Reviewing evidence for the cognitive model of auditory hallucinations: The relationship between cognitive voice appraisals and distress during psychosis

Clinical Psychology Review 30 (2010) 248–258

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Clinical Psychology Review

Reviewing evidence for the cognitive model of auditory hallucinations: The relationship between cognitive voice appraisals and distress during psychosis Amy Mawson a,⁎, Keren Cohen b, Katherine Berry c a b c

Division of Health Research, Lancaster University, Bailrigg, Lancaster. LA1 4YT, UK School of Psychology, London Metropolitan University, London, UK Psychological Services, Greater Manchester West Mental Health NHS Foundation Trust, Bury New Road, Prestwich, Manchester M25 3BL, UK

a r t i c l e

i n f o

Article history: Received 13 July 2009 Received in revised form 16 November 2009 Accepted 25 November 2009 Keywords: Hearing voices Auditory hallucinations Beliefs about voices Cognitive appraisals

a b s t r a c t Individuals who hear voices during psychosis may be vulnerable to increased distress. Cognitive models place emphasis on the role of subjective and cognitive appraisals of voices in influencing different emotional reactions. This paper systematically reviewed literature investigating the relationship between appraisals of voices and distress. The review included 26 studies, published between 1990 and 2008. Several types of appraisals were found to be linked to higher levels of distress in voice hearers, including voices appraised as malevolent, voices appraised as high in supremacy, voices appraised to have personal acquaintance with the individual, and attitudes of disapproval and rejection towards voices. However, results from cognitive therapy trials did not consistently report significant improvements in voice related distress post-intervention. One explanation for this finding is that mediating variables, such as social schemata, exist within the appraisal– distress relationship, variables which were not targeted in the cognitive therapy trials. Areas for future investigation may include developing a greater understanding of mediating variables, such as social schemata, within the appraisal–distress relationship, carrying out interventions aimed at addressing these mediating variables using randomized controlled trial designs, and understanding the relationship between positive affect and voice appraisals. © 2009 Elsevier Ltd. All rights reserved.

Contents 1. 2.

Introduction . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Definition of terms . . . . . . . . . . . . . . . . 2.2. Search procedure . . . . . . . . . . . . . . . . 2.3. Inclusion criteria . . . . . . . . . . . . . . . . . 3. Results . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Overview of reviewed studies. . . . . . . . . . . 3.2. Associations between voice appraisals and distress. 3.3. Malevolence . . . . . . . . . . . . . . . . . . . 3.4. Benevolence . . . . . . . . . . . . . . . . . . . 3.5. Voice supremacy . . . . . . . . . . . . . . . . . 3.6. Voice acquaintance. . . . . . . . . . . . . . . . 3.7. Approval and acceptance . . . . . . . . . . . . . 3.8. Methodological considerations of the studies . . . 3.9. Limitations of the review . . . . . . . . . . . . . 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . 4.1. Implications for future research . . . . . . . . . . 4.2. Implications for clinical practice . . . . . . . . . 5. Conclusions . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . .

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⁎ Corresponding author. Tel.: +44 1524 592970; fax: +44 1524 592981. E-mail addresses: [email protected] (A. Mawson), [email protected] (K. Cohen), [email protected] (K. Berry). 0272-7358/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2009.11.006

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1. Introduction The cognitive model of voices suggests that particular types of cognitive voice appraisals will influence the hearer's emotional reactions to such voices. The aim of this review is to systematically review, synthesize, and evaluate research evidence that suggests a link between cognitive voice appraisals and related distress. Voice hearing is the most commonly reported form of auditory hallucination, which are considered a core psychotic symptom by both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, American Psychiatric Association [APA], 1994) and the International Classification of Diseases and related health problems, tenth edition (ICD-10, World Health Organization [WHO], 1992) and have a lifetime prevalence of 70% in individuals diagnosed with schizophrenia and related disorders (Landmark, Merskey, Cernovsky, & Helmes, 1990). They are defined as a sensory perception that has a compelling sense of reality, but which occurs without external stimulation of the sensory organ (APA, 1994). In voice hearing, such ‘voices’ have properties of spoken language and are often personified, meaningful, and subjective to the individual experiencing them (David, 2004). Although high levels of depression and anxiety are reported in voice hearers (e.g., Birchwood & Chadwick, 1997; van der Gaag, Hageman, & Birchwood, 2003) not all hallucinations are experienced as distressing. Evidence of voice hearing in non-patients and community samples suggest that specific factors, other than the mere presence of the symptom, lead to distress (Birchwood, Iqbal, & Upthegrove, 2005; Honig et al., 1998). The cognitive model argues that the way an individual cognitively appraises their voices will influence their emotional and behavioral reactions to this experience (e.g., Chadwick & Birchwood, 1994). The cognitive model of voice hearing proposes that cognitive appraisals such as control, identity, power, and purpose occur following a voice hearing experience. These appraisals influence the individual's emotional, behavioral, and somatic responses to the voice hearing experience. The link between emotional and behavioral reactions and appraisals within the cognitive model are likely to be bidirectional. As such, emotional and behavioral responses can in turn serve to strengthen or weaken cognitive appraisals about voices. Morrison and colleagues have provided an explanation of how causal factors of intrusions and misattributions contribute to a maintenance cycle of auditory hallucinations. They argued that the experience of an auditory hallucination occurs when an individual misattributes some internal stimuli, such as unwanted intrusive thoughts, to an external source (Fig. 1). They suggested this misattribution then leads to cognitive appraisals about the experience (Morrison & Haddock, 1997; Morrison, Haddock, & Tarrier, 1995). Birchwood, Morrison and others have refined the above model, they suggested that the ways in which these appraisals develop may

