Cognitive Processing Associated With
Hallucinations For At Risk Mental State
Steven Bryce Leicester
Submitted in total fulfilment of the requirements of the
degree of Doctor of Philosophy
June 2013
School of Psychological Sciences
Faculty of Medicine, Dentistry and Health Sciences
The University of Melbourne
i
Abstract
To date there has been limited investigation of cognitive factors associated
with the experience of hallucinations for individuals identified as being at
Ultra-High Risk (UHR) for psychosis. This study is the first to
comprehensively examine the relationship between auditory hallucinations
within a UHR population and prominent cognitive models of perceptual
disturbances.
Source monitoring, appraisal of cognitive intrusions and metacognition
were compared between three groups: a UHR group reporting auditory
hallucinations, a UHR comparison group without hallucinations and a nonpatient comparison group. The UHR group reporting auditory
hallucinations displayed distinct deficits in source monitoring and appraisal
of cognitive intrusions, indicating that biases in cognitive processing
appear to be associated with the development of hallucinations for UHR
populations.
Additionally, follow up of the UHR participants was conducted in order to
examine the association between cognitive processing biases and
persistence of hallucinations. Source monitoring deficits as well as beliefs
about the omnipotence of voices were strongly associated with the
persistence of hallucinations over the follow up period.
This is the first study to demonstrate that distinct cognitive biases are
associated with the development of hallucinations during the UHR period.
These results provide evidence that cognitive biases may contribute to the
emergence of hallucinations, prior to the onset of frank psychosis.
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iii
Declaration
This thesis comprises only my original work, except where due
acknowledgement is made in the text to material used.
The thesis is less than 100,000 words in length, exclusive of tables,
references and appendices.
__________________________
Steven Leicester
__________________
Date
iv
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Acknowledgements
First of all I would like to thank Professor John Gleeson for his unwavering
patience, direction and encouragement throughout this project. His clarity
and optimism have been invaluable from the first seed of an idea through
to completion. John has been an inspiring example of how research and
clinical work can complement and enhance each other. He stretched his
role as supervisor well beyond what was required and extended his
generosity from start to finish. For this I hold immense gratitude.
I would also like to thank Associate Professor Carol Hulbert who stepped
in to provide stability during uncertain times.
Associate Professor Lisa Phillips has been an inspiration and motivator
throughout this project. Her wisdom and pragmatism has often cleared
my confusion, and her belief in me has never faltered.
There are several colleagues from Orygen I would like to extend my
gratitude toward for their consistent support throughout the journey: Dr.
Barnaby Nelson, Dr. Shona Francey, Dr. Jane Edwards, Dr. Andrew
Thompson, Kristan Baker, Dr. Mario Alvarez, Professor Alison Yung and
Professor Patrick McGorry.
This research would not have been possible without the participation of
the young people and their families who attend the PACE Clinic. They were
willing to contribute their time and knowledge during a challenging time in
their lives.
Lisa, Rose and Gemma - I will now be more available than ever. The
adventures that await us have kept me focused on completion and I can’t
wait to have our weekends back.
Finally, to Bob. You have been my inspiration and aspiration. This is for
you.
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Table of Contents
Abstract ...........................................................................................ii
Declaration ...................................................................................... iv
Acknowledgements ........................................................................... vi
Table of Contents ........................................................................... viii
List of Tables ................................................................................. xiv
List of Figures ................................................................................ xvi
List of Appendices.......................................................................... xvii
CHAPTER 1 Introduction and Overview ................................................ 1
1.1 Rationale – Hallucinations and High Risk Populations .................... 2
1.2 Hallucinations .......................................................................... 2
1.3 High Risk for Psychosis Populations ............................................ 3
1.4 Cognitive Processing Factors and Hallucinations ........................... 4
1.4.1 Source Monitoring. .............................................................. 5
1.4.2 Metacognition..................................................................... 5
1.4.3 Unwanted intrusive thoughts. ............................................... 6
1.4.4 Appraisal and response to hallucinations. ............................... 7
1.5 Hypotheses, Methods, Results and Discussion .............................. 7
CHAPTER 2 Source Monitoring and Hallucinations ................................. 9
2.1 Defining Source Monitoring ........................................................ 9
2.2 Source Monitoring and Hallucinations ........................................ 11
2.2.1 Neurophysiological evidence for misattribution and hallucinations
.............................................................................................. 12
2.2.2 Cognitive deficit models. .................................................... 13
2.2.3 Cognitive bias models. ...................................................... 16
2.3 Source Monitoring and Hallucination Studies .............................. 17
2.3.1 Delayed Source Monitoring Studies. .................................... 18
2.3.2 Cognitive effort and delayed source monitoring tasks. ........... 28
2.3.3 Summary of delayed source monitoring studies. ................... 31
2.4 Immediate and Short Delay Source Monitoring Studies ............... 31
2.4.1 Immediate source monitoring studies - Subjective ratings
designs .................................................................................... 32
2.4.2 Immediate source monitoring - Sensory recognition .............. 37
2.4.3 Immediate source monitoring - Signal detection tasks. .......... 42
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2.5 Summary .............................................................................. 46
CHAPTER 3 Metacognition and Hallucinations ..................................... 49
3.1 Defining Metacognition............................................................ 49
3.1.1 Theoretical dimensions of metacognition. ............................ 50
3.2 Metacognition and Emotional Disorders ..................................... 51
3.2.1 The Self-Regulatory and Executive Function (S-REF) model. .. 51
3.2.2 Metacognition and non-psychotic disorders. ......................... 53
3.3 Measuring Metacognition in Clinical Populations ......................... 55
3.4 Metacognition and Hallucinations.............................................. 57
3.5. Metacognition and Risk of Psychosis ........................................ 65
3.5.1 Metacognition and hallucination-proneness. ......................... 65
3.5.1.1 Metacognition and attention within HP studies. .................. 73
3.5.2 Summary of metacognition and HP studies. ......................... 75
3.5.3 Ultra-High Risk (UHR) studies and metacognition.................. 76
3.6 Summary .............................................................................. 83
CHAPTER 4 Unwanted Intrusive Thoughts and Hallucinations ............... 87
4.1 Definition .............................................................................. 87
4.2 UITs Compared To Other Common Negative Cognitive Phenomena 89
4.3 Measurement of Unwanted Intrusive Thoughts ........................... 92
4.4 Cognitive Models – UITs and Hallucinations. .............................. 93
4.4.1 A Top-down model – UITs and hallucinations. ...................... 93
4.4.1.1 UITs and empirical support for top down models........... 96
4.4.2 Bottom-up approaches: Deficits in intentional inhibition and
contextual memory. .................................................................. 98
4.4.2.1 Intentional inhibition deficits and auditory hallucinations.98
4.4.2.2 Deficits in contextual memory and auditory hallucinations
........................................................................................ 100
4.4.2.3 Summary of bottom-up models: Intentional inhibition and
contextual memory. ............................................................ 101
4.4.3 Inner speech, intrusive thoughts and hallucinations. ............ 102
4.5 Summary ............................................................................. 106
CHAPTER 5 Appraisal of Hallucinations – Beliefs about Voices.............. 109
5.1 The Power of Voices .............................................................. 109
5.2 Development of Beliefs Towards Hallucinations ......................... 113
5.2.1 Beliefs about hallucinations and self-appraisal. .................... 113
ix
5.3 Interpersonal Models of Hallucination Appraisal - Social Rank and
Relating Theory .......................................................................... 114
5.3.1 Social Rank Theory. ......................................................... 115
5.3.2 Relating theory. ............................................................... 116
5.4 Application to UHR Status – Beliefs, Appraisal and Symptom
Severity .................................................................................... 119
5.5 Can Beliefs and Appraisal Change Over Time? Cognitive Therapy and
Changes in Appraisal. .................................................................. 121
5.5.1 CBT and psychosis. .......................................................... 121
5.5.2 CBT and hallucinations. .................................................... 123
5.6 Summary ............................................................................. 124
CHAPTER 6 Rationale and Hypotheses .............................................. 127
6.1 Aims of the Current Study ...................................................... 127
6.2 Research Questions ............................................................... 128
6.3 Hypotheses .......................................................................... 128
6.3.1 Between Group Hypotheses. ............................................. 128
6.3.2 Hypotheses Related to Persistence of Hallucinations ............. 129
CHAPTER 7 Method ........................................................................ 131
7.1 Setting................................................................................. 131
7.2 Design ................................................................................. 131
7.3 Participants .......................................................................... 132
7.3.1 UHR participants .............................................................. 132
7.3.1.1 UHR hallucinating group (UHR-HG). ........................... 134
7.3.1.2 UHR Non-Hallucinating Group (UHR-NHG)................... 134
7.3.1.3 CAARMS Ratings for UHR Groups ............................... 135
7.3.2 Non-Psychiatric, Healthy Control Group (HCG). ................... 136
7.3.3 Inclusion and exclusion criteria. ......................................... 136
7.4 Measures ............................................................................. 137
7.4.1 Demographic Information ................................................. 137
7.4.2 National Adult Reading Test (NART). .................................. 138
7.4.3 Structured Clinical Interview for the DSM-IV (SCID –IV). ...... 138
7.4.4 Depression Anxiety Stress Scales (DASS). .......................... 140
7.4.5 Word Association Task (WAT). ........................................... 141
7.4.6 Metacognitions Questionnaire (MCQ-30). ............................ 142
7.4.7 Distressing Thoughts Questionnaire (DTQ). ......................... 143
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7.4.8 The Revised Beliefs About Voices Questionnaire (BAVQ-R). ... 143
7.4.9 Level of distress from hallucinations. .................................. 144
7.5 Procedure............................................................................. 144
7.5.1 Recruitment and informed consent..................................... 144
7.5.2 UHR participants.............................................................. 145
7.5.3 HCG participants. ............................................................ 145
7.5.4 Order of assessments. ...................................................... 145
7.6 Data Analysis ........................................................................ 146
7.6.1 Power analysis. ............................................................... 146
7.6.2 Data entry. ..................................................................... 147
7.6.3 Preliminary analysis and data screening. ............................ 147
7.6.4 Analysis of between-groups hypotheses. ............................ 147
7.6.5 Analysis of longitudinal hypotheses. ................................... 148
CHAPTER 8 Results: Group Comparisons .......................................... 151
8.1 Hypothesis 1: Group Differences in Source Monitoring. .............. 151
8.1.1 Ratings of control. ........................................................... 152
8.1.2 Ratings of internality. ....................................................... 153
8.1.3 Ratings of wantedness. .................................................... 154
8.2 Hypothesis 2: Group Differences in Metacognition ..................... 154
8.3 Hypothesis 3: Group Differences in Appraisal of Intrusive Thoughts.
................................................................................................ 156
8.3.1 Group differences in qualitative factors of the DTQ............... 158
8.4 Summary of Baseline Group Comparisons ................................ 160
CHAPTER 9 Results: Follow-Up of UHR Participants ............................ 161
9.1 Follow Up Grouping According to Persistence of Hallucinations .... 161
9.2 Hypothesis 4: Beliefs About Voices and Persistence of Hallucinations.
................................................................................................ 163
9.2.1 Comparisons of BAVQ-R Belief Subscales. ........................... 164
9.2.2 BAVQ-R and prediction of duration of hallucinations. ............ 165
9.2.3 Comparisons of BAVQ-R response subscales. ...................... 166
9.2.4 Distress From Hallucinations. ............................................ 167
9.3 Hypothesis 5: Metacognition and Continuation of Hallucinations .. 168
9.4 Hypothesis 6: Appraisal of Intrusive Thoughts and Continuation of
Hallucinations. ............................................................................ 168
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9.5 Hypothesis 7: Source Monitoring and Continuation of Hallucinations.
................................................................................................ 169
9.5.1 Relationship Between Baseline WAT Scales (Control, Internality
and Wantedness) and Follow Up Group. ...................................... 169
9.5.2 Relationship Between Baseline WAT Word-Type (Positive,
Negative and Neutral Stimuli) and Follow Up Group. ..................... 169
9.5.3 Relationship Between Final WAT Scales (Control, Internality and
Wantedness) and Follow Up Group. ............................................ 170
9.5.4 Relationship Between Final WAT Word-Type (Positive, Negative
and Neutral Stimuli) and Follow Up Group. .................................. 172
9.6 Summary of Follow Up Analyses .............................................. 174
CHAPTER 10 Discussion .................................................................. 177
10.1 Source Monitoring ............................................................... 177
10.1.1 Baseline Differences Between Groups. .............................. 177
10.1.2 Source Monitoring: Follow-Up .......................................... 178
10.1.3 Integration of Control, Internality, Wantedness and Salience
Findings with Previous Research. ............................................... 179
10.1.3.1 Control. ................................................................ 179
10.1.3.2 Internality. ............................................................ 180
10.1.3.3 Wantedness. ......................................................... 181
10.1.3.4 Salience. ............................................................... 181
10.2 Metacognition ..................................................................... 182
10.3. Intrusive Thoughts ............................................................. 185
10.4 Salience ............................................................................. 186
10.5 Beliefs ................................................................................ 188
10.6 A Potential Framework for Hallucinations Within UHR Populations
................................................................................................ 191
10.7 Clinical Implications ............................................................. 194
10.7.1 Assessment ................................................................... 194
10.7.2 Treatment ..................................................................... 195
10.8 Future Research .................................................................. 197
10.9 Limitations and Strengths of the Current Study ....................... 198
10.10 Conclusion ........................................................................ 200
REFERENCES ................................................................................ 201
APPENDICES ................................................................................. 235
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xiii
List of Tables
Table 2.1 Delayed Source Monitoring (SM) Studies ............................. 19
Table 2.2 Immediate Subjective Source Monitoring (SM) Studies .......... 33
Table 2.3 Real-Time, Sensory Recognition Source Monitoring Studies.... 38
Table 2.4 Signal Detection Studies .................................................... 44
Table 3.1 MCQ Scales ..................................................................... 56
Table 3.2 Metacognitions and Hallucinations in Psychosis ..................... 60
Table 3.3 Hallucination Prone (HP) Metacognition Studies .................... 67
Table 3.4 UHR and Metacognition Studies. ......................................... 77
Table 4.1 Properties and Dimensions of UITs (Clark & Rhyno, 2005) ..... 89
Table 4.2 Distinguishing Characteristics Between UITs and Other Negative
Cognitions (adapted from Clark & Rhyno, 2005). ................................ 90
Table 7.1 Mean for CAARMS Intensity Scores at Intake and Baseline
Assessment for UHR Groups ........................................................... 136
Table 7.2 Demographic Information for All Study Groups .................... 137
Table 7.3 Diagnoses at Assessment for UHR Participants .................... 139
Table 7.4 DASS Median Scores and Results of Group Comparisons from
Mann-Whitney U Tests ................................................................... 141
Table 7.5 Summary of Study Assessments........................................ 146
Table 8.1 Mean WAT Scale Scores: Control, Internality and Wantedness
................................................................................................... 152
Table 8.2 Mean Subscale MCQ-30 Scores.......................................... 156
Table 8.3 Mean and Post-Hoc Comparisons for DTQ Subscales ............ 158
Table 8.4 Means, Standard Deviations and Between Group Comparisons
for DTQ Qualitative Factors. ............................................................ 159
Table 9.1 Composition of Follow-Up Groups ...................................... 162
Table 9.2 Mean Time Between Assessments and CAARMS Perceptual
Abnormalities Ratings Across Follow Up Assessments ......................... 163
Table 9.3 Planned Comparison ANOVA for BAVQ-R Belief Subscales. .... 165
Table 9.4 Logistic Regression Predicting Persistence of Hallucinations
According to Beliefs About Voices .................................................... 166
Table 9.5 Planned Comparisons ANOVA for Distress From Hallucinations
................................................................................................... 167
xiv
Table 9.6 Correlation Coefficients (Pearson r) Between Ratings of Distress
from Hallucinations and BAVQ-R Subscales ....................................... 168
Table 9.7 Results for Planned Comparison ANOVA for Follow-Up WAT
Subscales ..................................................................................... 171
Table 9.8 Results of Logistic Regression of Persistence of Hallucinations
with Final Follow-Up WAT Subscales................................................. 172
Table 9.9 Results for Planned Comparison ANOVA for Follow Up WAT Word
Type ............................................................................................ 173
xv
List of Figures
Figure 3.1. Heuristic model of hallucinations based on Morrison and
colleagues (1995). .......................................................................... 58
Figure 5.1. Axes of Birtchnell’s Relating Theory. (Adapted from Sorrell et
al., 2010). .................................................................................... 117
Figure 7.1. Flow diagram of recruitment to the study……………………………133
Figure 10.1. Tentative Model of Hallucination Process in UHR Cohorts .. 193
xvi
List of Appendices
Appendix A: University of Melbourne Ethics Approval ......................... 236
Appendix B: Melbourne Health Ethics Approval .................................. 237
Appendix C: CAARMS Subscales Used to Determine UHR Status .......... 238
Appendix D: Advertisement for HCG Participants ............................... 242
Appendix E: NART ......................................................................... 243
Appendix F: DASS ......................................................................... 245
Appendix G: WAT .......................................................................... 247
Appendix H: MCQ-30 ..................................................................... 254
Appendix I: DTQ ........................................................................... 258
Appendix J: BAVQ-R ...................................................................... 271
Appendix K: Plain Language Statement and Consent Form ................. 276
xvii
CHAPTER 1
Introduction and Overview
This study investigated whether specific cognitive processing factors are
associated with the development of hallucinations in young people.
Cognitive processing factors were compared between three groups: an
ultra-high risk (UHR) group for psychosis reporting auditory hallucinations,
a UHR comparison group not reporting hallucinations and a ‘healthy’
comparison control group. Additionally, the UHR groups were monitored
across three follow up interviews over approximately five months in order
to examine the association between cognitive processing biases and
duration of hallucinations.
UHR participants were identified according to criteria based on a range of
state and trait characteristics including sub-threshold symptoms of
psychosis and family history of psychosis (Yung, Phillips, Yuen & McGorry,
2004). The UHR participants were recruited from a clinical service
specialising in the identification and treatment of UHR young people.
The specific cognitive processing factors assessed were source monitoring,
metacognitions and cognitive intrusions. Additionally, the personal
salience of hallucinations was assessed to examine if reactions to and
beliefs about hallucinations could account for variation in the duration of
hallucinations. These cognitive factors incorporate major elements of
previous research which has contributed to a ‘cognitive model’ of
hallucinations for people with established psychotic disorders (Bentall &
Slade, 1985; Frith, 1992; Morrison, Haddock & Tarrier, 1995; Rankin &
O’Carroll, 1995).
This is the first study to examine cognitive factors associated with
hallucinations within an ‘at-risk’ population. It is envisaged this research
will provide further insight into the psychological processes associated
with the development of psychosis.
1
1.1 Rationale – Hallucinations and High Risk Populations
Schizophrenia and associated psychotic disorders commonly have an
overwhelming and prolonged impact on patients and carers, as well as
impacting on the wider community in terms of economic costs and burden
on health resources (Knapp, Mangalore & Simon, 2004). Individuals with
psychotic disorders often experience poor social and vocational outcomes
(Marwaha & Johnson, 2004) and it is estimated that 5% of people with
schizophrenia will commit suicide (Palmer, Pankratz & Bostwick, 2005).
Few health conditions have such a pronounced impact at both an
individual and community level.
Over the past century there have been a number of frameworks used to
conceptualise the development of psychosis (Morrison, Renton, Dunn,
Williams & Bentall, 2004a). Kraepelin’s early twentieth century
perspective applied an illness model, whereby mental illnesses such as
psychosis were considered to be diseases of the brain. From this
perspective a clear dichotomy exists between normality and abnormality.
Zubin and Spring (1977) developed the stress vulnerability model and
proposed that stress would play an integral role in eliciting psychosis for
individuals who are predisposed to the condition.
1.2 Hallucinations
Further research toward prevention or ameliorating the impact of
psychosis and schizophrenia is clearly warranted. However, the immense
heterogeneity in the presentation of symptoms within psychosis creates
considerable research challenges. In light of this, numerous authors
advocate that research examining the aetiology of psychosis should focus
on specific symptoms rather than broad diagnostic classifications (Bentall,
1990; Bentall, Jackson & Pilgrim, 1988; Morrison, 2005; Morrison &
Haddock, 1997a).
Auditory hallucinations are the most common symptom experienced by
individuals with psychosis and schizophrenia (Slade & Bentall, 1988;
2
World Health Organisation, 1973). Despite the prominence of auditory
hallucinations within psychotic disorders, a comprehensive understanding
of the cognitive mechanisms associated with the aetiology and
phenomenology of hallucinations is lacking (Jones & Fernyhough, 2006).
1.3 High Risk for Psychosis Populations
The majority of research examining psychosis and hallucinations has been
conducted with acute or chronic populations. However, these
methodologies have been limited by only investigating experiences which
have been longstanding, and therefore are unable to extrapolate the
mechanisms which mediate the development of hallucinations during the
emergent or early stages of illness. A potential pathway to developing a
greater understanding of the development of psychotic disorders is to
identify individuals during the emerging stages of psychosis, or when
psychotic symptoms initially present. During the past two decades
considerable momentum has gathered to recognise the pre and early
stages of psychosis as an important time for intervention, which can
reduce the likelihood of prolonged disability (e.g., Cannon et al., 2008;
McGlashan et al., 2006; McGorry et al., 2009).
Identification of individuals during the ‘prodrome’ or onset phase prior to
acute psychosis has been proposed as offering an ideal opportunity to
intervene as early as possible (Mrazek & Haggerty, 1994; Yung &
McGorry, 1996). However, accurate identification of the prodrome has
been fraught with difficulties (Yung et al., 2007). A more viable approach
has involved identification and intervention for individuals assessed as
being at significant risk of developing psychosis (Yung, Phillips & McGorry,
2004). Rates of transition to psychosis within a 12 month period using
UHR criteria varies substantially across studies, ranging from 12% to 54%
(Haroun, Dunn, Haroun, & Cadenhead, 2006; Larsen, 2002; Mason et al.,
2004; Miller et al., 2002; Yung et al.; 2003;2007).
3
It is important to highlight that the prodrome can only be use as a
retrospective concept, confirmed only by the development of a threshold
disorder. Researchers widely acknowledge that identifying those at
heightened risk of developing psychosis does not necessarily mean these
individuals will inevitably develop psychosis. Therefore, the term ‘At Risk
Mental State’ has been adopted in preference to prodrome when referring
to the period of when heightened risk for psychosis may be present, but
psychosis is not inevitable (McGorry & Singh, 1995). Yung and colleagues
(2004) refer to the cohort of individuals with At Risk Mental State as the
‘ultra-high risk’ (UHR) group.
1.4 Cognitive Processing Factors and Hallucinations
Previous research has failed to provide substantial evidence as to whether
cognitive processing biases are a risk factor associated with the
development of hallucinations, or are a consequence of perceptual
disturbances. Assessing cognitive processing within a population
presenting with emerging psychotic symptoms, but below threshold for
frank psychosis, may provide greater insight into the temporal relationship
between cognitive processing factors and hallucinations, as well as to the
aetiology of psychotic symptoms.
Cognitive psychological models of hallucinations have incorporated source
monitoring, unwanted intrusive thoughts, metacognition and emotional
salience toward perceptual anomalies in the conceptualisation of
hallucinations. A central feature of these models is the process of
misattribution, which refers to the incorrect attribution of internally
generated cognitive material to an external source. Numerous studies
have demonstrated that people experiencing auditory hallucinations
display a stronger tendency to misattribute internal cognitive events to an
external source, when compared to people without hallucinations (Baker &
Morrison, 1998; Bentall et al., 1988; Heilbrun, Blum & Haas, 1983;
Henquet, Krabbendam, Dautzenberg, Jolles & Merckelbach, 2005; Johns &
McGuire, 1999). Additionally, several studies observed similar outcomes
for ‘hallucination prone’ individuals where symptoms were below threshold
4
for a diagnosis of psychosis (Bentall & Slade, 1985; Rankin & O’Carroll,
1995). Misattribution of cognitive stimuli is a core process investigated in
the current study.
1.4.1 Source Monitoring.
Chapter two provides a review of literature addressing source monitoring
in the formation and maintenance of hallucinations. Source monitoring
refers to the appraisal and attribution of both internally and externally
derived stimuli. Dysfunctional or biased source monitoring can
significantly compromise the capacity to distinguish reality from thoughts.
The role of source monitoring in hallucinations has received considerable
attention during the past two decades. Numerous studies have identified
source monitoring deficits amongst people reporting hallucinations with
psychosis (e.g. Baker & Morrison, 1998; Bentall, Baker & Havers, 1991;
Brebion et al.; 2000). Additionally, a tendency to attribute ambiguous
stimuli to an external source has been observed in studies amongst
‘hallucination prone’ participants without psychosis (Bentall & Slade,
1985; Rankin & O’Carroll, 1995). The current research is the first to
investigate source monitoring in a UHR cohort.
1.4.2 Metacognition.
Cognitive models of hallucinations have attempted to understand why
phenomena such as cognitive intrusions may lead to hallucinations.
Metacognition refers to the beliefs and appraisals of one’s own thoughts
and has been proposed as an important factor in the development of
hallucinations (Bentall, 1990). Morrison and colleagues (1995) proposed
that disturbing cognitive intrusions would be misattributed to an external
source if metacognitive appraisal judged such intrusions as intolerable.
This implies that metacognitive appraisal determines whether distressing
cognitive material is accepted as deriving from the self or external. Since
Morrison and colleagues (1995) proposal, empirical evaluation of the
association between metacognition and hallucinations has steadily
increased. Several studies have observed that people with hallucinations
5
score significantly higher on measures of dysfunctional metacognition,
compared to those without hallucinations (Baker & Morrison, 1998; Laroi
& Van der Linden, 2005; Morrison, Wells & Nothard, 2002). Furthermore,
recent studies have observed that dysfunctional metacognitive appraisal
was heightened amongst individuals identified as being prone toward
hallucinations and at high risk of developing psychosis (e.g. Jones &
Fernyhough, 2006; Morrison et al., 2002a; Morrison et al., 2006).
Metacognition is another cognitive process examined in the current study.
Chapter three provides a detailed review of metacognition and discusses
the growing body of evidence examining the association between
metacognition and hallucinations.
1.4.3 Unwanted intrusive thoughts.
The role of unwanted intrusive thoughts in eliciting hallucinations has
gained increased attention since the mid-1990s (Morrison et al., 1995).
Unwanted intrusive cognitive experiences have been suggested to form
the core material or stimuli for hallucinations. A range of studies have
observed that individuals with hallucinations report significantly higher
frequencies of intrusive mental imagery, as well as experiencing higher
levels of distress and uncontrollability regarding these thoughts, when
compared to individuals without hallucinations (Aleman, Bocker & De
Haan, 1999; Bocker, Hijman, Kahn & De Hann, 2000; Morrison & Baker,
2000; Morrison, Wells & Nothard, 2000). However, there have been no
studies examining unwanted cognitive intrusions amongst populations
identified as being at risk of psychosis. Therefore, it is not currently known
whether the frequency and sensitivity toward unwanted intrusions is a
contributing factor or consequence of hallucinations. The current study
addresses this issue by examining the relationship between unwanted
intrusive thoughts and hallucinations in a UHR cohort. A review of
theoretical models and empirical studies associated with intrusive
cognitive experiences and hallucinations is provided in chapter four.
6
1.4.4 Appraisal and response to hallucinations.
A further focus within psychological models of hallucinations has been the
appraisal and response characteristics toward hallucinations. Distress
associated with hallucinations appears to be shaped by the individual’s
appraisal of the hallucination’s perceived omnipotence. This is turn may
influence behavioural reactions, emotional states and subsequent
maintenance of the hallucinations (Birchwood & Chadwick, 1997;
Chadwick & Birchwood, 1994; Vaughan & Fowler, 2004). Whilst preceding
chapters address factors which influence the aetiology of hallucinations,
chapter five focuses on the effect of beliefs, appraisals and reactions on
the duration of hallucinations.
1.5 Hypotheses, Methods, Results and Discussion
Chapter six outlines the study aims as well as the key research questions
and hypotheses. The methodology of the study is provided in chapter
seven. This includes a description of the setting for recruitment of the UHR
participants from the Personal Assessment and Crisis Evaluation (PACE)
Clinic at Orygen Youth Health. The operational criteria used for identifying
young people at UHR for developing psychosis is described. Criteria for
determining participants identified as experiencing hallucinations, as well
as comparison control groups are outlined. Additionally, cognitive
processing measures and approaches for data analysis are described.
Chapters eight and nine contain the results of the study. Cognitive
processing differences between the three study groups are examined.
Additionally, analysis within the hallucinating group was conducted to
examine associations between individual cognitive processing biases as
well as the relationship between specific cognitive processing
characteristics and duration of hallucinations.
A discussion of the findings is provided in chapter ten. This includes a
detailed review of results as well as methodological limitations.
Implications of the study are examined regarding the contribution to
7
existing knowledge of UHR research and the potential clinical utility of the
findings.
8
CHAPTER 2
Source Monitoring and Hallucinations
A substantial body of research over the preceding 30 years has indicated
that difficulties in the self-monitoring and interpretation of thoughts is
strongly associated with the occurrence of perceptual disturbances,
particularly auditory verbal hallucinations (AVH). This chapter will examine
how source monitoring, or impediments in the source monitoring
processes, may play a causal role in the development of hallucinations. A
definition of source monitoring will be provided, followed by a review of
research examining the relationship between source monitoring and
hallucinations. Cognitive models of hallucinations which implicate source
monitoring will be discussed within the context of empirical studies.
2.1 Defining Source Monitoring
Source monitoring refers to the processes involved in making attributional
judgements about the origins of cognitive events, knowledge, beliefs and
experiences (Johnson, 1988; Johnson, Hashtroudi & Lindsay, 1993; Keefe,
Arnold, Bayen & Harvey, 1999). In this context the term source refers to
the characteristics of the origin of the cognitive event such as the spatial,
temporal, social or environmental situation (Johnson et al., 1993).
Source monitoring is an essential component of cognitive functioning
which enables the individual to recognise and integrate thoughts, beliefs
and information from their own internal experience with information from
their external environment (Johnson & Raye, 1981). Source monitoring
contributes to management of opinions and beliefs as well as facilitating
confidence and recognition of memories (Johnson et al., 1993; Johnson &
Raye, 1981). Disturbances in source monitoring can severely disrupt
functioning because the individual may fail to differentiate internal from
external experiences, leading to difficulties in distinguishing real from
imagined events (Johnson et al., 1993).
9
A theoretical source monitoring framework (SMF) has been developed
(Johnson et al., 1993; Johnson & Raye, 1981; 2000) and is widely
accepted as the primary conceptual model of source monitoring (Ditman &
Kuperberg, 2005; Garrett & Silva, 2003). The SMF outlines a number of
contexts in which source monitoring occurs. Firstly, reality monitoring
refers to discriminating between internally generated cognitive events and
memories of externally experienced events (e.g., the distinction between
memories of thoughts or images from memories of actual events).
Secondly, external source monitoring refers to discriminating between
externally generated sources, such as memories of several different
conversations. Thirdly, internal source monitoring refers to discriminating
between internally generated sources of memory (e.g., distinguishing
memories of thoughts from what was actually said). In the context of
psychotic experiences such as auditory hallucinations, reality monitoring is
the primary focus in source monitoring research.
According to the SMF, the perception of reality is not derived directly from
representations of memory or perceptual images. Instead, a series of
judgements are made based upon contextual information gained at the
time the memory is formed and then later utilised to make judgements
about the source of information. This is accomplished by comparing
contextual information with what is expected from similar examples
(Johnson et al., 1993; Johnson & Raye, 1981). This method of judgement
utilises automatic decisions based on qualitative perceptual details
associated with the memory experience and has been referred to as
‘heuristic source monitoring’ (Johnson & Raye, 2000).
Examples of heuristic source monitoring have been demonstrated in
studies whereby participants’ identification of particular contextual
characteristics was essential in the discrimination of the origins of
memories (Johnson, Foley & Leach, 1988a; Johnson, Foley, Suengas &
Raye, 1988b). For instance, by appraising a range of memory images
from contextual cues, participants were able to distinguish real from
imagined events by rating real events as having clearer sequential and
spatial cues, as well as richer perceptual detail (Johnson et al., 1988b).
10
Johnson and colleagues (1988a) demonstrated the importance of
contextual cues in source monitoring in a study examining how qualities of
contextual cues between real and imagined events affected the accuracy
of source monitoring. The study involved participants hearing and
imagining words, then after a short delay recalling whether words had
been imagined or were real. In the first condition, participants were asked
to imagine saying a set of words and listened to other words spoken in a
distinct accent. Under this condition, discrimination between the imagined
and heard sets of words was rated as ‘good’. However, in the second
study condition, when participants were required to imagine speaking the
word in the same accent as the spoken word, their discrimination between
imagined and heard events worsened considerably. These studies
indicated that distinguishable contextual cues available at the time of
memory formation significantly aided accurate source monitoring.
Within the SMF a second process involving strategic reasoning known as
systematic source monitoring operates independently of heuristic source
monitoring (Garrett & Silva, 2003; Johnson et al., 1993). Systematic
source monitoring involves assessing the plausibility of a source in relation
to previous experiences, knowledge or beliefs (e.g., ‘Is this plausible from
what I know, believe or have experienced previously?’) and tends to
function in conjunction with heuristic source monitoring (Garrett & Silva,
2003; Johnson et al., 1993).
In essence, the knowledge gained from previous experience appears to
form the basis for judgements regarding the source of new information,
including where internal cognitive activity derives from.
2.2 Source Monitoring and Hallucinations
During the past 30 years the SMF has provided a framework for
understanding potential cognitive mechanisms involved in the occurrence
of hallucinations. The earliest reference to source monitoring as an
explanation for auditory verbal hallucinations comes from Maudsley
(1886) when he suggested that hallucinations are “thoughts which the
11
patient hears rather than words actually heard with his ears”(cited from
Ditman & Kuperberg, 2005, p.281). There is general agreement that
hallucinations can be explained as a misattribution of internally generated
material (thoughts) to an external source (a perceptual image) and that a
failure or distortion within the source monitoring process is the central
mechanism associated with this misattribution (Ditman & Kuperberg,
2005).
2.2.1 Neurophysiological evidence for misattribution and
hallucinations
Studies of inner speech offered the first major paradigm for empirically
investigating whether a failure to monitor the origin of thought could be a
vital mechanism in the hallucinatory processes. Inner speech is important
for self-awareness by facilitating self-reflection, understanding and
integration of thoughts and experiences (Morin & Everett, 1990). Inner
speech is accompanied by subvocalisations involving vocal muscular
activity, which occur below audible threshold, and has been measured
using electromyogram (EMG) in a range of studies (Bentall, 2004). Given
that the most common form of hallucinations is auditory verbal
hallucinations (Slade & Bentall, 1988), it was logical to examine whether
subvocalisations associated with moment to moment thoughts may occur
during hallucinations.
Gould was the first to use EMG to measure subvocalisations for patients
experiencing auditory hallucinations and observed that increased vocal
muscular activity coincided with the onset of hallucinations (Gould, 1948;
1949; 1950). Subsequent EMG studies supported these findings, with
subvocalisation recordings becoming more active just prior to
hallucinations and intensifying as the onset of hallucinations occurred
(Inouye & Shimizu; 1970 ; McGuigan, 1966). Interestingly, studies in
which participants have attempted to block or disrupt subvocalisations via
motor, listening, verbal and reading distraction tasks have led to a
decrease in hallucinations during the period of assessment (Bick &
Kinsbourne, 1987; Gallagher, Dinan & Baker, 1994; Green & Kinsbourne,
12
1990; Margo, Hemsley & Slade, 1981; Slade, 1974). The results from
these studies indicate that inhibition of subvocalisation may serve to
inhibit hallucinations.
Continuing the investigation of the inner speech misattribution hypothesis,
a range of functional neuroimaging studies reported increased activation
in language production areas during periods of hallucinations. Utilising
single photon emission computer tomography (SPECT), higher blood flow
was observed in Broca’s area and the left temporal lobe during periods of
hallucination, compared to periods without hallucinations for schizophrenia
patients (McGuire, Shah & Murray, 1993). Further studies utilising
positron emission tomography (PET) and functional magnetic resonance
imaging (fMRI) have demonstrated increased activation in the
linguistically associated temporal cortices during periods of discrete
hallucinations, compared to periods without hallucinations (Shergill,
Brammer, Williams, Murray & McGuire, 2000; Silbersweig et al., 1995;
Stephane, Folstein, Matthew & Hill, 2000; Stevens & Livermore, 1982).
The outcomes from subvocalisation studies over the past 60 years provide
strong support for the theory that auditory hallucinations involve inner
speech. Specifically, that misattribution of inner speech and associated
cognitive activity leads to hallucinations (Bentall, 2004; Ditman &
Kuperberg, 2005; Li, Chen, Yang, Chen & Tsay, 2002).
2.2.2 Cognitive deficit models.
A number of cognitive models detail potential mechanisms of how and
why misattribution of internal cognitive material may lead to
hallucinations. Several authors have proposed that neurocognitive aspects
of information processing such as executive functioning, perceptual and
memory based mechanisms are critical to the disruption of regular source
monitoring processes (Frith, 1992; Keefe, 1998). These researchers have
posited that deficits occur in the formation and recognition of cognitive
material so that individuals experiencing positive psychotic symptoms,
particularly hallucinations, experience ‘autonoetic agnosia’, literally
13
meaning ‘the inability to identify self-generated mental events’ (Keefe,
1998). This implies that hallucinations and the associated external
attribution is a consequence of dismissing perceptual stimuli as being
internally generated. According to the source monitoring framework, this
constitutes a deficit in reality monitoring.
A number of researchers have focused on discrepancies in the information
processing of inner speech (Feinberg & Guazzelli, 1999; Frith, 1992; Frith
& Done, 1987). Such models lead on from earlier subvocalisation
hallucination studies by focusing on the misidentification of inner speech
processes. The central tenet of these models is that as abnormal selfmonitoring of inner speech occurs, cognitive material will be misattributed
to an external source in the form of hallucinations.
In order to recognise whether sensory information is self or externally
generated a central self-monitoring system based around a ‘feed-forward’
process is implicated. This feed-forward model of self-monitoring involves
a ‘corollary discharge’, which refers to the generation of an expected copy
of the external (i.e., heard, seen or felt) or internal (i.e., auditory image
or subvocalisation) experience. With internal material, executive functions
stimulate neural imagery processing to develop the corollary discharge.
This expected copy is formed from stored information relating to a ‘best
fit’ of what should be experienced. In the context of auditory
hallucinations, the expected copy would generally occur as an expected
body of verbal material. This paradigm has been referred to as the ‘selfmonitoring’ hypothesis (Cahill & Frith, 1996; Li et al., 2002).
The corollary discharge is used to assess the reality or appropriateness of
self-generated activity and is critical for monitoring the source and
suitability of perceptual and cognitive material. When the corollary
discharge does not match the self-generated material (i.e.,
subvocalisations experienced as verbal thoughts), the relevant material is
experienced as external in the form of hallucinations. Feed forward
principles of self-monitoring were initially developed in the context of
visual and tactile awareness (Sperry, 1950; von Holst, 1954) and have
14
since been extended to self-awareness of speech, motor and cognitive
domains (Blakemore, Smith, Steel, Johnstone & Frith, 2000; Frith, 1992).
Hoffman (1986) proposed a similar model in the explanation of mistaking
thoughts for perceptual experiences. Hoffman’s theory is also based
around impaired self-monitoring of thoughts, as the cognitive event takes
place. Hoffman suggested that a break down in linguistic information
processing, particularly in the planning of speech, results in unintended
inner speech occurring and subsequently not recognised as selfgenerated. Hoffman and colleagues demonstrated a statistical association
between disordered speech and auditory hallucinations amongst patients
with schizophrenia and bipolar disorder (Hoffman, Stopek & Andreasen,
1986). However, the sample selection in this study was problematic.
Despite manic and schizophrenia patients being included, mania patients
exhibiting signs of disordered or disorganised speech were excluded
(Bentall, 1990). Critics have also highlighted that if speech is preceded by
a plan, then the plan would have required a preceding plan, and so on,
leading to the problem of infinite regress (Akins & Dennet, 1986).
Feed forward models of misattribution have also been proposed for other
positive psychotic symptoms such as passivity phenomena. The ability to
monitor actions and thoughts allows accurate prediction of the expected
outcome. As the difference between predicted and actual sensory
feedback increases, so too is the likelihood that the stimulus has been
produced externally (Blakemore et al., 2000). The element of surprise or
unexpectedness of new material therefore appears to be an important
aspect of whether information would be accepted as deriving internally
(i.e. expected) or attributed to another source. Support for this has been
demonstrated in a study of tactile perception. Participants from a nonclinical group as well as psychiatric patients without hallucinations or
passivity phenomena described self-administered tactile experiences
(touching their palm with a piece of soft foam at the end of a rod) as less
intense, arousing (ticklish) or pleasant than when the experience was
administered by the experimenter. However, participants experiencing
hallucinations and/or passivity phenomena described no difference
15
between self-generated and externally administered stimuli (Blakemore et
al., 2000). The authors proposed that discrepancies in self-monitoring
affect the development of awareness of intended action. This may lead to
thoughts and actions being experienced as unintended.
