The voice of feelings: Exploring emotion regulation processes in voice-hearers

Kelly R Cusworth

doi:10.60867/00000084

The experience of voice-hearing, clinically known as auditory verbal hallucinations, is defined as the perception of speech in the absence of any corresponding external auditory stimulus. Evidence indicates emotion processing difficulties are associated with the experience of voice-hearing. However, the research on specified mechanisms underlying these difficulties remains broad and not well understood, with research often conflating constructs relating to different phases of emotion processing. Therefore, this thesis aimed to contribute to this area by conducting a comprehensive, multi-method investigation into the constructs of emotion processing and their relationships with voice-hearing onset in daily life, within a transdiagnostic sample of voice-hearers. Specifically, it aimed to gain an integrated understanding of emotional reactivity, regulation, and alexithymia, by applying an extended theoretical emotion model, guided by Gross’ Extended Process Model of Emotion Regulation (1998, 2015) and the integrated Attention-Appraisal Model of Alexithymia (Preece et al., 2017). The thesis comprised three distinct but conceptually linked studies. The first study was a cross-sectional study comparing a voice-hearing group (n=50) to a control group (n=53) using self-report questionnaire measures of emotional reactivity, emotion regulation ability, habitual regulation strategy use, and alexithymia. The second study used a 7-day ecological momentary assessment (EMA) design with 40 voice-hearers, investigating momentary triggers of voice-hearing. It specifically differentiated the temporal roles of perceived momentary stress, pleasure, and emotion valence and intensity. The third study utilised alexithymia questionnaire data alongside EMA data of 40 voice-hearers to examine the dynamic interplay between trait alexithymia and momentary emotion valence, intensity, and usage of emotion regulation strategies within daily life. Study One, a cross-sectional study, revealed that, compared to controls, voice-hearers exhibit significantly higher alexithymia and global deficits in regulating both positive and negative emotions, alongside greater use of expressive suppression, despite no differences in emotional reactivity. Building upon this, Studies Two and Three explored daily life data, demonstrating (1) the perception of stressful events, rather than the intensity of self-reported negative emotion, was a significant predictor of concurrent and subsequent voice-hearing, and (2) higher alexithymia was associated with more intense negative and less intense positive emotions. Crucially, during voice-hearing periods, voice-hearers used more disengagement emotion regulation strategies than non-voice-hearing periods. Higher alexithymia tended to impair engagement strategy use during experiences of low positive emotion intensity or during voice-hearing episodes. Collectively, these findings suggest a clinical shift from targeting emotional reactivity to addressing alexithymia and the cognitive appraisal of stress in voice-hearers. This refines theoretical models of voice-hearing, indicating interventions should build emotional awareness and skills to manage stress appraisals. Addressing deficits in positive emotion regulation is also implicated as crucial for fostering resilience and well-being.

The voice of feelings: Exploring emotion regulation processes in voice-hearers

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