The role of inner speech on the association between childhood adversity and ‘hearing voices’

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The role of inner speech on the association between childhood adversity and ‘hearing voices’ Cherise Rosen , Simon McCarthy-Jones , Kayla A. Chase , Nev Jones , Lauren Luther , Jennifer K. Melbourne , Niyati Sudhalkar , Rajiv P. Sharma PII: DOI: Reference:

S0165-1781(19)30698-5 https://doi.org/10.1016/j.psychres.2020.112866 PSY 112866

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Psychiatry Research

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25 March 2019 17 December 2019 13 February 2020

Please cite this article as: Cherise Rosen , Simon McCarthy-Jones , Kayla A. Chase , Nev Jones , Lauren Luther , Jennifer K. Melbourne , Niyati Sudhalkar , Rajiv P. Sharma , The role of inner speech on the association between childhood adversity and ‘hearing voices’, Psychiatry Research (2020), doi: https://doi.org/10.1016/j.psychres.2020.112866

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Highlights 

In psychosis, increased childhood adversity and dialogic inner speech are associated with abuse and dysfunction scores.

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Significant total effect of childhood adversity was found in both auditory verbal hallucination and delusions.

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Childhood adversity, inner speech and psychosis are partially influenced by dialogic inner speech.

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Inner dialogic speech could be a specific mechanism through which childhood adversity leads to greater severity of auditory verbal hallucinations.

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The role of inner speech on the association between childhood adversity and ‘hearing voices’

Cherise Rosen1*†, Simon McCarthy-Jones2†, Kayla A. Chase1, Nev Jones3, Lauren Luther1, Jennifer K. Melbourne1, Niyati Sudhalkar1, & Rajiv P. Sharma1

1. Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA. 2. Department of Psychiatry, Trinity College Dublin, Dublin, Ireland. 3. Department of Mental Health Law & Policy, University of South Florida, Florida, USA

†

Joint first authors.

Word count: 7040 *Corresponding Author. Cherise Rosen, University of Illinois at Chicago, Department of Psychiatry, 1601 West Taylor, Suite 489, Chicago, Illinois, 60612. Telephone: (312) 355-5234. Fax: (312) 413-4503. Email: [email protected] Key Words: Childhood adversity; inner speech; psychosis; auditory verbal hallucinations; hearing voices; delusions

Abstract

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Adverse childhood experiences are associated with later development of psychosis, particularly auditory verbal hallucinations and delusions. Although auditory hallucinations have been proposed to be misattributed inner speech, the relation between childhood adversity and inner speech has not been previously investigated. The first aim was to test whether childhood adversity is associated with inner speech in persons with psychosis. The second aim was to test for the influence of inner speech on the association between childhood adversity and auditory hallucinations. Our final aim was to test for evidence that would falsify the null hypothesis that inner speech does not impact the relationship between childhood adversity and delusions. In persons with psychosis, we found a positive association between childhood adversity and dialogic inner speech. There was a significant total effect of childhood adversity on auditory hallucinations, including an indirect effect of childhood adversity on auditory hallucinations via dialogic inner speech. There was also a significant total effect of childhood adversity on delusions, but no evidence of any indirect effect via inner speech. These findings suggest that childhood adversities are associated with inner speech and psychosis. The relation between childhood adversity and auditory hallucination severity could be partially influenced by dialogic inner speech.

1. Introduction Adverse childhood experiences, characterized by abuse (e.g., sexual, physical, or threats of harm) and neglect before 18 years of age, often co-exist with symptoms of psychosis, including hallucinations and paranoia (Bernstein et al., 2003; Dominguez et al., 2011; Read et al., 2005). Studies show that increased rates of early childhood trauma are proportionally associated with the likelihood of developing symptoms associated with psychosis (Álvarez et al., 2015; Loewy et al.,

