The self or the voice? Relative contributions of self-esteem and voice appraisal in persistent auditory hallucinations

BackgroundPersistent auditory hallucinations are common, disabling and difficult to treat. Cognitive behavioural therapy is recommended in their treatment though there is limited empirical evidence of the role of cognitive factors in the formation and persistence of voices. Low self-esteem is thought to play a causal and maintaining role in a range of clinical disorders, particularly depression, which is prevalent and disabling in schizophrenia. It was hypothesized that low self-esteem is prominent in, and contributes to, depression in voice hearers.MethodsBeliefs about persistent auditory hallucinations were investigated in 82 patients using the Beliefs About Voices Questionnaire — revised in a cross-sectional design. Self-esteem and depression were assessed using standardized measures.ResultsDepression and low self-esteem were prominent as were beliefs about the omnipotence and malevolence of auditory hallucinations. Beliefs about the uncontrollability and dominance of auditory hallucinations and low self-esteem were significantly correlated with depression. Low self-esteem did not mediate the effect of beliefs about auditory hallucinations- both acted independently to contribute to depression in this sample of patients with schizophrenia and persistent auditory hallucinations.ConclusionsLow self-esteem is of fundamental importance to the understanding of affective disturbance in voice hearers. Therapeutic interventions need to address both the appraisal of self and hallucinations in schizophrenia. Measures which ameliorate low self-esteem can be expected to improve depressed mood in this patient group. Further elucidation of the mechanisms involved can strengthen existing models of positive psychotic symptoms and provide targets for more effective treatments.