Introdução: Nos últimos anos, nosso Grupo de Pesquisa em Zumbido identificou um número crescente de pacientes que referiram percepções repetidas de músicas e vozes, além do zumbido. Tais fenômenos alucinatórios nos instigaram a estudar suas possíveis relações com o psiquismo destes pacientes. Objetivos: avaliar se os fenômenos alucinatórios dos pacientes com zumbido têm relação com a psicose e/ou a depressão, além de esclarecer seu conteúdo e função no psiquismo. Casuística e métodos: Dez sujeitos (8 mulheres, idade média de 65,7 anos) foram avaliados pelo Inventário Fatorial da Personalidade (IFP), Escala para Depressão de Hamilton (HAM-D), entrevista semi-dirigida e entrevistas psicanalíticas. Resultados: Todos apresentaram relação dos fenômenos auditivos com a neurose e sintomas depressivos. Nove pacientes evidenciaram nítida relação entre o psiquismo e o conteúdo ou função de seus fenômenos, os quais representaram ou resgataram aspectos da vida afetiva. A repetição dos fenômenos e do sofrimento ofereceu uma satisfação paradoxal, que foi marcante em todos os casos. Conclusões: Evidenciou-se uma importante relação entre zumbido, fenômenos alucinatórios auditivos e depressão sustentada na satisfação paradoxal com a repetição do sofrimento, o que está vinculado ao caráter neurótico. / In the last few years, our Tinnitus Research Group identified a growing number of patients that repeatedly reported, in addition to tinnitus, perceptions of music and voices. Such hallucinatory phenomena inspired us to study their possible relation with these patients psychism. Objective: To assess whether the delusive phenomena of tinnitus patients are psychosis and / or depression related, in addition to clarify its content and function in the psychism. Methods: Ten subjects (8 women, mean age 65.7 years) were assessed by the Factorial Inventory of Personality (FIP), the Hamilton Depression Rating Scale (HDRS), semi-structured interviews and psychoanalytic interviews. Results: All results showed a relationship between auditory phenomena and neurosis or depressive symptoms. Nine patients showed a clear relationship between the psychism and the content or function of their phenomena, which represented or rescued affective aspects of life. The repetition of the phenomena and the suffering offered a paradoxical satisfaction, which was noticeable in all cases. Conclusion: A significant relationship between tinnitus, hallucinatory phenomena and depression was evidenced by the paradoxical satisfaction with the repetition of suffering, which is linked to the neurotic trait.

Introdução: Nos últimos anos, nosso Grupo de Pesquisa em Zumbido identificou um número crescente de pacientes que referiram percepções repetidas de músicas e vozes, além do zumbido. Tais fenômenos alucinatórios nos instigaram a estudar suas possíveis relações com o psiquismo destes pacientes. Objetivos: avaliar se os fenômenos alucinatórios dos pacientes com zumbido têm relação com a psicose e/ou a depressão, além de esclarecer seu conteúdo e função no psiquismo. Casuística e métodos: Dez sujeitos (8 mulheres, idade média de 65,7 anos) foram avaliados pelo Inventário Fatorial da Personalidade (IFP), Escala para Depressão de Hamilton (HAM-D), entrevista semi-dirigida e entrevistas psicanalíticas. Resultados: Todos apresentaram relação dos fenômenos auditivos com a neurose e sintomas depressivos. Nove pacientes evidenciaram nítida relação entre o psiquismo e o conteúdo ou função de seus fenômenos, os quais representaram ou resgataram aspectos da vida afetiva. A repetição dos fenômenos e do sofrimento ofereceu uma satisfação paradoxal, que foi marcante em todos os casos. Conclusões: Evidenciou-se uma importante relação entre zumbido, fenômenos alucinatórios auditivos e depressão sustentada na satisfação paradoxal com a repetição do sofrimento, o que está vinculado ao caráter neurótico. / In the last few years, our Tinnitus Research Group identified a growing number of patients that repeatedly reported, in addition to tinnitus, perceptions of music and voices. Such hallucinatory phenomena inspired us to study their possible relation with these patients psychism. Objective: To assess whether the delusive phenomena of tinnitus patients are psychosis and / or depression related, in addition to clarify its content and function in the psychism. Methods: Ten subjects (8 women, mean age 65.7 years) were assessed by the Factorial Inventory of Personality (FIP), the Hamilton Depression Rating Scale (HDRS), semi-structured interviews and psychoanalytic interviews. Results: All results showed a relationship between auditory phenomena and neurosis or depressive symptoms. Nine patients showed a clear relationship between the psychism and the content or function of their phenomena, which represented or rescued affective aspects of life. The repetition of the phenomena and the suffering offered a paradoxical satisfaction, which was noticeable in all cases. Conclusion: A significant relationship between tinnitus, hallucinatory phenomena and depression was evidenced by the paradoxical satisfaction with the repetition of suffering, which is linked to the neurotic trait.

