Phenomenology of auditory verbal hallucination in schizophrenia: An erroneous perception or something else?

This study presents phenomenological features of auditory verbal hallucinations (AVH) in schizophrenia and associated anomalies of experience. The purpose is to compare the lived experience of AVH to the official definition of hallucinations as a perception without object. Furthermore, we wish to explore the clinical and research implication of the phenomenological approach to AVH. Our exposition is based on classic texts on AVH, recent phenomenological studies and our clinical experience. AVH differ on several dimensions from ordinary perception. Only a minority of schizophrenia patients experiences AVH localized externally. Thus, the official definition of hallucinations does not fit the AVH in schizophrenia. AVH are associated with several anomalies of subjective experiences (self-disorders) and the AVH must be considered as a product of self-fragmentation. We discuss the implications with respect to the definition of hallucination, clinical interview, conceptualization of a psychotic state and potential target of pathogenetic research.


Introduction
Hallucinations have always been considered as emblematic of psychosis.Although DSM-5 (American Psychiatric Association, 2013) does not define the term psychosis, it operates with the category of psychotic disorders characterized by the presence of at least one psychotic symptom.DSM-5 defines hallucination as "a perception-like experience with the clarity and impact of a true perception but without the external stimulation of the relevant sensory organ".More recently, the RDoC characterized hallucination as "a conscious sensory experience that occurs in the absence of corresponding external stimulation of the relevant sense organ and has sufficient sense of reality to resemble a veridical perception" (Ford, 2016).In these definitions, hallucination and perception are experientially identical and only differ by the absence of objective stimulus in the former.
Auditory verbal hallucinations (AVH) are in the DSM system considered as a type (species) of hallucination and should therefore comply with the general definition.AVH have traditionally been viewed as quite specific to schizophrenia, especially in the form of so-called Schneiderian first rank symptoms, i.e. voices discussing the patient in the third person or commenting her behavior.With the evolution of the operational diagnostic system since the DSM-3 in 1980(American Psychiatric Association, 1980), there have been a proliferation of psychiatric diagnoses and many of the original diagnoses have been considerably expanded to include psychotic symptoms, e.g.OCD, borderline personality disorder or post-traumatic stress disorder.So at present, hallucinations are allowed to occur in diverse psychiatric disorders.Unfortunately, there has been no concomitant attempt to explore whether hallucinations possess different phenomenological qualitative features specific to the disorders, in which they are claimed to occur.The insights of classical psychiatry, that recognized specificities of symptoms, have been largely forgotten in the case of hallucination.Recently, many researchers claim that most symptoms (including hallucinations) are trans-diagnostic (Insel et al., 2010;van Os and Reininghaus, 2016).However, a trans-diagnostic research program has failed to demonstrate robust results (Fusar-Poli et al., 2022).Here, the fundamental problem lies in the fact that comparing diagnostic entities on symptomatic profiles requires that the entities in question are characterized by some invariant or essential features (the so-called "whatness" or "quiddity"), which is not the case in contemporary psychiatry.
The purpose of this study is to present the evolution and phenomenological features of AVH in schizophrenia and their associations, with the alteration of the modes of conscious experience.This presentation will be followed by a discussion of clinical consequences for the psychiatric interview, therapeutic approaches and pathogenetic research.
The phenomenological approach presented in this study implies that the examination of the patient happens in a semi-structured conversational manner, allowing the interviewee to verbalize her experiences spontaneously.The purpose is to obtain as fateful a self-description as possible, i.e. undistorted by preconceived clinical categories.It also requires an interviewer that is a highly experienced psychopathologist and trained in conducting such interviews.The focus of the interview targets not only the content of the patient's experience, but the very mode of experiencing, i.e. the structure of consciousness operative in such an experience.The basic assumption is that the psychiatric symptom is not a "thingly" mental object awaiting a preformed question of the structured interview in order to come into full view (Nordgaard et al., 2013;Parnas and Sass, 2008;Parnas and Zahavi, 2002).This methodological requirement makes many studies using self-questionnaires and structured interviews irrelevant for our purpose.We will draw upon our clinical experience and a selection of recent studies that meet the phenomenological standard, as well as classic texts written by experienced psychopathologists dealing with AVH.
