Source : FISH ’S Clinical psychopathology

Hearing (auditory)

Hallucinatory voices were called ‘phonemes’ by Wernicke in 1900, although this term, a technical one derived from linguistics, is rarely used now.

Auditory hallucination may be elementary and unformed, and experienced as simple noises, bells, undifferentiated whispers or voices. Elementary auditory hallucinations can occur in organic states and noises, partly organised as music or completely organised as hallucinatory voices, in schizophrenia. In the latter they may form a part of the basis for the patient’s delusion that they are the victim of persecution or that their thoughts or actions are being controlled. ‘Voices’ are characteristic of schizophrenia and can occur at any stage of the illness. As well as occurring in organic states, such as delirium or dementia, they can occasionally occur in severe depression but they are usually less well formed than those described in schizophrenia.

Hallucinatory voices vary in quality, ranging from those that are quite clear and can be ascribed to specific individuals to those that are vague and which the patient cannot describe with any clarity. Patients are often undisturbed by their inability to describe the direction from which the voices come or the sex of the person speaking. This is quite unlike the experience of the healthy individual. The voices sometimes give instructions to the patient, who may or may not act upon them; these are termed ‘imperative hallucinations’. In some cases the voices speak about the person in the third person and may give a running commentary on their actions.

These are among Schneider’s first-rank symptoms, and although this was one thought to be diagnostic of schizophrenia, this is no longer the case since these symptoms have also been described in mania (Gonzalez-Pinto et al, 2003).

Auditory hallucinations may be abusive, neutral or even helpful in tone. At times they may speak incomprehensible nonsense or neologisms.

The effect of the voices on the patient’s behaviour is variable. A number of patients (becoming fewer in number with advances in treatment) have continuous hallucinations that do not trouble them. For others the persistence

of the hallucinations cuts across all activities so that the patient is seen to be listening and even replying to them at times. Sometimes activity may diminish due to preoccupation with the hallucinations.

One type of auditory hallucination is hearing one’s own thoughts spoken aloud and is also one of Schneider’s first-rank symptoms. Known in German as Gedankenlautwerden, it describes hearing one’s thoughts spoken just before or at the same time as they are occurring. Echo de la pensée (French) is the phenomenon of hearing them spoken after the thoughts have occurred.

Probably the best English term would be ‘thought echo’ or the alternative and more cumbersome ‘thought sonorisation’. Of note, SCAN classifies thought echo as a disorder of thought (World Health Organization, 1998) rather than as a hallucinatory experience. The patient may also complain that their thoughts are no longer private but are accessible to others. This is known as thought broadcasting or thought diffusion (also a first-rank symptom) and is best classified as a disorder of thought rather than a hallucinatory experience, since there is no necessary implication that thoughts must first be heard. However, there are different definitions of this phenomenon, some of which specify that the thoughts must first be audible, so that Gedankenlautwerden/echo de la pensee are prerequisites to thought broadcast (Pawar & Spence, 2003).

Patients explain the origin of the voices in different ways. They may insist that the voices are the result of witchcraft, telepathy, radio, television, and so on. Sometimes they claim that the voices come from within their bodies such as their arms, legs, stomach, etc. For example, one patient heard the voices of two nurses and the Crown Prince of Germany coming from her chest. Some patients hallucinate speech movements and hear speech that comes from their own throat but has no connection with their thinking. One patient complained bitterly of her ‘talky-talky tongue’ because she was continuously auditorily hallucinated and felt speech movements in her tongue. Thus she had both auditory and possibly somatic hallucinations.

However, it has been shown that sub-vocal speech movements occur in healthy subjects when they are thinking or reading silently, and it has also been demonstrated that           patients hearing voices have slight movements of the lips, tongue and laryngeal muscles and that there is an increase in the action potentials in the laryngeal muscles. It is perhaps surprising that more patients do not complain of voices coming from their throat or tongue.

A few patients deny hearing voices but assert that people are talking about them. Careful investigation of the content and nature of the things that others are alleged to have said may show that the patient has continuous hallucinations and attributes them to real people in the vicinity. As these are often abusive the patient may attack those whom they believe are responsible.

A good example of this was a Greek woman who had been a patient in a long-stay ward for many years. She always denied hearing voices but from time to time would make unprovoked attacks on fellow patients. One day she was asked if she would like some Greek newspapers or visits from someone who spoke Greek. She said that this was not necessary because everybody in the hospital spoke Greek. It became obvious that she heard continuous voices in Greek that she attributed to real people, and that her seemingly motiveless attacks were prompted by this. This clearly represented a delusional elaboration of a hallucinatory experience.