Benevolent voices are not so kind: the functional significance of auditory hallucinations

BACKGROUND: This study measures the impact of beliefs about auditory hallucinations on social functioning. SAMPLING AND METHODS: Twenty-nine subjects who met the ICD-10 criteria for schizophrenia or a schizo-affective disorder were included. Beliefs about voices and coping responses as measured by the Beliefs about Voices Questionnaire were compared with social functioning as assessed with the Life Skills Profile (LSP). RESULTS: The belief that voices are benevolent was associated with poor communication. Engagement with voices was correlated with the non-turbulence and the compliance factors of the LSP. Patients who held the belief that their voices were benevolent functioned significantly more poorly on the communication factor of the LSP than patients who interpreted their voices as malevolent. DISCUSSION: The results indicate that a positive relationship with voices may affect social functioning. However, the size of the sample is small and patients with benevolent voices are overrepresented. Nonetheless, these results have implications for the use of cognitive therapy for psychotic symptoms.     

World assumptions and the role of trauma in borderline personality disorder

The present study tested whether borderline personality disorder (BPD) is characterized by specific worldviews as hypothesized by cognitive models, using Janoff-Bulman's [(1989) Social Cognition, 7, 113-136] world assumptive model of negative effects of trauma. A second aim of this study was to investigate the role of trauma in the content of worldviews of BPD patients. Fifteen BPD patients, 14 patients with Cluster C personality disorders (PD), 19 patients with axis-I psychopathology and 21 non-patients filled out the World Assumptions Scale, the Personality Disorder Belief Questionnaire, a childhood trauma checklist (assessing physical, emotional and sexual abuse) and the BPD Checklist (severity of BPD psychopathology). BPD patients appear to view the world as malevolent and perceive less luck independent of trauma but dependent of BPD psychopathology. Furthermore, BPD patients have low self-worth and persist in specific beliefs independent of trauma or severity of BPD psychopathology. Pretzer's theory of BPD can be largely supported through Janoff-Bulman's world assumptive model. World assumptions of BPD patients can better be explained by the severity of BPD psychopathology than by the presence of trauma.     

Approche psychologique des hallucinations et de l’expérience d’entente de voix : prises en charge psychologiques fondées sur les preuves (partie II)

Despite the effectiveness of antipsychotic treatments in the management of auditory hallucinations, a significant number of individuals diagnosed with psychosis continue to hear voices associated with high emotional distress. The phenomenon of voice hearing must be considered as part of a continuum between normal and pathological and at a clinical level as a transdiagnostic phenomenon. Randomized controlled trials and meta-analyses highlight the effectiveness of psychological interventions in the management of auditory hallucinations. These interventions include voice self-management techniques for voice hearers and techniques from traditional behavioural and cognitive therapies such as: (1) changing beliefs about voices (including command voices, which are perceived as omniscient, omnipotent and malicious), and negative beliefs about self; as well as (2) to modify the relating of the hearer towards the voice, including increasing assertive voice behaviours through role-playing between the clinician and the voice hearer or the use of new interactive technologies such as avatars. Barriers to the implementation of CBTs for voices are discussed and the authors propose recommendations on the use of psychological interventions for hallucinations for clinicians.     

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.     

Audiovisual emotion recognition in schizophrenia: reduced integration of facial and vocal affect

Since Kraepelin called dementia praecox what we nowadays call schizophrenia, cognitive dysfunction has been regarded as central to its psychopathological profile. Disturbed experience and integration of emotions are, both intuitively and experimentally, likely to be intermediates between basic, non-social cognitive disturbances and functional outcome in schizophrenia. While a number of studies have consistently proven that, as part of social cognition, recognition of emotional faces and voices is disturbed in schizophrenics, studies on multisensory integration of facial and vocal affect are rare. We investigated audiovisual integration of emotional faces and voices in three groups: schizophrenic patients, non-schizophrenic psychosis patients and mentally healthy controls, all diagnosed by means of the Schedules of Clinical Assessment in Neuropsychiatry (SCAN 2.1). We found diminished crossmodal influence of emotional faces on emotional voice categorization in schizophrenics, but not in non-schizophrenia psychosis patients. Results are discussed in the perspective of recent theories on multisensory integration.     

Transcranial magnetic stimulation of left temporoparietal cortex in three patients reporting hallucinated "voices".

