Home | About IPJ | Editorial board | Ahead of print | Current Issue | Archives | Instructions | Contact us |   Login 
Industrial Psychiatry Journal
Search Articles   
    
Advanced search   
 


 
ORIGINAL ARTICLE
Year : 2022  |  Volume : 31  |  Issue : 2  |  Page : 248-254  Table of Contents     

The appraisal-distress relationship of auditory hallucinations in patients with schizophrenia: The moderating role of metacognitive beliefs


1 Department of Psychology, BHU, Varanasi, Uttar Pradesh, India
2 Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission30-Nov-2021
Date of Acceptance27-Dec-2021
Date of Web Publication08-Aug-2022

Correspondence Address:
Dr. Suprakash Chaudhury
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_248_21

Rights and Permissions
   Abstract 


Background: Appraisal of hallucinatory voices plays a significant role in anxiety and depression among patients with auditory hallucinations. Metacognitive beliefs are also associated with psychological distress in schizophrenia patients. However, there is a dearth of literature exploring the role of metacognitive beliefs on the appraisal-distress relationship, specifically, the overemphasis laid on the need to maintain consistency among thoughts and avoid cognitive dissonance. Aim: The aim of the study is to study the role of metacognitive beliefs on the appraisal-distress relationship. Materials and Methods: A total of 126 schizophrenia patients with auditory hallucinations were selected through purposive sampling technique. The participants were assessed on Hindi version of beliefs about voices questionnaire-revised (BAVQ-R), hospital anxiety and depression scale, metacognition questionnaire-short, and modified (MCQ-SAM). Results: Correlation analysis indicated significant relationship between the dimensions of BAVQ-R (i.e., benevolence, malevolence, and omnipotence) and MCQ-SAM (i.e., cognitive self-consciousness, positive beliefs about worry, importance of consistency of thoughts, and beliefs about normal experience of unwanted thoughts), depression and anxiety. Hierarchical regression analysis indicated that benevolence, malevolence, and importance of consistency of thoughts were predictors of anxiety; malevolence, importance of consistency of thoughts and positive beliefs about worry were predictors of depression. Results of moderation analysis indicated that malevolent beliefs about voices predict the intensity of distress among clinical voice-hearers, and importance of consistency of thoughts plays a moderating role in this appraisal-distress relationship. Conclusion: In schizophrenia patients with auditory hallucinations, the appraisal-distress relationship is strengthened when the need to maintain cognitive consistency is over-emphasized.

Keywords: Anxiety, auditory hallucinations, cognitive dissonance, depression, metacognitive beliefs


How to cite this article:
Choudhary A, Ranjan JK, Asthana HS, Chaudhury S. The appraisal-distress relationship of auditory hallucinations in patients with schizophrenia: The moderating role of metacognitive beliefs. Ind Psychiatry J 2022;31:248-54

How to cite this URL:
Choudhary A, Ranjan JK, Asthana HS, Chaudhury S. The appraisal-distress relationship of auditory hallucinations in patients with schizophrenia: The moderating role of metacognitive beliefs. Ind Psychiatry J [serial online] 2022 [cited 2022 Dec 2];31:248-54. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/248/353555



Hallucinations are involuntary perceptual experiences taking place in the absence of any appropriate stimulus while in the state of consciousness.[1] These experiences are often perceived as veridical, self-governing, discrete, unwanted, intrusive, disturbing and may continue despite intensive and persistent psychopharmacological treatment, and subsequently have a potential ability to influence patients' mood.[2] Auditory hallucinations are the most common and best known for their occurrence in patients with schizophrenia, with prevalence of 40%–80%.[3],[4],[5] The impact of auditory hallucinations often causes symptoms of depression and anxiety and may aggravate existing depressive and anxiety symptoms.[6] More than 50% of patients with schizophrenia have depressive symptoms, and existing positive symptoms were potential risk factors for the development of depressive symptoms.[7],[8] Apart from the experience of hearing voices itself, several other factors such as beliefs about voices[8] and content of the voices[9] are also responsible for voice-related distress.[9],[10] The experiences of auditory hallucinations are heterogenous; therefore, the content of the voices is linked with voice hearer's attitude and belief about hallucinations.[11]

