Reliability and validity of a new scale for measuring relationships with voices: The DAIMON Scale

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Reliability and validity of a new scalefor measuring relationships withvoices: The DAIMON ScaleS. Perona-Garcelánab, S. Escudero-Péreza, M.D. Barros-Albarrána,M.G. León-Palaciosa, J. Úbeda-Gómeza, J.M. García-Montesf,A.M. López-Jiménezc, O. Vallina-Fernándezd, R. Jiménez-García-Bóvedaa, C. Diez-Alegríae, J.F. Rodríguez-Testalb, M. Ruiz-Veguillaa

& M. Pérez-Álvarezg

a Virgen del Rocío Outpatient Mental Hospital, University HospitalVirgen del Rocío, Seville, Spainb Evaluation and Psychological Treatment Department, Universityof Seville Personality, Seville, Spainc Department of Experimental Psychology, University of Seville,Seville, Spaind Mental Health Unit, Sierrallana Hospital, Torrelavega, Spaine San Carlos Outpatient Mental Hospital, Hospital Clínico SanCarlos, Madrid, Spainf University of Almería Personality, Almeria, Spaing Evaluation and Psychological Treatment Department, Universityof Oviedo Personality, Oviedo, SpainPublished online: 14 Apr 2015.

To cite this article: S. Perona-Garcelán, S. Escudero-Pérez, M.D. Barros-Albarrán, M.G. León-Palacios, J. Úbeda-Gómez, J.M. García-Montes, A.M. López-Jiménez, O. Vallina-Fernández,R. Jiménez-García-Bóveda, C. Diez-Alegría, J.F. Rodríguez-Testal, M. Ruiz-Veguilla & M.Pérez-Álvarez (2015): Reliability and validity of a new scale for measuring relationships withvoices: The DAIMON Scale, Psychosis: Psychological, Social and Integrative Approaches, DOI:10.1080/17522439.2015.1028429

To link to this article: http://dx.doi.org/10.1080/17522439.2015.1028429

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Reliability and validity of a new scale for measuring relationshipswith voices: The DAIMON Scale

S. Perona-Garcelána,b*, S. Escudero-Péreza, M.D. Barros-Albarrána,M.G. León-Palaciosa, J. Úbeda-Gómeza, J.M. García-Montesf,A.M. López-Jiménezc, O. Vallina-Fernándezd, R. Jiménez-García-Bóvedaa,C. Diez-Alegríae, J.F. Rodríguez-Testalb, M. Ruiz-Veguillaa and M. Pérez-Álvarezg

aVirgen del Rocío Outpatient Mental Hospital, University Hospital Virgen del Rocío, Seville,Spain; bEvaluation and Psychological Treatment Department, University of SevillePersonality, Seville, Spain; cDepartment of Experimental Psychology, University of Seville,Seville, Spain; dMental Health Unit, Sierrallana Hospital, Torrelavega, Spain; eSan CarlosOutpatient Mental Hospital, Hospital Clínico San Carlos, Madrid, Spain; fUniversity ofAlmería Personality, Almeria, Spain; gEvaluation and Psychological Treatment Department,University of Oviedo Personality, Oviedo, Spain

(Received 5 September 2014; accepted 8 March 2015)

This article describes the construction and psychometric properties of theDAIMON Scale for measuring a person’s interaction with his/her voices fromthe point of view of their pragmatic and dialogical characteristics in a sample ofmental health service users who hear voices. Reliability was calculated using theChronbach’s α, and test–retest and concurrent validity by the Pearson correlationcoefficient with the VAY, BAVQ and PSYRATS scores. The results showed thatinternal consistency of this scale varied from 0.80 to 0.84 on the various sub-scales, and the test–retest reliability for two subscales (relationship of the voicewith the person and emotional reaction to interaction with the voices) was 0.71and 0.78, respectively. For the other two subscales (relationship of the person tothe voice and relationships among voices) it was 0.59 and 0.53, respectively.Concurrent validity was acceptable, showing a significant association with theVAY, BAVQ and PSYRATS subscales. It was concluded that the DAIMON scalecan be a valid, reliable instrument for use in both research on and interventionswith people who hear voices.

Keywords: hallucinations; psychosis; dialogical; relationship with voices;assessment

For over 30 years, extensive research in auditory verbal hallucinations (or voices) hasbeen conducted in which they have been studied as a psychological experience initself without being included under a more diagnostic entity such as schizophrenia. Infact, voices may appear in other mental disorders and even in individuals with nopathology (Aleman & Larøi, 2008).