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be the result of underlying schemata and metacognitive biases (e.g., Baker & Morrison, 1998; Birchwood et al., 2004; Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000; Loban, Haddock, Kinderman, & Wells, 2002). Of particular relevance to the present review is Birchwood and colleagues' theory, which focuses on explaining how the distress experienced by voice hearers is maintained within the cognitive model. Derived from ideas of social rank, the authors argued that current and past social relationships influence development of schemata based on issues of power and subordination. For example, individuals who experience powerlessness in social relationships may also appraise subjective powerlessness in response to their voices (Birchwood, et al., 2000, 2004). Andrew, Gray, and Snowden (2008) have also suggested that previous trauma may mediate the appraisal– distress relationship, or contribute to the development of subjective voice appraisals. Evidence for the cognitive model of voice hearing is growing. For example, authors have reported that different coping strategies are employed to manage voice experiences depending on the way in which individuals appraise their voices. Voices appraised by the individual as positive or benevolent are more likely to be courted and engaged, whereas voices perceived by the individual as negative or malevolent are more likely to be resisted (e.g., Sayer, Ritter, & Gournay, 2000; So & Wong, 2008). Researchers have also found that cognitive appraisals are a key determinant in complying with voice commands; voices appraised as more powerful than the individual are more likely to be complied with than voices appraised as less powerful (e.g., Braham, Trower, & Birchwood, 2004). In addition, individuals whose voices are interpreted as negative and hostile have higher levels of suicidal ideation than individuals whose voices are interpreted as positive (Fialko et al., 2006). Previous reviews which relate to the cognitive model of voices have focused on coping strategies and factors influencing compliance with command hallucinations (e.g., Braham et al., 2004; Farhall, Greenwood, & Jackson, 2007). However, there appears to be no systematic review looking at the relationship between cognitive voice appraisals and the distress experienced due to hearing voices. Synthesizing evidence concerning the relationship between voice appraisals and distress may provide valuable evidence in support or refinement of the cognitive model of voice hearing. Furthermore, understanding which appraisals are most closely associated with increased distress could inform treatment approaches of the key appraisals to target during cognitive therapy. For example, cognitive techniques aimed at altering or reducing maladaptive voice appraisals are proposed within the cognitive model to improve behavioral coping and reduce voice related distress (e.g., Chadwick & Birchwood, 1994; Morrison et al., 1995; Trower et al., 2004). This paper will therefore review studies investigating the relationship between cognitive appraisals and distress experienced by voice hearers and in doing so will evaluate evidence for a key component of the cognitive model. 2. Method 2.1. Definition of terms

Fig. 1. Model of the maintenance of auditory hallucinations (from Morrison et al., 1995).

‘Cognitive appraisals’ were defined for the present review as a judgment or opinion developed by the individual in order to determine some subjective meaning about the voice hearing experience. Physical characteristics of the experience, including voice frequency, clarity, loudness, and duration, were not considered to be cognitive appraisals. This definition was developed in line with distinctions made in common measures used to assess voice hearing experiences (e.g., Chadwick & Birchwood, 1994, 1995; Haddock, McCarron, Tarrier, & Faragher, 1999). However, the definition of ‘appraisals’ is an issue which is discussed further in the following sections. The term ‘distress’ was defined as any measurement of the degree of negative affect

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experienced by the voice hearing individual, for example depression, anxiety, or voice related distress. 2.2. Search procedure An electronic search of databases was conducted through academic search engines: Academic Search Complete, CINAHL, MEDLINE, Pre-CINAHL, and PsycINFO. Terms were entered for searching in the abstracts of articles; each term was linked with the instruction ‘OR’. A wildcard asterisk was applied to search for related terms in some instances. One search set related to appraisals of voices, and included the terms ‘beliefs,’ ‘attributes,’ ‘attitudes,’ ‘interpretations,’ ‘appraisals,’ ‘relationships,’ ‘perceptions,’ and ‘evaluations.’ A second search set related to hallucinations, including the terms ‘voices,’ ‘auditory hallucinations,’ and ‘command hallucinations.’ The final search set related to psychosis and included the terms ‘psychosis,’ ‘schizophrenia,’ and ‘psychotic.’ The search was limited to journals in the English language and excluded dissertation abstracts. The search produced 857 articles; this was reduced to 535 articles after excluding duplicates. These searches, along with a search of the Cochrane Library for Systematic Reviews using the terms ‘voices’ and ‘auditory hallucinations,’ revealed that no similar systematic review had previously been published under these terms. The abstracts of the 535 papers were manually reviewed. In cases of uncertainty over the inclusion of a specific article, the methodology and results sections were also reviewed. Finally, reference lists of included articles were reviewed for additional papers. 2.3. Inclusion criteria Studies were reviewed up to and including the year 2008. Studies were included if they used a quantitative methodology and their results tested associations between a measure of voice hearers' distress (for example depression, anxiety, or distress) and subjective appraisals of their voices (for example beliefs about meaning, power, or intrusiveness of the voices). A number of the measures that assess voice appraisals also incorporate separate subscales to assess physical characteristics of, and behavioral responses to, the voice hearing experience; these did not form part of the current review. Other criteria required that studies had included participants recruited from psychiatric samples, or who had a primary diagnosis of schizophrenia or related psychosis. After applying the above criteria, the final number of articles included in this review was 26. 3. Results 3.1. Overview of reviewed studies Table 1 provides an overview of each article, presented in date order. The majority of studies took place in the UK (N = 18). Sample size ranged from N = 12 to N = 199, with 7 studies recruiting fewer than 30 participants experiencing auditory hallucinations. The majority of studies employed a cross sectional design (N = 21) and used statistics of association, for example correlation or regression analyses, to test the relationship between voice appraisals and distress. A minority of studies (N = 5) investigated changes in voice appraisals and distress following an intervention. Of those employing an experimental design, only two used the randomized controlled trial (RCT) method. Distress was measured using several questionnaires and interview schedules. Depression, measured in 21 studies, was assessed using the Beck Depression Inventory (BDI, Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) and second edition (BDI–II, Beck, Steer, & Brown, 1996), the Hamilton Depression Rating Scale (HDRS, Hamilton, 1960), the Hospital Anxiety and Depression Scale (HADS, Zigmond & Snaith, 1983) or the Calgary Depression Scale (CDS, Addington, Addington, &

