Preliminary Evidence for Heterogeneity of Beliefs About Auditory Verbal Hallucinations Intent

ABSTRACT

Perceptions of patient's auditory verbal hallucinations (AVHs), commonly termed voices, have important impacts on their everyday lives. Despite research emphasizing the consequences of malevolent voices, preliminary results suggest that beliefs about voices may not be mutually exclusive. As such, we aimed to characterize the heterogeneity of beliefs about AVHs and describe their clinical correlates. We recruited 78 patients referred to a Voices group therapy for refractory and distressing voices. Based on the Revised Beliefs About Voices Questionnaire, clustering analysis yielded four subgroups of patients with distinct pattern of beliefs about AVHs. These subgroups differed significantly in terms of affective disturbances, engagement, and resistance to their voices. Furthermore, no significant changes in beliefs about voices were observed after 6 weeks. Results of the current study suggest that the heterogeneity regarding the beliefs about AVHs should be targeted in treatment to reduce their associated negative outcomes.

Psychotic symptoms and suicidal ideation in child and adolescent bipolar I disorder

OBJECTIVES

The purpose of this study was to explore associations between specific types of hallucinations and delusions and suicidal ideation in a sample of children and adolescents with bipolar I disorder.

METHODS

Participants (N = 379) were children and adolescents aged 6-15 years (M = 10.2, SD = 2.7) with DSM-IV diagnoses of bipolar I disorder, mixed or manic phase. The study sample was 53.8% female and primarily White (73.6% White, 17.9% Black, and 8.5% Other). Presence and nature of psychotic symptoms, suicidal ideation, and functioning level were assessed through clinician-administered measures. A series of logistic regressions was performed to assess the contribution of each subtype of psychotic symptom to the presence of suicidal ideation above and beyond age, sex, socio-economic status, age at bipolar disorder onset, and global level of functioning.

RESULTS

Hallucinations overall, delusions of guilt, and number of different psychotic symptom types were uniquely associated with increased odds of suicidal ideation after accounting for covariates. Other forms of delusions (eg, grandiose) and specific types of hallucinations (eg, auditory) were not significantly uniquely associated with the presence of suicidal ideation.

CONCLUSIONS

Findings of this study suggest the presence of hallucinations as a whole, delusions of guilt specifically, and having multiple concurrent types of psychotic symptoms are associated with the presence of suicidal ideation in children and adolescents with bipolar I disorder. Psychotic symptom subtypes, as opposed to psychosis as a whole, are an under-examined, potentially important, area for consideration regarding suicidal ideation in pediatric bipolar I disorder.

Pilot randomised controlled trial of culturally adapted cognitive behavior therapy for psychosis (CaCBTp) in Pakistan

BACKGROUND

Evidence for efficacy of cognitive-behavioural therapy (CBT) in treatment of schizophrenia is growing. CBT is effective and cost efficient in treating positive and negative symptoms. To effectively meet the needs of diverse cultural groups, CBT needs to be adapted to the linguistic, cultural and socioeconomic context. We aimed to assess the feasibility, efficacy and acceptability of a culturally adapted CBT for treatment of psychosis (CaCBTp) in a low-income country.

METHODS

Rater-blind, randomised, controlled trial of the use of standard duration CBT in patients with psychosis from a low-income country. Participants with a ICD-10 diagnosis of psychosis were assessed using Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Psychotic Symptom Rating Scales (PSYRATS), and the Schedule for Assessment of Insight (SAI) (baseline, 3 months and 6 months). They were randomized into the intervention group (n = 18) and Treatment As Usual (TAU) group (n = 18). The intervention group received 12 weekly sessions of CaCBTp.

RESULTS

The CaCBTp group had significantly lower scores on PANSS Positive (p = 0.02), PANSS Negative (p = 0.045), PANSS General Psychopathology (p = 0.008) and Total PANSS (p = 0.05) when compared to TAU at three months. They also had low scores on Delusion Severity Total (p = 0.02) and Hallucination Severity Total (p = 0.04) of PSYRATS, as well as higher scores on SAI (p = 0.01) at the same time point. At six months only the improvement in PANSS positive scores (p = 0.045) met statistical significance..

CONCLUSIONS

It is feasible to offer CaCBTp as an adjunct to TAU in patients with psychosis, presenting to services in a lower middle-income country.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02202694 (Retrospectively registered).

Prevalence and classification of hallucinations in multiple sensory modalities in schizophrenia spectrum disorders

BACKGROUND

Auditory hallucinations are experienced by 60-80% of all patients diagnosed with a schizophrenia spectrum disorder. However, in this patient group, the prevalence of hallucinations in multiple sensory modalities, i.e. multimodal hallucinations (MMHs), is unknown.

AIMS

To assess the prevalence of MMHs in patients diagnosed with a schizophrenia spectrum disorder, data were analyzed from 750 patients who participated in the Dutch Genetic Risk and Outcome of Psychosis (GROUP) study.

