and compare them to those in individuals with schizophrenia spectrum disorders (SSD). Clinical psychopathology was also explored. Eighty-nine adults participated and were categorized into four groups: BPD with voices, BPD without voices, SSD with high BPD traits, and SSD with low BPD traits. Among individuals with BPD, 81% reported visual and tactile hallucinations, 75% reported olfactory hallucinations, and 94% experienced delusions. When comparing BPD with and without voices, there were no significant differences in nonpsychotic psychopathology. Slight differences were found when hallucinations in BPD were compared with hallucinations in SSD, but overall the experiences were similar across diagnoses. The BPD group also reported significantly higher rates of paranoia/suspiciousness and delusions of guilt than the SSD group. Multisensory hallucinations and delusions occur in BPD and should be explored when treating people with BPD.

The psychological journey of weight gain in psychosis

BACKGROUND

Rapid weight gain is common with antipsychotic medication. Lost confidence, low mood and medication non-adherence often follow. Yet, the dynamic interactions between the physical and psychological consequences of weight gain, and implications for intervention, are unknown.

OBJECTIVES

We examined first-person accounts of weight gain to identify preferences for weight change interventions.

DESIGN

A qualitative design was used to explore patients' experiences of weight change in the context of psychosis.

METHOD

Semi-structured interviews, analysed using grounded theory, were conducted with 10 patients with psychosis. Sample validation was conducted with peer researchers with lived experience of psychosis.

RESULTS

Patients described that initially the extent and speed of weight gain was overshadowed by psychotic experiences and their treatment. This led to a shocking realisation of weight gain. The psychological impact of weight gain, most strikingly on the self-concept, was profound. Loss of self-worth and changed appearance amplified a sense of vulnerability. There were further consequences on mood, activity and psychotic experiences, such as voices commenting on appearance, that were additional obstacles in the challenging process of weight loss. Sedative effects of medication also contributed. Unsuccessful weight loss left little hope and few preferences for interventions. Early information about common weight gain trajectories and working with experts-by-experience were valued. Rebuilding self-confidence, efficacy and worth may be a necessary first step.

CONCLUSIONS

The journey of weight gain in patients with psychosis is characterised by loss of self-worth, agency and hope. There are multiple stages in the journey, each with different psychological reactions, that may need different treatment responses.

A narrative review of psychological theories of post-traumatic stress disorder, voice hearing, and other psychotic symptoms

BACKGROUND

Most voice hearers report childhood trauma. Many voice hearers report comorbid post-traumatic stress symptoms and that the content of their voices (auditory verbal hallucinations) is directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma is thematically similar) related to their trauma. The factors that maintain trauma-related voices are unknown, and there is limited research in this area. This study aimed to identify potential maintaining factors of trauma-related voices by reviewing models of post-traumatic stress disorder (PTSD) and positive symptoms of psychosis.

METHOD

Models of PTSD and positive symptoms were reviewed to identify potential factors that are unique and common to both sets of symptoms.

RESULTS

We reviewed 10 models of PTSD, 4 models of positive symptoms, and 2 trauma-informed models of voice hearing. One model provided a theoretical explanation of different types of trauma-related voices. Twenty-one factors were extracted from 16 theoretical models. No existing model incorporated all these factors.

DISCUSSION

Existing PTSD and positive symptom models present a range of common and unique factors. There may be value in extending existing integrative models to include a broader range of potential factors that could explain different pathways to, and expressions of, trauma-related voices. A future research agenda is presented to investigate how such an extension could lead to more complete individualized case formulations and targeted treatments.

Life Challenges and Barriers to Help Seeking: Adolescents' and Young Adults' Voices of Mental Health

Listening to the voices of adolescents and young adults regarding their lived experiences could be a way to identify important skills and abilities for adaptive and positive behaviour that will enable youth to deal effectively with the demands and challenges of everyday life. Hence, the aim with the current study is to explore the experiences and understandings of the life situation among adolescents and young adults of today, by making their voices heard in regards to mental health and help-seeking behaviour. A total of 6 group interviews were conducted with 22 adolescents and young adults (13 girls and 9 boys) ages 17-25 (M = 18.6 years). Data analysis was conducted using qualitative content analysis and resulted in two categories and five subcategories. The first category, Life challenges, included views on the sources of mental health, how to manage different types of relationships, and thoughts on accepted ways to express mental health problems. The second category, The need of present adults, highlighted important aspects for seeking help, such as an expressed need to be seen and heard by adults including parents, school staff, and other professionals as well as a need for adults' increased availability. The challenges to students' well-being and mental health are many, and there are no simple solutions. Based on the results in this study, life skills training should include elements to enhance the development of individual coping strategies, to be applied when life feels tough and when the body is experiencing stress reactions. Further, to minimize the risk of self-stigma and the internalization of negative stereotypes and self-blame, life skills training should include elements to increase knowledge of structural factors that have effects on the life situation as well as parents, school personnel, and other important adults.

