Inner Speech - Mental Disorders & Inner Speech

Mental Disorders & Inner Speech

How does inner speech change when our thought is affected by a disorder?

Now, we are going to examine the role that inner speech plays in various psychological disorders. Psychological disorders are characterized by abnormality or dysfunction (something not working the way that it usually does) in the way an individual thinks, behaves, or processes/regulates their emotions.

In the previous section, we discussed the potentially strong intertwinement between inner speech and cognition, behavior, and emotion regulation; thus, it should not be surprising that inner speech irregularities often come along with disorders involving those three psychological functions.

A quick note of caution before we proceed: it is important to note that research on inner speech in individuals with psychological disorders should be approached with caution. Just because a few studies have found a general trend does not mean it applies to all individuals with this disorder, since sample sizes are limited and within every disorder is a wide range of individual variation.

With that in mind, we will now discuss some of the findings from recent studies for some common mental disorders and mental disorders of particular interest.

Below are some psychological disorders with links to inner speech; click on the ones that interest you for more information about how someone with this disorder might use inner speech differently.

Schizophrenia: a psychological disorder characterized by issues with thinking, perception, emotional responsiveness, and social interactions. Symptoms include illogical thoughts, hallucinations (including auditory hallucinations), and bizarre behavior and speech (from the NIMH definition)

Thank you for your interest in inner speech as it relates to individuals with schizophrenia.

One of the most well-known symptoms of this disorder is auditory/verbal hallucinations, where an individual hears something that was not produced in their environment. While schizophrenia is a complex disorder with many symptoms that vary across individuals, we will focus on this particular symptom in our discussion.

Studies have found that the intensity of auditory/verbal hallucinations experienced by individuals with schizophrenia is often correlated with their scores on the "Other People in Inner Speech" section of the VISQ measurement system (for more information about the VISQ, see the What is inner speech? section). This indicates that people with schizophrenia may hear voices in their head that talk to them as a part of their inner speech.

Researchers have also examined the possibility that these voices are misattributions of the individual's own inner speech. Experiments have supported this idea, where people with schizophrenia have attributed self-produced sentences to others and vice versa (the opposite has shown less prevalence in studies). But there is still ongoing debate about whether or not this hypothesis holds water.

Interestingly, people with schizophrenia are able to distinguish these inner voices from their "own" inner voice as these voices interact. Researchers have even hypothesized that an increased amount of dialogic inner speech may lead to better relationships with these inner voices, although more investigation is needed in this area.

Overall, it is clear that individuals with schizophrenia experience many voices in their internal speech that interact with each other and the individual, differentiating their inner speech from that of someone who does not have the disorder. Additionally, that differentiation may lead them to interpret these internal voices within their inner speech as coming from an external source.

Autism Spectrum Disorder: a neurological and developmental disorder characterized by difficulty with communication and interaction with others, constricted areas of interest, and symptoms that affect their ability to function in daily life (from the NIMH definition)

Thank you for your interest in inner speech as it relates to individuals with autism spectrum disorder.

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterized by a wide range (spectrum) of symptoms, including social communication difficulties, repetitive behaviors, and restricted interests. While there are considerable differences among individuals with ASD, recent research has highlighted some commonalities in the way people with ASD use inner speech.

Many studies have shown that individuals with ASD use inner speech less than individuals without ASD. Specifically, individuals with ASD have demonstrated less use of inner dialogic (many voice/conversational) speech, and more monologic (one voice) speech. This lessened inner speech has been associated with decreases in cognitive performance.

This lessened use of dialogic inner speech has also been associated with poor emotional regulation, which is often a symptom of ASD. Researchers have found data that suggest individuals with ASD do not use inner speech when regulating their emotions, while individuals without ASD do.

A recent study measured the contribution of inner speech in individuals with ASD compared to individuals without ASD. The results showed that when solving puzzles, individuals with ASD used inner speech less. Researchers do caution, though, that these results might differ based on the verbal abilities of the individuals (since the disorder is a spectrum, some people with ASD may have better language ability and thus may be more likely to use inner speech) but they do not rule out the possibility that the inner speech itself is potentially structured differently.

