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Voices & Visions: A normal psychological process?
A contextual approach to Psychosis
Ciara McEnteggart & Yvonne Barnes-Holmes
National University of Ireland, MaynoothChristian Hopkins
Photography ©
Historically, voices were encapsulated by the psychoses and a
diagnosis of schizophrenia
Kraepelin coined the term ‘dementia praecox’ (disturbed metabolism)
Bleuler (1911) coined the term ‘schizophrenia’ (split mind) and was
the first to describe the notions of positive and negative symptoms
Early on, Bleuler believed ‘schizophrenia’ represented human conflict,
however, later he felt obliged to support the physical disease model
proposed by Kraeplin
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Histor ica l Perspect ives of Psychosis
‘Symptoms’
Often classified as positive and negative (Bleuler)
Positive:
Hallucinations
disorganised speech
delusions
Negative:
avolition/apathy (lack of energy, inability to conduct normal tasks),
alogia, anhedonia (lack of close relationships),
flat affect
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Early Theories
Early theories included:
Glucose Metabolism problems (i.e. low in pfc)
Brain Abnormalities: enlarged ventricles post mortem; atrophy in temporal and frontal regions; reduced volume in basal ganglia and limbic structures
Genetic: adoption & twin studies. But, authors noted importance of new environment
Prenatal complications (e.g. delivery complications, prenatal virus)
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Early Theories
Dopamine Hypothesis Investigated alongside anti-psychotic development (said to block dopamine at d2
receptors). But drugs that didn’t block these receptors had the same effects, and post-mortem patients show no difference in dopamine
Revised as the Dopamine-Serotonin Hypothesis
Krishnan and Nestler: “there is little evidence to implicate true deficits in serotonergic or dopaminergic neurotransmission”
Horgan: “Given the ubiquity of a neurotransmitter such as serotonin and the multiplicity of its functions, it is almost as meaningless to implicate it in depression as it is to implicate blood”.
Sarbin and Mancus (1980) conducted the largest study on schizophrenia by examining 60 studies suggesting schizophrenia is a disease and found only small differences between those diagnosed with schizophrenia and controls on experimental tasks
None of these biological explanations has provided sufficient evidence that these topographies are physical in nature.
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Early Treatments
Insulin Coma Therapy
poor efficacy for treatment of ‘symptoms’, severe side-effects (i.e. brain damage and even death, Sadler, 1953)
Psychosurgery
Lobotomies were proposed to sever the ‘fixed’ neural pathways involved in the type of suffering
Enormous side-effects through brain damage on both physical and emotional functioning
Deaths were as high as 12% through intracerebral haemorrhage
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Drug Treatments (i.e. antipsychotics and neuroleptics)
Profound physical and cognitive side-effects
akathisia, dizziness, sexual dysfunction, diabetes, insulin resiatance, weight gain, blurred vision, respiratory disorders, infertility, blood abnormalities, brain damage, extra-pyramidialsymptoms, tardive dyskinesia (PD), death, reduced altertness, motor speed, attention
Efficacy questioned
Pharma studies reliably find good drug outcomes both vs. placebo and vs. the older drugs, independently funded studies do not
McMonagle reviewed 2000 RCTs on the effectiveness of neuroleptics as an intervention for ‘schizophrenia’ and argued that argued that “The combination of low numbers, massive drop-out rates, unresponsive patients and short duration – the studies lasted on average six weeks – make most of the trials irrelevant to everyday clinical practice”
Early Treatments
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Hearing Voices
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What do we mean by hear ing voices?
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Topographies of Voices
Voices are not simply externalised thoughts
They may be:
your own voice but heard as another entity
the voice of someone you know/once knew
The voice of someone you are not familiar with
Voices can have different topographies (Larøi et al., 2012)
Locus, personalisation, acoustic and linguistic properties of the voices,
frequency, controllability; valence; voice change over time
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Prevalence
75% of the population have heard voices at one point in their lives (Longden et al.,
2012)
Hypnogogic & hypnopompic states
Hearing Mobile when not ringing
Hear someone calling your name
Famous People who hear voices:
Johnny Vegas
Lady Gaga
Anthony Hopkins
Freud
Aristotle
Ghandi
Joan of Arc
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Prevalence: Cl inica l vs . Non -cl in ica l
Clinical populations (i.e. psychiatric diagnosis) – 70% in schizophrenia and
80% in Dissociative Disorders
10-15% of the typical population hear voices and often 20%+ in Universities
(see Longden et al., 2012 for a review)
However, there are key differences between voice hearing in clinical suffering
and voice hearing in non-clinical contexts
Absence of social or occupational dysfunction (McCarthy-Jones, 2012a)
No apparent struggle with voices
The experience is not associated with pathology
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Prevalence: Chi ldren
Kelleher et al. (2012) - reviewed 4 population studies (N=2666) and found
voices more prevalent in younger children
21-23% of 11-13 year olds, 7% of 14-16 year olds
Bartels-Velthuis et al. (2010) – studied 7/8 year olds (N=3870)
9% heard voices within previous year
Only 15% had emotional or behavioural problems
Laurens et al. (2006) – studied 9-12 year olds (N= 548)
30% heard voices, 28% had visions
What causes these experiences?
