Researching Voice-Hearing Without Diagnosis: A Call for Participants

Ben Alderson-Day writes: If you have been following the project recently you may have seen some of our posts on Inner Voices for the Guardian, including Pete Moseley on the neuroscience of inner speech, Pat Waugh on the voices of Hilary Mantel and Virginia Woolf, and Marco Bernini’s take on inner speech and Samuel Beckett.

Last week I wrote a post on voice-hearing in people who don’t have psychosis or any other particular mental health problem (If you missed it, it’s still up here). At the end of that post we asked for people to get in touch if they have had experiences of voice-hearing, but haven’t needed psychiatric care.

We’ve had a great response so far, with lots of people getting in contact – but we would still like to hear from more. In particular, we would like to hear from people who are based in the UK and might be interested in taking part in some research in the future.

It’s really important that researchers get to hear from people who have had voice-hearing experiences but either haven’t been distressed by them, or haven’t needed to seek professional help. Why? Because firstly, it allows us to get a better idea of how common (and how normal) these experiences might actually be. And secondly, it could eventually help us to help others who are in distress, by looking at how voice-hearing works when it isn’t necessarily a problem. If that sounds like your experience, please get in touch.

If you have had an experience of voice-hearing without need for psychiatric care, contact us at Hearing the Voice.

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The Inner Voices of Writers and Readers

Many of us will recognise the experience of hearing, in our mind’s ear, the voices of people known to us. Memories of ferocious school teachers, passionate declarations of love, the everyday catchphrases of friends, and even the idiosyncratic trill of loud-mouthed celebrities – our minds are sometimes populated with a jumble of voices, each with its own distinctive auditory qualities.

So what’s it like to bring a new voice into being? And might writers – in the course of creating characters, imagined or historical – be uniquely well-placed to shed light on this?

Writers’ Inner Voices is a study being conducted by Hearing the Voice in collaboration with the Edinburgh International Book Festival. Its aim is to understand the ways in which writers and storytellers hear or imagine the voices of their characters and to explore what role this plays in the literary-creative process more broadly. 100 authors appearing at this year’s Edinburgh International Book Festival have completed our online questionnaire about their experience of their characters’ voices, and the preliminary results are fascinating. 70% of writers we surveyed said that they hear the voices of their characters out loud, and 57% could sense the presence of their characters in visual or other sensory modes.

During the course of the Festival itself, Dr Jenny Hodgson is conducting in-depth follow-up interviews with writers to find out more about the varied and complex ways in which they hear, experience, imagine and interact with their characters. She’ll be posting regular updates on twitter and on the Writers’ Inner Voices blog – so please do join in the conversation.

As a counterpart to the Writer’s Inner Voices project we’re also asking readers about their experiences of voices and characters. Since Saturday we’ve had nearly 1000 responses to our Readers’ Inner Voices study after it was profiled in the Guardian. and we hope to get many more over the course of the EIBF, with the ongoing events at Conversations With Ourselves and via our blogs for the Guardian. The link for the survey is  https://www.survey.bris.ac.uk/durham/innervoices, please consider participating, and spread the message far and wide!

Guardian Screen Grab

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‘Talking to ourselves: the science of the little voice in your head’ – by Peter Moseley

In a recent piece for the Guardian’s Inner Voices series, Psychology PhD student Peter Moseley writes: 

Most of us will be familiar with the experience of silently talking to ourselves in our head. Perhaps you’re at the supermarket and realise that you’ve forgotten to pick up something you needed. “Milk!” you might say to yourself. Or maybe you’ve got an important meeting with your boss later in the day, and you’re simulating – silently in your head – how you think the conversation might go, possibly hearing both your own voice and your boss’s voice responding.

 

This is the phenomenon that psychologists call “inner speech”, and they’ve been trying to study it pretty much since the dawn of psychology as a scientific discipline. In the 1930s, the Russian psychologist Lev Vygotsky argued that inner speech developed through the internalisation of “external”, out-loud speech. If this is true, does inner speech use the same mechanisms in the brain as when we speak out loud?