These findings have opened up a new approach towards therapeutic methods in ASD. While many methods have focused on developing communication skills with others, not many have focused on teaching individuals with ASD methods of communicating with themselves through inner speech. By developing inner speech skills, individuals with ASD may be better equipped to learn to regulate their emotions and (potentially) improve their performance on tests that measure cognitive skills.

Generalized Anxiety Disorder: characterized by unrealistic fear, worry, and constant feeling of being overwhelmed that is excessive and persistent through everyday life (from the NIMH definition)

Thank you for your interest in inner speech as it relates to individuals with generalized anxiety disorder.

One of the primary features of inner speech in individuals with generalized anxiety disorder (GAD) is the presence of worry-related negative thought spirals that are often repetitive. According to Borkovec, Robinson, Pruzinsky, & DePree, worry is defined as "a chain of thoughts and images, negatively affect-laden and relatively uncontrollable." Individuals with GAD find it challenging to suppress worry once it begins, and negative inner speech often accompanies it. This negative inner speech can include filtering out the positive aspects of a situation, catastrophizing with thought spirals that end in worst-case scenarios, and personalizing blame for situations, even when it is not warranted.

In addition to negative thought spirals, individuals with GAD typically experience more unwanted interruptions to their inner speech, known as thought intrusions, than those without GAD. These thought intrusions make it difficult for people with GAD to have a constant flow of inner speech and interrupt concentration, causing poorer scores on cognitive tests and overall decreased quality of life.

Inner speech in individuals with GAD is characterized by negative worry-focused content and frequent thought intrusions. Also, Fernyhough found that anxiety is correlated with motivational/evaluative inner speech (recall the VISQ!).

To address these issues, current treatments for GAD emphasize individual awareness of negative inner speech and encourage dialogical inner speech, in which the individual confronts the initial negative and unrealistic thought with a more forgiving and realistic one.

Obsessive-Compulsive Disorder (OCD): a common and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts ("obsessions") and/or behaviors ("compulsions") that he or she feels the urge to repeat over and over (from the NIMH definition)

Thank you for your interest in inner speech as it relates to individuals with obsessive-compulsive disorder.

Similarly to individuals with generalized anxiety disorder, individuals with obsessive-compulsive disorder (OCD) report intrusions to their inner speech. Unlike individuals with generalized anxiety disorder, however, these repetitive intrusions are characterized by specific “obsessions”, such as fears of contamination, the need to keep things in a specific order (for an example from pop culture, take Khloe Kardashian’s overly-sensationalized fridge organization obsession).

This phenomenon has prompted researchers to examine whether individuals with OCD might feel like they have less autonomy over their inner speech, as they have difficulty resisting the subsequent compulsions and seem unable to control the obsessions themselves. A study examining people with OCD and without OCD found that people with OCD were more susceptible to thoughts being “implanted” when they were told (falsely) that subliminal sounds could “insert” themselves into their minds.

It is important to distinguish this concept from schizophrenia, however, because people with OCD do not misattribute their own inner speech to an outer source like a person with schizophrenia might; in other words, people with OCD have shown less feeling of control over their inner speech, but do not feel as though their inner speech is not their own.

Overall, people with OCD have inner speech that is often characterized by the frequent and repetitive appearance of obsessions that disrupt the thinker’s life, and the intrusion of these obsessions feels uncontrollable.

Major Depressive Disorder (Clinical Depression): a disorder characterized by persistently low mood, decreased interest in fun activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, sleep disturbances, or suicidal thoughts (from the NIMH definition)

Thank you for your interest in inner speech as it relates to individuals with major depressive disorder (clinical depression).

A characteristic of inner speech in individuals with major depressive disorder is rumination, or repetitive thoughts about past experience (especially negative ones). Rumination in inner speech has been found to include dialogic (conversational) inner speech (but not exclusively verbal thought) – and promotes intensified negative thought patterns. Rumination has been linked with less ability to control one’s thoughts, meaning that individuals with major depressive disorder who ruminate will feel less in control of their thoughts.