Research in this area has concentrated on studying and explaining some of theircharacteristics and associated psychological processes. Among these are mainly

*Corresponding author. Email: [email protected]

© 2015 Taylor & Francis

Psychosis, 2015http://dx.doi.org/10.1080/17522439.2015.1028429

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studies related to failure of self-recognition, difficulty in controlling private eventsand explaining perceptual and emotional qualities of the voices (Waters et al., 2012).

Another field of research in auditory verbal hallucinations consists of studyingthe relationship between the person and his/her voices. Two lines of research havebeen developed on this subject to date.

One of them studies the interpersonal processes that intervene in establishing therelationship with the voices. Research using Gilbert’s Social Rank Theory (Gilbert& Allan, 1998) has found that voice hearers can establish a balance of power andsubordination with their voices very similar to what they do in their ordinary socialsettings (Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000). Moreover,research using Birtchnell’s Relating Theory (Birtchnell, 1996) suggests that peoplerelate to their voices on two axes: upper–lower and close–distant, and each of thesetypes of relationships can affect the person differently in terms of disturbance anddistress (Hayward, 2003). Some authors have tried to specify this type of two-wayrelationship between patients and their voices (Vaughan & Fowler, 2004).

The other line of research, developed by Leudar, Thomas, McNally and Glinskim(1997), suggests that voices are unusual forms of inner speech with pragmatic and dia-logical characteristics. From this framework, thought is understood to have a social ori-gin and emerge from a child’s interaction and dialogue with those who care for him/her.According to Vygotsky (1934), social dialogues become internalized and form innerspeech, integrating the various perspectives of reality with those the child comes in con-tact with throughout his/her development. According to Fernyhough (2004), matureinner speech is the result of continuous dialogue between those internalized perspec-tives which are maintained simultaneously by the subject. However, there is one charac-teristic of the voices that does not occur in ordinary inner speech, which is thedissociation of the person and his/her “inner voice”, and its personification. Accordingto Mead (1934), a child may internalize the reactions of significant people he/she liveswith and integrate them in what this author calls the “generalized other”. According toMead, the Self has a reflexive social structure consisting of a combination of “I” andthe “generalized other”. Therefore, from this perspective, the voices may be understoodas a dialogical relationship between two positions, the person and the voices(Perona-Garcelán, Pérez-Alvarez, García-Montes, & Cangas, 2015). Leudar et al.(1997) carried out a study in this sense to demonstrate that the voices have pragmaticand dialogical properties, confirming the results of their hypothesis.

To date, only scales for measuring the relationship with voices from the first perspec-tive, that is, interpersonal processes that intervene in the relationship with the voices, havebeen designed. Vaughan and Fowler (2004) developed “The Hearer to Voice” (HTV) and“The Voice to Hearer” (VTH) scales. However, these two scales have problems with thereliability of some of their subscales (Vaughan, & Fowler, 2004). To overcome theseproblems, Hayward, Denney, Vaughan, and Fowler (2008) constructed “The Voice andYou” (VAY), and found it to have good psychometric properties.

Nevertheless, as far as we know, there are no scales that measure the relationshipwith the voices from the perspective of their pragmatic and dialogical properties. Webelieve that the creation of a scale of this type can be of use in studying the charac-teristics of a person’s dialogue with his/her voices in greater depth, and analyzing thepsychopathological variables that could strengthen both development and mainte-nance of this dialogue. It could also contribute to the design of intervention strategiesconcentrating on phenomenological aspects of the voices. We think this scale wouldcomplement the VAY scale, because they evaluate different but complementary

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aspects of a person’s relationship with his/her voices. While the DAIMON scalemeasures the relationship with voices from a dialogical perspective, that is, from theway the dialogue and communication with the voices are established, the VAY scaledoes so from the interpersonal power and proximity processes given in socialrelations for ranking within a group.

The purpose of this article is therefore to describe the construction and study ofthe psychometric properties of the DAIMON Scale, developed in a Spanish-nationality population to measure a person’s interaction with his/her voices from theperspective of their pragmatic and dialogical properties.