METHOD

We drew on the section of the CASH (Comprehensive Assessment of Symptoms and History) that probes into the lifetime presence of auditory, visual, somatic/tactile, and olfactory hallucinations.

RESULTS

A lifetime prevalence of 80% was found in this group for hallucinations in any of these modalities. Within the whole group, 27% of the participants reported unimodal hallucinations and 53% MMHs. There were no significant differences in prevalence rate for Dutch versus migrant participants from Morocco, Turkey, Surinam or the (former) Dutch Antilles.

CONCLUSION

We conclude that MMHs, rather than auditory hallucinations, are the most frequent perceptual symptom of patients diagnosed with a schizophrenia spectrum disorder. Our data also suggest that hallucinations experienced in a single sensory modality (notably auditory ones) stochastically increase the risk for more sensory modalities to join in. We recommend that future studies take into account all 14 sensory modalities in which hallucinations can be experienced. For this we provide a classification of MMHs that allows characterization of their serial versus simultaneous occurrence and their congruent versus incongruent nature.

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.

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.

[The psychopathology of acute and transient psychotic disorder]

Acute and transient psychotic disorder remains an important element of the clinical field. It was first observed by Philippe Pinel in the 19th century. Other figures, such as Philippe Chaslin and Valentin Magnan, have contributed to the identification of the disorders and a psychopathological classification. While the central clinical element of acute and transient psychotic disorder is delusion and hallucinations, its resolution can be quick or it may be a sign of the gradual onset of a psychiatric pathology.

Elementary visual hallucinations and their relationships to neural pattern-forming mechanisms

An extraordinary variety of experimental (e.g., flicker, magnetic fields) and clinical (epilepsy, migraine) conditions give rise to a surprisingly common set of elementary hallucinations, including spots, geometric patterns, and jagged lines, some of which also have color, depth, motion, and texture. Many of these simple hallucinations fall into a small number of perceptual geometries-the Klüver forms-that (via a nonlinear mapping from retina to cortex) correspond to even simpler sets of oriented stripes of cortical activity (and their superpositions). Other simple hallucinations (phosphenes and fortification auras) are linked to the Klüver forms and to pattern-forming cortical mechanisms by their spatial and temporal scales. The Klüver cortical activity patterns are examples of self-organized pattern formation that arise from nonlinear dynamic interactions between excitatory and inhibitory cortical neurons; with reasonable modifications, this model accounts for a wide range of hallucinated patterns. The Klüver cortical activity patterns are a subset of autonomous spatiotemporal cortical patterns, some of which have been studied with functional imaging techniques. Understanding the interaction of these intrinsic patterns with stimulus-driven cortical activity is an important problem in neuroscience. In line with this, hallucinatory pattern formation interacts with physical stimuli, and many conditions that induce hallucinations show interesting interactions with one another. Both types of interactions are predictable from neural and psychophysical principles such as localized processing, excitatory-inhibitory neural circuits, lateral inhibition, simultaneous and sequential contrast, saccadic suppression, and perceptual opponency. Elementary hallucinations arise from familiar mechanisms stimulated in unusual ways.

[Delusions and hallucinations, definitions and mechanisms]

The semiology of delusions and hallucinations corresponds to precise definitions. Systematised or not, their mechanisms and their themes are varied. Psychodynamic and biological approaches give an insight into the therapies to use with patients who are affected.

[Auditory hallucinations. Nomenclature and classification]

BACKGROUND

We are rapidly increasing our knowledge about the correlates of auditory hallucinations. If we are to understand and integrate this new knowledge it is essential that the nomenclature for this special area is clear and unambiguous.

AIM

To review and to re-evaluate the concept of auditory hallucinations belonging to classical psychiatry.

METHOD

Relevant data were collected from books, PubMed, Embase and the Cochrane Library.

RESULTS

On the basis of our findings we present different classifications for auditory hallucinations.

CONCLUSIONS

Our review emphasises the need for a re-appraisal of these concepts, clearer definitions and an improved nomenclature. These will make it easier to set up, conduct and interpret neurological studies of these frequently occurring phenomena.

The Neuropsychiatric Inventory-Clinician rating scale (NPI-C): reliability and validity of a revised assessment of neuropsychiatric symptoms in dementia

BACKGROUND

Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages).

METHODS

Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity.

RESULTS

Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains.

CONCLUSION

Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

[Positive visual perceptual disorders. Nomenclature and classification]

BACKGROUND

Our knowledge about the neurobiological correlates of positive visual perceptual disorders is increasing rapidly. If we are to understand and integrate this emerging knowledge, the nomenclature needs to be clear and unambiguous.

AIM

To provide an overview of the different classifications of visual hallucinations to reach a better understanding of new neurobiological views in these phenomena.

METHOD

Relevant data were obtained from books, PubMed, Embase, and the Cochrane Library.

RESULTS

The results are presented in the form of various classifications of visual hallucinations, grouped according to the following guiding principles: shape, size, content, relation to the sleepwake cycle, co-occurrence with percepts in any of the other sensory modalities, and association with neurobiological correlates. In addition, a classification system for visual illusions and distortions is presented.

