Auditory hallucinations in adult populations

Citation:
Waters F (2014) Auditory hallucinations in adult populations. Psychiatric Times
http://www.psychiatrictimes.com/schizophrenia/auditory-hallucinations-adult-populations
Address for correspondence: A/Prof Flavie Waters, Clinical Research Centre, Private Mail Bag No 1.
Claremont, Perth. WA 6910, Australia. Telephone: +61 8 9347 6429, Facsimile: +61 8 9384 5128, Email: flavie.waters@health.uwa.edu.au

1.

Overview

Throughout history, auditory hallucinations (also termed voices) have been construed as
evidence of communication with divine powers, although 20th Century medical models have
often viewed these experiences as undesirable and a sign of mental illness. Until recently,
auditory hallucinations carried considerable weight in the diagnostic process as pointing to
schizophrenia-spectrum disorders. It is increasingly clear, however, that auditory
hallucinations occur in a range of psychiatric and medical disorders and in individuals without
mental illness. Despite these recent advances, there are important gaps in our understanding
of hallucinations outside of psychotic disorders. This article provides an up-to-date review of
current knowledge about auditory hallucinations, including their prevalence and characteristic
features in psychiatric illness, medical conditions, and in persons without mental illness. An
overview of assessment methods and assessment tools is also provided. Finally, a brief
review of the evidence-base on different types of treatment is presented. The current review
focuses specifically on adult populations, however see [1] for a discussion of hallucinations in
children and adolescents.

2.

Definition

Auditory hallucinations refer to auditory percepts experienced when awake, and which are not
elicited by an external stimuli. They may be experienced as coming from anywhere in
external space, in the mind or on the surface of the body. The contents vary widely and may
involve language (voices) or other sounds such as music, footsteps, telephone ringing,
buzzing, scratching, whistling, bangs, animal calls, water falling, and engines. Noise volume
varies from hardly audible (e.g. whispers) to very loud. Auditory hallucinations have veridical
perceptual qualities in the sense that individuals are often convinced of the objective reality of

the experience. However they are much more than auditory perceptions. The message carried
by hallucinated voices often contains such personalised, and emotionally-charged, contents
that it often resonates with the idea of a speaking character. Hence, the term voice hearers
is a preferred term by the influential Hearing Voices Movement as it makes a connection to a
meaningful human experience [2].
Given the complex and multifaceted nature of hallucinations, it is helpful to thematize the
multiple phenomenological dimensions of hallucinations (Table 1 [3]). In clinical settings
however, features such as frequency, emotional response and functional interference are the
most commonly used dimensions when evaluating treatment response.

3. Auditory hallucinations: Schizophrenia

Auditory hallucinations occur more commonly in people with a diagnosis of schizophrenia
than in any other disorder, with estimates ranging between 60% and75% [4] [5]. It is common
for people with schizophrenia to hear several different voices, and these are often recognised
as belonging to someone who is familiar (such as a neighbour, family member or TV
personality), or to entities such as God, the devil or angels. Voices in schizophrenia often
have negative and malicious contents (in 55% of cases), may speak to the person in a
derogatory or insulting manner, or give commands to perform an intolerable behaviour. These
negative voices cause considerable distress [6]. However, a significant proportion of voices
are pleasant and supportive (40% of cases), and some individuals report feelings of loss when
their treatment makes the voices disappear [7]. The content of voices is usually highly
personalized - the voices will describe what the person is feeling or thinking, and speak about
his/her fears or worries. The personalised contents and subjective reality of voices play a key
role in the development of strong beliefs about the intent and power of voices [8], and an
intense relationship may develop between the voice-hearers and their voices.
A significant proportion of persons with schizophrenia also experience non-verbal
hallucinations (music and other sounds). Often, there is complete absence of verbal material
although a message or meaning is communicated without being heard (soundless voices,
[9]). The clarity of hallucinated speech may be low or fuzzy but the message is always clear.
In schizophrenia, the intensity and frequency of symptoms fluctuate during the illness, but the
factor which determines whether hallucinations are central to the clinical picture is the degree
of interference with activities and mental functions. In many cases (but not always), auditory

hallucinations are intrusive and unwanted, and cause much functional disruptions in personal
and vocational functioning. The person with schizophrenia and auditory hallucinations may or
may not have insight.
For a long time, Schneiders [10] first-rank hallucinations (voices keeping up a running
commentary on the person's behavior or thoughts, or two or more voices conversing with each
other) were thought to be of diagnostic significance for schizophrenia. While this subtype
occurs prominently in schizophrenia, its specificity to schizophrenia has been questioned and
the special treatment of first-rank hallucinations in schizophrenia has since been eliminated
from the DSM-V [11].

