Heard But Not Seen: Tinnitus and Auditory Hallucinations When auditory hallucinations plague a patient, audiologists can be the front line for determining the root of the problem. All Ears on Audiology
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All Ears on Audiology  |   December 01, 2018
Heard But Not Seen: Tinnitus and Auditory Hallucinations
Author Notes
  • Robert M. Traynor, EdD, MBA, CCC-A, is CEO and an audiologist at Audiology Associates of Greeley, Inc. in Greeley, Colorado, and an adjunct professor of audiology at the University of Florida, Gainesville. traynordr@gmail.com
    Robert M. Traynor, EdD, MBA, CCC-A, is CEO and an audiologist at Audiology Associates of Greeley, Inc. in Greeley, Colorado, and an adjunct professor of audiology at the University of Florida, Gainesville. traynordr@gmail.com×
Article Information
Hearing Disorders / All Ears on Audiology
All Ears on Audiology   |   December 01, 2018
Heard But Not Seen: Tinnitus and Auditory Hallucinations
The ASHA Leader, December 2018, Vol. 23, 20-21. doi:10.1044/leader.AEA.23122018.20
The ASHA Leader, December 2018, Vol. 23, 20-21. doi:10.1044/leader.AEA.23122018.20
How do you treat a patient who hears nonexistent sounds or voices? While you may think it’s all in their head, several medical factors can intersect, causing this patient to experience auditory hallucinations.
About 30 million people suffer from tinnitus in the United States (see sources below). Some sources indicate that approximately 70–80 percent of these tinnitus patients can be treated with counseling, hearing aids and/or sound therapy. However, some sources estimate that 7.5–9.3 percent have debilitating tinnitus, and it is within this small percentage that the line between tinnitus and auditory hallucinations (or paracusia) often becomes unclear (see sources).
How are the two conditions different? Tinnitus can be a humming, tonal-type sound of any pitch and, in some cases, more than one pitch (see sources). It may also be a pulsing, clicking or frying (noisy) type of sound. Tinnitus may be subjective (only the person with the tinnitus can hear it) or objective (others can hear it).
Auditory hallucinations differ from objective tinnitus in that the noise is heard only by the person experiencing the event. Subjective tinnitus is usually some form of tonal sensation, but auditory hallucinations are associated with psychiatric, neurologic, otologic and other medical conditions (see sources). Auditory hallucinations are usually associated with psychiatric illness—but some patients without these disorders have reported experiencing auditory hallucinations (see sources).
Further complicating the differentiation between these disorders, some experts believe auditory hallucinations are also experienced by 10–15 percent of people who don’t have tinnitus or mental illness and may be verbal, musical, or related to sleep and other disorders (such as exploding-head syndrome—unreal but frightening noises that are loud and of short duration when falling asleep or waking up). These noises typically are not serious and occur only occasionally (see sources).
Healthy people with hallucinations are often taking prescription drugs, or experiencing sleep deprivation and/or migraines that trigger the illusion of sounds or sights that are not present (see sources). In these cases, the treatment usually involves managing such triggers. But the first step in helping patients experiencing auditory hallucinations is to determine the root cause.

Some experts believe auditory hallucinations are also experienced by 10–15 percent of people who don’t have tinnitus or mental illness.

Typical sources
Pinpointing the cause of the patient’s auditory hallucinations can help identify if they have severe, debilitating tinnitus or if it is related to mental illness or other causes, requiring referral and/or multidisciplinary rehabilitation.
Mental illness is a common factor. Research indicates that up to 75 percent of people admitted to the hospital for schizophrenia reported suffering from hallucinations. The patient may perceive voices coming from both inside or outside of the head. These voices may be positive or negative and may often argue with the person, tell them what to do or just describe what is happening. Auditory hallucinations may also occur with other mental illnesses including bipolar disorder, post-traumatic stress disorder and others.
Tinnitus can also be the root problem. During tinnitus treatment, audiologists may identify patients with auditory hallucinations. Although typical ringing or hissing tinnitus is not usually considered an auditory hallucination, persistent and bothersome tinnitus may increase the risk for auditory hallucinations, especially in people who have depression (see sources).

Pinpointing the cause of the patients’ auditory hallucinations can help identify if it’s severe debilitating tinnitus or related to mental illness or other causes.

Other sources
If you rule out tinnitus or mental illness as the cause of a patient’s auditory hallucinations, asking about certain risky behaviors and using the patient’s medical history as a guide can help the audiologist narrow the origin (see sources):
Alcohol and drug abuse. Heavy alcohol use and/or hallucinogenic drugs such as ecstasy, LSD, mescaline and psilocybin (found in “magic” mushrooms) can trigger hallucinations. Alcohol-related hallucinations tend to be localized in space and have a greater frequency than those related to schizophrenia.
Alzheimer’s disease and other types of dementia. Research shows that 40–50 percent of patients diagnosed with Alzheimer’s disease develop hallucinations in the latter stages of the illness, a finding also supported by neuroimaging studies.
High fevers and infections. High fevers and some infections, such as encephalitis and meningitis, cause auditory hallucinations.
Intense stress. It’s especially common to hear the voice of a loved one after their recent death. Other stressful situations can also trigger episodes.
Migraines. Auditory hallucinations uncommonly co-occur with migraines and usually feature human voices. Their timing and high prevalence in patients with depression may suggest that they are not necessarily a form of migraine aura, though they could be a migraine trait symptom. Auditory hallucinations due to migraines may contribute to phonophobia, sometimes seen in tinnitus patients.
Parkinson’s disease. Patients are more likely to experience visual hallucinations with Parkinson’s, but some of these patients hear things from the scenes they are visualizing, particularly patients who also have cognitive impairment.
Side effects of medicine. Patients may hear things when beginning a new medication or if prescribed a higher dose of medication that they already take. This concern most often affects older adults, as they usually take more medications. The higher the number of medications taken, the greater the possibility of auditory hallucinations due to the medications’ interactions. A number of psychiatric medications, sleeping pills, seizure medications and, in some rare cases, antibiotics may contribute to auditory hallucinations.
Sleep issues. It is normal to hear a sound while falling asleep or waking up, but auditory hallucinations are more likely if patients fall asleep randomly, such as in narcolepsy, or if they have difficulty falling asleep, such as in insomnia.
Thyroid disease. The thyroid gland produces hormones that regulate the body’s metabolic rate, as well as heart and digestive function, muscle control, brain development, mood, and bone maintenance. Myxedema is a rare condition in which the thyroid gland is not generating enough hormone, resulting in dangerously low levels. This life-threatening condition may also produce auditory hallucinations.
If a patient comes to you complaining of auditory hallucinations, taking the time to get to know their medical background and behaviors can help determine the cause and, ultimately, the treatment. Of course, when establishing the cause of auditory hallucinations, the audiological and medical history usually rules out many of these factors. If audiologists are concerned about a patient with auditory hallucinations, they should refer the patient to the primary care provider and possibly to a psychologist for further evaluation.
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December 2018
Volume 23, Issue 12