CONCLUSION

The overview emphasizes how important it is to reappraise the concepts of positive visual perceptual disorders that were developed during the era of classical psychiatry. By becoming familiar with these concepts we will find it easier to design, execute and interpret neurobiological studies of these frequently occurring phenomena.

Thalamic hyperperfusion in verbal hallucination of Parkinsonian patients

OBJECTIVE

We compared brain perfusion image using 3D-SSP analysis of (123)I-IMP SPECT between Parkinson's disease patients with auditory verbal hallucination and those without auditory hallucination.

METHODS

Eighty-three cases with Parkinson's disease were studied. In 6 of these patients, auditory hallucination was noted. Among them, four cases had verbal hallucination and two other cases had elementary hallucination. Auditory hallucination was not found in the other 77 cases.

RESULTS

Right thalamic perfusion was significantly increased in the verbal hallucination group compared to the group that lacked auditory hallucination.

CONCLUSION

In Parkinson's disease, the right thalamic hyperactive state may be related to verbal hallucination.

[Cenesthesia as a rare differential diagnosis of persistent idiopathic facial pain]

Cenesthesia is portrayed as a rare differential diagnosis to persistent idiopathic facial pain, including the resulting therapy with antipsychotics. In this case report a female patient developed persistent facial pain 2 years after manifestation of a depressive disorder. The symptoms appeared as a bizarre pain phenomenon closely resembling the psychotic phenomenon of cenesthesia (body hallucinations). Treatment with imipramine and doxepin or a combination of venlafaxin, carbamazepine, and tilidine N had not been successful. Based on diagnostic classification of the complaint as cenesthesia in the context of a depressive disorder, add-on therapy of the atypical antipsychotic ziprasidone was administered. This led to clear improvements in mood and pain symptoms after 4 weeks of treatment.

Persistent hallucinosis in borderline personality disorder

A case series of 10 patients with a diagnosis of borderline personality disorder (BPD) presenting with auditory hallucinosis is examined. In this series, the hallucinations were persistent, longstanding, and a significant source of distress and disability. Extrapolating from this series to our sample of 171 patients with BPD suggests that a form of auditory hallucinosis may occur in almost 30% of this population. The failure to emphasize this phenomenon in current systems of classification risks misdiagnosis or inappropriate treatment. Use of terms such as pseudohallucination or quasi hallucination dismisses the phenomenon as unimportant or as "not real." There is an emerging literature on the frequency of hallucinosis among nonpatients. A basis for understanding different forms of hallucination is discussed with reference to the concept of "normativity." We propose a nomenclature for hallucinosis that is expressed in positive terms, reflecting the clinical significance of the phenomenon in different contexts: (1) normative hallucinosis, (2) traumatic-intrusive hallucinosis (as in our series), (3) psychotic hallucinosis, and (4) organic hallucinosis.

Hallucinations in Parkinson's disease: A follow‐up study

To study prevalence of hallucinations in patients with Parkinson's disease (PD) during a 1-year period, and identify factors predictive of the onset of hallucinations in patients who were hallucination-free at baseline, 141 unselected outpatients with PD were evaluated prospectively for a set of demographic, clinical, and therapeutic variables and the presence of hallucinations during the previous 3 months. Patient groups were compared with nonparametric tests, and logistic regression was applied to significant data. Follow-up data were available for 127 patients. The hallucination prevalence rates (%) at the first and second evaluation were, respectively, 41.7 and 49.6 for hallucinations of all types (NS), 29.1 and 40.2 for minor hallucinations (i.e., presence or passage hallucinations, and illusions) (P = 0.02), 22.8 and 21.2 for formed visual hallucinations (NS), and 8.7 and 8.7 for auditory hallucinations (NS). Hallucinations rarely started or ceased during the study. The most labile forms were minor hallucinations, which developed in 20% of patients and ceased in 9%. During follow-up, 15% of patients started to hallucinate. Three factors, all present at the first evaluation, independently predicted the onset of hallucinations in patients previously free of hallucinations at baseline (odds ratio; 95% confidence interval): severe sleep disturbances (14.3; 2.5-80.9), ocular disorders (9.1; 1.6-52.0), and a high axial motor score (5.7; 1.2-27.4). Hallucinations have a chronic course in most parkinsonian patients. Factors predicting the onset of hallucinations point to a role of extranigral brainstem involvement and a nonspecific, facilitating role of ocular disorders.

Schizophrenia and narcolepsy: a review with a case report

Several reports emphasize the importance of differentiating between psychosis in schizophrenia and the psychotic form of narcolepsy. The failure to identify narcolepsy leads to the labeling of patients as refractory to standard treatments for schizophrenia and retards consideration of intervention for narcolepsy in which psychosis can improve with psychostimulant treatment. Psychosis in patients with narcolepsy can occur in three ways: (i) as the psychotic form of narcolepsy with hypnagogic and hypnopompic hallucinations; (ii) as a result of psychostimulant use in a patient with narcolepsy; and (iii) as the concurrent psychosis of schizophrenia in a patient with narcolepsy. The present case report describes a difficult-to-treat patient who likely had concurrent schizophrenia and narcolepsy. It then summarizes the literature related to the treatment of the three types of patients with psychosis associated with narcolepsy.

