Individuals who hear voices during psychosis may be vulnerable to increased distress. Cognitive models place emphasis on the role of subjective and cognitive appraisals of voices in influencing different emotional reactions. This paper systematically reviewed literature investigating the relationship between appraisals of voices and distress. The review included 26 studies, published between 1990 and 2008. Several types of appraisals were found to be linked to higher levels of distress in voice hearers, including voices appraised as malevolent, voices appraised as high in supremacy, voices appraised to have personal acquaintance with the individual, and attitudes of disapproval and rejection towards voices. However, results from cognitive therapy trials did not consistently report significant improvements in voice related distress post-intervention. One explanation for this finding is that mediating variables, such as social schemata, exist within the appraisal–distress relationship, variables which were not targeted in the cognitive therapy trials. Areas for future investigation may include developing a greater understanding of mediating variables, such as social schemata, within the appraisal–distress relationship, carrying out interventions aimed at addressing these mediating variables using randomized controlled trial designs, and understanding the relationship between positive affect and voice appraisals.