4. Auditory hallucinations: Other psychiatric disorders

Auditory hallucinations feature prominently in many psychiatric disorders other than
schizophrenia. They occur in 10-25% of persons with bipolar disorder (10% bipolar
depressed, 11% bipolar manic, 23% bipolar mixed, [12], 6% of people with major depression
[12]), 40-50% Post-Traumatic Stress Disorder (PTSD) [13, 14], and 25-50% of Borderline
Personality Disorder [15] [16].
Compared to schizophrenia, hallucinations in these other psychiatric disorders are often less
severe that is, less frequent and intrusive, and causing less functional interference. Studies
that have compared the characteristic features of hallucinations of persons with psychiatric
disorders against those of schizophrenia (on dimensions such as frequency, duration, location,
content, form, negative content) report greater similarities than differences [12] [15-17],
although the co-occurrence of auditory hallucinations with delusions and hallucinations in
other modalities is more common in schizophrenia. Other key characteristics of auditory
hallucinations in psychotic disorders are: (a) higher frequency of hallucinatory experiences,
(c) co-occurrence of other hallucinations and delusions, (c) greater linguistic complexity, (d)
greater emotional response, and (e) the extent to which patients believe that other people share
this experience [6] [7].
In all psychiatric disorders, the presence of hallucinations is linked to a more severe
psychopathological profile, and to a less favourable prognosis. Baethge et al [12] reported that
hospitalization for individuals with a range of psychotic disorders and hallucinations (all
modalities) averaged 17% longer than those who did not hallucinate. Individuals with
psychotic depression also have a more severe course, and an increased risk of relapse and
hospitalisation, relative to patients with nonpsychotic depression [18].
3

6. Auditory hallucinations in medical and neurological conditions

Multiple general medical and neurological conditions can cause auditory hallucinations (for
reviews see [19, 20]. Frequency is approximately 10% in autoimmune disorders involving the
central nervous system (such as Systemic Lupus Erythematosus - SLE), neuroinfections such
as viral encephalitis, and disorders arising from genetic mutations such as velocardiofacial
syndrome and Prader-Willi Syndrome. Auditory hallucinations may also be precipitated by
neurological conditions, focal brain lesions or cerebral tumours involving subcortical
structures or the temporal lobe.
Auditory hallucinations may also occur in dementia (in which symptoms may present several
years before the diagnosis), delirium, Parkinsons Disease, Huntingtons Disease, and
multiple sclerosis. The frequency of hallucinations increases with the progression of the
disease, and are associated with greater carer distress and mortality rates [21]. Finally,
auditory hallucinations are very common (> 50%) in the abuse of, or withdrawal from,
substances such as alcohol, cocaine and amphetamines.

7. Auditory hallucinations in the general population

People who experience auditory hallucinations do not necessarily suffer from a mental illness.
Transient and infrequent episodes are common in the general population without progression
to a persistent mental illness. It has been estimated that hallucinatory-like experiences occur
in 10%40% of people without a psychiatric illness as assessed using broad screening
questions [22-24]. Factors such as intoxication and withdrawal from substances, and other
physical states such as physical illness, stress and grief contribute greatly to these
experiences. Consequently, prevalence rates in the general population reduce to
approximately 4% when research criteria exclude hallucinations arising in the context of
drugs or medical problems [25, 26].
There are also healthy individuals in the community who experience hallucinations under no
special circumstances. For example, Romme and colleagues [27] conducted a survey of
auditory hallucinations in people who had responded to a television show in the Netherlands.
Approximately half of the sample who responded to questionnaires did not receive medical or
psychiatric treatment, suggesting that hallucinations can occur in community individuals
without the need for care. Descriptive studies have since showed remarkable similarities to
hallucinations reported by people with psychosis, but with key differences: hallucinations are

less frequent and intrusive, of shorter duration, and more positive than in people without
mental illness. In addition, healthy individuals tend to have greater control over their voices,
and report less interference [28, 29]. The absence of delusions is helpful to distinguish nonclinical hallucinatory experiences from psychotic disorders [30].

