Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research.

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Auditory verbal hallucinations in persons with and without a need for care

Results. Compared to both healthy and non-hallucinating clinical controls, hallucinating patients reported both significantly higher dissociative tendencies and childhood sexual abuse. Dissociation positively mediated the effect of childhood trauma on hallucination-proneness. This mediational role was particularly robust for sexual abuse over other types of trauma. Signal detection abnormalities were evident in hallucinating patients and patients with a history of hallucinations, but were not associated with pathological dissociative symptoms. Conclusions. These results are consistent with dissociative accounts of the trauma-hallucinations link. Dissociation, however, does not affect reality discrimination. Future research should examine whether other cognitive processes associated with both dissociative states and hallucinations (e.g. deficits in cognitive inhibition) may explain the relationship between dissociation and hallucinatory experiences. Received 16 February 2011 ; Revised 1 July 2011 ; Accepted 13 August 2011 ; First published online 6 September 2011

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Dissociation mediates the relationship between childhood trauma and hallucination-proneness.

Voice hearing (VH) is often regarded as pathognomic for schizophrenia. The purpose of this article is to review and integrate historical, clinical, epidemiological, and phenomenological evidence in order to suggest that VH may be more appropriately understood as a dissociative rather than a psychotic phenomenon. First, we discuss the lifetime prevalence of VH in the general population, which is estimated to range between 1% and 16% for adult nonclinical populations and 2% and 41% in healthy adolescent samples. Second, we demonstrate how the ubiquity of VH phenomenology, including variables like voice location, content, and frequency, limits its diagnostic and prognostic utility for differentiating psychotic from trauma-spectrum and nonclinical populations. Finally, we report on the empirical associations between VH, measures of dissociation, and trauma particularly (though not exclusively) childhood sexual abuse. There are 2 main conclusions from this review. First, we argue that available evidence suggests that VH experiences, including those in the context of psychotic disorders, can be most appropriately understood as dissociated or disowned components of the self (or self-other relationships) that result from trauma, loss, or other interpersonal stressors. Second, we provide a rationale for clinicians to use psychotherapeutic methods for integrating life events as precipitating and/or maintaining factors for distressing voices. Potential mechanisms for the relationship between trauma, dissociation, VH, and clinical diagnosis are described, including the relevance of literature from the field of attachment in providing a diathesis for dissociation. Suggestions for future research are also discussed.

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Dissociation, Trauma, and the Role of Lived Experience: Toward a New Conceptualization of Voice Hearing.

PAUL CHADWICK, MAX BIRCHWOOD, AND PETER TROWER: Cognitive Therapy for Delusions, Voices and Paranoia. John Wiley & Sons, Chichester, England, 1996, 210 pp., $55.00, ISBN 0-471-93888-2. It may seem anachronistic now, but there was a time when clinicians took seriously the psychotherapeutic treatment of schizophrenics and other psychotic patients. There used to be genuine optimism, at influential institutions such as Austin Riggs, that intensive psychoanalytic psychotherapy would be successful in alleviating psychotic symptomatology. With the remarkable efficacy of pharmacological treatments, clinicians currently pay little attention to the patient's internal psychological make-up, other than to use rehabilitation or psychoeducational approaches that represent efforts to help the patient accommodate to disturbing residual symptoms and functional deficits. In their new volume, Chadwick, Birchwood, and Trower challenge this pervasive skepticism, and take the psychotherapy of psychosis quite seriously. They claim that delusions, auditory hallucinations, and paranoia are amenable to relatively brief (20-30 sessions) psychotherapeutic interventions. Psychotherapy works, as they see it, because psychotic symptoms are merely exaggerations of normal psychological phenomena. Symptoms are not discontinuous with normal experience; rather, they are manifestations of basic cognitive mechanisms, regarding how people interpret and make inferences and attributions about events. As such, psychotic experiences will respond to cognitive therapy interventions. Although cognitive therapists have traditionally found psychotic patients to be untreatable, the authors label their approach "cognitive therapy," and scrupulously examine the beliefs and evaluations underlying psychotic experiences, engaging floridly paranoid individuals in ongoing psychotherapy. Using an ABC framework, they conceptualize all experiences and interactions in terms of Activating events, Beliefs, and emotional (or behavioral) Consequences. Delusions and paranoid thinking reflect beliefs about certain events and experiences, once those events are placed within an appropriate context. Even perceptual distortions, such as voices, are considered activating events, with associated beliefs and evaluations. As Chadwick et al. view it, these beliefs are the source of problems, not the psychotic experiences per se, and these beliefs may be changed. They will not directly confront a delusions, but they will subtly call it a belief (as opposed to a fact), challenge inconsistencies within the delusional logic, and ask about reactions to hypothetical contradictions. All these strategies are attempts to access the patient's self-evaluations. These three British psychologists ground their therapy in general social psychological theory, which may not be familiar to nonpsychologists. For example, they discuss self-other attributions, but make no mention of the concept of "projection." They speak of other-self or self-self evaluations in ways that are quite similar to object relations theorists, and yet there is no reference to this way of thinking. Considering the long tradition of conceptualizing psychosis in terms of lack of ego boundaries, it would have been useful to discuss the notion of paranoid delusions as a defense against fear of merger. …

Cognitive Therapy for Delusions, Voices and Paranoia

Over the years, the prevalence of auditory verbal hallucinations (AVHs) have been documented across the lifespan in varied contexts, and with a range of potential long-term outcomes. Initially the emphasis focused on whether AVHs conferred risk for psychosis. However, recent research has identified significant differences in the presentation and outcomes of AVH in patients compared to those in non-clinical populations. For this reason, it has been suggested that auditory hallucinations are an entity by themselves and not necessarily indicative of transition along the psychosis continuum. This review will examine the presentation of auditory hallucinations across the life span, as well as in various clinical groups. The stages described include childhood, adolescence, adult non-clinical populations, hypnagogic/hypnopompic experiences, high schizotypal traits, schizophrenia, substance induced AVH, AVH in epilepsy, and AVH in the elderly. In children, need for care depends upon whether the child associates the voice with negative beliefs, appraisals and other symptoms of psychosis. This theme appears to carry right through to healthy voice hearers in adulthood, in which a negative impact of the voice usually only exists if the individual has negative experiences as a result of their voice(s). This includes features of the voices such as the negative content, frequency, and emotional valence as well as anxiety and depression, independently or caused by voices presence. It seems possible that the mechanisms which maintain AVH in non-clinical populations are different from those which are behind AVH presentations in psychotic illness. For example, the existence of maladaptive coping strategies in patient populations is one significant difference between clinical and non-clinical groups which is associated with a need for care. Whether or not these mechanisms start out the same and have differential trajectories is not yet evidenced. Future research needs to focus on the comparison of underlying factors and mechanisms that lead to the onset of AVH in both patient and non-clinical populations.

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A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals

Many people hear voices but do not access psychiatric services and theirexperiences are largely unknown, not least because of the difﬁculty in contacting such people.This study investigates the beliefs held about voices, distress experienced, and provides atopographical account of the experience of hearing voices in a sample of individuals whohear voices in a non-psychiatric population.

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Catherine Lawrence

Papers

Hearing voices in a non-psychiatric population.