What Matters Most to Older Chinese Adults

Introduction:

Although an abundance of gerontological research has focused on subjective well-being, quality of life, and life satisfaction, we know little about what matters most to older adults in sub-cultural groups. The purpose of this study was to explore what matters to older Chinese adults.

Methods:

The study used a qualitative interpretive design, drawing influences from phenomenology and constructed meaning through participants’ lived experiences.

Results:

After data analysis, a core theme of cultural foundations and categorical themes emerged. This study emphasized the importance of hearing the voices of Chinese older adults and how they viewed well-being, quality of life, life satisfaction, and health care.

Discussion:

The findings of this study have added to the body of existing knowledge of what matters most to older adults. These insights may advance nursing as it pertains to culturally congruent health care.

Illusory social agents within and beyond voices: A computational linguistics analysis of the experience of psychosis

Objectives

Psychosis has a strong social component and often involves the experience of being affected by ‘illusory social agents’. However, this experience remains under‐characterized, particularly for social agents in delusions and non‐vocal hallucinations. One useful approach is a form of computational linguistics called corpus linguistics that studies texts to identify patterns of meaning encoded in both the semantics and linguistic structure of the text.

Methods

Twenty people living with psychosis were recruited from community and inpatient services. They participated in open‐ended interviews on their experiences of social agents in psychosis and completed a measure of psychotic symptoms. Corpus linguistics analysis was used to identify key phenomenological features of vocal and non‐vocal social agents in psychosis.

Results

Social agents i) are represented with varying levels of richness in participants’ experiences, ii) are attributed with different kinds of identities including physical characteristics and names, iii) are perceived to have internal states and motivations that are different from those of the participants, and iv) interact with participants in various ways including through communicative speech acts, affecting participants’ bodies, and moving through space. These representations were equally rich for agents associated with hallucinated voices and those associated with non‐vocal hallucinations and delusions.

Conclusions

We show that the experience of illusory social agents is a rich and complex social experience reflecting many aspects of genuine social interaction and is not solely present in auditory hallucinations, but also in delusions and non‐vocal hallucinations.

Practitioner Points

The experience of being affected by illusory social agents in psychosis extends beyond hallucinated voices.

They are a rich and complex social experience reflecting many aspects of genuine social interaction.

These are also likely to be a source of significant distress and disability.

Audiovisual identity perception from naturally-varying stimuli is driven by visual information

Identity perception often takes place in multimodal settings, where perceivers have access to both visual (face) and auditory (voice) information. Despite this, identity perception is usually studied in unimodal contexts, where face and voice identity perception are modelled independently from one another. In this study, we asked whether and how much auditory and visual information contribute to audiovisual identity perception from naturally-varying stimuli. In a between-subjects design, participants completed an identity sorting task with either dynamic video-only, audio-only or dynamic audiovisual stimuli. In this task, participants were asked to sort multiple, naturally-varying stimuli from three different people by perceived identity. We found that identity perception was more accurate for video-only and audiovisual stimuli compared with audio-only stimuli. Interestingly, there was no difference in accuracy between video-only and audiovisual stimuli. Auditory information nonetheless played a role alongside visual information as audiovisual identity judgements per stimulus could be predicted from both auditory and visual identity judgements, respectively. While the relationship was stronger for visual information and audiovisual information, auditory information still uniquely explained a significant portion of the variance in audiovisual identity judgements. Our findings thus align with previous theoretical and empirical work that proposes that, compared with faces, voices are an important but relatively less salient and a weaker cue to identity perception. We expand on this work to show that, at least in the context of this study, having access to voices in addition to faces does not result in better identity perception accuracy.

Sensing the presence of gods and spirits across cultures and faiths

The sensory presence of gods and spirits is central to many of the religions that have shaped human history—in fact, many people of faith report having experienced such events. But these experiences are poorly understood by social scientists and rarely studied empirically. We present a multiple-discipline, multiple-methods program of research involving thousands of people from diverse cultures and religions which demonstrates that two key factors—cultural models of the mind and personal orientations toward the mind—explain why some people are more likely than others to report vivid experiences of gods and spirits. These results demonstrate the power of culture, in combination with individual differences, to shape something as basic as what feels real to the senses.

