Does Hearing Voices Mean I'm Going Crazy?

“What brings you in?”

This is the question I typically lead with when I’m meeting a new patient. I usually have a prior mental health assessment that I can consult, but that’s rarely in the patient’s own words. I much prefer to hear the story from them to get a sense of how they experience their mental distress and the goals they have (which can differ from those I have in mind). I think of the question as fairly banal, so I was surprised when Sam, a 20-year-old male, began crying.

Source: Geralt/Pixabay

“I think I have schizophrenia,” he told me. I’ve worked with several patients with schizophrenia, and even though the illness has taken a different course with each of them, their negative symptoms are usually one of the first things I notice. Schizophrenia has both "positive" and "negative" symptoms. Positive symptoms are those which most associate with the illness: hallucinations and delusions. They are called positive because they are "added" to the person’s personality. Negative symptoms are everything which takes away from what the person used to be, robbing them of emotional affect, energy, and often even tone of voice. Sam wasn’t exhibiting any such symptoms, so I asked why he thought he was dealing with schizophrenia.

“Because I’ve been hearing these voices and feeling like I’m being watched all the time,” he told me through tears. I had seen Sam’s trauma history, and it was extensive. For most of his childhood, he had been sexually abused by an aunt who lived with them, and violence between his parents was not uncommon. Gently, I told Sam that we didn’t have to talk about all of that today, but those symptoms of being watched or followed, and even sometimes hearing negative voices, could also be explained by post-traumatic stress disorder. I could tell he didn’t really believe me, but he appeared somewhat comforted.

Sam is not alone; most patients I work with who have begun experiencing hallucinations tell me that they fear they’re going crazy. Both research and my own practice have shown that hallucinations are far more common than we used to think, and the mere presence of hallucinations does not merit a diagnosis of psychosis. A 2015 study from Harvard Medical School found that 5 percent of the general population, including those without a serious mental illness, experience hallucinations at some point in their lives. Most of the people I’ve seen who are grieving a loved one have seen them or heard their voice after they have died, and these patients have never experienced psychotic symptoms before and usually don’t again. While they are stigmatized in our culture, hallucinations aren’t viewed the same worldwide and indeed are an important part of some people’s religious or spiritual beliefs.

The neurologist Oliver Sacks catalogued the numerous reasons why people can experience hallucinations in an excellent book, simply titled Hallucinations. Charles Bonnet syndrome can cause the blind and vision-impaired to see things that aren’t there. Lack of sensory stimulation can cause the brain to go wild. Parkinson’s disease, narcolepsy, some forms of dementia, and epilepsy, among others, can cause hallucinations in the absence of any mental health concern.

Because of the profound stigma surrounding hallucinations, there is a lot that we don’t yet know. Science has given us profound advances in the understanding of hallucinations in the past few decades, yet many still feel as if hallucinations are a moral failure rather than random neurological firings of the brain.

According to Oliver Sacks, “Many cultures regard hallucinations, like dreams, as a special, privileged state of consciousness—one that is actively sought through spiritual practices, meditation, drugs, or solitude. But in modern Western culture, hallucinations are more often considered to portend madness or something dire happening to the brain—even though the vast majority of hallucinations have no such dark implications.” Sam’s hallucinations are an expected—albeit sad—result of his earlier experiences, but even if they were not, they would not necessarily signal the onset of a serious mental illness. Hopefully, society at large can catch up to the science to reduce the stigma surrounding those who experience the world differently.