This month in voices: January 2017

The first month of 2017 has seen a lot.

But we will limit ourselves here to the new research that has been published on voice-hearing, which this month includes aspects such as trauma, neurology, psychics, and suicide.

Trauma and voice-hearing

refugeesMette Nygaard and colleagues examined voice-hearing in 181 refugees with PTSD.

The majority came from Western Asia (Iraq, Kuwait, Lebanon, Palestine, Syria, Turkey). Most had experienced torture and imprisonment. Most had lived in a war zone.

74 of the 181 refugees with PTSD (i.e., 41%) had ‘psychotic experiences’.

The first question this paper allows us to answer is what the rates of hallucinations were in the overall sample of refugees with PTSD. This was a question which the authors didn’t focus on, but which I’m interested in as Eleanor Longden and I have argued that hearing voices should be a named symptom of PTSD.

Below are the rates in the overall sample (based on a review of medical records)

Rates of hallucinations in all refugees with PTSD (N=181)
Auditory hallucinations (any auditory experience) 27%
Auditory hallucinations (specifically voices) 17%
Visual hallucinations 12%
Olfactory hallucinations 3%
Tactile hallucinations 3%

Elsewhere I’ve estimated rates of voice-hearing in PTSD to be about 25%, so this in the ballpark we would expect.

The next question the paper answers is what these hallucinations were like.

Voices could be of known people (e.g., family members, perpetrators of abuse) or unknown people (“hearing people talking together”, “hearing voices from angry men”,“hearing children calling”). They could be commanding (“voice telling him he should shave his hair off”) and abusive (“hearing voices saying she is not worth anything”, “hearing reproachful voices from lost friends”).

Visual hallucinations included formed figures of family members (“see father, know it’s not real”, “get visits from brother, mother and neighbour’s dog”), people who had abused them (“see men responsible for torture approximately every second day”) or other things (“see dangerous animals showing their teeth”). Others saw unformed hallucinations such as shadows and ghosts.

Now, you may be wondering how many of these hallucinations could be said to be flashbacks (which are already named as a characteristic symptom of PTSD). The authors note that only five refugees had hallucinations described as being directly connected to flashbacks (e.g.; “angry voices in connection with flashbacks”, “flashbacks with airplane noise”.)

The paper then reports data on the rates of different modalities of hallucinations in the subset of refugees with PTSD who had ‘psychotic experiences’

Rates of hallucinations in refugees with PTSD with psychotic features (n=74)
Auditory hallucinations (any auditory experience) 66%
Auditory hallucinations (specifically voices) 41%
Visual hallucinations 30%
Olfactory hallucinations 7%
Tactile hallucinations 8%

Incidentally, this distribution of hallucinations is uncannily similar to that found in people diagnosed with schizophrenia. For example, in a paper which will be shortly be published by myself, Rob Dudley, and colleagues [McCarthy-Jones, S. et al. (accepted). Occurrence and co-occurrence of hallucinations by modality in schizophrenia-spectrum disorders. Psychiatry Research] we found the following lifetime rates of hallucination by modality:

Modality Ireland Australia
(n=205) (n=218)
Auditory 64% 80%
Visual 23% 31%
Olfactory 6% 10%
Tactile 9% 19%

The incidence of hallucinations by modality in schizophrenia and PTSD with psychotic features hence seem highly similar. Why are we set up to hallucinate in this way?

Anyway, it is clear from this paper that traumatised refugees who develop PTSD may well come to experience hallucinations. This needs to inform the services we provide for people and the form those services take.

 

Neurology

Two neuroimaging studies this month both pointed at a role for a part of the brain called the insula in voice-hearing. First, Alonso-Solís and colleagues reported altered neural activity in the insula in people diagnosed with schizophrenia who heard voices (when compared to people diagnosed with schizophrenia who did not hear voices). Second, Chang and colleagues reported altered connectivity between the insula (in the right hemisphere) and a range of other neural regions in medication-naive people diagnosed with first episode schizophrenia who heard voices (compared to equivalent patients who did not hear voices).

The theory behind an involvement of the insula in voice-hearing is that this region of the brain plays a key role in the brain’s salience network. When something is made salient to you, you attend to it; it ‘pops out’ at you.

connectivity-chang-et-al-2017The Chang et al. study was particularly interesting as it found evidence of altered neural connectivity in the specific regions shown on the right to be associated with voice-hearing.

These included altered connectivity between the anterior cingulate cortex (ACC) and the superior temporal gyrus (STG). The ACC is thought to help monitor whether experiences are internally or externally generated. The auditory cortex lives in the STG. Altered connectivity between these two regions is hence thought to reflect the ACC failing to regulate the STG as it normally would, leading to internally generated thoughts being mislabelled as other people’s voices. Chang and colleagues also found altered connectivity between the insula and the STG, which could be interpreted as leading to an alteration to the salience of thoughts. Connectivity was also altered between the insula and ACC. As Chang and colleagues note, the co-activation of these regions is associated with the detection and response to salient stimuli in the environment. Thus their findings are consistent with voices having origins in self-generated thoughts that the brain makes more salient and fails to correctly monitor.

A final study to mention on the neuroimaging front was one which looked at resting cerebral blood flow in people diagnosed with schizophrenia who heard voices. This also found voice-hearing to be associated with changes in a part of the brain associated with signalling salience; the striatum. It also pointed to auditory cortex changes associated with voice-hearing, but in the right, not left hemisphere.