Hearing the voice of God, feeling the presence of the dead, being possessed by a demonic spirit—such events are among the most remarkable human sensory experiences. They change lives and in turn shape history. Why do some people report experiencing such events while others do not? We argue that experiences of spiritual presence are facilitated by cultural models that represent the mind as “porous,” or permeable to the world, and by an immersive orientation toward inner life that allows a person to become “absorbed” in experiences. In four studies with over 2,000 participants from many religious traditions in the United States, Ghana, Thailand, China, and Vanuatu, porosity and absorption played distinct roles in determining which people, in which cultural settings, were most likely to report vivid sensory experiences of what they took to be gods and spirits.

Targeting dissociation using cognitive behavioural therapy in voice hearers with psychosis and a history of interpersonal trauma: A case series

OBJECTIVES

Previous studies have suggested that dissociation might represent an important mechanism in the maintenance of auditory verbal hallucinations (i.e., voices) in people who have a history of traumatic life experiences. This study investigated whether a cognitive behavioural therapy (CBT) intervention for psychosis augmented with techniques specifically targeting dissociative symptoms could improve both dissociation and auditory hallucination severity in a sample of voice hearers with psychosis and a history of interpersonal trauma (e.g., exposure to sexual, physical, and/or emotional abuse).

DESIGN

Case series.

METHODS

A total of 19 service users with psychosis were offered up to 24 therapy sessions over a 6-month intervention window. Participants were assessed four times over a 12-month period using measures of dissociation, psychotic symptoms severity, and additional secondary mental-health and recovery measures.

RESULTS

Sixteen participants engaged in the intervention and were included in last-observation-carried-forward analyses. Dropout rates were in line with those of other CBT for psychosis trials (26.3%). Repeated measures ANOVAs revealed large and significant improvements in dissociation (d_rm  = 1.23) and hallucination severity (d_rm  = 1.09) by the end of treatment; treatment gains were maintained 6 months following the end of therapy. Large and statistically significant gains were also observed on measures of post-traumatic symptoms, delusion severity, emotional distress, and perceived recovery from psychosis.

CONCLUSIONS

The findings of this case series suggest that the reduction of dissociation represents a valuable and acceptable treatment target for clients with auditory verbal hallucinations and a trauma history. Future clinical trials might benefit from considering targeting dissociative experiences as part of psychological interventions for distressing voices.

PRACTITIONER POINTS

Practitioners should consider the role of dissociation when assessing and formulating the difficulties of voice hearers with a history of trauma. Techniques to reduce dissociation can be feasibly integrated within psychological interventions for voices. Voice hearers with histories of trauma can benefit from psychological interventions aimed at reducing dissociation.

The role of characterisation in everyday voice engagement and AVATAR therapy dialogue

BACKGROUND

Voices are commonly experienced as communication with a personified 'other' with ascribed attitudes, intentionality and personality (their own 'character'). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural engagement with voices or within psychological therapy for distressing voices.

METHODS

Baseline characterisation (the degree to which the voice is an identifiable and characterful entity) of the dominant voice was rated (high, medium or low) using a newly developed coding framework, for n = 60 people prior to starting AVATAR therapy. Associations between degree of characterisation and (i) everyday behavioural engagement with voices (The Beliefs about Voices Questionnaire-Revised; n = 60); and (ii) interaction within avatar dialogue [Session 4 Time in Conversation (participant-avatar); n = 45 therapy completers] were explored.

RESULTS

Thirty-three per cent reported high voice characterisation, 42% medium and 25% low. There was a significant association between characterisation and behavioural engagement [H(2) = 7.65, p = 0.022, ɛ2 = 0.130] and duration of participant-avatar conversation [F(2,42) = 6.483, p = 0.004, η2 = 0.236]. High characterisation was associated with increased behavioural engagement compared with medium (p = 0.004, r = 0.34; moderate effect) and low (p = 0.027, r = 0.25; small-moderate effect) with a similar pattern observed for the avatar dialogue [high v. medium: p = 0.008, Hedges' g = 1.02 (large effect); high v. low: p = 0.023, Hedges' g = 1.03 (large effect)]. No differences were observed between medium and low characterisation.

DISCUSSION

Complex voice characterisation is associated with how individuals interact with their voice(s) in and out of therapy. Clinical implications and future directions for AVATAR therapy and other relational therapies are discussed.

