Confusions about ‘Inner’ and ‘Outer’ Voices: Conceptual Problems in the Study of Auditory Verbal Hallucinations

Both in research on Auditory Verbal Hallucinations (AVHs) and in their clinical assessment, it is common to distinguish between voices that are experienced as ‘inner’ (or ‘internal’, ‘inside the head’, ‘inside the mind’, ...) and voices that are experienced as ‘outer’ (‘external’, ‘outside the head’, ‘outside the mind’, ...). This inner/outer-contrast is treated not only as an important phenomenological variable of AVHs, it is also often seen as having diagnostic value. In this article, we argue that the distinction between ‘inner’ and ‘outer’ voices is ambiguous between different readings, and that lack of disambiguation in this regard has led to flaws in assessment tools, diagnostic debates and empirical studies. Such flaws, we argue furthermore, are often linked to misreadings of inner/outer-terminology in relevant 19th and early twentieth century work on AVHs, in particular, in connection with Kandinsky’s and Jaspers’s distinction between hallucinations and pseudo-hallucinations.publishedVersio

Feasibility and Acceptability of Using a Mobile Phone App for Characterizing Auditory Verbal Hallucinations in Adolescents With Early-Onset Psychosis: Exploratory Study

Background: Auditory verbal hallucinations (AVH) are the most frequent symptom in early-onset psychosis (EOP) and a risk factor for increased suicide attempts in adolescents. Increased knowledge of AVH characteristics can lead to better prediction of risk and precision of diagnosis and help identify individuals with AVH who need care. As 98% of Norwegian adolescents aged 12 to 16 years own a mobile phone, the use of mobile phone apps in symptom assessment and patient communication is a promising new tool. However, when introducing new technology to patients, their subjective experiences are crucial in identifying risks, further development, and potential integration into clinical care. Objective: The objective was to explore the feasibility and acceptability of a newly developed mobile phone app in adolescents with EOP by examining compliance with the app and user experiences. Indication of validity was explored by examining associations between AVH dimensions, which were correlated and analyzed. Methods: Three adolescents with EOP and active AVH were enrolled. Real-time AVH were logged on an iPod touch using the experience sampling method (ESM), for seven or more consecutive days. The app included five dimensions of AVH characteristics and was programmed with five daily notifications. Feasibility and acceptability were examined using the mean response rate of data sampling and by interviewing the participants. Validity was assessed by examining associations between the AVH dimensions using nonparametric correlation analysis and by visual inspection of temporal fluctuations of the AVH dimensions. Results: One participant was excluded from the statistical analyses but completed the interview and was included in the examination of acceptability. The sampling period of the two participants was mean 12 (SD 6) days with overall completed sampling rate of 74% (SD 30%), indicating adequate to high compliance with the procedure. The user experiences from the interviews clustered into four categories: (1) increased awareness, (2) personal privacy, (3) design and procedure, and (4) usefulness and clinical care. One participant experienced more commenting voices during the sampling period, and all three participants had concerns regarding personal privacy when using electronic devices in symptom assessment. The AVH dimensions of content, control, and influence showed moderate to strong significant correlations with all dimensions (P<.001). Days of data sampling showed weak to moderate correlations with localization (P<.001) and influence (P=.03). Visual inspection indicated that the app was able to capture fluctuations within and across days for all AVH dimensions. Conclusions: This study demonstrates the value of including patients’ experiences in the development and pilot-testing of new technology. Based on the small sample size, the use of mobile phones with ESM seems feasible for patients with EOP, but the acceptability of using apps should be considered. Further investigation with larger samples is warranted before definitive conclusions are made.publishedVersio

Self-supervised, mobile-application based cognitive training of auditory attention: A behavioral and fMRI evaluation

