Showing papers by "Iris E. C. Sommer published in 2012"

The Characteristic Features of Auditory Verbal Hallucinations in Clinical and Nonclinical Groups: State-of-the-Art Overview and Future Directions

Abstract: Despite a growing interest in auditory verbal hallucinations (AVHs) in different clinical and nonclinical groups, the phenomenological characteristics of such experiences have not yet been reviewed and contrasted, limiting our understanding of these phenomena on multiple empirical, theoretical, and clinical levels. We look at some of the most prominent descriptive features of AVHs in schizophrenia (SZ). These are then examined in clinical conditions including substance abuse, Parkinson's disease, epilepsy, dementia, late-onset SZ, mood disorders, borderline personality disorder, hearing impairment, and dissociative disorders. The phenomenological changes linked to AVHs in prepsychotic stages are also outlined, together with a review of AVHs in healthy persons. A discussion of key issues and future research directions concludes the review.

Self-recognition Deficits in Schizophrenia Patients With Auditory Hallucinations: A Meta-analysis of the Literature

Abstract: Theories about auditory hallucinations in schizophrenia suggest that these experiences occur because patients fail to recognize thoughts and mental events as self-generated. Different theoretical models have been proposed about the cognitive mechanisms underlying auditory hallucinations. Regardless of the cognitive model being tested, however, experimental designs are almost identical in that they require a judgment regarding whether an action was self-originated or not. The aim of the current study was to integrate all available literature for a meta-analysis on this topic and reach conclusions about self-recognition performance in (1) patients with schizophrenia compared with healthy controls and (2) patients with auditory hallucinations compared with patients without these symptoms. A comprehensive literature review identified 23 studies that contrasted the performance of schizophrenia patients with healthy controls (1370 participants) and 9 studies that directly compared patients with and without auditory hallucinations (315 participants). We found significantly reduced self-recognition performance in schizophrenia patients, which was morepronounced in patients with auditory hallucinations compared with patients without. In patients with hallucinations, this pattern of performance was specific to self-recognition processes and not to the recognition of new external information. A striking finding was the homogeneity in results across studies regardless of the action modality, timing delay, and design used to measure self-recognition. In summary, this review of studies from the last 30 years substantiates the view that self-recognition is impaired in patients with schizophrenia and particularly those with auditory hallucinations. This suggests an association, perhaps a causal one, between such deficit and hallucinatory experiences in schizophrenia.

Nonsteroidal anti-inflammatory drugs in schizophrenia: ready for practice or a good start? A meta-analysis.

Abstract: OBJECTIVE: Mounting evidence suggests that inflammation is involved in the pathogenesis of schizophrenia. This evidence implies that anti-inflammatory agents are potentially useful therapeutic strategies in schizophrenia. This article quantitatively summarizes the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) to augment antipsychotic treatment to reduce schizophrenia symptom severity. DATA SOURCES: An electronic search was performed using MEDLINE, Embase, the National Institutes of Health Web site clinicaltrials.gov, Cochrane Schizophrenia Group entries in PsiTri, and the Cochrane Database of Systematic Reviews. The following basic search terms were used: schizophrenia, nonsteroidal anti-inflammatory drug, and NSAID together with the name of each specific NSAID (ibuprofen, diclofenac, naproxen sodium, and acetylsalicylic acid). We applied no year or language restrictions. STUDY SELECTION: Studies were selected if they met the following inclusion criteria: (1) randomized, double-blind, placebo-controlled trials regarding augmentation of antipsychotic medication with an NSAID, (2) patients included had a diagnosis of a schizophrenia spectrum disorder according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, and (3) studies reported sufficient information to compute common effect size statistics, or corresponding authors could supply these data upon request. DATA EXTRACTION: The primary outcome measure was the mean change in total score on the Positive and Negative Syndrome Scale (PANSS). Secondary outcome measures included positive and negative symptom subscores of the PANSS. RESULTS: We could include 5 double-blind, randomized, placebo-controlled trials, reporting on 264 patients. Four studies applied celecoxib, and 1 used acetylsalicylic acid. We found a mean effect size of 0.43, which was significant at P =.02 in favor of NSAIDs on total symptom severity. For positive symptom severity, the mean standardized difference was 0.34 (P =.02). For severity of negative symptoms the mean standardized difference was 0.26 (P =.03). CONCLUSIONS: These results suggest that NSAID augmentation could be a potentially useful strategy to reduce symptom severity in schizophrenia. As these are the first studies on a relatively new strategy and the included sample size is modest, these results should be interpreted with caution. However, augmentation with acetylsalicylic acid may have the additional benefit of reducing cardiac and cancer mortality in schizophrenia. We therefore believe that application of NSAIDs in schizophrenia deserves further investigation as augmentation of antipsychotic treatment and reducing comorbid somatic diseases.