Recent reviews on the topic (Upthegrove et al., 2016) emphasize the need of studying AVH in qualitative phenomenological detail as well as associated anomalies of experience.

History of the definition
The definition of hallucinations changed between the 15th and the 18th century.During this period, hallucinations were ascribed to sensory diseases, first in the eyes and then to other sensory organs.A profound change in the understanding of hallucinations happened in the 19th century.Jean-Etienne-Dominique Esquirol, the author of the first modern textbook of psychiatry (Esquirol, 1838), linked hallucinations to delusion: "A delusional man who has an intimate conviction of an external sensation of an object which does not exist is in a state of hallucination" (Esquirol, 1817).In this way, hallucinations became associated with delusion and thus with madness (Frerejouan du Saint, 2019).Esquirol replaced the earlier term "vision" with the term "hallucination" in order to substitute the visual component by a more generic term of derailment or rambling (Berrios, 1996).In pathogenetic terms, he vacillated between allocating the causes of hallucinations to sensory organs or to psychic (cognitive) functions of judgment.On the whole, he was inclined to consider hallucinations as a cognitive problem of judgment, close to delusion, implying an apodictic conviction on the part of the patient and not as a purely sensory event.In this way, the issue of hallucination was now framed in the entirety of the psychological person and came to involve the notion of conviction, truth and reality.However, later interpreters of Esquirol continued to emphasize the sensory aspect of hallucinationsand so the incorrect idea, that Esquirol defined hallucinations as a perception without object, has been transmitted to our times (Ey, 1973;Lanteri-Laura, 1991).
Another French psychiatrist, Jules Baillarger distinguished the psycho-sensory hallucinations with sensory qualities from the "psychic" hallucinations.He described the latter as a kind of "speaking thoughts".Another influential French psychiatrist, Jean-Pierre Falret, considered hallucinations as a cognitive disorder, i.e. "a disorder of reason and judgement" and not as a purely passive sensory experience (Ey, 1973).In the subsequent years, the alienists following the anatomo-clinical model, inspired by phrenology, searched for the responsible organic substrate in the brain.Descriptive efforts were no longer emphasized and the link between hallucination and the hallucinated person faded away from the clinical interest.At the end of 19th century and the beginning of the 20th century, several psychiatrists described phenomena of voices talking about the patient or commenting his thoughts and behavior (Lévy-Valensi, 1927).Another French psychiatrist, Gaëtan Gatan de Clerembault, used the term of "major mental automatism" to cover phenomena of influence and commenting and discussing voices.Kurt Schneider elevated the phenomena of major mental automatism to be pathognomonic of schizophrenia, and the Anglophone literature refers to these symptoms as Schneiderian first rank symptoms.
Phenomenological psychiatrists of the 20th and 21st century have contributed to the descriptive efforts concerning hallucinations, and some of these contributions are incorporated below in our exposition of phenomenological features of AVH.

Experiential description of perception
As noted above, the DSM and the ICD define hallucination as a perception without a stimulating object.None of the diagnostic systems provide any description or definition of the concept of perception.We are of course all familiar with seeing a movie, listening to a conversation or tasting a good wine.However, in the context of our goal of describing AVH in schizophrenia, it is necessary to have an idea about experiential features of perception.Basically, the very talk of perception without an object is a senseless expression (Frerejouan du Saint, 2019) because we all understand perception as a form of contact with an environing world.Broadly speaking, the term perception may refer to a perceived object (when we have seen something, which we wanted to see), to a perceptual process of perceiving or to a cognitive-intentional modality or function of consciousness.