BACKGROUND: Prior studies suggest that auditory hallucinations of "voices" arise from activation of speech perception areas of the cerebral cortex. Low frequency transcranial magnetic stimulation (TMS) can reduce cortical activation. METHODS: We have studied three schizophrenic patients reporting persistent auditory hallucinations to determine if low frequency TMS could curtail these experiences. One hertz stimulation of left temporoparietal cortex was compared with sham stimulation using a double-blind, cross-over design. RESULTS: All three patients demonstrated greater improvement in hallucination severity following active stimulation compared to sham stimulation. Two of the three patients reported near total cessation of hallucinations for > or = 2 weeks. CONCLUSIONS: TMS may advance our understanding of the mechanism and treatment of auditory hallucinations.     

氦氖激光穴位照射治疗具有幻听症状的精神分裂症对照研究

目的：探讨氦氖激光穴位照射治疗具有幻听症状的精神分裂症的疗效。方法将120例具有幻听症状的精神分裂症随机分成二组,一组用氯丙嗪,另一组用氯丙嗪联合氦氖激光,对幻听消失情况及治疗前后BPRS评分进行比较。结果氯丙嗪联合氦氖激光治疗组较氯丙嗪组,幻听消失快,显效率高。结论氦氖激光对具有幻听症状的精神分裂症是一种有效的辅助治疗。     

Une approche psychologique des hallucinations : mécanismes psychologiques (partie I)

Anglo-Saxon psychology has produced a significant number of studies showing the involvement of psychological mechanisms in the development and maintenance of auditory hallucinations (voice-hearing). Likewise, numerous studies have shown that hallucinations are also described in other psychiatric (e.g. post-traumatic stress disorder) and neurodegenerative (e.g. Parkinson's disease) clinical populations as well as in a minority of the general population. However, despite these advances, hallucinations are still considered as a specific characteristic of schizophrenia, which in most cases, is understood from a biological point of view. For this reason, in this review, we are specifically interested in the psychological models of auditory hallucinations from a transdiagnostic point of view. More specifically, we will describe (1) the role of beliefs about voices and self-schemas, (2) the experience of voice understood as a fundamentally relational phenomenon between the voice hearer and the voices, (3) the role of emotions and emotional regulation strategies, and, finally, (4) the role of past traumatic experiences and dissociation. Regarding the role of beliefs about voices and self-schemas, numerous studies are showing that more important than the experience of hearing voices it is how the individual appraisal their experience that will ultimately impact on how they will cope with the experiences and how they will feel about it (distressed or not). Voices appraised as malevolent and powerful are more often associated with avoidant, escape, confrontation, and compliance coping strategies. Moreover, they are also associated with higher levels of depression and anxiety regardless of the frequency of hallucinations and duration of the disorder. Besides the beliefs about the voices, how the individual perceives him/herself is also essential. It has been shown, for example, that the more individuals feel depressed and inferior in comparison to others in interpersonal relationships, the more inferior they feel about their voices. The relational approach proposed that the experience of voice understood as a fundamentally relational phenomenon between the voice hearer and the voices. Indeed, phenomenological studies have been able to show that voice-hearers describe voices as possessing human characteristics. As a result, voice-hearers often develop a relationship of virtual intimacy with their voices, which often seems to be complex and characterised by a certain ambivalence similar to the interpersonal relationships encountered in everyday life. Thus, current research suggests that it is essential to take into account these relational aspects when working with voice-hearers. Alongside cognitive and relational variables, emotional states and processes play a significant role in the development and maintenance of auditory hallucinations. Indeed, it has been shown that stress, anxiety and depression are predictors of hallucinations. Also, increased use of non-adaptive emotion regulation strategies may play a major role in the phenomenon of voice agreement. Studies have demonstrated that emotional regulation strategies such as experiential avoidance and abstract rumination seem to contribute to the increased frequency of hallucinations and associated distress. Finally, there is now strong evidence showing the involvement of past adverse experiences in the onset and content of hallucinations. In this framework, dissociation is seen as a protective mechanism that allows individuals to psychologically detach themselves from events that they cannot cope with. Consequently, the experience is attributed to external sources, ultimately leading to the phenomenon of voice-hearing. In summary, in this brief review, we have tried to present the best validated psychological models for understanding the experience of voice agreement. The goal is to provide information on how these psychological processes can help us to the adoption of a person-centred approach in mental health care that allows the person to describe their experiences in their own words and thus formulate an understanding of their suffering.     

