Decoding the Voices of Schizophrenia

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Schizophrenia is a complex mental illness that affects about 1%...

Schizophrenia is a complex mental illness that affects about 1% of the U.S. population. It interferes with a person’s ability to think clearly, manage emotions, make decisions, and relate to others. People with schizophrenia may seem like they have lost touch with reality. In fact, one common symptom of the disorder is experiencing auditory hallucinations, often described as ‘hearing voices.’

The Voices in My Head

When it comes to schizophrenia, one of the most common questions is, where do these inner voices come from? It turns out that people with schizophrenia are actually hearing their own voices in their heads. While the exact cause of ‘hearing voices’ in schizophrenia is not fully understood, some researchers believe there is a connection between ‘hearing voices’ and a phenomenon called subvocal speech. Many of us experience subvocal speech but in a slightly different way.


Have you ever thought so intently about something that you subconsciously said it out loud? Most likely, the answer is yes. For example, you might mutter, “Take out the garbage,” after a partner reminds you for the 100th time. This is subvocal speech, and, for most of us, it’s a common part of everyday life.

Our brains process all language, even the private thoughts we have in our heads. These thoughts transform into subvocal speech when this cognitive function stimulates our speech muscles, even though that stimulation is usually not strong enough to generate a voice that anyone can hear. You might just mumble under your breath or make no sound at all.

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Subvocal Speech And Schizophrenia

In the ‘50s, a psychiatrist named Louis Gould decided to investigate whether auditory hallucinations in schizophrenia are related to this phenomenon of subvocal speech. Using a technique called electromyography, or EMG, which measures muscle activation over time, he recorded the vocal muscle activity in a group of patients with schizophrenia and a group of healthy patients.

When he compared the EMG recordings of patients with schizophrenia while they were experiencing auditory hallucinations to those of non-hallucinating patients, he noticed greater vocal muscle activation at times when the patients were hearing voices. This suggests that while the patients heard voices in their heads, they were simultaneously engaging in subvocal speech. Gould found that by pressing a microphone against the throat of one patient, he could actually hear the subvocal speech that the patient perceived as an external voice.

Dr. Brindusa Vanta, MD, says, “While Dr. Gould’s research suggests that subvocal speech may contribute to the experience of inner voices, more research is needed to understand this complex phenomenon. Several other theories have been developed to try to explain the origins of auditory hallucinations experienced by some individuals with schizophrenia.”

Inner vs. Outer Voices

When considering subvocal speech as a contributor to auditory hallucinations, it is important to note it is experienced in a different way in healthy individuals.    

Subvocal speech is a normal cognitive process experienced by many individuals. During this, thoughts are processed as if spoken aloud; however, they remain internal. In schizophrenia, subvocal speech appears to be altered (dysregulated), leading to the perception of external voices.

The Nature of Auditory Hallucinations

Auditory hallucinations, a hallmark symptom of schizophrenia, represent a complex phenomenon where individuals perceive sounds, most commonly voices, without any external stimulus. Unlike internal thoughts, which the individual recognizes as originating from within, auditory hallucinations are experienced as real and originating from outside the self. This distinction lies at the core of understanding the nature and impact of these hallucinations on those who experience them.

Differentiating from Internal Thoughts

The key difference between auditory hallucinations and internal thoughts lies in the perceived origin of the sound. Internal thoughts are recognized as self-generated; they are part of our inner dialogue and understood to be under our control.

In contrast, auditory hallucinations are perceived as external, not self-generated, and often uncontrollable. Individuals may hear these voices speaking to them or about them, discussing their actions, or even commanding them to perform tasks. This external perception makes hallucinations particularly distressing, as it can blur the line between reality and the internal experience, leading to confusion and, often, a profound sense of isolation.

This distinction is crucial for therapeutic interventions. Understanding that auditory hallucinations are perceived as external allows mental health professionals to tailor their approaches. They can focus on strategies that help people differentiate between self-generated thoughts and hallucinations, as well as ways to manage or reduce the impact of these experiences.

Treatment and Management of Auditory Hallucinations

Managing auditory hallucinations requires a multifaceted approach. Treatment options are designed not only to reduce the frequency and intensity of hallucinations but also to improve the individual’s ability to cope with them. The cornerstone of treatment includes antipsychotic medications, cognitive-behavioral therapy (CBT), and mindfulness practices. A comprehensive treatment plan that combines medication, therapy, and support systems is crucial for effective management.

Dr. Brindusa Vanta, MD, says, “Some auditory hallucinations are more complex than others. For example, hearing two or more voices engaging in dialogue ‘in the head’ may indicate a more severe symptom in schizophrenia, suggesting deeper disturbances in perception and cognition.” 

Antipsychotic Medications

Antipsychotic medications are the primary treatment option for managing auditory hallucinations. These drugs work by altering certain neurotransmitter activity in the brain, which can significantly reduce the severity of hallucinations and, in some cases, eliminate them. While antipsychotics can be highly effective, they may also come with side effects. Therefore, the choice of medication and its dosage must be carefully tailored to the individual’s needs and monitored regularly.

Cognitive-Behavioral Therapy (CBT)

CBT is a form of psychotherapy that has been adapted to help individuals with schizophrenia manage their symptoms, including auditory hallucinations. CBT for psychosis (CBTp) aims to change the way individuals think and react to their hallucinations. It involves identifying and challenging unhelpful beliefs about the hallucinations, enhancing coping strategies, and reducing the distress they cause. CBTp can help individuals gain a better understanding of their symptoms and develop more effective ways to deal with them.

Mindfulness Practices

Mindfulness involves focusing attention on the present moment while calmly acknowledging and accepting feelings, thoughts, and bodily sensations. For individuals experiencing auditory hallucinations, mindfulness can help reduce the distress associated with these experiences. By promoting a nonjudgmental awareness of hallucinations, mindfulness practices can enable people to observe their hallucinations without reacting emotionally or behaviorally, which can lessen their impact.

Comprehensive Treatment Plan

A comprehensive approach that combines medication, psychotherapy, and support systems significantly enhances the treatment’s effectiveness.

This includes:

  • Medication Management: Regular consultations with a psychiatrist are important to monitor the efficacy and side effects of antipsychotic medications.
  • Therapy: Regular sessions with a psychologist or therapist trained in CBTp can help the individual develop coping strategies and manage symptoms.
  • Support Systems: Involvement in support groups or community services can provide additional emotional and practical support. Family therapy may also be beneficial to educate family members and improve the support network around the individual.
  • Lifestyle Adjustments: Encouraging healthy lifestyle choices, such as regular exercise, a balanced diet, and adequate sleep, can also play a crucial role in managing symptoms.

A comprehensive and personalized treatment plan is the most effective way to manage auditory hallucinations. Collaboration among the individual, their healthcare providers, and their support network is essential to navigate the complexities of treatment and foster a supportive environment for recovery and symptom management.

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