Short summary

These years, there is a growing interest in whether auditory verbal hallucinations (AVH's) commenting or discussing the persons thoughts or behavior and other psychotic symptoms widely accepted at being important parts of the diagnostic criteria to schizophrenia actually should be perceived this way. One theory considers pronounced overlap between normal and schizophrenic behavior and draws upon dissociative processes as a way to explain pronounced parts of schizophrenic psychopathology

Rationale

Background & Objective

Hallucinations may occur in all sense modalities in schizophrenia. Yet, the most frequently reported hallucinations among this group of patients are auditory verbal hallucinations (AVHs)1. Traditionally, AVHs that comment on one's behaviour or two or more AVHs that discuss the patient among with each other constitute well-known first-rank symptoms described by Kurt Schneider2, which have strong diagnostic importance for schizophrenia in The ICD-10 classification of mental and behavioural disorders (WHO 1992)3.

Several models have been proposed, trying to describe how AVHs may arise in schizophrenia. For example, Henriksen et al. suggest that AVH's are best understood as a kind of 'cognitive phenomena' arising from partial dissolution of certain structures of self-consciousness. Henriksen et al. argue that certain alterations in the experience of space and morbid objectification of inner speech, reflected in various non-psychotic anomalous self-experiences, tend to precede the emergence of AVHs in schizophrenia. The increasing self-alienation inherent in these experiential alterations eventually leaves the patient unable to recognize part of her inner speech acts as her own4. This model resembles a model by Klosterkötter, who have described transitional sequences from early, non-psychotic basic symptoms to full blown AVHs and other first-rank symptoms5.

From another perspective, Moskowitz et al. have argued that commenting and conversing AVHs are non-specific for the diagnosis of schizophrenia, claiming that "these symptoms have no unique diagnostic specificity for schizophrenia" 6. Instead, Moskowitz proposes a pronounced overlap between normal and schizophrenic experiences and, in particular, he draws upon dissociative processes as a way to explain schizophrenic psychopathology 7. For example, he argues that voices (AVHs) are parts of the patient's personality, which have split-off due to earlier traumatic experiences. Thus, instead of describing how AVHs may arise, he offers an explanatory model of the aetiology of AVHs.

While Moskowitz argues for an overlap between classical experiences of schizophrenia and dissociation, he also suggests that one way to differentiate the so-called trauma-caused dissociative "voices" from AVHs in schizophrenia is whether the patient spontaneously communicates with her voices. If the patient does so, Moskowitz claims that we are dealing with dissociative experiences and not AVHs, belonging to schizophrenia. During the last decade, the trauma-based approach to "voices" as manifesting dissociative experiences rather than symptoms of psychosis has become accepted and implemented in many clinical settings with implications for treatment of these patients.

In brief, we have described two different types of models of AVHs: a descriptive model of the pathogenesis of AVHs informed by phenomenological psychopathology and an explanatory model of AVHs that bases the aetiology of AVHs in previous traumatic experiences.

A critical, yet so far unaddressed question is if patients with schizophrenia also communicate with their voices in a spontaneous way. If this is the case, then Moskowitz's proposed differentiating principle becomes problematic. To explore this issue, this project will carefully examine AVHs in patients with schizophrenia, clarifying how they experience their AVHs and, of course, if they spontaneously communicate with them. Finally, we will also review the existing literature to assess the evidence behind the claim that patients that spontaneously communicate with their "voices" should suffer from dissociative symptoms rather than psychosis.

Description of the cohort

Eligible participants are adult patients diagnosed with schizophrenia (F20.0-20.3) according to ICD 10. Included participants must present with or have experienced symptoms of AVHs. Participants are either hospitalized or assigned to community mental health services or OPUS-teams in the psychiatric departments of Region of Southern Denmark. The psychiatric departments in Svendborg, Odense, and Aabenraa will be invited to participate in the recruitment process.

Participants fulfilling the above criteria will be included independent of whether they receive pharmacological treatment. Moreover, participants must be able to understand Danish and provide verbal and written informed consent. Participants with a clinically significant, daily to weekly drug- or alcohol dependencies or misuse, organic aetiologies, mental retardation or forensic status will be excluded from this study.

Data and biological material

Research interviews:

Participants will be interviewed by means of a semi-structured interview, covering OPCRIT, PANSS and Examination of Anomalous Self-Experiences (EASE)8-11. Hereby, the clinical diagnosis will be verified. Afterwards qualitative semi-structured interviews considering first person accounts of personal experiences with AVHs are performed

Collaborating researchers and departments

Department of Psychiatry Svendborg

• Iben G Wallstrøm

Clinical department, SDU