Institute of Psychiatry, King’s College London

1. A Community of One Social Cognition and Auditory Verbal Hallucinations Vaughan Bell Institute of Psychiatry, King’s College London

2. Outline • Phenomenology • Social cognition of voice hearing • Social cognitive neuroscience and voice hearing • Towards a social cognitive approach to voices

3. An Interesting Paradox • Hallucinated voices are generated from within a single individual… • …but are typically experienced as a social phenomenon… • …that is, a form of communication from another speaker.

4. Case Example “I was sobbing uncontrollably when I felt a presence very near to me. I believed it was Jesus. I could speak with him and he consoled me. Then I heard the voices of the Father of Heaven and Mary, the Blessed Virgin. Jesus’ voice faded for the most part, and the voices of Mary and our Father remained with me during my odyssey into the depths of schizophrenia.” Fox (2002)

5. Case Example “I mean, there are two voices—Simon and Jeremy. Simon’s...um...like a demon really. He’s very demonic and he...says people read my mind and they know I’m evil.... I’ve got a year to live, that if I don’t do as I’m told the horrible horseman of the apocalypse will come and get me and kill me and Armageddon will come and the world will be destroyed. And then Jeremy—he’s just a little boy, he’s just full of fun, you know, he’ll tell me things like—um—‘Move the food from the cupboard and put it in mum’s chest of 7 drawers’. Just stupid things like that. It’s funny but it’s—it is annoying really.” Knudson and Coyle (2002)

6. Case Example “The first of my voices is male and has no name. He is nasty, very dominant, likes to be in charge and is very aggressive. The age of the ‘nasty’ one has gone from a young man to middle age. The second of my voices is female and her name is Joyce. She is also aggressive but tends to be dominated by my first voice. Joyce can be bossy, vindictive and very hurtful when talking to me. The third of my voices is a child’s voice, aged 7 to 8. I refer to this voice as ‘squente’, because that is how he talks.” ‘Jo’ from Romme et al. (2009)

7. Social Voices • Not all voice hearers have voices with such clear social identities. • Stephane et al. (2003) identified two clusters: • 1. low linguistic complexity, repetitive content, attributed to self • 2. high linguistic complexity, systematized content, multiple voices, attributed to others

8. Personal Identities: How Common? • Studies report between 30% and 69% experience voices as specific personal identities (e.g. God, celebrities, past acquaintances) • e.g. McCarthy-Jones et al (2012) – N=199 study: • 37% purely anonymous voices • 32% mix of known and unknown voices • 31% purely identifiable voices

9. Important Distinction • Personal identities are not the same as social identities • The first is about an identity that is tied to a specific person • The second is being able to reliably distinguish between individuals by personal characteristics

10. Important Distinction • Voices may have social identities but still be anonymous • e.g., identified only as an “unknown old woman” or “a man with a deep voice” • …as in Leudar et al. (1997)

11. Social Identities: How Common? • Nayani and David (1996) 61% knew the identity of their voices, but an additional 15% had voices that were ‘familiar but unknown’ • McCarthy-Jones et al. (2012) 70% voices that were “like” people they had spoken to in the past • Beavan (2011) characterising voice identity, regardless of citing a specific personal identity, a major theme in the experience of voice hearing

12. Social Nature of Voices • Social identity is a common and key experience of auditory hallucinations • Voices are as much hallucinated social identities as they are hallucinated words or sounds

13. Key Question • Is there evidence for social processes beyond phenomenology in voice hearing?

14. Social Cognition • Hayward et al. (2011) – systematic review of 18 studies on interpersonal aspects of voices. • Approaches: • Structural Analysis of Social Behaviour • Social Rank Theory • Relating Theory

15. Social Cognition • Hayward et al. (2011) conclusion: • “voice hearers understand their connection with the voices in terms of relationships and interact with their voices in ways that share many properties with interpersonal relationships within the social world”

