The first time I ever experienced an auditory hallucination, my body reacted with sheer terror. Not because I was afraid of the voice — it just sounded, to me, like someone said my name while I was alone in a sound-proofed booth at a radio station at 4:30am — but because I thought it meant I was insane. Or like, more insane. I thought it meant I was on the verge of having yet another diagnosis added to the alphabet soup of my medical records. Because certainly, hearing voices was one of those very, very clear signs that I was losing what was left of my mind.
I wasn’t. I was just extremely sleep deprived and hungry and my brain was misfiring in an attempt to keep me standing upright. I’ve since experienced this several times and it’s always when I had low blood sugar and was running on not enough sleep.
There aren’t a lot of binary Crazy/Not Crazy switches that most of us have internalized. Most of the symptoms of depression, anxiety, OCD, personality disorders, and even substance use disorders are more subtle and have to be observed in concert with others in order to lead to a diagnosis.
Disembodied voices, though, are generally viewed as a surefire sign that a person is experiencing Something Very Bad.
It’s not true; there are actually a lot of reasons why you might hear sounds in your head that didn’t come from the outside world. I mean, we don’t consider people with tinnitus to be mentally ill. But this belief is a hangover from a previous time in medicine and has proven persistent.
To be honest, I’d never really thought much about it until I was reading Hallucinations by Oliver Sacks this weekend and found his essay on the subject of hearing things and the brain.
Dr. Sacks aka The Truth says…
Are there people who lived and died, who you never met, who you were just absolutely crushed upon their passing? Of course there are. Prince and David Bowie existed in our lifetime. For me, it’s Dr. Oliver Sacks, a complicated, fascinating man who lived at least 37 different lives, who experienced so much, and who wrote so lyrically about it. I would’ve laid down my own life for this motorcycle-riding, muscle-bound, face-blind, soft-spoken gay icon.
Anyway, in Hallucinations, he specifically wrote about the role of the brain in the creation of the world we see, here, taste, and perceive. Essentially, it’s not unusual for the brain to telegraph sensations from within itself, rather than from the outside world.
“In the popular imagination,” he writes, “hallucinatory voices are almost synonymous with schizophrenia — a great misconception, for most people who do hear voices are not schizophrenic.”
Dr. Sacks recaps a 1973 study published by a Stanford psychologist, David Rosenhan. Rosenhan designed an experiment using a small group of individuals with no documented pattern of abnormal behavior other than hearing sounds — including thuds and other hollow noises — that were not present.
These “pseudopatients” were checked in to a clinical setting and observed by doctors and nurses who ultimately “emphasized, among other things, that the single symptom of ‘hearing voices’ could suffice for an immediate, categorical diagnosis of schizophrenia even in the absence of any other symptoms or abnormalities of behavior.”
As Dr. Sacks explained it:
Psychiatry, and society in general, had been subverted by the almost axiomatic belief that "hearing voices" spelled madness and never occurred except in the context of severe mental disturbance.
This binary thinking was, he theorized, the result of a change in the way patients were examined upon intake.
…By the 1970s, antipsychotic drugs and tranquilizers had begun to replace other treatments, and careful history taking, looking at the whole life of the patient, had largely been replaced by the use of DSM criteria to make snap diagnoses.
Instead of observing patients, as doctors may have done in previous eras, the psychiatrists of the 1970s were looking for more clinical diagnoses — which meant, just like a high white blood cell count means infection, the presence of auditory hallucinations meant insanity.
What this quick diagnosis might leave out, Dr. Sacks asserts, is the fact that there are lots of different kinds of auditory hallucinations. They come in a wide range of sounds, tones, and personals. That, says Dr. Sacks, is the key.
How holy are the voices in your head?
When thinking about auditory hallucinations, we tend to view it through our modern lens, wherein all sounds that “don’t exist” must be a symptom of insanity. But that leaves out the very broad tradition of disembodied voices in religion and spirituality. A psychic vision? A voice coming out of a burning bush? An angel speaking to you? The voice of God telling you to take your child up a mountain and burn him alive? These are stories that are deeply ingrained, but there are a lot of people who might take offense at the suggestion that Abraham was psychotic.