Pleasurable auditory hallucinations

OBJECTIVE: The focus in auditory hallucination (AH) research is usually on the negative impact of the experience itself. There are practically no studies on whether voices can be perceived as pleasurable. The aim of the present study was to assess the frequency of voices as a pleasurable experience in a psychotic patient population. METHOD: A total of 160 patients with AHs (89 schizophrenia and 17 other psychoses) were assessed with the psychotic symptom rating scale (PSYRATS) for AHs, including an added item on whether the experience was pleasurable. RESULTS: Twenty-eight patients (26%) reported the voices as a pleasurable experience and 10 of them did so frequently. Pleasurable hallucinations showed negative associations with amount and intensity of distress, degree of negative content and loudness. Positive associations were apparent with chronicity and perceived control over the voices. CONCLUSION: Pleasurable hallucinations can be detected in a substantial proportion of patients, and cross validated with existing instruments.     

酒精中毒性幻觉症的临床与犯罪──附3例报告

结合三个案例并复习文献讨论了酒精中毒性幻觉症的临床特点：患者在慢性酒精中毒的基础上由于减酒、戒酒或大量饮酒过后，在意识清晰状态下，出现斥责，威胁性第三人称的言语性幻听，对幻觉有强烈情感反应和行为。原始性幻听在该症也常出现，它进一步加强了患者对幻听的坚信。患者受幻听影响常出现逃避和自杀行为，而且也可出现严重的犯罪行为，应引起精神病学界及社会的重视，以尽早发现和治疗并采取防范措施。     

Auditory hallucinations and functional imaging

Auditory verbal hallucinations are a common symptom of schizophrenia. In general, hallucinations can affect all sensory modalities and occur in many neuropsychiatric disorders. They also serve the psychology of perception as the classic example of sensory experience in the absence of adequate external stimuli. Functional imaging studies showed the auditory cortex, the limbic system and language areas, both motor and sensory, to be active during auditory hallucinations. The psychological and neurophysiological models of hallucination can be integrated if we consider that patients with schizophrenia might ascribe internal monologues or dialogues to external sources. The activity of language areas during hallucinations would conform to such a model while the activity in auditory cortex might explain why auditory hallucinations are often so vivid and real for the patients suffering from them. Moreover, the activation of the limbic system might correspond to the emotional aspects of the content of the voices and the accompanying arousal. While the neurophysiological models of hallucination are thus already rather refined, the attempt at suppressing auditory cortex activity with repetitive transcranial magnetic stimulation in order to alleviate treatment-resistant acoustic hallucinations, which is based on the functional imaging findings, still needs further study. Treatment schemes that are based on the psychological theories are more varied and have shown more consistent and long lasting effects but also suffer from the difficulty in measuring hallucinations quantitatively. Future research with functional and structural imaging should go beyond correlating brain activity and symptoms and also address the functional and structural connectivity patterns in the brain that enable hallucinations.     

Regional cerebral blood flow in schizophrenic disorders

Regional cerebral blood flow was measured using a 133Xe inhalation technique in 16 schizophrenic patients and 20 healthy volunteers. The bilateral frontal blood flows in the patient groups were significantly lower than in the control group. In addition, the patient group having auditory hallucination showed a significantly increased blood flow predominantly in the left temporal region. On the other hand, the patient group without auditory hallucination showed a slightly increased flow in the right temporal region. These findings indicate that there are a hypofrontal activity and also a hypertemporoparietal activity in schizophrenics.     

Self-report of the frequency and phenomenology of verbal hallucinations

This study was an assessment of several parameters of verbal hallucinations ("voices") based on the self-report of 52 hallucinating psychiatric patients. These subjects were asked to estimate the frequency of their hallucinations and to rate phenomenological aspects (loudness, clarity, location, reality) of their most recent hallucination. Each parameter was assessed with two visual analogue scales which differed in their wording of the dimension. Results showed that the reliability of the subjects' estimates on the parameters differed greatly. Clarity was most reliably reported and reality was least reliably reported. Historical notions that schizophrenics characteristically perceive external "voices" and that such "voices" are perceived as more real were not supported. There was a significant negative correlation between the perceived location and the perceived clarity of hallucinations. No significant differences in mean parameter scores were found between two groups of subjects, schizophrenics and affective psychotics.     