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2018; Mondelli & Dazzan, 2019; Morgan & Gayer-Anderson, 2016; Varese et al., 2012). Specific type of childhood adversity, including sexual, physical or threats of harm, have been directly linked to hallucinations and/or delusions (Bentall et al., 2012; Larøi et al., 2018; Muenzenmaier et al., 2015; Sitko et al., 2014). However, other research has found this association only partially supported, with other elements of structural adversity including poverty, foster care, and overall community violence also being associated with psychosis (Longden et al., 2016; A. L. Rosen et al., 2018; van Nierop et al., 2015). One prominent hypothesis is that auditory verbal hallucinations stem from a misattribution of inner speech (Frith, 1992; Bentall, 2004; Fernyhough, 2004; Jones & Fernyhough 2007a, 2007b; Langdon et al. 2009). The case for this begins with phenomenological parallels between inner speech and auditory hallucinations (Jones, 2010). In terms of volume, tone, emphasis, and affect, inner speech can have qualities comparable to both articulated speech and auditory hallucinations (Hurlburt et al., 2013). The experience of reading silently often includes the internal formation of full characterological entities that are separate and distinct from self, which is similar to the subjective phenomenological experience of hearing voices as described by hearers (Vilhauer, 2016; Rosen et al., 2016a). Physiological evidence also suggests a role of inner speech in auditory hallucinations. For example, prior work has found activation in speech musculature during auditory verbal hallucinations (Green & Preston 1981; Rapin et al., 2013); activation of left Broca’s area during experiences of auditory hallucinations (Jardri et al., 2011); and associations between auditory hallucinations and white matter changes in the arcuate fasciculus (Geoffroy et al., 2014); all of these findings have also been proposed to be consistent with a role of inner speech in auditory verbal hallucinations. Yet as the current state of evidence is in some ways equivocal (McCarthy-Jones, 2017), there is need for more theoretical and empirical

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work to determine the nature of the association between auditory verbal hallucinations and inner speech. A theory of auditory verbal hallucinations based on misattributions of inner speech need not posit alterations to the understanding of inner speech itself. The cause of auditory verbal hallucinations could be limited to processes involved in the monitoring of inner speech itself. However, alterations to inner speech could encourage its misattribution (Jones & Fernyhough, 2007a). At present, associations between dimensions of inner speech and auditory verbal hallucinations in clinical populations remain poorly understood and understudied, with no consistent pattern of associations having yet emerged (de Sousa et al., 2016; Langdon et al., 2009; Rosen et al., 2018). Nevertheless, if auditory verbal hallucinations were, in part, a result of alterations to inner speech then, given adverse childhood experiences are associated with a vulnerability for auditory verbal hallucinations, it is possible to hypothesize that the association between childhood adversity and auditory verbal hallucinations is partially explained by alterations to inner speech. There are some theoretical, if indirect, reasons to believe this may be the case. For example, childhood adversity reduces the structural integrity of arcuate fasciculus (Poletti et al., 2015), with the arcuate fasciculus contributing both to inner speech (Geva et al., 2011) and altered in those with auditory verbal hallucinations (Geoffroy et al., 2014). While it has been argued that childhood adversity can cause profound changes in behavior, cognition, and affect as well as shattering the internal sense of self (Garety et al., 2001), there have been no studies into the associations between childhood adversity and experiences of inner speech. However, related research has found a well-established relationship between childhood adversity and psychosis, specifically auditory verbal hallucinations and delusions (Varese et al., 2012; Boyda et al., 2018). Specific interactions between kinds of early adversity

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and specific psychotic symptoms are also well established, and have suggested that childhood sexual abuse, specifically rape, is distinctly associated with auditory hallucinations, whereas paranoia has been associated with delusions (Bentall et al., 2007; Bentall & Fernyhough, 2008; Bentall et al., 2012). Additionally, the severity of childhood adversity has been associated with the severity of auditory hallucinations and delusions (Bailey et al., 2018). Often the content of the auditory verbal hallucinations is thematically related to the trauma, with negative voice-content as a mediator between childhood adversity and distressing voices (Hardy et al., 2005; Rosen et al., 2018). Thus, to build on these related lines of work, this study attempted to undertake the first study of the associations of childhood adversity with inner speech experiences. This study also aimed to test whether childhood adversity may indirectly lead to auditory hallucination through its effect on inner speech. While alterations to inner speech could be operationalized in multiple ways (AldersonDay & Fernyhough, 2015), we employed a measure of inner speech inspired by Lev Vygotsky (1987). This measure, the Varieties of Inner Speech Questionnaire focuses on aspects of inner speech, relating to Vygotsky’s theoretical framework, namely dialogicality, expanded-condensed dimensions, evaluative or motivational aspects, and incorporation of other people’s voices (McCarthy-Jones & Fernyhough, 2011). In terms of the expanded-condensed dimension, expanded inner speech is comparable to regular, fully-formed overt speech. In contrast, condensed inner speech is an abbreviated, personalized ‘short-hand’ version of inner speech, which would likely not be comprehensible to another if they could hear it (Fernyhough, 1996). The dialogicality of inner speech refers to the extent to which this form of speech retains the toand-fro quality of conversation. Other people in inner speech involves the extent to which the person’s inner speech is ‘shot through’ with the voices of other people. Finally, evaluative or