Method

Construction of the scale

The original items used for construction of the DAIMON Scale were proposed bythe members of our research group, all of whom are experts in the treatment ofindividuals with psychotic disorders, based on their own clinical experience and onthe Leudar et al. (1997) interview for assessing the pragmatic and dialogical proper-ties of the voices. Specifically, they concentrated on those elements of a patient’srelationship with his/her voices that best described the properties of communication.Items were generated in a group work session in which the goals of the scale werespecified and items were proposed. Of the items proposed, those that described asubject’s interaction with his/her voices from a pragmatic, dialogical viewpoint wereselected by consensus. The first version of the scale contained items measuringseveral different aspects of the relationship:

� The person’s relationship with his/her voices (12 items).� The voices’ relationships with the person (9 items).� The relationships of the voices with each other (6 items).� Duration and frequency of episodes of interaction with the voices (4 items).� Feeling of reality of those experiences (2 items).

The 33 items on this first version were scored on a six-point Likert-type scalefrom 0 (I have not talked to them in the past week) to 5 (I always talked to myvoices in the past week).

They asked about the general relationship with their voices and not the predomi-nant voice. The items on the first three aspects described either the person’s or thevoices’ verbal behavior in their dialogue. Thus items were included that referred tothe dialogical functions described by Leudar et al. (1997), and specifically, the direc-tive (the person/voice attempts to control the behavior of the other with orders,advice or suggestions), evaluative (the person/voice makes positive or negative com-ments about the other), interrogative (the person/voice asks for information aboutthe other) and informative (the person/voice informs the other on subjects that couldbe of interest to both) functions of dialogue between the person and his/her voices.

In the second stage, the 33-item scale was sent to a group of six experts withexperience in the treatment of and research in psychosis in Spain. They were each sentan email explaining the purposes of the study and asking them to evaluate the validityof this version of the questionnaire for measuring relationships with voices. They werealso asked to delete or modify those items they considered invalid, and suggest anyother new ones they considered more valid for the construction of this scale.

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Everyone in this group answered and made changes to the first version of thescale, correcting how some items were written to describe their content moreprecisely, eliminating items that had to do with the reality of those experiences(2 items) and those that had to do with quantity (frequency and duration) of epi-sodes of interaction with voices (4 items), because they did not think they were rele-vant to the purposes of the scale. One new item contributed to the assessment ofrelationships among voices, and 18 items were included to assess the person’semotions and behavior associated with the relationship with the voices. All theexperts considered it very important to include items in the scale that describe theperson’s reaction to his/her voices when relating with them.

With the contributions and corrections by the group of experts, a new version ofthe scale was designed, and was again sent to the same group of experts for the sec-ond revision. This revision consisted basically of correcting how the items werewritten. To assess comprehension of the scale, it was given to a group of fivepatients diagnosed with schizophrenia who heard voices in order to make the lastcorrections for the final version.

The final version of the DAIMON Scale consisted of 44 items divided into 4subscales:

� Dialogical relationship when the person addresses the voice (Dp-v: 10 items).� Relationship when the voice addresses the person (Dv-p: 9 items).� Relationships among voices (Dv-v: 7 items).� Emotional reaction and behavior of the person during those dialogues (Dem:18 items).

Participants

The sample was made up of 51 patients with auditory verbal hallucinations: 37 men(72.5%) and 14 women (27.5%) who were being cared for in the mental health unitsat the Virgen del Rocío Hospital (Seville, Spain), Sierrallana Hospital (Torrelavega,Spain) and San Carlos Clinical Hospital (Madrid, Spain). Table 1 shows the clinicaland demographic characteristics of participants in this study.

Instruments

VAY (Voice and You Scale, Hayward et al., 2008)

In this study, the Spanish version of the VAY consisting of 23 items (VAY-23, Per-ona-Garcelán et al., 2015) was used. This scale measures the interrelationshipsbetween the person who hears voices and his/her predominant voice based on twoaxes representing the power and proximity of that relationship. The interrelationshipwith the voices is evaluated on four subscales: “dominance of the voice”, “intrusive-ness of the voice”, “distance of the hearer” and “dependence of the hearer”. Eachitem is answered on a four-point Likert-type scale from 0 (almost never true) to 3(almost always true). The Spanish version has good psychometric properties, with aCronbach’s α for the four subscales of 0.74–0.82.

BAVQ (The Beliefs about Voices Questionnaire, Chadwick & Birchwood, 1995)

This scale measures the beliefs, emotions and behavior of the individual in reactionto auditory hallucinations. The items are grouped in five subscales – three on beliefs:

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“malevolence”, “benevolence” and “omnipotence”, and two on the emotionalreactions and behavior in reaction to the voices: “resistance to the voice” and“engagement with the voice”. The version that we used for this study was theSpanish version by Robles-García, Páez-Agraz, Zúñiga-Partida, Rizo-Méndez, andHernández-Villanueva (2004), which consists of 30 items and is the adaptation ofthe original scale by Chadwick and Birchwood (1995). It has a four-pointLikert-type answer format (0 = never, 3 = always) and good psychometric properties(reliability 0.84–0.90 for the various subscales).

