Dissociation, trauma, and the role of lived experience: Toward a new conceptualization of voice hearing.

Abstract

Voice hearing (VH) is often regarded as pathognomic for schizophrenia. The purpose of this article is to review and integrate historical, clinical, epidemiological, and phenomenological evidence in order to suggest that VH may be more appropriately understood as a dissociative rather than a psychotic phenomenon. First, we discuss the lifetime prevalence of VH in the general population, which is estimated to range between 1% and 16% for adult nonclinical populations and 2% and 41% in healthy adolescent samples. Second, we demonstrate how the ubiquity of VH phenomenology, including variables like voice location, content, and frequency, limits its diagnostic and prognostic utility for differentiating psychotic from trauma-spectrum and nonclinical populations. Finally, we report on the empirical associations between VH, measures of dissociation, and trauma particularly (though not exclusively) childhood sexual abuse. There are 2 main conclusions from this review. First, we argue that available evidence suggests that VH experiences, including those in the context of psychotic disorders, can be most appropriately understood as dissociated or disowned components of the self (or self-other relationships) that result from trauma, loss, or other interpersonal stressors. Second, we provide a rationale for clinicians to use psychotherapeutic methods for integrating life events as precipitating and/or maintaining factors for distressing voices. Potential mechanisms for the relationship between trauma, dissociation, VH, and clinical diagnosis are described, including the relevance of literature from the field of attachment in providing a diathesis for dissociation. Suggestions for future research are also discussed.

Hearing voices, dissociation, and the self: A functional-analytic perspective

“…Multiple reviews have indicated that early trauma is prevalent in voice hearers whether or not they are clinically distressed (e.g. Longden, Madill, & Waterman, 2012;Read et al, 2005). Indeed, Daalman et al (2012) demonstrated that both groups were equally likely to have experienced sexual and emotional abuse.…”

“…For example, Ross (2009) suggested that this lack of integration involves the conscious mind, ego, or executive self, and renders the sub-selves fragmented and disconnected. Similarly, Longden et al (2012) have argued that the dissociation of voice hearing reflects an alteration in the normal associative aspects of self and self-in-relation-to-others. Specifically, McIntee and Crompton (1997) suggested that dissociation results from an individual's attempt to develop a false self that reduces the impact of on-going trauma.…”

“…Dissociation also appears to mediate the relationship between trauma and voice hearing (see Longden et al, 2012, for a review). Specifically, Varese, Barkus et al (2012) found that dissociation precedes voice onset, and mediates the relationship between sexual abuse and voice-proneness (see also Anketell et al, 2010;Moskowitz & Corstens, 2007;Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009).…”

“…Many authors have argued that dissociation accounts for the relationship between trauma and voice hearing (Longden et al, 2012;Moskowitz & Corstens, 2007;Varese, Barkus, & Bentall, 2011;Varese, Barkus, & Bentall, 2012). Dissociation typically refers to a 'lack of normal integration of thoughts, feelings and experiences into the stream of consciousness and memory' (Bernstein & Putnam, 1986, p.727), and common presentations include amnesia, imaginative involvement, absorption, depersonalisation and derealisation.…”

“…Dissociation behaviours appear to serve several historical functions, one of which may be to avoid/escape the perspective from which your reality is being experienced, because physical escape is not possible. The model we propose bears considerable overlap, in our opinion, with a number of models outlined in the previous section, particularly those which pointed to the self and relationships with others as central to the dissociative process, in which there are alterations or fragmentations in order to escape from a painful context (Longden et al, 2012;McIntee & Compton, 1997;Mollon, 1996;Perona-Garcelan et al, 2015;Ross, 2009;Young, 1999). Furthermore, our model also complements those suggested by both Romme and Escher (2000) and by Ross (e.g.…”