16. Social Cognition • 80% of voice hearers report that they are able to engage in interactive conversations with their voices (Garrett and Silva, 2003; Leudar et al., 1997) • Judgements about the identity of voices rely on similar perceptual features used to judge spoken voice identity (Badcock and Chhabra, 2013)

17. Social Cognition • Relationships with voices experienced in terms of social power which reflect ‘outside world’ relationships (Paulik, 2012) • Childhood sexual and emotional abuse but not physical abuse predict the presence of auditory verbal hallucinations in adulthood (Bentall et al., 2012; Daalman et al., 2012) • Mourning has probably the highest incidence of post-event AVHs

18. Social Neurocognition • The majority of studies on the cognitive neuroscience of AVHs have not looked at “voices” as specifically social phenomena… • …but there is evidence that the neural networks involved in supporting these experiences have significant overlap… • …with areas that play a key role in social neurocognition.

19. Allen et al. (2008 / 2012) • Speech and language: • Superior / middle temporal gyrus, IFG (Broca’s), temporoparietal junction • Cognitive monitoring: • DLPFC, anterior cingulate and cerebellum • Emotion and affect regulation • anterior insula, hippocampal / parahippocampal areas, orbitofrontal cortex

20. ‘The Social Brain’ from Blakemore (2008)

21. Temporoparietal Junction • Argued to be key part of network involved in representing others’ mental states (Saxe, 2006) • Found to be active in the second before voice onset (Line et al., 1998) • rTMS to reduce TPJ activity reduces intensity of voices (Slotema et al., 2012) • Stimulation to enhance TPJ activity can induce a ‘sensed presence’ (Arzy et al., 2006)

22. Interim Summary • Voices are mostly experienced phenomenologically as social entities • They are perceived and managed as social entities psychologically • There is significant overlap between voice-related neural networks and social brain networks

23. Waters et al. (2012)

24. Waters et al. (2012) • Voices are considered to be misattributed thoughts • Key factors cited: • Cognitive monitoring (executive attention) • Alterations in language processing • Negative emotions • Despite the fact that inner-speech does not typically take the form of distinct personalities

25. Social Factors? • Just one sentence of explanation: • “The content of AH may be determined by factors such as perceptual expectations, mental imagery, and prior experience/knowledge (e.g. memories) that shape a perception of reality that is idiosyncratic and highly personalized.” • Despite clear social characteristics, current approaches are almost entirely individualistic information processing models* • *NB: Fernyhough exception

26. Toward a Social Cognition of Voices • Considering voices involve a misattribution of mental phenomena, we need to be clear about the phenomena that are being misattributed. • It would be most parsimonious to assume that these phenomena stem from our normal ability to internalise models of people and their voices… • …rather than voices involving a de novo generation of persistent and internally vocal social identities.

27. ‘Personality Models’ • First suggested by Park (1986) and Park et al. (1994) • Most recently studied by Hassabis et al. (2013) • Asked participants to imagine four individuals would be have in given situations • The individual being thought about could be inferred from activity patterns in the medial prefrontal cortex

28. Hypothesis • In addition to: • Alterations to speech production processes • Alterations to cognitive monitoring • It is hypothesised that there are • Alteration to the social neurocognitive systems that support internal models of social actors and their associated voice imagery

29. Implications • An ability to internalise models of social actors and generate associated imagery of their voices is a normal developmental process • Changes to the normal functioning of this system play a causal role in many voice-hearing experiences

30. Implications • Social stress may increase the chance of developing voices through its impact on our internal models of social actors • Internal social models of individuals associated with intense traumatic or emotional experiences should be less predictable - and resultant imagery more intrusive – even in non-voice hearers.

31. What We Need • Better studies on the phenomenology of social experience in voice hearing • Non-social vs incognito vs identifiable • Further studies on the extent to which social brain networks are associated with voice hearing

32. Conclusions • Voice hearing is most commonly a social experience • Current theories almost entirely cite individualistic information processing • There is evidence for social psychological and social neurocognitive involvement • Much more focus is needed on this area • Voices may be misidentified voice images from internalised models of social actors