افکار مزاحم و ارتباط آن با اندازه گیری بررسی بی خوابی: به سوی یک مدل شناختی بی خوابی

Several theories of auditory hallucinations implicate the involvement of intrusive thoughts and other theories suggest that the interpretation of voices determines the distress associated with them. This study tested the hypotheses that patients who experience auditory hallucinations will experience more intrusive thoughts and be more distressed by them and interpret them as more uncontrollable and unacceptable than the control groups. It also examines whether the interpretation of hallucinations is associated with the distress caused by them and whether there are differences in the way that patients respond to and interpret their thoughts and voices. A questionnaire examining the frequency of intrusive thoughts and the reactions to them was administered to a group of patients with a diagnosis of schizophrenia who experienced auditory hallucinations, a psychiatric control group and a non-patient control group. In addition, the patients in the first group completed a similar questionnaire in relation to their voices. Analyses of covariance showed that patients who experienced auditory hallucinations had more intrusive thoughts than the control groups and that they found their intrusive thoughts more distressing, uncontrollable and unacceptable than the control groups. Correlational analyses revealed that patients' interpretations of their voices were associated with the measures of distress in relation to them. Repeated measures analyses of covariance found no differences between thoughts and voices on the dimensions assessed. The theoretical and clinical implications of these findings are discussed.

There has been extensive research conducted in recent years examining cognitive intrusions and their role in psychopathology. Intrusive thoughts were originally defined by Rachman (1978) as being repetitive thoughts, images or impulses that are unacceptable or unwanted; subsequently Rachman (1981) added that they are usually accompanied by subjective discomfort and must interrupt ongoing activity. It has been found that normal intrusive thoughts are a common experience (Rachman and De Silva, 1978 and Salkovskis and Harrison, 1984) and it has been suggested that many everyday thoughts could be defined as being intrusive (Rachman & Hodgson, 1980). Several of the current theories regarding the development and maintenance of auditory hallucinations explicitly involve some notion of intrusions and others are certainly compatible with such notions. Hoffman (1986) has suggested that auditory hallucinations are the result of ‘parasitic memories’ which disrupt language production processes and that the unintendedness of verbal images is a key component of the phenomenology of voices. In addition, Hemsley's (1993) cognitive model of schizophrenia suggests that the “intrusion of unexpected/unintended material from long-term memory” is a cognitive abnormality associated with schizophrenia. Morrison, Haddock and Tarrier (1995) presented an heuristic model which suggests that auditory hallucinations may be experienced when intrusive thoughts are attributed to an external source, in order to reduce cognitive dissonance. They speculate that this dissonance is caused by the incompatibility of certain intrusive thoughts and metacognitive beliefs (in particular, beliefs about controllability). Bentall (1990) has also implicated metacognitive beliefs as a top-down factor that may influence the occurrence of auditory hallucinations. Baker and Morrison (1998) found that patients experiencing auditory hallucinations scored higher on metacognitive beliefs concerning both positive beliefs about worry and negative beliefs about uncontrollability and danger. Wells and Matthews' (1994) self-referent executive function (S-REF) model of emotional dysfunction would also suggest that the occurrence of hallucinations may be influenced by such metacognitive beliefs, as hallucinations would be conceptualised within their model as low-level intrusions mediated by self-beliefs. Such beliefs are likely to be associated with dysfunctional attempts at control which would be expected to increase the frequency of intrusions. These theories would also suggest that patients experiencing auditory hallucinations would interpret intrusive thoughts as being uncontrollable and dangerous and be more upset by such intrusions. Morrison (1998), in a cognitive analysis of the maintenance of auditory hallucinations, suggested that an internal or external trigger results in a normal auditory hallucination that is then misinterpreted as threatening the physical or psychological integrity of the individual (such as “I must be mad”, “The Devil is talking to me” and “If I do not obey the voices they will hurt me”). These misinterpretations produce an increase in negative mood and physiological arousal which produce more hallucinations leading to a vicious circle. Simultaneously, the misinterpretation of the hallucination elicits safety seeking behaviours (including hypervigilance) designed to prevent the feared outcome (e.g. madness, possession or obedience) which can both increase the occurrence of auditory hallucinations and prevent the disconfirmation of the misinterpretation (therefore maintaining it). There is considerable evidence that suggests that the interpretation of intrusions is central to the understanding of auditory hallucinations. Kingdon and Turkington (1993, p. 78) state that “the meaning invested in hallucinations may also be of importance — whether a person says to himself, ‘The devil is talking to me’ or ‘I must be going crazy’, or dismissively; ‘That was a strange sensation, I must have been overtired’“. Tarrier (1987) has noted that appraisals of positive symptoms elicited such responses, and Chadwick and Birchwood (1994) conclude that coping strategies chosen by patients experiencing auditory hallucinations (particularly engagement and resistance) appear to be driven by underlying beliefs about voices, and assert that “affective, cognitive and behavioural responses evolve together and are always meaningfully related” (p. 200). In a study utilising the beliefs about voices questionnaire (BAVQ; Chadwick & Birchwood, 1995) they found a strong positive relationship between appraisals of malevolence and resistance of the voices and between appraisals of benevolence and engagement with the voices. Therefore, it is likely that interpretations of hallucinatory phenomena will determine the affective responses. This study tests the hypothesis that intrusive thoughts in patients who experience auditory hallucinations will be experienced more frequently and be rated as more distressing emotionally and interpreted as more uncontrollable and unacceptable, in comparison with the psychiatric and non-patient control groups. It is also predicted that interpretation of hallucinations will be associated with the distress caused by them. It is also hypothesised that there will be differences in the way that patients who experience auditory hallucinations will respond to and interpret their thoughts and voices.