I have always thought of hallucinations as manifestations of the mind somewhat akin to dissociations. From listening to hundreds of impassioned descriptions of hallucinations from clients, they seem to fit a pattern. The thoughts and the feelings associated with the hallucination are often personally unacceptable to the client, yet seem like a possible human response to their circumstances.

For example, one of the most common auditory hallucinations involved self-deprecating statements, the client hears a voice telling them they aren't worth living, they ought to kill themselves, or their presence is a burden to everyone. Many of us go through feelings of worthlessness from time to time. People who are depressed often have thoughts and feelings like these. So it's not hard to imagine hearing the same thought as a disembodied voice belonging to a long lost authority figure, or someone you don't recognize. This hallucination is said to be "mood congruent" so most often associated with depressive symptoms.

Perhaps the next most common hallucination is one that has paranoid content. A client might report they hear a voice threatening them, or a commentary about someone who is plotting against them. Clients who have these symptoms often have much difficulty dealing with their own anger, feel that being angry is wrong despite experiencing many provocative experiences. So the client seems to "project" their own thought or feeling to another person. Instead of "I want to hurt you", the client hears a voice telling them that the object of their hostility is really out to get them. Being hostile toward someone else is so unacceptable, that the client has to put this intense feeling somewhere else, in a disembodied voice of another person.

Interestingly, I found reference to recent research on the subject in Medwire

Voices in schizophrenia differ greatly from normal thoughts
by Andrew Czyzewski (Psychol Med 2008; 8: 1167-1176). He talks about "auditory visual hallucinations." I've always understood visual hallucinations are rare in schizophrenia, so I'm wondering if this is a typo. I can't get a copy of the journal article for a year! I'm assuming it's a typo.

The majority of schizophrenia patients who experience auditory visual hallucinations (AVH) say they can readily distinguish their own thoughts from voices, a US study has found.

How patients made this distinction varied; many individuals stated that voices differ in verbal content from their own thoughts, some said that the sound of the voices are characteristic and non-self, others meanwhile reported less voluntary control over voices than their own thoughts.

"That AVHs are generally cast in specific, non-self speaking voices suggests neural activation incorporating temporal regions responsible specifically for voice identification based on sound characteristics," Ralph Hoffman (Yale-New Haven Psychiatric Hospital, Connecticut) and colleagues comment.

Writing in the journal Psychological Medicine the researchers note that around 60-80% of patients with schizophrenia report AVHs, which are associated with high levels of distress, functional disability, and behavioral dyscontrol. Furthermore, around 25% of AVHs are unresponsive to treatment.

"A more precise characterization of experiential characteristics of AVHs may provide insights into underlying mechanistic processes," Hoffman et al comment.

In the present study 50 schizophrenia or schizo-affective disorder patients with AVHs were administered a questionnaire pertaining to the voices they reported hearing. All patients experienced at least five AVH events per day.

In all 80% of the sample reported that they were able to differentiate AVHs from their usual verbal thoughts most of the time.

Seventy nine percent of patients reported that the voices were acoustically different from their own speaking voice either most of the time or all of the time. Smaller percentages of patients reported that subjective loudness and clarity of the AVHs were greater than that of their own verbal thoughts either most of the time or all of the time.

In total 46.7% of respondents reported that verbal content of voices was distinct from verbal thought either most of the time or all of the time; 30% of patients said they never had any control over voices.

Analysis revealed that most patients used a combination of verbal content, sound characteristic, and level of control to distinguish AVH from thoughts.

An interesting sub-finding was that 26.5% of patients reported that the voices were external and seemed to emanate exclusively from outside the head. Of the patients whose voices were internal, a large percentage said they could localize these voices within the head itself according to their markings on spatial outline of the head.

Based on their evidence Hoffman et al believe that voices may be explained by pre-illness social isolation.

They comment: "In this model, the 'social brain' produces spurious social meaning in the form of delusional 'plots', self-referential interpretations of environmental stimuli, and AVHs seemingly generated by actual speakers or beings, all in the service of filling in the 'blank slate ' due to withdrawal from the world."

While I buy this as one possible explanation, I don't think this theory will explain all hallucinations. Certainly social isolation can be a fertile ground for symptomatic thoughts.

It's been apparent to me for a number of years that there appeared to be problems with the concept of schizophrenia. Sub-types of the disorder have very different symptoms. Some include paranoia, some do not. Some include prominent disorganization, some do not. Today, I tripped over an article with information on another part of the disorder that fits only into some sub-types. Symptoms are roughly divided into three groups, positive (i.e. hallucinations, delusions, racing thoughts), negative (i.e. apathy, lack of emotion, poor or non-existant social functioning), and cognitive (disorganized thoughts, difficulty concentrating and/or following instructions, difficulty completing tasks, memory problems). Positive symptoms are common around the world. Negative and cognitive symptoms seem somewhat more prominent in the west where stigma and social ostracizing is compelling.

Most everyone agrees that there is an inherited element in the development of schizophrenia. There is also increasing research that finds in utero infections and immune reactions and other fetal brain insults may also play a role in some cases. Now research has associated negative and cognitive symptoms with income and education, NOT family history!

MedWire News

The socioeconomic status (SES) of family origin is significantly associated with schizophrenia subtype, whereas a family history of mental illness is not, US scientists have discovered.

[...Income and education] of family origin had a statistically significant association with deficit [negative and cognitive symptoms] versus non-deficit schizophrenia, at an odds ratio of 0.644. However, family history, race, and gender were not associated with schizophrenia subtype.

Further analysis of contingency tables and variance revealed that poverty was associated with deficit schizophrenia independently of family history, while family history had no net association with the type of schizophrenia.