8. Clinical assessment of auditory hallucinations

All assessments should begin with a detailed history taking. Care must be taken to consider
the cultural background of the person with hallucinations as some cultures and communities
encourage voice hearing and do not associate it with mental illness [31]. In clinical settings,
other neuropsychiatric symptoms (other hallucinations, delusions, insight, language disorders)
must also be assessed. Short scales with good reliability and validity for assessing general
psychopathology include the Brief Psychiatric Rating Scale (BPRS; [32]). Comorbidities such
as drug and alcohol misuse, depression and anxiety and other medical and neurological
disorders which have been linked to auditory hallucinations must be assessed. Laboratory
tests and brain scans can also be helpful in offering further clues as to an organic cause.
If communication and coherent thinking are not impaired, individuals are usually able to
describe their hallucinatory experiences, although challenges include suspiciousness,
guardedness and malingering for personal gain. A standard probe for auditory hallucinations
reads do you ever seem to hear noises or voices when there is nobody about, and no ordinary
explanation seems possible? [33]. A description of the experience in the patients own words
is required for a positive rating.
Many scales (self-report and interviews) have been developed to assess hallucinations. In
research settings, the most commonly used scale is the Psychotic Symptom Rating Scales
(PSYRATS) [34], and in clinical settings the Hallucinations Change Scale (HCS; [35]. See
Waters and Stephane [36] for a comprehensive description and evaluation of 120 ratings
scales on hallucinations and other symptoms.
True auditory hallucinations must be differentiated from:

Auditory distortions and illusions (misinterpretations of real existing stimuli),

Vivid auditory imagery (under volitional control),

Altered consciousness (sleep related hallucinations, delirium, hypnosis), and

Delusion of reference when individuals report that other people are talking about them.

10.

Explanatory models of auditory hallucinations

The multi-faceted nature of auditory hallucinations makes it very difficult to understand.

Frameworks incorporating an interplay between biological and environment factors are best
able to explain hallucinations. Of importance is the biographical context in which
hallucinations emerged. Negative life events and trauma have been causally linked to the
onset of hallucinations, and are also key influences on the content of voices, and on negative
appraisals and disability. In support, stress has been implicated in provoking episodes of
auditory hallucinations, as shown in high rates of hallucinations in bereavement, trauma and
sensory deprivations. In addition, in individuals with a vulnerability for psychosis, a
depressed mood increases significantly the risk of transition to a psychotic episode [30].
Hallucinations, in turn, also increase levels of stress. Both the content and the experience of
intrusive and personal voices can cause distress, and even suicide [37]. Depression, anxiety,
fear and anger occur in 25-40% of persons with auditory hallucinations [38-40].
The exact processes underlying auditory hallucinations remain largely unknown.
Neuroimaging techniques seek to examine the neural underpinnings of hallucinations with an
examination of the brain regions and networks associated with these symptoms.
Neuropsychological approaches, by contrast, target cognitive and psychological processes,
providing an explanation regarding how internal events are accepted as being real and
powerful.
Recent neuroanatomical findings are illustrated in Figure 1. One common formulation
suggests that verbal hallucinations (voices) represent the involvement of language brain
processes, and particularly inner speech processes referring to silent speech that people
engage in. There is support from neuroimaging studies showing that hallucinations with a
verbal content engage brain regions associated with language comprehension and production
such as the primary auditory cortex and Brocas area [41, 42]. However, people with
hallucinations report non-verbal sounds as well as speech, and language processes are not
always activated in imaging studies [43, 44].
A dominant hypothesis in explanatory models of hallucination is that of a dysfunction in
cognitive control [45, 46]. In view of the intrusive nature of hallucinations [47, 48] and
difficulties with cognitive inhibition [49], self-monitoring [50, 51], working memory brain
circuitry (21), set-shifting (Hugdahl, 23) and ruminations (44), an explanation based on
cognitive control dysfunctions is able to account for most salient features of hallucinations in
both psychiatric and non-psychiatric populations. That is, a diminution of inhibition and