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motivational inner speech, relates to internal comments or reflections on a given behavior or decision. It has been found that while the majority of people use dialogic, evaluative and positive/regulatory inner speech, at least sometimes, a minority of people report using condensed inner speech, and a smaller minority report experiencing other people in inner speech at least sometimes (Alderson-Day et al., 2018). To examine the relation between childhood adversity, inner speech, and psychosis, we first sought to test the hypothesis that adverse childhood event scores would be associated with inner speech scores. Second, we sought to explore whether childhood adversity indirectly impacts auditory hallucinations through inner speech (Figure 1). Finally, although there was a solid theoretical basis for hypothesizing that inner speech scores would influence the relation between childhood adversity and hearing voices, there is no clear reason to expect a link between delusions and inner speech (Rosen et al., 2018). We nevertheless set out to falsify the null hypothesis that there was no association in the relationship between childhood adversity and delusions via inner speech. A failure to disprove the null hypothesis would not be evidence of the absence of a role for inner speech in the relation between childhood adversity and delusions, as such a failure could be due to a lack of statistical power or measurement error. However, it would at least allow us to hypothesize that inner speech is specifically associated with the relation of childhood adversity and auditory verbal hallucinations, rather than of the relation between childhood adversity and psychosis, per se. Future research may then be performed to test this hypothesis. INSERT FIGURE 1 ABOUT HERE

2.

Methods

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The University of Illinois at Chicago IRB approved this research as part of a larger study and signed consent was obtained prior to initiation of any procedures (IRB2012-0113). The clinical sample was randomly selected from a large urban university medical center that included referrals from community treatment facilities. Inclusion criteria for the study was comprised of participants between the ages of 21 – 60 who met diagnostic criteria for schizophrenia or bipolar disorder with psychosis. Consensus diagnoses were determined by the SCID (First et al., 2002), and available collateral information. Exclusion criteria included current substance dependence, seizure disorders, and neurological conditions. Demographic characteristics and clinical metrics were obtained at the study evaluation. 2.1

Participants

Seventy-eight people experiencing present state psychosis (schizophrenia (n=57) and bipolar disorder (n=21)) and who had full data on primary variables used for this analysis. The sample consisted of persons with lifetime experience of auditory verbal hallucinations, of which 86% reported auditory verbal hallucinations in the prior week.

2.2

Measures

2.2.1 Adverse Childhood Experiences. To assess types of childhood adversity experienced, the Adverse Childhood Experiences questionnaire was utilized (Reavis, 2013). This ten-item self-report questionnaire assesses past childhood experiences of abuse (“emotional, physical, and sexual”), neglect (“emotional and physical”), and household dysfunction (“battered mother, parental abandonment, substance-abuse, mentally ill, or incarcerated household member occurring before a person’s 18th birthday”).

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Adverse Childhood Experiences total scores range from 0-10, with increased exposure reflected by higher scores. The internal reliability for this study was 0.79.

2.2.2 Varieties of Inner Speech Questionnaire (VISQ) The VISQ is a self-administered, 18-item scale which measures experiences of inner speech (McCarthy-Jones & Fernyhough, 2011), and is a theoretically informed measure based on language development by Vygotsky (Lev Vygotsky, 1987; McCarthy-Jones & Fernyhough, 2011). Values of the scale range from 1 - “Certainly does not apply to me” to 6 - “Certainly applies to me.” The measure consists of four unique dimensions of inner speech: dialogicality (“when I am talking to myself about things in my mind, it is like I am going back and forward asking myself questions and then answering them”), dimensions of evaluative and motivational characteristics (“I think in inner speech about what I have done, and whether it was right or not”), condensation (“I think to myself in words using brief phrases and single words rather that full sentences”) and dimensions that evaluate presence of other people (“I hear the voice of another person in my head. For example, when I have done something foolish, I hear my mother’s voice criticizing me in my mind”). Internal reliability was between 0.82 to 0.90 for all inner speech subscales.

