A lot of "voice hearing" isn't an auditory experience at all

The message from recent surveys is that it's not just people with a diagnosis of schizophrenia who hear voices in their heads, many people considered mentally well do to. This revelation may have a welcome de-stigmatising effect in terms of how people think about some of the symptoms associated with a diagnosis of schizophrenia, but a new study published in Psychosis asks us to hang on a minute – to say that one "hears voices" can mean different things to different people. You might assume that "hears voices" means that a person has an hallucinated auditory experience just like someone is talking to them. But what about hearing an inner voice that is experienced like an out-of-control thought rather than an external voice? Or a heard voice that's not like either a thought or an external voice?

Our knowledge of the experience of voice hearing among patients has been limited by the fact that a lot of psychiatric research in this area (though not all) has been categorical in nature. For instance, a typical psychiatric scale used in research or the clinic includes a vague item like "[Patient] Reports voices than no one else hears" and a tick here can conceal a huge range of different experiences.

For the new research, Nev Jones and Tanya Luhrmann conducted in-depth interviews with 80 people diagnosed with schizophrenia in the US, India and Ghana about their first-hand experiences of hearing voices. There was great variety between participants in their descriptions of voice hearing and also within each individual participant's own descriptions. Perhaps most importantly, while 79 per cent of the participants reported at least some limited experience of the hallucinated sound of external voices – as if someone was audibly speaking to them – a much smaller proportion (17.5 per cent) said this was their dominant experience of "voice hearing".

The most common dominant experience for the participants was to say they had a mixture of auditory and thought-like voices – 29 per cent reported having this. Another 15 per cent said their dominant experience was to hear thought-like voices that seemed "foreign and alien" but clearly "non-auditory". Other categories were "in-between", being neither auditory or thought-like; "limited auditory" (an auditory experience but just simple words or sounds); "transformed", which is when real voices or sounds were misheard as saying something different; and "multi-sensory", involving visual experiences as much as or more than auditory – for example, one participant described how "the voice will show me all my enemies".

Intriguingly, some participants described how a voice could begin as thought-like, but if they ignored it, then it became more auditory: "If I try ignoring them inside my brain, like they come out. They start telling me things."

The researchers said the interviews showed there is huge variety in the ways that people diagnosed with schizophrenia hear voices, and that it is very difficult for both patients and clinicians to find ways to accurately describe these experiences. Another thing – many of the participants said that what they found most difficult about "hearing voices" was the disruption to their thoughts, rather than the sensory aspect of the experience. Indeed, by emphasising the normality of the auditory aspect of hearing voices, the researchers said there was a risk of mental health professionals presenting a "misleading view of what at least some patients are in fact struggling with".

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Jones, N., & Luhrmann, T. (2016). Beyond the sensory: Findings from an in-depth analysis of the phenomenology of “auditory hallucinations” in schizophrenia Psychosis, 8 (3), 191-202 DOI: 10.1080/17522439.2015.1100670

--further reading--
The voices heard by people with schizophrenia are friendlier in India and Africa, than in the US
What's it like to hear voices that aren't there?
The same voices, heard differently?
You hear a voice in your head when you're reading, right?

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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