Beliefs about voices' identity, power, and purpose play an important role in the consequent reaction to the voices, i.e., obedience or disobedience.[8],[11] Patients with schizophrenia who consider the content of the voices as negative often find them to be chaotic and experience difficulty in concentrating and communicating with the outside world,[12] and vice-versa. The cognitive model of voices which incorporated an adaptive behavioral components framework and the Beck's model of distress, emphasizes that voice hearer's cognitive appraisal of voices plays an important role in the construction of set of beliefs about voices and consequent voice-related distress.[8] These beliefs about voice related to control, intent (i.e., malevolent or benevolent), identity, and power affect the individual's emotional, somatic, and behavioral responses toward the experience.[8]

Another significant factor associated with distress among voice-hearers is metacognitive beliefs.[13] The cognitive model of metacognitive beliefs on hallucinations,[14] posits that intrusive thoughts that are incongruent with the metacognitive beliefs are misattributed to an external source. The inconsistency between intrusive thoughts and metacognitive beliefs leads to cognitive dissonance–which is an uncomfortable state that motivates an individual to opt for an escape route.[14] Metacognitive beliefs might be a vulnerability marker and could also contribute in the maintenance of psychotic disorders by pouring maladaptive cognitive mechanisms like speculative processing, amplified self-focused attention, and threat monitoring, which in turn triggers counter-productive cognitive styles such as rumination and worry.[15]

Beliefs about voices play a significant role in psychological distress caused by hallucinatory experiences, and several researchers have conformed the appraisal-distress theory.[16],[17] Similarly, metacognitive beliefs have been associated with transient mood disturbances.[18],[19] However, there is a dearth of literature studying the role of metacognitive beliefs on the appraisal-distress relationship. Moreover, the studies that have explored the metacognitive beliefs and consequent distress have used metacognition questionnaire (MCQ)-30 questionnaire.[13],[20] The questionnaire has five subscales. However, the short and modified (SAM) version of the tool (MCQ-SAM) incorporates seven subscales, four of which are similar to MCQ-30: cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about uncontrollability of thoughts and danger. The three additional subscales are-experiencing unwanted thoughts, importance of consistency of thoughts, and beliefs about normal experience of unwanted thoughts. Out of these, beliefs about importance of consistency of thoughts-that have been found to be of more relevance to patients with psychotic disorders[21] and is based on the cognitive model that inconsistent metacognitive beliefs lead to cognitive dissonance which further leads to misattribution, and hence hallucination.[14] Therefore, the present study is first attempt at assessing the role metacognitive beliefs on the appraisal-distress relationship by using the SAM version of (MCQ-SAM).


   Materials and Methods Top


This cross-sectional study and was carried out on the inpatients and outpatients of psychiatric wards of a tertiary care hospital.

Sample

Patients with schizophrenia were selected through purposive sampling method based on the following inclusion and exclusion criteria: (a) Patients were diagnosed by the concerned psychiatrist according to International Classification of Diseases-10 Diagnostic Criteria for Research.[22] (b) Co-operative patients with manageable symptoms who were on treatment with second and first-generation antipsychotics and other medications and supportive psychotherapy. (c) Had a history of active auditory hallucinations. (d) Age range of the patients was 18–65 years. (e) Both male and female patients were included. (f) Patients were educated above Class 8 who could read and comprehend Hindi language properly. (g) Co-morbidity of any other significant physical, neurological, and psychiatric conditions like history of substance abuse; mental retardation and epilepsy were excluded. (h) Patients who had undergone electroconvulsive therapy in the last 1 week were also excluded from the study.