Maticka-Tyndale, 1993). Anxiety was assessed in three studies using the HADS, the Spielberger State Trait Anxiety Scale (SSTAS) Dutch version (van der Ploeg, Defares, & Spielberger, 1980) or the Beck Anxiety Inventory (BAI, Beck, Epstein, & Brown, 1988). ‘Distress’ was measured in 13 studies using the relevant subscales from the Psychotic Symptoms Rating Scales-Auditory Hallucinations Rating Scale (PSYRATS-AHRS, Haddock et al., 1999), the Hustig and Hafner (1990) self-report scale, or the Mental Health Research Institute Unusual Perceptions Schedule (MUPS, Carter, Mackinnon, Howard, Zeegers, & Copolov, 1995). Questionnaires used to measure voice appraisals are outlined in the associated categories below. 3.2. Associations between voice appraisals and distress Voice appraisals measured within the studies under review are synthesised into associated categories, as described in the following sections. 3.3. Malevolence Thirteen studies investigated associations between malevolent voice appraisals and distress. Malevolent appraisals were defined as voices perceived as evil or wanting to harm the person, as measured on the malevolence scale of the Beliefs About Voices Questionnaire (BAVQ, Chadwick & Birchwood, 1995) and revised version (BAVQ-R, Chadwick, Lees, & Birchwood, 2000), voices appraised as communicating negative or derogatory content, as measured on the Cognitive Assessment Schedule (CAS, Chadwick & Birchwood, 1994), or voices appraised as being negative, abusive, and threatening, as measured by the PSYRATS-AHRS. A consistent finding across studies was that voices appraised as malevolent were significantly and positively associated with distress (Birchwood & Chadwick, 1997; Haddock et al., 1999; Smith et al., 2006), depressed mood (Andrew et al., 2008; Chadwick, Lees, et al., 2000; Lucas & Wade, 2001; Simms, McCormack, Anderson, & Mulholland, 2007; Smith et al., 2006; Soppitt & Birchwood, 1997; van der Gaag et al., 2003) and anxiety (Andrew et al., 2008; Chadwick, Lees et al., 2000; van der Gaag et al., 2003). However, an exception to these findings was noted. In the study by van der Gaag et al. (2003) a measure of negative voice content produced no significant relationship to depression or anxiety. This study used two independent raters to assess voice content, to improve their method of assessment and to delineate the relative influence of both negative voice content and beliefs about voice malevolence on distress. Only where both raters agreed on how to categorize the voice content (positive, negative, or neutral) were these cases used in the analysis, which occurred in 43 of 54 cases. While independent rating should make their results more reliable, the authors did not state whether a reliable or valid tool, such as the CAS, was utilized to access information about voice content and this may have affected the reliability of the results. Furthermore, participants were recruited from a Dutch population and although the authors used the Dutch version of the STASS, the paper did not state whether other measures were translated, which may have affected the validity of these results. Further support for a relationship between voice appraisals and distress was found where voice malevolence was an independent and significant predictor of distress, after controlling for the influence of variables such as voice frequency and illness duration (Andrew et al., 2008; Birchwood & Chadwick, 1997; Hacker, Birchwood, Tudway, Meaden, & Amphlett, 2008; van der Gaag et al., 2003). However, there were two exceptions to these findings. In the study by Andrew et al. (2008) malevolent voice appraisals significantly predicted depression when measured on the BAVQ-R but not when measured on the PSYRATS-AHRS, though the low sample size may indicate that this study was not sufficiently powered (N = 22). Opposite findings were reported by Hacker et al. (2008) where malevolent voice appraisals

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measured on the PSYRATS-AHRS were a significant independent predictor of distress, but not when measured on the BAVQ-R. The above inconsistencies may be explained by differences across studies in the definition of ‘appraisals.’ Some studies defined voice content as more of a ‘topographical’ feature of voice hearing (e.g., Soppitt & Birchwood, 1997), while other articles considered the content of voices to be more than a physical characteristic of the experience (e.g., Haddock et al., 1999). Furthermore, Birchwood and colleagues reported in an earlier study that beliefs about voice malevolence and voice content measured on the CAS were unrelated in approximately 30% of cases (Chadwick & Birchwood, 1994). Inconsistencies above might suggest that voice malevolence and negative voice content are indeed independent concepts, can at times be incongruent, and may therefore have different correlates depending on how each is measured (this issue is returned to in the limitations section). Three intervention trials measured malevolent voice appraisals and distress as part of their outcome assessment (Trower et al., 2004; Valmaggia, van der Gaag, Tarrier, Pijnenborg, & Slooff, 2005; Wykes, Parr, & Landau, 1999). The studies by Valmaggia et al. (2005) and Trower et al. (2004) stated that the intervention involved addressing individuals' cognitions regarding the power, identity, meaning and dangerousness of their voices which, hypothesized within the cognitive model, should also reduce distress. Wykes et al. (1999) also defined their intervention as cognitive behavior therapy (CBT) but did not describe any specific techniques applied to change cognitive voice appraisals. For all three studies, changes on measures of distress and voice malevolence following cognitive therapy were largely insignificant (Trower et al., 2004; Valmaggia et al., 2005; Wykes et al., 1999). It is possible, at least in the two studies that explicitly stated the types of appraisals targeted, that appraisals of voice power, identity, meaning and dangerousness are not congruent to a definition of voice malevolence, hence the interventions not facilitating a significant level of change in malevolent voice appraisals. Indeed, significant changes on measures of voice power provided more promising evidence for these interventions (see Voice supremacy for details). However, the evidence suggests that such techniques had limited impact on both malevolent voice appraisals and distress and so do not provide any further support for the relationship between these concepts. 3.4. Benevolence Five studies reported on the relationship between benevolent voice appraisals and distress. Benevolent appraisals included voices rated as communicating positive content on the CAS and voices rated as ‘benevolent’ or having ‘good’ intentions on the BAVQ or BAVQ-R. This category also included voices appraised as positive experiences, using the positive interpretations of voices subscale from the Interpretations of Voices Inventory (IVI, Morrison, Wells, & Northard, 2002). The adapted version of the PSYRATS-AHRS used in Sanjuan, Gonzalez, Aguilar, Leal, and van Os (2004), who added an additional question regarding voices as pleasurable experiences, was also combined into this category. In comparison to voices appraised as malevolent, voices appraised as benevolent produced an inverse relationship to levels of distress (Sanjuan et al., 2004), anxiety (van der Gaag et al., 2003) and depression (Lucas & Wade, 2001; Simms et al., 2007; van der Gaag et al., 2003). Voices perceived as pleasurable were also negatively associated with degree of negative content and positively associated with perceived control in the study by Sanjuan et al. (2004). Two studies found no relationship between benevolent voice appraisals and levels of distress (Morrison, Nothard, Bowe, & Wells, 2004; van der Gaag et al., 2003). In the study by van der Gaag et al. (2003) however, the appraisals which were unrelated to distress were positive content appraisals. The authors did not state whether a validated clinical interview was followed to access these appraisals.

