The Pathogenesis
of Auditory Verbal
Hallucinations in
Schizophrenia:
A Clinical–
Phenomenological
Account
Abstract: Although hallucinations are among the
most studied psychiatric symptoms, their pathogenesis
remains largely unknown and their experiential com-
plexities are rarely accounted for. In schizophrenia,
auditory verbal hallucinations are by far the most
frequently reported type of hallucination. In this study,
we explore verbal hallucinations in schizophrenia
and we argue that these are best understood not as
abnormal perceptions, but as cognitive phenomena
arising from a partial dissolution of certain structures
of self-consciousness. Consistent with recent empirical
and conceptual studies in phenomenological psychia-
try, we claim that specific alterations of self-awareness
tend to precede the emergence of verbal hallucinations
in schizophrenia. We illustrate these altered states of
self-awareness in three detailed case vignettes of hallu-
cinating schizophrenia spectrum patients. We propose a
clinical–phenomenological account of the pathogenesis
of verbal hallucinations in schizophrenia, suggesting
that pathological changes in the experience of space
and morbid objectification of inner speech may lead to
crystalized verbal hallucinations.
Keywords: auditory verbal hallucinations, pathogen-
esis, schizophrenia, self-disorders, phenomenology
© 2016 by The Johns Hopkins University Press
Mads Gram Henriksen,
Andrea Raballo and
Josef Parnas
A
uditory verbal hallucinations
(AVHs) form an essential criterial feature
in the schizophrenia definition in the Diag-
nostic and Statistical Manual of Mental Disorders
(DSM)-IV (American Psychiatric Association
1994) and International Classification of Diseases
(ICD)-10 (World Health Organization 1992). In
both classificatory systems, the presence of a hal-
lucinatory voice that continuously comments the
patient’s behavior or thoughts, or the presence of
several voices that discuss the patient with each
other, is a sufficient criterion to diagnose schizo-
phrenia (if the duration criterion is fulfilled and
the exclusion criteria are not). The DSM-IV defines
a hallucination as “a sensory perception that has
the compelling sense of reality of a true percep-
tion but that occurs without external stimulation
of the relevant sensory organ” (American Psychi-
atric Association 1994). This definition is largely
consistent with the traditional definition of hallu-
cinations as perceptions without external stimuli,
which basically has remained unchanged in the
166  ■  PPP / Vol. 22, No. 3 / September 2015
history of psychiatry since Esquirol introduced the
term hallucination in 1817 (Berrios 1996, 37f.).
Despite the definition’s long endurance, it has been
widely criticized (Behrendt 1998; Leudar et al.
1997; Liester 1998; Lothane 1982; Stanghellini
and Cutting 2003)—not least because it presup-
poses, as Esquirol explicitly did (1838, 200f.), that
all hallucinatory experiences, independent of the
sense modality involved, are somehow uniform
and conceivable in the light of one specific type of
hallucination, namely that occurring in the visual
modality. Although hallucinations may occur in
all sense modalities in schizophrenia, patients most
frequently report auditory hallucinations and only
to a lesser extent visual and tactile hallucinations
(Baethge et al. 2005). Besides the debatable views
of uniformity and of the primacy of vision, there
are other problems with the definition. First, it is
simply not correct that hallucinations necessarily
occur without stimuli—often they have certain
experiential precursors (as we will show in this
article) and they may also be triggered by stimuli
from sense modalities not involved in the actual
hallucination (the so-called reflex hallucinations).
Second, obviously there are similarities between
perceptions and hallucinations, but there are also
important differences. For example, perceptions
are usually experienced actively in the sense that
they are controlled by a goal-directed or willed
attention and they occur in the public domain.
Moreover, they involve the integration of multiple
sense modalities and they are closely dependent on
a sensory motor reciprocity within the physical
space (e.g., the intensity of a sound is affected by
moving toward or away from its source or by the
interposition of barriers). In contrast, hallucina-
tions are typically experienced more passively (i.e.,
the patient does not control them), they usually
involve only a single sense modality, and they are
often experienced as intrinsically private. In other
words, hallucinations do usually not conform
to the physical constraints of the peri-personal,
sensorial space, but are rather ‘superimposed’ on
it (e.g., hallucinatory voices are ubiquitous and
unrestrained by physical barriers that would at-
tenuate sounds; Merleau-Ponty 2002, 395; Larøi
et al. 2010). From a phenomenological perspec-
tive, AVHs in schizophrenia are not primarily
sensory–perceptual but rather cognitive phenom-
ena arising from a partial dissolution of certain
structures of self-consciousness (Ey 1973; Sass
and Parnas 2003). The reason for voicing these
concerns is not merely a definitional matter (i.e.,
of having a more appropriate nosological descrip-
tion), but relates to the fact that research into the
pathogenesis of AVH in schizophrenia is likely to
be misleading, even flawed, as long as these are
defined as abnormal perceptions, which implicitly
facilitates a search for causes in terms of errors in
the processing of external sensory stimuli (Larøi
et al. 2010; Stanghellini and Cutting 2003).
During the last decades, attempts have been
made to redefine AVHs as disorders of self-con-
sciousness, and more specifically to explain their
pathogenesis by referring to the occurrence of cer-
tain altered states of self-awareness that frequently
precede the emergence of AVHs in schizophrenia
(Ey 1973; Naudin 1997; Naudin and Azorin 1997;
Sass 1992, 231-235; Tatossian 2007). Our article
complements phenomenological studies (Larøi et
al. 2010; Raballo and Larøi 2011; Sass and Parnas
2003; Stanghellini and Cutting 2003), which so
far have been quite theoretical, dense, and limited
with regard to clinical descriptions. Although these
studies have provided seemingly different explana-
tions to the explanandum (AVHs), for example,
‘hyperreflexivity’ (Sass 1992), ‘ipseity disturbance’
(Sass and Parnas 2003), and ‘morbid objectifica-
tion of inner dialogue’ (Stanghellini and Cutting
2003), these explanations are not really competing
or incompatible, but merely highlighting different
aspects of the same underlying experiential trans-
formation. The aim of our article is to further elu-
cidate the pathogenesis of AVHs in schizophrenia
by providing detailed clinical descriptions of the
altered states of self-awareness and their cohe-
sion, which will enable us to qualify, refine, and
clinically ground the existing phenomenological
accounts of AVHs. More generally, our intention is
to familiarize the clinician with these altered states
of self-awareness that often precede the formation
of AVHs and other psychotic symptoms in schizo-
phrenia, thereby enriching the psychopathological
resources to recognize impending psychotic states
before their full-blown manifestation.
