Moral emotions and auditory verbal hallucinations in schizophrenia

Adolescence and early adulthood are characterized by the development of cognitive and social skills necessary for autonomous functioning in adult roles. As classically described by Erik Erikson, this developmental process involves forging a meaningful sense of identity, comprising a worldview, set of moral values, and occupational aspirations. This may require individuals questioning or defying the expectations and norms they have learned within the social context of their upbringing; simultaneously they remain acutely sensitive to the judgment of their peers. This developmental period encompasses the age range in which schizophrenia and other psychotic illnesses are most likely to present. As early as 1914 Sigmund Freud postulated a connection between auditory hallucinations and the formation of an independent moral perspective, which served as the basis for his concept of the superego. However, the connection between processes of identity formation and development of psychosis has not been extensively investigated with the current technologies and knowledge base of biological psychiatry, possibly due to the challenges inherent in operationalizing and measuring aspects of personal and moral identity. In this theoretical review we aim to identify areas of overlap between normative developmental processes in the transition to adulthood, the experience of moral emotions, and the phenomenology of hallucinations in schizophrenia, to build a conceptual framework for novel approaches to the study of psychosis.