Voices beyond words
Authors: Flavie Waters
Journal: The Lancet Psychiatry (2015)

Drawing on the University of Durham's long tradition of medical humanities and phenomenological approaches, Woods and colleagues1Woods A Jones N Alderson-Day B Callard F Fernyhough C Experiences of hearing voices: analysis of a novel phenomenological survey.Lancet Psychiatry. 2015; (published online March 11.)http://dx.doi.org/10.1016/S2215-0366(15)00006-1Google Scholar explore the first-person experience of auditory hallucinations (also known as voices) in a community sample using a qualitative survey approach. Auditory hallucinations are common in psychiatric disorders, especially schizophrenia. During the past 10 years, researchers have learned that auditory hallucinations also occur in a small but notable proportion of the general population without the need for clinical care. However, very little is known about these individuals, and even less is known about their experience of hallucinations. Woods and colleagues study1Woods A Jones N Alderson-Day B Callard F Fernyhough C Experiences of hearing voices: analysis of a novel phenomenological survey.Lancet Psychiatry. 2015; (published online March 11.)http://dx.doi.org/10.1016/S2215-0366(15)00006-1Google Scholar gives a unique insight into the raw phenomenology of auditory hallucinations, undistorted by the clinical symptoms (eg, delusional interpretations) and cognitive compromise (eg, language disorders) that often accompany schizophrenia. Importantly, the findings of the study show new and surprising themes that direct attention beyond the immediate scope and remit of speech, and towards a more global and integrated experience. In the past 30 years, studies have been constructed with preconceived ideas about auditory hallucinations being composed of abnormal language processes or misattributed inner speech, such that language and speech have become common constitutive elements of any investigations. This language-centric approach has shaped interrogative questions about these experiences, and clinicians often ask questions such as “Do you hear voices in your head? What do they say?” Thus, verbal and lexical characteristics have become the norm in descriptions of the dimensional forms and features of auditory hallucinations (eg, verbalisation, speech content, replays of conversations, and complexity of utterances), and as targets in dialogue-based forms of clinical interventions. Language and speech are important in some hallucinations, especially those related to schizophrenia. However, the fact that non-verbal auditory hallucinations are also common is often forgotten; for example, they occur in roughly 40% of individuals with schizophrenia and other psychotic disorders2Nayani TH David AS The auditory hallucination: a phenomenological survey.Psychol Med. 1996; 26: 177-189Crossref PubMed Google Scholar and a substantial number of participants in Woods and colleagues’ study (11% reported musical musical and 21% reported non-verbal hallucinations).1Woods A Jones N Alderson-Day B Callard F Fernyhough C Experiences of hearing voices: analysis of a novel phenomenological survey.Lancet Psychiatry. 2015; (published online March 11.)http://dx.doi.org/10.1016/S2215-0366(15)00006-1Google Scholar These non-verbal phenomena include a range of experiences, such as music, ringing, buzzing, rattling, whistling, bangs, animal calls, water falling, and engines, which have acoustic and aural characteristics that are outside the syntactic and lexical properties used in verbalisation.3Waters F Jardri R Debunking the myth of language supremacy.Schizophr Bull. 2014; (published online Nov 27.)https://doi.org/10.1093/schbul/sbu166Crossref Scopus (17) Google Scholar Hallucinations therefore seem to be more heterogeneous than previously thought, with contents that include both speech and other acoustic (environmental, animal, or musical) material. Woods and colleagues’1Woods A Jones N Alderson-Day B Callard F Fernyhough C Experiences of hearing voices: analysis of a novel phenomenological survey.Lancet Psychiatry. 2015; (published online March 11.)http://dx.doi.org/10.1016/S2215-0366(15)00006-1Google Scholar findings go further than describing the contents of auditory hallucinations. When given the opportunity to describe their experiences with non-leading questions, roughly one in five survey participants preferred terms such as intuitive knowing or telepathic experiences compared with the common term voices. These terms correspond with reports of hallucinations in individuals who are born with hearing loss. Congenitally deaf people do not hear voices, but instead feel that they are being communicated with and perceive being signed to.4du Feu M McKenna P Prelingually profoundly deaf schizophrenic patients who hear voices: a phenomenological analysis.Acta Psychiatr Scand. 1999; 99: 453-459Crossref PubMed Scopus (41) Google Scholar Thus, although the meaning attributed to voices is generally regarded as being deeply entwined with speech contents, the social and communicative interface of voices seems to be able to present across a range of mental events besides verbal material. The participants in Woods and colleagues’ study1Woods A Jones N Alderson-Day B Callard F Fernyhough C Experiences of hearing voices: analysis of a novel phenomenological survey.Lancet Psychiatry. 2015; (published online March 11.)http://dx.doi.org/10.1016/S2215-0366(15)00006-1Google Scholar reported themes such as thought-like (non-language) hallucinations and other-body experiences, in addition to voices. The communicative meaning given to hallucinations therefore seems to reach beyond the usual syntactic and lexical anchors, and spans multiple sensory and motor modalities. Finally, irrespective of the contents and meaning, the form of voices, which remains predominantly perceptual (sensory), has been largely understated. The focus on language in research and clinical practice has distracted researchers from the core experiential form of hallucinations, which is immediate, non-reflexive, and perception-driven. An early definition states, quite simply, that “hallucinations are perceptions without an object”.5Lhermitte J Les hallucinations: clinique et physiopathologie. Doin, Paris1951Google Scholar Although terms such as auditory hallucinations and hearing voices can be regarded as stigmatising, perceptions cannot be denied. If hallucinations can be categorised as perceptions, they are no different from normal perceptions. Further work about auditory hallucinations is needed. To borrow from Strauss,6Strauss R Chapter 21: Phenomenology of hallucinations.in: West L Hallucinations. Grune & Stratton, New York1962: 221-231Google Scholar although perceptions and objects are usually associated in the mind, perceptions have their own organisational structure. For this reason, instead of focusing on pathological language processes, research and treatment efforts should focus on how these perceptions can become disconnected from their contents and spontaneously generated without external stimulation. The study of cognitive control mechanisms seems particularly promising, as do models that seek to understand processes by which self-disturbances occur.7Waters F Badcock JC First-rank symptoms in schizophrenia: re-examining mechanisms of self-recognition.Schizophr Bull. 2012; 36: 169-182Google Scholar I declare no competing interests. Experiences of hearing voices: analysis of a novel phenomenological surveyThis study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory hallucination and suggest potentially important new findings about the association between acoustic perception and thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations and characterological entities. Full-Text PDF Open Access