2.2.3 Cognitive bias models.
The previous section outlined perspectives focusing on deficits in cognitive
processing. However, a number of researchers propose a broader
approach, arguing for the involvement of emotional, schematic and
experiential factors in source monitoring difficulties associated with
hallucinations (e.g., Bentall 1990; Bentall, Fernyhough, Morrison, Lewis &
Corcoran, 2007; Morrison et al., 1995). These authors suggested that a
bias exists towards externalising particular cognitive events, especially
those with heightened emotional salience that are schematically
incongruent or unexpected. Bentall and colleagues (2007) highlighted that
deficit models of hallucinations are limited in that they offer minimal
regard to individual development, beliefs, experiences or
acknowledgement of variances in the content, form and meaning of
hallucinations. In contrast, proponents of bias models for hallucinations
highlight that factors such as developmental history, coping style, trauma
and perceived social standing are potential mediators in the development
and characteristics of hallucinations (e.g., Birchwood et al., 2004;
Fernyhough, 2004; Kilcommons & Morrison, 2005; Morrison, 1998). These
authors do not exclude deficit paradigms. Instead, they argue that a
broader approach incorporating environmental and psychological factors
be taken into account. In general, the bias theories posit that cognitive
deficits combine with psychological variables such as emotional states,
personal beliefs and developmental experiences to influence misattribution
of internally generated material.
The role of heightened emotional states in the occurrence of hallucinations
has received considerable focus within the field of cognitive bias research
(Bentall 1990; Bentall et al., 2007). Emotional arousal appears to
contribute to increased misattribution and hallucinations, as observed in
16
source monitoring studies involving emotional manipulation with people
prone to or experiencing hallucinations (Bentall & Slade, 1985; Ensum &
Morrison, 2003; Johns et al., 2001; Morrison & Haddock, 1997a; Rankin &
O’Carroll, 1995).
Within the cognitive bias framework, misattribution to an external source
serves a protective function. Reduction of discomfort may occur by
redirecting attention from cognitions that are distressing or incongruent
with metacognitive and schematic beliefs (Bentall, 1990; Morrison et al.,
1995). In essence, the distress reduction process may negatively reinforce
misattribution and subsequent hallucinations. Whilst deficit models
implicate feed-forward copies of expected experiences to the decision of
whether stimuli is internal or external, alternative approaches within the
cognitive bias framework have implicated individual beliefs and values as
the basis by which internal material is attributed to the self or other. The
influence of distressing intrusive thoughts and beliefs on hallucinations will
be discussed in later chapters.
2.3 Source Monitoring and Hallucination Studies
Studies have demonstrated that source monitoring difficulties are
heightened with people experiencing psychosis compared to non-clinical
populations (e.g. Brebion, Smith, Gorman & Amador, 1996; Henquet et
al., 2005; Keefe et al., 1999; Keefe, Arnold, Bayen, McEvoy & Wilson
2002). Additionally, several studies have identified impaired source
monitoring for cohorts identified as high risk for psychosis. Brunelin and
colleagues (2007) observed that siblings of people with schizophrenia
demonstrated higher rates of misattributions for internal events than
unaffected siblings. Johns and colleagues (2010) conducted a verbal selfmonitoring experiment involving acoustic manipulation of recorded
speech. Impaired verbal self-monitoring was observed for an UHR group
who made significantly more errors in identifying their own speech
compared to a healthy control group. However, the relationship between
source monitoring and specific symptoms such as hallucinations was not
differentiated in those studies. This section will focus specifically on
17
studies examining source monitoring difficulties associated with
hallucinations. The discussion has been organised according to the main
approaches to measuring source monitoring, which primarily involve
delayed and real time assessments.
2.3.1 Delayed Source Monitoring Studies.
Delayed source monitoring tasks endeavour to assess a fundamental
source monitoring and hallucinations hypothesis, i.e., whether internally
generated material will be more likely to be misattributed to an external
source by individuals experiencing hallucinations. Most delayed source
monitoring assessments require participants to recall the source of
previously presented information. Participants are typically required to
distinguish internally generated information, such as imagined or spoken
words, from external sources such as words previously read aloud by a
test administrator. An externalising attribution bias would be represented
by more false positive responses in reality discrimination tasks, as more
internally generated material would be rated as external. Memory
activation is obviously a key cognitive process in such tasks and there is
considerable variation in the delay time utilised between studies, ranging
from brief periods of a few minutes through to several weeks. Table 2.1
provides a chronological listing of the delayed source monitoring studies
discussed in the following section. A summary of sample descriptions,
assessments used and key findings are described throughout the table.
18
Table 2.1
Delayed Source Monitoring (SM) Studies
Study
Groups
Hallucination assessment
Delayed SM Task
Results
Heilbrun (1980)
12 psychiatric with
Any reports of
One week delay;
Externalising bias for
hallucinations;
hallucinations.
Recall of lexical, semantic
hallucinators.
Bentall et al., (1991)
8 psychiatric without
and syntactic elements of
hallucinations.
speech.
22 schizophrenia with
Charts & interviews.
One week delay;
Hallucinators misattributed
hallucinations;
Recall source from self,
more high-effort items;
16 schizophrenia patients,
other or new.
Cognitive effort influenced
without hallucinations;
accurate attribution for all
22 non-clinical.
participants.
Seal, Crowe and
10 schizophrenia with
Interviews, hallucinated in
One week delay.
No group differences after
Cheung (1997)
hallucinations;
previous two weeks;
Recall source from self,
controlling for IQ;
11 schizophrenia without
No hallucinations in two
other or new.
No effect for emotional
hallucinations;
months.
valence.
15 non clinical.
19
Table 2.1 (cont.)
Delayed Source Monitoring (SM) Studies
Study
Groups
Hallucination assessment
Delayed SM Task
Results
Keefe et al., (1999)
18 schizophrenia patients,
Symptoms rated by
Less than two days
More source errors for
mix of thought insertion,
interviewer.
delay;
schizophrenia patient group,
voices, made feelings, acts
Recall source from: said,
however, not symptom
or impulses;
imagined saying, heard,
specific.
10 schizophrenia patients
imagined hearing and
without any of above;
gender.
19 non-clinical.
Bocker et al., (2000)
Brebion et al., (2000)
13 schizophrenia with
Hallucinated in previous
Delay of two days to one
No group differences;
hallucinations;
week;
week;
Positive correlation between
19 schizophrenia without
PANSS.
Recall source from:
hallucination severity and
hallucinations;
perceived, imagined or
reality discrimination.
14 non-clinical.
new.
22 schizophrenia with
PANSS hallucination score
Five minute delay.
Externalising bias for
hallucinations;
above one.
Recall source from:
hallucinators. Positive
18 schizophrenia without
generated by self, other,
correlation between severity
hallucinations;
image or new.
of hallucinations and
40 non-clinical.
externalising bias.
20
Table 2.1 (cont.)
Delayed Source Monitoring (SM) Studies
Study
Groups
Hallucination assessment
Delayed SM Task
Results
Franck et al., (2000)
8 schizophrenia with
SAPS score above four.
Five minute delay.
Externalising bias for clinical
hallucinations;
Recall source from: overt
groups. More pronounced
9 schizophrenia without
speech, covert speech or
for hallucinators.
hallucinations;
new.
17 non-clinical.
Brebion, Gorman,
22 schizophrenic w/
PANSS hallucination score
Five minute delay.
Externalising bias for
Amador, Malaspina
hallucinations;
above one.
Recall whether items
hallucinators;
and Sharif (2002)
18 schizophrenic w/o
were generated by self,
Correlation between
hallucinations;
other, a picture or new.
hallucinations and reporting
40 non-clinical controls.
Keefe et al., (2002)
18 schizophrenic with
non-events.
Clinical interview.
Less than two days delay.
Both schizophrenic groups
positive symptoms;
Recall whether source
had externalising bias –
11 schizophrenic without
items were pictures, self
more pronounced for
target symptoms;
generated, read by
hallucinations and thought
19 non-clinical controls.
another or were new.
insertion.
21
Table 2.1 (cont.)
Delayed Source Monitoring (SM) Studies
Study
Groups
Hallucination assessment
Delayed SM Task
Results
Aleman, Bocker,
22 schizophrneia with
TVRS & PANSS;
Delayed and immediate;
No group differences in
Hijman, de Hann and
hallucinations;
No hallucinations in three
Maximum of one week
source monitoring task.
Kahn (2003)
35 schizophrenia without
months.
delay;
hallucinations;
Recall source from:
20 non-clinical
perceived, imagined or
new.
Brebion, David, Jones
40 schizophrenia patients,
and Pilowsky (2005)
23 with hallucinations.
Brunelin et al., (2006)
SAPS.
Five minute delay after
Response bias associated
word list;
with level severity of
Same task with no delay.
hallucinations.
30 schizophrenia with
PANSS hallucinatory
Recall source from: said,
Hallucinators significantly
hallucinations;
behaviour above three;
imagined, heard,
more likely to attribute
30 schizophrenia without
No hallucinations in three
imagined experimenter
imagined words to an
hallucinations.
months.
saying or new.
external source.
22
Table 2.1 (cont.)
Delayed Source Monitoring (SM) Studies
Study
Groups
Hallucination assessment
Delayed SM Task
Results
Costafreda, Brebion,
14 schizophrenia with
SAPS score greater than
Brief delay (i.e. time for
No difference between
Allen, Mcguire and Fu
hallucinations;
three;
control measures).
hallucinations or delusions.
(2008)
6 schizophrenia with
Recall source from:
More misattributions for
delusions;
generated by self or
active symptom groups;
10 schizophrenia without
other for neutral and
Both symptom groups more
delusions or hallucinations.
negative themes.
likely to misattribute
negative words externally.
Brebion, David,
41 patients with
Bressan, Ohlsen and
schizophrenia;
SAPS
Recall of word lists.
Hallucination score
significantly correlated with
Pilowsky (2009)
false recognition.
Bendall, Jackson and
43 first episode psychosis
PANSS greater than or
Recall after three minutes
No attribution bias for
Hulbert (2011)
patients. 20 with
equal to three.
of whether words were
hallucinators;
hallucinations, 23 without;
from self, experimenter
Emotional salience did not
26 healthy comparison.
or new.
influence source monitoring.
23
Heilbrun (1980) was the first to utilise a delayed recall design in a study
comparing source monitoring between psychiatric patients experiencing
hallucinations and a group who did not. Following a one week delay
participants were required to identify characteristics of their own
responses to open ended questions. There were no significant differences
in potential confounding variables of verbal memory, opinion stability and
communication skills between groups. Heilbrun’s hypothesis that
participants experiencing hallucinations would exhibit an externalising bias
was supported because the hallucinating group demonstrated significantly
more difficulties identifying their own statements than the nonhallucinating group. However, the poor source recognition observed in the
hallucinating group did not necessarily represent an externalising bias,
since an external source option (e.g., responses other than their own) was
not included.
Despite the limitations of Heilbrun’s study, it provided the platform to
employ the delayed-recall methodology, which is the most widely utilised
source monitoring study design with psychotic cohorts. Bocker and
colleagues recruited three groups consisting of participants with a
diagnosis of schizophrenia, either with or without hallucinations, as well as
a healthy comparison group (Bocker et al., 2000). They conducted a
range of assessments including a delayed source monitoring task requiring
participants to distinguish between 30 words which were perceived (read
aloud), imagined or new. No overall group differences in regarding reality
discrimination were reported, yet a positive correlation was observed
between severity of hallucinations rated on the Positive and Negative
Symptom Scale (PANSS: Kay, Fiszbein & Opler, 1987) and reality
discrimination errors. However, a number of issues may have
compromised reliability of the study. Firstly, the statistical power was
limited with only 13 participants in the hallucinating group. Additionally,
nine of the 13 participants from the hallucinating group experienced only
‘slight to mild’ hallucinations. The authors highlighted this limited the
conclusions that could be made about source monitoring for the total
hallucinating group. Furthermore, the time delay between the initial and
recall phase ranged from two days to one week. Ideally, the duration of
24
time from baseline to recall should have been consistent between
participants, or, that variation in recall time was included as a covariate to
control for the extent memory contributed to source monitoring
performance.
The same research group subsequently employed the perceived, imagined
or new source manipulation format with three groups of participants with
a diagnosis of schizophrenia, with and without hallucinations, as well as a
healthy comparison group (Aleman et al., 2003). The delay period was
more rigorously controlled, as participants were assessed immediately
after presentation (immediate recognition) and again after a 15 minute
delay (delayed recognition). Significantly more errors were found in the
delayed condition than immediate condition for all groups. However, no
significant group differences were found in the immediate or delayed
condition, indicating that having schizophrenia or hallucinations did not
clearly impact source monitoring performance. Interestingly, a positive
correlation was observed between hallucination severity as measured by
the Topography of Voices Scale (TVRS; Hustig & Hafner, 1990) and source
discrimination errors in the immediate and delayed recall tasks. However,
the association between hallucination severity and source discrimination
errors should be considered with caution as this correlation was not
observed when hallucinations were measured with the PANSS.
Brunelin and colleagues conducted a similar study with two schizophrenia
patient groups; hallucinating and non-hallucinating (Brunelin et al., 2006).
Participants were required to distinguish between five potential sources:
words they said, had imagined saying, had heard the experimenter say,
imagined the experimenter saying and new distractor words. The only
group differences observed were that hallucinators made significantly
more errors than the other groups in the hear-imagine condition, by
incorrectly attributing words they imagined the experimenter saying to
being said by the experimenter. This result supports the externalising
source monitoring bias for hallucinators hypothesis, particularly since the
hear-imagine condition included a source option which was truly external,
i.e., said by experimenter.
25
A number of studies by Brebion and colleagues have incorporated visual,
auditory and self-generated stimuli to manipulate the source of material
(Brebion et al., 2000; 2002). These studies included three groups
consisting of participants diagnosed with schizophrenia, with and without
hallucinations, as well as a healthy control group. During the initial phase,
a picture and a word spoken by the assessor were presented for eight
different topics (e.g. sports, animals, transport). Participants were also
required to produce their own word associated with each topic and to say
this aloud, which was noted by the experimenter. The participants were
not informed they would later be required to recall the items. After a five
minute delay which included a distraction task, the assessor read aloud a
list consisting of the 24 initially produced items as well as 24 distractor
words not presented at the initial phase, consisting of three words
associated with each of the eight topics. Compared to healthy control
participants, the patient groups displayed higher tendencies to confuse the
source by reporting misattributing spoken items as pictures. A positive
correlation was observed between severity of hallucinations and false
recognition of distractor items, indicating that hallucination severity was
related to impaired source monitoring.
Brebion and colleagues conducted a further series of word recognition
studies, which provided additional support for the association between
hallucinations and an externalising bias (Brebion et al., 2005; 2009). In
the first of these studies, a significant correlation was observed between
hallucination scores, as measured by the Scale for the Assessment of
Positive Symptoms (SAPS: Andreasen, 1984), and an increased response
bias toward false recognition of words. This was assessed via identification
of target words which had been previously presented from a list which
included the original target words as well as new words. The response bias
was observed during the first test condition when the identification list
was presented after a five minute delay. However, no response bias was
observed during the second test condition, when participants were
required to recognise words immediately after attempting to remember a
word list. This finding indicated that contextual memory may have been
26
the primary variable influencing the outcome. In a subsequent word recall
study Brebion and colleagues (2009) asked participants to recall a list of
words after they had been presented for 45 seconds. Four ‘target’ lists
were administered, including two non-related lists and two related lists.
Hallucination score, as measured by the SAPS, was significantly correlated
with both the level of extra-list (words not presented in any target list)
and intra-list (words from previous target lists) errors. The results support
the theory that hallucinations are associated with deficits in the
monitoring of internal speech and source recognition.
Keefe and colleagues conducted a delayed a source monitoring study
which involved discriminating between visual (pictures), self-generated,
experimenter generated (read aloud) or new items (Keefe et al., 2002).
Participant groups were schizophrenia patients with ‘target symptoms’
(hallucinations, passivity phenomena, thought insertion), schizophrenia
patients without target symptoms and a healthy comparison group. Unlike
Brebion and colleagues (2000; 2002), Keefe and colleagues (2002) did
not observe significant differences between schizophrenia patients and
healthy participants in the distinction of the source of visual or auditory
items. However, schizophrenia patients with target symptoms experienced
greater difficulties discriminating self-generated items from experimenter
generated or new items. Interestingly, this result did not support their
previous study (Keefe et al., 1999), where target symptoms were not
associated with source monitoring deficits. Instead, results from this
earlier study indicated a generalised source monitoring deficit for
schizophrenia patients compared to a healthy control group. The results
from both studies by Keefe and colleagues (1999; 2002) support the
hypothesis that generalised source monitoring deficits are associated with
schizophrenia. However, controlling for specific symptoms such as
hallucinations, rather than 'target' symptoms, would be required in order
to draw conclusions about the specificity of identifying precise source
monitoring characteristics.
Franck and colleagues conducted a source monitoring task with a short
delay period of only five minutes (Franck et al., 2000). During the initial
27
phase participants were required to read eight words aloud (overt speech)
and eight words silently (covert speech). Following the delay period
participants were required to distinguish from a list of 24 words which
items had been read aloud, silently or were not initially presented.
Participants with a diagnosis of schizophrenia displayed a significant bias
toward attributing covert speech to having been read aloud (an
externalising bias) compared to a control group. Furthermore, within the
group experiencing schizophrenia, the externalising bias of covert speech
was more pronounced for those experiencing hallucinations. Despite
providing support for the external attribution bias hypothesis for
hallucinators, the study was limited by a relatively small sample size with
only eight participants reporting hallucinations. Furthermore, the design
incorporated discrimination only between self-derived stimuli and new
items. By not including a source from an ‘other’ during the initial phase,
participants were not truly discriminating between an internal and external
source from the time of memory formation.
2.3.2 Cognitive effort and delayed source monitoring tasks.
A number of delayed source monitoring studies have attempted to assess
the influence of variables which could affect source monitoring
judgements, such as manipulation of cognitive effort and emotional
valence during the initial testing stage. This is based on the premise that
source monitoring is dependent on the quality of information gained at the
time the memory is formed, or in the case of hallucinations at the time
the cognitive perceptual activity occurs (Brebion et al., 2000). As such,
the richness of the quality of information, which includes emotional
valence and cognitive effort, would potentially influence the accuracy of
source recognition (Johnson et al., 1993).
Costafreda and colleagues (2008) aimed to investigate whether external
misattribution was affected by the affective content of the source
material. Three groups of participants with schizophreniform diagnoses
were recruited: those experiencing predominantly delusions, individuals
experiencing predominantly hallucinations and a group in partial to full
28
symptom remission. Emotional valence was manipulated via the stimulus
content, with the experimenter providing, and participants generating,
words associated with a series of neutral (e.g., utensils) and negative
themes (e.g., swear words). Participants were not aware they would
subsequently be required to participate in a recall task. Following a brief
assessment of psychopathology the experimenter read the previously
generated list in a random order and participants were required to identify
the source. No new distractor items were included. External misattribution
was significantly higher for both of the symptomatic groups compared to
the remitted group, and this was more pronounced for negative themes.
Covarying for intelligence and negative symptoms did not alter these
results. There were no significant source monitoring differences between
the symptomatic groups indicating that cognitive deficits associated with
schizophrenia, rather than hallucinations alone, influenced the
misattribution. Heightened external misattribution for emotionally salient
material is congruent with the bias-based models which postulate that the
emotional salience may elicit personal dissonance with the material
leading to externalising (Bentall, 1990; Morrison et al., 1995). Ideally
positively themed stimuli could have also been included in order to more
comprehensively assess influence of emotional valence, rather than the
influence of only negative or distressing material.
The interaction between emotional salience and externalising bias has
recently been investigated in young people experiencing a first episode of
psychosis (Bendall et al., 2011). Participant groups were first episode
psychosis patients, with and without hallucinations, as well as a healthy
comparison group. The intensity of hallucinations was measured on the
PANSS. A source monitoring task was administered which involved
participants identifying whether a list of words had been generated by
themselves, the experimenter or were new following a three minute delay.
The group experiencing hallucinations did not demonstrate an external
misattribution bias compared to other groups. Additionally, the emotional
salience of stimuli did not affect externalising even when the association
between prior trauma and traumatic stimuli was assessed for
misattribution bias. The authors observed that the externalising
29
tendencies amongst hallucinators were accounted for by overall memory
errors, rather than a specific externalising bias.
According to the source monitoring framework, memories containing
information about one’s own thought processing (e.g. problem solving)
are more likely to be attributed internally than externally (Ditman &
Kuperberg, 2005). Johnson and colleagues observed that misattributions
were less likely to occur when increased cognitive effort or complexity was
involved (Johnson, Raye, Foley & Foley, 1981). This finding influenced the
hypothesis that cognitive effort may be used as an additional information
cue during memory formation, thus aiding accurate source attribution.
Bentall and colleagues (1991) examined this hypothesis by comparing
source monitoring characteristics between schizophrenia groups with and
without hallucinations, as well as a healthy participant group. Manipulation
of cognitive effort was achieved by asking participants to generate
responses of low and high levels of complexity and one week later
recalling whether responses were generated by the participant, assessor
or were new. In support of Johnson and colleagues’ (1981) hypothesis, all
participants demonstrated greater accuracy identifying the source of high
compared to low complexity items. Significant differences were observed
between the schizophrenia groups in the types of error responses.
Specifically, the hallucinating group misattributed significantly more selfgenerated high cognitive effort items externally than both other groups.
This finding supported the hypothesis that when faced with uncertainty
regarding attribution hallucinators will tend to attribute externally.
Seal and colleagues (1997) attempted to replicate Bentall and colleagues’
(1991) findings by conducting a delayed source monitoring task with
virtually the same method of manipulation of cognitive effort.
Schizophrenia participants with and without hallucinations and a nonclinical group were included in the study. Additionally, emotional salience
of material was manipulated by participants generating their own words
for neutral and high “emotionality” themes, as well as the experimenter
also providing words from these themes. After controlling for verbal
intelligence and verbal memory no group differences were found on
30
source monitoring tasks, regardless of cognitive effort or emotional
salience of material. This finding led the authors to highlight that
inconsistent results from previous delayed source monitoring studies may
be attributed to a failure to effectively control for cognitive factors such as
intelligence and memory. Seal and colleagues’ (1997) study highlighted
the importance of careful recruitment of participants in order to match
sample groups as closely as possible on measures such as cognitive
performance and intelligence.
2.3.3 Summary of delayed source monitoring studies.
Overall, the delayed recall designs offer modest support for distinct
externalising patterns for hallucinators. Numerous design issues weaken
this body of research, including small sample sizes, considerable variation
in delay times and inconsistencies in the methods of source manipulation.
Despite these limitations most of the studies provide a moderate level of
support for an externalising bias associated with hallucinations, largely
evident through correlational associations between severity of
hallucinations and increased external misattribution.
2.4 Immediate and Short Delay Source Monitoring Studies
Numerous authors have highlighted that hallucinations are most likely to
occur in a moment to moment context, quite separate from activation of
memory processes. Frith (1992) proposed that misattribution leading to
hallucinations takes place as the individual fails to recognise an internally
derived action (i.e., inner speech) as it occurs, which leads to the external
misattribution. Therefore, because delayed source monitoring studies
primarily rely on memories for the identification of source it is
questionable whether such a method is attuned to the source monitoring
processes relevant for hallucinations. To address this issue source
monitoring assessment may be more effectively approached via designs
which avoid memory activation (Bentall, 2004; Ditman & Kuperberg,
2005; Li et al., 2002). The following sections describe immediate source
31
monitoring studies which utilised subjective rating ratings, sensory
recognition and signal detection designs.
2.4.1 Immediate source monitoring studies - Subjective ratings
designs
A range of studies have examined specific source monitoring biases
occurring at the time of thought formation by asking participants to
subjectively rate their levels of perceived control of thoughts. Table 2.2
contains a chronological listing of these studies and provides a summary
of sample descriptions, assessments used and key findings.
Morrison and Haddock (1997a) conducted a word association task
requiring participants to rate their responses according to levels of
perceived control (‘How much control did have over the word that came to
mind?’), internality (‘How much was the word that came to mind your
own?’) and involuntariness (‘How involuntary was your thought?’). They
assessed groups of schizophrenia patients with and without hallucinations,
as well as a non-clinical control group. No significant group differences
were observed on a delayed source monitoring task. However, on a word
association task requiring participants to immediately rate their subjective
levels of control and internality, hallucinators displayed a significant bias
toward external attribution of their immediate thoughts, as measured by
their internality ratings. Furthermore, hallucinators displayed an increased
externalising bias for emotionally salient material.
32
Table 2.2
Immediate Subjective Source Monitoring (SM) Studies
Study
Group
Hallucination
Immediate SM Task
Results
Assessment
Morrison and
15 schizophrenia with
KGV-R rating above
Word association task;
Externalising bias for
Haddock (1997a)
hallucinations;
two.
Subjective rating of control,
hallucinators;
15 schizophrenia without
internality and
Trend toward less control
hallucinations;
involuntariness;
for hallucinators;
15 non-psychiatric.
Immediate and delayed
No differences for delayed
task.
task.
Baker and Morrison
15 schizophrenia with
Self reporting as
Word association task;
Hallucinators rated lower
(1998)
hallucinations;
currently hallucinating.
Immediate subjective rating
for control, internality and
15 schizophrenia without
of control, internality and
wantedness for self-
hallucinations;
wantedness.
generated thoughts.
15 non-psychiatric.
33
Table 2.2 (cont.)
Immediate Subjective Source Monitoring (SM) Studies
Study
Group
Hallucination
Immediate SM Task
Results
Assessment
Ensum and Morrison
30 schizophrenia spectrum
Case notes and PANSS
Word association task;
Lower levels of control
(2003)
with hallucinations.
score above four.
Subjective ratings of
and internality when focus
control, internality and
of attention was directed
wantedness.
inward;
Self-focus manipulated via
Emotionally salient words
internal and external
produced lower levels of
narratives.
control and internality.
The Self-Focus Sentence
Hallucinations, delusions
Completion (SFSC; Exner,
and thought insertion
1973).
influenced externalising
Startup, Startup and
Sedgman (2008)
57 schizophrenia patients.
SAPS.
bias.
34
Baker and Morrison (1998) conducted a similar study but utilised only the
immediate source monitoring approach. Participants were asked to rate
their responses according to control, internality and wantedness (‘How
much did you want to think of that rather than another word?’) on a word
association task. The prompts in the word association task consisted of
positive, negative and neutral words. Results were compared between
groups of schizophrenia patients with and without hallucinations, as well
as a non-clinical control group. Hallucinators reported significantly lower
levels of internality and control than other groups, suggesting an
externalising bias may be present. They were also significantly less
satisfied with their responses than both other groups. All groups
demonstrated higher levels of external attribution for emotionally salient
words than neutral words. Both studies (Baker & Morrison, 1998; Morrison
& Haddock, 1997a) provide considerable support for the hypothesis that
external misattribution may occur as an immediate event rather than as a
delayed recall process. Additionally, the observation that emotional
salience contributed to external misattribution was consistent with
cognitive bias models which implicate cognitive dissonance for
psychological arousal as a mediating factor in hallucinations (e.g., Bentall,
1990; Morrison et al., 1995).
Levels of self-focused attention are likely to contribute to the experience
of hallucinations by increasing hyper-vigilance toward threat or
uncertainty, subsequently enhancing the likelihood of external
misattribution (Garety, Kuipers, Fowler, Freeman & Bebbington, 2001;
Morrison, 2001). This concept was supported by Morrison and Haddock
(1997b) who observed that level of self-focused attention was a predictor
of hallucinations in a study comparing patient groups with and without
hallucinations as well as a non-clinical group. Self focused attention was
controlled in an experimental design by Ensum and Morrison (2003).
Attention was manipulated by asking a group of schizophrenia patients
experiencing hallucinations to create short stories which were focused
either internally or externally. Immediately following the attentional
manipulation task, the word association task adapted from Morrison and
Haddock (1997a) was administered. Ratings for control and internality
35
were significantly lower for the internal-focus condition. Furthermore,
ratings of internality were lower for emotionally salient words and this
result was enhanced further during the internal-focus condition. This
demonstrated that focus of attention had a significant effect on source
monitoring characteristics, specifically externalising bias. Ensum and
Morrison (2003) argued that this finding challenged the deficit based
models which emphasised a global cognitive deficit for cause and
maintenance of hallucinations. Their findings provided support for the bias
paradigms which emphasised the need to externalise emotionally salient,
ego-dystonic material that elicits cognitive dissonance. However, a nonhallucinating comparison group was not included. Therefore, it was not
clear if the effect of attentional focus on source monitoring was specific for
individuals experiencing hallucinations.
Startup and colleagues (2008) aimed to test whether Ensum and
Morrison’s results could be replicated. Several modifications were utilised
in their design including the use of the SFSC task as a measure of selffocused attention. Externalising bias was measured by participants rating
the level they believed the SFSC sentences were their own. This was used
as an externalising score. Significant correlations were observed between
the presence of auditory hallucinations (only for commenting voices, not
for conversing voices), delusions of being controlled (not for other
delusions) and thought insertion. Results from logistic regressions
indicated that all of these symptoms were significantly and independently
related to an externalising bias. These findings were consistent with the
theory that thought insertions and passivity phenomena (i.e., delusions of
being controlled) share similarities with hallucinations, in that they may be
misattributed intrusive thoughts (Morrison, 2001). Unlike Ensum and
Morrison (2003), levels of self-focused attention and emotional salience of
material did not enhance externalising.
In summary, immediate source monitoring designs utilising subjective
ratings associated with external attribution have yielded promising results
regarding support for an externalising bias for hallucinators and the
impact of personal salience in reinforcing external misattribution.
36
However, there have only been three published studies utilising immediate
source monitoring designs (i.e., Baker & Morrison, 1998; Morrison &
Haddock, 1997a; Startup et al., 2008). All of these studies support the
hypothesis that the external bias is enhanced for hallucinators. Ideally
further research incorporating immediate source monitoring designs is
warranted.
2.4.2 Immediate source monitoring - Sensory recognition
Frith (1992) proposed that hallucinations occur due to a breakdown in the
awareness and expectation of self-generated action, specifically inner
speech. This model has influenced a range of studies that have
incorporated an experimental source monitoring approach to assess
misattribution as the event occurs, by manipulating the playback of
auditory recordings of participants’ speech, thus altering the perceptual
characteristics of the speech. A summary of samples, assessment
methods and key findings of sensory recognition source monitoring
studies are provided in Table 2.3. Most studies manipulated self-generated
stimuli via pitch distortion or replication with another person’s voice. By
creating a disparity between what was expected and what was perceived,
such studies have attempted to test Frith’s model by overtly altering
perceptual qualities of self-generated actions. These studies have been
referred to as “real time source monitoring paradigms” (Ditman &
Kuperberg, 2005). The experiments were designed to assess perceptual
discrimination (immediate discrimination) rather than source memory, by
attempting to replicate as close as possible the perceptual and cognitive
experience of hallucinations.
37
Table 2.3
Real-Time, Sensory Recognition Source Monitoring Studies
Study
Groups
Hallucination assessment
Real-Time SM Task
Results
Johns and McGuire
10 schizophrenia with
Interview.
Sensory recognition of
External misattribution
(1999)
hallucinations and
own voice;
for hallucinators,
delusions;
Positive, negative and
enhanced by negative
8 schizophrenia with
neutral words.
valence.
Sensory recognition of
Externalising bias for
hallucinations;
own and other’s voice;
hallucinators, enhanced
8 schizophrenia without
Positive, negative and
by emotional valence.
hallucinations;
neutral words.
delusions;
20 non-clinical.
Johns et al., (2001)
10 schizophrenia with
SAPS and SANS.
20 non-clinical.
Allen et al., (2004)
15 schizophrenia with
Delay up to two days;
Hallucinators more likely
hallucinations;
Recognition of
to misattribute their own
13 schizophrenia without
manipulated recordings
speech externally;
hallucinations;
of own and other’s voice.
Misattribution positively
15 non-clinical.
SAPS score above three.
correlated with
hallucination severity.
38
Table 2.3 (cont.)
Real-Time, Sensory Recognition Source Monitoring Studies
Study
Groups
Hallucination assessment
Real-Time SM Task
Results
Allen, Freeman, Johns
57 non-clinical
LSHS.
Delay up to two days.
External misattribution
and McGuire (2006)
volunteers.
Recognition of
associated with delusion
manipulated recordings
proneness, however not
of own and other’s voice.
for hallucination
Positive, negative and
proneness.
neutral words.
39
Johns and McGuire (1999) asked participants to read aloud positive,
neutral and negative words and listen through headphones in real time to
their voices in an unaltered state or distorted with pitch adjustment.
Participants were required to indicate whether they thought the voice was
their own, someone else’s or if they were unsure. Compared to a healthy
control group and a schizophrenia group without hallucinations, individuals
experiencing hallucinations were significantly more likely to indicate that
the voice was from someone else, rather than rating as unsure.
Furthermore, hallucinators were more likely to make externalising errors
for negative words, suggesting emotional valence affected external
misattribution. Johns and colleagues (2001) extended their earlier
research by examining real time source monitoring with three groups
including schizophrenia patients with and without hallucinations and a
healthy control group. Participants read positive, negative and neutral
words aloud and listened through headphones in real time as they spoke.
However, the playback manipulations were more elaborate than in their
original study. The conditions included participant’s voice unaltered, their
own voice distorted, someone else’s voice (alien), or alien distorted.
Participants were required to identify the source of the voice. Both patient
groups made significantly more source attribution errors than non-patient
groups. Hallucinators were significantly more likely to make external
attribution errors than the other groups when their voice was distorted,
but made fewer errors than the control group when presented with ‘alien’
feedback. The authors proposed this is consistent with theories that
suggest hallucinations are associated with impaired verbal self-monitoring.
Hallucinators were more likely to make errors for negative words, whilst
emotional valence did not have a significant effect on attribution
characteristics for the other groups. The results of Johns and colleagues’
(1999 & 2001) studies led the authors to conclude that dysfunctional
verbal self-monitoring appears to be associated with auditory
hallucinations and that negative emotional content may enhance this
process.
40
Allen and colleagues (2004; 2006) used a similar speech recognition task
to Johns and colleagues (1999; 2001). Allen and colleagues' (2004; 2006)
were not 'real time' studies because they involved delay periods of one to
two days. However, it is important to highlight these studies within the
context of other sensory recognition research, as they attempted to
examine Frith's (1992) model by assessing whether a disturbance in the
awareness of self-generated speech was evident amongst hallucinating
samples.
In Allen and colleagues (2004) study participants included a schizophrenia
group experiencing hallucinations and delusions (all of whom had recently
experienced hallucinations), a schizophrenia group without hallucinations
and minimal delusions, as well as a healthy control group. Participants
were initially asked to read a list of positive, neutral and negative words,
then later required to listen to a recorded list of the same words consisting
of their own and another person’s voice. The word list was played back in
a manipulated form by distorting pitch, making the speaker’s voice more
difficult to recognise. Hallucinating participants made significantly more
errors in recognising their own speech compared to the other groups, thus
confirming the hypothesised externalising bias. There were no group
differences for the effect of emotional valence. Given the sample
characteristics of the positive symptoms group (i.e. many of whom
experienced delusions), it was not clear that the externalising bias was
clearly associated with hallucinations or due to overall symptom severity.
Allen and colleagues extended their speech recognition studies, by
examining whether auditory hallucination proneness in a non-clinical
sample would be associated with a tendency to misattribute selfgenerated speech (Allen et al., 2006). Hallucination proneness was
assessed with the LSHS. Delusion proneness was measured with the
Peters et al. Delusions Inventory (PDI-21; Peters, Joseph & Garety,
1999). A bias toward external misattribution for participants’ own speech
correlated with delusion proneness. A trend was observed between
external misattribution and hallucination proneness, however this
association was not statistically significant. Additionally, emotional valence
41
did not have any effect on source attribution. The authors noted that the
failure to observe a significant correlation between auditory hallucination
proneness and misattribution errors possibly reflected the small sample
size (n=57) and that further source monitoring studies amongst nonclinical samples require greater numbers.
Real time and minimal delay source monitoring studies have yielded
support for a hallucination externalising bias, with results consistently
indicating that hallucinations influenced external misattribution. However,
only two of these studies incorporated immediate designs, leaving the
remaining studies to be affected by the accuracy of recollection rather
than awareness of self-generated material. Whilst Allen and colleagues
(2004; 2006) attempted to incorporate manipulation of source stimuli, the
use of a delayed rather than immediate source monitoring task may have
diminished or negated the purpose of creating ambiguity in the source. It
would appear appropriate to conduct further sensory recognition studies
incorporating real time designs, in order to replicate Johns and colleagues
(1999; 2001) studies.
2.4.3 Immediate source monitoring - Signal detection tasks.
Signal detection procedures typically require participants to detect
whether recorded words are present within a background of white noise.
In order to detect stimuli in ambiguous circumstances, signal detection
theory is based upon two key principles. Firstly, ‘perceptual sensitivity’
which refers to the acuity of perceptual processes and is a static deficit.
Secondly, ‘perceptual bias’ which refers to the tendency to assume stimuli
are present (Bentall, 2004; Li et al., 2002). From a source monitoring
perspective, hallucinators may be more likely to experience greater
difficulty detecting signals and/or an externalising bias to report signals
that have not occurred than non-hallucinators. Therefore, the strength of
signal detection studies is their potential to test hypotheses relating to
both the deficit (e.g. Frith & Done, 1987; Hoffman, 1986) and the
subjective bias models (e.g. Bentall, 1990). Table 2.4 provides a summary
of samples, assessments and major findings for signal detection studies
42
discussed within this section. All of these studies involved detection of
auditory signals within a background of distracting stimuli.
Bentall and Slade (1985) conducted signal detection assessments that
required participants to indicate when a voice was present within white
noise. There were no significant differences in sensitivity between
schizophrenia patients with and without hallucinations in detecting when
signals (i.e., words) were present. However, hallucinators displayed a
distinct externalising bias to report words which were not present. A
second experiment was conducted with a sample of non-clinical
participants who were divided into two groups according to high and low
ratings of ‘hallucination proneness’, as measured by the LSHS. Again, no
significant differences were observed in stimuli sensitivity, however, the
high-hallucination prone participants displayed a significant externalising
bias by reporting stimuli that were not present. This finding was replicated
by Rankin and O’Carroll (1995) in an almost identical study, into which
tertiary students were recruited and divided into high and low
hallucination proneness on the LSHS. Results from all three studies
provided supporting evidence that an externalising bias, rather than a
perceptual deficit, may contribute to a predisposition toward hallucinating.
An additional aspect to Bocker and colleagues’ (2000) study (referred to in
2.3.1) was the inclusion of auditory and visual signal detection
assessments. This involved assessment via the traditional method of
detecting words within a background of white noise, whilst the visual task
consisted of detecting words on a screen within a background of dots. No
differences were observed between hallucinating and non-hallucinating
schizophrenia patients and a healthy group on either the auditory or visual
tasks. However, a positive correlation was found between PANSS score of
the hallucinating group and externalising response bias in both the
auditory and visual modalities.
43
Table 2.4
Signal Detection Studies
Study
Groups
Hallucination assessment
Signal Detection Task
Results
Bentall and Slade
Part 1
Part 1
Detect voices within
No differences in
(1985)
10 schizophrenia with
Hallucinations at time of
background of white
perceptual sensitivity;
hallucinations;
assessment;
noise.
Significant externalising
10 schizophrenia without
Part 2
bias for hallucinators
hallucinations.
LSHS.
and hallucination prone.
Part 2
From 136 students:
10 highest-hallucination prone;
10 lowest- hallucination prone.
Rankin and O’Carroll
From 250 students:
(1995)
LSHS.
Detect voices within
No differences in
15 highest-hallucination prone;
background of white
perceptual sensitivity;
15 lowest- hallucination prone.
noise.
Externalising bias for
hallucination prone.
44
Table 2.4 (cont.)
Signal Detection Studies
Study
Groups
Hallucination assessment
Signal Detection Task
Results
Bocker et al.,
13 schizophrenia with
PANSS.
Auditory and visual
No group differences.
(2000)
hallucinations;
modes;
Positive correlation
19 schizophrenia without
Detect voices within
between hallucination
hallucinations;
background of white
severity and reality
14 non-clinical healthy controls.
noise;
discrimination.
Detect words within
background of dots.
Li et al., (2002)
28 schizophrenia with
Hallucinations within two
Detect voices within
Hallucinators did not
hallucinations;
months of assessment.
background of white
differ from other
noise.
schizophrenia group for
16 schizophrenia without
hallucinations;
sensitivity or response
22 mood disorders;
bias;
25 non-clinical controls
Decreased sensitivity of
signals for schizophrenia
groups compared to
others.
45
Another study utilising only the auditory signal detection approach was
conducted with a more comprehensive sample consisting of schizophrenia
patients with and without hallucinations, as well as a depressed group and
a non-clinical group (Li et al., 2002). Participants were not only required
to indicate whether they detected one of two possible signals within the
white noise, but to also rate their level of confidence in their judgement.
Contrary to the previous studies, the schizophrenia patients displayed
sensitivity deficits and no group differences were observed regarding
response bias. The authors suggested this finding may have been
associated with the lack of verbal content in the auditory signal. Auditory
hallucinations are predominantly verbal and source monitoring deficits for
hallucinations have primarily been associated with misattribution of verbal
cognitions associated with inner speech.
Only four signal detection studies have been conducted in the context of
hallucinations. Whilst results have been mixed, these studies have
provided a reasonable degree of support for a distinct perceptual
sensitivity deficit for hallucinators. In addition to measuring source
monitoring, signal detection tests potentially assess a ‘Jump to Conclusion’
(JTC) bias which may contribute to the expression of psychotic symptoms,
especially delusions (Garety & Freeman, 1999). The JTC bias represents a
tendency to form judgements in ambiguous contexts as quickly as
possible on the basis of less information, potentially as a means to reduce
uncertainty. This has been associated with delusion formation (Garety,
Hemsley & Wessely, 1991; Huq, Garety & Hemsley, 1988; Moritz &
Woodward, 2005). Hallucinators also provide more rapid and incorrect
responses when asked to identify words within a background of white
noise (Heilbrun et al., 1983). Therefore, it remains open as to whether
signal detection measures are assessing source monitoring or a bias
toward eliminating ambiguity and uncertainty as quickly as possible.
