The Self, Agency and Spatial Externalizations of Inner Verbal Thoughts, and Auditory Verbal Hallucinations

Abstract

Aim: Auditory Verbal Hallucinations (AVH) are experienced as the "voices" of others (O-AVH) or self (S-AVH) in internal space/inside the head (IS-AVH) or external space (ES-AVH), and are considered to result from agency and spatial externalizations of inner speech. Both types of externalizations are conflated, and the relationship between these externalizations and AVH experiences is unclear. In this paper, I investigate the relationship between cognitive agency and spatial externalizations and between these externalizations and the types of AVH experience. Method: Twenty-five patients with history of AVH and 24 matched healthy controls performed agency and spatial distinction tasks: distinction between self-generated (read) (S) sentences and other-generated (O) sentences, and between sentences read silently (experienced in internal space, IS) and sentences read aloud (experienced in external space, ES). Regression analyses between misattribution biases (S-O vs. IS-ES, and O-S vs. ES-IS) were obtained. t tests were used to compare misattribution biases between AVH subtypes (S-AVH vs. O-AVH, and IS-AVH vs. ES-AVH). Results: Regressions suggest that agency distinction is independent from spatial distinction in both groups. O-AVH and S-AVH subgroups differed only with respect to S-O bias, and IS-AVH and ES-AVH subgroups differed only with respect to IS-ES bias. Conclusion: These results suggest that agency and spatial externalizations of inner speech are independent at phenomenological and cognitive and levels; and that these externalizations are co-related across levels. I discuss the implications of these findings in the wider context of research on AVH and on the experience of self.

Keywords: cognition; hallucinations; inner speech; psychosis; the self.

Figure 1

Outlines of the self/other (S/O)—blue rectangles—and internal space/external space (IS/ES) distinction tasks—red rectangles. In the S/O task during the presentation phase, subjects alternately read aloud (RA) sentences appearing on the screen and heard (H) pre-recorded sentences played back while the screen remained blank. In the testing phase, the RA and H sentences were visually presented along with new (N) sentences one a time in random orders. Subjects were instructed to identify through button press the sentence type: RA, H or N. The IS/ES task followed the same general design. However, in the presentation phase, subjects instead alternately read aloud (RA) and read silently (RS) sentences visually presented on the screen. In the testing phase, the RA and RS sentences were visually presented along with new sentences (N), and subjects were instructed to identify the sentence type: RA, RS or N.

Figure 2

The relationship between self–other misattribution errors (S–O errors) and internal space–external space misattribution errors (IS–ES errors) (A), and between other–self misattribution errors (O–S errors) and external space–internal space misattribution errors (ES–IS errors) (B).

Figure 3

The relationship between self–other misattribution bias (S–O bias) and internal space–external space misattribution bias (IS–ES bias) (A), and between other–self misattribution bias (O–S bias) and external space–internal space misattribution bias (ES–IS bias) (B).

Figure 4

(A) Differences in self–other (S–O)—red lines—and other–self (O–S)—blue lines—misattribution bias between subgroups of patients defined according to the agency experience of AVH: “voices” experienced as those of Self (S-AVH), and “voices” experienced as those of Other (O-AVH)). Only S–O bias difference was significant. (B) Differences in internal space–external space (IS–ES)—red lines—and external space–internal space (ES–IS)—blue lines—misattribution bias between subgroups of patients defined according to the spatial experience of AVH: “voices” experienced in internal space (IS-AVH), and “voices” experienced in external space (ES-AVH)). Only IS–ES bias was significant. *denote significance.