 

We have known for about a century that inner speech is accompanied by tiny muscular movements in the larynx, detectable by a technique known as electromyography. In the 1990s, neuroscientists used functional neuroimaging to demonstrate that areas such as the left inferior frontal gyrus (Broca’s area), which are active when we speak out loud, are also active during inner speech. Furthermore, disrupting the activity of this region using brain stimulation techniques can interrupt both “outer” and inner speech.

 

So the evidence that inner speech and speaking out loud share similar brain mechanisms seems pretty convincing. One worry, though, is whether the inner speech we get people to do in experiments is the same as our everyday experience of inner speech. As you might imagine, it’s quite hard to study inner speech in a controlled, scientific manner, because it is an inherently private act.

 

Typically, studies have required participants to repeat sentences to themselves in their heads, or, sometimes, count the syllables in words presented on a computer screen. These lack both the spontaneity of typical inner experiences and the conversational quality (think of the conversation with your boss) and motivational purposes (“Milk!”) of inner speech. Although the experience is undoubtedly different for everyone (not everyone reports having “conversations” in their head, for example), what does seem clear is that inner speech is a complex and multifaceted phenomenon.

 

Why does it matter whether we have an accurate understanding of what’s going on in our brains when we use inner speech?

 

One reason is that understanding typical inner experience may be the key to understanding more unusual inner experiences. For example, psychologists have argued that hearing voices (“auditory verbal hallucinations”) might simply be a form of inner speech that has not been recognised as self-produced (although there are also important competing theories). Neuroscientists have found some evidence in favour of this theory. When they scanned the brains of people who reported hearing voices, they discovered that many of the same areas of the brain are active during both auditory hallucinations and inner speech. Broca’s area, for example, is often active in people when they’re hearing voices.

 

But if we really want to know what the difference between what happens in the brain during inner speech and voice hearing – and how inner speech might become hearing voices – then first we need to understand what our internal talk is usually like. A recent study by researchers in Finland attempted to address flaws in previous brain-imaging studies of inner speech. Using functional magnetic resonance imaging (fMRI), they studied the difference between activity in the brain when participants experienced an auditory verbal hallucination, and when they deliberately imagined hearing the same voice. In this way, they controlled for aspects of the experience such as the sound and the content of the voice.

 

They found the main difference between the two conditions was the level of activation in a cortical region known as the supplementary motor area (SMA), which contributes to the control of movement. When participants heard voices, there was significantly less activation in the SMA, which fits with previous hypotheses suggesting that recognising actions as one’s own might rely on signals from motor cortical areas reaching sensory areas of the brain.

 

Of course, none of this is to say that understanding what happens in the brain is the only, or the most important, aspect of research into hearing voices. We also need to understand what the experience is like, how we can help people who are distressed by it, and when there’s a need for psychiatric care. But to do any of this, we first need to know what typical inner speech is like, and the underlying neuroscience is part of that understanding.

This article was originally published here in the Guardian’s ‘Notes and Theories’ science blog on Thursday 21 August 2014.

 

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‘Samuel Beckett’s articulation of unceasing inner speech’ by Marco Bernini

In a recent piece for the Guardian’s Inner Voices series, our Postdoctoral Research Fellow in English Studies Dr Marco Bernini writes writes:

In a letter to Alan Schneider in 1957, Samuel Beckett wrote that: “My work is a matter of fundamental sounds (no joke intended), made as fully as possible, and I accept responsibility for nothing else. If people want to have headaches among the overtones, let them. And provide their own aspirin.”

This laconic statement has nourished a vast array of critical readings focusing on the sounds of words and the presence of music in Beckett’s fictional worlds. However, undoubtedly the most ubiquitous sound in Beckett’s work is that of the mysterious voices buzzing, murmuring or whispering within the heads of his characters. To borrow from the narrating figure in The Unnamable (1953), the narrative core of Beckett’s dark universes seems to be “all a matter of voices; no other metaphor is appropriate”. The question is: to what extent are voices in Beckett’s fiction just metaphorical presences?

The qualities of Beckett’s voices (alien, autonomous, without a recognisable source, and having aggressive or commanding contents) resonate with and sometimes even match the phenomenology of auditory verbal hallucinations (hearing voices in the absence of external stimuli).

