Auditory Hallucinations

1) Overview — What Are Auditory Hallucinations?

Auditory hallucination / Paracusia = auditory hallucinations / “hearing voices.”

It is the experience in which a person “hears sounds” – voices, speech, or other sounds – that feel completely real, but in reality there is no actual sound source in the environment: no one is speaking, the TV is off, no electrical devices are making abnormal noises, and yet the brain perceives those sounds as if they are really occurring.

Importantly, the body and the peripheral hearing system (e.g., pinna, ear canal, eardrum) do not necessarily have to be abnormal. The issue lies at the level of signal processing in the brain, which either “creates” the sound internally or misinterprets some signals as external sounds even though there are none.

In general, auditory hallucinations are considered one form of hallucination, which belong to the broader group of psychotic symptoms, but they can also be found in other disorders or in certain special situations, even in people with no clear prior history of psychotic illness.

From the patient’s experience, auditory hallucinations are often as vivid as real sounds:

• The voice can sound like a woman, a man, or a child.

• It can have a specific loudness, and a perceived direction, as if coming from the left, right, or from behind.

• Some people feel the sound is “coming from inside the head,” yet still feel that it is not their own voice.

This is different from simply “thinking in words” or “inner speech,” because the person experiences the voice as something happening to them, rather than a thought they themselves own. They usually feel they cannot control it, cannot stop it, and cannot “turn the volume down.”

The point at which auditory hallucinations become a “clinical symptom” is when:

• They do not occur only briefly or occasionally, such as hearing our own name faintly when we are extremely sleepy and then it goes away,

• But instead begin to occur repeatedly, become more frequent, last longer, and cause distress, fear, or significant interference in daily functioning – for example:
• Being unable to work,
• Insomnia,
• Avoiding people because of fear of the voices,
• Or fear that others will hear them talking back to the voices.

The most common form is Auditory Verbal Hallucinations (AVH) – i.e., hearing “voices” / “speech.”

Examples include:

• Voices insulting them,
• Voices criticizing,
• Voices threatening,
• Voices commanding them to do certain things,
• Or voices providing a running commentary of what they are doing.

In some cases, the voice may speak about the person in the third person, or there may be multiple voices arguing with each other about the person.

Auditory hallucinations are most commonly found alongside the Schizophrenia spectrum and other psychotic disorders, but they can also occur in:

• Major depressive disorder with psychotic features,
• Bipolar disorder with psychosis,
• PTSD,
• Certain brain diseases,
• Alcohol/ substance withdrawal,
• Or even in severe sleep deprivation.

However, having an experience of “hearing voices”:

• Does not automatically mean that person is “crazy” or “weak,”

• And does not automatically mean they must have schizophrenia.

To decide which disorder is present, clinicians must look at the broader context, such as:

• Mood state,
• Presence of delusions,
• Reality testing,
• Level of functioning in daily life,
• Physical/medical history,
• And history of substance use.

Some people who hear voices but still have good reasoning, can function well, and do not see the voices as divine or all-powerful may fall into the group often called “non-clinical voice-hearers” – they have voice-hearing experiences but do not meet full criteria for a psychotic disorder. However, if the voices begin to cause distress, fear, or safety risks (e.g., the voices command them to harm themselves), this is an important sign that they should be assessed by a professional.

In short:

Auditory hallucinations are “sounds that the brain generates by itself”,
while there is no corresponding sound in the external world.
If they occur frequently, cause significant distress, or disrupt life,
they are often a sign of underlying brain and mental health problems
that should be taken seriously and evaluated properly.

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2) Core Symptoms — Key Features of Auditory Hallucinations

This section explains in detail what “hearing voices” actually looks like – how it appears in clinical settings and in real life. It goes beyond a simple one-line definition like “hearing sounds that are not there,” and dives into the tone, content, context, and impact.

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2.1 Types of Perceived Sounds

Voices / Speech (voices / auditory verbal hallucinations, AVH)
This is the most frequently reported type in research and clinical practice.

• It may be a single voice heard repeatedly, or multiple voices at once.

• The voice may be identified as male / female / child, or as a voice that “sounds familiar but cannot be clearly identified.”

• Some people say it is the voice of someone they know, such as a parent, partner, friend, or someone who has passed away.

• Sometimes the voice is identified as the voice of a “sacred being / demon / deity” according to the person’s belief system.

Common patterns of communication:

• Speaking directly to the person (second-person), e.g.
  “You’re useless,” / “Get out of the house right now.”

• Speaking about the person (third-person), e.g.
  “She’s pathetic,” / “He’s not going to make it.”

• Multiple voices arguing with each other about the person, e.g.
  Two voices arguing: “He should die.” — “No, he shouldn’t.” etc.

Non-verbal sounds

• For example: music, humming, knocking on the door, footsteps following them, breathing sounds, someone’s breath close to the ear, high-pitched whistling, ringing, etc.

