Simon R. Jones

Do We Need Multiple Models of Auditory Verbal Hallucinations? Examining the Phenomenological Fit of Cognitive and Neurological Models

The causes of auditory verbal hallucinations (AVHs) are still unclear. The evidence for 2 prominent cognitive models of AVHs, one based on inner speech, the other on intrusions from memory, is briefly reviewed. The fit of these models, as well as neurological models, to the phenomenology of AVHs is then critically examined. It is argued that only a minority of AVHs, such as those with content clearly relating to verbalizations experienced surrounding previous trauma, are consistent with cognitive AVHs-as-memories models. Similarly, it is argued that current neurological models are only phenomenologically consistent with a limited subset of AVHs. In contrast, the phenomenology of the majority of AVHs, which involve voices attempting to regulate the ongoing actions of the voice hearer, are argued to be more consistent with inner speech-based models. It is concluded that subcategorizations of AVHs may be necessary, with each underpinned by different neurocognitive mechanisms. The need to study what is termed the dynamic developmental progression of AVHs is also highlighted. Future empirical research is suggested in this area.

Thought as action : inner speech, self-monitoring, and auditory verbal hallucinations

Passivity experiences in schizophrenia are thought to be due to a failure in a neurocognitive action self-monitoring system (NASS). Drawing on the assumption that inner speech is a form of action, a recent model of auditory verbal hallucinations (AVHs) has proposed that AVHs can be explained by a failure in the NASS. In this article, we offer an alternative application of the NASS to AVHs, with separate mechanisms creating the emotion of self-as-agent and other-as-agent. We defend the assumption that inner speech can be considered as a form of action, and show how a number of previous criticisms of applying the NASS to AVHs can be refuted. This is achieved in part through taking a Vygotskian developmental perspective on inner speech. It is suggested that more research into the nature and development of inner speech is needed to further our understanding of AVHs.

The phenomenology of inner speech: comparison of schizophrenia patients with auditory verbal hallucinations and healthy controls

BACKGROUND Despite the popularity of inner-speech theories of auditory verbal hallucinations (AVHs), little is known about the phenomenological qualities of inner speech in patients with schizophrenia who experience AVHs (Sz-AVHs), or how this compares to inner speech in the non-voice-hearing general population. METHOD We asked Sz-AVHs (n=29) and a non-voice-hearing general population sample (n=42) a series of questions about their experiences of hearing voices, if present, and their inner speech. RESULTS The inner speech reported by patients and controls was found to be almost identical in all respects. Furthermore, phenomenological qualities of AVHs (e.g. second- or third-person voices) did not relate to corresponding qualities in inner speech. CONCLUSIONS No discernable differences were found between the inner speech reported by Sz-AVHs and healthy controls. Implications for inner-speech theories of AVHs are discussed.

Rumination, reflection, intrusive thoughts, and hallucination-proneness: Towards a new model

Although rumination has been proposed to play an important role in the creation of hallucinations, direct empirical tests of this proposal have not yet been performed. Employing a distinction between ruminative and reflective self-consciousness, we set out to test a new model of the relations among rumination, reflection, intrusive thoughts, thought suppression, social anxiety, and hallucination-proneness. This model proposed that rumination would be related to hallucination-proneness through the mediating variable of intrusive thoughts, but that reflection would not be related to hallucination-proneness. The model was tested in a student population (N=296) using path analyses. A modified version of the model was found to be a good fit to the data, once a direct path from reflection to hallucination-proneness had been added. As hypothesized, rumination was related to hallucination-proneness only indirectly, through the mediating variable of intrusive thoughts. Implications for interventions and future directions for research are considered.

Theory of mind, schizotypy, and persecutory ideation in young adults

Introduction. Previous studies of the relation between theory of mind (ToM) and schizotypy have suggested that ToM deficits may be associated with positive signs (e.g., hallucination- and delusion-like experiences). Good theoretical reasons exist to suggest that this relation may be largely due to ToM deficits being predominantly associated with the occurrence of persecutory delusion-like beliefs. This study set out to test this hypothesis and address limitations of previous research. Method. Online administration of measures to a large nonclinical sample of young adults (N=828) was used to examine schizotypy, assessed by a new 30-item version of the Oxford-Liverpool Inventory of Feelings and Experiences (Mason, Claridge, & Jackson, 1995), persecutory delusion-like beliefs, assessed by the Persecutory Ideation Questionnaire (McKay, Langdon, & Coltheart, 2006), and ToM, indexed by the Hinting task (Corcoran, Mercer, & Frith, 1995) and a cartoon comprehension task (Corcoran, Cahill, & Frith, 1997). Results. No relations with ToM were found for global, positive, or negative schizotypy, nor persecutory delusion-like beliefs. This was the case both for whole group correlations and in analyses comparing groups formed by fifth-centile (top–bottom) splits by schizotypy scores. Scores on the two ToM tasks were not strongly correlated. Conclusion. Our findings point to no correlations with ToM for either schizotypy or persecutory ideation. These findings are discussed in relation to previous research.