Systemic Practice in the Time of COVID: Conversations Among Culturally Diverse Therapists

The COVID-19 pandemic has changed the delivery of clinical services and education of health professionals, including family therapists. This paper distils two separate Zoom conversations between myself (as the lead author) and two eminent family therapists, Professors Maurizio Andolfi and Harry Aponte, where challenges and opportunities for the profession during and after the pandemic are discussed. Creativity and resourcefulness are two important elements therapists and educators have needed to access during the pandemic to find alternative ways to continue to provide clinical services and teaching. Most therapists have transitioned using online technology and various platforms such as Zoom and Skype; for some this has been a somewhat familiar experience, for most it has been a novel one. Key themes emerged from the conversations including the personal and professional 'lived experiences' of the pandemic; the financial impact on clients and students; the importance of touch for human social connection; the use of 'self' as an instrument of change and alternative platforms of service delivery and teaching. We reflected on what has been lost, such as the nuances inherent in face-to-face human interactions, and what has been gained, such as observing families in situ in their own environments.

The Staff Views About Assessing Voices Questionnaire: Piloting a Novel Socratic Method of Evaluating and Training Multidisciplinary Staff's Cognitive Assessment of Patients' Distressing Voices

Cognitive features of auditory hallucinations (voices) have important clinical significance and their assessment is vital for cognitive behavior therapy to be more widely deployed by multidisciplinary staff. Using a new Socratic instrument-The Staff Views About Assessing Voices Questionnaire (SVAVQ)-we surveyed a community inpatient rehabilitation multidisciplinary workforce's (N = 50) assessment and attitude toward asking cognitive questions about patients' voices. We found that there were many clinically important gaps in what staff asked about in relation to cognitive features of voices. We identified a range of beliefs the staff hold that may prevent assessment of voice cognitive features. However, after attending the Socratic SVAVQ interview, 84% of staff said they planned to ask patients more questions about cognitive features of patients' voices. Research could now test if other psychosis services neglect the assessment of important cognitive features of patients' voices and if staff Socratic questioning improves their cognitive assessments.

The relationship between anxiety, depression, and subtypes of negative auditory verbal hallucination (AVH) content in affective and non-affective psychosis

The content of AVHs is a major predictor of distress. Although the relationship between mood and AVH content is considered of diagnostic relevance, research investigating the role of depression and anxiety in AVH content remains limited. This study investigated subtypes of negative AVH content, comprising critical, threatening, and self-harm commands in affective and non-affective psychosis. In addition, the study investigated relationships between negative, critical, threatening and self-harm related AVH content and depression and anxiety. Results showed that AVH content did not vary between affective and non-affective psychosis. Among affective voice-hearers, critical, threatening and self-harm content was predicted by anxiety. Whereas in non-affective voice-hearers, self-harm content was predicted by depression. Findings suggest that in affective psychosis, "mood" may be more relevant to whether people hear voices per se, given that by definition voices only arise in mood episodes, whereas anxiety appears to be important in influencing content. In contrast, anxiety and depression may have little influence over voice content in non-affective psychosis, with the exception of depression in self-harm commands. As such, anxiety should be considered in the formulation and treatment of negative AVHs in affective psychosis, and depression in non-affective voice-hearers with self-harm commands.

Comparing unfamiliar voice and face identity perception using identity sorting tasks

Identity sorting tasks, in which participants sort multiple naturally varying stimuli of usually two identities into perceived identities, have recently gained popularity in voice and face processing research. In both modalities, participants who are unfamiliar with the identities tend to perceive multiple stimuli of the same identity as different people and thus fail to "tell people together." These similarities across modalities suggest that modality-general mechanisms may underpin sorting behaviour. In this study, participants completed a voice sorting and a face sorting task. Taking an individual differences approach, we asked whether participants' performance on voice and face sorting of unfamiliar identities is correlated. Participants additionally completed a voice discrimination (Bangor Voice Matching Test) and a face discrimination task (Glasgow Face Matching Test). Using these tasks, we tested whether performance on sorting related to explicit identity discrimination. Performance on voice sorting and face sorting tasks was correlated, suggesting that common modality-general processes underpin these tasks. However, no significant correlations were found between sorting and discrimination performance, with the exception of significant relationships for performance on "same identity" trials with "telling people together" for voices and faces. Overall, any reported relationships were however relatively weak, suggesting the presence of additional modality-specific and task-specific processes.

AVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets

AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets along with information on acceptability and potential side effects. Interest in the approach is growing rapidly and this report acts as a necessary touchstone for future development.

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.

