Royal South Hants Hospital & Visiting Professor in Clinical Psychology, University of Exeter
Department of Psychology, University of Southampton
Director of Early Intervention Service, North Birmingham Mental Health Trust, and Professor of Psychology, University of Birmingham
Correspondence: Paul Chadwick, School of Psychology, University of Exeter, Washington Singer Laboratories, Perry Road, Exeter EX4 4QG, UK
Declaration of interest This study was supported by a University of Southampton grant to the first author.
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ABSTRACT |
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Aims To improve measurement of omnipotence, a pivotal concept in understanding auditory hallucinations, and elucidate links between beliefs about voices, anxiety and depression.
Methods Seventy-one participants with chronic auditory hallucinations completed the BAVQR, and 58 also completed the Hospital Anxiety and Depression Scale.
Results The mean Cronbach's for the five sub-scales was 0.86
(range 0.74-0.88). The study supports hypotheses about links between beliefs,
emotions and behaviour, and presents original data on how these relate to the
new omnipotence sub-scale. Original data are also presented on connections
with anxiety and depression.
Conclusions The BAVQR is more reliable and sensitive to individual differences than the original version, and reliably measures omnipotence.
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INTRODUCTION |
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The BAVQ had two specific weaknesses. First, participants answered yes or no to each of the 30 items. For this reason, small individual differences and subtle changes over time were missed. Second, although research shows that people's perception of auditory hallucinations as omnipotent is of central importance, the BAVQ contained but one item specially measuring omnipotence (My voice is very powerful). The revised version contains a further five items measuring omnipotence. Here we present data gathered using the new BAVQR from a fresh sample of 73 people with chronic, drug-resistant auditory hallucinations. These data are linked to scores on the Hospital Anxiety and Depression Scale (HADS) for 58 participants.
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METHOD |
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Measures
Beliefs About Voices QuestionnaireRevised
The BAVQ-R is a 35-item measure of people's beliefs about auditory
hallucinations, and their emotional and behavioural reactions to them. There
are three sub-scales relating to beliefs: malevolence (six items: e.g.
My voice is punishing me for something I have done); benevolence
(six items: e.g. My voice wants to protect me); and omnipotence
(six items). The five new items assessing omnipotence were obtained over a
period of 3 years. The wording of each item reflects statements which are
commonly made during psychological assessment or therapy.
Two further sub-scales, resistance and engagement, measure emotional and behavioural relationships to auditory hallucinations. Resistance has five items on emotion (e.g. My voice frightens me) and four on behaviour (e.g. When I hear my voice usually I tell it to leave me alone). Engagement has four items on emotion (e.g. My voice reassures me) and four on behaviour (e.g. When I hear my voice usually I listen to it because I want to).
All responses are rated on a 4-point scale: disagree (0); unsure (1); agree slightly (2); agree strongly (3). The measure thus assesses degree of endorsement of items. As with the original BAVQ, individuals hearing more than one auditory hallucination complete the questionnaire for their dominant voice. The BAVQ-R is available from the first author upon request.
Hospital Anxiety and Depression Scale
The HADS (Zigmond & Snaith,
1983) is a 14-item self-administered rating scale of depressive
(seven items) and anxious (seven items) symptoms. Like all such self-report
measures, the HADS is not diagnostic. Scores on the HADS for both depressive
and anxious symptoms are categorised as follows: normal range, 0-7; mild,
8-10; moderate, 11-14; severe, 15-21.
Statistical analysis
For each scale of the BAVQR the coefficient was calculated,
thus giving a measure of reliability drawn from a single administration of the
measure. We present descriptive statistical analysis of the distribution of
scores on all sub-scales (including skewness), and endorsement of each
omnipotence item. Pearson correlations are calculated for relationships among
the different BAVQR sub-scales, and between these and the HADS. All
analyses were carried out using SPSS 8 for Windows.
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RESULTS |
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Reliability and validity of the BAVQ-R
For each sub-scale of the BAVQR the coefficient was
calculated, thus giving a measure of reliability drawn from a single measure.
Cronbach's
scores for each sub-scale, including the new omnipotence
sub-scale, were uniformly high. Furthermore, comparison with data from our
previous study (Chadwick & Birchwood,
1995) showed that for malevolence, benevolence and resistance,
Cronbach's
scores were all higher on the BAVQR. For engagement,
the Cronbach's
scores were identical. It therefore appears that the
BAVQR continues to measure clear and stable aspects of individuals'
relationships with their auditory hallucinations.
Construct validity
The correlations between the different subscales of the BAVQR were
examined. As in previous studies (Chadwick & Birchwood,
1994,
1995;
Birchwood & Chadwick,
1997), we found a strong relationship between malevolence and
resistance (r=0.68, d.f.=69, P<0.01) and benevolence and
engagement (r=0.80, d.f.=69, P<0.01), with all other
correlations between these sub-scales being strongly negative.
Omnipotence scale
The descriptive statistics that follow take a conservative view of
endorsement of an item, as Agree slightly or Agree
strongly. The percentage level of endorsement of each item on the
omnipotence sub-scale is: My voice is very powerful (86%),
My voice seems to know everything about me (79%), I
cannot control my voice (75%), My voice rules my life
(63%), My voice makes me do things I really dont want to do'
(47%), and My voice will harm or kill me if I do disobey or resist
it (38%). In relation to the itemtotal correlations
(Table 1), the score for one
item (I cannot control my voices) is a little low (0.26).
However, this item is retained in the measure because it is of critical
importance clinically, and is one of the most highly endorsed on the entire
measure (mean score 2.2).
