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Are there more to visions than meets the eye?Are beliefs about visions, the self and others

associated with hallucinatory distress?

Selina Warlow

Submitted for the Degree ofDoctor of Psychology

(Clinical Psychology)

School of Psychology Faculty of Arts and Human Sciences

University of Surrey Guildford, SurreyUnited Kingdom September 2015

1

ABSTRACT

Objective:

The phenomena of visions (visual hallucinations) are poorly understood due to

limited research in this area. This study tested a cognitive model of visions. This

proposes that it is the appraisals of the vision and not the presence of a vision itself

that leads to distress. The aim of this study was to see whether the appraisals given

to visions are a predictor of distress, when controlling for the characteristics and

activity of the vision. This study was the first, to our knowledge to explore a wide

range of appraisals that might be associated with visions.

Design and Analyses:

The study adopted a quantitative, cross-sectional design. The hypotheses were tested

using multiple regression analysis.

Setting:

109 participants were recruited anonymously through international charity networks

that support people who experience visions. 66% (n= 72) of the participants were

female and 34% (n=37) were male.

Measures:

The Brief Core Schema Scales, Beliefs About Visions Questionnaire (adapted from

the Beliefs About Voices Questionnaires- Revised), Vision Activity and Impact

Scale (adapted from the Hamilton Program for Schizophrenia Voices Questionnaire)

and the short form Metacognitions Questionnaire were used. Participants also

2

completed the Patient Health Questionnaire, Generalised Anxiety Disorder

Assessment and the Satisfaction with Life Scale.

Results: Positive beliefs about self, metacognitive beliefs about uncontrollability

and danger and malevolent beliefs were all predictors of distress in people with

visions when the characteristics and activity of the vision was controlled for. The

study also found that the characteristics and activity of the vision also predicted 40%

of the variance in distress associated with visions.

Conclusions: The study shows some support for a cognitive model of visions as a

number of the appraisals of visions predicted distress when the characteristics and

activity of the vision were controlled for. In contrast to the voices literature,

characteristics and activity of the vision also accounted for a large proportion of

distress from visions. This suggests that the vision characteristics and activity may

also play a pivotal role in the distress, associated with visions. Therapeutic

interventions targeted at both characteristics, activity and appraisals may reduce

distress in people experiencing visions.

Keywords: Visual Hallucinations, Hallucinations, Visions, Appraisals, Beliefs,

Impact, Distress, Cross- sectional design.

This empirical paper is planned for the submission to the British Journal of Clinical

Psychology. This is the first journal to publish a study on the appraisals of visions.

3

ACKNOWLEDGEMENTS

I would like to thank my major research project supervisors Dr. Jason Spendelow,

Dr. Clara Strauss and Dr. Jo Billings for their support, guidance, knowledge and

encouragement. I would also like to thank all my clinical placements supervisors

who have supported me through each placement and shared their clinical experience

and expertise. I would also like to thank my clinical tutors Dr Lisa Butler and Dr

Vikky Petch for their support throughout my training. I would also like to thank my

parents, husband Nick and daughter Freya for their support and patience. Finally I

would like to thank the University of Surrey for funding my training and for offering

me this experience.

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TABLE OF CONTENTS

1. MAJOR RESEARCH PROJECT EMPIRICAL PAPER.................................62. MAJOR RESEARCH PROJECT EMPIRICAL PAPER APPENDICES......623. MAJOR RESEARCH PROJECT PROPOSAL............................................1364. MAJOR RESEARCH PROJECT LITERATURE REVIEW……...............1545. OVERVIEW OF CLINICAL TRAINING EXPERIENCE……………......2016. TABLE OF ACADEMIC ASSIGNMENTS…............................................204

MAJOR RESEARCH PROJECT EMPIRICAL PAPER

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Are there more to visions than meets the eye? Are beliefs about visions, the self and others associated with

hallucinatory distress?

May 2015

6

TABLE OF CONTENTS

1. INTRODUCTION.................................................................................................................... 111.1. Overview.............................................................................................................................. 111.2. Cognitive model of auditory hallucinations.................................................................131.3. Cognitive Behavioural Model of Visions......................................................................141.4. Beliefs about Visions......................................................................................................... 16

1.5.1 Metacognitive Beliefs and Visions.........................................................................................141.5.2 Beliefs about self and others and Visions............................................................................21

1.6. Rationale and Hypothesis.....................................................................................................221.6.1. Rationale........................................................................................................................... 221.6.2. Hypotheses....................................................................................................................... 22

2. METHOD................................................................................................................................... 242.1. Design and Power...............................................................................................................242.2. Participants......................................................................................................................... 24

2.2.1. Eligibility Criteria.......................................................................................................................242.2.2. Sample Characteristics..............................................................................................................25

2.3. Measures.............................................................................................................................. 252.3.1. The Brief Core Schema Scales (BCSS; Fowler et al, 2006).........................................262.3.2. Beliefs about Visions Questionnaire (BAVSQ; adapted from the Beliefs about Voices Questionnaires- Revised (BAVQ-R,Chadwick et al,2000)........................................272.3.3. Vision Activity and Impact Scale (VAIS) adapted from the Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ; Lieshout and Goldberg, 2007)................282.3.4. The short form metacognitions questionnaire (MCQ-30, Wells and Cartwright-Hatton, 2004)............................................................................................................................................ 292.3.5. The Patient Health Questionnaire (PHQ-9; Kroenke et al, 2001)...............................302.3.6. Generalised Anxiety Disorder Assessment (GAD-7, Spitzer et al, 2006)...............302.3.7. The Satisfaction with Life Scale (SWLS, Diener et al, 1985).....................................31

2.4.1. Data Collection................................................................................................................ 312.4.2. Recruitment..................................................................................................................... 322.5. Ethical Consideration....................................................................................................... 33

2.5.1. Ethical Approval..........................................................................................................................332.6. Planned Data Analysis...................................................................................................... 332.6.2. Assumptions of Multiple Regression..........................................................................34

3. RESULTS................................................................................................................................... 353.1. Descriptive statistics.......................................................................................................... 353.2 Correlational Findings.......................................................................................................373.3. Hypothesis Testing.............................................................................................................40

4. DISCUSSION............................................................................................................................. 454.1. Overview.............................................................................................................................. 454.2 Findings and Theoretical implications...........................................................................46

4.2.1. The Cognitive Behavioural Model for Visions.................................................................464.2.2. Beliefs about self and others....................................................................................................474.2.3. Metacognitive beliefs.................................................................................................................494.2.4. Beliefs about Malevolence, Benevolence and Omnipotence.......................................50

4.4. Strengths and Limitations................................................................................................514.5 Research Implications and Implications for Clinical Practice.................................53

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5.0 REFERENCES........................................................................................................................ 55Demographic.............................................................................................................................. 62Number (N) and Percentage (%)...........................................................................................62

LIST OF TABLESTable 1: Descriptive Statistics and Distributions of Research Variables…………………29Table 2: Bivariate Pearson’s Correlations (r) Between Research Variables….…….…….32Table 3: The prediction, of vision distress (VAIS- distress) by beliefs about self and others (BCSS subscales) whilst controlling for vision characteristics and activity (VAIS- characteristics and activity)……………………………………………...…………………35Table 4: The prediction of vision distress (VAIS- distress) by metacognitive beliefs (MCQ subscales) whilst controlling for vision characteristics and activity (VAIS- characteristics and activity)….......................................................................................................................36Table 5: The prediction of vision distress (VAIS- distress) by beliefs about voices (BAVQ subscales) whilst controlling for vision characteristics and activity (VAIS- characteristics and activity)………………………………………………………………………………...38

LIST OF APPENDICESAPPENDIX A: Demographic Information…………………………………………….…..56APPENDIX B: Ethnicity Demographics…………………… ……………………….…..57APPENDIX C: Web based Questionnaire………………..………………………………..58APPENDIX D: Brief Core Schema Scale………………………………..……………......79APPENDIX E: Beliefs About Visions Questionnaire (BAVSQ)……………………….....80APPENDIX F: Beliefs About Voices Questionnaire- Revised (BAVQ-R)……………......82APPENDIX G: Vision Activity and Impact Scale (VAIS)………………………………...83APPENDIX H: Hamilton Programme Schizophrenia Voices Questionnaire (HPSVQ)…..85APPENDIX I: Metacognitive Questionnaire-30 (MCQ-30)……………………………....88APPENDIX J: Patient Health Questionnaire (PHQ-9)…………………………………….91APPENDIX K: Generalised Anxiety Disorder Scale (GAD-7)……………………………92APPENDIX L: Satisfaction with Life Scale (SWLS)………………………………………93APPENDIX M: Organisations Involved in the Study……………………………...............94APPENDIX N: Application to Ethics………………………………………………………95APPENDIX O; Ethics Approval…………………………………………………………..107APPENDIX P: Cooks Distances…………………………………………………………..108APPENDIX Q: Normality Tests………………………………………………………..…109APPENDIX R; Histograms and Q-Q Plots………………………………………………..110

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ABSTRACT

Objective:

The phenomena of visions (visual hallucinations) are poorly understood due to

limited research in this area. This study tested a cognitive model of visions. This

proposes that it is the appraisals of the vision and not the presence of a vision itself

that leads to distress. The aim of this study was to see whether the appraisals given

to visions are a predictor of distress, when controlling for the characteristics and

activity of the vision. This study was the first, to our knowledge to explore a wide

range of appraisals that might be associated with visions.

Design and Analyses:

The study adopted a quantitative, cross-sectional design. The hypotheses were tested

using multiple regression analysis.

Setting:

109 participants were recruited anonymously through international charity networks

that support people who experience visions. 66% (n= 72) of the participants were

female and 34% (n=37) were male.

Measures:

The Brief Core Schema Scales, Beliefs About Visions Questionnaire (adapted from

the Beliefs About Voices Questionnaires- Revised), Vision Activity and Impact

Scale (adapted from the Hamilton Program for Schizophrenia Voices Questionnaire)

and the short form Metacognitions Questionnaire were used. Participants also

9

completed the Patient Health Questionnaire, Generalised Anxiety Disorder

Assessment and the Satisfaction with Life Scale.

Results: Positive beliefs about self, metacognitive beliefs about uncontrollability

and danger and malevolent beliefs were all predictors of distress in people with

visions when the characteristics and activity of the vision was controlled for. The

study also found that the characteristics and activity of the vision also predicted 40%

of the variance in distress associated with visions.

Conclusions: The study shows some support for a cognitive model of visions as a

number of the appraisals of visions predicted distress when the characteristics and

activity of the vision were controlled for. In contrast to the voices literature,

characteristics and activity of the vision also accounted for a large proportion of

distress from visions. This suggests that the vision characteristics and activity may

also play a pivotal role in the distress, associated with visions. Therapeutic

interventions targeted at both characteristics, activity and appraisals may reduce

distress in people experiencing visions.

Keywords: Visual Hallucinations, Hallucinations, Visions, Appraisals, Beliefs,

Impact, Distress, Cross- sectional design.

This empirical paper is planned for the submission to the British Journal of Clinical

Psychology. This is the first journal to publish a study on the appraisals of visions.

10

1. INTRODUCTION

1.1. Overview

Hearing voices (auditory hallucinations) can impact on the lives of those who

experience them in different ways, with people experiencing both positive and

negative responses to them (Chadwick & Birchwood, 1994). Subsequently,

Chadwick and Birchwood (1994) developed a cognitive model to understand

different emotional responses to hearing voices. There has, however, been little

research on understanding the impact of visions (visual hallucinations). In this study

a cognitive model is tested to understand the different emotional responses to visions.

In the introduction, we will review Chadwick and Birchwood’s (1994) model of

hearing voices and compare this to the cognitive behavioural model of visions

proposed by Collerton and Dudley (2004). We will also look at studies that show

some support for the cognitive behavioural model of visions. This includes exploring

the emotional consequences and beliefs associated with visions. Finally we will

explore the different appraisals of hearing voices including; metacognitive beliefs

and beliefs about self and others and consider how these appraisals may apply to

visions.

1.1.1 Hallucinations

A hallucination is an experience which occurs when a person perceives an external

event, without an external stimulus present and whilst they are awake. For example,

someone may hear a voice but there is no external stimulus making the sound

(auditory hallucination), or they may see an object but there is no external object

present (visual hallucination). Slade and Bentall’s (1988, p.23) full definition of

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hallucinations are ‘any percept- like experience which (a) occurs in the absence of

an appropriate stimulus, (b) has the full force or impact of the corresponding actual

(real) perception and (c) is not amenable to direct or voluntary control by the

experiencer.’ Many people who experience hallucinations face stigmatisation and

research has shown that using alternative terminology can reduce negative attitudes

(Kingdon, Vincent, Vincent, Kinoshita & Turkington, 2008). Therefore, the term

‘vision’ is often preferred to describe visual hallucinations and ‘voices’ to describe

auditory hallucinations.

Research suggests that, in the general population, 10-15% of people have

experienced hallucinations at least once (Slade & Bentall, 1988) with 12% of people

experiencing visions at some point (Tien, 1991). The experience of visions has

received little attention, despite findings showing that the experience can be very

distressing (Menon, 2005; Scott, Schein, Feur, & Folstein, 2000; Nesher, Nesher,

Epstein & Assia, 2001; Teunisse, Cruysberg, Hoefnagels, Verbeek & Zitman, 1996).

The current research is limited as it has not focused on the subjective impact of

visions in the general population but instead has focused primarily on clinical

populations with conditions including schizophrenia (Bracha, Wolkowitz, Lohr,

Karson & Bigelow, 1989), Parkinson’s disease (Fénelon, Mahieux, Huon & Ziégler,

2000) and visual degeneration (Salthouse, Howard & Ffytche, 2000). This contrasts

to the vast literature on other types of hallucination (e.g. auditory), which has found

that many people who experience hallucinations do not have physical or mental

health problems. Because of this a symptom based approach to researching

hallucinatory experiences (Bentall, 2004), where the symptoms (hallucinations)

rather than the diagnostic label (e.g. ‘schizophrenia’) is the focus.

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There has been a vast amount of research exploring the experience of voices

transdiagnostically and looking at the emotional consequences of voices (Close &

Garety, 1988; Nayani & David, 1996; Miller, O’Conner & DiPasquale, 1993).

Studies have found mixed results for emotional consequences of voices, with both

positive (Miller, O’Conner & DiPasquale, 1993; Romme & Escher, 1993) and

negative responses (Close & Garety, 1998; Nayani & David, 1996). Furthermore,

research on voices has clarified how these experiences cause distress. This has led to

the development of strategies for people distressed by voices (Chadwick &

Birchwood, 1994). In particular, cognitive models have looked at the beliefs

attributed to hallucinations and the emotional consequence of these (Chadwick &

Birchwood, 1994; Collerton & Dudley, 2004). These have been explored in detail in

the section below.

1.2. Cognitive model of auditory hallucinations

Chadwick and Birchwood (1994) developed a cognitive model to understand

the different emotional responses to hearing voices and to tease apart the

components of the hallucinatory experience. Chadwick and Birchwood (1994)

highlighted that, for people who hear voices, the voice is the activating event (A)

(e.g. a male voice issuing commands) to which a belief or meaning (B) (e.g.

‘someone has taken over my mind’, ‘I have to obey what the voice says’) is

attached. This leads to subsequent consequences (C) which can be both

behavioural (e.g. obeying voice commands) and emotional (e.g. distress).

Birchwood and Chadwick (1997) have found that in the majority of cases there

is no direct association between the content of a voice and the appraisal that is

formed of it. Furthermore, it is the appraisals and not the content of the voice

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that are associated with distress. This is supported by research, which has

shown that appraisals of malevolence or higher social rank have been

associated with distress. Whereas appraisals of benevolence are associated with

positive emotional consequences including finding the voice relaxing or

soothing (Birchwood & Chadwick, 1997).

1.3. Cognitive Behavioural Model of Visions

Collerton and Dudley (2004) developed a similar model for the treatment of

distressing visions that was based on the cognitive behavioural models of voices,

(Morrison, 1998; Chadwick & Birchwood, 1994) and of obsessional concerns

(Salkovskis, 1989). This model, however, has not been empirically tested. Similarly

to Chadwick and Birchwood’s (1994) model, this model suggests that it is the

appraisal of the vision and not the presence of the vision that leads to distress.

However, Collerton and Dudley (2004) also proposed that the appraisal might result

in reinforcing behavioural, physiological, attentional and environmental loops that

may maintain a cycle of distress. For example, if someone has visions of cameras

watching them and a belief that they are under surveillance, they may run away from

cameras or shout at them. The consequence of this might be that the police are called

and that people stop and stare which could reinforce their belief that they are under

surveillance. In addition, safety behaviours and behavioural avoidance (Salkovskis,

1991) may also reinforce the belief as people may make active attempts to prevent or

control their visions. This could prevent them from gathering disconfirming evidence

and modifying their beliefs (Collerton & Dudley, 2004).

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Collerton and Dudley (2004) also suggest that environmental features and visions

can be incorporated into templates that become situation specific. As a result of this,

the more a hallucination occurs in a particular situation, the more it will occur in that

specific environment; thus making the vision situationally bound. Finally, they

suggest that a third maintenance loop may occur as a result of an emotional arousal

interaction. High levels of arousal have been associated with increased experience of

verbal and visual experiences (Manford & Andermann, 1998) with periods of stress

and prolonged arousal potentially leading to further hallucinatory experiences.

Collerton and Dudley’s (2004) cognitive model of visions is of great interest as it is

the first well-developed cognitive behavioural model of visions. The model,

however, is limited as there has been little research exploring the relationship

between appraisals of the visions and distress. It has yet to be studied whether the

appraisals given to visions are the same or different to those given to voices. For

example, voices are often associated as coming from another person or spirit, so the

source of the voice has a perceived external identity (Chadwick & Birchwood, 1994).

Chadwick and Birchwood (1994) found that voice identity was one factor associated

with distress and that the source of voices are often attributed with similar

characteristics that we attribute to people in our social world. However, we do not

yet know whether visions of objects will be attributed an identity in the same way.

Therefore, we may find that it is a different set of appraisals that mediate distress in

relation to visions.

This study aims to test whether beliefs attributed to visions are associated with

distress in line with Chadwick and Birchwood’s (1994) model of voices. This has

15

been proposed by Collerton and Dudley (2004), but has not yet been empirically

tested. As there is limited research exploring the beliefs associated with vision

distress we chose to test whether beliefs, which we know are associated with voice

distress, are also applicable to vision related distress. These include; beliefs about

self and others, metacognitive beliefs and beliefs about voice power, malevolence,

outcome and identity. We might anticipate that other variables may also influence

distress but suspect that appraisals will more strongly predict distress as found in the

voices literature (Chadwick & Birchwood, 1994). The empirical literature in this area

is sparse, however there is some relevant research, that will now be reviewed.

1.4. Beliefs about Visions

There have been few studies that have looked at the link between appraisals and

hallucinatory distress in visions. One of the first studies to explore this link was

conducted by Gauntlett-Gilbert and Kuipers (2005). They explored appraisals of

visions in people with a psychiatric diagnosis who experienced visions currently or

in the past 12 months. Participants were recruited by contacting in-patient and

outpatient clinical teams and 20 participants met the criteria to take part. Participants

were interviewed using a semi-structured interview schedule, which was developed

using studies of voices. The interview was designed to collect data about the

phenomenology of visions and a person’s subjective response to them. Participants

were also required to make a number of quantitative ratings during the interview to

measure; vividness of vision, negative and positive affective response to vision, level

of disruption caused by vision, perceived control of vision, perceived negative

outcome of vision and perceived positive outcome of vision. The results of their

study showed that perceived negative outcome (visions having a negative influence

16

on their life in the long term) were associated with hallucinatory distress. The

appraisal of the vision was shown to predict distress more strongly than objective

aspects of the vision (e.g. vividness). Furthermore, they found that current mood was

not related to hallucinatory distress. They also looked at whether a higher number of

coping strategies were associated with increased perceived control and decreased

disruption caused by the vision. They found that patient’s ratings of disruption

caused by visions were unrelated to perceived control or the number of coping

strategies used. An exploratory analysis of the relationship between appraisal

categories and distress showed that people who appraised their vision as a sign of

election (meant they were in some way chosen or special) showed significantly less

distress and had a positive affective response to their vision. Those who suspected

the presence of a persecutor (someone who means harm to the person) showed a

trend towards a less positive affect. No other comparisons showed statistical

significance.

This study is of interest as it is the first study to examine the subjective impact of

visions and shows that, like the literature on voices, it was not the objective aspects

of the vision that were a predictor of distress, but the appraisal given to the vision.

Patient ratings of disruption from visions were unrelated to the level of perceived

control or the number of coping strategies used. This may be a result of the nature of

visions as by definition; visions are not entirely responsive to conscious control.

Therefore, it may be more important to know whether these experiences will lead to

good or bad outcomes (e.g. perceived outcome). Furthermore, coping strategies may

be ineffective and may function as safety behaviours, preventing disconfirmation of

beliefs about visions. The finding that there was no effect of current mood on

17

hallucinatory distress shows that the association between appraisal and distress may

not be accounted for by current mood. This provides further support for the

cognitive model of hallucinations, which suggests it is the appraisal of the vision that

is associated with distress. A further explanation for failing to find a significant

effect may be due to the small sample size (N=20). The small sample size may result

in the study being underpowered to detect anything other than large effect sizes and

so non-significant findings may simply represent a type II error. Subsequently

further adequately powered research in this area is needed.

It was not clear what the diagnoses, of the participants were or the severity of

their illness, which may have been confounding variables. In addition, the

interview used was based on a questionnaire for voices, therefore it may not be

a reliable or valid measure for visions. The study also relied upon ‘raters’

categorising the appraisals of visions, which may not have captured all types of

appraisals.

Dudley et al (2012) found further support for an association between appraisals and

distress in people with visions as they conducted a study to investigate whether

people with distressing visions report threat appraisals and use safety behaviours.

Sixteen people with visions participated in the study; with 16 (100%) having a

diagnosis of psychosis. Most of the people in the study found their visions distressing

13 (81%). This group was found to have negative appraisals of their visions. The

most common perceived threat was a threat to their mind or psychological wellbeing,

with fears that they would go mad or end up in hospital. They also found that people

with negative appraisals of their visions engaged in safety seeking behaviours with

18

the intent to reduce the likelihood of the perceived threat being realised. This study is

of interest as it provides further support for an association between negative

appraisals and distress from visions. There are a number of limitations of this study,

including that, due to the small sample size, it is likely that type II errors could have

been made. In addition, the appraisals and reactions to visions interview (ARVHI),

which was used in the study, did not have established indices of reliability and

validity. It is also unclear, due to the single group case design how negative

appraisals and distress are associated. It may be that negative appraisals are the

consequence of the distress rather than the cause. It can, therefore, only be concluded

that there is an association between negative appraisals and distress from visions.

Despite their limitations, these two studies both support that there is an association

between appraisals of visions and vision related distress. This is consistent with what

we would expect from the cognitive model of voices, however, some appraisal types

were not associated with distress and this may simply be due to the studies being

underpowered. In addition, the studies both recruited from clinical mental health

populations, limiting the variability found in types of appraisal and levels of distress.