Daytime parahypnagogia: a state of consciousness that occurs when we almost fall asleep

Based on a series of self-reports of a previously undescribed and undocumented experiential event, we are postulating the existence of a newly identified state of consciousness, daytime parahypnagogia (DPH). DPH is more likely to occur when one is tired, bored, suffering from attention fatigue, and/or engaged in a passive activity. Individuals describe DPH as a transient and fleeting episode that is dissociative, trance-like, dreamlike, uncanny, and often pleasurable; but, unlike a daydream, it is not self-directed. A DPH episode is spontaneous and may consist of a flash image, thought, and/or creative insight that is quickly forgotten. However, the individual remains aware of having had a DPH experience. This paper details the experiential characteristics associated with DPH. Through a brief review of the literature, the authors differentiate DPH from related phenomena and establish DPH as a unique and distinct altered state of consciousness.

Brain modules of hallucination: an analysis of multiple patients with brain lesions

We systematically reviewed the localization of focal brain lesions that cause isolated hallucination in a single sensory modality. Case reports of post-lesion nonparoxysmal hallucination in 1 (and only 1) of 3 sensory modalities (i.e., visual, auditory, somatic) were reviewed, and the content of the qualitative descriptions was analyzed for each modality. The lesion is practically always located in the brain pathway of the sensory modality of the hallucination. There seem to exist localized sensory brain circuits that in healthy people diminish the intensity of internal sensory representation. After a lesion, hallucinosis seems to be caused also by compensatory overactivation of tissue in the nearby brain sensory pathway. This type of hallucination may indeed be termed a "release" form, whereby patients are aware of the hallucinatory nature of their experience, but not usually of "dream centres" as proposed by Lhermitte. Instead, we propose that it is dreaming that should be considered a special case of neural "release."

Is reported childhood sexual abuse associated with the psychopathological characteristics of patients who experience auditory hallucinations?

OBJECTIVE

The aim of this study was to determine whether reported childhood sexual abuse is related to the severity of symptoms in patients who experience auditory hallucinations.

METHOD

A sample of 26 adult male and females with psychotic disorders involving auditory hallucinations were interviewed and were asked to complete three self-report measures: the Dissociative Experiences Scale (DES-II and DES-taxon versions); the Beck Depression Inventory (BDI); and the Beliefs About Voices Questionnaire (BAVQ). They were also asked about any history of sexual abuse in childhood.

RESULTS

A history of childhood sexual abuse was reported by 10 of the 26 patients (38.5%), and was associated with higher levels of depression and dissociation, as well as being linked to a tendency to regard the voices as more malevolent. The same three features were all associated with the age at first reported abuse, with a younger age of first experience being related to higher levels of psychopathology in all instances.

CONCLUSIONS

These results require replication and refinement in future research, but indicate a need for greater attention to be paid to the possible role of childhood sexual abuse when understanding and treating auditory hallucinations.

Relevance of cues for assessing hallucinated voice experiences

PURPOSE

To assess psychiatric nurses' views of the importance of itemized content represented on an Inventory of Voice Experiences (IVE) for ongoing assessment of atypical auditory sense perception in people who hear voices.

METHODS

Over 6 months, 317 experienced psychiatric nurses rated 58 assessment cues for hallucinated voice experiences. Cronbach's alpha, Cohen's kappa, and Bartko's intraclass correlation coefficients were used to measure concordance of the nurses' judgments against two hypothetical standards derived for purposes of the study.

FINDINGS

There was moderate support for both the internal consistency of the nurses' judgments concerning the importance of itemized content represented on the IVE and overall equivalence of the content. There was modest-to-moderate concordance of the nurses' original and subsequent judgments but a lack of concordance of the nurses' judgments with equally weighted judgments of the principal investigator even though the judgments of the investigator were based on extant literature and published reports of voice hearers.

CONCLUSIONS

Results may reflect the effects of repeated testing, but it also is possible that some nurses did not have enough knowledge or professional experience to quantify judgments about the importance of hallucinated voice descriptions tied to the items on the IVE. The findings are being used to refine the IVE.

PRACTICE IMPLICATIONS

Findings provide nurses with opportunities for discerning specific characteristics, antecedents, and consequences of voice hearing along with their implications for health and well-being. Discernment of this information will facilitate identification of more specific and meaningful options for helping voice hearers manage their voices.

