Hearing Voices: PTSD and Auditory Hallucinations

One of the greatest benefits of being affiliated with a major university is the opportunities that often arise to engage in interdisciplinary collaboration.  I was invited, by Composer and researcher Jonathan Berger, to present at the seventh annual Music and Brain Symposium, which was held earlier this month at Stanford University.  Jonathan is the Denning Family Provostial Professor in Music at Stanford, and is co-director of the Stanford Institute for Creativity and the Arts (SICA) and The Center for Computer Research in Music and Acoustics (CCRMA).

This year’s symposium was titled, “Hearing Voices,” and brought together an interdisciplinary panel (from the fields of music, psychology, anthropology, medical humanities and psychiatry) of researchers, scholars, and writers to examine the phenomena of auditory hallucinations.



Listening to the presentations of my co-panelists I was offered a rich array of diverse perspectives on auditory hallucinations and a unique opportunity to view this subject matter through the lens of colleagues who all come at this phenomenon from different angles: Diana Deutsch (University of California, San Diego), presented on Phantom Words, Musical Hallucinations and the Speech to Song Illusion; Chris Chafe (Stanford University), presented on The Acoustics of Imaginary Sound; Angela Woods (Durham University), spoke on the Taxonomies of Voice-Hearing; Judith Ford (University of California, San Francisco), spoke on The Phenomenology of Auditory Verbal Hallucinations and how internal experiences can sound external; Daniel B. Smith (The College of New Rochelle), gave an account of How Hallucination Got Its Name and Tanya Luhrmann (Stanford University) presented on her research regarding auditory hallucinations that involve hearing God.

My own presentation was preceded by a talk from Pulitzer Prize-winning combat journalist Paul Watson, as he spoke of his own lived experience of hearing the haunting voice of an American soldier whose corpse he photographed in the streets of Mogadishu in 1993. Paul’s heart wrenching story offered a personal view on the topic I was talking about: PTSD and Auditory Hallucinations, a controversial issue in my own field of psychiatry.

( For links to these presenters and video of the actual presentations please go to this link: http://www.ustream.tv/channel/music-and-brain-symposium)

Hallucinations and Combat Veterans with PTSD

Among combat veterans with PTSD, 30-40% report auditory hallucinations (AH). AH are more frequent in combat veterans with chronic PTSD and it has been suggested that this may reflect a distinct subtype of PTSD that may be under recognized for two reasons: first, patients are reluctant to report AH and, second, more emphasis has, traditionally, been placed on the intrusive images associated with PTSD and less on intrusive auditory hallucinations.

It is important to recognize that such patients do not have the overt changes in affect or bizarre delusions characteristic of other psychoses e.g. schizophrenia.  AH in PTSD appears to be seen more in veterans with higher combat exposure and more intense PTSD symptoms and who report more severe symptoms of hyperarousal. The AH are typically: ego-dystonic; contribute to an increases sense of isolation and shame; associated with feelings of lack of controllability; consist of combat-related themes and guilt; non bizarre; not associated with thought disorders and, overall, more refractory to treatment interventions.

Some researchers have pushed to establish the validity of PTSD with secondary psychotic features (PTSD-SP) as a separate diagnostic entity arguing that the Delineation of PTSD-SP from PTSD is notable and there are some biological studies that support the validity as a separate diagnostic entity.  Still, there is currently not enough evidence to support a separate diagnostic entity.

Part of the controversy, in the field of PTSD, is to do with how we explain the presence of AH in PTSD.  Recently, (and I tend to favor this theory over others) it has been suggested that hearing voices in PTSD may be better conceived of as a dissociative rather than a psychotic phenomenon and that dissociation is significantly related to AH and may indeed be a potential mediating mechanism for AH in PTSD.

The daylong event ended with “Visitations,” an evening-length program featuring two chamber opera commissions from Jonathan Berger, and librettist Dan O’Brien,  In keeping with the theme of the symposium, both operas, The War Reporter and Theotokia, present the stories of two men, each haunted by inner voices. The War Reporter depicts the true story of Pulitzer Prize-winning combat journalist Paul Watson, as he seeks to rid himself of the haunting voice of an American soldier whose corpse he photographed in the streets of Mogadishu in 1993.


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8 Responses to Hearing Voices: PTSD and Auditory Hallucinations

  1. Grace says:

    Dissociation is “locked in” for a child of repeated and traumatic abuse usually by age 9. The dissociation is a mechanism of the mind to protect the child from abuse memories. But the amnesia keeping the memories hidden loses its sustainability later in life. Voices are heard internally at least when amnesia begins to leak, if not earlier. It seems that for soldiers whose only trauma is war related, it would be auditory hallucinations…hearing words spoken during the traumatic incidents(s). Such memories are not trapped in amnesia as with someone who is dissociative. Perhaps a distinction needs to be made there.

  2. Shaili Jain, MD says:

    Thanks for the comment….to clarify, I view flashbacks assoc with PTSD as a dissociative phenomenon and a better explanation for the voices reported in PTSD.

  3. As a person with PTSD from severe childhood abuse, and as a composer, I understand what you are trying to do. I teach very advanced students in composition and take apprentices in music composition. See: http://www.bunitamarcus.com/teaching.html
    My primary focus is to develop what the young composer is hearing in their mind. So I am very interested in this subject. A lot of the time what one is hearing comes from the subconscious and can even be material the composer is unaware of. For example, I wrote a string quartet thinking of my father. It took me to some very strange and frightening places. Five years later I began to remember my father raping me. This work, The Rugmaker, is about the destruction of innocence, and remarkably, I wrote the whole thing without any memory of the abuse that clearly was the source. This has fascinated musicologists (see: http://www.newmusicbox.org/articles/Hearing-and-Remembering-Trauma-in-Bunita-Marcuss-The-Rugmaker/ which is part of an article on me: http://www.newmusicbox.org/articles/who-is-bunita-marcus/ ).
    I would make one suggestion though. Recent research has shown that 5 cups of coffee can cause auditory hallucinations. I would definitely take this into consideration since most people with PTSD do seem to drink a lot of coffee. (http://www.huffingtonpost.com/2011/06/09/high-coffee-intake-hallucinations_n_873861.html). I worked with composer Morton Feldman for 11 years and he wrote the most hallucinatory music imaginable. He also drank at least ten cups of coffee a day. Best of Luck, Bunita Marcus, Ph.D.

    • Shaili Jain, MD says:

      Thanks for sharing your moving story.
      And yes, we routinely inquire re : caffeine consumption and if high, as it so often is, recommend gradual reduction of intake to normal quantities, for many reasons not least the negative impact of excess caffeine on sleep quality

  4. Chris King says:

    Dr. Jain,
    Has anyone isolated those combatants who experienced loud auditory shock? Could there be a correlation between auditory hallucinations and hearing damage? And has anyone done an experiment with controlled audio frequencies to discover if they trigger hallucinations, or relieve them if the audio can create a wave canceling effect?
    Chris King

    • Shaili Jain, MD says:

      Thanks for your comments.i don’t know of any such studies but, yes, you raise a fascinating question.

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