Clinical characteristics of auditory verbal hallucinations by spatial location: objective and subjective comparisons in schizophrenia

The clinical characteristics of the spatial location of auditory verbal hallucinations (AVHs) has shown inconsistent results. This study compared AVHs characteristics by spatial location using both objective and subjective assessments. Eighty-five schizophrenia patients scoring 3 + on the hallucination item (P3) of the Positive and Negative Syndrome Scale for Schizophrenia (PANSS) were included. The spatial location of AVHs was categorized using the clinician-rated Psychotic Symptom Rating Scales - Auditory Hallucinations (PSYRATS-AH) and the self-report Hamilton Schizophrenia Voice Questionnaire (HPSVQ), both administered on the same day. The proportion of patients, severity, and linearity of AVHs categorized by spatial location were compared. Participants were categorized into three groups on each scale: inside, outside the head or both. Categorization differed across scales: on the PSYRATS-AH, 15 patients (17.6%) were classified as inside, 26 (30.6%) as outside, and 44 (51.8%) as both, while on the HPSVQ, 23 (27.1%) were inside, 40 (47.1%) outside, and 22 (25.9%) both. Of the 44 patients classified objectively as dual location, 10 (22.7%) were classified subjectively as inside the head, and 20 (45.5%) as outside the head. For both scales, total scores and emotional component scores increased in the order of inside < both < outside, with a significant linear trend. Clinicians were more likely to classify external AVHs as dual-location. Importantly, across both clinician- and self-reported assessments, external voices consistently emerged as more severe and distressing, affirming their clinical relevance.