Furthermore, these studies only measure a limited number of appraisals, which

contrasts the wide range of appraisals that have been explored in studies looking at

the emotional consequences of voices.

1.5.1 Metacognitive Beliefs and Visions.

Research on voices has looked at a wide range of appraisals and their relationship to

psychological distress. One area of focus in voice research is the association between

appraisals of thinking, or metacognitive beliefs, and their relationship to distress.

19

Metacognitive beliefs are appraisals of one’s own thought processes, for example,

the thought that ‘not being able to control my thoughts is a sign of weakness’ or ‘I

cannot control my worrying thoughts’ are both evaluations or beliefs of one’s own

thinking. There has been considerable research aimed at exploring the role of

metacognitive beliefs in voices and their relationship to psychological distress

(Morrison, Haddock & Tarrier, 1995; Hill, Varese, Jackson & Linden, 2012; Garcia-

Montes, Cangas, Perez-Alvarez, Fidalgo & Gutierrez, 2006).

One of the many theories of hallucinatory experiences was proposed by Morrison et

al (1995) who proposed that the origin of hallucinations are a result of a dissonance

which occurs between a person’s thoughts and their metacognitive beliefs. It is

believed that when this dissonance occurs the person may attribute their thoughts to

an external source (someone other than him- or herself). For example if someone

believes that they should have control over their thoughts (metacognitive belief) but

experience uncontrollable thoughts, then they are likely to attribute these to an

external source which might be experienced as a spoken voice (auditory

hallucination). There have been a number of studies, which show support for this

suggestion (Baker & Morrison, 1998; Hill et al, 2012).

Hill et al (2012) conducted a study that explored the relationship between

metacognitive beliefs and voice related distress in clinical and non-clinical voice

hearers compared to a non-clinical control group. They found that the clinical group

scored significantly higher than the two non-clinical groups on two sub-scales of the

metacognitive beliefs questionnaire (MCQ-30): negative beliefs about worry

concerning controllability and danger and negative beliefs about thoughts concerning

20

a need for control. Negative beliefs about need for control were the only significant

predictors of distress when controlling for hallucination content and activity. These

findings suggest that metacognitive beliefs may be associated with hallucinatory

distress independent of the content or activity of hallucinations, supporting Morrison

et al’s (1995) theory and supporting the cognitive model of voices.

We might expect that people with visions may experience similar types of

metacognitive appraisals as people with voices. There is limited research exploring

this link, therefore this study also aims to measure metacognitive beliefs associated

with visions and their relationship to distress.

1.5.2 Beliefs about self and others and Visions

Garety, Kuipers, Fowler, Freeman and Bebbington (2001) proposed that emotional

processes in psychosis reflect an interaction between biological, emotional, cognitive

behavioural and social factors. It has been postulated that early adverse experiences

create an enduring cognitive vulnerability, characterised by negative schematic

models of the self and others (e.g. I am vulnerable, others are dangerous) (Beck,

Rush, Shaw & Emery, 1979). Fowler (2000) suggests that the triggering of negative

schematic beliefs in individuals vulnerable to psychosis, may lead to them hearing

voices with threatening or critical content. Such a view suggests that it is also

negative schematic beliefs about self and others, rather than simply depressed mood,

that may be associated with hallucinatory distress.

Further support for this view was found by Smith et al (2006) who recruited 100

people who had experienced a recent relapse in psychosis. They found that

21

individuals with more depression and lower self- esteem had voices of greater

severity and more negative content. They also found these people were more

distressed by their voices. In addition, they also found these people had more

negative evaluations about themselves and others and had persecutory delusions of

greater severity and were more pre-occupied and distressed by them. This suggests

that negative beliefs about self may also have a role to play in the distress associated

with voices and this may equally apply to visions. A limitation of this study is that

due to the cross-sectional design the direction of these associations cannot be

ascertained. However, to date there is no research to our knowledge that has looked

at whether beliefs about self or others are associated with distress in people with

visions.

1.6. Rationale and Hypothesis

1.6.1. Rationale

Collerton and Dudley (2004) propose that, similarly to voices (Chadwick &

Birchwood, 1994), visions are associated with distress because of the appraisals

people make about them. This study aims to test this cognitive model of visions. This

study is the first, to our knowledge, that explores a wide range of appraisals that

might be associated with distress in response to visions.

1.6.2. Hypotheses

Based on Chadwick and Birchwood’s (1994) ABC model for voices, we predict that

a similar model may be relevant to visions. It is predicted that the appraisal given to

the vision will be a predictor of distress and disturbance and that this relationship

22

will remain when controlling for the characteristics and activity of the visual

hallucinatory experience. Specifically it is predicted that:

Hypothesis 1: There will be a positive relationship between negative self and other

schema and hallucinatory distress when controlling for the characteristics and

activity of the visual hallucinatory experience.

Hypothesis 2: There will be a positive relationship between negative metacognitive

beliefs and hallucinatory distress when controlling for the characteristics and activity

of the visual hallucinatory experience.

Hypothesis 3: There will be a positive relationship between beliefs about the power,

malevolence, outcome and identity of vision and hallucinatory distress when

controlling for the characteristics and activity of the visual hallucinatory experience.

23

2. METHOD

2.1. Design and Power

This study adopted a quantitative and cross sectional design and gathered data using

self-report online questionnaires completed by participants. There is no effect size

data for visions, therefore power calculations were based on previous studies looking

at the relationship between appraisals of voices and distress, which suggest a medium

effect size (r= 0.37, r= 0.44) (Chadwick, Lees & Birchwood, 2000). Green (1991)

estimates that a sample size of 104 plus 1 for each independent variable should be

sufficient to obtain a power of 80% and a medium effect size meaning that recruiting

107 participants was the target for this study.

2.2. Participants

2.2.1. Eligibility Criteria

To be included in the study people needed to have experienced visions in the past six

months and had at least two episodes of seeing visions. These criteria were set as a

minimum to ensure that the participants had experienced more than one visual

hallucinatory experience, so that they had time to develop beliefs about the

experience. In addition, a time frame of the past six months was given as minimum

criteria to ensure that the experience of having a vision would be current or recent. A

formal phenomenological inclusion criteria was used for vision which was defined as

follows ‘repetitive involuntary images of people, animals or objects that are

experienced as real during the waking state but for which there is no objective

reality.’ (Collerton et al, 2005, p. 736).

24

Participants were excluded if they were younger than 18 years and did not have

sufficient English language reading ability to complete the questionnaire. A

proficiency in English was important to ensure accurate responding to the

questionnaire. If participants did not meet these criteria then no further data was

collected, they were taken to a debriefing screen and organisations were suggested

for support.

2.2.2. Sample Characteristics

Demographic information can be found in Appendix A. 66% (n= 72) of the

participants were female and 34% (n=37) were male. The mean age was 36.97 (SD=

12.7; Range 18-72). The majority of the participants were White British (n=64,

58%). Further information on the ethnicity of participants can be found in Appendix

B.

195 people accessed the survey. 109 (56%) completed all measures, 38 (19%) did

not consent to take part and 48 (25%) withdrew before completing the survey.

No datasets included missing values due to the electronic mode of recruitment as

participants were asked to return to any questions that they may have skipped before

being able to move on to the next page.

2.3. Measures

The web based questionnaire (Apppendix C) required forced-choice answers with

options to write text into an ‘other’ box where appropriate. After the information and

consent screens participants proceeded to the questionnaires in the following order,

before proceeding to the debrief screen.

25

2.3.1. The Brief Core Schema Scales (BCSS; Fowler et al, 2006; Appendix D)

The 24-item BCSS has items relating to positive and negative beliefs about the

self and others. It first asks participants to choose ‘yes’ or ‘no’ to statements (12

items about the self: e.g. ‘I am unloved’ and 12 items about others: e.g. ‘Other

people are hostile’). They then rate any items they have endorsed on a five-point

Likert scale from 0–4 (from ‘believe it slightly’ to ‘believe it totally’). Scores

range between 0- 96. Higher scores indicate greater endorsement of a schema.

The scale has good construct validity as shown by a moderate to strong

association with the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965). The

negative-self and positive-self BCSS subscales had a moderate to strong

association (r = 0.64 and r = 0.65, p<0.001 respectively). The scale also has good

test-retest reliability: negative-self (r =0.84), positive-self (r = 0.82) negative-

other (r = 0.70) and positive-other (r = 0.72; all significant at p < 0.001).

Cronbach’s alpha in this study were between 0.92 and 0.96, indicating excellent

internal consistency; negative self ( = 0.93), positive self ( = 0.93), negativeα α

other ( = 0.96) and positive other ( =0.92). α α

2.3.2. Beliefs about Visions Questionnaire (BAVSQ; Appendix E) adapted from

the Beliefs about Voices Questionnaires- Revised (BAVQ-R, Chadwick et al,

2000; Appendix F)

The BAVSQ questionnaire is a 35-item measure of people’s beliefs about their

voices. The only change to the voices questionnaire is that the word ‘voice’ has

26

been replaced with the word ‘vision’. A definition of ‘vision’ was given in the

participant information sheet as well as prior to the questionnaire in

accordance with the Collerton et al (2005) definition of hallucinations given in

the Background section.

The original BAVQ- R is a 35-item self-report measure of patient’s beliefs. There

are three subscales that relate to beliefs: malevolence (six items), benevolence

(six items) and omnipotence (six items). For each subscale there is a maximum

score of 18. The measure assesses the degree of the endorsement of the items.

Higher scores for each subscale indicate how strongly they hold each type of

belief about their voices.

In addition, construct validity measures showed that there was a strong

relationship between malevolence and resistance (r= 0.68, d.f.= 0.69, p<0.01)

and benevolence and engagement (r= 0.80, d.f.= 0.69, p<0.01). This was a

similar finding to the first BAVSQ scale (Birchwood and Chadwick, 1997,

Chadwick and Birchwood, 1995), which suggests it is a robust analysis of

people’s relationships to their visions.

The reliability and validity measures for the voices version of the scale show

that the Cronbach’s alpha score for each subscale were high (0.84- 0.87) and for

this study were between 0.79- 0.89 indicating good internal consistency.

Cronbach’s alpha were; malevolence ( =0.89), benevolence ( = 0.88) andα α

27

omnipotence ( = 0.79), and supporting the amended version of the scale toα

focus on beliefs about visions rather than voices.

2.3.3. Vision Activity and Impact Scale (VAIS; Appendix G) adapted from the

Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ; Van

Lieshout and Goldberg, 2007; Appendix H)

No validated measure of visual hallucinatory experience could be found.

Therefore a validated measure from the voices literature was adapted to replace

each item with a semantically equivalent item. The VAIS is a 9- item

questionnaire used to assess two factors. Factor 1 is the distress and

disturbance of visions and factor 2 measures the activity and characteristics of

the voices. This two factor structure is based on a principle components factor

analysis of the HPSVQ (Kim et al, 2010). This analysis exhibited two factors

‘distress and disturbance’ and ‘characteristics and content’ of the voices. The

second factor of the VAIS has been relabelled ‘characteristics and activity’ as we

feel this is a truer representation of the questions asked about visions.

The HPSVQ is a 9-item questionnaire used to assess the content and activity of

voices as well as address the distress and disturbance that voices have on the

individual. It shows good test retest reliability over one week (ICC= 0.72). Total

HPSVQ scores range between 0-36. Scores of 0-7 are indicative of absent to

minimal auditory verbal hallucinations (AVH), scores of 8-13 are indicative of mild

severity, 14-25 are indicative of moderate severity and 26 and above are indicative of

severe AVH. Cronbach’s alpha for this study were between 0.72 to 0.90 indicating,

good internal consistency.

28

2.3.4. The short form metacognitions questionnaire (MCQ-30, Wells and

Cartwright-Hatton, 2004; Appendix I)

The MCQ-30 measures individual difference in a selection of metacognitive

beliefs, judgements and monitoring tendencies considered important in the

metacognitive model of psychological disorders. There are five subscales that

relate to metacognitive beliefs including: cognitive confidence (5 items),

positive beliefs (5 items), cognitive self-consciousness (5 items),

uncontrollability and danger (5 items) and need to control thoughts (5 items).

MCQ- 30 scores range between 30 to 120 points, and higher scores indicate

greater pathological meta-cognitive activity.

The MCQ-30 scale shows good internal consistency as Cronbach’s alpha scores

ranged from 0.72-0.93. Pearson’s re-test correlations for the total MCQ- 30 scale

were 0.75 (p<0.0005). Retest correlations showed a high level of stability for

four subscales with negative beliefs evidencing the lowest retest coefficient of

0.59.

For this study Cronbach’s alpha were between 0.90- 0.95 indicating excellent

internal consistency.

2.3.5. The Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer & Williams,

2001; Appendix J)

The PHQ-9 is a screening measure for depression. The PHQ-9 has high internal

consistency reliability (Cronbach’s alpha = 0.80 Lee et al., 2007), good test-

retest reliability (r = 0.84, Kroenke et al., 2001) and construct validity (r =0.73,

29

Martin, Rief, Klaiberg & Braehler, 2006). Items are based on experience of a

range of problems (presenting in the last two weeks), which are signs of

depressed mood. Items are on a four-point Likert scale from ‘not at all’ to ‘nearly

everyday’. Total scores range between 0 to 27. PHQ-9 scores of 5, 10, 15 and 20

represents mild, moderate, moderately severe and severe depression (Kroenke

et al, 2001). Cronbach’s alpha for this study was 0.94 indicating excellent

internal consistency.

2.3.6. Generalised Anxiety Disorder Assessment (GAD-7, Spitzer, Kroenke,

Williams & Lowe, 2006)

This 7-item self-report measure is used as a screening instrument and severity

measure for generalised anxiety disorder. The GAD-7 (Appendix K) has a scale

of 0-3, with higher scores indicating greater symptoms of anxiety in the past

two weeks: 0 corresponds to “not at all” and 3 to “nearly every day”. Total

scores range between 0 to 21. Scores of 5, 10 and 15 represent cut points for

mild, moderate and severe anxiety.

The GAD-7 has high internal consistency (Cronbach’s alpha = 0.92, Spitzer et al.,

2006), good test-retest reliability (r = .83, Spitzer et al., 2006) and construct

validity (r = 0.72 to r =0.74, Spitzer et al., 2006). Cronbach’s for this study was α

0.96 indicating excellent internal consistency

30

2.3.7. The Satisfaction with Life Scale (SWLS, Diener, Emmons, Larsen &

Griffin, 1985) (Appendix L)

This is a 5 item self-report measure of life satisfaction. Life satisfaction is one

factor in the more general construct of subjective wellbeing.

The internal consistency of the SWLS is good (Cronbach’s = 0.87). Test-retest α

reliability was also good (ICC= 0.82) over two months. There is also

considerable evidence for the convergence of the SWLS with numerous

measures of subjective well-being and life satisfaction. Total scores range

between 5-35.. Scores of 5, 15, 20, 25, 30 represent cut off points for; extremely

dissatisfied, slightly dissatisfied, equally satisfied and dissatisfied with life,

satisfied with life and highly satisfied. Cronbach’s alpha for this study was 0.84

indicating good internal consistency

2.4. Procedure

2.4.1. Data Collection

An interactive website was designed (Appendix B) which included the following

information in respective order: an information page, a consent screen, four

screening questions, participant demographics, the questionnaire measures and a

debriefing screen with suggested organisations for support. The questionnaire took

around 25 minutes to complete.

2.4.2. Recruitment

Participants were recruited through dedicated online websites for people who might

experience visions. A variety of organisations were approached in order to recruit

participants. A list of the organisations that agreed to take part can be found in

31

Appendix M. These organisations were approached and asked whether they would

disseminate information regarding the project to their members. Participants were

therefore not approached directly and instead this indirect recruitment strategy was

thought to be more in accordance with ethical guidance regarding Internet mediated

research (British Psychological Society, 2007). Participants were assured that their

details would be kept safe and secure and would not be shared with anyone else.

Involvement with mental health services or the presence of a mental health diagnosis

was not deemed necessary as inclusion criteria. This was because, in line with

theories on voice hearing, we predicted in our hypothesis that visions are not a pre-

requisite for distress. The recruitment strategy was designed in a way that attempted

to promote participation across clinical and non- clinical populations.

An Internet based recruitment strategy was chosen in order to reach a range of people

in terms of background and levels of distress associated with visions. It has been

noted that a limitation of this methodology is that it prevented those who did not

have access to the Internet or were too unwell to concentrate for 25 minutes from

taking part in the study. However, an advantage of this method is that it facilitates

recruitment across the globe and it made provide participants with reassurance about

the anonymity of their responses.

2.5. Ethical Consideration

2.5.1. Ethical Approval

The study was granted ethical approval from the University of Surrey’s Faculty of

Arts and Human Sciences Ethics Committee. Participants were offered an incentive

32

to participate in the study in the form of a prize draw to win Amazon vouchers. The

submission to ethics can be found in Appendix N and a copy of the ethics approval

can be found in Appendix O.

2.6.Planned Data Analysis

The internal consistency of all measures, including the adapted measures (i.e. the

BAVHQ, the VAIS), was assessed using Cronbach’s alpha.

After screening for outliers, calculating and reporting descriptive statistics and exploring

the distribution of variables the hypotheses were tested using multiple

regressions as follows. Cooks distances were checked in order to see if any

participants had a disproportional effect on the multiple regression model and

therefore may distort the accuracy of the regression model (Appendix P).

To test each hypothesis, bivariate associations between variables were analysed with

Pearson’s correlation (r). For each hypothesis, a forced entry multiple regression

analysis was conducted to measure characteristics and activity of the vision in block

1 (VAIS-characteristics and activity) and belief variables in block 2 (1. BCSS

scores/2. MCQ-30 scores/3. BAVSQ scores), with hallucinatory distress as the

dependent variables.

2.6.2. Assumptions of Multiple Regression

The following assumptions of multiple regression were checked for each regression

model included in the analysis according to Field (2013) including; linearity,

33

normality of residuals, homogeneity of error variance, multi-collinearity and

independence of errors (Appendix Q).

Each regression model was checked visually using histograms of the residuals to see

if the residuals were approximately normally distributed in addition to checking Q-Q

plots (Appendix R).

3. RESULTS

3.1. Descriptive statistics

All 109 participants (N) were included in the analysis. Table 1 shows the descriptive

statistics (mean and standard deviations) of the research variables.

Table 1: Descriptive Statistics and Distributions of Research Variables (N= 109)

34

Measures (Scale Min/Max) Mean (SD)

VAIS (distress and disturbance) (0/16) 6.89 (4.46)

VAIS (characteristics and activity)_ (0/20) 11.03 (3.71)

VAIS Total (0/36) 17.92 (7.40)

BCSS- Positive- self schema (0/24) 10.28 (6.64)

BCSS- Positive-other schema (0/24) 10.13 (5.53)

BCSS Negative-self schema (0/24) 7.89 (6.90)

BCSS Negative-other schema (0/24) 8.09 (7.03)

BAVSQ Voice Malevolence (0/18) 5.83 (5.62)

BAVSQ Voice Omnipotence (0/18) 8.57 (4.67)

BAVSQ Voice Benevolence (0/18) 5.37 (5.62)

MCQ-30- Cognitive Confidence (0/24) 13.72 (5.61)

MCQ-30- Positive Beliefs (0/24) 9.96 (4.40)

MCQ-30- Cognitive Self Consciousness (0/24) 15.75 (5.44)

MCQ-30- Uncontrollability and Danger (0/24) 13.75 (6.01)

MCQ-30- Need to control thoughts (0/24) 13.36 (5.57)

PHQ- 9 (0/27) 11.09 (8.65)

GAD-7 (0/21) 9.00 (7.11)

SWLS (0/35) 16.79 (8.94)

Note: VAIS= Vision Activity and Impact Scale, BCSS= Brief Core Schema Scale; BAVSQ= Beliefs about Visions

Questionnaire; MCQ-30= Metacognitive Questionnaire 30; PHQ9= Patient Health Questionnaire 9; GAD7= Generalised

Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.

As they were designed for this study, there are no norms for the BAVSQ

questionnaire adapted from the BAVQ Revised (BAVQ-R, Chadwick et al, 2000) or

VAIS adapted from the HPSVQ (Van Lieshout & Goldberg, 2007).

The mean Negative Self Scale (BCSS- NS) and Negative Other Scales (BCSS- NO)

were almost twice as high in the non-clinical sample reported by Fowler and

35

colleagues (BCSS-NS; 7.89 vs. 3.5, BCSS- NO; mean 8.09 vs. 4.0; Fowler et al.,

2006). This suggests that the sample, on average, had a greater degree of negative

beliefs about self and others than in a non- clinical sample.

The mean scores on the Metacognitive Questionnaire Short Form (MCQ-30) were

higher for all subscales compared to a non-clinical sample (Wells and Cartwright-

Hatton, 2004) Cognitive Confidence (13.72 vs. 9.51) Positive Beliefs (9.96 vs. 9.60)

Cognitive Self Consciousness (15.75 vs. 11.65) Uncontrollability and Danger (13.75

vs. 9.30) Need to control thoughts (13.36 vs. 8.34). This suggests that the sample, on

average, had a greater degree of negative metacognitive beliefs but also had a higher

degree of positive metacognitive beliefs than in a non-clinical sample.

The mean PHQ-9 depression score was in the moderate range (Kroenke et al, 2001)

and the mean GAD-7 anxiety score was in the mild range (Spitzer et al, 2000), but

both scales had relatively large standard deviations. The SWLS mean scores were in

the category of slightly below average for life satisfaction (Diener et al, 1985), and

the scale had a relatively large standard deviation. This suggests that the sample, on

average, were experiencing clinical levels of depression and generalized anxiety and

were below average for their rating of life satisfaction but that there was considerable

variability on these measures within the sample.

3.2 Correlational Findings

Bivariate Pearson’s (r) correlations were conducted to look at the relationship

between the study variables. From Table 2 it can be seen that the majority of

36

variables correlated with each other, in the expected direction. The specific

hypothesised relationships will be described in more detail below.

37

Table 2: Bivariate Pearson’s Correlations (r) Between Research Variables

38

Note * p< 0.05, ** p < 0.01, *** p<0.001

Note: VAIS= Vision Activity and Impact Scale, BCSS= Brief Core Schema Scale; BAVSQ= Beliefs about Visions Questionnaire; MCQ-30= Metacognitive Questionnaire 30; PHQ9= Patient

Health Questionnaire 9; GAD7= Generalised Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.