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Furthermore, the approach to the translation of their questionnaires was not stated by the authors. Both of these factors may have reduced the reliability of these findings. Additionally, in Morrison et al.'s (2004) study the positive interpretations of voices subscale measured beliefs about the usefulness of hallucinations. These might be better defined as ‘metacognitive’ beliefs (see Morrison et al., 2004) and might therefore constitute a different type of cognition than the voice appraisals more typically assessed in other studies. As such, the positive interpretations of voices subscale of the IVI may have different correlates compared to other measures within this section. 3.5. Voice supremacy This was the largest category within the review and these appraisals included a number of dimensions. Voice supremacy partly included voices appraised as intrusive and controlling, assessed using relevant subscales from the PSYRATS-AHRS, the Hustig & Hafner (1990) self-report scale, the IVI, the Distressing Voices Questionnaire (DVQ, Morrison & Baker, 2000), and the Characteristics of Auditory Hallucinations Rating Scale (CAHRS, Oulis et al., 2007). Voices appraised as dominant were also combined into this category, and were measured by using the relevant subscale from the ‘relating’ questionnaires (Vaughan & Fowler, 2004), later refined as the Voice and You measure (VAY, Hayward, Denney, Vaughan, & Fowler, 2008). Appraisals of voice power and superiority were the final variables to complete this category, measured via the Voice Rank Scale and Voice Power Differential scale (VRS and VPD respectively, Birchwood et al., 2000) and the omnipotence subscales of the BAVQ and BAVQ-R. Overall, findings suggested that higher perceived voice supremacy was associated with higher levels of distress (Birchwood & Chadwick, 1997; Hacker et al., 2008; Hayward et al., 2008; Hustig & Hafner, 1990; Morrison & Baker, 2000; Morrison et al., 2004), anxiety (Chadwick, Lees, et al., 2000; van der Gaag et al., 2003) and depression (Birchwood et al., 2000, 2004; Chadwick, Lees, et al., 2000; Gilbert et al., 2001; Lucas & Wade, 2001; Oulis et al., 2007; Simms et al., 2007; Smith et al., 2006; Soppitt & Birchwood, 1997; Vaughan & Fowler, 2004). Voices high in supremacy were also considered more able to shame and humiliate the individual and were associated with feelings of ‘entrapment’ (Birchwood et al., 2004; Gilbert et al., 2001; Hacker et al., 2008). When entered into regression analyses, voice supremacy variables were found to be independent predictors of distress and remained significant after controlling for the influence of variables such as voice duration, frequency, and behavioral reactions to voices (Birchwood & Chadwick, 1997; Gilbert et al., 2001; Hacker et al., 2008; Lucas & Wade, 2001; Morrison & Baker, 2000; Vaughan & Fowler, 2004). Voices deemed as supreme were also appraised as malevolent (Birchwood & Chadwick, 1997). This might suggest that voice malevolence and supremacy are somehow related. However, this may not be in a straightforward way given results of the intervention trials outlined in the above ‘malevolence’ section, which suggested malevolent voice appraisals were not effectively targeted by cognitive techniques aimed at reducing beliefs about the dangerousness, power, meaning, and identity of voices. Interestingly, two studies suggested that the relationship between supremacy and distress was mediated by social schemata (Birchwood et al., 2000, 2004). Individuals who perceived their voices as powerful were more likely to experience similar feelings of powerlessness in social relationships, compared to those with voices perceived as low in power. This social appraisal of power was suggested to be the mechanism by which voice power appraisals were related to distress (Birchwood et al., 2000, 2004). Gilbert et al. (2001) also found that feelings of inferiority in voice hearers were experienced during both social and voice relationships. Finally, Andrew et al. (2008) found that trauma variables predicted beliefs about voice power. These studies provide further refinement to the cognitive model of voices, by examining how appraisals of voice supremacy might have developed, for

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Table 1 Demographic and methodological features of included studies. Sample size

Design

Measures assessing voice appraisals and distress

Key findings regarding appraisals and distress

Hustig and Hafner (1990) Australia

Sample: N = 12

Cross sectional

Voice self-report scale—reliability established in a sample of people with a diagnosis of schizophrenia

Voices appraised as distressing were associated with higher anxiety and depression; for over half of participants intrusive voice appraisals were associated with higher anxiety and depression

Drop out: N = 2 Sample: N = 62

Cross sectional

BAVQ and BDI—reliability and validity established a sample of people with a diagnosis of schizophrenia; CAS—reliability established in a sample of people with a diagnosis of schizophrenia; voice self-report scale

Individuals with malevolent voice appraisals were significantly more distressed and depressed than those with benign or benevolent voice appraisals. Voice power appraisals were associated with more depression. Power and malevolent voice appraisals were significant independent predictors of depression

Drop out: N = 5 Sample: N = 21

Cross sectional

BAVQ; BDI; voice self-report scale

Malevolent and derogatory voice appraisals were associated with significantly higher levels of depression than benevolent and nonderogatory voice appraisals. Perceived intrusiveness of voices was positively correlated with levels of depression

Drop out: NS Sample HV: N = 56

Cross sectional

PSYRATS-AHRS—reliability and validity established in a sample of people with a diagnosis of schizophrenia

Significant positive correlations between distress and appraisals of the amount and degree of negative content of voices

Drop out: NS Sample: N = 21

Experimental

BAI—reliability and validity established in clinical samples; BAVQ; BDI; PSYRATS-AHRS

Improvements pre to post treatment in appraisals of the distress and disruption caused by voices. Skewed data showed trends towards significance for improvements in appraisals of ownership, control, and power of voices from pre to post treatment

BAVQ; BDI; voice self-report scale; VPD and VPD—reliability established in a sample of people with a diagnosis of schizophrenia

Voices appraised as high in power were associated with higher depression. Voice related distress was predicted by social superiority. Voice power appraisals were predicted by social power, and voice superiority appraisals were predicted by social superiority

Birchwood and Chadwick (1997) UK

Soppitt and Birchwood (1997) UK

Haddock et al. (1999) UK Wykes et al. (1999) UK

Drop out: N = 11 Birchwood et al. (2000) UK

Chadwick, Lees, et al. (2000) UK

Chadwick, Sambrooke, et al. (2000) UK

Sample: N = 59

6 weekly group sessions of protocol based CBT Cross sectional

Drop out: N = 0 Sample: N = 73

Cross sectional

BAVQ-R—reliability and validity established in a sample of people with a diagnosis of schizophrenia; HADS—reliability and validity established in clinical samples and samples with psychiatric histories

Malevolent and omnipotent voice appraisals were positively correlated with depression and anxiety

Drop out: NS Sample: N = 22

Experimental

HADS; voice self-report scale; Likert scales to measure levels of omnipotence, control and personal meaning—not validated

Significant reductions post-intervention in appraisals of voice omnipotence and control, no significant changes on measures of anxiety or depression

Sample HV: N = 15

8 weekly group sessions of manual based CBT Cross sectional

DVQ—not validated; HADS

Worry and sadness about voices significantly correlated with appraisals of disapproval and removal from voices; regression analysis found that worry about voices was significantly predicted by appraisals of disapproval of voices

Drop out: NS Sample HV: N = 66

Cross sectional

BDI; VPD; VRS

Depression was significantly associated with appraisals of voice power and superiority; voice power and superiority was associated with social power and superiority. Voice power was a significant, independent predictor of depression

Drop out: NS Sample: N = 30

Repeated measures

BAVQ; BDI

Voices appraised as malevolent were also perceived as more powerful than voices appraised as benevolent. Perceived power of voices and depression produced a significant positive correlation.