Uniform Manifold Approximation and Projection for Clustering Taxa through Vocalizations in a Neotropical Passerine (Rough-Legged Tyrannulet, Phyllomyias burmeisteri)

Vocalizations from birds are a fruitful source of information for the classification of species. However, currently used analyses are ineffective to determine the taxonomic status of some groups. To provide a clearer grouping of taxa for such bird species from the analysis of vocalizations, more sensitive techniques are required. In this study, we have evaluated the sensitivity of the Uniform Manifold Approximation and Projection (UMAP) technique for grouping the vocalizations of individuals of the Rough-legged Tyrannulet Phyllomyias burmeisteri complex. Although the existence of two taxonomic groups has been suggested by some studies, the species has presented taxonomic difficulties in classification in previous studies. UMAP exhibited a clearer separation of groups than previously used dimensionality-reduction techniques (i.e., principal component analysis), as it was able to effectively identify the two taxa groups. The results achieved with UMAP in this study suggest that the technique can be useful in the analysis of species with complex in taxonomy through vocalizations data as a complementary tool including behavioral traits such as acoustic communication.

Minding the Gap Between the Policy and Practice of Patient-Centeredness: Cocreating a Model for Tensional Dialogue in the "Active Patient Support" Program

Several studies identify obstacles to patient-centered care that can be eradicated by bridging the gap between policy goals and practice. In this article, "patient-centeredness" is theorized as an unstable entity riddled with intrinsic, ineradicable tensions. The purpose of the article is to propose a reflexive approach to the tensions as the most appropriate strategy for narrowing the gap between policy and practice. The reflexive approach is illustrated in an account of an action research project on a Danish, patient-centered initiative, "Active Patient Support." The account focuses on the development of a dialogic communication model through collaborative, reflexive analyses of the tensions in the enactment of "patient-centeredness" in dialogue between health care practitioners and citizens-in particular, the tension between empowerment and self-discipline. Finally, the conceptual expansion of one of the dimensions of patient-centeredness, "health-practitioner-as-person," is discussed as a platform for reflexivity, and the limitations of reflexivity are addressed.

Neural Correlates of Voice Perception in Newborns and the Influence of Preterm Birth

Maternal voice is a highly relevant stimulus for newborns. Adult voice processing occurs in specific brain regions. Voice-specific brain areas in newborns and the relevance of an early vocal exposure on these networks have not been defined. This study investigates voice perception in newborns and the impact of prematurity on the cerebral processes. Functional magnetic resonance imaging (fMRI) and high-density electroencephalography (EEG) were used to explore the brain responses to maternal and stranger female voices in full-term newborns and preterm infants at term-equivalent age (TEA). fMRI results and the EEG oddball paradigm showed enhanced processing for voices in preterms at TEA than in full-term infants. Preterm infants showed additional cortical regions involved in voice processing in fMRI and a late mismatch response for maternal voice, considered as a first trace of a recognition process based on memory representation. Full-term newborns showed increased cerebral activity to the stranger voice. Results from fMRI, oddball, and standard auditory EEG paradigms highlighted important change detection responses to novelty after birth. These findings suggest that the main components of the adult voice-processing networks emerge early in development. Moreover, an early postnatal exposure to voices in premature infants might enhance their capacity to process voices.

How does familiarity with a voice affect trait judgements?

From only a single spoken word, listeners can form a wealth of first impressions of a person's character traits and personality based on their voice. However, due to the substantial within-person variability in voices, these trait judgements are likely to be highly stimulus-dependent for unfamiliar voices: The same person may sound very trustworthy in one recording but less trustworthy in another. How trait judgements differ when listeners are familiar with a voice is unclear: Are listeners who are familiar with the voices as susceptible to the effects of within-person variability? Does the semantic knowledge listeners have about a familiar person influence their judgements? In the current study, we tested the effect of familiarity on listeners' trait judgements from variable voices across 3 experiments. Using a between-subjects design, we contrasted trait judgements by listeners who were familiar with a set of voices - either through laboratory-based training or through watching a TV show - with listeners who were unfamiliar with the voices. We predicted that familiarity with the voices would reduce variability in trait judgements for variable voice recordings from the same identity (cf. Mileva, Kramer & Burton, Perception, 48, 471 and 2019, for faces). However, across the 3 studies and two types of measures to assess variability, we found no compelling evidence to suggest that trait impressions were systematically affected by familiarity.

Empowering Voice through the Creation of a Safe space: An experience of Aboriginal Women in Regional Queensland

Background: Sharing stories creates a space for respectful conversation and contributes to both knowledge and a sense of fellowship. This paper reflects on the experience of the research team in supporting a group of Aboriginal women to create safe spaces and to share their stories of healing, social and emotional wellbeing. Methods: Secondary data of a study exploring community perceptions about cancer were analysed using the holistic model of Indigenous Wellbeing developed by the Rumbalara Aboriginal Cooperative (2008). Qualitative data were collected during yarning sessions with a group of Aboriginal women while creating a quilt. Results: Four elements of the Indigenous Wellbeing model were identified: connectedness, sense of control, threats and relationship with the mainstream. The yarning sessions promoted dialogue, identified needs and supported the voices of the participants. A duality of forces (positive and negative) influencing community wellbeing was identified. Conclusion: This project highlights the need for spaces that support people and the community to express concerns, identify needs, propose solutions and begin a dialogue that encourages empowerment. Community-driven conversation and the identification of safe and empowering spaces can serve to empower social and emotional wellbeing.

