David Smailes

Interdisciplinary Approaches to the Phenomenology of Auditory Verbal Hallucinations

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) “front-loading” research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.

The brain’s conversation with itself: neural substrates of dialogic inner speech

Inner speech has been implicated in important aspects of normal and atypical cognition, including the development of auditory hallucinations. Studies to date have focused on covert speech elicited by simple word or sentence repetition, while ignoring richer and arguably more psychologically significant varieties of inner speech. This study compared neural activation for inner speech involving conversations (‘dialogic inner speech’) with single-speaker scenarios (‘monologic inner speech’). Inner speech-related activation differences were then compared with activations relating to Theory-of-Mind (ToM) reasoning and visual perspective-taking in a conjunction design. Generation of dialogic (compared with monologic) scenarios was associated with a widespread bilateral network including left and right superior temporal gyri, precuneus, posterior cingulate and left inferior and medial frontal gyri. Activation associated with dialogic scenarios and ToM reasoning overlapped in areas of right posterior temporal cortex previously linked to mental state representation. Implications for understanding verbal cognition in typical and atypical populations are discussed.

Tailoring Cognitive Behavioral Therapy to Subtypes of Voice-Hearing

Cognitive behavioral therapy (CBT) for voice-hearing (i.e., auditory verbal hallucinations; AVH) has, at best, small to moderate effects. One possible reason for this limited efficacy is that current CBT approaches tend to conceptualize voice-hearing as a homogenous experience in terms of the cognitive processes involved in AVH. However, the highly heterogeneous nature of voice-hearing suggests that many different cognitive processes may be involved in the etiology of AVH. These heterogeneous voice-hearing experiences do, however, appear to cluster into a set of subtypes, opening up the possibility of tailoring treatment to the subtype of AVH that a voice-hearer reports. In this paper, we (a) outline our rationale for tailoring CBT to subtypes of voice-hearing, (b) describe CBT for three putative subtypes of AVH (inner speech-based AVH, memory-based AVH, and hypervigilance AVH), and (c) discuss potential limitations and problems with such an approach. We conclude by arguing that tailoring CBT to subtypes of voice-hearing could prove to be a valuable therapeutic development, which may be especially effective when used in early intervention in psychosis services.

Occurrence and co-occurrence of hallucinations by modality in schizophrenia-spectrum disorders

It is not only unclear why hallucinations in schizophrenia occur with different prevalence by modality, but also to what extent they do. Reliable prevalence estimates of hallucinations by modality in schizophrenia are currently lacking, particularly for non-auditory hallucinations. Studies have also tended to report lifetime, not point prevalence by modality. This study assessed the prevalence and co-occurrence of hallucinations, for both lifetime and point prevalence, across the auditory, visual, olfactory, and tactile modalities, in people diagnosed with chronic schizophrenia-spectrum disorders in Ireland (N=693) and Australia (N=218). Lifetime prevalence was 64-80% auditory, 23-31% visual, 9-19% tactile, and 6-10% olfactory. Past month prevalence was 23-27% auditory, 5-8% visual, 4-7% tactile, and 2% olfactory. The majority of participants had only hallucinated in one modality, with this nearly always being the auditory. Approximately one-third had hallucinated in two modalities, most commonly the auditory and visual. Most currently hallucinating patients also hallucinated in a single modality, again, nearly always the auditory. Whereas 30-37% of patients with lifetime auditory hallucinations had experienced visual hallucinations, 83-97% of patients with experience of visual hallucinations had experienced auditory hallucinations. These findings help delineate the modality distribution of hallucinations in schizophrenia, and provide an explanatory target for theoretical models.