The Treatment of Hallucinations in Schizophrenia Spectrum Disorders

Abstract: This article reviews the treatment of hallucinations in schizophrenia. The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2–4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. Blood levels should be above 350–450 μg/ml for maximal effect. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication. The success of CBT depends on the reduction of catastrophic appraisals, thereby reducing the concurrent anxiety and distress. CBT aims at reducing the emotional distress associated with auditory hallucinations and develops new coping strategies. Transcranial magnetic stimulation (TMS) is capable of reducing the frequency and severity of auditory hallucinations. Several meta-analyses found significantly better symptom reduction for low-frequency repetitive TMS as compared with placebo. Consequently, TMS currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated.

Pharmacological Augmentation Strategies for Schizophrenia Patients With Insufficient Response to Clozapine: A Quantitative Literature Review

Abstract: Background. When schizophrenia patients have insufficient response to clozapine, pharmacological augmentation is often applied. This meta-analysis summarizes available evidence on efficacy of pharmacological augmentation of clozapine treatment in schizophrenia spectrum disorder. Methods. Only double-blind randomized controlled studies were included. Primary outcome measure was total symptom severity, and secondary outcome measures were subscores for positive and negative symptoms. Effect sizes were calculated from individual studies and combined to standardized mean differences (Hedges's g). Results. Twenty-nine studies reporting on 15 different augmentations were included. Significant better efficacy than placebo on total symptom severity was observed for lamotrigine, citalopram, sulpiride, and CX516 (a glutamatergic agonist). The positive effect of lamotrigine disappeared after outlier removal. The other positive findings were based on single studies. Significantly better efficacy on positive symptom severity was observed for topiramate and sulpiride. The effect of topiramate disappeared after outlier removal. Results for sulpiride were based on a single randomized controlled trial. Citalopram, sulpiride, and CX516 showed better efficacy for negative symptoms than placebo, all based on single studies. Conclusions. Evidence for efficacy of clozapine augmentation is currently scarce. Efficacy of lamotrigine and topiramate were both dependent on single studies with deviating findings. The effect of citalopram, sulpiride, and CX516 were based on single studies. Thus, despite their popularity, pharmacological augmentations of clozapine are not (yet) demonstrated to be superior to placebo.

Childhood trauma and auditory verbal hallucinations

Abstract: BackgroundHallucinations have consistently been associated with traumatic experiences during childhood. This association appears strongest between physical and sexual abuse and auditory verbal hallucinations (AVH). It remains unclear whether traumatic experiences mainly colour the content of AVH or whether childhood trauma triggers the vulnerability to experience hallucinations in general. In order to investigate the association between hallucinations, childhood trauma and the emotional content of hallucinations, experienced trauma and phenomenology of AVH were investigated in non-psychotic individuals and in patients with a psychotic disorder who hear voices.MethodA total of 127 non-psychotic individuals with frequent AVH, 124 healthy controls and 100 psychotic patients with AVH were assessed for childhood trauma. Prevalence of childhood trauma was compared between groups and the relation between characteristics of voices, especially emotional valence of content, and childhood trauma was investigated.ResultsBoth non-psychotic individuals with AVH and patients with a psychotic disorder and AVH experienced more sexual and emotional abuse compared with the healthy controls. No difference in the prevalence of traumatic experiences could be observed between the two groups experiencing AVH. In addition, no type of childhood trauma could distinguish between positive or negative emotional valence of the voices and associated distress. No correlations were found between sexual abuse and emotional abuse and other AVH characteristics.ConclusionsThese results suggest that sexual and emotional trauma during childhood render a person more vulnerable to experience AVH in general, which can be either positive voices without associated distress or negative voices as part of a psychotic disorder.

