Characteristics Of Auditory Verbal Hallucinations Research Articles

Intersections of phenomenology, voice beliefs and distress in bipolar disorder: a comparison with schizophrenia.

Auditory verbal hallucinations (AVH), or voice-hearing, can be a prominent symptom during fluctuating mood states in bipolar disorder (BD). The current study aimed to: (i) compare AVH-related distress in BD relative to schizophrenia (SCZ), (ii) examine correlations between phenomenology and voice beliefs across each group, and (iii) explore how voice beliefs may uniquely contribute to distress in BD and SCZ. Participants were recruited from two international sites in Australia (BD=31; SCZ=50) and the UK (BD=17). Basic demographic-clinical information was collected, and mood symptoms were assessed. To document AVH characteristics, a 4-factor model of the Psychotic Symptoms Rating Scale and the Beliefs about Voices Questionnaire-Revised were used. Statistical analyses consisted of group-wise comparisons, Pearson's correlations and multiple hierarchical regressions. It was found that AVH-related distress was not significantly higher in BD than SCZ, but those with BD made significantly more internal attributions for their voices. In the BD group, AVH-related distress was significantly positively correlated with malevolence, omnipotence and resistance, However, only resistance, alongside mania and depressive symptoms, significantly contributed to AVH-related distress in BD. Our findings have several clinical implications, including identification of voice resistance as a potential therapeutic target to prioritise in BD. Factoring in the influence of mood symptoms on AVH-related distress as well as adopting more acceptance-oriented therapies may also be of benefit.

HALLUCINATION IN PATIENTS WITH BORDERLINE PERSONALITY DISORDER

In modern practice, hallucinations found in patients with borderline personality disorder (BPD) are often identified as ‘pseudohallucinations’ to state the suspicion that they do not qualify as true hallucinations. In the interest of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for BPD, it is stated that during times of tremendous stress, transient ideation of paranoid or dissociative symptoms may occur. BPD is defined as a mental health disorder with remarkable impulsivity, instability of mood and interpersonal relationships, along with suicidal behavior that can complicate medical treatment. It is crucial to identify this diagnosis to plan for further treatment. The existence and severity of hallucinations in BPD patients are closely related to posttraumatic stress disorder (PTSD), prior childhood adversities, as well as current adult life stressor. Auditory verbal hallucinations (AVH) were reported to be the most commonly observed types of hallucinations in patients with BPD. Similarities of the AVH characteristics between BPD patients and those with schizophrenia make it hard to diagnose and manage the hallucinations in BPD patients. Pharmacological management including both typical and atypical antipsychotic drugs may be beneficial in order to treat hallucinations in these patients, however, low-dose antipsychotics are preferred due to its adverse reaction. Psychotherapy such as cognitive behavior therapy (CBT) and non-invasive brain stimulation techniques may be helpful as well. Questioning patient’s psychotic symptoms in an untrue or “made-up” form is rarely advantageous and may leads to undesired therapeutic alliance dismissal. Keywords: hallucination, borderline personality disorder, depression.

On the phenomenology of auditory verbal hallucinations in affective and non-affective psychosis

Phenomenological comparisons of auditory verbal hallucinations (AVHs) in affective versus non-affective psychosis have not been adequately documented. The current study aimed to: a) comprehensively describe AVH phenomenology by diagnosis and mood state, b) investigate significant predictors of voice-related distress and functional impairment, and c) conduct qualitative thematic analysis of participants’ experiences. Participants were diagnosed with: a) bipolar disorder (n = 31), b) major depressive disorder (n = 34), c) schizophrenia (n = 50), or d) schizoaffective disorder (n = 26). Current voice-hearers were also subdivided into prevailing mood states: a) euthymic (n = 23), b) depressed (n = 51), or c) mania-mixed (n = 12). An in-depth, semi-structured interview was conducted, accompanied by mixed-methods analyses. Of the 34 AVH characteristics, significant group differences across diagnoses were identified only for frequency, number of voices, form of address, perceived location, level of conviction, beliefs regarding origin, and functional interference. Random forests modelling (RFM) showed experienced distress and functional interference were best predicted by discrete AVH variables. Qualitative thematic analysis revealed first-order themes: a) content, b) form, c) function, and d) non-voice. There were more similarities than differences in the phenomenology of AVHs across diagnoses, yet significant predictors of voice-related distress and functional impairment differed across affective and non-affective psychosis. This has important nosological and therapeutic applications.