 

The meanings of voice-hearing

This section starts with a great study from Powers, Kelley, and Corlett. This interviewed clairaudient psychics who received daily messages from voices. It then compared their voices to those heard by help seeking voice-hearers (people diagnosed with a psychotic disorder who heard voices).

psychicsFirst, have a look at the huge difference in ages between when the psychics, on average, first heard a voice, and when the people with a diagnosed psychiatric disorder first heard a voice (see right).

One has to suspect from this that two very different processes are going on here.

In terms of how the voices of the two groups compared, they were mostly similar in terms of their auditory characteristics, content, structure, syntax, and frequency.

However, the psychics were more able to control their voices (i.e., to be able to start and stop them), although this control was not always total. For example:

Researcher: When do the voices happen?

Psychic: If I allow it, it can happen all the time. Sometimes I can put a wall up, but if its meant to be heard or seen, it will be.

Another psychic stated: “when you’re open it will come. But it takes work.

Another explained they could shut the voices off simply by telling them to shut up; “I tell them to shut up… I say it out loud…”I’m off duty now. Go away.”

Consider also how the psychics wanted to hear their voices. One said:

“I’ve done a lot of meditation techniques to just make sure that the voices are clear so that
I can understand the message.”

This is very different to a process of trying to block out or dampen down the voices with antipsychotics. Indeed, it reminds me of reports of some patients smoking pot in order to make their voices louder and clearer, so that they could be better understood and coped with.

Other differences were that the psychics were less likely to find their voices bothersome, more likely to think they helped their personal safety, and more likely to think the source of the voices was God or another spiritual being.

Other potential differences hinted at in the paper were that the voices heard by the patients were more likely to be replays of things previously thought or spoken, and that the psychics’ voices were more likely to co-occur with other forms of hallucinations.

In term of other papers on the meanings of voice-hearing, a paper entitled “Hopeful conversations about voice hearing” explored one person’s experiences of voice-hearing in depth. Once I can get hold of a copy of this paper, I will add more on this.

 

Cognition

A study by Sara Siddi and colleagues found that set-shifting skills were worse in people diagnosed with a psychotic disorder who heard voices than in those who did not. Set shifting is the ability to move your attention from one task to another. The authors suggest this may be a mechanism underlying voice-hearing, although are not entirely how.

 

Clinical

Slotema and colleagues found that, in people diagnosed with borderline personality disorder, the experience of hearing voices was associated with more suicide planning and attempts.

An article, written in Dutch, whose title in English is “A personal diagnosis for patients who hear voices: symptoms can improve in a meaningful context” was published this month. In this, Corstens and Romme argue that making a ‘personal diagnosis’ for someone who hears voices can allow one to establish a relationship between the voices and events in a patient’s life, empower the patient, and, through revealing possible ways of solving the patient’s personal problems, lead to further treatment and recovery. If anyone has a copy of this in English, please let me know. Dank je!

Finally this month, a literature review from the University of Malta tried to assess the effectiveness of antipsychotic medication relative to the Hearing Voices Approach. It concludes that “it was not possible to conclude which one has the most beneficial outcomes”. I’m yet to get a copy of this to read myself, but will update this in due course. If you’re interested in issues in researching the Hearing Voices Approach, a paper led by Dirk Corstens, published in 2014, may be of interest.

 

Other things of interest

A podcast from Prof Pat Waugh on Virginia Woolf, including her voice-hearing experiences.

A powerpoint presentation on psychosocial interventions for distressing voice-hearing.

 

Wrap-up

That’s all for this month. For those of you within striking distance of Durham, it would be well worth a trip to hear these talks later this month:

And to see the art installation ‘Tuning into the Light: Experiencing Celestial Voices’ (11-25 Feb)

You can find out more about the fabulous voice-hearing related events taking place in Durham, organised by Charles, Angela, and the rest of the Hearing the Voice team at http://hearingvoicesdu.org/

As next month sees Valentine’s Day upon us, I thought I’d leave you with a paper on love and voice-hearing that myself and Larry Davidson penned a number of years ago.

Hope to see you again next month (hang on in there my American friends).

SMJ

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This month in voices: December 2016

Happy New Year, and thanks for coming back to the blog!

This time we have the research offerings of the festive/mucus season.

 

yom-kippurVoice-hearing and trauma

Crompton and colleagues examined voice-hearing in Israeli men who had been prisoners of war (POWs) during the 1973 Yom Kippur War.

240 Israeli combatants were captured and held in Egypt or Syria for between 2 and 8 months. As Crompton and colleagues describe:

“Most were held in solitary confinement in unhygienic conditions, handcuffed, blindfolded and subjected to deliberate and systematic abuse. Torture included beatings, electric shock, sexual abuse, burns and deprivation of medical treatment as well as food and water. They were also subjected to verbal abuse, mock executions, threats (of death, mutilation, killing loved ones), and demoralizing misinformation.”

Crompton and colleagues interviewed 99 former POWs, as well as 103 other Yom Kippur veterans who had not been POWs and did not have PTSD, collecting data in 1991 and 2003.

When they interviewed their participants they found the following rates of voice-hearing during the past two weeks (these are my calculations from their paper, done to simplify things a bit):

  • Rates of voice-hearing 18 years after the War (1991)
  • POWs with PTSD                     = 9.8%
  • POWs without PTSD               = 2.8%
  • Non-POWs without PTSD     = 5.2%
  • Rates of voice-hearing 30 years after the War (2003)
  • POWs with PTSD                       = 36.1%
  • POWs without PTSD                 =  5.6%
  • Non-POWs without PTSD        =  3.1%

The presence of PTSD in POWs predicted the later emergence of voice-hearing. More specifically, of the three key symptom dimensions of PTSD (intrusions, avoidance, and hyperarousal), it was levels of intrusions that predicted the later emergence of voices.