Auditory verbal hallucinations in patients with borderline personality disorder are similar to those in schizophrenia.

Abstract: Background. Auditory verbal hallucinations (AVH) in patients with borderline personality disorder (BPD) are frequently claimed to be brief, less severe and qualitatively different from those in schizophrenia, hence the term 'pseudohallucinations'. AVH in BPD may be more similar to those experienced by healthy individuals, who experience AVH in a lower frequency and with a more positive content than AVH in schizophrenia. In this study the phenomenology of AVH in BPD patients was compared to that in schizophrenia and to AVH experienced by non-patients. Method. In a cross-sectional setting, the phenomenological characteristics of AVH in 38 BPD patients were compared to those in 51 patients with schizophrenia/schizoaffective disorder and to AVH of 66 non-patients, using the Psychotic Symptom Rating Scales (PSYRATS). Results. BPD patients experienced AVH for a mean duration of 18 years, with a mean frequency of at least daily lasting several minutes or more. The ensuing distress was high. No differences in the phenomenological characteristics of AVH were revealed among patients diagnosed with BPD and those with schizophrenia/schizoaffective disorder, except for 'disruption of life', which was higher in the latter group. Compared to non-patients experiencing AVH, BPD patients had higher scores on almost all items. Conclusions. AVH in BPD patients are phenomenologically similar to those in schizophrenia, and different from those in healthy individuals. As AVH in patients with BPD fulfil the criteria of hallucinations proper, we prefer the term AVH over 'pseudohallucinations', so as to prevent trivialization and to promote adequate diagnosis and treatment.

Auditory Hallucinations Elicit Similar Brain Activation in Psychotic and Nonpsychotic Individuals

Abstract: While auditory verbal hallucinations (AVH) are most characteristic for schizophrenia, they also occur in nonpsychotic individuals in the absence of a psychiatric or neurological disorder and in the absence of substance abuse. At present, it is unclear if AVH in these nonpsychotic individuals constitute the same phenomenon as AVH in psychotic patients. Comparing brain activation during AVH between nonpsychotic and psychotic individuals could provide important clues regarding this question. 21 nonpsychotic subjects with AVH and 21 matched psychotic patients indicated the presence of AVH during 3T functional magnetic resonance imaging (fMRI) scanning. To identify common areas of activation during the experience of AVH in both groups, a conjunction analysis was performed. In addition, a 2-sample t-test was employed to discover possible differences in AVH-related activation between the groups. Several common areas of activation were observed for the psychotic and nonpsychotic subjects during the experience of AVH, consisting of the bilateral inferior frontal gyri, insula, superior temporal gyri, supramarginal gyri and postcentral gyri, left precentral gyrus, inferior parietal lobule, superior temporal pole, and right cerebellum. No significant differences in AVH-related brain activation were present between the groups. The presence of multiple common areas of AVH-related activation in psychotic and nonpsychotic individuals, in the absence of significant differences, implicates the involvement of the same cortical network in the experience of AVH in both groups.

Resting state functional connectivity in patients with chronic hallucinations.

