Can you live with the voices in your head?

[Hurricane]

Along the lines of the religious delusions thread...

There is a very interesting article in this weekend's NYT magazine: Can You Live With the Voices in Your Head?

It's pretty long, and some of the things it talks about include:
- people who hear voices and whether or not they should all be considered mentally ill
- a support organization called the Hearing Voices Network, which, although it was started by a psychiatrist, often finds itself in opposition to psychiatry
- a movement, mostly in the UK, towards using CBT to help "voice hearers" better cope with them. Also touches historical aspects of the use of psychotherapy for the treatment of schizophrenia.

Anyway, I think that if there are people out there who hear voices but are able to go on about their lives without it causing them any distress, then I wouldn't consider that to be a "disorder." But I would posit that there is something different about that person's brain. And regarding those for whom it is distressing, I would hope that such a support group would not discourage its members from seeking psychiatric help, in addition to whatever nonpharmacologic resources they may want to pursue.

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[toby jones]

> Anyway, I think that if there are people out there who hear voices but are able to go on about their lives without it causing them any distress, then I wouldn't consider that to be a "disorder."

Yeah. the most commonly accepted account of disorder / disease is that there must be both
1) Inner malfunction
2) That results in harm (to the individual and / or society)

for mental disorder. Since there doesn't seem to be harm / distress for these people they aren't mentally disordered.

> But I would posit that there is something different about that person's brain.

Do you mean there is something 'faulty' or 'malfunctioning' about it or just something 'different'?

> And regarding those for whom it is distressing, I would hope that such a support group would not discourage its members from seeking psychiatric help, in addition to whatever nonpharmacologic resources they may want to pursue.

If the distress is the result of people regarding them as 'abnormal' and 'crazy' and 'malfunctioning' and 'defective' and / or trying to fight with or ignore the voices... Then it might well be that accepting them is enough for the distress to be alleviated.

A case where someone has a funny nose and wants plastic surgery springs to mind. One could accept the funny nose (maybe with the help of therapy) or one could choose not to accept it and try and get intervention to stop it.

Hard to say what is best for the individual...

Surely there are other symptoms (more obviously harmful) for psychiatry to be worrying about??? Or cases where the individual is really very distressed and is unable to accept them (because of urges to act upon what they are saying or similar). It might well be the case that I hear voices just like these people do it is just that I choose to call mine 'thoughts'.

 

[Hurricane]

Do you mean there is something 'faulty' or 'malfunctioning' about it or just something 'different'?

I didn't mean "different" in a judgemental way - only that brain of a person who hears voices must be functioning in a manner different than that of the brains of the vast majority of people who do not. What the significance of that is... I don't know.

BTW, my favorite part of the article was this:

The most novel strategy, and the only one that seemed to cause the group's members to perk up, came under the heading of "Mobile Phones." If you have the temptation to yell at your voices in public, one suggestion went, you should do so with a phone to your ear. That way you can feel free to let loose, and no one who sees you will think you're crazy.

I don't think I'll ever be able to look at a person yelling into their cell phone quite the same way 😉

 

[Anasazi23]

>

Yeah. the most commonly accepted account of disorder / disease is that there must be both
1) Inner malfunction
2) That results in harm (to the individual and / or society)

for mental disorder. Since there doesn't seem to be harm / distress for these people they aren't mentally disordered.

This is a typical DSM type postulation, but it remains somewhat shortsighted for a number of reasons. An example would be an insidious onset of a disease, which yet by this definition we cannot call 'disease' that should be treated, and has no symptoms. Non pathogenic uti comes to mind. Indeed, some guidelines state not to treat asymptomatic uti's, but the majority of physicians do, when it is discovered, for fear of either future complications, future discomfort, or progression into worsening pathology. We get into trouble here when we think of "diseases" such child molestation or sexual attraction to children - the patient is not disturbed by this notion, and in the latter case, noone has been harmed.

