Georgie Paulik

The role of emotion regulation in auditory hallucinations

Emotion regulation involves the use of strategies to influence the experience and expression of emotions. Anxiety and depression are strongly associated with the positive symptoms of schizophrenia, such as auditory hallucinations (AHs). Individuals usually try to down-regulate (decrease) such emotions, consequently abnormal or maladaptive use of one or more of these down-regulatory processes (e.g. increased use of expressive suppression or maladaptive attentional deployment, i.e. rumination/worry) may play an important role in AHs (e.g. increasing AH severity and distress). This study examined the self-reported use of a range of emotion regulation strategies in individuals with schizophrenia and current AHs (SZ AH; N=34) and healthy controls (N=34). Two separable dimensions of hallucinatory experiences (severity and distress) were assessed together with measures of anxiety, depression and happiness. Within the SZ AH group, greater use of expressive suppression was associated with an increase in severity of AHs and greater disruption in daily life. In addition, rumination was significantly positively correlated with the distress (but not with the severity) associated with AHs. Within the control group, expressive suppression, rumination and worry were associated with more anxiety/depression and less happiness, as predicted. The implications of different emotion regulation strategies for the treatment of individuals with schizophrenia and AHs are discussed.

Dissociating the components of inhibitory control involved in predisposition to hallucinations.

Introduction. We have previously linked hallucinations in schizophrenia and hallucination predisposition to poor intentional inhibition. However, these previous studies have not systematically investigated the separable dimensions of inhibitory control involved, namely, intentional versus unintentional, and inhibition versus resistance to interference. The aim of this study was to clarify the critical component(s) of inhibitory control specifically related to hallucination predisposition. Methods. The Launay-Slade Hallucination Scale–Revised (LSHS-R) was completed by 589 undergraduate students, from which high- (n=28) and low- (n=25) hallucination predisposition groups were drawn. Participants were administered tasks measuring unintentional inhibition (Brown-Peterson variant task) and intentional resistance to interference (directed ignoring [DI] task). Results. The high LSHS-R group showed significant difficulties relative to the low LSHS-R group on the DI task only; although these differences did not remain significant when controlling for anxiety or delusional thinking. Regression analyses showed that anxiety, but not delusional thinking, independently contributed to variance in DI task performance above that accounted for by hallucination predisposition. Conclusions. Intentional rather than unintentional control of intrusive cognitions appears to play an important role in hallucination predisposition. The results indicate that difficulties with the intentional resistance to interference from concurrent external distractors may be a common mechanism underlying positive schizophrenia symptoms and anxiety. However, given previous findings reported by Paulik, Badcock, and Maybery (2007), we propose that hallucination predisposition is also characterised by a difficulty with the active suppression of intrusive cognitions—that is, intentional inhibition—which is not shared with anxiety or delusional symptoms.

Poor intentional inhibition in individuals predisposed to hallucinations.

Introduction. Intentional inhibition deficits have been found in hallucinating individuals with schizophrenia using the Inhibition of Currently Irrelevant Memories (ICIM) task. This study sought to investigate whether similar difficulties are found in healthy individuals predisposed to hallucinations. Methods. The Launay-Slade Hallucination Scale-Revised (LSHS-R) was completed by 589 undergraduate students, from which high- and low-predisposed groups were drawn. On the ICIM task, participants were asked to identify within-run picture repetitions, requiring them to inhibit memory traces of the same items seen in previous runs. Results. Compared to the low LSHS-R group, the high LSHS-R group showed significantly increased false alarms on critical “inhibitory” runs (incorrectly identifying previous-run items as within-run repetitions), but no group differences were found in first-run false alarms or in the identification of within-run targets. These results were specific to hallucination predisposition and could not be explained by other schizophrenia-related characteristics. Conclusions. Individuals predisposed to hallucinations show subtle, though consistent difficulties with intentional inhibition similar to patients with hallucinations. These findings demonstrate a continuity of cognitive processes in individuals predisposed to hallucinations and in patients with schizophrenia who hallucinate, consistent with a common neurodevelopmental pathway.

Bringing the 'Self' into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of “self” (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

Electrophysiological, cognitive and clinical profiles of at-risk mental state: the longitudinal Minds in Transition (MinT) study

The onset of schizophrenia is typically preceded by a prodromal period lasting several years during which sub-threshold symptoms may be identified retrospectively. Clinical interviews are currently used to identify individuals who have an ultra-high risk (UHR) of developing a psychotic illness with a view to provision of interventions that prevent, delay or reduce severity of future mental health issues. The utility of bio-markers as an adjunct in the identification of UHR individuals is not yet established. Several event-related potential measures, especially mismatch-negativity (MMN), have been identified as potential biomarkers for schizophrenia. In this 12-month longitudinal study, demographic, clinical and neuropsychological data were acquired from 102 anti-psychotic naive UHR and 61 healthy controls, of whom 80 UHR and 58 controls provided valid EEG data during a passive auditory task at baseline. Despite widespread differences between UHR and controls on demographic, clinical and neuropsychological measures, MMN and P3a did not differ between these groups. Of 67 UHR at the 12-month follow-up, 7 (10%) had transitioned to a psychotic illness. The statistical power to detect differences between those who did or did not transition was limited by the lower than expected transition rate. ERPs did not predict transition, with trends in the opposite direction to that predicted. In exploratory analysis, the strongest predictors of transition were measures of verbal memory and subjective emotional disturbance.

Beyond beliefs: A qualitative study of people’s opinions about their changing relations with their voices

This study sought to develop further understandings of the relationships that people can develop with the voices they hear, and to explore the development of these relationships over time. Qualitative data was gathered from 12 people attending peer support groups. A semi-structured interview was used to facilitate the interviews and analysis of the transcripts was guided by the principles of Thematic Analysis. Four themes emerged and suggested that the relationships between hearers and their voices can have a variable trajectory which is influenced by stress, talking with and about voices, and the acceptance of voices and/or resistance. Clinically, the findings have implications for the training of frontline staff, the provision of peer support and the adaptation of psychological therapies. Future studies should assess whether our findings generalise to more diverse samples of voice hearers and use longitudinal qualitative and quantitative designs to explore change processes in-depth from early to later stages of psychosis.

Cognitive Behavioural Relating Therapy (CBRT) for Voice Hearers: A Case Study

BACKGROUND There has been a recent focus on the interpersonal nature of the voice hearing experience, with studies showing that similar patterns of relating exist between voice hearer and voice as between voice hearer and social others. Two recent therapeutic approaches to voices, Cognitive Therapy for Command Hallucinations and Relating Therapy, have been developed to address patterns of relating and power imbalances between voice hearer and voice. AIMS This paper presents a novel intervention that combines elements of these two therapies, named Cognitive Behavioural Relating Therapy (CBRT). METHOD The application of CBRT is illustrated through a clinical case study. RESULTS The clinical case study showed changes in patterns of relating, improved self-esteem and reductions in voice-related distress. CONCLUSIONS The outcomes provide preliminary support for the utility of CBRT when working with voice hearers.