Voices in people's heads are far more varied and complex than previously thought, according to new research by Durham and Stanford universities, published in The Lancet Psychiatry today.
One of the largest and most detailed studies to date on the experience of auditory hallucinations, commonly referred to as voice hearing, found that the majority of voice-hearers hear multiple voices with distinct character-like qualities, with many also experiencing physical effects on their bodies.
The study also confirmed that both people with and without psychiatric diagnoses hear voices.
The findings question some of the current assumptions about the nature of hearing voices and suggest there is a greater variation in the way voices are experienced than is typically recognised.
The researchers say this variation means different types of therapies could be needed for voice-hearers, such as tailored Cognitive Behavioural Therapy (CBT) geared towards distinct voice sub-types or patterns of voice hearing.
Current common approaches to help with voices include medication, CBT, voice dialogue techniques and other forms of therapy and self-help.
Auditory hallucinations are a common feature of many psychiatric disorders, such as psychosis, schizophrenia and bipolar disorder, but are also experienced by people without psychiatric conditions. It is estimated that between five and 15 per cent of adults will experience auditory hallucinations during their lifetimes.
This is one of the first studies to shed light on the nature of voice-hearing both inside and outside schizophrenia, across many different mental health diagnoses.
Lead researcher Dr Angela Woods, from the Centre for Medical Humanities at Durham University, said: "Our findings have the potential to overturn mainstream psychiatric assumptions about the nature of hearing voices.
"We call into question the presumed auditory quality of hearing voices and show that there is an unrecognised complexity in the 'character' qualities of some voices.
"It is crucial to study mental health and human experiences such as voice-hearing from a variety of different perspectives to truly find out what people are experiencing, not just what we think they must be experiencing because they have a particular diagnosis. We hope this approach can help inform the development of future clinical interventions."
The researchers, funded by the Wellcome Trust, collected answers to open- and close-ended questions through an on-line questionnaire focused on description of experiences from 153 respondents. The majority of respondents had been diagnosed with a psychiatric condition but 26 had no history of mental illness. Participants were free to respond in their own words.
The large majority of respondents described hearing multiple voices (81 per cent) with characterful qualities (70 per cent).
Less than half the participants reported hearing purely auditory voices with 45 per cent reporting either thought-like or 'inbetween' voices with some thought-like and some acoustic qualities. This finding challenges the view that hearing voices is always a perceptual or acoustic phenomenon, and may have implications for future neuroscientific studies of what is happening in the brain when people 'hear' voices.
66 per cent of people felt bodily sensations while hearing voices, such as feeling hot or tingling sensations in their hands and feet. Voices with effects on the body were more likely to be abusive or violent, and, in some cases, be linked to experiences of trauma.
While fear, anxiety, depression and stress were often associated with voices, 31 per cent of participants said they also felt positive emotions.
Co-author Dr Nev Jones from Stanford University said: "Our findings regarding the prevalence and phenomenology of non-acoustic voices are particularly noteworthy. By and large, these voices were not experienced simply as intrusive or unwanted thoughts, but rather, like the auditory voices, as distinct 'entities' with their own personalities and content. This data also suggests that we need to think much more carefully about the distinction between imagined percepts, such as sound, and perception."
Rachel Waddingham is an independent trainer and consultant with Behind The Label and a trustee of the National Hearing Voices Network and the International Society for Psychological and Social Approaches to Psychosis.
Rachel hears voices, sees visions and has struggled with overwhelming beliefs.
Rachel explains: "I hear about 13 or so voices. Each of them is different - some have names, they are different ages and sound like different people. Some of them are very angry and violent, others are scared, and others are mischievous. Sometimes, I hear a child who is very frightened. When she is frightened I can sometimes feel pains in my body - burning. If I can help the voice calm down, by doing some grounding strategies, the burning pains stop.
"Since going to a Hearing Voices Group, I have found ways of making sense of and coping with my voices. I no longer feel terrorised by them even though some of them say some very frightening things. I now have a family of voices and have a better relationship with them. I can make a choice about how I respond to them - whether I listen to them, and how I reply. Some of them are now much more helpful - they can be a window to my feelings, letting me know about a problem that I have in my life that I need to address.
"Although in our society, people who hear voices are often seen as 'mad' or 'crazy', I do think things are changing. I find that lots of people are interested in voice-hearing. Many people have told me about experiences they have had - either in their childhood, or as an adult. It's as if by talking about voices we are starting to de-stigmatise the experience and opening the door for others to speak openly too.
"As long as we believe that voices are signs of pathology and illness, it makes little sense to really explore a person's lived experience. Instead we try to suppress or eliminate the voices as far as possible. Listening to them seems 'crazy'. Still, in my experience it can be really useful to be interested in people's lived experience of voice-hearing. Every one of us is different, and being curious about my experiences was one of the first steps to dealing with them.
"This research is a step forward. If we want to understand more about voice-hearing, it makes sense to ask a voice-hearer - and be willing to modify our perception of what it means to hear voices based on their answers. For me, the word 'voices' isn't sufficient. I use it, but it hides the embodied parts of my experience for which I have few words to describe.
"I would like to live in a world where we are curious about one another's experiences and seek to understand rather than pathologise. Everyone has a story and the world would be much kinder if we started to listen to it."