Articles
Experiences of hearing voices: analysis of a novel
phenomenological survey
Angela Woods, Nev Jones, Ben Alderson-Day, Felicity Callard, Charles Fernyhough
Summary
Background Auditory hallucinations—or voices—are a common feature of many psychiatric disorders and are also
experienced by individuals with no psychiatric history. Understanding of the variation in subjective experiences of
hallucination is central to psychiatry, yet systematic empirical research on the phenomenology of auditory
hallucinations remains scarce. We aimed to record a detailed and diverse collection of experiences, in the words of the
people who hear voices themselves.
Methods We made a 13 item questionnaire available online for 3 months. To elicit phenomenologically rich data, we
designed a combination of open-ended and closed-ended questions, which drew on service-user perspectives and
approaches from phenomenological psychiatry, psychology, and medical humanities. We invited people aged
16–84 years with experience of voice-hearing to take part via an advertisement circulated through clinical networks,
hearing voices groups, and other mental health forums. We combined qualitative and quantitative methods, and used
inductive thematic analysis to code the data and χ² tests to test additional associations of selected codes.
Findings Between Sept 9 and Nov 29, 2013, 153 participants completed the study. Most participants described hearing
multiple voices (124 [81%] of 153 individuals) with characterful qualities (106 [69%] individuals). Less than half of the
participants reported hearing literally auditory voices—70 (46%) individuals reported either thought-like or mixed
experiences. 101 (66%) participants reported bodily sensations while they heard voices, and these sensations were
significantly associated with experiences of abusive or violent voices (p=0·024). Although fear, anxiety, depression,
and stress were often associated with voices, 48 (31%) participants reported positive emotions and 49 (32%) reported
neutral emotions. Our statistical analysis showed that mixed voices were more likely to have changed over time
(p=0·030), be internally located (p=0·010), and be conversational in nature (p=0·010).
Interpretation This study is, to our knowledge, the largest mixed-methods investigation of auditory hallucination
phenomenology so far. Our survey was completed by a diverse sample of people who hear voices with various
diagnoses and clinical histories. Our findings both overlap with past large-sample investigations of auditory
hallucination and suggest potentially important new findings about the association between acoustic perception and
thought, somatic and multisensorial features of auditory hallucinations, and the link between auditory hallucinations
and characterological entities.
Funding Wellcome Trust.
Copyright © Woods et al. Open Access article distributed under the terms of CC BY.
Introduction
Auditory hallucinations—or voices—are a common feature
of schizophrenia. They also occur in other disorders and in
individuals with no psychiatric history.1 Understanding of
subjective experiences of hallucination—and how they vary
between different populations—is a central concern of
psychiatry, and can help with the development of new
causal accounts of auditory hallucination and more
effective therapeutic interventions.2,3
Although various resources document first-person
experiences of voice-hearing,4 systematic empirical
research on the phenomenology of auditory hallucinations remains scarce. Nayani and David’s 1996 study5
analysed clinical interview data from 100 patients
with psychosis with auditory hallucinations (61% of
100 individuals had ICD-10 schizophrenia diagnoses).
The investigators concluded that auditory hallucinations
www.thelancet.com/psychiatry Vol 2 April 2015
Lancet Psychiatry 2015;
2: 323–31
Published Online
March 11, 2015
http://dx.doi.org/10.1016/
S2215-0366(15)00006-1
This online publication has
been corrected. The corrected
version first appeared at
thelancet.com/psychiatry on
April 2, 2015
See Comment page 285
See Online for a podcast
interview with Angela Woods
and Ben Alderson-Day
Centre for Medical Humanities
and School of Medicine,
Pharmacy and Health
(A Woods PhD), Department
of Psychology
(B Alderson-Day PhD,
Prof C Fernyhough PhD), and
Centre for Medical Humanities
and Department of Geography
(F Callard PhD), Durham
University, Durham, UK;
Department of Anthropology,
Stanford University, Stanford,
CA, USA (N Jones PhD); and
Lived Experience Research
Network, Baltimore, MD, USA
(N Jones)
Correspondence to:
Dr Angela Woods, Centre for
Medical Humanities and School
of Medicine, Pharmacy and
Health, Durham University,
Durham DH1 1SZ, UK
angela.woods@durham.ac.uk
in this population are typically repetitive emotive
utterances that increase in number and complexity over
time. In 2014, McCarthy-Jones and colleagues6 analysed
auditory hallucination descriptions from 199 patients
(81% of individuals had a diagnosis of DSM-III-R
schizophrenia), obtained through the Mental Health
Research Institute (MHRI) Unusual Perceptions Scale.7
Cluster analysis of these findings suggested four
common factors: voices that were repetitive, commanding
or involved running commentary (86%); voices similar to
a person’s own thoughts (36%); voices that were clearly
reminiscent of specific memories (12%); and non-verbal
auditory hallucinations (42%).6
Although such surveys provide insight into the
experience of auditory hallucinations, the focus on
psychosis, particularly schizophrenia, leaves the potential
cross-diagnostic features of auditory hallucinations
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unexplored. Additionally, the semi-structured interviews
and closed-ended approaches often used make several
a priori assumptions about the key features of auditory hallucinations, which prioritise some structural
characteristics (eg, loudness) over others (eg, voice
identity). Clinical terminology is often itself loaded and
might prime or encourage participants to describe their
experiences in particular ways (eg, as auditory or
linguistic). From a phenomenological perspective, these
approaches might constrain understanding of auditory
hallucinations in potentially serious ways.8,9
To address these concerns, and as part of the Hearing the
Voice project and Lived Experience Network, we developed
a questionnaire on voices and voice-like experiences. We
drew on the expertise of philosophers, psychologists,
medical humanities scholars, and researchers with lived
experience of auditory hallucination, in consultation with
clinicians and people who hear voices, from the project’s
advisory group. We aimed to record a detailed and diverse
collection of experiences, in the words of the people who
hear voices themselves.