2.5 Summary
Within the field of research into cognitive processing associated with
hallucinations, there has been considerable interest in the role of source
46
monitoring. Researchers have hypothesised that a tendency for
hallucinators to externalise self-generated material leads to internal
cognitive activity being experienced as foreign.
Findings from the source monitoring studies offer mixed results. Designs
incorporating time delayed tasks have been the most widely adopted and
offer moderate support for a propensity for hallucinators to misattribute
their own speech and thoughts externally. However, these studies have
been limited by small sample sizes, differences in delay times and
considerable variation in hallucination assessment methods. Significantly,
the most rigorously designed of these studies (e.g., Seal et al., 1997)
failed to find any significant source monitoring differences between
hallucinators and non-hallucinating participants. An over-riding concern is
that delayed designs neglect the consideration of the immediacy of
hallucinations, instead relying on the attribution of source from memory.
Immediate source monitoring studies have attempted to address this
issue and have produced reasonably consistent findings of reduced control
and awareness of self-generated material for hallucinators, an effect
which is enhanced with emotionally salient material.
Whilst most source monitoring hallucination studies have included
participants who met diagnostic criteria for psychotic disorders, a small
subset of studies have included participants who may be prone to
experiencing hallucinations (Allen et al., 2006; Bentall & Slade, 1985;
Rankin & O’Carroll, 1995). These studies were designed to address the
question of whether cognitive mechanisms contribute to psychotic
symptoms such as hallucinations across the spectrum of symptom
severity. Interestingly, results of two of these studies (Bentall & Slade,
1985; Rankin & O’Carroll, 1995) showed distinct externalising biases for
the hallucination prone participants, indicating that a continuum may
exist. These studies utilised only ‘hallucination prone’ measures, whilst a
potentially more valid line of enquiry could include individuals with more
varied emerging psychotic features who are below threshold for a
diagnosis of a psychotic disorder.
47
Source monitoring is one of the most extensively examined cognitive
processes within hallucination research. However, the question of whether
source monitoring deficits operate as a trait-like risk factor which enhance
risk for the development of hallucinations, or emerge as a consequence of
hallucinations remains unclear. In order to address this question, source
monitoring studies which incorporate immediate measures with UHR
clients displaying emerging hallucinatory phenomena are warranted.
Additionally, given the importance of emotion within cognitive bias
models, further examination of the role of emotions in attribution is
required.
48
CHAPTER 3
Metacognition and Hallucinations
This chapter will examine the role of metacognition in the appraisal of
intrusive cognitive material and the subsequent effect on mediating
factors such as cognitive dissonance, which in turn influences the
occurrence of hallucinations. The process of evaluating whether the
content of thoughts are internally derived or attributed to an external
source in the form of hallucinations is purportedly determined by
metacognition.
This chapter provides an overview of the definitions, dimensions and
measurement of metacognitive processes. The role of metacognition
within psychopathology will be introduced, followed by a review of
research examining the potential influence of metacognition in psychosis,
particularly its role in the formation and maintenance of hallucinations. A
summary of research pertaining to metacognitive processes for individuals
at high risk of psychosis will also be provided.
3.1 Defining Metacognition
Metacognition refers to a range of cognitive processes that include the
appraisal, control and monitoring of thoughts. Wells (2005) proposed that
metacognitive procedures control most or all of our consciously activated
cognitive activity and that without metacognition conscious appraisal of
cognitive events such as thoughts, feelings and memories would not be
possible (Slife, 1987). Metacognition has been referred to as our beliefs
and attitudes toward our own thoughts, or ‘cognition about cognition’
(Flavell & Ross, 1981) and has been described as an active, conscious and
reflective process focused toward one’s own thoughts (Yussen, 1985).
Metacognitive beliefs are influenced by personal beliefs, values,
experience and knowledge. There is reasonable agreement that
metacognition is defined as the knowledge and control individuals have
49
toward their thoughts and learning (Allen & Armour-Thomas, 1991; Flavell
& Ross, 1981; Jacobs & Paris, 1987; Toneatto, 1999).
3.1.1 Theoretical dimensions of metacognition.
Metacognition has often been described as consisting of several distinct
dimensions including static knowledge, experiences and strategies
(Brown, 1987; Flavell & Ross, 1979; Schraw & Dennison, 1994; Wells,
2005; 2009). These dimensions interact simultaneously so that
metacognition functions as a flexible and adaptive mechanism, continually
adjusting in accordance with new cognitive and behavioural experiences
(Wells, 2009).
In relation to psychological disorders, two types of metacognitive
knowledge have been referred to; explicit (declarative) and implicit
(procedural) (Wells, 2000; 2009; Wells & Matthews, 1994). Explicit
metacognitive knowledge can be clearly identified, for example ‘worrying
will help me cope’. On the other hand, implicit metacognitive knowledge
refers to rules and techniques which direct thinking, such as cognitive
skills that influence attention and memories (e.g. focusing on easiest
principles first to assist in learning new material).
Wells (2009) described experiential metacognitive knowledge as the
appraisals and emotions individuals experience in response to their mental
states. For example, the guilt focused self-appraisals about adverse
circumstances which are commonly reported by depressed individuals, or,
the negative appraisal of intrusive thoughts experienced by individuals
with obsessive disorders.
Strategic metacognitive techniques are used to monitor, alter and react to
thoughts in order to regulate emotional states. These strategies are
usually directed toward the negative emotions by reducing particular
‘damaging’ thoughts and possibly enhancing positive cognition. The
subjective experience for many individuals with psychological disorders
involves feeling ‘out of control’ and metacognitive strategies operate to
50
salvage a sense of control over cognitions (Wells, 2009). For instance,
metacognitive strategies may involve attempts to suppress distressing
thoughts and memories, analyse experiences in order to feel better
prepared, or predict outcomes in order to avoid and protect from further
adverse outcomes. Wells (2009) highlighted that many metacognitive
strategies are focused toward avoiding threatening thoughts, emotions or
experiences which ultimately reinforces the sense of threat.
3.2 Metacognition and Emotional Disorders
Within the context of modern psychology, principles of metacognition
were initially referred to in the early 20th century in texts such as Dewey’s
(1933) discourse on self-reflection and awareness of thought (Jarman,
Vavrik & Walton, 1995). Jarman and colleagues (1995) suggested that
formal metacognitive theory was first applied during the 1960s with
research that examined learning processes in children via the assessment
of reflective reasoning during problem solving and task performance (e.g.,
Reese 1962). However, it was not until the late 1970s that Flavell (1979)
proposed that deficits in metacognitive processes, such as a lack of
cognitive monitoring, may leave individuals vulnerable to experiencing
emotional disorders.
3.2.1 The Self-Regulatory and Executive Function (S-REF) model.
More recently, metacognition has been identified as an important feature
in cognitive models of emotional disorders. Wells and Matthews (1994,
1996) developed a model of emotional disorder which incorporated
metacognition as a mediating factor. Their model known as the selfregulatory executive function (S-REF) theory was influenced by Beck’s
schema theory of emotional disturbance, as well as information processing
theory. Wells and Matthews (1996) suggested that previous cognitive
models of emotional disorders were overly simplified because excessive
focus was placed on the appraisals and beliefs associated with external
stimuli. As a result, consideration of internal cognitive mechanisms which
regulate processes of moment-to-moment thinking was neglected. As an
51
alternative, the S-REF theory provided an integrative model of emotional
disturbance which not only considered responses to external cues, but
incorporated an understanding of factors which regulate cognitive
processing, namely metacognition (Wells & Matthews 1994; 1996).
A central principle of the S-REF model is that vulnerability to psychological
distress and disorders is associated with a dysfunctional ‘cognitiveattentional’ pattern. This is characterised by heightened attention to the
self, resulting in compromised information appraisal, excessive rumination
and repetitive activation of dysfunctional beliefs (Morrison, 2001; Wells &
Matthews, 1994; 1996). Such a cognitive-attentional bias would be likely
to enhance vulnerability to psychological dysfunction because the capacity
and flexibility to integrate information, particularly material which may be
discordant with personal beliefs, would be significantly compromised
(Wells & Matthews, 1996).
This dysfunctional information processing is mediated by metacognitive
beliefs which direct the cognitive attentional syndrome. Specifically,
metacognitive processes which guide rumination and regulate how
cognitive experiences are integrated schematically are thought to be
involved. For instance, negative metacognitive beliefs such as ‘worrying
helps me stay in control’, or, ‘I should feel guilty for negative thoughts’
will most likely influence the appraisal and reaction to thoughts,
contributing to the risk of developing and perpetuating psychological
disorders (Wells, 2000; Wells & Cartwright-Hatton, 2004).
The S-REF model can be adapted to explain the experience of
hallucinations, as metacognitive beliefs purportedly mediate the
interpretation of hallucinations and intrusive thoughts (Morrison, 2001). In
support of this, Chadwick and Birchwood (1994) demonstrated that beliefs
about voices influence the emotional and behavioural responses to
hallucinations and mediate their severity. Additionally, heightened selffocused metacognitive beliefs have been associated with hallucinations
experienced by individuals with schizophrenia (Baker & Morrison, 1998),
52
and individuals highly prone to experiencing hallucinations (Morrison et
al., 2000; Morrison et al., 2002a).
In essence, Wells and Matthews (1994, 1996) highlighted that the content
of cognitions may not influence psychopathology as much as the appraisal
and reaction to cognitions (i.e. metacognition) (Wells, 1995; Morrison,
2001).
3.2.2 Metacognition and non-psychotic disorders.
Whilst metacognition can be a voluntary process, Wells and Matthews
(1996) suggested that voluntary control of appraisal of thoughts
(metacognitive control) is diminished during states of distress. A number
of factors contribute to reduced metacognitive control, including negative
appraisals of intrusive thoughts, heightened efforts to monitor and control
cognitions, as well as failure to recognise and activate control where
possible (Wells & Matthews, 1996). Based on the S-REF model, this
combination of maladaptive cognitive processes is likely to reinforce a
self-focused cognitive-attentional bias and contribute to the development
of psychological disorders.
Much of the initial focus of metacognition and psychopathology research
was on the development and maintenance of anxiety disorders,
particularly obsessive compulsive disorder (OCD). McFall and Wollersheim
(1979) were instrumental in developing the cognitive model of OCD. They
proposed that hyper-vigilance toward perceived threats (e.g., fear of
contamination) was based upon specific maladaptive beliefs, some of
which could clearly be considered as dysfunctional metacognitive
processes (e.g., the belief that ruminative thinking can prevent negative
events; the belief that certain thoughts are unacceptable and could lead to
adverse events). Most of the cognitive processes identified in OCD models
such as perceived responsibility, the compulsion response, effort to
control thoughts and beliefs around the importance of specific thoughts
are metacognitive processes (Clark, Purdon & Wang, 2003). Empirical
evidence is mounting that distinct dysfunctional metacognitive styles are
53
associated with OCD, including beliefs about the importance of controlling
negative thought, negative consequences occurring from failure to control
intrusive thoughts and positive beliefs about intrusive thoughts (Clark et
al., 2003; Garcia-Montes, Perez-Alvarez, Balbuena, Garcelan & Cangas,
2006; Wells & Papagorgiou, 1998).
With regard to generalised anxiety disorder (GAD), metacognitive biases
such as positive beliefs about worry have been identified as prominent
(Borkovec & Roemer, 1995; Cartwright-Hatton & Wells, 1997).
Furthermore, worry about worry, or 'type-two' worry (Wells, 2005), and
negative beliefs about the effects of worry are significantly associated with
GAD, but not social phobia or panic disorder (Wells & Carter, 2001).
Dysfunctional metacognition has also been associated with the
development and maintenance of borderline personality disorder (BPD)
and substance abuse. Several theorists have proposed that the capacity to
reflect on subjective thoughts and states, as well as the cognitive and
emotive experiences of others is significantly compromised in BPD (Perris
& Skagerlind, 1998; Ryle & Kerr, 2002; Semerari et al., 2005).
Additionally, deficits in metacognitions such as awareness of cognitive and
emotive experiences have been associated with BPD traits such as states
of emptiness, affective instability, dissociation and impulsivity (Fonagy,
Gergely, Jurist & Target, 2002; Linehan, 1993; Ryle & Kerr, 2002).
Toneatto (1999) identified that metacognitive effects (beliefs about the
effects of substances on cognition) and metacognitive consequences
(beliefs about the cognitive effects of refraining from substances)
significantly influenced decision making toward substance use for
substance abusers. He concluded that dysfunctional metacognitive beliefs
appear to be a significant protagonist for the continuation of substance
use and as such, may be a major barrier of treatment of substance use
disorders.
54
3.3 Measuring Metacognition in Clinical Populations
A number of questionnaires have been developed to assess dimensions of
metacognition. Most of these measures were initially developed to assess
metacognitive processes in anxiety disorders, but have since been utilised
in studies across a range of disorders such as depression and
schizophrenia. The following section describes a number of metacognitive
measures used with clinical populations.
The Thought Control Questionnaire (TCQ; Wells & Davies, 1994) was one
of the first metacognitive measures to be developed to assess strategies
for controlling intrusive cognitions. A factor analysis was used to identify
five subscales including distraction, social control, worry, punishment and
reappraisal (Wells & Davies, 1994). These five factors were replicated in a
subsequent study with patients experiencing depression and post
traumatic stress disorder (PTSD) (Reynolds & Wells, 1999). The TCQ has
demonstrated good discriminant validity in distinguishing non-clinical
groups from cohorts experiencing schizophrenia (Morrison & Wells, 2000),
OCD (Abramowitz, Whiteside, Kalsky & Tolin, 2003) and acute stress
disorder (Warda & Bryant, 1998).
The Meta-Worry Questionnaire (MWQ; Wells, 2005) aims to assess metaworry within the context of GAD. The questionnaire consists of seven
items, with each item comprising a corresponding frequency scale. Items
include statements about beliefs regarding the particular dangers of
worrying (e.g. “I’m making myself ill with worry”; “I’m losing out in life
because of my worrying”). A belief scale asks participants to endorse their
level of conviction of each belief. The MWQ demonstrated reasonable
discrminant validity, by differentiating GAD participants from individuals
experiencing other anxiety disorders and participants with no anxiety
(Wells, 2005).
The Metacognitive Questionnaire (MCQ) (Cartwright-Hatton & Wells,
1997) consists of 65 items and is the most extensively used measure of
metacognitive functioning. The MCQ was developed in order to assess
55
metacognitive processes believed to be associated with the development
of psychopathology, as outlined in the S-REF theory (Wells & Matthews,
1994, 1996). Factor analysis revealed five distinct and relatively stable
factors that address positive and negative metacognitive beliefs,
metacognitive monitoring and judgements about confidence in cognition.
The MCQ demonstrated good reliability with alpha coefficients ranging
from 0.72 to 0.89. The five scales are outlined in Table 3.1, as well as the
associated terms that are referred to throughout this chapter. A further
strength of the MCQ is that it has been specifically designed to measure
metacognitive appraisal of intrusive cognitions, making it particularly
relevant to cognitive models of hallucinations.
Table 3.1
MCQ Scales.
Scales
Terminology
Positive beliefs about worry
Positive Worry
Negative beliefs about uncontrollability and
Uncontrollability
danger
Cognitive confidence (regarding attention
Cognitive Confidence
and memory)
Negative beliefs regarding consequences of
Negative Beliefs
not controlling thoughts
Cognitive self-consciousness (tendency to
Cognitive Self Consciousness
focus attention on thought processing)
The MCQ has been adapted to a shortened 30-item questionnaire (MCQ30) which provides similar reliability to the original questionnaire, with
alpha coefficients ranging from 0.72 to 0.93 (Wells & Cartwright-Hatton,
2004). The MCQ has demonstrated good discriminant validity in
distinguishing specific clinical groups, including GAD (Wells & Carter,
2001), OCD (Wells & Papageorgiou, 1998), depression (Papageorgiou &
Wells, 2003) as well as individuals at risk of psychosis and with
established psychotic disorders (Baker & Morrison, 1998; Laroi & Van der
Linden, 2005; Morrison et al., 2000; Morrison & Wells, 2003). A more
detailed description of the MCQ-30 is provided in the method (7.4.6).
56
3.4 Metacognition and Hallucinations
Bentall (1990) suggested that personal beliefs and expectations influence
the likelihood and impact of hallucinations. Morrison and colleagues
(1995) further proposed that the interaction between intrusive thoughts
and metacognition is a central process in the occurrence of auditory
hallucinations. This hypothesis was largely influenced by the S-REF model
of emotional disturbance (Wells & Matthews, 1994; 1996).
Morrison and colleagues (1995) outlined a heuristic model of auditory
hallucinations whereby intrusive unwanted thoughts are misattributed to
an external source, in order to reduce cognitive dissonance and discomfort
provoked by the cognitive intrusion. Within this framework metacognitive
beliefs mediate the appraisal of the intrusive thought and influence
whether it is accepted as a thought, or determined to be unacceptable and
misattributed to an external source as a hallucination. The authors
suggested that this process is automatic and involuntary, requiring no
intentional appraisal. This differentiates metacognitive processes in
psychotic disorders from other disorders such as GAD and OCD, which
tend to operate in a conscious manner. Figure 3.1 provides an outline of
Morrison and colleagues’ (1995) heuristic model of hallucinations.
Morrison and colleagues (1995) suggested that metacognitive beliefs
associated with a perceived need for control are especially pertinent in
hallucination formation. This would occur due to a heightened need to
control thoughts, leading to an increase in distress and cognitive
dissonance when unexpected cognitive intrusions occur. The MCQ contains
several scales which measure beliefs associated with controlling thoughts,
including Uncontrollability, Negative Beliefs and Positive Worry. According
to the heuristic model, hallucinations play a defensive role in reducing
distress elicited from unwanted thoughts by generating a means to create
distance from disturbing intrusive thoughts and associated cognitive
dissonance (Morrison et al., 1995; Morrison, 2001).
57
Intrusive Cognitive Event
Metacognitive Beliefs
Beliefs & Values
appraise the event
Experience
Knowledge
Appraised as
unacceptable
Appraised as acceptable.
Reinforce metacognitive
beliefs.
Cognitive
dissonance
Misattributed
Reduction in cognitive
externally,
dissonance. Reinforcing
Hallucination.
metacognitive beliefs.
Figure 3.1. Heuristic model of hallucinations based on Morrison and
colleagues (1995).
Since the late 1990s a small body of research has provided preliminary
support for the heuristic model through significant associations between
metacognition and hallucinations in individuals diagnosed with psychotic
disorders (Baker & Morrison, 1998; Garcia-Montes et al., 2006; Lobban,
Haddock, Kinderman & Wells, 2002; Morrison & Wells, 2000). All of these
studies cited Morrison and colleagues’ (1995) heuristic model for
hallucinations in the rationale and design of their studies. Table 3.2
provides a summary of these studies in chronological order. Sample
descriptions, assessment instruments used and key findings are provided.
58
All of these studies adopted the MCQ as the primary measure of
metacognition.
Baker and Morrison (1998) were the first to utilise metacognition as a
principal variable in a study examining cognitive factors associated with
hallucinations. This study was an extension of previous research
examining source monitoring characteristics with hallucinators (Morrison &
Haddock, 1997). Hallucinations were measured using a standardised
structured clinical interview that provides ratings for affect, positive and
negative symptoms for individuals with psychosis (KGV-R; Krawiecka,
Goldberg & Vaughan, 1977, modified by Lancashire, 1994). Participants
with schizophrenia scored higher than a non-clinical group on all MCQ
scales, apart from Cognitive Self-Consciousness. Furthermore, the
hallucinating participants could be distinguished from non-hallucinating
schizophrenia participants and the healthy control group by their
significantly higher scores on two metacognitive scales, Uncontrollability
and Positive Worry. Logistic regression was conducted with hearing voices
as the dependent variable and a range of cognitive factors as independent
variables, including the MCQ Negative Beliefs scale, source monitoring,
anxiety and IQ. The only significant predictor of hallucinations was the
MCQ Negative Beliefs scale score. The authors highlighted these findings
supported Morrison and colleagues’ (1995) heuristic model, since a belief
that intrusions were dangerous (i.e., Negative Beliefs scale) as well as
holding positive appraisals toward worry (i.e., Positive Worry) may
enhance cognitive dissonance when intrusive thoughts occur. These
findings influenced a range of studies over the following decade.
59
Table 3.2
Metacognitions and Hallucinations in Psychosis.
Study
Groups
Eligibility Assessment
Metacognition
Results
Assessment
Baker and
15 schizophenia with halluciantions;
DSM-IV diagnostic criteria;
MCQ
Higher Uncontrollability and
Morrison
15 schizophrenia without
KGV-R.
(1998)
hallucinations within 3 years;
hallucinators;
15 non-clinical control participants.
Higher on all MCQ for
Positive Worry for
schizophrenia groups.
Lobban et
32 schizophrenia with hallucinations;
DSM-IV diagnostic criteria;
al., (2002)
23 schizophrenia, never hallucinated;
KGV-R;
MCQ-SAM.
When anxiety controlled for,
hallucinators scored
24 anxiety disorder patients;
significantly less Cognitive
28 non-patient control group.
Confidence than other groups.
Morrison
49 schizophrenia with hallucinations;
DSM-IV.
MCQ.
Hallucinators scored higher
and Wells
24 schizophrenia without
than at least two out of three
(2003)
hallucinations;
control groups on all scales
35 panic disorder;
apart from Cognitive Self-
50 non-clinical control group.
Consciousness.
60
Table 3.2 (cont.)
Metacognitions and Hallucinations in Psychosis.
Study
Groups
Eligibility Assessment
Metacognition
Results
Assessment
Garcia-
21 schizophrenia, current
DSM-IV;
MCQ.
Similar metacognitions
Montes et
hallucinators;
PANSS.
al., (2006)
22 schizophrenia, never hallucinated;
OCD;
16 schizophrenia, no hallucinations in
Hallucinators scored higher
six months;
than other groups on
23 OCD patients;
Uncontrollability and Negative
26 clinical control group;
Beliefs.
between hallucinators and
20 non-clinical control group.
61
In order to examine whether metacognition influences vulnerability for
specific disorders and symptoms, research designs incorporating groups
with multiple diagnoses is required. Accordingly, Morrison and Wells
(2003) examined metacognitive biases amongst a range of diagnostic and
symptom groups including schizophrenia participants with and without
hallucinations, as well as a panic disorder and healthy control group. The
hallucinating group scored significantly higher than at least two of the
three control groups on Positive Worry, Uncontrollability, Cognitive
Confidence and Negative Beliefs. In line with Morrison and colleagues’
(1995) model, these scales are associated with a perceived need for
control of thoughts. The authors also observed that the non-hallucinating
psychotic group and the panic disorder group shared very similar levels of
dysfunctional metacognitive beliefs, which were significantly higher than
the healthy control group. This finding provided further support for the SREF hypothesis (Wells & Matthews, 1994; 1996) that increased
dysfunctional metacognitions may have a generic influence toward
psychological disorders. The results also indicated that hallucinators
experienced significantly higher levels of dysfunctional metacognitions
than other clinical groups. The study could have been strengthened by
assessment of potential confounding variables such as depression and
anxiety. This would have enhanced discriminant validity by differentiating
the specific influence of the degree of emotional distress from symptom
group membership on metacognitive outcomes.
Lobban and colleagues (2002) expressed concern about the lack of
controlling for emotional factors including anxiety and depression in
metacognitive studies such as Baker and Morrison's (1998) study. Lobban
and colleagues (2002) highlighted that the MCQ was initially designed for
research within anxiety disorder groups, therefore they developed the
MCQ- SAM (Shortened and Modified) instrument for use with individuals
with schizophrenia. Scales consisted of the Cognitive Self-Consciousness,
Positive Worry, Cognitive Confidence and Negative Beliefs scales from the
MCQ. An additional three scales were created that assessed how cognitive
intrusions would be processed. These scales were referred to as appraisal
of unwanted thoughts, importance of consistency of thoughts and
62
normality of experiencing unwanted thoughts. After controlling for anxiety
and depression, schizophrenia patients who experienced hallucinations
reported significantly less Cognitive Confidence than the non-hallucinating
schizophrenia patients. The hallucinators displayed similar metacognition
scores to individuals experiencing anxiety disorders (OCD, GAD, PTSD),
with the only significant difference being that hallucinators scored higher
on beliefs about the need for consistency of thoughts. Therefore, once
emotional distress was controlled for metacognition had minimal or no
influence on hallucinations.
A similar design was employed to compare metacognitive beliefs between
participants diagnosed with schizophrenia who experienced hallucinations
and a range of other diagnostic groups (Garcia-Montes et al., 2006). This
is the most rigorous attempt to date to control for diagnosis as a
confounding variable (see Table 2 for sample description), by including
the largest selection of participant groups. Diagnoses were assessed using
the Diagnostic and Statistical Manual, version four (DSM-IV: American
Psychiatric Association, 1994) diagnostic criteria and the Positive and
Negative Syndrome Scale (PANSS: Kay, Opler & Lyndenmayer, 1988).
Consistent with cognitive theories which outline similarities in the intrusive
nature of thoughts for OCD and hallucinations (Morrison et al., 1995),
hallucinators displayed similar metacognitive characteristics to the OCD
group, with significantly higher scores for individuals who experienced
either current or past hallucinations on the Uncontrollability and Negative
Beliefs scales. The most important distinction between current
hallucinators and OCD was that the OCD group reported significantly
higher levels on the Cognitive Self-Consciousness scale. However, there
were no significant differences between current hallucinators and other
groups regarding cognitive self-consciousness. The authors suggest that
the hallucinators lower levels of self-consciousness or awareness
contributed to the likelihood of discordant thoughts being externally
attributed. Whilst this study identified similar metacognitive processes for
OCD and hallucinators, it did not distinguish clear metacognitive patterns
for hallucinators compared to other groups. As such, it could be argued
that it did not adequately support Morrison’s heuristic model of auditory
63
hallucinations. An obvious limitation of the study was the relatively small
samples sizes within the six participant groups, which compromised
statistical power to detect more subtle metacognitive differences between
groups.
Garcia and colleagues (2006) did not control for the severity of emotional
distress, arguing that distinguishing distress from hallucinatory
experiences is an artificial distinction. They based this decision upon
Freeman and Garety’s (2003) claim that emotional distress cannot be
measured separate to hallucinations and advocated against distinguishing
between psychosis and emotional distress in empirical studies. However,
this fails to recognise that some individuals report positive hallucinations
(e.g., Romme & Escher, 1989) and adapt with minimal or no distress.
The issue of statistically controlling for distress presents the greatest
methodological controversy across these studies. Once distress was
controlled for via depression and anxiety measures, hallucinators
displayed minimal differences in metacognition between other symptom
and diagnostic groups (Garcia-Montes et al., 2006; Lobban et al., 2002).
Whilst there is agreement that metacognition is associated with
psychological disturbance, the specificity of the relationship between
metacognitive dimensions and particular disorders is unclear (Lobban et
al., 2002; Morrison & Wells, 2003). Further research is required which
controls for common factors across diagnostic groups in order to
understand the distinction between emotional and hallucinatory
associations with metacognition. An additional limitation relates to the
considerable variance in duration of hallucinations across these studies, as
there was no controlling for the duration of psychotic disorders, or the
effects associated with chronicity and treatment. It is conceivable that
metacognitive biases may vary throughout the course of illness, however
the temporal relationship between metacognition and hallucinations over
the duration of illness has not been examined. Despite these limitations,
these studies provide evidence that specific metacognitive biases
contribute to the development of hallucinations.
64
3.5. Metacognition and Risk of Psychosis
Despite an expansion in metacognition models and increasing empirical
research over the past decade, there is limited understanding as to
whether metacognitive processes are trait-like risk factors for
hallucinations, or, epiphenomena of psychosis and hallucinations
(Morrison & Wells, 2003). Longitudinal designs involving ‘high-risk’
cohorts that include observations of the temporal relationship between
metacognitions and the development of hallucinations may offer additional
insight into whether dysfunctional metacognitions have a causal effect on
hallucinations (Lobban et al., 2002).
In recent years an increasing body of research has attempted to address
this issue by examining metacognitive processes endorsed by individuals
that are prone to hallucinations (e.g. Laroi & Van der Linden 2005;
Morrison et al., 2002a) and at ‘Ultra High Risk’ (UHR) of developing
psychosis (e.g. Morrison et al., 2006; Morrison, French & Wells, 2007a).
The following section includes a review of empirical studies which have
examined the interaction between metacognition and the emergence of
hallucinations prior to the onset of psychosis.
3.5.1 Metacognition and hallucination-proneness.
A range of studies have attempted to examine the relationships between
metacognitive processes and predisposition to psychosis by identifying
and selecting hallucination prone (HP) individuals. This approach assesses
the extent to which non-clinical participants endorse certain psychotic-like
phenomena and maintain positive beliefs associated with hallucinatory
phenomena. Examining hallucination-proneness is based on the well
established premise that psychotic symptoms occur across a continuum
from nil, to severe to recurrent symptomatology (e.g. Eysenck, 1952).
Proneness toward hallucinations may be considered as an initial stage
within a continuum (Verdoux & van Os, 2002). Examining cognitive
factors associated with ‘prone’ populations, in association with established
65
psychosis, may provide greater insight into how symptoms develop across
the psychosis continuum.
Table 3.3 provides a chronological listing of studies which have examined
the influence of metacognition on predisposition to hallucinations within
non-clinical populations. Participant details, measures and key findings are
contained within the table. The LSHS was the predominant measure of
hallucination proneness used by these studies. As with the studies
described in the previous section, the MCQ was the primary measure of
metacognition across all the HP studies.
66
Table 3.3
Hallucination Prone (HP) Metacognition Studies
Study
Groups
Assessments
Metacognitive
Association Between HP and
Assessment
Metacognition
Morrison et al.,
105 university
Revised Hallucination Scale
MCQ;
MCQ scales of Cognitive Self-
(2000)
students and health
(RHS);
TCQ.
Consciousness, Uncontrollability,
workers.
Grouping of high and low
Negative Beliefs associated with HP;
predisposition via median
Positive beliefs about hallucinations
split.
predicted auditory and visual HP.
Morrison et al.,
132 health workers.
(2002a)
RHS;
Three MCQ scales.
Positive Worry associated with auditory
The Interpretation of Voices
HP;
Inventory (IVI).
Uncontrollability, as well as Positive
Worry associated with visual HP.
Laroi et al.,
100 participants;
LSHS.
MCQ.
Significant differences on all MCQ scales
(2004)
High and low HP
between high and low HP groups;
groups.
Significant positive correlations between
HP and all MCQ scales.
67
Table 3.3 (cont.)
Hallucination Prone (HP) Metacognition Studies
Study
Groups
Laroi and Van der
331 university
Linden (2005)
students;
Assessments
LSHS.
Metacognitive
Association Between HP and
Assessment
Metacognition
MCQ;
Significantly higher for high HP on all
PDI-21.
MCQ scales, apart from Positive Worry.
High and low HP.
Uncontrollability and Positive Worry
were only predictive MCQ variables for
HP.
Cangas et al.,
81 non-clinical
RHS
MCQ.
Uncontrollability, Negative Beliefs and
(2006)
university students.
Cognitive laboratory battery
Cognitive Self-Consciousness correlated
(COGLAB: Spaulding,
with hallucination and delusion
Garbin & Dras, 1989);
proneness;
Continuous Performance
Negative Beliefs and attention
Test (CPT; Orzack &
difficulties predictive of hallucination
Kornetsky, 1971);
and delusion proneness.
Wisconsin Card Sorting Test
(WCST: Fey, 1952).
68
Table 3.3 (cont.)
Hallucination Prone (HP) Metacognition Studies
Study
Groups
Assessments
LSHS.
Metacognitive
Association Between HP and
Assessment
Metacognition
MCQ-30;
Uncontrollability correlated with HP;
Jones and
751 non-clinical
Fernyhough
undergraduate
White Bear
Cognitive Self-Consciousness, Cognitive
(2006)
students.
Suppression
Confidence and Uncontrollability were
Inventory (WBSI;
predictors of HP.
Wegner & Zanakos,
1994).
Stirling et al.,
106 non-clinical
LSHS;
MCQ;
Significant differences on all MCQ scales
(2007)
participants;
Oxford and Liverpool
MCQ-th.
apart from Positive Worry;
Low, medium and
Inventory of Feelings and
Significant differences for three of four
high HP group.
Experiences (O-LIFE;
scales for MCQ-th. Post-hoc analyses
Mason, Claridge & Jackson,
revealed significant difference for
1995).
Positive Worry.
69
Morrison and colleagues (2000) used a median split to distinguish high
and low HP groups of college students on the RHS (an adapted version of
the LSHS). The RHS is a 16-item questionnaire which incorporated
measurement of predisposition to visual hallucinations, as well as using a
4-point scale to measure hallucination frequency, rather than the
true/false rating used in the LSHS. An overall significant difference
between metacognitive beliefs of high and low HP individuals was
observed. The high HP group obtained significantly higher MCQ scores
across several scales, including Cognitive Self-Consciousness,
Uncontrollability and Negative Beliefs. These results were similar to Baker
and Morrison’s (1998) observations of schizophrenia participants
experiencing hallucinations. Compared to other variables such as anxiety,
depression and thought control strategies, positive beliefs associated with
experiencing hallucinations was the most powerful predictor of
predisposition toward hallucinatory experiences. Whilst positive beliefs
about hallucinations is not a MCQ scale, it could be conceptualised as a
meta-appraisal of anomalous experiences. Despite the authors’ suggestion
that the RHS could distinguish between predisposition toward auditory and
visual hallucinations, differences in metacognition were not examined
between these domains. The median split approach for grouping can be
criticised due to the arbitrary nature of creating a dichotomous variable
from a continuous variable (MacCallum, Zhang, Preacher & Rucker, 2002).
Specifically, concern can be raised about the meaningfulness of the
median cut off score as an indicator of whether a participant was prone to
hallucinations. However, the authors highlighted that the median split
approach results in a reduction in statistical power. Therefore, the group
differences were likely to be statistically robust.
An alternative to the median split approach was adopted by Laroi and
colleagues using a non-clinical, predominantly undergraduate sample
(Laroi, Van der Linden & Marczewski, 2004). They selected the highest
25% and lowest 25% responders on the LSHS across the entire sample to
create HP and non-HP groups. Significant differences between HP and
non-HP on all five scales of the MCQ were observed, as well as a
significant positive correlation between hallucination proneness and all
70
MCQ scales across the entire sample. They concluded that cognitive
factors such as increased emotional salience toward cognitive material,
external source monitoring biases and increased levels of dysfunctional
metacognitive beliefs all contribute to predisposition toward hallucinations.
Whilst this result supported top down cognitive models of hallucinations
(e.g., Bentall, 1990; Morrison et al., 1995), emotional distress and other
important potential confounding variables such as depression and anxiety,
which may have been heightened in the HP were not controlled for.
Morrison and colleagues (2002a) conducted two separate multiple
regressions to determine predictive variables associated with proneness to
both auditory and visual hallucinations. Independent predictor variables
included three scales of the MCQ (Positive Worry, Uncontrollability and
Negative Beliefs), trait anxiety measured with the State-Trait Anxiety
Inventory (STAI: Spielberger, Gorusch, Lushene, Vagg & Jacobs, 1983).
The IVI was developed for the study and comprised of three scales
measuring meta-physical beliefs about voices, positive beliefs about
voices and interpretation about loss of control. Variables that significantly
predicted predisposition to auditory hallucinations were positive beliefs
about voices, trait anxiety and Positive Worry. Variables that significantly
predicted predisposition to visual hallucinations included Positive Worry
and Uncontrollability. The authors suggested that these results imply that
positive and negative beliefs toward hallucinations, as well as positive
metacognitive beliefs (i.e., Positive Worry) may be conducive to
vulnerability toward hallucinations.
Stirling, Barkus and Lewis (2007) cited the influence of Morrison and
colleagues’ (2000; 2002a; Morrison & Wells, 2003) research in their study
examining the role of top down metacognitive processes as mediating
factors for HP and schizotypy. The MCQ, as well an adapted form of the
questionnaire known as the MCQ-Thinking (th) was administered to a nonclinical sample. The MCQ-th contained four scales by amalgamating the
Positive Worry and Cognitive Self-Consciousness scales. The sample was
divided into three groups of low, medium and high HP, by amalgamating
scores on the LSHS and the O-LIFE. Participants who obtained a HP score
71
at least 0.5 SDs above or below the mean were recruited to the high and
low HP groups respectively, whilst participants who obtained a HP within
0.5 SDs either side of the mean were recruited for the medium HP group.
As predicted, there was a significant positive linear association between
hallucination proneness and metacognition, with significant differences
observed between the three groups on all MCQ scales, apart from Positive
Worry. Similar outcomes were observed with the MCQ-th, as significant
differences were observed on three of the four MCQ-th scales across the
three groups. The authors concluded that high ratings of schizotypy were
associated with concerns about controllability of thoughts and that the
metacognitive patterns for hallucination prone participants were very
similar to that of individuals experiencing hallucinations with schizophrenia
(e.g., Baker & Morrison, 1998; Morrison & Wells, 2003).
In an expansion of HP studies, Laroi and Van der Linden (2005) assessed
metacognitions associated with both hallucination and delusion proneness,
using a median split approach with a sample of non-clinical university
students. Participants scoring high and low on delusion proneness were
identified using the PDI-21 and the LSHS was used to determine
hallucination proneness. Independent t-tests indicated that both the high
hallucination and delusion prone groups displayed significantly higher
scores on almost all MCQ scales than low hallucination and delusion prone
groups, apart from no significant differences for Positive Worry between
the high and low hallucination prone groups. Additionally, multiple
regressions indicated Uncontrollability as well as Positive Worry were
predictive of hallucination and delusion proneness. Negative Beliefs were
also found to be predictive of delusion proneness. Overall there appeared
to be only small differences between the metacognitive patterns
associated with delusion and hallucination proneness, highlighted further
by the observation that hallucination proneness was positively and
significantly predictive of delusion proneness.
Similarities in metacognition between hallucination and delusion
proneness raises the question of whether specific metacognitive factors
are implicated in the formation of hallucinations, or, if common cognitive
72
biases influence both perceptual disturbances and delusion formation. The
latter hypothesis is supported by findings from clinical and non-clinical
samples (Krabbendam et al., 2004; Van Os, Hanssen, Bijl & Ravelli,
2000). One possible explanation for this association is that delusional
interpretation of hallucinations may develop as a means of understanding
or integrating the hallucinatory experience (Birchwood & Chadwick, 1997;
Garety, Kuipers, Fowler, Freeman & Bebbington, 2001). However, such an
association would imply that delusions form as a secondary cognitive
process following the emergence of hallucinations, which would not
explain the occurrence of delusions without a history of hallucinations. It
is likely that separate cognitive processes are involved in the development
of hallucinations and delusions. Further research involving schizophrenia
populations experiencing hallucinations, delusions and both would aid in
identifying if separate metacognitive pathways exist for these symptoms.
3.5.1.1 Metacognition and attention within HP studies.
Jones and Fernyhough (2006) expanded upon models of metacognition in
psychosis by examining the interactions between metacognition and
thought suppression on HP. They utilised the MCQ as well as an
abbreviated version of the WBSI as a measure of cognitive intrusiveness
and thought suppression. The WBSI is a 15-item self-report measure of
cognitive intrusiveness and tendency to suppress thoughts. The WBSI
subscales were closely correlated with hallucination proneness, as well as
the MCQ-30 scale of Uncontrollability. The MCQ-30 scale of Cognitive SelfConsciousness was the strongest predictor of hallucination proneness,
followed by Cognitive Confidence and Uncontrollability. The authors
concluded that metacognition interacted with thought suppression to
enhance hallucination proneness, since only three of the five MCQ-30
scales were significant predictors of hallucination proneness, once the
WBSI scales of intrusiveness and suppression were controlled for.
The results of Jones and Fernyhough’s (2006) study led the authors to
propose a variation of previous cognitive models of hallucinations. In
summary, the content of auditory verbal hallucinations may be formed
73
from unwanted intrusive thoughts, which occur as a consequence of
thought suppression. This is based on the principle that attempts to
suppress a thought can paradoxically result in the thought intruding into
consciousness (Salkovkis & Campbell, 1994). Metacognition plays a
fundamental role in this model, because beliefs that thoughts are
uncontrollable and dangerous would contribute to thought suppression
and subsequent unwanted intrusive thoughts. Jones and Fernyhough
(2006) argued that Morrison and colleagues’ (1995) model placed too
much emphasis upon the role of dissonance between cognitive intrusions
and metacognitions. Given that cognitive self-consciousness (i.e.,
increased attention to thoughts) was the strongest predictor of
hallucination proneness, heightened awareness of thoughts may increase
likelihood of noticing when thoughts are incongruent with beliefs. This in
turn would lead to dissonance and subsequent externalising.
This revised theory was supported by Cangas and colleagues who
observed significant correlations between the MCQ scales
Uncontrollability, Negative Beliefs and Cognitive Self-Consciousness with
predisposition to both auditory and visual hallucinations, as measured on
the RHS (Cangas et al., 2006). The Negative Beliefs scale was particularly
relevant, accounting for a significant proportion of variance for both
auditory and visual hallucinations when other factors including depression,
executive planning and attention were included in multiple regressions.
The cognitive tests were selected from the COGLAB and included the CPT
and WCST to measure attention. Attention was a strong predictor of both
auditory and visual hallucination proneness. In line with Jones and
Fernyhough’s (2006) theory, Cangas and colleagues’ (2006) suggested
that hallucination predisposition may be associated with metacognitive
processes associated with heightened self-focused attention and a
reduction in attention toward external stimuli.
