Psychosis, insight and hearing voices

People with psychosis are said to lack insight when they have a poor awareness that they are mentally ill and don't think they need to get help. Lack of insight is associated with poorer outcomes and worse adherence to treatment while improved insight has been linked to better treatment compliance and less hostility. A team of researchers led by Guillem Lera from the Hospital de la Ribera in Valencia looked into the links between insight and auditory hallucinations in a study of 168 psychotic patients. They found that patients with persistent auditory hallucinations had significantly less insight than patients with occasional or no hallucinations. The further away the hallucinations were thought to come from the less insight people had. The patients who heard voices 'in their head' showed better insight than those who heard voices coming from outside themselves.

Lera, Guillem ... [et al] - Insight among psychotic patients with auditory hallucinations
Journal of Clinical Psychology, 67(7), 1-8

Why people do what the voices tell them to do

People who hear voices often report being given commands by them but not everyone obeys such commands. Researchers from the Adult Learning Disability Service in Prescot, Merseyside and the University of Manchester studied 49 people who were hearing voices. They classified the commands the participants had been given as benign, self-harm or harm-others. The study found that obeying their last self-harm command was associated with 'elevated voice malevolence,' worse symptoms and perceived negative consequences for non-compliance. Compliance with the last harm-others command was associated with more severe symptoms, worse perceived consequences for non-compliance and higher levels of social rank attributed to the voice.

Barrowcliff, Alastair L. and Haddock, Gillian - Factors affecting compliance and resistance to auditory command hallucinations: perceptions of a clinical population Journal of Mental Health, 2010; 1–11, iFirst article

TMS and hearing voices - study shows disappointing results

Transcranial magnetic stimulation (TMS) involves the use of strong, fluctuating magnetic fields to stimulate the surface layers of the brain's cortex. Some studies have shown TMS to be effective in treating auditory hallucinations but a study by researchers at the University of New South Wales has had disappointing results. Eighteen people with schizophrenia had either genuine TMS or a sham treatment for three days. The study found no difference in people's hallucinations between the group who received the genuine TMS treatment and the group who had the sham treatment.

Loo, C.K. ... [et al] - A sham-controlled trial of left and right temporal rTMS for the treatment of auditory hallucinations Psychological Medicine April 2010, 40(4), 541-546

Little people hearing voices

Although hearing voices is one of the main symptoms of psychosis there are thought to be many more people who hear voices than who suffer from psychosis. This is particularly true of children and adolescents and the great majority of children who hear voices do not go on to develop psychosis. Researchers from the University of Groningen in the Netherlands looked into the auditory vocal hallucinations of 3,870 seven and eight-year-olds. They found that over the course of the year 9% of the children heard voices. 15% of the children who heard voices suffered psychological distress and/or had problem behaviour. More children heard voices in rural areas but the consequences of doing so were more severe in urban ones. There was no link between the level of the children's development and their propensity to hear voices.

Bartels-Velthuis, Agna A. ... [et al] - Prevalence and correlates of auditory vocal hallucinations in middle childhood British Journal of Psychiatry January 2010, 196(1), 41-46

Caffeine and hallucinations

People who drink large amounts of tea and coffee may be more prone to hallucinations, according to a study of 200 students, carried out by researchers at Durham University. High caffeine users, those people who consumed more than the equivalent of seven cups of coffee a day, were three times more likely to have heard a person's voice when there was nobody there than low caffeine users who drank less than a cup a day. This could be because caffeine stimulates the release of the stress hormone cortisol, or because those students who are more prone to hallucinations use caffeine to cope with their experiences.

You can find out more about this research at

http://www.sciencedaily.com/releases/2009/01/090113203901.htm

Trauma and hearing voices

The cognitive behavioural model of voice hearing states that it is not the occurence of voices per se that causes distress but the beliefs people hold about them that produce negative behavioural and emotional consequences. Whether voices are seen as malevolent or benevolent, powerful or benign is influenced - according to this theory - by core beliefs that are in turn influenced by people's life history. A Welsh study of 43 voice hearers compared those with predominantly positive beliefs about their voices to those with predominantly negative beliefs. Both groups had had a high prevalence of traumatic life events but those with negative beliefs about their voices were more likely to be experiencing a form of post-traumatic stress disorder (PTSD) and were more likely to have experienced childhood sexual abuse. Current trauma symptoms (re-experience, avoidance and hyper-arousal) were found to be a significant predictor of beliefs about voices and also accounted for a significant proportion of the variance in anxiety and depression.

Andrew, E.M., Gray, N.S. and Snowden, R.J. - The relationship between trauma and beliefs about hearing voices: a study of psychiatric and non-psychiatric voice hearers Psychological Medicine October 2008, 38(10), 1409-1417

Cognitive therapy for voice hearers

Most people with schizophrenia hear voices which can be insulting to them or give commands to harm themselves or other people and can contribute greatly to the distress experienced by people with mental illness. There is an emerging body of evidence that documents the efficacy of cognitive interventions for modifying appraisals linked with voice hearing. A U.S. study of 65 people with schizophrenia divided them up into two groups. One group received treatment as usual while the other group received 12, 90-minute sessions of cognitive interventions delivered by a mental-health nurse. Those who had received the cognitive intervention reported less severe hallucinations even a year after treatment and were over thirteen times as likely to maintain a reduction in their hallucinations.

England, Margaret - Significance of cognitive intervention for voice hearers Perspectives in Psychiatric Care January 2008, 44(1), 40-47

Auditory hallucinations in children

Hallucinations are considered to be a significant symptom of psychopathology in adulthood but children also experience auditory hallucinations. Children with conduct and emotional disorders, affective syndromes, migraines, anxiety, and adjustment disorders can all have auditory hallucinations. An Australian study of children being seen by community mental health services found strong associations between auditory hallucinations in non-psychotic children and family dysfunction and break-up. The children who heard things also had significant levels of anxiety and depression. Half of the children in the study had imaginary friends.

Best, Nicole T. and Mertin, Peter - Correlates of auditory hallucinations in nonpsychotic children Clinical Child Psychology and Psychiatry October 2007, 12(4), 611-623

Imaginary friends and verbal hallucinations

One of the most interesting psychological features of young children are their relationships to their imaginary friends. Between 28-65% of young children have imaginary friends and contrary to stereotypes of such children being emotionally disturbed, withdrawn and shy recent research has shown having an imaginary friend to be associated with positive developmental outcomes. Some psychologists have wondered how having an imaginary friend in childhood might affect development in adulthood and have observed how talking to an imaginary friend bears a similarity to symptoms of psychopathology such as verbal hallucinations. A study of 80 young children (4-8) in Australia and the north of England asked them whether they had an imaginary friend and then carried out a jumbled speech task on them which measures participants' likelihood of perceiving words in meaningless but speech-like auditory stimuli. The researchers found that those children who had an imaginary friend were more likely to report hearing words and phrases in the jumbled speech task independent of their age, sex and verbal ability. The findings of the study were consistent with the hypothesis that engaging with imaginary friends is one aspect of a general susceptibility to imaginary verbal experiences.

Fernyhough, Charles ... [et al] - Imaginary companions and young children's responses to ambiguous auditory stimuli : implications for typical and atypical development Journal of Child Psychology and Psychiatry November 2007, 48(11), 1094-1101