Methods
Participants
For the project website see
http://www.hearingthevoice.org
We made the questionnaire available via the project
website for 3 months for anonymous online completion.
We invited people aged 16–84 years with experience of
voice-hearing to take part via an advertisement circulated
through clinical networks, hearing voices groups, and
other mental health forums. We asked participants if they
had ever received a psychiatric diagnosis, and if so, to
report their present or most recent diagnosis. Participants
consented to use of their data in the study before accessing
the questionnaire and confirmed this upon completion.
All procedures were approved by Durham University
ethics committee.
Statistical analysis
We analysed the data using a mixture of qualitative and
quantitative methods. First, we integrated responses
into single narratives. We then did an inductive
thematic analysis.12,13 Each member of the research
team initially coded 20 responses. Once collated, we
refined and organised the lists of codes into a coding
framework with inclusion and exclusion criteria noted
for each code. Two independent raters (AW and NJ)
then coded the data using NVivo 10 software. Once high
inter-rater reliability (κ=0·85) was established for
30% of the sample, the raters divided and coded the
remaining data independently. Responses were
analysed as single integrated narratives that could be
assigned each code a maximum of once. Any ambiguous
instances were resolved through discussion and a
consensus-based decision.
The nature of some questions allowed for mutually
exclusive categorical coding of responses (eg, codes for
child, adolescent, and adult onset). However, most of the
codes that we used were not mutually exclusive because
participants often described a range of phenomenological
and structural characteristics.
We used coded data to calculate descriptive statistics for
common features of voice-hearing across the full sample.
We used a mixed-methods priority-sequence model, in
which we used quantitative analyses (χ² tests) to test
additional associations of selected codes that were either
identified in the principal qualitative analyses or suggested
by previous studies.14 We applied a false discovery rate
correction15 to correct for multiple comparisons. We did
not calculate any post-hoc measures of power for the
study, mainly because specific hypothesis testing was not
the focus of the study (as this would contradict key
components of the phenomenological method), but also
because of theoretical concerns about the notion of posthoc power.
Procedures
See Online for appendix
324
Participants completed a 13 item questionnaire that was
available online through Qualtrics (Provo, UT, USA;
appendix). Recognising that no term is neutral or
universally accepted, we chose to use the term voices
because it is widely understood and used in non-clinical
and clinical contexts. Many people who hear voices
regard the term auditory hallucination as stigmatising
because it implies that their experiences are not real.10,11
Furthermore, we did not want to restrict the study by
implying that the phenomena in question are necessarily
always auditory or perceptual. We designed the questions
to be unbiased, non-leading, and non-hierarchising
prompts that aimed to elicit phenomenologically rich
data. The questionnaire combined closed-ended and
open-ended questions (eg, “Please try to describe your
voice(s) and/or voice-like experiences”; “How, if at all, are
these experiences different from your own thoughts?”).
All questions were optional and no word limit was
imposed on responses.
Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication.
Results
157 participants completed the survey, and we excluded
four responses that did not discuss voice-hearing experiences, for a total of 153 responses. Various diagnoses were
reported (table 1), the most common of which were
schizoaffective disorder (24 [16%] of 153 individuals) and
bipolar disorder (21 [14%] individuals). The total length
of the responses ranged from 24 to 2474 words (mean
510 words, SD 432). Table 2 shows demographic details of
the survey population.
