Auditory verbal hallucinations (AVHs) and related psychotic phenomena in mood disorders: analysis of the 2010 Survey of High Impact Psychosis (SHIP) data
Introduction
Auditory verbal hallucinations (AVHs), also known as ‘hearing voices’, refer to the perception of verbal utterances in the absence of corresponding external stimuli. This complex, multifaceted phenomenon has served as a key diagnostic feature for psychosis, most notably schizophrenia (SCZ). The phenomenology of AVHs has been extensively examined in SCZ (McCarthy-Jones et al., 2014, Nayani and David, 1996), but has been studied less in affective psychosis (Toh et al., 2015). Adequate characterisation of the lived experiences of AVHs in affective psychosis provides an essential starting point for designing disorder-specific interventions, and may offer significant prognostic value.
AVHs have been reported in mood disorders, and tend to be more prevalent during mania in bipolar disorder (BD), rather than depressive episodes, but are known to occur in both phases (Black and Nasrallah, 1989, Goodwin and Jamison, 2007). A systematic literature review of AVHs in mood disorders (Toh et al., 2015) found few comparative studies of AVHs between diagnostic groups (with the exception of Shinn et al., 2012). This approach goes to the heart of whether AVHs are truly cross-diagnostic symptoms, or if there are features specific to each disorder in which they occur.
Point prevalence estimates of AVHs in BD and other mood disorders show considerable variability: from 11% (Black and Nasrallah, 1989) to 68% (Baethge et al., 2005) in large-scale studies of BD, and up to 41% in depressive psychosis (DP; Baethge et al., 2005). In BD mania/mixed phases, these estimates ranged from 13% to 67% (Baethge et al., 2005, Black and Nasrallah, 1989). There is limited data available on the lifetime prevalence of AVHs in mood disorders, with the exception of Shinn et al. (2012), who reported an estimate of 34% for BD (n.b. 40% in BD was listed in summary data presented by Badcock, 2015). Moreover, studies examining current prevalence have not consistently accounted for phase of illness and its influence on AVH experiences. Nevertheless, Baethge et al. (2005) concluded that BD patients in a manic or mixed, rather than depressed, phase were significantly more likely to experience hallucinations (though not necessarily AVHs); and BD patients in a depressed phase were in turn significantly more likely to experience hallucinations than DP patients. Likewise, Black and Nasrallah (1989) reported that BD patients in a manic phase were most likely to experience hallucinations relative to other mood disordered groups.
Common forms of AVHs in the clinical literature include running commentary and voices conversing (McCarthy-Jones et al., 2014, Shinn et al., 2013). Negative voices or those with abusive, accusatory or persecutory content occur frequently as well (Daalman et al., 2011, Jenner et al., 2008, Nayani and David, 1996). Of these, running commentary and voices conversing have classically been seen as ‘first rank’ symptoms (FRS) characteristic of SCZ, alongside thought interference, passivity experiences and delusional mood (Schneider, 1958). However, FRS do not appear specific to SCZ. For instance, Rosen et al. (2011) found that 27% of BD patients with psychosis versus 55% of SCZ patients heard running commentary or voices conversing from index hospitalisation through to 20-year follow-up (with significantly greater symptom severity noted in SCZ). Likewise, Shinn et al. (2012) reported similar rates in BD with psychotic features: 21% running commentary, 19% voices conversing, and 31% either. Yet empirical studies of hallucinations have focused on BD or combined affective psychosis (Kumari et al., 2013, Okulate and Jones, 2003), with a paucity of reports for DP (Toh et al., 2015). Understanding whether these types of AVHs arise in DP as well as BD may have prognostic value, as FRS in first-episode mania have been associated with earlier onset, severe negative symptoms, and poorer psychosocial outcomes (Conus et al., 2004, Jorgensen and Aagaard, 1988). There has been scant research on negative voices per se, but several studies have reported negative content as less characteristic of SCZ relative to affective (Kumari et al., 2013) and other disorders (Slotema et al., 2012, Wearne and Genetti, 2015). Yet in one SCZ study, 75% of patients (c.f. 48% of community participants) reported negative voices (Jenner et al., 2008). The majority of respondents also reported that their first AVH was mostly likely experienced in the form of a negative voice. Furthermore, an early study of negative voice content in mood disorders found that clinicians were more likely to rate voices in BD and DP as mood congruent (Winokur et al., 1985), but there has been little subsequent research.