There is ample evidence that auditory hallucinations do not exist as solitary symptoms, and that failure to treat a prodromal state may result in resistance to treatment later, or to shorter time to relapse. So, while a philosophical definition of disease or mental illness is good to discuss, it all becomes different when and if the patient presents in your office - either on their own accord or by someone else.

 

[Psychintern2006]

I have noticed that most of the patients being discharged out of inpatient are still hearing voices, but the voices stop bothering them, or they are merely noises in the background, or the patient is in control and knows not to act on them (most difficult scenario !). I have seen most of them who come back have stopped medications. I am sure that medications keep them to stay out of the hospital and live life independently. Inpatient rotation has been very inspiring, and I am very impressed by the improvement the patients make from the time of admission to the time of discharge. Same person who was running naked, cursing, and yelling will be thanking you and smiling on day 5 !

People who just hear voices, and always benign in nature - as if they are thinking loud/they speakup their thoughts??? basically they are poor historians and / or the possibility of alternate diagnosis.

It won't be the best advise to not admit a patient with bizzarre delusions and hallucinations, and tell him to go home and use his cell phone - when in Public, don't know if that NYT author/s will like to share a subway ride with someone like that 'just talking' on the cell phone.

 

[toby jones]

> brain of a person who hears voices must be functioning in a manner different than that of the brains of the vast majority of people who do not.

well... do you think that the people who know how to cook a good chili have brains that are functioning in a manner different from that of the brains of the vast majority of people who do not?

i just mean to say that on the basis of behavioural symptoms (that appear to exist on a continuum of severity) we really can't assume that there is some brain difference that applies to all and only those people.

> There is ample evidence that auditory hallucinations do not exist as solitary symptoms

Is there? I thougth there was a great deal of difficulty assessing precisely what counts as an auditory hallucinatory experience and what does not (e.g., if they are mislabeling their thoughts as 'voices' then it comes down to a simple mistranslation of what they are saying).

> failure to treat a prodromal state may result in resistance to treatment later, or to shorter time to relapse

Is there evidence for this in the hallucinatory case?

 

[Anasazi23]

> brain of a person who hears voices must be functioning in a manner different than that of the brains of the vast majority of people who do not.

well... do you think that the people who know how to cook a good chili have brains that are functioning in a manner different from that of the brains of the vast majority of people who do not?

In a way, yes, but the outcome, in your analogy, becomes benign and is not indicitive of a disease process.

i just mean to say that on the basis of behavioural symptoms (that appear to exist on a continuum of severity) we really can't assume that there is some brain difference that applies to all and only those people.

In some ways, behavioral symptoms are all we have. Psychiatry does not exist in a time where we can use a blood test or a definitive radiological technique and tell you what disease you have, a la, blood culture or CXR.

We need to be careful to not under pathologize in a clinical situation. Much harm comes to patients who are deemed on a spectrum of 'normal' rather than on a spectrum of 'abnormal' for the purposes of diagnosis and treatment.

When a liver is dysfunctional, we see an abnormality in LFTs, when the kindey is malfunctioning, we see abnormality in Bun/Cr, Protein, specific gravity, etc.

When the brain malfunctions, we see aberration in behavior. Behavior, in this case, is manifested in very subtle ways - a small change in speech, sleepinng pattern, all the way up to overt psychotic or manic symptoms.

> There is ample evidence that auditory hallucinations do not exist as solitary symptoms

Is there? I thougth there was a great deal of difficulty assessing precisely what counts as an auditory hallucinatory experience and what does not (e.g., if they are mislabeling their thoughts as 'voices' then it comes down to a simple mistranslation of what they are saying).

While it can exist is so-called "latent schizophrenics" or the unpopular nuclear schizophrenic, it can happen. Any psychiatrist should be able, on the majority of occasions, be able to distinguish between internal monologue and auditory hallucinations. Refined interview techinques and a developed acuity for thought disorder pathology helps the psychiatrist greatly in this regard.

> failure to treat a prodromal state may result in resistance to treatment later, or to shorter time to relapse

Is there evidence for this in the hallucinatory case?

There is evidence for this in PSYCOTIC patients. So the implication is yes. Dissecting need-for-treatment down to minutia throws the baby out with the bath water.