Tools

Metacognition questionnaire–short and modified

The MCQ-SAM assesses individual differences in seven factors important in the metacognitive model of psychological disorders. It has 28 items and the responses are measured on a 4-point Likert scale. The seven subscales of the MCQ-SAM are cognitive confidence, positive beliefs about worry, cognitive self-consciousness, negative beliefs about uncontrollability of thoughts and danger, experiencing unwanted thoughts, importance of consistency of thoughts, and beliefs about normal experience of unwanted thoughts. The Hindi version was used in the study. The internal consistency of the subscales of the translated tool was between 0.75 and 0.94. The exploratory factor structure yielded the initial seven factors and the tool had satisfactory convergent validity.[21]

Hindi version of beliefs about voices questionnaire-revised

The Hindi version of beliefs about voices questionnaire-revised is a 35-item measure of people's beliefs about auditory hallucinations, and their emotional and behavioral reactions to them. There are five sub-scales relating to beliefs: malevolence, benevolence, omnipotence, resistance, and engagement. The first three components measure the belief pattern, and the remaining two measures the behavioral component–or the reaction to the voices. The Cronbach's alpha for the five sub-scales ranges from 0.60 to 0.94, with high convergent and divergent validity. In the present study, only the belief component was included.[23]

Hospital anxiety and depression scale

It is a self-administered rating scale assessing the presence and severity of anxiety and depression through seven items each in Hindi language. Scoring for each item ranges from 0 to 3, wherein three denotes highest anxiety or depression level. The internal consistency of both anxiety (α = 0.80) and depression (α = 0.76) subscales is high.[24]

Procedure

The study started after obtaining ethical approval from the Institutional ethical committee of the hospital. Patients with schizophrenia were selected on the basis of the abovementioned inclusion and exclusion criteria for the assessment of the objective of the study. Initially, the written informed consent was taken from the patients, and the sociodemographic details were recorded. After successful rapport establishment, the aforementioned tools were administered. Finally, obtained responses were statistically analyzed for the estimation of the role of beliefs about voices and metacognitive beliefs on anxiety and depression.

Statistical analysis

Correlation analysis was done using Pearson's product moment correlation followed by hierarchical regression analysis through SPSS 19.0 (IBM, Atlanta, USA). Based on the results of both the analysis, moderation analysis was conducted using process macro version 3.3, wherein the beliefs about voices acted as the predictor variable, depression and anxiety acted as the criterion variable, and metacognitive beliefs were hypothesized to play the moderating role.


   Results Top


The sociodemographic characteristics of 126 patients with auditory hallucinations are given in [Table 1]. The dimensions of metacognitions such as positive beliefs about worry and the importance of consistency of thoughts are significantly and positively correlated with anxiety [Table 2]. The patients who overemphasized to maintain consistency between reality-oriented versus hallucinatory-oriented thoughts experienced anxiety and depression to a greater extent. In addition, those patients who appraised voices as malevolent and omnipotent also experienced significant anxiety and depression. On the other hand, patients, who were least concerned about unwanted thoughts and experienced these thoughts as normal thoughts, hardly experienced anxiety and depression. Similarly, patients who appraised hallucinatory voices as benevolent hardly experienced anxiety and depression.
Table 1: Sociodemographic characteristics of the schizophrenia patients (n=126)

Click here to view
Table 2: Correlation between dimensions of metacognitive beliefs, beliefs about voices, and anxiety and depression

Click here to view


The correlation between dimensions of beliefs about voices and metacognitive beliefs of the patients experiencing auditory hallucinations indicate that patients with auditory hallucinations who had malevolent and omnipotent beliefs about hallucinatory voices also had a greater tendency to constantly monitor their thoughts along with overemphasis on the need to establish and maintain consistency between reality-oriented thoughts and hallucinatory oriented thoughts, and also have positive beliefs about worry [Table 3].
Table 3: Correlation between dimensions of metacognitive beliefs and beliefs about voices

Click here to view


A hierarchical multiple regression analysis was computed to examine the role of metacognitive beliefs (e.g., positive beliefs about worry, importance of consistency of thoughts, beliefs about normal experience of unwanted thoughts) and beliefs about voices (e.g., benevolence, malevolence and omnipotence) as risk factors for the development of anxiety and depression among schizophrenia patients experiencing auditory hallucinations. It is evident that demographic variables (e.g., gender, age, marital status, and education) did not account for a significant amount of variance for anxiety and depression among patients with auditory hallucinations [Table 4].
Table 4: Summary of hierarchical regression analysis predicting depression and anxiety

Click here to view


Further, the results of hierarchical regression analysis indicated that malevolent beliefs and importance of consistency of thoughts were the two best predictors of anxiety and depression. From the aforesaid findings, it can be inferred that patients who perceived the hallucinatory voices as malevolent and had a tendency to overstress on the need to maintain cognitive consistency between reality oriented and hallucinatory-oriented thoughts, experienced anxiety and depression.