Drop out: N = 17 Morrison and Baker (2000) UK

Gilbert et al. (2001) UK

Lucas and Wade (2001) Australia

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Authors, date and location

Table 1 (continued) Authors, date and location van der Gaag et al. (2003) Netherlands

Birchwood et al. (2004) UK

Copolov et al. (2004) Australia

Sanjuan et al. (2004) Spain

Trower et al. (2004) UK

Design

Measures assessing voice appraisals and distress

Key findings regarding appraisals and distress

Medication as usual Cross sectional

BAVQ; BDI; SSTAS—validity established in a clinical sample

Malevolent voice appraisals were related to higher depression and anxiety, whilst benevolent voice appraisals were related to lower anxiety and depression. Positive and negative voice content showed no significant relationships to anxiety or depression. Depression was independently predicted by malevolent voice appraisals; anxiety by power and benevolent voice appraisals.

Drop out: NS Sample: N = 125

Cross sectional

BAVQ: BDI; voice self-report scale; VPD; VRS

Voices appraised as more powerful and superior were significantly related to higher levels of distress and depression. Appraisals of voice power and superiority were associated with social power and superiority. Social rank and power mediated the relationship of voice rank and power with voice related distress and depression

Drop out: NS Sample: N = 199

Cross sectional

MUPS—reliability established in a sample of people with a diagnosis of schizophrenia

Negative affect was significantly greater when voices were perceived as having personal meaning and importance to the individual

Drop out: NS Sample HV: N = 41

Cross sectional

IVI—reliability and validity established in a none-clinical sample; PSYRATS-AHRS

Appraisals of loss of control and metaphysical beliefs about voices were significantly associated with higher distress. Positive beliefs produced no significant relationship with distress. Metaphysical beliefs about voices were a significant independent predictor of voice related distress.

Drop out: NS Sample: N = 106

Cross sectional

PSYRATS-AHRS plus added question about perception of experience as pleasurable (this question was not validated)

Pleasurable appraisal of voices was significantly negatively associated with amount and intensity of distress and degree of negative content, and was significantly positively associated with appraisals of control over voices.

RCT

BAVQ; CAS; CDS—reliability and validity established in a sample of people with a diagnosis of schizophrenia; PSYRATS-AHRS; VPD

Cognitive therapy led to significant reductions in appraisals of voice power, control, omniscience, and voice related distress. No significant changes in depression, appraisals of voice malevolence or negative content post-intervention. Significant positive correlations between voice related distress and appraisals of voice power and omniscience

Cross sectional

BDI–II—reliability and validity established in a clinical sample; voice self-report scale; relating questionnaires—reliability established in a sample of people diagnosed with schizophrenia

Voices appraised as dominant and intrusive were associated with higher levels of depression and distress. Multiple regressions found appraisals of voice dominance to be an independent predictor of distress.

RCT

PSYRATS-AHRS

CBT intervention more successful than supportive counselling intervention for reducing negative cognitive interpretations about voices but not for improving voice related distress

Sample HV: N = 57

16 sessions of protocol based CBT or Supportive Counselling Cross sectional

BDI–II; PSYRATS-AHRS

Individuals with higher levels of depression reported more negative voice content, perceived their voices to be less controllable and more disruptive and were more distressed in relation to their voices.

Drop out: NS Sample: N = 100

Cross sectional

CAHRS—reliability and validity established in a sample of people with a diagnosis of schizophrenia; HDRS—validity established in a clinical sample

Emotional impact of voices (appraisals of control and affective congruence with content) correlated positively to levels of depression.

Drop out: N = 34 Sample: N = 38 (therapy group: N = 18)

Individual cognitive therapy or treatment as usual Vaughan and Fowler (2004) UK

Valmaggia et al. (2005) Netherlands

Smith et al. (2006) UK

Oulis et al. (2007) Greece

Drop out: N = 31 Sample: N = 30

Drop out: N = 19 Sample: Intent to treat: N = 58. (CBT group: N = 36) Drop out: N = 20

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Morrison et al. (2004) UK

Sample size Drop out: N = 18 Sample: N = 54

example due to earlier social or traumatic experiences, as well as highlighting the process by which a relationship can exist between voice appraisals and distress, through previous social experiences. Three intervention studies stated that an aim of their therapy protocol was to reduce voice power cognitions (Chadwick, Sambrooke, Rasch, & Davies, 2000; Trower et al., 2004; Valmaggia et al., 2005) and as indicated previously one study (Wykes et al., 1999) did not state any specific appraisals which were targeted by the intervention. These four intervention studies reported reductions in appraisals of voice supremacy following CBT, although in two studies the findings only showed a ‘trend’ towards significance, most probably due to low sample sizes (Chadwick, Sambrooke et al., 2000; Wykes et al., 1999). However, reductions in distress were less consistent. While Wykes et al. (1999) reported improvements on a measure of voice related distress by their post-intervention assessment period, Chadwick, Sambrooke et al. (2000) found no significant changes on measures of anxiety and depression following their intervention. Results were also inconsistent in the two studies with more robust RCT designs and larger sample sizes. In the study by Trower et al. (2004), while general distress was significantly reduced post-intervention, levels of depression did not significantly change. In the study by Valmaggia et al. (2005), no changes in levels of distress were noted post-intervention. These outcomes suggest appraisals of voice supremacy may be targeted through CBT. However, the results are less conclusive regarding whether a direct link exists between power appraisals and distress, as was indicated by the correlational designed studies, and as proposed by the cognitive model.

Drop out: NS

3.6. Voice acquaintance

Notes: NS = Not Specified. HV = Hearing Voices.