It would have been very interesting to know what the voices were saying, but this data was not collected.

vet

What jumps out as slightly odd is that 18 years after the war, 1-in-10 POWs with PTSD were hearing voices, and yet this rate shot up to 1-in-3 after a further 12 years.

Why?

The authors speculate this could be due to increased retrospection and further stress (e.g., family deaths) as veterans aged more.

 

The meaning(s) of voice-hearing

This thesis by Emma Heath-Engel looks intriguing. It explores psychosis

“using the Two-Eyed Seeing Framework, developed by Mi’kmaw Elders Albert and Murdena Marshall, of the Eskasoni First Nation in Cape Breton, Nova Scotia, which ensures readers appreciate each perspective on ‘psychosis’ in its own right, and invites readers to imagine and notice ways in which the healing perspectives presented, can be and are combined, in order to create new and important healing possibilities.”

 

Cross-diagnostic studies

Llorca and colleagues examined how the modalities that people diagnosed with schizophrenia hallucinate in compares to those experienced by people with Parkinson’s Disease. A very helpful diagram in the paper gives the results at a glance (well, more of a squint than a glance in this reproduction, so check out the figure in the paper itself)

results

 

Neuroimaging studies of voice-hearing

Branislava Curcic-Blake and colleagues reviewed 50 studies looking at associations between voice-hearing and alterations to neural connectivity.

rap4Their basic conclusion was that voice-hearing is associated with areas of the brain involved in speech production and speech perception (Broca’s and Wernicke’s area) either receiving too little, too much or erroneous input.

These brain areas nevertheless still try to communicate with each other, but this ends up being in an “aberrant” manner, which manifests as voices. The authors come out fairly strongly for the proposal that voices may represent “unstable memories”.

Here, memories occur and then are fed into the language production and comprehension system, resulting in voices.

Chinese study also looked at neural connectivity this month. It examined blood flow in the brain (when at the person was at rest), and found alterations associated with voice-hearing in two brain regions associated with inner speech monitoring. First they found reduced blood flow in voice-hearing people diagnosed with schizophrenia, compared to non voice-hearing people diagnosed with schizophrenia, in the dorsolateral prefrontal cortex. They note that this area is involved in monitoring our speech production. Secondly, they found reduced blood flow in patients with voices, compared to patients without voices, in a region of the brain called the supplemental motor area. The functional effect of this is proposed to be the loss of the feeling that your inner speech is self-generated.

mytwocentsThrowing in my own two-cents, I would note, as others have before, that damage to the supplemental motor area is found in alien limb syndrome. In this, your arm makes movements, such as reaching out and grabbing things, but you don’t feel as if you caused it to do it.

Could voice-hearing be an analogue of this; your brain creates speech but you don’t feel like you produced it?

 

Voice-hearing in those without a need for care 

Hang on, you might say, surely we all need care? Don’t worry, this is just the latest nomenclaturic fumbling in the search for a better term than ‘healthy voice-hearer’, which we flagged as contentious in the last installment of this blog.

The continuum model of psychosis argues that the same kinds of mechanisms that underpin voice-hearing in people impaired and distressed by them (i.e., who likely have a psychiatric diagnosis) also underpin voice-hearing in hallucination-prone people in the general population.

sauce-monitoring

Sauce monitoring – an entirely unrelated skill

To test this, Garrison and colleagues examined if the ability to differentiate between things you perceived and things you imagined, or things you did and things someone else did (skills which fall under the bucket term of ‘source monitoring’) was reduced in hallucination-prone people in the general population (it is fairly reliably reduced in clinical populations of people hearing voices).

 

They found no association between hallucination-proneness and worse source monitoring abilities. These findings could be interpreted in many ways, but one possibility is that the mechanisms involved in voice-hearing in people who have ended up in the psychiatric system, and the types of briefer, fleeting experiences undergone by members of the general population, are different.

 

Other things of potential interest

A Clinical Psychology Doctoral Thesis by Samantha Wong entitled “A systematic review and empirical study investigating cognitive and social models of voice-hearing“.

An interesting powerpoint presentation by Josie Davies, a Trainee Clinical Psychologist, on mediators between the link between trauma and psychosis.

 

That’s all for 2016, onwards to 2017 next time!

SMJ

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This month in voices: Autumn 2016

Thanks to some encouraging words from someone who will remain semi-mysteriously known as simply TML, This Month In Voices returns with a round up of the research that fell across my desk in the fall.

It has a new format, due to time continually contracting around me, and I will be grouping the research into themes, offering some brief words, and letting you follow-up anything that interests you.

Some free things first!

ebook

 

My colleagues and I recently published a free ebook on hallucinations.

It is comprised of a number of journal articles on hallucinations, which cover aspects such as trauma, the self, sleep, psychological therapies, neurostimulation, and philosophical perspectives.

Hopefully there is something for everyone in here.

 

 

hearing-voices-durham

I’d also like to mention the fabulous (and free!) hearing voices exhibition running until the 26th of Feb 2017 at Durham University in the UK.

Charles, Angela, the rest of the Hearing the Voice team, and their collaborators have done an amazing job and I’d highly recommend a visit.

http://hearingvoicesdu.org/

 

assyrian-section

 

Finally, if you’re interested in voice-hearing in the Ancient World, you might find my latest blog post Silence of the Ancients to be of interest.

 

 

Anyway, now onto the research!

What does Voice-Hearing Signify?

Back in the day it was thought that if you had a certain type of hallucination, such as hearing voices conversing or offering a running commentary on you, then this was indicative of schizophrenia. A review by Flavie Waters and Charles Fernyhough found that there was no evidence that any particular property of a hallucination (e.g., its content or form) was specifically associated with schizophrenia. The only aspect of hallucinations that were associated with schizophrenia were that they began in late adolescence.