Personality and psychosis: use of the Standardized Assessment of Personality

The Standardized Assessment of Personality, a semistructured interview for use with an informant, was used with a relative or a close friend to determine the premorbid personality of 100 consecutive patients admitted with major psychiatric disorders - major affective disorders (18 manics, 35 depressives), schizophrenia (28) and other functional psychoses (19). Forty-four per cent of the entire sample had an abnormal personality as defined by the presence of one of 10 prominent traits to a marked degree. A further 6% had the same traits to a lesser degree. The proportion of patients with an abnormal personality (all types) was comparable across the four diagnostic groups (manics 39%, depressives 54%, schizophrenics 39%, other functional psychotics 37%). However, if one included all traits (marked and mild), patients with an affective disorder had more between them than did the non-affective groups. This difference was largely accounted for by cyclothymic, anxious and obsessional traits. The schizophrenics and other functional psychotics had surprisingly few prominent traits and, in particular, a schizoid personality rarely preceded a schizophrenic illness.     

Object representations in the early memories of sexually abused borderline patients

OBJECTIVE: This study analyzed psychological representations in 58 subjects in order to achieve a better understanding of the relation between adult borderline personality disorder and reported histories of childhood sexual and physical abuse. METHOD: The subjects were 29 inpatients with borderline personality disorder diagnosed according to the Diagnostic Interview for Borderlines, 14 nonborderline inpatients with major depressive disorder according to the Research Diagnostic Criteria, and 15 normal comparison subjects recruited from the community and screened for the absence of psychopathology. Earliest memories were used as the source of mental representations in all subjects. The memories were reliably coded for malevolent affect tone, presence of deliberate injury, and effectiveness of helpers. Family histories of childhood sexual and physical abuse were obtained with the Familial Experiences Interview, a structured interview. Abuse histories for a subset of the subjects were corroborated by interviews with family members. RESULTS: A reported history of sexual abuse, but not a reported history of physical abuse, predicted the presence of extremely malevolent representations in these earliest memories as well as representations involving deliberate injury. These two kinds of representations also discriminated borderline patients who reported histories of sexual abuse from borderline patients who did not report sexual abuse. Mean affect tone (from malevolent to benevolent) did not, however, discriminate sexually abused or physically abused subjects. CONCLUSION: The results suggest that malevolent representations associated with the borderline diagnosis in previous research may be partially related to a history of childhood sexual abuse. Implications for the object relations theory of borderline personality disorder are noted.     

Personality and Neuropsychological Profiles in Friedreich Ataxia

Friedreich ataxia, an autosomal recessive mitochondrial disease, is the most frequent inherited ataxia. Many studies have attempted to identify cognitive and affective changes associated with the disease, but conflicting results have been obtained, depending on the tests used and because many of the samples studied were very small. We investigated personality and neuropsychological characteristics in a cohort of 47 patients with genetically confirmed disease. The neuropsychological battery assessed multiple cognition domains: processing speed, attention, working memory, executive functions, verbal memory, vocabulary, visual reasoning, emotional recognition, and social cognition. Personality was assessed with the Temperament and Character Inventory, and depressive symptoms were assessed with the Beck Depression Inventory. We found deficits of sustained attention, processing speed, semantic capacities, and verbal fluency only partly attributable to motor deficit or depressed mood. Visual reasoning, memory, and learning were preserved. Emotional processes and social cognition were unimpaired. We also detected a change in automatic processes, such as reading. Personality traits were characterized by high persistence and low self-transcendence. The mild cognitive impairment observed may be a developmental rather than degenerative problem, due to early cerebellum dysfunction, with the impairment of cognitive and emotional processing. Disease manifestations at crucial times for personality development may also have an important impact on personality traits.     