Do I have chronic schizophrenics that hear voices chronically and are stable in all other regards? Yes. Do I mess with their med regimens despite this? No.

I think most psychiatrists would also not change, for not other reason, a schizophrenic's medication regimen who hears chronic Aud Halluc., and has no other symtpoms.

Bleuler and Schnieder describe quite well the schizophrenic structure. It isn't easily broken down to A vs. B, and hallucinations or not. It is a core process, one that affects the very centrality of the patient. Its manifestations are unfortunately broken down into minute processes and the focus on the trees loses the forest, so to speak. It's important not to lose this basic understanding of the essential fracturing of self that occurs in schizophrenia.

 

[Demosthenes]

This discussion reminds me of William Cowper, an English poet of the late 18th century. He was hospitalized for hearing Satan talking to him.

They let him go when he "realized" it was actually God.

I had a lot more to say about this, but the more I type it, the less courage I have to go on. Suffice to say, I believe that hearing voices is a serious symptom that needs to be evaluated.

 

[Zoom-Zoom]

This discussion reminds me of William Cowper, an English poet of the late 18th century. He was hospitalized for hearing Satan talking to him.

They let him go when he "realized" it was actually God.

I had a lot more to say about this, but the more I type it, the less courage I have to go on. Suffice to say, I believe that hearing voices is a serious symptom that needs to be evaluated.

I agree. The fact that these people are "otherwise ok" is irrelevant in my opinion. Hearing voices should qualify as a harmful dysfunction, with or without other behavioral manifestations. The number and complexity of coping skills these people have adapted to ignore and/or mask the hallucinations are ample evidence of, at the very least, a quality of life issue. It's funny and sad to see the antics people go through to avoid the stigma of an unflattering diagnosis or med schedule. I guess they'll have to keep carrying cell phones around.

FWIW, I would posit that there is something different with the chili cook's brain, but that's a whole other debate 😉

 

[toby jones]

> There is ample evidence that auditory hallucinations do not exist as solitary symptoms

I'm still concerned about this. Auditory hallucinations occur across a range of different disorders. They also occur in the context of drug taking or sensory deprivation or sleep deprivation. There has been some talk of their being a continuum of hallucinatory or hallucination-like experiences.

I'm quoting from Bentall:

'The first systematic study of hallucinations in ordinary people was conducted in Britain in the end of the ninteenth century by the Society for Psychical Research. The society assumed that their findings would have implications for the understanding of apparently supernatural phenomena. A large team of interviewers questioned over 14,000 men and women. Although no attempt was made to obtain a truely random sample, anyone suffering from obvious signs of mental or physical illness were excluded. Of those questioned, nearly 8% of men and 12% of women reported at least one vivid hallucinatory experience... Fifty years later, the society attempted to check these findings by conducting a much less extensive survey, obtaining very similar results...

Modern surveys have continued to provide evidence that hallucinations are experienced by people who appear otherwise to be normal, and who do not regard themselves as mentally ill, and who have not felt the need to obtain psychiatric treatment. For example, in the United States, psychologists Thomas Posey and Mary Losch questioned 375 college students and found that 39% had heard a voice speaking their thoughts aloud... Perhaps even more surprisingly, 5% reported holding conversations with their hallucinations. Subsequent surveys of students in Britain... and in the United States... Have obtained comperable results.

Of course college students are hardly representative of the population as a whole, so it may be wrong to generalise from student samples. However, this limitation does not apply to the most comprehensive survey of hallucinations in the general population so far conducted... Although the definition of hallucinations used by Tien was taken from the DSM III R his findings were remarkably similar to those obtained almost a century earlier by the Society for Psychical Research. He estimated that the proportions of the 18,000 ECA participants who had experienced hallucinations at some time in their lives was between 11 and 13 per cent...

