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Summary Behavioral Disorders (PSY4062)
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An extensive summary of all tasks for the Neuropsychology Masters Course; Behavioral Disorders (PSY4062)
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Neuropsychology period 1Behavioral Disorders
Task 1 Dichotomy or continuum? – Psychosis, (Auditory Verbal) Hallucinations &
integration of neuroscience in DSM-V
DSM-V criteria schizophrenia
Hallucinations
Auditory verbal hallucinations (AVHs) → an entity by
themselves & not necessarily indicative of transition along
the psychosis continuum
➔ A sensory experience that takes place in the
absence of any external stimulation whilst in a
fully conscious state
➔ With a sufficient similarity to the real percept that
the individual attributes the event to be out of
his/her own control
Prevalence AVH & related phenomena (auditory
hallucinations, auditory perceptions, voice hearing,
psychotic experiences, psychosis)
➔ Hallucinations are most present in diagnosed
psychotic disorders such as schizophrenia and schizoaffective disorder
o It also occurs in other disorders; bipolar, substance (ab)use, dementia
➔ Estimated prevalence of AVH is between 5 – 28% in the general population
o 25% meets criteria for a psychotic disorder
o 75% experiences AVH who are considered healthy
▪ Possible implications of non-clinical AVH:
• Healthy AVH may present as an isolated symptom and may not be
related to any sort of predisposition for a psychotic disorder.
• AVH may form part of a genetic predisposition toward psychotic illness.
They can co-occur alongside other attenuated psychotic symptoms
, including paranoid ideation, odd/unusual behavior, delusions and
inefficient cognitive processing
• AVH are hypothesized to lie on a continuum of risk ranging from
normal experiences to pathological psychotic suggesting that clinically
relevant AVH could be an extension of the processes occurring in
otherwise healthy hallucinators.
o Later meer over continuum!
➔ Childhood
o A great majority of children reporting AVH never make the transition to psychotic
disorder, factors seem to mediate the likelihood of hallucinatory experiences becoming
pathological.
▪ In most cases → spontaneous cease!
• For example hearing voices at age 7-8 disappears in 76% at age 12-13
• 75-90% of child psychotic-like experiences are transitory and regress
over time
o Further evidence for this can be drawn from the existence of
imaginary companions which spontaneously cease, often when
children begin school
▪ It has been reported that 46.2% of children between the
ages of 5 and 12 years report the existence of at least
one imaginary companion
▪ The experience of imaginary companions could be a
young child’s explanation for hearing voices, although
evidence does exist that children are able to distinguish
between AVH and imaginary companions
▪ The existing literature does not yet provide us with
sufficient information to determine whether imaginary
companions are comparable to AVH.
o AVH in this group is mostly present in late childhood & early adolescence
o 10% prevalence 7-11 years
o Musical hallucinations → under investigated & often related to damage in ears
o Often in conjunction with; Anxiety, Migraines, Depression, Conduct disorder
▪ 100% of clinical AVH also met criteria for CD → greater persistence and severity
of AVH experiences (antisociale gedragsstoornis)
➔ Adolescence and adulthood
o Similar to that of children → between 5 - 16%
o Healthy adults begin to hear voices at an age of 12 years
▪ The most common experiences reported by non-clinical adults
• Take place on average every 3 days,
• For 2–3 min,
• Controllable for around 60% of the time
• Cause little to no distress or disruption to daily life
• However, there do seem to be some healthy individuals who experience
hearing voices to the same frequency and qualities as clinical patients
with schizophrenia
o Clinical adults begin to hear voices at an age of 17 years → Later
Given that the majority of childhood AVH resolve prior to adolescence, the rates in adulthood
suggest that there are a significant group of individuals who develop hallucinations during
adolescence and early adulthood which persist onward
o The onset for prodromal symptoms for psychosis and other mental health disorders often
emerge during mid- to late adolescence
, ▪ But lack of studies examining the prevalence of non-clinical auditory
hallucinations
o Adolescence is the onset of a series of rapid changes in hormones and brain
development. From a biopsychosocial perspective these changes are often cited as a
possible explanation for the initiation and presentation of mental health symptoms
which can evolve into schizophrenia
▪ The brain’s connections are at their greatest during adolescence before
pruning and decreasing neuronal connectivity reduces them to adulthood levels.
▪ The stress associated with these changes has previously been cited as a trigger
for psychopathology in certain individuals.