• Often comes with a sense that “someone or something is nearby,” even though nothing can be seen.

Here we must differentiate from ordinary tinnitus (ringing in the ears):

• Tinnitus is typically a persistent “hissing, buzzing, ringing” sound with no clear semantic content, and can often be explained by ear-related conditions.

• Hallucinations, on the other hand, are tied to meaning / context, e.g., hearing footsteps specifically when they feel someone is following them.

Location and direction of the sound (location)

• Some people feel the sound comes from outside, such as:
• From the room next door,
• From behind the curtain,
• From the balcony,
• Or from behind them.

• Others feel the sound is “inside the head”, but still do not experience it as “their own thoughts.”

• Sometimes the person can point to a specific location, e.g.

“Over there, in that corner,” or “next to this ear.”

Quality of the sound (quality)

• Some people say the voice is even clearer than a real person speaking.

• Others say it sounds like it comes through a loudspeaker, megaphone, radio, or from far away.

• The loudness may be stable or may get louder when the person is stressed, alone, or about to fall asleep.

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2.2 Phenomenological Features (Deep Subjective Experience)

The feeling that “the voice is not mine” (sense of alienness)

• The core issue is not merely that there “is a sound,” but that the sound feels alien.

• Patients often say things like:
  “It’s not a voice I’m thinking up myself. It comes from outside / from someone or something.”

• This feeling is different from “thinking in words,” where we usually know it is “my own thought.”

Loss of control

• People often feel they cannot “switch the voice off.” Telling it to stop doesn’t make it stop.

• Some try turning on the TV or music to drown it out, but the voice still breaks through.

• This sense of powerlessness over the voices is a major factor in emotional distress.

Self-referential content

Most of the content revolves around the person’s sense of self:

• Critical voices: “You’re a failure / You’re worthless.”

• Insulting or demeaning voices: Using abusive language that induces shame and feelings of inferiority.

• Threatening voices: “If you don’t do X, something terrible will happen.”

• Command voices: Ordering them to do things, such as:

• Not leaving the house,
• Not eating,
• Harming themselves,
• Harming others, etc.

In some cases, the voice may be “soothing” in content, e.g.:

• Saying “It’s okay, I’m here,” giving the person a sense that someone is there to keep them company.

Emotional impact

Voices with negative content often induce:

• Fear, high anxiety, panic,
• Feelings of guilt, shame, self-hatred,
• Anger, irritability, and emotional outbursts toward others.

Voices that feel protective can lead the person to form a bond with the voice, as if it were a “secret friend” or a “guardian.”

Behavioral correlates

• Turning the head / looking towards the perceived source of the sound (even though no one is actually there),

• Speaking back or arguing with the voice (which from the outside looks like “talking to oneself”),

• Avoiding places or activities that seem to make the voices louder, e.g.:
• Not wanting to sit alone in silence,
• Not wanting to be in the dark,

• Following the voice’s commands partially or completely (especially command hallucinations).

Frequency and temporal pattern (frequency & temporality)

• Some people hear voices intermittently, for example a few times a day.

• Others hear voices almost all day with only brief periods of silence.

• For some, the voices become particularly loud:
• Before sleep,
• At night,
• Or when it’s quiet, because external stimuli are reduced.

Level of insight into the experience

• Some people partially recognize: “This is probably a symptom,” but still feel it is extremely real.

• Others are fully convinced the voices are “100% real” – as actual people/beings/sacred entities communicating with them.

• This insight is very important for overall assessment and treatment planning.

Relationship with the voices

• Some people hate the voices, constantly resist them, curse them back, leading to ongoing internal conflict.

• Others “accept” or “bond” with the voices, treating them like close friends or as an authority that must be obeyed.

• This dynamic is directly relevant to certain therapeutic approaches, such as:
• CBT for psychosis,
• Therapies that work specifically on the relationship between “the self and the voices.”

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3) Diagnostic Criteria — Overall Principles of Assessment

This section explains what mental health professionals (psychiatrists / clinical psychologists) look for when assessing “hearing voices,” and how they distinguish true auditory hallucinations from other phenomena such as inner thoughts, flashbacks, sensory distortions from other illnesses, or religious/spiritual beliefs.

Emphasis:

Auditory hallucinations = a symptom,
not a stand-alone disorder.

The final diagnosis must answer:

• Is this Schizophrenia?

• Major depressive disorder with psychotic features?

• Bipolar disorder with psychosis?

• PTSD?

• Substance-induced psychotic disorder?

• Neurocognitive disorder? Etc.

Below are major assessment principles based on international guidelines (DSM-5-TR / ICD-11) and real-world clinical practice.

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3.1 First Confirm: “Is This Really a Hallucination?” (and Not Something Else)

No external auditory stimulus

• Check the situation:
• When the voice is heard, are other people present?
• Is the TV/radio/phone on?

