One of the symptoms that is nearly pathognomic of schizophrenia is hearing voices. In particular, the voices are heard with the ears (not inside your head like the voice or voices we all hear in our heads), they go quite a bit of the time (for significant periods a day to continuously), there is often more than one of them, they often comment on the person’s behavior as it is happening, they often speak about the person in the third person, and they often say bad or insulting things about the person.
Although voices can be heard in other illnesses, especially Bipolar Disorder and Major Depression, they often take on a different quality than we see with schizophrenia. In Bipolar Disorder, the voices are more fleeting than continuous, and there is often only one voice. During Psychotic Mania, the voice may as likely tell the person how special and great they are than anything else. Voices in Psychotic Depression generally do not go on all the time, are limited to a single voice, and tend to focus around themes of guilt, fatalism, serious illness, death, suicide, homicide, nonexistence and other morbid topics.
Honestly, there is nothing strange, odd or disordered about hearing the occasional voice. Many persons will experience hearing a voice or voices at rare, once in a blue moon intervals in their lives. Clinicians properly regard this as within the normal realm of human experience. It only when voices are regular, annoying, distracting, terrifying or depressing that there is a need to intervene.
People generally do not understand what it means to hear voices. Many people think that the voice inside your head is a “voice” and they confuse this with the voices heard in a psychosis. The truth is that we all have a voice or voices inside of our heads. That is called our inner voice. Nor is there anything special about having more than one voice in your head or having two voices arguing with each other in your head. In fact, it is more common than you think.
I have met many OCD sufferers who complain of “voices,” but they are always confusing their inner voice inside their head with the auditory hallucinations of psychosis.
There is a ready way to tell the difference.
Hallucinated voices are heard with your ears. If you were to hear an auditory hallucination right now and you were alone at home, the first thing you would do would be to start searching around your place for someone hiding in your residence. You might look behind the couch, under the bed, in the closet, out the window, etc.
This is because auditory hallucinations sound exactly like the voices of the humans around you that you have been hearing all of your life. You hear with them with your ears, not your head. If you could not find anyone in your place, you might start looking around for the transmitter or loudspeaker that is somehow piping the human voices into your abode. You won’t be able to find it.
You may tell other people about the voices and enlist their help in searching for the person hiding in the house. If you are in a vehicle, you might hear voices coming out of the radio. You might try to take your radio apart to find the “transmitter” inside of it. You might try to take part of your home apart, particularly the vents, to find the “speakers” (voices in residences often come out of heating vents).
I befriended a schizophrenic man once and we become very good friends. We hung out nearly every day for a year. He was always trying to enlist my help to take apart the vents in his house. He also wanted to take apart my car radio to find the transmitter in it.
Periodically, he would look up and say, “You hear that?” That is because he heard a voice. Of course, I heard nothing and I would say I heard nothing. He never believed me and he always looked at me like I was crazy. He heard the voice as clear as a bell and it seemed ridiculous that I could somehow not hear it. After a while, I got tired of fighting with him and I started making up excuses, telling him that he had bad hearing and that was why I cold not hear the voices.
He would be incredulous that I could not hear it. I started saying, “Well, I believe that you heard something coming out of the radio, but I didn’t hear anything there.” I left it an open question whether there was really a transmitter in the radio or not. This is the best way to deal with these people because they absolutely will not accept that you do not hear the voices too and they reject the notion that they are hallucinating them. Trust me when I say that debating with a psychotic person about their delusions and hallucinations is a hopeless endeavor.
Schizophrenics also hear voices in public that are much harder to figure out. For instance they might walk by a room full of a group of people and experience an auditory hallucination coming from one of the persons in the room. The voice will seem exactly as if that person said it out loud. So this is a voice placed onto the body of an existing person.
With the schizophrenic, he went with me to my doctors’ office once and as we were walking away, he hallucinated a voice coming from a man in the waiting room. The voice made it seem as if the man was accusing him of something. “There he is. He’s the one who did it!” It went something along those lines. It was so hostile that it seemed as if the man was trying to start a fight with my friend. My friend wanted very much to go back to the waiting room and have it out with the man and demand to know why he said those things to my friend. It took quite a bit of convincing to keep him from going back and challenging the man.