Less than half of participants described literally auditory
experiences (ie, voices indistinguishable from voices or
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Female
(n=100)
Male
(n=40)
Other*
(n=13)
Number of
participants
(n=153)
Schizoaffective disorder
14 (9%)
9 (6%)
1 (1%)
Bipolar disorder
16 (10%)
5 (3%)
0
Country
Major depression
11 (7%)
2 (1%)
1 (1%)
UK
48 (31%)
Schizophrenia
5 (3%)
9 (6%)
0
USA
76 (50%)
Post-traumatic stress disorder
9 (6%)
1 (1%)
1 (1%)
Australia
Dissociative identity disorder
7 (5%)
0
4 (3%)
Canada
Borderline personality disorder
5 (3%)
2 (1%)
0
Other
Depression (mixed)
4 (3%)
2 (1%)
1 (1%)
Ethnic origin*
Generalised anxiety disorder
5 (3%)
0
1 (1%)
White
Psychosis (NOS)
2 (1%)
1 (1%)
1 (1%)
Mixed-race
16 (10%)
Obsessive compulsive disorder
1 (1%)
1 (1%)
1 (1%)
Country-defined
13 (8%)
Other diagnosis
3 (2%)
1 (1%)
1 (1%)
Black or ethnic minority
18 (12%)
7 (5%)
1 (1%)
Other
3 (2%)
Not specified
6 (4%)
No diagnosis
Not all patients gave all details, therefore percentages do not always sum to
100%. NOS=not otherwise specified. *Other includes androgyny, genderfluid,
genderqueer, transgender, non-binary, and bigender.
Table 1: Diagnostic information by gender
other sounds), and 14 (9%) individuals reported exclusively
thought-like voices (ie, with no auditory qualities; table 3).
We encouraged description of the differences in the
characteristics of these experiences (panel 1) by using
questions that directly invited participants to compare
voices with their thoughts and actual voices in the room
(appendix). 56 (37%) participants—coded as auditory–
thought mixed—reported either a combination of auditory
and thought-like voices or experiences that were somewhere between literally auditory and thought-like.
Notably, most individuals who described their
experiences as non-literally auditory still referred to
them as voices. About a fifth (30 individuals) of the
sample deemed voice an inadequate term for their
experience, instead using terms such as “intuitive
knowing” or “telepathic experience”, or descriptors
such as “alters”, “parts”, or “fellow system members”.
124 (81%) participants reported the presence of several
voices, with only 10 (7%) individuals reporting a single
voice. Most participants reported having had multiple
voices, with a quarter (39 individuals) reporting undifferentiated or ambiguous collections of voices, such
as crowds, gangs, or classroom groups. Voices with a
physical location were equally likely to be external or
internal.
Most voices were described as being characterful in
some way (table 4)—ie, people or person-like entities with
distinct characteristics, such as gender, age, patterned
emotional responses, or intentions.
“I hear distinct voices. Each voice has their own
personality. They often try to tell me what to do or try to
interject their own thoughts or feelings about a certain
subject or matter […] My voices range in age and
maturity. Many of them have identified themselves and
given themselves names.”
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9 (6%)
7 (5%)
13 (8%)
106 (69%)
9 (6%)
Sexuality*
Heterosexual
89 (58%)
Bisexual
19 (12%)
Homosexual, gay, or lesbian
13 (8%)
Queer or pansexual
10 (7%)
Asexual
Other
Not specified
9 (6%)
2 (1%)
11 (7%)
Religious beliefs*
Christian
45 (29%)
None or atheist
44 (29%)
Spiritual or mixed
9 (6%)
Pagan or pantheistic
8 (5%)
Buddhist
4 (3%)
Jewish
2 (1%)
Other
Not specified
7 (5%)
34 (22%)
How did you hear about the study?
Social media (Twitter, Tumblr, Facebook)
32 (21%)
Hearing the Voice project
27 (18%)
Referred by a friend
24 (16%)
Other (unspecified)
21 (14%)
Mental health forum or blog
18 (12%)
Referred by a mental health professional
11 (7%)
Lived Experience Research Network
10 (7%)
Intervoice
7 (5%)
Newspaper article
6 (4%)
Other hearing voices groups
3 (2%)
Not all patients gave all details, therefore percentages do not always sum to 100%.
*Codes derived from free-text responses.
Table 2: Demographic information
“I hear a mixture of men and women, but no children.
They usually tell me to do things, but not dangerous
things. Like they’ll tell me to take out the garbage or
check the lock on the window or call someone.
Sometimes they comment on what I’m doing and
whether I’m doing a good job or what I could be doing
better.”
