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A paracusia, or auditory hallucination, is a form of hallucination that involves perceiving sounds without auditory stimulus. Auditory hallucinations need to be distinguished from endaural phenomena in which sounds are heard without any external acoustic stimulation but arise from disorders of the frontal lobe, temporal lobe, language processing system, ear or auditory system.
A common form of auditory hallucination involves hearing one or more talking voices. This may be associated with psychotic disorders, and holds special significance in diagnosing these conditions. However, individuals without any psychiatric disease whatsoever may hear voices.
There are three main categories into which the hearing of talking voices often fall: a person hearing a voice speak one's thoughts, a person hearing one or more voices arguing, or a person hearing a voice narrating his/her own actions. These three categories do not account for all types of auditory hallucinations.
Other types of auditory hallucination include exploding head syndrome and musical ear syndrome. In the latter, people will hear music playing in their mind, usually songs they are familiar with. This can be caused by: lesions on the brain stem (often resulting from a stroke); also, sleep disorders such as narcolepsy, tumors, encephalitis, or abscesses. This should be distinguished from the commonly experienced phenomenon of getting a song stuck in one's head. Reports have also mentioned that it is also possible to get musical hallucinations from listening to music for long periods of time. Other reasons include hearing loss and epileptic activity.
Robert Schumann, a famous music composer, spent the end of his life experiencing auditory hallucinations. Schumann’s diaries state that he suffered perpetually from imagining that he had the note A5 sounding in his ears. The musical hallucinations became increasingly complex. One night he claimed to have been visited by the ghost of Schubert and wrote down the music that he was hearing. Thereafter, he began making claims that he could hear an angelic choir singing to him. As his condition worsened, the angelic voices developed into demonic ones.
Joan of Arc claimed to hear the voices of Saints who were the force that guided her and was resolved to obey these messages as she believed they were sent directly from God. She first began hearing voices when she was thirteen and soon after had visions of St. Michael, St. Catherine and St. Margaret.
Brian Wilson, songwriter and co-founder of the Beach Boys, has schizoaffective disorder that presents itself in the form of disembodied voices. They formed a major component of Bill Pohlad's Love & Mercy (2014), a biographical film which depicts Wilson's hallucinations as a source of musical inspiration, constructing songs that were partly designed to converse with them. Wilson has said of the voices: "Mostly [they're] derogatory. Some of it's cheerful. Most of it isn't." To combat them, his psychiatrist advised that he "talk humorously to them", which he says has helped "a little bit".
The onset of delusional thinking is most often described as being gradual and insidious. Patients described an interest in psychic phenomena progressing to increasingly unusual preoccupations and then to bizarre beliefs "in which I believed wholeheartedly". One author wrote of their hallucinations: "they deceive, derange and force me into a world of crippling paranoia". In many cases, the delusional beliefs could be seen as fairly rational explanations for abnormal experiences: "I increasingly heard voices (which I'd always call ‘loud thoughts’)... I concluded that other people were putting these loud thoughts into my head". Some cases have been described as an "auditory ransom note".
The ancient world viewed hallucinations as it did most of the natural world, with awe and superstition. As such, it was viewed as either a gift or curse by God, or the gods (depending on the specific culture). During the reign of Tiberius (A.D. 14–37), a sailor named Thamus heard a voice that told him the God Pan was dead. The oracles of ancient Greece were known to experience auditory hallucinations while breathing in certain neurologically active vapors (such as the smoke from bay leaves), while the more pervasive delusions and symptomology were often viewed as possession by demonic forces as punishment for misdeeds.
Treatment in the ancient world is ill documented, but there are some cases of therapeutics being used to attempt treatment, while the common treatment was sacrifice and prayer in an attempt to placate the gods. The Dark Ages saw the most horrific accounts where those with auditory hallucinations were subjected to trepanning or trial as a witch. In other cases of extreme symptomatology individuals were seen as being reduced to animals by a curse, these individuals were either left on the streets or imprisoned in insane asylums. It was the latter response that eventually led to modern psychiatric hospitals.
Auditory hallucinations were rethought during the enlightenment. As a result, the predominant theory in the western world beginning in the late 18th century was that auditory hallucinations were the result of a disease in the brain (e.g. mania), and treated as such.
There were no effective treatments for hallucinations at this time. Conventional thought was that clean food, water, and air would allow the body to heal itself (Sanatorium). Beginning in the 16th century Insane Asylums were first introduced in order to remove “the mad dogs” from the streets and left them chained to walls and living in their own filth. These asylums acted as prisons until the late 18th century. This is when doctors began the attempt to treat patients. Often attending doctors would douse patients in cold water, starve them, or spin patients on a wheel. Soon, this gave way to brain specific treatments with the most famous examples including Lobotomies, shock therapy and branding the skull with hot iron.
- Bipolar disorder
- Borderline personality disorder
- Depression (mixed)
- Dissociative identity disorder
- Generalized anxiety disorder
- Major depression
- Obsessive compulsive disorder
- Post-traumatic stress disorder
- Psychosis (NOS)
- Schizoaffective disorder
However, numerous persons surveyed reported no diagnosis. In his popular 2012 book Hallucinations, neurologist Oliver Sacks describes voice hearing in patients with a wide variety of medical conditions, as well as his own personal experience of hearing voices.