2.2.3 Psychotic Symptom Rating Scales (PSYRATS) PSYRATS evaluates auditory verbal hallucinations and delusions (Haddock et al., 1999). The auditory verbal hallucinations subscale measures “frequency, duration, location, loudness, beliefs regarding origin of voices, controllability, disruption, negative content (amount and intensity) and

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distress (amount and intensity)”. The delusions subscale measures “preoccupation (amount and duration), conviction, distress (amount and intensity), and disruption to life caused by beliefs.” PSYRATS utilizes a 5-point Likert scale along a severity continuum ranging from 0 to 4. Internal reliabilities of the auditory verbal hallucinations and delusions subscale were 0.88 and 0.94, respectively.

2.4

Data Analysis

Statistical analysis was performed with SPSS version 24.0. Bivariate correlations using Pearson’s r with confidence intervals were computed using 1,000 bootstrapped samples and were examined between childhood adversity cumulative and subscale scores and inner speech subscales. Total, direct, and indirect associations between childhood adversity scores and PSYRATS auditory verbal hallucinations subscale were measured by PROCESS computational tool (Hayes, 2018), to test for the association using a regression-based approach. Bias corrected, 5,000 bootstrapped, 95% confidence intervals were used to test for an indirect relationship between three of four inner speech subscales; examination of the relation was suggested if intervals did not include zero. The other people inner speech subscale and PSYRATS auditory verbal hallucinations subscale (r=0.56, p<0.001) were found to be positively associated. This was expected due to the overlap between other people inner speech subscale items and voice-hearing experience. Thus, the other people subscale was hence excluded from these analyses, due to amount of variance in PSYRATS auditory verbal hallucinations scores it would account for. Age and sex were entered as covariates. A parallel model of association was employed (PROCESS model 4). Covariates were used in models of both the intermediate and the dependent variable. Finally, we repeated this

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approach to test for total, direct, and indirect associations between childhood adversity scores and PSYRATS delusion subscale scores.

3. Results 3.1.

Descriptive demographic characteristics

Participants consisted of primarily African-American persons with schizophrenia who experienced current and persistent psychotic symptoms (Table 1). Duration of illness mean score was 25.77 years in persons diagnosed with schizophrenia and the duration of illness mean score for persons diagnosed with bipolar with psychosis was 25.04 years. Demographic variables were not different between subjects with schizophrenia and bipolar with psychosis, thus, the sample was combined in analysis. INSERT TABLE 1 ABOUT HERE

3.2

Relations between childhood adversity and inner speech scores

Bivariate correlations between childhood adversity scores and inner speech scores are presented in Figure 2. There was a positive correlation between adverse childhood event total score and dialogic inner speech subscale. When we broke this down further, examining correlations between childhood adversity subscale scores and the dialogic subscale, it emerged that the positive correlation between the adverse childhood event total score and dialogic was driven by a significant correlation between dialogic inner speech and both childhood abuse and dysfunction scores. Dialogic inner speech was not correlated with childhood neglect scores.

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There were no relations between adverse childhood experiences total scores and condensed inner speech subscale, nor any of childhood adversity subscale (abuse, neglect, and dysfunction) scores. Adverse childhood experiences total scores and other people inner speech subscale scores were positively correlated. This relationship also held for other people subscale and neglect and dysfunction. Likewise, the evaluative and motivational inner speech subscale and childhood adversity total scores revealed a positive correlation. When childhood adversity scores were broken down by subscale, it was found that only childhood abuse correlated with evaluative and motivational characteristics of inner speech and not childhood neglect or dysfunction . INSERT FIGURE 2 ABOUT HERE

3.3

Testing for indirect effects of childhood adversity on auditory verbal hallucinations via

inner speech The PROCESS computational tool was used to assess total, direct, and indirect associations between total childhood adversity scores and PSYRATS auditory verbal hallucinations scores in the 78 persons with psychosis who had full data on all these variables. The three inner speech subscales (excluding other people inner speech subscale) were entered as intermediate variables, and age and gender were selected as covariates. There was a significant total effect of adverse childhood event total scores on PSYRATS auditory verbal hallucinations scores. Evidence was found of an indirect effect of adverse childhood event total scores on PSYRATS auditory verbal hallucinations scores via dialogic inner speech subscale scores. Given the relation between adverse childhood experience total scores and inner speech subscales masked some specific relations between childhood adversity subscale

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scores and inner speech subscales, we repeated the analyses for childhood abuse, neglect, dysfunction scores (Table 2, Figure 3). There was also evidence of an indirect effect of childhood abuse and dysfunction (but not childhood neglect scores) on PSYRATS auditory verbal hallucinations scores via dialogic inner speech subscale scores. See Supplemental table 1 for details of model. INSERT TABLE 2/FIGURE 3 ABOUT HERE

