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

What predicts stigmatisation about schizophrenia? Results from a general population survey examining its underlying cognitive, affective and behavioural factors

peer reviewedStigmatisation towards individuals diagnosed with schizophrenia (SZ individuals) remains an important problem, yet few studies to date have examined a theoretically comprehensive set of predictors of stigmatisation. This study aimed to evaluate cognitive, emotional and behavioural aspects of stigmatisation towards SZ individuals in the Belgian general population in order to better understand its underlying factors. A sample of 544 participants completed online questionnaires assessing common stereotypes regarding schizophrenia, desired social distance, level of contact and the Behaviours from Intergroup Affect and Stereotypes map. Most respondents believed SZ individuals are unpredictable and have a poor prognosis. Around 10% believed that they are dangerous. The most frequently reported emotions were pity and fear. Around 65% of the sample indicated that they would have positive behavioural reactions (passive/active facilitation). Around 33% of the sample indicated that they would distance themselves from SZ individuals, and around 20% would flee if in contact with a SZ individual. Fear and stereotypes of dangerousness and incompetence best predicted these fleeing and avoidance reactions. Fear was also explained by stereotypes of dangerousness and unpredictability. These factors should be accounted for when developing anti-stigma campaigns. The effect of contact should be further investigated

Relations between a computerized shopping task and cognitive tests in a group of persons diagnosed with schizophrenia compared with healthy controls

Cognitive deficits are clearly associated with poor everyday life functioning in persons diagnosed with schizophrenia. However, previous studies have primarily used questionnaires to assess everyday life functioning. We developed a computerized real-life activity task (shopping task), where participants are required to shop for a list of seven grocery store items. Thirty individuals diagnosed with schizophrenia and 30 healthy controls were administered an extensive battery of cognitive tests and the computerized shopping task. Performances on the computerized shopping task significantly differentiated patients and healthy controls for several variables. Moreover, performance on the shopping task was significantly correlated with verbal episodic memory, cognitive flexibility, planning, processing speed, and inhibition. Finally, performance on the computerized shopping task was significantly correlated with various clinical variables and with a global measure of social functioning. These findings suggest that the computerized task used in the present study provides an indication of the level of everyday life functioning and cognitive functioning of persons diagnosed with schizophrenia, and, therefore, may be viewed as a valuable instrument in both an evaluation and remediation context. (JINS, 2010, 16, 180-189.

Performance on an Everyday Life Activity in Persons Diagnosed with Alcohol Dependency Compared to Healthy Controls: Relations between a Computerized Shopping Task and Cognitive and Clinical Variables†

Aim: Persons diagnosed with alcohol dependency often suffer from cognitive impairments. Little is known, however, concerning how these cognitive deficits impact complex, everyday life activities. We set out to better characterize the nature of everyday life difficulties in patients with alcohol dependency using a computerized shopping task. Methods: A computerized real-life activity task (shopping task) required participants to shop for a list of eight grocery store items. Twenty individuals diagnosed with alcohol dependency and 20 healthy controls were administered a battery of cognitive tests, clinical scales and the shopping task. Results: Performance on the shopping task significantly differentiated patients and healthy controls for several variables and, in particular, for total time. Total time to complete the task correlated significantly with poor performance on measures of processing speed, verbal episodic memory, cognitive flexibility and inhibition. Total time was significantly correlated with poorer everyday life functioning and longer duration of illness. Conclusion: This computerized task is a good proxy measure of the level of everyday life and cognitive functioning of persons diagnosed with alcohol dependenc

Hallucinations Under Psychedelics and in the Schizophrenia Spectrum: An Interdisciplinary and Multiscale Comparison

The recent renaissance of psychedelic science has reignited interest in the similarity of drug-induced experiences to those more commonly observed in psychiatric contexts such as the schizophrenia-spectrum. This report from a multidisciplinary working group of the International Consortium on Hallucinations Research (ICHR) addresses this issue, putting special emphasis on hallucinatory experiences. We review evidence collected at different scales of understanding, from pharmacology to brain-imaging, phenomenology and anthropology, highlighting similarities and differences between hallucinations under psychedelics and in the schizophrenia-spectrum disorders. Finally, we attempt to integrate these findings using computational approaches and conclude with recommendations for future research

Correlates of hallucinatory experiences in the general population: an international multi-site replication study