Abstract: Auditory verbal hallucinations (AVH) are not only among the most common but also one of the most distressing symptoms of schizophrenia. Despite elaborate research, the underlying brain mechanisms are as yet elusive. Functional MRI studies have associated the experience of AVH with activation of bilateral language-related areas, in particular the right inferior frontal gyrus (rIFG) and the left superior temporal gyrus (lSTG). While these findings helped to understand the neural underpinnings of hearing voices, they provide little information about possible brain mechanisms that predispose a person to experience AVH, i.e. the traits to hallucinate. In this study, we compared resting state connectivity between 49 psychotic patients with chronic AVH and 49 matched controls using the rIFG and the lSTG as seed regions, to identify functional brain systems underlying the predisposition to hallucinate. The right parahippocampal gyrus showed increased connectivity with the rIFG in patients as compared to controls. Reduced connectivity with the rIFG in patients was found for the right dorsolateral prefrontal cortex. Reduced connectivity with the lSTG in patients was identified in the left frontal operculum as well as the parietal opercular area. Connectivity between the lSTG and the left hippocampus was also reduced in patients and showed a negative correlation with the severity of hallucinations. Concluding, we found aberrant connectivity between the seed regions and medial temporal lobe structures which have a prominent role in memory retrieval. Moreover, we found decreased connectivity between language-related areas, indicating aberrant integration in this system potentially including corollary discharge mechanisms.

Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: a randomized controlled trial.

Abstract: Objectives. This study investigates whether depression can be ameliorated by weakening the associations between auditory verbal hallucinations and easily activated networks with negative self-evaluations, by strengthening the access to competing memories of positive self-esteem. Design. A randomized controlled clinical trial comparing competitive memory training (COMET) with treatment as usual (TAU) in schizophrenia patients with persistent auditory hallucinations. Methods. Patients with schizophrenia-spectrum disorders were randomized into COMET (n = 39) versus TAU (n = 38). COMET consisted of seven sessions with four stages: (1) identification of aspects of negative self-esteem reinforced by the voice; (2) retrieval and re-living of memories associated with positive self-esteem; (3) positive self-esteem is brought in to compete with the content of the voices to weaken the association between voice content and negative self-evaluation; and (4) learning to disengage from the voices and to accept the voices as psychic phenomena. Results. Compared to TAU the COMET group improved on depression but there were no significant effects on auditory hallucinations. The effect of COMET on depression was fully mediated by self-esteem and acceptance of voices, and partially mediated by social rank and attributed power to the voices. Conclusions. COMET can be helpful in reappraising the meaning and changing the emotional impact of auditory hallucinations. These findings are consistent with the results of comparable COMET protocols applied in other psychiatric diagnoses. The technique can be used within regular cognitive behavioural therapy.

Auditory Verbal Hallucinations

Abstract: Auditory verbal hallucinations (AVH) have been described in a broad range of individuals, ranging from patients with a neurological or psychiatric disorder to hearing-disabled and healthy individuals. Although multiple studies have been conducted – and numerous theories have been proposed to account for their origins – at present, the pathophysiology of AVH remains largely unknown. As they represent a highly variegated group of phenomena, various studies have sought to classify them and to compare their characteristics in different groups. Those studies might aid in elucidating the neural basis of AVH, as phenomenologically different types of AVH are believed to result from different neurobiological mechanisms.

Neuroimaging of Voice Hearing in Non-Psychotic Individuals: A Mini Review

Abstract: Auditory verbal hallucinations (AVH) or “voices” are a characteristic symptom of schizophrenia, but can also be observed in healthy individuals in the general population. As these non-psychotic individuals experience AVH in the absence of other psychiatric symptoms and medication-use they provide an excellent model to study AVH in isolation. Indeed a number of studies used this approach and investigated brain structure and function in non-psychotic individuals with AVH. These studies showed that increased sensitivity of auditory areas to auditory stimulation and aberrant connectivity of language production and perception areas is associated with AVH. This is in concordance with investigations that observed prominent activation of these areas during the state of AVH. Moreover, while effortful attention appears not to be related to AVH, individuals prone to hallucinate seem to have an enhanced attention bias to auditory stimuli which may stem from aberrant activation of the anterior cingulated regions. Furthermore, it was observed that decreased cerebral dominance for language and dopamine dysfunction, which are consistently found in schizophrenia, are most likely not specifically related to AVH as these abnormalities were absent in healthy voice hearers. Finally, specific aspects of AVH such as voluntary control may be related to the timing of the supplementary motor area and language areas in the experience of AVH.

Oscillatory Cortical Network Involved in Auditory Verbal Hallucinations in Schizophrenia

Abstract: Background: Auditory verbal hallucinations (AVH), a prominent symptom of schizophrenia, are often highly distressing for patients. Better understanding of the pathogenesis of hallucinations could increase therapeutic options. Magnetoencephalography (MEG) provides direct measures of neuronal activity and has an excellent temporal resolution, offering a unique opportunity to study AVH pathophysiology. Methods: Twelve patients (10 paranoid schizophrenia, 2 psychosis not otherwise specified) indicated the presence of AVH by button-press while lying in a MEG scanner. As a control condition, patients performed a self-paced button-press task. AVH-state and non-AVH state were contrasted in a region-of-interest (ROI) approach. In addition, the two seconds before AVH onset were contrasted with the two seconds after AVH onset to elucidate a possible triggering mechanism. Results: AVH correlated with a decrease in beta-band power in the left temporal cortex. A decrease in alpha-band power was observed in the right inferior frontal gyrus. AVH onset was related to a decrease in theta-band power in the right hippocampus. Conclusions: These results suggest that AVH are triggered by a short aberration in the theta band in a memory-related structure, followed by activity in language areas accompanying the experience of AVH itself.

Comparison of auditory hallucinations across different disorders and syndromes

Abstract: Auditory hallucinations can be experienced in the context of many different disorders and syndromes. The differential diagnosis basically rests on the presence or absence of accompanying symptoms. In terms of clinical relevance, the most important distinction to be made is between auditory hallucinations occurring in the context of psychotic disorders and those that are due to a somatic disorder. Auditory hallucinations are also quite common in otherwise healthy individuals and are therefore not necessarily disease-related. As auditory hallucinations are often accompanied by hallucinations in other modalities, pinpointing the modality in which hallucinations are experienced most frequently may provide a first – albeit coarse – indication of whether the auditory hallucinations are part of a neurological disorder (mainly visual), a psychiatric disorder (mainly auditory), an ear disorder (mainly auditory) or whether they occur in the absence of any disorder (mainly auditory). Epilepsy is the most important exception to this coarse differentiation. Another traditional distinction between hallucinations occurring in the context of neurological and psychiatric disorders is that the former are assumed to start at an advanced age, whereas hallucinations in the context of psychiatric disorders typically begin in late adolescence or early adulthood. Although there are many exceptions to this rule of thumb – as in psychotic depression, late-onset schizophrenia and epilepsy – age of onset can still be a valuable clinical indicator. The content of auditory hallucinations is notoriously unreliable for differential diagnosis and the safest way to an accurate diagnosis rests with the detection of psychiatric and somatic comorbid symptoms.

Hallucinations of Bodily Sensation

Abstract: The umbrella term “bodily hallucination” refers to a group of widely divergent and only rudimentarily understood corporeal sensations, such as tactile hallucinations, somatic hallucinations, sexual hallucinations, the coenesthesiopathies, proprioceptive hallucinations, kinesthetic hallucinations, vestibular hallucinations, hallucinated pain, and thermal hallucinations. This chapter provides a classification of those various phenomena and highlights what is known about their neurobiological underpinnings. In clinical practice, it may be helpful to let the diagnosis of bodily hallucination depend on the co-occurrence of a delusional explanation by the patient, but even this procedure is not airtight. Future studies seeking to enhance our understanding of these phenomena will have to address – as always, in biomedicine – neurobiological as well as conceptual issues.

Classical Somatic Treatments: Pharmacotherapy and ECT

Abstract: The treatment of hallucinations rests basically on psychoeducation, psychosocial interventions, psychotherapy, medication, and a number of additional somatic therapies. The present chapter will focus on medication and electroconvulsive treatment (ECT), whereas other types of treatment will be discussed elsewhere in this book. We will offer recommendations for the pharmacological and electroconvulsive treatment of hallucinations in psychotic disorders, Parkinson’s disease, dementia, delirium, epilepsy, and sensory impairment, although the main focus will be on psychosis.