• If there is no clear sound source → it is more likely to be a hallucination.

Other people do not hear the same sound (idiosyncratic perception)

• If the sound is supposedly loud enough that others should hear it, but no one else does,

• It suggests the experience is individual, not a sound that exists in the external environment.

Differentiate from inner speech / intrusive thoughts / flashbacks

• Normal inner speech:
  We feel “I am thinking this myself.” It does not have the quality of an external sound.

• Intrusive thoughts / obsessions:
  Unwanted, disturbing thoughts that intrude, but usually the person still knows “these are my thoughts.”

• Flashbacks (e.g., in PTSD):
• The person re-experiences scenes from the past, including images, sounds, and feelings, as if transported back into the event.
• But the person can still recognize that this is past memory “flooding back.”

• Auditory hallucinations:
  The person experiences it as a “new sound occurring now,” not just a replay of a past memory.

Not just normal hypnagogic / hypnopompic experiences

• If the voices occur only when:
• Drifting off to sleep (hypnagogic), or
• Just waking up (hypnopompic),
  and do not cause significant distress or functional impairment,
  they are often considered semi-normal phenomena seen in the general population.

• But if they become more frequent, intense, or are accompanied by other symptoms → a more detailed assessment is needed.

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3.2 Assess Frequency, Duration, and Severity

During history taking, the clinician will ask questions such as:

Frequency

• Do you hear the voices every day?

• How many times a day does it happen?

• Are they brief episodes or long periods?

Duration

• How long does each episode last?

• Is it a short burst (a few seconds to minutes) or continuous without stopping?

Severity in terms of distress and functional impairment

• How much fear, stress, or insomnia do the voices cause?

• Do they interfere with studying, work, or social life?

• Have you ever had to quit a job or take leave from school/work because you could not tolerate the voices?

Triggers

• When do the voices tend to become louder?
• When under stress,
• When alone,
• When using substances (alcohol, drugs),
• When sleep-deprived, etc.

These are not strict numeric DSM thresholds (e.g., X times per week), but are used to judge whether the symptom has reached “clinical significance” – i.e., frequent/severe enough to be considered part of a mental disorder, rather than just a strange but transient experience.

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3.3 Assess Content and Its Impact on Thoughts and Behavior

Content (what the voices say)

• What do the voices most often say to you?

• Are they:
• Insulting, critical, demeaning,
• Threatening,
• Commanding,
• Or having casual conversations?

• Is the content related to other themes, such as:
• Guilt/sinfulness (common in severe depression),
• Grandiosity, being special or chosen (in grandiose delusions / psychotic bipolar),
• Suspiciousness, being followed or controlled (in persecutory delusions)?

Command hallucinations = red flag

What do the voices command you to do?

• Self-harm: telling you to commit suicide, saying “No point staying alive,” etc.

• Harm others: telling you to harm family members or strangers.

• Other risky behaviors:
• Running away from home,
• Setting things on fire,
• Putting yourself in dangerous situations, etc.

Clinicians must ask clearly:

• How much do you believe and obey the voices?

• Have you ever followed the voices’ commands?

If command hallucinations are present and the person has acted on them or is likely to act on them → this is a high-risk situation, and a safety plan must be put in place immediately.

Impact on thought process

• Do the voices make your thinking more repetitive or ruminative?

• Do they impair your ability to focus and think about other things?

• Are there delusions built around the voices, for example:
• “These voices come from CCTV cameras beaming signals into my head,”
• “A secret organization is communicating with me through satellites,” etc.?

Impact on real-life behavior

• Speaking back to the voices out loud (others see this as “talking to oneself”),

• Avoiding other people or social situations because they are afraid others will see them arguing with the voices,

• Changing lifestyle behavior, such as:
• Stopping going out,
• Stopping work,
• Avoiding friends
  because the voices tell them not to go.

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3.4 Look at the Pattern of Other Symptoms to Find the Main Diagnostic Group (Diagnostic Context)

Clinicians will not look only at isolated “hearing voices,” but at the overall pattern of accompanying symptoms and see which diagnostic group it fits.

Schizophrenia spectrum and Schizoaffective disorder

Presence of at least some of:

• Delusions,
• Disorganized speech (loose, tangential, incoherent),
• Disorganized behavior or catatonia,
• Negative symptoms (flattened affect, reduced speech, lack of motivation).

Symptoms persist for months, and there is clear and significant decline in functioning.

Major depressive disorder with psychotic features

• Prominent depressive symptoms:
• Persistent sadness,
• Loss of interest,
• Insomnia / hypersomnia,
• Weight change,
• Poor concentration,
• Feelings of worthlessness, etc.

• Auditory hallucinations tend to be mood-congruent, e.g.:
• Voices repeatedly telling them they are evil, worthless, or should die.