Appraisals of voice dominance and intrusiveness were significantly and positively correlated with voice related distress and appraisals of voice malevolence and omnipotence. BAVQ-R; CAS, PSYRATS; VAY—reliability and validity established in a sample of people with a diagnosis of schizophrenia Cross sectional Hayward et al. (2008) UK

Drop out: N = 11 Sample: N = 30

Intensity of distress in relation to voices was significantly and independently predicted by appraisals of voice omnipotence and negative content. BAVQ-R; CAS; HADS; PSYRATS-AHRS Cross sectional Hacker et al. (2008) UK

Drop out: N = 3 Sample: N = 30

Malevolent voice appraisals were a significant independent predictor of depression; however only trauma variables independent predicted levels of anxiety. Trauma variables significantly predict appraisals of voice malevolence, benevolence and omnipotence. BAI; BAVQ-R; BDI–II; PSYRATS-AHRS Andrew et al. (2008) UK

Drop out: N = 6 Psychiatric sample: N = 22

Cross sectional

Positive correlation approaching significance between appraisals of voice malevolence and depression; negative correlation between depression and appraisals of voice benevolence. BAVQ-R; BDI, BHS Cross sectional Simms et al. (2007) UK.

Drop out: N = 2 Sample HV: N = 15

Acceptance of voices negatively correlated with levels of depression and appraisals of voice power. Acceptance of voices was an independent predictor of depression over scores on the BAVQ-R. BAVQ-R; CDS; PSYRATS; VAAS—reliability and validity established in a sample of people with a diagnosis of schizophrenia Shawyer et al. (2007) Australia

Cross sectional

Key findings regarding appraisals and distress Design Sample size

Drop out: NS Sample: N = 41

Measures assessing voice appraisals and distress

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Authors, date and location

Table 1 (continued)

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Appraisals of voices acquaintance were investigated in five studies and included voices deemed to be personally significant, important, or having omniscient knowledge of the individual. These were assessed using the ‘relationship’ section of the MUPS, the metaphysical subscale of the IVI and the omniscience subscale of the BAVQ. Although less frequently studied than the categories above, the evidence suggested that voices appraised as having personal acquaintance to the individual were related to higher levels of negative affect than voices lacking qualities of personal acquaintance (Copolov, Mackinnon, & Trauer, 2004; Morrison et al., 2004; Trower et al., 2004). Interestingly, in Birchwood and Chadwick's (1997) study voices appraised as high in personal acquaintance showed a trend towards being perceived as more benevolent. This may seem at odds with the above findings, as benevolent voices were reported to significantly relate to lower levels of distress (e.g., Simms et al., 2007). As Birchwood and Chadwick's (1997) finding did not reach 95% confidence level (p = 0.06) and has not been replicated in other studies, it is possible this is an anomalous finding. Voices perceived as having personal acquaintance to the individual were not consistently identified as being perceived as more supreme (Birchwood & Chadwick, 1997; Trower et al., 2004), which might suggest these are distinct concepts. However, in Birchwood et al.'s (2004) study power and omniscience were significantly related. This study (Birchwood et al., 2004) did recruit significantly more participants (N = 126) than the other two studies, and indeed Trower et al.'s (2004) study was slightly under power—with their sample size calculation being higher (N = 46) than their achieved recruitment (N = 38). As personal acquaintance was a relatively understudied concept and considering that some results are contradictory, conclusions regarding the relevance of this concept to the cognitive model and in particular how it relates to levels of distress are tenuous. 3.7. Approval and acceptance Approval and acceptance appraisals were assessed in two studies, using the relevant subscales of the DVQ to assess attitudes of approval and the Voice Acceptance and Action Scale (VAAS, Shawyer et al.,

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2007) to assess acceptance attitudes. The findings revealed that attitudes of disapproval towards voices were significantly and positively correlated with higher levels of sadness and worry (Morrison & Baker, 2000), whereas attitudes of acceptance towards voices were significantly negatively correlated with levels of depression (Shawyer et al., 2007). These correlations were all above r = .50, suggesting medium to high associations between variables. Results also remained significant after partialing out the variance explained by other voice related variables, such as physical characteristics and appraisals of voice supremacy and persecution. However, given that little attention was paid to these attitudes across other studies, these relationships are yet to be fully supported. 3.8. Methodological considerations of the studies Some methodological considerations affect the interpretation of the above findings. A number of studies recruited relatively low numbers of participants, with 7 studies recruiting fewer than 30 participants. These studies may have lacked the statistical power necessary to detect subtle differences, which may affect the conclusions that can be drawn. Furthermore, the statistically significant results reported by Hustig and Hafner (1990) were subject to reporting biases. The authors reported that due to having a non-homogenous sample, correlations were calculated separately for each of the 12 participants. Statistically significant scores for a link between appraisals and distress were only found ‘for half or more of the patients.’ Calculating separate statistics reduces the reliability of these findings. Drop-out rates were also high across all five intervention studies reviewed and ranged from 25.6% in the study by Valmaggia et al. (2005) up to 44.9% in the study by Trower et al. (2004). High drop-out rates may have resulted in these studies recruiting a biased sample. This may have increased the significance of the findings reported as participants who completed the trials will have been more likely to have experienced the interventions as helpful. This criticism will be especially relevant for the majority of studies where ‘intent to treat’ analyses were not conducted (however see Valmaggia et al., 2005). Another methodological limitation of note is that two of the subscales in the Voice to Hearer questionnaire utilized by Vaughan and Fowler (2004) were not internally valid. Although these subscales were excluded from their analyses this may have affected the overall reliability of the measure, and indeed the authors recommended further psychometric evaluations (Hayward et al., 2008; Vaughan & Fowler, 2004). Several studies also used newly validated measures to assess voice appraisals (Birchwood et al., 2000; Chadwick, Lees et al., 2000; Haddock et al., 1999; Hayward et al., 2008; Hustig & Hafner, 1990; Oulis et al., 2007; Shawyer et al., 2007). Other studies used nonvalidated Likert scales (Chadwick, Sambrooke et al., 2000), questionnaires that had been adapted without subsequent validation (Morrison & Baker, 2000; Sanjuan et al., 2004) and measures that had only been validated in non-clinical populations (Morrison et al., 2004). In such cases the concepts being measured may not have been perfected or robust, and so the integrity of the findings reported may have been affected. Furthermore, many of the studies assessing depression did not report whether negative psychotic symptoms, which have significant overlap with symptoms of depression, were controlled (e.g., Addington et al., 1993). Nevertheless, in Birchwood and Chadwick's (1997) study the relationship between voice malevolence and depression remained significant after controlling for the influence of negative symptoms, which may suggest that the appraisal–distress relationship is not a function of negative symptomatology. The CDS however, which was reported to have the ability to distinguish depressive symptomatology from negative symptoms in individuals diagnosed with schizophrenia (Addington et al., 1993), was only utilized in two of the studies included for review. In Shawyer et al.'s (2007) study, the negative association found between acceptance attitudes and depres-

