Georgie Paulik-White

Background
In psychosis spectrum disorders, maladaptive mental imagery is associated with auditory verbal hallucinations (AVHs). This study evaluates the feasibility, acceptability, and effectiveness of the following 4 imagery techniques in targeting mental imagery and AVHs severity: Imagery Rescripting (ImRs), Promoting positive Imagery de novo (Pos-Im), Metacognitive Imagery techniques (Meta-Im), and playing Tetris.

Study Design
Four replicated single-case series experimental designs were used. Participants were randomized to 1 of the 4 treatment conditions. Primary, we measured the severity of mental imagery and AVHs thrice daily on an 11-point VAS scale during a 2-week baseline, throughout 3 weeks of therapy, and during a 2-week follow-up phase. Randomization tests were used to examine whether daily severity levels of momentary mental imagery and AVHs decreased post-therapy. Secondary, questionnaires assessing the severity of AVHs, mental imagery characteristics, and levels of mood, anxiety, and functioning were administered at baseline, before, and posttreatment.

Results
Twenty-eight participants completed all treatment sessions. Mental imagery significantly decreased after ImRs (P < .001, d = 1.13) and Pos-Im (P = .039, d = 0.22), with no significant effects observed following Meta-Im or Tetris. AVHs significantly decreased with all treatment conditions, with largest effects for ImRs (P = .001, d = 1.39) and Pos-Im (P < .001, d = 1.99). Secondary results demonstrated reductions in the severity of AVHs, mood, anxiety, imagery frequency, and appraisals.

Conclusions
Imagery techniques appear feasible and acceptable for addressing mental imagery and AVHs in the psychosis continuum and may be valuable additions to current treatment for AVHs.

Background
Negative emotions and stress are theorised to play a role in the onset and maintenance of voice-hearing experiences. However, previous research has not explored these temporal relationships in daily life using differentiated psychological constructs.

Aim
Using ecological momentary assessment, this study examined the moment-to-moment relationships between negative and positive emotion valence and intensity, stressful and pleasurable events, and voice-hearing onset.

Materials & Methods
Forty voice-hearers completed seven days of smartphone-based surveys, rating their emotions and their intensity, perceived stress and pleasure of life events, and presence of voice-hearing.

Results
Multilevel modelling showed that stressful events, but not pleasurable events, were significantly predictive of voice-hearing, both concurrently and in the next time point. Neither negative nor positive emotion intensity predicted voice-hearing, nor did they moderate the relationship between voice-hearing onset and stressful or pleasurable events, respectively.

Discussion
These findings suggest that factors which differentiate perception of stressful events from self-reported negative emotions may be useful intervention targets, such as mitigating prolonged external stressors, reducing sensitivity to external stressors and targeting negative perceptions or resistance to these stressors.

Conclusion
Clinically, our findings underscore the relevance of stress and a negative perception of externally oriented events, with further research needed to explore useful interventions for targeting these mechanisms.

Many trauma-affected voice hearers report comorbid posttraumatic stress and voices (auditory verbal hallucinations) that are directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma are thematically similar) related to their trauma. Models of PTSD and positive symptoms of psychosis are insufficient in explaining the comorbidity between PTSD and voices, and interventions based on these models have limited effectiveness in treating voices. This study presents a model that generates novel research into the factors underlying trauma-related voices that may inform effective interventions. Maintaining factors from existing models of PTSD and positive symptoms were combined into an integrative model of trauma-related voices. Theorised relationships between factors were used to identify possible differential pathways to direct and indirect voices. An integrative, trauma-related voices (TRV) model was developed that identifies multiple causal pathways to trauma-related voices. A future research agenda is proposed to test novel hypotheses based on the integrative model. The TRV model is a practical tool for complex case conceptualisation and generates novel hypotheses that may inform more effective treatments. Future studies are needed to test elements of the TRV model and should recruit transdiagnostic samples with diverse posttraumatic stress and voice hearing symptoms.

Introduction
Visual hallucinations (VH) are more common than previously thought and are linked to higher levels of distress and disability in people with a psychotic illness. Despite this, scant attention has been given to VHs in the clinical literature, and the few therapy case series of cognitive behavioural therapy (CBT) published to date have not demonstrated reliable change. In other areas of clinical research, problematic mental imagery has been found to be more strongly related to negative affect in psychological disorders than negative linguistic thinking, and imagery focused techniques have commonly been found to improve the outcomes in CBT trials. Given VHs have many similarities with visual mental imagery and many of the distressing beliefs associated with VHs targeted in CBT are maintained by accompanying mental imagery (i.e., imaging a hallucinated figure attacking them), it seems plausible that an imagery-focused approach to treating VHs may be most effective.

Methods
The current study is a multiple baseline case series (N = 11) of a 10-session imagery-focused therapy for VH in a transdiagnostic sample.

Results
The study had good attendance and feedback, no adverse events and only one [seemly unrelated] drop-out, suggesting good feasibility, safety and acceptability. The majority of clients reported reduction on both full-scale measures (administered at 3 baselines, midtherapy, posttherapy and 3-month follow-up) and weekly measures of VH severity and distress, ranging from medium to large effect sizes.

Conclusions
The case series suggests that an imagery-focused approach to treating VHs may be beneficial, with a recommendation for more rigorous clinical trials to follow.