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 167
The Phenomenological
Architecture of AVHs in
Schizophrenia
When referring to verbal hallucinations in
schizophrenia, there is an implicit tendency to
understand them as univocal and quite well-
defined phenomena. From a phenomenological
or clinical perspective, hallucinatory voices are
not just ‘voices.’ Rather, they form a wide and
heterogeneous group of phenomena marked by
multiplicity of manifestations, for example, with
regard to their clarity (ranging from murmur to
voices), volume (from whispering to shouting),
linguistics (they can be only words, sentences, or
full dialogues), content (which often is demeaning,
humiliating, or threatening), and form of address
(where running commentary or arguing voices are
particularly important in schizophrenia). In addi-
tion, they may vary with respect to their location
(i.e., they can be experienced as located within
the patient’s interior psychic space or as located
externally) and degree of insight (patients may
recognize the hallucinations as abnormal)—these
two aspects in particular have influenced the clini-
cally and theoretically dubious distinction between
hallucinations and pseudohallucinations (Berrios
1996, 49-59; Berrios and Dening 1996), where the
latter often is taken to mean either hallucinations
with insight or vivid internal imaginary (Taylor
1981). For example, when a chronic schizophre-
nia patient from time to time becomes aware of
the fact that she is hallucinating, this insight into
illness does not necessarily alter the phenomenal
quality of her AVHs in any significant way. Besides
varying along these lines, a closer exploration of
what patients refer to as ‘hearing voices’ further
blurs the picture, for example, patients will often
say that the hallucinatory voices do not neces-
sarily have a clear acoustic or auditory quality,
and they hardly ever say that they hear the voices
through their ears. In contrast, when asked to
further describe their hallucinatory voices, some
of our patients said: “often, I cannot tell if I have a
thought, if it’s the voice, or if it’s a feeling I have,”
“the voice seems partly real, but at the same time
distorted. It can also appear as a face or a text. I
cannot really describe the sound,” or “before the
voices appeared, I had a tinnitus-like whistling
like a beeping sound from a television. Then I
got the impression of hearing somebody talking
about me. Now, the voices are like a murmur
in the background.” Similarly, one of Bleuler’s
patients described the indistinct auditory quality
of his ‘voices’ in the following way: “The voices
are unlike spoken voices but are as if thought”
(Bleuler 1950, 114). In our view, hallucinatory
voices seem to be given to patients in a sort of
direct inner intuition (Anschauung) rather than in
a sensory perception (Sinneswahrnehmung)—or,
quoting Sass, “as if heard with the mind rather
than the ear” (1992, 233).
Additionally, it is important to note that pa-
tients rarely seem to mistake their hallucinatory
voices for real voices in the external world. For
example, Zucker (1928) found that hallucinating
patients that were presented with a real analogue
of their hallucinatory experience (created by the
experimenters) were able to distinguish the hal-
lucinatory experience from the real perception
and identify which one was real. Comparably,
Aggernæs (1972) examined seven pairs of ‘real-
ity qualities’ (sensation vs. ideation, behavioral
relevance vs. irrelevance, publicness vs. private-
ness, objectivity vs. subjectivity, existence vs. non-
existence, involuntary vs. voluntary, independence
vs. dependence) in 45 hallucinations (41 auditory
[39 verbal], 3 visual, and 1 tactile) in 41 chronic
schizophrenia patients. Although he found that
most hallucinations resembled normal percep-
tions with regard to 6 of the 7 reality qualities,
the crucial quality of publicness was negative in
30 of 45 hallucinations (Aggernæs 1972). These
studies seem to suggest that the majority of verbal
hallucinations are experienced as private and inac-
cessible to others, that is, that patients with schizo-
phrenia rarely mistake their hallucinatory voices
for voices that are ‘real’ in the sense of existing in
the intersubjective space. Consequently, we find
the predominant cognitivist conception of AVHs
as errors of source or reality monitoring debatable
(Bentall and Slade 1985; Garrett and Silva 2003;
Morrison and Haddock 1997), because it seems
to presuppose that patients believe that their hal-
lucinatory voices are real. In other words, we are
skeptical about some of the underlying presump-
168  ■  PPP / Vol. 22, No. 3 / September 2015
tions, for example, that a propositional belief
about the reality status of the hallucination neces-
sarily is involved in the experience, that ‘voices’
constitute a quite univocal phenomenon, and that
mistaking ‘voices’ for real is at all essential to the
hallucinatory experience. The French phenom-
enologist, Merleau-Ponty, argued against related
positions in his seminal book Phenomenology of
Perception: “But in fact the insane do not believe
they see, or, when questioned, they correct their
statements on this point. A hallucination is not a
judgment or a rash belief, for the same reasons
which prevent it from being a sensory content: the
judgment or the belief could consist only in posit-
ing the hallucination as true, and this is precisely
what the patients do not do” (2002, 390; author’s
italics). In our view, Merleau-Ponty’s account is
too radical, because some patients report that
they at some point in the course of illness were
confused about the ‘voice’s’ status of reality (e.g.,
patients sometimes say that when the ‘voice’ first
appeared, they turned around to see if someone
was standing there or that they once asked their
intimates if they could hear someone talking
about them). Other cognitivist accounts of AVHs
are more consistent with the phenomenological
conception of these phenomena as involving a
disturbance of intentionality (Hoffman 1986)
and being preceded by certain deformations of
self-awareness (Frith 1979).
Experiential Precursors to
AVHs
In this section, we present a different account
of AVHs in schizophrenia, one that focuses on
experiential precursors to fully formed AVHs,
namely, schizophrenia-specific alterations of self-
awareness and disorders of cognition, rather than
beliefs and failures of reality testing. We suggest
that, although the preceding pathological process
may vary, certain deformations of self-awareness
and cognition are constitutive for the restructuring
of self-consciousness in the prodromal phase of
schizophrenia and for the subsequent formation
of AVHs. We present detailed clinical material of
these alterations shortly, but in advance just note
that what seems to underlie their various manifes-
tations is the presence of a pervasive experiential
distance or dissociation between the sense of
self (ipseity) and the flow of consciousness. This
experiential distance tears apart or disunites the
normally unbreakable unity of the experiencing
self and its thinking and brings along disturbing
forms of defamiliarization and self-alienation,
which potentially affect all modalities of con-
sciousness and threatens to fragment the self from
within. What seems to be essential to auditory
hallucinatory experiences are, in our view, not
really their acoustic or auditory properties, but
rather that the experiential distance in this case
has brought about pathological changes in the
experience of space and an incipient morbid au-
tomation and objectification of inner speech. Both
aspects are examined carefully and illustrated with
quotes and vignettes from schizophrenia spectrum
patients describing non-psychotic alterations of
self-awareness and cognition.
The basic idea that certain deformations of self-
awareness are core features of schizophrenia was a
view shared by many classical psychopathologists
(Berze 1914; Berze and Gruhle 1929; Blankenburg
1971; Bleuler 1911/1950; Conrad 1959; Kraepe-
lin 1913; Minkowski 1927; Schneider 1950; Ey
1973). For example, Ey wrote: “depersonalization
is the negative primary disorder [le trouble négatif
primordial] of the whole hallucinatory experi-
ence. And in this sense it corresponds to the first
manifestation of the destructuration of the field of
consciousness” (1973, 298; our translation). What
is meant here with “destructuration” of the field
of consciousness is a decomposition of the normal
structures of experiencing, which primordially af-
fects the phenomenal character of the experience
itself, that is, the evidentness of lived experience
in the very actuality of its manifestation to the
experiencing subject (Parnas and Sass 2010).