3.4

Testing for indirect effects of childhood adversity on delusions via inner speech

The PROCESS computational tool was used to assess total, direct and indirect associations between total childhood adversity scores and PSYRATS delusions subscale scores in the 78 persons with psychosis who had full data on all these variables. The three inner speech subscales (excluding other people inner speech subscale) were entered in the analysis as intermediate variables, and age and gender as covariates. There was a significant total effect of adverse childhood experience total scores on PSYRATS delusions scores, effect size=0.55 (95% CI = 0.14 – 0.96), SE=0.20, p=0.009. This was comprised of a significant direct effect, [effect size=0.45 (95% CI = 0.03 – 0.88), SE=0.22, p=0.04] but no indirect effect on any of three inner speech subscales examined. Similarly, there were no indirect effects of either childhood abuse, neglect, or dysfunction on PSYRATS delusions scores, via any of the three inner speech subscales examined.

4. Discussion This is the first study to investigate the relationships between childhood adversity and inner speech, and the first study to test for evidence consistent with inner speech alterations influencing

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the relationship between childhood adversity and symptoms of psychosis (i.e. hearing voices and delusions). Results of this study provide evidence of a positive association between cumulative exposure of childhood adversity, including specific types of adversity (i.e., abuse, neglect, and dysfunction), types of inner speech, and psychosis. Additionally, this study also provides evidence consistent with the hypothesis that the relation between childhood adversity and auditory verbal hallucinations is influenced by inner speech, specifically increases in dialogic inner speech. 4.1

Adverse childhood experiences and inner speech subscales

Interestingly, we found that cumulative exposure to childhood adversity was associated with greater dialogic, other people, and evaluative or motivational characteristics of inner speech, but that it was not associated with levels of condensed inner speech. Adverse childhood experiences that were related to physical and/or sexual abuse were significantly correlated with higher dialogic and evaluative or motivational inner speech, whereas childhood neglect was associated with greater other people inner speech. Lastly, overall environmental dysfunction was associated with more dialogic and other people inner speech. These findings suggest that the extent of exposure and type of childhood adversity are related to, and perhaps even shape specific types of inner speech. These findings also align with prior research. For example, our previous research showed that the content of voices and delusions were often associated with cumulative lifetime exposure to adverse experiences, including childhood adversity (Rosen et al., 2017; Chase et al., 2018). Consistent with our finding that childhood adversity had a direct effect on AHVs, several prior studies have identified evidence supporting a causal relationship between trauma and the manifestation of hallucinations, with some studies reporting a five-fold increase in verbal

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hallucinations associated with trauma (Freeman and Fowler, 2009; John Read et al. 2003). Similarly, a recent qualitative study by Vallath et al. (2018) suggests that exposure to adverse life experiences can be a contributing factor in the pathogenesis of auditory verbal hallucinations. The observed relationships between childhood adversity and inner speech are also consistent with theoretical models examining the development of auditory hallucinations. Auditory verbal hallucinations have long been considered a misattribution of inner speech in that they similarly consist of words and sentences that are heard exclusively by the voice-hearer (Gould, 1949; Leudar et al., 1997). Multiple models regarding the genesis of auditory verbal hallucinations have been put forward (Jones 2010), including some suggesting select types of auditory hallucinations may actually be memories of earlier traumatic experiences (Hardy et al., 2016). Here, the content of voices is likely to mirror elements of negative past experiences or may actually be experienced as the voice of their former abuser (Daalman et al., 2012). Likewise, consistent with the direct effect we observed between childhood adversity and delusions, multiple studies have reported on the relationship between trauma and delusions (Catone et al. 2016; Longden et al., 2016; van Nierop et al., 2015). Risk of experiencing delusions has been linked to childhood adversity (Scott et al., 2007). Adverse childhood experiences and other negative life experiences have been shown to be directly related to content of both auditory hallucinations and delusions, and that content is not random but rather part of the individual’s life narrative (Moernaut et al. 2018; Reiff et al. 2012; Vallath et al. 2018). Although our study supports a cross-sectional association between trauma and auditory hallucinations, future longitudinal work could help to identify a causal link between these variables.

