Auditory hallucinations, or “hearing voices,” is one of the most prevalent symptoms of schizophrenia, reported by as many as 75% of patients.1 It is also seen in other psychiatric conditions, such as bipolar and unipolar depression and personality disorders, as well as in nonclinical populations.
Auditory hallucinations in schizophrenia are heterogenous in nature. According to Simon McCarthy-Jones, PhD, associate professor in the Department of Psychiatry at Trinity College Dublin, Ireland, “Hearing voices is a varied experience. It can involve hearing single or multiple voices, whose identity the hearer may or may not know, who speak in turn or all at the same time, who may be saying new things or repeating what has been heard before, and who can give comments or commands, insults or encouragement. Most commonly though, people diagnosed with schizophrenia will hear multiple voices that are male, nasty, repetitive, commanding, and interactive, where the person can ask the voice a question and get some kind of answer.”
According to Dr McCarthy-Jones, there are many theories as to what causes people to hear voices: Some focus on events that happened to the person,2 whereas others focus on brain changes less clearly linked to life events. Mark Hayward, PhD, DClinPsy, director of research and honorary senior research fellow at the University of Sussex, United Kingdom, adds, “The cause of auditory hallucinations is often, but not always, rooted in traumatic early experience. Almost all of our patients have experienced significant adversity for extended periods of their lives, and this adversity is often reflected in the identity of their voices. For example, the voice may be a mother or father who was neglectful or abusive, or bullies from school, and the comments they make may be critical and derogatory.”
Unlike auditory hallucinations in nonclinical populations, which are largely neutral or positive, those in schizophrenia tend to be negative and controlling, taking a huge toll on the emotional well-being and quality of life of the individual. Depression, significant stress, and increased suicidal attempts have all been linked to the severity of auditory hallucinations in people with schizophrenia.3 “Hearing a repetitive stream of abuse from an unseen entity, which you may initially have no control over, can be extremely upsetting and can get in the way of you living your life,” explains Dr McCarthy-Jones. “Imagine trying to talk to your boss whilst your least favorite colleague whispers abuse in your ear.”
According to Joshua Kantrowitz, MD, associate professor of clinical psychiatry at Columbia University Department of Psychiatry in New York City, “For most schizophrenia patients, antipsychotics are the treatment of choice and are effective for most patients.” However, he also points out that, “[a]bout 30% of patients have treatment-resistant auditory hallucinations, for which the standard of care is to increase the dose of antipsychotics,” which he believes may not be so effective. “Clozapine is sometimes effective for treatment-resistant symptoms, including auditory hallucinations.”
Treatment resistance and drug adverse effects have led to the development of new interventions to help patients with schizophrenia cope with auditory hallucinations.4 Cognitive behavioral approaches, in particular, are widely used, including distraction techniques (listening to music, reading, art) or focusing techniques (rational responding, generating compassion towards the voice, mindfulness).5 However, some of these techniques can be more commonly used than is warranted by the evidence, and clinical decisions about which techniques to use should always be informed by research evidence.6
When the root cause of auditory hallucinations can be traced to trauma, Dr Hayward opines that for some patients, it can be important to revisit and generate new meanings around these root causes. He also points out, however, that “other patients may not have a sense of these root causes or may not want or need to revisit these very difficult early experiences.” As a consequence, within therapy, it is important to ensure there is an exploration of at least the effect of the pervasive adversity on current functioning and future recovery (eg, working on the low self-esteem that is reinforced by the negativity of voice comments), but this exploration may not need to extend to the root causes of the hallucinations.
Digital technologies are also facilitating novel approaches to the treatment of auditory hallucinations.7 AVATAR therapy, for example, enables the patient to have a conversation with the digital representation (AVATAR) of the voice. Dr Hayward believes that AVATAR therapy “has enormous potential to create ‘exposure’ to the voice in the safety of a therapeutic environment and creates the opportunity to have an experience of responding to the voice in a different, more assertive manner.” However, he also questions the necessity of the digital aspect of AVATAR therapy when traditional roleplays can be used to create the same exposure experience.8
Transcranial direct current stimulation is another approach for treating auditory hallucinations in patients who are refractory to treatment with antipsychotics. It is a noninvasive brain stimulation technique that alters the neuronal membrane resting potential, causing changes in motor-cortical excitability.9 According to Dr Kantrowitz, “There is some reasonably convincing evidence that transcranial direct current stimulation + antipsychotics is more effective than antipsychotics alone, but further studies are needed.”
As new research throws more light on the neuronal basis of auditory hallucinations and different pharmacological and psychological approaches are designed to treat auditory hallucinations, it is important to understand the individual differences of those with schizophrenia and plan treatment accordingly.
“Patients who are distressed by hearing voices often have a complex range of needs and mental health problems that require a biopsychosocial approach to care and treatment,” explains Dr Hayward. “The choice of interventions for distressing voices should always be informed by the evidence base, and these interventions should be integrated into a comprehensive care/recovery plan. Moreover, the patient should be involved in the process of reviewing and selecting the interventions that best fit with their needs and preferences.”
1. Waters F, Fernyhough C. Hallucinations: a systematic review of points of similarity and difference across diagnostic classes. Schizophr Bull. 2017;43(1):32-43.
2. Luhrmann TM, Alderson-Day B, Bell V, et al. Beyond trauma: a multiple pathways approach to auditory hallucinations in clinical and nonclinical populations. Schizophr Bull. 2019;45(Suppl 45):S24-S31.
3. Janaki V. Suzaily W, Abdul Hamid AR, et al. The dimensions of auditory hallucination in schizophrenia: Its association with depressive symptoms and quality of life. Int Med J Malaysia. 2017;16(2):55-64.
4. Mccarthy-Jones S, Hayward M, Waters F, Sommer IE. Editorial: hallucinations: new interventions supporting people with distressing voices and/or visions. Front Psych. 2016;7:1418.
5. Turkington D, Lebert L, Spencer H. Auditory hallucinations in schizophrenia: helping patients to develop effective coping strategies. BJPsych Advances. 22;(6):391-396.
6. Hayward, M. Evidence-based psychological approaches for auditory hallucinations: commentary on auditory hallucinations in schizophrenia. BJPsych Advances. 24;3:174-177.
7. Thomas N, Bless JJ, Alderson-Day B, et al. Potential applications of digital technology in assessment, treatment, and self-help for hallucinations. Schizophr Bull. 2019;45(Suppl 45):S32-S42.
8. Hayward, M. Continuing the conversation about AVATAR Therapy. Lancet Psychiatry. 2018;5(3):196.
9. Janovik N, Cordova VH, Chwal B, Ogliari C, Belmonte-de-Abreu P. Long-term response to cathodal transcranial direct current stimulation of temporoparietal junction in a patient with refractory auditory hallucinations of schizophrenia. Braz J Psychiatry. 2019;41(3):271-272.