39

Measures VAIS (distress and disturbance)

BAVSQ Malevolen

ce

BAVSQ Benevolen

ce

BAVSQ Omnipote

nce

BCSS Negative

Self

BCSS Positive

Self

BCSS Negative

Other

BCSS Positive Other

MCQ Cognitive Confidenc

e

MCQ Positive Beliefs

MCQ Cognitive

Self Conscious

ness

MCQ Need for Control

MCQ Uncontrollability and

Danger

VAIS- (characteristics and activity)

.64*** .52*** 0.15 .61*** .31*** -0.13 .20* -0.03 .21* .38*** 0.12 .36*** .34***

VAIOS (distress and disturbance)

.78*** -.37*** .64*** .50*** -.391** .376** -.27** .29*** .33** 0.16 .51*** .55***

BAVSQ Malevolence

-.33*** .73*** .59*** -40*** .42*** -.31*** .26** .26** 0.12 .46** .50***

BAVSQ Benevolence

-0.04 -.30 ** .37*** -25** .31*** -12 .23* 0.03 -.19* -30**

BAVSQ Omnipotence

.45*** -.33*** .27** -0.20 .30 ** 0.15 .16* .40*** .42***

BCSS Negative Self

-.50*** .70*** -45*** .46*** 0.14 .20** .66*** .63***

BCSS Positive Self -31*** .70*** -26** -0.06 0.13 -33*** -34 ***

BCSS Negative Other

-48*** .47*** 0.11 .22** .57*** .69***

BCSS Positive Other

-.33*** 0.01 -0.02 -37*** -.37***

Measures VAIS (distress and disturbance)

BAVSQ Malevolen

ce

BAVSQ Benevolen

ce

BAVSQ Omnipote

nce

BCSS Negative

Self

BCSS Positive

Self

BCSS Negative

Other

BCSS Positive Other

MCQ Cognitive Confidenc

e


MCQ Cognitive

Self Conscious

ness


MCQ Uncontrollability and

Danger

MCQ Cognitive Confidence

0.13 .18* .52*** .48***


0.18 .36** .26**

MCQ Cognitive Self Consciousness

.36*** .26**


.70***

Note * p< 0.05, ** p < 0.01, *** p<0.001

Note: VAIS= Vision Activity and Impact Scale, BCSS= Brief Core Schema Scale; BAVSQ= Beliefs about Visions Questionnaire; MCQ-30= Metacognitive Questionnaire 30; PHQ9= Patient Health Questionnaire

9; GAD7= Generalised Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.

40

3.3. Hypothesis Testing

None of the assumptions of the multiple regressions were violated, including;

linearity, normality of residuals, homogeneity of error variance, multi-collinearity

and independence of errors (Appendix Q). Cooks distances were used to identify

potential outliers that might have an undue influence on the multiple regression

model. No significant outliers were identified (Appendix P).

For all three hypotheses forced entry multiple regression was used. The same

variable (VAIS- characteristics and activity) was entered into block 1 for each

multiple regression which indicated that characteristics and activity of the

hallucinatory experience accounted for 40.5% of the variance (R2= 40.5 F(1,107)=

72.9, p <0.001) in distress at seeing visions (Table 3). The additional variables for

each hypothesis (BAVQ-R/MCQ-30/BCSS) were added separately into block 2 for

each multiple regression and the results of these are outlined below.

Hypothesis 1: Negative Beliefs about Self and Others will predict hallucinatory

distress (VAIS- distress) when controlling for the characteristics and activity of the

hallucinatory experience (VAIS- characteristics and activity).

Table 2 shows Bivariate Pearson’s (r) correlations between all the variables. These

correlations show that Negative Beliefs about Self and Others positively correlated

with hallucinatory distress (r= -0.50, r= 0.38, p< 0.01) and Positive beliefs about

Self and Others negatively correlated with hallucinatory distress (r=- 0.39, r=-0.27,

p< 0.01 respectively)

41URN: 6200053 Selina Warlow- E-Thesis

In block 2 of the multiple regression beliefs about self and others accounted for a

further significant 13.6% of the variance when controlling for characteristic and

activity of the hallucinatory experience (R2= 54.1 F(5,103)= 24.2, p <0.001) in vision

distress.

Table 3: The prediction, of vision distress (VAIS- distress) by beliefs about self and

others (BCSS subscales) whilst controlling for vision activity and characteristics

(VAIS- characteristics and activity)

Note: VAIS= Vision Acitivity and Impact Scale, BCSS= Brief Core Schema Scale; BAVHQ= Beliefs about Visual Hallucinations Questionnaire; MCQ-30= Metacognitive Questionnaire 30; PHQ9= Patient Health Questionnaire 9; GAD7= Generalised Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.

As can be seen in Table 3, it was found that visions and activity of the hallucinatory

experience significantly predicted hallucinatory distress. When characteristics and

activity of the vision were controlled for positive beliefs about self were significant

negative predictors of hallucinatory distress. Negative beliefs about self and others

and positive beliefs about others were not significant predictors. This partially

supports hypothesis 1 as this shows that even after controlling for the characteristics

and activity of visions, that positive beliefs about the self are associated with lower

levels of distress.


Unstandardised beta Standardised beta T P

Block One VAIS- (characteristics and activity)

0.765 0.637 8.541 0.000

Block Two VAIS- (characteristics and activity)

0.648 0.539 7.579 0.000

BCSS-Negative Self 0.104 0.161 1.520 0.132

BCSS-Positive Self -0.159 -0.235 -2.320 0.022

BCSS-Negative Other 0.056 0.087 0.865 0.389

BCSS-Positive Other 0.022 0.027 0.263 0.793

Hypothesis 2: Negative metacognitive beliefs (MCQ-30 scores) will predict visual

hallucinatory distress (VAIS- distress) when controlling for the characteristics and

activity of the hallucinatory experience (VAIS- characteristics and activity).


correlations show that metacognitive beliefs about cognitive confidence, positive

beliefs, need for control and beliefs about uncontrollability and danger were

positively correlated with hallucinatory distress (r=0.29, 0.33, 0.51, 0.55, p< 0.01).

Metacognitive beliefs about self consciousness were not correlated with

hallucinatory distress (r= 0.16, p>0.05).

In block 2 of the multiple regression metacognitive beliefs accounted for a further

significant 13.8% of the variance when controlling for characteristics and activity of

the hallucinatory experience (R2= 54.3 F (6,102)= 20.17, p <0.001).

Table 4: The prediction of vision distress (VAIS- distress) by metacognitive

beliefs (MCQ subscales) whilst controlling for vision activity and

characteristics (VAIS- characteristics and activity)


Block One VAIS- (characteristics and activity)

0.765 0.637 8.541 p < .001

Block Two VAIS- (characteristics and activity)

0.582 0.484 6.397 p < .001

MCQ-Cognitive Confidence -0.022 -0.027 -0.342 0.733

MCQ- Positive Beliefs 0.022 0.022 0.293 0.770

MCQ-Cognitive Self Consciousness

-0.024 -0.029 -0.410 0.683

MCQ-Uncontrollability and Danger

0.221 0.297 3.075 0.003

MCQ-Need for Control 0.119 0.149 1.448 0.151

Note: VAIS= Vision Activity and Impact Scale, BCSS= Brief Core Schema Scale; BAVHQ= Beliefs about Visual Hallucinations Questionnaire; MCQ-30= Metacognitive Questionnaire 30; PHQ9= Patient Health Questionnaire 9; GAD7= Generalised Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.


As can be seen in Table 4, it was found that characteristics and activity of the

hallucinatory experience significantly predicted hallucinatory distress. When vision

characteristics and activity were controlled for metacognitive beliefs about

uncontrollability and danger were significant predictors of hallucinatory distress.

Metacognitive beliefs about cognitive confidence, positive beliefs and cognitive self-

consciousness and need for control were not significant predictors. This partially

supports Hypothesis 2 as this shows that even after controlling for the characteristics

and activity of visions that metacognitive beliefs about uncontrollability and danger

and need for control are associated with higher levels of distress.

Hypothesis 3: Beliefs about the power, malevolence, outcome and identity of visions

(BAVHQ scores) will predict hallucinatory distress when controlling for the vision

characteristics and activity of the hallucinatory experience (VAIS-characteristics and

activity score).


correlations show that malevolence and omnipotence positively correlated with

hallucinatory distress (r=0.78, 0.55 p< 0.001). Beliefs about benevolence negatively

correlated with hallucinatory distress (r= -0.37, p<0.001).

In block 2 of the multiple regression beliefs about voices accounted for a further

significant 33.4% of the variance in distress when controlling for characteristics and

activity of the hallucinatory experience (R2= 73.9 F(4, 104)= 77.4, p <0.001).


Table 5: The prediction of vision distress (VAIS- distress) by beliefs about voices

(BAVQ subscales) whilst controlling for vision activity and characteristics (VAIS-

characteristics and activity).


Block One VAIS (characteristics and activity)

0.765 0.637 8.541 p < .001

Block Two VAIS (characteristics and activity)

0.518 0.431 6.534 p < .001

BAVSQ-Malevolence 0.329 0.414 5.041 p < .001

BAVSQ-Benevolence -0.266 -299 -5.179 p < .001

BAVSQ-Omnipotence 0.060 0.062 0.791 0.431

Note: VAIS= Vision Activity and Impact Scale, BCSS= Brief Core Schema Scale; BAVHQ= Beliefs about Visual

Hallucinations Questionnaire; MCQ-30= MetaCognitive Questionnaire 30; PHQ9= Patient Health Questionnaire 9; GAD7=

Generalised Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.

As can be seen in Table 5 it was found that characteristics and activity of the

hallucinatory experience significantly predicted hallucinatory distress. In addition

malevolent beliefs and benevolent beliefs negatively predicted hallucinatory distress.

Omnipotent beliefs were not significant predictors of hallucinatory distress after

controlling for the other variables in the model. This partially supports Hypothesis 3

as this shows that even after controlling for the characteristics and activity of visions,

malevolent beliefs were associated with higher levels of distress and benevolent

beliefs were associated with lower levels of distress.


4. DISCUSSION

4.1. Overview

This is the first study that has explored a wide range of appraisals that are associated

with distress in response to visions. When controlling for the characteristic and

activity of visions: malevolent beliefs, metacognitive beliefs about uncontrollability

and danger and need for control were associated with higher levels of distress.

Benevolence and positive beliefs about self were associated with lower levels of

distress. Negative beliefs about self and others, positive beliefs about others,

metacognitive beliefs about cognitive confidence, positive beliefs and cognitive self-

consciousness and omnipotent beliefs were not significant predictors of hallucinatory

distress after controlling for characteristics and activity of visions. The findings

showed that, similarly to the findings for voices, a wide range of appraisals predicted

distress in people with visions even when controlling for the characteristics and

activity of visions. However, this study has highlighted some differences in the types

of appraisals that are associated with distress in visions compared to voices. In

addition, the findings also showed that in contrast to the voices literature, the

characteristics and activity of visions also predicted a large percentage (40%) of

distress associated with visions. This section will review the results in detail, and

also provide a fuller description of the different types of appraisal associated with

hallucinatory distress. The role of vision characteristics and activity in association

with hallucinatory distress will also be discussed.


4.2 Findings and Theoretical implications

4.2.1. The Cognitive Behavioural Model for Visions

This study makes a novel contribution to the literature about visions whilst lending

some support to the cognitive model of visions in its entirety that has been

demonstrated in previously published studies. The study showed that when the

vision’s characteristics and activity were controlled for a number of appraisals of

visions predicted distress, in line with the cognitive model. This is similar to the

findings for voices (Chadwick & Birchwood, 1994) whereby it is proposed that it is

the appraisal of the voice and not the voice itself that causes distress. However, the

current study also found that vision characteristics and activity accounted for 40% of

the variance in the distress from visions. This suggests that vision characteristics and

activity may play a more pivotal role in the distress associated with visions than

previously expected. This is not emphasized in Collerton and Dudley's (2004)

cognitive behavioral model of visions which suggests that it is the appraisal and not

the characteristics and activity of the visions that predicts distress.

An explanation for this could be that the distinction between content and

appraisal is not always clear. All humans universally experience and express the

emotion of fear as a signal of danger during situations that may be a potential

threat to survival (LeDoux, 1996). Therefore the characteristics and activity of

some visions, we would expect would cause distress e.g. a tiger approaching.

This negative response may appear to be an automatic response to the vision’s

content but the appraisal may still mediate the relationship. To find the image of

a tiger distressing there needs to be an appraisal of the image as threatening.

LoBue, Rakison and DeLoache (2010) suggest that there are some threats,


which are privileged in human perception and have perceptual biases that

enable us to respond to them quickly. They have also found that humans have

the ability to learn to respond quickly to specific kinds of threat stimuli.

Therefore, it is a combination of visual perception and learning that enable

people to respond quickly to threats. This suggests for visions, learnt threat

appraisals may continue to mediate the relationship between vision

characteristics and distress.

4.2.2. Beliefs about self and others

The current findings showed that there was a positive correlation between negative

beliefs about self and others and hallucinatory distress and a negative correlation

between positive beliefs about self and others and hallucinatory distress. The

findings showed, however, that when vision characteristics and activity were

controlled for only positive beliefs about self negatively predicted hallucinatory

distress. Negative beliefs about self and negative and positive beliefs about others

were not significant predictors.

Based on the cognitive models of both visions and voices we did not expect that

there would be a loss in the association between negative self and other schema

when vision characteristics and activity were controlled for. These findings contrast

to the voices literature, which suggests that early adverse experiences can create a

cognitive vulnerability, which can be characterized by negative model of self and

others (Garety et al, 2000). One possible explanation for this difference could be the

influence of other factors on distress. One possible explanation could be the effect of

culture and the environment on the phenomenology of hallucinations. There is

evidence showing that there are higher numbers of reported visions in non-western


cultures (Ndetei & Singh, 2007; Ndetei & Vadher, 1948; Azhar , Varma, & Hakim,

1993) than in western cultures (Ndetei & Singh, 2007; Mueser, Bellack & Brady,

1990). Al-Issa (1995) proposed that in societies where there are high numbers of

people experiencing visions people might be more accepting of the experience of

visions. Therefore in countries such as Pakistan where there is a greater acceptance

of ‘seeing spirits’ it may lead to an increased willingness to report the experience and

subsequently result in a higher frequency of reported visions. As our sample

captured predominantly Western cultures, it may be that the experience of visions

themselves are distressing based on culturally held beliefs. As our study did not

capture cultural appraisals we cannot conclude this is the case, however further

research in this area would be of interest.

These findings do, however, show that positive beliefs about self may be a

protective factor in the distress associated with visions. This is supported in a series

of case studies by Mayhew and Gilbert (2008) who delivered compassionate mind

training to psychotic voice hearers. Compassionate mind therapy aims to help people

develop and work with experiences of inner warmth, safeness and soothing via

compassion and self-compassion. They found that participants in their study found

their voices became less malevolent, less persecuting and more reassuring. This

might suggest that strengthening people’s positive beliefs through self-compassion

may reduce distress associated from visions. However, due to the cross- sectional

design of the study an alternative explanation may be that positive beliefs about self

may be the consequence of the vision rather than the cause. We can therefore only

conclude that positive evaluative beliefs about self are correlated with less distress to

visions.


4.2.3. Metacognitive beliefs

The current findings showed that when vision characteristics and activity were

controlled for, metacognitive beliefs about controllability and danger were predictors

of hallucinatory distress. Whereas metacognitive beliefs about cognitive confidence,

positive beliefs, cognitive self-consciousness and need for control were not

significant. This is similar to findings where people who hear voices were found to

score higher than people without voices on beliefs about uncontrollability and danger

(Baker &Morrison, 1998).

Morrison et al’s (1995) heuristic model of voices, suggests that voices are

experienced when intrusive thoughts are attributed to an external source in order to

reduce cognitive dissonance. This dissonance is caused by the incompatibility

between certain intrusive thoughts and metacognitive beliefs e.g. beliefs about

controllability. Based on Morrison et al’s (1995) heuristic model a similar model

may be applied to visions, however rather than experiencing intrusive thoughts it

may be that an intrusive image is attributed to an external source in order to avoid

cognitive dissonance.

Rachman (1978, 1981) states that intrusive thoughts can also take the form of

repetitive images. Therefore, Morrison et al’s (1995) model may also be applicable

to visions whereby a cognitive dissonance occurs between an intrusive image and

metacognitive beliefs about uncontrollability therefore attributing this to an external

source such as a vision. People experiencing visions may experience more distress

when they feel less in control of the image and are more inclined to believe that

images should be controlled and are dangerous. This finding that negative beliefs


about uncontrollability and danger were predictors of hallucinatory distress suggests

that this type of metacognitive belief may play a crucial role in the distress caused by

visions. However, due to the cross-sectional design of the study we can only

conclude that beliefs about uncontrollability and danger are associated with visions,

and the causal direction of this association is still unclear and requires further

research.

4.2.4. Beliefs about Malevolence, Benevolence and Omnipotence

The current findings showed that when vision characteristics and activity were

controlled for, malevolent beliefs predicted hallucinatory distress and benevolent

beliefs negatively predicted hallucinatory distress.

These results mirror the findings of Chadwick and Birchwood (1994) who found that

in people who hear voices, malevolent beliefs were associated with negative

emotions (anger, fear, depression, anxiety) and benevolent voices were associated

with positive emotions amusement, reassurance, calm, happiness). These findings

provide some support for the cognitive behavioural model of visions where it is the

appraisal of the vision and not the vision itself that causes distress (Collerton &

Dudley, 2004). Although the categories of appraisal differed slightly, our results

share similar findings to those of Gauntlett-Gilbert and Kuipers (2005) who found

that people who appraised their vision as meaning that they were in some way

special (benevolent belief) showed less distress than those who suspected the

presence of a persecutor (malevolent belief).


The findings from the current study differ from research on voices, as they did not

show omnipotent beliefs to be a significant predictor of hallucinatory distress

(Chadwick & Birchwood, 1994, 1997). It may be that visions do not hold the same

level of perceived power as voices. However, this may be due to the image of an

object being less likely to be attributed to an individual who could hold power over

the person experiencing the vision.

4.4. Strengths and Limitations

The main limitation of this study is that it uses a cross-sectional design; therefore

causation between variables cannot be inferred. For example, we cannot assume that

negative beliefs about self directly cause hallucinatory distress or whether they are

the result of hallucinatory distress.

An internet recruitment strategy may pose a risk in that we cannot control the

recruitment of participants which raises the potential for bias in the study and we

could not guarantee that participants were experiencing visions. However, we aimed

to reduce this risk by recruiting through charities, which support people with visions.

In addition, we created a clear definition of visions to ensure participants were

experiencing visions and not flashbacks or intrusive images. This method of

recruitment has a number of benefits that outweigh the risks, as there have been no

other studies with large sample sizes that have explored appraisals associated with

visions. A strength of this approach is that it enabled us to capture people with visual

hallucinations in the general population and not just clinical populations as had been

previously tested. An additional benefit of this method is that the sample was from

different cultures and countries and permitted all English-speaking people to


participate. This ensured a wide range of people who experience visions were able to

participate. Furthermore, our sample scored above the clinical mean on all our

measures, which suggests that the recruitment strategy was effective at recruiting

participant who were significantly impacted upon by their experiences but may not

have accessed services. An additional strength was that due to the large sample size

the study was adequately powered.

A strength of the study was that it was the first study to develop a measure for a wide

range of appraisals of visual hallucinations. However, a limitation of this was that

the majority of measures used were adapted from measures used for people who

experience voices. A strength of this study is that Cronbach’s alpha completed on the

measures showed good to excellent internal consistency for all adapted measures

although further research would be needed to test the validity of the measures we

adapted and assess the psychometric properties of these. As the current study was

underpowered a confirmatory factor analysis could not be performed on the VAIS.

Further research is needed to support whether a two factor structure measuring

‘distress and disturbance’ and ‘characteristics and activity’ exists.

A further limitation of the study is that a large proportion of participants experienced

other types of hallucinations (auditory, gustatory, olfactory, tactile and somatic)

therefore these hallucinations may interact and impact on the level of distress

experienced (e.g. a talking vision). The study aimed to assess the impact of the

vision itself by asking specifically about the distress associated with this alone,

however, this may be difficult for the participant to untangle.


4.5 Research Implications and Implications for Clinical Practice

This study has highlighted that similarly to research on voices, appraisals of visions

are associated with distress. Therefore, interventions that change appraisals may, as

for voices, help to ease the distress from visions (Chadwick & Birchwood, 1994).

This is also the first study to investigate a wide range of appraisals associated with

distress from visions. The results showed, however, that the appraisals that we

measured did not fully account for the variance in clinical distress. This suggests that

there are other factors that might be associated with distress from visions. One

possible explanation could be that there are additional appraisals associated with

hallucinatory distress, which were not measured in this study. For example

appraisals associated with cultural beliefs about visions may be an area of interest for

future research as Al-Issa (1995) suggests that there are higher numbers of reported

visual hallucinations in cultures that are more accepting of the experience of visual

hallucinations.

Another area for future research would be to explore the effect of current mood on

hallucinations. Gauntlett-Gilbert and Kuipers (2005) found preliminary evidence to

suggest mood may have an effect on the type of appraisals made, however, this

relationship did not meet statistical significance, possibly due to a low sample size.

It would also be of interest to explore whether there is an association between mood

and the onset of visual hallucinations.

Another area for future research would be to expand the research on Collerton and

Dudley’s (2004) cognitive behavioural model of visions which also suggests that the

appraisal may result in reinforcing behavioural, physiological, attentional and


environmental loops that may maintain a cycle of distress. Future empirical research

to explore the impact that these maintenance cycles may have on distress would be

of interest to expand our knowledge of the distress associated with visions and tailor

treatment appropriately.


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4. APPENDICES

APPENDIX A: Demographic Information

Table of Demographic Information ( N =109)


Demographic Number (N) and Percentage (%)

Female 72 (66)Male 37 (34)

age 18-20 8 (7)

age 21-30 36 (33)

age 31-40 27 (25)

age 41- 50 21 (19)

age 51-60 13 (12)age 61-70 3 (3)age 71-80 1 (1)No formal qualifications 7 (6)

Secondary/High school qualifications 43 (39)

Undergraduate degree 42 (39)Postgraduate degree 17 (16)

Auditory hallucinations 90 (83)

Olfactory hallucinations 42 (39)

Gustatory hallucinations 15 (14)

Tactile hallucinations 48 (44)

Somatic hallucinations 23 (21)

Appendix B. Ethnicity of Participants

* Please note- categories were defined based on open responses given

White1. English/Welsh/Scottish/British 642. American 153. Australian 114. Canadian 25. Dutch 16. Russian 17. Romanian 28. South African 29. Israeli 110. French 111. German 112. Flemmish 1

Asian/Asian British13. Asian American 114. Japanese 1

Black/African/Carribean/Black British15. African 216. British 1

Other Ethnic Group17. Alien 118. BJHCC 1


Appendix C: Online Questionnaire



=




















APPENDIX D: Brief Core Schema Scale : beliefs about self and others

This questionnaire lists beliefs that people can hold about themselves and other people. Please indicate whether you hold each belief (NO or YES). If you hold the belief then please indicate how strongly you hold it by ticking the box which best describes how you feel. Try to judge the beliefs on how you have generally, over time, viewed yourself and others. Do not spend too long on each belief. There are no right or wrong answers and the first response to each belief is often the most accurate.