Finally, the results of moderation analysis reported in [Table 5] and [Table 6] indicated that importance of consistency of thoughts significantly moderates the relationship between malevolent beliefs about voices and consequent distress such as anxiety and depression as the interaction of the predictors had a significant effect on the criterion variables. The interaction term of the variables accounted for a significant amount of variance for anxiety (R2 = 0.91, ΔF1, 122 = 7.85, P < 0.01) and depression (R2 = 0.64, ΔF1, 122 = 4.99, P < 0.05).
Table 5: Summary of interaction effect (outcome - anxiety)

Click here to view
Table 6: Summary of interaction effect (outcome - depression)

Click here to view


In addition, [Figure 1] and [Figure 2] depict an interaction effect among the malevolent beliefs, the importance of consistency of thoughts, and anxiety and depression in the schizophrenia patients. As the degree of inconsistency of thoughts increases concurrently degree of malevolence beliefs and the severity of anxiety and depression also increase.
Figure 1: Interaction of malevolence, importance of consistency of thoughts and anxiety

Click here to view
Figure 2: Interaction of malevolence, importance of consistency of thoughts and depression

Click here to view



   Discussion Top


The present study confirms the appraisal-distress relationship. Hallucinatory voices perceived as malevolent and omnipotent are positively correlated with both anxiety and depression. As, the malevolent and omnipotent appraisal of hallucinatory voices, hallucinator perceives voice as powerful as evil and intending to harm him.[8] Therefore, malevolent and omnipotent beliefs about voices considered as possible causes for the genesis and maintenance of depression[16],[17] and anxiety[16],[25] among clinical voice-hearers. Vice-versa, voices perceived as benevolent are negatively associated with both anxiety[26] and depression.[17] Although, results of certain studies are not at par with the appraisal-distress theory,[13] the findings of the present study confirm that appraisal of the voices are significant predictors of anxiety and depression among schizophrenia patients with auditory hallucinations.

Metacognitive beliefs have been found to play a significant role in perpetuating emotional distress in patients with psychotic disorders.[20] The present study highlights that the metacognitive beliefs such as positive beliefs about worry, importance of consistency of thoughts and beliefs about normal experiences of unwanted thoughts are significantly associated with levels of anxiety and depression. Therefore, when the intrusive thoughts or voices do not comply with the individual's own beliefs, a negative state of arousal transpires i.e., cognitive dissonance.[14] Hence, it may be inferred that metacognitive beliefs regarding consistency of thoughts (or, noncognitive dissonant thoughts) can play a crucial role in resisting the voices and lowering the distress caused by hallucinations.

Findings of the present study indicated that metacognitive beliefs mainly importance of consistency of thoughts play a significant moderating role in the relationship between beliefs about voices and anxiety and depression. Specifically, when the appraisal of the voices is malevolent in nature, the severity of anxiety and depression increases and this relationship is moderated by the metacognitive belief, namely importance of consistency of thoughts. The interpretation can be illustrated through the following diagram [Figure 3]. The present findings can be discussed in the context of Festinger's cognitive dissonance theory.[27] According to cognitive dissonance theory, when an individual's action contradicts his or her opinions and beliefs, an underlying psychological tension is formed.[27] As humans have constant urges to maintain cognitive consonance, when the need to maintain consistency among thoughts is overemphasized, there might be an increase in internal conflict and anxiety.[16],[27] In the case of patients with auditory hallucinations, if the voices are perceived as negative and harmful and then there is presence of an overemphasized need to maintain cognitive consistency, it further leads to development and maintenance anxiety and depressive symptoms.
Figure 3: Relationship between beliefs about voices, metacognitive beliefs, depression and anxiety