From psychologist Louis Sass and philospher Gilles Deleuze, who first spoke of a “schizoid voice” in Beckett’s work, to investigators on the recent Beckett and Brain Science project, critics have highlighted correspondences between the distorted perceptions of Beckett’s characters and a wide gamut of psychiatric disorders. Nonetheless, this pathological framework of interpretation can be, if not reversed, at least complemented by non-pathological approaches which draw on contemporary cognitive research.

In fact, recent research in cognitive science and other fields has shown that hearing voices is more common than we think, including among people with no psychiatric diagnosis. The restless sound of our inner speech is a key experience of this commonality.

As the Dutch neurobiologist Bernard J Baars reminds us, “we are a gabby species” and “the urge to talk to ourselves is remarkably compelling”. Can Beckett’s voices be interpreted as the fictional rendering of our inner monologues – of the dialogues we constantly entertain within ourselves? Inner speech is hard to stop or to escape from, exactly as the sound described in Molloy (1951): “[it] is not a sound like other sounds, that you listen to, when you choose, and can sometimes silence, by going away or stopping your ears, no, but is a sound which rustles in your head, without you knowing how, or why. It’s with your head you hear it, not your ears, you can’t stop it, but it stops itself, when it chooses.”

Psychologists and cognitive scientists are, like Molloy, still struggling to understand the role and modalities of inner speech. What is certain is that for most of us it is, as the narrator of The Unnamable says, a “sound that will never stop”. A better understanding of inner speech can therefore help revisit the pathological framework through which Beckett’s voices have been largely interpreted. At the same time, Beckett’s fictional rendering and exploration of the pervasiveness of inner voices can expand the field of research by pointing, for instance, at new relationships between the internal dialogue we entertain with ourselves in inner speech and the imaginary creation/reception of literary characters; or even at the tight entanglement of inner speech and the narrative construction of our sense of selfhood.

Take, for example, works like Ohio Impromptu (1981). This late piece for theatre features an identical reader and listener. The reader tells the listener the story of the listener’s life. If we look at this work through the lens of the new research on inner speech, it appears as a masterful rendition of the simultaneous narrative and receptive activities that go on in our inner life. This inner relation in which we voice ourselves to ourselves relies extensively on our capacity to use our inner voice to allow multiple imaginative perspectives to emerge, as we do when wesilently voice characters when reading literature.

If inner speech is the raw material for hallucinatory phenomena, it is also at the centre of our imaginary engine – supporting our simple need for, as the homonymous text by Beckett portrays, an intimate Company (1980) in the inaccessible dark of our subjectivity.

This article was originally published here in the Guardian’s Books blog on 19 August 2014.

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VoiceWalks at the Shuffle Festival: Part 2

Roz Oates, a doctoral student in Durham’s Centre for Medical Humanities and Department of Geography, who is also part of the Hearing the Voice research team, continues our ‘two-post special’ on VoiceWalks:   

On Saturday 2 August, I gave a talk to the people taking part in the Hearing the Voice VoiceWalks taking place in Tower Hamlets Cemetery as part of the Shuffle Festival. There were five voice-hearers who gave talks on the course of this walk. My talk addressed stigma and voice-hearing, so it was fitting that opposite me was a building that was formerly St Clements mental hospital. I could see the doorway to the hospital through which they used to carry the bodies to bury them in the cemetery.

People participating on the VoiceWalk listen to Roz's story

People participating on the VoiceWalk listen to Roz’s story

Each person taking part in the walk had been given a copy of the magazine Voicewalks, that was co-edited by the ‘Hearing the Voice’ research team and Stepaway magazine. I read a short extract from my short story, ‘Behind the Wall’, and then I spoke of how I had not mentioned even to friends for many years that I sometimes heard voices, as I feared their reactions. Entering the mental health system many years later led to a stigmatizing diagnosis, and being given low expectations by mental health professionals, which I found very difficult. I then spoke about how since that time I have struggled with so-called self stigma. I did not make a recovery, until I moved to a different city, when a very helpful psychiatrist suggested that I enter therapy, and this led me to make connections between voices and trauma, and to normalize my voice-hearing experiences. I was then able to reengage with postgraduate academic work and my interests, and I developed a social network again. I mentioned in my talk that a crucial turning point for me was meeting Rachel Waddingham, another voice-hearer on our walk. I met Rachel at the Hearing Voices Groups Facilitators Training Course in 2009 that was run by Camden Mind, and I saw that Rachel functioned well with voices, and had a fulfilling life. This planted the hope that I, too, could recover and work again. I shared that I am now hoping to set up a hearing voices group with another facilitator in the autumn.

