Auditory Hallucinations

What Are They, Causes, and More

Author: Lily Guo

Editors: Alyssa Haag,Ian Mannarino, MD, MBA

Illustrator: Jessica Reynolds, MS

Copyeditor: David G. Walker

Modified: 30 Jun 2022

What are auditory hallucinations?

Auditory hallucinations refer to the false perception of sounds, such as internal voices or noises. An individual can experience auditory hallucinations that range from hearing simple sounds (e.g., repeated clicking or tapping noises) to hearing one or multiple voices speaking in the absence of a true auditory stimulus. The voices may be saying new things or repeating what has been heard before and can give comments, commands, insults, or encouragement.

Illustration of cartoon figure covering his ears to drown out the sounds of internal voices.

What causes auditory hallucinations?

Mental illness, such as schizophrenia or schizophreniform disorders, is one of the most common causes of auditory hallucinations. As many as 75% of individuals with schizophrenia have reported experiencing auditory hallucinations. The voices individuals with schizophrenia hear tend to be negative and controlling and can take a toll on one’s emotional well-being. Auditory hallucinations are also seen in other psychiatric conditions, such as bipolar disorder; borderline personality disorder; and some forms of dementia, such as Parkinson disease and late-stage Alzheimer disease. Brain tumors found in varying locations in the brain, such as the cerebellum and the ventricles, have also been tied to auditory hallucinations

Another cause may be drug and alcohol use, which impair cognitive function and can result in the distortion of reality. Examples of drugs that can elicit auditory hallucinations include 4-methylenedioxy-methamphetamine (MDMA) and lysergic acid diethylamide (LSD). Both MDMA and LSD can have hallucinogenic effects while the individual is taking them or as a result of drug withdrawal

Epilepsy, a disorder characterized by recurrent seizures, can impact the brain area that processes hearing (i.e., auditory cortex) and cause the individual to hear ringing in the ears (i.e., tinnitus) or voices. In some cases, epileptic seizures can distort sounds so that individuals cannot hear auditory stimuli as loudly or as clearly. 

In rare cases, other underlying medical conditions, such as chronic kidney failure, vitamin B12 and vitamin D deficiencies, electrolyte imbalances, and hepatic encephalopathy can lead to psychotic episodes and hallucinations

Vivid auditory hallucinations may also be experienced when falling asleep (hypnagogic) or when waking up (hypnopompic). These are typically normal and are not a sign of mental or physical illness, though they may be more commonly experienced in people with sleep disorders.

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What are the signs and symptoms of auditory hallucinations?

An individual experiencing auditory hallucinations may hear sounds or voices through their ears, on the surface of the body, in their mind, or anywhere in external space despite a lack of external stimuli. The sounds or voices can occur frequently and daily or can be limited to a single, isolated episode. The intensity and volume of the hallucination can also vary. Individuals experiencing talking voices may also respond to the voice.

How are auditory hallucinations diagnosed?

Diagnosis of auditory hallucinations is typically made by a mental health professional based on a general psychiatric interview that includes details of when the hallucinations started, timing and frequency of hallucinations, if there are any specific triggers, history of psychiatric diagnoses both in oneself and within the family, history of substance use, and history of trauma. The mental health professional can also perform a mental status examination to address the patient’s mood, affect, appearance, behavior, speech, thought content, thought process, insight, and judgment. The individual should also be asked to elaborate on whether the hallucinations command them to perform certain acts or behaviors to assess their safety and the safety of others. 

Lastly, non-psychiatric causes of auditory hallucinations should be ruled out using laboratory analysis that can include urine toxicology, complete blood count with differential, vitamin B12 and D levels, renal function test, serum electrolytes, hepatic function test, and blood alcohol. Imaging scans using computed tomography (CT) or magnetic resonance imaging (MRI) should be considered if a brain tumor is suspected. In cases of suspected epilepsy, an EEG can be ordered. 

How are auditory hallucinations treated?

The treatment for auditory hallucinations depends on the underlying cause. For those with schizophrenia, treatment usually involves antipsychotic medications (e.g., chlorpromazine, fluphenazine, haloperidol). However, approximately 30% of individuals have treatment-resistant auditory hallucinations. In those cases, the standard treatment is to increase the dose of antipsychotics or to use clozapine, an antipsychotic that can be effective for treatment-resistant symptoms, including auditory hallucinations. Additionally, transcranial direct current stimulation is another approach for treating auditory hallucinations in schizophrenia. It is a noninvasive brain stimulation technique that alters the neuronal membrane resting potential, causing changes in motor-cortical excitability. Psychological interventions, including cognitive behavioral approaches, are currently being studied for auditory hallucinations that are resistant to medications. This includes distraction techniques (e.g., listening to music, reading, art) or focusing techniques (e,g,, rational responding, generating compassion towards the voice, mindfulness).

For causes of auditory hallucinations related to dementia, treatment typically involves offering reassurance and support to the individual, maintaining routines, and using distractions, such as soothing music. Alzheimer disease is typically treated with cholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine). Pimavanserin is the medication of choice to treat hallucinations and delusions associated with psychosis experienced with Parkinson disease dementia. If a brain tumor is the underlying cause of auditory hallucinations, the physician may decide to treat the tumor with surgery or chemotherapy. Patients with drug and alcohol induced hallucinations may see a resolution of symptoms once the substances are eliminated from the body or once they are no longer in withdrawal from the substance. Epilepsy can be treated with anti-epileptic medications (e.g., sodium valproate, carbamazepine, lamotrigine), which can help reduce the frequency of auditory hallucinations. Lastly, addressing and treating underlying medical conditions may help resolve auditory hallucinations, such as administering vitamins, correcting electrolyte imbalances, and treating renal or hepatic disease.  

What are the most important facts to know about auditory hallucinations?

Auditory hallucinations are a type of hallucination that involves the perception of hearing voices and sounds despite a lack of external stimuli. They are commonly experienced by those with psychiatric disorders and can be seen in up to 75% of people with schizophrenia. It is also caused by brain tumors, common types of street drugs (e.g., MDMA, LSD), alcohol use, and epilepsy. Auditory hallucinations may also be experienced when falling asleep or waking. Diagnosis typically relies on a mental health professional who will typically conduct a thorough psychiatric interview; a mental status examination; and various laboratory and imaging tests to rule out non-psychiatric causes, such as brain tumors and epilepsy. Treatment depends on the underlying cause and can include antipsychotic medications, teaching coping strategies through cognitive behavioral therapy, transcranial direct current stimulation to treat schizophrenia, cholinesterase inhibitors to treat Alzheimer's disease, or anti-epileptic medications to treat epilepsy. 

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Resources for research and reference

Coebergh, J.A.F., Lauw, R.F., Sommer, I.E.C., & Blom, J.D. (2019). Musical hallucinations and their relation with epilepsy. Journal of Neurology, 266: 1501-1515. DOI: 10.1007/s00415-019-09289-x

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Mansfield, A.S., & Qian, Q. (2009). 71-year-old man with chronic kidney failure and sudden change of mental status. Mayo Clinic Proceedings, 84(11): e5-e8. DOI: 10.1016/S0025-6196(11)60673-3

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