What is fundamental in the process of perception is that perception presents its object in an incomplete or perspectival way, experienced from a certain sensory motor situation or point of view (Merleau-Ponty, 1945).Perception is closely linked to our bodily movements and is a dynamic process with a temporal contour.As we mentioned above, the perceived object (e.g. in visual perception) is always given through a certain visible aspect or profile, which is a function of our sensory motor situation.When I see my computer in front of me, I only see the screen and the keyboard, but not the backside of the computer.However, I can go around the computer or turn it around to see its backside.When I look at my computer, I see the entire computer, I say that I see the computer and not only the front of it.These momentarily not visible aspects or profiles are co-intended in my look and articulate the consciousness of a computer as a solid three-dimensional entity.The profiles of aspects, which are momentarily invisible for my point of view, are open to other potential perspectives, endowing the object with its public or intersubjective character accessible to other people.This perspectival character of perception is the fundamental feature that accounts for the fact that we see the object, so to say, "in person" or "in flesh and bones", as real objects in the real world (Leibhaftigkeit) (Jaspers, 1997).Through our perceptual and motor activities we constitute a shared social space, which is populated by objects and creatures that appear as objective and mind independent.
Correspondingly, when I hear an acoustic object, I hear it from a certain direction; the sound has a duration and indicates its physical source (Murata, 2015).When I listen to an uttered sentence, the sentence refers to a spatiotemporally located speaker and is embedded in what has been said and the anticipation of what is going to be said.In other words, the acoustic object is given in a certain contextual perspective and is located, although more diffusely than a visual object, in the shared social perceptual space.
Perception is often rich in details with multimodal characteristics.When I see a surface with a rough texture, my tactile abilities are involved in the perceptual process.Lastly, it is worth mentioning that a perception of an object is never a perception of an isolated object without a background; the minimal perception is a perception of a figure upon a background.Thus, the perceptual field consists of several perceptual objects reciprocally connected by relations of meaning and significance, ultimately referring to the shared, stable, perceptual world.

Onset
In a substantial number of patients, the onset of AVH can be dated back to childhood.In fact, hallucinations are the best predictor of schizophrenia in the longitudinal birth-cohort studies (Scott et al., 2009).This is the case even though the data collection in these studies is limited to a very few and simple questions concerning behavior and experience.
AVH typically begin with single words and evolves in time into brief sentences (Klosterkötter, 1988;Yttri et al., 2022).The Schneiderian phenomena of voices discussing the patients or commenting their behaviors, typically occur late in the course of AVH.An important issue is a lengthy time lag between the onset of voices and their disclosure to other people.Moreover, there is a substantial time-interval between first contact with psychiatric treatment facilities and the disclosure of voices (in the study of Yttri et al., 2020 it was 7.2 years) (Yttri et al., 2020).This contact with treatment facilities is typically brought about, not by complains about hallucinations, but because of other psychiatric phenomena, such as apparent depression, suicidal ideation or anxiety.The term "voices" is frequently acquired by the patient from the surroundings and often from the treating staff (Jones and Luhrmann, 2016): Vignette 1: The psychiatrist explained to me that it was "voices.""What did you call them before?"Thoughts."So, you did not think upon them as "voices"?No, I thought upon them as thoughts.Thoughts I am forced to think.By my brain or something (Yttri et al., 2020).
Thus, it appears that the process of naming the experiences as "voices" elevates them to the status of a psychiatric symptom.One important reason for this long duration of AVH before disclosure is their phenomenal nature and the patient's attitude to those phenomena (see below).
The majority of AVH patients suffer from concomitant psychopathology such as thought pressure, thought aloud, thought echo and thought interference (Jones and Luhrmann, 2016).It seems that the AVH do not arise ex nihilo but are preceded and accompanied by the anomalies of subjective experiences, which are currently called selfdisorders.