Hearing Voices and Trauma

The quest continues to find out exactly how trauma leads to hallucinations. Gibson and colleagues reviewed potential mechanisms. Geddes and colleagues, in a new empirical study, examined what predicted whether someone went on to have hallucinations after being assaulted. They found that the way the person processed the trauma at the time (a lack of self-referential processing, and dissociation), the way they processed the trauma afterwards (thought suppression, rumination, and numbing), and factors such as self-blame, predicted the emergence of hallucinations. You may also be interested in an Iranian single case study documenting a relation between physical abuse and hallucinations in a child, and the authors’ discussion of this.

Voice-Hearing Without Need for Care

A really interesting study looked at voice-hearing in clairaudient psychics, a systematic review was published on healthy voice-hearing (although the use of this term is becoming increasingly problematic), and a study from Iris Sommer’s group looked in more detail at children who are seeking help for voice-hearing.

Coping with Voices

One study found that (in both clinical and non-clinical voice-hearers), greater levels of neuroticism (a personality trait characterized by emotional instability and proneness to experiencing anxiety, fear, and sadness) were associated with more maladaptive reactions to voices (e.g., being more distressed). Another study, involving Salvador Perona-Garcelán, Mark Hayward and colleagues, found that greater levels of mindfulness were associated with having a better relationship with your voices.

Other bits and bobs

De Sousa and colleagues marched into the debate on inner speech and hallucinations, and an interesting study looked at psychosis and help-seeking in KwaZulu Natal.

And finally…

cherise-nev-sarahI’d like to pass thanks on again to the superstars that are Nev Jones, Cherise Rosen, and Sarah Keedy for organizing a great meeting of the International Consortium on Hallucinations Research in Chicago in September, and for being wonderful hosts.

Looking forward to seeing everyone again in Lille in 2017!

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This month in voices: August 2014

This month’s voice-hearing research covered topics ranging from changing how you relate to your voices, brain tumours, interdisciplinary approaches to voice-hearing and ‘friends interventions’.

 

Brighton-and-Hove-20120717-01469

Brighton Rock: The much better selling sequel to Snickers in Southampton. This blog’s regular readers may wonder why Graham Greene puns don’t continue through this month’s blog. They were going to, until I found out that Greene was a man with “a definite quirk for brothels” (he kept a list of his favourite 47 prostitutes – favourite 47?!), and that there are some very serious allegations made about him. He will hence feature here no further.

Brighton, UK. Mark Hayward and colleagues allow us to pier into the future (boom, boom!) to see the design for a trial of a relatively new psychological therapy to help people who are distressed by hearing voices.

Accessible summary: This proposed study draws on work which explores hearing voices from an interpersonal perspective, examining the interactions that can occur between the hearer and their voice(s). As Mark Hayward has put it “if relating to voices is influenced by relationships in the real world, it is likely to be imbued with all the complexity and idiosyncrasy of social relationships”. This therapeutic trial will draw on Relating Therapy which aims to re-balance the power relations between the hearer and their voice(s), as well as the proximity between the person and their voice (i.e., how intrusive the voice is, whether the person distances themselves from their voices, or feels close to them)

The study will assess the success of the therapy by examining changes in voice-related
distress, rather than things like whether the frequency of the voices, or how loud they are, change. A further study will then test whether any  changes in voice-related distress occur because of factors such as people finding their voices to be less dominant and intrusive as a result of the therapy.

Basically, the therapy will run as follows (drawing on the book Overcoming Distressing Voices)

  1. A consideration of how people typically respond to voices that relate to them in a negative way, such as by giving in, fighting back, or trying to escape. This is followed by introducing the idea of relating differently to voices.
  2. An exploration of whether how the person relates to their voices may be linked to how they relate to other people in their lives (including identifying themes of abuse, disempowerment, or rivalry).
  3. The exploration and development of assertive approaches to relating, both to the voice(s) and other people in their social world.

Fingers crossed for some good results.

Link to paper (free to read): Hayward et al. paper

 

HTVDurham, UK. Marco Bernini and Angela Woods discuss interdisciplinary research using a project on hearing voices at Durham University (‘Hearing the Voice‘) as an example.

Accessible summary: First I should say that I am also a member of this project, so my view of it is not unbiased! Anyway, how, asks the paper, do you integrate the cognitive sciences (neuroscience, cognitive psychology, and philosophy of mind), phenomenology, and humanistic disciplines (literature, narratology, history, and theology). You may think the answer is the same way that you would try to integrate a fox armed with an assault rifle, a chicken covered in banana yoghurt, and a gorilla who can only communicate by drumming Phil Collins songs but who has had his drumsticks stolen, i.e., you don’t. And if you do it will be, at best, atonal and sticky, and at worst, a squawkhowling bloodbath.

Indeed, as Bernini and Woods note, disciplinary incursions have previously been viewed as hostile colonial encounters, and fears raised that disciplines will “overflow into each other like anarchic lava lamps”. These are both salient metaphorical concerns. And literal ones: I once opened one of my housemates lava-lamps and tried to explore what the stuff inside actually was. It never worked properly again (sorry, Ed).

But never one to be pessimistic, the Hearing the Voice project is trying (successfully) to overcome these barriers “to attain a new holistic understanding of voice-hearing, examining its significance as an aspect of personal narrative and as psychiatric symptom, conducting empirical studies into its cognitive and neuroscientific mechanisms, performing culturally sensitive investigations of its personal, social, and historical significance, and leading translational research into its therapeutic management.”