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sion may thus be more reliable due to using the CDS. Trower et al. (2004) also used the CDS as part of their outcome assessment. Yet, scores on this measure, although these may be more reliable, did not notably change following intervention. However, this is perhaps due to mediating variables within the appraisal–distress relationship, such as social schemata, which were not addressed via the intervention. Another issue relating to the measures used in studies is that the assessment of ‘distress’ using the Hustig and Hafner (1990) scale and the measure of ‘omnipotence’ on the BAVQ are both based on just one question, which may not have been sensitive enough to measure the concepts fully. In addition, the BAVQ is a dichotomous rating scale and has previously been criticized for not measuring voice appraisals on a continuum (Morrison et al., 2004). The BAVQ-R has addressed these concerns, having a subscale of ‘omnipotence’ to measure power beliefs and using a more sophisticated 4-point Likert scale (Chadwick, Lees et al., 2000). Thus, studies using the revised BAVQ-R may have more accurately or fully assessed appraisals of voice omnipotence and may therefore have obtained more robust findings compared to studies using the earlier version of this questionnaire or the Hustig and Hafner (1990) scale. Finally, all of the studies reviewed here were undertaken in western societies, therefore making it difficult to generalize these findings. It is possible that different appraisals of voices are present across different cultures, and these may be related to distress in different ways. 3.9. Limitations of the review The definition of ‘appraisals’ across different studies affects the interpretation of the synthesised results of voice malevolence and benevolence. Although Chadwick and Birchwood (1994) found that beliefs about voice malevolence and negative voice content were in approximately 30% of cases unrelated, in the other 70% of instances the authors reported that individuals used examples of negative content as evidence to support the congruent malevolent beliefs they held about their voices. Furthermore, the finding that voice malevolence and negative voice content can be unrelated has not been corroborated in later studies (Close & Garety, 1998; van der Gaag et al., 2003). Indeed, van der Gaag et al. (2003) suggested that it is voices appraised as neutral in content that are more likely to give rise to a varied set of voice appraisals (for example both malevolence and benevolence). Nonetheless the authors suggested that voice content alone does not predict distress (van der Gaag et al., 2003). This might suggest that synthesizing malevolent voice appraisals alongside negative voice content, as done in the present review, is not always reliable and may have affected the interpretation of some of the above results. However, voice content can still be viewed as an appraisal or interpretation of the voice hearing experience. The assignment of ‘negative’ or ‘positive’ to the content of the voices' communications suggests some level of meaning making within this experience. For the present review, any aspect of voice hearing other than voice frequency, clarity, loudness, or duration was considered an appraisal of the experience. This was decided in order to include a wider range of voice appraisals as investigated using different measures, and by different researchers. However, researchers and clinicians should be mindful of which measures of voice appraisals are most likely to access the concept of interest, and they might consider comparing responses on different measures where uncertainty exists about the concept being assessed. The present review used the cognitive model to understand how a relationship might exist between voice appraisals and distress. However, in order to have a more focused examination with well defined variables, this review did not consider the relationship between voice appraisals and symptoms such as behavioral reactions. Previous reviews have considered factors associated with behavioral compliance with command hallucinations (e.g., Braham et al., 2004). However, there are a number of other areas of behavioral symptoms that might

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be related to cognitive appraisals of voices, for example self-harm and suicidal behaviors (e.g., Simms et al., 2007) submissiveness and closeness, (e.g., Hayward et al., 2008) and coping strategies such as safety behavior use, resistance and engagement (e.g., Chadwick & Birchwood, 1995; Hacker et al., 2008). Future reviews of this literature may provide further information in support or refinement of the cognitive model of voices. 4. Discussion The associations between cognitive appraisals of voices and distress were, at large, found across the reviewed studies. However, experimental designs indicated that modifying cognitions of malevolence and supremacy did not consistently reduce voice related distress, a reduction that is hypothesized by the cognitive model. It is possible that another underlying mechanism is involved within the appraisal–distress relationship. Indeed, results from Birchwood et al. (2000, 2004; Gilbert et al., 2001) suggest that underlying social schemata may mediate the relationship between cognitive appraisals of voice supremacy and malevolence and voice related distress. This may explain why studies have found a correlational relationship, but why cognitive interventions have not successfully reduced distress. It is possible that changes in voice related distress cannot be addressed via voice appraisals alone; perhaps mediating variables need to be the target for interventions to observe these changes. Furthermore, studies should be interpreted with caution given the limitations noted above. 4.1. Implications for future research The limitations of the studies included in this review, and the limitations of the review itself, indicate a number of important future investigations in order to continue to understand the suitability of the cognitive model as an explanatory framework for voice hearing. • The relationship between negative and malevolent voices. Uncertainty remains regarding whether voice hearers experience differently voices appraised as negative and voices appraised as malevolent. Although van der Gaag et al. (2003) suggest that negative voice content does not alone predict distress, evidence from the present review suggests that negative and malevolent voice appraisals share certain definitional properties and seem to typically correlate to voice distress in a similar direction. Thus, researchers may consider combining more than one assessment tool, such as both the CAS and the BAVQ-R, to measure similar voice appraisals within their research. This may help to delineate which aspect of the voice hearing experience the researchers are most interesting in accessing, and may help to highlight subtle differences in how each appraisal is related to voice distress. • Additional cognitive voice appraisals. Appraisals such as acceptance and personal acquaintance were seldom investigated across the included studies. Given that acceptance based treatments are becoming a contemporary approach to addressing common psychological issues (e.g., Bach & Hayes, 2002), the relationship of these attitudes towards voice related distress requires further investigation and may have significant implications for treatment. • The role of distress. While the small number of intervention studies included in this review reported preliminary evidence that CBT interventions may reduce beliefs about voice supremacy, distress was not consistently improved through intervention. Understanding the discrepancy between improvements on measures of voice appraisals and distress should be a key aim of future intervention trials, and directly addressing mood, anxiety, or distress during therapy may be a necessary refinement to these protocols. • Assessing mood. The review suggests that the measures used by researchers to assess voice related distress require more care and

