Voices and Pseudo-Voices in Psychosis and OCD: Differential

Diagnosis

Robert Lindsay

One of the symptoms that is nearly pathognomic of schizophrenia is

hearing voices. In particular, the voices are heard with the ears (not
inside your head like the voice or voices we all hear in our heads),
they go quite a bit of the time (for significant periods a day to
continuously), there is often more than one of them, they often
comment on the person's behavior as it is happening, they often
speak about the person in the third person, and they often say bad or
insulting things about the person.
Although voices can be heard in other illnesses, especially Bipolar
Disorder and Major Depression, they often take on a different
quality than we see with schizophrenia.
In Bipolar Disorder, the voices are more fleeting than continuous,
and there is often only one voice.
During Psychotic Mania, the voice may as likely tell the person how
special and great they are than anything else.
Voices in Psychotic Depression generally do not go on all the time,
are limited to a single voice, and tend to focus around themes of guilt,
fatalism, serious illness, death, suicide, homicide, nonexistence and
other morbid topics.
Honestly, there is nothing strange, odd or disordered about hearing
the occasional voice. Many persons will experience hearing a voice or
voices at rare, once in a blue moon intervals in their lives. Clinicians
properly regard this as within the normal realm of human experience.
It only when voices are regular, annoying, distracting, terrifying or
depressing that there is a need to intervene.
People generally do not understand what it means to hear voices.
Many people think that the voice inside your head is a "voice" and
they confuse this with the voices heard in a psychosis. The truth is
that we all have a voice or voices inside of our heads. That is called
our inner voice. Nor is there anything special about having more than
one voice in your head or having two voices arguing with each other
in your head. In fact, it is more common than you think.
I have met many OCD sufferers who complain of "voices," but they
are always confusing their inner voice inside their head with the
auditory hallucinations of psychosis.
There is a ready way to tell the difference.
Hallucinated voices are heard with your ears. If you were to hear an
auditory hallucination right now and you were alone at home, the first
thing you would do would be to start searching around your place for
someone hiding in your residence. You might look behind the couch,
under the bed, in the closet, out the window, etc.
This is because auditory hallucinations sound exactly like the voices of
the humans around you that you have been hearing all of your life.
You hear with them with your ears, not your head. If you could not
find anyone in your place, you might start looking around for the
transmitter or loudspeaker that is somehow piping the human voices
into your abode. You won't be able to find it.
You may tell other people about the voices and enlist their help in
searching for the person hiding in the house. If you are in a vehicle,
you might hear voices coming out of the radio. You might try to take
your radio apart to find the "transmitter" inside of it. You might try to
take part of your home apart, particularly the vents, to find the
"speakers" (voices in residences often come out of heating vents).
I befriended a schizophrenic man once and we become very good
friends. We hung out nearly every day for a year. He was always
trying to enlist my help to take apart the vents in his house. He also
wanted to take apart my car radio to find the transmitter in it.
Periodically, he would look up and say, "You hear that?" That is
because he heard a voice. Of course, I heard nothing and I would say
I heard nothing. He never believed me and he always looked at me
like I was crazy. He heard the voice as clear as a bell and it seemed
ridiculous that I could somehow not hear it. After a while, I got tired
of fighting with him and I started making up excuses, telling him that
he had bad hearing and that was why I cold not hear the voices.
He would be incredulous that I could not hear it. I started saying,
"Well, I believe that you heard something coming out of the radio, but
I didn't hear anything there." I left it an open question whether there
was really a transmitter in the radio or not. This is the best way to
deal with these people because they absolutely will not accept that
you do not hear the voices too and they reject the notion that they
are hallucinating them. Trust me when I say that debating with a
psychotic person about their delusions and hallucinations is a hopeless
endeavor.
Schizophrenics also hear voices in public that are much harder to
figure out. For instance they might walk by a room full of a group of
people and experience an auditory hallucination coming from one of
the persons in the room. The voice will seem exactly as if that person
said it out loud. So this is a voice placed onto the body of an existing
person.
With the schizophrenic, he went with me to my doctors' office once
and as we were walking away, he hallucinated a voice coming from a
man in the waiting room. The voice made it seem as if the man was
accusing him of something. "There he is. He's the one who did it!" It
went something along those lines. It was so hostile that it seemed as
if the man was trying to start a fight with my friend. My friend wanted
very much to go back to the waiting room and have it out with the
man and demand to know why he said those things to my friend. It