Chronic hallucinatory psychosis, bouffée délirante, and the classification of psychosis in French psychiatry

The conflict between French nosology and international classifications is mainly linked to the French concepts of chronic hallucinatory psychosis and bouffée délirante. However, these discrepancies are now largely reduced by the evolution of the recent versions of international classifications. The term chronic hallucinatory psychosis is used to describe a chronic hallucinatory and delusional disorder that differs from paranoid schizophrenia in the absence of formal thought disorder and intellectual impairment. This concept appears to be quite similar to paranoid schizophrenia as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD). However, the recent statement that deficit and nondeficit schizophrenia are separate diseases rediscovered French distinctions between chronic hallucinatory psychosis and schizophrenia. The term bouffée délirante describes an acute nonaffective and nonschizophrenic psychotic disorder, which is largely similar to DSM-III-R and DSM-IV brief psychotic and schizophreniform disorders, and was taken up in ICD-10 under the name acute polymorphic psychotic disorder.

The internal structure of the phenomenology of auditory verbal hallucinations

BACKGROUND

Auditory verbal hallucinations (AVH) do not have uniform pathological significance. They affect patients with different brain disorders, and vary along multiple phenomenological dimensions. Evidence indicates that some of the phenomenological variables have specific neural substrates. Therefore, a comprehensive characterization of the phenomenological variations of AVH and the interrelationship between these variables was undertaken.

METHOD

Twenty phenomenological variables were identified; on each AVH had a binary value (present or absent). Information about 11 of these variables were obtained from 30 patients. Hierarchical cluster (HC) and multidimensional scaling (MDS) analyses were performed to investigate the hidden structure and dimensions of these variables.

RESULTS

HC yielded two main clusters with further sub-clusters in each. The first cluster included hallucinations with low linguistic complexity, repetitive content, attributed to self, located in outer space, and associated with different kinds of control strategies. The second cluster included hallucinations with high linguistic complexity, systematized content, multiple voices, attributed to others, and located in inner space. In MDS, three dimensions were identified: linguistic complexity, self-other attribution, and inner-outer space location.

CONCLUSION

The patterns of clustering and dimensional configuration of AVH characteristics were in accord with intuitive expectation and validated the patients' descriptions of their experiences. These findings could reflect aspects of the neural mechanisms of AVH. For example, the presence of neural specificity for each phenomenological variable, intermediate neural commonality for groups of variables, and a final common pathway for all subtypes of AVH. Another example is a differential level of language dysfunction according to the linguistic complexity of AVH.

The efficacy of using a personal stereo to treat auditory hallucinations. Preliminary findings

This article presents preliminary findings from the first participant to complete an experiment assessing the efficacy of the personal stereo in treating auditory hallucinations. O.C., a 50-year-old woman, took part in a controlled treatment trial in which 1-week baseline, personal stereo, and control treatment (nonfunctioning hearing aid) stages were alternated for 7 weeks. The Positive and Negative Syndrome Scale, Clinical Global Impression Scales, Beliefs About Voices Questionnaire, Rosenberg Self-Esteem Scale, and Topography of Voices Rating Scale were used. The personal stereo led to a decrease in the severity of O.C.'s auditory hallucinations. For example, she rated her voices as being fairly distressing during baseline and control treatment stages but neutral during personal stereo stages. A slight decrease in other psychopathology also occurred during personal stereo stages. Use of the personal stereo did not lead to a decrease in self-esteem, contradicting suggestions that counterstimulation treatments for auditory hallucinations may be disempowering.

Pseudohallucinations: a pseudoconcept? A review of the validity of the concept, related to associate symptomatology

"Pseudohallucination" is a concept used in the classification of nonpsychotic perceptual disorders. This report describes the history of the concept and investigates whether pseudohallucinations can be differentiated from related psychopathological symptoms, such as hallucinations, re-experiencing, and dissociative phenomena. We performed a literature review, which shows that pseudohallucinations and related symptoms have low construct validity and are, accordingly, clinically ambiguous. Most likely, pseudohallucinations are placed on an overlapping continuum of symptomatology that includes perceptual disorders, re-experiencing, (dissociative) imagery, and normal thought and memory processes. Recommendations are made regarding the specification of dimensions of this continuum. The term "nonpsychotic hallucinations" is preferred over "pseudohallucination."

The relationship between command hallucinations and violence

OBJECTIVE

The purpose of this study was to describe the relationship between command hallucinations and violent behavior.

METHODS

One hundred and three psychiatric inpatients completed measures of command hallucinations, other psychotic symptoms, violent behavior, and social desirability response biases.

RESULTS

Thirty percent of the patients reported having had command hallucinations to harm others during the last year, and 22 percent of the patients reported they complied with such commands. Logistic regression analyses suggested that patients who experienced command hallucinations to harm others were more than twice as likely to be violent, even when the analysis controlled for demographic variables, history of substance abuse, and social desirability response biases.

CONCLUSIONS

The results support the clinical utility of asking about command hallucinations when assessing the risk of violence in patients with major mental disorders.

