Schizophrenia patients with auditory hallucinations have distinct morphological abnormalities, but whether this population have a progressive gray matter atrophy pattern and specific transmission chain of causal effects remains unclear. This study was designed to construct a causal structural covariance network in schizophrenia patients with persistent auditory hallucinations.

T1-weighted MRI images were acquired from 90 schizophrenia patients with persistent auditory hallucinations (pAH group) and 83 healthy controls (HC group). Stage-specific independent t tests of gray matter volume (GMV) comparisons between the two groups were used to depict the GMV atrophic pattern and locate the atrophic origin. In the pAH group, the causal structural covariance network (CaSCN) was constructed to map causal effects between the atrophic origin and other regions as the auditory hallucination severity increased.

With the ascending of hallucinatory severity, GMV reductions began from the thalamus, bilateral medial frontal gyri, left Rolandic operculum, and left calcarine, and expanded to other frontal and temporal regions, hippocampal complex, insula, anterior cingulate gyri, fusiform, and cerebellum. Using the peak region (thalamus) as the causal origin in the network, transitional nodes including the right opercular part of the inferior frontal gyrus, bilateral postcentral gyri, left thalamus, and right middle frontal gyrus received the casual information and projected to target nodes from the frontal, temporal, parietal, and occipital cortices, limbic system, and cerebellum.

Our study revealed causal effects from the thalamus and a specific transmission pattern of causal information within the network, indicating a thalamic–cortical–cerebellar circuitry dysfunction related to auditory hallucinations.