Further, individuals with major depressive disorder (similarly to those with generalized anxiety disorder and obsessive-compulsive disorder) experience unwanted thought intrusions, or uncontrollable interruptions to their inner speech.

Researchers have suggested that individuals who experience uncontrollable interruptions try to replace the thought they are fixated on with another thought, rather than trying to stop the rumination itself. The search to help with the consistently negative inner speech that individuals with major depressive disorder continues to this day.

Attention-deficit/hyperactivity disorder (ADHD): marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development (from the NIMH definition)

Thank you for your interest in inner speech as it relates to individuals with attention-deficit/hyperactivity disorder.

In studies of children with ADHD compared to children without ADHD, researchers found that the children with ADHD tended to use external self-talk (private speech) more than their peers without it. This private speech was used to regulate and formulate their thoughts. They also found that teachers would discourage and suppress the childrens' private speech, and encouraged teachers not to do this, but to provide a safe space for the children to talk to themselves since it may be important for their self-regulation.

They also found that the private speech of these children was different from their peers - they talked more to themselves in general, and what they talked about tended to be more irrelevant to whatever they were told to do. They also didn't talk to themselves silently (internal speech) as much as children without ADHD. The researchers think this is probably due to the difficulties with inhibition that come with ADHD.

See below for how the researchers categorized the private speech in these children - children with ADHD tend towards the far left more often than children without ADHD.

Conclusions from our exploration of mental disorders & inner speech

Evidently, inner speech frequency, quality, and type has been found to differ with various psychological disorders (we've covered a lot but not all of them here) and potentially affect some of their symptoms; its role in mental well-being is demonstrably important, but has yet to be fully investigated.

While I (and the scientific literature) definitely do not yet have the answers to all of the questions you may have, I (we) might have some of them. Check out the next page for an inner speech FAQ!

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References (by section) check out this section for further reading!

(1) Schizophrenia

Brébion G, Stephan-Otto C, Ochoa S, Roca M, Nieto L and Usall J (2016) Impaired Self-Monitoring of Inner Speech in Schizophrenia Patients with Verbal Hallucinations and in Non-clinical Individuals Prone to Hallucinations. Front. Psychol. 7:1381. doi: 10.3389/fpsyg.2016.01381

National Institute of Mental Health (2023) Schizophrenia. https://www.nimh.nih.gov/health/statistics/schizophrenia#:~:text=Schizophrenia%20is%20a%20mental%20disorder,be%20both%20severe%20and%20disabling

de Sousa, P., Sellwood, W., Spray, A., Fernyhough, C., & Bentall, R. P. (2016). Inner speech and clarity of self-concept in thought disorder and auditory-verbal hallucinations. Journal of Nervous and Mental Disease, 204(12), 885–893. https://doi.org/10.1097/NMD.0000000000000584

Stephane, M., Kuskowski, M., McClannahan, K., Surerus, C., & Nelson, K. (2010). Evaluation of speech misattribution bias in schizophrenia. Psychological medicine, 40(5), 741–748. https://doi.org/10.1017/S003329170999081X

(2) Autism Spectrum Disorder (ASD)

Albein-Urios, N., Youssef, G., Klas, A. et al. Inner Speech Moderates the Relationship Between Autism Spectrum Traits and Emotion Regulation. J Autism Dev Disord 51, 3322–3330 (2021). https://doi.org/10.1007/s10803-020-04750-7

Alderson-Day, B., & Fernyhough, C. (2015). Inner Speech: Development, Cognitive Functions, Phenomenology, and Neurobiology. Psychological Bulletin, 141, 931 - 965.

Granato, G., Borghi, A.M., Mattera, A. et al. A computational model of inner speech supporting flexible goal-directed behaviour in Autism. Sci Rep 12, 14198 (2022). https://doi.org/10.1038/s41598-022-18445-9

National Institute of Mental Health (2023) Autism Spectrum Disorder. https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd#:~:text=Autism%20spectrum%20disorder%20(ASD)%20is,first%202%20years%20of%20life.