Believe it slightlyBelieve it moderately

Believe it very much Believe it totally

MYSELFI am unloved No YesI am worthless No YesI am weak No YesI am vulnerable No YesI am bad No YesI am a failure No YesI am respected No YesI am valuable No YesI am talented No YesI am successful No YesI am good No YesI am interesting No Yes

OTHER PEOPLEOther people are hostile No YesOther people are harsh No YesOther people are unforgiving No YesOther people are bad No YesOther people are devious No YesOther people are nasty No YesOther people are fair No YesOther people are good No YesOther people are trustworthy No YesOther people are accepting No YesOther people are supportive No YesOther people are truthful No Yes


APPENDIX E- Beliefs About Visions Questionnaire (BAVSQ)

There are many people who see visions. It would help us to find out how you are feeling about your visions by completing the questionnaire. Please read each statement and tick the box which best describes the way you have been feeling in the past week.

Disagree Unsure Agree Slightly Agree Strongly

1. My vision is punishing me for something I have done2. My vision wants to help me3. My vision is very powerful4. My vision is persecuting me for no good reason5. My vision wants to protect me6. My vision seems to know everything about me7. My vision is evil

8. My vision is helping me to keep sane9. My vision makes me do things I really don’t want to do10. My vision wants to harm me11. My vision is helping me to develop my special powers and abilities12. I cannot control my vision13. My vision wants me to do bad things14. My vision is helping me to achieve my goal in life


15. My vision will harm or kill me if I disobey or resist it16. My vision is trying to corrupt or destroy me.17. I am grateful for my vision18. My vision rules my life19. I experience visions because it is how my brain works20. Experiencing visions is a normal part of human experience21. I experience visions because others are trying to communicate with me22. My visions mean that I am going insane23. My visions are part of my religious beliefs or spirituality24. My visions have no special meaning25. If my visions carry on they will be a bad influence on my life26. If my visions carry on they will be a good influence on my life

APPENDIX F: Beliefs about Voices Questionnaire- Revised (Original)88

URN: 6200053 Selina Warlow- E-Thesis

APPENDIX G: Vision Activity and Impact Scale (VAIS)


Please tick the box that best describes your experience of visions during the past two weeks including today.

1. How frequently do you see visions?

No visions Less than once a day

Once or twice a day

Several times a day

All of the time/ Constantly

2. How bad are the visions that you see?

No visions are bad

Not that bad Fairly bad Very bad Horrible

How vivid are the visions in contrast to the background?

Visions not present

Not very vivid Fairly vivid Very vivid

4. How long do the visions usually last?

Visions not present

A few seconds to 1 minute

A few minutes

More than 10 minutes but less than 1 hour

Longer than 1 hour/they just seem to persist

5. How much do the visions interfere with your daily activities?

No interference A little bit Moderately Quite a bit Extremely interfering

6. How distressing are the visions that you see?

No visions are distressing to me

A little bit Moderately Quite a bit Extremely distressing

7. How bad (worthless/useless) do the visions make you feel about yourself?

No visions make me feel bad

A little bit Fairly bad Very bad Extremely bad (as bad as I can feel)

8. How clearly do you see the visions?

Visions not present

Very blurred Fairly blurred

Fairly clear Very clear visions

9. How often do you do what the visions want you to do?

No vision tell me what to do

Rarely Sometimes Often Always



10. In what part of the day do you see the visions most often?

Morning Afternoon Evening Just before bed

The voices are equally as likely at all times of the day

11. What kind of social situations are you in most often when the visions start?

When I am alone

When I am with a few people (like in a group)

When I am around a lot of people (like in a mall or busy street)

No situation in particular/ they occur equally in all social situations

12. Where do the visions come from?

From inside my head From outside my head From both inside and outside my head

13. Would you say the last week is like a typical week of your seeing visions?

Yes No

APPENDIX H: Hamilton Programme Schizophrenia for Voices Questionnaire

HPSVQ Name:_________________Date:_________________

Office Use Only Total Score:

Please circle the ONE box that best describes your experience of voices DURING THE PAST WEEK, including today.

How frequently did you hear a voice or voices?

No voices Less than once a day

Once or twicea day

Several times a day

All of the time/ constantly

How bad are the things the voices say to you?

No voices saying bad

things

Not that bad Fairly bad Very bad Horrible

How loud are the voices?

Voices not present

Very quiet(like

whispering)

Average (same as my own

voice)

Fairly loud Very loud(yelling or shouting)

How long do the voices usually last?

Voices not present

A few seconds to 1 minute

A few minutes More than 10 minutes but less than an

hour

Longer than 1 hour/they just

seem to persist

How much do the voices interfere with your daily activities?

No interferenc

e

A little bit Moderately Quite a bit Extremely interfering

How distressing are the voices that you hear?

No voices are A little bit Moderately Quite a bit Extremely


distressing me distressing

How bad (worthless/useless) do the voices make you feel about yourself?

No voices make me feel

bad

A little bit Fairly bad Very bad Extremely bad (as bad as I

can feel)

How clearly do you hear the voices?

Voices not present

Very mumbled Fairly mumbled

Fairly clear Very clear voices

How often do you DO what the voices say?

No voices telling me what to do

Rarely Sometimes Often Always

In what part of the day do you hear the voices most often?a

Right when I wake up

Morning Afternoon Evening Just before bed

The voices are equally as likely at all times of

the day

What kind of social situations are you in most often when your voices start?

When I am alone When I am with a

few people (like in ‘group’)

When I am around a lot of people (like

in a mall or on a busy street)

No situation in particular/they

occur equally in all social situations

12. Where do the voices come from?a

From Inside my head From Outside my head From both Inside and Outside

13. Would you say the last week is like a typical week of your hearing

voices?a


Yes No (Please explain below)

…………………………………………………………………………………………

………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………

…………………………………………………………………………………………

a These items are qualitative in nature and are not included in the calculation of the total score


APPENDIX I: Meta Cognitive Questionnaire (MCQ-30)

Below are thirty statements with which you may agree or disagree. Using the 1-4 scale below, indicate your agreement with each item by ticking the box which best described how you feel. Please be open and honest in your responding.

1Do not agree

2Agree

Slightly

3Agree

Moderately

4Agree Very Much

I do not trust my memoryI have poor memoryI have little confidence in my memory for actionsI have little confidence in my memory for placesI have little confidence in my memory for words and namesMy memory can mislead me at timesWorry helps me to get things sorted out in my mindWorrying helps me copeI need to worry in order to work wellWorrying


helps me to solve problemsI need to worry in order to remain organisedWorrying helps me to avoid problems in the futureI am constantly aware of my thinkingI pay close attention to the way my mind worksI think a lot about my thoughtsI constantly examine my thoughtsI monitor my thoughtsI am aware of the way my mind works when I am thinking through a problemMy worrying thoughts persist no matter how I try to stop themWhen I start worrying I cannot stopI could make myself sick with worryingI cannot ignore my worrying thoughtsMy worrying could make me


go madMy worrying is dangerous for meIf I could not control my thoughts I would not be able to functionNot being able to control my thoughts is a sign of weaknessI should be in control of my thoughts all of the timeIt is bad to think certain thoughtsIf I did not control a worrying thought and then it happened, it would be my faultI will be punished for not controlling certain thoughts


APPENDIX J: Patient Health Questionnaire -9 Scale

Over the last 2 weeks, how often have you been bothered by any of the following problems?

How much in the past two weeks were you bothered by the following problems. (please tick the box which best describes how often)

Not at allSeveral days

More than half the days

Nearly every day

1. Little interest in pleasure in doing things2. Feeling down, depressed, or hopeless3. Trouble falling or staying asleep, orsleeping too much4. Feeling tired or having little energy5. Poor appetite or overeating6. Feeling bad about yourself, or that youare a failure, or have let yourself oryour family down

7. Trouble concentrating on things, such asreading the newspaper or watchingtelevision


Appendix L: The Satisfaction with Life Scale

DIRECTIONS: Below are five statements with which you may agree or disagree. Using the 1-7 scale below, indicate your agreement with each item by ticking the box which best described how you feel. Please be open and honest in your responding.

Strongly Disagree

Disagree Slightly Disagree

Neither Agree or Disagree

Slightly Agree

Agree Strongly Agree

1. In most ways my life is close to my ideal.2. The conditions of my life are excellent.

3. I am satisfied with life.

4. So far I have gotten the important things I want in life5. If I could live my life over, I would change almost nothing.


APPENDIX M: List of Organisations Involved in the Study

The Hearing Voices Network- UK and AustraliaIntervoiceRethinkParkinson’s UK


Appendix N: Application to Ethics

Factors associated with Distress and Disturbance in Visual Hallucinations

Detailed Protocol

Summary

The project will look at factors associated with distress and disturbance for people experiencing visual hallucinations. The research hopes to contribute to the understanding of the experience of visual hallucinations in a number of diagnostic groups. The project will depend on questionnaire data taken from online respondents who have experience(d) visual hallucinations.

Horowitz (1975, p. 163) defines visual hallucinations as an ‘image experience in which there is a discrepancy between subjective experience and actual reality’. However most definitions of visual hallucinations do not formally distinguish between self-generated imagery, dreams and hallucinations therefore there is no consensus definition or classification (Cutting, 1997). For the purpose of this paper we will focus on recurrent visual hallucinations (RCVH) which are defined as ‘repetitive involuntary images of people, animals, or objects that are experienced as real during the waking state but for which there is no objective reality.’ (Collerton et al, 2005, p.736)

Hallucinations can occur in any of the sensory modalities including; auditory, visual, olfactory, gustory and tactile. They are not always associated with distress or with a mental health diagnosis (Romme & Escher, 1993) and when they are, hallucinations can occur in a range of mental health and physical health conditions (Teeple et al, 2009; Romme & Escher, 1993). Because of this, a symptom based approach to researching hallucinatory experiences has been called for (e.g. Bentall, 2004), where the symptom (hallucinations) rather than the diagnostic label (e.g. ‘schizophrenia’) is the focus.

There has been a vast amount of research exploring the experience of auditory hallucinations transdiagnostically and developing cognitive models (David & Nayani, 1996; Romme & Escher, 1994; Birchwood and Chadwick, 1997; Chadwick and Birchwood, 1994; Close and Garety, 1998). However, there have been few studies exploring the experience of visual hallucinations and there has been little attempt to develop cognitive models of these experiences.


Theories on hearing voices (auditory hallucinations) posit that distress associated with hearing voices is not as a result of the content or frequency of the voice but is the meaning given to the voices (Chadwick and Birchwood, 1994). This is in line with Ellis’ (1962) cognitive ABC model which refers to three components of experience that can be used to understand individual’s emotional and behavioural difficulties. The ‘A’ refers to the activating events; the ‘B’ refers to beliefs and thoughts about the activating event. The ‘C’ refers to the consequent emotion and behaviour in relation to the event, given the Bs.

Chadwick and Birchwood (1994) outlined that for people who experience auditory hallucinations the voice hearing experience is the activating event (A) to which the individual attaches a belief or meaning (B) which leads to subsequent emotional and behavioural consequences (C). Chadwick and Birchwood’s (1994) model is supported by empirical evidence that shows that beliefs about voices are associated with distress at hearing voices (Birchwood and Chadwick, 1997) even when controlling for voice activity (Clarke, 2012)

More than one million adults in Britain, while awake repeatedly see people, animals, or objects that appear real but are not visible to others (Collerton et al 2005). Visual hallucinations are common in a range of mental health and physical health conditions including; dementing illnesses, delirium, eye disease and schizophrenia. There is reason to expect that the same ABC model (Chadwick and Birchwood, 1994) would apply to visual hallucinations and that it would be the beliefs about visual hallucinations and not the content or frequency of the hallucination that would be associated with distress. However currently there are no published studies which could be found that have tested the ABC model in relation to visual hallucinations.

A number of studies have found similar variability in the emotional consequences of visual hallucinations as in the auditory hallucination literature. Participants with visual hallucinations compared to similar groups without hallucination were found to score higher for depression (Fenelon et al, 2001; Holroyd et al, 2000; Barnes and David, 2001) anxiety (Holroyd et al, 2000; Delespaul et al, 2002) and were also found to report visual hallucinations as disturbing (Yellowlees and Cook, 2006). Whereas in other studies visual hallucinations were not rated as pleasant or distressing (Mosimann et al,2008) Although this research suggests emotional variability as a result of visual hallucinations it is limited due to a number of methodological limitations including small sample sizes and the use of unvalidated measures of visual hallucinations. In addition the variability in the findings could be accountable by a number of confounding variables such as severity of illness. However these findings are consistent with Chadwick and Birchwood’s (1994) ABC model whereby variability in emotional consequences would be expected if it is the appraisal given to the visual hallucinations and not the content of the hallucinations that is related to emotional consequences.

Studies have also explored the attributions given to visual hallucinations and their emotional consequences as these studies have found people with visual hallucinations were concerned about evaluation from others including beliefs about being labelled ‘insane’ (Menon, 2005; Teunisse et al, 1996) or perceived as ‘crazy’


(Scott et al, 2000). Between 75% and 90% of hallucinators do not spontaneously reveal their experiences (Nesher et al 2001; Scott et al 2001; Teunisse et al, 1996).

Gauntlett-Gilbert and Kuipers (2005) conducted a study which further supports the application of the ABC model (Chadwick and Birchwood, 1994) for visual hallucinations as they found that appraisals given to visual hallucinations were a predictor of distress and did not follow from the content, frequency or duration of the hallucination. In addition Dudley et al (2012) found that people who had negative appraisals of visual hallucinations reported them as distressing and also engaged in safety seeking behaviours that maintained their distress. However in both studies they measured a limited range of appraisals and did not measure the type of appraisals that have been associated with auditory hallucination distress so it is not possible to draw clear conclusions from their studies about the relevance of the ABC model to visual hallucinations.

In summary, although there is a small body of research exploring the experiences and appraisals of visual hallucinations, none of these studies allow a test of the ABC model. The proposed study aims to address this limitation by testing the ABC model of visual hallucinations.

Research Question

‘Are beliefs about visual hallucinations, the self and others associated with visual hallucinatory distress and disturbance? Does this remain true when taking account of visual hallucinatory content and activity?’

Main Hypothesis

Based on Chadwick and Birchwood’s (1994) ABC model for auditory hallucinations we would predict that a similar model may be applied to visual hallucinations. Therefore it is predicted that it will be the appraisal given to the visual hallucination that will be a predictor of distress and disturbance and that this will remain true when controlling for hallucinatory content and activity. Specifically it is predicted that:

Beliefs about self (negative self-schema) and beliefs about others (negative other-schema) will predict hallucinatory distress and disturbance to quality of life. This will remain true when controlling for the content and activity of the hallucinatory experience.

Beliefs about the power, malevolence, outcome and identity of visual hallucinations will predict hallucinatory distress and disturbance to quality of life. This will remain true when controlling for the content and activity of the hallucinatory experience.

Participants


107 participants will be recruited, 104 plus 1 participant for each independent variable will need to be recruited in order to assume a medium effect size With 80% power and a p value of 0.05 (Green, 1991).

Participants will be recruited through advertisements posted on charity and support group websites for people who fall in diagnostic groups that might experience visual hallucinations (e.g. Parkinson’s Disease charities, the Hearing Voices Network). Participants will be recruited online internationally from English speaking countries.

Participant inclusion criteria are as follows:- be 18 years over- Have experienced visual hallucinations in the past six months- Will have had at least two episodes of visual hallucinatory experience.- Will have sufficient English language reading ability to complete the battery of questionnaires. This will be assesed using self-report.

MeasuresThe Brief Core Schema Scales (BCSS; Fowler et al., 2006)

The 24-item BCSS has items relating to positive and negative beliefs about the self and others. It first asks participants to choose ‘yes’ or ‘no’ to statements (12 items about the self: e.g. ‘I am unloved’ and 12 items about others: e.g. ‘Other people are hostile’). They then rate any items they have endorsed on a five-point Likert scale from 0–4 (from ‘believe it slightly’ to ‘believe it totally’).

The scale has good construct validity as shown by a moderate to strong association with the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) the negative-self and positive-self BCSS subscales had a moderate to strong association (r = 0.64 and r = 0.65, p<0.001 respectively). However, correlations between the RSES and BCSS negative-other and positive-other scales were weak (r = 0.20 and r = 0.26, p<0.001, respectively) indicating that they might be measuring different constructs.

Cronbach’s scores are between 0.78 and 0.88, indicating good internalα consistency reliability. The scales also have good test-retest reliability: negative-self (r =0.84), positive-self (r = 0.82) negative-other (r = 0.70) and positive-other (r = 0.72; all significant at p < 0.001).

Beliefs about Visual Hallucinations Questionnaire (BAVHQ; adapted from the Beliefs about Voices Questionnaires – Revised, BAVQ-R (Chadwick et al 2000)

The Beliefs about voices questionnaiore is a 35-item measure of people’s beliefs about their voices as well as their reactions and behaviour towards them.


The only change to the voices questionnaire is that the word ‘voice’ has been replaced with the word ‘vision’. A definition of ‘vision’ will be given in the participant information sheet as well as prior to the questionnaire in accordance with the Collerton et al (2005) definition of hallucinations given in the Background section. The internal consistency of the BAVHQ will be reported when presenting findings of the current study.

The original BAVQ- R is a 35-item self report measure of patients beliefs, emotions and behaviour about their auditory hallucinations. There are three subscales that relate to beliefs: malevolence (six items), benevolence (six items) and omnipotence (six items).

The reliability and validity measures for the scale show that the cronbach αscore for each subscale were high (0.84, 0.88, 0.74, 0.85, 0.87) which suggests the items within the scales are measuring the same construct.

In addition construct validity measures showed that there was a strong relationship between malevolence and resistance (r= 0.68, d.f.= 0.69, P<0.01) and benevolence and engagement (r= 0.80, d.f.= 0.69, P<0.01). This was a similar finding to the first BAVQ scale (Birchwood and Chadwick, 1997, Chadwick and Birchwood, 1995) which suggests it is a robust analysis of people’s relationships to their visual hallucinations.

Visual Hallucination Activity Scale (VHAS; adapted from the Hamilton Program for Schizophrenia Voices Questionnaire, HPSVQ, Lieshout and Goldberg, 2007)

The Impact of Visual Hallucinations Scale (IVHS; adapted from the Hamilton Program for Schizophrenia Voices Questionnaire, HPSVQ, Lieshout and Goldberg, 2007)

No validated measure of visual hallucinatory experience could be found. Therefore a validated measure from the auditory hallucination literature has been adapted to replace each item with a semantically equivalent item . The internal consistency of the VHAS and the IVHS will be reported when writing up findings of the current study.

The HPSQ is a 9 item questionnaire used to assess the characteristics and content of auditory hallucinations as well as address the subjective impact that voices have on the individual.

It showed a good test retest reliability over one week (ICC= 0.72). Cronbach’s alpha indicated the internal consistency was acceptable (0.74). Results showed substantial agreement at initial testing with a valid clinician led measure (r=0.76, p= 0.001).

North East Visual Hallucinations Interview (NEVHI; Mosimann et al, 2008)


The NEVHI was designed to be used as an semi structured interview tool for identifying and assessing visual hallucinations. The NEVHI consists of three sections. Section 1 includes screening questions for hallucinationsand a detailed assessment of the phenomenology. Section 2 assesses the temporal aspects of hallucinations, Section 3 evaluates emotions, cognitions and behaviours associated with recurrent visual hallucinations using a five-point Likert Scale.

Only section 3 of the interview will be used in the questionnaire which consists of 9 questions which refer to perceived control, pleasantness, perceived distress and perceived awareness of hallucinations.

The interview has good face validity as most patients (92.9%) with recurrent visual hallucinations accepted that the interview was about hallucinations and accepted theterm ‘hallucination’. The content validity of the interview is good. All clinicians (100%) agreed that the NEVHI is assessing ‘abnormal visual experiences’, the ‘phenomenology of visual hallucinations’. The majority of clinicians judged that NEVHI is assessing the ‘onset and end of visual experiences’ (91.7% yes answers); the ‘emotional impact of visual hallucinations’ (83.3%yes answers). There was agreement that the interview does not assess delusions (91.7% no answers),

The Patient Health Questionnaire (PHQ-9) Kroenke et al., (2001) The PHQ-9 is a screening measure for depression. The PHQ-9 has high internal consistency reliability (Cronbach’s alpha = .80 Lee et al., 2007), good test-retest reliability (r = .84, Kroenke et al., 2001) and construct validity (r =.73, Martin et al., 2006). Items are based on experience of a range of problems, presenting in the last two weeks, which are signs of depressed mood such as ‘Little interest of pleasure doing things’ and ‘feeling tired and having little energy’. Items are on a four-point Likert scale from ‘not at all’ to ‘nearly everyday’.

Generalized Anxiety Disorder assessment (GAD-7) Spitzer et al (2006)

This a 7-item self-report measure of anxiety which is used as a screening instrument to measure generalised anxiety disorder. The GAD-7 has a scale of 0-3, with higher scores indicating greater symptoms of anxiety in the past two weeks: 0 corresponds to “not at all” and 3 to “nearly every day”. The GAD-7 has high internal consistency reliability (Cronbach’s alpha = .92, Spitzer et al., 2006), good test-retest reliability (r = .83, Spitzer et al., 2006) and construct validity (r = 0.72 to r =0.74, Spitzer et al., 2006).

The Satisfaction with Life Scale (SWLS) (Diener et al, 1985).

This is a 5 item self report measure of life satisfaction. Life satisfaction is one factor in the more general construct of subjective wellbeing.


The internal consistency of the SWLS is good (Cronbach ‘s ( = .87). Test retest αreliability was also good (ICC=.82) over two months. There is also considerable evidence for the convergence of the SWLS with numerous measures of subjective well-being and life satisfaction.

Procedure

Part 1

1. Participants are to be recruited through advertisements posted on charity and support group websites for people who fall in diagnostic groups that might experience visual hallucinations (e.g. Parkinson’s organisations, Hearing Voices Network).

2. Support organisations will be asked to put a link to the study website on their own websites and a donation of up to £50 will be made to thank organisations for their support

3. A participant information document (attached) will be given to support organisations to distribute to their members. This will include the study website address. Visits to support group meetings can be made, if necessary, to bolster participant numbers.

4. Participants who wish to take part will be directed to the study website. The first page on the website will contain the attached participant information (attached), followed by the consent screen (attached). Participants will be assured of the anonymity of their responses and their right to withdraw at any time without giving a reason.

5. Participants will be informed that they will be entered into a prize draw for three prizes: £50, £40 or £30 worth of Amazon vouchers to thank them for their participation, they will be informed that failure to complete the questionnaire will not disqualify them from this. Participants will also be informed of the closing date of entry, the nature of the prize, how the winner will be notified and how and when the winner will be announced.

6. Participants will not be able to proceed to the self-report questionnaires until they have agreed to all statements on the consent form.