The Role of Face and Voice Cues in Predicting the Outcome of Student Representative Elections

First impressions formed after seeing someone's face or hearing their voice can affect many social decisions, including voting in political elections. Despite the many studies investigating the independent contribution of face and voice cues to electoral success, their integration is still not well understood. Here, we examine a novel electoral context, student representative ballots, allowing us to test the generalizability of previous studies. We also examine the independent contributions of visual, auditory, and audiovisual information to social judgments of the candidates, and their relationship to election outcomes. Results showed that perceived trustworthiness was the only trait significantly related to election success. These findings contrast with previous reports on the importance of perceived competence using audio or visual cues only in the context of national political elections. The present study highlights the role of real-world context and emphasizes the importance of using ecologically valid stimulus presentation in understanding real-life social judgment.

The Acceptability, Feasibility and Potential Outcomes of an Individual Mindfulness-Based Intervention for Hearing Voices

BACKGROUND

A prominent area of advancement in the psychological treatment for people with persisting psychosis has been the application of mindfulness-based therapies. Recent literature has recommended the investigation of focused mindfulness interventions for voices (auditory hallucinations) as a specific experience. To date, only mindfulness programs in group format have been examined.

AIMS

This non-randomized pilot study aimed to assess the acceptability, feasibility and potential outcomes of an individual mindfulness program for persistent voices on the negative impact of voices on the subjective experience of mental health and wellbeing, depression and voice-related distress and disruption. Also, it aimed to identify potential psychological and neurocognitive mechanisms of change.

METHOD

A new 4-week individual Mindfulness Program for Voices (iMPV) was developed, and piloted with a group of 14 participants with a schizophrenia-spectrum disorder and persisting voices. Participants completed clinical and neurocognitive measures pre- and post-intervention and at 2-month follow-up.

RESULTS

Results revealed low attrition rates, high formal practice engagement levels and positive participant feedback. Pre-post outcomes suggested small to moderate effects for a reduction in the negative impact of voices on experience, depression and disruption. Large effects for changes in mindful responding and attentional switching were also identified.

CONCLUSIONS

Our findings suggest that this novel treatment protocol is appropriate, engaging and safe for persistent voice hearers. Findings for mindful responding and attentional switching suggest these to be potential mechanisms of change for further investigation. Further RCTs are warranted to ascertain the feasibility and efficacy for focused mindfulness interventions for voices of individual format.

Auditory hallucinations, not necessarily a hallmark of psychotic disorder

Auditory hallucinations (AH) are often considered a sign of a psychotic disorder. This is promoted by the DSM-5 category of Other Specified Schizophrenia Spectrum And Other Psychotic Disorder (OSSSOPD), the diagnostic criteria for which are fulfilled with the sole presence of persistent AH, in the absence of any other psychotic symptoms. And yet, persistent AH are not synonymous with having a psychotic disorder, and should therefore not be uncritically treated as such. Many people who seek treatment for persistent AH have no other psychotic symptoms, have preserved reality-testing capacities, and will never develop a schizophrenia spectrum disorder. Instead, hallucinations may be the result of many different causes, including borderline personality disorder, post-traumatic stress disorder (PTSD), hearing loss, sleep disorders or brain lesions, and they may even occur outside the context of any demonstrable pathology. In such cases, the usage of the DSM-5 diagnosis of OSSSOPD would be incorrect, and it may prompt unwarranted treatment with antipsychotic medication. We therefore argue that a DSM-5 diagnosis of Schizophrenia Spectrum Disorder (or any other type of psychotic disorder) characterized by AH should require at least one more symptom listed under the A-criterion (i.e. delusions, disorganized speech, disorganized or catatonic behavior or negative symptoms). Adhering to these more stringent criteria may help to distinguish between individuals with persistent AH which are part of a psychotic disorder, for whom antipsychotic medication may be helpful, and individuals with AH in the absence of such a disorder who may benefit from other approaches (e.g. different pharmacological interventions, improving coping style, trauma-related therapy).