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Laing said it was a strategy for carrying on with life in an unliveable situation
Metaphorical expression of what cannot be said – why voices/visions often have
metaphorical meaning
Links with creativity
Creates a world (real to them) where painful aspects of their lives are relived or changed
Functions as an escape from reality
It is a way of coping with the world, and your place in it.
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Sense of Self Threatened
Family Dynamic
Early researchers suggesting parenting style was cold, dominant and conflict ridden (i.e. “the schizophrenic mother”)
Early family relationships (Johnstone)
Blurred boundaries in relationships
Difficulty achieving separated independence
Confusions about identity
Confused communications
Physical, emotional and sexual intrusiveness
Social isolation
Marital disharmony
Problems often appear during separation from home environment in adolescence as the child is often unaware of any fractures in their sense of self before this time
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Childhood Adversities
Extensive evidence suggesting trauma or severe stress precede and even precipitates voice hearing experiences (e.g.Daalman et al., 2012; Shevlin et al., 2007).
Physical and sexual abuse is the most common reported in both clinical and non-clinical groups (McCarthy-Jones, 2011)
Janssen et al. (2004) found a dose-response relationship when controlling for other relevant variables
Read et al (2005) carried out an epidemiological review and found childhood trauma (esp. CSA & CPA) was more significantly associated with voices than any other symptom of psychosis
Daalman et al. (2012) found that clinical and non-clinical voice hearers were equally more likely to have experienced sexual and emotional abuse than non-voice hearing controls
Later context predicts outcomes and distress
Highest prevalence in Low SES groups, but this may be correlational due to lack of earning potential due to problem associated with sufferingMay also be attractive as less social pressure in these areas
Read et al. (2008) also found the same result with regard to outgroups in specific geographical areas (e.g., being black in a predominately white neighbourhood)
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Social Inequalities
Cultural Differences
In other cultures, voice hearers are worshipped
Example: Shamanism
“The shaman uses ecstatic techniques to enter the shamanic state of consciousness (SSC) travel out of the body, make contact with spirit guides and power animals and therefore effect changes in ordinary reality, working closely with nature and the elemental forces. Shamanic practice and techniques help us reconnect to ourselves, each other, the Earth and to the great mystery that we are all a part of.”
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Interpreting Voices and Visions
Originally viewed as untreatable, because it was a “biological disease”
When you consider the context in which these individuals developed, what may seem completely incoherent experiences, actually start to appear more coherent
Often difficult for people to see this as the experiences are often metaphorical or thematic
Beliefs surrounding these experiences (often called “delusions/paranoia”) are there to offer some intuition (“making sense”) about the experiences for those who may not make the link with their own past experiences to their voices/visions
Mediating factors which help recovery are: Home, job, social support, hope, and independence, validation (i.e. normalisation)
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IRAP Research
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Is it a normal verbal process?
Much of the literature, even as far back as the 60s, adheres to the view that these experiences reflect the operations of normal, rather than abnormal,verbal processes (e.g. (Johns & van Os)
This perspective assumes a continuum of normal psychological functioning with regard to voice hearing, which can be traced back Galton (1883) and James (1892).
This model has been supported by the numerous studies on the large prevalence of voice hearing in the general population and the link between childhood adversities and voice hearing
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Research to date comparing non-clinical and clinical voice hearers has been phenomenological, hence focusing on topographical features, e.g. Locus of voices, negativity etc.
However, other researchers have sought a more functional difference between the two groups and have suggested that they may differ in terms of how they interact or respond to voices and indeed this feature has been found to be a precise predictor of coping.
