Listen Up: More to Auditory Hallucinations Than Hearing Voices

Pam Harrison

March 18, 2015

A novel survey of individuals who experience auditory hallucinations reveals that the phenomenon is far more varied, complex, and nuanced than simply "hearing voices" ― findings that challenge mainstream psychiatric assumptions.

"We were expecting to find very clear patterns in people's experience of hearing voices, but we didn't," study investigator Angela Woods, PhD, Centre for Medical Humanities and School of Medicine, Pharmacy and Health, Durham University, in the United Kingdom, told Medscape Medical News.

"The heterogeneity and the diversity of people's experience hearing voices were pretty overwhelming."

The study was published online March 11 in the Lancet Psychiatry.

In Their Own Words

Auditory hallucinations are a common feature of many psychiatric disorders but are also experienced by individuals with no psychiatric history, the investigators note. However, they add, there is little research into the subjective experiences of individuals who experience such hallucinations.

The aim of the study was to "record a detailed and diverse collection of experiences in the words of the people who hear the voices themselves."

For the study, the researchers developed a 13-item questionnaire that they made available online for 3 months. The questionnaire consisted of a combination of open-ended and closed-ended questions. Researchers invited people aged 16 to 84 years who heard voices to take part in the survey.

A total of 153 participants completed the study.

Although the majority (127) of the participants had been diagnosed with a psychiatric disorder, 26 had no history of mental illness. The majority (81%) of the group described hearing multiple voices; only 7% of individuals reported hearing a single voice.

More than two thirds of the group described the voices they heard as having certain characterful qualities, such as being personlike entities with distinct characteristics, investigators note.

Nonverbal Experiences

In addition, almost half of the sample (46%) reported either thoughtlike or mixed experiences when they heard voices.

"We have this impression that people hearing voices are having some sort of auditory experience, so they are really hearing voices as though they are listening to somebody talking in the room, only nobody's there," said Dr Woods.

"And while for some people that's an accurate way of describing their experience, there were others in our study who described much more 'thoughtlike' experiences, so it's not that they could hear the voice per se, but they understood its presence very clearly, they understood its message very clearly, so they were more intimately aware of the meaning and emotions conveyed by this voice, but it wasn't a voice that could become sound-related," she said.

Furthermore, two thirds of participants reported changes in bodily experience while they heard voices. These bodily experiences varied substantially but included sensations such as tingling in the hands and feet, forms of pressure or pain, or feeling hot.

Participants with bodily experiences were more likely to report voices that were abusive or violent (P = .024) and to anticipate the voices they heard (P = .025) than those who experienced no bodily effects, investigators add.

The voices were accompanied by fear, anxiety, depression, and stress in about one third of the group. Another third reported neutral emotions during their voice-hearing experiences. The final third reported feeling positive emotions.

"Our findings regarding the prevalence and phenomenology of nonacoustic voices are particularly noteworthy. By and large, these voices were not experienced simply as intrusive or unwanted thoughts but rather like the auditory voices, as distinct 'entities' with their own personalities and content," study coinvestigator Nev Jones, PhD, Stanford University, in California, said in a release.

"I think this study shows that there is real value in talking to people about what's really going on with them, about what the voices say, about the different kinds of voices they are experiencing and how it feels," said Dr Woods. "There's a lot to be gained from those initial conversations with people which, sadly, don't always happen in a clinical setting."

Dr Woods also noted that the findings have the potential to overturn mainstream psychiatric assumptions about the nature of hearing voices.

"It is crucial to study mental health and human experiences such as voice-hearing from a variety of different perspectives to truly find out what people are experiencing, not just what we think they must be experiencing because they have a particular diagnosis," Dr Woods said in a statement.

"We hope this approach can help inform the development of future clinical interventions."

Challenges Assumptions

Commenting on the study for Medscape Medical News, Flavie Waters, PhD, associate professor, School of Psychiatry and Clinical Neurosciences, University of Western Australia, in Perth, said that for nearly 100 years, the study of auditory hallucinations has been the realm of schizophrenia researchers.

"Since language disorders are common in schizophrenia and since 'voices' often include verbal contents, it has long been assumed that voices are fundamentally rooted in language experiences," she said.

Findings from Dr Woods and her team challenge the assumption that the raw material of voices is made of speech, she added.

Dr Waters pointed out that nearly half of the study sample revealed that they experienced nonverbal hallucinations involving novel features, such as other body experiences.

Many of those surveyed also preferred the term "intuitive knowing" rather than "voices."

"In my opinion, the obsession on the language or lexical features of voices has distracted us from our quest to understand and treat unwanted hallucinations," Dr Waters said.

"This study clearly shows that this phenomenon is not a two-dimensional experience which can be merely described in terms of syntactic and lexical characteristics," she said.

"Rather, the experiential core of hallucinations has, in fact, all the qualities of real perceptions ― that is, rich, multiplex, detailed, and vivid ― and this gives the experience substance and reality."

The study was funded by the Wellcome Trust. Dr Woods and Dr Waters report no relevant financial relationships.

Lancet Psychiatry. Published online March 11, 2015. Full text

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