• When the severe depressive episode resolves, the voices typically fade or disappear as well.

Bipolar disorder with psychosis

• History of both manic/hypomanic and depressive episodes.

• Voices often occur during extreme mood states, and the content may reflect grandiosity or paranoia, e.g.:
• Voices saying, “You are the chosen one; you must save the world,”
• Or warning that enemies are coming to harm them.

PTSD and trauma-related disorders

• History of severe trauma: accidents, assaults, torture, abuse, etc.

• Voices may relate to the traumatic event, such as:
• The voice of the perpetrator,
• Or repeated phrases from the trauma scene.

• Other PTSD symptoms present:
• Flashbacks,
• Nightmares,
• Hypervigilance,
• Avoidance of trauma reminders.

Neurocognitive disorders (e.g., dementia)

• Progressive memory decline, impaired judgment, confusion about time/place/people.

• Auditory and/or visual hallucinations may appear as part of the middle-to-late stages of illness.

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3.5 Rule Out Medical and Substance Causes

Before concluding that the person has a “primary psychiatric psychotic disorder,” clinicians must ensure the symptoms are not due to medical conditions or substances.

Substances / alcohol

• Take a detailed history of:
• Heavy alcohol use (both intoxication and withdrawal),
• Drug use: amphetamines, methamphetamine, cocaine, cannabis, ketamine, LSD, etc.

• Assess whether the onset of voices correlates with periods of using or stopping these substances.

Medical and neurological conditions

• Brain tumors, especially in the temporal lobe,

• Lesions in temporal lobe from stroke or other cerebrovascular disease,

• Epilepsy (especially temporal lobe epilepsy),

• Metabolic or endocrine disorders,

• Brain infections or inflammatory conditions.

If the history suggests such possibilities, the clinician may order further tests such as:

• CT/MRI,
• EEG,
• Laboratory tests, etc.

Medication-induced

• Some medications (especially those affecting dopamine, acetylcholine, etc.) can cause psychosis/hallucinations as a side effect, e.g.:
• Certain Parkinson’s disease medications (dopamine agonists),
• High-dose steroids,
• Some anticholinergic drugs.

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3.6 Assess Insight and Reasoning About the Experience

What does the patient think about the voices?

• Do they see them as a “symptom of illness,”
  or as something truly supernatural?

• Do they believe the voices have power to control their life?

Are they able to question the voices?

• For example:
• “Maybe the voices are not real,”
• Or “Even if the voices tell me to do X, I don’t believe them and won’t do it.”

Cognitive flexibility

• If the person can take in new information such as “the voices might come from the brain,” there is more potential for CBT/psychotherapy to help.

• If they firmly believe the voices are objective facts 100%, and build strong delusions around them, the overall severity is higher.

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3.7 The Importance of “Clinical Significance” in Treatment Decisions

Finally, when clinicians consider diagnosis and treatment, they don’t just ask:

“Do you hear voices or not?”

They also ask:

• How much distress do the voices cause?

• How much do they interfere with work, school, and relationships?

• Are there safety risks (to self or others)?

• How long has this been going on, and is it getting worse?

If the voices are becoming more frequent, more intense, more terrifying in content, or are commanding dangerous acts, this is the point where more intensive treatment (medication + psychotherapy + safety planning) becomes highly necessary.

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4) Subtypes or Specifiers — Subtypes of Auditory Hallucinations

4.1 By Complexity of the Sound

Elementary auditory hallucinations

• Simple sounds: hissing, whistling, echoing, ringing, high-pitched tones with no linguistic content.

• Sometimes hard to distinguish from tinnitus, but true hallucinations:
• Have no real stimulus, and
• Are more clearly associated with psychiatric or neurological conditions.
  (Wikidoc+1)

Complex auditory hallucinations / auditory verbal hallucinations (AVH)

• Sentences, dialogues, music, or content that forms a story.

• This subtype is most strongly associated with Schizophrenia and PTSD.
  (Wikipedia+1)

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4.2 By Person / Form of Speech (Schneiderian Types)

Based on Kurt Schneider and older DSM traditions referring to “first-rank symptoms” related to voices: (PMC+2 PMC+2)

Voices commenting / running commentary

• A voice that narrates the person’s actions like a play-by-play commentator, e.g.:
  “Now she’s walking to the bathroom… She thinks no one can see her…”

Voices arguing / discussing

• Two or more voices “arguing” or talking about the person in the third person, e.g.:
  “He’s really stupid.” — “Yes, he’ll never make it.”

Audible thoughts / thought echo

• The feeling that “one’s own thoughts are being spoken out loud” in the head, or as if there is a loudspeaker broadcasting their thoughts.
  (Wikipedia+1)

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4.3 By Mood Congruence

Mood-congruent AVH

• The content matches the person’s mood, e.g., someone with severe depression hears voices saying:
  “You’re worthless,” “You should just die.”