7. Once the consent form has been completed, participants will be able to proceed to the attached study questionnaires in the following order :

a. Background information sheet (attached)b. Beliefs about Visual Hallucinations Questionnaire c. Visual Hallucination Activity Scale (VHAS) and The Impact

of Visual Hallucinations Scale (IVHS) (9 items)


d. North East Visual Hallucinations Interview (NEVHI) (9 items)

e. Brief Core Schema Scales (24 items)f. Patient Health Questionnaire depression scale (PHQ-9) (9

items)g. The Generalized Anxiety Disorder (GAD-7) measure of

anxiety (7 items)h. The Satisfaction with Life Scale (SWLS) (5 items)

8. Once all study questionnaires have been completed participants will be directed to a screen thanking them for their participation and giving debriefing information (attached). This includes information about support organisations.

9. If participants choose to abandon the questionnaires prematurely, possibly due to finding the questions distressing, they will also be re-directed to the final screen. In order to do this, participants can choose to exit the study by clicking where indicated on a grey bar end of each screen. This reads:-

‘If you want to exit the study, click here. This will take you to the information screen.’

As explained above, this will provide them with a de-brief as well as information about support organisations.

10. Participants will be asked to forward a link to our website if they know anyone else who might be interested in participating:-

If you know anyone who may be interested in participating with our research,please suggest they visit our website:

http://www.fahs.surrey.ac.uk/survey/visions [this is an example- link not live]

Data analysis and hypotheses

The internal consistency of the adapted measures (i.e. the BAVHQ, the VHAS and the IVHS) will be reported using Cronbach’s alpha.

After screening data for outliers and exploring the distribution of variables the Hypotheses will be tested using multiple regressions as follows:

a) Hypothesis 1: Beliefs about self (BCSS scores) and beliefs about others (BCSS scores) will predict hallucinatory distress (IVHS score, NEVHI score) and disturbance to quality of life (LSQ score). This will remain true when controlling for the content and activity of the hallucinatory experience (VHAS score) and for anxiety and depression (PHQ-8 and GAD-7 scores).


http://www.fahs.surrey.ac.uk/survey/visions

Two multiple regression analysis with disturbance to quality of life and hallucinatory distress as dependent variables and beliefs about self and others as predictors.

b) Beliefs about the power, malevolence, outcome and identity of visual hallucinations (BAVHQ scores) will predict hallucinatory distress (IVHS score) and disturbance to quality of life (LSQ score). This will remain true when controlling for the content and activity of the hallucinatory experience (VHAS score) and for anxiety and depression (PHQ-8 and GAD-7 scores).

Two multiple regression analysis with disturbance to quality of life and hallucinatory distress as dependent variables and (1) BAVQ- R malevolence, (2) BAVQ-R omnipotence (3) BAVQ-R power as predictors.

Assumptions of multiple regression will be checked (e.g. that residuals are approximately normally distributed) and reported.

5) PHQ-9 depression will be added to the model as a covariate and it is predicted that this will reduce but not eliminate the above associations.

6) GAD-7 anxiety will be added to the model as a covariate and it is predicted that this will reduce but not eliminate the above associations.

Feasibility

A project on voice hearing used a similar methodology and recruited through the Hearing Voices Network. This study recruited 180 participants in 9 months. The proposed study will be recruiting through the Hearing Voices Network but also on charity and support group websites for people who fall in diagnostic groups that might experience visual hallucinations.

If the project fails to recruit 107 applicants a second ethics application will be submitted to do a qualitative research study with a small group of participants with visual hallucinations to add to the quantative data using a mixed model design.

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Yellowlees, P.M., & Cook, J.N. (2006) Education about hallucinations using an internet virtual reality system: A qualitative survey. Academic Psychiatry, 30 (6), 534-539

Van, R. J., & Goldberg J.O. (2007) .Quantifying Self-Reports of Auditory Verbal Hallucinations in Persons with Psychosis. Canadian Journal of Behavioural Science,39, 73-77


Appendix O: Ethical Approval


APPENDIX P: Cooks Distances


Statistical reliabiliy tests: Cooks DistancesScale Minimum Maximum Mean Standard

DeviationBCSS .000 .100 .009 .016MCQ-30 .000 .180 .011 .023BAVSQ .000 .159 .009 .018

Note. * p < . 05, ** p < .001. K-S- Komogorov- Smirnov test of Normality was used.

Note:, BCSS= Brief Core Schema Scale; BAVSQ= Beliefs about Visions Questionnaire; MCQ-30= Metacognitive

Questionnaire 30

APPENDIX Q: Normaility Tests


Statistical reliabiliy tests: values of Skewness and Kurtis

Note. * p < . 05, ** p < .001. K-S- Komogorov- Smirnov test of Normality was used.

Note: VAIS= Vision Activity and Impact Scale, BCSS= Brief Core Schema Scale; BAVHQ= Beliefs about Visual

Hallucinations Questionnaire; MCQ-30= Metacognitive Questionnaire 30; PHQ9= Patient Health Questionnaire 9; GAD7=

Generalised Anxiety Disorder Questionnaire 7; SWLS= Satisfaction with Life Scale.


Scale Skewness Kurtis K-SSE SE p

VAIS- distress

.328 .277 -.939 .548 .000**

VAIS- content

-.393 .277 .242 .548 .000**

BCSS- NS .385 .277 -.914 .548 .200BCSS- PS .232 .277 -.879 .548 .001**BCSS-NO .415 .277 -.761 .548 .200BCSS-PO .133 .277 -.619 .548 .023PHQ9 .040 .277 -1.194 .548 .045GAD7 .263 .277 -1.239 .548 .058SWLS .504 .277 -1.015 .548 .200MCQ- CC .092 .277 -1.090 .548 .099MCQ- PB 1.766 .277 3.085 .548 .004*MCQ-CSC -.486 .277 -.871 .548 .000**MCQ-UD .245 .277 -1.378 .548 .200MCQ-NC .124 .277 -1.328 .548 .000**BAVQ-M .691 .277 -.972 .548 .015*BAVQ-B .756 .277 -.639 .548 .012*BAVQ-O .076 .277 -1.080 .548 .000**

APPENDIX R: Histograms of Residuals , Normality Curves and Q-Q Plots













APPENDIX Q: Q-Q PLOTS










MAJOR RESEARCH PROJECT PROPOSAL

‘Are beliefs about visual hallucinations, the self and others associated with hallucinatory distress and disturbance? Does this remain true when taking

account of hallucinatory content and activity?’


CONTENTS

Background and Theoretical Rationale 138

Research Question 142

Main Hypothesis 142

Method 143

Signatures 153

References 154


BACKGROUND AND THEORHETICAL RATIONALE

Horowitz (1975, p. 163) defines visual hallucinations as an ‘image experience in

which there is a discrepancy between subjective experience and actual reality’.

However most definitions of visual hallucinations do not formally distinguish

between self-generated imagery, dream and hallucinations therefore there is no

consensus definition or classification (Cutting, 1997). For the purpose of this

paper we will focus on recurrent visual hallucinations (RCVH) which are

defined as ‘repetitive involuntary images of people, animals, or objects that are

experienced as real during the waking state but for which there is no objective

reality.’ (Collerton et al, 2005, p.736)

Hallucinations can occur in any of the sensory modalities including; auditory,

visual, olfactory, gustory and tactile. They are not always associated with

distress or with a mental health diagnosis (Romme & Escher, 1993) and when

they are, hallucinations can occur in a range of mental health and physical

health conditions (Teeple et al, 2009; Romme & Escher, 1993). Because of this, a

symptom based approach to researching hallucinatory experiences has been

called for (e.g. Bentall, 2004), where the symptom (hallucinations) rather than

the diagnostic label (e.g. ‘schizophrenia’) is the focus.

There has been a vast amount of research exploring the experience of auditory

hallucinations transdiagnostically and developing cognitive models (David &

Nayani, 1996; Romme & Escher, 1994; Birchwood and Chadwick, 1997;

Chadwick and Birchwood, 1994; Close and Garety, 1998). However, there have


been few studies exploring the experience of visual hallucinations and there has

been little attempt to develop cognitive models of these experiences.

Theories on hearing voices (auditory hallucinations) posit that distress

associated with hearing voices is not as a result of the content or frequency of

the voice but is the meaning given to the voices (Chadwick and Birchwood,

1994). This is in line with Ellis’ (1962) cognitive ABC model which refers to

three components of experience that can be used to understand individual’s

emotional and behavioural difficulties. The ‘A’ refers to the activating events;

the ‘B’ refers to beliefs and thoughts about the activating event. The ‘C’ refers to

the consequent emotion and behaviour in relation to the event, given the Bs.

Chadwick and Birchwood (1994) outlined that for people who experience

auditory hallucinations the voice hearing experience is the activating event (A)

to which the individual attaches a belief or meaning (B) which leads to

subsequent emotional and behavioural consequences (C). Chadwick and

Birchwood’s (1994) model is supported by empirical evidence that shows that

beliefs about voices are associated with distress at hearing voices (Birchwood

and Chadwick, 1997) even when controlling for voice activity (Clarke, 2012)

More than one million adults in Britain, while awake repeatedly see people,

animals, or objects that appear real but are not visible to others (Collerton et al

2005). Visual hallucinations are common in a range of mental health and

physical health conditions including; dementing illnesses, delirium, eye disease


and schizophrenia. There is reason to expect that the same ABC model

(Chadwick and Birchwood, 1994) would apply to visual hallucinations and that

it would be the beliefs about visual hallucinations and not the content or

frequency of the hallucination that would be associated with distress. However

currently there are no published studies which could be found that have tested

the ABC model in relation to visual hallucinations.

A number of studies have found similar variability in the emotional

consequences of visual hallucinations as in the auditory hallucination literature.

Participants with visual hallucinations compared to similar groups but without

hallucination were found to score higher for depression (Fenelon et al, 2001;

Holroyd et al, 2000; Barnes and David, 2001) anxiety (Holroyd et al, 2000;

Delespaul et al, 2002) and were also found to report visual hallucinations as

disturbing (Yellowlees and Cook, 2006). Whereas in other studies visual

hallucinations were not rated as pleasant or distressing (Mosimann et al,2008)

Although this research suggests emotional variability as a result of visual

hallucinations it is limited due to a number of methodological limitations

including small sample sizes and the use of unvalidated measures of visual

hallucinations. In addition the variability in the findings could be accountable by

a number of confounding variables such as severity of illness. However these

findings are consistent with Chadwick and Birchwood’s (1994) ABC model

whereby variability in emotional consequences would be expected if it is the

appraisal given to the visual hallucinations and not the content of the

hallucinations that is related to emotional consequences.


Studies have also explored the attributions given to visual hallucinations and

their emotional consequences as these studies have found people with visual

hallucinations were concerned about evaluation from others including beliefs

about being labelled ‘insane’ (Menon, 2005; Teunisse et al, 1996) or perceived

as ‘crazy’ (Scott et al, 2000). Between 75% and 90% of hallucinators do not

spontaneously reveal their experiences (Nesher et al 2001; Scott et al 2001;

Teunisse et al, 1996).

Gauntlett-Gilbert and Kuipers (2005) conducted a study which further supports

the application of the ABC model (Chadwick and Birchwood, 1994) for visual

hallucinations as they found that appraisals given to visual hallucinations were

a predictor of distress and did not follow from the content, frequency or

duration of the hallucination. In addition Dudley et al (2012) found that people

who had negative appraisals of visual hallucinations reported them as

distressing and also engaged in safety seeking behaviours that maintained their

distress. However in both studies they measured a limited range of appraisals

and did not measure the type of appraisals that have been associated with

auditory hallucination distress so it is not possible to draw clear conclusions

from their studies about the relevance of the ABC model to visual hallucinations.

In summary, although there is a small body of research exploring the

experiences and appraisals of visual hallucinations, none of these studies allow


a test of the ABC model. The proposed study aims to address this limitation by

testing the ABC model of visual hallucinations.

RESEARCH QUESTION

‘Are beliefs about visual hallucinations, the self and others associated with

visual hallucinatory distress and disturbance? Does this remain true when

taking account of visual hallucinatory content and activity?’

MAIN HYPOTHESIS

Based on Chadwick and Birchwood’s (1994) ABC model for auditory

hallucinations we would predict that a similar model may be applied to visual

hallucinations. Therefore it is predicted that it will be the appraisal given to the

visual hallucination that will be a predictor of distress and disturbance and that

this will remain true when controlling for hallucinatory content and activity.

Specifically it is predicted that:

1. Beliefs about self (negative self-schema) and beliefs about others (negative

other-schema) will predict hallucinatory distress and disturbance to quality of

life. This will remain true when controlling for the content and activity of the

hallucinatory experience.


2. Beliefs about the power, malevolence, outcome and identity of visual

hallucinations will predict hallucinatory distress and disturbance to quality of

life. This will remain true when controlling for the content and activity of the


METHOD

Participants

107 participants will be recruited, 104 plus 1 participant for each independent

variable will need to be recruited in order to assume a medium effect size With

80% power and a p value of 0.05 (Green, 1991).

Subject to approval from the organisations, participants will be recruited from a

number of charity websites for people that might be experiencing visual

hallucinations (Appendix 1)

Participants will be: aged 18 years or older, will have experienced visual

hallucinations in the past six months, will have had at least two episodes of

visual hallucinatory experience and will confirm that they have sufficient

English language reading ability to complete the battery of questionnaires.

The phenomenological inclusion criteria will be that participants have or are

experiencing repetitive involuntary images of people, animals, or objects that

are experienced as real during the waking state but for which there is no


objective reality. Participants will be excluded from the study if they are

experiencing unusual vivid imagery which is under a degree of conscious

control or are experiencing post traumatic flashbacks, which are dissociative

experiences.

In line with the recommended symptom based approach to understanding

hallucinatory experiences, diagnosis will not be inclusion criteria, although self-

reported diagnosis will be recorded and reported. By recruiting participants

online their identity will remain anonymous which may increase the potential

pool of participants as they may be too ashamed to access services. The end of

the study will also provide participants with further information about where

they can access help regarding their hallucinations.

This study is taking a transdiagnostic approach with potential participants

drawn from a range of diagnostic and community groups. A recent MRP by third

year trainees using a similar recruit strategy for people experiencing auditory

hallucinations recruited 180 participants in one year. By recruiting through a

number of online charities for different diagnostic groups the expected pool of

participants should be at least 107, which is the number needed for the study.

Design

The study will be a cross-sectional survey design using online materials.


Measure

A questionnaire will be used in the study. No validated measure of beliefs about

visual hallucinations could be found. It was therefore decided to adapt a

validated measure of beliefs about auditory hallucinations (see Appendix 2 for

both the original and adapted versions);

5. Beliefs about Visual Hallucinations Questionnaire (BAVHQ; adapted

from the Beliefs about Voices Questionnaires – Revised, BAVQ-R

(Chadwick et al 2000)

The only change to the voices questionnaire is that the word ‘voice’ has been

replaced with the word ‘vision’. A definition of ‘vision’ will be given in the

participant information sheet as well as prior to the questionnaire in

accordance with the Collerton et al (2005) definition of hallucinations given in

the Background section. The internal consistency of the BAVHQ will be reported

when presenting findings of the current study.

The original BAVQ- R is a 35-item self report measure of patients beliefs,

emotions and behaviour about their auditory hallucinations. There are three

subscales that relate to beliefs: malevolence (six items), benevolence (six items)

and omnipotence (six items).


The reliability and validity measures for the scale show that the cronbachs α

score for each subscale were high (0.84, 0.88, 0.74, 0.85, 0.87) which suggests

the items within the scales are measuring the same construct.

In addition construct validity measures shored that there was a strong

relationship between malevolence and resistance (r= 0.68, d.f.= 0.69, P<0.01)

and benevolence and engagement (r= 0.80, d.f.= 0.69, P<0.01). This was a

similar finding to the first BAVQ scale (Birchwood and Chadwick, 1997,

Chadwick and Birchwood, 1995) which suggests it is a robust analysis of

people’s relationships to their visual hallucinations.

6. Visual Hallucination Activity Scale (VHAS; adapted from the Hamilton

Program for Schizophrenia Voices Questionnaire, HPSVQ, Lieshout and

Goldberg, 2007)

7. The Impact of Visual Hallucinations Scale (IVHS; adapted from the

Hamilton Program for Schizophrenia Voices Questionnaire, HPSVQ,

Lieshout and Goldberg, 2007)

No validated measure of visual hallucinatory experience could be found.

Therefore a validated measure from the auditory hallucination literature has

been adapted to replace each item with a semantically equivalent item (see

Appendix 3).The internal consistency of the VHAS and the IVHS will be reported

when writing up findings of the current study.


The HPSQ is a 9 item questionnaire used to assess the characteristics and

content of auditory hallucinations as well as address the subjective impact that

voices have on the individual.

It showed a good test retest reliability over one week (ICC= 0.72). Cronbachs

alpha indicated the internal consistency was acceptable (0.74). Results showed

substantial agreement at initial testing with a valid clinician led measure

(r=0.76, p= 0.001).

8. Brief core schema scales (Fowler et al, 2006)

The brief core schema scale (BCSS) (Appendix 4) is a self report assessment of

schemata concerning self and others. The scales assess four dimensions of self

and other evaluation: negative self, positive self, negative other, positive other.

Test-retest reliability (Pearson’s r) for the negative-self, positive-self, negative-

other and positive-other scales respectively were r=0.84, 0.82, 0.7 and 0 . 72 (all

significant p<0.001). Cronbachs alpha indicated the internal consistency was

high (0.74). Results showed moderate to strong associations with other valid

clinician led measures.

9. PHQ depression scale (PHQ-9) (Kroenke, 2001)


The PHQ-9 (Appendix 5) is a 9 item self administered diagnostic instrument

used to grade the severity of depression.

The internal reliability is excellent with Cronbachs alpha of 0.89. Test retest

reliability is also excellent over 48 hours (0.84). Results showed strong

associations with other valid clinician led measures.

10. GAD-7 (Spitzer et al, 2006)

The GAD-7 (Appendix 6) is a 9 item self administered diagnostic instrument

used to grade the severity of generalised anxiety disorder.

The internal consistency of the GAD-7 was excellent (Cronbach α = .92). Test-

retest reliability was also good (intraclass correlation = 0.83). Comparison of

scores derived from the self-report scales with those derived from the MHP-

administered versions of the same scales yielded similar results (intraclass

correlation = 0.83), indicating good procedural validity

11. The Satisfaction with Life Scale (SWLS) (Appendix 7) (Diener et al,

1985). [you need a measure of quality of life / satisfaction with life to

test your hypotheses]

This is a 5 item self report measure of life satisfaction. Life satisfaction is one

factor in the more general construct of subjective wellbeing.


The internal consistency of the SWLS is good (Cronbachs = .87). Test retestα

reliability was also good (ICC=.82) over two months. There is also

considerable evidence for the convergence of the SWLS with numerous

measures of subjective well-being and life satisfaction.

Procedure

A secure website will be built to host the study questionnaires. A link to this

website will be added to charity websites who agree to the host link. The

questionnaire will be placed on the websites mentioned above with an advert

(Appendix 8) as to the nature of the study. The first page of the questionnaire

will provide participants with information about the study (Appendix 9) and

give them the option whether they wish to give consent (Appendix 10) to take

part in the study. If participants choose to take part in the study the first section

will be questions to screen participants to ensure that only participants that

have experienced visual hallucination will be included in the study. The next

section will be used to find out demographic details. The questionnaire used can

be found in Appendix 11 and will be presented in the same order as the

questionnaire in the Appendix.


Ethical Considerations

All personal data is held and processed in the strictest confidence, and in

accordance with the Data Protection Act (1998). The web based questionnaire

will be hosted on a secure server and participants will remain anonymous.

There us a prize draw for participants to win £30, £40 and £50 of Amazon.co.uk

vouchers. To preserve the anonymity of participants, they will be asked to send

an email at the end of the study if they wish to be entered into the prize draw.

Email address’ of participants will not be linked to the data. Only the

researchers will have access to this data. The retention period for the data will

be for five years.

Written informed consent (Appendix 10) will be sought from participants after

being given a full explanation of the nature, purpose and likely duration of the

study (Appendix 9). Participants will be informed that they have the right to

withdraw from the study at any time without needing to justify their decision

and without prejudice.

All participants will be debriefed at the end of the study with more information

about the nature of the research (Appendix 12). Should participants find

answering the questionnaire upsetting, they will be provided with information

at the end of the study about support organisations and also given contact

details of the researchers should they wish to discuss this further.


The study will require ethical approval from the Surrey university faculty

ethical committee. This will be requested at the end of November 2012.

The study does not require R& D ethical approval.

Proposed Data Analysis

The internal consistency of the adapted measures (i.e. the BAVHQ, the VHAS

and the IVHS) will be reported using Cronbach alpha.

After screening data for outliers and exploring the distribution of variables the

Hypotheses will be tested using multiple regressions as follows:

c) Beliefs about self (BCSS scores) and beliefs about others (BCSS scores) will

predict hallucinatory distress (IVHS score) and disturbance to quality of life

(LSQ score). This will remain true when controlling for the content and

activity of the hallucinatory experience (VHAS score) and for anxiety and

depression (PHQ-8 and GAD-7 scores).

d) Beliefs about the power, malevolence, outcome and identity of visual

hallucinations (BAVHQ scores) will predict hallucinatory distress (IVHS

score) and disturbance to quality of life (LSQ score). This will remain true

when controlling for the content and activity of the hallucinatory experience

(VHAS score) and for anxiety and depression (PHQ-8 and GAD-7 scores).


Assumptions of multiple regression will be checked (e.g. that residuals are

approximately normally distributed) and reported.

Service User and Carer Consultation/ Involvement

Consultation will be sought from service users on the layout and acceptability of

the study website before it goes live.

Feasibility Issues

International charities representing a range of mental health and physical

health groups will be contacted to host a link to the study website in order to

ensure a large pool of potential participants.

Dissemination strategy

This project would be submitted to the British Journal of Clinical Psychology

and presented at the annual BABCP conference.

Timeline

- MRP course approval- Mid September 2012

- Ethics submission- End November 2012


- R & D submission n/a

- Data collection started - End January 2013

- Data analysis started/completed- End December 2013

- Date for completing draft;

Introduction- July 2013

Methods- July 2013

Results- December 2013

- Discussion- January 2014

- Completed draft submission to supervisor- January 2014

Signatures

MAJOR RESEARCH PROJECT - LITERATURE

REVIEW

April 2012


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Haddock & P. Slade (eds) Cognitive Behavioural Interventions for Psychosis;

London, Routledge

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visual hallucinations. Behavioural and Brain Sciences. 28, 737-794

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internet virtual reality system: A qualitative survey. Academic Psychiatry, 30 (6),

534-539


LITERATURE REVIEW

Appraisals of visual hallucinations and their emotional consequences: Literature

Review


ABSTRACT

There have been a number of studies that have looked at the appraisals of auditory

hallucinations and their emotional consequences. Subsequently Chadwick and

Birchwood (1994) developed a cognitive model to understand the components of

auditory hallucinations. Their model highlights that the emotional consequences are

the product of the meaning/belief attached to the voice and not the content of the

voice itself (Chadwick & Birchwood, 1994). Little research has been done to

explore whether this model could be applied to visual hallucinations therefore the

aim of this review was to identify and critique the literature on the beliefs attributed

to visual hallucinations and the emotional consequences of these beliefs. The second

purpose of the review was to ascertain if Chadwick and Birchwood’s (1994) ABC

model of auditory hallucinations could also be applied to visual hallucinations. A

systematic search of five databases was performed (PsychINFO, Web of Science,

Ovid MEDLINE, Embase AND CINAHL) and sixteen papers met the inclusion

criteria and were reviewed. The results of the review showed evidence to suggest

that Chadwick and Birchwood’s (1994) ABC model may also be applicable to visual

hallucinations as showed emotional consequences were the product of appraisals of

visual hallucinations and not the content. These findings warrant further

investigation as a number of the studies have methodological implications. Evidence

was also found to suggest that the episode of illness in people with bipolar disorder

might also have an impact on beliefs attributed to visual hallucinations, however, the

reason for this remains unclear. The role of mood in this relationship is discussed

and identified as an area for future research.


