“Have you ever heard voices or sounds that no one else can hear?”
We are in the middle of a clinical interview at an ordinary hospital, it doesn’t matter which one. A while passes before any answer. Suddenly the man in front of the doctor starts to look down and his voice begins to tremble.
Fear of being judged; concern about consequences. With this simple question comes an emotional load that hinders communication and sometimes makes it difficult to find the correct diagnosis. It is frightening to speak about voices, but the thing that scares the most is the mark of mental illness.
The standard classification of mental disorders used by mental health professionals around the world is the Diagnostic and Statistical Manual of Mental Disorders. The fifth edition (DSM-5) will be published in May 2013. It has been in development for a number of years and a few but significant potential changes seem set to break with the past and bring a breath of fresh air to many people’s lives.
Hearing voices – that is, the perception of voices in the absence of auditory stimuli – can be normal. This is one of the ground-breaking changes to have emerged from the advance publication of the DSM-5 Status of Psychotic Disorders. In contrast to the previous edition (DSM-IV), hearing voices will no longer be considered sufficient and specific for the diagnosis of schizophrenia. It is a big step forward for people who live with voices every day but do not intend to give up their right to be called “normal”.
Schizophrenia is surely one of the most well-known psychotic disorders, familiar to the public thanks to some poignant and remarkable performances on the big screen. Psychosis, medically speaking, is defined by reality distortion (delusions and hallucinations) and severe disorganisation (of speech, for example).
But symptoms like auditory hallucinations, taken alone, are not necessarily a sign of schizophrenia. In fact, they can be found in other diseases such as brain tumors and epilepsy, and also occur in around 10 to 15 per cent of the general population. They are an example of phenomena called “out-of-the-ordinary” or “psychotic-like” experiences, which do not always lead to psychiatric conditions and can sometimes be a positive part of human experience.
Hallucinations are also very common in people who experience trauma, loss or other stressful events. It is important, therefore, to evaluate them in the appropriate context, relating their meaning to the individual’s underlying problems (for example, there is a strong association between psychotic-like experiences and severe childhood sexual abuse).
How can people manage with the unusual experience of hearing voices? A study conducted by Dr Heriot-Maitland and colleagues, published this year in the British Journal of Clinical Psychology, evaluated the nature and context of psychotic-like phenomena in people who did (clinical) or did not (non-clinical) go on to use mental health services. People in both groups experienced these phenomena during periods of significant negative emotion, sometimes associated with isolation and concern about the meaning of their existence. However, the non-clinical group showed greater ability to make sense of these experiences in their lives, considering them to be transient and enhancing, not dangerous.
International associations like Intervoice (International network for training, education and research into hearing voices) share this non-pathological vision of the phenomenon, fighting against prejudice and the stigmatisation of mental illness. They aim to support people to manage this “normal though unusual variation in human behaviour”, underlining that “the problem is not hearing voices but the inability to cope with the experience”.
However, while it may be true that hearing voices does not necessarily imply mental illness, particularly in childhood, in other cases we could risk underestimating a considerable problem if people choose not to seek help or advice. It shouldn’t be forgotten that individuals with psychotic-like experiences are at significantly increased risk of clinical psychotic disorders, which can have severe effects on health and quality of life.
What, then, is the right response? Can Joan of Arc and other famous historical and religious figures who lived with auditory hallucinations simply be considered psychotic? My impression is that we are moving away from a strict psychiatric interpretation, based on outdated models of mental illness, of the spectrum of human experiences.
This new awareness could encourage people to speak out, allowing a better evaluation of the extent of the phenomenon. The inner noise debate is still open, and we need to listen more to the people who hear voices.
This article was shortlisted in the Wellcome Trust Writing Science Prize 2012 and published on Wellcome Trust blog website.