executive control processes in individuals with hallucinations produces cortical release of

auditory signals and (often emotionally charged) mental events which are unintentional and
unwanted. As a consequence, hallucinations allow perceptions and thoughts to come to the
foreground of mental experiences, while these events typically remain in the background in
healthy perceptions.
Hallucinations also occur when the brain detects an ambiguous signal from the brain centres
that are active during normal perceptions. People with hallucinations tend to allow the
processing of mental events which would not usually be processed. There is a lower threshold
in accepting a signal is real, such that the brain decides that spontaneous activity in the early
sensory cortices is real and meaningful when it is in fact a random event, contributing to
much confusion regarding where these events come from [46, 52, 53]. These biases in signal
detection explain why individuals report an auditory experience in the absence of any
perceptual input. A brain system which is excessively tuned-in to internal acoustic
experiences may therefore report an auditory perception in the absence of any external sound.
Individuals with auditory hallucinations have excessive attentional focus towards internally
generated events and may be attentively listening to these spontaneous sensory activity which
is largely ignored by other people [54].
11.

Treatment of auditory hallucinations

Hallucinations do not need medical treatment if the experience is not intrusive, and if it does
not interfere with personal or vocational functioning. When treatment is required,
antipsychotic medication is usually the treatment of choice in organic and psychiatric
conditions [55]. Clinicians should provide information and discuss the benefits and sideeffects of each drug. In view of such side-effects, clinicians should make sure to monitor the
physical health of patients regularly. Few studies have compared the efficacy of different

neuroleptic treatments, but it is understood that hallucinations often persist despite intensive
and prolonged pharmacological treatment [56].
In recent years, neurostimulation methods have attracted increasing interest. Repetitive
transcranial magnetic stimulation (rTMS) over the left temporoparietal areas have been
proposed as a useful treatment method. Used as an adjunct to antipsychotic medication,
studies show that rTMS can reduce the frequency and severity of auditory hallucinations [57,
58], although the duration of positive rTMS effects may be less than one month [59].

Newer neurostimulation applications include transcranial direct-current stimulation (tDCS)

which have the advantage of offering simultaneous inhibitory and excitatory action at
different sites, thereby allowing greater coverage of distinct brain systems. Emerging studies
show promise for the treatment of treatment-resistant hallucinations [60], although more
studies are needed.
Psychologies therapies are widely recommended in practice guidelines, often as a
complementary approach to neuroleptics, and especially for treatment-resistant hallucinations.
Much of this work derives from the seminal work by Marius Romme and Sandra Escher [61]
which showed that the restructuring of AH in the form of voices, and as personally
meaningful, had strong therapeutic effects. This led the way for a new generation of
psychological theories, of which Cognitive and Behavioural Therapy for psychosis (CBTp) is
the most common ([62, 63]). The focus is on assisting the person with hallucinations to
reframe beliefs about voice identity, power and intent of voice. By changing the persons
relationship with voices, CBTp approaches aim to reduce distress and the power of voice [62,
64].
Another approach showing impressive success is that of Hallucination-focused Integrative
Treatment (HIT) [65] which includes CBTp with additional motivation components,
rehabilitation and crisis management. Other psychological therapies include Acceptance and
Commitment Therapy (ACT) [66], mindfulness training, Competitive Memory Training
(COMET; [67]) and computer-assisted therapy assisted with an avatar) ([68]). A combination
of treatments comprising family and psychological interventions, as well as medication, may
be the most beneficial treatment for auditory hallucinations [69].
Finally, cognitive deficits underlying hallucinations have become targets of treatment
themselves with cognitive remediation strategies. Recent trials show increasing convergence
between theory and practice by focusing on deficits found to be linked to auditory
hallucinations. For example, recent work has tended to give patients practice in techniques on
how to recognise the source of their voices [70].