Emerging evidence of the validity of collecting data in natural settings using smartphone applications has opened new possibilities for psychological assessment, treatment, and research. In this study we explored the feasibility and effectiveness of using a mobile application for self-supervised training of auditory attention. In addition, we investigated the neural underpinnings of the training procedure with functional magnetic resonance imaging (fMRI), as well as possible transfer effects to untrained cognitive interference tasks. Subjects in the training group performed the training task on an iPod touch two times a day (morning/evening) for three weeks; subjects in the control group received no training, but were tested at the same time interval as the training group. Behavioral responses were measured before and after the training period in both groups, together with measures of task-related neural activations by fMRI. The results showed an expected performance increase after training that corresponded to activation decreases in brain regions associated with selective auditory processing (left posterior temporal gyrus) and executive functions (right middle frontal gyrus), indicating more efficient processing in task-related neural networks after training. Our study suggests that cognitive training delivered via mobile applications is feasible and improves the ability to focus attention with corresponding effects on neural plasticity. Future research should focus on the clinical benefits of mobile cognitive training. Limitations of the study are discussed including reduced experimental control and lack of transfer effects

Confusions about ‘Inner’ and ‘Outer’ Voices: Conceptual Problems in the Study of Auditory Verbal Hallucinations

Both in research on Auditory Verbal Hallucinations (AVHs) and in their clinical assessment, it is common to distinguish between voices that are experienced as ‘inner’ (or ‘internal’, ‘inside the head’, ‘inside the mind’, ...) and voices that are experienced as ‘outer’ (‘external’, ‘outside the head’, ‘outside the mind’, ...). This inner/outer-contrast is treated not only as an important phenomenological variable of AVHs, it is also often seen as having diagnostic value. In this article, we argue that the distinction between ‘inner’ and ‘outer’ voices is ambiguous between different readings, and that lack of disambiguation in this regard has led to flaws in assessment tools, diagnostic debates and empirical studies. Such flaws, we argue furthermore, are often linked to misreadings of inner/outer-terminology in relevant 19th and early twentieth century work on AVHs, in particular, in connection with Kandinsky’s and Jaspers’s distinction between hallucinations and pseudo-hallucinations

Training switching focus with a mobile-application by a patient suffering from AVH, a case report

Auditory verbal hallucinations complicate many psychiatric disorders. Antipsychotic medication is effective in the majority, but a significant minority experiences high burden from resistant hallucinations. Here, we aim to improve executive control, in an attempt to decrease burden from hallucinations. We describe the use of a cognitive trainings app by a young woman with highly resistant hallucinations. With modest training, a significant decrease in the duration of hallucinations was reached. Possibilities of this training technique are discussed

Laterality across languages: Results from a global dichotic listening study using a smartphone application

Left-hemispheric language dominance has been suggested by observations in patients with brain damages as early as the 19th century, and has since been confirmed by modern behavioural and brain imaging techniques. Nevertheless, most of these studies have been conducted in small samples with predominantly Anglo-American background, thus limiting generalization and possible differences between cultural and linguistic backgrounds may be obscured. To overcome this limitation, we conducted a global dichotic listening experiment using a smartphone application for remote data collection. The results from over 4,000 participants with more than 60 different language backgrounds showed that left-hemispheric language dominance is indeed a general phenomenon. However, the degree of lateralization appears to be modulated by linguistic background. These results suggest that more emphasis should be placed on cultural/linguistic specificities of psychological phenomena and on the need to collect more diverse samples

Estradiol driven change in hallucination proneness across the menstrual cycle as studied with a white noise paradigm