During the last 25 years, the search for schizo-
phrenia specific alterations of self-awareness has
been systematically incorporated into clinical
research programs aiming at identifying and de-
tecting non-psychotic alterations of self-conscious-
ness in schizophrenia—the most distinguished
psychometric assessment instruments to detect
these alterations are the BSABS (Bonn Scale for
the Assessment of Basic Symptoms; Gross et al.
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 169
1987), EASE (Examination of Anomalous Self-
Experience; Parnas et al. 2005a), and SPI (Schizo-
phrenia Proneness Instrument; Schultze-Lutter et
al. 2007). Empirical studies founded on the BSABS
have documented transitional sequences from non-
psychotic disorders of cognition and stream of
consciousness (the so-called ‘basic symptoms’) to
florid Schneiderian first-rank symptoms, and they
found that of particular importance were thought
pressure, thought interference, and obsessive-
like perseveration (Klosterkötter 1988, 1992;
Klosterkötter et al. 2001). The majority of schizo-
phrenia spectrum patients, who later develop
hallucinatory voices, report these self-perceived,
non-psychotic changes in the prodromal phase.
It seems, therefore, reasonable to have a closer
look at how patients experience these phenomena,
which are often accompanied by a panoply of
other disturbances involving other domains such
as self-presence, bodily experiences, and demarca-
tion problems. We are aware of the risk that the
following clinical descriptions of certain anoma-
lous self-experiences (or ‘self-disorders’) might
be interpreted as either strictly necessary for the
subsequent formation of verbal hallucinations or
as reified, independent symptoms merely occurring
together. Initially, we therefore warn against such
interpretations. Our aim is not to overly emphasize
certain self-disorders or infuse the selected ones
with strong pathogenetic value at the expense
of others that might be virtually as relevant, but
to portray a self-constellation or, we could say,
a structure of self-consciousness vulnerable to
schizophrenia and the emergence of AVHs. Despite
the fact that these anomalous self-experiences tend
to persist, the self-constellation is to some extent
dynamic in the sense that, even though there seems
to be a baseline of trait-like self-disorders, these
may, as in any other psychiatric symptomatology,
fluctuate in terms of intensity, while other anoma-
lies may appear or disappear dependent on, for
example, situational stressors and life events. We
agree with Parnas and Sass (2008, 268f.), when
they claim that these anomalous self-experiences
reflect a primary ipseity disturbance that not only
prefigures the positive and negative symptoms that
may emerge but also elicits some rather automatic
consequences (e.g., non-volitional hyperreflection
or attentional disturbances) and evokes certain
compensatory responses (e.g., introspective scru-
tinizing to reassert a feeling of control). These
consequential and responsive outcomes of the
ipseity disturbances can, as indicated in the follow-
ing vignettes, contribute to the ways in which the
diachronic pathogenetic pathways are played out
in schizophrenia, for example, by increasing the
sense of self-alienation, the feeling of disembodi-
ment, and the fragmentation of meaning.
Case Vignettes
In this section, we present vignettes of clusters
of anomalies of self-experience reported by three
schizophrenia spectrum patients. The vignettes
were retrieved from first-admitted patients hos-
pitalized at the Psychiatric Center Hvidovre dur-
ing the clinical field test of a novel psychometric
instrument for the examination of anomalous
self-experience, namely, the EASE scale (Parnas
et al. 2005a). All patients were recruited upon
informed consent. The patients portrayed in the
vignettes exemplify typical cases of referrals to
public mental health setting. In this sense, they
do not display any extraordinary or unusual
psychopathology, but exemplify the combination
of behavioral and experiential phenomena that
subtend some prototypical presentations of clinical
schizophrenia spectrum conditions.
Case 1
Hanna, 29, describes persistent thought pres-
sure disabling her from having any peace of
mind—“it feels as if my head is exploding, like a
pressure boiler with the lid blowing off.” Thoughts
may come so rapidly that she does not have time
to “think them through,” and the content of these
thoughts is often totally disconnected from the
context of her main line of thoughts. Although she
clearly recognizes these thoughts as her own, she
still conceives them as “strange and impersonal,”
primarily because she lacks control of them. She
reports that her thoughts, besides being spoken
aloud internally by her own voice, also occur in
moving images—“like an inner movie.” She de-
scribes that this inner movie always runs and that
her main line of thoughts and the imaged thoughts
170  ■  PPP / Vol. 22, No. 3 / September 2015
expressed in the inner movie not necessarily cor-
respond, and that she therefore may have two dif-
ferent lines of thoughts occurring simultaneously.
When she closes her eyes, the images in the inner
movie often become macabre, for example, she
often sees children screaming. Despite its pictorial
content, this pseudo-obsession occurs with only
minimal resistance and it does not really provoke
anxiety. Rather, she describes that the macabre
images are somehow intertwined with a feeling
that she is supposed to help someone and this co-
incides with her general attitude—“I feel that I am
brought into this world to help others.” Moreover,
she frequently experiences that she cannot express
her thoughts, that is, that her expressions do not
correspond with what she wanted to express—“it’s
as if my brain and mouth are disconnected.” She
claims that the alterations of cognition described
are the source of her long-lasting concentration
difficulties and that since her teens she regularly
has inflicted pain on herself (cutting) to dampen
her thoughts and gain a moment of inner peace.
Moreover, the patient reports multiple self-
disorders in the domain of self-awareness and that
of existential reorientation, scoring 20 EASE items
in total. She has negative symptoms, vague delu-
sions, and a hallucinatory voice that constantly
comments her thoughts and actions—fulfilling the
criteria for paranoid schizophrenia. With regard
to the male voice she hears, she may sometimes
argue with it aloud or try to provoke it, and she is
sometimes able to spatially locate this voice to the
right side of her head, whereas her own thoughts
are located to the left.
Case 2
David, 29, reports that he already from child-
hood felt different from others, “robot-like” as
he puts it, and he often doubted “if others have a
soul or any feelings.” He does not know who he
is, and he can feel that his identity is dissolving.
He describes a worsening at the time of puberty. It
started, he explains, when he began to analyze all
kinds of words, which caused not only the mean-
ing of these words, but “every meaning to float
until nothing made sense.” He felt apathetic and
distanced from the world and others—“as if I was
living inside a glass case or bubble.” For years, he
has been living inside this bubble and regularly it
gets, as he puts it, “so foggy that I lose contact
with the outside world.” In these situations, he
is unable to communicate with others, but more
generally he also finds that his native language is
not sufficiently precise to express his experiences.