When the voices start putting false voices into actually existing people, this illness can get quite bizarre and disturbing as you might imagine.
In OCD, sometimes the OCD creates an alternate voice in your head that is a different voice from the voice you are used to or your inner voice. At times, more than one voice may be created. I have met OCD’ers who had all sorts of voices going in their heads all at once. Some had whole room-fulls or even stadium-fulls. Others had the sounds of various animals going in their heads. A few have who farms or menageries of animals vocalizing away inside their heads.
These people are often terrified that they are developing schizophrenia, but I reject this. Just as OCD can create a new voice in your head or change your existing one, of course it could create more than two voices or possibly an unlimited number of voices. It cannot also create animal sounds and anything else the mind wants to conjure up. I see no grounds for referring to any of these phenomena as auditory hallucinations. With the OCD voices in the head, this is a person who is simply making up the voices or sounds their own in their heads. Or the OCD is making them up, whichever way you prefer. So this is someone who is creating a lot of mental chaos for themselves apparently for the perverse purpose of tormenting themselves or making themselves upset. These head voices are much more under voluntary control than schizophrenic voices and many OCD sufferers can shut them on or off and on proper medication, they often stop altogether. Or the person learns that they are doing this to themselves on purpose and decides to stop torturing themselves.
Unfortunately, many clinicians do not seem to be able to untangle the voices of one’s own inner thoughts and auditory hallucinations. Adding to this problem is the fact that many OCD sufferers will describe their OCD thoughts as “voices.” In these cases, careful questioning should reveal that the “voices” are actually inner thoughts and not auditory hallucinations.
It is uncertain how the notion of “voices in your head” got started. Schizophrenics are said to hear “voices in their heads.” This makes no sense as we all have voices in our heads, namely our inner voice or voices. Apparently since auditory hallucinations are the creation of a person’s mind and do not exist in the environment, it could make sense to describe auditory hallucinations as voices in your head considering that the voices are originating in the mind of the hearer and not externally. However, the very phrase “voices in the head” completely confuses the situation and I think it is best to drop this psychiatrically illiterate phrase from the discourse of educated speakers on grounds that it causes unnecessary confusion.
There may be some cases where the hallucinated voices actually seem to be originating from inside the skull of the hearer. Imagine what it sounds like when a person is talking next to you. Now examine that same experience, yet the voice is emanating directly from your skull. This would be the only case where “voices in your head” would be a logical phenomenological description.
OCD sufferers, especially those with the Schizophrenic OCD theme or what sufferers have called the “Schiz OCD” variant of the illness, often say that they hear voices.
Caution is needed here. I have heard many OCD sufferers inform me that they are actually experiencing auditory hallucinations. In these cases, careful questioning will generally reveal a person who is scanning the environment in a hypervigilant way and then misinterpreting ordinary sounds in the environment as possible “voices.”
They also often report hallucinations or quasi-hallucinations during the hypnagogic period between sleep and wakefulness. Many a bizarre thing happens to ordinary persons during the hypnagogic state, so it is best not to make too much of this. The period between sleep and wakefulness is odd and dream states may spill over into wakefulness, the mind may start to run wild and thought and dream may become confused. Once again, these are hypervigilant persons with high anxiety examining their hypnagogic states for signs of psychosis. It is a good maxim that when humans go looking for something, they often find what they are looking for in one way or another.
Once hypnagogic confusion, inner voices and misinterpretations of environmental sounds are eliminated, the clinician will find that the OCD sufferer rarely if ever experiences an actual auditory hallucination.
At times, normals may even think they hear a voice. Last winter, I pulled into a drug store parking lot at 8 PM. It was dark and raining fairly hard. The rain was creating quite a bit of environmental racket. As I opened my car door, a heard a voice off in the rainy parking lot say my name, “Bob.” I looked around a bit, saw no one there, thought for a bit about what just happened, concluded that I did not have an auditory hallucination but instead misread some odd environmental sound in the rainy racket, brushed it aside, and went into the store.
The truth is that even if it was a voice, I would not worry and neither should anyone else. Hallucinated voices are quite common. 14% of the population regularly experience them, most are not psychotic and many are probably quite normal. I have told myself that if I ever start hearing schizophrenic type voices going all the time, I am going to get concerned, but in the meantime, I am not going to worry.