VoiceWalksSlogan

Voice Walk: Lose the Labels, Hear the Stories

It was an inspiring experience to be walking with other voice-hearers, who were carrying banners that had printed on them strong messages, such as ‘We hear voices. Listen to us’.It felt as if we were challenging stigma together, and that this was, in fact, a civil rights issue, given the marginalization, isolation and powerlessness that voice-hearers have historically experienced. The second speaker, Brian, spoke of how psychological therapies are less likely to be offered to black and minority ethnic voice-hearers. Adam, the third speaker, described himself as a ‘24/7 voice-hearer’, and said that he wanted to combat stigma, and to speak for voice-hearers who are less able to challenge prejudice. Finally, there was a co-presentation by Molly, who had unusual experiences as a teenager, and Rachel. Molly thought that it was very important for a young person to share their unusual experiences with someone they trusted. While Rachel stressed that despite now hearing up to thirteen voices, the voices are parts of her, and she would choose to live with them. Rachel now works creatively with young people who are voice-hearers, and encourages them not to be afraid of their voices.

The people participating in the walk asked all five of us voice-hearers interesting questions. There were also informal conversations as we walked together, and people said that they had learnt more about voice-hearing. Some people said that their ideas about voice-hearing had changed in a positive way.

Part 1 of ‘VoiceWalks at the Shuffle Festival’, by Mary Robson, is here.

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VoiceWalks at the Shuffle Festival: Part 1

This year, Hearing the Voice was once again asked to take part in Mile End’s Shuffle Festival. In part one of a ‘two-post special’, HtV’s creative facilitator Mary Robson writes about her part in the proceedings:

Adam Plus One, the short film that Hearing the Voice made with voice-hearer Adam, was shown at last year’s Shuffle Festival, held in the grounds of St Clement’s Hospital, built as a workhouse in the mid nineteenth century and closed over a century later as an asylum. Shuffle Festival started as campaigning initiative to help reclaim local space for the local community and is run by a small group of individuals and helped by hundreds of volunteers. This year, HtV was invited to run some Voice Walks. What are Voice Walks? Guided walks in the course of which people encounter voice-hearers and listen to their stories. The notion was pioneered at last year’s event and organised by Molly Carroll.

In conversation with voice-hearers, we decided to give this year’s event an ‘anti-stigma’ theme, not least to avoid any idea of Voice Walks being a voyeuristic opportunity. The voice-hearers were in charge of their tales and not exhibits.

This year’s venue is Tower Hamlets Cemetery Park  which is overlooked by St Clement’s. The site is imbued with references to incarceration and freedom. There is a door from the hospital that leads to a gate in the cemetery fence, through which patients who had died would be carried to their final resting place. The closed has become a wild and overgrown place, home to mature trees and with signs of burgeoning life everywhere. St Clement’s is now London’s first Community Land Trustoffering permanently affordable houses based on local incomes – there will be green space and hopefully healthier living there.

I made a reconnaissance trip to the park to plan our hour-long walks, guided by the Festival’s Science Director, Grace Boyle. I was struck by how powerful it would be to hear voice-hearers freely declaim their stories in the shadow of the institution where their like would have been incarcerated in the past. So the first encounter was sited near that gate, with another four following close by, giving the walkers time for a reflective stroll back through the woodland. (Please read Roz Oates’ companion blog post for more detail of the encounters.)

The day before the event was spent writing placards that were placed at each encounter.

VoiceWalks Placards

The slogans invited all to listen and potentially rethink their attitudes to voice hearers:

VOICE WALKS: We Listen to Voice Hearers
VOICE WALKS: Lose the Labels, Hear the Stories

Some came from the lived experience of the participants:

DON’T CAGE THE VOICES
5 YEARS OFF THE MEDS AND I WALK TALL

The latter refers to Akathisia, sometimes called the Largactil Shuffle, that is a side- effect of taking anti-psychotic medication.