Therefore, he considers learning Latin, because he
at one point was told that it is the most precise
language in the world. Moreover, he is able to
spatially locate his thoughts inside the bubble and
he is “almost able to see” his thoughts, which he
reports appear like on a filmstrip. He describes
a peculiar distance to his own thoughts—“they
are my thoughts but not me,” which he further
explains with an analogy: “it’s like when I put
on my jacket. It’s my jacket, but it’s not me.” He
experiences thought blockage, which he describes
as “a kind of paralysis or feeling of emptiness” or
“a shrieking emptiness or silence,” and intrusive
forms of derealization.
In addition, the patient reports self-disorders in
the remaining EASE domains, most pronounced
are passivity phenomena, Weltuntergangsstim-
mung, transitivistic experiences, primary self-refer-
ence, and solipsistic grandiosity. In total, he scored
27 EASE items dispersed over all five domains. In
addition, he has hallucinatory voices commenting
on his behavior, and bizarre, religious, and perse-
cutory delusions. He was diagnosed with paranoid
schizophrenia.
Case 3
John, 30, fears that his “brain might burn out”
and that he regularly feels a “sort of pressure on
the brain”—“I experience a murmur inside the
head. It’s as if I am standing in a field in stormy
weather listening to the wind. It feels as if wind
is blowing directly on my brain.” This experience
is usually accompanied by a complete empti-
ness of thoughts, and in such situations, he can
transiently experience a disruption of normally
automatic movements. For example, he may find
it difficult to walk because, as he puts it, “when I
expect to move the left foot, the body moves the
right foot.” When he hears the murmur or wind
blowing on his brain, it captivates his attention
and everything else recedes into the background.
He describes it as a vacuum-like state in which
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 171
all his thoughts and feelings are subdued and he
experiences a distinct lack of resonance and spon-
taneous engagement with the world to the extent
that “it feels unreal” and he feels “like a specta-
tor” watching the world from afar. In addition, he
experiences silent thought echo (i.e., his thoughts
are automatically repeated), perceptualization of
thoughts (i.e., some thoughts occur in the form of
images), and pictorial pseudo-obsessions with a
content that is directly violent or sexually perverse.
He reports that these pseudo-obsessions, which he
feels compelled to live through, tend to start from
contextually disconnected thoughts that interfere
with his main line of thoughts, and owing to their
bizarre content, he feels that he does not really
produce them, but rather witnesses them. Com-
parably, he has the impression as if he is divided
into two parts, a good and a bad part, where he
lacks control of the latter. This contributes to his
pervasive lack of identity, which involves dissocia-
tive depersonalization (sometimes he feels as if he
is observing himself from outside) and identity
confusion. With regard to mirror phenomena,
he reports that he used to stare intensely into the
mirror until his face changed and he was unable to
recognize it. Recently, however, he was involved in
an accident in which he got facial scars, and since
then he rarely looks into the mirror. Instead, he
has a photo of himself from before the accident,
which he then scrutinizes.
In total, he scored 30 EASE items shared among
all five domains. He has poor rapport with oth-
ers and isolation, pseudo-obsessions, perceptual
disturbances, and micro-psychoses (fleeting AVHs
and vague persecutory delusions)—fulfilling the
criteria for schizotypal personality disorder.
Transition from
Non-Psychotic Anomalies
of Experience to Florid
Hallucinations
The three case vignettes describe a multiplic-
ity of alterations of cognition and self-awareness
that illuminate core features of a self-constellation
prone to schizophrenia. All patients reported first-
rank verbal hallucinations, although of varying
intensity and duration. From our perspective,
AVHs in schizophrenia emerge from a partial
dissolution of the structures of self-consciousness,
which, as shown in the vignettes, entails a panoply
of different disturbances of cognition and self-
awareness that are not to be conceived as inde-
pendent symptoms, but rather as interdependent
and mutually implicative aspects of the same psy-
chopathological Gestalt. For this reason, it seems
dubious to account for the pathogenesis of AVHs
by systematically listing these disturbances and
forming assumptions about their possible causal
relations. Still, this does not imply that all efforts
to understand the transition from these early, non-
psychotic anomalies of self-experience to florid
psychosis are in vain. A famous phenomenological
study aiming at establishing such an understand-
ing is found within the so-called basic symptom
approach. A brief recollection of this study and
its main results seems appropriate.
In a study of 121 patients with paranoid schizo-
phrenia, Klosterkötter (1992) examined by means
of the BSABS the transitional sequences from basic
to first-rank symptoms. At the onset of 48 symp-
tom sequences ending in AVHs, cognitive deficits
such as thought pressure, thought inference,
thought blockage, obsessive-like perseveration,
and decreased abilities to discriminate between
thought and perception were found to be signifi-
cant. He explained the transition in the three steps
(Klosterkötter 1992, 618-621): First, the presence
of these cognitive deficits and the inherent loss of
cognitive control caused incessant thought infer-
ence and blockage. The combination of increasing
thought pressure and a decreasing ability to dis-
criminate thoughts from internal auditory images
led the patients to the experience of not really
knowing if they, so to say, thought their thoughts
or listened to them inside their own head. Second,
patients began hearing their pressing thoughts
spoken aloud with their own voice internally,
and these thoughts included self-instructions,
self-commands, and self-conversations. It became
increasingly difficult to discriminate between inner
auditory images and outer acoustic perceptions,
and the louder the thoughts became, the more it
seemed as if they were spoken by external voices.
Third, the leap into frank first-rank verbal hallu-
cinations was marked by a loss of feeling that the
172  ■  PPP / Vol. 22, No. 3 / September 2015
heard thoughts belonged to the listening subject.
The former inner self-instructions turned into
external alien commands, the self-comments into
external alien remarks on behavior or thoughts,
and the self-conversations into a dialogue between
external alien voices.
This model is plausible clinically and the ini-
tial cognitive disturbances identified in his study
are also well-reflected in the patient vignettes we
have presented. Nonetheless, the main focus on
subjective disorders of cognition in the transitional
sequences might result in a too restrictive outlook
at the premorbid and prodromal experiential
changes. In our view, subjective disorders of cogni-
tion are just one (although perhaps one of the most
recurrent in clinical settings) of the possible expres-
sions of the manifold alteration of self-awareness
that occur in schizophrenia spectrum conditions
and which may contribute to the development of
AVHs. In this sense, the transitional sequences
from cognitive-perceptual basic symptoms detailed
by Klosterkötter might be reconceived in a broader
phenomenological framework.
As already noted, we propose that pathological
changes in the experience of space and an incipient
morbid objectification of inner speech are essential
to the formation of AVHs. To substantiate this
claim, we first clarify exactly what we mean with
“space” and then account for the pathological
changes occurring in latent schizophrenia. On this
basis, we elucidate the morbid objectification and
automation of inner speech. These two features
(i.e., the pathological changes in the experience
of space and the morbid objectification of inner
speech) are mutually interdependent and result
from a disturbance of what we call ‘primordial
presence.’