74
3.5.2 Summary of metacognition and HP studies.
An association between HP and increased levels of dysfunctional
metacognitions has been consistently reported. Despite these results,
caution needs to be applied when interpreting findings. First, minimal
efforts have been made to control for the influence distress may have on
metacognition. A clearer understanding of the way depression and anxiety
correlate with hallucination proneness would aid in strengthening
discriminant validity across HP studies. A further limitation across the HP
studies is the questionable reliability of the LSHS as an adequate measure
of hallucination predisposition (Laroi & Van der Linden, 2005). The LSHS
factor loadings for HP have varied considerably between studies,
indicating that a reliable measure for HP has yet to be developed. Laroi
and Van der Linden (2005) highlighted that numerous LSHS items
considered to be independent from hallucinations (e.g. daydreaming,
vividness of thoughts) were included in HP factors in several studies
(Morrison et al., 2000; 2002a). Whilst other LSHS items previously
identified as being associated with HP (e.g. “I hear a voice speaking my
thoughts aloud” and “I have had the experience of hearing a person’s
voice and then found no one was there”) were not loaded as factors.
Additionally, to date there have been no follow-up studies of whether
individuals rated as highly prone to hallucinations using the LSHS are
actually at increased risk of developing hallucinations, compared to
individuals rated as not prone. Therefore, whilst the concept of
‘hallucination-prone’ may be defined, its actual predictive validity is
currently unknown.
The limitations associated with the LSHS highlight the challenges
associated with attempting to measure a predisposition toward a
phenomenon, rather than measuring the phenomenon itself.
75
3.5.3 Ultra-High Risk (UHR) studies and metacognition.
A small number of studies have attempted to examine cognitive factors
including metacognitions endorsed by young people who meet UHR
criteria. The criterion for UHR includes individuals who may be
experiencing psychotic symptoms, as opposed to being symptom-prone,
however the severity or duration of their symptomatology is below
threshold for a psychotic diagnosis. UHR status is usually assessed using a
purpose developed instrument such as the Comprehensive Assessment of
At Risk Mental State (CAARMS: Yung et al., 2005) or the Structured
Interview for Prodromal Symptoms (SIPS: Miller et al., 2002) and the
Scale of Prodromal Symptoms (SOPS: Miller et al., 2003). There are a
number of reasons that studies involving UHR groups offer a more valid
representation of the predictive validity of cognitive processes in the onset
of psychosis, compared to HP studies. By examining metacognition with
UHR populations, a unique opportunity exists to gauge whether cognitive
biases develop over the course of psychosis starting with the early stages
of symptoms, or operate as static processes within an individual’s system
of beliefs. In other words it is possible to examine whether these
processes are present prior to the onset of symptoms or emerge alongside
the onset of symptoms. Therefore, it is possible to develop an
understanding of how cognitive mechanisms such as metacognition
interact with hallucinations during the early stages of symptom
development.
Details of studies specifically addressing metacognition within UHR cohorts
are outlined in Table 3.4. All of these studies determine the presence of
UHR status using the CAARMS or the PANSS. Participant details, key
assessments and major findings related to metacognition are outlined
within the table.
76
Table 3.4.
UHR and Metacognition Studies.
Study
Groups
Morrison et al.,
58 UHR ;
(2006)
56 non-clinical.
UHR Assessment
PANSS.
Metacognitive
Association Between UHR and
Assessment
Metacognition
MCQ.
UHR group scored significantly higher on
all MCQ scales apart from Positive
Worry.
Morrison et al.,
73 psychosis
Clinical interview;
(2007a)
(schizophrenia,
CAARMS.
MCQ.
Psychosis and UHR groups scored
significantly higher than control group
schizoaffective or
on all negative belief MCQ scales;
schizophreniform disorder);
Psychosis group scored higher on
43 UHR;
Positive Worry than other groups,
188 non-clinical students.
no difference on this scale between UHR
and control group.
77
Table 3.4 (cont.)
UHR and Metacognition Studies.
Study
Groups
UHR Assessments
CAARMS.
Metacognitive
Association Between HP and
Assessment
Metacognition
MCQ;
No MCQ differences between psychosis
SCL-90-R.
and UHR groups;
Brett Johns,
27 with psychotic disorder;
Peters and
32 UHR;
McGuire (2008)
24 with psychotic-like
UHR scored higher than control group
experiences (PLE), without
on all MCQ scales, apart from Positive
need for care;
Worry;
32 healthy control group.
UHR scored higher than the PLE group
on Negative Beliefs.
78
Table 3.4 (cont.)
UHR and Metacognition Studies.
Study
Groups
Assessments
Metacognitive
Association Between HP and
Assessment
Metacognition
MCQ.
UHR scored higher than non-clinical on
Barkus et al.,
95 non-clinical participants,
UHR;
(2010)
Divided into low, medium,
Schizotypal
Uncontrollability, Cognitive Confidence
high schizotypy groups;
Personality
and Negative Beliefs;
58 UHR (from Morrison et
Questionnaire (SPQ:
UHR scored higher than all schizotypy
al., 2006) study.
Raine, 1991)
groups on Uncontrollability, Cognitive
LSHS.
Confidence and Negative Beliefs;
UHR higher than low schizotypy for
Cognitive Self-Consciousness;
UHR group scored higher than all state
and trait groups on Uncontrollability;
UHR scored higher than state or trait
and control groups on Cognitive
Confidence and Negative Beliefs.
79
Morrison and colleagues (2006) reported that a UHR group scored
significantly higher on measures of dysfunctional metacognitive beliefs
including Uncontrollability, Cognitive Confidence, Negative Beliefs and
Cognitive Self-Consciousness compared to a healthy control group. These
results were consistent with Morrison’s previous studies involving
hallucination-prone samples (Morrison et al., 2000; 2002a). Furthermore,
there were positive associations between many of the metacognitive belief
scales and symptom measures. The General Health Questionnaire (GHQ;
Goldberg & Hillier, 1979) was included as a measure of ‘psychiatric
caseness’ and whilst the authors noted the control group attained “a high
level of psychiatric caseness”, the UHR group scored significantly higher
on the GHQ. Therefore, it is feasible that differences in responses to
metacognitive measures may in part be attributed to generic ‘psychiatric
caseness’ or other psychiatric conditions. Individuals meeting UHR criteria
are known to experience a range of psychopathologies beyond UHR
features, including depression, anxiety, personality disorders and
substance use disorders (Meyer et al., 2005; Svirskis et al., 2005).
Therefore, controlling for the effect of such conditions, or at least distress,
should be considered. Whilst the study did not distinguish UHR
participants who were experiencing hallucinations from those who were
not, it provides further evidence that metacognitive beliefs may contribute
to the development and maintenance of psychotic phenomena.
Morrison and colleagues (2007a) enhanced the design of their study by
comparing metacognition between a UHR group, a group with a diagnosed
psychotic disorder and a non-clinical control group. As predicted, they
observed that both the psychotic and UHR groups scored significantly
higher on all the negative MCQ scales than the non-clinical group.
Additionally, the psychotic group scored significantly higher than other
groups on the Positive Worry scale, whilst the UHR and non-clinical group
did not differ on this scale. Interestingly, Positive Worry has been
identified as being significantly higher in psychotic groups in numerous
studies (e.g., Baker & Morrison, 1998; Morrison & Wells, 2003).
Comparisons of metacognition were not made between hallucinators and
non-hallucinators or individuals with schizophrenia and affective
80
psychoses. Despite this limitation, this study provides considerable
support for the theory that dysfunctional metacognitive beliefs contribute
to psychological disorders and that metacognitive beliefs are associated
with symptoms during the period of at risk mental state.
Brett and colleagues examined the relationships between metacognition,
psychotic experiences, distress resulting from psychotic experiences, as
well as depression and anxiety (Brett et al., 2008). The MCQ and
Symptom Checklist 90 - Revised (SCL-90-R; Derogatis, 1983) were
administered to four groups: individuals diagnosed with a psychotic
disorder, a group identified as UHR according to CAARMS criteria, a group
with psychotic-like phenomena (identified as having experienced any first
rank psychotic symptom, without needing treatment) and a healthy
control group. Both the UHR and psychotic disorder groups scored
significantly higher on most MCQ scales than the control group and scored
significantly higher than the psychotic-like phenomena group on the
Negative Beliefs scale. However, most group differences became nonsignificant when anxiety and depression were controlled for. Few
associations were observed between metacognition, psychotic-like
anomalies and distress associated with psychotic experiences. The authors
concluded that metacognitive beliefs appeared to be associated with
participants' need for clinical care. However, it is important to note that
the UHR group differed from the psychotic-like experiences group on only
one MCQ scale, therefore, need for treatment appeared to have only a
partial influence on MCQ results. Whilst this study did not include
hallucination as a variable, it has been the only known study to date to
include both UHR and psychosis groups. The results indicate that
metacognition characteristics between psychosis and UHR groups are
similar.
Barkus and colleagues examined the influence of metacognition on
schizotypy and UHR status (Barkus et al., 2010). The authors included the
same UHR group as Morrison and colleagues (2006) and recruited an
additional healthy comparison group. The UHR group scored significantly
higher than the healthy comparison group on MCQ scales of
81
Uncontrollability, Cognitive Confidence and Negative Beliefs. The
comparison group was also divided into low, medium and high schizotypy
groups according to their scores on the SPQ. There were no significant
differences between groups on Positive Worry. The UHR group scored
significantly higher than all three control schizotypy groups on the MCQ
scales of Uncontrollability, Cognitive Confidence and Negative Beliefs. For
the Cognitive Confidence scale, the UHR group only scored significantly
higher than the low schizotypy group. Further analyses were conducted to
examine the effects of metacognition on psychotic symptoms as measured
by the LSHS (state factors), schizotypy (traits) and UHR status. The
healthy participant group was divided into three groups: one which scored
above the means on both SPQ and LSHS ‘trait + state’, one group which
scored above the means on either the SPQ or LSHS ‘trait or state’ and a
group which scored below the means on both scales ‘control’. There were
no significant differences between the UHR or other groups on Positive
Worry and Cognitive Confidence. However, for Uncontrollability, the UHR
group scored significantly higher than all other groups. For Cognitive
Confidence and Negative Beliefs, the UHR group differed significantly from
the ‘state or trait’ and ‘control’ groups. Several important issues can be
identified from these results. Firstly, UHR individuals may be distinguished
from high schizotypy groups on the majority of metacognitive scales.
Further, UHR cohorts may present with more metacognitive difficulties
than HP groups. Unfortunately, comparisons between the UHR group and
a hallucination prone group as measured by the LSHS were not described
in the analyses.
The results from the UHR and metacognition studies have provided
support for the hypothesis that metacognition is an important factor in the
emergence of psychotic disorders. In general, UHR individuals have
demonstrated significantly increased levels of dysfunctional
metacognitions than non-clinical individuals. Furthermore, positive worry
was consistently found to not be significantly higher amongst UHR groups,
a finding also observed in the majority of HP studies (Laroi & Van der
Linden, 2005; Jones & Fernyhough, 2006; Morrison et al., 2000; Stirling
et al., 2007). Whilst it appears likely that negative metacognitive beliefs
82
are associated with UHR status and HP, Positive Worry may be a result of
schizophrenia or frank psychosis (Barkus et al., 2010). This finding is
consistent with the S-REF model because positive or negative
metacognitive beliefs may contribute to ‘low-level’ or mild symptoms.
However, a combination of both negative metacognitive beliefs about
thoughts, as well as positive beliefs about worry and rumination would
likely increase distress and prolong symptoms (Morrison et al. 2007a;
Wells & Matthews, 1994).
Given the heterogeneity of symptoms and presentations associated with
emerging psychotic disturbances, further investigation into the
relationship between metacognition and specific psychotic phenomena is
warranted. A number of critical questions remain unclear surrounding
metacognition and the emergence of hallucinations within UHR groups.
Firstly, can differences in metacognition be observed between UHR groups
with and without hallucinatory phenomena? This addresses whether
metacognitive biases are specifically attributed to hallucinations, rather
than psychosis in general. Secondly, are metacognitive biases such as
negative beliefs about uncontrollability and positive beliefs about worry
epiphenomena of hallucinations, or, mediating factors in their emergence?
Thirdly, could metacognition contribute to the persistence of hallucinations
and influence the likelihood of transition to psychosis? Further UHR
studies which recruit and follow up UHR participants with and without
hallucinations may provide insights towards addressing these important
questions.
3.6 Summary
There is a growing body of research indicating that metacognitive beliefs
are associated with a range of psychological disorders. Further, psychotic
individuals experiencing hallucinations display higher levels of
dysfunctional metacognitions than individuals without hallucinations. This
appears to be most consistently related to fears about uncontrollability of
thoughts and their corresponding danger, as well as positive beliefs about
worry (Baker & Morrison, 1997; Lobban et al., 2002; Morrison & Wells,
83
2003). This finding supports Morrison and colleagues’ (1995) heuristic
model of hallucinations, which proposed that metacognitive beliefs
associated with a perceived need to control thoughts were particularly
important in the development of hallucinations.
Morrison and colleagues (2007a) suggested that whilst negative
metacognitive beliefs (e.g. negative beliefs about uncontrollability of
thoughts and thoughts in general) may predispose individuals to a more
generalised psychological vulnerability, positive beliefs about worry could
be the most important metacognitive factor in the development of
hallucinations, provided it is accompanied by negative metacognitive
beliefs. This has been observed in a number of studies conducted with
psychotic populations (Baker & Morrison, 1997; Lobban et al., 2002;
Morrison & Wells, 2003). Additionally, positive beliefs about worry was not
observed to be elevated amongst UHR populations (Barkus et al., 2010;
Morrison et al., 2006, 2007a), indicating it may be a metacognitive
process occurring as a result of psychosis, rather than as a precursor.
However, these findings are by no means conclusive because controlling
for distress has been found to virtually eliminate these differences
between psychotic groups with and without hallucinations (Lobban et al.,
2002). The important issue of understanding the impact of distress on
metacognition remains a fundamental problem when examining the
specificity of metacognitive influence on hallucinations. Whilst there is an
argument that controlling for distress is not warranted because it is
integral to the hallucinatory experience (Garety & Freeman, 2003), efforts
to control for emotional factors such as anxiety, depression and distress
appear warranted (Lobban et al., 2002). Future research which employs
experimental designs to manipulate mood and anxiety may be appropriate
for examining these relationships further.
By including HP and/ or UHR groups, a number of studies have attempted
to examine the role metacognition has in the development of
hallucinations and psychotic phenomena. Most HP studies reported similar
findings to studies involving psychotic participants, with hallucination-
84
prone individuals reporting higher levels of negative beliefs about
uncontrollability and danger than groups who scored low on hallucination
proneness (Jones & Fernyhough, 2006; Laroi & Van der Linden, 2005;
Laroi et al., 2004; Morrison et al., 2000; 2002a). Despite the strength of
evidence from HP studies, it could be argued that UHR studies may offer
the greatest insight into the role of metacognition in the emergence of
psychotic phenomena. There have only been four known studies
examining metacognition within UHR populations and these have reported
reasonably consistent results, with all UHR samples reporting significantly
higher levels of negative metacognitive beliefs than non-clinical samples.
However, no studies have differentiated between UHR symptom groups
when examining metacognition, therefore the relationship between
metacognitive processes and emerging hallucinatory experiences remains
unclear.
Further metacognition research involving UHR populations, with a clear
delineation of symptom groups and utilising designs which control for
emotional factors may contribute significantly to current understandings of
cognitive factors in the emergence of hallucinations. Additionally,
prospective follow-up designs that include UHR samples could offer further
information regarding the temporal relationship between metacognitive
beliefs and the development of hallucinations (Lobban et al., 2002). A
greater understanding of this temporal relationship may reveal whether
particular metacognitive patterns alter as psychotic phenomena
progresses, or, if metacognition acts as a trait-like aspect of cognition,
having a causal role in the emergence and progression of hallucinations.
Morrison and colleagues (2007a) highlighted that if metacognitions are
revealed to have a causal influence on hallucinations, then metacognitivefocused cognitive therapy (e.g. Morrison et al., 2004a; Wells, 2000) which
assists in modifying metacognitive beliefs and attentional biases may be
of great value.
85
86
CHAPTER 4
Unwanted Intrusive Thoughts and Hallucinations.
This chapter includes a review of theoretical models and empirical studies
that have been designed to test the proposition that unwanted intrusive
cognitions are significant in the phenomenology of hallucinations.
Definitions and characteristics of unwanted intrusive thoughts (UITs) will
be presented, with particular attention to their role in association with
hallucinations.
4.1 Definition
It has been estimated that humans experience many thousand distinct,
individual thoughts on a daily basis (Klinger, 1996). It is reasonable to
expect that a significant proportion of these thoughts, which may take the
form of images, will include unwanted intrusions which have at least a
moderate impact on our cognitive attention and performance (Clark &
Rhyno, 2005). Intrusive imagery and thoughts are not always a negative
phenomenon and may be an adaptive aspect of human cognition,
especially positive cognitions associated with creativity, problem solving
and relief from boredom leading to increased motivation (Salkovskis,
1989).
The experience of unwanted or uncomfortable images is a normal and
regular occurrence throughout the conscience stream of thought (Clark &
Purdon, 1995; Wegner, 1992). Such intrusions may include common
thought types such as worry, distractions or obsessions, often leading to
significant interruptions in focused and productive thinking (Sarason,
Pierce & Sarason, 1996). However, UITs are considered as separate
phenomena to standard thoughts and have been identified as an
important feature in a range of psychological disorders, including post
traumatic stress disorder (PTSD) (Falsetti, Monnier & Resnick, 2005),
obsessive compulsive disorder (OCD) (Badcock, Waters & Maybery, 2007;
87
Clark & Purdon, 1995), generalised anxiety disorder (GAD) (Wells, 2005)
and psychosis (Morrison & Baker, 2000).
Rachman (1981) defined UITs as repetitive, unwanted or unacceptable
thoughts, images or impulses that interrupt activity, are attributed as
originating internally and are difficult to control. In order for a thought to
be considered intrusive, rather than just unwanted, it causes interruptions
to immediate task performance and is problematic to control or direct
attention away from (Rachman, 1981).
Whilst there has been considerable focus on the occurrence of UITs within
clinical cohorts, there is substantial evidence that UITs are a common
occurrence for individuals without clinical disorders. Rachman & de Silva
(1978) observed that 84% of a non-clinical sample experienced unwanted
intrusive thoughts, images or impulses, which were very similar in content
to clinical obsessions. Further studies have observed similar results, with
80-90% of non-clinical participants experiencing unwanted and intrusive
cognitions on a daily or weekly basis (Freeston, Ladoucer, Thibodeau &
Gagnon, 1991; 1992; Niler & Beck, 1989; Purdon & Clark, 1993). Clark
and Rhyno (2005) surmised that the key differences in the experience of
UITs between clinical and non-clinical individuals was to do with process
characteristics, rather than the content of the thoughts. In particular,
clinical populations may experience their UITs as more frequent,
distressing and less controllable compared to non-clinical individuals. This
proposal has been supported empirically in several studies. Based on
interviews with 124 non-clinical and eight OCD participants, Rachman and
de Silva (1978) reported that intrusive thoughts are normal across the
general population, and share considerable similarities to obsessive
thoughts. However, obsessions were more difficult to dismiss and often
resulted in a behavioural response. Janeck & Calamari (1999) observed
that personally relevant, highly intrusive material was common in thought
reported by 32 participants with OCD and 33 non-clinical participants.
However, the OCD group experienced negative intrusions more often and
were less able to control their responses.
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Clark and Rhyno (2005) detailed the primary characteristics of UITs,
which are presented in Table 4.1.
Table 4.1
Properties and Dimensions of UITs (Clark & Rhyno, 2005).
Distinct thoughts, images or impulses that enter conscious awareness;
Generally attributed to an internal source;
Subjectively unacceptable or unwanted;
Interferes in ongoing cognitive and/or behavioural activity;
Unintended and non-volitional or has wilful independence;
Often recurrent or repetitive;
Captures attentional resources;
Associated with negative affect;
Difficult to control or dispel.
4.2 UITs Compared To Other Common Negative Cognitive
Phenomena
UITs are one form of negative cognitive experience. There are numerous
other forms of commonly occurring negative cognitions including
obsessions, worries, ruminations and negative automatic thoughts. Whilst
there is overlap amongst these clusters of cognitions, there are
distinguishing features between the experiences. The principal
characteristics of these negative cognitions are presented in Table 4.2.
Compared to UITs, obsessions have been described as occurring more
frequently, elicit more behavioural reactions such as compulsions and are
associated with greater distress than UITs (Clark & O’Connor, 2005). It
has been proposed that due to dysfunctional beliefs associated with the
need to control unwanted thoughts, UITs experienced by obsession-prone
individuals can escalate to become obsessions (Clark & Purdon, 1995).
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Table 4.2.
Distinguishing Characteristics Between UITs and Other Negative Cognitions (adapted from Clark & Rhyno, 2005)
Characteristics
UITs
Obsessional Thoughts
Worry
Rumination
Negative Automatic
Thoughts
Frequency
Infrequent
Frequent
Frequent
Frequent
Frequent
Distress
Varies
Distress congruent
Anxiety congruent
Congruent with
Associated with
depression
Distressing
Resistance
Minimal
High resistance
Minimal
Minimal
Minimal
Control
No Control
Minimal
Moderate
Moderate
Moderate
Ego
Dystonic.
Dystonic
Syntonic
Syntonic
Syntonic
Duration
Brief
Persistent
Persistent
Persistent
Brief
Behavioural reaction
Varies
High association
Associated with
Associated with
Minimal
coping
passivity
Moderate
Minimal
Interference
High
High
Moderate
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A distinction has been made between UITs and negative automatic
thoughts, which have primarily been associated with anxiety and
depressive conditions. Negative automatic thoughts are often difficult to
dismiss and have the potential to adversely affect mood as well as
influence the development and maintenance of depressive and anxiety
disorders. Negative automatic thoughts have been described as mood
congruent and ego-syntonic, therefore less surprising or unexpected than
UITs (Clark & Purdon, 1995; Wang & Clark, 2002; Wenzlaff, 2005).
Worry is a common cognitive phenomenon and is a fundamental
component of anxiety disorders, especially GAD (Rapee, 1991; Wells,
2005). Worry is comprised of a sequence of thoughts focused toward
future negative outcomes which are accompanied by fear (MacLeod,
Williams & Bekerian, 1991). Wells (1999) suggested that whilst worry
may be experienced as ‘uncontrollable’, it can be regulated and functions
as a coping strategy which is actively engaged as a means to prepare for
perceived danger. Clark and Rhyno (2005) highlighted that whilst UITs
and worry share a range of similarities (e.g. diverting attention,
unpleasant), they have a number of important differences. Studies
examining UITs and worry revealed that compared to UITs, worry
generally presents in a verbal form, is more realistic, is less resisted and
tends to be more persistent (Clark & Claybourn, 1997; Langlois, Freeston
& Ladouceur, 2000).
A further common negative cognitive occurrence is repetitive rumination,
which has been closely associated with depression (Papageorgiou & Wells,
2004). Rumination tends to be repetitive, pervasive (i.e. long duration)
and strongly associated with depression. It has been described as
excessive thinking about one’s own depressive symptoms, causes and
consequences (Nolen-Hoeksema, 2004). Depressive rumination is similar
in nature and consequence to worry observed in anxiety disorders
(Borkovec, Ray & Stober, 1998)
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4.3 Measurement of Unwanted Intrusive Thoughts
The assessment of UITs has primarily focused on content, frequency and
qualitative features associated with individual thoughts. Several
questionnaires have been developed to assess distressing intrusive
thoughts, most of which have endeavoured to measure the level of
controllability, associated discomfort, dismissability and other reactions to
cognitive intrusions.
The first questionnaire to measure the frequency and dismissability of
intrusive thoughts was developed by Rachman and De Silva (1978) from a
structured interview. However, it was not used beyond this study.
The Intrusive Thoughts and Impulses Survey (ITIS, Niler & Beck, 1989)
was largely influenced by Rachman and De Silva’s questionnaire and
includes 60 items consisting of unwanted thoughts and impulses and each
item is rated on frequency, dismissability and distress. It has
demonstrated low to moderate correlations with measures such as StateTrait Anxiety Scale, Beck Depression Inventory and Perceived Guilt, (Clark
& Purdon, 1995).
Clark & Purdon (1995) argued that assessments of intrusive thoughts
should avoid focusing solely on content characteristics. Instead, they
proposed that assessments should provide examples of unwanted
intrusive thoughts, rather than to expect individuals to be able to
generate their own. Unless examples were provided, participants were
required to distinguish between intrusive and non-intrusive thoughts, or,
negative automatic thoughts from unwanted intrusive thoughts, which in
turn raised concerns about construct validity. The Distressing Thoughts
Questionnaire (DTQ: Clark & de Silva, 1985) addresses this issue by
listing 12 distinct unwanted intrusive thoughts which are presented as
depressive and anxious statements. Respondents rate their endorsement
of each statement according to frequency, the level of distress each
statement evokes and their capacity to shift focus from the statement.
The DTQ has good to excellent internal validity, with the anxious and
depressive total scales having a Cronbach α of 0.89 and 0.95 respectively
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(Clark & de Silva, 1985). The DTQ is used in the current study and a more
detailed description is provided in the Method, chapter seven.
4.4 Cognitive Models – UITs and Hallucinations.
A number of cognitive paradigms of psychosis implicate UITs in the
development and maintenance of hallucinations. However, there are
considerable differences between these models. Some theorists have
proposed ‘top-down’ approaches which imply that subjective beliefs,
appraisals and emotions associated with the UITs are the central
processes which elicit hallucinations. Top down models suggest that
higher order thinking influences how the individual perceives their
environment and experiences. Top down models are based upon the
proposition that UITs are attributed to an external source in order to
reduce cognitive dissonance which is elicited when intrusive thoughts are
at odds with schematic values and metacognitive beliefs (Bentall, 1990;
Gumley, White & Power, 1999; Morrison, 2001; Morrison et al., 1995).
Conversely, a number of researchers have advocated a ‘bottom-up’ role
for UITs in hallucinations. Bottom-up theories propose lower order
cognition as the primary system which influences hallucination
development. Cognitive deficits associated with bottom-up processing,
such as inner speech and inhibitory discrepancies, have been associated
with intrusive thoughts being experienced as external perceptions
(Hoffman, 1986; Hoffman & Rapaport, 1994; Waters, Badcock, Michie &
Maybery, 2006).
Regardless of the model, there appears to be general agreement that UITs
act as an intrusive stimulus in the development of auditory hallucinations.
The following sections outline the major cognitive models of hallucinations
which implicate UITs.
4.4.1 A Top-down model – UITs and hallucinations.
Cognitive models of anxiety disorders, particularly panic disorders,
indicate that emotional disturbance is precipitated by the
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misinterpretations of personally salient thoughts as potentially dangerous
(Clark, 1986). Such misinterpretations, characterised by an overestimated
sense of perceived threat, are theoretically the primary source of distress.
This process may be reinforced by selective attention toward arousing
thoughts and physiological arousal, which are perceived as signalling
imminent danger. Whilst avoidance of distressing thoughts provides
respite from immediate distress, the associated short-term relief
negatively reinforces beliefs that certain thoughts are ‘threatening’ and
unable to be managed. Similar cognitive models based around
misinterpretation, selective attention and avoidance have been developed
for OCD and hypochondriasis (Salkovskis, 1985; Salkovskis, Forrester &
Richards, 1998).
These influential cognitive principles associated with the development of
anxiety disorders have been adapted as a basis for understanding the role
of intrusive thoughts in the occurrence of hallucinations (Morrison, 1998;
2001; 2005; Morrison et al., 1995). Morrison and colleagues’ approach
was influenced by previous accounts of the development of psychotic
symptoms from authors such as Bentall (1990), who proposed that
hallucinations and delusions occurred due to biases in monitoring one’s
own thoughts, particularly personally salient intrusive material.
The close relationship between unwanted intrusive thoughts and auditory
hallucinations is evident by the considerable similarities in their content
and form (Morrison et al., 1995). They are both usually personally salient
and often elicit significant distress due to their incompatibility with
personal values and beliefs (Chadwick & Birchwood, 1994; Morrison et al.,
1995). Furthermore, both auditory hallucinations and UITs are often
experienced as uncontrollable and unacceptable (Rachman 1981; Morrison
et al., 1995), as well as tending to increase during periods of heightened
stress (Clark & Rhyno, 2005; Nayani & David, 1996). These observations
have influenced numerous authors to suggest that hallucinations can be
understood as occurring within a continuum of normal experiences, in that
they are an extreme yet understandable reaction to distressing unwanted
intrusive thoughts (Beck & Rector, 2003; Bentall, 1990; Morrison 1998;
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2001). The primary distinction between UITs and hallucinations is that
hallucinations are experienced as perceptual phenomena and generally
attributed to an external source (Bentall, 1990; Garety et al., 2001;
Morrison et al., 1995).
Morrison and colleagues (1995) proposed that certain UITs, which are
perceived as ego-dystonic or unwilled (i.e., unwanted or uncontrollable),
elicit considerable emotional disturbance. These thoughts may be
interpreted as psychologically threatening due to their incompatibility with
an individual’s beliefs. The discrepancy between UITs and personal beliefs
creates a state of cognitive dissonance, elicited when cognitions directly
contradict or oppose each other (i.e., intrusive ego-dystonic thoughts and
personal beliefs). This in turn leads to significant discomfort due to a
perceived sense of accountability and potential negative consequences,
from which the individual is motivated to escape (Cooper & Fazio, 1984).
For example, experiencing aggressive thoughts about a loved one or child
is likely to be at odds with personal beliefs, subsequently eliciting
discomfort. It is not merely the content of the thought that elicits distress,
rather, that the thought was self-derived which evokes dissonance.
Several researchers have highlighted that metacognitive beliefs,
particularly beliefs about controllability of thoughts, significantly influence
the appraisal of UITs and their inconsistencies with personal beliefs
(Bentall, 1990; Morrison, 2001; Morrison et al., 1995). A number of
similarities have been identified for psychotic-related intrusions and UITs
such as the personal salience of the content and that a sense of ‘mental
pollution’ is induced due to the unacceptability of the thoughts (Haddock,
Bentall & Slade, 1993; Morrison et al., 1995; Rachman, 1994).
Theoretically, UITs are misattributed to an external source in the form of
hallucinations which in turn reduces distress (Bentall, 1990; Morrison,
2001; Morrison et al., 1995). This misattribution is akin to safety
behaviours in relation to anxiety disorders, in that it serves to reduce
immediate discomfort, however the beliefs that such thoughts are
‘dangerous’ and are not derived internally are negatively reinforced.
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4.4.1.1 UITs and empirical support for top down models.
Morrison and colleagues attempted to evaluate elements of their model
empirically (Morrison et al., 2002b). By conducting semi-structured
interviews they examined whether intrusive mental imagery was
associated with psychotic symptoms and affective disturbance with a
clinical cohort experiencing hallucinations and delusions. Participants were
asked to identify mental images associated with their psychotic
symptoms, then asked about content, frequency and relevance to
emotional states. The investigators observed that a large subgroup
(74.3%) identified a distinct mental image in relation to their psychotic
symptoms. A high proportion of this subgroup (69.2%) reported these
mental images were recurrent and connected the mental image with a
particular belief. The authors proposed that these findings supported the
theory that images associated with beliefs may elicit psychotic symptoms
and that intrusive, emotionally salient material is likely to precede
psychotic experiences. However, there was no indication that the intrusive
mental imagery identified in the interviews was associated more with
hallucinations or delusions. Whilst this may have been an exploratory
study to gauge the potential applicability of paradigms from other
disorders, it raises some notable issues. Firstly, without a non-clinical or
non-psychotic group it is impossible to assess whether similar intrusive
imagery and thoughts may be experienced preceding other modes of
increased arousal. Furthermore, the semi-structured nature of the
interview required participants to identify and elaborate their own
intrusions and images. This may raise concerns regarding the discriminant
validity of the responses, as highlighted by Clark and Purdon (1995).
Intrusive thoughts have been identified as a having a direct relationship to
hallucination proneness (Jones & Fernyhough, 2009). A pathway analysis
was used to test a model of the relations among rumination, reflection,
though suppression, intrusive thoughts and hallucinations proneness
measured on the LSHS. Rumination was related to hallucinationsproneness, however, only as mediating variable to intrusive thoughts
which had a direct relationship to hallucination proneness. The authors
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indicated that the findings provided evidence that intrusive thoughts play
a major role in predisposition to hallucinations.
Morrison and Baker (2000) conducted the only study to date which has
examined conventionally defined UITs with people experiencing
hallucinations. The DTQ was used as the primary measure of UITs, with a
sample consisting of participants with schizophrenia, with and without
hallucinations, as well as a non-psychiatric control group. The
hallucinating group reported experiencing significantly more UITs than
other groups. Furthermore, compared to other participants, the
hallucinators’ UITs were more distressing, uncontrollable and
unacceptable. This study provided clear supporting evidence for an
association between UITs and hallucinations. Furthermore, the results
indicated that the emotional salience of the UITs was more likely to elicit a
state of cognitive dissonance for individuals experiencing hallucinations.
In summary, Morrison and colleagues have proposed a cognitive model for
hallucinations which focused upon interpretations and reactions toward
UITs (Morrison, 1998, 2001; Morrison et al., 1995). Their approach
encompassed psychological principles of psychopathology such as
perceived threat, personal defence processes, core beliefs and emotional
arousal. However, whilst it provides explanations for why UITs and mental
imagery may be externally attributed, there is limited detail regarding the
mechanisms of how external misattribution transpires. Additionally, this
model is congruent with contemporary stress-vulnerability approaches
associated with the development of many psychopathologies, however, it
does not account for hallucinations which are innocuous or pleasurable
which do not elicit states of cognitive dissonance or schematic distress.
Despite these limitations, Morrison’s work has provided a platform for
examining how appraisal of UITs directly influences the development and
maintenance of hallucinations.
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4.4.2 Bottom-up approaches: Deficits in intentional inhibition and
contextual memory.
Waters and colleagues (2006) conceptualised auditory hallucinations as
intrusive auditory mental imagery derived from unintended memories
which may include irrelevant or innocuous cognitive material. They
proposed that a combination of two specific cognitive deficits needed to
transpire in order for auditory hallucinations to occur, specifically, deficits
in intentional inhibition and contextual memory.
4.4.2.1 Intentional inhibition deficits and auditory hallucinations.
Inhibition is a fundamental cognitive process which allows filtering and
suppression of stimuli, so that appropriate cognitive material can be
attended to and irrelevant material ignored or suppressed. Automatic
inhibition occurs without awareness, whereas, intentional inhibition refers
to the deliberate suppression of irrelevant cognitive material as a
conscious and deliberate effort (Nigg, 2000). Waters and colleagues
(2006) proposed that a failure or deficit in intentional inhibition may result
in intrusive thoughts comprising of aural imagery entering consciousness.
Two studies have demonstrated deficits in intentional inhibition in
participants experiencing auditory hallucinations (Badcock, Waters,
Maybery & Michie, 2005; Waters, Badcock, Maybery & Michie, 2003).
The first of these studies assessed differences in intentional inhibition
between a group experiencing schizophrenia and a healthy control group
(Waters et al., 2003). Inhibition tasks included the Hayling Sentence
Completion Test (HSCT; Burgess & Shallice, 1996) and the Inhibition of
Currently Irrelevant Memories Task (ICIM; Schnider & Ptak, 1999). The
HSCT assessed the capacity for voluntary suppression of active cognitive
material, requiring participants to provide single word completion to
sentences, with the requirement that each completion was unrelated to
the preceding sentence. Type A errors involved the participant completing
the sentence in a plausible or obvious manner (e.g. ‘most cats see very
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well at ...night’) and type B errors involved sentence completion which
was less obvious, yet semantically connected (e.g. ‘the dough was put in
the hot...kitchen’). Administration of the ICIM involved presentation of
four sets of 52 pictures, with four different pictures repeated within each
set. Participants were required to identify which pictures were repeated.
Performance on the final three sets required active inhibition of previously
repeated pictures. The number of false alarms on the final three sets was
used as an index of capacity to inhibit irrelevant memories.
The schizophrenia group made significantly more Type A and B errors
than the control group on the HSCT. A significant correlation was
observed between the amount of Type A errors and hallucination severity,
indicating that increased hallucination severity was associated with a
deficit to inhibit ‘active’ or pertinent cognitive material. There were no
significant correlations observed between Type B errors and auditory
hallucination severity, demonstrating that hallucination severity was not
associated with inhibition of material with minimal salience. Regarding
inhibition of irrelevant memories, the rate of false alarms on the ICIM did
not differ between groups on the first run. However, as predicted the
schizophrenia group made significantly more false alarms than the control
group on the subsequent three sets. A significant correlation between
auditory hallucination severity and false alarms on the final three sets of
pictures was observed, indicating that failure to inhibit memories was
associated with hallucinations. Additional analyses revealed no further
correlations between other types of symptoms (as measured using the
PANSS) and inhibition according to the HSCT and ICIM, providing further
support that intentional inhibition deficits were specifically associated with
hallucinations. In summary, Waters and colleagues (2003) demonstrated
that auditory hallucination severity was associated with deficits in the
capacity to regulate emotionally powerful intrusions.
Waters and colleagues’ (2003) results offered preliminary support for the
hypothesis that auditory hallucinations are associated with a failure to
inhibit active cognitive intrusions and irrelevant memories. However,
given their findings were based on correlational analyses, the study did
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not adequately distinguish whether inhibitory deficits were specifically
associated with auditory hallucinations, an epiphenomenon of
hallucinations or a more generalised aspect of schizophrenia (Beck &
Rector, 2003). Badcock and colleagues (2005) addressed this issue by
conducting a similar study using the ICIM and including several groups:
individuals with schizophrenia currently experiencing hallucinations, as
well as a ‘non-hallucinating’ group with schizophrenia who had not
experienced hallucinations during the previous four weeks and a healthy
control group. The ability to correctly detect repeated items was
significantly higher for the healthy control group than both schizophrenia
groups, however there was no difference between accuracy of detection
between the schizophrenia groups. Regarding the primary measure of
intentional inhibition (i.e., amount of false alarms on the final three sets of
pictures), the current hallucinating group performed significantly worse
than all other groups. There were no significant differences between the
‘non-hallucinating’ schizophrenia group and healthy control group.
Additionally, there were no differences between the schizophrenia groups
for intelligence measured with the National Adult Reading Test-Revised
(NART: Nelson & Willison, 1991), duration of illness, negative and general
symptoms measured with the PANSS or levels of depression measured
with the Beck Depression Inventory (BDI-II; Beck, Steer, Ball & Ranieri,
1996). Therefore, the inhibitory impairment did not appear to be a
‘general feature’ of schizophrenia, rather, a specific deficit associated with
or a consequence of auditory hallucinations.
4.4.2.2 Deficits in contextual memory and auditory hallucinations
The second cognitive deficit proposed in Waters and colleagues’ (2006)
model was contextual memory, which is necessary in order to distinguish
one memory from another via recognition of contextual cues and details.
Deficits in accessing contextual cues may result in deficient
representations of memories and confusion surrounding the origins of
memories, particularly the source of speech or sound fragments which are
often present in hallucinations. This may account for many hallucinations
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being experienced as nonverbal or nonsensical, in that they consist of
reconstructions or fragments of memories (Waters et al., 2006).
Waters and colleagues studied the association between psychosis and
contextual memory deficits between people with schizophrenia and a
healthy control group (Waters, Maybery, Badcock & Michie, 2004).
However, participants experiencing auditory hallucinations were not
distinguished within the sample. Contextual memory was assessed via a
newly developed task, whereby participants were shown 24 household
objects. Over two sessions separated by 30 minutes participants were
required to pair objects together and observe the experimenter pairing
objects. Following a five minute break participants were required to recall
which objects were paired together, who conducted the pairing and in
which session. It was speculated this procedure tested the recognition of
contextual cues and the ability to connect these cues together. The
schizophrenia patients group demonstrated significantly more difficulties
recognising contextual cues, including source and temporal
characteristics, when compared to a healthy control group. Without a
separate hallucination group it is not possible to conclude that this study
provides specific support for Waters and colleagues’ (2006) claims that
contextual memory deficits influence the content auditory hallucinations in
the form of intrusive memories.
4.4.2.3 Summary of bottom-up models: Intentional inhibition and
contextual memory.
Waters and colleagues (2006) inferred that deficits in intentional inhibition
and contextual memory significantly influenced the misattribution of
cognitive intrusions, leading to auditory hallucinations. Relatively strong
evidence for an association between deficits in intentional inhibition and
auditory hallucinations were observed (Badcock et al., 2005; Waters et
al., 2003). However, a number of concerns remain with their proposal.
There is minimal reference to the emotional salience and distress often
associated with hallucinatory experiences. Emotional arousal has been
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identified as an important factor in the initiation and maintenance of
hallucinations (e.g., Clark & Rhyno, 2005; Horowitz, 1975; Nayani &
David, 1996). Additionally, whilst a deficit in binding contextual cues from
memory is proposed as a mechanism for auditory hallucinations to occur,
the empirical evidence is lacking with regard to specificity for
hallucinations. A potential confounding issue within this field may be the
construct validity of the assessments. For instance, whilst the ICIM
assesses inhibition of memories, there has been inference that it may also
operate as an assessment of contextual memory (Waters et al., 2006).
