What immediately comes to mind when you think of schizophrenia? Most people would say hallucinations. Hallucinations, at least according to pop culture, are the defining feature of schizophrenia. But is that true?

Today’s episode discusses how many people living with schizophrenia hallucinate and if hallucinations are all the same. Do people in different countries or from different backgrounds hallucinate differently? Join us to learn the answers to these questions and more!

Paul Fitzgerald, PhD

Paul Fitzgerald, PhD completed his medical degree at Monash University and subsequently a Master of Psychological Medicine whilst completing psychiatric training. He then undertook a Clinical and Research Fellowship at the University of Toronto and The Clarke Institute of Psychiatry, Toronto, Ontario, Canada. On returning to Melbourne, he worked as a psychiatrist and completed a PhD in transcranial magnetic stimulation in schizophrenia. Since completing this PhD, he has developed a substantial research program including a team of over 25 psychiatrists, registrars, postdoctoral researchers, research assistants, research nurses, and students.

Professor Fitzgerald runs a research program across both MAPrc and Epworth Clinic using brain stimulation and neuroimaging techniques including transcranial magnetic stimulation, functional and structural MRI, EEG, and near infrared spectroscopy. The primary focus of this program is on the development of new brain stimulation-based treatments for psychiatric disorders. Visit him online at www.paulbfitzgerald.com.

Rachel Star Withers

Rachel Star Withers creates videos documenting her schizophrenia, ways to manage and let others like her know they are not alone and can still live an amazing life. She has written Lil Broken Star: Understanding Schizophrenia for Kids and a tool for schizophrenics, To See in the Dark: Hallucination and Delusion Journal. Fun Fact: She has wrestled alligators.

To learn more about Rachel, please visit her website, RachelStarLive.com.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To learn more about Gabe, please visit his website, gabehoward.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Rachel Star Withers: We want to give a quick trigger warning. We will be discussing descriptive content of hallucinations in schizophrenia in this episode.

Announcer: You’re listening to Inside Schizophrenia. Hosted by Rachel Star Withers, an advocate who lives openly with Schizophrenia. We’re talking to experts about all aspects of life with this condition. Welcome to the show!

Rachel Star Withers: Welcome to Inside Schizophrenia, a Healthline media podcast, I’m your host, Rachel Star Withers, here, as always, with my wonderful co-host Gabe Howard. One of the most common symptoms of schizophrenia that everybody knows is hallucinations. In movies, you always see the person with schizophrenia, hearing voices, seeing people that aren’t there, you know, being commanded to do things like kill and fight and hurt, and it’s like terrifying. It’s also the most exciting part of schizophrenia.

Gabe Howard: It’s fascinating that you say exciting part, it’s like this is the exciting part. Hearing and seeing things that aren’t there. It’s also terrifying to many people who live with schizophrenia, but it is utterly fascinating.

Rachel Star Withers: And as far as the general population, it is like the one thing they know about schizophrenia, any type of movie where you have a schizophrenic, they’re going to be having some sort of hearing voices or flat out seeing full on people who aren’t there. It’s crazy because that is the part of society that is obsessed with our disorder is that we have hallucinations.

Gabe Howard: And it is the one thing that they get correct. I’m not saying that the way that they envision hallucinations is correct, but the majority of people with schizophrenia do hallucinate.

Rachel Star Withers: Roughly 70 percent of people with schizophrenia experience hallucinations. Now what’s interesting is of the general population, 10 to 15 percent of people will experience hallucinations at some point in their life, whether it is through grief of losing a loved one through sensory deprivation, lack of sleep and then throughout history, people have taken drugs specifically to induce hallucinations.

Gabe Howard: One of the things I want to touch on before we get into the facts of hallucinations are people envision hallucinations as being terrifying. They’re always bad. Somebody is trying to harm you, harm somebody that you love.

Rachel Star Withers: Well, I want to stop you right there. Hold on, I want to stop you right there because

Gabe Howard: Ok.

