Hearing voices that don’t exist in the outside world is the most common form of hallucination experienced by people with a diagnosis of schizophrenia or related conditions and it can be very distressing. However, there is a growing recognition that hearing voices is not always pathological. Many mentally well people hear voices (or “auditory verbal hallucinations”) – in fact, around 6-7 per cent of adults in the general population report having had such experiences at some point in their lives.
This has led some experts to propose a “continuum model” in which the same fundamental underlying mechanism leads to hearing voices in healthy people and in patients with a clinical diagnosis, but that for various reasons, such as a traumatic past, the experience is more troublesome and distressing for the patients. However, a new open-access paper in Schizophrenia Bulletin challenges the continuum model, finding an important brain difference between patients who hear voices and voice-hearing healthy controls.
Various visual impairments and abnormalities, such as unusual eye movement patterns, blink rates and retinal problems, are more common than usual in people diagnosed with schizophrenia, suggesting these issues may contribute to the development of the condition. Yet paradoxically, since the 1950s, there have also been intriguing hints that people who are blind from birth or an early age are less likely to develop schizophrenia and other kinds of psychoses, suggesting blindness can act as a protective factor against the illness.
Before now, findings – mostly from case-study type research – suggested that cortical blindness (resulting from abnormalities in the occipital cortex of the brain, rather than the eyes) may even be completely protective. As far as the authors of a new study are aware, not a single case of schizophrenia has ever been reported in someone who is cortically blind.
“Note that most authors are cautious to add that ‘absence of evidence is not evidence of absence’,” Vera Morgan at the University of Western Australia told me. But a total of zero documented cases among such people to date is striking.
Aerobic exercise – any activity that gets your heart pumping harder – improves mood, anxiety and memory. It can help people with major depressive disorder, bipolar disorder and anxiety disorder. Now there’s evidence, from a randomised controlled trial published in Frontiers in Psychiatry, that a programme of regular aerobic exercise also reduces psychopathology in people diagnosed with schizophrenia. And it seems to have a particular impact on so-called “negative” symptoms, such as apathy and loss of emotional feeling, which are not improved by standard drug treatments.
“[W]hile antipsychotics [drug treatments] are essential in treating schizophrenia, interventions other than antipsychotic treatment…may be needed to achieve better outcomes,” write the authors of the new study, led by Peng-Wei Wang at Kaohsiung Medical University Hospital in Taiwan.
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? Continue reading “A lot of “Voice Hearing” isn’t an auditory experience at all”→
We’re in the midst of a “migrant crisis” as tens of thousands of brave, desperate people seek new lives in Europe, risking life and limb to get here. Amidst the tragedy and controversy, the continued plight of those people who actually make it to relative safety is often forgotten. Unsurprisingly, given all they’ve endured, refugees often have serious mental health problems, including hallucinations. As an indicator, research published in 2011 reported that 80 per cent of 130 young Somali refugees surveyed in Minnesota had symptoms of psychosis.
Now a timely, heart-wrenching study published in the journal Psychosis has reported the results of in-depth interviews with seven African refugees or asylum seekers in the UK (aged 26 to 43; one woman), all of whom reported experiencing symptoms of psychosis. The researchers’ aim was to gain insight into the “lived experience” of their participants. This is the first time the first-hand perspective of refugees with psychosis has been documented. “Such information is crucial for understanding and working with such clients,” the researchers said.
Clinical psychologist John Rhodes and his colleagues analysed the interview transcripts and identified six key, recurring themes in their participants’ accounts. The first was bleak agitated immobility – the participants’ sense that their lives were going nowhere. One participant likened the feeling to being in a never-ending race. Similarly, Amine (aged 43) said: “I feel like I’m finished. There’s no life, there’s no future, there’s no anything anymore. I think everything is going to become like darkness.”
The second theme was trauma-related voices and visions. These tended to be the sounds or sights of lost relatives or attackers from the past. Belvie (aged 30, female) heard voices of a past torturer and the torture itself also had a voice: “Some voice I have it’s like from the past. But some of them are not from the past. I don’t know. Sometimes it’s like a voice of the thing that was done to me when I was back home, when I was tortured. Sometimes I hear the voice of that person.”
Reflecting on the nature of such symptoms, the researchers see them as distinct from the flash-backs associated with post-traumatic stress (PTSD). “The trauma-related intrusions did not appear to be relived experiences in the classic ‘PTSD’ sense,” they explained, “but rather to be engrossing and believable perceptions ‘flavoured’ by past trauma.” Such experiences do not fill well with conventional Western psychiatric categories, they argued. Rather than interpreting their participants’ hallucinations as indicative of schizophrenia or PTSD, they suggest a neutral description: “complex trauma with perceptual disturbance.”