Mood-incongruent AVH

• The content is not consistent with the mood, e.g., a depressed person hears:
  “You are the chosen one who will save the world.”

This specifier is used in mood disorders with psychotic features (MDD/Bipolar).
(jneuropsychiatry.org+1)

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4.4 By Context of the Primary Disorder

• Schizophrenia spectrum / schizoaffective (NCBI+1)

• Mood disorders (MDD, Bipolar) (ScienceDirect+1)

• PTSD / trauma-related

• Dissociative disorders

• Neurocognitive disorders (e.g., Alzheimer’s) (Wikipedia+1)

• Substance-induced psychosis

• Non-clinical voice-hearers (no formal diagnosis but with voice-hearing experiences) (Wikipedia+1)

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5) Brain & Neurobiology — Brain and Neural Mechanisms in Auditory Hallucinations

This section answers the question:

“What is happening in the brain when someone hears a sound that does not exist in reality?”

We will look at three main levels:

• Which brain regions are altered,

• Processing models (e.g., inner speech, predictive coding),

• Neurotransmitters and excitation–inhibition balance.

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5.1 Major Brain Networks Involved

From neuroimaging studies (fMRI, PET, EEG source localization, etc.), during auditory verbal hallucinations (AVH), the network for “language + hearing + self-monitoring” appears to be out of sync or misconfigured, for example:

Superior Temporal Gyrus (STG) / Heschl’s gyrus — primary auditory cortex

• This is the primary auditory center of the brain.

• Studies show that during AVH, this area becomes active as if real sounds were present, even though there is no external auditory input.

• In other words, the brain behaves as if it is hearing something, but the stimulus is generated within the system itself, not from actual sound waves.

Wernicke’s area (posterior superior temporal gyrus in the left hemisphere)

• Involved in language comprehension.

• In AVH, both the auditory cortex and Wernicke’s area light up together, as if the brain is “listening to and decoding speech.”

Broca’s area and frontal language regions

• Normally engaged when we speak out loud and when we talk to ourselves silently (inner speech).

• Many studies have found that during AVH, there is activation in Broca’s area similar to when we are generating speech.

• But the temporal/auditory regions misinterpret that internally generated speech as “coming from outside”, instead of recognizing it as self-produced.

Default Mode Network (DMN)

• A set of regions active when “the mind is wandering,” engaged in inner thoughts, self-related processing, and autobiographical memory.

• In people with AVH, the DMN shows abnormal connectivity with language and auditory networks, causing internal mental activity (inner mentation) to be experienced as if it were external input.

• It is as though the boundary between “the inner world” and “the external world” becomes blurred.

Salience network (anterior cingulate cortex + insula)

• Responsible for deciding what is important and deserves attention.

• If this network is out of sync, it can assign excessive importance to certain internal signals and aggressively push them into conscious awareness.

• As a result, internal noise that the brain would normally ignore becomes a fully conscious “voice.”

Frontotemporal connectivity overall

• AVH is not just a problem in a single spot, but a network disorder.

• The frontal lobe (especially the prefrontal cortex) normally monitors and regulates signals from the temporal lobe.

• When frontotemporal connectivity is impaired, the brain fails to recognize that the voice originates from within the self → it is experienced as the voice of “someone else.”

In simple terms:

During AVH, the brain areas used for “listening” and “inner talking”
function similarly to when there is real speech,
but the sounds are generated by internal circuits,
and the system responsible for tagging them as “self-produced” is malfunctioning.

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5.2 Key Mechanistic Models: Where Does the Brain Go Wrong?

Researchers have proposed several models to explain where “the voice in the head” comes from. Here are three major ones:

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5.2.1 Inner-Speech Misattribution Model

Core concept:

• Everyone has inner speech – we “talk to ourselves in our head” all the time.

• Normally we know “this voice in my head is mine” because the self-monitoring system works.

What happens in AVH?

• The brain generates inner speech (verbal thought) as usual.

• But the self-monitoring / source monitoring system that should label it as “my own voice” fails.

• As a result, our own thoughts are misinterpreted as “voices from outside.”

This leads to the experience:

• “Someone else is talking to me,”

• Even though neurophysiologically it started from our own inner speech circuits.

This model fits well with fMRI data:

• During AVH, Broca’s area (speech production) and the auditory cortex are active,

• As if we are speaking and then listening to ourselves – but we “forget” that we were the ones who generated it.

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5.2.2 Predictive Coding / Corollary Discharge Defect

Another very important modern neuroscience idea is that “the brain is not a camera recording the world; it is a prediction machine.”

Predictive coding basics:

• The brain constantly predicts upcoming sensory input.

• It then compares the prediction with the actual input.

• The mismatch is called a prediction error, which is used to update the brain’s model of the world.