9.

Conclusion

The concept of auditory hallucinations has changed markedly in the past 100 years, from
early medical models that viewed hallucinations as a sign of mental illness to its
contemporary view which acknowledges their existence in a continuum stretching from the

general population to a range of medical and psychiatric conditions. There are many gaps in
our understanding of hallucinations. However the work of the International Consortium on
Hallucination Research (hallucinationconsortium.org) [71, 72] is making good progress by
stimulating international collaboration and encouraging multi-site studies. Given the
complexity of hallucinations, only such a concerted effort and large pooled sample sizes have
the potential to give rise to truly novel advances in clinical developments. Hallucinations
represent a fascinating phenomenon for further study and an important target for clinical
interventions for individuals with intrusive and unwanted hallucinations.

Table 1: Phenomenological forms of auditory hallucinations (adapted from Stephane et al, 2003; with permission)

Forms
Acoustic qualities

Location
Number of voices
Direction
Linguistic
Content
Order

Replay

Source attribution
Time course
Mode of occurrence
Happens when

Control strategies

Affective relatedness

Dimensions
Clarity
Personification
Loudness
Inner space
Outer space
One, more than one
Voices talk among themselves
Voices talk to the patient
Syntax
Complexity
Range
Focus
First order (hear voices)
Second order (talk back to the voices)
Third order (converse with the voices)
Experiential (heard in real life)
Arising from patients speech
Arising from patients thoughts
Self
Other
Time dimension
Modulation
Spontaneous
Triggered
Speaking or listening to speech
Listening to non-speech sounds
Activities requiring attention
Listening to speech or speaking
Listening to non-speech sounds
Activities requiring attention
Comforting
Bothersome/intrusive

Characteristics
Clear (like external speech) vs deep (like internal speech/thinking in words)
Man, woman, other (alien, robot, angel, etc.)
Softer, louder or similar to normal conversation volume
In the head, or other parts of the body

First (I), second (You, name) or Third person (he/she, name)

Hearing words, sentences or conversations
Repetitive or systematized
Self or non-self

Someone familiar, or God/spiritual being, or deceased person

Infrequent, constant, vs episodic
Worsening or improving
By intentional will or by other triggers

10

Figure 1 shows quantified coupling between brain correlates of self-reported verbal

hallucinations and neural networks, during functional magnetic resonance imaging (fMRI)
(reprinted from Raij et al48 with permission). The methods consisted in the comparison of
correlations (or coupling) of signal between the inferior frontal gyrus (IFG) and other brain
regions, referring to a quantification of the co-contribution of distributed neural networks.
The figure shows that the stronger the perception of verbal hallucinations, the stronger
coupling of the IFG with the right ventral striatum (A), the middle right anterior cingulate
cortex (B), the right posterior temporal lobe (C), the auditory cortex (D), and the left nucleus
accumbens (E). The colour shows the scale for statistical significance (F). The inferior frontal
gyrus is involved in the production of overt and inner speech, consistent with the verbal
nature of these hallucinations. The coupling of the IFG with cingulate cortex and temporal
lobe is also consistent with the involvement of executive control components and perception
networks.

11

Case vignettes:
J. has a diagnosis of schizophrenia and reports hearing voices all the time, which command
him to harm himself (kill yourself). There are 5 voices, all male, unfamiliar to him, which
comment on his thoughts and actions. He also hears singing voices, and has functional
hallucinations through machinery and radio. J. thinks some of the voices may come from his
body (near his stomach). The voices interfere significantly with his life, but they have
decreased with medication.

P. has Post-Traumatic Stress Disorder (PTSD). P. was involved in a tour of military duties in
Afghanistan. His presenting complaints are of nightmares, difficulties sleeping and
concentrating, and intrusive memories of major ground combat. He also reports distressing
hallucinations of combat experiences. He hears explosions and gunfire, and people shouting
and screaming, both at night and during the day, and with startling vividness. He also
describes visual hallucinations of a woman in front of him, covered in blood. A combination
of antipsychotic medications and psychological intervention has reduced the intensity and
frequency of these hallucinations.

12

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