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A two-tailed examination was made of the new omnipotence sub-scale in relation to the other sub-scales of the BAVQ. The relationship between omnipotence and malevolence was found to be strongly positive (r=0.70, d.f.=69, P<0.01), as was the relationship between omnipotence and resistance (r=0.50, d.f.=69, P<0.01). The sub-scales of omnipotence and engagement had a negative relationship (r=-0.26, d.f.=69, P<0.05). There was no significant relationship between the omnipotence and benevolence sub-scales.
Correlations between BAVQ-R and HADS scores
Fifty-eight participants completed the HADS.
Table 2 shows mean scores on
the HADS, and the number of participants falling into the different ranges of
severity. Previous findings (Chadwick &
Birchwood, 1996) had led us to expect a relationship between
malevolence and depressive symptoms (hereafter called simply
depression). This was found in the present study
(r=0.37, d.f.=56, P<0.01). There was also a relationship
between depression and both omnipotence (r=0.44, d.f.=56,
P<0.01) and resistance (r=0.32, d.f.=56,
P<0.05). Depression was negatively associated with engagement
(r=-0.42, d.f.=56, P<0.01).
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Anxious symptomatology (hereafter called simply anxiety) was related to malevolence (r=0.30, d.f.=56, P<0.05), resistance (r=0.40, d.f.=56, P<0.01) and omnipotence (r=0.33, d.f.=56, P<0.05). There was a negative relationship between anxiety and engagement (r=0.36, d.f.=56, P<0.05). Scores on the HADS showed a significant relationship between anxiety and depression (r=0.59, d.f.=56, P<0.01).
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DISCUSSION |
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Importance of omnipotence
The central importance of people's perceptions of auditory hallucinations
as very powerful was observed first by Bauer
(1970). In a seminal paper, he
reported how auditory hallucinations can be imbued with a "terrifying
and compelling quality" and how individuals can feel "caught in a
voice's power" (p. 169). The new omnipotence sub-scale may be thought of
as an attempt to operationalise this quality. Descriptive data confirm that
omnipotence is a vital part of an analysis of these participants'
relationships with their auditory hallucinations.
Omnipotence has the highest mean score and lowest standard deviation (11.1, s.d.=4.5) of the three sub-scales which measure beliefs. Indeed, so important do we judge omnipotence to be that we have developed and evaluated a group-based cognitive behaviour therapy which principally targets beliefs about omnipotence (Chadwick et al, 2000).
Defining the concept of omnipotence
The present study helps to define our concept of omnipotence, which has
hitherto been used as loosely equivalent to that of power.
Clearly, perceiving an auditory hallucination to be very powerful remains an
important attribute of omnipotence. In the present study 86% of the sample
agreed with the statement My voice is very powerful. Yet 75%
also endorsed the item I cannot control my voices, and 79% the
item My voices seem to know everything about me. This makes it
clear that the concept of omnipotence implies more than mere power. In future,
it may therefore be helpful to refer to power or powerfulness as one specific
aspect of omnipotence. The word omnipotence would then be
reserved for describing the broader concept, as measured by the BAVQR
sub-scale.
Does a predominant profile emerge for clinical cases of this
sort?
Data from this and other studies suggest that a profile may
be emerging which would describe the majority of patients using psychiatric
services who experience auditory hallucinations. First, as in the present
study, participants almost invariably perceive their dominant hallucinations
as a considerable problem and source of distress, notwithstanding the fact
that particular aspects of their relationships with auditory hallucinations
may be positive. Second, omnipotence scores are very high (cf.
Close & Garety, 1998).
Third, the dominant auditory hallucination is predominantly perceived as
malevolent, evoking behavioural resistance and negative affect. Fourth, the
person is likely to experience at least a moderate level of anxiety symptoms
and mild or moderate depressive symptoms. Yet it is important to note that for
many people the experience of auditory hallucinations is a positive one; in a
community sample (n=173) of patients and non-patients, Romme &
Escher (1989) found that 15% of
participants perceived their auditory hallucinations as positive.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Birchwood, M.J. & Chadwick, P.D.J. (1997) The omnipotence of voices: testing the validity of a cognitive model. Psychological Medicine, 27, 1345-1353.[CrossRef][Medline]
Chadwick, P. & Birchwood, M. (1994) The omnipotence of voices. A cognitive approach to auditory hallucinations. British Journal of Psychiatry, 164, 190-201.[Abstract]
Chadwick, P. & Birchwood, M. (1995) The omnipotence of voices. II: The Beliefs About Voices Questionnaire. British Journal of Psychiatry, 166, 773-776.[Abstract]
Chadwick, P. & Birchwood, M. (1996) Cognitive therapy for voices. In CognitiveBehavioural Interventions for Psychotic Disorders (eds G. Haddock & P.D. Slade). London: Routledge.
Chadwick, P., Sambrooke, S., Rasch, S., et al (2000) Challenging the omnipotence of voices: group cognitive behaviour therapy for voices. Behaviour Research and Therapy, in press.
Close, H. & Garety, P. (1998) Cognitive assessments of voices: further developments in understanding the emotional impact of voices. British Journal of Clinical Psychology, 37, 189-197.[Medline]
Romme, M. & Escher, S. (1989) Hearing voices. Schizophrenia Bulletin, 15, 209-216.[Medline]
Zigmond, A. S. & Snaith, R. P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370.[Medline]
Received for publication October 13, 1999. Revision received February 10, 2000. Accepted for publication February 15, 2000.