Perception › Hallucination

Auditory Hallucination

An auditory hallucination is hearing a sound, word, or voice that has no external source, experienced with the same sense of realness as an ordinary sound heard through the ears. It happens alongside normal hearing rather than replacing it, and the person is not usually trying to imagine or produce the sound themselves.

Descriptive psychiatry has traditionally drawn a hard line between a hallucination and a misperceived real stimulus (an illusion): a hallucination has no external trigger at all, whereas an illusion is a distorted reading of something that is actually there.

Also known as

Elementary auditory hallucination

An unformed sound (a click, buzz, or tone) rather than a fully formed word or voice.

Imperative hallucination

A voice giving the person direct commands or instructions, of particular clinical concern when the commands involve harm.

Recognition features

• Experienced as coming from outside the head, or at least as having the perceptual quality of a real sound, rather than as an inner thought
• Occurs without any conscious effort to produce it
• Ranges from simple, unformed sounds (clicks, buzzing, a single tone) to fully formed words, sentences, or conversations
• Content is often, though not always, unpleasant, critical, or threatening

Eliciting it at interview

• Ask in an open, non-leading way first: "Do you ever hear sounds or voices that other people around you don't seem to hear?"
• If the answer is yes, ask whether the voice sounds as real and as loud as your own voice does right now, to gauge how perceptual (rather than thought-like) the experience is
• Ask about content, number of voices, whether they talk to the patient or about them, and whether they give instructions
• Ask what the patient believes is causing the voices, since the explanation the patient gives is often as clinically informative as the hallucination itself

Distinguishing features

• Unlike an illusion, there is no real external sound being misread
• Unlike a pseudohallucination, it is experienced with full perceptual force, not as an inner or 'as-if' experience
• Unlike an obsessional thought, it is not experienced as the person's own thinking that they are struggling against

Common misconceptions

• That hearing voices always means psychosis; auditory hallucinations also occur in severe mood disorders, in some organic and substance-related states, in bereavement, and occasionally in people with no diagnosable illness at all
• That the person hearing voices necessarily believes they are supernatural or externally implanted; many people retain some insight that the voices are a symptom

Related phenomena

Thought Echo · Running Commentary Voices · Pseudohallucination · Hallucinosis

Practice this

A man reports hearing a voice, with no one else present, that has the same perceptual quality and force as an actual person speaking aloud in the room, apparently coming from outside his head, saying critical things about him. He makes no effort to produce this and cannot stop it. What is this? · A grieving widow reports hearing her late husband's voice, but is clear that it feels like an inner experience rather than a real external sound — she describes it as 'in my mind, not in my ears' and knows, even as it happens, that it is not really him speaking aloud. Before revealing the answer: is this a true auditory hallucination? · A patient describes hearing something with no external source. Before revealing the answer, decide what distinguishes a true auditory hallucination from a pseudohallucination. · You are assessing a patient for auditory hallucinations. Before revealing the answer, decide what you would ask. · Explain why the perceptual force and location of an auditory experience, rather than its content, is what actually determines whether it is a true hallucination.

Illustration

A 24-year-old graduate student tells the interviewer, "For the last two weeks I've been hearing someone say my name when I'm alone in my flat. It sounds exactly like my downstairs neighbour, and I've gone and checked the corridor twice, but no one's there." He is otherwise coherent, has not slept properly in several days, and is worried he is 'losing his mind,' which he says is not something he has ever experienced before.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 3, 'Disorders of Perception'.