took quite a bit of convincing to keep him from going back and
challenging the man.
When the voices start putting false voices into actually existing
people, this illness can get quite bizarre and disturbing as you might
imagine.
In OCD, sometimes the OCD creates an alternate voice in your head
that is a different voice from the voice you are used to or your inner
voice. At times, more than one voice may be created. I have met OCD
sufferers who had all sorts of voices going in their heads all at once.
Some had whole room-fulls or even stadium-fulls. Others had the
sounds of various animals going in their heads. A few have who farms
or menageries of animals vocalizing away inside their heads.
These people are often terrified that they are developing
schizophrenia, but I reject this. Just as OCD can create a new voice in
your head or change your existing one, of course it could create more
than two voices or possibly an unlimited number of voices. It cannot
also create animal sounds and anything else the mind wants to
conjure up. I see no grounds for referring to any of these phenomena
as auditory hallucinations.
With the OCD voices in the head, this is a person who is simply
making up the voices or sounds their own in their heads. Or the OCD
is making them up, whichever way you prefer. So this is someone who
is creating a lot of mental chaos for themselves apparently for the
perverse purpose of tormenting themselves or making themselves
upset. These head voices are much more under voluntary control than
schizophrenic voices and many OCD sufferers can shut them on or off
and on proper medication, they often stop altogether. Or the person
learns that they are doing this to themselves on purpose and decides
to stop torturing themselves.
Unfortunately, many clinicians do not seem to be able to untangle the
voices of one's own inner thoughts and auditory hallucinations. Adding
to this problem is the fact that many OCD sufferers will describe their
OCD thoughts as "voices." In these cases, careful questioning should
reveal that the "voices" are actually inner thoughts and not auditory
hallucinations.
It is uncertain how the notion of "voices in your head" got started.
Schizophrenics are said to hear "voices in their heads." This makes no
sense as we all have voices in our heads, namely our inner voice or
voices.
Apparently since auditory hallucinations are the creation of a person's
mind and do not exist in the environment, it could make sense to
describe auditory hallucinations as voices in your head considering
that the voices are originating in the mind of the hearer and not
externally. However, the very phrase "voices in the head" completely
confuses the situation and I think it is best to drop this psychiatrically
illiterate phrase from the discourse of educated speakers on grounds
that it causes unnecessary confusion.
There may be some cases where the hallucinated voices actually
seem to be originating from inside the skull of the hearer. Imagine
what it sounds like when a person is talking next to you. Now
examine that same experience, yet the voice is emanating directly
from your skull. This would be the only case where "voices in your
head" would be a logical phenomenological description.
OCD sufferers, especially those with the Schizophrenic OCD theme
or what sufferers have called the "Schiz OCD" variant of the illness,
often say that they hear voices.
Caution is needed here. I have heard many OCD sufferers inform me
that they are actually experiencing auditory hallucinations. In these
cases, careful questioning will generally reveal a person who is
scanning the environment in a hypervigilant way and then
misinterpreting ordinary sounds in the environment as possible
"voices."
They also often report hallucinations or quasi-hallucinations during
the hypnagogic period between sleep and wakefulness. Many a bizarre
thing happens to ordinary persons during the hypnagogic state, so it
is best not to make too much of this. The period between sleep and
wakefulness is odd and dream states may spill over into wakefulness,
the mind may start to run wild and thought and dream may become
confused. Once again, these are hypervigilant persons with high
anxiety examining their hypnagogic states for signs of psychosis. It is
a good maxim that when humans go looking for something, they
often find what they are looking for in one way or another.
Once hypnagogic confusion, inner voices and misinterpretations of
environmental sounds are eliminated, the clinician will find that the
OCD sufferer rarely if ever experiences an actual auditory
hallucination.
At times, normals may even think they hear a voice. Last winter, I
pulled into a drug store parking lot at 8 PM. It was dark and raining
fairly hard. The rain was creating quite a bit of environmental racket.
As I opened my car door, a heard a voice off in the rainy parking lot
say my name, "Bob." I looked around a bit, saw no one there, thought
for a bit about what just happened, concluded that I did not have an
auditory hallucination but instead misread some odd environmental
sound in the rainy racket, brushed it aside, and went into the store.
The truth is that even if it was a voice, I would not worry and neither
should anyone else. Hallucinated voices are quite common. 14% of
the population regularly experience them, most are not psychotic and
many are probably quite normal. I have told myself that if I ever start
hearing schizophrenic type voices going all the time, I am going to get
concerned, but in the meantime, I am not going to worry.