Auditory hallucinations: A review of the ERC “VOICE” project

In this invited review I provide a selective overview of recent research on brain mechanisms and cognitive processes involved in auditory hallucinations. The review is focused on research carried out in the “VOICE” ERC Advanced Grant Project, funded by the European Research Council, but I also review and discuss the literature in general. Auditory hallucinations are suggested to be perceptual phenomena, with a neuronal origin in the speech perception areas in the temporal lobe. The phenomenology of auditory hallucinations is conceptualized along three domains, or dimensions; a perceptual dimension, experienced as someone speaking to the patient; a cognitive dimension, experienced as an inability to inhibit, or ignore the voices, and an emotional dimension, experienced as the “voices” having primarily a negative, or sinister, emotional tone. I will review cognitive, imaging, and neurochemistry data related to these dimensions, primarily the first two. The reviewed data are summarized in a model that sees auditory hallucinations as initiated from temporal lobe neuronal hyper-activation that draws attentional focus inward, and which is not inhibited due to frontal lobe hypo-activation. It is further suggested that this is maintained through abnormal glutamate and possibly gamma-amino-butyric-acid transmitter mediation, which could point towards new pathways for pharmacological treatment. A final section discusses new methods of acquiring quantitative data on the phenomenology and subjective experience of auditory hallucination that goes beyond standard interview questionnaires, by suggesting an iPhone/iPod app.     

Emotional and personality changes following brain tumour resection

Psychological distress has a high prevalence in brain tumour patients, and understanding the emotional and personality changes that may follow neurosurgery is important for clinical management of these patients. We aimed to characterise these emotional and personality changes using subjective, observer-rated and clinical measures. We examined subjective changes in emotional experience and observer-rated changes to personality disturbances following neurosurgery for brain tumours (n = 44), compared to a control group that had undergone spinal surgery (n = 26). Participants completed the Hospital Anxiety and Depression Scale and a Subjective Emotional Change Questionnaire. Observers who knew the patients well also completed the Iowa Rating Scale of Personality Change. Compared to controls, patients with tumours reported significantly more changes to their subjective experience of emotions following neurosurgery, particularly anger, disgust and sadness. For the observer-ratings, tumour patients were described as having significant changes in the personality disturbances of irritability, impulsivity, moodiness, inflexibility, and being easily overwhelmed. Anxiety and depression were not significantly different between groups. Neurosurgical resection of a brain tumour is a major life event that changes patients’ subjective experiences of different emotions, and leads to observer-rated changes in personality. In this study, these changes were not accompanied by increases in anxiety or depression. We conclude with a discussion of biological and psychosocial mechanisms that can impact emotional functioning and personality in patients with brain tumours.     

Revisiting Arieti's ��Listening Attitude�� and Hallucinated Voices

Silvano Arieti proposed that auditory/verbal hallucinations (AVHs) are triggered by momentary states of heightened auditory attention that he identified as a “listening attitude.” Studies and clinical observations by our group support this view. Patients enrolled in our repetitive transcranial magnetic stimulation trials, if experiencing a significant curtailment of these hallucinations, often report an episodic sense that their voices are still occurring even if they no longer can be heard, suggesting episodic states of heightened auditory expectancy. Moreover, a functional magnetic resonance study reported by our group detected activation in the left insula prior to hallucination events. This finding is suggestive of activation in the same region detected in healthy subjects during “auditory search” in response to ambiguous sounds when anticipating meaningful speech. AVHs often are experienced with a deep emotional salience and may occur in the context of dramatic social isolation that together could reinforce heightened auditory expectancy. These findings and clinical observations suggest that Arieti''s original formulation deserves further study.     

Left superior temporal blood flow increases in schizophrenic and schizophreniform patients with auditory hallucination: A longitudinal case study using123I-IMP SPECT

Summary Serial assessments of regional cerebral blood flow were performed using¹²³I-IMP SPECT in two schizophrenic and three schizophreniform patients with persistent auditory hallucination. The initial SPECT study in the period with prominent auditory hallucination revealed an increased accumulation of¹²³I-IMP in the left superior temporal area which corresponded to the auditory association cortex. In the follow-up SPECT study performed after clinical improvement, the distribution of¹²³I-IMP had normalized. One of the case with schizophrenia showed a similar increased uptake of¹²³I-IMP in the left superior temporal area in the third SPECT scan performed when a psychotic relapse with auditory hallucination occurred. MRI scans in two of the five patients demonstrated reduced volume of the temporal lobes. These findings suggest that the auditory hallucinations in schizophrenia may be involved in functional hyperactivity in the left superior temporal cortex which might be based partly on structural abnormalities in the temporal lobes.