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Number of
participants
(n=153)
Number of
participants
(n=153)
Auditory*
67 (44%)
Characteristics
Thought-like*
14 (9%)
Characterful*
Mixed auditory or thought-like*
56 (37%)
Not characterful*
External
69 (45%)
Recognised individual
33 (22%)
Internal
67 (44%)
Supernatural entity
24 (16%)
10 (7%)
Simple address
16 (10%)
No direct address
16 (10%)
Single*
Multiple*
124 (81%)
106 (69%)
22 (14%)
Undifferentiated voices
39 (25%)
Commenting voices
18 (12%)
Voice as inadequate description
30 (20%)
Conversational voices
56 (37%)
Data are n (%).Not all patients gave all details, therefore percentages do not always
sum to 100%. *Mutually exclusive categorical codes.
Table 3: Nature and location of voices
Commanding voices
8 (5%)
Abusive and violent voices
54 (35%)
Positive and helpful voices
46 (30%)
Spiritual purpose
24 (16%)
Emotions
Panel 1: Nature of experiences
Fear
63 (41%)
Positive
48 (31%)
Auditory
“[M]ost of the time I can hear it like it was just someone
standing next to me. It’s a different feeling than when you
think words inside of your head, when you think inside your
head your voice isn’t distinct like it is when you speak out
loud. You think words, not tone. But there is definite distinct
tone and individuality that’s unfamiliar with the voices.”
Neutral
49 (32%)
Thought-like
“I did not hear the voices aurally. They were much more
intimate than that, and inescapable. It’s hard to describe how
I could ‘hear’ a voice that wasn’t auditory; but the words the
voices used and the emotions they contained (hatred and
disgust) were completely clear, distinct, and unmistakable,
maybe even more so than if I had heard them aurally.”
Shame
21 (14%)
Loneliness
16 (10%)
Mixed
“I have all kinds of voice-type experiences […] Some are
voices that are clearly in my head but which feel ‘different’
from my own thoughts. Some are voices that seem to come
from outside but which I know don’t.”
Roughly a fifth (33 [22%] of 153) of participants described voices that were recognised as specific, existing
individuals. 24 (16%) participants described voices that
were understood to be supernatural or spiritual entities.
Common characteristics of address were conversational
voices (engaging the voice-hearer directly) or voices that
commented on specific things. Few people reported only
so-called simple voices—single words or brief phrases—
or voices that did not address them directly. Only 8 (5%)
participants reported voices which predominantly issued
negative commands; overall experiences of abusive or
violent voices were much more common.
Although many voices were described as either positive
or neutral in tone, negative emotions were often
associated with them, especially fear, anxiety, depression,
and stress.
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Anxiety
47 (31%)
Depression
44 (29%)
Anger
32 (21%)
Stress
26 (17%)
Suicidal
26 (17%)
Sadness
21 (14%)
Other kinds of experiences
Bodily effect*
101 (66%)
No bodily effect*
41 (27%)
Tiredness
10 (7%)
Sleep disturbance
20 (13%)
Mania
13 (8%)
Paranoia
23 (15%)
Musical
17 (11%)
Non-verbal
21 (14%)
Other hallucinations
43 (28%)
Multisensory
28 (18%)
Access to other minds
21 (14%)
Access to other information
19 (12%)
Data are n (%). Not all patients gave all details, therefore percentages do not
always sum to 100%. *Mutually exclusive categorical codes.
Table 4: Character, emotion, experiences associated with voices
“Starting when I was about 20 years old, I heard the voices
of demons screaming at me, telling me that I was damned,
that God hated me, and that I was going to hell… The voices
were so frightening and disruptive that much of the time
I was unable to focus or concentrate on anything else.”
“To a point, they generally are anything but kind to me.
They can be brutally sarcastic and intrusive.”
About two-thirds of participants (101 individuals)
reported changes in bodily experience when they heard
voices (table 4), which varied substantially.
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Number of
participants
(n=153)
Voice onset
Auditory voices
(n=67)
Mixed voices
(n=56)
Internal location*
19 (28%)
33 (59%)
External location
34 (51%)
28 (50%)
8 (12%)
12 (21%)
Child*
52 (34%)
Multisensory
Adolescent*
32 (21%)
Conversational*
18 (27%)
31 (55%)
Adult*
29 (19%)
Direct influence
25 (37%)
30 (54%)
Structured longitudinal change*
Circumstances
19 (28%)
29 (52%)
Positive
17 (11%)
Access to other minds*
4 (6%)
13 (23%)
Negative
36 (24%)
Access to information
4 (6%)
11 (20%)
Traumatic
35 (23%)
Bodily effect
40 (60%)
41 (73%)
Substance use
10 (7%)
Change, influence, and anticipation
Structured change to voices
53 (35%)
Change within a voice
19 (12%)
Influence
Can influence directly
69 (45%)
Can influence indirectly
54 (35%)
Cannot influence
34 (22%)
Anticipation
Can generally anticipate
32 (21%)
Can specifically anticipate
35 (23%)
Cannot anticipate
70 (46%)
Continuous voices
22 (14%)
Effect on personal relationships
General negative effect
61 (40%)
Direct negative effect
48 (31%)
Positive effect
14 (9%)
No effect
42 (27%)
Data are n (%).Not all patients gave all details, therefore percentages do not always
sum to 100%. *Mutually exclusive categorical codes.