CONTENTS

1. INTRODUCTION 162

2. SEARCH STRATEGY 165

3. RESULTS 166

3.1. Emotional consequences of visual hallucinations 167

3.1.1. Organic Populations 167

3.1.2. Mental health populations 171

3.1.3. Non clinical populations 172

3.1.4. Emotional consequences of visual hallucinations- Summary of findings 174

3.2. Beliefs about visual hallucinations 175

3.2.1. Beliefs about Malevolence/ Omnipotence and Magical/Spiritual sources 175

3.2.2. Beliefs about social evaluation and cause of visual hallucinations 176

3.2.3. Beliefs about outcome following visual hallucinations 180

3.2.4. Beliefs associated with predisposition to visual hallucinations 183

3.2.5. Beliefs about hallucinations- Summary of findings 185

4. DISCUSSION 186

5. REFERENCES 190

6. APPENDIX 198


1. INTRODUCTION

Slade and Bentall (1988, p. 23) define hallucinations as “any percept-like experience

which (a) occurs in the absence of an appropriate stimulus, (b) has the full force or

impact of the corresponding actual (real) perception and (c) is not amenable to direct

or voluntary control by the experiencer.” Hallucinations can occur in any of the

sensory modalities including: auditory, visual, olfactory, gustatory and tactile.

Hallucinations are not necessarily an indication of a physical or mental health

problem; surveys of hallucinatory experiences suggest that 10-25% of the general

population have reported experiencing hallucinations at least once (Slade and

Bentall, 1988). Hallucinations have, however, been associated with a wide range of

conditions including physical disorders such as progressive sensory loss (Scott et al,

2001), neurological disorders including; Parkinson’s disease, Lewy body dementia

and Epilepsy (Fenelon et al, 2000; Panayiotopoulos, 1998; Perry et al, 2006) and a

number of psychiatric disorders including; Schizophrenia, Post Traumatic Stress

Disorder (PTSD) and Bipolar Disorder (Nayani & David, 1996; Mueser & Butler,

1987; Baethge et al, 2005). Brasic (1998) listed more than 40 medical and

psychiatric conditions in which hallucinations may occur.

There have been a number of studies that have focused on the emotional

consequences of auditory hallucinations and found mixed results with studies linking

auditory hallucinations with both negative (Close & Garety, 1998; Nayani & David,

1996) and positive emotional consequences (Miller, O’Conner & DiPasquale, 1993;

Romme & Escher, 1993). Romme and Escher (1993) have been at the forefront of


illuminating non- clinical voice hearing groups in the general population as many

people hear voices but are not always perturbed by these.

Chadwick and Birchwood (1994) developed a cognitive model to understand and

tease apart the components of the experience of auditory hallucinations. At the time

this model was revolutionary as prior to this the general consensus was that visual

hallucinations were not understandable from a psychological perspective and not

amenable to psychological therapies. The model is described as the ABC model and

was an adaptation of Ellis’ (1962) cognitive ABC model. Ellis’s model refers to

three components of experience that can be used to understand individual’s

emotional and behavioural difficulties. The ‘A’ refers to the activating event, the ‘B’

refers to the belief given to the activating event which is used to build a picture of

the world and guide how we evaluate ourselves and the world. The ‘C’ refers to the

consequent emotion and behaviour in relation to the event.

Chadwick and Birchwood (1994) adapted the model to consider auditory

hallucinations to be the activating event (A) and beliefs and thoughts about these

hallucinations were considered separately.(B). Chadwick and Birchwood (1994)

outlined that for people who experience auditory hallucinations the voice is the

activating event (A) to which the individual attaches a belief or meaning (B) and

these lead to subsequent consequences (C) which can be both emotional and

behavioural reactions.

We know that auditory hallucinations occur across a number of disorders and people

show different levels of emotional response to the hallucinations (Birchwood &

Chadwick, 1997). The cognitive model suggests that it not the hallucination itself

that causes distress but the belief that is attached to it. There is strong empirical

support for this model including evidence that beliefs about voice power are


associated with symptoms of depression (Chadwick & Birchwood, 1996).

Furthermore it has been found that there is variation in beliefs about voice identity

and content and the person’s associated feelings and behaviour. (Chadwick,

Birchwood & Trower, 1999).

This model has been developed into a comprehensive therapeutic approach for

working with auditory hallucinations, which focuses on understanding and

evaluating beliefs about voices rather than focusing on the content of the voice itself.

This model was specifically developed to understand the components and

experiences associated with auditory hallucinations. The relevance of this model to

other forms of hallucination has received little research interest. This seems

surprising due to the high number of people who experience visual hallucinations.

Bracha et al (1989) found that 56% of their inpatient sample experienced visual

hallucinations, furthermore Tien (1991) found in the general population an incidence

of visual hallucinations in 2% of men and 1.3% of women.

Due to the high number of people presenting with visual hallucinations particularly

in inpatient settings this is an area that would benefit further research. The scope of

this paper is to review the literature on visual hallucinations in relation to Chadwick

and Birchwood’s (1994) ABC model.

Visual Hallucinations

Visual hallucinations are images, which appear externally located, are unpredictable

and outside of the person’s control (Ffytche, 2004).

Marsh (1979) suggested there are three different categories of visual hallucination

including; superimposed hallucinations which are characterised by flashes of light,

colour and patterns; spatial and depth distortions characterised by disturbances in


depth perception and loss and sense of perspective and animations which are when

inanimate objects become animated.

There have been few studies, which have explored the relationship between the

content of visual hallucinations and beliefs about these hallucinations (Gauntlett-

Gilbert & Kuipers, 2005). A number of studies have explored the consequence of

visual hallucination both emotionally and behaviourally within specific diagnostic

groups (Hammersley et al 2010; Fenelon et al, 2000). However there is little research

that explores the link between visual hallucinations and emotional and behavioural

consequences transdiagnostically.

The purpose of this review is to identify and critique the literature on the beliefs

attributed to visual hallucinations and emotional consequences of these beliefs. A

second purpose is to ascertain if Chadwick and Birchwood’s (1994) ABC model of

auditory hallucinations can also be applied to visual hallucinations.

2. SEARCH STRATEGY

An electronic systematic search of five databases was performed (PsychINFO, Web

of Science, Ovid MEDLINE, Embase AND CINAHL), including all papers

published up to January 2012 and relevant papers from their reference lists. The

search was carried out in relation to Chadwick and Birchwood’s (1994) ABC model.

Both searches included titles and abstracts. The search terms used were to explore

the literature on beliefs attributed to visual hallucinations and the emotional

consequences of visual hallucinations. The search terms used were:

(VISU* AND HALLUCIN*) AND (APPRAISAL or MEANING or BELIEF) AND

(DISTRESS or IMPACT or DEPRESS* or ANXI*).


The search was conducted on the 10th January 2012 and produced 788

papers. The following exclusion and inclusion criteria were applied to the papers

Exclusion Criteria;

- Studies on post-traumatic stress disorder flashbacks which are dissociative

experiences.

- Studies focusing primarily substance use hallucinatory experiences.

- Studies on hallucinations during sleep or awaking from sleep.

- Studies not focused on visual hallucinations.

- Papers not written in English

Inclusion Criteria;

- Papers written or transcribed to English

- Any paper exploring the belief attached to visual hallucinations

- Any paper exploring the emotional consequences of visual hallucinations

Using these inclusion and exclusion criteria 16 papers were judged eligible for

review by the author and their supervisor. One of these papers was taken from a

review paper as did not come up in the search but met the inclusion criteria

(Yellowlees & Cook, 2006)

3. RESULTS

Sixteen studies met the inclusion criteria. Table 1 (Appendix 1) includes information

about: the main aim of the study, the sample size and sampling criteria, the method

of data collection, the scales/questionnaires used and the main findings from each

study. The studies have been divided into two sections: the first looking at the

emotional consequences of visual hallucinations and the second section exploring the


beliefs attributed to visual hallucinations and the consequences of these beliefs. The

motivation for this outline was to enable the reader to quickly identify specific areas

of interest.

Seven studies looked at the emotional consequences of visual hallucinations. Nine

studies explored the belief attributed to visual hallucinations and the consequences of

these. These were looked at in organic, mental health and non-clinical populations.

3.1. Emotional consequences of visual hallucinations

3.1.1. Organic populations

Four studies were found that explored the emotional consequences of visual

hallucinations in organic populations. Three studies explored the phenomenology of

visual hallucinations in participants with Parkinson’s disease (Holroyd et al, 2001;

Fenelon et al, 2000; Barnes & David, 2001). One study explored the phenomenology

of visual hallucinations in participants with visual and/or cognitive impairments

(Mosimann et al, 2008).

Barnes and David (2001) asked participants (N= 21) with a diagnosis of Parkinson’s

disease with visual hallucinations to complete a questionnaire developed by the

authors about the nature and properties of these. Participants were also given a

clinical interview about their experiences. These participants were compared against

a control group of participants with Parkinson’s disease without visual hallucinations

(N= 23).

The results of the study showed that participants with visual hallucinations showed

varied emotional responses to the hallucinations and these were often in line with the

severity of their hallucinations. The emotions experienced were: frustration, anger,


fear and in a few participants indifference. Participants with visual hallucinations

also showed more depressed mood.

Fenelon et al (2000) conducted a similar study in which participants with

Parkinson’s disease were interviewed about their experience of visual hallucinations

(N=86) and were compared to a control group without hallucinations (N=136).

Fenelon et al (2000) found similar results including higher depression scores in

people with visual hallucinations compared to participants without visual

hallucinations. However, when depression was analysed according to the Centre for

Epidemiologic Studies Depression Scale (CES-D) (Fuhrer & Rouillon, 1989) the

difference was not significant. In their study they also found that 27.6% of

participants said they experienced anxiety as a result of their visual hallucinations.

Similar results were also found by Holroyd et al (2001) who compared participants

with a diagnosis of Parkinson’s disease who experienced visual hallucinations (N=

26) and did not experience hallucinations (N= 72). Participants were asked to

complete a number of questionnaires to assess for visual acuity, cognition,

depression, disease severity and other clinical variables. Participants with visual

hallucinations were also interviewed about their experiences these. Like the findings

of Fenelon et al (2000) and Barnes and David (2001) results also showed that

participants with visual hallucinations had a higher score on the geriatric depression

scale (GDS) than non-hallucinators.

The findings across all three studies suggest that there is some link between visual

hallucinations and their emotional consequences. However, all three studies share

similar limitations as there were a number of confounding variables that may have

affected the results. It was found that participants with visual hallucinations also had;

greater disease severity (Barnes & David, 2001; Holroyd et al, 2012) cognitive


impairment (Barnes & David, 2001; Holroyd et al, 2012), longer disease duration

(Fenelon et al, 2000), were older (Fenelon et al, 2000), had more sever motor state

(Fenelon et al, 2000), and lower visual acuity (Holroyd et al, 2012). Due to the

number of confounding variables across all three studies we cannot assume a causal

link between visual hallucinations and their emotional consequences. This may be a

result of the other confounding variables, and hallucinations may just be an artefact

of this relation.

In addition, two of the studies (Barnes & David, 2001; Holroyd et al, 2012)

developed their own questionnaires to measure the experience of visual

hallucinations. These may not be reliable or valid tools to measure this experience. It

must also be taken into consideration that all three studies relied on self-report data,

which may be subject to recall bias and therefore may not capture the hallucinatory

experiences accurately. Due to the number of methodological limitations across all

three studies the link between emotional consequences and visual hallucinations

remains unclear.

Mosimann et al (2008) conducted a study to pilot The North East Visual

Hallucination Interview (NEVHI) with a sample of 80 older people with visual

and/or cognitive impairments compared with a control group of participants without

visual or cognitive impairments (N=34). Participants were screened for visual

hallucinations (N=70) and additional informants views were assessed in a separate

room. The results of the study showed that the mean score for pleasantness of the

visual hallucination (scored from 1-4) was low (mean 0.4, SD 0.8) indicting that

hallucinations were rarely perceived to be pleasant. There was also a low score for

distress (scored from 1-4) (mean 1.3; SD 1.2) indicating that visual hallucinations

were also rarely associated with distress. Hallucinations were grouped into simple


and complex hallucinations. Complex hallucinations referred to hallucinations

formed of images e.g. figures, objects, animals and forms and simple hallucinations

referred to hallucinations in the absence of forms and included; flashes, dots, lines,

shapes, swirls and patterns. The findings showed that the pleasantness scores were

significantly higher for complex hallucinations (mean 0.6, SD 0.9) than for

participants with simple hallucinations (mean 0.1; SD 0.4). Ratings of distress did

not differ between the two groups.

The results of this study suggest there may be a link between the content of

hallucinations and the emotional consequences. However, this could also be linked

to the appraisal given to the different hallucinations but this is unclear. The study

shares similar limitations to previous studies, as there were a number of confounding

variables. Participants with visual hallucinations were also found to be: older, less

educated, visually and cognitively more impaired than controls. It was also found

that there was a lack of agreement between the patient and the informant, which

suggests that the experience of visual hallucinations is subjective and we cannot rely

on informants for this information, as it may be unreliable.

The scale showed good criterion validity, face validity and content validity. There

was also high internal consistency with α=0.71 and the inter rater reliability was also

high with K= 0.83 for complex hallucinations and simple hallucinations. This

suggests that the questionnaire is a good tool to measure the experience of visual

hallucinations. These results also suggest that the findings from the study are a good

representation of the emotional consequences of visual hallucinations in people with

visual and/or cognitive impairment. This scale was the first to assess visual

hallucinations and not primarily auditory, therefore, it would be of interest to use it

across other populations.


All the studies so far have been studied participants with organic health conditions.

These studies show some variability in the findings with three studies on Parkinson’s

disease identifying a link between people with visual hallucinations showing higher

scores of depression (Barnes & David, 2001; Fenelon et al, 2000; Holroyd et al,

2012). One study in a sample of participants with visual/cognitive impairments

rarely perceived their visual hallucinations to be distressing or pleasant. Due to the

variability in the findings across diagnostic groups and the number of confounding

variables across the studies the link between visual hallucinations and their

emotional consequences remains unclear. The next section explores the emotional

consequences of visual hallucinations in a sample of participants with severe mental

illness.

3.1.2. Mental Health Populations

Only one study was identified that explored the emotional consequences of both

visual and auditory hallucinations in a sample of participants with severe mental

illness (Delespaul et al, 2002).

The study was methodologically rigorous and compared two groups of participants

including: hallucinating and non-hallucinating participants diagnosed on the

schizophrenia spectrum (N=57), and a group of affective disorder participants

(N=37). Data were collected using the Experience Sampling Method (ESM) over 1

week. Participants with visual hallucinations rated themselves as significantly more

de-realised, more obsessive and had more fear of losing control than participants

without visual hallucinations. It was also found that more participants suffering from

schizophrenia reported significantly more hallucinations (62.5%) than the non-

affective group (10.5%). The intensity of visual hallucinations was also reported to

be lower than for auditory hallucinations. In addition they found in participants with


visual hallucinations, anxiety co –varied with hallucinatory intensity however for

auditory hallucinations no anticipatory anxiety was found. Furthermore visual

hallucinations were more disturbing and were linked to higher levels of anxiety than

auditory hallucinations.

These findings suggest that anxiety may not be an antecedent for visual

hallucinations but that it may be an emotional consequence of the visual

hallucination. However a limitation of this study is that by using a self-assessment

technique participants responses may have been over or under exaggerated due to

social desirability bias. Also some people experiencing psychosis may not identify a

visual hallucinations a hallucinatory experience (that is they may believe it to be a

‘real’ experience and not report it as a hallucination). Due to the diagnostic accuracy

the study does give a good understanding of the link between visual hallucinations

and mood across two diagnostic groups. Due to the relatively small sample size and

limited diagnostic groups it would be of interest to explore the hallucinatory

experiences in other diagnostic groups to see whether the findings would be similar

in a wider population of people with mental health disorders and in non-clinical

samples to see whether similar results are found. The next group of studies include

participants from non-clinical populations and their experiences of visual

hallucinations.

3.1.3. Non clinical populations

Two studies were identified that looked at the experience of visual hallucinations in

non-clinical populations (Ohayon, 2000; Yellowlees & Cook, 2006).

Ohayon (2000) looked at the prevalence of hallucinations in the general population

across three European countries (N= 13057). Participants were given interviews over

the telephone and asked questions from the Sleep- AVAL knowledge based system,


which was developed by the authors. The phenomena under study included: visual,

auditory, olfactory, haptic, gustatory hallucinations and out of body experiences.

Only fourteen participants overall reported experiencing visual hallucinations at least

once a week. The variables that were associated with visual hallucinations included:

current use of drugs, past use of alcohol, anxiety, bipolar, depressive psychotic

disorders and too short sleep duration. Due to the number of confounding variables

in this study it is unclear what the link is between anxiety and visual hallucinations

and whether visual hallucinations are an artefact of the other variables. There are

also a number of methodological limitations. As interviews were conducted over the

telephone people may not have been honest about their experiences due to social

desirability biases. Also people with hallucinations are not always aware that they

are unreal so may not report that they are experiencing hallucinations, therefore the

data may not be representative of all people with visual hallucinations. There is also

little information about what the questions from the Sleep AVAL knowledge based

system were included in the study. There is also no published evidence for reliability

and validity for this tool, so it is difficult to ascertain any clear findings on the

emotional consequences of visual hallucinations from this study. However this study

is of interest as it is one of the first large studies looking at the prevalence of visual

hallucinations across the general population. It would be of interest to replicate the

study but control for confounding variables to gain a greater insight into the

experience of visual hallucinations in a non-clinical sample.

An interesting study was conducted by Yellowlees and Cook (2006) who used a

virtual reality system to simulate auditory and visual hallucinations for non-clinical

populations. 579 people completed the study and completed a questionnaire about

their experience. The results showed that 279 (48%) of the participants found the


experience disturbing. However, it was not clear whether this was related to the

visual or auditory hallucinations, as they were not clearly separated in the study. This

study is of great interest as allows the experimenters to control the experience of

visual and auditory hallucinations to make a clear distinction between this and

emotional consequences. It is unclear what the level of disturbance experienced by

participants was and as no pre-test was given it not clear how this changed during the

experiment. Also due to the nature of the study it cannot be assumed that the virtual

reality experience is the same as the real experience of hallucinations as often this

can be accompanied by additional symptoms (for example; people with

Schizophrenia will often also have delusions and negative symptoms). Furthermore

the participants had insight that the experience was not real, whereas people with

hallucinations often will question whether the hallucination is real or not. This study

is the first to look at the emotional consequences in simulated visual hallucinations

and it would be important to explore this further.

3.1.4. Emotional consequences of Visual Hallucinations-Summary of findings

The studies exploring the emotional correlates of visual hallucinations are of interest.

The findings show some variability in the emotional consequences of visual

hallucinations. Participants with visual hallucinations were found to score higher for

depression (Fenelon et al, 2001; Holroyd et al, 2000; Barnes & David, 2001), anxiety

(Holroyd et al, 2000; Delespaul et al, 2002; Ohayon, 2000) and reported the

experience of visual hallucinations disturbing (Yellowlees & Cook, 2006). However

Mosimann et al, 2008 also found that participants with visual hallucinations did not

rate their visual hallucinations as depressing or distressing. Due to the number of

methodological limitations across the studies the link between visual hallucinations


and emotional consequences remains unclear. However, it is of interest to explore

whether the variability across and within studies is a result of the content or appraisal

of the visual hallucinations or whether it is due to a confounding variable.

3.2. Beliefs about Visual Hallucinations

Nine papers were identified that explored the belief and consequences of visual

hallucinations. These papers looked at different populations including: organic,

mental health and non-clinical populations. This section is divided into the different

types of beliefs found to be associated with visual hallucinations.

3.2.1. Beliefs about Malevolence/Omnipotence and Magical/Spiritual sources.

Hammersley et al (2010) conducted a study to investigate the attributions for

hallucinations (both auditory and visual) in a sample of participants with bipolar

disorder (N=19). Participants were required to complete a questionnaire adapted

from Chadwick and Birchwood’s (1995) beliefs about voices questionnaire to

include questions on visual hallucinations. Also detailed subjective descriptions of

participant’s hallucinatory experiences were recorded and categorised into four

groups of attributions these included hallucinations caused by: illness,

magical/spiritual source, omnipotent or malevolent source, stress, punishment and

any other source. Inter-rater reliability for these categorisations was 90% (Kappa=

8.75). The results showed that 17 of the 19 participants reported visual hallucinations

and 16 of these participants experienced these when they were in a hyper manic

state. Eight participants reported auditory hallucinations and 7 of these participants

experienced these when depressed. The majority of participants held more than one

attribution for their hallucination. 17 of the 19 participants attributed their

hallucination to illness when they were euthymic. One third of the participants held


omnipotent/malevolent attributions whilst in episode, however, post episode only 1

participant held this belief. Interestingly the majority of participants that held

omnipotent/malevolent attributions also had auditory hallucinations or were

depressed. In addition the majority of participants that held magical/extrasensory

attributions for their hallucinations did so when manic or hypomanic.

These findings are of interest as suggest that there is a difference in the attribution

given to hallucinations at different stages of illness in bipolar disorder and it may be

that omnipotent/malevolent beliefs are linked with depression and

magical/extrasensory attributions are linked with mania and hyper mania. The

limitation of this study is that it relies on retrospective data that may not be reliable

and may be subject to recall bias. The scale used was also adapted from one designed

to measure auditory hallucinations so may not be a reliable or valid measure of

visual hallucinations. Despite these methodological implications this study is of

interest as suggests that attributions held about hallucinations may differ in relation

to episode of illness in bipolar disorder. However, it remains unclear why this is and

whether attributions given to hallucinations could be related to mood.

