PTSD flashbacks trigger hearing nonexistent voices, and dissociation serves as a mediator of this symptom, according to a new study.1
A study team led by Emily Piesse, of the school of psychology and exercise science at Murdoch University in Western Australia. explored the relationship between hearing voices, dissociation, and PTSD symptoms. Previous research suggested dissociation often stands in between voice hearing and PTSD, serving as a mediator.2 While prior studies followed a cross-sectional model, Piesse and colleagues used a mixed-methods research design, including a qualitative, semi-structured interview and a qualitative symptom measure to uncover the interrelationships between the 3 variables.1
“These results are broadly consistent with the theoretical and experimental research literature,” the team wrote. “The finding that PTSD symptoms occur in close temporal relationship to voices is consistent with cross-sectional research which has found an association between voices and greater frequency of trauma memory intrusions.”
Participants were recruited from the Pert Voices Clinic, a specialist clinical psychology service for voice hearing. Participants aged 27 – 68 years old (n = 7) were involved in the study, and all of them could hear voices within the past week.
Measures included the self-reported Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ), which measured auditory verbal hallucinations. The HPSVQ assessed the amount of negative content, volume, frequency, and the level of distress created by the voice, as well as other aspects of hallucinations.
The second measure was the Dissociative Experiences Scale-Taxon, also self-reported, which indicated whether an individual’s dissociation symptoms were pathological (relating to a dissociative disorder) or “normal” dissociative experiences like daydreaming.
The third measure was the PTSD Checklist for DSM-5, a self-reported measure that was a symptom checklist for PTSD. The test measured distress related to symptoms over the past month.
As for the semi-structure interview, the research aimed to answer the question: “What if the nature of the relationship between voices, dissociation, and PTSD symptoms?” The interview included 5 primary questions and follow-up questions. An example of a question would be “Please describe for me, in as much detail as possible, what happens when you hear your voice/s, from before they occur until after they finish.”
The interview also inquired about PTSD symptoms and dissociative symptoms.
The participants scored higher on the HPSVQ (M, 24.14 [SD, 6.87]) than the control sample of schizophrenia and schizoaffective disorder patients (M, 18.8 [SD, 6.0]). Thus, the participants in the study with PTSD had more severe voice hearing. Even during the study, 4 out of the 7 participants experienced PTSD during the interview. These 4 participants reported hearing voices either right before or right after experiencing the PTSD symptoms.
One participant recalled only hearing the voice before the PTSD intrusion, while another participant only heard voices after the PTSD flashback.
“[The finding] supports the findings of an EMA study, which found trauma memory intrusions were associated with voice hearing in real time—specifically, voices were more likely to occur when trauma memory intrusions were more frequent across a specified timeframe of 1 hour,” the investigators wrote.
Six out of 7 of the participants reported experiencing dissociative symptoms, such as losing track of time, detachment, and derealization. Three participant experienced severe dissociative symptoms.
Investigators pointed out there was no consistent relationship between hearing voices and PTSD symptoms or dissociations—voices could be heard before or after PTSD symptoms and dissociative episodes. Though, for some participants, voices appeared to be triggered by PTSD dissociative symptoms.
For the 5 of the 6 participants who described dissociative symptoms, they said it occurred “temporally adjacent to their voices.” For some participants, this meant that for 1 second, they would hear the voices, and then they would go into a quiet dissociative state in their mind, and the voices would disappear. However, when the dissociation ended, the voices returned.
For other participants, they were still hearing voices while experiencing a dissociative state—they just lost their sense of time during this period. For another participant, they felt like they were “split into two,” so they didn’t think of themselves as the one hearing the voices despite acknowledging the fact the voices were there.
Meanwhile, 1 participant did not hear voices temporally adjacent. Rather, the individual went into a dissociative state and heard no voices.
“It should be noted that there was greater variability in participants' accounts of their dissociation symptoms—as they pertained to voices—compared to PTSD intrusion symptoms,” the investigators wrote. “This variability poses the question as to whether voices are differentially related to dissociative states, depending on the type of dissociation experienced.”
- Piesse E, Paulik G, Mathersul D, Valentine L, Kamitsis I, Bendall S. An exploration of the relationship between voices, dissociation, and post-traumatic stress disorder symptoms [published online ahead of print, 2023 Oct 6]. Psychol Psychother. 2023;10.1111/papt.12493. doi:10.1111/papt.12493
- Sun, P., Alvarez-Jimenez,M., Lawrence, K., Simpson, K., Peach, N., & Bendall, S. (2018). Investigating the prevalence of dissociative disorders and severe dissociative symptoms in first episode psychosis. Early Intervention in Psychiatry, 13, 1–7.https://doi.org/10.1111/eip.12773