Two subsequent studies have provided broad support for Tien's findings. Jim Van Os and his colleagues conducted psychiatric interviews with over 7,000 randomly selected people randomly selected from the general population of Holland. When abnormal experiences secondary to drug-taking or physical illness were excluded, 1.7 were found to have experienced 'true' hallucinations, but that a further 6.2% had experienced hallucinations that were judged not clinically relevant because they were not associated with distress. Comperable results were obtained in a survey of 716 residents of Dunedin, New Zealand...

To appreciate the significance of these findings it may help to compare them with the available epidemiological data on schizophrenia. Recent estimates suggest that, in most countries, fewer than 1% of the general population receive a dx of schizohrenia in their lives. It now appears that about 10 times that many people have experienced hallucinations'. pp. 96-96

> We need to be careful to not under pathologize in a clinical situation. Much harm comes to patients who are deemed on a spectrum of 'normal' rather than on a spectrum of 'abnormal' for the purposes of diagnosis and treatment.

But we also need to be careful not to overpathologise too.

> Any psychiatrist should be able, on the majority of occasions, be able to distinguish between internal monologue and auditory hallucinations.

But one of the leading theories of auditory hallucinations is that they just are internal monologues that are interpreted as being externally generated. Evidence for this includes sub-vocalisations (by measuring facial muscle movement) and activity in language production areas.

> I think most psychiatrists would also not change, for not other reason, a schizophrenic's medication regimen who hears chronic Aud Halluc., and has no other symtpoms.

Right. But do you mean to pathologise voice hearing in the absence of other symptoms?

Some more Bentall:

As we walked through the pristene white corridoors of the brand new conference centre one morning, Romme and I discussed our different approaches and, in the middle of this conversation, he said something that I will never forget:

"I really like your research on hallucinations, Richard. But the trouble is, you want to *cure* hallucinators, whereas I want to *liberate* them. I think they are like homosexuals in the 1950's - in need of liberation, not cure".

It took me a little time to recognise the power of this simple idea. If people can sometimes live healthy, productive lives while experiencing some degree of psychosis (and the evidence we considered in Chapter 5 suggests they can), if the boundaries between madness and normality are open to negotiation (and the cross-cultural evidence we considered in Chapter 6 suggests they are), and if (as we have seen in this Chapter) our psychiatric services are imperfect and sometimes damaging to patients, why not help some psychotic people just to *accept* that they are different from the rest of us? *Fear of madness* may be a much bigger problem than madness itself.

[with respect to the cross cultural variation the basic idea is that many cultures have hallucinatory experiences as an important part of them. surely we don't want to pathologise the shamen and religious leaders of societies as being latently schizophrenic when their only symptom is hallucinatory experiences]

Of course this suggestion does not imply that people in distress should not be offered the most affective treatment that is available (drugs or psychotherapies). It also does not imply that steps should not be taken to protect society from the very small number of patients who behave dangerously towards others. However, it acknowledges that, for many people experiencing psychosis, treatment may not be the most helpful way forward in their lives. pp. 511-512.

http://www.amazon.com/Madness-Explained-Richard-P-Bentall/dp/0140275401

(winner of the british psychological society book award 2004)

 

[Anasazi23]

Look, as a physician, the clinician, the expert, the authority, you are either able to distinguish what is pathological inherent bleulerian or schneiderian first rank symptoms, or you're not.

A psychologist asking college kids if they hear a voice isn't science, and I don't trust their recording methods or what are likely inadequate paper-and-pencil screening devices.

When you see enough patients, you know what is schizophrenia, and what is not. People with psychosis "aren't just different from us." They suffer from a progressive, chronic, often debilitating disease that often manifests subtly. If these people were so healthy aside from this one "non-symptom," then they wouldn't be in the clinic...the office...the hospital.

Facial muscle movements are in no way proof that hallucinations are simply people talking to themselves, and are interpreted as hallucinations. Face validity is still a player here.

The vast majority of schizophrenics are unemployed. They are unable to deal effectively with life. They've got a diesease that's more debilitating then HTH, DM, and many cancers. Calling every type of pathology that has been copiously described since the classical literature a variation on normal doesn't do the patient justice, in my opinion.