The Structure and Measurement of Unusual Sensory Experiences in Different Modalities: The Multi-Modality Unusual Sensory Experiences Questionnaire (MUSEQ)

Hallucinations and other unusual sensory experiences (USE) can occur in all modalities in the general population. Yet, the existing literature is dominated by investigations into auditory hallucinations (“voices”), while other modalities remain under-researched. Furthermore, there is a paucity of measures which can systematically assess different modalities, which limits our ability to detect individual and group differences across modalities. The current study explored such differences using a new scale, the Multi-Modality Unusual Sensory Experiences Questionnaire (MUSEQ). The MUSEQ is a 43-item self-report measure which assesses USE in six modalities: auditory, visual, olfactory, gustatory, bodily sensations, and sensed presence. Scale development and validation involved a total of 1,300 participants, which included: 513 students and community members for initial development, 32 individuals with schizophrenia spectrum disorder or bipolar disorder for validation, 659 students for factor replication, and 96 students for test-retest reliability. Confirmatory factor analyses showed that a correlated-factors model and bifactor model yielded acceptable model fit, while a unidimensional model fitted poorly. These findings were confirmed in the replication sample. Results showed contributions from a general common factor, as well as modality-specific factors. The latter accounted for less variance than the general factor, but could still detect theoretically meaningful group differences. The MUSEQ showed good reliability, construct validity, and could discriminate non-clinical and clinical groups. The MUSEQ offers a reliable means of measuring hallucinations and other USE in six different modalities.

Mismatch Negativity to Threatening Voices Associated with Positive Symptoms in Schizophrenia

Although the general consensus holds that emotional perception is impaired in patients with schizophrenia, the extent to which neural processing of emotional voices is altered in schizophrenia remains to be determined. This study enrolled 30 patients with chronic schizophrenia and 30 controls and measured their mismatch negativity (MMN), a component of auditory event-related potentials (ERP). In a passive oddball paradigm, happily or angrily spoken deviant syllables dada were randomly presented within a train of emotionally neutral standard syllables. Results showed that MMN in response to angry syllables and angry-derived non-vocal sounds was significantly decreased in individuals with schizophrenia. P3a to angry syllables showed stronger amplitudes but longer latencies. Weaker MMN amplitudes were associated with more positive symptoms of schizophrenia. Receiver operator characteristic analysis revealed that angry MMN, angry-derived MMN, and angry P3a could help predict whether someone had received a clinical diagnosis of schizophrenia. The findings suggested general impairments of voice perception and acoustic discrimination in patients with chronic schizophrenia. The emotional salience processing of voices showed an atypical fashion at the preattentive level, being associated with positive symptoms in schizophrenia.

Comparing the experience of voices in borderline personality disorder with the experience of voices in a psychotic disorder: A systematic review

OBJECTIVE

In clinical settings, there is substantial evidence both clinically and empirically to suggest that approximately 50% of individuals with borderline personality disorder experience auditory verbal hallucinations. However, there is limited research investigating the phenomenology of these voices. The aim of this study was to review and compare our current understanding of auditory verbal hallucinations in borderline personality disorder with auditory verbal hallucinations in patients with a psychotic disorder, to critically analyse existing studies investigating auditory verbal hallucinations in borderline personality disorder and to identify gaps in current knowledge, which will help direct future research.

METHOD

The literature was searched using the electronic database Scopus, PubMed and MEDLINE. Relevant studies were included if they were written in English, were empirical studies specifically addressing auditory verbal hallucinations and borderline personality disorder, were peer reviewed, used only adult humans and sample comprising borderline personality disorder as the primary diagnosis, and included a comparison group with a primary psychotic disorder such as schizophrenia.

RESULTS

Our search strategy revealed a total of 16 articles investigating the phenomenology of auditory verbal hallucinations in borderline personality disorder. Some studies provided evidence to suggest that the voice experiences in borderline personality disorder are similar to those experienced by people with schizophrenia, for example, occur inside the head, and often involved persecutory voices. Other studies revealed some differences between schizophrenia and borderline personality disorder voice experiences, with the borderline personality disorder voices sounding more derogatory and self-critical in nature and the voice-hearers' response to the voices were more emotionally resistive. Furthermore, in one study, the schizophrenia group's voices resulted in more disruption in daily functioning. These studies are, however, limited in number and do not provide definitive evidence of these differences.

CONCLUSION

The limited research examining auditory verbal hallucinations experiences in borderline personality disorder poses a significant diagnostic and treatment challenge. A deeper understanding of the precise phenomenological characteristics will help us in terms of diagnostic distinction as well as inform treatments.

