Auditory Hallucinations

Auditory Hallucinations

This article relates to Under This Red Rock

Neely, the main character in Mindy McGinnis's Under This Red Rock, experiences auditory hallucinations (AHs). Since an early age, Neely has heard people clapping for her, children laughing and playing, and the voice of a young girl asking for water. She's developed techniques for managing her symptoms, but she still suffers emotionally and socially because of these voices, and she's afraid of getting help after seeing her father's hallucinations worsen with treatment. Many people today suffer from either temporary or long-term AHs, and pharmaceutical and psychological treatments have been developed to help manage or eliminate these aberrant sounds.

The National Institutes of Health defines AHs as "the sensory perceptions of hearing noises without an external stimulus." It's estimated that 5-28% of Americans have experienced AHs, with many cases being temporary and harmless. Up to 70% of individuals experience AHs when falling asleep or waking up at some point in their lives; these instances are considered normal. However, some cases are indicative of a more serious underlying mental health or neurological condition, such as schizophrenia, post-traumatic stress disorder, bipolar disorder, anxiety, major depression, narcolepsy, brain tumors, or Parkinson's disease. Other health conditions including sleep deprivation, extreme hunger, migraines, and some infections have been associated with AHs, as have drug and alcohol use.

AHs vary between cases, and the specifics of the hallucinations are unique to each individual. Some experience verbal hallucinations, in which they hear voices, while others hear music, nature sounds, or non-specific background noises. AHs occur with varying degrees of frequency and volume, and might present as a single voice or multiple noises coming from multiple sources. Individuals who hear voices may hear people talking directly to them, or they may hear unseen people talking to one another, and the topics of conversation may be insignificant or highly personal.

Despite extensive research, the mechanism of AHs remains unknown. Imaging studies of individuals with schizophrenia who experience AHs have shown abnormal inhibitory responses within the auditory pathways of the brain, leading to spontaneous activation of the sensory neurons within the ear; the brain consequently processes a sound without any external source. Additional research using imaging has shown that the primary auditory cortex—the part of the brain that processes sound—is activated when AHs are occurring. There is also some evidence suggesting that abnormal levels of neurotransmitters such as dopamine, acetylcholine, or serotonin may lead to the occurrence of AHs. Altered levels of these chemicals either due to illness or drug use have been associated with both visual and auditory hallucinations and can be alleviated by drugs that stabilize neurotransmitter levels.

The treatment for AHs depends on the cause, and a detailed medical history along with a psychological evaluation, brain imaging, blood tests, and toxicological testing may be used to direct treatment. AHs caused by transitory conditions such as sleep deprivation, hunger, or migraines will end when the inciting condition is resolved. Cases resulting from chronic conditions are typically treated with medication, therapy, or a combination of the two. Individuals with severe depression or mania may be treated with psychotropic drugs such as antidepressants or mood stabilizers, while individuals with schizophrenia are often treated with neuroleptics (antipsychotics). Neuroleptics block dopamine receptors, and the effectiveness of this treatment lends credence to the hypothesis that AHs are linked to abnormal levels of neurotransmitters.

Psychotherapy is also often used in conjunction with medication. Cognitive behavioral therapy (CBT) is the most common form of psychotherapy for individuals experiencing AHs; CBT aims to help individuals modify their experience of AHs using reality testing, or asking questions to determine whether the voices or sounds are real. Additional psychotherapy techniques that have been shown to help individuals with AHs include acceptance and commitment therapy, which involves acknowledging and accepting AHs to reduce their impact on thoughts and feelings in the moment, using distraction techniques to help quiet the voices, or taking control by standing up to the voices or ignoring them altogether. Regardless of the treatment, support from family and friends has been found to be important for positive outcomes.

Neely's experiences in Under This Red Rock show the impact that auditory hallucinations and untreated mental illness can have on an individual's relationships as well as their social and occupational functioning. Although research is still needed to determine exactly how AHs occur, there exists a range of both pharmaceutical and behavioral treatment options to help people cope with them.

Filed under Medicine, Science and Tech

This "beyond the book article" relates to Under This Red Rock. It originally ran in April 2024 and has been updated for the October 2025 paperback edition. Go to magazine.