Absolutely, and there is now good epidemiological evidence for this. See Hearing Voices Network, who stress this point. It has been known for well over a century that those with ear disease are predisposed to auditory hallucinations (and resultant paranoia). I suspect that AHs in those without neurological or psychiatric disease arise from subtle and reversible inner ear dysfunction, specifically Meniere spectrum disorder.

Yes! I completely agree with the answer by Anthony Gordon.

For common people, like individuals from the general population or even healthy individuals with no history of psychiatric or severe physical disorders is it possible to experience this psychotic "symptom". Probably, healthy individuals would not believe that the voice actually exist, they are usually able to say that it was a subjective experience, I mean that they usually have insight. A recent and good review about prevalence of psychotic symptoms in general population is the study by Nuevo et al. published in Schizophrenia Bulletin last year (Title: The continuum of psychotic symptoms in the general population: a cross-national study).

Many studies have shown that there is little if any difference in the content of auditory hallucinations in normal and abnormal populations. What differs is the reaction to them, the distress they cause, or whether a plausible narrative can be constructed. Those experiencing simple hallucinations (tinnitus) first think these noises come from external sources, and it may take a long time to deduce that they are imaginary internal noises. Insight is easy if the people know or realize they have ear disease, but not otherwise.

Ear disease may pre-dispose but it's not a prerequisite. Most healthy adults experience these sorts of phenomenon to some degree as youngsters...

Go out in the bush, (sorry- I'm an Aussie- go out in the woods or the forest or the jungle or the fields or the mountains or the desert or the scrub or them thar boondocks), BUT whatever natural environment you go out into, do it by yourself...

Sit.

Wait.

If you are all alone. after a while, you will hear murmuring voices in the constant white noise of emptyness, wind, flowing water, leaves rustling, waves, rain etc.

This is normal.

Your nervous systemn is a machine, built by boot-strapping adaptive mechanisms, perfectly evolved to detect signals amongst noise.

Our nervous systemns are over-responsive to potential signals, rather than under-responsive, largely because for the vast majority of our evolution, it has been adaptive to treat every rustle in the bushes as a potential ambush predator (think tigers. leopards. jaguars, lions) and counterproductive to ignore such noises, (even if 99% were false alarms).

When someone's "threat detectors" are over active, (as in psychosis or extreme situations) then even the background noise of an airconditioner quietly humming in the ceiling is actually a hub-bub of ranting voices.

As Anthony and Silvia have already stated, it's how people respond to these symptoms, not whether they experience them, that's important.

Silvia, I can't find the article you mentioned. Can you post a link?

Paul.

Dear Paul,

Nice explanation! Here you have the paper I mentioned.

The scenario described by Paul is exactly how I think hallucinations are constructed out of internal noises (tinnitus of aural origin). A good example of spooky natural noises is in underground caves, where they lead to hallucinations in normals, and in some societies complex mystical belief systems are founded on them (J Anthrop Archaeol 2007;26:47).

If otological disorder is not essential for (musical) hallucinations, can Paul please supply a reference to any such published case? Cases with neurological lesions supposedly causing musical hallucinations have been published, actually very few, but none as far as I know have seen the need for a comprehensive otological examination, let alone shown normal otological function, and in particular with no inkling of Meniere spectrum disorder. I have been appealing without success for many years in academic journals for such non-otological cases.

We may have an issue of semantics here. In the visual realm, we typically refer to misperceptions (with subsequent misinterpretation, eg, magic tricks) in the visual field as illusions. It goes without saying that misperceptions in the aural field also occur. These can be due to ambiguous auditory stimuli and their misinterpretation. There can also be auditory misperceptions due to medical causes and stress (activation of the SNS). Is "hallucination" the right word to describe an auditory misperception, or should the term be limited to a psychiatric/substance use-related context?

Hallucinations in psychopathology are described as perception without a real/present object. As far as I know, when there is a real stimuli (visual, auditory, etc.) you may talk about illusions rather than hallucinations.

Hallucinations, as perception without object, can be present or experienced by individuals suffering psychiatric disorders (not limited to psychotic disorders which are typically characterized by a impaired contact with reality), individuals suffering other diseases or disorders or healthy individuals as I mentioned earlier.