Thought suppression and persecutory delusion-like beliefs in a nonclinical sample

Introduction. Thought suppression may play a role in the formation and/or maintenance of persecutory delusions, although this possibility has not yet been empirically studied. We investigated thought suppression levels in relation to the presence of persecutory delusion-like beliefs (PDLBs), and hypothesised that only when levels of anxiety or negative affect were high would thought suppression predict levels of PDLBs. Method. Thought suppression, anxiety, negative affect, social desirability, and persecutory ideation were assessed in a nonclinical sample (N=183) using online questionnaires. Results. When gender, anxiety, and negative affect were controlled, the interaction between thought suppression and anxiety predicted levels of PDLBs. Further analysis of this interaction showed that thought suppression was positively associated with PDLBs only when anxiety was high. Neither thought suppression by itself, nor the two-way interaction between negative affect and thought suppression, nor the three-way interaction between negative affect, anxiety, and thought suppression, were predictors of PDLB levels. Conclusion. The results are consistent with a proposed interaction between thought suppression and anxiety in the development of PDLBs. Possible causal mechanisms underlying this relation are considered further, future research in the area proposed, and potential clinical implications examined.

Re-expanding the phenomenology of hallucinations : lessons from sixteenth-century Spain

The paradigm within which hallucinations are studied, and the explanatory frameworks employed, may bias the phenomenological analysis of these experiences. After introducing the new term, hallucination, this paper undertook an inter-disciplinary study of the phenomenology of hallucinations identified by the sixteenth-century theologians, St John of the Cross and St Teresa of Avila. It was examined whether the phenomenological properties they highlighted are identified and addressed by contemporary psychological research. Many of these properties were indeed found to be acknowledged and studied by contemporary research in psychiatric patients, as well as in healthy individuals during hypnagogia, near-death experiences and at times of stress. However, many experiences, such as “internal voices,” “soundless voices,” and “voices that save,” were found to be neglected by contemporary research, as was the potential for hallucinations to communicate novel/original information. Finally, it was examined how these phenomenological insights may be “front-loaded” into future experimental designs.

Paranoia: The 21st-century fear

Following suggestions (Bentall, 2006; Frith, 1992) that research should attempt to explain specific experiences and beliefs commonly associated with psychosis, such as auditory hallucinations and persecutory delusions, a significant body of research has now been generated in these areas. This book by Daniel Freeman, one of the pre-eminent researchers into cognitive mechanisms associated with persecutory ideation, and his brother, the writer Jason Freeman, represents the fruits of such an approach, applied to paranoia, and summarised for a general readership. Paranoia, the ‘‘unfounded belief that someone is out to hurt us’’ (p. 8), is so prevalent, the authors claim, that at any one time ‘‘around a quarter of the population are having regular paranoid thoughts’’ (p. 153). In this book they examine what paranoia is, what may cause it, and how it may be combated. The book is highly readable and integrates complex research with the likes of Shakespeare, Seinfeld, and Woody Allen. Research findings are summarised in a clear and easily understandable manner and the book is commendable for its attempt to examine not only cognitive factors associated with paranoia, but also to consider some macroscopic, societal-level factors. The first two chapters ask what paranoia is, discuss its prevalence in the general population, and argue, contra Jaspers, that paranoia is not ununderstandable. The authors argue that suspicious thoughts in the general population lie on a spectrum with clinically relevant persecutory delusions, with the similarities between them outweighing their differences. They argue that the position of an individual on this spectrum is determined by the conviction, preoccupation, distress, and social incapacity associated with their paranoid thought(s). I was left feeling somewhat unclear as to what the precise prevalence of paranoid thoughts in the general population is. Freeman (2007) has previously argued that a ‘‘conservative estimate is that 10 15% of the general population regularly experience paranoid thoughts’’ (p. 430). However, in this book (as already noted), the authors repeatedly claim that a around a quarter of us regularly have paranoid thoughts. The authors also claim that frequent paranoid thoughts are experienced by ‘‘15 to 20 per cent of the population’’ (p. 10). Notwithstanding the lack of a precise COGNITIVE NEUROPSYCHIATRY 2009, 14 (3), 257 260

Factores familiares en la recaída de pacientes esquizofrénicos

ResumenNuestro estudio de la atmosfera emocional de los hogares de los pacientes esquizofrenicos en California del Sur ha replicado los descubrimientos britanicos en relacion con la influencia del ambiente familiar sobre el curso de la esquizofrenia. Como en los estudios britanicos, las criticas y la implicacion emocional excesiva de un familiar clave para el paciente en el momento de su ingreso constituyen el mejor predictor aislado de recaida sintomatica en los nueve meses posteriores al alta hospitalaria. Al igual que en los resultados britanicos, la asociacion entre la emocion expresada de los familiares y la recaida fue independiente de todas las demas variables investigadas. Los resultados transculturales sobre los efectos preventivos de la medicacion sugieren que los clinicos deben considerar la atmosfera emocional del hogar, a la hora de explicar los fracasos de la medicacion.