If you have ever had the experience of hearing a voice when nobody else was with you, or when nobody else present seemed to have heard the voice, you probably never told anyone about it. For a couple of very good reasons: one, the fear that they would think you were flaky. And two, your own fear that you could be going down that slippery slope to la-la land.
A majority of people perceive those who “hear voices” as being unstable and dangerous, and even believe that they should be locked away. For centuries, hearing voices (or “auditory hallucinations”, as it is called in medical parlance) has been considered a hallmark of mental illness. The stigma became well-entrenched. And the corollary followed: “normal” people don’t hear voices.
That is why the whole truth about hearing voices can be surprising. For instance:
» Many people have had at least one experience of hearing a voice when there was no one around them. A large international study found that as many as 5% of the general population experience hallucinations at some point in their lives.
» According to research published in The British Journal of Psychiatry, only around 25 % of people who experience auditory hallucinations suffer from a mental illness that requires psychiatric treatment.
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» Many of those who hear voices on a regular basis are comfortable about their aural spectres. This group includes high-functioning, successful persons. Celebrities, including Anthony Hopkins, and musicians Pete Townsend, Carlos Santana and Jennifer Hudson, have openly talked about the voices and the music only they can hear. Other famous voice-hearers include Socrates, Charles Dickens, Sigmund Freud – and Gandhi, who described in elaborate detail the “inner voices” he heard, which guided him in the course of the freedom struggle. “Charitable critics impute no fraud to me, but suggest that I am highly likely to be acting under some hallucination... I can offer no proof to the contrary.... But what I did hear was like a Voice from afar and yet quite near. It was as unmistakable as some human voice definitely speaking to me, and irresistible. I was not dreaming at the time I heard the Voice. The hearing of the Voice was preceded by a terrific struggle within me. Suddenly the Voice came upon me. I listened, made certain it was the Voice, and the struggle ceased. I was calm. The determination was made accordingly, the date and the hour of the fast were fixed…”
» Contrary to popular belief, not all voice-hearing experiences are negative or menacing. Some hallucinations are pleasant, or even downright mundane. Also, they may speak about the voice-hearer in the third person: “She is leaving the building”; “She is unlocking the door”.
As researchers are discovering, auditory hallucinations are neither rare, nor necessarily a sign of serious mental illness. Mental-health professionals and voice-hearers themselves are beginning to view them as a meaningful part of the human experience and not just as a problem that needs to be treated or eliminated.
While “hearing voices” is the most common type of hallucination experienced by people with a psychotic disorder such as schizophrenia, there is a large number of organic conditions not involving mental illness that can bring on auditory hallucinations. They include:
» Falling asleep, waking up and / or coming out of a dream. Auditory hallucinations have long been known to occur in the twilight consciousness between wakefulness and sleep. Many people report hearing very brief sounds or – less frequently – hearing voices calling their names or saying something brief just as they are on the point of falling asleep, and / or are just waking up from a dream. These hallucinations are caused by brain activity that occurs as we are entering or coming out of a dream state.
» Recent bereavement. Recently bereaved widows and widowers may “hear” their dead spouse or even communicate with them. Some people report that, during the early days of grief following the death of someone very close, this is the only way that they can mentally cope with the loss. The hallucinations appear to be a part of their grief processing and are effectively a coping mechanism.
» Deprivation states. Prolonged deprivation of food (starvation), water (dehydration) or sleep can bring on auditory hallucinations. So can extreme social isolation over an extended period (e.g., solitary confinement; being lost or marooned over a long stretch of time).
» Illness or injury. A whole range of “organic conditions” and physical diseases can cause a person to hear voices. They include brain tumour/ brain injury; epilepsy; Parkinson’s disease; dementias, including Alzheimer’s; hyperthyroidism; migraine headaches. Many people report hearing spiritual voices after being involved in serious accidents.
Even those who suffer from hearing loss in one or both ears can “hear voices”. They may hear irregular sounds, vocal or instrumental melodies, and even the spoken word. This is phantom hearing (akin to phantom limb pain). The brain perceives sensations (e.g., “hears music”) even without input from the body.
» Delirium caused by high fever, as a result of severe physical illness, can bring on auditory hallucinations, especially in older persons.
» Medications. Various prescription as well as over-the-counter medications can induce auditory hallucinations in certain users. The list includes anti-depressants, corticosteroids, anti-histamines, anti-hypertensives (i.e., blood pressure medications), anti-epileptic drugs, certain antibiotics, and even DXM, the “extra-strength” cough syrup, dextromethorphan (which is sometimes mixed with alcohol or another drug of abuse for use as a recreational drug). The risk of auditory hallucinations from medications is typically related to dosage strength – i.e., the higher the dose, the greater the likelihood of experiencing the hallucinations. They can occur after taking the drug or during the period of withdrawal of the drug.
» Street drugs. Hallucinogenic drugs such as LSD (“acid”), Psilocybin mushrooms (also called “magic mushrooms”) and Ketamine (a.k.a. “K”, or “Special K”) can all induce auditory hallucinations as part of their effects on the central nervous system. So can a whole range of other illicit drugs.
» Religious ritual and trance states. Voices may be heard (and visions seen) during profoundly religious or mystical experiences, including conversion.
Voices heard in mental illness
In and of itself, hearing voices does not constitute a basis for a diagnosis of a mental illness like schizophrenia. Auditory hallucinations must appear with other symptoms, persist for a specified length of time and impede day-to-day functioning in order to become part of a diagnosable syndrome. The mental illnesses in which such hallucinations may occur include:
» Schizophrenia. Approximately 75 per cent of patients diagnosed with schizophrenia hear voices, and for the majority the experience is overwhelmingly negative. Those voices may issue commands, comment sarcastically on everyday actions, or berate, curse and insult the hearer. As many as one in five schizophrenics hears voices that command him to kill himself.