During the last walk (we ran two), the placards were picked up and carried along, so that by its last stage there was an impromptu march, with voice-hearers, walkers, researchers et al walking and talking together. People who came on the walk commented that “It was overwhelming, fascinating and moving”… “Inspiring stuff – remember these stories . . . ”

The walkers were invited to each write a self-addressed postcard detailing their thoughts and reactions and leave it with us. We will be posting them in a few weeks’ time to prompt memories of the afternoon they spent listening to and coming to some understanding of tales of extraordinary experiences.

I spent the afternoon running an information table near the main entrance to the park, telling anyone who was showed an interest about the project and the walks. A security man told me about his nephew’s experience of schizophrenia, and his colleague revealed that he had been given a diagnosis in 2010 and was coping very well ‘on the meds’. My early misgivings about voice hearers being ‘put on show’ in some way were unfounded. This kind of event can help make the invisible visible, and encourage attitudinal change along the way.

It also made apparent the serious attention Hearing the Voice pays to forging meaningful, two-way relationships with voice hearers.   Nothing made this more clear than when one of the voice-hearers, Rai Waddingham , posted the following on Twitter:

Rais tweet

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‘Do You Hear Voices? You Are Not Alone’ by Ben Alderson-Day

In a recent piece for the Guardian’s ‘Notes and Theories’ science blog, our postdoctoral research associate in psychology Dr Ben Alderson-Day writes:

Hearing voices is an experience that is very distressing for many people. Voices – or “auditory verbal hallucinations” – are one of the most common features of schizophrenia and other psychiatric disorders. But for a small minority of people, voice-hearing is a regular part of their lives, an everyday experience that isn’t associated with being unwell. It is only in the past 10 years that we have begun to understand what might be going on in “non-clinical” voice-hearing.

Most of what we know comes from a large study conducted by Iris Sommer and colleagues at UMC Utrecht in the Netherlands. In 2006 they launched a nationwide attempt to find people who had heard voices before but didn’t have any sort of psychiatric diagnosis. From an initial response of over 4,000 people, they eventually identified a sample of 103 who heard voices at least once a month, but didn’t have psychosis. Their voice-hearing was also not caused by misuse of drugs or alcohol.

Twenty-one of the participants were also given an MRI scan. When this group was compared with voice-hearers who did have psychosis, many of the same brain regions were active for both groups while they were experiencing auditory hallucinations, including the inferior frontal gyrus (involved in speech production) and the superior temporal gyrus (linked to speech perception). Subsequent studies with the same non-clinical voice-hearers have also highlighted differences in brain structure and functional connectivity (the synchronisation between different brain areas) compared with people who don’t hear voices.

These results suggest that, on a neural level, the same sort of thing is going on in clinical and non-clinical voice-hearing. We know from first-person reports that the voices themselves can be quite similar, in terms of how loud they are, where they are coming from, and whether they speak in words or sentences.

Knowing that voice-hearing in clinical and non-clinical groups is similar allows us to investigate hallucinations in isolation from other aspects of psychosis, such as having delusional or disorganised thoughts. But it’s just as important to look for the differences between clinical and non-clinical voice-hearing, because it’s the differences that might hold the key to providing better support for those who are unwell or in distress.

There is some evidence that non-clinical voice-hearing tends to start early (around 12 years of age), while voices associated with psychosis usually start in late adolescence and early adulthood. The voices heard in non-clinical groups are also much more likely to be positive and helpful than those experienced by people with psychosis, but it’s not clear why. For many non-clinical voice-hearers, the voice they experience is very important to them. It may provide support and guidance, or have a spiritual aspect.

There is also evidence of subtle cognitive differences between clinical and non-clinical voice-hearers. For example, voice-hearers with psychosis sometimes have difficulty with managing their attention when listening to external sounds. In contrast, a recent study by researchers in Norway suggested that voice-hearers without psychosis don’t appear to have that problem. Voice-hearers with psychosis are also more likely to use an atypical network of brain areas for language, whereas non-clinical voice-hearers seem to show more typical patterns of language functioning.

Knowing more about how voice-hearing develops, especially after being experienced for the first time, is vital to provide better care for those who seek help. Identifying some of the cognitive differences between clinical and non-clinical voice-hearing could also provide clues about the kind of skills you might need to manage voices and make them less disruptive – the protective factors that allow people to hear a voice but carry on with their lives.