"Overall, our findings support the hypothesis that, while risk of schizophrenia in general is genetically based, the specific form of the psychosis stems from environmental stressors including fetal brain insults such as in utero infection," the team concludes.

This is a topic I've written about before. I include an excerpt below. If I peak your interest, read the whole article. It's a provocative opinion. Comments would be appreciated. It's a topic dear to my heart.

Now there is evidence that early intervention in the course of schizophrenia with psychotherapy, medication, and consistently applied community based supports may sometimes prevent the usual long-term permanent disability. Medication alone is not sufficient treatment. What has always been assumed as a manifestation of the illness, may in fact be a by-product of a paternalistic and de-humanizing treatment by the community and service agencies as well as isolation due to the pervasive experience of stigma and discrimination by the individual.

[..]Could it be that our culture's stigma is so overwhelmingly ostracizing and isolating, the very experience of living with schizophrenia leads to brain deterioration that has heretofore been attributed to the illness itself? I find no compelling evidence to argue that the illness itself accounts for the virtual shrinking of the grey matter in the brain, the ventricles and the brain's neuronal interconnections. There is plenty of anecdotal evidence that there could be similar effects produced by isolation, under-stimulation and high stress.

[..]My own clinical experience has contributed to the development of my perspective. Most everyone I've treated in the varying treatment settings in which I've worked, had many complicating psychosocial factors such as a history of abuse, neglect, and a dysfunctional support system. Very few of the people I've treated came from healthy families who were consistently and effectively supportive. Certainly, there were families who were high achievers, successful and seemed to exude the American dream, but can you imagine the kind of virtual isolation and shame a minimally functional family member would experience just from not fitting into conversations, sharing common experiences and success. The personal aspect of stigma can be the most damaging of all.

[..]Focusing more funding on early intervention in the early stages of illness seems to be good policy. Secondly, consumers of mental health services need a direct hand in developing policies, programs and most importantly their own treatment plan. We need to reassess community-based programs and make them more consumer friendly. Community-based care needs to be more client driven.

For those of you who frequent my blog, you'll see a common reference to the next recommendation. There needs to be a fundamental change in how we prepare our children. Emotional development has been largely ignored at the level of social policy. It has at times been addressed, sometimes effectively, by generational wisdom of some families and the sub-cultural effects of many religions. But we have plenty of evidence-based knowledge that can be brought to bear to teach emotional development as well as parenting skills to our children. Community education within school districts could be used to teach the rest of the population. High risk families could benefit from additional knowledge we have for emotional development. Clearly we need more specialized curricula to meet these needs.

Finally, we as professionals need to go out of our way to be welcoming and accepting of persons with mental illness. The isolation and stigma they experience on a daily basis may well account for the most disabling and long-lasting symptoms. We need to listen closely with their concerns, negotiate a working relationship with them and compromise on treatment strategies to enhance their perception of control and direction of treatment. Their sense of personal control and effectiveness may have more to do with their recovery as their medication or treatment regime.

[Updated] Ideas about treating schizophrenia seem to be gradually coming full circle. What began as little more than blaming, shaming and confining, evolved over hundreds years into a state policy of institutional care with "humane treatment". Over the next hundred years treatment has evolved into primarily a highly professionalized medication regime with an inconsistently available community based supports.

Now there is evidence that early intervention in the course of schizophrenia with psychotherapy, medication, and consistently applied community based supports may sometimes prevent the usual long-term permanent disability. Medication alone is not sufficient treatment. What has always been assumed as a manifestation of the illness, may in fact be a by-product of a paternalistic and de-humanizing treatment by the community and service agencies as well as isolation due to the pervasive experience of stigma and discrimination by the individual.

In this article, I will review some of the relevant history of treating schizophrenia, and reveal the uncanny convergence of new seemingly unrelated research that could shift the paradigm in the treatment of schizophrenia. This article is an expression of my opinion, not peer reviewed literature. In fact, I invite my peers to comment tell me where I'm wrong or help me develop the ideas presented herein.

Anti-psychotic medication has gotten very expensive, especially when compared to long standing generics. Now research is finding the generics work just as well as the new "atypicals". But the fact is, medication has to be subscribed one client at a time. While on average, some of the generics work as well with low side effects, some individuals have extreme side effects from the generics or don't benefit from them any where near as effectively as the new "atypicals". In particular, the worse permanent side effect, tardive dyskinesia appears less likely with new atypicals in individuals prone to that problem.

So when we have journal articles pointing out the excesses of the pharmeceutical industry, we need to be sure we don't eliminate the best option for the minority of persons who need the new "atypical" anti-psychotic medications.

Archives of General Psychiatry

In people with schizophrenia whose medication is changed for clinical reasons, there is no disadvantage across 1 year in terms of quality of life, symptoms, or associated costs of care in using FGAs rather than nonclozapine SGAs. Neither inadequate power nor patterns of drug discontinuation accounted for the result.

Here is a NAMI.org press release supporting my position.

“For Medicare, Medicaid, and the Department of Veterans Affairs, it would be a grave mistake to use the study to restrict access to newer medications, based on general findings that older medications seem to work as well as the newest generation,” Duckworth said. “General findings cannot be substituted for specific choices made in treating individuals with schizophrenia. One size does not fit all. It is critical that the study’s limitations be recognized.”

For one, the British study relies heavily on an older drug, sulpiride that has never been approved by the Food & Drug Administration (FDA) and is unavailable in the United States. In addition, the study’s comparisons are limited to classes of drugs, rather than specific medications. The study does not include comparison of doses of drugs, either between classes or specific medications.

Although longer than clinical trials required for FDA approval of specific drugs, the study’s one-year test period is still largely inadequate for evaluating treatment outcomes over time.