[Sidebar: there are modern psychological examinations of Biblical characters; in a 2012 paper, Evan D. Murray, M.D. Miles G. Cunningham, M.D., Ph.D., and Bruce H. Price, M.D. “analyzed the religious figures Abraham, Moses, Jesus, and St. Paul from a behavioral, neurologic, and neuropsychiatric perspective to determine whether new insights can be achieved about the nature of their revelations. Analysis reveals that these individuals had experiences that resemble those now defined as psychotic symptoms, suggesting that their experiences may have been manifestations of primary or mood disorder-associated psychotic disorders.” You can read that paper here. It’s very interesting.]
“Until the eighteenth century, voices — like visions — were ascribed to supernatural agencies: gods or demons, angels or djinns,” explains Dr. Sacks. “No doubt there was sometimes an overlap between such voices and those of psychosis or hysteria, but for the most part, voices were not regarded as pathological; if they stayed inconspicuous and private, they were simply accepted as part of human nature, part of the way it was with some people.”
Later, as secularism and science began to lead the way in diagnoses and care, hallucinatory visions and voices “came to be seen as having a physiological basis in the overactivity of certain centers in the brain.”
Which is to say, we began to see an auditory hallucination as a call that was coming from inside the house. But after that switch was flipped, the train couldn’t be stopped. Once we decided that voices were pathological, we determined that they could only be pathological.
This isn’t to say that auditory hallucinations are not a symptom of psychosis — researchers believe that around 75% of people with schizophrenia experience voices, as well as “20-50% of individuals with manic depression, 10% of individuals with major depression, and 40% of individuals with PTSD.” So that’s a lot of hallucinations, often tied with trauma or mental disorders. But hearing things isn’t necessarily a one-way ticket to a new diagnosis.
But, because we, culturally, don’t separate out the different kinds, they’re all grouped in with either “ringing in the ears” or “you’re nuts.”
And, depending on the reason or the cause, the voices or sounds — as well as how people interact with them — can vary greatly. Again, Dr. Sacks:
It is clear that attitudes to hearing voices are critically important. One can be tortured by voices…or accepting and easygoing. Behind these personal attitudes are the attitudes of society, attitudes which have differed profoundly in different times and places.
I mentioned tinnitus — a persistent ringing, rushing, or swishing in the ears — earlier which, while it definitely maddening to the person who experiences it, is not considered a symptom of psychosis. This is one of the few instances of auditory hallucinations that we have managed to separate out. We know it’s not pathological and that tinnitus is caused by a “an underlying condition, such as age-related hearing loss, an ear injury or a problem with the circulatory system,” according to the Mayo Clinic. Therefore, there’s no assumption that it’s really “all in your head.”
So why don’t we do the same kind of parsing with other sounds and voices?
The voices experienced by people living with schizophrenia markedly different than those that are, say, due to sleep deprivation or even like, loneliness. Rather than the common ones — hearing your own name, hearing a knock at the door or a cell phone vibe that didn’t happen — these voices are menacing and typically linked to the specific pathology of the patient. Some people hallucinate music. Others hallucinate a terrifying evil version of themselves telling them to jump into the sea.
The presence of white noise can stir some people’s brains to look for low tones, but then, too much silence can cause others to fill in the blanks with imagined sounds. There’s really a wide range of things you might think you hear, because there’s a wide range of why you might hear them.
“Various explanations have been offered for why people hear voices, and different ones may apply in different circumstances,” explains Dr. Sacks. “It seems likely, for example, that the predominantly hostile or persecuting voices of psychosis have a very different basis from the hearing of one's own name called in an empty house; and that this again is different in origin from the voices which come in emergencies or desperate situations.”
I’ll leave this with a long excerpt from Dr. Sacks, because I think he summarizes it very well:
Auditory hallucinations may be associated with abnormal activation of the primary auditory cortex; this is a subject which needs much more investigation not only in those with psychosis but in the population at large — the vast majority of studies so far have examined only auditory hallucinations in psychiatric patients.
Some researchers have proposed that auditory hallucinations result from a failure to recognize internally generated speech as one's own (or perhaps it stems from a cross-activation with the auditory areas so that what most of us experience as our own thoughts becomes "voiced").
Perhaps there is some sort of physiological barrier or inhibition that normally prevents most of us from "hearing" such inner voices as external. Perhaps that barrier is somehow breached or undeveloped in those who do hear constant voices. Perhaps, however, one should invert the question — and ask why most of us do not hear voices.
I’m not sure about anyone else, but I’m going to start asking more people in my life if they’ve ever heard voices. In part to break the stigma, and in part because I’m dying to hear that they (the voices) say.