The qualitative nature of AVH and their hearing
In the psychiatric texts on AVH, we find the terms "acoustic" and "auditory" very frequently and these terms are used interchangeably.The term acoustic refers to the sound being emitted, whereas auditory refers to listening and hearing, in other words to the receptivity of the mind.However, it seems that AVH are neither truly acoustic nor auditory.The voices frequently begin as thoughts that speak the patient's intended meanings -and later perhaps, verbalized meanings without the patient's intention.Some of the speaking is often devoid of any sensorial quality (silent voices) (Bleuler, 1950), whereas in some cases the experience is acoustic only because the patient uses the easily available vocabulary of voices.The majority of patients consider their AVH as thoughts, and -as mentioned above -learn the AVH terminology through contact with treatment facilities.The patients say that the voices are not "like the normal voices", the voices may possess gender or be without identifiable characteristics.Frequent descriptions include terms such as thought-voices, "mechanical, digital" or "malfunctioning radio-signal".The patient may even say that although he no longer hears his voices, he feels that "they are still there".This latter statement testifies to a sense of some alien object-like presence in the midst of the patient's immanent life.The sentences are most frequently short interpellations, commands or comments, abruptly thrown at the patient at once without any proper temporal unfolding.Thus, the voices appear as if emerging from nowhere, as isolated fragments, resembling figures devoid of their background.The voices are hyperproximate, which means that the patient feels totally exposed, without any possibility of evasion or retreat, because the patient cannot escape from himself or jump away from his shadow.The subject is thus in a condition of total passivity.In the so-called "listening attitude" (i.e., the auditory element), the patient is perhaps in a state of waiting receptivity or immersed in attending to and understanding the messages, rather than engaging in what we normally call listening (Lagache, 1934).Apart from certain acute states, the patients do not confuse their hallucinatory experience with normal perception: Vignette 2: I have always known that this was my place; this was my reality.Away from other people's reality.I live in this world just like all humans.And then I also have my own reality.Of course, I know that there is not a man standing there talking to me ….It all takes place in my head.I know that.And I am completely aware of that.But to me, it is my reality.I have lived like that for years.I really feel that I live in two worlds."Is one of the worlds more real than the other world?"No, there is no difference in the level of reality (Yttri et al., 2020).
In sum, the character of voices is completely non-perspectival and acontextual in contrast to a normal perceptual experience.Unlike perception, the experience of voices manifests an extreme phenomenological poverty and lack of temporal contour.What the voices throw at the patient does not invite any further active exploration, there is simply nothing more for the subject to explore.The mode of givenness of hallucination cannot be properly described as a relation between the subject and hallucination as an intentional object, but, rather, has a character of a disclosure and revelation within the subject (Charbonneau, 2001;Naudin, 1997).Hallucinations may sometimes be described in multisensory terms (Jones and Luhrmann, 2016).For example, a patient says: "The red voice comes from fifty centimeters above my head and the black voice from a meter behind my head".This strange coupling of "voice with color" perhaps testifies that the experience in question must have some spatial features, because we cannot experience colors without extension.
Finally, it must be added that in approximately one third of the cases, the voices cannot be distinguished from the phenomena of influence.A patient of ours offers the following illuminating account of his experience: Vignette 3: There are two worlds.There is the unreal world, which is the world I am in and we are in.And then there is the real world.The only thing that is real in the unreal world is my own self.Everything else -buildings, trees, houses -is unreal.All other humans are extras.My body is part of the charade.There is a real world somewhere and from there someone or something is trying to control me by putting thoughts into my head or by creating (…) screaming voices inside my head (Parnas and Henriksen, 2016).
Many, if not a majority of patients with schizophrenia, appear to simultaneously live in two different realities or ontological dimensions, which is illustrated in vignette 2 and 3. Eugène Bleuler (Bleuler, 1950) described crucial aspects of this phenomenon with the notion of 'double bookkeeping', to which we will return below.