attention. Measurement of distress may need to be more comprehensive than utilizing just one unvalidated Likert scale or a one question measure such as the Hustig and Hafner (1990) self-report scale. Moreover, it seems that measures that are able to distinguish between depressive symptomatology and negative symptoms of psychosis, such as the CDS, will help yield more reliable results in future research. If such measures are inaccessible to the researchers, the review suggests that the influence of negative symptoms should be controlled for during statistical analysis. • Mediating factors. Social cognition was found to be a mediator in the link between depression and voice supremacy (e.g., Birchwood et al., 2004). Researchers should therefore consider whether there is a role for incorporating interventions to improve social cognition within standard CBT protocols for distressing voices. Furthermore, it may be interesting to examine whether similar or different mediating variables affect the associations found between approval and acceptance attitudes and voice related distress. • Behavioral symptoms. As outlined above, a systematic review synthesizing the evidence of various cognitive voice appraisals and their relationships with behavioral reactions to voices such as coping, selfharm behavior and relating styles is necessary. This may provide further evidence in support of the cognitive model of voice hearing and may have significant implications for individuals seeking treatment for distressing voices. 4.2. Implications for clinical practice Results of the studies included for review lend some support to the cognitive model of voices. As preliminary understandings suggest, mediating variables such as social cognition may affect the voice appraisal–distress relationship. As such, incorporating interventions aimed at addressing these variables may be clinically relevant and produce effective treatment outcomes. For example, relational based approaches are emerging in the clinical literature (e.g., Hayward & May, 2007). Such interventions engage in conversational exchanges between the hearer and the voice, employing techniques from Gestalt and narrative therapy to develop more positive hearer-voice dynamics. As individuals have been found to relate to voices in a similar way to their style of social relating (e.g., Birchwood et al., 2004; Hayward, 2003), this may help inform relational interventions by understanding the typical patterns of relating the individual engages in. Clinicians may also be able to develop conversational exchanges between voice hearers and social others to develop more balanced relationships in these domains too. Reducing voice related distress during intervention requires greater attention, perhaps by incorporating cognitive techniques directly aimed at improving distress. However, given that some of the CBT trials in this review had high drop-out rates (e.g., Trower et al., 2004) alternative approaches may also need to be considered. Interventions such as compassionate mind training may be helpful for individuals experiencing distressing voices. Compassionate mind theory draws on attachment and evolutionary understandings of human experience. It suggests that where early attachment relationships were adverse the development of the affective ‘soothing’ system can be interrupted, leaving individuals more prone to experience their environment as threatening. The approach argues that by stimulating the affective soothing system, this regulates the experience of internal and external threats (Gilbert, 2005). In a recent case series of individuals experiencing distressing, malevolent voices, Mayhew and Gilbert (2008) found that by increasing the felt experience of positive, self-soothing emotions individuals were able to reduce the perceived hostility of their voices (Mayhew & Gilbert, 2008). Although originally developed for use with individuals with high levels of shame and self-criticism (e.g., Gilbert & Procter, 2006), compassionate mind training applied to voice hearing (Mayhew & Gilbert, 2008) may also hold promise for individuals experiencing distressing voices, especially if this distress

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has not been effectively targeted by other treatments. Acceptance and commitment therapy (e.g., Bach & Hayes, 2002) might also be appropriate where individuals hold attitudes of disapproval and rejection in relation to their distressing voices. This approach focuses on altering the individual's relationship with their attitudes, rather than the content of these attitudes. Once more, this might be particularly helpful if therapeutic interventions have previously been unsuccessful in reducing voice related distress. 5. Conclusions This review has found evidence for an association between several different appraisals of voices and distress; in particular, that voices appraised as malevolent and supreme were associated with higher distress. Future research will be beneficial to understand how the association between voice appraisals and distress are mediated by other underlying variables, and whether different mediators are evident for different voice appraisals. Experimental studies should consider which approaches are most likely to improve both cognitive appraisals and distress related to voices, and in particular whether addressing mediating factors such as social schemata produces more successful outcomes. Future research should also concentrate on using robust measures, larger sample sizes, cross-cultural validation, and RCT-designed experimental studies. Further replication of some of the more understudied voice appraisals, such as disapproval, acceptance and personal acquaintance, may provide more evidence in support or refinement of the cognitive model of voice hearing. Finally, the role of positive affect within voice appraisals is yet to be established. References1 Addington, D., Addington, J., & Maticka-Tyndale, E. (1993). Assessing depression in schizophrenia: The Calgary depression scale. British Journal of Psychiatry, 163(suppl. 22), 39−44. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 4th Ed. Washington, DC: Author. *Andrew, E. M., Gray, N. S., & Snowden, R. J. (2008). The relationship between trauma and beliefs about hearing voices: A study of psychiatric and non-psychiatric voice hearers. Psychological Medicine, 38, 1409−1417. Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129−1139. Baker, C. A., & Morrison, A. P. (1998). Cognitive processes in auditory hallucinations: Attributional biases and metacognition. Psychological Medicine, 28, 1199−1208. Beck, A. T., Epstein, N., & Brown, G. K. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893−897. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck depression inventory, 2nd Ed. San Antonio: The Psychological Corporation. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561−571. *Birchwood, M., & Chadwick, P. (1997). The omnipotence of voices: Testing the validity of a cognitive model. Psychological Medicine, 27, 1345−1353. *Birchwood, M., Gilbert, P., Gilbert, J., Trower, P., Meaden, A., Hay, J., et al. (2004). Interpersonal and role-related schema influence the relationship with the dominant ‘voice’ in schizophrenia: A comparison of three models. Psychological Medicine, 34, 1571−1580. Birchwood, M., Iqbal, Z., & Upthegrove, R. (2005). Psychological pathways to depression in schizophrenia. European Archives of Psychiatry and Clinical Neuroscience, 255, 202−212. Birchwood, M., Meaden, A., Trower, P., Gilbert, P., & Plaistow, J. (2000). The power and omnipotence of voices: Subordination and entrapment by voices and significant others. Psychological Medicine, 30, 337−344. Braham, L. G., Trower, P., & Birchwood, M. (2004). Acting on command hallucinations and dangerous behavior: A critique of the major findings in the last decade. Clinical Psychology Review, 24, 513−528. Carter, D. M., Mackinnon, A., Howard, S., Zeegers, T., & Copolov, D. L. (1995). The development and reliability of the Mental Health Research Institute unusual perceptions schedule (MUPS): An instrument to record auditory hallucinatory experience. Schizophrenia Research, 16, 157−165. Chadwick, P., & Birchwood, M. (1994). The omnipotence of voices: A cognitive approach to auditory hallucinations. British Journal of Psychiatry, 164, 190−201. Chadwick, P., & Birchwood, M. (1995). The omnipotence of voices II: The Beliefs About Voices Questionnaire, BAVQ. British Journal of Psychiatry, 166, 773−776.

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