Table 5: Causes and effects of voices
“My body and brain felt like they were on fire when
I heard the voices; I had constant tingling sensations
throughout my extremities and shock-like sensations
in my solar plexus.”
“Yes, my body felt more distant from me—the whole
experience felt a bit dreamlike (like living a dream),
surreal, other worldly.”
“At the very beginning I experienced a heat and a strong
irritation in the right frontal part of my brain.”
28 (18%) people had multisensory voices, suggesting
that their voices were perceived simultaneously
through more than one sensory modality. 43 (28%)
participants reported distinct hallucinations in other
senses, and some people also described voices that gave
access to other minds, or information that would not
otherwise be available. A few (10–20) participants
reported experiences of tiredness, sleep disturbance,
and mania.
In cases where participants described their first voice
experiences, the experiences often occurred in childhood
(table 5). Many participants reported negative or explicitly
traumatic circumstances, with few voices (17 [11%]
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Data are n (%). Percentages are for participants within a subgroup receiving that
code. Not all patients gave all details, therefore percentages do not always sum to
100%. *Significant associations (all p<0·05, corrected for false discovery rate).
Table 6: Characteristics of voice-hearing associated with type of nature
of voices
of 153 individuals) arising in positive or neutral
circumstances. More than a third (53 of 153 individuals)
of participants described structural transformations in
the number and presence of voices over time, with a few
(19 [12%] individuals) also reporting changes in voice
content, frequency, or valence (emotional reaction
elicited). Only one respondent specifically stated that
their voice had not changed over time. Although 34 (22%)
participants stated that they were unable to influence
their voices, 54 (35%) reported that they could influence
their voices indirectly (through strategies of avoidance,
medication, or environmental change), and 69 (45%)
individuals reported influencing their voices by engaging
directly with them or exploring their meaning. The effect
of the voices on participants’ relationships with others
was largely negative: 48 (31%) participants cited direct
negative effects (eg, voices interrupting conversation or
making it difficult to understand what others were
saying), and 61 participants (40%) referenced a general
negative effect, including experiences of stigma, fear, and
loneliness.
To investigate the distinction between auditory and
mixed auditory and thought-like voices, we compared
numbers of people reporting each type of voice for a
selection of the codes identified during the qualitative
analysis (table 6). Participants with mixed auditory and
thought-like voices were more likely than those with purely
auditory experiences to report voices that were internal
(p=0·010), conversational (p=0·010), had changed over
time (p=0·030), and gave access to other minds (p=0·026).
Mixed voices trended non-significantly towards being
associated with voices that gave access to information that
was otherwise unknown by the participant (p=0·051). No
other contrasts were significant (table 6).
We compared participants with and without characterful
voices (table 7). People who heard characterful voices were
significantly more likely to be able to influence their voices
(p=0·040) and, at the non-significant trend level, were
more likely to experience voices that were abusive or violent
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Characterful
(n=106)
Not characterful
(n=22)
Direct influence*
60 (57%)
6 (27%)
Bodily effect
74 (70%)
15 (68%)
Abusive or violent
41 (39%)
3 (14%)
Fear
48 (45%)
5 (23%)
Anxiety
35 (33%)
6 (27%)
Depression
32 (30%)
5 (23%)
Data are n (%). Percentages are for participants within a subgroup receiving that
code. Not all patients gave all details, therefore percentages do not always sum to
100%. *Significant associations (all p<0·05, corrected for false discovery rate).
Table 7: Characteristics of voice-hearing associated with characterful voices
Bodily effect
(n=101)
No bodily effect
(n=41)
Multisensory
21 (21%)
5 (12%)
Positive or useful
25 (25%)
18 (44%)
Abusive or violent*
43 (43%)
7 (17%)
Traumatic circumstances
28 (28%)
4 (10%)
Fear
47 (47%)
13 (32%)
Anxiety
35 (35%)
8 (20%)
Shame
17 (17%)
1 (2%)
Anticipation*
48 (48%)
9 (22%)
Data are n (%). Percentages are for participants within a subgroup receiving that
code. Not all patients gave all details, therefore percentages do not always sum to
100%. *Significant associations (all p<0·05, corrected for false discovery rate).