In the motor & speech system, there is something called corollary discharge / efference copy:

• When we move a limb, the brain sends signals to the muscles and sends a “copy” of that command back to itself, essentially saying:
  “There will be movement; you are the one doing this.”

• That’s why we don’t get startled every time we move ourselves.

• For speech, it’s similar: when we speak or think in words, the brain sends a copy of the signal saying:
  “There will be speech/inner speech; this is self-generated.”

In AVH:

• The corollary discharge / prediction system for inner speech breaks down.

• The brain does not properly predict or cancel out those self-generated signals → inner speech is processed as if it were new external input.

• The result: an “intrusive voice” that feels like it does not belong to the self.

This model explains:

• Why people with AVH feel like the voice “intrudes” rather than being something they created,

• And links directly to disruptions in frontal–temporal circuits responsible for generating and monitoring speech.

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5.2.3 Excitation–Inhibition Balance & Neurotransmitters

Imbalance at the network level is rooted in cellular-level changes:

Glutamate (excitation) & GABA (inhibition)

• These are the two main systems that control the “accelerator and brake” of neuronal firing.

• If glutamate is excessive and/or GABA braking is insufficient, a given network can become overactive, turning into internal “noise.”

• There is evidence that NMDA receptor dysfunction (a type of glutamate receptor) in psychosis disrupts cortical network balance.

Dopamine in the mesolimbic pathway

• Associated with salience – assigning importance to stimuli.

• If dopamine fires at the wrong time in the wrong place, the brain tags certain internal signals as “highly important.”

• In psychosis, internal noise can become tagged with pathological salience, turning into hallucinations and delusions that feel highly convincing.

Serotonin, acetylcholine, etc.

• Involved in modulating mood, sleep–wake cycles, and perception.

• Alterations in these systems can also influence the likelihood of hallucinations (e.g., some drugs that act on serotonin receptors can induce hallucinations).

In summary:

• AVH = the combined result of:
• Language–auditory–self-monitoring circuits being miswired,
• A prediction/cancellation system (predictive coding) that is failing,
• And an imbalance of glutamate–GABA–dopamine that pushes “internal noise” into conscious awareness as if it were real sound.

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6) Causes & Risk Factors — Causes and Risk Factors

This section answers:

“What factors increase the likelihood that someone will develop auditory hallucinations?”

Crucially:

• There is no single cause.

• It arises from a mixture of:
• Genetics,
• Brain factors,
• Life experiences,
• Environment,
• Substances/medications,
• Behavior.

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6.1 Psychiatric Conditions

Schizophrenia / Schizoaffective disorder

• These are the diagnostic groups in which auditory hallucinations are most frequently seen.

• They often co-occur with:
• Delusions (e.g., of being followed or controlled),
• Disorganized speech/behavior,
• Negative symptoms (apathy, reduced speech, flat affect).

• In many guidelines, having AVH—especially “voices commenting” or “voices arguing”—is considered a key sign.

Mood disorders with psychotic features (MDD / Bipolar)

• In Major depressive disorder with psychotic features:
• Severe depression is the central feature.

• The voices are usually mood-congruent, e.g.:

• Voices harshly criticizing them as evil, worthless, deserving to die.

• In Bipolar disorder with psychosis:

• During manic episodes, voices may be grandiose or paranoid, such as:

  “
• You are a special person chosen to save the world,”
• Or “A powerful organization is watching you.”
• During depressive episodes, voice content can resemble that in MDD.

PTSD and trauma-related disorders

• People who have experienced severe trauma (shock, assault, abuse, war, etc.) have a higher risk of developing “voices” later.

• Sometimes the voices:
• Are the perpetrator’s voice,
• Or repeat phrases from the traumatic event.

• The experience may blend flashbacks with hallucinations (a borderline zone that requires careful differentiation).

Dissociative disorders

• In some forms of dissociation (e.g., DID), patients may report hearing “voices of other identities” within themselves.

• These experiences can sometimes be conceptualized within a hallucination framework or within a dissociative framework, depending on assessment.

Other psychiatric conditions

• Severe anxiety, certain personality disorders, or very severe OCD may occasionally involve experiences resembling voices, but careful evaluation is needed to determine whether they are true hallucinations or intrusive thoughts plus hypervigilance.

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6.2 Biological and Medical Factors (Neurological / Medical)

Lesions / structural brain problems

• Brain tumors, especially in the temporal lobe,
• Cerebrovascular disease (focal hemorrhage or ischemia),
• Temporal lobe epilepsy,
• Traumatic brain injury.

These abnormalities can disrupt circuits related to hearing, language, and memory, producing auditory phenomena.

Neurodegenerative disorders (e.g., Alzheimer’s, Lewy body dementia)

• As these illnesses progress, both visual and auditory hallucinations can occur.

• In some types (e.g., Dementia with Lewy bodies), hallucinations are a signature symptom.