Pathological Changes in the
Experience of Space
When trying to articulate what we normally
mean with “space,” one may be tempted to use the
metaphor of an infinite container. Such an under-
standing of space seems largely comparable with
the three-dimensional Euclidian space known from
geometry. However, phenomenologists argue that
our primordial relation to space is not geometrical
in nature and that mathematical spaces (Euclidian
as well as non-Euclidean) only are possible on the
basis of the “life-world” (Husserl 1970) or “lived
space” (Ströker 1987), that is, the spatiality that
is given and pre-reflectively experienced in our
daily, pre-scientific life. We do not provide an ex-
haustive account of the phenomenology of space,
but only highlight three key points crucial to our
subsequent analysis of the pathological changes
in the experience of space in schizophrenia. First,
phenomenological analyses of perception stress
that all spatial objects appear in a perspectival
way, that is, they never appear in their totality,
but always in a certain profile, that is, from a
specific angle and distance (e.g., we cannot see
the rear of a tree, but if we move around it, we
can see another front). This perspectival incom-
pleteness is characteristic of spatial objects and it
implies that all appearances involve not only an
appearing object but also a subject for whom the
object appears. Second, the experiencing subject
is not conceived as a world-less entity (existing
initially by itself only later to relate to the world),
but as world-constituting (Husserl 1983, 109-12;
Merleau-Ponty 2002, 499f.). Thus, the subject is
not merely “in” space like the match is “inside”
the matchbox. Rather, the idea is that the subject’s
spatiality enables perceptual objects to appear in
their spatiality. For example, Heidegger argued
that spatial objects appear in a specific profile,
because the subject already has a certain direction
(Ausrichtung) or orientating in the world (the
window is to my left, but if I turn around, it is to
my right), thereby bringing relevant objects into its
own proximity (the man struggling to remain on
his feet in stormy weather is closer to me than the
window through which I perceive him or the floor
on which I stand; 2007, 135-48). He suggested
that the subject’s spatiality (Raumlichkeit) consists
in “giving space” (Raum-geben) and “making
room” (Einräumen) by which he emphasized
that our primordial experience of space and spa-
tial objects quintessentially is determined by our
involvements and orientation in the shared world
(Heidegger 2007, 146). Third, although Heidegger
argued for the primacy of what we might call the
space of action over that of plain sensory percep-
tion, other phenomenologists have, in our view,
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 173
rightfully criticized him for leaving out of account
the most basal relation to space, namely, that
constituted by corporeality (e.g., Merleau-Ponty
2002, 192). Already Husserl argued that cor-
poreality makes perceptual experiences possible
(1989, 61), that is, perceptions presuppose and
co-occur with a form of bodily self-awareness,
which he also referred to as “kinaesthetic sen-
sations” (Husserl 1997). This idea of the lived
body (Leib) is closely related to his notion of
“operative intentionality” (i.e., a non-objectifying,
non-propositional, and ante-predicative form of
intentionality encompassing, e.g., desires, affects,
and passive syntheses), which is distinguishable
from “act intentionality” (articulating that the
majority of conscious experiences are directed
toward an intentional object, e.g., the book in
front of me). Operative intentionality functions
as a tacit, pre-reflective background organization
of the field of consciousness. Following Husserl
(1973), Merleau-Ponty argued that act intentional-
ity is grounded in operative intentionality and that
the latter constitutes our primary relation to the
world (2002, 498), which he described as a pri-
mordial “inalienable presence” (2002, vii). Ströker
suggested something similar when proposing that
“attuned space” forms our basic, pre-reflective
orientation in the world, that is, “an immediate
affinity with the world” (1987, 20). In our view,
the pathological changes in the experience of space
in schizophrenia result from disturbances or insta-
bilities in the most fundamental relation to space,
namely, the primordial presence in the world. In
schizophrenia spectrum disorders, this primordial
presence is not as “inalienable” as Merleau-Ponty
seemed to suggest.
The concept of primordial presence signifies
that our pre-reflective immersion in the world and
pre-reflective sense of self are, in fact, inseparable:
“At the heart of the subject himself we discov-
ered, then, the presence of the world” (Merleau-
Ponty 2002, 498). Primordial presence may be
described as a basic, pre-reflective self-awareness
(ipseity) that renders everything I experience as
my experiences, that is, it makes me implicitly
aware that I am the one who perceives, thinks,
imagines, and so on. All experiences are given to
me from within my first-person perspective, and
consequently there is no distance between me and
my thoughts, feelings, and corporeality. Moreover,
primordial presence as this form of minimal,
pre-reflective self-identity encompasses a normal
sense of vitality and agency, a continual unity in
the ever-changing stream of consciousness, and
a definite feeling that one’s own conscious life is
private and clearly demarcated from the world
and others. Some of the earliest and most alarming
subjective experiences of beginning schizophre-
nia involve disturbances of primordial presence,
which hinder patients from being spontaneously
immersed in the world. Some patients specifically
complain about a compromised phenomenality
of experience when describing that they don’t feel
fully present—“I feel a sort of emptiness in my
head as if I am not awake. I feel detached or airy
as if I am not present. It’s like having a cold, as if
my head is stuffed with cotton.” David described
persistent experiences of diminished presence and
the associated distance to the shared world, when
stating that he for years has been “living inside a
glass bubble,” which regularly gets “so foggy”
that he loses “contact with the outside world.”
Comparably, John described a “vacuum-like
state” in which all his thoughts and feelings were
subdued and he experienced a distinct lack of
resonance with the world, which he then felt as
“unreal” and himself “like a spectator” watching
the world. It was in the midst of this emptiness
that the hallucinatory voice surfaced, initially as a
murmur inside his head as if he was “standing in
a field in stormy weather listening to the wind.”
Others patients who experience disturbances
of primordial presence report that the normally
implicit sense of being a self no longer saturates
their experiences—“I feel caught off guard. As
if the thoughts aren’t really coming from me. If
they were my thoughts, I would be able to control
them and I would not think them.” These experi-
ences often involve a disturbing feeling of being
radically different from others—“robot-like” (as
David put it) or, as some of our other patients put
it, “I feel like I don’t belong here,” “I feel like an
alien,” and “I cannot find myself” (cf. Parnas and
Henriksen 2014, 253).
Additionally, diminished presence is associated
frequently with abnormalities in the normal sense
174  ■  PPP / Vol. 22, No. 3 / September 2015
of embodiment (e.g., “the body feels awkward as
if it doesn’t really fit,” “it feels like the body isn’t
really me, as if it is rather a machine controlled
by my brain, as if the body is a mere appendage,”
and “the body feels alien as if it doesn’t belong
to me. There’s no connection between my mind
and my body. I might as well have been a dog”).