Click here to view


The results of the study have both theoretical and applied value. The findings can be of great help to mental health practitioners as well specifically while implementing techniques of Cognitive-behavioral therapy targeting the metacognitive beliefs pertaining to importance of consistency of thoughts can help to reduce the distress among patients with auditory hallucinations. The present finding invites future investigation to examine the role of cognitive bias model in the formation and maintenance of auditory hallucinations.

Limitations

Even though present study is a novel attempt to assess the moderating role of metacognitive beliefs on the appraisal-distress relationship, this study has certain limitations. For instance, the study uses self-report measures for measuring study variables, therefore, the possible response bias cannot be ruled out. Secondly, the study addressed and distinguished between depression/anxiety but did not incorporate any measure related to distress caused by the voices. Thirdly, there may be other neurocognitive factors such as the deficits in executive functioning that may play a significant role in hallucinations and related distress.


   Conclusion Top


The present study confirms the appraisal-distress relationship among patients with auditory hallucinations. At the same time, the study also highlights the role of metacognitive beliefs, specifically overemphasized need to maintain consistency among one's thoughts and beliefs, in moderating the relationship between the beliefs bout voices and consequent depression and anxiety among clinical voice hearers. The present proposed model will be suitable for planning and implementing cognitive therapy and/or cognitive-behavior therapy for managing auditory hallucination of schizophrenia patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Beavan V, Read J, Cartwright C. The prevalence of voice-hearers in the general population: A literature review. J Ment Health 2011;20:281-92.  Back to cited text no. 1
    
2.
Connor C, Birchwood M. Power and perceived expressed emotion of voices: Their impact on depression and suicidal thinking in those who hear voices. Clin Psychol Psychother 2013;20:199-205.  Back to cited text no. 2
    
3.
Chaudhury S. Hallucinations: Clinical aspects and management. Ind Psychiatry J 2010;19:5-12.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Aleman A, Larøi F. Hallucinations: The Science of Idiosyncratic Perception. Washington DC: American Psychological Association; 2008.  Back to cited text no. 4
    
5.
Hartley S, Barrowclough C, Haddock G. Anxiety and depression in psychosis: A systematic review of associations with positive psychotic symptoms. Acta Psychiatr Scand 2013;128:327-46.  Back to cited text no. 5
    
6.
Gozdzik-Zelazny A, Borecki L, Pokorski M. Depressive symptoms in schizophrenic patients. Eur J Med Res 2011;16:549-52.  Back to cited text no. 6
    
7.
Lako IM, Taxis K, Bruggeman R, Knegtering H, Burger H, Wiersma D, et al. The course of depressive symptoms and prescribing patterns of antidepressants in schizophrenia in a one-year follow-up study. Eur Psychiatry 2012;27:240-4.  Back to cited text no. 7
    
8.
Chadwick P, Birchwood M. The omnipotence of voices. A cognitive approach to auditory hallucinations. Br J Psychiatry 1994;164:190-201.  Back to cited text no. 8
    
9.
Larøi F, Thomas N, Aleman A, Fernyhough C, Wilkinson S, Deamer F, et al. The ice in voices: Understanding negative content in auditory-verbal hallucinations. Clin Psychol Rev 2019;67:1-10.  Back to cited text no. 9
    
10.
Waters F, Allen P, Aleman A, Fernyhough C, Woodward TS, Badcock JC, et al. Auditory hallucinations in schizophrenia and nonschizophrenia populations: A review and integrated model of cognitive mechanisms. Schizophr Bull 2012;38:683-93.  Back to cited text no. 10
    
11.
Chadwick P, Birchwood M. The omnipotence of voices. II: The beliefs about voices questionnaire (BAVQ). Br J Psychiatry 1995;166:773-6.  Back to cited text no. 11
    