 

[qtpai]

A psychologist asking college kids if they hear a voice isn't science, and I don't trust their recording methods or what are likely inadequate paper-and-pencil screening devices.

These studies are standard psychiatric epidemiology. It is a fact that the experience of "psychotic symptoms" is many several factors more prevalent in the general population than in those who have received a schizophrenia diagnosis.

 

[Anasazi23]

Exactly....and this is reinforcing the point that simply because a symptom or "sign" exists, it is not pathognomonic of a specific disease.

i.e. Headache is a symptom of acoustic neuromas. 80% of the population experiences headaches. A tiny fraction of these have acoustic neuromas.

While experiencing auditory hallucinations may be a sign of a type of schizophrenia, it doesn't mean that every college student that thinks they hear their thinking out loud is schizophrenic.

I think that in some way, like Toby said, we are talking past each other on some of these points.

 

[toby jones]

Perhaps my last post was more inspired by zoom-zoom's claim:

> Hearing voices should qualify as a harmful dysfunction, with or without other behavioral manifestations.

I wanted to deny this.

> Look, as a physician, the clinician, the expert, the authority, you are either able to distinguish what is pathological inherent bleulerian or schneiderian first rank symptoms, or you're not.

Sure. What I'm questioning is whether the presence of ONE symptom (hallucination) constitutes malfunction IN THE ABSENCE of other symptoms. Though... I still have this worry about hallucinations being a proper subset of delusions (in which case if you judge hallucination to be present you get delusion to be present for free). I haven't seen anybody else make this latter point, however, so it is indeed possible that I'm missing something.

> When you see enough patients, you know what is schizophrenia, and what is not.

Yeah... What I'm trying to figure is just how you know that. My theory is that during your training / practice you are acquainted with many exemplars / prototypes and learning how to diagnose is a matter of matching novel cases to past exemplars / prototypes in such a way that your judgement comes into line with other psychiatrists. Inter-rater reliability does NOT establish that there is a real category in nature, however. Bentall questions the distinctions between bi-polar and schizophrenia. He provides evidence to try and dissolve the distinction between them. He provides evidence to try and dissolve the distinction between psychosis and normality. I'm interested in his account because I'm interested in dimensional vs categorical classification systems. Just because something is a matter of degree (and there may well be funny borderline cases) doesn't mean we don't have clear consensus on the majority of cases, however.

> People with psychosis "aren't just different from us." They suffer from a progressive, chronic, often debilitating disease that often manifests subtly. If these people were so healthy aside from this one "non-symptom," then they wouldn't be in the clinic...the office...the hospital.

Right. So this is the notion that YES hearing voices can be present in people in the absence of other signs of pathology. In the majority of cases these people wouldn't present in the clinic. If people are distressed by those voices then they may well be likely to appear, however. Lets say someone has a hallucination like this:

> My dead husband talks to me regularly commenting on what I'm doing and I have conversations with him in my head.

Hallucination. But also... Delusion? ('My dead husband is alive and is talking to me)? Is this enough to meet 2 first rank symptoms (getting fairly close to a dx of schizophrenia). I am concerned about the notion that people with a dx of schizophrenia have a progressive and chronic disease. Maybe believing it... Is one causal factor in making it so...

> Facial muscle movements are in no way proof that hallucinations are simply people talking to themselves, and are interpreted as hallucinations. Face validity is still a player here.

It goes someway towards supporting the hypothesis. The facial muscle movements seem to be the same as the facial muscle movements (sub-vocalisations) that people have when they are thinking. They made this device that was able to catch the words of the subvocalisations (microphone I think). When they were played back to the patients they were astounded that the content of their hallucinatory voices had been captured.

> Calling every type of pathology that has been copiously described since the classical literature a variation on normal doesn't do the patient justice, in my opinion.

People with Huntington's have a distinctive genetic pattern that I would similarly consider to be a 'variation on normal'. This doesn't undermine the very real suffering of people with Huntington's. This doesn't undermine the fact that we would like to help the people who are suffering.