Hallucinatory experiences commonly co-occur with delusions in SCZ, and this also seems to be the case in mood disorders. Baethge et al. (2005) reported that 66% and 58% of their BD and DP patients respectively had hallucinations accompanied by delusions. Elsewhere, it has been suggested that AVHs in BD tend to be associated with high levels of delusions and accompanying distress (Braunig et al., 2009). In BD, delusional themes of persecution (31%), reference (23%) and guilt (19%) were most common, followed by grandeur (12%), hypochondria (9%), and poverty (8%; Baethge et al., 2005). In contrast, Pini et al. (2004) reported a disparate pattern of delusional themes experienced during mania in BD: persecutory (83%), grandiose (79%), referential (69%), bizarre (31%), control (24%), broadcasting (21%), somatic (17%), and guilt (14%).
Most AVH research in clinical populations has focused on its occurrence within SCZ, with relatively little attention paid to mood disorders, particularly DP. Yet a small literature has suggested that AVHs play an important role in BD and DP symptomatology. The current study therefore aimed to examine the presence of hallucinations, and in particular, types of AVHs, within the selected mood disorders, in a representative sample of people with psychotic disorders. AVHs of specific interest were i) running commentary, ii) voices conversing, and iii) negative voices. A secondary aim was to examine patterns of associated delusional themes in the mood disordered groups. In the current study, we designated BD and DP as the clinical focus groups, with SCZ and schizoaffective disorder (SAD) serving as the clinical reference groups. Specific aims were to:
1. To examine the presence and severity of hallucinations (in any modality) in mood disorders with a history of psychosis, where it was expected that BD>DP (Baethge et al., 2005, Black and Nasrallah, 1989).
1a. To examine the presence and severity of running commentary and voices conversing, where it was also expected that BD>DP.
1b. To report on the presence and severity of negative voices, especially focusing on DP.
2. To examine patterns of hallucinations, and AVHs in particular, significantly associated with specific delusional themes in affective psychosis (Baethge et al., 2005).
Section snippets
Design
Data analysis was based on information collected as part of the 2010 Australian Survey of High Impact Psychosis (SHIP). A complete description of the method and design of the study has been published (Morgan et al., 2014, Morgan et al., 2012). In brief, this survey constituted a representative, population-based study of almost 1.5 million Australian adults aged 18–64 years (approximately 10% of the national population in this age range). It was carried out at seven mental health service sites
Sociodemographic and clinical characteristics
Based on the disorder subset selected, 1 550 participants were involved in the analyses presented. The most common diagnosis was SCZ (55%), followed by BD (21%), SAD (19%), and DP (5%). Group-wise differences in relation to sociodemographic and clinical variables are presented in Table 1. There were no significant differences in any of the demographic variables between the BD and DP groups, and this related to age, sex, premorbid IQ as well as marital and employment status. However, the BD
Discussion
Findings from the current study specifically relate to a representative sample of people with psychotic disorders. Our main intent was to explore the nature of AVHs across mood disordered groups, and our sampling framework was a population-based subset of people experiencing psychosis. From a demographic perspective, the BD group demonstrated elevated mean age and IQ, but it is unlikely that these differences should have any bearing on phenomenological considerations (given age <52 years and
Disclosure
The authors do not have any conflicts of interests.
Funding
Funding for this project was partially provided by a Barbara Dicker Brain Sciences Foundation (BDBSF) grant. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the BDBSF.
Prof Badcock receives funding from the Medical Research Foundation, Perth (Infrastructure grant), and from the Cooperative Research Centre – Mental Health.
Acknowledgement
This publication is based on data collected in the framework of the 2010 Australian National Survey of High Impact Psychosis. The members of the Survey of High Impact Psychosis Study Group are: V. Morgan (National Project Director), A. Jablensky (Chief Scientific Advisor), A. Waterreus (National Project Coordinator), R. Bush, V. Carr, D. Castle, M. Cohen, C. Galletly, C. Harvey, B. Hocking, A. Mackinnon, P. McGorry, J. McGrath, A. Neil, S. Saw, H. Stain. Ethics approvals for the study were
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