Fuchs (2005) has described the “disembodiment
of the self” that frequently occurs in schizophrenia
conditions and has argued that in such cases the
patients no longer inhabit their body in the normal
sense, but that they due to the psycho-psychical
split, which results from the loss of basic self-
awareness (ipseity), may come to experience their
body as a sort of machine potentially steered by
external forces. Similarly, Stanghellini spoke of
“deanimated bodies” in schizophrenia, that is,
a kind of mechanization or objectification of the
lived body, stemming from a lack of presence and
sensory self-consciousness (2004, 127ff., 153ff.).
A core aspect of the disturbances of primordial
presence is, we argue, pathological changes in the
experience of space. More specifically, the distur-
bance or discontinuation of primordial presence
enables a construction of a sort of persistent, inner
space that continuously articulates itself, thereby
allowing schizophrenia patients to experience their
own interiority as a space and their thoughts and
feelings with spatial qualities. David, for example,
can locate his thoughts spatially inside the glass
bubble and almost see his thoughts, and Hanna
sees some of her thoughts in an on-going inner
movie. Other patients can locate their thoughts
spatially to one side of the brain or describe how
certain thoughts move from the neck to the fore-
head, and so on. Often, the hallucinatory voice has
a different location than the thoughts they consider
their own. John described that he does not feel like
he produces the pictorial pseudo-obsessions with
bizarre content, but that he rather witnesses them.
Furthermore, Hanna and David heard their own
thoughts spoken aloud internally. Normally, we
do not listen to our thoughts, witness them, or see
them to know what we are thinking—they have
no spatial qualities or sound and there is, so to
say, no temporal delay between my thoughts and
myself. I simply inhabit my thoughts. From the
disturbances of primordial presence and the as-
sociated pathological changes in the experience of
space emerges an experiential distance between the
self and its thoughts. David provided an example
of this subtle loss of thought ipseity (Gedanke-
nenteignung), when describing the estrangement
he experienced toward his own thoughts—“they
are my thoughts but not me.” The experiential
distance enables a self-alienation to grow from
within the disturbed subjectivity, by which one’s
thoughts, feelings, or parts of the body eventually
may be experienced as strange or alien.
Furthermore, schizophrenia spectrum patients
frequently complain about “living in the head”
and being unable to be absorbed in daily, practical
activities. This typical complaint is, in our view,
neither trivial nor should we understand it merely
metaphorically. Normally, we never experience
our own interiority as a space or experience our
thoughts with spatial qualities, but schizophre-
nia patients often do so. For example, a patient
reported that when he listens to music, he is not
really listening to the sound, but rather observing
himself listening—that is, his gaze is somehow
turned inward instead of outward. Stanghellini
(2004) sought to articulate this separation of the
self from the mediating processes it normally in-
habits with the term “disembodied spirits.”
Morbid Objectification of
Inner Speech
To characterize the morbid objectification
of inner speech, we must first describe the pre-
morbid inner speech. Normally, a substantial part
of our thinking occurs in the form of a so-called
inner speech, which has a verbal and dialogical
structure (Sass 1992, 193-7; Vygotsky 1986).
In other words, I am engaged with myself in an
inner dialogue in the sense that one part of me
asks questions and gets replies from another part
of me. Although I experience these two parts as
somehow distinct, I experience them at the same
time as deeply integrated, and the underlying feel-
ing of unity in this duality remains perfectly intact
(Stanghellini and Cutting 2003, 126). In schizo-
phrenia spectrum conditions, this unity disunites
as we have described, and an experiential distance
emerges between the self and its thoughts. In our
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 175
view, this dissociation between the sense of self and
the inner speech is essential to understanding the
pathogenesis of AVHs. It reflects a fundamental
weakening of the implicit sense of being in touch
with oneself and introduces an unbridgeable gap
between the normally unified dialoguing parts
of inner speech. Frequently, patients report that
certain thoughts, usually interfering or pressing
thoughts, feel, as Hanna put it, “strange and im-
personal.” Partly because they are not controlled,
they may be experienced as if they were not really
generated by the patient. This was also the case
with John’s pseudo-obsessions. The experiential
distance transforms the inner speech and enables
the patient to introspect his thoughts. The inner
speech that normally functions as an implicit or
silent medium for self-presentation becomes now
the object of explicit awareness and in this objec-
tifying process, thoughts get reified and acquire
properties not completely unlike those of physical
objects. This kind of alienating self-consciousness
has been described by Sass (1992) under the head-
ing “hyperreflexivity.” It involves a distortion of
the structures of awareness (such as foreground–
background, explicit–implicit, focal–tacit) in the
sense that something normally tacit becomes
focal, enabling aspects of oneself or one’s inner
life to be experienced with qualities similar to
those of external objects (Sass and Parnas 2003).
As noted, some patients, like Hanna, are able to
locate specific thoughts spatially, whereas other
patients, like John, experience their thoughts au-
tomatically being repeated or doubled in the form
of silent echoes (l’écho de pensée). Moreover, the
inner speech often acquires an acoustic quality,
that enables the patient to listen to her thoughts
(Gedankenlautwerden, la pensée parlée) as in the
case of Hanna. Another typical form of this per-
ceptualization and spatialization of inner speech
is described in the patient vignettes, when they
report that they are able to see their own thoughts
inside their head. However, the morbidly objecti-
fied inner speech may not only appear as sharply
delimited objects locatable in space, but also as
objects instantaneously given as a whole, appear-
ing, so to say, in a glance.
Another non-psychotic, anomalous self-experi-
ence, which some patients report, is the so-called I-
split (Ich-Spaltung). John gave an example hereof,
when describing that he felt as if he was divided
into two separate parts. Another patient reports
that she for a long time has heard two different
voices spoken aloud inside her head. She recogniz-
es both voices as her own, and she describes how
these voices constantly discuss even the slightest
matter. For example, if one voice says, “Now that’s
funny,” then the other will instantly reply, “No,
it’s not.” She distinguishes between the thoughts
she thinks (and also hears aloud internally), which
she spatially locates to her neck, and the discuss-
ing thoughts, which she locates to her mouth.
This continuous inner discussion captivates her
attention and makes it nearly impossible for her
to concentrate, initiate new lines of thoughts, and
remember things for more than a few minutes.
Like John, she also has the impression of being
divided into two separate parts (corresponding
with the two discussing voices) and she identi-
fies more with the one part than with the other.
We may consider such experiences of I-split as a
manifestation of the dissociation between the self
and its inner speech, and in that sense the I-split
reflects a vulnerability to verbal hallucinations.
In our view, AVHs in schizophrenia arise from
inner speech dialogues between thoughts that have
acquired quasi-acoustic qualities and become in-
creasingly loud, and that, owing to the increasing
experiential distance (which involves both patho-
logical changes in the experience of space and a
morbid objectification of inner speech), eventually
seem to be so unfamiliar and alien that the patient
is unable to recognize them as her own thoughts.