Rachel Star Withers: That is the assumption when hallucinations are connect with schizophrenia. That is not what people think of hallucinations in general. You know, there’s people throughout history who have taken drugs just to get hallucinations, to bring them closer to God, to get messages, to feel certain ways go through things. It’s just hallucinations with schizophrenia that are considered bad, horrible, evil even and the type you need to be afraid of. So that brings us to what sets hallucinations as a symptom of schizophrenia apart from other hallucinations. Do all schizophrenics have them? What types do we all have? The same hallucinations or different? And what causes hallucinations? We have an amazing guest today, Dr Paul Fitzgerald, who is a professor and he’s also a researcher in how the brain functions, and he’s going to be coming on later in the show to help us understand some of the inner workings of the brain.

Gabe Howard: I found Dr. Fitzgerald to be very illuminating now, anybody experiencing a hallucination is going to think, I don’t need to listen to this, I already experience it and I would have felt that way too if there was a doctor talking about mania. I’d be like, I don’t need to listen to this. I live with mania. So the very fact that you found this so incredibly interesting when you live with hallucinations and you manage them and know so much about them and still got something out of it tells me that 90 percent of our listeners need to listen to this. You looked really engaged and really shocked at the process. And I was I was a little bit surprised by that, and I just want to get that out of the way real quick just real early in the show.

Rachel Star Withers: Yeah, I can be a nerd sometimes, and that kind of stuff is actually really interesting. He brought up so many things that I’d never considered, and I just flat out didn’t know which is crazy when you think how much research I’ve done over the years into schizophrenia. And then there are still people who can just like, drop all this knowledge on me, and I’m like, Wait, what? That’s incredible.

Gabe Howard: Rachel, what is an hallucination?

Rachel Star Withers: The easiest definition, it is a false perception. You are experiencing something, but there is no external stimulus that’s causing it. Now there is a difference between a hallucination and a disturbance. A disturbance is, you know, if you rub your eyes and you kind of see little spots, ringing in your ears, that kind of all falls under a disturbance.

Gabe Howard: Now, a hallucination, and please correct me if I’m wrong, is it hearing or seeing something that is in fact not there?

Rachel Star Withers: And it can go even further than that. It could be smelling, it could be feeling it could be feeling things inside of you that aren’t really there. It’s just any kind of perception that you might have now. And I know that’s kind of hard to understand. But it’s funny because so much of my life when people would ask me if I had audio hallucinations, I would tell them no, because to me, an audio hallucination was hearing voices. It was like what you saw on TV. You had a voice talking to you, and I was like, Oh God, that never happens to me. What does happen to me since I was a kid was this constant ticking and like a radio was playing in the other room, and it never occurred to me that that was a hallucination also. And then now, as I’m 36 looking across my life, I’m like, Oh my goodness, I have audio hallucinations constantly throughout the day. It just wasn’t a big, booming voice like I saw on TV or in movies screaming at me to do things.

Gabe Howard: Once again, pop culture has really let us down.

Rachel Star Withers: It has. There are two types of hallucinations you have simple elementary hallucinations or complex and simple ones can be pretty basic lights, colors, geometric shapes as far as audio, simple hallucinations, hissing, whistling, odd tones that aren’t there. When it comes to complex hallucinations. Those are your full on figures, your people hearing voices that are speaking to you in sentences, hearing music. Those are usually tied to some sort of feeling. Unfortunately, with schizophrenia, it tends to be aggressive. A simple visual hallucination, I might just kind of see some waves or shapes or characters, but I don’t really. I’m not scared of them. They’re just like, Well, that’s kind of trippy. A complex hallucination is I see the monster and I am scared right away. I feel internal fear. Even though the monster may not be doing anything, it’s more tied to emotions that I’m experiencing. I don’t know, that’s why it is the next level. With complex hallucinations is that’s when it’s usually you’re experiencing it through multiple senses. You might hear and see it. You might see and feel it. That’s where it gets a little, I don’t want to say scary, but it is scary.

Gabe Howard: Now, when you say it’s scary, Rachel, again, putting this back on you, you hallucinate often. So are you always scared?