Part of this is about what in fact is likely to help these people. Telling them (or acting towards them) such that they are given the message they are 'chronic' isn't likely to help them IMHO. Medication may help / provide some relief. Therapy may help / provide some relief. Joining a network where people help them come to accept that hearing voices is okay may also help / provide some relief.

We don't have to be missionaries about Western Psychiatric treatment - do we? There are more than enough patients already, I would have thought...

 

[Anasazi23]

Coincidentally, I've been reading Menninger's "The Human Mind." On page 267, he describes that 200 seniors at the Univ. of Michigan report on questioning that they have "fixed ideas coming involuntarily and unsolicited and remain in spite of efforts to get rid of them."

Menninger appears puzzled by this, as he goes on to state, "...the obsessions of patients are usually a little more elaborate and vivid than those of the ordinary healthy-minded person. Hence they make good illustrations."

He then goes on to describe an obsessive who ruminates on human death after having killed a fly which had been annoying him.

Menninger states, in his "Symptoms" chapter, that "hallucinations, on the other hand, are rare in everyday life. Most individuals have never experienced them, although twenty out of one of my classes of two hundred students claimed to have done so. Usually, however, they indicate rather serious mental ill health."

This latter statement concedes, like we discussed above, that more than expected average people experience these phenomena. However, he implies, and goes on to explain in more detail thereafter, that they are indicitive of a concerning "mental ill health."

This doesn't prove a point either way, of course, but is interesting to note from an observational standpoint. I interpret this comment by Menninger to mean that he can tell the difference between a hallucination, and a 'hallucination.' ...akin to the headache, and the 'headache.' One means nothing, the other means a great many things.

Incidentally, I agree with you in that some patients who chronically experience some sort of symptom...whether they be a delusion of persecution or of reference, for example, or a hallucination, "learning to live" with this type of occurrance, and not allow it to condemn one to hospitals or misery, is helpful and even imperitive.

 

[toby jones]

> "...the obsessions of patients are usually a little more elaborate and vivid than those of the ordinary healthy-minded person. Hence they make good illustrations."

The 'usually' seems to be doing a lot of work.

> "hallucinations, on the other hand, are rare in everyday life. Most individuals have never experienced them, although twenty out of one of my classes of two hundred students claimed to have done so. Usually, however, they indicate rather serious mental ill health."

Again, the 'usually' seems to be doing a lot of work. Does he think that the majority (over 10) of the people in his class had serious mental ill health or does he think that it is unfair to generalise from a student population, I wonder.

> However, he implies, and goes on to explain in more detail thereafter, that they are indicitive of a concerning "mental ill health."

He might well assert this but he seems to have a worrying lack of studies to back up his assertion.

> I interpret this comment by Menninger to mean that he can tell the difference between a hallucination, and a 'hallucination.' ...akin to the headache, and the 'headache.' One means nothing, the other means a great many things.

He seems to be claiming that on the basis of the symptom (hallucination) one can predict that the individual is mentally unwell. Bentall's data would seem to provide evidence against this claim.

I do have concerns with Bentall's studies, however. One concern I have emerges from this part:

> Jim Van Os and his colleagues conducted psychiatric interviews with over 7,000 randomly selected people randomly selected from the general population of Holland. When abnormal experiences secondary to drug-taking or physical illness were excluded, 1.7 were found to have experienced 'true' hallucinations...

Now it would seem to me that psychiatrists do indeed attempt to assess whether hallucinations are due to drug-taking or physical illness. These are EXCLUSION criteria. When hallucinatory experiences with those origins were excluded we have the greatly reduced figure of 1.7% of the sample.

Bentall also said that

> in most countries, fewer than 1% of the general population receive a dx of schizohrenia in their lives...

Now, I don't know very much about statistics but when you present a finding (1.7%) that you want to generalise back to the population (1.7% of people without serious mental illness experience hallucination that is not due to general medical condition or drug intoxication) then don't you need a margin of error?

I think that there are significant problems with the notion of 'margin of error' (something to do with making up data in order to make up a margin of error if my simplistic understanding of a rather technical seminar serves me rightly). Still, I am wondering whether this might be a bit of a problem.