PSYRATS Auditory Hallucinations Scale (The Psychotic Symptom Rating Scales,Haddock, Mccarron, Tarrier, & Faragher, 1999)

The PSYRATS is a semi-structured interview designed to evaluate the subjectivecharacteristics of hallucinations and delusions. It consists of two scales, one measur-ing 6 dimensions of delusions and the other measuring 11 dimensions of hallucina-tions. In this study, only the Spanish version of the hallucinations scale was used(González, Sanjuán, Cañete, Echánove, & Leal, 2003). Each dimension is evaluatedon a five-point Likert-type scale (0–4). This version has adequate psychometricproperties, and specifically, interrater reliability was over 0.80 for each of its dimen-sions. For this study, we used the classification of dimensions of the English version:F1: Emotional characteristics of the voices (Dimensions 6, 7, 8, 9), F2: Physicalcharacteristics of the voices (Dimensions 1, 2, 4) and F3: Cognitive interpretation ofthe voices (Dimensions 3, 5, 10 and 11).

Table 1. Demographic and clinical characteristics.

GenderMen 37 (72%)Women 14 (28%)Age (mean and standard deviation) 38 (10.24)Marital statusSingle 43 (84%)Married 5 (10%)Separated 3 (6%)EmploymentDisabled 25 (49%)Unemployed 23 (45%)Protected employment 2 (4%)Student 1 (2%)DiagnosisSchizophrenia 42 (82.4%)Schizoaffective 4 (8%)Unspecified nonorganic psychosis 3 (6%)Borderline personality disorder 2 (4%)PANSS-Hallucinations (mean and standard deviation) 5 (0.91)Age disorder onset (mean and standard deviation) 22.65 (6.30)Time disorder had been developing (years: mean and standard deviation) 16 (10.22)Time with voices (years: mean and standard deviation) 14 (10.40)Number of hospital admissions (mean and standard deviation) 2.10 (2.68)

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The Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Lindenmayer,1988)

The Spanish version by Peralta and Cuesta (1994) was used. It is a semi-structuredinterview for measuring the presence and severity of positive and negative psychoticsymptoms. In this study, only the interview subscale for measuring hallucinationswas used. The answers were scored on a seven-point scale in which one pointindicates “absent” and seven “extreme”.

Procedure

Written informed consent and demographic and clinical data were requested from allpatients participating before the tests were given. The scales were given in thefollowing order: PANSS, PSYRATS, DAIMON, VAY-23 and BAVQ. Assessmentwas done in two sessions one week apart. The second session was used to evaluateDAIMON test–retest reliability.

Results

Descriptive analysis

The mean scores found for the DAIMON subscales were 9.92 (s.d. = 8.72) on theDp-v subscale, 11.09 (s.d. = 8.14) on the Dv-p, 10.66 (s.d. = 8.53) on the Dv-v and17.47 (s.d. = 9.55) on the Dem. Skewness statistics were 1.33 (s.e. = 0.33) for theDp-v, 0.30 (s.e. = 0.33) for the Dv-p, 0.45 (s.e. = 0.33) for the Dv-v, and 0.30 (s.e. =0.33) for the Dem.

Reliability of the DAIMON scale

Internal consistency of the DAIMON scale was analyzed using the Cronbach’s α.The criterion used was elimination of items with a correlation to the whole scaleunder 0.3 (Kline, 1986). The Cronbach’s α for each of the subscales were:

� The Dp-v subscale originally had a Cronbach’s α of 0.75, but two items had alow item-total correlation (<0.3). When they were eliminated, internal consis-tency was 0.80.

� On the Dv-p subscale, the Cronbach’s α was 0.76, and when three items wereeliminated because of their low item-total correlation, the score was 0.82.

� The Dv-v subscale had a Cronbach’s α of 0.83 and the item-total correlationswere all over 0.3.

� The Dem subscale had a Cronbach’s α of 0.73. After 11 items were eliminatedbecause of their low item-total correlation, internal consistency was 0.84.

Stability over time had acceptable test–retest correlation coefficients (≥0.70) for theDv-p subscale (r = 0.71, p < 0.001) and the Dem subscale (r = 0.78, p < 0.001). Forthe Dp-v and Dv-v subscales, the correlation coefficients were also significant butbelow 0.70 (r = 0.59, p < 0.001 and r = 0.53, p < 0.001 respectively).