Hearing loss / impaired hearing

• Severe deafness or hearing loss can increase the likelihood that the brain will “fill in” missing inputs with internally generated sound (similar to Charles Bonnet syndrome but in the auditory domain).

• The brain tries to compensate for lack of sensory input by creating pseudo-input, which can manifest as hallucinations.

Metabolic / systemic conditions

• Severe hypoxia, kidney or liver failure, electrolyte disturbances, etc., can lead to delirium with hallucinations.

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6.3 Substances and Medications (Substance- and Medication-Related)

Alcohol

• Both heavy intoxication and withdrawal (alcohol withdrawal delirium) can produce hallucinations.

• The voices often come with intense fear, confusion, and sometimes visual hallucinations.

Stimulant drugs

• Amphetamines, methamphetamine, cocaine, etc.

• Heavy, prolonged use + sleep deprivation can lead to psychosis with auditory hallucinations and persecutory delusions.

Cannabis and other hallucinogens

• In some people (especially those with genetic vulnerability), cannabis or hallucinogens can “trigger” psychosis.

• This can lead to AVH plus delusions that may persist and not return fully to baseline even after stopping use.

Medications used for physical illnesses

• Certain Parkinson’s disease medications (dopamine agonists),

• High-dose steroids,

• Some anticholinergic drugs,
  → can cause psychotic symptoms including hallucinations as side effects.

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6.4 Behavioral and Environmental Factors

Sleep deprivation

• Several nights of severe sleep deprivation can make the brain’s processing system “start to unravel.”

• The typical sequence:
  Irritability → poor concentration → increased suspiciousness → emerging visual/auditory hallucinations → temporary psychosis-like state.

• If sleep deprivation continues without recovery, symptoms can become severe enough to resemble a transient schizophrenia-like psychosis.

Severe and chronic stress

• Chronic stress alters cortisol and other neurochemicals, disrupting limbic–prefrontal–temporal connectivity.

• In some people (especially those with pre-existing vulnerability), stress becomes the “spark” that ignites psychosis/AVH.

Everyday stimulants (e.g., very high doses of caffeine)

• Excessive intake (mega-doses + lack of sleep + stress) can push the nervous system into overdrive.

• There are case reports linking such patterns to the onset of auditory hallucinations.

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6.5 Individual, Genetic, and Trauma-Related Factors

Genetic vulnerability

• Having first-degree relatives with schizophrenia, schizoaffective disorder, or bipolar disorder with psychosis increases the risk of hallucinations/psychosis.

• This does not mean “you will definitely develop it,” but rather that the brain baseline is more sensitive to triggers.

Childhood trauma / adverse childhood experiences (ACEs)

• Physical abuse, sexual abuse, severe bullying, neglect, growing up in a violent household, etc.

• Many studies link such experiences to later hearing voices in adulthood.

Approximate mechanism:

• Trauma disrupts the development of brain networks involved in self, emotion, and memory.

• Traumatic images/sounds intrude into current perception, blending memory intrusion with hallucinatory experiences.

Personality and cognitive style

• Individuals with a tendency to interpret neutral stimuli as personally meaningful (aberrant salience, self-referential bias) may be at greater risk.

• Low metacognitive ability (difficulty distinguishing thoughts vs. reality) increases the risk of misattributing inner speech as external voices.

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6.6 Big Picture: Risk ≠ Destiny

This is important when writing for the web so readers don’t panic:

• Having risk factors = “having soil that is favorable for symptoms to grow.”

• Whether the symptom “sprouts” depends on specific triggers in certain periods (substances, stress, trauma, sleep, etc.).

• Many people with risk factors never experience hallucinations in their lifetime.

• Conversely, some people with no obvious risk history may still develop AVH at some point (e.g., due to intense stress + sleep deprivation + substance use).

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7) Treatment & Management — Treatment and Coping

Treatment aims to:

• Treat the underlying disorder,

• Reduce the frequency and intensity of the voices,

• Reduce distress,

• Improve coping and functioning.

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7.1 Medication (Pharmacological Treatment)

Antipsychotic medications

• First-line for AVH in the context of psychotic disorders.

• Act primarily on dopamine (D2) and, for some drugs, serotonin and other receptors.

• There is strong evidence that they reduce the frequency and severity of hallucinations in schizophrenia spectrum and mood disorders with psychotic features. (NCBI+1)

If the root cause is a mood disorder

• Add:
• An antidepressant (in MDD with psychotic features), or
• A mood stabilizer (in bipolar disorder)

• Together with an antipsychotic. (Cleveland Clinic+1)

If related to medical/neurological conditions or drug toxicity

• Treat the underlying disease,

• Adjust or discontinue the offending medication/substance.

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7.2 Psychotherapy and Psychosocial Interventions

Cognitive Behavioral Therapy for psychosis (CBTp)

• Helps patients learn to question the meaning of the voices.

