Imaginary Companions, Inner Speech, and Auditory Verbal Hallucinations: What Are the Relations?

A resurgence of interest in inner speech as a core feature of human experience has not yet coincided with methodological progress in the empirical study of the phenomenon. The present article reports the development and psychometric validation of a novel instrument, the Varieties of Inner Speech Questionnaire (VISQ), designed to assess the phenomenological properties of inner speech along dimensions of dialogicality, condensed/expanded quality, evaluative/motivational nature, and the extent to which inner speech incorporates other people's voices. In response to findings that some forms of psychopathology may relate to inner speech, anxiety, depression, and proneness to auditory and visual hallucinations were also assessed. Anxiety, but not depression, was found to be uniquely positively related to both evaluative/motivational inner speech and the presence of other voices in inner speech. Only dialogic inner speech predicted auditory hallucination-proneness, with no inner speech variables predicting levels of visual hallucinations/disturbances. Directions for future research are discussed. Copyright © 2011 Elsevier Inc. All rights reserved.

Summary Background Auditory hallucinations—or voices—are a common feature of many psychiatric disorders and are also experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the people who hear voices themselves. Methods We made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged 16–84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks, hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used inductive thematic analysis to code the data and χ2 tests to test additional associations of selected codes. Findings Between Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the participants reported hearing literally auditory voices—70 (46%) individuals reported either thought-like or mixed experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were significantly associated with experiences of abusive or violent voices (p=0·024). Although fear, anxiety, depression, and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time (p=0·030), be internally located (p=0·010), and be conversational in nature (p=0·010). Interpretation This study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities. Funding Wellcome Trust.

The relation between early fantasy/pretense and children's knowledge about mental life was examined in a study of 152 3- and 4-year-old boys and girls. Children were interviewed about their fantasy lives (e.g., imaginary companions, impersonation of imagined characters) and were given tasks assessing their level of pretend play and verbal intelligence. In a second session 1 week later, children were given a series of theory of mind tasks, including measures of appearance-reality, false belief, representational change, and perspective taking. The theory of mind tasks were significantly intercorrelated with the effects of verbal intelligence and age statistically controlled. Individual differences in fantasy/pretense were assessed by (1) identifying children who created imaginary characters, and (2) extracting factor scores from a combination of interview and behavioral measures. Each of these fantasy assessments was significantly related to the theory of mind performance of the 4-year-old children, independent of verbal intelligence.