Testing continuum models of psychosis: No reduction in source monitoring ability in healthy individuals prone to auditory hallucinations

People with schizophrenia who hallucinate show impairments in reality monitoring (the ability to distinguish internally generated information from information obtained from external sources) compared to non-hallucinating patients and healthy individuals. While this may be explained at least in part by an increased externalizing bias, it remains unclear whether this impairment is specific to reality monitoring, or whether it also reflects a general deficit in the monitoring of self-generated information (internal source monitoring). Much interest has focused recently on continuum models of psychosis which argue that hallucination-proneness is distributed in clinical and non-clinical groups, but few studies have directly investigated reality monitoring and internal source monitoring abilities in healthy individuals with a proneness to hallucinations. Two experiments are presented here: the first (N = 47, with participants selected for hallucination-proneness from a larger sample of 677 adults) found no evidence of an impairment or externalizing bias on a reality monitoring task in hallucination-prone individuals; the second (N = 124) found no evidence of atypical performance on an internal source monitoring task in hallucination-prone individuals. The significance of these findings is reviewed in light of the clinical evidence and the implications for models of hallucination generation discussed.

A commentary on: Affective coding: the emotional dimension of agency

We welcome Gentsch and Synofziks (2014) review of the role of affect in modulating a persons sense of agency (SoA). The review is timely and synthesizes a great deal of evidence. However, we feel that their claims concerning the role of affect in modulating a persons SoA could be usefully extended to the study of auditory hallucinations (AH), one unusual experience not discussed in their review. In this commentary, we describe recent findings that suggest that one way in which negative affect plays a role in the development of AH is by reducing the SoA associated with self-generated cognitions and suggest that the insula may play an important role in mediating the effect of affect on SoA. Cognitive models of AH (e.g., Bentall, 1990; Waters et al., 2012) suggest that they occur when a cognition is misattributed to an external, non-self-source. Consistent with this claim, people who experience AH tend to show a bias toward accepting the presence of a verbal stimulus on tasks designed to measure reality discrimination (i.e., they tend to confuse internal, self-generated events for external, non-self-generated events, but not vice versa; Brookwell et al., 2013). This is often demonstrated using an auditory signal detection task (SDT), in which participants must try to detect speech in an ambiguous auditory stimulus (typically white noise). On trials where the speech is absent, participants have the opportunity to make a false alarm; that is, to report that speech was present in the white noise, when it was not. Presumably, when participants make a false alarm, they have mistaken their internal representation of the speech for the externally presented, “real” speech. Two recent studies have demonstrated a causal relation between increases in negative affect and weaker reality discrimination. Smailes et al. (2014) reported that participants who performed an auditory SDT after completing a negative mood induction (recalling an unpleasant autobiographical memory) made more false alarms, but not more hits, than did participants who performed the task after completing a neutral mood induction. Similarly, Hoskin et al. (2014), despite employing a different mood induction and a modified SDT, reported that participants were more likely to make false alarms during a condition in which they were exposed to a stressor than during a control condition. Thus, both studies showed that when participants experienced negative affect, they were more likely to misattribute internal, self-generated cognitions to an external source. These findings are consistent with data from studies that have shown that negative affect tends to precede the onset of AH in the daily lives of psychosis patients (Nayani and David, 1996; Delespaul et al., 2002), and suggest that negative affect is associated with the onset of AH, at least in part, because it modulates SoA for cognition. Gentsch and Synofzik propose that three stages of agency processing—prospective, immediate, and retrospective—exist. First person accounts (e.g., Romme et al., 2009; Scholtus and Blanke, 2012) suggest that people who experience AH do not go through a deliberative process to determine whether an unusual auditory percept was self-generated, or was a result of an external, non-self agent. Instead, an AH is experienced “in the moment” as something that was not self-generated. Thus, in terms of Gentsch and Synofziks proposed stages, it seems likely that the effect of negative emotions on a persons reality discrimination abilities would correspond to either prospective or immediate affective coding, rather than retrospective affective coding. That is, negative affect may reduce a persons SoA over cognition by interfering with action planning or with the generation of an accurate sensory outcome representation of a cognition. The most prominent cognitive models of AH suggest that a forward model system acts to predict the sensory outcomes of motor commands, and that dysfunction at one of a number of comparators can lead to a lack of agency over self-generated actions (Jones and Fernyhough, 2007). Interference with either action planning or accurate prediction could therefore lead to external misattributions of self-generated processes. A potential avenue for research would be to investigate whether negative affect can modulate, for example, the sensory attenuation which is associated with successful prediction via forward modeling. Gentsch and Synofziks review only briefly discusses the brain regions that may be involved in mediating the effects of negative affect on SoA. At two points, however, they cite evidence suggesting that damage to/atypical activity in the insula can lead to disorders of SoA. We concur that the insula is a good candidate for mediating the effects of negative affect on SoA. This is because, in addition to the evidence cited by Gentsch and Synofzik, a number of studies have shown (a) that different agency experiences are associated with changes in insula activity (e.g., Farrer and Frith, 2002; Farrer et al., 2003), (b) that insula activity is atypical in people who report AH (Wylie and Tregellas, 2010) and (c) that increases in negative affect are associated with changes in insula activity (Phan et al., 2002; Harrison et al., 2008). Research that examines whether negative affect brings about reductions in a persons SoA over their cognitions through modulation of activity in the insula is required. Demonstrating that affective problems may play an important role in the development of AH is important for a number of reasons. First, affect-induced changes in the SoA a person has over their cognitions can help to explain why AH are typically not experienced constantly (this issue is sometimes raised as a problem for cognitive models of AH; Gallagher, 2004). Seconds, and perhaps more importantly, it opens up the possibility of novel therapeutic interventions. While the primary focus of such interventions may be on ameliorating the affective problems reported by people who hear voices, they may indirectly reduce the frequency of AH by preventing negative affect-induced modulations of a persons SoA over their cognitions.