Voice hearing (or auditory verbal hallucinations) is a commonly reported experience across a range of psychiatric diagnoses, and is often associated with high levels of distress and disruption to everyday functioning. Many people troubled by voices see little benefit from antipsychotic medication, prompting attempts to understand and target psychological mechanisms underlying both the emergence of voices and associated distress. Research to date has typically adopted a cross-sectional approach, identifying factors associated with the tendency to hear distressing voices. However, less is known about the ‘proximal' mechanisms associated with fluctuations in voices and distress during the daily lives of voice hearers. Psychological therapies for distressing voices have demonstrated limited success in reducing voice-related distress, and it is suggested that a better understanding of the proximal mechanisms underlying voices may facilitate advancements in these interventions. The studies within this thesis utilise the Experience Sampling Method (ESM), an ecological momentary assessment (EMA) approach that allows the intensive, ‘micro-longitudinal' sampling of voice hearing experiences in the natural contexts in which they are experienced. First, ESM is used to investigate the antecedent and modulating roles of stress and dissociative experiences in voice hearing (N=31). Next, the role of behavioural responses and voice appraisals in the maintenance of voice-related distress during daily life are explored (N=31). Then, a data-based illustration of the potential of ESM for delineating key psychological mechanisms underlying gains in psychological interventions for distressing voices is provided (N=2). Finally, factors associated with stress-induced depersonalisation as a proximal mechanism for voice hearing are explored (N=29). Current findings support the role of depersonalisation as a mediator in the observed relationship between daily life stress and increases in voice intensity. Findings additionally support a role for negative voice appraisals in the experience of momentary voice distress, and a role of behavioural responses in maintaining both distress and voice appraisals over time. Preliminary evidence was obtained for a range of processes involving changes in voice appraisals and emotional reactivity potentially underlying therapeutic gains during cognitive behavioural therapy for psychosis. These findings encourage a greater focus of interventions on targeting mechanisms associated with daily life voice hearing and associated distress, including stress-induced depersonalisation, negative voice appraisals, and maladaptive behavioural responses to voices. They also suggest a parallel use for ESM as a means of enhancing treatment efficacy within the context of psychological interventions.

Auditory Verbal Hallucinations (AVH) are a generally distressing phenomena that can have a negative impact on the quality of life of the experiencer. Furthermore, individuals diagnosed with psychotic disorders often display deficits in social/cognitive domains. Despite this, little is known about how AVHs directly affect social functioning and mental status. Because of this dearth of information, exploratory research is needed to generate potential avenues for future experimental research. Qualitative themes about how AVHs influence behavior were derived from interviews with mental health social workers. Eight primary domains were identified: Behavior, social ability, observable traits, voice plasticity, life difficulty, beneficial auditory hallucinations, coping strategies, and stigmas. Implications of this research could guide future direction for experimental research as well as contribute to assessment and treatment procedures of psychotic individuals.