Concurrent validity of the DAIMON Scale

To examine the concurrent validity, the Pearson’s correlation coefficients for theDAIMON subscales with the PSYRATS dimensions and the VAY-23 and BAVQ

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Table

2.Correlatio

nsbetweenDAIM

ON

subscalesandPSYRATSdimensions.

Physicalcharacteristics

Emotionalcharacteristics

Cognitiv

einterpretatio

n

DAIM

ON

12

46

78

93

510

11

Person-voice

0.29*

0.38**

0.10

−0.22

0.01

−0.06

−0.07

0.10

0.13

0.11

−0.12

Voice-person

0.44**

0.33*

0.33*

0.32*

0.47**

0.35*

0.27

−0.01

0.31*

0.49***

0.20

Voice-voice

0.42**

0.29*

0.12

0.11

0.27

0.04

0.11

0.01

0.14

0.17

−0.20

Emotion

0.25

0.32*

0.37**

0.48***

0.42**

0.50***

0.33*

0.01

0.32*

0.51***

0.21

Notes:Dim

ension

s:1:

Frequ

ency;2:

Duration;

3:Location;

4:Lou

dness;

5:Beliefs

reorigin

ofvo

ices;6:

Amou

ntnegativ

econtent;7:

Degreenegativ

econtent;8:

Amou

ntdistress;9:

Intensity

distress;10

:Disruption;

11:Con

trol.

***p

<0.00

1(two-tailed);**

p<0.01

(two-tailed);*p

<0.05

(two-tailed).

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subscales were calculated. The results are shown in Tables 2–4. It may be seen inthese tables that each of the DAIMON subscales shows specific significant correla-tions with each of the other scales, so profiles can be established for each of theDAIMON subscales as mentioned in the Discussion.

Discussion

The purpose of this study was to develop a scale for evaluating the extent ofpragmatic, dialogical relationships with the voices. The final DAIMON scale (seeFigure 1) is comprised of 28 items evaluated on a 6-point Likert-type scale (0 = norelations with the voices in the past week and 5 = maximum relations during thepast week). It is made up of four subscales with the following characteristics:

� Dp-v measures the relationship in which the person addresses the voice (eightitems). The items describe situations in which the person addresses the voiceand converses with it directly, asking it to do things, forbidding others, askingit questions, or giving it information. High scores on this subscale show thatthe person’s relationship with the voices is closer and more interested.

� Dv-p measures the relationship in which the voice addresses the person (sixitems). In this subscale, the items describe situations in which the voice is theone who addresses the person and asks him/her to do things, forbids others,asks questions, gives information, or makes evaluative comments. High scoresshow a stronger relationship of the voice with the person.

� Dv-v measures the relationships among the voices (seven items). These itemsdescribe situations in which the voices relate to each other, and the person is apassive observer of their relations. The higher the score, the more the voicesrelate to each other.

� Dem measures the person’s emotional reaction to the relationship with his/hervoices (seven items). High scores are related to high levels of anxiety andavoidance of contact with the voices.

Table 3. Correlations between the DAIMON and VAY-23 subscales.

DAIMON Dominance Intrusiveness Dependence Distance

Person-voice 0.08 0.39** 0.39** −0.07Voice-person 0.64*** 0.50*** 0.25 0.50***Voice-voice 0.20 0.22 0.04 0.19Emotion 0.73*** 0.29* 0.05 0.65***

***p < 0.001 (two-tailed); **p < 0.01 (two-tailed); *p < 0.05 (two-tailed).

Table 4. Correlations between the DAIMON and BAVQ subscales.

DAIMON Benevolence Malevolence Omnipotence Resistance Engagement

Person-voice 0.44*** 0.05 0.22 −0.07 0.56***Voice-person 0.17 0.64*** 0.59*** 0.54*** 0.17Voice-voice 0.18 0.34** 0.14 0.16 0.28*Emotion −0.19 0.73*** 0.52*** 0.72*** −0.08

***p < 0.001 (two-tailed); **p < 0.01 (two-tailed); *p < 0.05 (two-tailed).

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Figure 1. Items on the DAIMON Scale.

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The DAIMON Scale is available from the first author upon request. The resultsof this study show that the DAIMON Scale has adequate psychometric properties.Internal consistency of all its subscales is good, varying from 0.80 to 0.84. Test–retest reliability was significant for all the subscales at p < 0.001, and better for theDv-p and Dem subscales, for which it was over 0.7.