Voice-hearing might be a distressing experience for many, but it doesn’t have to be. Another 10 years of research with non-clinical voice-hearers will allow us to understand how and why that’s possible.

This article was originally published here in the Guardian’s ‘Notes and Theories’ science blog on Wednesday 13 August 2014.

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‘Telling the Real from the Unreal’ by Charles Fernyhough

In his blog ‘The Voices Within’ for Psychology Today, our project director Charles Fernyhough writes:

800px-White-noise

A plot of normally distributed white noise. Source: Wikipedia

A person hears a voice in the absence of any speaker. Did the utterance really happen, or was it an internally generated event that somehow got mistaken for something that happened out there in the world? The idea that voice-hearing relates to how people draw the line between imagination and reality has been well supported by scientific research. People who experience auditory hallucinations tend to make more mistakes on tasks that require them to state whether an event really happened or whether they just imagined it. In one widely used task, participants listen to blocks of white noise, some of which have snippets of speech embedded in them. The volunteers have to say whether or not a block contained some speech. Several studies have shown that people who are prone to auditory hallucinations are more prone to making false alarms on this task: In other words, they say that speech was there when it wasn’t really. It’s as if they are more likely to say “Yes, I heard the speech” when actually they had just imagined it.

In a new study1, my PhD student David Smailes was intrigued by the finding that negative emotions precede voices for some voice-hearers. David explains: “My interest in the link between emotion and psychotic experiences comes, in part, from the work of people like Daniel Freeman and Philippa Garety, who have suggested that emotions might be more important in the development of psychosis than we had previously thought. Looking at that link is potentially one way of understanding how and why psychotic experiences fluctuate–for example, why a person hears voices, or experiences paranoid thoughts, at some times, but not others.”

Is there any evidence that voices and emotions are linked like this? David goes on: “Several studies (like this one and this one) involving people who hear voices suggest that some kind of negative emotion often precedes the onset of voice-hearing in people’s day-to-day lives, with anxiety perhaps playing the most important role. If reality discrimination is as important as we think it is in understanding why a person hears voices, then one possibility is that negative emotions predispose a person to hear voices by weakening their reality discrimination abilities.”

David’s study didn’t focus on voice-hearers, but rather ordinary university undergraduates. He wondered whether, if you could change people’s emotions through a mood induction (manipulating people’s mood artificially), you could affect how likely they were to make reality discrimination errors on the white noise task. “We created a neutral mood or a negative mood in participants by asking them to recall and write about a neutral memory, or a negative memory. We found that participants who completed a reality discrimination task after recalling a negative memory confused internal, mental events for external, ‘real’ events more often than did participants who completed the task after recalling a neutral memory.” Two other recent studies (this one and this one) have reported similar findings.

One obvious limitation to the study is that it only looked at university students, who aren’t very representative of the general population. And these processes might work differently in people who hear voices, especially those with psychiatric diagnoses. Addressing these concerns is part of David’s ongoing research plans: “It would be really helpful to know whether we can replicate our finding in a sample of people who hear voices, and that is something we are planning to do in the near future.”

What about implications for people who are distressed by the voices they hear? David thinks there could be several. “If we can show that negative emotions weaken reality discrimination in people who hear voices, one implication is that interventions (such as this one) that aim to improve voice-hearers’ reality discrimination abilities should focus on improving voice-hearers’ emotion regulation skills, as well as their cognitive skills.”

All of this work is being conducted within a cognitive model of voice-hearing in which it is useful to think about the distinction between reality and imagination. Many voice-hearers find their voices positive, if not merely neutral, and would strongly reject the idea that their experiences are ‘unreal’. Voice-hearers’ experiences are very real, and often very meaningful. Asking questions like this isn’t about trying to explain these mysterious experiences away, but rather to delve deeper into the psychological and neural processes that underlie them.

1 Smailes, D., Meins, E., and Fernyhough, C. (2014). The impact of negative affect on reality discrimination. Journal of Behavior Therapy and Experimental Psychiatry, 45, 389-395. (You can read the full text of the article here.)

 

 

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