The participants also described their powerful feelings of fear and mistrust. Belvie feared a man on a bus was planning to kill her just because he looked at her. All the participants also had a sense of a broken self. “My emotional state has changed and my personality has changed, … I really haven’t been alright,” said Frederic (aged 39). They also described the pain of losing everything. “The degree of loss for these participants is difficult for us to understand,” the researchers said. “They have lost their worlds. A new location or role does not replace ‘home’, that place of familiarity and warmth.” Consistent with this, many of the painful feelings described by the interviewees, such as there being no future, were the same regardless of whether they’d be granted asylum (as four of them had) or if they were still waiting to hear about their status.
The final theme concerned the attraction of death. Several of the participants described past suicide attempts and the unbearable strain of life. “The worst part,” said Sando (aged 26), “is I keep harming myself, … and you know knocking my head to the wall, kinda too much stuff in there, you know, I just want to open my head and finish with this.” Yet, the participants also expressed optimism. The researchers described the participants’ wish to die “held in tension with their wish to live and build a purposeful and worthwhile life.” This final theme is important for clinical services, the researchers said, which “need to recognise that while many [refugees] speak of building a new life, there is an attraction to suicide as escape.”
Rhodes, J., Parrett, N., & Mason, O. (2015). A qualitative study of refugees with psychotic symptoms Psychosis, 1-11 DOI: 10.1080/17522439.2015.1045547
The label “schizophrenic” is loaded with connotations. For many, its utterance provokes thoughts of madness, of violence and oddity. No wonder that clinical psychologist Lorna Howe and her colleagues found the people they interviewed – all diagnosed with the illness – had strived to avoid the label.
In all, the researchers conducted in-depth interviews lasting up to 90 minutes with seven participants diagnosed with schizophrenia. There were three men, four women (average age 44), and they’d been diagnosed between 6 and 17 years previously. They were currently under the care of an NHS community mental health team in England.
Howe’s team transcribed the interviews and looked for interconnecting themes in the participants’ testimonies – a process known as interpretative phenomenological analysis. The overall picture was of a dilemma, in which the participants needed the diagnosis to access treatment, but had feared and avoided it because of its stigma. “I was too scared to tell the doctors what my real symptoms were so they could treat me,” said Carol.
Once they’d received a diagnosis of schizophrenia, the participants described how they attempted to hide it from other people. They mentioned the media’s role in propagating the violence-schizophrenia link, and the way that mental health professionals used alternative terms, such as psychosis, as if they were conscious of the stigma associated with the s-word. “People are always afraid of saying that word to me,” said Carol. “… because it is a dirty word.”
The participants also spoke of the lack of understanding about schizophrenia, and the chasm between the perspectives of their clinicians who tended to see it as a biological illness (a “chemical imbalance”) and the perspectives of other people in their lives. “My mother … all she said was ‘I told you, it’s because you’re psychic …,” said Janet. The biological emphasis from professionals was seen as limiting hope for recovery, and the researchers said this encouraged “individuals to become passive recipients of care.”
Another theme was managing stigma. Janet said she avoids telling people about her diagnosis – “nobody likes rejection, so I just don’t put myself in that position”. Most of the participants saw themselves as “normal” despite their diagnosis. “… to have people treat me like that, you want to say, ‘Look, I’m not that bad’,” said Ben.
The final theme from the interviews was “accepting diagnosis” – the participants described how the label had given them access to treatment and an understanding of their problems. “It was like a relief in a way that at least they knew now what I already knew, that I’d got this schizophrenia,” said David. There was one exception – Janet said she accepts that she has mental health problems, but she rejects the idea that she has schizophrenia.
Howe and her colleagues pointed to some useful lessons from their interviews. Untreated schizophrenia is associated with poorer outcomes, so the results suggest more needs to be done to overcome delays in treatment caused by ill people’s fearful avoidance of a diagnosis. Clinicians’ evasion of the term schizophrenia, and their focus on biological models, may spread confusion and undermine hope. “Professionals may need to take the lead and break their ‘conspiracy of silence’ surrounding schizophrenia to allow the public and those with a diagnosis to follow,” said Howe and her colleagues.
