Hearing Voices: When is it, and when is it not, psychotic?

If a person hears voices, there are three possibilities:

[NOT PSYCHOTIC] No diagnosis or condition. Some people hear a voice at times. If the voice is religious, it is considered normal in that person’s culture. The person knows that other people cannot hear what they hear. Unlike multiple personality, the perceived speaker (if any) is not three-dimensional, is not highly interactive, and is not like a person with their own story. It does not cause distress or dysfunction. 

Psychosis. As in schizophrenia (or any of numerous other psychotic illnesses). Psychosis means an impaired ability to distinguish what is subjective from what is objective. (“Everyone can hear it, or they would, if they had the same computer chip in their brain.”) The main causes and treatments are biological (but psychosocial issues must be addressed, too).

[NOT PSYCHOTIC] Multiple Personality. The voices are the voices of personified psychological beings—they think, therefore they are—with minds of their own. It is not psychotic: Even though it is experienced as very real, the person knows that it is subjective. It is psychological (originating as a way to cope with traumatic experiences in childhood). The alternate identities and their voices are not treatable with medication. It is a diagnosable mental illness only if it causes distress or dysfunction. Otherwise, it is normal, and may be an asset (e.g., to write novels).

Many years ago, when psychiatrists realized that hearing voices did not necessarily mean that a person had schizophrenia (or some other psychosis), Dr. Kurt Schneider proposed that there were certain kinds of voices (and other symptoms) that were seen in psychosis only. These are called “Schneiderian first-rank symptoms.” For example, he said you could be sure that people had psychosis if they heard voices talking among themselves. But he was wrong.

It turns out that this and certain other of his so-called first-rank symptoms are more common in multiple personality than in schizophrenia (Kluft R: First-rank symptoms as a diagnostic clue to multiple personality disorder. Am J Psychiatry 1987;144:293-298.) If someone hears voices conversing, it is less likely to be a person with schizophrenia, and more likely to be a novelist whose characters are talking to each other.