[Truncated abstract] Auditory hallucinations (AHs) are one of the most common symptoms of schizophrenia, and are associated with high levels of distress, functional impairment, and need for care. However, current understanding of the exact causes and thus treatment of AHs is still in its infancy. Recently, Badcock and colleagues proposed a cognitive dual-deficit model of AHs, which stipulates that intentional inhibition deficits underlie the intrusive and unintentional nature of AHs, while context memory binding deficits explain the source misattribution (Waters, Badcock, Michie, & Maybery, 2006). While this model seems to best explain the different features of AHs, the precise components of inhibitory control involved, and the evident role of negative affect in the production of AHs, have not been empirically examined. Thus, the first two aims of this thesis were to clarify the critical component(s) of inhibitory control specifically related to AHs, and to examine the relationships between negative affect (chiefly anxiety), AHs and inhibitory control. Finally, AHs are also commonly reported by individuals in the general population, consistent with a continuum approach to AHs. Accordingly, the third aim of this thesis was to investigate whether similar relationships exist between hallucinatory-type experiences, inhibitory processes and negative affect in both hallucination predisposition and schizophrenia. The first study presents the findings from two related investigations of hallucination predisposition. ... However, the study revealed a significant relationship between intentional inhibition and trait anxiety (which was independent of hallucination predisposition) allowing the possibility that more severe or longer lasting changes in anxiety may indeed exacerbate difficulties with intentional inhibition. The final study sought to determine whether the pattern of relationships between AHs, inhibitory impairments and anxiety in schizophrenia are similar to those found in hallucination predisposition. The same three cognitive tasks previously employed (ICIM, B-P, and DI) were administered to schizophrenia (N = 61) and healthy control (N = 34) participants. Schizophrenia participants overall exhibited difficulties intentionally resisting interference from distracting stimuli, however did not have difficulties [intentionally or unintentionally] inhibiting task-irrelevant memory traces. Consistent with the continuum approach, AHs were related only to difficulties with intentional inhibition, and these difficulties existed independently from anxiety (although anxiety was related to intentional inhibition) and were unrelated to other schizophrenia symptoms. Together, the studies support the first component of Badcock et al.'s dual-deficit model of AHs, with hallucinatory experiences in both hallucination predisposition and schizophrenia associated with specific intentional inhibition impairments. The findings also suggest that while anxiety may contribute to the production of AHs by exacerbating v existing intentional inhibition impairments, it is likely that anxiety has additional routes of influence. These findings provide strong support for the continuum approach to AHs. The implications of these findings and possible avenues for future research are discussed.