4.4.3 Inner speech, intrusive thoughts and hallucinations.
Hoffman and colleagues (Hoffman, 1986; Hoffman & Rapaport, 1994)
conceptualised a model for auditory hallucinations that involved the
disruption of inner speech by unwanted intrusive mental imagery, which
they referred to as ‘parasitic memories’. Inner speech, which can be
conceptualised as a form of verbal mental imagery, is a normal element of
thinking and consciousness (Hoffman, 1986) and has been demonstrated
to coincide with the occurrence of auditory hallucinations (Inouye &
Shimizu, 1970). If inner speech is disturbed or interrupted by parasitic
memories, then it is plausible that the resulting cognitive experience in
the form of verbal mental imagery would be experienced as unintended
and deriving from an external source.
The mechanisms involved in the development of auditory hallucinations
may involve a breakdown within the dynamics between inner speech,
language production and memory (Hoffman et al., 1986; Hoffman &
Rapaport, 1994). Hoffman’s theory is based on the premise that impaired
self-monitoring and awareness of thoughts occurs on a moment-tomoment basis. This hypothesis is in concordance with feed-forward
models of expected outcome of cognitions, involving the generation of a
corollary neural discharge (or expected template) in order to recognise
that cognitions and mental image are self-derived. Hoffman (1986)
suggested that a break down in linguistic information processing,
particularly in the planning of speech, resulted in unintended inner speech
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occurring, leading to an intrusive cognitive event not being recognised as
self-generated.
Hoffman (1986) proposed that a number of components are important to
the inner speech model of hallucinations. First, that auditory verbal
imagery, which constitutes a considerable proportion of language planning
in the form of inner speech, has very similar sensory properties to
auditory verbal mental imagery (e.g. Morrison et al., 1995; Rachman
1981). Second, auditory verbal hallucinations are essentially verbal
images which are accompanied by a perception lack of control. This aspect
reflects the feed-forward paradigm of self monitoring whereby an
expected copy of the cognitive experience facilitates recognition that the
experience was internally generated (Frith, 1992; Li et al., 2002). Further
details of the feed-forward paradigm are outlined in chapter two, section
2.2.2.
A further component of Hoffman’s (1986) inner speech model is a deficit
in discourse planning. A structured discourse planning process is required
for all speech in order for coherence and contextual expression to occur.
An abstract plan is typically developed immediately prior to speech and is
reflective of the aim of the intended spoken message. The speech plan is
then adapted to the common rules of language to reflect grammatical,
sentence and paragraph structure. In essence, this facilitates the
formation of a coherent message. However, Hoffman emphasised that a
deficit within this language processing planning could result in incoherent
speech processing, leading to language and thought disorder as is
commonly observed in psychotic disorders. Hoffman (1986) suggested
that discourse planning discrepancies may be a causal factor for
unintended verbal imagery, which is subsequently experienced as auditory
verbal hallucinations due to not being recognised as self-generated.
Hoffman’s empirical research has focused on examining speech discourse
dysfunction associated with the awareness of speech processes, which
may elicit unintended imagery (Hoffman et al., 1986; 1995; Hoffman,
Rapaport, Mazure & Quinlan, 1999). Hoffman and colleagues (1986)
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conducted an analysis of discourse planning for spontaneous speech
between groups experiencing schizophrenia (with and without
hallucinations), mania and no clinical disorders. Participants were required
to answer a series of open-ended questions and responses were analysed
according to several modes of ‘discourse deviance’ which contributed to
what the authors described as ‘discourse incoherence’. Those experiencing
schizophrenia displayed less structure in their speech compared to the
mania and healthy control groups. Between the schizophrenia groups,
disturbances in discourse planning were significantly higher for
participants with hallucinations compared to those without. Hoffman and
colleagues (1986) argued this demonstrated a clear statistical association
between disordered speech discourse and hallucinations, thus supporting
their overall hypothesis for the development of AVHs. However, this study
received considerable criticism due to the exclusion of manic participants
who exhibited disordered speech discourse, yet minimal hallucinatory
experiences (Bentall & Slade, 1986; Posey, 1986; Schwartz, 1986).
Furthermore, assessment of verbal intelligence was not conducted, raising
concerns regarding whether the study adequately controlled for
confounding variables that would have likely influenced verbal discourse.
In a further study Hoffman and colleagues (1995) proposed that intrusive
or spontaneous cognitive experiences associated with hallucinations
resulted from deficits in neuronal connectivity. They hypothesised this
would lead to disjointed intrusions from working memory, since a
reduction in neuronal connectivity would facilitate “word percepts” (i.e.
fragmented verbal memory) to emerge spontaneously. The authors
modelled this concept experimentally by asking participants to repeat
narrative speech, whilst distractor noises occurred around them.
Compared to a group experiencing schizophrenia without AVHs and a
healthy control group, a group with schizophrenia experiencing AVHs
displayed significant speech tracking impairments. The authors suggested
this supported their hypothesis that speech processing deficits contributed
to the occurrence of intrusive mental imagery and hallucinations.
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Hoffman and colleagues (1999) extended their speech processing
research by including a masked speech tracking task. Participants were
required to track recorded speeches that were ‘masked’ by being
combined with a background of low-frequency unintelligible speech,
making the narrative speech unclear. Participants were required to
recount the content of the speech. The masked speech tracking task
allowed researchers to assess whether working memory expectations, as
outlined in feed-forward paradigms (e.g., Frith, 1992), may compromise
perceptual processing. Participants with schizophrenia experiencing AVHs
displayed significant impairments on both the masked speech tracking
task and a verbal working memory task, compared to those experiencing
schizophrenia without AVHs and a healthy control group. These results
provided further support that disrupted speech perception appeared to
contribute to cognitive deficits which lead to AVHs.
The fourth element of Hoffman’s (1986) model involved discrepancies
between cognitive intrusions and the individual’s goals. In a similar
mechanism outlined in Morrison’s model, Hoffman proposed that
discrepancies between verbal imagery and cognitive goals can evoke
the sense that imagery derives from an external source. This may in part
account for thoughts and images which are not planned yet unlikely to
evoke significant arousal or hallucinatory sensations, as they are
congruent with overt cognitive goals. Hoffman (1986) argued that it is
normal to momentarily experience ‘hallucination-like’ experiences when in
passive cognitive states without cognitive goals, such as daydreaming or
tiredness. In such conditions mental imagery may be momentarily
experienced as deriving externally, but quickly dismissed when
reorientation to the environment occurs. However, AVHs could more likely
occur when intrusive verbal imagery is discordant with overt cognitive
goals such as intended speech.
Hoffman’s inner speech model for hallucinations was based upon a
complex sequence of neuropsychological processes which may contribute
to unintended verbal cognitive material emerging and being misattributed
externally. Whilst there has been some empirical support for this
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proposition, via possible deficits in speech processing and discourse
planning, his overall paradigm has received considerable criticism. First, if
speech requires a cohesive plan then logic suggests that the plan itself
requires a plan, leading to the problem of infinite regress (Akins &
Dennett, 1986; Bentall, 2004; Fernyhough, 2004). In Hoffman’s defence,
this critique could be targeted at all feed-forward models of cognition and
language. Further criticism has focused on the lack of acknowledgement
of the diversity in presentations for individuals with AVHs. Many people
experiencing AVHs do not display disorganised speech or discourse
difficulties and many hallucinations are not verbal. Bentall (1990)
suggested this is a problematic issue associated with studying broad,
generalised syndromes rather than specific symptoms.
4.5 Summary
The empirical evidence summarised within this chapter indicates there is a
strong association between unwanted cognitive intrusions and
hallucinations. The mechanisms of how this is activated and maintained
varies considerably across the different models. Morrison and colleagues
approached their bias based theory with an emphasis on the role of
emotional experience and conceptualised the notion of hallucinations
occurring within a continuum of ‘normal’ experience. Waters’ and
Hoffman’s deficit theories focused upon the neuro-cognitive mechanisms
involved in initiating and maintaining hallucinations and provide minimal
explanation for the role of emotional distress or disturbance. As a group of
theories they offer a comprehensive and complementary paradigm toward
conceptualising how unwanted intrusive cognitions manifest, impair
cognitive processing, influence emotions and elicit hallucinations.
There are a number of limitations in this field of research. First, despite a
theoretical basis for the role of emotional arousal in the phenomenology of
UITs and hallucinations, the empirical evidence remains scarce. Further
research incorporating designs which manipulate or assess emotional
salience of both cognitive intrusions and hallucinations appear to be
warranted, especially given the background of evidence associating
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distress and UITs (e.g. Rachman & De Silva, 1978), as well as with
psychotic disturbances (Birchwood & Chadwick, 1997). Second, whilst an
association has been observed between hallucinations and UITs, the
direction of influence remains unclear. Studies of emerging psychotic
symptoms may aid in understanding the causal association between
hallucinations and UITs. To date there has been no studies examining the
relationship between UITs and UHR populations, an issue which the
current study aims to examine. Thirdly, whilst numerous researchers have
conducted experiments to assess factors which influence cognitive
intrusions (e.g. Hoffman et al., 1999; Morrison et al., 2002a; Waters et
al., 2003), only one study to date has included a specific assessment of
UITs (Morrison & Baker, 2000). Consistent measurement of UITs appears
to be a fundamental issue in order to validate and strengthen the current
cognitive theoretical models of hallucinations.
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CHAPTER 5
Appraisal of Hallucinations – Beliefs about Voices
The preceding chapters reviewed characteristics of cognitive processing
associated with the vulnerability toward, and subsequent development of
hallucinations. This section will review research examining how beliefs and
appraisal toward voices potentially influence the severity and persistence
of hallucinations. This is an important field of psychosis research that can
provide insights into the processes which influence distress associated
with hallucinations and how individuals cope with such experiences. Whilst
this research has primarily been conducted with cohorts with established
psychosis, reference will be made as to how beliefs about voices are
applicable to the phenomenology and duration of hallucinations within
UHR populations.
5.1 The Power of Voices
Over the past two decades increasing focus has been given toward the
emotional and behavioural responses to hallucinations. This has led to the
development of theoretical models incorporating fundamental cognitive
psychology principles such as self-beliefs, self perception and relational
experiences in order to conceptualise the appraisal and distress associated
with hallucinations (Benjamin, 1989; Bentall, 1990; Birchwood &
Chadwick, 1997; Birchwood, Meaden, Trower, Gilbert & Plaistow, 2000;
Chadwick & Birchwood, 1994; Morrison et al., 1995).
Paul Chadwick and Max Birchwood conducted pioneering work developing
a cognitive approach toward understanding the persistence of
hallucinations (Birchwood & Chadwick 1997; Chadwick & Birchwood
1994). They explored why emotional and behavioural responses to
hallucinations, specifically voices, vary between individuals. Chadwick and
Birchwood considered Beck’s cognitive model of depression when
developing their cognitive paradigm of voice hearing. Beck proposed that
the primary emotional and behavioural symptoms of depression derive
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from negative beliefs about the self and the environment, rather than
purely as a response toward discreet events (Beck, Rush, Shaw & Emery,
1987). Similarly, Birchwood and Chadwick proposed that the beliefs about
voices would have greatest influence over emotional and behavioural
reactions, rather than the specific content of the voice. Previous research
had already established that the variation in coping with voices was
largely attributed to appraisal of the power, hostility and acceptance of
the experience (Benjamin, 1989; Romme & Escher, 1989).
Utilising a semi-structured interview with individuals experiencing chronic
schizophrenia, Chadwick and Birchwood (1994) made a number of
important observations regarding the perceived power of voices. Firstly, in
all cases voices were perceived as being highly omnipotent and
omniscient. Additionally, a variety of beliefs regarding the intent of voices
were observed including malevolence, benevolence, mixed and uncertain.
Beliefs about the identity and power of voices were influenced to some
extent by content, however, power was greatly influenced by the level
that the voice was perceived as omniscient or ‘all knowing’ about the
individual. This finding was a major step toward understanding how
relationships with voices develop, as it became evident that the appraisal
of voices extended beyond verbal content alone. A distinct pattern of
behavioural reactions emerged which correlated with affective appraisal,
in that all malevolent voices were resisted whilst benevolent voices were
engaged with. There was no clear pattern of behavioural reactions toward
uncertain voices. The authors suggested the results from this study
supported a cognitive model of hallucinations, in that the emotions and
reactions toward hallucinations were associated with the beliefs about the
perceived power and meaning of the hallucinations, rather than the
content of the experiences alone.
Close and Garety (1998) attempted to replicate Chadwick and Birchwood's
(1994) study by conducting semi-structured interviews with 30 people
experiencing auditory verbal hallucinations with a diagnosis of
schizophrenia. Similar rates of participants perceived their voices as
malevolent and there were no differences between studies in the
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participants’ behavioural or affective responses toward malevolent voices.
However, participants from Close and Garety’s study were less likely to
perceive their voices as either omnipotent or benevolent. One explanation
for this difference may be that participants from Close and Garety’s study
had experienced hallucinations for longer than Chadwick and Birchwood’s
participant group. The authors suggested that the extended duration of
voices potentially led to a sense of ‘resignation and withdrawal’ toward
voices. They highlighted that the beliefs toward voices could change over
time and as voice hearers become more familiar with their hallucinations
their perceived power may reduce.
Birchwood and Chadwick (1997) continued their line of enquiry by
empirically testing the model developed from their 1994 study. Sixty-two
voice hearers with psychotic diagnoses were assessed for voice activity
(i.e., form, content, frequency), beliefs about voices, coping responses, as
well as levels of anxiety and depression. Standardised measures were
used including the Beliefs About Voices Questionnaire (BAVQ; Chadwick &
Birchwood, 1995) and the Cognitive Assessment Schedule (CAS;
Chadwick & Birchwood, 1995). In support of the authors’ cognitive model,
beliefs about the power and meaning of voices significantly influenced
emotional and behavioural coping responses, whilst voice form and
content had considerably less influence. Also consistent with their
previous findings, malevolent voices were resisted whilst benevolent
voices were actively engaged with. Using step-wise regression the authors
observed that the high rate of depression reported by participants was
primarily associated with beliefs about the malevolence and power of
voices. This result indicated that beliefs about voices were likely to be a
contributing factor to co-morbidity experienced by the sample.
Subsequent independent studies have consistently provided strong
support for these findings (Birchwood et al., 2004; Close & Garety, 1998;
Peters, Williams, Cooke & Kuipers, 2011; Sayer, Ritter & Gournay, 2000;
Vaughan & Fowler, 2004).
An additional aim of Chadwick and Birchwood’s work was to develop a
reliable instrument to measure components of the cognitive model
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proposed in their 1994 study. The 30 item BAVQ contains two subscales
related to beliefs, Malevolence and Benevolence, as well two subscales
related to behavioural responses, Resistance and Engagement (Chadwick
& Birchwood, 1995). Chadwick and colleagues subsequently added a
further five questions to create a third belief scale measuring
Omnipotence (BAVQ-R: Chadwick, Lees & Birchwood, 2000). The BAVQ
and BAVQ-R have become the most widely used instruments for the
assessment of beliefs about voices.
Although Close and Garety speculated that beliefs about voices influenced
the duration of the experience, Csipke & Kinderman (2006) have
conducted the only known study to assess this proposition. They recruited
46 participants with a mean duration of schizophrenia of approximately
ten years and assessed beliefs about voices over 6 months. The authors
hypothesised two possible pathways for the interaction between beliefs
with hallucination frequency and severity. The first was that changes in
frequency and severity of voices would coincide with changes in beliefs
about voices. The alternative pathway would follow Morrison’s (1998)
hypothesis which proposed that beliefs would remain stable, regardless of
variations in the hallucinations, because beliefs would be reinforced
through safety behaviours and selective appraisal. The results indicated
that whilst hallucinations changed in severity and frequency over a six
month period, beliefs about voices remained stable, therefore supporting
Morrison’s (1998) model.
It is difficult to define a single cognitive model, however as a general
principle responses to hallucinations are mediated by cognitive processes
associated with personal beliefs and appraisal (Birchwood & Chadwick,
1997). The studies outlined provide empirical support for a cognitive
model of auditory hallucinations, because emotional and behavioural
reactions toward voices appear to be dependent on beliefs and appraisal
about the voice’s power, identity and purpose, rather than the specific
verbal content.
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5.2 Development of Beliefs Towards Hallucinations
Numerous theoretical models have been proposed and tested to explore
how beliefs toward hallucinations develop. The following section will
outline several key paradigms including the influence of self-perception on
voice appraisal, as well as models involving social rank and relating
theory.
5.2.1 Beliefs about hallucinations and self-appraisal.
Contemporary theories of hallucinations ascribe beliefs about the self as
having a significant influence on appraisals and content of voices (Bentall
et al., 2007; Close & Garety, 1998; Freeman & Garety, 2003).
Observations of voice content within schizophrenia cohorts revealed that
most voices contained highly negative themes, congruent with low selfesteem and depression (Chadwick & Birchwood, 1994; Birchwood &
Chadwick, 1997; Close & Garety, 1998; Norman & Malla, 1991).
Garety and colleagues proposed that negative emotions and low selfimage have a pivotal role in the development and maintenance of positive
symptoms including hallucinations (Garety et al., 2001; Freeman &
Garety, 2003). Within this framework emotional variance occurs in
response to both life events and psychotic experiences. Additionally,
emotive experiences may contribute to further psychotic experiences by
influencing the content of hallucinations, as well as the beliefs and
subsequent appraisal of hallucinations (Fowler, 2000; Garety et al, 2001).
In this sense, a reciprocal interaction exists between emotional
disturbances, appraisal of psychotic experiences and maintenance of
hallucinations.
A strong association between self-esteem, mood and hallucination
characteristics has been reported in a number of studies (Fannon et al.,
2009; Smith et al., 2006). Smith and colleagues (2006) investigated the
relationship between emotional disturbance and psychotic symptoms with
100 participants experiencing schizophrenia. Using a cross-sectional
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analysis, depression, self-esteem and negative self-beliefs were examined
in relation to specific positive psychotic symptoms. Severity of depression,
negative self-beliefs and poor self-esteem were significantly correlated
with the level of distress associated with hallucinations, as well as higher
levels of negative content. Additionally, depression severity and low selfesteem were associated with lower perceived control of the hallucinations,
whilst no association was observed between self-beliefs and controllability.
Fannon and colleagues (2009) examined mediating and moderating
relationships between self-esteem, appraisal of hallucinations and
depression in a cohort of 82 individuals experiencing persistent auditory
hallucinations. Depression, low self-esteem and beliefs that voices were
malevolent and omnipotent were prominent across the sample. Beliefs
associated with the dominance and uncontrollability of voices were
significantly associated with depression and self-esteem. However, selfesteem was not a mediator between the beliefs about voices and
depression, instead self-esteem and hallucinations contributed
independently to the level of depression. Therefore, beliefs about voices
may operate independently from the individual's beliefs about themselves.
Overall, these studies demonstrated an association between beliefs about
self and beliefs toward hallucinations, which may be strengthened or
mediated by emotional disturbances. However, the mechanism of
interaction between beliefs about self, beliefs about voices and emotional
distress is a complex process which varies between individuals (Fannon et
al., 2009).
5.3 Interpersonal Models of Hallucination Appraisal - Social Rank
and Relating Theory
A substantial body of research has also focused on applying interpersonal
theories of social dynamics to conceptualise how appraisals toward
hallucinations develop. A number of researchers propose that the
individual’s relationship to voices is associated with the schematic
foundations which influence social relationships. Therefore, beliefs about
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social functioning are likely to be reflected in the appraisal and
relationships toward hallucinations (Benjamin 1989, Birchwood &
Chadwick, 1997; Birchwood et al., 2000).
Just as interpersonal relations are dynamic, beliefs pertaining to the
relationship with a hallucination can change over time as the individual
adapts, responds and possibly challenges the intent of the voice
(Birchwood & Chadwick, 1997; Romme & Escher, 1994). In light of this,
appraisal of whether voices are deemed to be malevolent or benevolent is
likely to be influenced by an individual’s beliefs about social dynamics,
developed from past experiences and influential relationships (Birchwood
& Chadwick, 1997; Goddard, Dritschell & Burton, 1996).
5.3.1 Social Rank Theory.
A major field of interpersonal theory which has been applied to examining
the appraisal of hallucinations is Gilbert and Allan's (1998) Social Rank
Theory (SRT). According to SRT the subordination or domination of others
develops according to social comparisons, which in turn lead to the
formation of social ranks. The appraisal of social rank involves comparison
of the strength and power of oneself to others, as well as attractiveness or
compatibility (Gilbert & Allan, 1998).
Birchwood and colleagues applied SRT to hypothesise that perceived social
rank would determine the perceived power and subsequent responses
toward voices (Birchwood et al., 2000). The authors interviewed 59
individuals experiencing schizophrenia with hallucinations. Consistent with
their predictions, perceived social rank was significantly lower among
individuals who were highly subordinate to their voices. Not surprisingly,
these individuals were also more depressed than other participants. The
authors surmised that the difference in rank between voice and voice
hearer was mirrored in the voice hearer’s perception of differences in
social rank between themselves and others in their social environment.
Voices were rated as being more frequent and louder when they were
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appraised as more powerful, indicating that frequency and persistence
was directly associated with perceptions of power.
In an attempt to examine the direction of the relationship between voices,
distress and beliefs, Birchwood and colleagues interviewed 125 individuals
with schizophrenia who experienced auditory verbal hallucinations
(Birchwood et al., 2004). The perceived power toward the dominant voice
was strongly associated with the level of distress and depression. In other
words a perception of a very powerful voice was associated with
heightened distress and depression. Additionally, subjective beliefs of
being powerless and inferior in general relationships were associated with
the perceived power of voices. Social rank and power were identified as
the primary influences of appraisal of voice power, distress and
depression.
All of the social rank studies discussed provide evidence for a role of
perceived social rank in interpersonal relationships in determining the
appraisal of power of hallucinations. Additionally, the level of perceived
power of hallucinations was strongly associated with severity of pathology.
5.3.2 Relating theory.
Birtchnell’s relating theory (Birtchnell, 1996; 2002) is another prominent
interpersonal paradigm examining the relationships, appraisals and
responses individuals have toward hallucinations. Mark Hayward has
examined how Relating Theory can be applied to understanding
relationships with hallucinations (Hayward, 2003; Hayward, Berry &
Ashton, 2011; Hayward, Denney, Vaughan & Fowler, 2008; Hayward,
Overton, Dorey & Denney, 2009; Sorrell, Hayward & Meddings, 2010).
According to Relating Theory, individuals relate to each other via two
primary dimensions, proximity and power. These dimensions operate as
intersecting axes (see Figure 5.1). Proximity refers to the distance
between individuals, which relates to levels of intimacy, whilst power is
the degree of influence an individual has toward another.
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UPPERNESS
(Relating from a position of strength)
DISTANCE
CLOSENESS
(Remaining separate)
(Being Involved)
LOWERNESS
(Relating from a position of weakness)
Figure 5.1. Axes of Birtchnell’s Relating Theory. (Adapted from Sorrell et
al., 2010).
Hayward (2003) applied Relating Theory to examine the dynamics
between 27 individuals experiencing hallucinations and their voices. A
semi-structured interview was conducted with 27 individuals experiencing
hallucinations. Significant correlations were observed between the
dimensions of relating to voices and dimensions of relating socially (i.e.,
proximity and power). These correlations were independent from beliefs
or distress associated with the voices.
Vaughan & Fowler (2004) applied Relating Theory to examine whether
distress experienced by voice hearers was mediated by the relationship
toward the voice. The authors predicted that dominance of the voice,
combined with submissiveness from the voice hearer would be associated
with heightened distress. Thirty individuals with a variety of diagnoses
who experienced auditory hallucinations were assessed. The Voice to
Hearer (VTH) and Hearer to Voice (HTV) questionnaires were developed
for the study in order to measure relating dynamics and the BAVQ was
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used to assess beliefs about voices. Consistent with Birchwood and
colleagues’ (2000) findings, distress was uniquely associated with voices
presenting in a dominating and insulting manner, and for individuals to
respond with suspicion and distance to these types of voices.
Vaughan and Fowler’s (2004) study provided support for the application of
Relating Theory toward relating to voices, however, by the authors’ own
admission there were concerns regarding the reliability of several
subscales of the VTH and HTV. Hayward and colleagues built on Vaughan
and Fowler’s work by developing a more robust measure of relating to
voices, known as the Voice and You (VAY) questionnaire (Hayward et al.,
2008). Consistent with Vaughan and Fowler’s (2004) findings, Hayward
and colleagues (2008) reported that a desire to create distance from
dominant voices was significantly related to the distress experienced by
the voice hearer. Together these studies indicated that perceived
dominance, rather than discrete beliefs such as malevolence influenced
distress.
The VAY was used by Sorrell and colleagues (2010) in a study which
compared voice hearing experiences between 32 clinical and 18 nonclinical voice hearers. Non-clinical voice hearers reported experiencing
auditory verbal hallucinations in the previous six months, however were
not involved with mental health services. Distress was significantly
associated with voices being dominant and intrusive, as well as the voice
hearers’ tendency to distance themselves from the voice. However, in
contrast to Vaughan and Fowler’s (2004) findings, the relationship to
voices and distress were not independent of beliefs about voices. Sorrell
and colleagues (2010) suggested that beliefs about voices, particularly
malevolence and omnipotence, may mediate or moderate between voicerelating styles and distress. Compared to the clinical group, the nonclinical voice hearers reported less distress, perceived their voices as less
dominant, intrusive, malevolent and omnipotent. This finding indicated
that the distress and appraisal toward hallucinations may be a pivotal
factor in differentiating between clinically relevant and non-clinically
relevant hallucinations.
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Hayward and colleagues also demonstrated that Relating Theory is a
clinically relevant paradigm to consider in the treatment of hallucinations
(Hayward et al., 2009). Five participants were provided cognitive therapy
based on core principles of Relating Theory: enhancing insight and
challenging the relationship with their dominant voice by exploring
similarities between relating socially and relating to their voice; enhancing
reciprocity in the relationship with the voice so that being a passive figure
in the dynamic with the voice can be altered; exploring different ways of
relating to their voice. Positive results were achieved, with a reduction in
distress and increased control reported by several participants.
Furthermore, a reduction in negative voices was reported by four of the
five participants. However, due to the small sample and lack of
randomisation to treatments caution needs to be taken when interpreting
these findings.
In a comprehensive review of the application of interpersonal theories and
hallucinations, Hayward and colleagues (2011) concluded that the
perceived power of the voice was the prominent appraisal factor and that
the individual’s sense of social empowerment was reflected in the
relationship toward the voices.
5.4 Application to UHR Status – Beliefs, Appraisal and Symptom
Severity
To date there has been minimal research investigating the beliefs,
appraisal and emotional responses to voices in hallucination prone or UHR
populations. The only known study to assess beliefs about psychotic-like
experiences (PLEs) within a UHR population was conducted by Taylor and
colleagues (Taylor, Parker, Mansell & Morrison, 2013). Using an
experimental design, participants were randomised to receive either
negative or neutral information regarding an anomalous experience (a
card tick involving computerised ‘guessing’ of a card selected by
participants). Participants were subsequently asked to rate a series of
psychotic (non-plausible) and non-psychotic (plausible) appraisals of how
the card trick was conducted. When results from the entire sample were
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analysed, higher conviction in non-psychotic appraisals were associated
with lower levels of distress. However, there were no differences in
distress or anxiety between the experimental groups, indicating that
manipulation of appraisal had minimal effect on emotional responses
within a UHR sample.
A number of empirical studies have examined beliefs toward perceptual
disturbances amongst hallucination prone cohorts and non-clinical voice
hearers. As mentioned in chapter three, Morrison and colleagues (2000;
2002a) observed that within non-clinical samples, positive beliefs toward
experiencing unusual perceptual phenomena was the best predictor for
being predisposed toward hallucinations. Morrison proposed that it may be
the development of negative beliefs about hallucinations that underlies the
transition from normal to pathological experiences (Morrison et al.,
2002a). This was evident in the differences between the clinical and nonclinical voice hearers interviewed in Sorrell and colleagues’ (2010) study.
A shift from non-clinical to clinical status may be mediated by
hallucinations being appraised as uncontrollable or dangerous, which in
turn adversely influences aspects of functioning such attentional capacity,
distress, occupation and social competency (Morrison, 2001; Morrison et
al., 2000).
A common observation throughout these studies was that non-clinical
populations appraised perceptual disturbances as relatively positive and
hallucinations appeared to have minimal or no associations with distress
or compromised functioning. However, these findings may not be
applicable to UHR populations, since UHR individuals tend to be
experiencing significant distress, functional decline and actively seek
clinical interventions (McGorry at al., 2009). The UHR criteria is
determined by the frequency and intensity of perceptual disturbances,
rather than the appraisal which determines the transition from at risk
status to psychosis. This is most evident in criteria for UHR on instruments
such as the CAARMS which use frequency and intensity of attenuated
psychotic phenomena as the determinants for classification of UHR status
(Yung et al., 2005).
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5.5 Can Beliefs and Appraisal Change Over Time? Cognitive
Therapy and Changes in Appraisal.
Due to the scarcity of research investigating appraisals of hallucinations in
UHR populations, an understanding of how variables such as beliefs and
emotional responses to hallucinations develop and interact through the
course of psychosis is limited. A potential strategy to investigate this
process is to examine how changes in frequency, intensity and emotional
response to hallucinations occur when appraisal and beliefs are altered.
Trials involving CBT for psychosis provide the ideal platform to examine
these processes, since the fundamentals of treatment involve the
modification of beliefs and appraisals with the aim of decreasing distress
and reducing the perceived omnipotence of the psychotic experiences
(Hagen & Turkington, 2011). Trials involving CBT for psychosis provide
support for the notion that appraisal of hallucinations can be adjusted and
potentially influence responses as well as symptom severity.
5.5.1 CBT and psychosis.
The evidence base for the efficacy of CBT for addressing positive
symptoms in psychosis has progressively developed over the past two
decades (Chadwick & Birchwood, 1994; Penn et al., 2009; Sensky et al.,
2000). Several large systematic reviews indicate that CBT is associated
with a reduction in persistent positive psychotic symptoms for cohorts
with schizophrenia (Rector & Beck, 2001; Tarrier, 2005; Wykes, Steel,
Everitt & Tarrier, 2008).
The utility of CBT has also been examined with early psychosis and UHR
populations. Results from CBT trials with first episode psychosis cohorts
indicated that CBT may aid in reducing positive symptoms (Drury,
Birchwood & Cochrane, 2000; Jackson et al.; 2005; 2008; Lewis et al.,
2002; Tarrier et al., 2004). However, these results are not conclusive and
there is minimal evidence to suggest that benefits from CBT are
maintained over follow up periods (Drury, Birchwood & Cochrane, 2000;
Lewis et al., 2002; Tarrier et al., 2004). Morrison and colleagues (2004)
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obtained promising results when comparing CBT with symptom monitoring
over a six month period for UHR participants. A reduction in attenuated
psychotic symptoms and a reduced transition rate to psychosis was
observed for participants receiving six months of CBT, compared to
monitoring (French, Shryane, Bentall, Lewis & Morrison, 2007; Morrison et
al., 2004b; Morrison et al., 2007b).
There are a number of limitations to consider when reviewing the results
for CBT, since the studies were designed to address a range of outcomes
such as functional recovery, distress reduction and relapse prevention in
addition to symptom reduction. The CBT interventions were predominantly
formulation based and therefore varied according to the diverse needs of
the participants (Wykes et al., 2008). Whilst these design characteristics
were not weaknesses per se, it is not possible to conclude that changes in
beliefs were the primary mediator influencing shifts in hallucination
frequency or duration. However, the major limitation outlined in a
comprehensive review of 34 trials using CBT for schizophrenia, was that
only modest effects were found for target positive symptoms (Wykes et
al., 2008).
Up to 50% of individuals receiving CBT for psychosis have no or very
limited response to CBT (Garety, Fowler & Kuipers, 2000). Beliefs about
symptoms appear to play a critical role in the effectiveness of CBT and
strong convictions regarding the origins of hallucinations have been
identified as the primary barrier to modifying appraisals relating to power
and control of the hallucinations (Chadwick & Birchwood, 1994; Thomas,
Rossell, Farhall, Shawyer & Castle, 2011; Trower et al., 2004). Results
from a number of studies indicate that higher conviction in the power of
psychotic experiences predict poorer symptom recovery, irrespective of
intelligence or reasoning capacity (Brabban, Tai & Turkington, 2009;
Garety et al., 1997; Naeem, Kingdon & Turkington, 2008; Turkington,
Kingdon & Turner, 2002).
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5.5.2 CBT and hallucinations.
A number of studies have included CBT specifically for the treatment of
hallucinations. All of these studies have focused on altering the appraisal
and beliefs toward hallucinations as the cornerstone of treatment
(Chadwick & Birchwood, 1994; Thomas et al., 2011; Trower et al., 2004;
Shawyer et al., 2012).
Chadwick and Birchwood’s seminal study included the provision of CBT for
voices with a small sample of four individuals experiencing hallucinations.
The intervention involved testing and disputing beliefs about the voices
heard by participants, specifically those pertaining to identity, meaning,
power and compliance (Chadwick & Birchwood, 1994). All four participants
reported a reduction in the frequency and duration of their hallucinations.
Additionally, clinically significant and stable reductions in the conviction of
beliefs about voices were reported for three out of the four participants.
Trower and colleagues (2004) conducted a randomised controlled trial
comparing ‘treatment as usual’ (primarily a needs based intervention)
with cognitive therapy for hallucinations. Adopting principles of Social
Rank Theory, the cognitive therapy targeted modifying beliefs associated
with the perceived power of the voices. Compared to the treatment as
usual group, the cognitive therapy group reported large and significant
reductions in distress as well as reductions in levels of compliance and
perceived power of the voices. This finding supports the theory that by
shifting beliefs toward hallucinations the impact of the experience on the
individual’s well-being can be significantly altered. However, no changes
were observed in hallucination frequency, loudness and content which
challenges the hypothesis that beliefs and appraisal may mediate the
frequency and duration of hallucinations.
A recent Australian study examined the efficacy of CBT which used a
formulation based approach to address appraisals and responses to
hallucinations for individuals with schizophrenia (Thomas et al., 2011).
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Significant post-treatment improvements were observed for symptom
severity, as measured with the Psychotic Symptom Rating Scale
(PSYRATS; Haddock, McCarron, Tarrier & Faragher, 1999) and the PANSS
(Kay et al., 1987) positive and general scales. In contrast to previous
studies, improvements were not related to levels of insight or conviction in
the hallucinations, indicating that interventions aiming to shift beliefs and
appraisal should still be considered regardless of insight.
The same group of researchers recently conducted a randomised
controlled study comparing acceptance-based CBT and befriending for
command hallucinations (Shawyer et al., 2012). Participants who received
the acceptance-based CBT reported greater improvement in coping with
hallucinations. However there were no significant group differences on any
of the outcome measures associated with domains of functional
improvement, distress and symptom severity.
The range of findings from CBT trials for psychosis and hallucinations
conducted over the past two decades provide evidence that a significant
interacting relationship exists between beliefs, appraisal and emotional
response. Whilst beliefs and appraisal may influence the frequency of
hallucinations it remains unclear as to how this interaction manifests.
5.6 Summary
Since Paul Chadwick and Max Birchwood (1994; 1997) introduced their
cognitive framework for understanding the interaction between
hallucinations, emotions and beliefs, a considerable body of research has
developed in this field. In summary, a number of cognitive factors appear
to operate independently from voice content that influence the appraisals
and emotional responses toward hallucinations. These include beliefs
about the power of voices, self-esteem, perceived social standing and
style of social relating.
Despite this growing area of research, there has been no known study to
specifically examine how beliefs and appraisals affect the persistence of
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hallucinations. Further research focusing on how beliefs and appraisals
influence the development of hallucinations during the period of at risk
mental state may aid in identifying individuals at most risk of experiencing
prolonged hallucinations and transitioning to psychosis.
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CHAPTER 6
Rationale and Hypotheses
The current study investigated whether specific cognitive processing
factors were associated with the development of hallucinations for young
people identified as being ‘ultra-high risk’ (UHR) for psychosis. This study
has a number of strengths over previous research in that it is the first
study to examine the relationship between auditory hallucinations
reported within a UHR population and prominent cognitive models of
perceptual disturbance. Additionally it incorporates a prospective design in
order to evaluate factors which may be predictive of persistence of
hallucinations within a UHR group.
6.1 Aims of the Current Study
The first aim of this study was to examine specific cognitive biases
experienced by UHR young people reporting auditory hallucinations.
Cognitive biases that were investigated were those previously observed to
be heightened in individuals with psychosis experiencing hallucinations.
Comparisons of source monitoring, metacognition and appraisal of
intrusive thoughts were made between a UHR group reporting
hallucinations (UHR-HG), a UHR group with no experience of
hallucinations (UHR-NHG) and a healthy comparison group (HCG).
The second aim of the study was to examine cognitive biases including
source monitoring, appraisal of intrusive thoughts and beliefs about
hallucinations which may influence the persistence of hallucinations
experienced by a UHR group. The persistence of hallucinations was
assessed retrospectively and prospectively over approximately five
months. Follow-up assessments were conducted with all UHR participants
and the cohort was divided into three groups including participants who
experienced no persistence of hallucinations, partial persistence or
persistent hallucinations throughout the follow-up period.
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6.2 Research Questions
The main research questions this study sought to address were:
Will cognitive biases observed amongst individuals experiencing
hallucinations with longstanding psychotic disorders also be observed
amongst UHR young people reporting hallucinations?
Is it possible to predict which individuals will be most likely to experience
longer duration of hallucinations within a UHR group?
6.3 Hypotheses
Based on the research questions, the following hypotheses were
developed. The first set of hypotheses focused on comparing differences
in endorsement of cognitive biases between the participant groups. The
second set of hypotheses focused on differences in cognitive appraisal
endorsement for participants experiencing the longest duration of
hallucinations over the follow up period.
6.3.1 Between Group Hypotheses.
Hypothesis 1: Participants in the UHR-HG would demonstrate an
externalising bias characterised by lower levels of perceived control,
ownership and satisfaction on an immediate source monitoring task
compared to the UHR-NHG and the HCG.
Hypothesis 2: Participants in the UHR-HG would demonstrate higher levels
of dysfunctional metacognitive beliefs than the UHR-NHG and HCG.
Hypothesis 3: Participants in the UHR-HG would report higher levels of
disturbance associated with appraisals of distressing intrusive thoughts
compared to the UHR-NHG and HCG.
128
6.3.2 Hypotheses Related to Persistence of Hallucinations
Hypothesis 4: UHR participants who continue to report hallucinations at
the final follow-up assessment would be more likely than other UHR
participants to report heightened levels of beliefs pertaining to the
perceived power of voices and be more likely to attend to their voices by
either engagement or resistance.
Hypothesis 5: UHR Participants who continue to report hallucinations at
the final follow-up assessment would rate higher on levels of dysfunctional
metacognitions than other UHR participants.
Hypothesis 6: UHR Participants who continue to report hallucinations at
the final follow-up assessment would report more disturbances associated
with the appraisal of distressing intrusive thoughts and report less control
of these experiences compared to other UHR participants.
Hypothesis 7: UHR Participants who continue to report hallucinations at
the final follow-up assessment would demonstrate an externalising bias on
an immediate source monitoring task compared to other UHR participants.
129
130
CHAPTER 7
Method
7.1 Setting
The study was conducted at the Personal Assessment and Crisis
Evaluation (PACE) Clinic. PACE is an outpatient clinic providing treatment
for young people presenting as Ultra-High Risk (UHR) for psychosis. The
PACE Clinic offers a clinical service for young people consisting of case
management, psychological therapy and psychiatric support for up to
twelve months. PACE operates as part of the clinical program at Orygen
Youth Health (OYH), a specialist mental health service for young people
aged 15 to 25 years in the Western metropolitan region of Melbourne.
OYH offers a range of clinical services including an inpatient unit, group
programs and a 24-hour crisis support team. OYH also provides a range of
outpatient clinics for early psychosis, mood disorders and emerging
personality disorders.
7.2 Design
The study incorporated a cross sectional analysis of cognitive processing
characteristics for three groups: a group reporting auditory hallucinations
recruited from a UHR population (UHR-HG), a non-hallucinating UHR
group (UHR-NHG) and a non-psychiatric healthy control group (HCG).
Additionally, a naturalistic follow-up for three assessments over
approximately five months was conducted with all the UHR participants in
order to examine cognitive processing factors that may have been
predictive of the persistence of auditory hallucinations. Attendance at the
PACE Clinic reduces after six months for many clients who experience
good clinical outcomes. The follow-up period for this study was selected
for pragmatic purposes, to best ensure access to participants whilst they
were still attending the Clinic. Three follow-up assessments at one month
intervals were initially planned, however the gap between assessments
131
was extended to approximately six weeks due to difficulties accessing
participants who required regular clinical support.
The study was in conducted accordance with ethical guidelines outlined by
the University of Melbourne Behavioural and Social Sciences Human Ethics
Subcommittee (Appendix A) and the Melbourne Health Mental Health
Research and Ethics Committee (Appendix B).
7.3 Participants
7.3.1 UHR participants
A total of 70 UHR participants were recruited from the PACE Clinic
between August 2007 and August 2009. Three other studies were
conducted at the PACE Clinic during the recruitment period and
recruitment to all four studies occurred on a rotational basis. In general,
PACE clients did not participate in more than two studies. Details of
recruitment to this study and rates of follow-up participation are
presented in Figure 7.1.
The PACE Clinic has developed screening criteria for identifying UHR
individuals, which has demonstrated a 41% transition rate to psychosis
over a 12-month period (Yung et al., 2003). The UHR criteria, which
determines eligibility to the PACE Clinic, has been operationalised
according to scores on the ‘Comprehensive Assessment of At Risk Mental
States’ (CAARMS: Yung et al., 2001; 2005).
