Skip to main content Accessibility help

Cognitive biases and auditory verbal hallucinations in healthy and clinical individuals

  • K. Daalman (a1), I. E. C. Sommer (a1), E. M. Derks (a2) and E. R. Peters (a3) (a4)



Several cognitive biases are related to psychotic symptoms, including auditory verbal hallucinations (AVH). It remains unclear whether these biases differ in voice-hearers with and without a ‘need-for-care’.


A total of 72 healthy controls, 72 healthy voice-hearers and 72 clinical voice-hearers were compared on the Cognitive Biases Questionnaire for psychosis (CBQp), which assesses ‘intentionalizing’, ‘jumping to conclusions’, ‘catastrophizing’, ‘dichotomous thinking’ and ‘emotional reasoning’ in vignettes characterized by two themes, ‘threatening events’ and ‘anomalous perceptions’.


Healthy voice-hearers scored intermediately on total CBQp between the control and clinical groups, differing significantly from both. However, on four out of five biases the scores of the healthy voice-hearers were comparable with those of the healthy controls. The only exception was ‘emotional reasoning’, on which their scores were comparable with the clinical group. Healthy voice-hearers demonstrated fewer biases than the psychotic patients on the ‘threatening events’, but not the ‘anomalous perceptions’, vignettes. CBQp scores were related to both cognitive and emotional, but not physical, characteristics of voices.


Most cognitive biases prevalent in clinical voice-hearers, particularly with threatening events themes, are absent in healthy voice-hearers, apart from emotional reasoning which may be specifically related to the vulnerability to develop AVH. The association between biases and both beliefs about voices and distress/emotional valence is consistent with the close links between emotions and psychotic phenomena identified by cognitive models of psychosis. The absence of reasoning biases might prevent the formation of threatening appraisals about anomalous experiences, thereby reducing the likelihood of distress and ‘need for care’.


Corresponding author

*Address for correspondence: K. Daalman, Ph.D., Neuroscience Division, University Medical Center Utrecht and Rudolf Magnus Institute for Neuroscience, A01.468, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. (Email:


Hide All
Andreasen, NC, Flaum, M, Arndt, S (1992). The Comprehensive Assessment of Symptoms and History (CASH). An instrument for assessing diagnosis and psychopathology. Archives of General Psychiatry 49, 615623.
Andrew, EM, Gray, NS, Snowden, RJ (2008). The relationship between trauma and beliefs about hearing voices: a study of psychiatric and non-psychiatric voice hearers. Psychological Medicine 38, 14091417.
Barkus, E, Stirling, J, French, P, Morrison, A, Bentall, R, Lewis, S (2010). Distress and metacognition in psychosis prone individuals. Journal of Nervous and Mental Disease 198, 99104.
Beavan, V, Read, J, Cartwright, C (2011). The prevalence of voice-hearers in the general population: a literature review. Journal of Mental Health 20, 281292.
Bebbington, P, Jonas, S, Kuipers, E, King, M, Cooper, C, Brugha, T, Meltzer, J, McManus, S, Jenkins, R (2011). Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England. British Journal of Psychiatry 199, 2937.
Beck, AT (1979). Cognitive Therapy for Emotional Disorders. Penguin: New York.
Birchwood, M, Chadwick, P (1997). The omnipotence of voices: testing the validity of a cognitive model. Psychological Medicine 27, 13451353.
Brett, CMC, Peters, EP, Johns, LC, Tabraham, P, Valmaggia, LR, McGuire, P (2007). Appraisals of anomalous experiences interview (AANEX): a multidimensional measure of psychological responses to anomalies associated with psychosis. British Journal of Psychiatry 191 (Suppl. 51), S23S30.
Chadwick, P, Birchwood, M (1994). The omnipotence of voices. A cognitive approach to auditory hallucinations. British Journal of Psychiatry 164, 190201.
Clark, DM (1999). Anxiety disorders: why they persist and how to treat them. Behaviour Research and Therapy 37 (Suppl. 1), S5S27.
Cottam, S, Paul, SN, Doughty, OJ, Carpenter, L, Al-Mousawi, A, Karvounis, S, Done, J (2011). Does religious belief enable positive interpretation of auditory hallucinations? A comparison of religious voice hearers with and without psychosis. Cognitive Neuropsychiatry 16, 403421.
Daalman, K, Boks, MPM, Diederen, KMJ, de Weijer, AD, Blom, JD, Kahn, RS, Sommer, IEC (2011). The same or different? A phenomenological comparison of auditory verbal hallucinations in healthy and psychotic individuals. Journal of Clinical Psychiatry 72, 320325.
Daalman, K, Diederen, KMJ, Derks, EM, van Lutterveld, R, Kahn, RS, Sommer, IEC (2012). Childhood trauma and auditory verbal hallucinations. Psychological Medicine 42, 24752484.
Diederen, KM, Daalman, K, de Weijer, AD, Neggers, SF, van Gastel, W, Blom, JD, Kahn, RS, Sommer, IEC (2011). Auditory hallucinations elicit similar brain activation in psychotic and nonpsychotic individuals. Schizophrenia Bulletin 38, 10741082.
Escher, S, Romme, M, Buiks, A, Delespaul, P, van Os, J (2002). Independent course of childhood auditory hallucinations: a sequential 3-year follow-up study. British Journal of Psychiatry 181 (Suppl. 43), s10s18.
Evans, JS, Newstead, SE, Byrne, RMJ (1993). Human Reasoning: The Psychology of Deduction. Lawrence Erlbaum Associates Ltd: Hove.
First, MB, Spitzer, RL, Gibbon, M, Williams, JBW (1995). The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Part 1: description. Journal of Personality Disorders 9, 8391.
Freeman, D, Dunn, G, Fowler, D, Bebbington, P, Kuipers, E, Emsley, R, Jolley, S, Garety, P (2012). Current paranoid thinking in patients with delusions: the presence of cognitive-affective biases. Schizophrenia Bulletin. Published online 7 December 2012. doi:10.1093/schbul/sbs145.
Freeman, D, Garety, PA (2003). Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations. Behaviour Research and Therapy 41, 923947.
Garety, PA, Bebbington, P, Fowler, D, Freeman, D, Kuipers, E (2007). Implications for neurobiological research of cognitive models of psychosis: a theoretical paper. Psychological Medicine 37, 13771391.
Garety, PA, Freeman, D, Jolley, S, Dunn, G, Bebbington, PE, Fowler, DG, Kuipers, E, Dudley, R (2005). Reasoning, emotions, and delusional conviction in psychosis. Journal of Abnormal Psychology 14, 373384.
Garety, PA, Kuipers, E, Fowler, D, Freeman, D, Bebbington, PE (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31, 189195.
Gracie, A, Freeman, D, Green, S, Garety, PA, Kuipers, E, Hardy, A, Ray, K, Dunn, G, Bebbington, P, Fowler, D (2007). The association between traumatic experience, paranoia and hallucinations: a test of the predictions of psychological models. Acta Psychiatrica Scandinavica 116, 280289.