Table 8: Characteristics of voice-hearing associated with bodily effect
Clinical
(n=127)
Non-clinical
(n=26)
Auditory
52 (41%)
15 (58%)
Positive and useful voices
34 (27%)
12 (46%)
Abusive and violent voices
49 (39%)
5 (19%)
Fear*
60 (47%)
3 (12%)
Anxiety
41 (32%)
6 (23%)
Depression*
43 (34%)
1 (4%)
Bodily effect
87 (69%)
14 (54%)
Data are n (%). Percentages are for participants within a subgroup receiving that
code. Not all patients gave all details, therefore percentages do not always sum to
100%. *Significant associations (all p<0·05, corrected for false discovery rate).
Table 9: Characteristics of voice-hearing associated with diagnosis
(p=0·051) than were those who heard non-characterful
voices (table 7).
We compared participants who specifically reported
effects on the body with those who did not (table 8).
Participants with bodily experiences were more likely to
report voices that were abusive or violent (p=0·024) and
to be able to anticipate their voices (p=0·025) than were
those with no bodily effect. Reporting of bodily
experiences seemed to be associated with reporting of
traumatic circumstances when participants first heard
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voices, voices that were associated with shame, and few
positive and useful voices (p=0·05–0·06; table 8).
A unique characteristic of our sample was its crossdiagnostic nature, including some participants who
specifically reported that they had never received a
psychiatric diagnosis (26 [17%] of 153 individuals). Based
on previous research with similar populations,16–18 we
compared people who had received a clinical diagnosis
with those who had not (table 9). Participants who had
not been clinically diagnosed were significantly less
likely to associate their voices with fear (p=0·010) or
depression (p=0·015) than were those with a clinical
diagnosis. We detected no differences for any other
categories (table 9).
To help with comparison with previous studies, we also
did an exploratory analysis to compare participants who
reported schizophrenia-related diagnoses (schizophrenia
or schizoaffective disorder, n=38) with all other
participants for a selection of codes associated with the
classic understanding of auditory hallucinations in
schizophrenia as auditory, externally located, and
commanding phenomena. We identified no significant
differences, even if we used an uncorrected p value cutoff
(codes used: auditory, auditory-thought mixed, internal
location, external location, single voice, multiple voices,
and commanding nature).
The sample of respondents included a large proportion
of female participants. To check for the effect of gender,
we did χ² analyses to compare men and women for group
membership in the four subgroups analysed (auditory
voices, characterful voices, bodily effect, and clinical
diagnosis), and in association with all codes analysed (to
avoid type II errors, we did not apply a false discovery rate
correction). We detected no significant associations
between gender and subgroup, and only three codes were
significantly associated: paranoia was more likely in men
(p=0·036), while childhood onset (p=0·001) and
structured longitudinal change (p=0·039) was more likely
in women. However, the relative percentage of women
did noticeably vary between diagnostic groups (appendix).
Discussion
We used an open-ended, internet-based survey to obtain
detailed information about the phenomenology of auditory
hallucination from a diverse array of individuals, including
those without psychiatric diagnoses (panel 2). Several of
our findings are consistent with other large-sample studies
of auditory hallucinations5,6,18,19 and longstanding clinical
observations—ie, the high prevalence of multiple voices,
typically with distinct characteristics; variations in acoustic
properties, linguistic complexity and location; and strong
associations with negative emotion, especially for
individuals with psychiatric diagnoses.5,6,20–22
However, unlike the published scientific literature, our
findings also suggest novel and under-researched aspects
of auditory hallucination phenomenology. Specifically,
we focus on distinctions between thought-like, mixed,
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and strictly auditory voices; voices with somatic effects;
and the experiential complexities of characterful voices.
Although auditory hallucinations are usually understood as predominantly perceptual experiences, nearly
half of our participants described their voices either as
thought-like or as having both auditory and thought-like
qualities. Such mixed voices were significantly more
likely to be conversational, show change over time, and
be experienced as giving access to other minds. So-called
sound talk (mentions of loudness, timbre, pitch,
resonance, accent, and rhythm) was very common
throughout the sample, complicating clear distinctions
between thoughts and perceptions (eg, “My thoughts are
shouting” or “I experience a silent scream […] a presence,
an emotional energy, or potential that I can feel but not
hear”). These findings are similar to historical, cognitive,
and phenomenological research on the qualities of
imagined sound23,24 and raise the question of whether
some voices might be better understood as passive or
uncontrolled imagined perceptions, rather than
perceptual hallucinations. The extent to which the
message of auditory hallucinations can be understood
without being heard is also worthy of further study.