Rachel Star Withers: I usually kind of guesstimate that I hallucinate 90 percent of the time. Most of it is, I would say, those simple hallucinations just kind of things being off things, not making sense objects moving around, people’s faces changing. And those really don’t bother me. I would say I definitely have no emotional attachment to them. It’s just kind of like, Oh, that’s weird, and I keep rolling. As far as the complex hallucinations, I would say at least once a day to a few a week. And thankfully, I’ve learned a lot of coping mechanisms, and I’m not scared of most of them. However, new ones that just kind of pop up. Yes. If it’s one I’ve never experienced before, it always kind of puts me on edge. It can be like just unnerving because I wasn’t expecting it, but I’ve learned what we talked about in our wonderful cognitive behavioral therapy episode. Learning ways to see your hallucinations in a different light and that’s been something I’ve been focusing on the past five years, is getting used to my hallucinations and taking the fear out.

Gabe Howard: People hear, oh, well, if you’re having hallucinations, you’re not getting care. You’re not getting good care. You’re not in recovery. Is it fair to say that perhaps it removing all hallucinations is not always practical for people living with schizophrenia? Because you use the use the magic word, you’ve learned coping skills to manage them. For some reason, many people hearing this think that zero symptoms is the goal versus symptom management, which is a much more reasonable goal for schizophrenia.

Rachel Star Withers: I’ve been treated for schizophrenia since my very early 20s. I’ve been on so many different medications and luckily found a lot of different therapy, some that works, some that hasn’t worked. A big portion of people with schizophrenia do get labeled as treatment resistant schizophrenia, meaning that medication doesn’t work as well as it should on us. It doesn’t mean it won’t work, but it has a harder time working on certain people, and I think that’s just something you have to think about. I fall under this category and they’re kind of finding out. More and more people with schizophrenia tend to fall under this category, where it’s not as simple as taking antipsychotic and everything’s fine. Start a therapy program and you bounce back. Everything’s fine. It’s the reality for a very large portion of the schizophrenic population that hallucinations are not going anywhere, and you’re going to have to. If you want to have an amazing life or even a not horrible life, you’re going to have to find a way to deal with them and accept them. But if you’re listening out there, I don’t want you to get like, sad. I’m like, Oh, that’s really depressing. And no, OK. I do hope like, hey, if there is a pill that works for you, amazing. I found some over the course of my life that worked great, and then they stopped working. And that’s kind of been my constant battle is I’ll find something that works and it does amazing for a few months. And then they upped the dosage up the dosages that I’m at the max and they have to pull me off.

Gabe Howard: I know that it can be hard to publicly say, Hey, I’m in recovery with schizophrenia, but I’m still managing my hallucinations because again, too many people, especially people learning about schizophrenia, they believe that if you have hallucinations, you’re in trouble. And if you don’t have hallucinations, you’re cured. And there just doesn’t seem to be a lot of talk about the spectrum, the middle of the road, the managing the symptoms, et cetera. And I just I want to introduce that to the conversation because if anybody is listening and they are reducing, they’re hallucinations, they’re managing them. Yeah, you’re well on your way. And you may already be in recovery and able to lead as Rachel Star Withers always says, a badass life. But you’re sort of believing this external factor that any hallucinations means you’re not well, and we just sort of want to add a little nuance to that conversation.

Rachel Star Withers: Now, Gabe, this blew my mind, I learned this actually a few years ago, but wouldn’t you expect if you had someone with schizophrenia who grew up in America? Let’s use me, for example, I’m a woman in my mid-30s, grown up in the southern part of America. And then let’s say we have somebody from a completely different country. Ok, and let’s say it’s a male in China who is in his 50s. Just life experiences are probably completely different, correct?

Gabe Howard: Yeah, yeah. Culturally, we all have differences.

Rachel Star Withers: Yeah. Wouldn’t you just assume that because he’s lived a completely different life than me, that his hallucinations would be different than mine?

Gabe Howard: It would stand to reason.

