Auditory hallucinations are hallucinations Opens in new window of the hearing modality and may range from elementary noises to fully formed complex voices. Voices may be single or multiple and may talk to or about the person.
Elementary hallucinations are simple, unstructured sounds, e.g. whirring, buzzing, whistling or single words.
Elementary hallucinations commonly occurs in acute organic states; for example the patient hears whirring noises or rattles, whistling, machinery or music. Often, the noise is experienced as very unpleasant and frightening.
Of interest are musical hallucinations, which tend to occur in older women with deafness or brain disease and no history of psychiatric illness (Berriors, 1990). There are, therefore, similarities with Charles Bonnet’s syndrome Opens in new window, described here Opens in new window.
Audible thoughts (first person): patients hear their own thoughts spoken out loud as they think them. When patients experience their thoughts as echoed by a voice after they have thought them, it is termed ‘thought echo’.
Second person auditory hallucinations: patients hear a voice or voices talking directly to them. Second person hallucinations can be persecutory, highly critical, complimentary or issue commands to the patient (command hallucinations).
Second person hallucinations are often associated with mood disorders with psychotic features and so will be critical or persecutory in a depressed patient or complimentary in a manic patient, i.e. mood-congruent hallucinations.
Third person auditory hallucination: patients hear a voice or voices speaking about them, referring to them in the third person. This may take the form of two or more voices arguing or discussing the patient among themselves; or one or more voices giving a running commentary on the patient’s thoughts or actions.
Hearing voices are one of the most important symptoms for the diagnosis of psychosis, especially schizophrenia. Voices in auditory hallucinations are sometimes called phonemes (confusion exists, unfortunately, because the word is used with a totally different meaning in linguistics Opens in new window, in which phonemes are the units of speech-sound from which words are made).
Usually in organic states the phonemes are simple words or short sentences, often spoken to the patient in the second person as either peremptory orders or persecutory remarks.
These persecutory or imperative phonemes also occur in schizophrenia Opens in new window, but other more complicated speech is also heard; the voices may be single or multiple, male or female or both, people known and recognized by the patient or not known. They are experienced as coming from outside his head or his self.
The voice is clear, objective and definite and is assumed by the patient to be a normal percept that at the same time may be baffling and incomprehensible in its import.
Particularly characteristic of schizophrenia (as mentioned earlier) are voices that say the patient’s own thoughts out loud, which give a running commentary on the patient’s actions or voices, which argue or discuss vigorously with each other. They refer to the patient in the third person (Schneider, 1959).
Auditory hallucinations in schizophrenia are generally private events, but several early writers observed vocalizations that corresponded with the content of the voices taking place at the same time as the hallucinations.
Normal people occasionally vocalize their own thoughts sotto voce; in the psychotic equivalent of this, it seems that sometimes those with schizophrenia are vocalizing their hallucinations at the same time as they experience them. Green and Preston (1981) increased the audibility of the whispers of such a patient to an intelligible level using auditory feedback.
Sometimes, patients with schizophrenia describe abnormal perceptions in both the visual and the auditory modalities. The examiner should be careful not to assume that there are both auditory and visual hallucinations present; there may be a different form, particularly for the visual experience.
A man aged 45 described his experience as follows: ‘I hear my nephews talking [about me]l. “He is a poofter [homosexual] and a pervert” … I see them as well. The curtains move and I know that it is them moving them’.
This is a description of a persecutory auditory hallucination, but the visual experiences is a delusional interpretation of a normal perception, not a visual hallucination Opens in new window. Patient’s descriptions of their phonemes vary greatly. Sometimes, patients talk openly and quite blandly about their ‘voices’.
Not uncommonly, a patient may deny voices but assert that he hears ‘spoken messages’ or ‘transmissions’ or some other spoken sound, and it may be difficult to decide whether this is a real perception or an auditory hallucination.
The phonemes may be so insistent, compelling and interesting that ordinary conversation with the doctor is found boring, and even unreal, in comparison.
The voices may form an insistent background to life, so ensuring that a large part of the patient’s speech and behavior is occupied in answering and obeying the voices.
Psychiatric nursing staff often observe that the auditory hallucinations described by patients are as real to them as any other remembered conversations, and both hallucinatory and real auditory perceptions form the memories on which patients base their life and behavior in the present.
Auditory hallucinations occur when there is a combination of vivid mental imagery and poor reality testing in the auditory modality (Slade, 1976b). This has been investigated using a battery of tests including the verbal transformation effect.
The word ‘trees’ was repeated on a tape recorder to the subjects for 10 minutes. After a time, subjects began to hear other words and syllables. Normal subjects and schizophrenics who were not auditorily hallucinated usually heard words that were phonetically linked to the original monosyllable, but psychotic patients who were auditorily hallucinated heard words that were quite different phonetically as often as those that were linked.