12.
Mawson A, Cohen K, Berry K. Reviewing evidence for the cognitive model of auditory hallucinations: The relationship between cognitive voice appraisals and distress during psychosis. Clin Psychol Rev 2010;30:248-58.  Back to cited text no. 12
    
13.
van Oosterhout B, Krabbendam L, Smeets G, van der Gaag M. Metacognitive beliefs, beliefs about voices and affective symptoms in patients with severe auditory verbal hallucinations. Br J Clin Psychol 2013;52:235-48.  Back to cited text no. 13
    
14.
Morrison AP, Haddock G, Tarrier N. Intrusive thoughts and auditory hallucinations: A cognitive approach. Behav Cogn Psychother 1995;23:265-80.  Back to cited text no. 14
    
15.
Morrison AP, Wells A. A comparison of metacognitions in patients with hallucinations, delusions, panic disorder, and non-patient controls. Behav Res Ther 2003;41:251-6.  Back to cited text no. 15
    
16.
Andrew EM, Gray NS, Snowden RJ. The relationship between trauma and beliefs about hearing voices: A study of psychiatric and non-psychiatric voice hearers. Psychol Med 2008;38:1409-17.  Back to cited text no. 16
    
17.
Simms J, McCormack V, Anderson R, Mulholland C. Correlates of self-harm behaviour in acutely ill patients with schizophrenia. Psychol Psychother 2007;80:39-49.  Back to cited text no. 17
    
18.
Sellers R, Wells A, Morrison AP. An experimental manipulation of negative metacognitive beliefs in non-clinical paranoia: Effects on intrusions and state anxiety. J Exp Psychopathol 2018;9:jep. 062117.  Back to cited text no. 18
    
19.
Hill K, Varese F, Jackson M, Linden DE. The relationship between metacognitive beliefs, auditory hallucinations, and hallucination-related distress in clinical and non-clinical voice-hearers. Br J Clin Psychol 2012;51:434-47.  Back to cited text no. 19
    
20.
Østefjells T, Melle I, Aminoff SR, Hellvin T, Hagen R, Lagerberg TV, et al. An exploration of metacognitive beliefs and thought control strategies in bipolar disorder. Compr Psychiatry 2017;73:84-92.  Back to cited text no. 20
    
21.
Lobban F, Haddock G, Kinderman P, Wells A. The role of metacognitive beliefs in auditory hallucinations. Pers Individ Dif 2002;32:1351-63.  Back to cited text no. 21
    
22.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders Diagnostic Criteria for Research. Geneva: World Health Organization; 1993.  Back to cited text no. 22
    
23.
Choudhary A, Ranjan JK, Asthana Psyc H. Psychometric properties of the hindi version of beliefs about voices questionnaire-revised. Indian J Soc Psychiatry 2020;36:141-5.  Back to cited text no. 23
  [Full text]  
24.
Rishi P, Rishi E, Maitray A, Agarwal A, Nair S, Gopalakrishnan S. Hospital anxiety and depression scale assessment of 100 patients before and after using low vision care: A prospective study in a tertiary eye-care setting. Indian J Ophthalmol 2017;65:1203-8.  Back to cited text no. 24
[PUBMED]  [Full text]  
25.
Chandwick P, Lees S, Birchwood M. The revised beliefs about voices questionnaire (BAVQ-R). Br J Psychiatry 2000;177:229-32.  Back to cited text no. 25
    
26.
van der Gaag M, Hageman MC, Birchwood M. Evidence for a cognitive model of auditory hallucinations. J Nerv Ment Dis 2003;191:542-5.  Back to cited text no. 26
    
27.
Harmon-Jones E, Mills J. An introduction to cognitive dissonance theory and an overview of current perspectives on the theory. In: Harmon-Jones E, editor. Cognitive Dissonance: Reexamining a Pivotal Theory in Psychology. 2nd ed. Washington DC: American Psychological Association; 2019. p. 1-24.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
  
 
  Search
 
  
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed1361    
    Printed44    
    Emailed0    
    PDF Downloaded56    
    Comments [Add]    

Recommend this journal