How does it do this? Well, central to this project is “Voice-Club”, facilitated by the artist Mary Robson, and attended by all members of the core Durham-based team. Here, there occurs a “cognitively integrated system of extended disciplinary minds”, which interact in what Bernini and Woods call ‘enhancing loops’ (“feedback loops which produce cognitive enhancement, i.e., they disclose theoretical and/or testable hypotheses previously unthinkable by a single disciplinary mind”). In concrete terms, these loops involve things such as:

  • Intuition Pumps: These are tools which stimulate specific kinds of thinking and are present in every discipline, whether it be Plato’s cave or Aesop’s short stories. In Voice Club new intuition pumps can be generated and previous pumps powered by the output of other pumps, or re-engineered to pump out different products.
  • Front Loading: What we learn from disciplines such as phenomenology or the humanities can be ‘front-loaded’ into the design of scientific experiments. What to load and how has been the subject of two Hearing the Voice ‘neurohackathons’ in which humanities researchers have participated directly in experimental design.
  • Terminological Negotiations: Each discipline has different words for describing a similar concept, or the same word signifying completely different meanings. By exploring these, loops can be created that lead to unexpected terminological and conceptual innovations.
  • Enactive Constraining: Interdisciplinarity is not a form of ‘knowing-that’ but of  ‘know-how’. Disciplinary minds discover in the interaction and extension with other minds what is possible to do and what is not.

As Bernini and Woods reiterate, these processes all function to produce thoughts and outcomes that were unthinkable or unpredictable before. In the always lyrical prose of Fitzgerald and Callard, the Hearing the Voice project seeks “experimental entanglements”, where “To be entangled is precisely not simply to labour together, or to compare – or engage in ‘dialogue’ about – our different disciplinary perspectives. It is to proceed, instead, on the assumption that entanglements … might produce something new in the world, even as the forms that that newness might take are undecided, and undecidable, prior to the moments of experimentation”.

How could you not love this project?

Link to paper (free to read): http://dx.doi.org/10.1002/wcs.1305

 

Rudi

Howzat for a paper! (sorry, wrong Rudi).

Colwyn Bay, Wales: Rudi Coetzer discusses a case of voice-hearing after a brain tumour.

Accessible summary: So, a woman in her mid-60s, with no history of previous psychiatric problems, presents to hospital with a history of progressively worsening
lethargy, headaches, and left leg weakness.

Let’s get the whiteboard out and figure out what’s causing this.

It’s Lupus! Grab the prednisone and start the plasmapheresis! Sorry, I’ve been watching too much House M.D. No , it wasn’t Lupus.

A brain scan revealed a solitary meningioma (brain tumour) in the right frontal lobe. This was surgically removed, but the lady then started hearing voices. The voices never went into remission, despite her trying antipsychotic medication. The voices said she was being controlled by persons in the neighborhood or poisoned, and the experience also involved hearing the voices of dead people.

Does this mean there is a role for the right frontal brain region in causing some voice-hearing experiences? Perhaps so.

Link to paper: http://journals.psychiatryonline.org/article.aspx?articleid=1893502

 

Other papers:

  • Swiney and Sousa march into the debate about the mechanics of the relation between inner speech and hearing voices, offering a thoughtful consideration of the comparator account of hearing voices. The paper is free to read here.
  • Brockman and colleagues examine the psychometric properties of the short-versions of the Voices Acceptance and Action Scale (VAAS). Link to abstract here.
  • Mark Ellerby argues that “Hallucinating also sounds a lot better and much less dangerous to me than saying someone hears voices. I am aware that many patient groups would disagree with what I have said here because hearing voices is so common and uses everyday language. However, ‘hallucinations’ only suggests another more medical sounding label, which still may not be readily understood, but carries less associations of stigma”. Link to paper here.
  • A ‘friends interventions’ for young people with psychosis. Link to abstract here.
  • One theory runs that excess striatal dopamine causes hallucinations, so drugs which increase striatal dopamine should cause hallucinations? Yes. Link here.

Thanks for reading. More soon!

SMJ

 

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This month in voices: September 2014

There wasn’t a great quantity of research published in September, but the two papers I summarise below are hopefully helpful in showcasing how cognitive behavioural therapy is actually done for voice-hearing, and how researchers are looking at the role of altered neural connectivity in voice-hearing.

BostonBoston, USA. Wigand and colleagues examine if changes to the wiring in the brain that link the auditory areas in the left hemisphere to the auditory areas in the right hemisphere may play a role in causing voice-hearing.

CC auditory

The corpus callosum (blue) extracted from the rest of the brain (side view, front of the brain on the left). The part which links the left and right auditory areas is show in orange (taken from Wigand et al).

Accessible summary: The corpus callosum is a bundle of white matter fibers (the brain’s signalling cables) which link the right and left hemispheres of the brain. This pathway has an important role in hearing because we process language primarily in our left hemisphere (if you are right handed). This means that when speech comes into the right hemisphere of the brain (which happens when sound goes into our left ear, due to the way the brain is wired), this info is transferred to the left hemisphere,via the corpus callosum, for processing.

ShufflebotI could tell you of a study in Italian nightclubs testing the implications of this, i.e., that we should favour listening with our right ear, because this is linked directly to our language dominant left hemisphere. This involved female researchers approaching random people in Italian nightclubs, mumbling “an inaudible meaningless utterance, such as ‘babababa’ while maintaining a face-to-face position and direct eye contact” (which wouldn’t freak you out too much) to see if people really did favour listening with their right ears in situations where it is hard to hear. But to discuss this in length would be a digression, and this blog hates digressions.