• Reduces the belief that the voices are “all-powerful” or absolutely uncontrollable.

• Decreases distress and reduces harmful behavioral responses to the voices. (Cleveland Clinic+1)

Working on the “relationship with the voices” (relational / acceptance-based approaches)

• For example, helping the person view the voices as one part of internal experience, rather than an external omnipotent force.

• Includes techniques used in:
• Hearing Voices Movement approaches,
• Compassion-focused approaches.

Psychoeducation + family interventions

• Educating patients and families about what auditory hallucinations are, what causes them, and the importance of:
• Medication adherence,
• Sleep,
• Stress management.

• Reduces stigma and misunderstandings such as:
• “He is possessed,”
• “It’s a ghost,”
  which otherwise delay access to proper treatment.

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7.3 Coping Strategies for Daily Life

Examples from research and self-help guides:

• Listening to music, podcasts, or white noise to compete for auditory channel resources,

• Shifting attention to activities using other sensory modalities (drawing, writing, crafts, etc.),

• Setting a specific “time for arguing with the voices” and then returning to normal activities,

• Practicing mindfulness / grounding techniques to reduce the pull of the voices.

(These should supplement, not replace, professional evaluation and treatment.) (Cleveland Clinic+1)

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7.4 Brain Stimulation (Research and Specialized Settings)

• rTMS (repetitive transcranial magnetic stimulation) over the left temporoparietal cortex has been used in some studies on treatment-resistant AVH.

• tDCS has also been explored to modulate language networks and reduce AVH.
• Some evidence suggests these methods can reduce voice severity in treatment-resistant patients, but they remain adjunctive, not standard everywhere. (Epi+1)

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8) Notes — Important Points

• Hearing voices ≠ automatically having schizophrenia.
  It can occur in multiple disorders and even in some people with no clear psychiatric diagnosis. (Wikipedia+1)

• There is a continuum between “normal” and “pathological.”
  Many people have at some point heard their name called when extremely tired, stressed, or drifting in and out of sleep (hypnagogic / hypnopompic hallucinations), without having a psychotic disorder, as long as it does not significantly impair daily life. (Wikipedia+1)

• Command hallucinations that tell the person to harm themselves or others are a danger signal.
  Clinically, this requires immediate risk assessment and often justifies more intensive treatment (e.g., hospitalization). (NCBI)

• Cultural context matters.
  In some cultures, “hearing the voice of a deity or spirit” may be interpreted differently. However, if the voices cause distress, functional impairment, or push the person toward dangerous behavior, they are still symptoms that warrant medical/mental health evaluation.

• All of the above information is for academic understanding.
  Actual diagnosis requires a detailed history, mental state examination, and medical assessment by qualified professionals.

Read Schizophrenia

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References

Alderson-Day B, et al. Auditory Hallucinations and the Brain’s Resting-State Networks. Schizophrenia Bulletin. 2016. PMC

Barber L, et al. A review of functional and structural neuroimaging studies of auditory verbal hallucinations. Translational Psychiatry. 2021. Nature

de Leede-Smith S, Barkus E. A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals. Frontiers in Human Neuroscience. 2013. PMC

Corlett PR, et al. Hallucinations and Strong Priors. Trends in Cognitive Sciences. 2019. (Predictive coding model for hallucinations.) Cell

Hjelmervik H, et al. A 1H-MRS Study of the Neurochemistry of Auditory Verbal Hallucinations in Schizophrenia: Glutamate and GABA in the Left Superior Temporal Gyrus. Schizophrenia Bulletin. 2020. OUP Academic

Mo F, et al. Network Localization of State and Trait of Auditory Verbal Hallucinations in Schizophrenia. Molecular Psychiatry. 2024. PMC

Alderson-Day B, Fernyhough C. Auditory Verbal Hallucinations and Inner Speech. In: The Oxford Handbook of Inner Speech. NCBI

Psychiatric Times. Auditory Hallucinations in Psychiatric Illness. (Overview of psychiatric, medical, and substance-related causes.) psychiatrictimes.com

Wearne D, et al. Exploring the relationship between auditory hallucinations, trauma and dissociation. BJPsych Open. 2020. PMC

Shinn AK, et al. Assessing Voice Hearing in Trauma Spectrum Disorders. Frontiers in Psychiatry. 2020. Frontiers

Begemann MJH, et al. Auditory verbal hallucinations and childhood trauma: A cross-diagnostic cluster analysis. Psychology and Psychotherapy. 2022. Taylor & Francis Online

Scott M, et al. Childhood trauma, attachment and negative schemas in relation to negative content of auditory verbal hallucinations. Psychiatry Research. 2020. ScienceDirect

NCBI Bookshelf. Chapter 4—Mental and Substance-Related Disorders. (Substance-induced psychosis & hallucinations.) NCBI

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