Moreover, concurrent validity of the DAIMON scale was studied by means of itscorrelations with other scales that study aspects related to the voices (PSYRATS,VAY-23 and BAVQ), and concurrent validity of each of the DAIMON subscalesshowing very specific profiles as described below.

The Dp-v subscale is observed to be associated with physical characteristics ofthe voices and their frequency and duration, that is, the person who relates to thevoice experiences it frequently and for long periods of time. However, these epi-sodes of voices are not associated with high levels of emotion, as shown by the lackof correlation of Dp-v with the PSYRATS emotional dimensions. In any case,although the correlation was not significant, we found a negative association tendingto significance between Dp-v and negative content of the voices. That is, the moreinitiative the person shows in relating to the voices, the less emotional distresshe/she feels. Furthermore, when the relationship with the VAY is examined, it isfound that high scores on this subscale may be associated with greater dependenceon the voice, that is, an interest in relating with them and being near them, althoughperceived as being intrusive, in the sense of their omnipresence in his/her life. Apartfrom this, the Dp-v had a positive correlation with the BAVQ in beliefs of benevo-lence and engagement with them. These results are coherent with those found byresearchers who show that individuals who perceive their voices positively, usuallyperceive them as benevolent and tend to engage with them, maintaining a relation-ship of closeness and dependence (Hayward, 2003; Hayward et al., 2008).

The Dv-p subscale measures the relationship of the voice with the person. Insuch cases, as observed in our results with the PSYRATS, when it is the voice thatcarries the initiative in the relationship, it is experienced intensely, very frequently,and for long periods, as shown by its association with the physical characteristics ofthe voices. We also found a positive correlation with the emotional dimensions ofthis scale. The person is very distressed in this type of relationship, and perceives itas very intrusive in his/her daily life, as shown by its association with the disruptiondimension of the PSYRATS. The results with the VAY show, in a manner coherentwith what was described above, that the person perceives the voice as very dominantand intrusive in the relationship, and tries to stay away from it, as shown by itsassociation with the VAY distance subscale. The correlations with the BAVQ showthat people with high scores on this subscale think their voices are malevolent andomnipotent, and their reaction is resistance to them (Chadwick & Birchwood, 1995;Hayward et al., 2008).

A different pattern is observed in a validity study of the Dv-v subscale, in whichthe person remains passive to the voices and his/her only action is to observe howthey relate to each other, although he/she is expecting problems to arise. This isclearly seen in its correlation with the BAVQ malevolence subscale, where thevoices are perceived as dangerous, but at the same time he/she is waiting to see whatthey will do, as shown by its correlation with the engagement scale. However, wedid not find any correlation with the VAY subscales, which is coherent, since at thattime the person was not relating to them, but just observing and waiting to see what

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the voices would say to each other. However, the voices are frequent and lasting, asshown by the association with those two PSYRATS dimensions.

Finally, the Dem subscale measures the individual’s emotional reaction to speci-fic episodes of relating to the voices. The validity of this subscale is clearly seen inits correlation with the four PSYRATS emotional dimensions, the beliefs of malevo-lence and omnipotence, and with the BAVQ voice resistance reaction. The negativeemotional reaction to the voices is associated with the VAY perception of the voiceas dominant and intrusive, and with distancing.

The DAIMON can be a useful scale in the field of assessment and psychothera-peutic intervention. It can be used as an instrument supplementing the clinical inter-view and providing relevant information for case formulation. It may also be usefulfor assessing the efficacy of intervention in which the purpose is to modify thepatient’s relationship with his/her voices. Furthermore, its use in clinical practicecould make the patient more sensitive to the aspects dealt with in this questionnaire,and facilitate communication between the therapist and patient in intervention forvoices, by considering their dialogical characteristics. In conclusion, we can statethat the DAIMON scale is a valid, reliable instrument for assessing a person’sdialogical relationship with his/her voices.

However, more studies are necessary to solve the problem of Dp-v and Dv-vsubscale stability over time, using longer periods of time between test and retest. Infuture studies, it would also be desirable to assess predictive validity of the sub-scales and their sensitivity to change, to determine their usefulness in assessing theeffectiveness of therapeutic intervention in patients with voices. Furthermore, itwould be of interest to study the psychometric properties as a function of popula-tion, for example, distinguishing between chronic and acute populations, or subjectsin a first psychotic episode. And finally, this scale must be validated in largersamples for a factor analysis of its underlying factorial structure.

Disclosure statementNo potential conflict of interest was reported by the authors.

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