_________________________________ Howe, L., Tickle, A., & Brown, I. (2014). ‘Schizophrenia is a dirty word’: service users’ experiences of receiving a diagnosis of schizophrenia. Psychiatric Bulletin, 38 (4), 154-158 DOI: 10.1192/pb.bp.113.045179 [open access]
The August issue of Psychiatric Bulletin is a themed issue on stigma in mental health
When a patient with schizophrenia hears voices in their head, is the experience shaped by the culture they live in? Tanya Luhrmann and her colleagues investigated by interviewing twenty people diagnosed with schizophrenia living in San Mateo, California; twenty in Accra, Ghana; and twenty others in Chennai India. There were similarities across cultures, including descriptions of good and bad voices, but also striking differences.
In San Mateo the interviewees talked about their condition as a brain disease, they used psychiatric diagnostic terms to describe themselves, and their experiences were almost overwhelmingly negative. Fourteen described hearing voices that told them to hurt others or themselves. Eight people didn’t know the identity of their voices and few described having a personal relationship with their voices.
By contrast, in Chennai, the interviewees frequently spoke of their relationships with their voices – that is, they heard the voices of relatives or friends, giving them advice or scolding them. These patients rarely used diagnostic terms, and rarely talked of voices instructing them to commit violence. Instead, distress, when it occurred, usually arose from their voices talking about sex. Nine interviewees described voices that were significantly good – in terms of being playful or entertaining.
In Accra, yet another picture emerged. Most of the interviewees here mentioned hearing God. This isn’t simply a case of this sample being more religious – the interview groups in all three locations were predominantly religious. Half the interviewees in Accra reported that their voice hearing was mostly or entirely positive. Others frequently emphasised the positive. Use of diagnostic labels was rare, as were incitements to violence by voices.
Luhrmann and her team said their most striking finding was that the experiences of voice hearing in the two non-Western samples were less harsh and more “relational” – that is, patients perceived their voices as other people, who could not be controlled. The researchers believe this difference is likely due to Western cultures emphasising independence and individuality – in which case heard voices are experienced as a violation – whereas African and Asian cultures emphasise how each person’s mind is interwoven with others. “We believe that these social expectations about minds and persons may shape the voice-hearing experience of those with serious psychotic disorder,” the researchers said.
These results need to be replicated with larger samples matched more precisely for illness severity, and with more tightly controlled measures (the current study was deliberately qualitative and exploratory). If replicated, the findings would imply the experience of hearing voices in schizophrenia is to some extent malleable, which could have exciting therapeutic implications. Indeed, it’s notable that the outcomes for patients with schizophrenia outside the West, especially in India, are known to be more positive – perhaps because of the way patients relate to their voices. “The harsh violent voices so common in the West may not be an inevitable feature of schizophrenia,” the researchers said. _________________________________
Luhrmann, T., Padmavati, R., Tharoor, H., & Osei, A. (2014). Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study The British Journal of Psychiatry DOI: 10.1192/bjp.bp.113.139048
Traditionally, when a person says they can hear voices that don’t exist in external reality (not to be confused with inner speaking), psychiatry has treated this as a sign of mental illness. However, it’s become clear in recent years that many people hear hallucinated voices without it causing them distress. To improve our understanding of how voice-hearing becomes problematic it’s clear we need to understand more about the different ways that people experience hearing voices.
Now Lucy Holt and Anna Tickle have published a “meta-ethnographic synthesis” of what we know so far about the varieties of people’s voice-hearing experiences. The researchers trawled the peer-reviewed literature using key-word searches to find studies of adequate quality that involved asking adults to describe their voice-hearing experiences first-hand. This process uncovered seven papers, published between 2003 and 2011, involving the first-hand accounts of 139 people aged 19 to 84 (52 per cent were women).
Holt and Tickle analysed the papers looking for recurring themes in people’s descriptions of their voice-hearing. The results are fascinating and some insights potentially useful for clinicians. The first theme is that most people gave the voices they heard an identity – often they named them, or they attributed a gender to them. Some people heard voices that belonged to real people encountered in the past, other voices were seen as belonging to God or a spiritual force.
Another important theme was the amount of power that people perceived their heard voices as having, and, related to that, how much power they felt they had over them. There was a continuum such that some people felt completely powerless over their heard voices, while others felt they could take them over. Intriguingly this appeared to be related to the explanations people gave for their heard voices. Those who subscribed to a biomedical account, believing that their voices were caused by a chemical imbalance in the brain, tended to feel less in control of their voices. The perceived power of voices was also linked to the voices’ identity, particularly if they were attributed to an authoritarian figure.
