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.

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).

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 χ 2 tests to test additional associations of selected codes.

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.

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.

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 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.

Although various resources document first-person experiences of voice-hearing,systematic empirical research on the phenomenology of auditory hallucinations remains scarce. Nayani and David's 1996 studyanalysed 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 in this population are typically repetitive emotive utterances that increase in number and complexity over time. In 2014, McCarthy-Jones and colleaguesanalysed 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.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%).

A new phenomenological survey of auditory hallucinations: evidence for subtypes and implications for theory and practice.

The development and reliability of the Mental Health Research Institute Unusual Perceptions Schedule (MUPS): an instrument to record auditory hallucinatory experience.

A new phenomenological survey of auditory hallucinations: evidence for subtypes and implications for theory and practice.

Auditory hallucinations—or voices—are a common feature of schizophrenia. They also occur in other disorders and in individuals with no psychiatric history.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.

Better than mermaids and stray dogs? Subtyping auditory verbal hallucinations and its implications for research and practice.

Report on the Inaugural Meeting of the International Consortium on Hallucination Research: a clinical and research update and 16 consensus-set goals for future research.

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.

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 (χtests) to test additional associations of selected codes that were either identified in the principal qualitative analyses or suggested by previous studies.We applied a false discovery rate correctionto 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 post-hoc power.

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 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.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.

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.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.

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.

Results

Table 1 Diagnostic information by gender Female (n=100) Male (n=40) Other * * Other includes androgyny, genderfluid, genderqueer, transgender, non-binary, and bigender. (n=13) Schizoaffective disorder 14 (9%) 9 (6%) 1 (1%) Bipolar disorder 16 (10%) 5 (3%) 0 Major depression 11 (7%) 2 (1%) 1 (1%) Schizophrenia 5 (3%) 9 (6%) 0 Post-traumatic stress disorder 9 (6%) 1 (1%) 1 (1%) Dissociative identity disorder 7 (5%) 0 4 (3%) Borderline personality disorder 5 (3%) 2 (1%) 1 (1%) Depression (mixed) 4 (3%) 2 (1%) 1 (1%) Generalised anxiety disorder 5 (3%) 0 1 (1%) Psychosis (NOS) 2 (1%) 1 (1%) 1 (1%) Obsessive compulsive disorder 1 (1%) 1 (1%) 1 (1%) Other diagnosis 3 (2%) 1 (1%) 1 (1%) No diagnosis 18 (12%) 7 (5%) 1 (1%) Not all patients gave all details, therefore percentages do not always sum to 100%. NOS=not otherwise specified. Table 2 Demographic information Number of participants (n=153) Country UK 48 (31%) USA 76 (50%) Australia 9 (6%) Canada 7 (5%) Other 13 (8%) Ethnic origin * * Codes derived from free-text responses. White 106 (69%) Mixed-race 16 (10%) Country-defined 13 (8%) Black or ethnic minority 9 (6%) Other 3 (2%) Not specified 6 (4%) Sexuality * * Codes derived from free-text responses. Heterosexual 89 (58%) Bisexual 19 (12%) Homosexual, gay, or lesbian 13 (8%) Queer or pansexual 10 (7%) Asexual 9 (6%) Other 2 (1%) Not specified 11 (7%) Religious beliefs * * Codes derived from free-text responses. 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 7 (5%) Not specified 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%. 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.

Table 3 Nature and location of voices Number of participants (n=153) Auditory * * Mutually exclusive categorical codes. 67 (44%) Thought-like * * Mutually exclusive categorical codes. 14 (9%) Mixed auditory or thought-like * * Mutually exclusive categorical codes. 56 (37%) External 69 (45%) Internal 67 (44%) Single * * Mutually exclusive categorical codes. 10 (7%) Multiple * * Mutually exclusive categorical codes. 124 (81%) Undifferentiated voices 39 (25%) Voice as inadequate description 30 (20%) Data are n (%). Not all patients gave all details, therefore percentages do not always sum to 100%. Panel 1 Nature of experiences 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.” 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.” 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.” Less than half of participants described literally auditory experiences (ie, voices indistinguishable from voices or 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.

Table 4 Character, emotion, experiences associated with voices Number of participants (n=153) Characteristics Characterful * * Mutually exclusive categorical codes. 106 (69%) Not characterful * * Mutually exclusive categorical codes. 22 (14%) Recognised individual 33 (22%) Supernatural entity 24 (16%) Simple address 16 (10%) No direct address 16 (10%) Commenting voices 18 (12%) Conversational voices 56 (37%) Commanding voices 8 (5%) Abusive and violent voices 54 (35%) Positive and helpful voices 46 (30%) Spiritual purpose 24 (16%) Emotions Fear 63 (41%) Positive 48 (31%) Neutral 49 (32%) Anxiety 47 (31%) Depression 44 (29%) Anger 32 (21%) Stress 26 (17%) Suicidal 26 (17%) Sadness 21 (14%) Shame 21 (14%) Loneliness 16 (10%) Other kinds of experiences Bodily effect * * Mutually exclusive categorical codes. 101 (66%) No bodily effect * * Mutually exclusive categorical codes. 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%. 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.”

“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.”

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.

“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.

“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.

Table 5 Causes and effects of voices Number of participants (n=153) Voice onset Child * * Mutually exclusive categorical codes. 52 (34%) Adolescent * * Mutually exclusive categorical codes. 32 (21%) Adult * * Mutually exclusive categorical codes. 29 (19%) Circumstances Positive 17 (11%) Negative 36 (24%) Traumatic 35 (23%) 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%. 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%] 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.

Table 6 Characteristics of voice-hearing associated with type of nature of voices Auditory voices (n=67) Mixed voices (n=56) Internal location * * Significant associations (all p<0·05, corrected for false discovery rate). 19 (28%) 33 (59%) External location 34 (51%) 28 (50%) Multisensory 8 (12%) 12 (21%) Conversational * * Significant associations (all p<0·05, corrected for false discovery rate). 18 (27%) 31 (55%) Direct influence 25 (37%) 30 (54%) Structured longitudinal change * * Significant associations (all p<0·05, corrected for false discovery rate). 19 (28%) 29 (52%) Access to other minds * * Significant associations (all p<0·05, corrected for false discovery rate). 4 (6%) 13 (23%) Access to information 4 (6%) 11 (20%) Bodily effect 40 (60%) 41 (73%) 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%. 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 ).

Table 7 Characteristics of voice-hearing associated with characterful voices Characterful (n=106) Not characterful (n=22) Direct influence * * Significant associations (all p<0·05, corrected for false discovery rate). 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%. 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 (p=0·051) than were those who heard non-characterful voices ( table 7 ).

Table 8 Characteristics of voice-hearing associated with bodily effect Bodily effect (n=101) No bodily effect (n=41) Multisensory 21 (21%) 5 (12%) Positive or useful 25 (25%) 18 (44%) Abusive or violent * * Significant associations (all p<0·05, corrected for false discovery rate). 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 * * Significant associations (all p<0·05, corrected for false discovery rate). 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%. 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 voices, voices that were associated with shame, and few positive and useful voices (p=0·05–0·06; table 8 ).

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et al. The same or different? A phenomenological comparison of auditory verbal hallucinations in healthy and psychotic individuals. Table 9 Characteristics of voice-hearing associated with diagnosis 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 * * Significant associations (all p<0·05, corrected for false discovery rate). 60 (47%) 3 (12%) Anxiety 41 (32%) 6 (23%) Depression * * Significant associations (all p<0·05, corrected for false discovery rate). 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%. A unique characteristic of our sample was its cross-diagnostic 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,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).