Hallucinatory space
The official definition of hallucination as a perception without object is typically understood in the sense that the voices should be located in the external social space.In other words, the hallucinatory object is vicariously "perceived" for the absent real object.Therefore, many psychiatrists understand hallucinatory voices as being located outside the patient, with clear sensory characteristics (Bogen-Johnston et al., 2019;Upthegrove et al., 2016).However, only a minority of patients hear voices exclusively in the outer space, and even in these cases the nature of this outer space is quite dissimilar from our shared social space.For example, a patient may hear voices that come from another city, or may hear his colleagues talking at place of work while he himself is sitting at home.In these cases, it is clear that the rules that govern the spatiality of the patient's experiences are far away from the commonly understood physical laws; there is a clear breakdown of the objective social space.Many patients are either unable to localize the voices because they seem to be diffusely everywhere and nowhere, or changing their location, equally many patients only experience voices in their head (Jones and Luhrmann, 2016;Jones and Shattell, 2016;Yttri et al., 2022).The peculiar nature of the hallucinatory space is well illustrated by the following vignette: Vignette 4: One of our patients wrote to the last author: I have read the text that you have recommended [on phenomenology of thinking].What surprised me was that our thoughts are separated from each other.That your thoughts belong to you and just to you and my thoughts belong to me and just to me.Since I was a child, I have been of the conviction that all peoples' thoughts and voices were mixed together in a collective whole.From this whole, came my voices, knocking sounds, mumblings, whispers, or this occasional screaming (Parnas et al., 2021).
This vignette illustrates several phenomena at the same time: 1) that the hallucinatory space seems to be some sort of extra-sensorial and extra-corporeal collective space, 2) that there is some continuity between voices and thoughts, 3) that the patient's self-demarcation is quite permeable (transitivism) and 4) most importantly, that the sense of ownership (mineness) of thinking is clearly deficient.
In conclusion, the hallucinatory space is neither a normal space of phantasy, nor an intersubjective social space, but rather a pathological modification of the patient's private immanent sphere.In the words of the French philosopher Maurice Merleau-Ponty, hallucinations in schizophrenia "are not of this world" but rather in front of it (Merleau-Ponty, 1945).

Alterations of the structure of consciousness
Jones and Luhrmann conclude in their study that the majority of AVH patients suffer from a multitude of anomalous self-experiences."Our findings also raise questions as to whether or not clinicians are always addressing what is in fact most disturbing about "voices": many of our participants stressed the greater difficulty coping with various forms of thought disruption (including perceived loss of control over "thinking") (Jones and Luhrmann, 2016).Jones and Luhrmann refer to anomalies of subjective experiences of cognition and affectivity, which typically co-occur with AVH (Yttri et al., 2020).These disorders are today conceptualized as varieties of self-alienation (aka self-disorders).In order to grasp the nature of such structural changes of selfhood it is necessary to have an idea about ordinary conscious life.
A normal stream of consciousness involves mutually interpenetrating perceptions, imaginations, thoughts and sensations.Thinking itself consists of strings of meaning, often supported by imagistic or linguistic elements (inner speech) (Bennett and Hacker, 2003).This stream is unified because it is saturated by the sense of self as my stream of consciousness (Zahavi, 2005).In other words, the multiplicity of experiences is unified by their givenness to a single subject.There is no experiential distance between my thinking, its meaning and my sense of subjecthood.When I think about a recent comment, which I made at a party, the self who is reflecting, and the self-reflected upon, are experientially unified.I have no need to observe or listen to my thoughts because I inhabit them.It can also be said that consciousness is transparent.Most of the time, we are "not in our heads" but are involved in the perceptual world, or with some practical or cognitive task.In contrast, the patient with schizophrenia very frequently reports a persisting sense of interiority, as if his immanent sphere acquired spatial characteristics.The patient typically calls it "living only in the head".This phenomenon refers back to what has been said on a pathological modification of the patient's immanent sphere, in the section above on the hallucinatory space.
