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Auditory hallucination
Classification and external resources
ICD-10 R44.0
ICD-9 780.1

An auditory hallucination, or paracusia,[1] is a form of hallucination that involves perceiving sounds without true auditory stimulus. A common form involves hearing one or more talking voices. This may be associated with psychotic disorders such as schizophrenia or mania, and holds special significance in diagnosing these conditions. However, individuals may hear voices without suffering from diagnosable mental illness.[2] The Hearing Voices Movement is a support and advocacy group for people who hallucinate voices, but do not otherwise show signs of mental illness or impairment.

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. Recent reports have also mentioned that it is also possible to get musical hallucinations from listening to music for long periods of time.[3] This can be caused by: lesions on the brain stem (often resulting from a stroke); also, tumors, encephalitis, or abscesses.[4] Other reasons include hearing loss and epileptic activity.[5] Auditory hallucinations may also result of attempting wake-initiation of lucid dreams.


Famous examples

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 transmogrified into demonic voices.[6]

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. Francis, St. Catherine and St. Margaret.[6]

Individual accounts

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". [7]



Ancient history


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). The oracles of ancient Greece were known to experience auditory hallucinations while breathing in certain neurologically active vapors, while the more pervasive delusions and symptomology were often viewed as possession by demonic forces as punishment for misdeeds.[6]


Treatment in the ancient world is ill documented, but there are some cases of therapeutics being used to attempt treatment, while the much more common treatment was sacrifice and prayer in an attempt to placate the gods. The dark ages saw the most horrific accounts where the suffered of auditory hallucinations were subjected to trepanning or trial as a witch.[6] In other cases of extreme symptomology 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.[8]



Auditory hallucinations, like most everything else in Europe, was rethought during the enlightenment. As a result, the predominant theory in the western world beginning in the late 1700’s was that auditory hallucinations were the result of a disease in the brain and treated as such.[8]


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 1500’s 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.[8] These asylums acted as prisons until the late 1700’s. 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.[8]

Conventional views

Potential causes

Associated diseases

The premier cause of auditory hallucinations in the case of psychotic patients is schizophrenia. In these cases, patients show a consistent increase in activity of the thalamic and strietal subcortical nuclei, hypothalamus, and paralimbic regions; confirmed via PET scan and fMRI.[9][10] 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.[11][12] This implies both functional and structural abnormalities in the brain can induce auditory hallucinations, both of which may have a genetic component.[13][14][15] Mood disorders have also been known to cause auditory hallucinations, but tend to be milder than their psychosis induced counterpart.

Non-disease associated causes

Auditory hallucinations have been known to manifest as a result of intense stress, sleep deprivation, drug abuse, and errors in development of proper psychological processes.[16] Genetic correlation has been identified with auditory hallucinations,[15] but most work with non-psychotic causes of auditory hallucinations is still ongoing.[17][16]

Conventional 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).

Psychological therapies

Cognitive-Behavioral Therapy has been shown to help decrease the frequency and distressfulness of auditory hallucinations, particularly when other psychotic symptoms were presenting.[18] 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.[18] Other cognitive and behavioral therapies have been used with mixed success.[19][20]

Non-conventional therapies

Electroconvulsive therapy or ECT has been shown to reduce psychotic symptoms associated with schizophrenia, mania, and depression, and is often used in psychiatric hospitals.

Ongoing research

Non-psychotic symptomology

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.[21] These studies indicate a remarkably high percentage of children (up to 14% of the population sampled[22]) 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,[23] he proposes two alternative hypotheses on the origins of auditory hallucinations in the non-psychotic. Both of which rely on understanding of the internalization process of the inner voice.[22][24][16]

Internalization of the inner voice

The internalization process of the inner voice is the process of creating an inner voice during early childhood, and can be separated into four distinct levels.[22][24][16]

Level One (External Dialogue) involves the 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.