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Adverse childhood experiences, inner speech, auditory verbal hallucinations and clinical

implications Although this study could not assess causation due to its cross-sectional nature, we falsified the null hypothesis that inner speech does not influence the relation between childhood adversity scores and auditory verbal hallucination severity. Specifically, we found evidence consistent with greater levels of childhood adversity being associated with greater levels of dialogic inner speech, which in turn predicted greater severity of auditory verbal hallucinations. In contrast, we failed to find evidence falsifying the null hypothesis that the relation between childhood adversity and delusions is not influenced by inner speech. However, as absence of evidence is not evidence of absence, better powered studies into this question are needed. Nevertheless, this allows us to hypothesize that inner speech is specifically impacts the childhood adversity -auditory verbal hallucinations relation, rather than of the relation between childhood adversity and psychosis, per se. Further research is needed to test this proposal. We also note that we found no evidence that either condensed or evaluative inner speech significantly influenced the relations between childhood adversity and auditory verbal hallucinations. Together, this suggests that inner dialogic speech could be a specific mechanism through which childhood adversity leads to greater severity of auditory verbal hallucinations. If this pattern of findings was replicated by future longitudinal work, then these findings support future clinical treatment strategies that underscore the interconnectedness and triangulation of childhood adversity, dialogic inner speech, and auditory verbal hallucinations. Specifically, any such future findings would suggest that psychotherapeutic strategies with greater attention to the impact of childhood adversity on dialogic inner speech may, in turn be effective in reducing auditory hallucinations. Similarly, targeting dialogic speech could help to reduce the

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impact childhood adversity has on AVH severity. This triangulation would require a multipronged approach that transcends the parameters of clinical intervention to also include issues of societal structural adversity, prevention, and protective factors. These findings highlight the importance of approaches that help to protect against the impact of childhood adversity. A recent publication by Crush et al. (2018) reported that a supportive social structure may protect against either onset or intensity of subsequent psychosis in persons who have experienced childhood adversity. This would require that persons at the interface, including clergy, teachers, first responders, criminal justice systems, mental health providers and other various service systems are knowledgeable of, and part of developing overarching trauma-informed systems (Ko et al., 2008). Thus, one of the first steps in developing trauma-informed systems is to evaluate childhood adversity as part of the clinical assessment process. A recent meta-analysis of 21 studies examining the prevalence of the evaluation of childhood adversity such as abuse or neglect conducted by mental health professional showed that less than one-third (28%) receive an evaluation of childhood abuse and neglect, and amongst mental health service users this percentage is even lower, ranging from 0% to 22% (Read et al., 2018). In addition to the evaluation of childhood adversity, trauma informed care requires systemwide and inter-system education regarding the identification and impact of trauma, and finally the integration of this knowledge into policies, procedures, and practices (Oral et al., 2016; SAMHSA, 2015) Results of this research also suggest a need for developing interventions that integrate the link between childhood adversity, inner speech and voices. Given this complexity and interrelated dynamics, insights into the experiential world using phenomenological informed assessments and

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psychotherapy to guide and individualize interventions that provide the foundation by which one can move toward recovery (Škodlar and Henriksen, 2018). Such interventions may place increased attention to inner speech in relation to trauma (Merrick et al., 2018). In persons who have experienced childhood adversity and experience hearing voices, interventions that incorporate strategies to address negative content of inner speech related to such adversity may serve to help manage and reduce distressing voices related to trauma. Our findings of an indirect effect of childhood adversity in auditory verbal hallucinations via dialogic inner speech, if replicable and causal, would suggest the need to explore why childhood adversity should increase the presence of such inner speech and precisely how this plays a role in making auditory verbal hallucinations more severe. Overarching strategies to target these domains could include the Maastricht approach, phenomenological assessments and psychotherapy, cognitive analytical therapy, or emotion regulation strategies (Corstens, et al. 2008; Larøi et al. 2018; Ryle, et al. 1990; Vallath et al. 2018). This work occurs in a context of multiple studies showing that interpersonal dialogical relating between voice-hearer and auditory verbal hallucinations are effective in reducing level of distress and increasing control over the experience of hearing voices (Hayward et al., 2009; Thomas et al., 2014). Therapies that focus on active engagement with voices is considered one of the primary interventions in changing the relationship thus decreasing level of distress (Corstens,et al. 2012; Romme, et al. 2009). A recent exploration of effective components of avatar therapy has also identified dialoguing with voices as a primary element of the intervention in reducing level of distress (Dellazizzo et al., 2018). Likewise, compassion focused therapy involves dialoguing with voices and working toward understanding the positive intention of voices while integrating greater self-compassion by utilizing biopsychosocial strategies. (Heriot-