The estrogen hypothesis for schizophrenia suggests neuroprotective effects of estrogen for the development of the disorder and for symptom severity, including auditory hallucinations. Furthermore, estrogen has shown enhancing effects on cognitive control, a function that is also implicated in auditory hallucinations. Whether estrogen affects the tendency to hallucinate in healthy participants, and the potential mediating role of cognitive control, has not yet been studied. Therefore, the current study aimed to test these relationships by using a white noise paradigm in combination with a N-back working memory task in which cognitive load could be manipulated. The paradigm used simulates a hallucinatory state by induction of negative emotions and drainage of cognitive resources. The simultaneous exposure to white noise elicit experiences of hearing voices (false alarms). In a between-subject design, forty-two participants were tested during the menstrual cycle in either the early follicular phase (low estradiol) or late follicular phase (high estradiol). A 2(Cycle Phase) x2(N-back task) ANOVA showed a main-effect of cycle phase on number of experienced hallucinations in the white noise task, with a significantly higher number of reported hallucinations in the early follicular phase. Furthermore, estradiol was found to predict number of hallucinations. No interaction effect of cycle phase and available cognitive resources was found. The results suggest an estradiol-related change in hallucination proneness across the menstrual cycle, but the idea that cognitive functioning mediates this relationship was not supported. Overall, the study supports protective effects of estradiol on hallucination proneness in line with the estrogen-hypothesis of schizophrenia, and that such effects are not specific to the disease

In the twilight zone: An epidemiological study of sleep-related hallucinations.

[en] BACKGROUND: Few studies have investigated hallucinations that occur at the onset/offset of sleep (called hypnagogic/hypnopompic hallucinations; HHHs), despite the fact that their prevalence in the general population is reported to be higher than the prevalence of daytime hallucinations. We utilized data from an epidemiological study to explore the prevalence of HHHs in various modalities. We also investigated phenomenological differences between sleep-related (HHHs) and daytime hallucinations in the auditory modality. We hypothesized that individuals with only HHHs would not differ from controls on a range of mental health and wellbeing measures, but that if they occur together with daytime hallucinations will pose a greater burden on the individual experiencing them. We also hypothesize that HHHs are qualitatively different (i.e. less severe) from daytime hallucinations. METHODS: This study utilized data from a cross-sectional epidemiological study on the prevalence of hallucinations in the Norwegian general population. The sample (n = 2533) was divided into a control group without hallucinations (n = 2303), a group only experiencing sleep-related hallucinations (n = 62), a group only experiencing daytime hallucinations (n = 57), and a group experiencing both sleep-related as well as daytime hallucinations (n = 111). Prevalence rates were calculated and groups were compared using analyses of variance and chi-square tests where applicable. RESULTS: The prevalence for HHHs in the auditory domain was found to be 6.8%, whereas 12.3% reported multimodal HHHs, and 32.2% indicated out-of-body experiences at the onset/offset of sleep. Group comparisons of hallucinations in the auditory modality showed that individuals that experienced only auditory HHHs scored significantly (p 20.9 > 19.1). CONCLUSIONS: Sleep-related hallucinations are common experiences in the general population, with the auditory modality being the least common. They occur mostly in combination with daytime hallucinations. However, some individuals (2.4%) experience only (auditory) sleep-related hallucinations and this group can be seen as more closely related, on a range of health-related factors, to non-hallucinating individuals than individuals who experience daytime hallucinations. Finally, there is a clear need for more research in this field, and ideas for future studies are presented

Auditive training effects from a dichotic listening app in children with dyslexia

Dichotic listening (DL) taps information on the brain's language laterality, processing, and attention. Research has shown that DL responses in dyslexia deviate from the typical pattern. Here, effects of DL training and its correspondence to rapid naming (RAN) and digit span (DS) in typical children and children with dyslexia were assessed. Three groups of third graders participated: two training groups, control training (CT) and dyslexia training (DT), and a control group that received no training (control no training, CnT). All took part in testing pretraining and posttraining. DL measures were on laterality, response scores, and attention. The three groups showed different response patterns: minor changes in CnT, change in all measures in CT, and some changes in DT. RAN and DS scores correlated significantly with some of the DL measures, especially with the attention scores. Our findings support arguments that brain architecture for language in dyslexia is lateralised in the same way as in children without dyslexia. However, the ability to modulate attention during DL is weaker in dyslexia than in typically developing children. A training‐induced normalisation of lateralisation was observed in free recall in the dyslexia group, which suggests that DL training may be a promising intervention approach

Temporal signatures of auditory verbal hallucinations : An app-based experience sampling study

Non peer reviewe