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European Journal of Trauma & Dissociation
Volume 1, n° 1
pages 37-46 (janvier 2017)
Doi : 10.1016/j.ejtd.2017.01.003
Received : 30 December 2016 ;  accepted : 8 January 2017
Auditory verbal hallucinations and the differential diagnosis of schizophrenia and dissociative disorders: Historical, empirical and clinical perspectives
 

Andrew Moskowitz a, , Dolores Mosquera b, Eleanor Longden c
a Touro College Berlin, Am Rupenhorn 5, 14055 Berlin, Germany 
b Institute for the Research and Treatment of Trauma and Personality Disorders, Avenida de Oza 5, 15006 La Coruña, Spain 
c Psychosis Research Unit, Greater Manchester West Mental Health NHS Foundation Trust, Harrop House, Bury New Road, Prestwich, M25 3BL Manchester, United Kingdom 

Corresponding author.
Abstract
Introduction

Despite the long association between auditory verbal hallucinations (AVH) or voice hearing and schizophrenia, recent research has demonstrated AVH's presence in other disorders and in persons without a diagnosis, particularly amongst those with a history of traumatization. But are there differences in the type of voices between these populations?

Objective

To consider the status of the relationship between AVH and schizophrenia, in comparison to certain posttraumatic disorders, and the implications of this relationship both conceptually and clinically.

Method

The relationship between AVH and schizophrenia was reviewed from an historical and empirical perspective, in comparison to the posttraumatic or dissociative disorders, borderline personality disorder (BPD), posttraumatic stress disorder (PTSD) and dissociative identity disorder (DID). The relationship between AVH in general and dissociation was also considered. A psychotherapeutic approach to working with voices from a dissociation perspective was presented, along with a clinical case.

Results

AVH in schizophrenia appear to be very similar to AVH in other disorders, with some apparent differences disappearing when the person's attitude toward their voices changes. However, compared to BPD, PTSD, or DID, AVH in schizophrenia tend to be first experienced much later in life (adulthood as opposed to adolescence or even childhood), rarely include ‘child’ voices, and exert significantly less control over the person's behavior.

Conclusion

AVH are common in schizophrenia and posttraumatic disorders, and are not significantly differently manifested in these disorders. We contend that all voices are dissociative in nature, and can be most successfully treated through respectful engagement, which seeks to recognize the underlying purpose/concern of the voices, and transform the person's relationship with their voices. The dissociative etiology of AVH in schizophrenia, however, may be somewhat different from that in other disorders – a ‘bursting through’ of dissociative parts associated with severe depersonalization, as opposed to a more gradual development through absorption and intense focus on internal states. In concert with Bleuler's original proposal of schizophrenia as ‘split mind’, it is proposed that schizophrenia might represent a ‘low level’ dissociative disorder. Research to further explore this proposal is suggested.

The full text of this article is available in PDF format.

Keywords : Schizophrenia, Hallucinations, Dissociation, Differential diagnosis, Absorption


1  The theory of SDP considers most, but not all, cases of BPD to be dissociative disorders. But all BPD cases are characterized by structural dissociation of the personality. For the sake of simplicity, we will consider BPD and PTSD to be dissociative disorders because they are characterized by structural dissociation of the personality (as described below). What is clear is that the level of dissociation increases from PTSD through BPD to DID, and that schizophrenia manifests lower levels of dissociation than these disorders. It is less important, for the sake of our argument, whether BPD and PTSD are called ‘dissociative’, ‘posttraumatic’, or ‘trauma-related’ disorders.
2  The only other symptom so emphasized was ‘bizarre delusions’, which was not defined in the criteria per se (examples given in the texts were experiences of being controlled, or of thoughts being inserted or withdrawn, which were other ‘first-rank’ symptoms from Schneider).
3  However, the DSM-5 has a new diagnosis, Other Specified Schizophrenia Spectrum and Other Psychotic Disorder , which requires only ‘persistent auditory hallucinations’ to fulfill its symptom criteria (APA, 2013, p. 122).


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