Schizophrenia (SZ) is a complex and chronic psychotic disorder that affects approximately 1% of the world's population and is associated with positive, negative, and cognitive symptoms. Auditory verbal hallucinations (AVHs) are a key symptom of SZ that cause functional impairments and distress. Despite antipsychotic medication treatments, 25% of patients experience medication resistant AVHs. Additional research into the underlying neuronal mechanisms of AVHs is needed to develop alternative treatments. The mismatch negativity (MMN) is an auditory event-related potential that represents pre-attentive detection of stimulus deviance. MMN deficits are prominent in SZ and are associated with greater AVH frequency. MMN deficits may also be related to qualitative features of AVHs, which have yet to be extensively assessed. The primary aim of this work was to assess differences in MMN features (amplitude and latency) between SZ patients and healthy controls (HCs) using two different versions of the MMN five deviant multi-feature task (pure tone and speech-based sounds). The second aim was to examine relationships between MMN features, clinical ratings of AVH severity (The Psychotic Symptom Rating Scale [PSYRATS] total score, Positive and Negative Syndrome Scale [PANSS] item 3 ["hallucinatory behaviour"]) and self-report measures of AVH features in SZ patients (i.e., the Beliefs About Voices Questionnaire-Revised [BAVQ-R], Voice Acceptance and Action Scale [VAAS] and the Voice Power Differential Scale [VPDS]), the latter has yet to be assessed. The secondary aim was to directly compare differences in the MMN responses between SZ and HC groups across the two tasks. Finally, exploratory aims included examining differences in MMN responses to low and high frequency and intensity deviants in the tone task and assessing differences in the MMN response between groups at the mastoid sites (TP9/TP10), where the polarity reversal of the MMN occurs. These more methodological aims have not been previously assessed, to our knowledge. The SZ group (n = 16) had significantly smaller MMN amplitudes to the frequency, gap and intensity deviants compared to the HC group (n = 17) in the MMN tone task. In the MMN speech task, the SZ group had significantly smaller MMN amplitudes to the frequency, intensity, vowel duration and consonant deviants compared to the HC group. The correlation analysis revealed that the most pronounced relation was a positive association between MMN amplitudes to the intensity deviant (tone task) and total scores on the VPDS (i.e., smaller/less negative MMN amplitudes were associated with higher VPDS scores). For the secondary analyses, the SZ group had smaller MMN amplitudes to the frequency deviant in both the tone and speech MMN tasks. Finally, the exploratory mastoid analysis in the tone task revealed that the SZ group had smaller MMN amplitudes to the frequency deviant at both mastoid sites. In the speech task, MMN amplitudes were larger at the left mastoid site (TP9) compared to the right mastoid site (TP10) across all deviant types. The HC group also had larger MMN amplitudes at the left mastoid site (TP9) compared to the SZ group. This study revealed MMN deficits in SZ patients across a variety of deviant types, including both pure tone deviants and speech-based deviants. MMN deficits were most pronounced for the frequency and intensity deviants across both tasks, suggesting that SZ patients with persistent AVHs may have more generalized deficits in the automatic processing of basic units of speech and pure tones, rather than impaired processing of specific acoustic features. Associations between MMN features and subjective measures of AVHs revealed that impaired processing of pure tone intensity deviants is related with a greater perceived "power" of the voice, impaired processing of speech-based frequency deviants is related to greater clinical AVH severity, and that impaired and less efficient processing of both vowel and pure tone deviants are related to a higher perceived hostility of the voice. This study adds valuable information to the literature regarding relationships between MMN features and subjective aspects of the AVH experience in SZ patients. Importantly, this work is novel as it is the first to directly compare MMN responses across two tasks (speech and sound) in SZ patients with persistent AVHs. This thesis emphasizes the importance of examining subjective aspects of the AVH experience in the context of the MMN to gather a more complete understanding of how AVHs are impacting brain responses.

Hearing distressing voices (also known as auditory verbal hallucinations) is a common symptom associated with a number of mental health problems. Psychological therapies, specifically cognitive behaviour therapy (CBT) can be an effective intervention for this patient group. The aim of CBT for voices (CBTv) is to reduce the distress associated with the experience, by encouraging the patient to re-evaluate their beliefs about the voice's omnipotence, omniscience, and malevolence. Despite the evidence for CBTv, very few patients are offered this therapy; largely due to a lack of resources. The aim of this thesis was to develop and begin to evaluate a CBT-based intervention for voices that was resource-light; in the hope that it could be more easily be implemented into clinical services, and therefore increase access. This thesis begins with an introduction to the research area, and is followed by a review and evaluation of the methods used in this thesis. Chapter 6 is a systematic review and meta-analysis of the current literature on brief (< 16 NICE recommended sessions) CBT for psychosis (CBTp). Chapters 7 and 8 describe the process of developing a brief CBT intervention for voices, based on the CBT self-help book ‘Overcoming Distressing Voices'. Both people who hear voices, and mental health clinicians were consulted on the intervention concept and design. The outcome of these studies was guided self-help CBTv, and an accompanying therapy workbook to guide the intervention. Chapters 9 and 10 detail the design and findings of a randomised controlled trial of guided self-help CBTv delivered by Clinical Psychologists, versus a wait-list control group. Data was collected at baseline (pre-randomisation) and 12 weeks post-randomisation. The primary outcome was voice-related distress. The findings across all of the studies are then summarised and reflected upon within the Discussion chapter – including consideration of the extent to which the overall aim of this thesis (increasing access) has been achieved.