The Changing Face of Hallucination Research: The International Consortium on Hallucination Research (ICHR) 2015 Meeting Report

This article reports on the Third Biennial Meeting of the International Consortium on Hallucinations Research, held in Melbourne, Australia, in October 2015. Following a public conference in which research findings were considered in relation to subjective experience and practice, 9 multidisciplinary working groups examined key current issues in progressing the conceptualization and research of hallucinations. Work group topics included: multicenter validation of the transdiagnostic and multimodal Questionnaire for Psychotic Experiences; development of an improved outcome measure for psychological therapies; the relationship between inhibition and hallucinations across multiple levels of explanation; hallucinations in relation to sleep phenomena; emotion and hallucinations; multiple interactions between the experience of self and hallucinations; interactions between language, auditory and memory networks; resting state networks including the default mode; and analyses arising from functional magnetic resonance imaging (fMRI) data-sharing. Major themes in hallucinations research identified during the meeting included (1) progression beyond the auditory verbal modality in schizophrenia to consider hallucinations across modalities and different populations; (2) development of new measures; (3) the central role of multisite collaboration through shared data collection and data pooling; (4) study of time-based and interactive models of hallucination; and (5) the need to increase the accessibility and availability of "real-life" interventions for people with persisting and distressing hallucinations.

Neural Dynamics of Emotional Salience Processing in Response to Voices during the Stages of Sleep

Sleep has been related to emotional functioning. However, the extent to which emotional salience is processed during sleep is unknown. To address this concern, we investigated night sleep in healthy adults regarding brain reactivity to the emotionally (happily, fearfully) spoken meaningless syllables dada, along with correspondingly synthesized nonvocal sounds. Electroencephalogram (EEG) signals were continuously acquired during an entire night of sleep while we applied a passive auditory oddball paradigm. During all stages of sleep, mismatch negativity (MMN) in response to emotional syllables, which is an index for emotional salience processing of voices, was detected. In contrast, MMN to acoustically matching nonvocal sounds was undetected during Sleep Stage 2 and 3 as well as rapid eye movement (REM) sleep. Post-MMN positivity (PMP) was identified with larger amplitudes during Stage 3, and at earlier latencies during REM sleep, relative to wakefulness. These findings clearly demonstrated the neural dynamics of emotional salience processing during the stages of sleep.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTITIONER POINTS

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

Theta Burst Transcranial Magnetic Stimulation for Auditory Verbal Hallucinations: Negative Findings From a Double-Blind-Randomized Trial

BACKGROUND

Auditory verbal hallucinations (AVH) in schizophrenia are resistant to antipsychotic medication in approximately 25% of patients. Treatment with repetitive transcranial magnetic stimulation (rTMS) for refractory AVH has shown varying results. A stimulation protocol using continuous theta burst rTMS (TB-rTMS) showed high efficacy in open label studies. We tested TB-rTMS as a treatment strategy for refractory AVH in a double-blind, placebo-controlled trial.

METHODS

Seventy-one patients with AVH were randomly allocated to TB-rTMS or placebo treatment. They received 10 TB-rTMS or sham treatments over the left temporoparietal cortex in consecutive days. AVH severity was assessed at baseline, end of treatment and follow-up using the Psychotic Symptom Rating Scale (PSYRATS) and the Auditory Hallucinations Rating Scale (AHRS). Other schizophrenia-related symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS).

RESULTS

Seven patients dropped out before completing the study. In the remaining 64, AVH improved significantly after treatment in both groups as measured with both PSYRATS and AHRS. PANSS positive and general subscores also decreased, but the negative subscores did not. However, improvement did not differ significantly between the TB-rTMS and the placebo group on any outcome measure.

CONCLUSIONS

Symptom reduction could be achieved in patients with medication-resistant hallucinations, even within 1 week time. However, as both groups showed similar improvement, effects were general (ie, placebo-effects) rather than specific to treatment with continuous TB-rTMS. Our findings highlight the importance of double-blind trials including a sham-control condition to assess efficacy of new treatments such as TMS.

A qualitative method for analysing multivoicedness

'Multivoicedness' and the 'multivoiced Self' have become important theoretical concepts guiding research. Drawing on the tradition of dialogism, the Self is conceptualised as being constituted by a multiplicity of dynamic, interacting voices. Despite the growth in literature and empirical research, there remains a paucity of established methodological tools for analysing the multivoiced Self using qualitative data. In this article, we set out a systematic, practical 'how-to' guide for analysing multivoicedness. Using theoretically derived tools, our three-step method comprises: identifying the voices of I-positions within the Self's talk (or text), identifying the voices of 'inner-Others', and examining the dialogue and relationships between the different voices. We elaborate each step and illustrate our method using examples from a published paper in which data were analysed using this method. We conclude by offering more general principles for the use of the method and discussing potential applications.