Anyway, returning to the Boston study in-hand, this used a technique called diffusion tensor imaging (DTI) to examine the integrity of the ‘cable’ in the brain that links the left and right hemisphere auditory areas. DTI looks at the direction of flow of water in these cables of the brain. If the water is all flowing in pretty much the same direction, this is seen as the cabling being ordered and intact (imagine troops marching in a ordered column to a battle).

ShufflingHowever, if the water tends more to be flowing in all different directions (imagine troops marching to the battle whilst all listening to LMFAO on their iPods, and dancing/shuffling there in a slightly chaotic, manner), then this is seen as representing some form of damage to the cabling.

The study found that people with a history of hearing voices had reduced integrity in the part of the corpus callosum that links the right and left auditory regions, compared to people who didn’t hear voices. Furthermore, findings emerging from the use of a specific measure of structural integrity called radial diffusivity, suggested that this change may specifically involve demyelination. Demyelination is a reduction to the fatty myelin sheath that surrounds signalling cables (axons) in the brain that helps electrical signals travel quickly along them. This finding can be tied into a popular contemporary theory (I won’t say that it’s sexy and it knows it) that proposes that the brain has an internal signalling system which gives auditory regions a ‘heads-up’ that we are producing thoughts in our head. If the signals involved in letting auditory regions know that we are thinking to ourselves don’t get there in time (i.e., they are ‘shuffling’, to continue the LMFAO analogy), then we may not ‘be told’ that these thoughts are our own, and hence experience them as a voice of another person instead.

Link to paper: http://informahealthcare.com/doi/abs/10.3109/15622975.2014.948063

 

Essex

An inoffensive picture of Essex. This took me a while to find.

Essex, UK. Mankiewicz and Turner present a single case study of a psychological therapy (cognitive behaviour therapy) for voice-hearing.

Accessible summary: Raymond, aged 40, was referred to a specialist service for adults with psychosis. He was hearing threatening voices (“You’ve wasted your life, you screwed it all!”, “You should be punished and dead, you will pay!”), and had paranoid delusions and high levels of anxiety. As a result of these experiences he lived an isolated life on his own in a house, where he had installed surveillance cameras, in which he barricaded his bedroom at nights. No clear information was given on what was happening in Raymond’s life when the voices started, but a distressing home situation and alcohol/drug use are mentioned.

During his initial assessment with the psychologist, Raymond identified a number of
triggers of his voices. He would hear voices while he was bored at home, kept silent, or had nothing to occupy his mind with, and the voices would become particularly active in the late evening, as night drew in. Raymond agreed on the following intervention goals for his psychological therapy: enhancement of strategies to cope with voices, paranoid/delusional beliefs and anxiety, and reestablishment of autonomy at nights.

Techniques used to achieve these goals included:

  • Understanding links between his own thoughts and his voices. Raymond recognised he had recurrent negative internal dialogues (which would tend to occur when he was bored), which frequently preceeded the experiences of auditory hallucinations. The voices, in turn, seemed to represent his own worries about his life, e.g., “I’ve wasted my life.” To address this, Raymond begun changing his inner dialogue, saying things to himself such as “I do not need to be punished for anything, as I have never hurt anyone. I have already improved my life, quit drinking and drugs, and deserve to be happier.”
  • Challenging negative appraisals of the voices, i.e., was what he believed about the voices true? Guided discovery was used to help Raymond see that there was no evidence to support his persecutory beliefs about voices, with Raymond realising that he had remained safe and had not been attacked or even threatened by anyone for years.
  • Examining safety behaviours, seeing that they stopped disconfirmatory evidence being obtained, and using behavioural training to change this. Raymond had the assumption that “If I do not remain isolated and vigilant, activate the security system and barricade the bedroom, then I’ll be assaulted.” He learnt that by barracading himself in his room he could never see if this assumption was actually true. Raymond’s assumption was slowly reframed by first getting him to remove the doorstop, then unlocking the bedroom door, then substituting watching security cameras in the evening with watching movies, and eventually removing the barricade. He was also encouraged to get involved in social situations, such as taking walks, shopping, and visiting family.

Whereas before therapy Raymond felt that his voices were “scary and they freak me out”, at the end of therapy he now felt that “They’re still there but I don’t attend to them as much now”. Whereas he used to think his voices meant that “I’m being chased and will be punished”, he now felt that “These are probably my own thoughts”. As a result he now felt that “I’m not as anxious as before. I can relax more often now.” whereas before he’d fel “I cannot cope. I’m losing control.”

As a result of this, his abilities to cope with voices and persecutory beliefs increased and his anxiety reduced, and Raymond decided to explore evening courses provided in the local college and pursue further qualifications.

Link to paper: http://dx.doi.org/10.1155/2014/124564

 

Other papers this month

More voice-hearing research next month, when I’ll try to explain voxel based morphometry using Katy Perry’s greatest hits.

SMJ

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This month in voices: November 2013

Well, as I last posted on Christmas day, it seems appropriate to start up again on Easter Sunday. I’ll try and get through the backlog of research as soon as possible.

 

ICHR photoDurham, UK. Flavie Waters, Angela Woods and Charles Fernyhough report on what went on at the 2nd International Consortium on Hallucination Research, held in Durham.

Accessible summary: This is a clear and concise paper, plus free to read, so I won’t summarise it here. You can access it below.

Link to paper (free to read): http://dx.doi.org/10.1093/schbul/sbt167

 

Melbourne3Melbourne, Australia. Bendall and colleagues examine how childhood sexual abuse may lead to voice-hearing.