Milan,

This is not my area of expertise, so I would have to defer to those familiar with neuropathology, both organic and functional. I would surmise, however, that there is not a single cause (either structural or biochemical) that can explain all psychiatric auditory hallucinations.

Silvia,

Thanks for your comments. The DSM-IV specifically excludes the experience of falsely hearing one's name called as being classified as a hallucination. This experience can occur either with or without external stimuli (although I suspect that it often arises from white noise or other ambiguous external stimuli), but it can also arise from a psychological state of stress. Are there other "normal" hallucinations - for want of a better term - that do not require external stimuli, as Paul and Anthony outlined above? Can we always trace a non-psychiatric hallucination back to some form of external percept?

Auditory hallucinations they are common. Since XIX century, is knowing that normal persons have experiences of hearing voices, some simples, and other, very complex. New empirical studies they produce similar results. Likewise, since XIX century is a common, and very debated question, the patognomonic value of hallucinations. Is true that little is know nowadays about the descriptive properties of visual hallucinations; likewise, the olfactory, gustative and haptic hallucinations, they are very difficult phenomena for description. In this sense, the historical research in hallucinations (see Berrios and Markovà, 2012; DOI 10.1007/978-1-4614-0959-5_5) dispute the perceptual model underlying the hallucinations. On the other hand, the descriptive research in complex auditory verbal hallucinations, to show that your descriptive characters point to a dialogical relation between the AVH and the hallucinator ( see McCarthy-Jones et al, in press, DOI: 10.1093/schbul/sbs156).

Like to show the book of Aleman and Laroy (2008), auditory hallucinations they are complex phenomena, and they require multifactorial models. Likewise, your perceptual character is questioned nowadays (see aforementioned Berrios and Markovà paper). In this sense, is very interested the point of view of Romme and Escher, and the voice hearers movement: the difference between auditory hallucinations in normal subjects and patients, is in the coping. Acceptance of voices, curiosity, and meaning about this experience, to prevent that hearing voices one becomes in a mental symptom.

Is "hallucination" a good term? I think that no: Esquirol proposed this term in 1817. Hallucinations is a term with a complex etymology, and it suggest that this set of phenomena are unitarian and perceptual. In fact, Esquirol constructed your concept on the theory of the vision in this time. I think that the term "hearing voices" is most experiential, and captures well your pragmatical properties like a form of human behavior. Likewise, the hallucinations they are a complex set of phenomena, and is very different e.g., an auditory hallucination in a psychotic break, and in Parkinson´s disease; that is to say, the descriptive properties and the relation of patient with this experience is different in neurological and in psychotic cases. They are not a unitarian phenomenon.

Goodnight to all, and excused my awful english.

Neil question: "Can we always trace a non-psychiatric hallucination back to some form of external percept?". Yes, the case of functional hallucinations, surged in a context full of white noise (e.g., auditory, like the sound of water falling of the faucet).

White noise of any kind can produce the illusion of voices, as the mind leaps to find structure and meaning in a mass of chaos.

Individual level of insight into the nature of these misperceptions, and resulting attentional focus, might decide how the person responds to the misperception. All perception is not veridical. We see what we expect to see, or want to see;

http://www.wjh.harvard.edu/~cfc/Simons1999.pdf

.

We all perceive mostly what we have been conditioned to expect to perceive, and often fail to notice the incongrous but obvious gorrilla on the basketball court.

http://www.npr.org/2011/06/20/137086464/why-seeing-the-unexpected-is-often-not-believing

.

This extends to what we hear (or imagine we hear);

http://www.peerreviewedbymyneurons.com/2012/06/22/remember-the-famous-invisible-gorilla-experiment-the-same-thing-can-happen-with-sound/

Can an auditory illusion, (everytime my neighbour's dog barks it sure sounds a lot like he's shouting "Bob! Bob!") if taken seriously by the hearer, entrain or induce hallucinations and/or accompanying delusions (so that I'm having involved conversations with the dog in my mind when I'm not even home?)?

Or are these completely different kettles of fish?

Paul.

Dear Neil (and the rest in this discussion!),

I would try to answer you from my personal experience and opinion.

You asked: Are there other "normal" hallucinations - for want of a better term - that do not require external stimuli, as Paul and Anthony outlined above? Can we always trace a non-psychiatric hallucination back to some form of external percept? I don't have any paper in mind about this, I just have experience interviewing people from general population (non-clinical samples) about the so-called psychotic experiences or psychotic-like experiences (I am attaching a nice meta-analysis about this phenotype). Some individuals report the experience of hearing voices, maybe just one voice or more, talking or murmuring... Some individuals said that they hear them like they were far away. Most of these individuals did not present any clinically relevant psychiatric symptom and they are able to explain to you how was the situation/s when they heard voices. Some of them heard voices when there was silence. So, I would dare to say that not always you can trace back the hallucination with an external percept.

Did I understand correctly your question?

Francisco, you may be relieved to know that you do not have to read through the English literature to find an alternative to hallucination, since Teresa of Avila has come up with what I think is the best word for auditory verbal hallucinations or voices, namely locutions.

I think normal perception, misperception and auditory hallucinations are all based on auditory input. This can be external, eg misheard speech; white noise; noises from the wilds of Australia; birdsong morphing into speech, etc. Much more interesting is an internal source (tinnitus), not necessarily at a conscious level. It is often said that persons hallucinate in silence, but if asked carefully, it usually (?always) turns out that tinnitus has started, been unmasked, or become more prominent.

Milan, it is hardly surprising that the left hemisphere lights up when voices are experienced. But which side of the brain and part of the cortex (and subcortex!) lights up when a schizophrenic, or indeed anyone else, hears elementary hallucinations (tinnitus) or complex non-verbal ones (music)?

Silvia,

Thanks for your response regarding external percepts, based on your clinical experiences. Thanks also for posting the meta-analysis by van Os, whose work I am familiar with and find very helpful.

A question for Anthony Gordon: you know references about the relationship between tinnitus and auditory verbal hallucinations? I know the relationship between tinnitus and musical hallucinations (I have a clinical case nowadays), but not in the case of auditory verbal hallucinations.

Thank you very much for your reference to the works of Teresa of Ávila; sincerely, I don,t know your works (paradoxically, since I am spanish!)

Silvia,

Thanks very much for the PDF of that paper.

P.

Normal people under extreme stress, or sleep deprivation can have hallucinations. Hypnogogic hallucinations (while going to sleep) and Hypnopompic Hallucinations, while getting up from sleep are also hallucinations in the absence of psychiatric disorder

Thanks for the above link, Milan. However, the paper does not say what type of auditory hallucinations the patients had, and in any case any anatomical difference could be the result of the hallucinations as much as their cause. Brain scans give no indication of how hallucinations developed in the first place, nor why they occur at any particular instant. We need non-verbal theories for auditory hallucinations.

The link between tinnitus, ear disease and musical hallucinations has long been established clinically, and enough cases have been published (but not too many so that they cannot all be checked!) to establish that they do not have neurological or psychiatric causes, only otological.

To answer Francisco, for verbal hallucinations it is more complicated and inferential, as speech areas in the brain get involved. However, there are a number of arguments supporting a common etiology:

1. Parsimony (Occam).

2. As far as I can tell, all the myriad risk factors, causes or triggers for voices are the same as those for musical hallucinations.

3. Tinnitus, music and voices often co-occur.

4. Many patients report a temporal continuum from noises to music to voices, then back again from voices to noises as their disorder improves.

5. I am sure there are no brain lesions that cause music. I suspect the same is true for voices, but I have not been able to completely check the literature on this. If anyone knows such a non-otological case of voices with causative brain lesion I would like to know.

6. Angel song is a characteristic musical hallucination, ie vocal and choral, not instrumental. These often have a mystical quality.

7. Several other reasons I can't think of this minute.

I am still waiting for Paul to cite non-otological cases of musical hallucinations, since he thinks ear disease is not essential. In the meantime, can anyone else help him out?

Thank You very much for your response Anthony. I know cases in the literature about musical hallucinations, and I know some esparce cases in my clinical practice in that I observe a relationship between tinnitus and auditory hallucinations, but AH descriptively simple (e.g., achoasmus). In clinical cases with auditory verbal hallucinations more complex (e.g., some voices, in second and third person, command voices, etc.), I not observed nowadays this association. Evidently, I can not extract general conclusions since my clinical practice.

Hi Anthony,

I don't know of any studies that clearly demonstrate >.

Auditory hallucinations (in general) are what we are talking about, not musical hallucinations (specifically).

The aetiolgical path you suggest sounds plausible and a promising avenue of inquiry, but have you strong evidence of a necessary association?

I would suggest that it is reasonable to assume that people can experience auditory hallucinations without having ear disease, because anyone can experience auditory illusions or misperceptions without having ear disease. I'd further suggest it is reasonable to suspect that similar symptoms arising in different people might be caused by a variety of different causal agents.

>

http://onlinelibrary.wiley.com/doi/10.1348/014466502163813/abstract

.

This study (below) clearly identifies tinnitus as having a potential contributing causal or confounding role in some cases, but differentiates between cases of tinnitus, tinnutus + auditory hallucinations, and auditory hallucinations - tinnitus.

>

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=403786

Paul.

Anyone can experience an auditory hallucination. Romme and Escher did a lot of work on this.

Thanks Danielle,

"Romme" + "Ecsher" + "auditory hallucination" + 0.06 seconds on google scholar = >20 highly relevant articles, and lots of leads in "related articles" links.

http://scholar.google.no/scholar?q=auditory+hallucination+author%3A%22Romme%22+author%3A%22Escher%22&btnG=&hl=en&as_sdt=0%2C5

.

Paul.

Thanks, Paul for checking out the literature in musical hallucinations, and confirming independently that there are no non-otological cases in the literature. I take the default position that verbal and non-verbal auditory hallucinations have a common origin and lie on a continuum. This can be readily disproved by listing risk factors for VAHs that do not also cause NVAHs.

Thanks for linking to studies on MHs with at least some otological information so that others here can read them. Allowing for the fact that these studies rely on small samples from self-segregating clinical populations, I don't think there is anything in them that contradicts my posting from two days ago.

It is reasonable to assume that people can experience auditory hallucinations without ear disease. However, I simply think this is untrue. The onus is now on persons who believe this commonsense view is correct to check it out on population samples, or cite any references I have missed.

Definitions of tinnitus and hallucinations are identical. If it sounds like a duck, and looks like a duck, it is a duck.

G’day Anthony,

I do tend to agree that verbal and non-verbal auditory hallucinations are probably related phenomenon that would involve many of the same neurological pathways, but this doesn't mean all cases of auditory hallucination are caused by one mechanism.

Oh- also- sorry, but I can’t take credit for > for a couple of reasons;

A) I haven’t checked out the literature in any serious way,

and

B) Unless every study on auditory hallucinations ever published tested the participants for tinnitus, you can’t confirm any such thing.

I have seen a couple of your papers out there.

http://www.sciencedirect.com/science/article/pii/S0306987797902164

.

And as I said above, I think this is an excellent description of one way in which auditory hallucinations might arise.

I stumbled upon this title;

Tricyclic-induced musical hallucinations and states of relative sensory deprivation

Takeshi Terao 1995

http://dx.doi.org/10.1016/0006-3223(95)00058-O

And then your article;

Tricyclic-induced musical hallucinations

A.G. Gordon 1996

http://www.biologicalpsychiatryjournal.com/article/0006-3223(96)00066-2/abstract

TCAs can induce auditory hallucinations. So can SSRIs, Parkinson’s disease. Why assume a single and unidirectional causative agent?

>

Unless it’s a rail, or a coot, or a grebe, or a well-painted decoy duck carved out of wood.

You know I probably just imagined that quacking noise when I saw a duck-shaped object…

…maybe I should get my hearing checked?

Paul.

Anthony,

Earlier you invoked Occam's razor, and now you write;

>

The principle of maximum parsimony doesn't mean cleave to the simplest explanation you can think of.