Participants also frequently reported multisensory
voices, concurrent somatic events, and hallucinations in
other sensory modalities. Whether we classify these othersensory or somatic features as adjunctive components of
auditory hallucinations or instead as events distinct from
specifically auditory hallucinations, the implications of
our findings are potentially important to attempts to
understand and assign subtypes to hallucinatory
phenomena. The high prevalence of multisensory voices
and somatic features is also important in view of the
scarce attention to such features in existing clinical
interventions, and could inform further development of
theoretical models that link self-recognition to deficits in
sensory-motor control at the level of body schema.25
Notably, voices with effects on the body were also
significantly more likely be associated with an overall
experience of voices that were abusive or violent, and
voices that could be anticipated in some way. Although we
did not detect a significant association between voices
with somatic aspects and trauma, the strong associations
between abusive voices and childhood adversity,26
especially sexual and physical trauma,27 suggest that this
association might be promising for future study.
Command hallucinations are widely regarded as
distressing and indicative of high risk of harm to self and
others,28 and yet their content, severity, and importance
have tended to be assumed rather than fully investigated.
Command hallucinations were reported by 84% of 100
participants in Nayani and David’s study5 and “constant,
commanding and commenting” auditory hallucinations
were reported by 86% of 199 participants in McCarthyJones and colleagues’ study.6 We coded voices that issued
negative commands or instructions to do harmful things
as commanding, distinct from voices that issued requests
www.thelancet.com/psychiatry Vol 2 April 2015
Panel 2: Research in context
Systematic review
Before constructing the survey, we did a systematic review of
the published literature on hallucinations across diagnostic
(and non-clinical) populations. We initially employed the
search terms “phenomenology” and “hallucinations”—
where possible also limiting the methods employed to
“qualitative”—across the PsycINFO and PubMed databases.
These searches returned 237 and 125 initial articles,
respectively. Each article abstract was then reviewed
individually; of those directly relevant to our project (ie,
moderate to large-sample [n>50] phenomenological studies
of auditory or verbal hallucinations), we searched cited
references to identify any additional relevant articles, in
addition to future articles that used the base article as a
reference. We searched cited references until no additional
articles of relevance could be identified. Although we were
able to identify a sub-set of articles employing structured
or semi-structured measures and comparing the
phenomenology of hallucinations across specific diagnostic
groups (eg, Parkinson’s disease vs schizophrenia), we did not
identify any published studies that simultaneously surveyed
both clinical and non-clinical individuals; included individuals
with any diagnosis (psychiatric, neurological, or medical); and
used open-ended (unstructured) prompts.
Interpretation
We report the findings of what is, to our knowledge, the
largest open-ended survey of the phenomenology of voices
and voice-like events in the published scientific literature.
We departed from other large-sample qualitative studies of
auditory hallucination by targeting a diverse, naturalistic
sample of individuals with and without clinical histories and
with a broad range of (self-reported) diagnoses. Potentially
important new findings concern the association between
acoustic perception and thought, somatic and multisensorial
features of auditory hallucinations, and the link between
auditory hallucinations and characterological entities.
Awareness and further investigation of these characteristics
has substantial implications for experimental and applied
clinical research programmes, especially with respect to further
development of interventions targeting the way voice-hearers
relate to their voices.
or instructions to do things that were benign or helpful.
Thus defined, command hallucinations characterised the
overall experience of voice-hearing for only 8 (5%) of
153 participants. This discrepancy between our study and
other phenomenological surveys could be caused by
differences in populations and settings between studies:
command hallucinations might be the dominant experience for individuals with a schizophrenia diagnosis, or
those who are reporting on their voices in a clinical context
and engaging with health-care services. Alternatively, a
substantial number of people who hear voices who receive
advice or strong suggestions from their voices might have
329
Articles
been mislabelled as experiencing commands that are
presumed to be inherently violent or potentially harmful.
The characterful or person-like nature of voices has been
widely documented,4,10 is directly addressed by existing
psychological interventions for voices,29 and was one of the
most common aspects of voice-hearing reported in our
analysis. However, little investigation has been done on the
different ways that voices might be experienced as
personified. The descriptions in our data suggest a range
of person-like qualities, from amorphous entitativity (an
undefined disembodied personality), to stereotypical
person-like presentations (an angry man, an old woman),
spiritual entities with anthropomorphic traits, specifically
recognisable individuals, and voices that are subjectively
experienced as representing all or part of the person’s own
self. Characterful voices were also distinguishable from
other voices in their susceptibility to influence by the voicehearer: more characterful voices could be directly engaged
with in a meaningful way. These findings raise important
conceptual, philosophical, and clinical questions for future
research, including how the characterological features of
voices are shaped by individuals’ explanatory beliefs and
local cultures.30 The heterogeneity of characterful voices
also underscores the importance of existing relational
interventions29,31 to address variability in the types of voices
and their person-like qualities.