The CAARMS is a semi-structured, clinician rated interview consisting of
seven subscales: Disorders of Thought Content, Perceptual Abnormalities,
Disorganised Speech, Motor Changes, Concentration and Attention,
Disorders of Emotion and Affect, Subjectively Impaired Energy and
Impaired Tolerance to Normal Stress. However, only results from the
Unusual Thought Content, Non-Bizarre Ideation, Perceptual Abnormalities
and Disorganised Speech scales are used to determine if UHR criteria has
been met. An intensity and frequency rating is recorded for each of the
132
subscales. The four UHR criteria subscales were used in the current study
and a copy is attached in Appendix C.
Referred to and attended PACE
(n=264)
Refused or unable to participate
in PACE research (n=107)
Recruited to research at PACE
(n=157)
Recruited to current study
(n=70)
UHR-HG
UHR-NHG
n=38
Baseline
n=32
n=38; 100%
Follow-up 1
n=31; 97%
n=36; 95%
Follow-up 2
n=26; 81%
n=36; 95%
Follow-up 3
n=31; 97%
Figure 7.1. Flow diagram of recruitment to the study
There are three separate sets of intake criteria for UHR individuals on the
CAARMS. First is the ‘Attenuated Psychotic Symptoms’ group who
experience sub-threshold psychotic symptoms for at least seven days, but
less than five years. The ‘Brief Limited Intermittent Psychotic Symptoms
(BLIPS)’ group consists of individuals who experience symptoms at
psychotic intensity for less than seven days before resolving without
treatment. Finally, the ‘Trait and State Risk Factors’ group includes
individuals who experience a significant drop in functioning for at least
one month occurring in the previous year, as well as having a first degree
relative with a known history of either a psychotic disorder or schizotypal
personality disorder.
133
Yung and colleagues (2005) have demonstrated that the CAARMS has
good concurrent validity with the Brief Psychiatric Rating Scale (BPRS)
(Overall & Gorham, 1962) and the Comprehensive Assessment of
Symptoms and History (CASH) (Andreasen, 1987). The CAARMS has also
been shown to have good discriminant validity, with UHR subjects
displaying consistently higher scores than healthy controls on all domains
(p <0.001) and good to excellent inter-rater reliability across all domains,
with inter-rater agreement at 0.85 (Yung et al., 2005).
7.3.1.1 UHR hallucinating group (UHR-HG).
The UHR-HG consisted of 38 individuals attending PACE who reported
experiencing auditory perceptual abnormalities during their initial clinical
assessment. All UHR-HG participants met UHR criteria as part of the
‘Attenuated Psychotic Symptoms’ or BLIPS groups. Eligibility for the study
was considered from CAARMS scores obtained from the initial clinical
assessment conducted as part of entry to Orygen clinical services.
Eligibility to the UHR-HG required a severity rating on the Perceptual
Abnormalities Scale of the CAARMS of at least three (moderately severe)
and a frequency of at least three (once a month to twice weekly, more
than one hour per occasion, or, three to six times per week, less than one
hour per occasion).
The average duration of hallucinations reported by the UHR-HG
experienced prior to assessment was 20.08 weeks (SD = 21.15). The
duration of hallucinations ranged from three to 96 weeks.
7.3.1.2 UHR Non-Hallucinating Group (UHR-NHG).
A non-hallucinating PACE group consisting of 32 individuals was included
in order to control for the effect of meeting UHR criteria as an influence on
the outcome of cognitive processing measures. The inclusion of the UHR-
134
NHG mirrors cross-sectional designs from numerous other studies
assessing cognitive factors and hallucinations within psychotic
populations. These studies have often included a ‘non-hallucinating
psychiatric control group’ in order to control for the influence of the effect
of psychosis, or, psychiatric disability in general, on cognitive processing
measures (Baker & Morrison, 1998; Bentall et al., 1991; Morrison &
Baker, 2000; Morrison & Haddock, 1997b). In the case of the current
study the UHR-NHG was included to specifically control for the effect of
UHR status.
The UHR-NHG consisted of individuals who met UHR criteria for PACE, but
scored an intensity rating of two or lower on the Perceptual Abnormalities
Scale of the CAARMS. These participants met UHR criteria as part of the
Trait and State Risk Factors group, and they met criteria on the CAARMS
on scales other than the Perceptual Abnormalities scale.
7.3.1.3 CAARMS Ratings for UHR Groups
No participants made transition to psychosis between initial clinical
assessment for attending PACE and the baseline assessment for the
study. There was no significant difference in weeks between initial clinical
assessment and assessment for the study between the UHR-HG (M=10.6,
SD=4.9) and the UHR-NHG (M=10.3, SD=3.5); t(68) = .336, p=.146
(two tailed). The means and standard deviations for CAARMS intensity
subscales for the UHR groups at initial clinical assessment and at baseline
assessment for the study are provided in Table 7.1. Paired samples tTests indicated there were significant differences between intake and
baseline CAARMS scores for the UHR-HG on the Unusual Thought and
Non-Bizarre Ideation scales, and for the UHR-NHG on the Non-Bizarre
Ideation scale.
135
Table 7.1
Mean for CAARMS Intensity Scores at Intake and Baseline Assessment for
UHR Groups
Group
Unusual
Non- Bizarre
Perceptual
Disorganised
Thought
Ideation
Abnormality
Speech
I
BL
I
BL
I
BL
I
BL
1.92
1.39*
2.95
2.50*
4.47
4.29
.29
.47
(1.98)
(1.53)
(1.58)
(1.35)
(.51)
(.65)
(.77)
(.89)
UHR-
2.06
1.66
3.56
3.13*
.41
.25
.88
.91
NHG
(1.93)
(1.77)
(1.32)
(1.59)
(.71)
(.72)
UHRHG
(1.39) (1.35)
Note: Intake (I); Baseline (BL); Standard deviation in brackets.
*p < .05
7.3.2 Non-Psychiatric, Healthy Control Group (HCG).
A healthy control group consisting of 35 individuals between the ages of
15-25 years were recruited between October 2009 and July 2010. These
participants did not have a current DSM-IV mental disorder and had not
received prior treatment for a mental health related condition.
Additionally, participants from the HCG did not have a prior history of
untreated major depressive disorder, psychotic disorder, anxiety disorder,
personality disorder or substance use disorder. Screening for prior history
of mental illness was based on self-reporting from the HCG. The HCG was
recruited from advertisements (Appendix D) placed in local newspapers,
community agencies and public notice boards.
7.3.3 Inclusion and exclusion criteria.
All participants were aged between 15 and 25 years, fluent in English and
able to read English. None of the participants had a prior or current
diagnosis of a psychotic disorder. Participants were required to have an IQ
above 70. Participants were required to be free from substance
intoxication at the time of assessments.
136
7.4 Measures
7.4.1 Demographic Information
Basic demographic information was collected for all participants including
gender, age and years of formal education and estimated IQ.
Demographic data for the three participant groups are shown in Table 7.2.
There were no significant differences in age or estimated IQ on the
National Adult Reading Test (NART: Nelson & Williams, 1991) between the
three groups.
Table 7.2
Demographic Information for All Study Groups
Variable
Female (%)
HCG
2
P
43.8
45.7
2.432
.296
71.1
59.4
48.6
23.7
21.9
28.6
5.3
18.8
22.9
UHR-
UHR-
HCG
F
P
HG
NHG
UHR-
UHR-
HG
NHG
60.5
Education (%)
Secondary education
not completed
Completed secondary
education
Completed postsecondary training
Variable (M, SD)
(2,
102)
Estimated IQ (NART)
105.20 103.99 107.45
(M, SD)
(6.40)
(7.35)
(6.94)
Age (years) (M, SD)
19.24
19.03
19.20
(2.84)
(2.40)
(2.98)
2.214
.053
.114
.948
137
7.4.2 National Adult Reading Test (NART).
The NART (Nelson & Willison, 1993) has generally been used to measure
‘premorbid’ intellectual capacity. Participants were asked to read aloud a
list of 50 words, which have atypical grapheme to phoneme translations,
whilst the accuracy of their pronunciation is recorded. Using an equation
based on Australian norms that considers NART error score and education
level (Willshire, Kinsella & Prior, 1991), an estimated full scale Wechsler
Adult Intelligence Scale – Revised (WAIS-R: Wechsler, 1981) IQ score can
be calculated. The NART has been used in numerous studies assessing
people with psychotic phenomena (Crawford et al., 1992; Morrison,
Sharkey, Allardyce, Kelly & McCreadie, 2000; O’Carroll et al., 1992). The
NART has demonstrated high internal consistency of 0.93 (Nelson &
Willison, 1991), high inter-rater reliability ranging from 0.96 to 0.98 and a
high test-retest coefficient of 0.98 (Crawford, Parker, Stewart, Besson, &
Delacy, 1989; O’Carroll, 1987). The NART is attached in Appendix E.
7.4.3 Structured Clinical Interview for the DSM-IV (SCID –IV).
The Structured Clinical Interview for DSM-IV (SCID-IV; First, Spitzer,
Gibbon & Williams, 1996) was used to determine diagnoses of participants
at the baseline assessment for the study. The SCID-IV was developed for
use in research and operationalizes criteria from the DSM-IV using a
categorical rating system. Inter-rater reliability has been reported as good
to excellent, with kappa ratings ranging from .82 to 1 (Martin, Pollock,
Bukstein & Lynch, 2000; Ventura, Liberman, Green, Shaner & Mintz,
1998).
Additionally, all diagnoses made from the SCID-IV interview for the UHR
groups were subsequently checked with the participant’s treating team
(comprising of case manager and psychiatrist) to validate accuracy of
diagnoses and to inform the treating team of relevant clinical issues.
Where there were discrepancies between the SCID-IV assessment the
treating team’s diagnoses, the most conservative approach was adopted
by only agreed upon diagnoses being noted for this study.
138
Diagnoses for both UHR groups are presented in Table 7.3. As already
indicated, no members of the HCG received a current or past mental
health diagnosis. All UHR participants received at least one diagnosis. The
most common presenting diagnosis was Major Depressive Disorder
(MDD). There were no significant differences in rates of diagnoses
between UHR groups.
Table 7.3
Diagnoses at Assessment for UHR Participants
Diagnosis
UHR-HG
N=38 (%)
UHR-NHG
2
P
N=32 (%)
MDD
36 (94.7)
28 (87.5)
.421
.562
Generalised Anxiety
11 (28.9)
9
(28.1)
.000
1.000
Social Phobia
4 (10.5)
4
(12.5)
.000
1.000
Obsessive Compulsive
0
2
(6.3)
.712
.399
Panic Disorder
3 (7.9)
7 (21.9)
1.749
.186
Post Traumatic Stress
5 (13.2)
2 (6.3)
.313
.576
17 (44.7)
9 (28.1)
1.403
.236
15 (39.5)
6 (18.8)
2.634
.105
1 (2.6)
2 (6.3)
.023
.879
Disorder (GAD)
Disorder (OCD)
Disorder (PTSD)
Substance Use
Disorder
Borderline Personality
Disorder (BPD)
Antisocial Personality
Disorder (ASPD)
The combined average duration of DSM-IV (APA, 1994) disorder
experienced by both UHR groups was 13.4 months (SD = 11.02). There
was a significant difference in duration of primary psychological disorder
between the UHR-HG (M =16.16, SD = 12.94) and UHR-NHG (M = 10.19,
SD = 7.11); t (59.17), p = .02. This result indicated that the UHR-HG
group had experienced psychological disorders for a significantly longer
period than the UHR-NHG prior to treatment at the PACE Clinic.
139
7.4.4 Depression Anxiety Stress Scales (DASS).
The DASS (Lovibond & Lovibond, 1993) is a 42-item self-report measure
that provides scores for depression, anxiety and stress across three
separate scales. Participants rate their endorsement of the 42 emotion
based statements from the previous week on a four point severity/
frequency scale. The DASS has displayed good internal consistencies for
each of the three scales: Depression (α = 0.91); Anxiety (α = 0.84);
Stress (α = 0.90). The DASS has demonstrated high correlations with
other well established measures such as the Beck Anxiety Inventory (BAI)
and the Anxiety scale and ( r=0.81), as well as the Beck Depression
Inventory (BDI) and the Depression scale (r=0.74) (Lovibond & Lovibond,
1995). The DASS is often utilised as a measure of psychological distress
and this was its purpose in the current study. A copy of the DASS is
attached in Appendix F.
Levene’s test indicated that the DASS Stress scale satisfied homogeneity
of variance across groups (F(2, 102) = .22, p = .80). However,
homogeneity of variance was violated across the other DASS scales,
including Anxiety (F(2, 102) = 7.13, p = .001), Depression (F(2, 102) =
16.22, p < .001) and DASS Total (F(2, 102) = 6.68, p = .002).
Given that the majority of DASS scales did not fulfil assumptions of
homogeneity for parametric analyses, non-parametric comparisons of
DASS scores were conducted. Four sets of comparisons were performed,
therefore a Bonferroni adjustment indicated that a p-value of less than
.0125 was required for significance. Medians and results of nonparametric comparisons are presented in Table 7.4. A series of KruskalWallis tests for each subscale revealed a significant difference across
groups for all DASS scales; Stress (H(2) = 40.83, p <.001), Anxiety,
(H(2) = 39.22, p <.001), Depression (H(2) = 51.56, p <.001) and DASS
Total (H(2) = 52.08, p <.001).
Post hoc analyses using Mann-Whitney U tests were conducted in order to
identify which groups differed. The healthy control group obtained
140
significantly lower levels (p < .001) than both UHR groups across all DASS
subscales and DASS total score. There were no significant differences in
DASS scores between the two UHR groups, indicating that stress, anxiety
and depression was not significantly different between the hallucinating
and non-hallucinating UHR groups. Given that all participants in the UHR
groups were experiencing psychiatric diagnoses and actively seeking
mental health treatment, it was expected they would experience
considerably higher levels of stress, anxiety and depression than the
healthy control group. In light of this, DASS scales were not included as
covariates within subsequent comparative analyses between study groups.
Table 7.4
DASS Median Scores and Results of Group Comparisons from MannWhitney U Tests.
DASS Subscales
DASS Stress
DASS Anxiety
DASS Depression
DASS Total Score
PHG
PCG
b
27
b
21
26.5
b
69.5
b
HCG
21.5
b
16.5
b
b
24
b
60
P
a
<.001
a
<.001
7
5
a
6
<.001
a
21
<.001
Note: Values with different letters are significantly different at post-hoc
analyses.
7.4.5 Word Association Task (WAT).
The Word Association Task (WAT: Baker & Morrison, 1998) is an
adaptation of the source monitoring task used by Morrison and Haddock
(1997) which incorporated words of high emotional salience rated by
anxiety patients. The WAT was used to measure source monitoring
characteristics. The WAT incorporates Kinderman’s (1994) list of 15 word
prompts rated for emotional salience by patients experiencing psychosis.
The list of words includes five emotionally salient positive words (calm,
wise, capable, positive, realistic), five emotionally salient negative words
(lazy, weak, foolish, childish, obnoxious) and five emotionally neutral
words (pale, ripe, resident, domestic, hydraulic). A copy of the WAT is
attached in Appendix G.
141
The word prompts were presented verbally to the participant in a
randomised order. Participants were asked to think of the first word that
came to their mind immediately following the presentation of each of the
15 word prompts. Following each response the participant was asked to
rate their perceived level of control (‘How much control did you have over
the word that came to mind?’), internality (‘How much was the word that
came to mind your own?’), and wantedness (‘How much did you want to
think of that word rather than another word?’). The ratings were
conducted using a 0-100 visual analogue scale. The WAT has
demonstrated to have good discriminant validity, with hallucinating
patients displaying significantly lower scores than other psychiatric
patients without hallucinations and a healthy control group on all of the
scales, i.e., internality (p <0.01); control (p <0.01); wantedness (p
<0.05) (Baker & Morrison, 1998).
7.4.6 Metacognitions Questionnaire (MCQ-30).
The MCQ-30 (Wells & Cartwright-Hatton, 2004) was used as a measure of
dysfunctional metacognitive beliefs. The MCQ-30 is a shortened, selfadministered 30-item version of the original 65-item questionnaire
developed by Cartwright-Hatton and Wells (1997). The original MCQ
displayed good internal consistency and test re-test reliability and had
been used in studies involving participants experiencing psychosis and
hallucinations (Morrison & Wells, 2003) as well as with participants who
were highly predisposed toward hallucinations (Morrison et al., 2000).
The questionnaire comprises of 30 statements pertaining to beliefs about
thoughts, which the respondent scores according to their level of
agreement on a four-point Likert scale. As with the original MCQ, the
MCQ-30 generates scores for five scales specifically related to
metacognitions, including: 1) positive beliefs about worry (Positive Worry)
2) negative beliefs about uncontrollability and danger (Uncontrollability)
3) cognitive confidence regarding attention and memory (Cognitive
Confidence) 4) negative beliefs about consequences of not controlling
thoughts (Negative Beliefs) and 5) cognitive self consciousness related to
142
attention on thought processing (Cognitive Self-Consciousness).
Exploratory factor analysis revealed the MCQ-30 supports a five factor
structure, which is almost identical to the solution obtained for the full
MCQ in previous studies. The MCQ-30 scales have demonstrated good to
excellent internal consistency (α = .72 to .93) and acceptable to good test
re-test reliability (.59 to .87, total scale = .75) (Wells & CartwrightHatton, 2004). A copy of the MCQ-30 is attached in Appendix H.
7.4.7 Distressing Thoughts Questionnaire (DTQ).
The Distressing Thoughts Questionnaire (DTQ: Clark & de Silva, (1985)
was included in order to measure the frequency and effect on the
individual of distressing intrusive thoughts. This questionnaire has been
used to assess distressing thoughts in a non-clinical sample (Clark et al.,
1985) and for people experiencing psychosis (Morrison et al., 2000). The
questionnaire is made up of 12 distressing thought statements that
include six Anxious and six Depressive items. A further five questions are
used to assess qualitative factors about each statement (frequency,
sadness, worry, removal and dismissal). All items are scored using a nine
point Likert scale. The DTQ has demonstrated good to excellent internal
validity, with the anxious and depressive total scales obtaining a Cronbach
α of 0.89 and 0.95 respectively (Clark & de Silva, 1985). Furthermore,
three-month test-retest reliability demonstrated a Pearson productmoment correlation of 0.67 for the Anxious scale total and 0.64 for the
Depressive scale total (Clark, 1984). A copy of the DTQ is attached in
Appendix I.
7.4.8 The Revised Beliefs About Voices Questionnaire (BAVQ-R).
The characteristics of the relationship and impact of hallucinations on
participants were assessed using the BAVQ-R (Chadwick, Lees &
Birchwood, 2000). The questionnaire consists of 35 items relating to
beliefs about auditory hallucinations and emotional and behavioural
reactions to them. Three subscales are generated relating to beliefs about
the hallucinations: Malevolence, Benevolence and Omnipotence. A further
143
two subscales are generated which measure behavioural and emotional
reactions to the hallucinations: Resistance and Engagement.
The original BAVQ (Chadwick & Birchwood, 1995) contained 30 items
across four scales. The revised version added a further five questions to
create the Omnipotence subscale and discarded the original version’s ‘yes’
or ‘no’ response format to include a four-point Likert scale allowing the
degree of endorsement toward questions to be measured. Both the
original BAVQ and the BAVQ-R have been used in numerous studies with
people experiencing auditory hallucinations (Birchwood & Chadwick, 1997;
Chadwick & Birchwood, 1995; Chadwick et al., 2000). The BAVQ-R offers
high reliability with Cronbach’s α for the five subscales ranging from 0.74
to 0.88 (mean = 0.86) and the original BAVQ displayed high test-retest
reliability (mean = 0.89). A copy of the BAVQ-R is attached in Appendix J.
7.4.9 Level of distress from hallucinations.
The level of distress experienced from the hallucinations was assessed
using a self-report, 10-point Likert scale ranging from ‘not at all
distressed’ (1) to ‘extremely distressed’ (10). This relatively simple
method for measuring distress associated with hallucinations was
previously used by Vaughan and Fowler (2004).
7.5 Procedure
7.5.1 Recruitment and informed consent.
A plain language statement describing the aims of the project, the
expected time commitments and potential risks was given to potential
participants. Written informed consent was obtained via the plain
language statement after the project had been explained by the
researcher, the eligible participant had read the plain language statement
and the researcher was confident the eligible participant understood the
project. A copy of the plain language statement is attached in Appendix K.
144
7.5.2 UHR participants.
All young people attending the PACE Clinic were asked if they would like
to participate in a range of research activities focusing on validation of risk
factors for psychosis and evaluating interventions to reduce transition to
psychosis. Potential participants attending the PACE Clinic who met UHRHG or UHR-NHG criteria were approached by their case managers about
the project. Informed written consent was obtained from participants
before any assessments were conducted.
7.5.3 HCG participants.
The HCG was recruited from the general public via advertisements placed
in local newspapers, public notice boards and community centres.
Participants were able to contact the researcher by phone and the
assessment was conducted at a location of most convenience for the
participant.
7.5.4 Order of assessments.
The UHR-HG undertook all assessment measures at baseline. The
measures administered at each interview are shown in Table 7.5. The
UHR-HG was the only group to have the entire assessment battery
administered. The HCG did not participate in the follow up assessments.
145
Table 7.5
Summary of Study Assessments
UHR-HG
Scale
Baseline
UHR- NHG
Follow Up
1
2
Baseline
3
HCG
Follow Up
1
2
Baseline
3
SCID-IV


CAARMS

DASS


NART


WAT

MCQ-30



DTQ



BAVQ

Distress

















Scale
All efforts were made to ensure that the assessment battery was as least
intrusive as possible and could be administered in a relatively short period
of time. Most participants were able to complete the assessments within
one hour. All participants were reimbursed (AUD $20) for their time and
travel expenses.
7.6 Data Analysis
7.6.1 Power analysis.
Using the conventional significance level of 5% and power of 80%, the
sample size needed to detect a moderate effect between groups using a
two-tailed analysis of variance, was calculated to be 53 cases for each of
the three groups. However, due to slowness in recruitment it was deemed
sufficient to obtain approximately 35 participants for each study group.
This sample size is comparable to previous cross sectional studies which
have observed significant differences with similar cognitive measures for
participants experiencing hallucinations (e.g., Baker & Morrison, 1998;
Ensum & Morrison, 2003; Henquet et al., 2005; Morrison & Baker, 2000;
Morrison & Haddock, 1997; Morrison & Wells, 2002).
146
7.6.2 Data entry.
All raw data was entered into a data base developed using Statistical
Package for the Social Sciences (SPSS) Version 16.0 for Windows (SPSS
Inc, 2007). All statistical procedures were conducted using SPSS 16.0
(SPSS Inc, 2007).
Prior to analyses, data was screened for errors by checking all ranges for
all variables were within acceptable limits. Additionally, a second check
was conducted prior to statistical analyses to ensure all raw data recorded
on scoring sheets corresponded with data entered on SPSS.
7.6.3 Preliminary analysis and data screening.
All variables were tested for normality of distribution and adjustments in
analysis via the use of non-parametric statistical techniques were
undertaken as required. Most of the cognitive bias measures incorporated
in this study had not previously been used with UHR cohorts, therefore
internal consistency was assessed for all measures using Cronbach’s
alpha. Prior to analyses of group comparisons appropriate assumption
testing was conducted for univariate normality (i.e., visual inspection of
histograms and scatterplots as well as inspection of outliers from
boxplots), multivariate normality for multiple analyses of variance
(MANOVA) and homogeneity of variance. Violations of assumptions of
variance were addressed where appropriate (e.g., selection of most robust
comparative statistical coefficients).
7.6.4 Analysis of between-groups hypotheses.
The first hypothesis examined group differences in source monitoring
between study groups. A series of one-way ANOVAs with Bonferroni
adjustments were used with each of the primary WAT scales (Control,
Internality and Wantedness), with post-hoc comparisons to examine
specific groups differences. These analyses were followed by 3x3 mixed
factorial ANOVAs to assess group differences for the influence of word-
147
type (i.e., positive, negative or neutral) within each of the primary WAT
scales. Additional analysis using a one-way ANOVA with post-hoc
comparisons was conducted to examine the overall group differences for
responses to word type.
Hypotheses two and three examined group differences across
metacognition and appraisal of intrusive thoughts. Similar analyses were
conducted for both hypotheses. MANOVAs were used since multiple
dependent variables were compared between groups. Where an overall
effect was observed, post-hoc univariate comparisons were conducted
using Bonferroni adjustments.
One-way ANOVAs with planned comparisons between the UHR-HG and all
other participants had been considered in the analyses of hypotheses one
to three. However, this would not have allowed comparisons between the
UHR-HG and UHR-NHG, which was considered essential for examining
cognitive biases specific to individuals presenting with emerging
hallucinations.
Effect sizes were calculated as a measure of the magnitude of group
differences for specific variables. The effect size coefficient used was
(eta squared). An
2
2
of .01, .06 and .14 represent small, medium and
large effect sizes respectively (Pallant, 2011).
7.6.5 Analysis of longitudinal hypotheses.
Hypotheses four to six focused on the follow-up assessments for all UHR
participants. These hypotheses were more exploratory than the previous
hypotheses and examined the potential for cognitive biases to predict
continuation of hallucinations over the follow up assessments.
The participants who were followed up were categorised into three groups
according to their experience of perceptual abnormalities over the followup assessments, ranging from no experience to continued perceptual
abnormalities. The CAARMS rating on the Perceptual Abnormalities
148
intensity subscale measured at each follow-up assessment was used to
determine follow up groupings. When determining follow-up grouping a
rating of three or above on the Perceptual Abnormalities intensity subscale
was used as the anchor rating for determining grouping. This was less
stringent than the CAARMS criteria used for eligibility to the UHR-HG (i.e.,
rating of four), because the focus of the follow-up analyses was the
persistence of hallucinations over a five-month period.
MANOVAs were conducted to see if there were overall differences between
participant groups for measures of beliefs about voices, metacognition,
appraisal of intrusive thoughts and source monitoring. Where overall
effects were significant one-way ANOVAs with planned comparisons were
conducted. This was considered preferable to post-hoc comparisons
because the hypotheses addressed the identification of factors that were
unique to participants who reported hallucinations at the final assessment.
Following planned comparisons, the categorization of follow-up
participants (into persistent and non-persistent hallucinating groups)
enabled logistic regression to be performed. This was deemed preferable
to multiple regression due to the limited range of the CAARMS Perceptual
Abnormalities intensity subscale.
149
150
CHAPTER 8
Results: Group Comparisons.
The results of the present study are divided into two chapters. This
chapter provides results of comparisons of cognitive bias measures
between the three study groups at baseline. Chapter 9 includes the results
of analyses pertaining to hypotheses which predicted the duration of
hallucinations within the UHR groups over the follow up period.
The results of analyses detailed in this chapter aimed to assess the
hypotheses that the UHR hallucinating group would differ from other
groups at baseline on measures of metacognition, source monitoring and
intrusive thoughts.
8.1 Hypothesis 1: Group Differences in Source Monitoring.
The WAT was used as a measure of immediate source monitoring across
the entire sample. The WAT had not previously been utilised with UHR
populations, therefore the internal reliability was assessed using
Cronbach’s alpha. The total WAT was found to have good reliability
(Cronbach  = .95), as did the scales: Internality (Cronbach  = .877),
Control (Cronbach  = .902) and Wantedness (Cronbach  = .869). Visual
inspection of residual plots and results from Levene’s test indicated that
the data was normally distributed and met assumptions for homogeneity
of variance.
The means and standard deviations for ratings of control, internality and
wantedness, as well as word type for each group are displayed in Table
8.1.
151
Table 8.1
Mean WAT Scale Scores: Control, Internality and Wantedness.
Subscale
Word Type
UHR-HG
UHG-NHG
HCG
Control
Positive
232.63
284.50
368.29
(102.53)
(103.26)
(84.99)
230.00
288.97
351.86
(116.12)
(125.43)
(90.98)
249.53
299.22
394.00
(96.41)
(94.56)
(139.60)
712.16
872.69
887.79
(270.82)
(282.08)
(306.67)
262.89
295.16
372.71
(111.40)
(95.23)
(81.92)
268.55
324.22
352.86
(105.40)
(97.54)
(87.64)
295.66
302.28
385.14
(126.69)
(85.22)
(114.52)
Internality
809.74
921.66
1090.29
Total
(255.76)
(249.97)
(226.35)
Positive
255.66
272.19
390.86
(94.90)
(99.54)
(73.36)
225.92
277.97
427.43
(112.53)
(91.49)
(326.13)
274.58
280.09
392.97
(201.65)
(82.24)
(133.30)
Wantedness
685.63
830.25
1133.54
Total
(240.57)
(228.79)
(190.31)
Negative
Neutral
Control Total
Internality
Positive
Negative
Neutral
Wantedness
Negative
Neutral
Note: Standard deviation in brackets
8.1.1 Ratings of control.
A one-way ANOVA was conducted to compare group differences on
perceived levels of control. There was a significant main effect for group
with a large effect size (F(2,102) = 18.89, p<.001,
2
= .27 ). Post hoc
152
comparisons using Tukey HSD indicated that the HCG reported
significantly higher perceived ratings of control than both the UHR-HG
(p<.001) and the UHR-NHG (p=.003). These results indicate that both
UHR groups experienced significantly lower levels of perceived control for
self generated words than the healthy participants. Differences in levels of
perceived control were compared between the UHR groups. The UHR-HG
obtained significantly lower control ratings than the UHR-NHG (p = .034).
This result indicates that participants with hallucinations reported
significantly lower levels of perceived control for self-generated words
than both the healthy participants and UHR participants without
hallucinations.
A mixed factorial 3x3 ANOVA was conducted to assess the main effect of
word type across all participants (main effect) and between groups (group
by word effect). There was no significant main effect for word type, (F(2,
101) = 3.014, Wilk’s Lambda = .944, p = .054) or group by word effect
(F(4, 202) = .411, Wilk’s Lambda = .984, p = .80).
8.1.2 Ratings of internality.
A one way ANOVA was conducted to compare group differences on
perceived levels of internality. There was a significant main effect for
group with a large effect size (F(2,102) = 12.09, p<.001,
2
= .19). Post
hoc comparisons using Tukey HSD indicated that the HCG reported
significantly higher perceived ratings of internality than both the UHR-HG
(p<.001) and the UHR-NHG (p =.016). These results indicate that both
UHR groups experienced significantly lower levels of perceived internality
for self generated words than the healthy participants. There were no
significant differences between perceived level of internality between the
UHR groups (p = .142).
A mixed factorial 3x3 ANOVA was conducted to assess the main effect of
word type across all participants (main effect) and between participants
(group by word effect). There was not a significant main effect for word
type, (F(2, 101) = 1.158, Wilk’s Lambda = .978, p =.318) and there was
153
no significant group by word effect (F(4, 202) = .2.239, Wilk’s Lambda =
.917, p = .066).
8.1.3 Ratings of wantedness.
A one way ANOVA was conducted to compare group differences on
perceived levels of wantedness. There was a significant main effect for
group with a large effect size (F(2,102) = 38.43, p<.001,
2
= .43). Post
hoc comparisons using Tukey HSD indicated that the HCG reported
significantly higher perceived ratings of control than both the UHR-HG
(p<.001) and the UHR-NHG (p<.001). These results indicate that both
UHR groups experienced significantly lower levels of perceived
wantedness for self generated words than the healthy participants.
Differences in levels of perceived control were compared between the UHR
groups. The UHR-HG reported significantly lower control ratings than the
UHR-NHG (p = .021). This result indicates that participants with
hallucinations reported significantly lower levels of perceived control for
self-generated words than both the healthy participants and UHR
participants without hallucinations.
A mixed factorial 3x3 ANOVA was conducted to assess the main effect of
word type across all participants (main effect) and between participants
(group by word effect). There were no significant main effects for word
type, (F(2, 101) = 1.037, Wilk’s Lambda = .980, p =.358) or group by
word effect (F(4, 202) = .789, Wilk’s Lambda = .969, p = .534).
8.2 Hypothesis 2: Group Differences in Metacognition
The MCQ-30 had not previously been utilised with UHR populations,
therefore the internal reliability was assessed using Cronbach’s alpha. The
MCQ-30 was found to have good internal consistency (Cronbach  =
0.91). Internal consistency for all subscales was good: Cognitive
Confidence (Cronbach  =.845); Positive Worry (Cronbach  = .898);
Cognitive Self Consciousness (Cronbach  = .899); Uncontrollability
(Cronbach  = .914); Negative Beliefs (Cronbach  = .809).
154
Results from Levene’s test indicated that assumptions of homogeneity
were violated on a number of subscales including Cognitive Self
Consciousness (p = 0.018), Uncontrollability (p = .014) and Negative
Beliefsl (p = .016). It was decided to use parametric statistics due to
complications associated with correction of mild deviations within
moderate sized samples (Grayson, 2004). Given that a substantial
proportion of the scales met homogeneity of variance non-parametric
measurements were considered inappropriate.
A MANOVA was performed to assess whether there was an overall
difference between participant groups on the MCQ-30 subscales.
Participant group was the independent variable and scores across the five
MCQ-30 subscales were the dependent variables. Preliminary assumption
testing was conducted to check for multivariate normality with
Mahalanobis distance, visual inspection of linearity from scatterplots,
inspection of histograms and boxplots for outliers as well as
multicollinearity, with no violations occurring. Given that moderate
violations of assumptions were observed regarding homogeneity of
variance, Pillai’s Trace was selected as a more robust coefficient than
Wilk’s Lambda. There was a significant overall effect for the combined
MCQ-30 subscales (F(10, 198) = 6.19, p<.001; Pillai’s Trace = .476;
2
=
238).
Separate univariate ANOVAs were performed on the MCQ-30 subscales,
using a Bonferroni adjusted alpha level of .01. Several subscales reached
statistical significance including Cognitive Confidence, Uncontrollability
and Negative Beliefs. Results from MCQ-30 group comparisons, including
means, standard deviations and effect sizes (
2
) are presented in Table
8.2.
155
Table 8.2
Mean Subscale MCQ-30 Scores.
MCQ Subscales
Cognitive
Confidence
Positive Worry
UHR-
UHR-
HG
NHG
15.00b
(4.51)
10.00
(5.19)
Cognitive SelfConsciousness
Uncontrollability
Negative Beliefs
16.55
a,b
(5.68)
17.29
b
2
HCG
F (2,101)
P
13.28b
10.54a
11.09
<.001
.179
(3.94)
(3.63)
10.91
9.71
.609
.546
.019
4.47
.014
.081
25.33
<.001
.332
17.17
<.001
.252
(4.61)
(3.82)
b
14.23a
(3.81)
(5.49)
17.91
15.44
b
9.66
a
(5.44)
(4.89)
(3.64)
15.55 b
13.44 b
9.74
(5.03)
(4.35)
(3.13)
a
Note: Values with different letters were significantly different at .05 level
from post-hoc analysis with Bonferroni adjustment. Standard deviation in
brackets.
Post-hoc between group comparisons were conducted for the Cognitive
Confidence, Uncontrollability and Negative Beliefs subscales in order to
identify the location of group differences. On the Cognitive Confidence
subscale the HCG scored significantly lower than the UHR-HG (p<.001)
and UHR-NHG (p =.021). On the Uncontrollability subscale, the HCG
scored significantly lower than the UHR-HG and UHR-NHG (p<.001). On
the Negative Beliefs subscale the HCG scored significantly higher than the
UHR-HG (p<.001) and the UHR-NHG (p =.002). There were no significant
differences between the UHR groups on any of the MCQ-30 subscales.
8.3 Hypothesis 3: Group Differences in Appraisal of Intrusive
Thoughts.
The DTQ was used as a measure for assessing the appraisal of intrusive
thoughts across the entire sample. Visual inspection of residual plots and
results from Levene’s test indicated that the data was normally distributed
and met assumptions for homogeneity of variance. Given that the DTQ
156
had not previously been used within UHR populations internal consistency
was assessed using Cronbach’s alpha. The DTQ was found to have good
reliability (Cronbach  = .979). The subscales also obtained good
reliability, with Anxiety (Cronbach  = .950) and Depressive (Cronbach 
= .978).
A MANOVA was performed to assess whether there was an overall
difference between participant groups on the Anxiety and Depressive
thought subscales. Participant group was the independent variable and
scores across the two subscales were the dependent variables. Preliminary
assumption testing was conducted to check for multivariate normality with
Mahalanobis distance, visual inspection of linearity from scatterplots,
inspection of histograms and boxplots for outliers as well as
multicollinearity, with no violations occurring. There was a significant
overall group effect for the combined MCQ-30 subscales (F(4, 202) =
17.801, p<.001; Wilk’s Lambda = .547;
2
= .61).
Separate univariate ANOVAs were conducted on the Anxiety and
Depressive subscales, using a Bonferroni adjusted alpha level of .025.
Both subscales reached statistical significance with a large effect size for
these comparisons. Results from the DTQ group comparisons, including
means, standard deviations, effect sizes (
2
) and post-hoc comparisons
are presented in Table 8.3.
157
Table 8.3
Mean and Post-Hoc Comparisons for DTQ Subscales.
Subscale
UHR-HG
UHR-NHG
HCG
F (2,
2
P
102)
Anxiety
Depressive
176.63c
147.03b
105.09a
(45.82)
(49.32)
(46.79)
c
207.68
b
177.75
100.94a
(44.43)
(57.99)
(52.84)
21.02
<.001
.29
40.77
<.001
.44
Note: Values with different letters are significantly different at .05 level
from post-hoc analysis with Bonferroni adjustment. Standard deviation in
brackets.
Post-hoc between group comparisons on the Anxiety subscale indicated
that the HCG scored significantly lower than both the UHR-HG (p < .001)
and the UHR-NHG (p = .001). Additionally, the UHR-HG scored
significantly higher on the Anxiety subscale than the UHR-NHG (p = .031).
A similar pattern of results was observed for the Depressive subscale, as
the healthy control group scored significantly lower than the UHR-HG and
the UHR-NHG (p < .001). There was a trend toward a difference between
the UHR groups on the Depressive subscale, however this did not reach
statistical significance (p =.053).
8.3.1 Group differences in qualitative factors of the DTQ.
Further analysis was conducted to examine which factors within the
subscales contributed to the differences between groups. A one way
ANOVA was conducted on ratings of the five qualitative factors within each
subscale including anxiety, sadness, worry, ability to remove thoughts
(removal) and capacity to dismiss thoughts (dismissal). After a Bonferroni
adjustment, there was a highly significant effect at the p < .01 for group
across all factors within the Anxiety and Depressive subscales. Means,
standard deviations, group comparisons and effect sizes (
2
) for
qualitative factors within each of the DTQ subscales are presented in Table
8.4.
158
Table 8.4
Means, Standard Deviations and Between Group Comparisons for DTQ
Qualitative Factors.
Subscales
UHR-HG
UHR-
HCG
NHG
F (2,
P
2
102)
Anxiety
Frequency
Sadness
35.66b
31.06b
22.34a
(10.16)
(9.17)
(10.62)
35.29
b
(10.31)
Worry
Removal
Dismissal
34.24
b
29.84
b
(11.09)
28.53
b
22.40a
16.41
<.001 .243
13.29
<.001 .207
13.25
<.001 .206
18.68
<.001 .268
17.47
<.001 .255
40.11
<.001 .440
36.34
<.001 .416
29.57
<.001 .367
34.84
<.001 .406
24.46
<.001 .324
(10.73)
21.31a
(10.63)
(10.89)
(10.67)
35.87b
28.28c
19.57a
(10.80)
(11.98)
(11.44)
35.58b
29.31b
19.46a
(11.75)
(12.63)
(10.72)
41.84b
37.25b
19.60a
(10.29)
(12.43)
(10.57)
43.71b
38.34b
21.94a
(9.09)
(12.59)
(12.06)
41.84b
35.75b
20.97a
(10.07)
(13.12)
(12.35)
40.76b
33.56c
18.46a
(10.42)
(14.38)
(9.75).
39.53b
32.84b
19.97a
(10.78)
(13.37)
(12.16)
Depressive
Frequency
Sadness
Worry
Removal
Dismiss
Note: Values with different letters are significantly different at .05 level
from post-hoc analysis with Bonferroni adjustment.
Post Hoc comparisons on the Anxiety subscale indicated that the HCG
scored significantly lower (p <.001) than the UHR-HG on all qualitative
factors. The HCG also scored significantly lower on the Anxiety subscale
than the UHR-NHG for all qualitative factors, including Anxiety (p = .002),
159
Sadness (p = .016), Worry (p = .021), Removal (p = .007) and Dismissal
(p = .002). The only significant difference in qualitative factors between
the UHR groups was that the UHR-HG obtained significantly higher levels
for Removal (p = .020) compared to the UHR-NHG.
Post hoc comparisons were conducted to examine the location of group
differences in qualitative factors within the Depressive subscale. The
healthy control group scored significantly lower (p <.001) than the UHR
hallucinating group and the UHR non-hallucinating on all qualitative
factors. In a similar pattern to the Anxiety subscale, the only significant
difference between the UHR groups was that the UHR hallucinating group
obtained significantly higher levels for Removal (p = .033) compared to
the UHR non-hallucinating group.
8.4 Summary of Baseline Group Comparisons
A number of notable differences were observed between the study groups.
Both the UHR groups significantly differed from the HCG on all of the
cognitive processing measures, apart from two subscales from the MCQ30.
Elements of several hypotheses were supported. As predicted by
Hypothesis 1, the UHR-HG reported significantly less subjective feelings of
control and wantedness toward their self generated words. However,
there was no difference between ratings of perceived internality between
the UHR groups. Word type did not appear to affect ratings within each of
the WAT scales. Hypothesis 2 was not supported because there were no
differences observed between the UHR groups on any of the
metacognitive belief scales. Partial support was provided for Hypothesis 3,
as the UHR-HG scored significantly higher than the UHR-NHG for anxiety
based ratings toward intrusive thoughts on the DTQ. This pattern was not
observed for depressive ratings toward intrusive thoughts, however a
non-significant trend was observed. Subjective ratings of difficulty for
removal of intrusive thoughts were significantly higher for the UHR-HG
than the UHR-NHG across both anxiety and depressive intrusive thoughts.
