Hearing voices, time traveling, and being hit with a high-heeled shoe

Mr. P confesses that he denied hallucinations on admission because he feared he would remain in the hospital for years if he revealed the truth that he had been experiencing auditory hallucinations almost continuously from age 10. He reports that the voices distracted him when he worked; seem to be male; often spoke gibberish; and alternate between deprecating and positive and supportive. Mr. P is reluctant to disclose more about what the voices actually say, although he acknowledges that they are not commenting or conversing with him, and that he has never believed the voices were his own thoughts but did believe that they came from inside his brain.

With haloperidol, the voices stopped. They resumed, however, when haloperidol was discontinued.

When we ask what happened to him at age 10, Mr. P shrugs.

The author’s observations

In community samples of children and adolescents, auditory hallucinations are not rare and usually do not cause distress or dysfunction. In a study of 3,870 children age 7 and 8,¹ 9% endorsed auditory hallucinations. Most heard 1 voice, once a week or less, at low volume. In 85% of children who experienced hallucinations, they caused minimal or no suffering; 97% reported minimal or no interference with daily functioning. Among children who experienced auditory hallucinations at age 7 or 8, 24% continued to hallucinate 5 years later.² Persistent hallucinations were associated with more problematic behaviors at baseline and follow up.

In a group of 12-year-old twins, 4.2% reported auditory hallucinations.³ In that study, hallucinations were not related to Cannabis use; rather, they were heritable and related to risk factors such as cognitive impairment; behavioral, emotional, and educational problems at age 5; and a history of physical abuse and self-harm at age 12. The authors noted that these are risk factors and correlates of schizophrenia, but are not specific to schizophrenia.

Hallucinations and delusions have been found in 4% to 8% of children and adolescents referred for psychiatric treatment,⁴ far more than the prevalence of childhood-onset schizophrenia (0.01% of children).⁵ Psychotic symptoms in children have been associated with bipolar disorder, but also with anxiety disorders, obsessive-compulsive disorder, PTSD, pervasive developmental disorder, conduct disorder, and substance abuse.⁴

Childhood-onset schizophrenia is rare and would require that Mr. P have a diagnosis of schizophrenia as an adult. It is possible that Mr. P’s childhood symptoms were related to substance abuse but he was not asked for this history because it seemed unlikely in a 10-year-old boy. A PTSD diagnosis requires a traumatic event, which Mr. P did not reveal. It is possible that at age 10 he did not have a psychiatric disorder.

Among adults in the general population, 10% to 15% report auditory hallucinations.⁶ Hallucinations could be caused by substance abuse or psychiatric conditions other than schizophrenia; however, in adults—as in children—auditory hallucinations can occur in the absence of these conditions (Table 1) and rarely cause distress or dysfunction.⁶ In Sommer and colleagues’⁶ study of 103 healthy persons, none who heard voices had disorganization or negative symptoms. Those who heard voices had significantly more schizotypal symptoms and more childhood trauma, including emotional, physical, and sexual abuse, than those who did not hear voices.⁶

Conditions associated with hallucinations

PTSD is associated with auditory hallucinations and other psychotic symptoms.⁷ Most studies are of combat veterans with PTSD, in whom auditory hallucinations and delusions were associated with major depressive disorder, not a thought disorder or inappropriate affect.⁸ In a community sample,⁹ psychotic symptoms—particularly auditory hallucinations—were associated with PTSD. Subjects with PTSD and psychotic symptoms were more likely to have other psychiatric disorders, including major depressive disorder and substance use disorder, than patients with PTSD but no psychotic symptoms; however, the relationship between PTSD and psychosis remained after controlling for other psychiatric disorders.

Hallucinations can occur in persons with dissociative disorders in the absence of distinct personality states.¹⁰ Hallucinations have been seen transiently and chronically in persons with borderline personality disorder and can be associated with comorbid conditions such as substance abuse disorders, mood disorders, and PTSD.¹¹

Mr. P lacked the reduced capacity for interpersonal relationships required for a schizotypal personality disorder diagnosis. A diagnosis of PTSD or dissociative disorder requires a history of trauma, which Mr. P did not report.