Deprived all sense of mineness, the unity of the
dialoguing parts of inner speech “shatters into a
mere dichotomy” (Stanghellini and Cutting 2003,
126), enabling patients to experience or hear their
own “loud” or unfamiliar thoughts as alien voices.
Discussion
Our account of the pathogenesis of AVHs
complements a range of empirical or phenom-
enological studies of the formation of verbal
hallucinations in schizophrenia, in particular the
works of Ey (1973), Klosterkötter (1988, 1992),
Sass (1992), Stanghellini and Cutting (2003), Sass
176  ■  PPP / Vol. 22, No. 3 / September 2015
and Parnas (2003), Larøi et al. (2010), Raballo
and Larøi (2011), and Parnas and Sass (2011). We
have proposed that verbal hallucinations in schizo-
phrenia tend to arise from preceding alterations
of self-awareness that involve both pathological
changes in the experience of space and a morbid
objectification of inner speech. We recognize that
our account of the pathogenesis of AVHs in schizo-
phrenia comes with certain limitations. First, the
reduction of this heterogeneous group of mental
phenomena to specific structures of experience
inevitably involves some generalizations, which
may prove too crude. Second, clinicians familiar
with the psychopathology of schizophrenia know
that verbal hallucinations sometimes occur quite
suddenly or acutely, and in those cases our account
does not really contribute to the understanding
of their formation. This limitation touches on the
inherent unpredictability of the schizophrenic
disorder and the associated incomprehensibility.
Although the formation of verbal hallucinations
in such cases is not reconstructable in the manner
described, we maintain that AVHs tend to arise
from manifold alterations of self-awareness—the
majority of which were exemplified in the case
vignettes and the subsequent analysis. Klosterköt-
ter (1992) identified some of these alterations,
namely, the subjective disorders of cognition, but
as we have tried to show, cognitive disorders are
just one of the possible expressions of the deforma-
tions of self-awareness in schizophrenia spectrum
conditions that precede the formation of AVHs.
To articulate the pervasive self-alienation imma-
nent in the manifold alterations of self-awareness,
we used the term experiential distance. This
term illuminates a core aspect of a phenomenon,
which has been thematized under headings such
as ‘hyperreflexivity’ (Sass 1992), “disturbances
of presence” (Parnas and Handest 2003, 124),
“diminished self-affection” (Parnas and Sass 2003,
429), and “instability of minimal self” (Parnas and
Sass 2011, 533). Addressing this phenomenon is
hardly a new idea; the specificity of the first-rank
symptoms consists in structural alterations of self-
awareness in which the unifying abnormality is
the decreased sense of mineness (Meinhaftigkeit)
of experience and the associated loss of ego-
boundaries (Schneider 1950). The experiential
distance and the intrinsic feelings of losing con-
trol or lack of control of, say, one’s thoughts and
bodily movements, precede prodromal feelings as
if being controlled as well as crystallized delusions
of control and other first-rank symptoms such as
commenting or arguing voices, thought insertion,
thought broadcasting, and thought withdrawal.
We have used the term self-alienation to des-
ignate broadly the variety of forms of estrange-
ment and self-estrangement experienced and
encountered in schizophrenia spectrum conditions.
Hence, self-alienation encompasses the notion of
experiential distance, which articulates a crucial
aspect of the altered structures of self-awareness,
but self-alienation may also refer to disturbances
involved in more reflected facets of personhood
such as social withdrawal, isolation, idiosyncra-
sies, suicidal ideation, and so on. Although alien-
ation (alienatio) traditionally has been equated
with insanity (alienatio mentis), its etymology is
also linked to distancing (Entfremdung, Verfrem-
dung) and externalizing (Veräusserung). From a
clinical–phenomenological perspective, we have
argued that both distancing (in the sense of the
increasing experiential gap between the sense of
self and the experiential stream, i.e., the loss of
mineness of experience) and externalizing tenden-
cies (in the sense of spatialization of experience
and morbid objectification of inner speech) are es-
sential to the formation of AVHs in schizophrenia,
and more generally that they are at the very root
of the schizophrenia spectrum disorders. We chose
the term self-alienation over alienation because
the former indicates that the alienation in schizo-
phrenia seems to grow from within the disturbed
subjectivity. Obviously, we do not dispute that
some of the earliest as well as prime manifesta-
tions of schizophrenic vulnerability occur in the
intersubjective sphere, for example, interpersonal
difficulties (including social withdrawal and isola-
tion), perplexity (Störring 1939), and lack of com-
mon sense (Blankenburg 1971, 2001), but we do
claim that schizophrenia spectrum conditions seem
to begin as a fragmentation from within, which
gradually leaves the patient trapped in a prison of
his or her own deserted interiority.
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 177
Empirical Studies on
Self-Disorders
An increasing amount of empirical studies
supports the hypothesis that anomalous self-
experiences (i.e., self-disorders) are pivotal to the
psychopathology of schizophrenia. For example,
Huber, Klosterkötter, and their collaborates found
many non-psychotic “basic symptoms” to be
specific to schizophrenia (Huber 1983; Huber et
al. 1979; Klosterkötter 1988, 1992). Danish and
Norwegian studies showed elevated levels of self-
disorders in the initial prodrome of schizophrenia
(Møller and Husby 2000; Parnas et al. 1998).
Self-disorders have been found to aggregate selec-
tively in schizophrenia and schizotypal personality
disorder (Nordgaard and Parnas 2014; Parnas
et al. 2005b; Raballo et al. 2011; Raballo and
Parnas 2012) but not in bipolar disorders (Par-
nas et al. 2003; Haug et al. 2012a). In the study
by Haug et al. (2012a), the mean EASE score of
the schizophrenia group (n = 57) was 25.3 (SD =
9.6), whereas the mean EASE score of the bipolar
psychosis group (n = 21) was 6.3 (SD = 4.8). In
the study by Raballo and Parnas (2012), the mean
EASE score of the schizophrenia group (n = 19)
was 21.4 (SD = 9.6), and the mean EASE score of
the schizophrenia group (n = 46) was 19.63 (SD
= 8.39) in the study by Nordgaard and Parnas
(2014). Furthermore, self-disorders have been
found to occur in genetically high-risk individu-
als (Raballo and Parnas 2011), to be predictive of
incident cases of schizophrenia spectrum disorders
in a 5-year follow-up study of 155 first-admitted
patients (Parnas et al. 2011), and to predict the
transition to psychosis in an ultra–high-risk sample
(Nelson et al. 2012). Finally, self-disorders have
been correlated with other variables, including
positive and negative symptoms, formal thought
disorders, and perceptual disturbances (Nor-
dgaard and Parnas 2014), suicidality (Haug et
al. 2012b; Skodlar and Parnas 2010), and social
dysfunction (Haug et al. 2014)—see Parnas and
Henriksen (2014) for a review of empirical studies
on self-disorders.