Rachel Star Withers: And that’s actually not the case across the board, people with schizophrenia tend to have a lot of the same trends in their hallucinations. That’s just crazy to me. And it’s also so reassuring because so much of the time, people with serious mental disorders like us, Gabe, we feel alone.

Gabe Howard: We do.

Rachel Star Withers: And then you find out that, wait a minute, there’s all these people who experience these exact same thing as I do. So I want to talk about some of these characteristics of schizophrenia hallucinations, because as I was reading through them, I was like, Oh my gosh, all of these fit me and I’m reading articles, you know, from India, from all these different countries, and yet I connect with all of these. To my people with schizophrenia out there, I hope like, you’re geeking out like I did.

Gabe Howard: [Laughter]

Rachel Star Withers: And just like, Oh my goodness, there’s so many people exactly like me. First of all, the frequency of hallucination. So it does vary, but they can be anywhere from seconds to minutes. Now they can go on for like extended periods of time. But most people are schizophrenic. They tend to have. I don’t want to say flashes, but they’ll have one for a little bit. It’ll ease off and then it comes back. Usually, individuals who have schizophrenia, we can’t change the hallucinations. We can’t make it go away. We can’t tell them to stop. And that’s definitely been true of me. I’ve never had any control over mine. They’re just either there or they aren’t there.

Gabe Howard: That is a concept that comes up constantly, are hallucinations triggered? Yes, no.

Rachel Star Withers: I would say the answer is it depends on the person, if you’re going through a stressful time in your life. Yes, that can trigger a lot of your psychotic symptoms, but it doesn’t have to be. You could just be normal getting off work and you had a great day and then suddenly you realize you’ve started to hallucinate. It’s going to depend on you and your situation. There are some physical properties when we see the hallucinations that are also the same, they tend to be life sized, which I never thought about gay. But yeah, I’ve never had a hallucination of like a little mini person or like a giant, like, I’ve never hallucinated like a giant foot. They tend to be life size and relative to you. Most hallucinations are three dimensional, and they can have depth and shadows. They can be colorful or black and white. I’ve never had a black and white hallucination. I don’t think I feel like I’ve had all black ones, shadow people and things, but I don’t feel like I’ve had a black and white one. And then hallucinations. They can be static or they can’t have movement. Now something very interesting when it comes to having hallucinations in schizophrenia, your hallucinations are usually coming from the outside. So meaning if I’m hearing a voice, the voice is coming from outside, I might be hearing it to the left of me, to the right of me inside of a wall in another room. However, with dissociative disorders, another type of mental disorder, usually you hear those voices inside your head. They say it comes from the back of your head, more of like an internal voice, but you might not have control over that voice. That’s something very interesting. I thought, when you see people with schizophrenia and movies and stuff, I think it comes off as they’re hearing it in their head, usually like a booming voice as opposed to another room. Now, if you have schizophrenia and a dissociative disorder, you’re probably going to be hearing everything, every which way. As I’ve had some dissociative episodes and I’m like, Oh yeah, that that’s yeah, hearing it from all over the place.

Gabe Howard: But it does sound like you’re saying that one size does not fit, all right.

Rachel Star Withers: You’re correct.

Gabe Howard: Everybody hears voices differently, although there’s some trends or some commonalities. The important thing is don’t say, Oh, I’m not hallucinating, because Rachel said that it would sound like this. It could very much sound different to you.

Rachel Star Withers: Mm-hmm. I think it’s important to point that out, though, because one of my warning signs that I’m about to go into a full psychotic episode is I start thinking in third person and I start kind of losing the ability to control those thoughts. And that is, like, I would say, a dissociation kind of situation going on there. That’s one of my flags that, OK, I need to get home and I need to get safe because probably within the next five hours, I’m going to be having some full on complex hallucinations going. So I do think it’s good if you’re having hallucinations to kind of like, realize these little trends that they can kind of help you see when you might be getting worse or even better as far as the voices go. You can hear male or female voices, but most people tend to hear male voices, and many times the voices will not match the person who’s hearing them. Accent, that’s so weird to me. Like, you would hear different accents from different regions, even different social classes. Unfortunately, my voice is it’s always like a radio being left on in the other room. So I’ve never like been able to tell details about them. It’s more just like people talking, and I can’t tell you that all males, all female. It’s just like a voices talking in another room. But I did think that was interesting. Like, you would hear different accents gave. Like, I don’t know, I would have like a British person like voice that sounds cool to me.

