04 November, 2013

Voices in my head: what do they mean?

What might it mean if you hear voices in your heard?

What do Anthony Hopkins, Zoë Wanamaker and Sigmund Freud all have in common? It is something they share with John Frusciante, former guitarist with the Red Hot Chilli Peppers; Mahatma Ghandi, the father of Indian Independence; and Joan Of Arc, the revolutionary French saint. They all describe hearing “voices” as an intimate part of their mental lives. They hear voices when there is no one there.

Some have this experience as an exceptional event under extreme circumstances; others live with their “voices” on a regular basis for a prolonged time. Some see them as part of their health and adaptation to life; for others. the “voices” are indicative of mental distress. The experience is very real for them and we know about it because they have written it down. Vinnie Jones, the English footballer, the writer Philip K Dick, Socrates the Greek philosopher, or John Forbes Nash, the mathematician, have all written about their “voices”.

What do people mean when they say they hear voices? Are “voices” always indicative of mental illness? Clearly we need to assess this phenomenon to understand why so many people describe this experience. The truth is that there are many reasons to explain it.

For some people who speak of hearing “voices”, these vivid experiences represent inner thoughts, hopes and dreams and they are filled with the themes of their private mental life. These so called “voices” may be entirely normal. Each of us has an internal monologue. For some, this “inner speech” can take the form of an intense and realistic inner dialogue with the self. These thoughts are always recognised as belonging to the self and they are always experienced inside the “head”. That is to say they are not heard as coming from any external source.

Other forms of psychological “voices” may be more distressing. These are obsessions and they are experienced as unwelcome parts of an individual’s private mental life. Their content can be so upsetting that they seem completely alien to the character of their host. Some people ask themselves “How can these ideas or thoughts be in my head?” As though to emphasise this alienation from their content the sufferer may refer to these experiences as “voices”. When Charles Walker, the British Member of Parliament (MP), told the House of Commons of his long struggle with obsessive compulsive disorder (OCD), he referred to his unwelcome thoughts as “voices”, although at no stage did he suggest he was hearing any one else talking to him.

Anyone under stress may make a mistake and misconstrue a sound that is potentially alarming or threatening. These “voices” are illusions; misinterpretations of an external stimulus. These voices tend to be brief and inconsistent, and are usually heard in a particular context of distress, or exhaustion or hunger.

“Voices” may emerge in any brain disorder that involves a clouding of consciousness (or a delirium). In these circumstances, the person may be intoxicated or feverish or may be suffering from a dementia.

Others describe hearing “voices” where they mean that someone was speaking to them, even though objectively no one was there. For these people, the voice is perceived as an external experience, even though there is no external source. This form of “voice” is referred to as an auditory hallucination, a perception in the absence of an external stimulus, and these voices are always significant of mental distress and may indicate mental disorder. Auditory hallucinations of this kind are heard in a number of mental disorders, most notably in schizophrenia, and bipolar mood disorder with psychosis.

In schizophrenia, “voices” may be very organised and developed and they may involve a number of people talking to each other as though in a conversation. These voices may talk to each other about the person, referring to them as “he” or “she”, or they may continue with a running commentary on the actions of the person, or they may reiterate their inner thoughts like an echo.

In bipolar mood disorder, “voices” are typically less elaborate, but they intervene and are heard as coming from outside, and saying things which endorse or reinforce the general mood of the person; in mania to say things like “you are special” or in depression to say things like “you are bad, you deserve to die”. These can be very frightening experiences for the person.

Recent biological studies using brain-scanning techniques such as Magnetic Resonance Imaging (MRI) or Positron Emission Tomography (PET) have made a remarkable discovery. It appears that the brain in the subject describing an auditory hallucination, in the cortex of the brain and in particular the auditory cortex (or hearing parts of the brain), actually lights up during these hallucinations. In other words, it appears the brain is really doing the work of hearing, even though there is nothing to hear. The patient is not simply misinterpreting or imagining the “voice”, but they are having an experience that is a false nonetheless.

The clinical key message for each of us is to offer the person a respectful and supportive response that neither dismisses the experience nor alarms the person. When seen in the context of person's overall function and health, clearly “voices” associated with mental disorder can be recognised, and these need to be assessed and if necessary treatment offered.

One of the many striking findings from the recent Psychiatric Epidemology Research across the Lifespan (PERLstudy from the Royal College of Surgeons of Ireland (RCSI) (Prof Mary Cannon, 2013) was the data that one in 10 of our young adults reported the experience of psychotic symptoms such as hearing “voices” over the course of their lifetime. Some of these “voices” are indicative of a mental condition known as psychosis.

But what is psychosis? What are its symptoms, its causes, and how can we recognise its signs. What do we do if we notice signs of mental difficulties or psychosis in our young people? 

What is psychosis and what are its features? 

Psychosis is a mental condition that affects people’s thoughts emotions, perceptions and behaviours. People who have a psychosis can get confused between what’s real and what’s not real. Most people with psychosis experience either delusions, which are fixed false beliefs about themselves and the world, or hallucinations, which is seeing or hearing or smelling things that aren’t in reality.