Atypical Charles Bonnet hallucinations: an elf in the woodshed, a spirit of evil, and the cowboy malefactors

In this article, the authors review the literature on the Charles Bonnet syndrome (CBS), a condition involving visual hallucinations in normal persons with severe sight loss. Attempts to assess the characteristics of this "phantom vision" have resulted in descriptions of a "typical" CBS hallucination. However, the many exceptions to a modal CBS experience cause the authors to postulate two other general categories of CBS hallucinations: a) the atypical sensory/perceptual (ASP), and b) the atypical psychodynamic (APD) hallucinations. Case studies illustrating these two types are provided. Extending the categories of Charles Bonnet hallucinations allows for more specific diagnosis, treatment, and may result in the possibility of greater precision in future research.

Clinical homogeneity of DSM-IV schizophrenic disorders

We investigated the lifetime fulfillment of five subcriteria of diagnostic criterion A in 94 inpatients with a definite diagnosis of DSM-IV schizophrenic disorder. Among the five diagnostic features captured by criterion A, only delusions were found to be almost universal, whereas of the remaining four, only hallucinations and negative symptoms occurred in more than half of all the cases. Overall, almost 60% of the 28 possible patterns of combination among the five subcriteria were found to be fulfilled although 60% of the cases were accounted for by only 4 patterns, which were also identified by means of a cluster analysis, as accounting for the totality of the cases. The first cluster was characterized by the fulfillment of subcriteria 1,2 and 5, the second by subcriteria 1 and 2, the third by subcriteria 1 and 5 and the fourth by subcriteria 1,2, and 3. The substantial clinical heterogeneity of the DSM-IV category of schizophrenic disorders with respect to their diagnostically characteristic features captured in criterion A is traced to the polythetic character of its five subcriteria.

Psychotic features and illness severity in combat veterans with chronic posttraumatic stress disorder

BACKGROUND

Psychotic symptoms may be present in up to 40% of patients with combat-related posttraumatic stress disorder (PTSD). In this study, we hypothesized that severity of psychotic symptoms would also reflect severity of PTSD symptoms in patients with well-defined psychotic features.

METHODS

Forty-five Vietnam combat veterans with PTSD but without a primary psychotic disorder diagnosis underwent a Structured Clinical Interview for DSM-III-R with Psychotic Screen, and the Clinician Administered PTSD Scale (CAPS). Patients identified as having psychotic features (PTSD-P), (n = 22) also received the Positive and Negative Syndrome Scale (PANSS) and the Hamilton Depression Rating Scale (HDRS).

RESULTS

There was a significant positive correlation between the CAPS and PANSS global ratings (p < .001) and the HDRS and PANSS (p < .03) in the PTSD-P patients. Many CAPS and PANSS subscales also demonstrated significant intercorrelations; however, the CAPS-B subscale (reexperiencing) and the PANSS positive symptom scale were not correlated, suggesting that psychotic features may not necessarily be influenced or accounted for by more severe reexperiencing symptoms. Fifteen (68%) of the PTSD-P patients had major depression (MDD). Both CAPS and PANSS ratings were significantly higher in the PTSD-P patients with comorbid MDD.

CONCLUSIONS

As postulated, patients with more severe psychosis ratings are likely to have more severe PTSD disease burden if psychotic features are present. This study further documents the occurrence of psychotic features in PTSD that are not necessarily due to a primary psychotic disorder, suggesting that this may be a distinct subtype; however, a significant interaction likely exists between PTSD, depression, and psychotic features.

Dimensions of schizophrenic positive symptoms: an exploratory factor analysis investigation

Current psychopathology classifies schizophrenic positive symptoms into four groups: delusions, hallucinations, formal thought disorder, and catatonic symptoms. The present study explores the factor structure of different positive symptoms to refine this classification. The 35 positive symptoms of 429 psychiatric patients, consecutively admitted to any of 95 mental hospitals, with diagnosis of the ICD-10 F20 schizophrenia, were studied. After excluding those items with a base rate of 10% or less, factor analysis yielded six factors. The first factor was loaded by most of Schneider's first-rank symptoms and two specific auditory hallucinations; the second by all the catatonic symptoms and incoherence; the third by bodily delusions/hallucinations; the fourth by delusions of persecution and reference; the fifth by grandiose and religious delusions; and the sixth by visual and miscellaneous hallucinations. The finding that schizophrenic positive symptoms may have more than four dimensions suggests the need for reclassification of schizophrenic symptoms and for reconsideration of evidence-based diagnostic criteria for the disorder.

Toward a new definition of hallucination

Two major flaws in the DSM-IV definition of hallucination are addressed: 1) it fails to distinguish pathological from nonpathological experiences; and 2) it fails to consider cultural beliefs in determining whether an experience is hallucinatory. These omissions are discussed within the context of an evolving concept of the term hallucination and an expanding vocabulary used to describe unshared sensory experiences. A revised definition is proposed.

[Phenomenology of cycloid axis syndromes and their delineation from a schizophrenic core group]

The concept of cycloid psychoses means a certain species as part of the group of schizophrenias. From our clinical point of view, the subtypes of Leonard and their poles are axial syndromes. They can occur simultaneously or intermingle during one phase. In the present phenomenological study the inner connections of these axial syndromes are shown. Apart from these connections, cycloid psychoses can be differentiated from core schizophrenia by three conditions: (1) the lack of deformation of affect and affect expression; (2) the lack of deformaton of thought structure; and (3) the lack of certain movement deformations, e.g., parakinesis. Our concept of phenomenon is explained to criticize the current operational definitions of cycloid psychoses. A different approach is suggested.