160
CHAPTER 9
Results: Follow-Up of UHR Participants
The analysis described in this chapter assessed the hypotheses which
predicted that beliefs about voices and results from cognitive bias
measures at baseline would be predictive of hallucinations continuing at
follow up assessments.
9.1 Follow-Up Grouping According to Persistence of Hallucinations
For the analyses in this chapter the UHR participants were divided into
three groups according to each participant’s level of reported perceptual
disturbances over the three follow-up assessments. This method enabled
grouping of participants according to their persistence of perceptual
disturbance over the follow-up period. The CAARMS intensity of perceptual
disturbance scale was used as the measure of hallucinations. Utilising the
intake criteria for the study, a score of at least three was used as the cutoff to assess whether a participant experienced perceptual disturbances at
each follow-up. These groups will be referred to as the ‘follow up groups’.
The follow-up groups were Persistent Hallucinators, Partial Hallucinators
and Non-Hallucinators. Persistent Hallucinators consisted of participants
who reported hallucinations at the final follow-up assessment and at least
one other assessment after baseline (N=23). Partial Hallucinators were
participants who reported hallucinations at follow-up assessments one
and/or two, but not at the final assessment (N=14). Non-Hallucinators
were participants who did not report hallucinations at any of the follow-up
assessments (N=33).
Not surprisingly, the Persistent Hallucinators comprised of participants
from only the UHR-HG. One individual from the UHR-NHG reported
perceptual disturbances at one follow-up interview and was included in the
Partial Hallucinators group. The composition of each of the follow-up
161
groups according to their original baseline participant group status is
detailed in Table 9.1.
Table 9.1
Composition of Follow-Up Groups.
Follow Up Group
N
UHR-HG
UHR-NHG
Persistent Hallucinators
23
23
0
Partial Hallucinators
14
13
1
Non-Hallucinators
33
2
31
Table 9.2 provides details of the rates of follow up time between
assessments and the means for the CAARMS Perceptual Intensity scores
across the follow up assessments. Rates of completed interviews across
the three follow up assessments ranged from 89 to 99% for the UHR
sample. There were no significant differences between groups in time
between follow up interviews.
162
Table 9.2
Mean Time Between Assessments and CAARMS Perceptual Abnormalities
Ratings Across Follow Up Assessments
Follow Up One
Persistent
Partial
Non-
Total
Hallucinators
Hallucinators
Hallucinators
Follow Up Rate (%)
23 (100)
14 (100)
32 (96.9)
69 (98.6)
Weeks from Baseline
5.17
5.57
5.22
5.28
CAARMS Perceptual
4.09
3.36
0.19
2.13
Persistent
Partial
Non-
Total
Hallucinators
Hallucinators
Hallucinators
Follow Up Rate (%)
22 (95.7)
13 (92.9)
27 (81.8)
62 (88.6)
Weeks from Baseline
11.05
11
10.2
10.68
CAARMS Perceptual
3.82
2.38
.15
1.92
Persistent
Partial
Non-
Total
Hallucinators
Hallucinators
Hallucinators
Follow Up Rate (%)
23 (100)
14 (100)
30 (90.9)
67 (95.7)
Weeks from Baseline
17.35
16.71
15.90
16.57
CAARMS Perceptual
3.78
1.50
.20
1.70
Intensity
Follow Up Two
Intensity
Follow Up Three
Intensity
9.2 Hypothesis 4: Beliefs About Voices and Persistence of
Hallucinations.
The BAVQ-R was administered to the UHR-HG at baseline assessment.
Hypotheses four predicted that beliefs about voices measured by the
BAVQ-R would be associated with continuation of hallucinations at followup assessments.
The association between beliefs about voices and continuation of
hallucinations were analysed by comparing BAVQ-R differences between
the follow-up groups. The analyses of the BAVQ-R were divided into the
subscales associated with beliefs about voices (Malevolence, Benevolence
163
and Omnipotence) and the subscales associated with responses to voices
(Resistance and Engagement).
Only two participants who were from the UHR-HG (and therefore
completed the BAVQ-R) were subsequently in the follow-up NonHallucinators group. This potentially compromised comparative analyses
between follow up groups because assumption testing such as
homogeneity of variance-covariance may have been compromised.
Therefore, a conservative multivariate coefficient (Pillai’s Trace) was
selected to assess group differences.
9.2.1 Comparisons of BAVQ-R Belief Subscales.
A MANOVA was performed to assess whether there was an overall effect
for follow-up groups on the BAVQ-R belief subscales (Malevolence,
Benevolence and Omnipotence). Follow-up group was the independent
variable and scores across the three belief subscales were the dependent
variables. Preliminary assumption testing was conducted to check for
multivariate normality across the 70 follow-up participants. Multivariate
normality was achieved from Mahalanobis distance and visual inspection
of histograms, scatterplots and boxplots indicated univariate normality
and linearity were satisfied. Homogeneity of variance-covariance and
multicollinearity were also satisfied. An overall effect for the BAVQ-R belief
subscales was observed (F(6, 68) =2.7.2, p = 020, Pillai’s Trace = .387,
2
= .194).
A one way ANOVA with planned comparisons was conducted to explore
the association of beliefs about voices and continuation of hallucinations
over the follow-up period. Participants from the Persistent Hallucinators
were compared to the other groups. Results from Levene’s test indicated
acceptable homogeneity of variance between groups. Three sets of
comparisons were conducted, therefore a Bonferroni adjustment indicated
that a p-value of .017 was required for significance. Results from the
group comparisons, including means t-values and effect sizes (
2
) are
presented in Table 9.3.
164
Table 9.3.
Planned Comparison ANOVA for BAVQ-R Belief Subscales
Subscale
Persistent
Partial and
Halluc.
Non – Halluc.
Mean, (SD)
Mean (SD)
Malevolence
10.48 (4.59)
Benevolence
Omnipotence
2
t(1,35)
P
6.33 (4.07)
-2.00
.053
.18
5.17 (4.56)
2.47 (3.31)
-2.10
.043
.12
11.00 (3.69)
6.47 (3.34)
-3.33
.002
.30
There was a significant difference between the Persistent Hallucinators
and other groups on beliefs about the Omnipotence of their voices. A
trend toward differences was observed between Persistent Hallucinators
and the other groups for Malevolence and Benevolence, however these
differences did not reach statistical significance.
9.2.2 BAVQ-R and prediction of duration of hallucinations.
In order to further investigate the associations between beliefs about
voices and the persistence of hallucinations over time a logistic regression
was performed. The dependent variable was hallucination status at the
final follow-up assessment. It is important to note that the single
participant who was in the UHR-NHG (i.e., did not complete a BAVQ-R)
and included in the Partial Hallucinators group did not report perceptual
disturbances at the final follow-up. Participants were coded according to
whether they continued to report perceptual abnormalities at the final
follow-up assessment (CAARMS Perceptual Abnormality  3) or whether
they reported no perceptual abnormalities at final follow up (CAARMS
Perceptual Abnormality  3). The model contained three independent
variables associated with beliefs toward voices including Malevolence,
Benevolence and Omnipotence. The full model containing all predictors
was highly significant (2 (3, N = 38) = 16.080, p = .001), indicating that
the combined predictive variables were able to distinguish between
participants who continued to experience hallucinations at the final followup assessment and those that did not. As shown in Table 9.4, none of the
165
predictor variables were significant in their own right for predicting
persistence of hallucinations at final follow-up assessment. The combined
predictive variables accounted for between 34.5% (Cox and Snell R
Square) and 46.7% (Nagelkerke R Square) of the variance in
hallucinations status at final follow-up assessment and correctly classified
81.6% of cases. The model equation enabled correct classification for
87% of those continuing to experience hallucinations at final assessment
and 73.3% of those not experiencing hallucinations at final assessment.
Table 9.4
Logistic Regression Predicting Persistence of Hallucinations According to
Beliefs About Voices
B
S.E.
Wald
Df
p
Odds
95.0% C.I. for
Ratio
Odds Ratio
Lower
Upper
Malevolence
.08
.126
.39
1
.53
1.08
.85
1.39
Benevolence
.16
.109
2.02
1
.16
1.17
.94
1.45
Omnipotence .32
.179
3.29
1
.07
1.38
.97
1.96
Constant
1.36
7.06
1
.01
.03
-3.62
9.2.3 Comparisons of BAVQ-R response subscales.
Two separate MANOVAs were performed to assess whether there was an
overall difference between follow-up groups on the BAVQ response scales
of Resistance and Engagement. The emotional, behavioural and total
scores for the Resistance and Engagement scales were included in the
analyses. Follow-up group was the independent variable and scores across
the dependent variables of Resistance and Engagement were analysed
separately. Preliminary assumption testing indicated there were no
significant violations for multivariate or univariate normality, homogeneity
of variance and linearity across all the BAVQ response subscales. There
was no overall effect for the Resistance subscales (F(4, 68) = .727, p =
577, Pillai’s Trace = .08,
2
= .04) or the Engagement subscales (F(4, 68)
= .1.53, p = 204, Pillai’s Trace = .161,
2
= .08).
166
9.2.4 Distress From Hallucinations.
A one way ANOVA with planned comparisons was conducted to assess
whether subjective ratings of distress from hallucinations was associated
with continued perceptual abnormalities at final follow-up assessment.
The Persistent Hallucinators group was compared to the other follow-up
groups. Results from Levene’s test indicated that acceptable homogeneity
of variance was achieved between groups. Results from the group
comparisons, including means t-values and effect sizes (
2
) are presented
in Table 9.5. There was no significant difference in subjective ratings of
distress associated with hallucinations between the Persistent
Hallucinators and other follow-up groups.
Table 9.5
Planned Comparisons ANOVA for Distress From Hallucinations
Subscale
Distress
Persistent
Partial and Non
Halluc.
– Halluc.
Mean, (SD)
Mean (SD)
7.74 (1.76)
6.53 (2.1)
t(1,35)
p
-.714
.480
2
.127
In order to examine the association between subjective ratings of distress
associated with hallucinations and beliefs about voices, correlation
coefficients were calculated between the hallucination distress scale and
the BAVQ-R subscales. A p-value of less than .008 (.05/6 = .008) was
required for significance using the Bonferroni approach to control for Type
1 errors. Correlation coefficients between subjective distress from
hallucinations and BAVQ-R subscales are shown in Table 9.6. There were
no significant correlations between subjective distress and the BAVQ-R
subscales.
167
Table 9.6
Correlation Coefficients (Pearson r) Between Ratings of Distress from
Hallucinations and BAVQ-R Subscales
Distress
Distress
Omnip.
Malev.
Benev.
Resist.
Engage.
1
.31
.11
-.20
.40
-.19
9.3 Hypothesis 5: Metacognition and Continuation of
Hallucinations
A MANOVA was performed to assess whether there was an overall
difference between follow-up groups on the MCQ-30 subscales. Follow-up
group was the independent variable and scores across the five MCQ-30
subscales were the dependent variables. Preliminary assumption testing
was conducted to check for multivariate normality across the 70 follow-up
participants. No violations were observed for Mahalanobis distance,
multicollinearity as well as outliers from visual inspection of scatterplots,
histograms and boxplots. Pillai’s Trace was selected as the multivariate
comparative coefficient due to moderate violations of homogeneity of
variance (Cognitive Self-Consciousness, p = .006). There was no overall
effect for the combined MCQ-30 subscales (F(10, 128) = 1.106, p = 363,
Pillai’s Trace = .159,
2
= .08).
9.4 Hypothesis 6: Appraisal of Intrusive Thoughts and
Continuation of Hallucinations.
A MANOVA was performed to assess whether there was an overall
difference between follow-up groups on the Anxiety and Depressive total
scales. Follow up group was the independent variable and scores across
the two scales were the dependent variables. Preliminary testing indicated
assumptions of normality were met. There was no overall effect for the
combined DTQ Anxiety and Depressive total scales (F(4,132) = 1.83, p =
.127, Wilk’s Lambda = .898,
2
= .053). As no overall effect was observed
for each of the main scales, further analyses of the five subscales which
contribute to the Anxiety and Depressive scales was not conducted.
168
9.5 Hypothesis 7: Source Monitoring and Continuation of
Hallucinations.
9.5.1 Relationship Between Baseline WAT Scales (Control,
Internality and Wantedness) and Follow-Up Group.
A MANOVA was performed to assess whether there was an overall
difference between follow-up groups on the baseline scores of the WAT
Control, Internality and Wantedness subscales. Follow-up group was the
independent variable and scores across the three subscales were the
dependent variables. Preliminary assumption testing indicated there were
no significant violations for multivariate or univariate normality,
homogeneity of variance and linearity across all the WAT scales. There
was no overall effect for the combined Control, Internality and
Wantedness subscales of the WAT (F(6,130) = 1.96, p = .076, Wilk’s
Lambda = .841,
2
= .083).
9.5.2 Relationship Between Baseline WAT Word-Type (Positive,
Negative and Neutral Stimuli) and Follow Up Group.
A MANOVA was performed to assess whether there was an overall
difference between follow-up groups on the baseline scores of positive,
negative and neutral words on the WAT. Follow-up group was the
independent variable and scores across the three words groups were the
dependent variables. Preliminary assumption testing indicated there were
no significant violations for multivariate or univariate normality,
homogeneity of variance and linearity across all the word types. There
was no overall effect for the combined word-type of the WAT (F(6,130) =
1.40, p = .218, Wilk’s Lambda = .882,
2
= .061).
169
9.5.3 Relationship Between Final WAT Scales (Control, Internality
and Wantedness) and Follow-Up Group.
A MANOVA was performed to assess whether there was an overall
difference between follow-up groups on Control, Internality and
Wantedness scales of the WAT measured at final follow-up assessment.
Follow-up group was the independent variable and scores across Control,
Internality and Wantedness were the dependent variables. Preliminary
assumption testing indicated there were no significant violations for
multivariate or univariate normality, homogeneity of variance and linearity
across all the Control, Internality and Wantedness scales. There was an
overall effect for the combined WAT scales from the follow-up assessment
(F(6,124) = 2.75, p = .015, Wilk’s Lambda = .779,
2
= .117).
A one way ANOVA with planned comparisons was conducted to explore
the association of the final WAT assessment results and continuation of
hallucinations over the follow-up period. Participants from the Persistent
Hallucinators were compared to the other follow-up groups. Results from
Levene’s test indicated that homogeneity of variance was violated for
Control (.013) and Internality (.011). For these scales contrast tests did
not assume equal variance. Three sets of comparisons were conducted,
therefore a Bonferroni adjustment indicated that a p-value of .017 was
required for significance. Results from the group comparisons, including
means t-values and effect sizes (
2
) are presented in Table 9.7. There
was a significant difference between the Persistent Hallucinators and other
follow-up groups for perceived level of Control. These results indicate that
the participants in the Persistent Hallucinators follow-up group reported
significantly lower perceived levels of control of their response words
during the WAT conducted at the final assessment.
170
Table 9.7
Results for Planned Comparison ANOVA for Follow-Up WAT Subscales.
Subscale
Persistent Hall. Partial and
2
t(df)
P
.006
.121
.084
.032
.086
.085
Non – Hall.
Control
Internality
Wantedness
731.09
853.98
3.39
(131.03)
(173.57)
(1, 64)
876.96
935.00
1.76
(114.47)
(169.86)
(1, 64)
854.35
921.93
1.74
(89.59)
(142.21)
(1,64)
Note: Standard deviation in brackets.
A logistic regression was performed to investigate the influence of the
follow-up WAT Control, Internality and Wantedness scales with
persistence of hallucinations. The dependent variable was hallucination
status at the final follow-up assessment and the independent variables
were the Control, Internality and Wantedness WAT scales from final
follow-up. The full model containing all predictors was highly significant
(2 (3, N = 67) = 14.239, p = .003), indicating that the combined
predictive variables were able to distinguish between participants who
continued to experience hallucinations at the final follow-up assessment
and those that did not. The combined predictive variables accounted for
between 19.1% (Cox and Snell R Square) and 26.5% (Nagelkerke R
Square) of the variance in hallucinations status at final follow-up
assessment and correctly classified 80.6% of cases. As shown in the
regression results displayed in Table 9.8, both Control (p = .005) and
Internality (p = .04) made significant contributions in their own right to
the prediction of hallucinations persisting at final follow-up. The model
equation enabled correct classification for 56.5% of those continuing to
experience hallucinations at final follow-up assessment and 93.2% of
those not experiencing hallucinations at final follow-up assessment. These
results indicate that increase in the level of perceived control would
decrease the likelihood of reporting hallucinations at final assessment.
Conversely, an increase in the reported level of internality indicated an
increased likelihood of reporting hallucinations at final assessment.
171
Table 9.8
Results of Logistic Regression of Persistence of Hallucinations with Final
Follow-Up WAT Subscales.
B
Control
S.E.
Wald
df
p
Odds
95.0% C.I. for
Ratio
Odds Ratio
Lower
Upper
-.01
.00
8.05
1
<.01
.99
.98
.99
.01
.00
4.21
1
.04
1.01
1.00
1.02
Wantedness -.00
.00
.60
1
.44
.99
.99
1.00
Constant
2.48
1.46
1
.23
19.85
Internality
2.99
9.5.4 Relationship Between Final WAT Word-Type (Positive,
Negative and Neutral Stimuli) and Follow-Up Group.
A MANOVA was performed to assess differences between follow-up group
for Positive, Negative and Neutral words on the WAT at final assessment.
Follow-up group was the independent variable and scores across word
types were the dependent variables. Preliminary assumption testing
indicated there were no significant violations for multivariate or univariate
normality, homogeneity of variance and linearity. There was an overall
effect for the combined WAT scales from the follow-up assessment
(F(6,124) = 2.75, p = .001, Wilk’s Lambda = .698,
2
= .164).
A one way ANOVA with planned comparisons was conducted to explore
the association between word type measured on the WAT at final
assessment and continuation of hallucinations over the follow-up period.
Participants from the Persistent Hallucinators were compared to the other
follow-up groups. Results from Levene’s test indicated that homogeneity
of variance was violated for positive words (.03). For this scale contrast
tests did not assume equal variance. Three sets of comparisons were
conducted, therefore a Bonferroni adjustment indicated that a p-value of
.017 was required for significance. Results from the group comparisons,
including means, t-values and effect sizes (
2
) are presented in Table 9.9.
The Persistent Hallucinators had significantly lower levels of responses for
172
neutral and positive words than other follow-up groups. There was a trend
for the Persistent Hallucinators follow-up group to respond significantly
lower to negative words, however this difference failed to reach
significance when Bonferroni adjustment was taken into account.
Table 9.9
Results for Planned Comparison ANOVA for Follow-Up WAT Word Type.
Subscale
Persistent Hall.
Partial and
t(df)
P
.017
.066
.028
.108
.002
.255
2
Non – Hall.
Positive
Negative
Neutral
820.00
920.35
2.47
(156.23)
(194.72)
(1, 47.49)
785.87
883.75
2.25
(133.17)
(156.40)
(1, 64)
641.96
824.55
3.26
(153.14)
(203.77)
(1, 64)
A logistic regression was performed to investigate the influence of the
WAT follow-up Positive, Negative and Neutral scales with persistence of
hallucinations. The model contained the three word type categories as
independent variables. The full model containing all predictors was highly
significant (2 (3, N = 67) = 14.152, p = .003), indicating that the
combined predictive variables were able to distinguish between
participants who continued to experience hallucinations at the final followup assessment and those that did not. Table 9.10 provides the logistic
regression results and shows that the Neutral scale (p = .02) was the only
scale which made a significant contribution in its own right to the
prediction of hallucinations persisting at final follow-up. The combined
predictive variables accounted for between 19.0% (Cox and Snell R
Square) and 26.3% (Nagelkerke R Square) of the variance in
hallucinations status at final follow-up assessment and correctly classified
70.1% of cases. The model equation enabled correct classification for
39.1% of those continuing to experience hallucinations at final follow-up
assessment and 86.4% of those not experiencing hallucinations at final
follow-up assessment.
173
Table 9.10
Results of Logistic Regression of Persistence of Hallucinations with FollowUp WAT Scores for Word Type.
B
S.E.
Wald
df
p
Odds
95.0% C.I. for
Ratio
Odds Ratio
Lower
Upper
Positive
.00
.00
.01
1
.94
1.00
.99
1.00
Negative
-.00
.00
.19
1
.66
.99
.99
1.00
Neutral
-.01
.00
5.37
1
.02
.99
.99
.99
2.10
4.09
1
.04
69.85
Constant 4.25
9.6 Summary of Follow-Up Analyses
At the final follow-up assessment 23 UHR participants continued to report
hallucinations and all of these participants were from the UHR-HG. This
group was referred to as the ‘Persistent Hallucinators’. The hypotheses
from this chapter focused on how Persistent Hallucinators differed from
the rest of the UHR participants.
Partial support was provided for Hypothesis 4 because the Persistent
Hallucinators reported higher levels conviction at baseline regarding
beliefs about the omnipotence of their voices compared to other follow-up
groups. However, this finding was not observed for beliefs about
malevolence and benevolence toward voices, or for resistance and
engagement with voices. It was observed that the combined BAVQ belief
scales of Omnipotence, Malevolence and Benevolence were highly
significant as a predictive model of likelihood for continuing to report
hallucinations at the final follow up assessment.
Hypotheses 5 and 6 were not supported because significant differences for
metacognition and appraisal of intrusive thoughts at baseline were not
observed between the Persistent Hallucinators and other follow-up groups.
Partial support was provided for Hypothesis 7. Whilst differences between
follow-up groups were not observed from the WAT assessed at baseline, a
174
number of significant differences were observed for ratings of the WAT
assessed at the final follow-up. A significant difference was observed
between the Persistent Hallucinators and other follow-up groups for
ratings of Control measured at follow-up. Additionally, the combined
follow-up ratings of Control, Internality and Wantedness were highly
predictive as a model for participants likely to continue to report
hallucinations at final follow-up assessment. Also, ratings of Control and
Internality measured at follow-up made significant individual contributions
to the model. Significant findings were observed for the influence of word
type from the WAT assessed at final follow-up. The Persistent
Hallucinators differed from other follow-up groups in their responses to
neutral and positive stimuli, however this was not observed for negative
words. The combined model of responses to word type was highly
predictive for participants reporting hallucinations at final follow-up, with
neutral words being the only individual significant predictor within the
model.
175
176
CHAPTER 10
Discussion
This study investigated cognitive processing biases by people reporting
auditory hallucinations who were identified as being at ‘ultra-high risk’
(UHR) for developing psychotic disorders. The study was divided into two
sections. First, measures of source monitoring, metacognition and
appraisal of intrusive thoughts were compared between a UHR group
reporting hallucinations (UHR-HG), a UHR group who had not experienced
hallucinations (UHR-NHG) and a comparison group who were not
experiencing mental health concerns (HCG). Second, three follow-up
assessments were conducted over approximately five months with both
UHR groups in order to examine cognitive processing factors that were
predictive of the continuation of auditory hallucinations. This has been the
first attempt to examine cognitive factors which may contribute to the
persistence of hallucinations in a UHR sample.
This chapter presents the findings from these investigations accompanied
by discussions surrounding their implications. Limitations of the study and
suggestions for future research are also presented.
10.1 Source Monitoring
10.1.1 Baseline Differences Between Groups.
In relation to source monitoring it was first hypothesised that the UHR-HG
would report significantly lower levels of control, internality and
wantedness for self generated words in a word association task (WAT).
Additionally, it was hypothesised that the emotional salience of the WAT
prompt words would influence participants’ ratings, which would be
especially noticeable in the UHR-HG. There was support for the first
hypothesis, since the UHR-HG reported significantly lower subjective
ratings for control and wantedness than both other groups. The UHR-HG
reported significantly lower ratings of internality than the HCG, however
177
there was no significant difference in internality ratings between the UHR
groups. The salience of word type did not appear to influence participants’
ratings within each subscale. Thus, the secondary, salience hypothesis
was not supported.
10.1.2 Source Monitoring: Follow-Up
The second source monitoring hypothesis predicted that UHR participants
continuing to report hallucinations at the final follow-up would endorse
significantly lower levels of control, internality and wantedness on the
WAT compared to other UHR participants. Results from the WAT measured
at baseline and final follow-up were analysed to test this hypothesis.
There were no differences between follow-up groups on baseline WAT
scores. However, there were a number of significant results relating to the
WAT responses assessed at the final follow-up. First, participants who
continued to report hallucinations at final follow-up reported significantly
lower perceived levels of control than the other participants. Additionally,
the combined follow-up ratings of control, internality and wantedness
were able to identify individuals who continued to report hallucinations at
final follow up. Follow-up ratings of control and internality both made
significant individual contributions to the prediction of hallucinations
persisting at final follow-up.
Participants who continued to report hallucinations at final follow-up
scored significantly lower follow-up ratings for neutral stimuli than nonhallucinators, however there were no significant differences between
follow-up groups for positive and negative words rated at follow-up. The
responses to word type in the follow-up WAT was predictive of reporting
hallucinations at final follow-up and neutral words made a significant
individual contribution to the model.
The relationship between persistence of hallucinations and the follow-up
WAT assessments, but not baseline assessments, supports the proposition
that source monitoring capacity operates as a moment-to-moment
178
process interacting with positive psychotic symptoms, rather than a deficit
trait (Brebion et al., 2000; Morrison & Haddock, 1997a). This implies that
source monitoring biases vary in accordance with changes in the severity
of hallucinations. However, as Henquet and colleagues (2005) highlighted,
if source monitoring deficits are present when infrequent or low-level
symptoms are occurring, the interaction between source monitoring and
hallucinations may not be entirely state dependent.
10.1.3 Integration of Control, Internality, Wantedness and
Salience Findings with Previous Research.
This was the first study to examine source monitoring within an
operationally defined UHR population and the first study to utilise the WAT
with a UHR sample. Overall, results from the current study are consistent
with previous studies which have indicated that individuals identified as
'hallucination prone', using instruments such as the LSHS (Launay &
Slade, 1981), demonstrated an externalising source monitoring bias
(Bentall & Slade, 1985; Rankin & O'Carroll, 1995). Additionally, the results
were generally consistent with studies that have used word association
tasks with groups diagnosed with psychotic disorders who experience
hallucinations (Baker & Morrison, 1998; Ensum & Morrison, 2003;
Morrison & Haddock, 1997a). This provides further support for the
hypothesis that externalising biases contribute to the development of
hallucinations, potentially operating in a continuum from vulnerability, to
initiation and maintenance of hallucinatory experiences.
10.1.3.1 Control.
A lower perceived level of control for those reporting hallucinations
compared to other participants was the most consistent WAT difference.
These group differences were observed for the UHR-HG, compared to the
UHR-NHG and HCG at baseline, as well as for the persistent hallucinating
group compared to other follow up groups. Lowered perceived control
amongst the UHR-HG was consistent with findings from previous studies
179
involving hallucinators with established psychotic disorders (Baker &
Morrison, 1998; Ensum & Morrison, 2003). Perceived control of thoughts
has been identified as an integral part of differentiating reality from
imagined events (Aggernaes, Haugstedm Myschetzky,Paikin & Viger,
1976) and therefore an important component of source monitoring
(Garrett & Silva, 2003). The finding that lowered perceived control was
associated with hallucinations is consistent with models implicating deficits
in self monitoring associated with ‘feed forward’ processes (e.g., Cahill &
Frith, 1996; Frith, 1992;Hoffman, 1986; Li et al., 2002). Feed forward
processes involve generation of an expected copy or image in order to
make attributional judgements for cognitive material. In the example of
the WAT, this would be likely to involve generation of an unexpected
response word, which could be indicative of abnormal or dysfunctional
cognitive monitoring. Dysfunctional cognitive monitoring leads to thoughts
not being recognised as internally derived, since source monitoring errors
are more likely to occur when characteristics of the memory are dissimilar
from what would be expected from the source (Cahill & Frith, 1996; Frith,
1992; Hoffman et al., 1995; Hoffman et al., 1999; Johnson et al., 1993).
In the current study, a lack of perceived control implies that selfgenerated responses may be less expected, therefore enhancing the
likelihood of experiencing cognitive material as unexpected which
subsequently increases the likelihood of an external attribution.
10.1.3.2 Internality.
In the current study, the finding that ratings of internality did not differ
between the UHR-HG and UHR-NHG was not consistent with previous
source monitoring studies involving participants with established psychotic
disorders (Baker & Morrison, 1998; Ensum & Morrison, 2003). This result
implies that the lower internality ratings may have been associated with
meeting UHR criteria, rather than specifically related to experiencing
hallucinations.
180
Whilst the observed control and wantedness characteristics may imply
that an externalising bias exists in association with UHR status, they may
also represent other phenomena such as discomfort, uncertainty or
dissonance in response to self generated cognitive material. This reflects a
concern regarding the external validity of the WAT and its feasibility for
assessing cognitive mechanisms specifically associated with hallucinations.
Compared to control and wantedness, internality ratings may be the
closest the WAT comes to assessing whether a thought was attributed to
the self or derived externally (i.e. "How much was the word that came to
mind your own?"). To date the WAT has been considered to be an overall
measure of externalising, without weighting or specificity applied to the
individual scales. However, it may be more appropriate to consider the
combination of perceived control and internality as an index of
externalising.
10.1.3.3 Wantedness.
The UHR-HG reported lower levels of wantedness compared to other
groups. The only other study of hallucinations to incorporate wantedness
within assessment of source monitoring was that of Baker and Morrison
(1998). The result from the current study is consistent with their findings
that hallucinators reported lower levels of wantedness compared to a
psychosis group without hallucinations and a healthy control group. Baker
and Morrison suggested that increased unwanted thoughts amongst
hallucinators was consistent with the model proposed by Morrison and
colleagues (1995), that intrusive thoughts experienced by hallucinators
would be likely to elicit dissonance and be misattributed. Results from the
current study indicate that this process could be applicable to a UHR
group during the early period of hallucinations developing.
10.1.3.4 Salience.
The emotional salience, or word type, did not influence ratings of control,
internality or wantedness for any of the participant groups. This finding
181
was inconsistent with previous studies involving individuals with
established psychotic disorders, which reported that word type had a
significant influence on control and internality ratings (Baker & Morrison,
1998; Ensum & Morrison, 2003; Morrison & Haddock, 1997a).
It is feasible that during the UHR period both hallucinations and source
monitoring biases are in the preliminary or formation stages. In the case
of source monitoring, word type may be yet to influence attribution bias
because associations or meanings have yet to be formed between
intrusive thoughts and schema. This could be especially relevant to
adolescent populations regardless of experience of hallucinations, such as
in the present study, where there may be a high degree of plasticity in
schema as beliefs and values are still forming (Roberts, Walton &
Viechtbauer, 2006; Young, Klosko & Weishaar, 2003).
Participants who continued to report hallucinations at follow-up scored
lower total scores for neutral and positive words compared to other follow
up participants. This was the only instance in this study when word type
influenced source monitoring. A potential explanation for this finding is
that neutral stimuli may lead to higher levels of ambiguity regarding their
source. This may occur as neutral stimulus may be less likely to elicit a
clear sense of meaning or point of reference for the individual, compared
to negative stimuli which would elicit a more definitive appraisal. This
explanation may also be applied to positive word type. Individuals may
have experienced difficulty integrating positive stimuli, particularly if they
were experiencing and accustomed to high amounts of negative
cognitions. However, further research is required with both UHR and
psychotic samples to clarify this process further.
10.2 Metacognition
It was hypothesised that the UHR-HG would demonstrate greater levels of
dysfunctional metacognitions than both the UHR-NHG and the HCG.
Furthermore, it was predicted that a higher degree of dysfunctional
182
metacognitions would be evident for UHR participants continuing to report
hallucinations at the final follow-up assessment.
There were no significant differences between participant groups on the
Positive Beliefs about Worry or Cognitive Self-Consciousness scales. The
only group differences in metacognition were that the HCG scored
significantly lower than both UHR groups on three of the five scales:
Cognitive Confidence, Uncontrollability and need to Negative Beliefs.
Therefore, contrary to the main metacognition hypothesis, there were no
significant differences between the UHR groups on any scales. Thus, there
does not appear to be a relationship between metacognition and the
experience of hallucinations within the UHR cohort. Additionally, there
were no differences in metacognition between UHR participants who
continued to report hallucinations and those who did not, indicating that
metacognitive beliefs do not appear to influence the persistence or
duration of hallucinations.
The results from the present study are inconsistent with previous studies
conducted with non-clinical populations that reported hallucination
proneness was associated with dysfunctional metacognitions (Cangas et
al., 2006; Jones & Fernyhough, 2006; Laroi & Van der Linden, 2005;
Laroi, Van der Linden & Marczewski, 2004; Morrison et al., 2000; 2002a;
Stirling, et al., 2007). This inconsistency suggests that hallucination
proneness may have minimal relationship to being at risk of psychosis, or
the development of hallucinations. Hallucination proneness is measured
and defined in a distinctly different manner to UHR status and should be
clearly distinguished from being at risk of psychosis. Instead, hallucination
proneness may be more indicative of being open to hallucinatory
experiences, as supported by previous research which indicated that the
strongest predictor for hallucination proneness was positive beliefs about
having hallucinatory experiences (Morrison et al., 2000; 2002a).
Previous studies have primarily compared differences in metacognition
between operationally defined UHR groups and other groups, without
183
consideration of specific symptoms such as hallucinations (Barkus et al.,
2010; Morrison et al., 2006; 2007a). Higher levels of dysfunctional
metacognitive processes for the UHR groups, compared to healthy control
groups, were consistently observed for most or all MCQ scales across
these studies. The current study is consistent with earlier findings, since
both UHR groups scored significantly higher than the HCG on beliefs about
cognitive confidence, negative beliefs about uncontrollability and need to
control thoughts.
As previously described, the S-REF theory (Wells & Matthews, 1994) and
Morrison and colleagues’ (1995) heuristic model of hallucinations have
been the most influential paradigms for research examining the
interaction between cognitive beliefs and hallucinations. Therefore, it is
important to consider how these models translate to the current study.
Wells and Matthews (1994; 1996) stated that dysfunctional metacognition
was integral to the development of emotional disorders. Given the
considerable level of psychopathology reported by both UHR groups, and
higher DASS scores than the HCG, the current study provides tentative
support for the Wells and Matthews' (1994; 1996) S-REF model. However,
it is unclear whether metacognition contributed to symptoms of
psychopathology as a mediating factor, or were affected as a consequence
of the symptoms. Further research examining the stability of
metacognitive beliefs over time is warranted in order to examine this
process. Additionally, the cohort recruited for the current study could be
considered to be an adolescent population, which is recognised as a
transitional period of development when beliefs are continuing to form in
accordance with new life experiences (Roberts et al., 2006; Young et al.,
2003). Therefore, it is possible that the recruitment of an adolescent
sample would have affected the stability of assessment of beliefs,
particularly when measuring metacognition.
It may be more appropriate to consider the S-REF model in the context of
maintenance of hallucinations rather than the development of
hallucinations during the period of at risk mental state. It is feasible that
the prolonged experience of hallucinations compromises metacognitive
184
processes over time, rather than initiating hallucinations (Jones &
Fernyhough, 2006). Metacognitive insight may be compromised as hypervigilance toward intrusions increase following an intensifying of psychotic
symptoms such as delusional themes and thought disorder. Hypervigilance toward intrusions would therefore reinforce the primary
components of the S-REF, including self-focused attention, and attentional
bias toward fear and rumination.
The current study supports the theory that a generalised increase in
dysfunctional metacognitions may be associated with the development of
psychiatric symptoms, including UHR status. However, more specific
cognitive biases such as beliefs about the need to control thoughts and
positive beliefs about worry may progressively develop through the course
of a psychotic episode in a self-perpetuating manner, rather than serve to
precipitate hallucinations.
10.3. Intrusive Thoughts
The hypotheses related to intrusive thoughts predicted that the UHR-HG
would report higher levels of distress associated with their appraisals of
intrusive thoughts and lower levels of perceived control toward intrusive
thoughts compared to other groups. Additionally it was predicted that
participants from the UHG-HG who continued to report hallucinations at
final follow up would report higher levels of distress and less control in
their appraisal of intrusive thoughts at the baseline assessment compared
to other participants.
A number of group differences were found from baseline comparisons
which supported the hypotheses. Firstly, both UHR groups scored
significantly higher than the HCG on the Anxiety and Depressive scales of
the DTQ. The UHR-HG scored significantly higher than the UHR-NHG on
the Anxiety scale and there was a non-significant trend reflecting similar
results on the Depressive scale. These findings indicate that the UHR-HG
appeared to be more affected by intrusive thoughts, particularly anxiety
based cognitive material than other participants.
185
Analyses of the qualitative subscales of the DTQ Anxiety and Depressive
scales provided additional details about how the different groups were
affected and responded to intrusive thoughts. The HCG scored
significantly lower across all qualitative factors than both UHR groups.
This indicated that differences in appraisals of intrusive thoughts between
the HCG and the UHR groups were apparent across all qualitative domains
including frequency, emotional responses and cognitive impact (i.e.,
capacity to remove and dismiss the thought). These results were
consistent with the higher levels of anxiety and depressive features in the
UHR groups, indicated by high DASS scores and DSM-IV (APA, 1994)
diagnoses.
The UHR-HG scored significantly higher than both the HCG and UHR-NHG
for difficulty with removal of intrusive thoughts across both the DTQ
Anxiety and Depressive scales. Therefore for participants experiencing
hallucinations, unwanted intrusive thoughts were more likely to remain in
their consciousness. This would likely affect their capacity to shift focus
away from unwanted material and increase rumination on intrusive
material.
This finding is consistent with previous studies that demonstrated
individuals with hallucinations experience clear deficits inhibiting cognitive
intrusions (Beck & Rector, 2003; Waters et al., 2003). The results support
Morrison and colleagues' (1995) heuristic model of the development of
hallucinations, as an increased vulnerability for unwanted intrusions
remaining in consciousness would heighten the risk of experiencing
cognitive dissonance and subsequent externalising of the intrusions.
10.4 Salience
This is the first known study to examine the relationship between beliefs
about voices and persistence of hallucinations. It is also the first study to
examine beliefs about hallucinations within a UHR sample. It was
hypothesised that beliefs about hallucinations held by the UHR-HG would
186
be associated with the continuation of hallucinations over the period of
follow up. The BAVQ-R was used to assess beliefs about voices and
administered at the baseline interview. An additional Likert scale was
included for participants to rate their level of distress associated with
hallucinations.
Participants who continued to experience hallucinations at final follow-up
reported significantly higher ratings for beliefs about the omnipotence of
their voices compared to UHR-HG participants whose hallucinations did
not persist to final follow up. The association between malevolence and
benevolence with persistence of hallucinations at follow up did not reach
statistical significance.
The lack of clear association between duration of hallucinations with
ratings of malevolence and benevolence could be viewed as inconsistent
with previous research. Positive beliefs about hallucinations have been
observed to be predictive of hallucination proneness and tend to be
engaged with by individuals with psychosis, potentially extending the
frequency and duration of hallucinations (Chadwick & Birchwood, 1994;
Miller, O’Connor & DiPasquale, 1993; Morrison et al., 2000, 2002a).
Ratings of both malevolence and subjective distress were not associated
with duration of hallucinations for those who continued to experience
hallucinations at final follow-up. This is consistent with Sorrell and
colleagues' (2010) observation that 'non-clinical voice hearers' were
significantly less distressed than 'clinical voice hearers' about their
experiences. It is interesting to note that in the current study the mean
score for beliefs about omnipotence of voices were very similar to Sorrell’s
clinical voice hearers’ ratings. This suggests that the UHR cohort from the
current study presented with significant clinical concerns surrounding their
hallucinations, despite these symptoms occurring at below psychosis
threshold.
There were no differences in engagement and resistance toward voices
between the follow-up groups, indicating that responses to voices were
187
not directly associated with the duration of hallucinations over the followup period. This is consistent with Birchwood's previous work examining
the interaction between relationships and reactions to voices (Birchwood &
Chadwick, 1997; Birchwood et al., 2000). The authors noted that
responses were dependent on the perceived relationship to the voice,
particularly the perceived level of malevolence or benevolence. Therefore,
resistance would only occur if the voice was perceived as malevolent,
whilst engagement would occur if there was a clear perception of
benevolence.
In the current study logistic regression analysis indicated that when
combined, the three belief scales of omnipotence, malevolence and
benevolence were highly predictive for estimating the likelihood of
hallucinations continuing over the follow-up period. However, none of the
BAVQ-R scales were significant in their own right in predicting persistence
of hallucinations over the follow-up period. Overall, these findings support
the hypothesis that beliefs about hallucinations influenced the
maintenance of hallucinations over the study period. It could be
speculated that the perceived power of the voices acted as a mediating
factor to extend the episode of hallucinations from a fleeting phenomenon
to a more prolonged experience. However, further research is required to
clarify the mediating effects of beliefs and duration of hallucinations.
10.5 Beliefs
The hypothesis that persistence of hallucinations would be associated with
beliefs and responses was based on previous research which has
demonstrated a relationship between appraisals and reactions to voices
(Birchwood & Chadwick 1997; Birchwood, et al, 2004; Chadwick &
Birchwood, 1994; Vaughan & Fowler, 2004). This research indicated that
cognitive reactions toward hallucinations, mediated by beliefs about the
voices, serve to reinforce maladaptive coping and prolong hallucinations.