Gabe Howard: It is weird because I would have thought that you would hear it almost in your own voice. Maybe a slight change, but in general, if you would have asked me before we did the research, I would have been like, Well, aren’t you essentially hearing either your own voice or the voice of a loved one, or maybe a character on a movie or television? I would. I would have just thought it would have been recognizable. But it turns out that it’s in many cases, not all. It’s entirely different. All right, Rachel, I have another question. I realize that it’s not the same for everybody, but in general, what are the content of these hallucinations as pop culture shows you? It’s always the, you know, monsters and murderous clowns. But in reality, typically, what are the content of these hallucinations, both visual and auditory?

Rachel Star Withers: A very strong theme with schizophrenia is religious stuff. Actually, God is seen. Thirty three percent of the time, but God angels, the devil saints and even fairies are actually pretty common when it comes to schizophrenia. From my own experiences that we’ve talked about here with the church and everything, I’m in a very religious area. I kind of always assumed that’s why mine were religious focused. But it is interesting to me that people who might not be in a religious area would also have these sort of hallucinations. Hallucinations and schizophrenia tend to be more frightening than hallucinations due to other things, for instance, due to Parkinson’s, Huntington’s all different other disorders that might cause them. A very common hallucination, visual one, is shadow people. And that’s one of my main ones I’ve had ever since I was a kid were these kind of shadow people that are hard to like, describe. They’re just kind of in the dark humanoid type creatures that’s very common with schizophrenia and also bipolar disorder, kind of these shadowy figures that just hang out many times on the edge of your peripheral vision.

Rachel Star Withers: Fifty five percent of audio hallucinations. So hearing voices tend to be malicious and content usually kind of hollering at the person making them feel bad. One of those common tactile hallucinations. So like we pointed out earlier, it’s not just audio and visual. There’s actually tactile feeling things that aren’t there. And this is kind of the trigger warning that I wanted to stress earlier. A very common sensation with schizophrenia is feeling that your skin is being stretched out across your face and your body, even to the point of like hurting and not feeling like your skin is your own. This is one that I’ve had a lot and it’s very, very jarring, and I’d never thought about it until doing the research, and that came up as the most common tactile hallucination. I’m like, Oh, I have that like, and that was just weird to me because I’d never thought of that honestly, as a hallucination and the fact that it was a common one, it kind of made me feel better because it’s just something I’d brought up to the dermatologist before.

Rachel Star Withers: And they told me it was just, Oh, your skin gets really dry, OK? But yeah, like, that’s a little comforting to know I’m not the only one feeling that. Another common tactile hallucination is that people schizophrenia, they feel things crawling on them or inside of them. Sometimes they feel like their body isn’t theirs, or pieces of their body isn’t theirs. They’ll think that they have an organ that they need to get out, or there’s something inside of them that they need to get out and they can feel it. You know, everyone else in the world might be saying, Look, you’re crazy, you’re clawing at your skin, trying to remove something that’s not there. But we having schizophrenia might actually feel this thing, and that is very, very scary and alarming situation to be in. Now, Gabe, I do have a question. So we know schizophrenia, lots of hallucinating. What about bipolar? Because some people do hallucinate with bipolar.

Gabe Howard: So me personally, I have bipolar disorder with psychotic features, so I have experienced psychosis, but I haven’t experienced hallucinations like, you know, I don’t see things that aren’t there or hear things that aren’t there. I’ve experienced what are referred to as delusions. Let’s use an under the bed analogy. Somebody experiencing visual hallucinations would see the person under the bed, somebody experiencing an auditory hallucinations that would hear the person under the bed. Somebody experiencing a delusion would know the person is under the bed, but they wouldn’t see them there or hear them there. It’s a bit of a weird sensation just to know something. I sort of liken it to you ever been walking along and you know there’s somebody behind you. You don’t see them, you don’t hear them, you just feel this presence and this is this generally makes people look to their left or right or behind them to figure out where the person is before you have turned around to make sure there is somebody behind you and you know it, you know it. That’s what a delusion would be.