Accessible summary. It has been proposed that childhood sexual abuse (CSA) results in intrusive experiences associated with posttraumatic stress disorder (e.g., thinking about the event when you didn’t
mean to), which in turn underpin voice-hearing experiences. This study found, within people with first episode psychosis who had experienced CSA, that there was a trend for greater levels of post-traumatic intrusions to be associated with more severe hallucinations. The authors conclude that hallucinations in psychosis may involve posttraumatic intrusions, and that clinicians should be alert to the importance of assessing for childhood trauma and the symptoms of PTSD in people diagnosed with psychosis.

Link to paper: http://www.ncbi.nlm.nih.gov/pubmed/24177480

 

Groningen2Groningen, Netherlands. Curčić-Blake and colleagues examine the role of neural connectivity in voice-hearing.

Accessible summary: A number of theories of voice-hearing focus on how changes to the connections between different areas of the brain, particularly those involved in speech production and speech perception, may underpin voice-hearing. This study found evidence that a number of signalling pathways (white matter) in the brain had decreased structural integrity in people diagosed with schizophrenia who heard voices, compared to people diagnosed with schizophrenia who did not hear voices. For example, decreased integrity in the signalling pathway between the two hemispheres (the corpus callosum), as well as in pathways (such as the arcuate fasiculus) linking the frontal parts of the brain (e.g., those involved in speech production) to the temporal parts of the brain (e.g., those involved in speech perception) were found to be associated with hearing voices. The authors conclude that “hallucinations in schizophrenia patients are associated with a complex set of white matter abnormalities [i.e., changes in the signalling pathways of the brain] that involve at least three distinct systems: the language network, putatively in the ‘inner speech’ domain [thinking silently in words to yourself] ; and the central in attention and perception loop; and the limbic system, providing the emotional edge.” One could muse on how this study might link with the previous one discussed, e.g., could there be a role for childhood trauma in changing the signalling pathways in the brain?

Link to paper: http://dx.doi.org/10.1007/s00429-013-0663-y

 

BandungBandung, Indonesia. Suryani and colleagues examine voice-hearing in Indonesian people diagnosed with schizophrenia.

Accessible summary. This was a qualitative study (very basically: sit down and have a chat with people, then later examine what was said to find common themes across participants) of 13 Indonesian people diagnosed with schizophrenia who heard voices. The first theme that emerged from this study was of people “feeling more like a robot than a human being”. In Indonesian culture reference to not being a human being is to suggest a point of difference in which the person no longer has the capacity to live a normal life with the freedom to make personal choices as part of daily living. In this case, this was due to people feeling powerless to resist what the voices told them to do, e.g., “2 years ago, the voices instructed me to climb a mountain. At the time, I just followed their instruction. I could not reject it”.

The second theme was “Voices of Contradiction—A Point of Confusion”. This reflected how voices would often give contradictory commands, and tell people to do things which conflicted with their social and religious norms. The third theme was “Tattered Relationships and Family Disarray”. In this participants described how ‘family
relationships and family life imploded as the mental illness and the hallucinations took grip of the person’s life leaving them with feelings of chaos’. One participant stated how “I feel inferior and ashamed. I seemed to talk alone like a crazy man. I felt ashamed…about being mentally ill and hearing voices, I am in the process of divorce with my wife”. The final theme was “Normalizing the Presence of Auditory Hallucinations as Part of Everyday Life”. This theme reflected for a number of the participants, normalizing the voice-hearing was the most effective way of being able to live with them. One participant stated that “Hearing voices? Nothing special, like a conversation, the voices sometimes appear, but sometimes don’t. I get used to hearing the voices. It’s like part of my life.”

Link to paper: http://dx.doi.org/10.1016/j.apnu.2013.08.001

 

Wills Kate wombatSydney, Australia. Amanda Waegeli, John Watkins and I wrote a paper considering the relation between spirituality and voice-hearing.

Accessible summary: I hope the paper is fairly easy to read, and you can check it out on-line, as it is free to read (thanks to the kind people at the Wellcome Trust). We begin by examining the ways which spirituality may help people with hearing voices, including offering an alternative explanation for people not satisfied by medical explanations, aiding coping, enhancing social support, allowing the person to undertake a defined social role, and enabling forgiveness. We then consider the flip side, how spirituality may have a detrimental effect, such as through encouraging people to have frightening or coercive interpretations of their voices, and missing opportunities for potentially successful medication or psychotherapeutic interventions. We then have a think about the categories of ‘spiritual’ and ‘psychotic’ voice-hearing, and highlight people’s right to their own interpretations of their experiences.

Link to paper (free to read): http://dx.doi.org/10.1080/17522439.2013.831945

 

Other studies

More soon. SMJ

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This month in voices: October 2013

Adam West's tribute to Monroe seemed a good idea at the time.

The consensus was that the vent had been kinder to Marilyn Monroe.

As I mentioned in a previous post, Melbourne might currently be voice-hearing’s second city (after Utrecht), and sure enough, this month we’ll start with some research from this fine city.

As a quick aside, the city now known as Melbourne was originally called Batmania, self-named by one of the first white people to live there, the magnificently named John Batman, a syphilitic farmer from Sydney. Why would anyone want to change such a magnificent city name? Well, for a number of reasons, see a quick history of Batmania here. But, I have digressed, let’s get back to the research.

 

Melbourne, a town so cool even its Rhinos skateboard.

A Melbourne tram advert. The town is so cool even its Rhinos skateboard.

Melbourne, Australia. Neil Thomas and colleagues examine the relationship between what people think of themselves and other people, and what they believe about their voices.

