Thursday, November 30, 2023

Auditory Hallucinations in Schizophrenia


 Dr. MUPK Peris / Dr. Ruwan M Jayatunge   

People with schizophrenia can experience auditory perceptions without external stimuli or for any other rational reasons to explain such an experience. These perceptions known as auditory hallucinations are unintentional and intrusive. For the patients, these sensory perceptions are often compelling and experienced in quality of true perceptions (Patricia Casey et al 2019). These voices are internally generated speech perceptions (Hugdahl et al., 2008) and generally cause distress which in turn may affect a patient’s functionality.

Typically, 70% of individuals with schizophrenia experience Auditory hallucinations (a plethora of sounds) (Sartorius et al., 1986) and it has been considered a part of the positive symptoms of schizophrenia. Auditory hallucinations result from spontaneous activation of the auditory network and can be described in terms of parameters of loudness, pitch, and clarity.

Auditory hallucinations are not specific or unique to schizophrenia. They are also found in normal healthy individuals and also in patients with borderline personality disorder, post-traumatic stress disorder (PTSD), hearing loss, sleep disorders, seizure disorders, and brain lesions to name a few.  However, Schizophrenia auditory hallucinations can be identified with Comorbid negative symptoms of schizophrenia spectrum disorder and also by the characteristics of the auditory hallucinations themselves.

Waters and team (2006) suggest that auditory hallucinations are auditory representations derived from the unintentional activation of memories and other irrelevant current mental associations. Lennox and team (200) indicate that auditory hallucination reflects abnormal activation of normal auditory pathways. McGuire   Shah and Murray (1993) observed increased blood flow in Broca's area during auditory hallucinations in schizophrenia. Auditory hallucinations are associated with gray matter volume (GMV) reductions in the superior temporal gyrus (Allen et al., 2012).

 Patients experience auditory hallucinations and auditory perceptual illusions during periods of high cognitive load or stress and on some occasions, hallucinations command the patient to hurt himself or others known as command hallucinations leading to dangerous behaviour in such patients J Junginger 1995. They have deficits in emotional prosodic processing (Shea et al., 2007).  According to Linn (1977), hallucinations appear to be related to the schizophrenic's sense of society's disparagement of him.

Auditory hallucinations aka voice-hearing experiences are often shaped by local culture. Luhrmann (2011) proposes that hallucinations are shaped both by culture and particularly by local theories of mind and by practices of mental cultivation. Hallucinations occur as phenomena that arise from the interaction between biological, psychological, social, and cultural factors (Laroi et al., 2014). Some researchers believe that auditory hallucinations conform to cultural expectations and that culture forms the content of auditory hallucinations.

Auditory hallucinations in schizophrenia can vary. A 38-year-old male diagnosed with Schizophrenia used to hear first-person auditory illusions regularly. He heard his own ideas, and thoughts spoken out loud to him. Another 18-year-old young patient heard second-person auditory hallucinations. He heard an anonymous female voice constantly talking directly to him giving commands. A woman in her mid-forties who was a known Schizophrenia patient used to hear critical voices addressing her by her name or in reference to her   (third-person auditory hallucinations) always telling hideous things about her.  As described by the patient she was hearing several voices referring to her in the third person. These voices were giving a running commentary making her extremely distressed.  

 The patients react in different ways to the auditory hallucinations.  Most of them experience anxiety and panic feelings with entrapment while hearing voices and may continue to talk as a normal dialogue which others interpret as self-talking or muttering to themselves. Some experience fear and humiliation and may end up causing harm to themselves or others. Some patients challenge the voices with shouting and swearing. Some give up and show appeasement and may use earplugs of anything to cover their ears ( loudly playing headphones). Self-medication and alcohol and drug abuse are also common among patients who want to suppress their auditory hallucinations.

The first treatment option for hallucinations in schizophrenia is antipsychotic medication (Sommer et al., 2012).  Behavioral and coping-focused interventions can be used as an adjunctive therapy. Psychological therapies tend to foster healing, recovery, and personal growth (Pandarakalam, 2016). Recent developments include the application of acceptance- and mindfulness-based approaches (Thomas et al., 2014).  Furthermore, Hallucination-focused integrative treatment (HIT) can be recommended to treat auditory hallucinations, along with anti-psychotics. HIT seems to be an effective treatment strategy with long-lasting effects for treatment-refractory voice-hearing patients (Jenner et al.,2006). Pharmacological and psychological treatments are essential for reducing distress and risk of violence in patients.   

Dr. MUPK Peris 

Dr. MUPK Peris obtained his basic medical degree MBBS from the Faculty of Medicine Colombo Sri Lanka in 1982. Following completion of the Postgraduate training for specialization in Psychiatry, he obtained MD(Psych) in 1992 with Board certification as a specialist in Psychiatry. He further completed the training in Psychiatry at the Oxford Rotation in the UK in 1993 and got the membership of the Royal College of Psychiatrists UK in 1995. Dr Peris subsequently worked as a Consultant Psychiatrist at Whakatane Hospital New Zealand, and took up the post of senior Lecturer in Psychiatry at the University of Kelaniya Sri Lanka and also discharged duties as the honorary consultant Psychiatrist at the North Colombo Teaching Hospital Ragama Sri Lanka from Feb 2002 till Sept 2023 when he retired.


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