Global functional connectivity density alterations in patients with bipolar disorder with auditory verbal hallucinations and modest short-term effects of transcranial direct current stimulation augmentation treatment-Baseline and follow-up study.

ObjectivesTo investigate the neuroimaging characteristics of auditory verbal hallucinations (AVHs) in patients with bipolar disorder (BP) experiencing depressive episodes with and without AVHs, and alterations in those characteristics after transcranial direct current stimulation (tDCS).MethodsFor a baseline pilot study, we recruited 80 patients with BP and depressive status (40 with and 40 without AVHs), and 40 healthy controls (HCs). Their global functional connectivity density (gFCD) was screened by functional magnetic resonance imaging (fMRI). Voxel‐wise one‐way analysis of covariance (ANCOVA) was conducted to detect intergroup differences in gFCD. In a follow‐up study, the effects of 5 weeks of tDCS augmentation treatment on clinical symptoms and gFCD were assessed in the 40 BP patients with AVHs.ResultsCompared to HCs, BP patients with and without AVHs exhibited increased gFCD in the central parietal lobe, insular lobe, and middle cingulate cortex, with decreased gFCD in the posterior parietal cortex, lateral prefrontal cortex, and occipital lobe (all bilateral). Only patients with AVHs showed increased gFCD in the Broca and Wernicke regions, and decreased gFCD in the hippocampus (all bilateral). After 5 weeks of tDCS, AVHs were slightly alleviated and gFCD abnormalities in the hippocampus were mildly attenuated.ConclusionsPatients with BP and AVHs showed disturbances in the brain's communication capacity mainly in the left frontoparietal network, control network, and memory circuitry. Five weeks of tDCS alleviated AVHs slightly, without improving depressive symptoms, and attenuated hippocampal gFCD alterations in these patients.

Differences between self-reported and clinician-rated evaluations of 1-year changes in auditory verbal hallucinations among schizophrenia patients

Auditory verbal hallucinations (AVHs) constitute a frequent and distressing symptom of schizophrenia, associated with physical, emotional, and cognitive challenges. Despite their clinical importance, changes in the multiple dimensions of AVHs during treatment have rarely been examined, and subjective views thereof have received minimal attention. Here, we evaluated 87 patients with schizophrenia-related AVHs using the Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ; a self-report questionnaire) and the Psychotic Symptom Rating Scales-Auditory Hallucination Subscale (PSYRATS-AH; a clinician-rated scale) at baseline and after 6 months and 1 year of treatment. We explored dimensions that changed from the perspectives of both clinicians and patients and the relationships between these perceptions over the year. The test–retest reliabilities of the HPSVQ and PSYRATS-AH were generally fair. Improvements in AVHs were evident over the first 6 months; the PSYRATS-AH revealed a broader range of symptom improvement than did the HPSVQ. The “interference with life” dimension on the HPSVQ was not reduced, but the “disruption to life” score on the PSYRATS-AH was. At both baseline and 6 months, the physical characteristics of AVHs (frequency, duration, and loudness) were significantly correlated with both distress and life interference/disruption; all correlations except that for frequency were reduced at 1 year. The clinician-rated and self-reported personal perspectives on AVHs exhibited both differences and similarities; physical AVH components and subjective distressful experiences changed in different ways in those with chronic, persistent AVHs. The HPSVQ and PSYRATS-AH data were complementary, improving our understanding of the clinical implications of AVHs and subjective patient distress.

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

BackgroundAuditory 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.ObjectiveThe 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.MethodsThree 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.ResultsOne 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.ConclusionsThis 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.

Auditory Verbal Hallucinations in Borderline Personality Disorder and the Efficacy of Antipsychotics: A Systematic Review.

Background: Auditory verbal hallucinations (AVH) are experienced more frequently by patients with borderline personality disorder (BPD) than previously assumed. However, consensus is lacking on how to treat them.Objective: To provide a systematic review of studies reporting on AVH in patients with BPD, with a focus on the efficacy of treatment of psychotic symptoms.Methods: For this review a systematic search was made in the PubMed and Ovid databases, and mean weighted prevalence rates, adjusted for sample size, were computed.Results: The search yielded 36 studies describing a total of 1,263 patients. Auditory hallucinations (including AVH) were reported in 27% of hospitalized BPD patients; AVH were reported in 25% of all patients and in 24% of outpatients. Of the hallucinating patients, 78% experienced AVH at least once per day, for a duration of several days to many years. On the whole, patients with BPD regarded their voices as malevolent and omnipotent in nature. Compared to patients with schizophrenia, the phenomenological characteristics of AVH were similar and the ensuing distress was equal or even higher, whereas scores for other positive symptoms were lower. The presence of AVH in BPD was associated with an increase of suicide plans and attempts, and more frequent hospitalization. Moreover, AVH in the context of BPD were associated with higher prevalence rates for post-traumatic stress disorder and emotional abuse. The efficacy of antipsychotics was investigated in 21 studies. Based on these studies, we conclude that both typical and atypical antipsychotics tend to have positive effects on AVH experienced in the context of BPD. The efficacy of cognitive-behavioral therapy and non-invasive brain stimulation has not yet been systematically assessed.Conclusions: These findings indicate that AVH experienced in the context of BPD are in need of proper diagnosis and treatment, and that antipsychotics tend to be beneficial in treating these (and other psychotic) symptoms.There is an urgent need for studies assessing the efficacy of cognitive-behavioral therapy and non-invasive brain stimulation in this underdiagnosed and undertreated group.

Prevalence of auditory verbal hallucinations in a general population: A group comparison study.

The present study was specifically designed to investigate the prevalence of auditory verbal hallucinations (AVH) in the general population, and sought to compare similarities and differences regarding socio‐demographics, mental health and severe life events between individuals who have never experienced AVH with those who had. The study also aimed to compare those who sought professional help for their experience of AVH with those who had not sought help. Through a postal questionnaire, 2,533 participants ages 18 and over from a national survey completed the Launay‐Slade Hallucinations Scale and other measures examining AVH characteristics and other areas related to AVH. In total, 7.3% of the sample reported a life‐time prevalence of AVH. Those with AVH were more likely to be single and unemployed, reported higher levels of depression and anxiety, and experienced a higher number of severe life events compared with those without AVH. Only 16% of those who experienced AVH in the general population sought professional help for these experiences. Compared to those who did not seek professional help, participants that had were more likely to experience AVH with a negative content, experience them on a daily basis, undergo negative reactions when experiencing AVH, and resist AVH. In conclusion, the prevalence of AVH was found to be relatively high. The results also revealed higher levels of reduced mental health for individuals who sought professional help, followed by those who did not, compared with those who had never experienced AVH.

Prevalence of auditory hallucinations in Norwegian adolescents: results from a population-based study.

Knowing the prevalence and characteristics of auditory verbal hallucinations (AVH) in adolescents is important for estimations of need for mental health care and assessment of psychosis risk. In this report we assess the prevalence of AVH in a population-based sample of 16–19 years old Norwegian adolescents (n = 9,646, 46.4% male) using two items assessing AVH (from the extended Launay-Slade Hallucination Scale). The prevalence of hearing a voice speaking thoughts aloud was 10.6%. The prevalence of being troubled by voices was 5.3%, showing that negative emotionality about AVH is less frequent than the experience of hearing voices. Female respondents had slightly increased risk for being troubled by voices than males (odds ratio = 1.3), while age did not modulate prevalence. This AVH prevalence is in line with earlier reports in smaller samples of adolescents and indicates that AVH are not uncommon in this period of life. Further longitudinal studies are needed to investigate the value of AVH in predicting psychiatric disorder.

EPA-1018 - Source-based morphometry of gray matter volume in patients with schizophrenia who have persistent auditory verbal hallucinations

Abnormal brain structure of frontal and temporal brain regions has been suggested to occur in patients with schizophrenia who have frequent auditory verbal hallucinations (AVH). However, it is unknown whether this is specific to this patient subgroup. In this study tested the hypothesis that frontotemporal gray matter volume changes would characterize patients with persistent AVH (pAVH) in contrast to healthy controls and patients without AVH. Using structural magnetic resonance imaging at 3T, we studied 20 patients with schizophrenia and 14 matched healthy controls. Ten patients were classified as having chronic and treatment resistant AVH, whereas the remaining 10 patients either never had AVH in the past or were in full remission with regard to AVH (nAVH). Using a multivariate statistical technique for structural data, i.e. 'source-based morphometry' (SBM), we investigated naturally grouping patterns of gray matter volume variation among individuals, the magnitude of their expression between-groups and the relationship between gray matter volume and AVH-specific measures. SBM identified a lower expression of medial and inferior frontal as well as bilateral temporal gray matter volume between pAVH and nAVH. This pattern did not differ between nAVH patients and controls and was associated with 'physical' AVH characteristics (such as symptom duration, location, frequency and intensity) in the pAVH patient group. These results suggest that a pattern of lower gray matter volume in medial frontal and bilateral temporal cortical regions differentiates between patients with persistent AVH and non-hallucinating patients. Moreover, the data support a specific role of this neural pattern in AVH symptom expression.

