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Associations between responses to voices, distress and appraisals during daily life: an ecological validation of the cognitive behavioural model

Published online by Cambridge University Press:  10 July 2020

Sarah F. Fielding-Smith
School of Psychology, University of Sussex, Brighton, UK
Kathryn E. Greenwood
School of Psychology, University of Sussex, Brighton, UK Research & Development Department, Sussex Partnership NHS Foundation Trust, Hove, UK
Marieke Wichers
University of Groningen, University Medical Centre of Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), University Medical Centre of Groningen, Groningen, the Netherlands
Emmanuelle Peters
Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK
Mark Hayward*
School of Psychology, University of Sussex, Brighton, UK Research & Development Department, Sussex Partnership NHS Foundation Trust, Hove, UK
Author for correspondence: Mark Hayward, E-mail:



Cognitive models propose that behavioural responses to voices maintain distress by preventing disconfirmation of negative beliefs about voices. We used Experience Sampling Methodology (ESM) to examine the hypothesized maintenance role of behavioural responses during daily life.


Thirty-one outpatients with frequent voices completed a smartphone-based ESM questionnaire 10 times a day over 9 days, assessing voice-related distress; resistance and compliance responses to voices; voice characteristics (intensity and negative content); appraisals of voice dominance, uncontrollability and intrusiveness.


In line with predictions, behavioural responses were associated with voice appraisals (dominance and uncontrollability), but not voice characteristics. Greater resistance and compliance were reported in moments of increased voice distress, but these associations did not persist after controlling for concurrent voice appraisals and characteristics. Voice distress was predicted by appraisals, and, unexpectedly, also by voice characteristics. As predicted, compliance and resistance were related to increases in distress at subsequent timepoints, whilst antecedent voice appraisals and characteristics had no such effect. Compliance, but not resistance, additionally predicted subsequent increases in voice uncontrollability. In both cases, the reverse models showed no association, indicating directional effects of responses on subsequent distress, and of compliance on uncontrollability appraisals.


These results provide support for the cognitive model by suggesting that momentary behavioural and emotional responses to voices are associated with concurrent negative voice appraisals. Findings suggest that behavioural responses may be driven by voice appraisals, rather than directly by distress, and may in turn maintain voice appraisals and associated distress during the course of daily life.

Original Article
Copyright © The Author(s), 2020. Published by Cambridge University Press

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