The purpose of this study was to test the hypothesis that the hearing distressing voices simulation training, Developing Empathy for the Lived Experience of Psychiatric Disability: A Simulation of Hearing Distressing Voices (HDVS), developed by Patricia E. Deegan, Ph.D., will affect counseling students’ empathy for clients diagnosed with schizophrenia, as measured by the Jefferson Scale of Empathy – Health Professions Students version (JSE-HPS). The experimental design was a quasi-experimental, one-group, pre-test/ post-test, and the Jefferson Scale of Empathy – Health Professions Students version was used to measure empathy. A total of 55 participants were drawn from a convenience sample of master’s counseling students from CACREP-accredited programs in southern Louisiana and Chicago, Illinois. A two tailed, paired samples t-test revealed that there was a significant difference (pM=116.11, SD=9.76) and post-test empathy scores (M=121.85, SD=8.9). This study suggests the HVDS is an effective tool to assist counseling students with developing empathy, decreasing stigmatizing attitudes, and avoiding disempowerment and marginalization within the counseling relationship.

The aim of this study was to explore the experience of hearing voices in the general New Zealand adult population. This included mapping the topography of voices and the impact of the experience on participants’ lives, exploring participants’ explanatory models, investigating coping strategies and support structures, and developing a model of the essence of hearing voices. Quantitative and qualitative analyses of questionnaire (n=154) and interview (n=50) data revealed a great diversity of experiences, both within and among participants. Of all topographical variables significantly related to emotional impact (content, form, duration, intrusiveness and control), voice content was the only significant predictor variable, accurately predicting the emotional response of 93.3% of participants. Overall, participants who valued their voice experiences tended to have spiritual beliefs, a more positive emotional reaction and less contact with mental health services. In contrast, participants who experienced mostly unwanted voices tended to have biological and/or psychological understandings of their voice experiences, a more negative emotional reaction to them, and increased contact with mental health services. Participants reported using a vast array of coping strategies, with varying degrees of success. Individualised techniques were reported to be the most effective, followed by setting aside a time to listen to the voices. In terms of help and support, participants called for a model of intervention that accepted their voice experiences as real, took an holistic approach incorporating contextual, cultural and spiritual factors, and worked with voice-hearers, their families and the public to provide information about voice phenomena and normalise the experience. Using a phenomenological approach, a model of the essential structure of hearing voices is proposed, comprising five components: the content of the voices is personally meaningful to the voice-hearer; the voices have a characterised identity; the person has a relationship with their voices; the experience has a significant impact on the voice-hearer’s life; and the experience has a compelling sense of reality. The implications of this research include validating voice-hearers’ perspectives of the experience, informing clinical work with voice-hearers, and informing the development of local and national-level services, such as a New Zealand Hearing Voices Network.

The aim of this study was to explore the experience of hearing voices in the general New Zealand adult population. This included mapping the topography of voices and the impact of the experience on participants’ lives, exploring participants’ explanatory models, investigating coping strategies and support structures, and developing a model of the essence of hearing voices. Quantitative and qualitative analyses of questionnaire (n=154) and interview (n=50) data revealed a great diversity of experiences, both within and among participants. Of all topographical variables significantly related to emotional impact (content, form, duration, intrusiveness and control), voice content was the only significant predictor variable, accurately predicting the emotional response of 93.3% of participants. Overall, participants who valued their voice experiences tended to have spiritual beliefs, a more positive emotional reaction and less contact with mental health services. In contrast, participants who experienced mostly unwanted voices tended to have biological and/or psychological understandings of their voice experiences, a more negative emotional reaction to them, and increased contact with mental health services. Participants reported using a vast array of coping strategies, with varying degrees of success. Individualised techniques were reported to be the most effective, followed by setting aside a time to listen to the voices. In terms of help and support, participants called for a model of intervention that accepted their voice experiences as real, took an holistic approach incorporating contextual, cultural and spiritual factors, and worked with voice-hearers, their families and the public to provide information about voice phenomena and normalise the experience. Using a phenomenological approach, a model of the essential structure of hearing voices is proposed, comprising five components: the content of the voices is personally meaningful to the voice-hearer; the voices have a characterised identity; the person has a relationship with their voices; the experience has a significant impact on the voice-hearer’s life; and the experience has a compelling sense of reality. The implications of this research include validating voice-hearers’ perspectives of the experience, informing clinical work with voice-hearers, and informing the development of local and national-level services, such as a New Zealand Hearing Voices Network.