In schizophrenia, the patient may experience thoughts that have lost their sense of mineness, varieties of thought interference, thought pressure, varieties of spoken or written thoughts or a strange distance to one's own thoughts (Klosterkötter, 1988).In thought interference, certain thoughts acquire an unusual salience attracting their attention (e.g., thought interference).In other words, certain thoughts pop up as unwanted and autonomous, deprived of connection with this stream of consciousness and with diminished sense of ownership (mineness).These thoughts become akin to spatialized entities within the patient's immanent sphere and attract his attention.There emerges an increasing sense of experiential distance between the sense of subjecthood and the thoughts in question leading to the articulation of quasi-spatial interiority; a part of the subject (her thoughts) becomes an object of attention.Thus, a part of the subject converts into an object (Ey, 1973).In summary, the voices are fragments of the self-acquiring autonomous existence.It is important to understand that here, we do not speak of a projection in the psychodynamic sense, but of a structural transformation of subjectivity.The following vignette partly illustrates this increasing level of alienation, experienced synchronically: Vignette 5: First level is, as I said, my own voice, which has my personality, my character and my way of formulation.It is not like listening to my voice inside my head, because I don't hear it.It is just there (…) And the second level, which has no personality or character, it's neither a man nor a woman.But now I have decided in my head that it is a man (…) And then there is the third level which is rare.Level two works in the shadows.I barely have contact with him.I cannot ask a question and get an answer.I cannot force him to come.He is there when he is there.But on the third level there is a voice and a character and a personality, but it is not the same.And it can be heard, not inside the head but outside.As when I am lying in my bed and trying to get some sleep, I relax and I am calm, and suddenly there is a person who is shouting at me.I cannot make out what is being said, there is just shouting (Sandsten et al., 2022b).
This self-fragmentation is linked to the basic vulnerability in schizophrenia, which consists in the instability of first-person perspective (Henriksen et al., 2021;Nordgaard et al., 2022;Raballo et al., 2021).This instability implies that mental processes and mental contents (such as imagination and the images) can momentarily lose their sense of subjecthood or feeling of mineness.
Initially, the patients say that they cannot catch up with themselves (Bleuler, 1950) and be themselves in an unproblematic and automatic way.This disorder of selfhood is typically associated with the alienation from the shared social world, which may appear enigmatic and therefore requiring reflection.The very existence and social relations may feel as an oppressive burden (for more details see in (Parnas and Handest, 2003)).Self-disorder appears to be a fundamental trait feature of schizophrenia, preceding the articulation of psychotic phenomena (Koren et al., 2020;Nordgaard et al., 2021;Sandsten et al., 2022a).

Insight and double bookkeeping
In psychiatry, the insight of the illness is defined as an awareness of the illness, its symptoms, consequences, risk factors etc.If I suffer from a type 2 diabetes, I am informed, that I am at an increased risk of cardiovascular disease and I try to follow sugar free diet and exercise as much as possible.On a psychological level, such insight is characterized by an experiential and ontological distance between me as a subject and the illness as the object.Given the situation that psychotic symptoms (e.g.hallucinatory phenomena) articulate themselves within the patient's immanent sphere of selfhood, it is simply not possible for structural reasons to engage in such reflection.Professor Ellen Sachs provides the following description: Vignette 6: "I completely recognized that the things I was saying and doing and feeling would be thought to amount to a diagnosis of schizophrenia; but I thought that it was not true-I did not really have the illness (…) So, my thinking went, I looked like I had schizophrenia (…) but if we knew enough, we would see that I really did not" (Saks, 2009).
We sense in this vignette that the person considers the psychotic phenomena as a deep, privately accessible reality, so far unrecognized by other people as well as scientific studies.In our experience and clinical studies (Yttri et al., 2020(Yttri et al., , 2022)), most patients do not consider their condition as being comparable to a medical illness.The patient's attitude is characterized by what Eugene Bleuler called "double bookkeeping".This term implies that the patient lives in a double ontological orientation: on the one hand, the patient lives and copes in our shared social reality, on the other hand, he concomitantly lives in the reality of his private immanent sphere, where the articulation of psychotic phenomena takes place.This private ontological orientation may sometimes give the patient a sense of access to deep layers of reality inaccessible to other people.It is a private reality, and it carries with it a conviction of truth and relevance and should not be confused with some sort of fiction or exaggerated imagination (Henriksen and Parnas, 2014;Parnas et al., 2021).When the DSM talks about hallucinations as "a perception-like experience with the clarity and impact of a true perception…", it misunderstands not only hallucinations as an erroneous perception, but also the nature of the experiential truth.The truth of the hallucinatory experience has nothing to do with the perceptual world but is a revelation within the pathological modification of the patient's immanence sphere.