In the case of psychotic patients the premier cause of auditory hallucinations is schizophrenia. In schizophrenia, patients show a consistent increase in activity of the thalamic and strietal subcortical nuclei, hypothalamus, and paralimbic regions; confirmed via PET scan and fMRI. Other research shows an enlargement of temporal white matter, frontal gray matter, and temporal gray matter volumes (those areas crucial to both inner and outer speech) when compared to control patients. This implies both functional and structural abnormalities in the brain, both of which may have a genetic component, can induce auditory hallucinations.
Mood disorders and dementias
Mood disorders have also been known to correlate with auditory hallucinations, but tend to be milder than their psychosis induced counterpart. Auditory hallucinations are a relatively common sequelae of Major Neurocognitive Disorders (formerly dementia) such as Alzheimer's disease.
Auditory hallucinations have been known to manifest as a result of intense stress, sleep deprivation, drug use, and errors in development of proper psychological processes. Genetic correlation has been identified with auditory hallucinations, but most work with non-psychotic causes of auditory hallucinations is still ongoing.
High caffeine consumption has been linked to an increase in the likelihood of experiencing auditory hallucinations. A study conducted by the La Trobe University School of Psychological Sciences revealed that as few as five cups of coffee a day could trigger the phenomenon.
Diagnosis and treatments
The primary means of treating auditory hallucinations is antipsychotic medications which affect dopamine metabolism. If the primary diagnosis is a mood disorder (with psychotic features), adjunctive medications are often used (e.g., antidepressants or mood stabilizers). These medical approaches may allow the person to function normally but are not a cure as they do not eradicate the underlying thought disorder.
Cognitive-Behavioral Therapy has been shown to help decrease the frequency and distressfulness of auditory hallucinations, particularly when other psychotic symptoms were presenting. Enhanced Supportive Therapy has been shown to reduce the frequency of auditory hallucinations, the violent resistance the patient displayed towards said hallucinations, and an overall decrease in the perceived malignancy of the hallucinations. Other cognitive and behavioral therapies have been used with mixed success.
Electroconvulsive therapy or ECT has been shown to reduce psychotic symptoms associated with schizophrenia, mania, and depression, and is often used in psychiatric hospitals.
In recent years, repetitive transcranial magnetic stimulation (rTMS) has been studied as a biological method of treatment for auditory hallucinations. rTMS plays a role in altering neural activity over language cortical regions. Studies have shown that when rTMS is used as an adjunct to antipsychotic medication in treatment-resistant cases, the frequency and severity of auditory hallucinations can be reduced.
Another source of non-conventional techniques to cope with the voices are provided by the research and findings of the Hearing Voices Movement
There is on-going research that supports the prevalence of auditory hallucinations, with a lack of other conventional psychotic symptoms (such as delusions, or paranoia), particularly in pre-pubertal children. These studies indicate a remarkably high percentage of children (up to 14% of the population sampled) experienced sounds or voices without any external cause, though it should also be noted that "sounds" are not considered by psychiatrists to be examples of auditory hallucinations. Differentating actual auditory hallucinations from "sounds" or a normal internal dialogue is important since the latter phenomena are not indicative of mental illness.
The causes of auditory hallucinations are unclear.
Dr. Charles Fernyhough, of the University of Durham poses one theory among many but stands as a reasonable example of the literature. Given standing evidence towards involvement of the inner voice in auditory hallucinations, he proposes two alternative hypotheses on the origins of auditory hallucinations in the non-psychotic. They both rely on an understanding of the internalization process of the inner voice.
Internalization of the inner voice
Level one (external dialogue) involves the capacity to maintain an external dialogue with another person, i.e. a toddler talking with their parent(s).
Level two (private speech) involves the capacity to maintain a private external dialogue, as seen in children voicing the actions of play using dolls or other toys, or someone talking to themselves while repeating something they had written down.
Level three (expanded inner speech) is the first internal level in speech. This involves the capacity to carry out internal monologues, as seen in reading to oneself, or going over a list silently.
Level four (condensed inner speech) is the final level in the internalization process. It involves the capacity to think in terms of pure meaning without the need to put thoughts into words in order to grasp the meaning of the thought.
Disruption to internalization
A disruption could occur during the normal process of internalizing ones’ inner voice, where the individual would not interpret their own voice as belonging to them; a problem that would be interpreted as level one to level four error.
Alternatively, the disruption could occur during the process of re-externalizing one's inner voice, resulting in an apparent second voice that seems alien to the individual; a problem that would be interpreted as a level four to level one error.
Psychopharmacological treatments include anti-psychotic medications. Psychology research shows that first step in treatment is for the patient to realize that the voices they hear are creation of their own mind. This realization is argued to allow patients to reclaim a measure of control over their lives. Some additional psychological interventions might allow for the process of controlling these phenomena of auditory hallucinations but more research is needed.
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