The available empirical studies suggest that
self-disorders discriminate schizophrenia spectrum
patients from non-spectrum individuals (healthy
controls and patients from other diagnostic
groups), indicating that the disturbances of self-
consciousness in schizophrenia are different from
disturbances found in other mental disorders. For
example, in cases of senile dementia, the mineness
of experience, which is unstable or even shattered
in schizophrenia, remains perfectly intact. As
Kimura puts it, “an Alzheimer’s patient, who no
longer knows with whom she is speaking or what
her own name is, will hardly ever say that she is not
herself, or that she is someone else” (2001, 332).
In contrast with Alzheimer’s disease and other
memory disorders where the disturbances of self-
hood affect the so-called narrative or extended self,
we agree with Cermolacce et al., when they argue
that the disturbances of self-awareness in schizo-
phrenia primarily affect “the sense of minimal
self” or “ipseity” (2007, 712). Consequently, we
also embrace the so-called “ipseity disturbance”
model proposed by Sass and Parnas (2003), which
suggests that schizophrenia can be understood
as a self-disturbance with two complementary
distortion of self-awareness, namely, diminished
self-affection and hyperreflexivity.
Anomalous Self-Experiences
Outside the Spectrum
Finally, we briefly address a pertinent question
that seems to challenge our account. Individuals in
different diagnostic groups may describe anoma-
lous self-experiences quite similar to those por-
trayed in the case vignettes. If these deformations
of self-awareness are constitutive for the formation
of verbal hallucinations, then why don’t these pa-
tients develop verbal hallucinations regularly? It is
perfectly correct that, for example, patients with
major depressive disorders or depersonalization
disorders sometimes report self-experiences fairly
similar to those portrayed in the vignettes (e.g., a
fragile sense of identity, diminished presence, and
decreased vitality). Moreover, victims of torture
often describe subtle experiences of derealiza-
tion, a lack of basic trust, and a global crisis of
meaning (see, e.g., Brison 2003, ix; Delbo 1995,
260ff.; Ortiz and Davis 2002, 51, 138ff.), which
also resemble some of the core self-experiences
described in the vignettes. Obviously, we do not
178  ■  PPP / Vol. 22, No. 3 / September 2015
dispute that these individuals as well as others can
have experiences quite similar to those described
in the vignettes, but we do argue that such ex-
periences only are similar with regard to certain
aspects. When empirical studies suggest that self-
disorders are specific to schizophrenia, this does
not mean that such anomalous self-experiences
are exclusive to and cannot be found outside the
schizophrenia spectrum, but simply that the differ-
ence in the number of anomalous self-experiences
is statistically highly significant between spectrum
and non-spectrum individuals. In other words,
when schizophrenia patients describe experiences
of inner void, unreality, and lack of presence, these
experiences are not isolated to specific situations,
but embedded in a globally changed experiential
framework, which reflect the comprehensive
structural alteration of subjective experience in
schizophrenia (Henriksen and Parnas 2012; 2014;
Henriksen and Nordgaard 2014; in press; Parnas
and Bovet 1991; Parnas et al. 2002). It is, more
specifically, the psychopathological Gestalt that is
schizophrenia specific, not any anomalous experi-
ences per se, and it is this Gestalt that is constitu-
tive for the formation of AVHs in schizophrenia.
Non-spectrum individuals can therefore have
anomalous self-experiences that in some respects
resemble those found within the spectrum, but
without the same underlying psychopathological
Gestalt these individuals rarely develop the same
form and quality of verbal hallucinations as those
frequently found in schizophrenia—in particular
running commentary or arguing voices.
However, some empirical studies attest that
verbal hallucinations also occur in normal popu-
lations (Barrett and Etheridge 1992; Posey and
Losch 1983; Tien 1991). If we maintain that
the psychopathological Gestalt of schizophrenia
is constitutive for the formation of AVHs, how
can we then account for the presence of AVHs in
non-spectrum individuals? Does the presence of
hallucinatory voices in non-clinical populations
not somehow indicate that the pathogenetic causes
must be sought elsewhere and that we have got
it all wrong? Again, we argue that the empirical
studies described suggest that deformations of
self-awareness are highly characteristic of schizo-
phrenia spectrum conditions, indicating that the
pathogenesis of AVHs in schizophrenia is different
from that of AVHs found in populations outside
the spectrum—recall that the mean EASE score of
patients with schizophrenia ranges from 19.63 to
25.3 (Haug et al 2012a; Nordgaard and Parnas
2014; Raballo and Parnas 2012). In comparison,
the mean EASE score of a healthy control group
(n = 52) was 2.37 (SD = 2.45; Nelson et al. 2012).
Bearing in mind the heterogeneity of AVHs, it
seems, in our view, highly questionable if the phe-
nomena actually are of the same form and quality
in schizophrenia and normal populations. The
mere fact that most voice-hearers in the so-called
normal population rarely, if ever, seek help for
their abnormal experiences seems to indicate that
these voices are qualitatively different from those
that typically torment schizophrenia patients.
In an interesting study, Stanghellini et al. (2012)
compared hallucinatory experiences in a clinical
sample of schizophrenia patients (n = 23) with
hallucinatory-like experiences in a non-clinical
sample (n = 60) and found that the phenomenal
quality of these experiences was “remarkably dif-
ferent” in the two samples. In the schizophrenia
sample, the hallucinatory experiences were closely
related to the patients’ identity, which was marked
by persistent anomalies in their sense of self and
by metamorphosis of the self–world relationship,
whereas the hallucinatory-like experiences in the
non-clinical sample were related to circumstantial
events or reported as a single experience (Stang-
hellini et al. 2012). Further research that explores
the heterogeneity of hallucinatory voices might
provide the details needed to establish a genuine
and sound differentiation of these complex mental
phenomena.
Conclusion
We have put forth a phenomenological account
of the pathogenesis of AVHs in schizophrenia that
complements, elucidates, and clinically grounds
contemporary phenomenological accounts of
AVHs in schizophrenia. More specifically, we
have proposed that verbal hallucinations tend to
arise from preceding alterations of self-awareness,
which involve both pathological changes in the
experience of space and a morbid objectification
 Henriksen, Raballo, and Parnas / Pathogenesis of Hallucinations  ■ 179
of inner speech, and we have provided clinical
descriptions of these pervasive alterations. In
addition, we have suggested that “experiential
distance,” which arises from disturbances of
primordial presence, is at the very core of the
deformations of self-awareness in schizophrenia
spectrum disorders and that it may function as a
precursor to florid first-rank symptoms, such as
verbal hallucinations and delusions. Furthermore,
we dispute that AVHs in schizophrenia should
be conceived in terms of abnormal perception,
but rather as cognitive phenomena arising from
a partial dissolution or reorganization of certain
structures of self-consciousness. Finally, we sug-
gest that clinically grounded phenomenological
models of the pathogenesis of AVHs may guide
the empirical search for the neurobiological basis
of these complex phenomena.
Funding
M.G.H. is funded by the Carlsberg Foundation
(#2012010195).
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