These experiences can be very frightening and upsetting for the person with psychosis, as well as distressing for the people around them. But the good news is that now psychosis can be treated very successfully and most people recover from the experience. The earlier the experience is detected and treated the better, so it is really important that people are aware of the signs and symptoms and how to get help if they are worried about themselves or someone they know who might be distressed in this way.

As well as hallucinations and delusions, people with psychosis can have disorganisation of thinking and speech and behaviour. They may say strange or unusual things and may be hard to understand. They may act in ways that are out of character. Psychosis can limit their range of emotional expression so that it may seem as though the person isn’t really feeling anything at all and they may seem to others as emotionally “flat”. Reduced speech and reduced concentration and difficulties in getting ordinary things done are common features of psychosis.

What are the causes of psychosis?

Any one can have a psychosis and some predictable factors increase the risks. These include genetic factors, as well as the experience of stress and trauma. Psychological factors, including poor coping skills, are also important. There may be biological factors such as changes in brain structure, brain injury or even dementia. There may be social factors such as isolation, deprivation, poverty and being the victim of crime. There is a definite relationship with substance misuse and in particular cannabis, which is a significant factor in the psychosis seen in young people. 

Andy’s story

To illustrate some of these issues I want to describe the experience of Andy who is a 19-year-old student of computer sciences at a college in Dublin.

Andy is in his first year at college. He is the eldest of four boys and grew up in the midlands of Ireland. He has had two passions all his life, computers and Gaelic football. He was always a good student at school but he began to struggle with his work once he came to Dublin. Since then he has found it very difficult to complete his assignments. Privately he was hearing “voices” telling him he was bad and discouraging him.

Some of his close friends noticed that he was taking less care of himself and his personal hygiene declined. Andy also stopped eating regular meals. His sleep deteriorated. He stayed up longer at night watching the same programme over and over again on the Internet. The next day, he was so tired he would sleep throughout the morning and afternoon. When he rose in the evening, he was more irritable and anxious. Gradually he began withdrawing from his friends and family and his old social activities.

His closest friends noticed that he had become very suspicious about them. Even though he said less to them, when he did speak he expressed strange beliefs about some of them being involved in a conspiracy against him and plotting to harm him.

The voices variously told him he was special or that he was wicked and, as time went on, he became more and more perplexed. Andy had been hearing a number of voices telling him that he had “the X factor”. This experience was heightened whenever he smoked marijuana with his college classmates. He came to believe the Internet was sending special messages to him and was conversing with him.

Any one of these features might be commonplace and would not necessarily be significant, but the combination and duration of these features was indicative of psychosis. Andy’s features were also persistent and associate with a decline in his overall functioning. His behaviour was out of character and it was definitely having a negative impact on his life.

Andy’s friends were concerned for him. They chose a time when he seemed relaxed and they let him know they were worried about him. They didn’t overreact when he told them of his strange experiences and wisely they didn’t try to argue with him. His closest pals acknowledged that these experiences must be very distressing and confusing.

Perhaps because his friends handled it so well he agreed to go with them to talk to a GP about his experiences. Andy remained biddable and pleasant. The GP was reassuring and calm. The GP was able to assess the situation and she recognised that Andy was suffering from the features of an acute psychosis. Andy had no family history of psychosis, but he had struggled with the transition from school to college life. The shift from his hometown to student existence in Dublin had been isolating. The biggest stress in his life had been the loss of his father who died suddenly of a massive heart attack during Andy’s transition year. Since then Andy had been using marijuana regularly and more heavily with his friends perhaps to dull the pain of his bereavement and to calm his anger at his distress.

Andy agreed to work with the counsellor in the practice. The GP explained that the marijuana was distorting his thinking and damaging his brain. With his best friend, he agreed to stop his use of it for a year. In the meantime he agreed to take a small amount of an antipsychotic and happily he found this helped him to sleep and reduced his experience of distressing voices.

The GP practice counsellor agreed to contact the college tutor on his behalf and, together, they negotiated to reschedule his assignments as they worked on his day-to-day routine. Andy had given up playing football since he came to Dublin. With his friends encouragement Andy began to train again at the GAA club in his college. He is now making steady progress on a road to genuine recovery.

Today, Andy is well, and he accepts that his recovery will need a continued engagement with his mental health on the road to sustained wellness. The plan that gets you well is the recovery plan that keeps you well.

Tags:   psychosis  


Prof Jim Lucey

Prof. Jim Lucey was Medical Director of St Patrick’s Mental Health Services, Dublin, from 2008 to 2019. He is Clinical Professor of Psychiatry at Trinity College Dublin. He has been working for more than 30 years with patients suffering from mental health problems. In addition to medical management, he maintains his clinical practice at St Patrick`s, where he specialises in the assessment, diagnosis and management of Obsessive Compulsive Disorder (OCD) and other anxiety disorders. He gives public lectures and is a regular broadcaster on mental health matters on RTÉ radio, featuring on ‘Today with Sean O’Rourke’.