» Bipolar disorder. In the mania phase of this disorder (marked by heightened energy and euphoria), the voices generally talk directly to the person, and the content of what they say is usually in line with the person’s elevated mood.
» Major depression with psychotic features. The auditory hallucinations that are occasionally experienced are usually transient and limited to single words or short phrases, and generally say things that are consistent with the person’s depressed mood.
» Post-partum psychosis. A mother suffering from post-partum psychosis may hear the newborn crying (when it isn’t), or may hear voices accusing her of not being a competent mother or telling her to kill her baby.
» Post-traumatic stress disorder (PTSD). Traumatic experiences such as natural disasters, being the victim of a crime, or serving in combat may result in PTSD. Although not everyone with this condition hears voices, it is not an uncommon experience. Some combat veterans with PTSD have reported hearing persistent voices of a depressive nature, including cries for help or conversations concerning battle.
» Dissociative Identity disorder (DID), formerly known as Multiple Personality Disorder.
» Borderline Personality Disorder.
If you hear voices
As a first step, visit a GP in order to rule out causes that are unrelated to mental illness. For instance, if there is a likelihood that the hallucinations have been brought on by current medication that you’re taking, the doctor can try either altering the dosage or switching to another drug. Do not, however, stop taking a prescribed medication without consulting a doctor.
If the history-taking warrants it, your GP may refer you to a psychiatrist. Specific criteria are used to determine which, if any, mental illness is diagnosable from the symptoms. As far as the auditory hallucinations go, too, the psychiatrist will look for particular markers: Voices that speak in the third person, echo a person’s thoughts or provide a running commentary on his actions are considered classically indicative of schizophrenia.
Medication is typically prescribed to extinguish, or at least mitigate, voices. About 80 per cent of patients experience a reduction in voices from medication alone (though this does not always translate into an equal improvement in day-to-day functioning).
Drugs apart, psychotherapy has a proven track record in helping persons to reduce the distress caused by hearing voices, and the stigma associated with it. But by and large, psychotherapy has been used as an adjunct to drugs, and little more.
A not-so-silent revolution
A growing area of controversy has, however, emerged with regard to the psychiatric approach to dealing with the experience of “hearing voices”. The conventional view among psychiatrists, dating back to the post-World War II period, looks at auditory hallucinations as a bio-medical glitch, one which needs to be “fixed” with whatever modern drug therapy offers. The standard line has been, “Don’t talk to the patient about the voices, it’ll only make things worse”. Talking to a patient about what his voices were saying has been considered to be tantamount to colluding in a kind of hallucinatory world that wasn’t real.
This mainstream view of voices as simply “symptoms” of mental illness has been challenged by an increasingly vocal movement spearheaded by the UK-based Hearing Voices Network (HVN). It has a presence in about 40 countries today, its adherents comprising not just voice-hearers but also avant-garde psychiatrists and psychologists. HVN challenges the purely bio-medical approach to voice-hearing. Voices, they say, are not just neural junk to be discarded. Instead, they are messengers, communicating important information about emotional problems. HVN therefore pushes for an approach that will seek to understand the events that led to the emotional distress that the voices are expressing.
This stance gains some credence from the fact that one of the most significant triggers of voices is trauma, especially if it occurred in childhood – e.g., physical or sexual abuse; loss of a parent; a major accident. Research seems to bear that out: as many as 70 % of voice-hearers report having experienced some form of trauma. And the voices that they hear often mimic either the sound and language of their abusers (demonic, threatening, demanding) or of the victims (pleading, angelic; fearful).
The voices, it is therefore suggested, are a psychological coping mechanism that the brain has created to help deal with major stress. And it is important to try and deconstruct the message behind the words, and then do something positive about it. Voice-hearers have tried this approach on their own, and many report that it is helpful. In one case, for example, a 20-year-old, whose inner voices were urging him to study Buddhism for hours each day, cut a deal with his demons, telling them he’d say Buddhist prayers for one hour each day, no more, no less. It worked, he reported – the voices subsided and he was able to taper his dose of psychosis drugs.
What seems to work, therefore, for many voice-hearers, is not to engage in a psychic civil war with their voices, but to hear them out. Even the negative voices serve a purpose, alerting them to the need to address a problem before it becomes overwhelming.
Increasingly, psychotherapists are incorporating this approach in their healing techniques –guiding and supporting clients in “managing” their responses to the voices they hear, rather than squashing the voices out of existence. Therapists do this by urging voice-hearers to develop relationships with their hallucinated voices – e.g., by negotiating with the voices on times when you will listen to them, and times when you will not. A vital first step is learning to distil a metaphorical meaning from what the voices are saying literally. So, for example, voices which threaten to attack your home you learn to interpret as your own sense of fear and insecurity in the world, rather than as an actual, objective danger.
As enlightened therapists resonate increasingly with this view of hearing voices, it has led to a growing emphasis on talking therapies, and to empowering voice hearers – treating them as a community of people, rather than as just patients.
The mainstream is slowly being drawn into the ambit of this evolution. For instance, the British government has sanctioned a loan towards research that will investigate whether people with early signs of a psychotic disorder can be prevented from developing a full-blown mental illness, using only the non-drug approaches of psychotherapy.
To boot medication right out of the picture in favor of talking therapies alone would be an unjustified risk for those in whom voice hearing is part of a syndrome of full-blown psychotic illness. Instead, the way forward might be to open the door rather wider to psychotherapy as it partners psychiatry in the mitigation of auditory hallucinations. And perhaps it is time that psychiatrists asked their voice-hearing clients not just one question (“What are your symptoms?”), but a second one – “What is your story?”
(The author, a former editor of 'Health & Nutrition' magazine, now works as a counselling therapist)