People also spoke of the strategies that their voices used to maintain power, such as criticising the person and exploiting his or her weaknesses. Other participants described strategies they used to regain control of their voices, such as using distraction or, opposite to that, deliberately engaging with the voices.
The way that heard voices affected people’s relationships was another theme. People described how hearing voices made it difficult to lead an ordinary life. Heard voices could interfere with social relationships, for example by making critical comments about friends or family. But voices could also play a beneficial role by reducing loneliness. “I have not got many friends … so the only thing I can stay very close to are the voices and I do stay very close to them,” said one person.
Yet another theme related to whether people saw a distinction between their own thoughts and the voices they heard. Most people recognised a clear difference between the two, perceiving heard voices as “coming from outside the self but manifested inside the body”. One exception to this was a study conducted in a psychiatric setting. Here most of the participants endorsed a biomedical explanation for their voices, and they saw their heard voices and own thoughts as one.
Holt and Tickle said their review contained useful insights for therapists, most of all by showing that “‘voice hearing’ is clearly not a homogenous experience.” The findings also suggest ways that therapists might help their clients who hear voices, for example by boosting their feelings of self-worth. Therapists could also benefit by realising that heard voices sometimes have an adaptive function.
Unfortunately, the quality of the studies identified in this review was disappointing. Many failed to provide quotes from participants; others failed to acknowledge the influence of the researcher’s own interpretative stance on the results. “It is evident that the quality of research investigating the first person perspective of hearing voices warrants improvements,” Holt and Tickle said. _________________________________
Holt L and Tickle A (2013). Exploring the experience of hearing voices from a first person perspective: A meta-ethnographic synthesis. Psychology and psychotherapy PMID: 24227763
Unusual, psychotic-like symptoms, such as hearing voices, are not as rare among the general population as you might think. For example, it’s estimated that ten per cent of us hear voices that aren’t there, with only a small minority of hearers likely to ever receive a clinical diagnosis. According to a new study, this means that the factors that cause psychotic-like symptoms are likely different from those that lead to a diagnosis of pathological psychosis. Charles Heriot-Maitland and his colleagues argue that this distinction has been missed by the majority of past studies that hunted the causes of psychosis by focusing only on patients, neglecting those who live happily with their psychotic-like experiences.
To make a start rectifying this situation, Heriot-Maitland’s team interviewed six patients with psychosis (recruited via psychosis teams in SE England) and six “healthy” non-patients, who reported similar unusual experiences (recruited via UK networks involved with spiritual or psychic phenomena). Across both groups, these experiences included: receiving visions from God, hearing voices, and feeling that their body had been taken over. Based on their symptoms alone, you couldn’t tell which group a participant belonged to – clinical or non-clinical. The researchers asked all the participants open-ended questions about the circumstances that led to the onset of their unusual experiences, how they felt about them, and how their friends, relatives and other people had responded.
Using a qualitative method called Interpretative Phenomenological Analysis, the researchers looked for emerging themes in the participants’ answers. Both similarities and differences emerged. In both groups, their unusual psychotic experiences had started after a period of negative emotion, most often accompanied by feelings of isolation and deep contemplation about the meaning of life. However, the groups differed in how they responded to and perceived their odd experiences. Members of the non-clinical group had been more aware of non-medical interpretations of their symptoms; they viewed them as transient and desirable; and people close to them shared this non-pathologising perspective. By contrast, the patients encountered invalidating, medical interpretations of their experiences and were themselves less able to accept their experiences and to incorporate them into their personal and social worlds.
From a theoretical point of view, Heriot-Maitland and his colleagues said there was a need for a more precise approach to the study of psychosis, which distinguishes risk factors for psychotic experiences from risk factors for actual clinical vulnerability. “It would seem that the more out-of-the-ordinary experiences are associated with clinical psychosis, the less chance people have of recognising their desirability, transiency, and psychological benefits, and the more chance they have of detrimental clinical consequences.”
The researchers added that this has important clinical implications: “psychotic experiences should be normalised,” they said, “and people with psychosis should be helped to re-connect the meaning of their out-of-the-ordinary experiences with the genuine emotional and existential concerns that preceded them.” They also acknowledged that more studies, including quantitative investigations, are needed to build on this initial work. _________________________________
Heriot-Maitland, C., Knight, M., and Peters, E. (2011). A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations. British Journal of Clinical Psychology DOI: 10.1111/j.2044-8260.2011.02011.x