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Maitland et al. 2019). Finally, metacognitive approaches have been shown to be effective in treating both psychosis and posttraumatic stress independently; thus, interventions designed to address multipronged elements of childhood adversity and psychosis simultaneously may be beneficial (Lysaker et al. 2018; Wells and Colbear 2012). Given the high prevalence of persons with both childhood adversity and psychosis, and that our data show an indirect effect of childhood adversity on PSYRATS auditory verbal hallucinations scores via dialogic inner speech, a more integrated approach that examines the degree and type of childhood adversity in relation to inner speech and auditory verbal hallucinations is warranted. However, our findings do need to be considered in relation to the inconsistent patterns of previous findings relating to auditory verbal hallucinations and dialogic inner speech. Langdon et al. (2009) found only weak evidence for dialogic inner speech being associated with auditory verbal hallucinations, although they did not use a psychometrically tested measure of dialogic inner speech. de Sousa et al. (2016) failed to find an association between dialogic inner speech and hallucinations in a clinical population, but did not use a specific measure of auditory verbal hallucinations. Alderson-Day et al. (2018) failed to find evidence for an association between auditory verbal hallucinations and dialogic inner speech. However, they included items from the Other People inner speech subscale in their regression analyses, and also controlled for levels of dissociation. Thus, it needs to be considered what the best way, if at all, to use the Other People inner speech subscale in auditory verbal hallucinations research, as well as what range of confounding/mediating variables are necessary to build testable models of the adverse childhood experiences - auditory verbal hallucinations relationship. 4.3. Limitations

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First, the adverse childhood experiences results reported are of retrospective data, collected at one time-point, and thus can only establish correlations, not causality. While we had no additional methods for establishing veracity of childhood adversity disclosures, retrospective accounts of adversity in populations with psychosis have shown this information to be reliable and valid (Darves-Bornoz et al. 1995; Fergusson et al. 2000; Fisher et al. 2011; Goodman et al. 1999). Another limitation of this study is that the small sample size increased the likelihood of Type II errors, and better powered follow-up studies are needed. The predominately African-American sample of this study were situated in a segregated urban environment, layered with complex trauma, increased exposure to childhood adversity, and community/structural adversity that may limit generalizability of findings (Rosen et al., 2017). Additionally, there are limitations by which conventional quantitative measures can capture the deep underlying phenomenological constructs of auditory verbal hallucinations and delusions, as they typically co-exist and at times can be indistinguishable (Jones & Luhrmann, 2016; Rosen et al. 2016b). Thus, to better capture these nuances, future research should be designed to include a phenomenological mixed-methods investigation of inner speech vis-à-vis voices and delusions. It should also be noted that, subsequent to the design of this study, a revised version of the VISQ scale has been published (Alderson-Day et al., 2018), which includes new items that loaded onto a ‘positive/regulatory’ factor. This factor captures the ability of a person to use their inner speech to self-regulate, such as the ability to use inner speech to control mood. Given such regulation is a key function of dialogic inner speech, it would be interesting for a future study to use the revised VISQ to test the hypothesis that the indirect effect we found of childhood adversity on auditory verbal hallucinations via dialogic speech is due to individuals being less able to use dialogic inner speech to regulate their cognition and affect.

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In conclusion, in this first study of the interrelationship between childhood adversity, inner speech and psychosis (auditory verbal hallucinations and delusions), we consider our results as follows. Our study suggests that childhood adversity is associated with alterations to specific forms of inner speech. These changes are associated with auditory verbal hallucinations, but not delusions. Thus, individualized phenomenological informed clinical interventions that aim to target auditory verbal hallucinations severity may in future target and consider the influence of both childhood adversity and inner speech (particularly dialogic inner speech). Future work is also needed to elucidate a better understanding of causal/determining factors, dynamics, underlying mechanisms, and related outcomes of the association between childhood adversity and auditory verbal hallucinations. As part of this, it is essential that persons with lived experience of early childhood trauma and psychosis, particularly hearing voices, are collaborators in future research development to move this area further into nuances of the triangulation of early childhood trauma, inner speech and psychosis.

Acknowledgement The authors would like to thank all the individual who participated in this study as their contribution made this research possible.