3.2.2. Beliefs about social evaluation and cause of hallucinations

Four studies were identified that explored beliefs about social evaluation and cause

of hallucinations (Menon, 2005; Scott et al, 2000; Nesher et al, 2000; Teunisse et al,

1996)

Menon (2005) conducted a study to explore the experience of visual hallucinations in

visually impaired participants and compared these against a control group without

visual hallucinations (N=48). 63% of participants admitted to experiencing visual

hallucinations. 57% expressed concern about their visual hallucinations and 23% had

experienced disturbing or frightening images. They also found that 63% of


participants had negative beliefs about themselves and feared that they would be

labelled as ‘insane’ and 33% were fearful they would ‘become insane’ as a result of

the visual hallucination. In addition 94% of the participants that expressed concern

about their visual hallucination (N=17) admitted to deriving emotional comfort from

the explanation that their hallucination was due to visual impairment and not

imminent insanity.

These findings suggest that there may be a link between level of distress associated

with visual hallucination and the belief attributed to its cause rather than the content

of the hallucination. These results also showed that re-evaluation of beliefs about the

cause of visual hallucinations led to improvement in participant’s emotional and

psychological wellbeing. This supports that there may be a link between the belief

attributed to visual hallucinations and the emotional consequence of these.

Scott et al (2000) found similar findings in a study exploring the phenomenological

nature of visual hallucinations among participants with retinal disease (N=86). They

found that in a univariate analysis visual hallucinations were significantly associated

with: female sex, worse visual acuity, probable or definite emotional distress,

decreased functional status and decreased quality of life. They also found that only

two participants (15.3%) had informed their physicians of their hallucinations. The

reason for this was because 5 participants feared that they would not be believed, and

6 thought that they would be perceived as ‘crazy.’ This study also supports that there

may be a link between visual hallucinations and emotional distress; this may be due

to the beliefs about social evaluation (what others will think) and beliefs about the

cause of the hallucination. As with previous studies there were a number of

confounding variables that may also have been associated with emotional distress.

These included: decreased functional status and worse visual acuity therefore we


cannot assume emotional distress is a direct result of visual hallucinations. In

addition the scale used was developed by the authors and therefore may not be a

reliable or valid tool for the measure of visual hallucinations.

In a similar study Nesher et al (2001) explored visual hallucinations in glaucoma

participants with low vision (N=11) and looked at the frequency of visual

hallucinations in patients with Charles Bonnet Syndrome. Although they did not

explore the emotional consequences of visual hallucinations, they did find that of the

11 participants that admitted to experiencing visual hallucinations in the past year

only one patient had previously shared their experience of visual hallucinations with

another person. It was also reported that they reported to be relieved once they could

share the experience without feeling ‘ashamed’ or ‘insecure’ about it. Although this

study appears to support that people with visual hallucinations may hold beliefs

about the social evaluation of others, the study does not clearly say why participants

did not share their experience with others. The relief experienced by the participants

also was not measured but was an observation of the authors. Therefore, the link

between appraisal of the hallucination and the emotional consequences is not

empirically supported and therefore may not be accurate.

Teunisse et al (1996) found similar results to Nesher et al (2001) in a study of

participants with a diagnosis of Charles Bonnet syndrome (N=60). Participants were

interviewed about their experiences of visual hallucinations. As in the previous

studies (Menon, 2005; Scott et al, 2000; Nesher et al, 2000) a similar result was

found that 73% of participants had not mentioned their hallucinations to doctors

before. 15 participants feared the doctor would not take them seriously and would

think that they were insane. 20 thought it was not a complaint to go to the doctor for

and 9 did not give an explanation. Only 1 person had consulted their doctor.


The results also showed that 77% of participants did not report any personal

relevance to the hallucination even when the hallucinations were familiar to them.

5% of participants were unsure of the personal meaning of their hallucination, for

example, one gentleman was intrigued by recurrent hallucinations of children and

wondered whether this was related to his unfulfilled wish of wanting to become a

father. 17% of participants experienced both emotionally important and unimportant

hallucinations. Only 2% of participants experienced visual hallucinations that with

personal, emotionally relevant content. The emotional response towards the

hallucination was reported to be negative by 19 participants (32%) with anxiety in 14

and irritation reported by 5. 11 (18%) participants reported mixed emotions and 22

(27%) reported their emotional response as neutral. Feelings of wellbeing were also

reported to be disturbed in 72% of participants and 28% felt that they suffered as a

result of their hallucinations.

These findings suggest that as the majority of participants did not feel as though the

content of the hallucination was emotionally or personally relevant to them but there

was still variability in the emotional consequences experienced that it may not be the

content of the hallucination that is linked to level of distress, but rather the appraisal

given to the hallucination. This study also shows similar results to the previous

studies (Menon, 2005; Scott et al, 2000; Nesher et al, 2000) which would propose

that emotional distress may be due to beliefs about social evaluation and beliefs

about the cause of the hallucination. These results are of interest as suggest that in

organic populations that there is a fear of becoming or being labelled as insane as a

results of visual hallucination. These findings could have clinical implications when

considering the emotional consequences of giving a psychiatric ‘label’ when people

with mental health disorders experience visual hallucinations.


3.2.3. Beliefs about outcome following visual hallucinations

Two further studies explored beliefs about outcome in organic (Schultz & Melzack,

1993) and mental health populations (Gauntlett-Glbert & Kuipers, 2005).

Schultz and Melzack (1993) looked at the level of distress of visual hallucinations in

fourteen participants with Charles Bonnet Syndrome (CBS). They asked participants

to complete the Beck’s Depression Inventory (BDI) and the State Trait Anxiety

Inventory (STAI). They found that the majority of participants (64%) had none or

minimal depression. 21% had mild to minimal depression and one person was in the

moderate to severe level. On the STAI the anxiety level for the group was low.

These results suggest that the hallucinations in this sample caused little distress in

the majority of participants. It was also noted that there may have been a link

between the content of the hallucination and the distress as the person that scored

highest on level of distress had hallucinations about an eye. It was hypothesised that

this might have been related to the loss of her sight, compared to the other people in

the study where the hallucinations appeared to lack personal meaning e.g.

hallucinations about buildings, animals and people. This finding suggests that it

could have been the content of the hallucination that caused increased distress in one

individual. However, it is not possible to generalise from one person to the wider

population.

Gauntlett- Gilbert and Kuipers (2005) conducted a study to test the hypothesis that

appraisals of visions would predict distress associated with visions. They also looked

at whether as with voices a higher number of coping strategies is associated with


higher perceived control and decreased disruption from the hallucination. Twenty

participants with a psychiatric diagnosis were included in the study were recruited on

the basis of having visual hallucination in the past twelve months. Participants were

given a semi-structured interview based on those used in studies on voices (e.g.

Birchwood & Chadwick, 1997; Nayani & David, 1996). Two independent raters

rated the emotional quality of the visual hallucination, how much the hallucination

followed directly from the content and assigned appraisals into categories. Five

categories of appraisal were identified including: ‘election’, which was given to

people that experience their visions to mean that they are in some way special or

chosen. ‘Imperative’, which was assigned to those which included specific acts e.g. I

must kill a man or to stop being a sinner. ‘Persecutor’ appraisals were assigned to

people who caught a glimpse or saw people watching them that want to persecute

them, ‘delusion’ appraisals and appraisals that are a sign of ‘going mad’. The

findings showed that people who gave ‘Election’ appraisals to their hallucination

were significantly less distressed and showed a higher positive affect response than

people who gave other forms of appraisal. The appraisal of ‘going mad’ was not

included in the analysis as only three people fell into this category. No other

comparisons reach statistical significance.

The results of the study showed that the majority of participants felt overwhelmed or

frightened by the hallucination and 45% experienced positive feelings. The findings

also showed that perceived negative outcome of visual hallucinations was strongly

related to hallucinatory distress and perceived positive outcome was inversely related

to hallucinatory distress. Perceived control and relationship of current mood to

appraisal were both unrelated to hallucinatory distress.


The findings from this study suggest that, like auditory hallucinations, it is the

appraisal given to the hallucination that predicts distress. They also found that

control over visual hallucinations was not a predictor of distress providing further

support that is it may be the appraisal and not the control that lead to the distress.

However, some of the results may have shown a significant result if the sample size

was larger as due to the small sample size the study lacks power so it is more likely

that a type II error could have been made. For example, the objective negative

content of the vision might also have been a predictor of distress if a larger sample

size were available to test.

The findings also showed that that appraisals and distress were not influenced by

current mood. However, due to the small sample size it did not reach statistical

significance but this may be due to the low power of the study. This does not fit with

the findings of Hammersley et al (2010) who found that people held different

appraisals to their hallucinations when in different episodes of their bipolar disorder.

Further research with a larger sample size would be needed to see whether current

mood and appraisals of visual hallucinations are related.

Many people reported to have developed strategies to cope with the visual

hallucinations, but these did not reduce distress associated with the hallucinations. A

reason for this could be because so-called coping strategies are functioning as safety

behaviours and so people are not able to gather disconfirming evidence for their

beliefs about their hallucination.

Although this study was methodologically rigorous there were a few limitations that

would benefit further investigation to ensure the findings are an accurate

representation of visual hallucination experiences in a mental health population. Due

to the small sample size it is unclear whether type II errors could have been made


therefore it would be beneficial to repeat the study with a large sample and conduct a

multiple regression to establish the weight of the different variables. The study also

did not make clear what diagnosis the participants had that were included in the

study as this may also be a confounding variable. In addition the questionnaire was

based on one for auditory hallucinations so may not be reliable or valid for visual

hallucinations. Furthermore, the types of appraisals given to hallucinations were also

categorised which may not capture all types of appraisals given to visual

hallucinations. In addition, only externally located visual hallucinations were

included in the study so it did not include distortions of visual objects, by excluding

these the findings may not represent the appraisal that people give to this type of


Despite the methodological implications of this study it is of interest as shows some

support that it is the belief attributed to visual hallucinations and not the content that

is associated with emotional consequences experience.

3.2.4. Beliefs associated with predisposition to visual hallucinations

One study was found that explored beliefs associated with predisposition to visual

hallucinations (Morrison et al, 2000).

Morrison et al (2000) adapted the Launay Slade Hallucination Scale (LSHS) to

measure the predisposition to auditory and visual hallucinations in a non-clinical

sample (N=105). Participants were also asked to complete a number of additional

questionnaires assessing: paranoia, meta-cognitive beliefs, thought control strategies,

anxiety, depression and beliefs about unusual perceptual experiences. A multiple

regression analysis was performed which indicated that the predictor variables for

visual hallucinations were: anxiety and depression, paranoia and positive and

negative beliefs about unusual perceptual experiences. The multiple R² was 0.66 and


significant (F (6,79)= 10.0, p <0.0001). The adjusted R² was 0.39 indicating that a

large amount of variance was accounted for by these predictor variables.

The results of the study showed that positive beliefs about hallucinatory experiences

were associated with predisposition to visual hallucinations. It was also found that

participants who scored higher on a measure of predisposition to hallucinations also

scored higher on both positive beliefs about hallucinations but also on self-

consciousness and negative beliefs about uncontrollability and danger. However, the

findings on controllability, self-consciousness and danger did not clearly separate

people with visual and auditory hallucinations, therefore it is unclear whether these

findings would apply to visual hallucinations alone.

The analysis for this study employed a mean split as a grouping factor which

artificially dichotomises variables and therefore could have led to a loss in data.

However, as the effect of this reduces the statistical power we can assume the results

are robust. Again a limitation of this study is that the LSHS was adapted to apply to

visual hallucinations so may not a reliable or valid scale for the measure of

experience of visual hallucinations. In addition, the participants were not screened

for illicit drug use, which could be a confounding factor. Also by using a non-clinical

sample it cannot be assumed that hallucinations are similar to those experienced in

clinical populations. However, the study is of interest as is the first to look at

predisposition to visual hallucinations and suggests that beliefs about hallucinatory

experiences are associated with predisposition to hallucinations.

Garcia- Montes et al (2006) replicated the study Morrison et al (2000) and controlled

for anxiety. 150 participants were recruited for the study. The results showed that

once the effect of trait anxiety was controlled for similar results were found for

predisposition for auditory and visual hallucinations. In both cases, ‘loss of cognitive


confidence’ and ‘worry techniques of thought control’ made independent

contributions. These findings might suggest that non- clinical samples are not

comparable with clinical samples as non-clinical studies may not be measuring

predisposition to visual hallucinations but rather people insecurities about their

perceptual processes. However, these findings could also be supported by the fact

that we are aware that participants with schizophrenia often have cognitive

difficulties. This study is of interest as its findings question the role anxiety plays in

people with visual hallucinations. The findings suggest anxiety may not be linked to

the predisposition of visual hallucinations however further evidence is needed to

explore its link to the content and belief attributed to the hallucination. An

implication of this study is that there was no control for the use of illicit drug use or

level of depression, which could be confounding variables.

3.4.5. Beliefs about Visual Hallucinations- Summary of findings

The findings are of interest as suggest that there may be a link between the belief

attributed to visual hallucinations and the emotional consequences across clinical and

non- clinical populations (Menon, 2005; Scott et al, 2000; Nesher et al, 2000;

Teunisse et al, 1996; Gauntlett- Gilbert & Kuipers, 2005). The review also

highlighted that attributions of visual hallucinations differed in relation to episode of

illness (Hammersley et al, 2010). Furthermore, evidence was also found to suggest

that beliefs attributed to visual hallucinations were also associated to predisposition

to hallucinations (Morrison et al, 2000; Garcia-Montes et al, 2006). However, there

were a number of methodological implications with these studies which warrant

further investigation to clarify the link between beliefs attributed to visual


hallucinations and their emotional consequences. The implications of these findings

will be discussed.

4. DISCUSSION

The purpose of this review was to identify and critically evaluate the literature on

beliefs about visual hallucinations and the emotional consequences of these in order

to ascertain whether Chadwick and Birchwood’s (1994) ABC model to explain

auditory hallucinations could be applied to visual hallucinations.

The review of the literature revealed that there is variability across studies in the

emotional consequences of visual hallucinations with studies showing that people

with visual hallucinations have higher scores of depression (Fenelon et al 2000;

Holroyd et al, 2001; Barnes & David, 2001) and anxiety (Holroyd et al, 2001).

Whilst in a study by Mosimann et al (2008) participants with visual hallucinations

did not rate them as pleasant or distressing,

The variability in the findings could be accounted for by a number of confounding

variables not controlled for in the studies. Further investigation would be needed to

control for these variables in order to gain clarity about the link between visual

hallucinations and their emotional consequences. However, these mixed results show

that the emotional consequences vary between individuals. This is consistent with

Chadwick and Birchwood’s (1994) ABC model whereby variability in emotional

consequences would be expected if it were the appraisal given to visual

hallucinations and not the content of the hallucinations that are related to emotional


consequences. The evidence from the review further supports this theory in the

number of studies that explored the attributions of visual hallucinations and their

emotional consequences.

Three studies found similar attributions towards visual hallucinations in populations

of people with visual impairments (Menon, 2005; Scott et al, 2000; Nesher et al,

2000; Teunisse et al, 1996) as they found that participants were concerned about

evaluation from others including: beliefs of being labelled ‘insane’ (Menon, 2005;

Teunisse et al, 1996) or perceived as ‘crazy’ (Scott et al, 2000). People also reported

feeling ‘ashamed’ and ‘insecure’ about their hallucination (Nesher et al, 2000). In

two of these studies these were also associated with more reported negative

emotional consequences than control groups without visual hallucinations (Menon,

20005; Scott et al, 2000). These studies showed that it was the belief attributed

towards the hallucination and not the content of the hallucination that appeared to be

associated with emotional consequences. However, there were a number of

methodological implications with the studies so a causal link between belief and

emotional consequences in relation to the visual hallucinations cannot be assumed

and warrants further investigation. These studies are of interest as show some

support for Chadwick and Birchwood’s (1994) ABC model as suggest that it is the

belief attached to the hallucination that causes distress and not the content.

Further support for the application of Chadwick and Birchwood’s (1994) model was

found in the studies where participants reported ‘emotional comfort’ (Menon, 2005)

and ‘relief’ (Nesher et al, 2001) when feeling able to share their experience (Nesher

et al, 2001) and being reassured that their hallucination was not an indication of

imminent insanity (Menon, 2005). This suggests, that by working with the appraisal

of visual hallucinations it has an impact on the emotional consequences.


These findings also highlight a key clinical implication when working with people

with visual hallucinations as suggest that work to normalise and reassure clients

about their experiences may have an impact on the distress they experience as a

result of their visual hallucinations. However, further research would be needed to

explore whether this would beneficial in the long term.

Gauntlett- Gilbert and Kuiper’s (2005) study was of interest as explored attributions

towards visual hallucinations and emotional consequences of these. The results

found that the appraisal given to visual hallucinations was associated with distress

thus supporting Chadwick and Birchwood’s (1994) ABC model. This was further

supported by the finding that appraisals and distress were not influenced by current

mood which suggests that mood was not a predictor of visual hallucinations and

appraisals. Montes et al (2006) also explored the effect of current mood when

looking at the predisposition to visual hallucinations. Montes et al (2006) found that

in the replication of the study done by Morrison et al (2000), when trait anxiety was

controlled for similar variables including: ‘ loss of cognitive confidence’ and ‘worry

techniques of thought control’ made independent contributions. These findings

suggest that anxiety may not be linked to the predisposition of visual hallucinations.

Therefore it may be assumed that it is a consequence of them.

Hammersley et al (2010) finding’s are of interest as found that attributions held

about hallucinations differed in relation to episode of illness. It was unclear from the

study why this is and whether it is related to mood. However, the above studies

would suggest that appraisals and distress are not related to mood. Due to the

number of methodological implications of the studies it would be of interest to look

in more detail about the role that current mood and emotion play in the appraisals

given to hallucinations and the level of distress associated with these. In particular, it


would be of interest to explore why different appraisals are held at different episodes

of illness. This highlights a gap in the literature that would be beneficial to explore in

future research, especially when considering applying the ABC model (Chadwick

and Birchwood, 1994) to different diagnostic groups.

One of the common clinical implications across all but one study in the review was

that they did not use reliable or validated tool for measuring the experience of visual

hallucinations. Mosimann et al (2008) was the first study to develop a tool to

measure visual hallucinations. An area of future research would be to conduct further

reliability and validity measures so that this tool can be used by clinicians to provide

further information about visual hallucinations.

In addition the study by Yellowlees and Cook (2006) was of interest as was the first

study to look at creating a virtual reality experience of visual hallucinations. A

replication of this study to identify the appraisals associated with visual

hallucinations in both clinical and non-clinical populations would also help to clarify

the link between beliefs attributed to visual hallucinations and the emotional

consequences of these in a controlled environment.

This review has highlighted that there are very few studies that have explored the

beliefs attributed to visual hallucinations and the emotional consequences of these.

Of the studies identified evidence suggests that Chadwick and Birchwood’s (1994)

ABC model may be applicable to visual hallucinations however further research is

needed to provide clear evidence to begin to consider applying this model when

working with clients with visual hallucinations.


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Author (s), Year and Country

Main aim of study

Sample size and sampling criteria Data Collection Scale(s)/Questionnaires used

Main findings

Barnes and David (2001), UK

To carry out a clinical comparison of patients with Parkinson’s disease with and without visual hallucinations.

N= 24 (participants experiencing visual hallucinations)N= 27 (control group)Participants were recruited from branches of the Parkinson’s Disease Society and neurology clinic at Kings College Hospital.

Multiple questionnaire assessments and questionnaire developed by the authors to explore nature and properties of visual hallucinations.

A questionnaire was developed by the authors covering the nature and properties of visual hallucinations.

The Mini Mental State Examination (MMSE; Folstein et al, 1975)

Becks Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961)

-

Two groups differed significantly on duration of illness (t (42)= 2.34, p <0.05)

In the cognitive screening participants with hallucination scored significantly poorer in the memory test for faces.

In the cognitive screening there were different resultsThe hallucinators had greater disease severity (as assessed by the Hoehn and Yahr Scale) but did not differ on the MMSE.

Emorional responses at interview were varied, often in line with severity of the hallucinations experiences: frustration, anger, fear and in a few patients indifference

Delespaul, deVries and Van Os (2002), The Netherlands

To gather information on hallucinatory experiences in real-life situations in comparison between patients with a diagnosis on the schizophrenia spectrum and those with affective disorders

N= 51 (Schizophrenia spectrum)N= 37 (Affective disorder patients)All patients were recruited from severe mental illness services. Patients were in remission but still suffering from residual symptoms that needed ambulatory or clinical professional mental health care.

133 patients were diagnosed with DSM-IV criteria by one of the authors. Diagnostic accuracy was checked independently using case-not material and the OPCRIT computerised diagnostic procedure (McGuffin et al, 1991)

Data were collected using the Experience Sampling Method (ESM)

Experience sampling forms.

Experience Sampling Forms (developed by the author) for assessment of; On-going thoughtMoodPsychopathologyActivity appreciationPhysical wellbeingDescriptions and rating of social circumstances and places that the person frequencies

People with visual hallucinations (VH) rated themselves more obsessive (F (1, 10)= 4.08; p ,< 0.07), more derealised (F(1, 10)= 10.58;p<0.09), had more fear of losing control (F(1,14)=7.48; p <0.02) and were ‘hearing voices’ more often (F(1,14)= 5.42; p < 0.04)

Overall the intensity of VHs (X=3.37) was lower than AHs (x= 4.21)

Overall compared to other mental states, anxiety was the strongest predictor of hallucinatory intensity. The prediction of hallucinatory intensity improved by including anxiety levels with the phases in the equation. Anxiety co-varied with hallucinatory intensity, primarily for the first and last beep of the episode. In contrast with auditory hallucinations (AH) no anticipatory anxiety was found for VH.

Compared to AH more subjects reported at least one occurrence of VH during the sampling week.

Also VH were most disturbing (high anxiety)

Fluctuations in mood co-varied with hallucinatory severity- more for VHs than for AHs- the most prominent emotion was ‘anxiety’


6. APPENDIX

Fenelon et al (2000), France

To determine the phenomenology, prevalence and risk factors of hallucinations in Parkinson’s disease.

N= 216 (N= 86 had experienced hallucinatory phenomena)

Participants were recruited from two Parkinson’s disease hospitals in Paris, and met the UK Parkinson’s Disease Brain Bank clinical diagnosis for ‘definate’ Parkinson’s disease (Hughes et al, 1992)

Dementia was also assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV) (American Psychiatric Association, 1994)

Multiple questionnaire assessments and semi structured questionnaire to record characteristics of hallucinations.

Unified Parkinson’s Disease Rating Scale (Fahn and Elton, 1997)

Mini Mental Parkinson (MMP) (Mahieux et al 1995; Mahieux and Fénelon, 1998)

Centre for Epidemiologic Studies depression self-rating scale (CES-D) (Fuhlrer and Rouillion, 1989)Characteristics of hallucinations recorded using a semi structured questionnaire developed by the authors

Participants with visual hallucinations compared to those with isolated minor hallucinations scored higher on anxiety 27.6% compared to 3.2%; had higher scores of delusions in 8.5% compared to 0%, and had less insight than those with minor hallucinations 77% compared to 96.8%

Depression was more frequent in patients with minor hallucinations (50%) than those without any hallucinations- but did not reach significance

Patients with visual hallucinations compared to those without hallucinations were older, had longer disease duration, had more severe motor state, had more depressive symptoms, more likely to have cognitive impairment, daytime somnolence and history of ocular pathology.

