Many philosophers and psychologists have sought to explain experiences of auditory verbal hallucinations (AVHs) and “inserted thoughts” in schizophrenia in terms of a failure on the part of patients to appropriately monitor their own inner speech. These self-monitoring accounts have recently been challenged by some who argue that AVHs are better explained in terms of the spontaneous activation of auditory-verbal representations. This paper defends two kinds of self-monitoring approach against the spontaneous activation account. The defense requires first making some important clarifications concerning what is at issue in the dispute between the two forms of theory. A popular but problematic self-monitoring theory is then contrasted with two more plausible conceptions of what the relevant self-monitoring deficits involve. The first appeals to deficits in the neural mechanisms that normally filter or attenuate sensory signals that are the result of one’s own actions. The second, less familiar, form of self-monitoring approach draws an important analogy between Wernicke’s aphasia and AVHs in schizophrenia. This style of self-monitoring theory pursues possible connections among AVHs, inserted thoughts, and the disorganized speech characteristic formal thought disorder (FTD).
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This is not to suggest that all reports of inserted thoughts are reports of experiences that are voice-like. For instance, some patients seem to conceive of their inserted thoughts as “picture-like” (see, e.g., Mellor (1970, p. 17)). The point is rather that all or at least many of the experiences reported as AVHs may constitute a subset of the kind of experiences reported as inserted thoughts—roughly, the inserted thoughts that are voice-like.
Nayani and David (1996) conducted a phenomenological survey of where 49 % of the 100 people reporting AVHs reported hearing the voices as coming “through air, as external stimuli”, whereas 38 % hear voices as located only “in internal space,” while 12 % reported both locations variably. In another study, Hoffman et al. (2008) found similarly ambiguous results when querying patients on the nature of the “voices” they hear: 79 % reported that the AVH ‘voice tone’ usually did not sound like their own voice, which might seem to support a view on which the experienced voices are similar to cases of hearing (setting aside the other 21 %). However, 70 % reported that their AVHs were not usually “louder” than their own verbal thought—which would suggest that the AVHs are more similar to cases of inner speech. Additionally 80 % said that their AVHs were not usually clearer than their own verbal thought; and 26.5 % reported that the voice seemed to come exclusively from outside the head. Laroi et al. (2012) report similarly wide-ranging phenomenological traits for AVHs in schizophrenia. The overall picture of the phenomenology of AVHs one gets from these studies is that they are in some ways very much like experiencing one’s own inner speech, but in other ways not. We should fully expect that patients might describe the overall experience differently—some holding that it is like hearing another speak, others emphasizing its similarity to cases of their own thought.
While these terms tend to be used interchangeably in the hallucinations literature, a referee alerts me that elsewhere they have distinct meanings. Self-monitoring views are generally based in theories of motor agency that appeal to phenomena such as corollary discharge (see Section 3 below), while the notions of source monitoring and reality monitoring are used in the memory literature to refer to processes by which the source and veridicality of an apparent memory are determined based on subjectively available features of the memory experience.
Formal thought disorder is another common symptom of schizophrenia, diagnosed on the basis of patients exhibiting scattered, inscrutable, and semantically impoverished overt speech.
Of course, as a referee notes, if by invoking “self-monitoring” one has in mind specific mechanisms (such as a forward model and comparator (Wolpert et al. 1998)) with which the task of monitoring one’s own actions is carried out, then the claim is not at all a truism.
Compare Frith et al.’s (2000) discussion of anarchic hand syndrome.
Wu (2012, p. 100–102) uses the term ‘automatic’ to describe actions and mental states that are not caused by one’s intentions, whereas Wu and Cho (2013) opt for the term ‘spontaneous’ to describe mental states that are caused neither by one’s intentions, nor by perception of an appropriate external stimulus. I stick with the term ‘spontaneous’ for ease of exposition.
A referee correctly observes that, just as parts of visual cortex are “special” with respect to face perception (e.g., the fusiform face area), so too are parts of auditory cortex devoted to speech perception. This may seem to render less unlikely the possibility that random activation there would result in the representation of coherent speech. However, as the referee also notes, it remains extremely unlikely that random activation of these speech perception areas would result in long strings of coherent speech without simultaneous activation of speech production areas (such as the inferior frontal gyrus, which is not a part of auditory cortex). And it is the latter possibility to which Wu & Cho appeal.
Vicente (2014) raises a similar challenge to self-monitoring views.
Wu & Cho propose that AVHs seem not to be under patients’ control because they are not intended and they have a phenomenological richness that is just like an experience of hearing someone else speak. “All that is required for the attributed externalization” writes Wu, “is that patients have an auditory experience that represents the presence of another’s voice” (2012, p. 99). Taking this proposal at face value, it would only explain the AVHs that are indeed like hearing someone else speak. As reviewed in the phenomenological studies above (fn. 1), this leaves very many cases of “hearing voices” untouched, including all that tend to be reported as inserted thoughts.
Here it is assumed that inner speech need not always be conscious, and is ultimately to be understood as a kind of neural process carrying auditory-phonological information.
The fact that we often engage in inner speech that has the characteristics of another person’s voice (e.g., when imagining a conversation) still coheres with this picture of inner speech as overt speech with the motor element suppressed. In such cases we may be seen as suppressing overt speech that would have someone else’s vocal characteristics, as when we imitate another person’s accent and manner of speaking. This parallel would be challenged, however, if it turned out that our ability to imagine another’s voice did not closely constrain and influence our ability to vocally mimic the voice. As far as I know, it is an open empirical question whether this constraint holds.
While Christoffels and colleagues interpret this finding as support for the view that speech involves matching predicted sensory input with actual sensory input, the results are equally compatible with a view on which specific auditory features characteristic of one’s voice are automatically filtered, or attenuated, when a motor command has been issued to engage in speech.
Lesions to the arcuate fasciculus can result in conduction aphasia, which is marked by many of the same language-production deficits as Broca’s aphasia.
In a fascinating unpublished report, Arciniegas (unpublished) describes a patient with schizophrenia whose longstanding AVHs seemed to be eliminated after a stroke that left him with global aphasia. (Patients with global aphasia show language difficulties characteristic of both Broca’s and Wernicke’s aphasia). The patient’s widespread lesions were to primary auditory cortex, the lateral temporal cortex, and perisylvian areas. This patient’s lesions and aphasia do not provide a crucial test of the theories in question. Both would predict that lesions to primary auditory cortex will lead to a decrease in AVHs.
McKenna and Oh (2005) provide an excellent overview of the relation between formal thought disorder and language deficits in schizophrenia
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I am grateful to two anonymous reviewers for this journal, to Wayne Wu, and to Aimee Dietz, for their helpful comments, criticisms, and suggestions. This research was supported by a grant from the Taft Research Center at the University of Cincinnati.
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Langland-Hassan, P. Hearing a Voice as one’s own: Two Views of Inner Speech Self-Monitoring Deficits in Schizophrenia. Rev.Phil.Psych. 7, 675–699 (2016). https://doi.org/10.1007/s13164-015-0250-7
- Auditory Cortex
- Motor Command
- Superior Temporal Gyrus