Objective People who hear voices (auditory verbal hallucinations) often have post‐traumatic stress disorder (PTSD) symptoms. Cognitive behavioural therapies (CBT) have yielded inconsistent findings when treating voices and PTSD symptoms in voice hearers. Preliminary evidence suggests imagery rescripting (ImRs) is associated with large reductions in voice hearing and PTSD symptoms. This study replicated past studies using a larger sample to examine the effectiveness of ImRs in reducing such symptoms. Method Participants ( N = 49; 65.3% female; M age = 35.86) were clients at an Australian transdiagnostic clinic for voice hearers. A one‐arm open trial design was used with three pre‐treatment baselines and a mid‐treatment, post‐treatment and 3‐month follow up assessments of PTSD symptoms (Posttraumatic Diagnostic Scale for DSM‐5), voices (Hamilton Program for Schizophrenia Voices Questionnaire) and emotional symptoms (Depression Anxiety and Stress Scales‐21). Five single‐item measures were administered weekly to explore the trajectories of change in trauma intrusions, voice‐related distress, voice frequency and positive and negative voice valance. Results ImRs was associated with very large reductions in PTSD symptoms and voices (both emotional and physical characteristics of voices) and emotional symptoms at post‐treatment and follow‐up (η 2 p = 0.24–0.44). There were medium‐large to large reductions in weekly symptoms of intrusions, voice‐related distress, voice frequency and negative voices (η 2 p = 0.12–0.16) and a non‐significant increase in positive voices (η 2 p = 0.05). Conclusions This study provides further evidence that ImRs is an effective treatment for voices and PTSD symptoms in voice hearers with a range of diagnoses. Randomised controlled trials are needed to compare the efficacy of ImRs to CBT protocols.

The experience of hearing voices is common to an estimated 7% of the general population, with the presence of negative content being the best predictor of whether individuals will require clinical support. Whilst largely neglected in the literature to date, there are calls to consider the significance of voice content for reducing voice-related distress. However, no quantitative and comprehensive measure of voice content with suitability for research and clinical use exists. This pilot study aimed to demonstrate preliminary psychometric properties of a newly developed measure, the Perth Voice Content Questionnaire (PVCQ), designed to measure the intensity and themes of positively and negatively valenced voice content, primarily of the dominant voice. The PVCQ and measures of voice severity and related beliefs were completed by 47 voice-hearing participants. The measure was found to be internally consistent, loaded onto two distinct factors of positive and negative content, and these factors were associated with voice-related distress and negative beliefs about voices and positive beliefs about voices, respectively, indicating good validity. The PVCQ offers the first self-report measure of voice content, with preliminary psychometric properties indicating its suitability for clinical and research use.

Objectives
Extensive research has shown voice hearing to be associated with symptoms of Post-Traumatic Stress Disorder (PTSD) and dissociation. However, most studies have adopted a quantitative design, using cross-sectional data sampling methods, precluding temporal relationships between variables from being defined.

Design
Using a qualitative design, this study sought to identify potential symptom relationships by addressing the research question: what is the nature of the temporal relationship between voices, dissociation and PTSD symptoms?

Methods
Seven voice hearers (aged 27 to 68 years) participated in a semi-structured interview exploring voice hearing, PTSD symptoms, and dissociation. The interviews were analysed using Interpretative Phenomenological Analysis.

Results
One superordinate theme was identified in the data. Voices were observed to occur in dynamic interrelationship with PTSD symptoms and dissociation, and were frequently experienced before and after PTSD symptoms and dissociative episodes.

Conclusions
Implications for theoretical understandings of voice hearing and future research are discussed.

It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non‐emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non‐emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full‐text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non‐emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non‐emotional mental imagery.

Objective
Hearing voices is a highly stigmatised experience, despite being common across clinical and non-clinical populations. The stigma held by healthcare professions of the clinical populations they work with can have a detrimental impact on the recovery trajectory of people with mental illness, with early career professionals and students thought to have among the most negative attitudes.

Method
The current study examined the efficacy of an education intervention to reduce implicit and explicit stigma surrounding voice hearing in psychology students (N = 49). With the world turning to digital delivery methods in the face of COVID-19, the study also examined the impact of intervention delivery mode: comparing online with face-to-face delivery.

Results
Results indicated that the education intervention was associated with improvements to explicit – but not implicit – stigma towards voice hearing. Comparisons between education delivery type suggested online and face-to-face delivery methods found no difference in associated reductions to explicit stigma.

Conclusions
These findings provide further support for the use of education interventions to reduce stigma surrounding voice hearing and support the online administration of such interventions to allow for more widespread education delivery to a broader audience.

Background
A range of traumas have been linked to voices (auditory verbal hallucinations) and unusual perceptual experiences (UPEs) in other perceptual-sensory domains. Models of PTSD and positive symptoms of psychosis are insufficient in explaining the relationship between trauma and voices. The trauma-related voices (TRV) model was developed to generate novel research in this area.

Aims
This study aimed to investigate pathways from trauma to the frequency of UPEs based on a subset of hypothesised relationships in the TRV model.

Materials
The PTSD Diagnostic Scale for DSM-5, State Adult Attachment Measure, Depression Anxiety and Stress Scales-21, Perth Emotion and Regulation Competency Inventory, Dissociative Experiences Measure Oxford, and Multi-modality Unusual Perceptual Experiences Questionnaire.

Methods
We used path analysis in a non-clinical sample (N = 528) to model indirect effects from diverse trauma experiences to the frequency of multi-sensory UPEs via a subset of mediators within the TRV model: insecure attachment, emotion regulation deficits, negative affect and dissociation.

Results
Our model was an excellent fit to the data and accounted for 37.1% of variance in UPE frequency, and all direct (βs = .14–.61) and indirect pathways (βs = .01–.08) were significant (ps < .001).

Discussion
Our findings suggest that insecure attachment may link diverse trauma experiences to emotion regulation deficits and negative affect, which are linked to UPE frequency via dissociation.

Conclusion
Our findings provide preliminary evidence for a subset of relationships within the TRV model. Future studies are needed to gather stronger evidence of temporality and causation between these factors, and to test broader pathways within the TRV model.