Source-based morphometry of gray matter volume in patients with schizophrenia who have persistent auditory verbal hallucinations

Abnormal structure of frontal and temporal brain regions has been suggested to occur in patients with schizophrenia who have frequent auditory verbal hallucinations (AVH). However, it is unknown whether this is specific to this patient subgroup. This study tested the hypothesis that frontotemporal gray matter volume changes would characterize patients with persistent AVH (pAVH) in contrast to healthy controls and patients without AVH. Using structural magnetic resonance imaging at 3T, we studied 20 patients with schizophrenia and 14 matched healthy controls. Ten patients were classified as having chronic and treatment resistant AVH, whereas the remaining 10 patients either never had AVH in the past or were in full remission with regard to AVH (nAVH). Using a multivariate statistical technique for structural data, i.e. "source-based morphometry" (SBM), we investigated naturally grouping patterns of gray matter volume variation among individuals, the magnitude of their expression between-groups and the relationship between gray matter volume and AVH-specific measures. SBM identified a reduction of medial and inferior frontal, insular and bilateral temporal gray matter volume between pAVH and nAVH. This pattern did not differ between nAVH patients and controls and was associated with "physical" AVH characteristics (such as symptom duration, location, frequency and intensity) in the pAVH patient group. These results suggest that a pattern of lower gray matter volume in medial frontal, insular and bilateral temporal cortical regions differentiates between patients with persistent AVH and non-hallucinating patients. Moreover, the data support a specific role of this neural pattern in AVH symptom expression.

Characteristics of Auditory Hallucinations and Associated Factors in Older Adults with Schizophrenia

To examine the characteristics of auditory verbal hallucinations and associated factors in older adults with schizophrenia. One hundred ninety-eight persons aged 55 and older living in the community who had developed schizophrenia before age 45 years were assessed for the presence, topography, content, and subjective qualities of auditory hallucinations. George's social antecedent model of psychopathology was used to examine 17 predictor variables of auditory hallucinations. Thirty-two percent experienced auditory verbal hallucinations. More than half heard voices daily, heard good/pleasant voices, or had command hallucinations; 25% obeyed "bad" voices, whereas 87% obeyed "good" voices. There were no significant differences in depression and social functioning between persons judging their voices to be good versus bad. In logistic regression analysis, depressive symptoms, Positive and Negative Syndrome Scale delusion score (>2), and male gender were associated with auditory verbal hallucinations. Older adults with schizophrenia had a lower rate of auditory verbal hallucinations than had been reported previously for younger persons with schizophrenia. For most features of auditory verbal hallucinations, older adults had similar rates to younger persons. However, older adults were more apt to judge their voices as good and more likely to obey the good voices than those voices perceived as bad. From a clinical standpoint, this may be construed as a potentially useful coping strategy. However, subjective judgments about voices did not significantly affect mood or functioning, and the presence of auditory verbal hallucinations was associated with more depressive symptoms.

How do auditory verbal hallucinations in patients differ from those in non-patients?

Auditory verbal hallucinations (AVHs) are experienced by individuals with various clinical diagnoses, such as psychosis, but also a significant minority of healthy individuals from the general population may experience them. Although much research has been carried out the past few decades, the mechanisms and factors underlying the emergence of AVHs is still poorly understood. One way of clarifying this issue involves comparing AVHs in patient and non-patient populations. In particular, differences between these groups will provide important information concerning the emergence of AVHs. After a general presentation and discussion of the notion of a continuum hypothesis, studies comparing patients with non-patients experiencing AVHs will be reviewed. This will comprise studies examining the phenomenological characteristics of AVHs in addition to neuroimaging and cognitive studies. Although we are beginning to elucidate important differences on a phenomenological level between these two types of AVHs, far too few studies have directly compared patient and non-patient AVHs in terms of underlying cerebral correlates and cognitive mechanisms. Nevertheless, and based on recent research on phenomenological differences, two issues stand out that need to be addressed, namely, the highly negative emotional content of AVHs in patients and the early onset of AVHs in non-patients populations. Suggestions for future research will be discussed.

The Same or Different?