The double bookkeeping is a phenomenon that may be already inchoately articulated in the pre-onset phases of the illness and in schizotypal disorder.Professor Sachs describes double bookkeeping in the following way: Vignette 7: My life truly began to operate as though it were being lived on two trains, their tracks side by side.On one track, the train held the things of the 'real world'-my academic schedule and responsibilities, my books, my connection to my family (…) On the other track: the increasingly confusing and even frightening inner workings of my mind.The struggle was to keep the trains parallel on their tracks, and not have them suddenly and violently collide with each other (Saks, 2007).
Many patients with schizophrenia in the so-called stable phase continue to have access to this private interiority, where hallucinations may persist in a more or less articulated way.This aspect of hallucination causes a conceptual difficulty on the distinction between an active episode and remission (Jones and Shattell, 2016).However, the configuration of double bookkeeping may break down in an acute exacerbation, where the patient loses his connection to the social world and acts on the content of hallucinations and delusions.

Conclusions and implications
As pointed out by Jones and Luhrmann (2016) the official definition of AVH, as a perception without object, does not correspond to the nature of AVH in schizophrenia and is therefore empirically incorrect.We believe that it would be appropriate to define the AVH in schizophrenia, not as an erroneous perception, but in more descriptive terms, useful for the clinician and the researcher alike.We think that the term "thoughtvoices" would be more appropriate and should be accompanied by a narrative description of the varieties of hallucinatory experience.
The current psychopathology embodied in the DSM and ICD has gone too far in the descriptive simplification of psychiatric phenomena, and therefore this simplification exerts a negative influence on the training of psychiatrists.In a clinical situation, the psychiatrist has only a limited familiarity with abnormal conscious phenomena.Being familiar with the perceptual model of AVH, he/she is prone to consider only "external voices" as true hallucinations.
As emphasized by JM Henry: "The patient's difficulties to articulate the details of the nature of hallucinations is less a sign of the reticence on the part of the patient than an expression of the psychiatrist's insistence on framing the hallucination in the perceptual space to which it does not belong" (Charbonneau, 2001).A similar view has been expressed by Jones and Luhrmann (2016).
The psychiatric examination is not adequate if it is simplified to a question: "Do you hear voices?"Rather, it is crucial to perform a psychiatric interview that is conductive to the patient's spontaneous self-description.Such an interview requires that "the patient accepts to share with us some aspects of his lived experience, which means that he has a sufficient confidence in the clinician and is able to reflect on his own experience" (Esquirol, 1838) [our translation].We can extend the point that we are making about AVH to other forms of psychopathology and to the general issue of the status and importance of psychopathology in contemporary psychiatry (Parnas et al., 2013).It is important to keep in mind that AVH in isolation are not a marker of schizophrenia unless they are associated with the structural changes of the patient's subjectivity, currently called self-disorders.
In terms of treatment, AVH can never be a primary and singular target of intervention.As described above, the voices articulate a private experiential realm or ontological orientation that possesses a certain validity for the patient.Thus, in addition to psychopharmacological intervention, it is necessary to help the patient to negotiate a balance between his private reality and his social situation in our shared world.
Concerning pathogenetic research, it is perhaps timely to refocus our attention from well-developed psychotic symptoms to the more basic and generative disorder of the structure of subjectivity.The voices and so on were not that important.I think that the enduring and pervasive feeling of being unreal is the disease itself.When I realized this condition of looking at myself as in a movie was permanent, I understood it would eventually destroy the core of my life (Møller and Husby, 2000).

Declaration of competing interest
We do not have conflict of interest.