Previous studies were conducted with participants who were diagnosed
with a psychotic disorder and had been experiencing hallucinations over a
considerably longer period of time than participants from the current
188
study. However, the findings from the current study indicate that for a
UHR population, neither distress nor reactions toward hallucinations
influenced the duration of hallucinations. It would appear that emotional
and behavioural reactions may be more likely to develop after the UHR
period, when hallucinations become more prominent following
development of a psychotic disorder. This is a novel and important finding
that indicates that appraisals and reactions toward hallucinations may be
quite different within UHR populations compared to individuals with
established psychotic disorders.
It is possible that during the UHR period psychotic symptoms such as
hallucinations are in their developmental or formation stage. During this
period, insight and awareness regarding the origin of symptoms is likely to
be partially impaired, yet remain considerably more intact than those who
experience a full-threshold psychotic episode (Lappin et al., 2007).
Hallucinations may be appraised as powerful due to perceived lower levels
of control compared to normal cognitions (Morrison, 1998). However, due
to a reasonable degree of insight surrounding awareness of the origin of
experience during the UHR period, the intrusions have yet to be
integrated with beliefs. Therefore, the hallucinations may not be perceived
as threatening to the individual's well being and consequently not
perceived as significantly distressing.
A correlation between distress and omnipotence was not observed,
indicating that these factors may operate independently during the early
stages of hallucinations. Distress about hallucinations is likely to be
influenced by a range of factors beyond omnipotence, such as personal
relevance and relationship to the voice (Sorrell et al., 2010). Given the
hallucinations are in their developmental or formative stages, specific
beliefs about their origin, intent or relevance may yet to be consolidated.
Therefore, the individual can observe them as unusual experiences
without appraising them as containing meaning relevant to their values or
beliefs.
189
Birtchnell (2002) developed Relating Theory to describe that the process
of relating to individuals incorporates multiple dimensions involving power
and proximity. Relating theory has been applied to understanding the
relationships individuals have toward their voices (Sorrell et al., 2010;
Vaughan & Fowler, 2004). In the current study many participants
perceived hallucinations as powerful, however, the influence or impact on
the individual appeared limited. Within UHR populations there is likely to
be less 'proximity' to the hallucination compared to populations with
psychosis, since insight would remain intact and frequency of the
experience would be remaining relatively low (compared to full threshold
psychosis). Consequently, the hallucinations are not experienced as
personally threatening or salient, so resistance or engagement is not yet
employed. This process is consistent with the theory that relationships
develop as proximity with the voice builds, subsequently influencing
beliefs about malevolence or benevolence, as well as emotional and
behavioural responses to the hallucination (Birchwood & Chadwick, 1997;
Vaughan & Fowler, 2004).
Whilst hallucinations may evoke distress during the at risk mental state
period, the shift to these experiences taking on a personally salient
connection could indicate the progression from UHR to psychosis. An
increase in beliefs about the negative power of voices, including their
potential for threat, has been proposed to mark the transition from a nonclinical, transient experience to a psychotic phenomenon (Morrison et al.,
2000; 2002a). The shift to perceiving hallucinations as personally salient
to one's beliefs is dependent on the level of insight as to whether the
experience is derived internally or externally (Garety et al., 2001;
Morrison et al., 1995). In light of this, it is likely that personal beliefs may
have minimal influence in the development of hallucinations during the at
risk mental state period. Instead, beliefs or schema are more influential
when insight surrounding the hallucinations becomes increasingly
compromised as transition to psychosis progresses. However, this
summation of the influence of beliefs on the persistence of hallucinations
is largely speculative, drawing upon theory and research from a range of
190
perspectives. In order to examine further, prospective studies from UHR
cohorts is required.
In summary, the comparison of cognitive measures between the
participant groups indicated that the UHR-HG demonstrated distinct biases
involving source monitoring and appraisal of intrusive thoughts.
Additionally, UHR participants displayed distinct biases across all variables
compared to the HCG. There were no intelligence differences between
groups, as measured by the NART, therefore cognitive biases could not be
attributed to IQ. Furthermore, there were no differences between UHR
groups from DASS scores or rates of psychiatric diagnoses, indicating that
distress was not the primary factor influencing cognitive biases.
10.6 A Potential Framework for Hallucinations Within UHR
Populations
A speculative model of the interaction between source monitoring biases,
appraisal of intrusive thoughts and beliefs about hallucinations within a
UHR cohort is illustrated in Figure 10.1. The primary components of this
model incorporate findings from the current study relating to source
monitoring, appraisal of intrusive thoughts and beliefs about power toward
hallucinations.
Commencing from the top of the figure, the UHR participants presented
with heightened levels of distress, characterised by high DASS scores, as
well as high rates of depressive and anxiety disorders. This high level of
psychopathology may have led to substantial rates of distressing intrusive
thoughts for all UHR participants. However, the response toward the
intrusive thoughts differed for the UHR-HG compared to all other
participants, potentially because the intrusions were considerably more
difficult to remove from consciousness for these participants. This may
have been associated with lowered perceived control toward intrusive
material. Increased difficulties with removal of intrusive thoughts would
likely lead to an increase in distressing intrusions remaining in awareness,
which in turn heightens the opportunity for rumination and compromises
191
the capacity to develop alternative appraisals. Such a cognitive pattern
would be consistent with the dysfunctional cognitive attentional pattern
outlined in the S-REF model (Morrison, 2001; Wells & Matthews, 1994).
At this point the source monitoring biases interplay with distressing
intrusions. Lowered perceived cognitive control is reinforced by difficulties
removing or shifting intrusions, which enhances the dissatisfaction (i.e.,
wantedness) toward the intrusive cognition. Consistent with Morrison's
and colleagues' (1995) heuristic model, the interaction between lowered
perceived control and response to unwanted intrusions elicits discomfort
and cognitive dissonance. The combination of difficulty removing
intrusions, low cognitive control and dislike of intrusions interacts in a
multidirectional manner contributing to the overall experience of
discomfort and cognitive dissonance.
Incorporating theories from previous cognitive models (Bentall, 1990;
Morrison, 2001; Morrison et al., 1995), hallucinations occur as intrusions
are misattributed to an external source in order to reduce dissonance and
relieve immediate distress. The misattribution is likely to reinforce the
belief that unwanted intrusions are intolerable and need to be avoided in
order to protect the individual from excessive discomfort (Bentall, 1990;
Morrison et al., 1995). Within this framework misattribution can be
considered to be an avoidant, safety seeking action which serves to
maintain hallucinations as further unwanted intrusions will continue to be
interpreted as intolerable, beyond control and powerful (Morrison, 2001).
192
Depression/ Anxiety
Reinforces
Increased intrusive
negative
distressing thoughts
beliefs
UHR-NHG
Appropriate
perceived control
UHR-HG
Low perceived control
of thoughts
Unable to remove intrusions,
Avoidance
enhance rumination
reinforces power
of voices
Dislike of
Lowered
intrusions
control
Discomfort &
Discomfort &
dissonance
Dissonance
reduced
Misattribute as
Omnipotence
Hallucination
Figure 10.1. Tentative Model of Hallucination Process in UHR Cohorts
193
In the current study beliefs about the omnipotence of voices were
associated with the maintenance of hallucinations over the follow-up
period. In this model perceived omnipotence of voices may interact in
several ways to maintain the misattribution process. Heightened beliefs
about the power of voices would enhance a state of distress and
discomfort, as well as reinforcing a perceived lack of control surrounding
intrusive experiences. Therefore, omnipotence about voices would interact
with the appraisal of intrusive experiences and feed back into the
misattribution cycle.
However, it remains unclear as to why beliefs about omnipotence were
heightened for some individuals experiencing hallucinations and why
omnipotence was associated with the persistence of hallucinations.
Emotional responses toward hallucinations (Chadwick & Birchwood, 1995),
schematic beliefs associated self image and social rank (Bentall et al.,
2007; Birchwood et al., 2000; 2004) have been proposed as factors which
influence beliefs toward voices. Alternatively, cognitive biases such as
lowered perceived control of thoughts or appraisal discrepancies toward
intrusive thoughts may enhance the perceived omnipotence of voices. It is
likely that omnipotence would promote focus toward further
hallucinations, which in turn may reinforce lowered perceived control of
thoughts and difficulty shifting focus from intrusions. This is a significant
gap within the model which clearly requires further theoretical and
empirical research focus.
10.7 Clinical Implications
10.7.1 Assessment
Current assessment of attenuated psychotic symptoms for UHR criteria
involves measurement of duration, frequency and intensity of psychoticlike experiences. The results from the present study indicate that
assessment could additionally review beliefs associated with the power
and influence of hallucinations. This may aid in identifying individuals who
are at highest risk of experiencing prolonged perceptual disturbance.
194
Appraisal of intrusive thoughts could also be included within the
assessment and formulation to gauge how intrusive cognitions affect the
individual and influence hallucinations. Instruments such as the BAVQ-R
and the DTQ would be relatively simple to administer and incorporated
within an extended assessment battery for UHR individuals reporting
hallucinations.
Formulation based treatments that are tailored to individual client needs
and reflect an understanding of the development and appraisal of
symptoms have been recommended for UHR populations (Francey &
Jackson, 2006; Morrison et al., 2004; Phillips, Francey, Leicester, Bechdolf
& Morrison, 2008). A UHR assessment which includes a review of
symptom frequency and severity, as well as capturing the beliefs
surrounding psychotic-like experiences would aid in the development of
individualised treatment plans.
10.7.2 Treatment
Within UHR populations interventions may be most effective targeting the
distress and disability associated with psychotic experiences, rather than
focusing on reducing the occurrence of psychotic symptoms (Morrison,
1998; Morrison et al., 2006). The current study has demonstrated that
appraisal of intrusions and beliefs about hallucinations are important
clinical factors to target in treatment. Therefore, established psychological
treatments such as traditional CBT techniques that assist promotion of
insight, challenging beliefs and enhancing control of responses toward
intrusions are appropriate to apply in this context (Bowe, French &
Morrison, 2006; Morrison, 2005; Phillips & Francey, 2004). By enhancing
monitoring and insight, CBT treatments could assist clients to recognise
that hallucinations are internally derived, subsequently reducing external
attributions and loss of perceived control.
In addition to conventional CBT approaches which focus on increasing
insight, a diversity of evidence based approaches is required to assist
individuals to alter their appraisals to psychotic experiences (Thomas et
195
al., 2011). Cognitive approaches including mindfulness and acceptance
based cognitive therapy may provide an additional suite of techniques to
compliment established CBT treatments. These approaches endeavour to
alter the beliefs and appraisals toward psychotic experiences by defusing
rather than challenging beliefs. In recent years considerable interest has
developed surrounding the role of psychological interventions such as
mindfulness and acceptance therapy for psychosis (Gaudiano, Herbert &
Hayes, 2010; Tai & Turkington, 2009). Such treatments may be ideally
suited in treating difficulties associated with responses toward intrusive
thoughts (Wilkinson-Tough, Bocci, Thorne & Herlihy, 2010). Furthermore,
mindfulness and acceptance approaches have been shown to assist
individuals to reduce conviction toward hallucinations, disengage from
hallucinations, reduce symptom frequency and increase capacity to cope
with hallucinations (Bach & Hayes, 2002; Gaudiano et al., 2010; Hutton,
Morrison & Taylor, 2012; Shawyer et al., 2007; Taylor, Harper &
Chadwick, 2009). Whilst no known studies have actively incorporated
mindfulness or acceptance approaches with UHR groups, these treatments
may offer an ideal opportunity to address beliefs pertaining to the power
and control of hallucinations. The results from the current study suggest
that treatments which decrease the perceived omnipotence of
hallucinations are likely to aid in the reduction or cessation of symptoms.
Treatment approaches which suppress awareness, such as avoidance
based distraction techniques to reduce immediate distress may not be
appropriate because they could potentially prolong hallucinations
(Morrison & Haddock, 1997a). Suppression based approaches have been
demonstrated to promote further intrusions (Lavy & van den Hout, 1990).
Additionally, avoidance approaches such as distraction have been
associated with poorer outcomes for people experiencing hallucinations
(Romme & Escher, 1993). Therefore, exploring and understanding
hallucinations within a formulation driven, therapeutic context would offer
a greater opportunity to re-appraise hallucinations and intrusions, as well
as diffusing their omnipotence.
196
10.8 Future Research
The current study focused on examining the influence of several cognitive
variables on hallucinations within a UHR sample. Future research in this
field could expand to include participants in different stages of illness in
order to examine how cognitive biases interact with hallucinations
throughout the course of illness. Studies which involve groups consisting
of UHR, early psychosis and patients experiencing longer term psychotic
illnesses could investigate whether cognitive biases and beliefs about
hallucinations develop and change over time. Additionally, analyses of
cohorts across the spectrum of psychotic illness would allow for further
modelling of the temporal relationship between cognitive biases, beliefs
and hallucinations. Such studies would provide insight in to whether
cognitive biases perform a role in the development and progression of
hallucinations, or develop as a response to the psychotic experience.
Beliefs regarding the perceived power of voices appeared to influence the
persistence of hallucinations amongst participants in the current study.
However, it was not clear how beliefs influenced hallucination duration, or
what factors elicited and reinforced such beliefs. Further research may
include a wider range of variables which potentially interact with beliefs,
such as measurements of schema, self esteem and perceived social rank.
This may provide insights into how beliefs toward hallucinations develop
and persist through the UHR period, as well as how treatments such as
cognitive therapies can be tailored specifically toward hallucinations.
Previous intervention trials with UHR populations were conducted without
discrimination toward symptom presentation. Given the results of the
present study it may now be appropriate to consider the development of
treatments more explicitly targeting hallucinations within UHR groups.
Examining the effectiveness of psychological interventions targeting
beliefs about hallucinations, particularly appraisal of power, is an
important and feasible option. Addressing beliefs about psychotic
symptoms has been used in previous UHR trials (McGorry, et. al, 2002;
Morrison, et.al, 2004b), however further studies could extend this
197
principle for tailored treatments according to specific symptom clusters
such as hallucinations.
Whilst the current study included repeated assessments, this follow up
period was limited. Longer term follow up studies of UHR populations over
more than four years have revealed associations between cognitive
functioning and prognosis to transition to psychotic disorders (Lin et al.,
2011). Similar follow up studies over extended periods would enable
analyses of the predictive influence that cognitive biases such as
metacognition, source monitoring and appraisal of intrusions have on
transition to psychosis and prognosis of hallucinations.
Research involving experimental designs which manipulate affect and
attention may provide further insights into the responses and appraisal
characteristics for UHR populations experiencing hallucinations. This would
allow for further extrapolation of the influence of emotional variance on
appraisals toward intrusions and hallucinations. Additionally, a greater
understanding could be gained regarding the interaction between stress
and reality discrimination during the UHR period.
10.9 Limitations and Strengths of the Current Study
The sample size restricted the analyses that could be performed. In
particular, statistical techniques such as structural equation modelling
could not be conducted. Such analysis would have facilitated examination
of the directional relationship between variables. Despite the limitations of
the sample size, it is important to note that the UHR sample recruited for
this study is larger than previous studies examining cognitive biases with
UHR groups.
Exposure to mental health treatment provided by OYH was a potential
confounding factor for both UHR groups. Treatment exposure may have
affected the insight and appraisal toward hallucinations, as well as the
potential frequency of attenuated psychotic symptoms. The average time
between initial clinical assessment at OYH and baseline assessment
198
specifically for this study was approximately 10.5 weeks. During this
period the UHR participants had exposure to psychological treatments
targeted toward reducing distress and coping with psychotic symptoms;
psycho-education regarding UHR status and co-occurring disorders; as
well as psychiatric medication such as antidepressants where indicated.
Additionally, all clients of Orygen Youth Health have access to 24-hour
crisis support and family support services. Withholding clinical
interventions for UHR individuals attending PACE is not a viable option on
ethical grounds, considering the significant distress and co-occurring
psychiatric conditions experienced by this population (McGorry, Yung &
Phillips, 2001; Yung et al., 2004). However, the range of treatments prior
to baseline assessment for the study and across the follow-up period may
have impacted on the primary cognitive variables, as well as improving
levels of psychopathology and decrease in distress. For instance, beliefs
about voices, distress associated with hallucinations and responses toward
distressing intrusive thoughts may all have been affected by cognitive
therapy and general clinical support provided from clinicians at the PACE
Clinic. A shorter period between initial clinical assessment and baseline
assessment for the study would have minimised the confounding impact
of treatments received by the UHR participants.
Finally, the current study utilised measures which primarily involved
subjective ratings from participants on questionnaires and scales. Further
research could be strengthened by including experimental measures which
can be objectively measured by the investigator, allowing for greater
reliability of ratings across assessments. Objectively rated experimental
measures could include delayed source monitoring and sensory
recognition tasks, as well as inhibitory tasks such as the Hayling Sentence
Completion Test (HSCT: Burgess & Shallice, 1996) and the Inhibition of
Currently Irrelevant Memories Task (ICIM: Schnider & Ptak, 1999) to
assess the capacity to suppress intrusive material.
199
10.10 Conclusion
An Ultra-High Risk (UHR) group for psychosis who reported auditory
hallucinations demonstrated distinct cognitive processing biases,
compared to a UHR group without hallucinations and a group with no
mental health concerns. These differences were characterised by deficits
in source monitoring of self generated thoughts and difficulties with
shifting focus away from unwanted intrusive thoughts. These results
support previous research conducted with individuals assessed with
established psychotic disorders. Additionally, beliefs about the
omnipotence of hallucinations were associated with the continuation of
hallucinations.
This is the first study to demonstrate that distinct cognitive biases are
associated with the development of hallucinations during the UHR period.
These results provide evidence that distinct and measurable cognitive
biases may contribute to the emergence of hallucinations, prior to the
onset of frank psychosis.
200
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234
APPENDICES
235
Appendix A: University of Melbourne Ethics Approval
236
Appendix B: Melbourne Health Ethics Approval
237
Appendix C: CAARMS Subscales Used to Determine UHR
Status
238
239
240
241
Appendix D: Advertisement for HCG Participants
Participants wanted for research
about styles of thinking.
Are you aged between 15 – 25?
Have no previous history of mental illness?
An interview will involve questionnaires about thinking
styles, emotions and coping.
Assessments take approximately 60 mins.
You will be reimbursed $20 for your time.
Please call Steven on 0413 022 776 if you are interested
in participating.
This project is being conducted as part of a PhD at the School of Behavioural Sciences, University of Melbourne. It
has ethics approval from the Royal Melbourne Hospital, North West Mental Health, Human Research and Ethics
Committee and the University of Melbourne Human Research and Ethics Committee.
242
Appendix E: NART
243
244
Appendix F: DASS
DASS
Initials:
Age:
Date:
Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the
statement applied to you over the past week. There are no right or wrong answers. Do not
spend too much time on any statement.
The rating scale is as follows:
0
1
2
3
Did not apply to me at all
Applied to me to some degree, or some of the time
Applied to me to a considerable degree, or a good part of time
Applied to me very much, or most of the time
1
I found myself getting upset by quite trivial things
0
1
2
3
2
I was aware of dryness of my mouth
0
1
2
3
3
I couldn't seem to experience any positive feeling at all
0
1
2
3
4
I experienced breathing difficulty (eg, excessively rapid breathing,
breathlessness in the absence of physical exertion)
0
1
2
3
5
I just couldn't seem to get going
0
1
2
3
6
I tended to over-react to situations
0
1
2
3
7
I had a feeling of shakiness (eg, legs going to give way)
0
1
2
3
8
I found it difficult to relax
0
1
2
3
9
I found myself in situations that made me so anxious I was most
relieved when they ended
0
1
2
3
10
I felt that I had nothing to look forward to
0
1
2
3
11
I found myself getting upset rather easily
0
1
2
3
12
I felt that I was using a lot of nervous energy
0
1
2
3
13
I felt sad and depressed
0
1
2
3
14
I found myself getting impatient when I was delayed in any way
(eg, lifts, traffic lights, being kept waiting)
0
1
2
3
15
I had a feeling of faintness
0
1
2
3
16
I felt that I had lost interest in just about everything
0
1
2
3
17
I felt I wasn't worth much as a person
0
1
2
3
18
I felt that I was rather touchy
0
1
2
3
19
I perspired noticeably (eg, hands sweaty) in the absence of high
temperatures or physical exertion
0
1
2
3
20
I felt scared without any good reason
0
1
2
3
21
I felt that life wasn't worthwhile
0
1
2
3
245
DASS
Scoring Template
Initials………….
Age…………….
Date……………
S
A
D
A
D
S
A
S
A
D
S
S
D
S
A
D
D
S
A
A
D
246
Appendix G: WAT
Date:
Initials:
Participant Group: Hallucinating ___
Participant No:
PACE Control ____
Control ____
Word Association Task
To be read by the assessor
I am going to read to you a list of 15 words. After each word I would like you to say
the first word that comes to your mind, you can say whatever word you want. If you’re
not familiar with any of the words, just say so & I’ll give a quick explanation. After
each of your responses I will be asking you a series of 3 questions, which include:
How much control did you have over the word that came to mind?
How much was the word that came to mind your own?
How much did you want to think of that word rather than another word?
I will ask you to rate your answers on a 0-100 scale. Here’s the scale (show
participant), see how ‘0’ means “not at all” and ‘100’ means “could not be more so”.
This task is a little unusual, so we’ll have a bit of a practise run before we get to the
real thing.
Practise Run
Proceed through the following 2 examples, display the 0-100 scale after each
question and check after the first example that the procedure is clearly understood:
“Hat”
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
“Drawing”
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
Please turn over to commence the task.
247
1.
Capable
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
2.
Weak
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
Pale
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
248
4.
Hydraulic
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
5.
Domestic
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
6.
Calm
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
249
7.
Obnoxious
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
8.
Realistic
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
9.
Ripe
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
250
10.
Positive
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
11.
Childish
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
12.
Resident
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
251
13.
Foolish
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
14.
Lazy
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
15.
Wise
Response Word
_____________________________________
How much control did you have over the word that came to mind?
Internality Score
_______
How much was the word that came to mind your own?
Control Score
_______
How much did you want to think of that word rather than another word?
Wantedness Score _______
252
Scoring Template WAT
Date:
Initials:
Participant Group: Hallucinating ___
Participant No:
PACE Control ____
Control ____
Positive
No. Word
1
6
8
10
15
Control
Internality
Wantedness
Control
Internality
Wantedness
Control
Internality
Wantedness
Capable
Calm
Realistic
Positive
Wise
Totals
Negative
No. Word
2
7
11
13
14
Weak
Obnoxious
Childish
Foolish
Lazy
Totals
Neutral
No. Word
3
4
5
9
12
Pale
Hydraulic
Domestic
Ripe
Resident
Totals
253
Appendix H: MCQ-30
Metacognitive Questionnaire (MCQ 30)
It would help us to understand more about how you think about your own thoughts.
Please read each statement and tick the box that is most accurate for you.
Thank you for your help.
Date:…………….
Initials: …………. (for coding only)
Age: ………….
Do Not
Agree
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Agree
Slightly
Agree
Moderately
Agree
Very
Much
I do not trust my memory
I have a poor memory
I have little confidence in my
memory for actions
I have little confidence in my
memory for places
I have little confidence in my
memory for words and names
My memory can mislead me at times
Worrying helps me to get things
sorted out in my mind
Worrying helps me cope
I need to worry in order to work well
Worrying helps me solve problems
I need to worry in order to remain
organised
Worrying helps me to avoid
problems in the future
I am constantly aware of my
thinking
I pay close attention to the way my
mind works
I think a lot about my thoughts
I constantly examine my thoughts
I monitor my thoughts
I am aware of the way my mind
works when I am thinking through a
problem
My worrying thoughts persist, no
matter how I try to stop them
When I start worrying I cannot stop
I could make myself sick with
worrying
254
Do Not
Agree
22
23
24
25
26
27
28
29
30
Agree
Slightly
Agree
Moderately
Agree
Very
Much
I cannot ignore my worrying
thoughts
My worrying could make me go mad
My worrying is dangerous for me
If I could not control my thoughts, I
would not be able to function
Not being able to control my
thoughts is a sign of weakness
I should be in control of my thoughts
all of the time
It is bad to think certain thoughts
If I did not control a worrying
thought and then it happened, it
would be my fault
I will be punished for not controlling
certain thoughts
255
Metacognitive Questionnaire (MCQ 30)
Scoring Sheet
Initials………………..
Age……………………
Date………
1
2
3
4
5
6
I do not trust my memory
I have a poor memory
I have little confidence in
my memory for actions
I have little confidence in
my memory for places
I have little confidence in
my memory for words and
names
My memory can mislead
me at times
Do Not
Agree
Agree
Slightly
1
1
1
2
2
2
1
2
3
4
1
2
3
4
1
2
3
4
Cognitive Confidence
7
Worrying helps me to get
things sorted out in my
mind
8 Worrying helps me cope
9 I need to worry in order to
work well
10 Worrying helps me solve
problems
11 I need to worry in order to
remain organised
12 Worrying helps me to
avoid problems in the
future
Total =
1
2
3
4
1
1
2
2
3
3
4
4
1
2
3
4
1
2
3
4
1
2
3
4
Positive Beliefs about Worry
13 I am constantly aware of
my thinking
14 I pay close attention to the
way my mind works
15 I think a lot about my
thoughts
16 I constantly examine my
thoughts
17 I monitor my thoughts
Agree
Agree
Moderately Very
Much
3
4
3
4
3
4
Total =
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
256
18 I am aware of the way my
mind works when I am
thinking through a
problem
Do Not
Agree
Agree
Slightly
1
2
Cognitive Self-Consciousness
19 My worrying thoughts
persist, no matter how I
try to stop them
20 When I start worrying I
cannot stop
21 I could make myself sick
with worrying
22 I cannot ignore my
worrying thoughts
23 My worrying could make
me go mad
24 My worrying is dangerous
for me
Total =
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
Uncontrollability and Danger
25 If I could not control my
thoughts, I would not be
able to function
26 Not being able to control
my thoughts is a sign of
weakness
27 I should be in control of
my thoughts all of the time
28 It is bad to think certain
thoughts
29 If I did not control a
worrying thought and then
it happened, it would be
my fault
30 I will be punished for not
controlling certain
thoughts
Agree
Agree
Moderately Very
Much
3
4
Total =
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
Need to Control Thoughts
Total =
257
Appendix I: DTQ
Distressing Thoughts Questionnaire (DTQ)
Initials:………………………………. (For coding only)
Age:…………………….
Date:……………………
Over the following pages there are 12 statements about distressing thoughts. After each
statement there are 5 questions. Please read each statement then reply to each question by
circling the number which applies to you the most.
If you have any questions, please ask.
Thankyou for your involvement.
258
1. Thoughts or images that something is, or may in the future, be wrong with my health.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
259
2. Thoughts or images of a personally embarrassing, humiliating or painful experience.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
260
3. Thoughts or images of personally unacceptable sexual acts.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
261
4. Thoughts or images of saying rude and/or unacceptable things to someone.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
262
5. Thoughts or images of the death of a close friend or family member.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
263
6. Thoughts or images that a friend or a family member is going to have an accident, or be harmed in some way.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
264
7. Thoughts or images that my future is bleak.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
265
8. Thoughts or images that I am a failure.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
266
9. Thoughts or images asking what is the matter with me.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
267
10. Thoughts or images of why my life is not going the way I want it to.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
268
11. Thoughts or images of why can’t I ever succeed.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
269
12. Thoughts or images of wishing I were a better person.
Never
How often does this thought or image enter your mind?
1
Less than
monthly
2
3
At least
twice
monthly
4
Not at all
5
Weekly
6
7
Daily
8
Moderately
9
Extremely
How sad or unhappy does this thought or image make you feel?
1
2
3
4
5
6
7
8
9
How worried does this thought make you feel?
1
2
3
4
5
6
7
8
9
How difficult is it for you to remove this thought or image from your
mind?
1
2
3
4
5
6
7
8
9
How much do you disapprove of having this thought or image enter your
mind?
1
2
3
4
5
6
7
8
9
270
Appendix J: BAVQ-R
Beliefs About Voices Questionnaire (BAVQ – R)
There are many people who hear voices. It would help us to find out how you are
feeling about your voices by completing this questionnaire. Please read each
statement and tick the box that best describes the way you have been feeling in the
past month.
If you hear more than one voice then please complete the form for the voice that is
dominant. Thank you for your help.
Initials: ……………… (for coding only)
Age: ……………
Date: ……………
Disagree Unsure
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Slightly
Agree
Strongly
Agree
My voice is punishing me for
something that I have done
My voice wants to help me
My voice is very powerful
My voice is persecuting me for no
good reason
My voice wants to protect me
My voice seems to know
everything about me
My voice is evil
My voice is helping me to keep
sane
My voice makes me do things that
I really don’t want to do
My voice wants to harm me
My voice is helping me to develop
my special powers or abilities
I cannot control my voices
My voice wants me to do bad
things
My voice is helping me to achieve
my goal in life
My voice will harm or kill me if I
disobey or resist it
My voice is trying to corrupt or
destroy me
I am grateful for my voice
271
Disagree Unsure
Slightly
Agree
Strongly
Agree
Disagree Unsure
Slightly
Agree
Strongly
Agree
18 My voice rules my life
19
20
21
22
23
24
25
26
My voice reassures me
My voice frightens me
My voice makes me happy
My voice makes me feel down
My voice makes me feel angry
My voice makes me feel calm
My voice makes me feel anxious
My voice makes me feel confident
When I hear my voice, usually …
27
28
29
30
31
32
33
I tell it to leave me alone
I try and take my mind off it
I try and stop it
I do things to prevent it talking
I am reluctant to obey it
I listen to it because I want to
I willingly follow what my voice
tells me to do
34 I have done things to start to get in
contact with my voice
35 I seek the advice of my voice
272
Beliefs About Voices Questionnaire (BAVQ – R)
Scoring Sheet
Initials…………..
Age……………...
Date…………….
KEY
M Malevolence B
E Engagement R
1
2
3
4
5
6
7
8
9
10
11
12
13
14
BELIEFS ABOUT
VOICES
My voice is punishing
me for something that I
have done
My voice wants to help
me
My voice is very
powerful
My voice is persecuting
me for no good reason
My voice wants to
protect me
My voice seems to
know everything about
me
My voice is evil
My voice is helping me
to keep sane
My voice makes me do
things that I really
don’t want to do
My voice wants to
harm me
My voice is helping me
to develop my special
powers or abilities
I cannot control my
voices
My voice wants me to
do bad things
My voice is helping me
to achieve my goal in
life
Benevolence O
Resistance
Disagree
Unsure
0
Omnipotence
1
Slightly
Agree
2
Strongly
Agree
3
M
0
1
2
3
B
0
1
2
3
O
0
1
2
3
M
0
1
2
3
B
0
1
2
3
O
0
0
1
1
2
2
3
3
M
B
0
1
2
3
O
0
1
2
3
M
0
1
2
3
B
0
1
2
3
O
0
1
2
3
M
0
1
2
3
B
273
15
16
17
18
BELIEFS ABOUT
VOICES
My voice will harm or
kill me if I disobey or
resist it
My voice is trying to
corrupt or destroy me
I am grateful for my
voice
My voice rules my life
EMOTIONAL
Disagree
Unsure
1
Slightly
Agree
2
Strongly
Agree
3
0
O
0
1
2
3
M
0
1
2
3
B
0
1
2
3
O
Disagree
Unsure
Slightly
Agree
Strongly
Agree
0
0
0
1
1
1
2
2
2
3
3
3
E
R
E
0
1
2
3
R
0
1
2
3
R
0
1
2
3
E
0
1
2
3
R
0
1
2
3
E
Disagree
Unsure
0
1
Slightly
Agree
2
Strongly
Agree
3
R
0
1
2
3
R
0
0
1
1
2
2
3
3
R
R
0
1
2
3
R
0
1
2
3
E
REACTIONS
19 My voice reassures me
20 My voice frightens me
21 My voice makes me
happy
22 My voice makes me feel
down
23 My voice makes me feel
angry
24 My voice makes me feel
calm
25 My voice makes me feel
anxious
26 My voice makes me feel
confident
When I hear my voice, usually …
27
28
29
30
31
32
BEHAVIOURAL
REACTIONS
I tell it to leave me
alone
I try and take my mind
off it
I try and stop it
I do things to prevent it
talking
I am reluctant to obey
it
I listen to it because I
want to
274
BEHAVIOURAL
REACTIONS
33 I willingly follow what
my voice tells me to do
34 I have done things to
start to get in contact
with my voice
35 I seek the advice of my
voice
Malevolence total
Benevolence total
Omnipotence total
Resistance total
of which emotional of which behavioural Engagement total
of which emotional of which behavioural -
Disagree
Unsure
1
Slightly
Agree
2
Strongly
Agree
3
0
E
0
1
2
3
E
0
1
2
3
E
___
___
___
___
___
___
___
___
___
0 – 18)
0 – 18)
0 – 18)
0 – 27)
(range 0 – 12)
(range 0 – 15)
( range
0 – 24)
(range 0 – 12)
(range 0 – 12)
(range
(range
(range
(range
275
Appendix K: Plain Language Statement and Consent Form
Participant Information and Consent Form
Version 5 Dated 28/02/06
Site: PACE Clinic, ORYGEN Youth Health
Cognitive Processing Factors Associated with Hallucinations in Young
People.
Principal Researcher:
Associate Professor John Gleeson
Associate Researcher(s):
Steven Leicester
This Participant Information and Consent Form is 7 pages long. Please make sure
you have all the pages.
1.
Your Consent
You are invited to take part in this research project.
This Participant Information contains detailed information about the research
project. Its purpose is to explain to you as openly and clearly as possible all the
procedures involved in this project before you decide whether or not to take part
in it.
Please read this Participant Information carefully. Feel free to ask questions about
any information in the document. You may also wish to discuss the project with a
relative or friend or your local health worker. Feel free to do this.
Once you understand what the project is about and if you agree to take part in it,
you will be asked to sign the Consent Form. By signing the Consent Form, you
indicate that you understand the information and that you give your consent to
participate in the research project. You will be given a copy of the Participant
Information and Consent Form to keep as a record and the original will be
retained by the researcher.
2.
Purpose and Background
At the PACE Clinic we are trying to determine the best ways to assist young
people who may be experiencing a range of difficulties. The purpose of this
project is to study different patterns in the way people process their thoughts, so
that we can gain a better understanding about why some people experience
hallucinations and others do not. The results from this study may offer further
insight into how hallucinations develop and ways which may help to reduce their
occurrence.
276
Previous research has shown that there are certain patterns in thought processing
which occurs for people who have experienced hallucinations over many years.
We would like to explore these ideas with people who have only experienced
hallucinations over a short period of time.
This project is being conducted by Steven Leicester and will form the basis of a
PhD being carried out through the School of Behavioural Sciences at the
University of Melbourne. The project is being supervised by Ass. Prof. John
Gleeson.
This research project will involve 159 young people.
You are invited to participate in this research project because you have been
referred to and attended the PACE Clinic, or, you are of a similar age to young
people attending the PACE Clinic.
3.
Procedures
The project will include people attending PACE who have experienced
hallucinations, people from PACE who have not experienced hallucinations, as
well as people of a similar age do not attend PACE and who have not experienced
hallucinations.
Participation in this project will involve:
1. A brief reading task which will take up to 15 minutes;
2. A questionnaire about emotions and stress which will take up to 10
minutes;
3. Several questionnaires about different types of thoughts and how they
affect you. This will take up to 30 minutes;
4. For people attending PACE who are involved in this project we would also
like to briefly ask you about your symptoms once a month for 3 months
and conduct 1 of the questionnaires again at 3 months;
5. If you consent to participate we would also require information including
your age, sex and schooling level. For PACE participants we would also
need some information from your clinical file.
4.
Possible Benefits
You may not experience specific benefits for yourself from this study. However,
we believe that the results from this project will aid in furthering our
understanding of how symptoms such as hallucinations develop. It is hoped that
this knowledge will eventually assist in developing treatments to reduce
hallucinations and the distress associated with them.
5.
Possible Risks
We do not believe that you will be harmed by the assessments or involvement in
the project in any way. However, if you feel distressed or concerned about the
assessments you are welcome to take a break or withdraw from the project at
any time. It can be organised for you to see your case manager, or for
participants not attending PACE a counsellor can be arranged who will be
independent from the study.
277
6.
Alternatives to Participation
Participation is voluntary and your decision to participate or not will not affect
your treatment and support at PACE. If you would like to withdraw your consent
after you have signed the consent form you will be free to do so at any stage. In
such instances any information you have provided for the research will be
destroyed and not used in the study.
7.
Privacy, Confidentiality and Disclosure of Information
All information gathered in the research will be kept in securely stored files at the
PACE Clinic for a period of 5 years and then destroyed following completion of the
study. Only those directly involved in the study may have access to your
assessments. All data will be de-identified, meaning that all information that
could identify participants will be removed from publication. It is likely that
reports will be written from this project including presentations at conferences,
journal articles and Steven Leicester’s PhD submission. In all of these instances
your individual information will not be identifiable. On occasions it is possible for
data to be subject to subpoena, freedom of information or mandated reporting.
8.
New Information Arising During the Project
During the research project, new information about the risks and benefits of the
project may become known to the researchers. If this occurs, you will be told
about this new information. This new information may mean that you can no
longer participate in this research. If this occurs, the person(s) supervising the
research will stop your participation. In all cases, you will be offered all available
care to suit your needs and medical condition.
9.
Results of Project
We aim to make results available of the project available to all participants
through the Pace Clinic website.
10.
Further Information or Any Problems
If you require further information of if you have any concerns about the project,
please do not hesitate to contact one of the researchers involved:
Steven Leicester
PACE Clinic
Ph: 9317 6300
11.
Associate Professor John Gleeson
School of Behavioural Sciences
University of Melbourne
8344 6377
Other Issues
If you have any complaints about any aspect of the project, the way it is being
conducted or any questions about your rights as a research participant, then you
may contact
Name:
Dr Stacey Gabriel,
Position:
Secretary, Mental Health Research and Ethics Committee
Telephone:
9342 7098
You will need to tell Dr. Gabriel the name of one of the researchers given in
section 10 above.
Furthermore, you can contact the Executive Officer, Human Research Ethics, The
University of Melbourne, ph: 8344 2073; fax 9347 6739.
278
12.
Participation is Voluntary
Participation in any research project is voluntary. If you do not wish to take part
you are not obliged to. If you decide to take part and later change your mind, you
are free to withdraw from the project at any stage.
Your decision whether to take part or not to take part, or to take part and then
withdraw, will not affect your routine treatment, your relationship with those
treating you or your relationship with The PACE Clinic.
Before you make your decision, a member of the research team will be available
to answer any questions you have about the research project. You can ask for
any information you want. Sign the Consent Form only after you have had a
chance to ask your questions and have received satisfactory answers.
If you decide to withdraw from this project, please notify a member of the
research team before you withdraw. This notice will allow that person or the
research supervisor to inform you if there are any health risks or special
requirements linked to withdrawing.
13.
Ethical Guidelines
This project will be carried out according to the National Statement on Ethical
Conduct in Research Involving Humans (June 1999) produced by the National
Health and Medical Research Council of Australia. This statement has been
developed to protect the interests of people who agree to participate in human
research studies.
The ethical aspects of this research project have been approved by the Mental
Health Research and Ethics Committee.
14.
Reimbursement for your costs
You will not be paid for your participation in this project. However you will be
reimbursed $20 for inconvenience due to the time taken to participate.
279
Consent Form
Version 5 Dated 28/02/06
Site: PACE Clinic, ORYGEN Youth Health
Cognitive Processing Factors Associated with Hallucinations in Young
People.
Participation in the project is voluntary and you will be free to withdraw at any
time, and free to withdraw any data you may have contributed. All information
you provide this project will remain confidential and recorded in a de-identified
format. It is possible for data to be subject to subpoena, freedom of information
request or mandated reporting by some professions.
I have read, or have had have had read to me and I understand the Participant
Information version 1 dated 17/10/05.
I freely agree to participate in this project according to the conditions in the
Participant Information.
I will be given a copy of the Participant Information and Consent Form to keep
and the researcher will retain my original signed copy of the Consent Form.
The researcher has agreed not to reveal my identity and personal details if information
about this project is published or presented in any public form.
Part A: For PACE participants only.
I agree that my clinical file may be accessed for the purposes of
this research project.
Y
Yes
No
Part B: For all participants.
Participant’s Name (printed) ……………………………………………………
Signature
Date
Name of Witness to Participant’s Signature (printed) ……………………………………………
Signature
Date
Researcher’s Name (printed) ……………………………………………………
Signature
Date
Note: All parties signing the Consent Form must date their own signature.
280
THIRD PARTY CONSENT FORM
(To be used by parents/guardians of minor children.)
Version 5 Dated 28/02/06
Site: PACE Clinic, ORYGEN Youth Health
Cognitive Processing Factors Associated with Hallucinations in Young
People.
Participation in the project is voluntary and you will be free to withdraw at any
time, and free to withdraw any data you may have contributed. All information
you provide this project will remain confidential and recorded in a de-identified
format. It is possible for data to be subject to subpoena, freedom of information
request or mandated reporting by some professions.
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REVOCATION OF CONSENT FORM
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Revocation of Consent Form
Cognitive Processing Factors Associated with Hallucinations in Young
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Minerva Access is the Institutional Repository of The University of Melbourne
Author/s:
Leicester, Steven Bryce
Title:
Cognitive processing associated with hallucinations for At Risk Mental State
Date:
2013
Citation:
Leicester, S. B. (2013). Cognitive processing associated with hallucinations for At Risk
Mental State. PhD thesis, Melbourne School of Psychological Sciences, Faculty of Medicine,
Dentistry & Health Sciences, The University of Melbourne.
Persistent Link:
http://hdl.handle.net/11343/38406
File Description:
Cognitive processing associated with hallucinations for At Risk Mental State
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