The effect of arousal and eye gaze direction on trust evaluations of stranger's faces: A potential pathway to paranoid thinking

BACKGROUND AND OBJECTIVES When asked to evaluate faces of strangers, people with paranoia show a tendency to rate others as less trustworthy. The present study investigated the impact of arousal on this interpersonal bias, and whether this bias was specific to evaluations of trust or additionally affected other trait judgements. The study also examined the impact of eye gaze direction, as direct eye gaze has been shown to heighten arousal. METHODS In two experiments, non-clinical participants completed face rating tasks before and after either an arousal manipulation or control manipulation. Experiment one examined the effects of heightened arousal on judgements of trustworthiness. Experiment two examined the specificity of the bias, and the impact of gaze direction. RESULTS Experiment one indicated that the arousal manipulation led to lower trustworthiness ratings. Experiment two showed that heightened arousal reduced trust evaluations of trustworthy faces, particularly trustworthy faces with averted gaze. The control group rated trustworthy faces with direct gaze as more trustworthy post-manipulation. There was some evidence that attractiveness ratings were affected similarly to the trust judgements, whereas judgements of intelligence were not affected by higher arousal. LIMITATIONS In both studies, participants reported low levels of arousal even after the manipulation and the use of a non-clinical sample limits the generalisability to clinical samples. CONCLUSIONS There is a complex interplay between arousal, evaluations of trustworthiness and gaze direction. Heightened arousal influences judgements of trustworthiness, but within the context of face type and gaze direction.

Recall of threat material is modulated by self or other referencing in people with high or low levels of non-clinical paranoia

BACKGROUND AND OBJECTIVES Biased processing of negatively valenced, and particularly threat-related material plays an important role in the development of paranoid thinking. This has been demonstrated by superior memory for threat-related information in patients with persecutory delusions and in non-clinical paranoia-prone participants. This study examined how emotional material was recalled having been encoded in relation to one self or to another person, in people high or low in paranoid ideation. It was predicted that people high in paranoia would recall more threat related material about others than people low in paranoia owing to being particularly alert to threats from other people. METHODS Participants who reported high (N = 30) or low (N = 30) levels of sub-clinical paranoid thinking were presented with a series of threat-related and positive words and were asked to process them in terms of the self, or in terms of a fictional character. RESULTS As predicted, when words were processed in terms of another person, the high paranoia group recalled more threat-related words than positive words, but when words had been processed in terms of the self, recall of threat-related and positive words did not differ. In contrast, there was no interaction between word-valence and referent in the low paranoia group. LIMITATIONS These findings are drawn from an analogue sample. Replication in a sample of clinical participants who report persecutory delusions is required. CONCLUSIONS People high in sub-clinical paranoid ideation recalled threat preferentially in relation to other people. Such information processing biases may help understand the development and maintenance of persecutory beliefs.