Haddock, G, McCarron, J, Tarrier, N, Faragher, EB (1999). Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychological Medicine 29, 879889.
Janssen, I, Hanssen, M, Bak, M, Bijl, RV, de Graaf, R, Vollebergh, W, McKenzie, K, van Os, J (2003). Discrimination and delusional ideation. British Journal of Psychiatry 182, 7176.
Johns, LC, Cannon, M, Singleton, N, Murray, RM, Farrell, M, Brugha, T, Bebbington, P, Jenkins, R, Meltzer, H (2004). Prevalence and correlates of self-reported psychotic symptoms in the British population. British Journal of Psychiatry 185, 298305.
Larøi, F, Marczewski, P, Van der Linden, M (2004). Further evidence of the multi-dimensionality of hallucinatory predisposition: factor structure of a modified version of the Launay–Slade Hallucinations Scale in a normal sample. European Psychiatry 19, 1520.
Larøi, F, Sommer, IE, Blom, JD, Fernyhough, C, Ffytche, DH, Hughdahl, K, Johns, LC, McCarthy-Jones, S, Preti, A, Raballo, A, Slotema, CW, Stephane, M, Waters, F (2012). The characteristic features of auditory verbal hallucinations in clinical and nonclinical groups: state-of-the-art overview and future directions. Schizophrenia Bulletin 38, 724733.
Lawrence, E, Peters, E (2004). Reasoning in believers in the paranormal. Journal of Nervous and Mental Disease 192, 727733.
Lovatt, A, Mason, O, Brett, C, Peters, E (2010). Psychotic-like experiences, appraisals, and trauma. Journal of Nervous and Mental Disease 198, 813819.
Moritz, S, Verckenstedt, R, Randjbar, S, Vitzthum, F, Woodward, TS (2011). Antipsychotic treatment beyond antipsychotics: metacognitive intervention for schizophrenia patients improves delusional symptoms. Psychological Medicine 41, 18231832.
Moritz, S, Woodward, TS (2007). Metacognitive training for schizophrenia patients (MCT): a pilot study on feasibility, treatment adherence, and subjective efficacy. German Journal of Psychiatry 10, 6978.
Morrison, AP (2001). The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioral and Cognitive Psychotherapy 29, 257276.
Morrison, AP, Nothard, S, Bowe, SE, Wells, A (2004). Interpretations of voices in patients with hallucinations and non-patient controls: a comparison and predictors of distress in patients. Behaviour Research and Therapy 42, 13151323.
Peters, E, Moritz, S, Wiseman, Z, Greenwood, K, Kuipers, E, Schwannauer, M, Donaldson, C, Klinge, R, Ross, K, Ison, R, Williams, S, Scott, J, Beck, A, Garety, P (in press). The Cognitive Biases Questionnaire for psychosis (CBQp). Schizophrenia Bulletin.
Romme, M, Escher, S (1993). Accepting Voices. Mind Publications: London.
So, SH, Garety, PA, Peters, ER, Kapur, S (2010). Do antipsychotics improve reasoning biases? A review. Psychosomatic Medicine 72, 681693.
Sommer, IE, Daalman, K, Rietkerk, T, Diederen, KM, Bakker, S, Wijkstra, J, Boks, MPM (2010). Healthy individuals with auditory verbal hallucinations; who are they? Psychiatric assessments of a selected sample of 103 subjects. Schizophrenia Bulletin 36, 633641.
Tien, AY (1991). Distributions of hallucinations in the population. Social Psychiatry and Psychiatric Epidemiology 26, 287292.
Van Os, J, Hanssen, M, Bijl, RV, Ravelli, A (2000). Strauss (1969) revisited: a psychosis continuum in the general population? Schizophrenia Research 45, 1120.
Van Os, J, Linscott, RJ, Myin-Germeys, I, Delespaul, P, Krabbendam, L (2009). A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness–persistence–impairment model of psychotic disorder. Psychological Medicine 39, 179195.
Varese, P, Smeets, F, Drukker, M, Lieverse, R, Lataster, T, Viechtbauer, W, Read, J, van Os, J, Bentall, RP (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient–control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin 38, 661671.
Verdoux, H, van Os, J (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophrenia Research 54, 5965.
Waller, H, Freeman, D, Jolley, S, Dunn, G, Garety, P (2011). Targeting reasoning biases in delusions: a pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions. Journal of Behavior Therapy and Experimental Psychiatry 42, 411421.


Cognitive biases and auditory verbal hallucinations in healthy and clinical individuals

  • K. Daalman (a1), I. E. C. Sommer (a1), E. M. Derks (a2) and E. R. Peters (a3) (a4)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed