From Kraepelin to DSM 5, auditory hallucinations have included sounds, noises, murmurs, clicks, whispers, music, etc, and not just voices. In the absence of any criteria for distinguishing what an otologist would call tinnitus and a psychiatrist a nonverbal auditory hallucination, all variants should should be lumped together and regarded as belonging to the same continuum of auditory hallucination. In which case, I would guess the commonest types are buzzing, whistling or clicking.

voices of f external authority , (God, Devi) typically giving commands ror internal voices of consciousnes, more often about "gul ilt" than about "greaness". Frequent arei, also voices making commend to the patient's ongoing activities in a neutral tone. Tese are usually rsembling the patients' own voice and diction

A great deal of care has to be taken with a question like this one because is you ask about 'clinical populations' you must remember that such populations are subject to inclusion fallacies as hallucinations are a primary diagnostic criteria. It is normal for people to have hallucinatory experiences, especially when intoxicated, at the threshold of sleep, or when ill - yet these are not 'clinical' symptoms.

Auditory hallucinations are very common diagnostic symptoms for schizophrenia - yet these hallucinations are seldom purely auditory. When a newsreader starts speaking to a patient from the TV set, is it auditory or multimodal, including visual stimuli? How is it recorded and reported?

Obviously troubling hallucinations are going to be reported more frequently than the voices of imaginary friends and benevolent spirits because hallucinations really only become 'symptoms' when they become a problem.

I find the question slightly imprecise as it does not state which clinical diagnosis we are discussing. In psychotic depression, psychotic mania, schizophrenia, delirium or substance-indices psychosis the most common types of auditory hallucinations might be completely different.

Adam,

Of course, you are correct. In this question forum it is not practical to ask a 1000-word question, specifying all the potential types of psychoses and the types of auditory hallucinations.

So if you wished, you could simply select one of types of psychoses (eg, psychotic depression) and report the type of hallucinatory content that one might see most often. If you were interested, you could address each of the types of psychoses and suggest the most common types of hallucinations for each type. This option would provide an interesting opportunity to compare and contrast the types.

"In psychotic depression, psychotic mania, schizophrenia, delirium or substance-indices psychosis the most common types of auditory hallucinations might be completely different."

Yes, but in practice they are found to be remarkably similar. AHs in normals or in religious mystics could also be added to the list. This is important and relevant, since it immediately invalidates all explanations for voices that only apply to schizophrenia, for example. A generic explanation for AHs must be the first step.

Another interesting facet of this, touched upon above is the meaning of voices. Understanding the meaning, symbolism and benefits or negatives of the hallucinatory experiences helps us engage with the person experiencing them. Beliefs about a voices omnipotence or benevolence or malevolence are key in predicting associated mood states and suicidality. Romme & Escher (1989) found that 15% of participants perceived their auditory hallucinations as positive.

In general there is a positive association between derogatory hallucinations of whatever modality and depressed affect and suicidality (Birchwood, Chadwick et al's work here is worth reviewing) and I would recommend the Beliefs About Voices Questionnaire to tease these issues out- a good summary paper can be found http://bjp.rcpsych.org/content/177/3/229.full (BAVQ revised Chadwick Lees and Birchwood. The British Journal of Psychiatry (2000) 177: 229-232 doi: 10.1192/bjp.177.3.229.

"Another interesting facet of this, touched upon above is the meaning of voices."

I agree people may assign meaning and influence to voices depending on their mood and the tone of the voices. However, I don't think it is helpful to say or imply that voices have an intrinsic meaning. People will see meaning in dots moving randomly on a screen. In the old days, people were terrified to go out into the woods at night, because they thought they were full of demons or spirits. They were interpreting the natural forest noises, or indeed auditory hallucinations, as indicating purposeful and sinister machinations of unseen entities. I don't think it helps to collude in what may well be a quite reasonable though mistaken interpretation of the world. I think one should say there is a natural and non-threatening explanation for the unsettling noises, that there are no fairies!

Most of the descriptions I see above are consistent with the kinds of hallucinations experienced in schizophrenia. It is also important to note that the content of such hallucinations can vary according to culture. (See Social and cultural aspects of hallucinations.Al-Issa, Ihsan. Psychological Bulletin, Vol 84(3), May 1977, 570-587. doi: 10.1037/0033-2909.84.3.570)

The hallucinations I see with people who have Parkinson's disease, however, tend to be more visual, nonthreatening, and involve misinterpreting things with similar visual characteristics. For example, one of the people I worked with started having a conversation with a chair: It was a decorative wooden chair that had a oval piece at the top, which got misinterpreted for the head of a small child. He thought that he was talking to a young girl standing at his kitchen table. If someone with Parkinson's has delusions, however, the visual hallucinations may be consistent with the delusions. For example, a client was having delusions that his wife was cheating on him, and regularly hallucinated hickies and other bruises on her skin that he interpreted as proof of the affair.

Culture has enormous impact on the character of delusions and related hallucinations. Over my time in mental health I have seen an emergence in the UK for example of the "Truman Show" influence on psychopathology whereby there is a fixed belief of being observed for the entertainment of others with varied responses of having to escape the country in order to watch themselves or to collude happily with the belief as it allows them to put their best behaviour forward for public examination. Organic hallucinations in Charles Bonnet Syndrome are also very interesting- linked in the parkinson's theme above. It is said that a defining feature of these visual hallucinations are that they lack personal meaning to the person losing their sight.

The case of Sir Robert Liston, who spoke ten languages and could read fourteen, was written up in great detail (Edin Med Surg J 1836;46;334), and is relevant here as an example of Charles Bonnet Syndrome. It was entitled a Case of Spectral Illusions, which I think is a more accurate descriptor than "hallucinations". As with most (?all) CB cases, he had ocular problems (bad cataracts). His visions were commoner at night, which would support the idea that they were constructions of an intact brain from very imperfect and fragmentary visual input that resulted from poor light, poor vision and poor surroundings (a spooky Scottish country house, peopled by unreliable servants).

The spectral figures took various forms: disconnected heads; figures from ancient history; his own countenance, changing from youth to old age; clear figures, but much smaller than life; his late wife, floating round the room, beckoning him to follow, so that he jumped out of the window after her.

From: P McBride The causes of tinnitus aurium Med Times Gaz 1882;2:243

"There is a form of hallucination which is by many authors classed as tinnitus. I allude to the hearing of various melodies, or of animal and even human voices, which have no objective existence. Brunner and Hartmann, however, regard these phenomena as psychic in their nature, and due to irritation of the higher cerebral centres. That such is the case is evident; but whether this irritation may not be produced by stimulation of the peripheral extremity of a sensory nerve -- more especially the auditory -- we must, I think, leave an open question.."

And, as far as the general literature on this topic is concerned, this question has still not been answered (or even asked!).

To illustrate the great variation in character of hallucinations or sounds described by sufferers, McBride (above) copies this from Wilde's textbook on Aural Surgery:

"Persons from the country or rural districts draw their similitudes from the objects and noises by which they have been surrounded, as the falling and rushing of water, the singing of birds, the buzzing of bees, and the waving or rustling of trees; while, on the other hand, persons living in town, or in the vicinity of machinery or manufactures, say that they hear the rolling of carriages, hammering, and the various noises caused by steam-engines. Servants almost invariably add to their other complaints that they suffer from the ringing of bells in their ears; while in this country, old women, much given to tea-drinking, sum up the caegory of their ailments by saying that all the kettles in Ireland are boiling in their ears. The tidal sound, or that we can produce by holding a conch-shell to the ear, is, however, what is most frequently complained of."

As McBride says, "It seems perfectly obvious that tinnitus must arise from a stimulus, either applied to the auditory nerve or conducted by other channels to its centre".

This citation is translated from Finnish from prof Salokangas' (in psychiatry) paper on different types on hallucinations and their etiology. : Hallucinations occur in 10-27% of the "normal population". Psychiatrists and neurologists need to co-operate to determine the etiology of hallucinations. Schizophrenia is characterized by delusions of hearing own thoughts, hearing comments about own movements and activities as well as of arguments between two or more voices - often commenting on the patient. Also, instructing and otherwise manipulating voices are not uncommon. According to various studies 60-90% of schizophrenia patients suffer from auditory hallucinations (Yager and Gitlin, 2000).Yager J, Gitlin MJ. Clinical manifestations of psychiatric disorders. Kirjassa

Sadock BJ, Sadock VA, toim. Kaplan & Sadock’s Comprehensive

textbook of psychiatry. Vol. I. 7. painos. Philadelphia: Lippincott

Williams & Wilkins, 2000, 789–823.

"Psychiatrists and neurologists need to co-operate to determine the etiology of hallucinations."

By far the commonest forms of auditory hallucinations are noises in the ears (tinnitus), the cause of which is ear disease, for which patients (and hopefully psychiatrists) consult otologists to determine the cause.

RAIMO K. R. SALOKANGAS: Aistiharha – neurologinen

vai psykiatrinen häiriö? [Hallucination - a neurological

or psychiatric disorder?] professor Salokangas is an expert in this area. I regret that you cannot read the paper.

http://www.ebm-guidelines.com/xmedia/duo/duo94491.pdf

" professor Salokangas is an expert in this area"...

..who seems to be a psychiatrist. Judging by the refs in the above link, he does not discuss tinnitus. Which makes my point that the otological (and old psychiatric) literature needs to be consulted. Or are people arguing that tinnitus is not an auditory hallucination?

Written 2004. Psychological effects of persistent tinnitus may cause irritability, fatigue, and on occasions, clinical depression and musical hallucinations.

Tinnitus annoyance is more strongly associated with psychological symptoms than acoustic characteristics. Other psychological problems such as depression, anxiety, sleep disturbances and concentration difficulties are common in those with worse tinnitus.

Mansoor, David, Ganzini, Linda (2014). Musical hallucinations successfully treated with antipsychotic medications: Three case reports.

. Psychosomatics: Journal of Consultation and Liaison Psychiatry55.2 (Mar 2014): 191-193.

Case reports about musical hallucinations comment on the relative lack of effectiveness of antipsychotics. We present three cases of musical hallucinations, all in patients with comorbid mental disorders, who experienced psychological distress or loss of reality testing as the hallucinations worsened. In all cases, the hallucinations completely resolved with antipsychotic treatment. Presentation of these cases was approved by the Institutional Review Board of the Portland Veterans Affairs Medical Center. (PsycINFO Database Record (c) 2014 APA, all rights reserved)

Beatrice, I am not sure what point you are making. I have not yet read this Mansoor paper, but I would bet a large sum of money that there has been no audiological or neuro-otological examination, and that McBride's question (1882) has not been addressed (see my comment of Apr 2, 2014).

Here is an excellent description by Ch. Roesch of the continuum model of auditory hallucinations. I cannot find any mention of this theory, let alone any critique, in current psychiatric textbooks or papers : (Annales d'hygiene Publique.. 1838;20:5)

"C. Hallucinations ebrieuses des sens...

Les hallucinations augmentent graduellement d'intensite chez tous les buveurs. A l'egarde de l'ouie, c'est d'abord un bourdonement de plus en plus fort, que le malade percoit, et qu'il prend pour le bruit d'une pluie battante, celui d'une chute d'eau, le roulement du tonnere dans le lointain, etc., ou pour un bruit de cloches, pour de la musique. Enfin, il entend des voix humaines, d'abord des mots sans suite, puis des discours entiers, qui lui sont adresses, et qui determinent meme a lier conversation... L'education premiere du malade influe beaucoup sur ce qu'il croit ainsi entendre et voir, car l'imagination joue toujours un grande role dans la production de ces phenomenes."

Note:

1. The continuum from tinnitus to environmental sounds to music to words to conversations.

2. Even with simple tinnitus (hissing, ringing, buzzing), there is already a search for meaning, an external attribution.

3. More intelligent persons may be better able to deconstruct their abnormal perceptual experiences. This might explain the lower IQ of those bothered by their schizophrenogenic experiences.

4. Since simple auditory hallucinations seem to be necessary, though not sufficient, for the development of more complex ones, non-verbal ones will be far commoner than verbal ones in the general population, if only because of the high incidence of alcoholism.

I agree that the continuum idea is compelling. In fact the imperfect match between perception and experience means that all people have the capacity to be fooled by what they believe they perceive. This leads to one of the most commonly accepted hypotheses for hallucinatory experience – the illusion-hallucination continuum (eg, Brébion et al., 2000; Frith & Done, 1988; Harvey, 1987; Johns et al., 2001). But while direct studies of this phenomenon do demonstrate significant illusion/hallucination correlations, and therefore a possible role in psychosis, the effect size is much smaller than psychotic symptoms warrant, and therefore make a poor explanation (Aleman, Böcker, Hijman, de Haan, & Kahn, 2003; Woodward, Menon, & Whitman, 2007). Take akinesia or waxy flexibility as examples - how would tinnitus explain these?

At risk of sounding like an egotist, I would like to refer readers to my own paper, which explains schizophrenic hallucinations reasonably cojently, especially as schizophrenic hallucinations tend to be multi-modal as I mentioned above, and not only auditory (I might hallucinate a figure speaking to me on tv for instance.)

It's open source and available on Researchgate somewhere: Golembiewski, Jan. (2013). The subcortical confinement hypothesis for schizotypal hallucinations. Curēus, 5 (5), e118. doi: 10.7759/cureus.118

If you have an interest in singular mode hallucinations, rather than schizophrenia per se, try looking at dementia with lewy bodies. I think that might be a better place to start.

Also, as an aside, don't just accept that patients with sz have lower IQ's. If anything the only cross sectional data I've seen (eg. McGrath et al 2009) tells a different story, with 84-93 % of cases having had good/fair school performance prior to developing the schizophrenia prodrome (that's more than the percentage with auditory hallucinations, by the way).

McGrath, John A., Avramopoulos, Dimitrios, Lasseter, Virginia K., Wolyniec, Paula S., Fallin, M. Daniele, Liang, Kung-Yee, . . . Pulver, Ann E. (2009). Familiality of Novel Factorial Dimensions of Schizophrenia. Arch Gen Psychiatry, 66(6), 591-600. doi: 10.1001/archgenpsychiatry.2009.56

"Take akinesia or waxy flexibility as examples - how would tinnitus explain these?"

The tinnitus model explains auditory hallucinations, a prominent symptom of schizophrenia. It may, or may not, be relevant to other symptoms, delusions for example.

The most likely cause for the tinnitus is Meniere Spectrum Disorder, a hyperactive state of the inner ear, the vestibular part of which may be responsible for other important symtoms -- visual hallucinations, depersonalisation, catatonia, etc

"Also, as an aside, don't just accept that patients with sz have lower IQ's."

See various meta-analyses, including:

"Neuropsychology. 2009 May;23(3):315-36. doi: 10.1037/a0014708.

Neurocognition in first-episode schizophrenia: a meta-analytic review.

Mesholam-Gately RI1, Giuliano AJ, Goff KP, Faraone SV, Seidman LJ.

Compromised neurocognition is a core feature of schizophrenia. Following Heinrichs and Zakzanis's (1998) seminal meta-analysis of middle-aged and predominantly chronic schizophrenia samples, the aim of this study is to provide a meta-analysis of neurocognitive findings from 47 studies of first-episode (FE) schizophrenia published through October 2007. The meta-analysis uses 43 separate samples of 2,204 FE patients with a mean age of 25.5 and 2,775 largely age- and gender-matched control participants. FE samples demonstrated medium-to-large impairments across 10 neurocognitive domains (mean effect sizes from -0.64 to -1.20). Findings indicate that impairments are reliably and broadly present by the FE, approach or match the degree of deficit shown in well-established illness, and are maximal in immediate verbal memory and processing speed. Larger IQ impairments in the FE compared to the premorbid period, but comparable to later phases of illness suggests deterioration between premorbid and FE phases followed by deficit stability at the group level. Considerable heterogeneity of effect sizes across studies, however, underscores variability in manifestations of the illness and a need for improved reporting of sample characteristics to support moderator variable analyses."

In my clinical experience the most frequent auditory hallucinations are one or more denigratory voices directed towards the psychotic patient. Less frequent are the ones mood linked that can be experienced e.g. by bipolar patients.

Has anyone got recent data on all types of auditory hallucinations in clinical and non-clinical populations?