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 ones self, 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.[22][24][16]


Alternatively, the disruption could occur during the process of re-externalizing ones 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.[22][24][16]


Given the current trends in research, a new approach must be taken towards treatment of these hallucinations. A process that would necessarily begin with the patient being helped to realize that the voices they hear are from their own mind. This realization would allow them to reclaim a measure of control over their lives, and begin the process of controlling their own alien voices.[16]


  1. ^ "Medical dictionary". 
  2. ^ Thompson, Andrea (September 15, 2006). "Hearing Voices: Some People Like It". Retrieved 2006-11-25. 
  3. ^ Young, Ken (July 27, 2005). "IPod hallucinations face acid test". Retrieved 2008-04-10. 
  4. ^ "Rare Hallucinations Make Music In The Mind". August 9, 2000. Retrieved 2006-12-31. 
  5. ^ Engmann, Birk; Reuter, Mike: Spontaneous perception of melodies – hallucination or epilepsy? Nervenheilkunde 2009 Apr 28: 217-221. ISSN 0722-1541
  6. ^ a b c d Laqueur, Thomas (2007-09-03). "Spirited Away". pp. 36-42. 
  7. ^ Stanton, Biba (2000). "First-person accounts of delusions". Psychiatric Bulletin 20: 333–336. 
  8. ^ a b c d Boyer, Paul S: "Insane Asylums." The Oxford Companion to United States History. Oxford University Press. 2001. 22 Nov. 2009
  9. ^ Silbersweig, D.A. (1995). "A functional neuroanatomy of hallucinations in schizophrenia". Nature 378: 176-179. 
  10. ^ SHERGILL, SUKHWINDER S. (2004). "Neuroanatomy of ‘Hearing Voices’: A Frontotemporal Brain Structural Abnormality Associated with Auditory Hallucinations in Schizophrenia". Cerebral Cortex 14: 91-96. 
  11. ^ Shin, Sang-Eun (2005). "Segmented volumes of cerebrum and cerebellum in first episode schizophrenia with auditory hallucinations". Psychiatry Research: Neuroimaging 138: 33-42. 
  12. ^ SHERGILL, SUKHWINDER S. (2003). "Temporal course of auditory hallucinations". BRITISH JOURNAL OF PSYCHIATRY 182: 525-531. 
  13. ^ Boksa, Patricia (2009). "On the neurobiology of hallucinations". J Psychiatry Neuroscience 34(4): 260–262. 
  14. ^ Spencer, Kevin M (2009). "Left auditory cortex gamma synchronization and auditory hallucination symptoms in schizophrenia". BMC Neuroscience 10:85: 1-13. 
  15. ^ a b Hugdahl, Kenneth (2008). "Auditory hallucinations in schizophrenia: the role of cognitive, brain structural and genetic disturbances in the left temporal lobe". Frontiers in Human Neuroscience 1: 1–10. 
  16. ^ a b c d e f g Fernyhough, Charles; Jones, Simon R.: “Thinking Aloud About Mental Voices”
  17. ^ Stip, Emmanuel (2009). "Psychotic Symptoms as a Continuum Between Normality and Pathology". The Canadian Journal of Psychiatry 54: 140-151. 
  18. ^ a b Penn, David L. (2008). "Professional A randomized controlled trial of group cognitive-behavioral therapy vs. enhanced supportive therapy for auditory hallucinations". Schizophrenia Research 109: 52–59. 
  19. ^ HAYASHI, NAOKI md, phd; IGARASHI, YOSHITO md; SUDA, KIYOKO md; NAKAGAWA, SEISHU md: Auditory hallucination coping techniques and their relationship to psychotic symptomatology Psychiatry and Clinical Neurosciences 61” 2007: 640–645
  20. ^ Shergill, Sukhwinder S. (1998). "Auditory hallucinations: a review of psychological treatments". Schizophrenia Research 32: 137–150. 
  21. ^ Askenazy, Florence L. (2007). "Auditory hallucinations in pre-pubertal children: A one-year follow-up, preliminary findings". European Child Adolescence Psychiatry 16: 411–415. 
  22. ^ a b c d e Jones, Simon R. (2007). "Neural correlates of inner speech and auditory verbal hallucinations: A critical review and theoretical integration". Clinical Psychology Review 27: 140–154. 
  23. ^ ALLEN, PAUL (2007). "Inner speech models of auditory verbal hallucinations: Evidence from behavioural and neuroimaging studies". International Review of Psychiatry 19(4): 409–417. 
  24. ^ a b c d Fernyhough, Charles (2004). "Alien voices and inner dialogue: towards a developmental account of auditory verbal hallucinations". New Ideas in Psychology 22: 49–68. 

Further reading

External links


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