• The range of neurological, emotional and social changes which take
place in adolescence may put predisposed individuals in a heightened
state of vulnerability to psychopathology
o Some authors have proposed that aberrant synaptic pruning accounts for the onset of
hallucinations.
▪ However, given the consistency in the estimates for adolescent AVH and child
AVH it is unlikely that this explains all cases.
• The resolution of childhood AVH coincides with early adolescence
• There are a small subset of individuals who begin to re-experience an
imaginary companion during adolescence.
o However, these individuals have not been investigated to
differentiate them from their counterparts or for the persistence
of the imaginary friends during adolescence.
Persistence of AVH
➔ Persistence indicates a more severe underlying pathology
➔ Besides psychosis, the presence of childhood AVH are concurrently associated with depression
and anxiety and schizophrenia-spectrum disorders in their early twenties
Under the biopsychosocial framework of AVH development, it is evident that there are certain
mechanisms which contribute to the maintenance of hallucinatory experiences past the stage of initial
development.
➔ A specific factor associated with the persistence of hallucinatory experiences in children is the
formation of secondary delusions (wanen)
o May be due to aberrant salience, or attributed importance, to AVH
o Delusional ideation is more likely to occur under situations of affective dysregulation
- Affective dysregulation in and of itself has been linked to the formation of
psychotic symptoms in adult populations, warranting the need for investigation
in children and adolescents.
- When states of anxiety, depression and stress interact with pre-existing
hallucinatory phenomena affective disturbances can culminate to create
delusional pathology
➔ Some authors have suggested that the combination of secondary delusions and emotional
factors provides the mechanism for healthy AVH to become pathological experiences.
The persistence-impairment model
- Suggests that the progression to increased impairment from psychotic-like experiences occurs at a
point where the individual is exposed to sufficient environment stressors.
- The increasing independence required to navigate adolescence successfully would present many
opportunities for increasing environmental stressors of a social (e.g., peer interactions, increased
academic expectations) and biological (substance use) nature.
- Develop when you get exposed
, The development of the Clinical Staging model
- Distinguishes residual symptoms or early signs in order for them to be detected more readily
before progression to full psychopathology.
- The key factors implicated would be the persistence of the AVH, the presence of distress, other
mental health symptoms and any type of help seeking behavior.
Comparison of clinical and non-clinical hallucinations in adult populations
AVH are only associated with other attenuated psychotic symptoms when they require care.
➔ Non-clinical AVH in and of themselves do not seem to be indicative of the progression to mental
health disorders.
➔ Additional clues to the developmental trajectories which differentiate clinical from healthy AVH
can be derived from consideration of the phenomenology, cognitive mechanisms, and emotional
regulation differences between the two populations.
➔ Non-clinical AVH become pathological when they persist, lead to the development of other
symptoms and cause distress and functional impairment.
o Accordingly, it could be argued that they do lie on a continuum of risk, ranging from
normal healthy experiences, through to pathological psychotic.
➔ The most commonly reported difference is the emotional valence of the voice, with a negative
emotional appraisal of the voice having a predictive value of 88% for the presence of a
psychotic disorder
➔ Anxiety has the most predictive power for the predisposition to hallucinate in non-clinical groups,
over and above depression and stress ratings. Depression in clinical groups however, has been
specifically associated with AVH of greater severity compared to their non-depressed counter
parts. Higher depression ratings may be indicative of greater severity of the AVH to the individual,
whilst hi3gher anxiety is more strongly related to the level of distress those AVH illicit.
➔ Cognitive capacities
o Only a partial overlap between the 2 groups
o The metacognitive component of low cognitive confidence was found to significantly
predict auditory hallucinations
o The higher the cognitive confidence the higher the risk
o It is believed that difficulties in memory lead to fragmented retrieval, which in turn
creates confusion and a lack of confidence for the individual.
- AVH have been hypothesized to come about from a breakdown in the
processes monitoring memory retrieval and the source of those memories.
➔ Inhibitory control
o Inhibitory control and intentional cognitive inhibition specifically, is a reduction in the
ability to inhibit the intrusive memories and thoughts.
o Executive resources in the prefrontal cortex
o Impaired memory processes in clinical group VS emotional dysregulation in non-clinical
group
➔ Content of thought
o Most individuals with AVH hear sentences or words which they do not recognize as their
own.
- The normal workings of inner speech for an individual usually change
according to the pervasive mood of the person at the time, and also the
situations which surround them.
- Contrastingly, the content of AVH in diagnosed psychotic disorders usually
reflects a more derogatory pattern of communication; characterized by a low
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