Hallucinatory experiences can occur in both clinical and nonclinical groups. However, in previous studies of the general population, investigations of the cognitive mechanisms underlying hallucinatory experiences have yielded inconsistent results. We ran a large-scale preregistered multisite study, in which general-population participants (N = 1,394 across 11 data-collection sites and online) completed assessments of hallucinatory experiences, a measure of adverse childhood experiences, and four tasks: source memory, dichotic listening, backward digit span, and auditory signal detection. We found that hallucinatory experiences were associated with a higher false-alarm rate on the signal detection task and a greater number of reported adverse childhood experiences but not with any of the other cognitive measures employed. These findings are an important step in improving reproducibility in hallucinations research and suggest that the replicability of some findings regarding cognition in clinical samples needs to be investigated

Item-specific overlap between hallucinatory experiences and cognition in the general population: A three-step multivariate analysis of international multi-site data

Hallucinatory experiences (HEs) can be pronounced in psychosis, but similar experiences also occur in nonclinical populations. Cognitive mechanisms hypothesized to underpin HEs include dysfunctional source monitoring, heightened signal detection, and impaired attentional processes. Using data from an international multisite study on non-clinical participants (N = 419), we described the overlap between two sets of variables - one measuring cognition and the other HEs - at the level of individual items. We used a three-step method to extract and examine item-specific signal, which is typically obscured when summary scores are analyzed using traditional methodologies. The three-step method involved: (1) constraining variance in cognition variables to that which is predictable from HE variables, followed by dimension reduction, (2) determining reliable HE items using split-halves and permutation tests, and (3) selecting cognition items for interpretation using a leave-one-out procedure followed by repetition of Steps 1 and 2. The results showed that the overlap between HEs and cognition variables can be conceptualized as bi-dimensional, with two distinct mechanisms emerging as candidates for separate pathways to the development of HEs: HEs involving perceptual distortions on one hand (including voices), underpinned by a low threshold for signal detection in cognition, and HEs involving sensory overload on the other hand, underpinned by reduced laterality in cognition. We propose that these two dimensions of HEs involving distortions/liberal signal detection, and sensation overload/reduced laterality may map onto psychosis-spectrum and dissociation-spectrum anomalous experiences, respectively

Visual hallucinations in the psychosis spectrum and comparative information from neurodegenerative disorders and eye disease

Much of the research on visual hallucinations (VHs) has been conducted in the context of eye disease and neurodegenerative conditions, but little is known about these phenomena in psychiatric and nonclinical populations. The purpose of this article is to bring together current knowledge regarding VHs in the psychosis phenotype and contrast this data with the literature drawn from neurodegenerative disorders and eye disease. The evidence challenges the traditional views that VHs are atypical or uncommon in psychosis. The weighted mean for VHs is 27% in schizophrenia, 15% in affective psychosis, and 7.3% in the general community. VHs are linked to a more severe psychopathological profile and less favorable outcome in psychosis and neurodegenerative conditions. VHs typically co-occur with auditory hallucinations, suggesting a common etiological cause. VHs in psychosis are also remarkably complex, negative in content, and are interpreted to have personal relevance. The cognitive mechanisms of VHs in psychosis have rarely been investigated, but existing studies point to source-monitoring deficits and distortions in top-down mechanisms, although evidence for visual processing deficits, which feature strongly in the organic literature, is lacking. Brain imaging studies point to the activation of visual cortex during hallucinations on a background of structural and connectivity changes within wider brain networks. The relationship between VHs in psychosis, eye disease, and neurodegeneration remains unclear, although the pattern of similarities and differences described in this review suggests that comparative studies may have potentially important clinical and theoretical implications. © 2014 The Author

Culture and Hallucinations: Overview and Future Directions

A number of studies have explored hallucinations as complex experiences involving interactions between psychological, biological, and environmental factors and mechanisms. Nevertheless, relatively little attention has focused on the role of culture in shaping hallucinations. This article reviews the published research, drawing on the expertise of both anthropologists and psychologists. We argue that the extant body of work suggests that culture does indeed have a significant impact on the experience, understanding, and labeling of hallucinations and that there may be important theoretical and clinical consequences of that observation. We find that culture can affect what is identified as a hallucination, that there are different patterns of hallucination among the clinical and nonclinical populations, that hallucinations are often culturally meaningful, that hallucinations occur at different rates in different settings; that culture affects the meaning and characteristics of hallucinations associated with psychosis, and that the cultural variations of psychotic hallucinations may have implications for the clinical outcome of those who struggle with psychosis. We conclude that a clinician should never assume that the mere report of what seems to be a hallucination is necessarily a symptom of pathology and that the patient’s cultural background needs to be taken into account when assessing and treating hallucinations