Although higher CES-D score than patients without hallucinations, this score was not a predictive factor in the multivariate analysis.

Garcia-Montes et al (2006), Spain

To examine the relationship between predisposition to hallucinations and meta-cognitive variables and thought control techniques, controlling for the possible effect of anxiety.

N= 150

Participants were university students taking part in different courses at the University of Almería and University of Oviedo.

Same scale as used by Morrison et al (2000)- very slight variation on a number of factors.

State trait anxiety inventory

Meta cognitions questionnaire

Same scale used by Morrison et al (2000) which is a 16 item questionnaire based upon the Launay Slade Hallucination Scale (Launay and Slade, 1981) with a slight adaptation on the second item.

State Trait Anxiety Inventory (Speilberger et al, 1983)

Thought Control questionnaire (TCQ; Wells and Davies, 1994)

Meta- cognitions Questionnaire (MCQ; Cartwright-Hatton & Wells, 1997)

For predisposition to visual hallucinations the proportion of explained variance was significant (F (3,145)=14.90, p= .00000001.When trait anxiety was controlled similar results were obtained for auditory and visual hallucinations. In both cases meta cognitive beliefs about cognitive confidence and thought control strategies of worry made independent significant contributions to predispositions to auditory and visual hallucinations.

These relationships held when trait anxiety was controlled.

Without controlling for trait anxiety, the final equation for visual hallucinations was significant (F(3,145)= 15.71, p= .000000006. The meta cognitive belief dimension of uncontrollability and danger made an additional contribution to the equation.

Gauntlett- Gilbert and Kuipers (2005), UK

To test the hypothesis that appraisals of visions would predict distress associated with visions, and to describe typical appraisals of visions

N= 20 participants with visual hallucinations and with psychiatric diagnosis (unclear what diagnosis were)

Participants were recruited by contacting in-patient and outpatient clinical teams in person and requesting referrals from team members.

Semi structured interview

Responses to all questions were coded in the interview and were coded into response categories.

A semi structured interview schedule was developed using studies of voices (Birchwood & Chadwick; Nayani & David, 1996) and drawing on authors clinical experience.

Visual analogues scales were used to rate affective response to

Visual hallucinations made most participants feel overwhelmed and frightened. A minority (45%) experienced positive feelings.

Perceived negative outcome was strongly associated with hallucinatory distress r(20)= 0.11, p >0.05.

Perceived positive outcome also showed a strong negative relationship to distress, Rs (20)= -0.75, p <0.01


For two questions participants were required to sort cards describing common stressors.

Visual analogue scales

visual hallucinations and appraisals to hallucinations.

Becks Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961)

Perceived control failed to predict distress Rs (20)=- 0.1, p >0.6

The relationship of negative and positive outcome to distress Rs (20)= 0.57, -0.75, respectively was as predicted stronger than that of objective hallucinatory characteristics such as vividness Rs (20)= 0.04, p> 0.05 or the objective negative quality of the vision Rs (20)= 0.38, p> 0.01

Mood was not related to participants level of hallucinatory distress Rs (20)= 0.20, p= 0.04 or perceptions of negative outcome Rs (20) = 0.39, p>0.01

Participants with a higher number of coping strategies showed higher distress, Rs (20)= 0.61, p= 0.05 which was the opposite to the predicted relationship.

There was no relationship between perceived control and the number of coping strategies reported, Rs (20)= 0.36, p> 0.1

Participants did not make these appraisals as a direct consequence of the content of the vision.- around 2/3 of appraisals had no direct relationship to content of vision1/3 ‘ requiring inference’

Novel appraisal categories were related to hallucinatory distress. There were no more than 6 participants in each category so formal analysis is precluded as null results would be meaningless.However despite very low statistical power, participants who appraised their vision as a sign of election showed significantly less distress than their counterparts, U (20)= 10, p= 0.006.

Participants who perceived election also showed stronger positive affective response to their vision U (20)= 13, p = 0.015 and those suspecting the presence of a persecutor showed a trend towards less positive affect U (20)= 16.5, p= 0.666. No other comparisons reached statistical significance.

Hammersley et al (2010), UK

To investigate attributions for hallucinations in bipolar with regard to prevalence, modality and mood state.

N= 40 with diagnosis of Bipolar Disorder (N= 19 reported visual hallucinations)

Participants were drawn from a larger national randomised control trial. Diagnosis was confirmed in this RCT.

QuestionnaireAnd detailed subjective descriptions of hallucinatory experience were

Adaptation of Chadwick and Birchwood’s (1995) beliefs about voices questionnaire to include visual hallucinations.

Inter-rater reliability for categorisations of visual hallucinations was 90% (Kappa= 8.75)

Visual hallucinations were most commonly reported predominantly in manic or hypomanic states (N=16).8 participants reported auditory hallucinations, 7 of these


recorded and categorised.

participants did so when depressed.

The majority of participants held dual attributions for hallucinations.

- 20% of participants reported that they attributed hallucinations to illness when in episode.- 89% attributed hallucinations to illness when euthymic.- 1/3 reported omnipotent/malevolent attributions and all but one of these had auditory hallucinations..Of the participants that held magical extrasensory attributions for their hallucinations all reported visual hallucinations and all but one reported hallucinating when manic or hyper-manic on at least one occasion.

Holroyd et al (2012), USA

To determine the prevalence of hallucinations and delusions in Parkinson’s disease and explore the phenomenology of visual hallucinations in Parkinson’s disease.

N= 98 examined with Parkinson’s disease (N= 29 had visual hallucinations)

Participants were selected from the University of Virginia movement disorder clinic diagnosed with Parkinson’s disease.

Diagnosis was made by the movement disorder subspecialists using internationally accepted criteria.

Multiple questionnaire assessments and semi structured interview

Telephone Interview of cognitive status (Brandt, Spencer and Folstein, 1988)

Geriatric depression scale (GDS) (Brink, Rose and Lum, 1983)

Unified Parkinson’s Disease Rating Scale (Fahn and Elton, 1997)

A MANOVA was performed to determine if the presence of hallucinations was associated with dependent variables (p value of 0.005 used. The dependent variable were then examined using a t test or Fishers exact test and showed hallucinations were associated with lower cognitive score, worse vision as measured by lower visual acuity in patients ‘best eye, a higher score on GDS and a higher score on disease severity scale.

Menon (2005), UK To study visual hallucinations in individuals with visual impairments

N=48 visually impaired individualsN= 48 control group with no visual impairments

Visually impaired individuals were recruited from outpatient clinics, pre-theatre examinations, accident and emergency clinics and ophthalmic wards.

An arbitrary cut-off of visual acuity of 20/2000 or worse in better eye were included in visually impaired participants.

Control group had visual acuity of 20/40 or better.

Semi structured interview (developed by authors)


63% of subjects admitted to having visual hallucinations. None of control group had hallucinations.

All patients manifested insight into the unreality of their hallucinations.

-57% expressed of participants expressed concern about their hallucinations- 23% had experienced disturbance or frightening images-63% feared being labelled ‘insane’ if they were to admit their hallucination.- 33% were fearful that they were becoming insane or senile- 33% had previously admitted their hallucinations to others-94% of 17 patients concerned about their hallucinations, admitted to deriving emotional comfort from sympathetic explanation that their hallucination represented a release phenomena in the context of visual impairment and represented neither sinister pathology or insanity.


The mean SD cognitive score was higher among hallucinating subjects (mean, 27.3 ± 1.0 [range, 25-28]) than among non-hallucinating subjects (mean 26.8± 1.4 [range 24-28])

Mosimann et al (2008), UK

To develop a reliable, valid semi structured interview to identify and assess visual hallucinations in older people with eye disease and cognitive impairment

N=80 (participants at risk of visual hallucinations)N=34 (without known risks of visual hallucinations

Patients were recruited from the Department of Opthamology, from voluntary support groups for the visually impaired, and from the Centre for the Health of the Elderley.

Visual acuity was measure at presentation binocularly using Landolt broken rings or Snellen Charts.The control group included spouse of patients, volunteers recruited for a local church and health controls from Newcastele DLB cohortVision was assessed6 binocularly using Landolt broken rings or Snellen Charts


North East Visual Hallucination interview developed by authors


Visual hallucinations occurred in 70 patients (87.5%).

The factor structure of questions referring to emotions, cognitions and controllability of visual hallucinations was analysed.

Control (mean 0.4; SD 0.8) and pleasantness scores (0.4; SD 0.8) were low and indicated that patients with recurring visual hallucinations during the last month did not feel they had any control over the hallucination onset, end or content and rarely perceived hallucinations as pleasant.

Hallucinations were seldom perceived as distressing (mean 1.3; SD 1.2). The awareness about experiencing hallucinations was high (mean 3.5; SD 1.0)

Unpleasant hallucinations tended to be associated with acting out.The pleasantness score was higher for complex hallucinations than for simple hallucination.

Ratings of perceived control and distress did not differ between patients with recurrent simple or complex hallucinations

Morrison et al (2000), UK

To measure predisposition to auditory and visual hallucinations and examine the relationship between meta-cognition and predisposition in non-psychiatric population.

N= 105.

Participants were undergraduate students or health professionals who volunteered to participants.No applicable

Multiple questionnaires

Visual analogue scales

A 16 item questionnaire based upon the Launay Slade Hallucination Scale (Launay and Slade, 1981) revised by the authors.

Several 0-100 visual analogue scales were used to assess tendency towards depression and positive and negative beliefs about unusual perceptual experiences.

State Trait Anxiety Inventory (Speilberger et al, 1983)

Thought Control questionnaire (TCQ; Wells and Davies, 1994)

A multiple regression was conducted or visual hallucinations which was significant R² was 0.66 and significant (F (6, 69)= 10.0, p <0.001) . The adjusted R² was 0.39 indicating that a large amount of the variance was accounted for by these predictor variables.

The results showed that beliefs about hallucinatory experiences were associated with predisposition to visual hallucinations as when tolerances of individual variables were examined when beliefs were entered the increment in R² was 0.5 and significant (F= 3.21, p<0.05)


Meta- cognitions Questionnaire (MCQ; Cartwright-Hatton & Wells, 1997)

Nesher et al (2001) To characterise the nature and frequency of Charles Bonnet syndrome in glaucoma patients with low vision.

N= 89 participantsN= 11 (12.3%) admitted to having experienced visual hallucinations.

Participants were recruited from the Glaucoma Clinic at the Department of Ophthalmology medical centre.

Each patient underwent complete ocular examination. All patients with visual acuity of 20/80 or less in both eyes were included in the study.

Patients were included in the study only when the interviewer was convinced that the sight perceived by the patient was not a distorted figure, an entopic phenomenon, a dream or an unclear shadow of an actual object.

Semi structured interview and questionnaire.

Abbreviated Mini Mental Test (Koenig, 1996)

Semi structured interview developed by authors.

All patients were aware of the unreal nature of the hallucinations and rejected the possibility that they had misinterpreted a blurred image because of low vision.

Only one patient had previously shared the experience of visual hallucinations with another person.

Most patients seemed to be relieved once they could finally share this experience without feeling ashamed and insecure about it

Ohayon (2000), USA To provide additional data on the prevalence of hallucination in the general population of three European countries and to study their association with organic diseases, mental disorders and psychoactive substance use.

N= 4972 (UK)N= 4115 (Germany)N=3970 (Italy)

Individuals were selected from official consensus data and were selected from each household as a function of age, gender and by the Kish method (Kish, 1965)

Telephone interviews the Sleep- EVAL which is a non-monotonic , level 2 expert system endowed with a causal reasoning mode capable of formulating diagnostic hypotheses and then validating these through further queries and deductions.

14 respondents overall reported experiencing visual hallucinations at least once a week. Variables significantly associated with this type of hallucination included current use of drugs, anxiety disorders, psychotic disorders and organic diseases.

All cases except one had an associated mental disorder, organic or toxic pathologies. Anxiety and sleep disorders were found in approximately one third of the cases.

In subjects with monthly visual hallucinations the following variables emerged as significant factors in the multivariate model: current use of drugs, past use of alcohol, anxiety, bipolar, depressive and psychotic disorders and too short sleep duration.

Scott et al (2000), USA

To investigate the prevalence and phenomenology of visual hallucinations among patients with retinal disease and to investigate whether presence of hallucinations is a significant predictor of functional status,

N=86 participants with retinal disease (N=13 screened positive for visual hallucinations)

Participants were recruited from a retinal disease centre.

Patients visual acuity was summarised in terms of weighted average logarithm of minimal angle of resolution. With better eye given a weight of 0.75 and worse eye 0.25

Multiple questionnaire assessments and semi structured interview.

- The Sickness Impact profile (Bergner et al, 1976)- The Community Disability Scale (Basset and Folstein, 1991)- The General Health Questionnaire (Goldberg, 1979)- The Visual Phenomena interview (Scott et al, 2000)- - The Eysenck Personality Questionnaire (Eysenck and Eysenck, 1975)

Twelve of the patients (92.3%) reported their visual hallucination were intense over half of the time.

None were accompanied by other hallucinations (olfactory etc.)

Only two participants (15.3%) had informed their physicians of their hallucinations.The reason for this was;- 5 participants feared that they would not be believed.- 6 thought they would be perceived as ‘crazy’


quality of life and/or emotional distress after adjusting for visual acuity.

- The Telephone Interview for Cognitive Status (Brandt et al, 1988)- A health status survey adapted from the National Health and Nutrition Examination Surveys (Cornoni- Hunteley , Huntley and Feldman, 1990; Harris et al,1989)

A univariate analysis revealed that variables statistically significantly associated with experiencing hallucinations were female sex, worse visual acuity, bilateral visual impairment, probable or definite emotional distress, decreased functional status and decreased quality of life

Schultz and Melzack (1993), USA

To evaluate the mental state of patient labelled as having Charles Bonnet Syndrome with visual hallucinations.

N= 14 participants with Charles Bonnet Syndrome with visual hallucinations.

Visual acuity was 20/200 or less

Subjects were recruited from a database of clients served by the Montreal Association for the Blind.


Mini Mult (Kincannon, 1968)

71 short- form version of the Mini Minnesota Multiphasic Personality Inventory (MMPI)

Beck Depression Inventory (Beck et al, 1961)

State Trait Anxiety Inventory (Spielberger et al, 1970)

Mini- Mental State Examination Cognitive Screen (Folstein et al, 1975)

The majority of the group had minimal levels of depression. Three individuals indicated mild to moderate levels of depression and one participants had moderate to severe.

Anxiety as a group was generally low and the group as a whole also had intact cognitive status.

One of the three people who scored highest on measures of distress related that to the content of their hallucination which was an eye and reflected that she had not accepted the loss of her sight.

Teunisse et al (1996), Netherlands

To explore the psychopathological characteristics of the hallucinations, their personal meanings and influencing factors and to assess the extent of distress associated with the syndrome.

N= 505 gave consent to participate in the study.

N= 63 had complex visual hallucinations in 4 week period before screening.

Participants were recruited from the Low Vision Unit of the Department of Ophthamology to which visually handicapped patients are referred to received reading aids from an optometrist

The psychiatrist checked whether the definition of hallucinations in the DSM was met and checked whether criteria for CBS were met.

Semi structured Interview and psychiatric examination

Semi structured interview on visual hallucinations designed by the authors.

Psychiatric Examination was conducted with the Geriatric Mental State Schedule (Copeland et al, 1976)

46 (77%) of the patients could not detect and personal relevance to the hallucinations. Even if hallucinated objects were familiar to them, they were emotionally of no apparent importance

3 (5%) of patients were uncertain whether or not some of their hallucinations had a personal meaning

10 (17%) patients experienced hallucinations involving emotionally important as well as unimportant objects

Only one (2%) patient had hallucinations with an exclusively personal, emotionally relevant content

The emotional response to the hallucinations was mainly negative in 19 (32%) patients: anxiety in 14 and irritation in 5.11 (18%) patients showed mixed emotions and in 22 (27%) the emotional response was neutral.8 (13%) had felt joy or amusement during the experiences.General feeling of well-being were not disturbed by the


hallucinations in 43 (72%) patients. 17 (28%) suffered from their hallucinations and hoped that they would disappear, only 6 felt enough distress to consider taking medication to suppress their hallucinations.

44 (73%) had not mentioned their experiences to doctors. 15 feared their doctor would not take them seriously and think they were insane. 20 thought it was not the kind of complaint to consult a doctor with. 9 gave no explanation. Only 1 person had consulted a doctor.

Yellowlees and Cook (2006), USA

To simulate auditory and visual hallucinations in a non clinical sample

N= 579

Non clinical sample recruited from online ‘Second Life Population.’

Questionnaire after participants explored internet based virtual reality environment to simulated auditory and visual hallucinations

Questionnaire developed by the authors.

276 (48%) reported finding the experience disturbing


OVERVIEW OF CLINICAL EXPERIENCE

Over the three years of my clinical psychology training I have had the opportunity to

have clinical placements working in: an adult community mental health team, a

community learning disabilities team, an older adult community mental health team, a

child and adolescent community mental health team and a specialist outpatient family

psychology service for families where a parent has cancer. Below I will give a brief

overview of my three years of clinical experience. I will outline the nature of each

placement and the clinical experience gained on each.

Adult

I had a year long placement within the adult community mental health team. I had the

opportunity to work with a supervisor who had trained as a clinical psychologist and also

as a family therapist. Therefore during this placement I was able to develop my skills

drawing upon both Cognitive Behavioural Therapy (CBT) techniques and Systemic

Theory. I was also given the opportunity to work on both a male and female inpatient

mental health ward in the family therapy service for one day a week for 6 months of my

placement. For the second 6 months I worked within the inpatient mental health team co-

facilitating a support group for the service users. I was also provided with the opportunity

to deliver 1:1 therapy to a wide diversity of service users. I also completed two cognitive

assessments and delivered a presentation on Autism and Asperger Syndrome to the team.

208

Learning Disabilities

I had a six-month placement working within a community learning disability service. I

had the opportunity to work with service users with a wide range of learning disabilities.

During this placement I drew heavily on CBT techniques, however, had to adapt these to

the needs of the service users I worked with. This placement also enabled me to work

closely with other members of the multi disciplinary team including; speech and language

therapists, psychiatrists and nurses. I also had the opportunity to complete a sexual

capacity assessment and several cognitive assessments. I worked within a variety of

settings including; community day services, residential support homes and schools. I also

presented a summary of the BPS guidelines on ethical principles to the team.

Older Adult

This was a six-month placement working within a community older adult mental health

team. This placement was split with working one day a week at an outpatient

rehabilitation service for older people. During this placement I was again fortunate to

have a supervisor who was trained in family therapy. Therefore during this placement I

developed my skills further in systemic therapy. In addition, I continued to develop my

skills in cognitive behavioural therapy. Working within a health setting enabled me to

experience working with other medical professionals and explore the association between

physical health and mental health and the effect they have on each other. I also was also

given the opportunity to co-facilitate a group for people who had falls and explore the

impact this can have psychologically. I also had the opportunity to complete a number of

209

cognitive assessments and also co-facilitate a cognitive stimulation group for people with

early stages of Dementia.

Child

I had a six-month placement within a child and adolescent community mental health

team. I worked with children aged between 5- 18 years. During this placement I had the

opportunity to spend 1 morning a week working as part of the reflective team within the

family therapy team. I continued to develop my skills in CBT and systemic therapy and

also drew upon narrative and behavioural approaches. I gained a greater understanding of

the developmental stages of children and drew heavily of the developmental approach

and attachment theory. I also had the opportunity to complete two child cognitive

assessments.

Specialist

This was a six-month placement working within a family psychology service for families

where a parent has cancer. During this placement I drew heavily upon systemic theory

when working with families. I also had the opportunity to work 1:1 with children and

used both narrative and CBT techniques. I had the opportunity to present to the team

about working with people with autism and also presented to the nursing school-how to

support a family when a parent has cancer. I have had to work closely with other medical

professionals within the multi disciplinary team and explored the impact cancer can have

on an individual and their family. I also had the opportunity to attend a four day training

course on how to support a family when a parent has cancer.

210

TABLE OF ASSESSMENTS

Year I Assessments

PROGRAMME COMPONENT

TITLE OF ASSIGNMENT

Fundamentals of Theory and Practice in Clinical Psychology (FTPCP)

Short report of WAIS-III data and practice administration

Research –SRRP A service evaluation to gain feedback from staff from two mental health inpatient wards and a community mental health team about their experience of working with families and how further training could enhance this

Practice case report Cognitive Behavioural Therapy for a young women presenting with panic disorder.

Problem Based Learning – Reflective Account

‘The relationship to change’

Research – Literature Review

Appraisals of visual hallucinations and their emotional consequences: Literature Review

Adult – case report Cognitive Behavioural Therapy for a Young Woman Presenting with Panic Disorder/ Social Phobia

Adult – case report Cognitive Behavioural Therapy for a man in his early fifties presenting with sexual addiction

Research – Qualitative Research Project

Clinical Psychology Trainee’s Perspectives on Future Job Prospects

Research – Major Research Project Proposal

‘Are beliefs about visual hallucinations, the self and others associated with hallucinatory distress and disturbance? Does this remain true when taking account of hallucinatory content and activity?’

Year II Assessments

PROGRAMME COMPONENT

TITLE OF ASSESSMENT

Research - SRRP A service evaluation to gain feedback from staff from two

211

mental health inpatient wards and a community mental health team about their experience of working with families and how further training could enhance this

Research Research Methods and Statistics testProfessional Issues Essay

The Kings Fund published - ‘Leadership and engagement for improvement in the NHS: Together we can’ (2012).What role can the clinical psychology profession make in effecting change and how might this contribution be received by other managerial professional groups?

Problem Based Learning – Reflective Account

Child Protection Domestic Violence and Learning Disabilities and Kinship Care

People with Learning Disabilities/Child and Family/Older People – Case Report

A Psychometric Assessment of a Lady in Late Adolescence with a Learning Disability, Cerebral Palsy, Left Side Hemiplegia and Epilepsy

Personal and Professional Learning Discussion Groups – Process Account

Personal and Professional Learning Discussion Groups Process Account

People with Learning Disabilities/Child and Family/Older People – Oral Presentation of Clinical Activity

Older people oral presentation of clinical activity.

Year III Assessments

PROGRAMME COMPONENT

ASSESSMENT TITLE

Research - SRRP A service evaluation to gain feedback from staff from two mental health inpatient wards and a community mental health team about their experience of working with families and how further training could enhance this

Research – MRP Portfolio

Are there more to visions than meets the eye?Are beliefs about visions, the self and others associated with hallucinatory distress?

Personal and Professional Learning –

On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of

212

Final Reflective Account

training

Child and Family/People with Learning Disabilities/ Older People/Specialist – Case Report

Understanding trichotillomania from a Developmental Perspective with a 5-year-old girl using a multi modal approach to treatment

213

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