Factor structure of symptoms in functional psychoses

Global ratings from the Scale for the Assessment of Positive Symptoms and Scale for the Assessment of Negative Symptoms were subjected to principal-component analysis (PCA) in 80 schizophrenia patients, 76 patients with schizophreniform disorder, 80 patients with schizoaffective and mood disorders, and 78 patients with delusional, brief reactive, and atypical psychoses. The resulting factors were correlated with depressive, manic, and catatonic syndromes, and subjected to a multivariate analysis of variance across DSM-III-R diagnoses. PCAs revealed that psychosis, disorganization, and negative factors were also present in each of the nonschizophrenic groups. The disorganization factor tended to be related to the manic syndrome, and the negative factor to depressive and catatonic syndromes. Overall, the three factors had little diagnostic relevance in functional psychoses, although the negative factor was relatively more characteristic of schizophrenia. The data suggest that positive, negative, and disorganization factors are not specific to schizophrenia; this is consistent with a dimensional view of psychopathology in functional psychoses.

Subsyndromes of chronic schizophrenia: a phenomenological study

Statistical grouping of clinical symptoms and signs is one method of classifying schizophrenia. This study attempted to find factors of symptoms generated through clinical ratings on three scales, namely the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS) and the Comprehensive Psychopathological Rating Scale (CPRS) in a sample of 80 stable chronic schizophrenics diagnosed by DSM-III-R. It was found that the positive-negative dichotomy could not be replicated. Inappropriate affect was found to be a clear misfit in the cluster of negative symptoms. Inclusion of CPRS led to the generation of a factor loading high on depressive and asthenic items, and this could be clearly distinguished from the factor of negative symptoms. This factor had not hitherto been identified.

What voices can do with words: pragmatics of verbal hallucinations

BACKGROUND

In this paper we consider verbal hallucinations as inner speech with pragmatics. The specific pragmatic properties of verbal hallucinations investigated included the number of voices, the characteristics that individuate the voices, the sequential characteristics of the dialogues between voice hearers and their voices, the dialogical positioning of voices hearers, voices and other individuals, and how the voices influence voice hearers' activities.

METHODS

These properties were examined in structured interviews with 28 individuals, 14 of whom had a diagnosis of schizophrenia, while 14 were students who did not use psychiatric services.

RESULTS

The analysis showed that voices were most frequently individuated with reference to individuals significant to voice hearers. The talk with voices was typically mundane and related to voice hearers' on-going activities, as is the case for ordinary inner speech. The voices were typically orientated towards the voice hearer, without direct access to each other or to other people. Contrary to received wisdom, the voices typically did not impel actions of voice hearers, rather they influenced voice hearers' decisions on how to act. This was so irrespective of the diagnostic status of informants. Finally, we have found some differences between the voices of informants with, and without, schizophrenia. These concerned the alignment of voices, the type of action required by a voice and the degree of dialogical engagement between voices and voice hearers.

CONCLUSIONS

We conclude that verbal hallucinations can be fruitfully considered to be a genus of inner speech. Pragmatics can be used as a framework to distinguish verbal hallucinations in different populations.

Subclinical hallucinations and delusions in nonpsychotic adolescents

A number of studies have suggested that clinical populations of adolescents may report hallucinations and/or delusions without meeting criteria for a psychotic disorder. The purpose of this study was to provide information about the prevalence and symptom correlates of these subclinical hallucinations and delusions that occur in a nonpsychotic population of adolescents. Thirty-eight adolescents from a residential program and day treatment center were assessed with respect to hallucinatory experiences, ideas of reference, paranoid ideation, dissociative experiences, depressive symptomatology, and schizotypal cognitions. Results of this study indicated that 33% of the participants reported having experienced auditory hallucinations, and 24% reported having had delusional ideas. In addition, the results suggest that subclinical auditory hallucinations may have an especially strong relation with dissociative processes, whereas subclinical delusions appeared to be most strongly correlated with schizotypal thought processes. The results of this study begin to clarify the phenomenon of hallucinatory and delusional experiences in a nonpsychotic population.