Vissers CTWM, Tomas E and Law J (2020) The Emergence of Inner Speech and Its Measurement in Atypically Developing Children. Front. Psychol. 11:279. doi: 10.3389/fpsyg.2020.00279

(3) Generalized Anxiety Disorder (GAD)

Borkovec T. D., Robinson E., Pruzinsky T., DePree J. A. (1983). Preliminary exploration of worry: Some characteristics and processes. Behaviour Research and Therapy, 21, 9–16.

Fox, E., Dutton, K., Yates, A., Georgiou, G. A., & Mouchlianitis, E. (2015). Attentional Control and Suppressing Negative Thought Intrusions in Pathological Worry. Clinical Psychological Science, 3(4), 593–606. https://doi-org.proxy.wm.edu/10.1177/2167702615575878

Kellogg RT, Chirino CA and Gfeller JD (2020) The Complex Role of Mental Time Travel in Depressive and Anxiety Disorders: An Ensemble Perspective. Front. Psychol. 11:1465. doi: 10.3389/fpsyg.2020.01465

National Institute of Mental Health (2023) Generalized Anxiety Disorder. https://www.ncbi.nlm.nih.gov/books/NBK441870/#:~:text=Generalized%20anxiety%20disorder%20is%20a,unrealistic%20worry%20about%20everyday%20things

Munir S, Takov V. Generalized Anxiety Disorder (2022). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441870/?report=classic

“Positive Thinking: Stop negative self-talk to reduce stress” (2022). https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/positive-thinking/art-20043950

(4) Obsessive-Compulsive Disorder (OCD)

Corinthios, A. (2019). Khloé Kardashian, a 'Control Freak,' Meets with Exposure Therapist About 'Obsessive Cleaning'.

https://people.com/tv/khloe-kardashian-ocd-exposure-therapy-kuwtk/

Fradkin, I., Eitam, B., Strauss, A. Y., & Huppert, J. D. (2019). Thoughts as Unexpected Intruders: Context, Obsessive-Compulsive Symptoms, and the Sense of Agency Over Thoughts. Clinical Psychological Science, 7(1), 162–180. https://doi-org.proxy.wm.edu/10.1177/2167702618797102

National Institute of Mental Health (2023). Obsessive-Compulsive Disorder. https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd&sa=D&source=docs&ust=1680536706624893&usg=AOvVaw0zPoqASKPTUJh03-GlEkFl

(5) Major Depressive Disorder (MDD)

Hertel, P. T., Maydon, A., Ogilvie, A., & Mor, N. (2018). Ruminators (Unlike Others) Fail to Show Suppression-Induced Forgetting on Indirect Measures of Memory. Clinical Psychological Science, 6(6), 872–881. https://doi.org/10.1177/2167702618785339

Donaldson, C., & Lam, D. (2004). Rumination, mood and social problem-solving in major depression. Psychological Medicine, 34(7), 1309–1318. doi:10.1017/s0033291704001904

Moffatt, J., Mitrenga, K. J., Alderson-Day, B., Moseley, P., & Fernyhough, C. (2020). Inner experience differs in rumination and distraction without a change in electromyographical correlates of inner speech. PloS one, 15(9), e0238920. https://doi.org/10.1371/journal.pone.0238920

Park, R.J., Goodyer, I.M. and Teasdale, J.D. (2004), Effects of induced rumination and distraction on mood and overgeneral autobiographical memory in adolescent Major Depressive Disorder and controls. Journal of Child Psychology and Psychiatry, 45: 996-1006. https://doi.org/10.1111/j.1469-7610.2004.t01-1-00291.x

(6) Attention deficit/hyperactivity disorder (ADHD)

Corkum, P., Humphries, K., Mullane, J. C., & Theriault, F. (2008). Private speech in children with ADHD and their typically developing peers during

problem-solving and inhibition tasks. Contemporary Educational Psychology, 33(1), 97–115. doi:10.1016/j.cedpsych.2006.12.003 10.1016/j.cedpsych.2006.12.003

Hum, M., Masellis, M., Humphries, T., Schachar, R. J., & Tannock, R. (1999). Teacher telephone interview: systematic assessment instrument for disruptive behavior disorders. In Presented at the 46th annual meeting of the American Academy of Child & Adolescent Psychiatry, Chicago, Illinois

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