It means tend towards the simplest explanation that accounts for the available evidence.

This question is about auditory hallucinations in general, not musical hallucinations specifically.

Do you have credible evidence that ear disease is a pre-requisite for auditory hallucinations?

Have you conducted some sort of meta-study and found results that contradict the commonsense view?

If not, then why is the onus on other people to disprove what you think?

Paul.

I am, personally, far more interested in the ontological aspects of hallucinations than the otological ones...

:)

Paul.

I did a reasonably complete review of musical hallucinations in 1997, and short mini-reviews since. I am quite discouraged from doing a comprehensive update by the almost total lack of interest in the otological theory.

I am definitely not looking out for evidence to prove my theory, as that way you get trapped inside a filter bubble, but am looking hard, without success so far, for contrary evidence so I can move onto something else. My simplistic theory ought to be very easy to refute if untrue.

Consistent with my theory, otitis media is a very strong risk factor for schizophrenia, likewise a recent epidemiological study following up those with hearing loss at age 5

Hearing and speech impairment at age 4 and risk of later non-affective psychosis.

Fors A, Abel KM, Wicks S, Magnusson C, Dalman C.

Psychol Med. 2012 Nov 30:1-10. [Epub ahead of print]

This would easily account for the auditory hallucinations.

When reviewing the literature on drugs and MHs (eg J Nerv Ment Dis 1998;186:652), I was surprised to find just how many quite different drugs were implicated, consistent with a unitary otological mechanism (Meniere spectrum disorder), but not a unitary pharmacological one.

By all means get your hearing checked, Paul. Only ignore non-otologists who tells you your hearing is no worse than theirs, or even otologists who say that your pure-tone audiogram is normal, or even normal for your age, therefore there can be nothing wrong with your cochlea.

Hi Anthony,

Undiagnosed Otitis media and other hearing impairments are recognised risk factors for false diagnosis of learning problems, attention deficits, cognitive deficits and behavioural disorders in young children.

http://scholar.google.com.au/scholar?q=otitis+media+misdiagnosis+ADHD&hl=en&as_sdt=0&as_vis=1&oi=scholart&sa=X&ei=vnBIUe_mEOaYiAew7IG4Ag&ved=0CC4QgQMwAA

.

Sorry I don't have any literature to mind, but I would suggest based on clinical experience that it's also a risk factor for developing these sorts of problems if unrecognised for long.

I will get my hearing checked, thanks.

In turn, I heartily encourage all readers to take care of their dental health.

Paul.

Thanks for the refs. As far as I have been able to work out, Auditory Processing Disorder is due to previous, usually temporary, ear disease preventing proper development of the language and speech areas in the brain. There is no known brain damage or disorder that leads to APDs. I think the most damaging ear disorder is not a fixed cochlear loss or even a dead ear but constantly fluctuating hearing within and between ears, as with changes in middle ear pressure, such that consistent normal ear dominance cannot be established.

Incidentally, I do not think the child problems listed above are falsely diagnosed, the children really have them, but as a result of previous hearing problems or otitis media.

Your dental advice is too late, I'm afraid. I was eating some rice yesterday, when one of my teeth suddenly fell out.

They are probably more common, particularly in children and adolescents than had previously been thought. You might look at normative data on the items assessing auditory and visual hallucinations from the Child Behavior Checklist as well as the Youth Self-Report and the Young Adult Self-report (all from Achenbach).

You guys should visit a spiritualist church, the whole dam lot are listening to voices! People who channel probably feel sorry for the non hearers.... Many children have invisible friends and many cultures talk with the ancestors, why would this be so prevalent around the world and for so long if its pure hallucination or false belief? Gosh even Socrates ran around behaving like a mad man yet his wisdom's were recognized later.

Check out a discussion called 'Could Socrates be diagnosed within the schizophrenia spectrum? Could schizophrenia patients be considered in the light of Socratic insights?' Borut Skodlar and Jon Ploug Jorgensen, Copenhagen, 2012.

Further reference for that is.... Psychosis (ISPS journal), Vol 5, No.1, 17-25, http:??dx.doi.org?10.1080/17522439.2012.669395