The relationship between appraisals of voices (auditory verbal hallucinations) and distress in voice-hearers with schizophrenia-spectrum diagnoses: A meta-analytic review.

Cognitive-behavioural models of auditory verbal hallucinations (voices) predict that the interpretation of voices determines the levels of distress experienced by voice-hearers. Examining the contribution of these voice appraisals is central to the delivery of effective psychological interventions for the management of distressing psychotic symptoms. This meta-analysis synthesised evidence from studies that tested the relationship between a range of appraisals and several distress measures (voice-related and emotional distress) in individuals with schizophrenia-spectrum diagnoses. A database search (PsycINFO, PubMed and Web of Science) was conducted for articles published up to August 2020. Twenty-eight eligible studies, comprising of 1497 clinical participants examined the association between eight voice appraisals and distress. Moderate to large summary effects (r ranging between 0.30 and 0.50) were observed in several analyses focusing on 'maladaptive' appraisals and beliefs about voices (malevolence, power, metaphysical beliefs, beliefs about loss of control, voice intrusiveness), with voice dominance having a large summary effect, r = 0.58, 95% CI [0.43, 0.69]. Positive appraisals and beliefs had small negative summary effects on distress. The magnitude of the observed effects was similar across subgroup analyses considering measures of voice-related distress, anxiety and depression. The findings of this evidence synthesis broadly corroborate cognitive-behavioural models of distressing voices, but suggested that factors other than voice appraisals may also predict the distress and impairment caused by hallucinatory experiences in people with schizophrenia-spectrum disorders. Nonetheless, our findings confirm that voice appraisals are an important and meaningful target for treatment in help-seeking voice hearers with psychosis.