Whereas auditory verbal hallucinations (AVHs) are most characteristic of schizophrenia, their presence has frequently been described in a continuum, ranging from severely psychotic patients to schizotypal personality disorder patients to otherwise healthy participants. It remains unclear whether AVHs at the outer borders of this spectrum are indeed the same phenomenon. Furthermore, specific characteristics of AVHs may be important indicators of a psychotic disorder. To investigate differences and similarities in AVHs in psychotic and nonpsychotic individuals, the phenomenology of AVHs in 118 psychotic outpatients was compared to that in 111 otherwise healthy individuals, both experiencing AVHs at least once a month. The study was performed between September 2007 and March 2010 at the University Medical Center, Utrecht, the Netherlands. Characteristics of AVHs were quantified using the Psychotic Symptoms Rating Scales Auditory Hallucinations subscale. The perceived location of voices (inside/outside the head), the number of voices, loudness, and personification did not differentiate between psychotic and healthy individuals. The most prominent differences between AVHs in healthy and psychotic individuals were the emotional valence of the content, the frequency of AVHs, and the control subjects had over their AVHs (all P values < .001). Age at onset of AVHs was at a significantly younger age in the healthy individuals (P < .001). In our sample, the negative emotional valence of the content of AVHs could accurately predict the presence of a psychotic disorder in 88% of the participants. We cannot ascertain whether AVHs at the outer borders of the spectrum should be considered the same phenomenon, as there are both similarities and differences. The much younger age at onset of AVHs in the healthy subjects compared to that in psychotic patients may suggest a different pathophysiology. The high predictive value of the emotional content of voices implies that inquiring after the emotional content of AVHs may be a crucial step in the diagnosis of psychotic disorders in individuals hearing voices.

Stabilization of the Internal Structure of Persistent Auditory Verbal Hallucinations in Schizophrenia

Numerous studies have been conducted to investigate the phenomenological characteristics of auditory verbal hallucinations in schizophrenia. Difficulties in understanding the clinical significance of auditory verbal hallucinations may be attributed to the changes in symptom structure over the long-term course of the illness. The purpose of the present study was therefore to investigate the longitudinal changes in the phenomenological dimensions of auditory verbal hallucinations in patients with schizophrenia. Using the Psychotic Symptom Rating Scales-Auditory Hallucination Subscale, 40 patients meeting DSM-IV criteria for schizophrenia (drug-naive first-episode schizophrenia, n=21; and drug-free chronic schizophrenia, n=19) who reported persistent auditory verbal hallucinations were assessed before the initiation of antipsychotic treatment and after 6 months of treatment. To detect the changes in underlying clusters of phenomenological variables, hierarchical clustering and multidimensional analysis were performed. The phenomenological variables of auditory verbal hallucinations formed two main clusters with 6 month treatment: emotional and cognitive. Physical characteristics failed to indicate a stable cluster. Psychosocial disruption, which initially formed a cluster with cognitive variables, congregated with emotional variables at 6 months. Subgroup analysis indicated that the cluster structure of the first-episode group showed more dynamic changes than did that of the chronic schizophrenia group. Phenomenological variables characterizing persistent auditory verbal hallucinations can be differentiated into emotional and cognitive clusters with achievement of symptom stabilization, and the changes in physical characteristics may not be the sole sign of clinical improvement.

The internal structure of the phenomenology of auditory verbal hallucinations

Background: Auditory verbal hallucinations (AVH) do not have uniform pathological significance. They affect patients with different brain disorders, and vary along multiple phenomenological dimensions. Evidence indicates that some of the phenomenological variables have specific neural substrates. Therefore, a comprehensive characterization of the phenomenological variations of AVH and the interrelationship between these variables was undertaken. Method: Twenty phenomenological variables were identified; on each AVH had a binary value (present or absent). Information about 11 of these variables were obtained from 30 patients. Hierarchical cluster (HC) and multidimensional scaling (MDS) analyses were performed to investigate the hidden structure and dimensions of these variables. Results: HC yielded two main clusters with further sub-clusters in each. The first cluster included hallucinations with low linguistic complexity, repetitive content, attributed to self, located in outer space, and associated with different kinds of control strategies. The second cluster included hallucinations with high linguistic complexity, systematized content, multiple voices, attributed to others, and located in inner space. In MDS, three dimensions were identified: linguistic complexity, self-other attribution, and inner-outer space location. Conclusion: The patterns of clustering and dimensional configuration of AVH characteristics were in accord with intuitive expectation and validated the patients' descriptions of their experiences. These findings could reflect aspects of the neural mechanisms of AVH. For example, the presence of neural specificity for each phenomenological variable, intermediate neural commonality for groups of variables, and a final common pathway for all subtypes of AVH. Another example is a differential level of language dysfunction according to the linguistic complexity of AVH.