Funding This work was supported in part by PHS grant (NIH) R01 MHO094358 (R.P.S).

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C Rosen and R Sharma conceived and planned the experiments. C Rosen, KC Chase, JK Melbourne and N Sudhalkar carried out the experiments. C Rosen, KC Chase, JK Melbourne and N Sudhalkar contributed to sample preparation. C Rosen and S McCarthy-Jones were lead authors. All authors contributed to the interpretation of the results and writing the manuscript. All authors provided substantial and critical feedback and helped shape the research, analysis and manuscript.

Conflict of Interest: There are no actual or potential conflict of interest that could inappropriately influence or be perceived to influence this work.

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285). Wells, A., & Colbear, J. S. (2012). Treating posttraumatic stress disorder with metacognitive therapy: a preliminary controlled trial. Journal of Clinical Psychology, 68(4), 373–381. doi: 10.1002/jclp.20871

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Table 1: Demographic and clinical characteristics of sample Psychosis 78

Total (n) Sex (n) Race (n)

Female Male Caucasian, non-Hispanic Black, non-Hispanic Hispanic

49% (38) 51% (40) 17% (13) 75% (59) 8% (6) Mean SD Age 46.69 11.17 Age at onset of illness 19.56 7.08 Duration of untreated psychosis 5.63 8.60 Duration of illness 27.01 13.21 Note. SD = Standard deviation. Age, age at onset, duration of untreated psychosis and duration of illness are all given in years

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Table 2: Total, direct and indirect associations between adverse childhood experiences scores and PSYRATS - auditory verbal hallucination scores, via dialogic inner speech subscale, in psychosis sample (n=78). Total Effect

Direct Effect

Significant Indirect Effects

effect size (95% CI), standard error

effect size (95% CI), standard error

effect size (95% CI), standard error

ACE total

1.44 (0.56-2.33), 0.45, p =.002

1.28 (0.38-2.18), 0.45, p=.006

VISQdialogic 0.53 (0.04-1.28), 0.32, p<.05.

ACE abuse

0.85 (-1.00-2.70), 0.93, p=.36

0.62 (-1.21-2.45), 0.92, p=.50

VISQdialogic 0.89 (0.01-2.15), 0.56, p<.05.

ACE neglect

4.75 (1.96-7.54), 1.40, p=.001

4.50 (1.73-7.28), 1.39, p=.002

All non-significant

ACE dysfunction

3.39 (1.53-5.25), 0.93, p=.0005

2.94 (1.04-4.83), 0.95, p=.003

VISQdialogic 1.04 (0.03-2.64), 0.67, p<.05.

Note: Figure abbreviation are noted as such: VISQdialogic = dialogic inner speech subscale. ACE = adverse childhood experiences and specific subscale.

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Figure 2. Relations between childhood adversity and inner speech

ACEs_total

ACEs_abuse

ACEs_neglect

ACEs_dysfunction

0.110 [-0.104, 0.313] VISQ 0.284[0.072, 0.485] 0.226 [0.023, 0.422] 0.293 [0.084, 0.486] p = 0.34 dialogic p = 0.01 p =0.05 p = 0.009 0.094 [-0.111, 0.301] 0.056 [-0.155, 0.253] 0.204 [0.009, 0.389] 0.005 [-0.208, 0.234] VISQ p = 0.41 p =0.63 p = 0.07 p = 0.97 cond 0.186 [-0.049, 0.414] VISQ 0.309 [0.063, 0.512] 0.308 [0.097, 0.497] 0.256 [0.016, 0.465] p = 0.10 other p = 0.006 p = 0.006 p = 0.02 0.087[-0.119, 0.297] 0.211 [-0.005, 0.400] VISQ 0.246 [0.051, 0.439] 0.239 [0.022, 0.422] p = 0.45 p = 0.06 evalmot p = 0.03 p = 0.04 Note. Confidence intervals calculated using 1,000 bootstrapped samples; *p≤0.05. **p≤0.01. ***p≤0.00 Figure abbreviation are noted as such: VISQ dialogic = dialogic inner speech subscale; VISQ cond = condensed inner speech subscale; VISQ other = other people inner speech subscale; VISQ evalmot = evaluative or motivational inner speech subscale. ACE= adverse childhood experiences and specific subscale.

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Figure 3: Associations between childhood adversity, inner speech, and auditory verbal hallucinations

Note: Analysis (with covariates). All coefficients are unstandardized and significant at p < 0.05.

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