Accessible summary: The meanings someone gives to their voices are influenced by what they think about themself and other people in their world (i.e., in psychology speak, the schemas they have). For example, research has already shown that people who feel powerless in relation to their voices tend to feel a lack of power in relationships with other people in their social world. This interesting study set out to examine the relationship between what people believed about their voices, and how they viewed themselves and other people in their social world.

After controlling for a range of variables, it was found that the more negatively voice-hearers viewed other people, the more malevolent they perceived their voices to be (i.e., the more they believed their voices wished to do evil to them). However, the more negatively voice-hearers viewed themselves, the more all-powerful they were likely to believe their voices to be.

However, the authors could not establish the direction of causation. So, for example, whilst it could be that having negative views of others makes you more likely to interpret your voices as malevolent, it is also possible that how malevolent you perceive your voices to be influences what you think about other people (or both!).

The authors note that “Beliefs in voice malevolence are not easy to directly modify into an alternative belief without either colluding with the idea that voices are sentient others, or challenging the person’s overall explanatory model”. Collusion seems a strong word here.

The authors conclude that techniques such as acceptance and mindfulness-based therapies that can defuse the impact of negative beliefs about oneself might be helpful for voice-hearers.

Link to paper: http://www.ncbi.nlm.nih.gov/pubmed/24103156

 

Coventry, England. Marwaha and colleagues examine the role of mood instability in psychosis.

Accessible summary: Mood stability was assessed in this study using the question, “Do you have a lot of sudden mood changes?”. People answering ‘yes’ were defined as having mood instability.

The study found that the higher mood instability was in members of the general population, the higher people’s levels of auditory hallucinations were. The authors then examined if the data was consistent with the hypothesis that childhood sexual abuse led to increased mood instability which in turn led to auditory hallucinations (i.e., whether mood instability mediated the relation between child sexual abuse and voice-hearing). The data was consistent with this (although the nature of the study didn’t allow causation to be established).

People’s levels of mood instability were also found to predict their levels of auditory hallucinations 18 months later. However, when people’s levels of general negative mood were controlled for, this relationship was no longer significant (i.e., it was plausible the association was just due to chance).

The authors conclude by suggesting that “direct therapeutic targeting of MI [mood instability] may reduce the propensity to recrudescence of psychotic symptoms”. After looking up what ‘recrudescence’ means, I think the authors are saying that therapy to help make peoples moods more stable might stop their voices re-occurring (of course, this makes the assumption that the voices breaking out again isn’t of any help to the person, which might not be true if we take seriously the idea that some voices are meaningful messangers).

Link to paper: http://dx.doi.org/10.1093/schbul/sbt149 (free to access).

 

Durham: Photo taken c.1400 (nothing changes!)

Durham: Not originally known as Batham.

Durham, England. Pete Moseley and colleagues examine the potential for neurostimulation to help us understand voice-hearing.

Accessible summary: This paper examines the use of neurostimulation techniques, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), to help people with their voices (see previous posts for how these techniques work). The paper examines the evidence for whether these techniques work, and how they might have their potential effects (e.g., improving people’s abilities to recognise their own internally-generated mental creations as their own). It would take too long to summarise this paper, and in any case it is very readable and free to access.

Link to paper: http://dx.doi.org/10.1016/j.neubiorev.2013.10.001 (free to access)

 

Show me the Monet!

Show me the Monet!

Sandviken, Norway. Johnsen and colleagues examine the effectiveness of antipsychotics for hallucinations.

Accessible summary: This study randomly assigned 226 adults, who had been admitted to an emergency ward for psychosis, to be treated with one of four antispsychotics (risperidone, olanzapine, quetiapine, or ziprasidone). The study was particularly interested in whether these drugs helped people with their hallucinations when they were re-assessed 6 weeks later and then 2 years later.

At the start of the study 68% of patients had hallucinations. After 6 weeks this figure had decreased to 33%. Rates of hallucinations decreased quicker (over the two year period) in the patients who took quetiapine or ziprasidone. The authors conclude that “Hallucinations are fairly responsive to antipsychotic drug treatment”.

Is this a reasonable conclusion to reach from the authors’ findings?

No.

First, there was no unmedicated control group. Basically put, until you know what would have happened to people’s rates of hallucinations if they were admitted and supported in  a similar way, but not medicated, you have no good leg to stand on in order to argue that the antipsychotics caused the hallucinations to reduce.

Second, 52% (i.e., over half) of the patients didn’t make it to the 6 week follow up stage. It is quite possible that the people who dropped out were more likely to have hallucinations than those who didn’t drop out. This would have artificially reduced the percentage of people with of hallucination at the 6 week stage.

Third,  people were counted as having hallucinations even if they were only rated as having “One or two clearly formed but infrequent hallucinations, or else a number of vague abnormal perceptions which do not result in distortions of thinking or behavior” (equating to a score of 3 on a measure called the Positive and Negative Syndrome Scale). This is in contrast to many other studies which require a score of 4 or more on this scale (reflecting more severe hallucinatory experiences) in order for hallucinations to be defined as being present.

Antipsychotics may well reduce hallucinations, but unfortunately this study does not prove it (see Appendix A of my book for further discussion on antipsychotics and hallucinations).

Link to paper: http://www.biomedcentral.com/1471-244X/13/241 (free to access)

 

Other papers:

How does tDCS have it’s effect in helping voice-hearing? Link here.

What is the significance of “psychotic symptoms” in children. Free access to paper here.

Altered auditory steady state response to stimuli in people with  auditory hallucinations. Link here.

Is hallucination-proneness related to use of cannabis or cocaine? Link here (paper free to access).

Psychosis in Alzheimer’s Disease. Link here.

Hallucinations in dementia. Link here.

More next month, in the meantime Happy Christmas!

SMJ

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