For example, clinical voice hearers report greater fear, inability to control their voices and are more likely to resist them, whereas non-clinical voice hearers report less fear, and are more likely to engage with them (Andrew, Gray & Snowden, 2008; Honig et al., 1998).
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Clinical vs. Non-clinical
Clinical vs. Non-clinical
Specifically, Brett et al. (2007) reported that non-clinical voice hearers use less avoidance strategies with regard to voices and fully accept the presence of voices, although this was not the case with clinical voice hearers.
Similarly, Daalman et al. (2010) reported that lower perceived controllability of voices predicts a clinical diagnosis of psychosis and increased contact with mental health services
Some studies have suggested that voice valence (i.e. positive or negative) may influence perceptions of controllability and levels of avoidance
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IRAP Research
The Implicit Relational Assessment Procedure (IRAP) is a measure of verbal process which was derived from a modern behavioural account of human language and cognition: -- Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001).
It allows us to measure the verbal processes involved in specific domains of interest and has already been highly beneficial in the investigation of psychological suffering in several other domains.
IRAP could potentially parse out precise implicit differences at the level of process between voice hearing populations.
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Research Questions
1. Does Voice Valence influence controllability?
2. Do non-clinical voice hearers perceive voices and visions more positively than clinical voice hearers?
3. Do non-clinical voice hearers accept voices more than clinical voice hearers?
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Research Questions
3 Populations: Non-clinical (N=20), Clinical (N=11), Controls (N=20)
2 IRAPs
1. Valence:
voices bad, voices good, visions bad, visions good
2. Controllablity
Pleasant Accept, Pleasant Avoid, Annoying Accept, Annoying Avoid
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1. Valence Irap
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Research Questions
The voices I hear The things I see
Devalue me Lift me
Are frightening Give me guidance
Are scary Help me
Are against me Are kind
Annoy me Calm me
Are a hindrance Are funny
Frustrate me Are my friend
Undermine me Feel good
2. Controllability IRAP
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Research Questions
If my voices are pleasant I If my voices are annoying I
Welcome them Block them out
Try to keep them Ignore them
Accept them Suppress them
Listen to them Try to stop them
Cherish them Abstract myself
Am open to them Shut them up
• Participants also completed a set of explicit measures:
VAAS (Voices Acceptance and Action Scale),
BAVQ-R (Beliefs about Voices Questionnaire)
CAPE (Community Assessment of Psychotic Experiences)
PSYRATS (Psychotic Symptom Rating Scales)
AAQ-II (Psychological Flexibility)
ATQ (Automatic Thoughts Questionnaire)
SAB (Stigmatising Attitudes Believability)
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Research Questions
Valence
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-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
0.05
Visions Good Visions Bad Voices Good Voices Bad
Non-clinical Clinical Controls
+ve
-ve
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Controllability
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Pleasant Accept Pleasant Avoid Annoying Accept Annoying Avoid
non-clinicals clinical controls
Accept
Avoid
Results
Found Non-clinical voice hearers to be more neutral (slightly positive) towards voices
Clinical Voice Hearers highly negative towards voices
Non-clinical voice hearers were equally likely to accept positive and negative voices, but clinical voice hearers were more likely to avoid positive voices than negative voices
IRAP reliably predicted distress on self-report measures and those who were more distressed perceived voices more negatively and showed less acceptance towards voices in both clinical and non-clinical samples.
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Results
So, if we look at this functionally, perhaps what separates out these populations is, levels of distress, how negative voices are perceived and how accepting they are towards voices.
Of course, there are many other contextual factors which may influence voice hearers ability to cope, as mentioned earlier.
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Conclusions
• This data and other data collected thus far is beginning to show some differences between the groups, particularly with regard to valence and controllability and is at least suggested that the IRAP is a potentially useful tool for, not only observing differences between these groups, but ultimately for answering two critical questions:
1. Is voice hearing a normal verbal process?
2. Does something happen to this normal verbal process to create the type of suffering that often accompanies voice hearing?
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Further Questions
• This work has just opened up a can of worms!
• So little functional-analytic work done on psychosis
• New theories believe psychosis is actually dissociative in nature – problem with the self
• Is the self dissociated? How does this process happen (developmentally)? Does this process happen in all individuals, and only get skewed in severe contexts, or just in those somehow predisposed to voices?
• Answering these questions will help us fully answer the question of whether psychosis is a normal verbal process with more conviction.
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