“PLEASE CONSULT a NEUROLOGIST, and/or a PSYCHIATRIST“
Auditory Verbal Hallucinations (AVH) are experiences of hearing voices or speech without an external sound source. The voices are perceived as real and distinct from one’s own internal thoughts.
They might be more common than many people assume and occur across multiple clinical and non-clinical populations.
What They Typically Involve
AVH can vary widely in form:
- A single voice or multiple voices
- Male, female, familiar, or unfamiliar voices
- Speaking in second person (“You are worthless”)
- Third person commentary (“He is failing”)
- Command voices (“Do this”)
- Conversational voices arguing or discussing the person
The key distinction is that the voice is experienced as external or not self-generated, even though no one is speaking.
Conditions Commonly Associated With AVH
AVH are most classically linked to:
- Schizophrenia
- Schizoaffective disorder
- Bipolar disorder (with psychotic features)
- Major depressive disorder (with psychotic features)
However, they are also found in:
- Trauma-related disorders (especially complex trauma)
- Dissociative disorders
- Severe stress or sleep deprivation
- Neurological conditions, CONSULT A NEUROLOGIST, PLEASE
- Substance use or withdrawal
Importantly, some people experience voices without meeting criteria for a psychiatric disorder.
How AVH Differ From Normal Inner Speech
| Inner Speech | Auditory Verbal Hallucination |
|---|---|
| Recognized as your own thoughts | Experienced as not self-generated |
| Under voluntary control | Often intrusive and uncontrollable |
| Occurs “inside” your mind | Often perceived as external or spatially located |
CONSULT A NEUROLOGIST, PLEASE
Neurocognitively, one leading model suggests AVH may involve misattributed inner speech, where self-generated verbal thought is experienced as coming from outside the self.
Neurobiological Findings
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Research shows involvement of:
- Auditory cortex activation (as if real sound is present)
- Language production areas
- Reduced connectivity between speech production and self-monitoring systems
In other words, the brain may be producing speech internally but failing to label it as self-generated.
Trauma and Dissociation Connection
In trauma populations, voices often:
- Reflect internalized abusers
- Represent dissociated self-states
- Contain shame-based or protective content
From a structural dissociation perspective, some voices may function as parts of the personality, rather than psychotic phenomena per se.
Clinical Questions That Matter
- Frequency and duration
- Emotional tone (hostile, neutral, supportive)
- Command content (especially harmful commands)
- Level of distress
- Insight (does the person question the reality of the voice?)
- Functional impairment
Distress and loss of control are often more clinically significant than the mere presence of voices.
Treatment Approaches
Depending on etiology:
- medication: CONSULT A PSYCHIATRIST
- Trauma-focused therapy
- Cognitive Behavioral Therapy for Psychosis (CBTp)
- Voice dialogue approaches
- Grounding and self-monitoring training
Increasingly, treatment focuses not on “eliminating” voices, but on changing the person’s relationship to them.
Shervan K Shahhian
LIBERTY PSYCHOLOGICAL ASSOCIATION 