[The PANSS (Positive And Negative Symptom) Scale]

The PANSS scale, first proposed by Kay et al. (1987) and translated into French is an evaluation scale of 30 disparate items scored from 1 to 7 for psychopathological symptoms observed in patients presenting psychotic syndromes, especially schizophrenic states. A semi-structured interview (translated into French by J.P. Lindenmayer) and precise definition of the different degrees of symptomatic, severity make it possible to obtain satisfactory between-assessor and test-retest fidelity. Three scores obtained with this evaluation tool are generally calculated for evaluating three dimensions of the syndrome: positive, negative and general psychopathology, as part of a categorial or dimensional perspective. The main studies validating the PANSS scale have involved several factorial analyses and comparison with data obtained using other schizophrenia scales such as Nancy Andreasen's SANS and SAPS scales. The three main factors isolated correspond to the clinical dimensions: positive, negative and "disorganization". Currently, the PANSS scale is being used increasingly more often. It allows study of the symptomatic profile in a wide population of psychotic patients and evaluation of the prognostic influence of positive and negative dimensions. It does however appear to be susceptible to change. Recent research projects are attempting to confirm initial findings and to analyse the general relevance of the reference conceptual model used by the authors.

Influence of season on manifestation of schizophrenic subtypes

In the modern classification systems ICD-10 and DSM-III-R, the term seasonality has been given a separate significance in the diagnostic categorization of affective disorders. Its definition is oriented not merely to the increased seasonal prevalence in the autumn and winter months, but also to symptoms that do not occur in nonseasonal attacks. To date, research work on seasonality in schizophrenia has concentrated on birth seasonality, while no results based on large populations of patients have yet become available on the manifestation seasonality of schizophrenic subtypes. Within the framework of a retrospective study carried out in the period between 1983 and 1995, involving 2, 119 patients suffering from recurrent attacks of schizophrenia, seasonal manifestations were recorded in accordance with the criteria defined in DSM-III-R. It was found that the two subtypes of paranoid hallucinatory and schizoaffective psychoses met the criterion of seasonality significantly more frequently than did the subtypes disorganized and catatonic disorders. In addition, seasonal courses within the groups just mentioned clearly differed from the nonseasonal forms in terms of their symptomatology.

[Psychometric properties of PANSS (Positive and Negative Syndrome Scale) in the French version in a sample of schizophrenic patients]

Our study focuses on psychometrics properties of the french version of the Positive and Negative Syndrom Scale (PANSS). 85 schizophrenic subjects, in accordance with DSM III-R criteria were included in this study. Our results allow us to discuss the construct validity and the reliability of this scale. The traditional 3 dimensions of the PANSS (positive, negative and general psychopathology) are discuss. We show that expect positive scale and general psychopathology scale average several symptomatic dimensions. We propose a 5 dimensions solution (negative, hostility, positive, disorganization, anxiety), which represent 54% of the total inertie. The internal consistency of this solution is presented.

[A four-dimensional model of chronic schizophrenia based on the factorial structure of the Positive and Negative Syndrome Scale (PANSS). A study of a group of 153 chronic schizophrenic patients and comparison with the factorial structure of the BPRS]

The aim of the study is to explore the latent dimensions in chronic schizophrenia using factorial analysis methods. 153 subjects (89 males, 64 females) with a mean age of 38.83 years (sd = 10.15) meet the RDC criteria for chronic schizophrenia and were included in the study. They were 127 inpatients and 26 outpatients and the mean duration of the illness since the first psychotic episode was 14.69 years (sd = 9.64). The majority of the schizophrenics received antipsychotic treatment with a mean dose (in chlorpromazine-equivalent) of 401.86 mg (sd = 368.13). The schizophrenics were rated using the French versions of the Positive and Negative Syndrome Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS). Two successive principal components analyses (PCA) were carried out on the correlation matrix of the 30 PANSS and 18 BPRS items. The numbers of factors were limited using several guidelines : eigenvalues higher than 1, screen test and the parallel analysis of Horn. Then an orthogonal equamax rotation was made and the saturation value was chosen using and ad-hoc paradigm. The results have shown a four-factors solution for the PANSS with the following factors : negative, positive-hostility, disorganization-impulsivity, depressive-anxious. The composition of the four preceding factors was respectively : negative [N1, N2, N3, N4, N6, N7, G7, P4 (-)]; positive-hostility (P1, P2, P3, P5, P6, P7, G8, G9, G12, G15, G16); disorganization-impulsivity (G5, G10, G11, G13, G14, N5); depressive-anxious (G1, G2, G3, G4, G6). The ACP of the BPRS have shown a three factors solution (positive-disorganization, negative, depressive-anxious). The factorial structure of the PANSS was discussed with the different studies. Our results confirm the division of the productive symptomatology into two components, delusions-hallucinations and cognitive (disorganization). Moreover depressive and negative symptomatology constitute two separate dimensions. Contrary to the others studies we did not find an excited component, the corresponding items were found in the positive and disorganization factors. The inclusion of solely chronic schizophrenics could explain the lack of the excited component. Our data in chronic schizophrenia allow us to propose a four-dimensional model explaining the symptomatology of this disease.

Factor analysis of schizophrenic symptoms using the OPCRIT checklist

Factor analysis was performed on OPCRIT checklist psychotic symptoms rated on 102 patients with DSM-III-R schizophrenia. An initial three-factor solution produced positive, negative, and disorganisation factors. However, application of the scree test suggested five substantive factors, with the positive factor dividing into three factors characterised, respectively, by paranoid symptoms, first rank delusions and first rank hallucinations.