One limitation of the present study was the coding of
characteristics derived from free-text written responses;
some participants might have had particular experiences
(such as command hallucinations), but not independently
volunteered this information in our questionnaire. Our
results might therefore underestimate the prevalence of
features we coded for. Conversely, characteristics that are
routinely discussed in clinical settings (such as voice
location) might have been over-represented compared with
less studied aspects of auditory hallucination experience.
Ultimately, phenomenological investigation provides “no
means to check the ‘truth’ of the responses recorded”, as
noted by Nayani and David,5 and the departure from
psychometrically validated measures limits the extent to
which comparisons can be drawn between this study and
other studies of auditory hallucination phenomenology.
However, adoption of an exploratory, rather than
prescriptive, approach to what counts as a voice or voicelike experience yields new insights into what people who
hear voices themselves regard as most important. These
insights are potentially of great importance to existing
research frameworks that depend on assumptions that our
data call into question, such as a focus on auditory
hallucination as a primarily perceptual event.
Second, the online questionnaire was accessible only to
English-speakers with basic internet literacy and access.
Although the online platform might be thought to limit
participation, results from research have shown that people
with severe mental illness have rates of smartphone access
and usage similar to the general public.32 We mainly
recruited to the study through existing research, clinical,
330
and service-user networks. High-functioning users of
social media who are already engaged in such networks or
communities might be over-represented, while individuals
who are currently in acute care settings are almost certainly
under-represented. Moreover, although the capacity to
participate anonymously might have encouraged frank
responses from some participants, we were unable to verify
participants’ self-reports. Because these self-reports include
self-reported diagnoses, we have restricted ourselves to
clinical versus non-clinical diagnoses and schizophreniaspectrum versus other comparisons, rather than more
specific distinctions between clinical diagnoses. In-depth
comparison of voice phenomenology in different diagnostic
contexts—including dissociative identity disorder and posttraumatic stress disorder—is a crucial topic for future
studies of this kind.
Third, our overall sample shows substantial bias in terms
of gender and ethnicity, limiting the representativeness and
generalisability of our findings. 2·5 times as many women
as men completed the study, which might be indicative of
wider trends in survey response rates33 and hallucination
proneness,34 and the cross-diagnostic nature of our sample.
Although people from black and minority ethnic origins
are up to nine times more likely than people from other
ethnic origins to present with symptoms of psychosis,35
they were under-represented in our study. When we
analysed gender effects in our data, we detected differences
for only three codes: paranoia (which was more likely in
men), childhood onset, and structured longitudinal change
(which were both more likely in women than in men).
These results might be caused by differences worthy of
future attention, but their exploratory nature makes these
findings tentative at best.
Despite these limitations, our methods allowed us to
reach a demographically and diagnostically diverse sample,
which included participants with little or no current contact
with mental health services. The use of more prescriptive
clinical tools, or confining of our sample to clinical settings,
would possibly have limited the range of experiences
reported. If full understanding of the phenomenology of
auditory hallucination is important, across diagnoses and
between clinical and non-clinical populations,2,21 then such
methods are a necessary starting point.
By engaging a sample of people who hear voices with
varying diagnoses and clinical histories, we report both
overlap with past qualitative investigations of auditory
hallucination and potentially important new findings
that depart from previous studies of the phenomenology
of voices. These findings underscore the importance of
future investigations of the association between acoustic
perception and thought, the somatic and multisensorial
features of auditory hallucination, and the link between
auditory hallucination and characterological entities.
Contributors
AW, NJ, and CF conceived the study. All authors contributed to the
study design. AW and NJ coded, analysed, and interpreted the data, in
liaison with other authors. BA-D did the statistical analyses and
produced the tables. AW drafted the initial manuscript, with extensive
www.thelancet.com/psychiatry Vol 2 April 2015
Articles
contributions from NJ and BA-D. All authors contributed to editing and
finalising the report.
Declaration of interests
We declare no competing interests.
Acknowledgments
This study was funded by a Wellcome Trust Strategic Award
(WT098455MA). We thank Matthew Ratcliffe for contributing to the
conceptualisation and design of the study, and Sam Wilkinson and
David Smailes for contributing to the preliminary data analysis.
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