Rachel Star Withers: And you can get a perfect storm when you have hallucinations and delusions at the same time. So not only are you paranoid that you feel, think that there’s something under your bed. You might also see it and hear it under your bed and hear it scratching in the walls. There is one hallucination that tends to be only experienced in schizophrenia, and those are command hallucinations. And it could be you’re hearing it from outside your head or even inside, but their commands to do things. So not necessarily like a voice that’s just talking all the time, but this voice just tells you to do things. This is a very kind of scary one that has popped up in a lot of movies. It’s popped up also in real life where people have done crimes and whatnot, and they’ll be like, Well, someone’s telling me. Sometimes they’re telling the truth. Sometimes they’re also just trying to get out of a crime. But command hallucinations can be very scary. They can be as simple as stand up, shut the door, you know, like things that that honestly don’t matter, to telling the person to hurt themselves, to doing things that can cause harm.

Rachel Star Withers: I’ve had a few of these and they have always terrified me. The one that I had that most shook me up was at the time I was working at a gym, did a lot of cleaning and it told me to drink the bleach. And it was just like someone telling me, Do this and it was almost like this. I was like thinking I wanted to do what it said. And I remember it freaked me out so bad that I called my little brother and he kind of talked me down, but that that was how jarring it was to me because I knew it was bad. But suddenly it told me to do it, and I had this very strong desire to do what it said without questioning it. So, yeah, it kind of threw me. I’ve had one other one that really scared me, and it was again about hurting myself. And luckily, both the times that stand out to me, it was so jarring that I immediately called or got a hold of someone because I was that scared. When it comes to schizophrenia, that’s going to be one of my top ones of hard to deal with hallucinations. Coping mechanisms, reaching out to someone, have helped me with them. But definitely I say the scariest.

Gabe Howard: From your description, it sounds terrifying. Now part of the treatment for hallucinations is learning to recognize hallucinations. But learning those coping skills and recognizing hallucinations, that’s not something that just automatically appears one day. You’ve worked hard for that.

Rachel Star Withers: Yes, I wish I could say that I walked into a doctor’s office and told them my hallucinations in that first day, they were like, Oh, OK, don’t worry, lots of people have these. My experience and why it took me so long in the beginning to get diagnosed is I had the opposite. I first went to a Christian counselor who was like, What? No one has these. You’re full of demons. Which was not reassuring. And then even going to a couple normal doctors having them, one of them right away was like, Oh wow, this is way over my head. You need to see a specialist. Which was, I would say, good advice on their part for knowing that this wasn’t an area they should treat, but very bad on their part of the way they reacted. They reacted like I was about to bomb the building. It was just like, you need to get out of here. I don’t know what you have. Like, I genuinely felt I scared them, which did not help me because I was undiagnosed at the time, trying to get help. And I still, you know, even to this day, had issues with certain doctors, them just not knowing what to do with me because they weren’t used to people coming in with schizophrenia and they weren’t used to people with serious mental disorders being as open as I am. Because I talk about schizophrenia so much. I’m like, I’m coming into the doctors. I’m like, All right, let’s break it down. Here’s all the stuff I’ve been dealing with, you know? And they’re like, Whoa, OK, usually takes months for me to dig this out of someone, and you brought a list and I’m like, Yep, chop chop paying for this hour. Let’s roll.

Gabe Howard: I know that you’re joking with the chop chop paying by the hour, let’s go, but it did speed up the process and that that is one of the reasons that we do this podcast because we want to help people get there faster. To learn about hallucinations or become unafraid of them or get verbiage to talk about them.

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Gabe Howard: And we’re back discussing hallucinations and schizophrenia.

Rachel Star Withers: So let’s talk, what in the world causes these hallucinations, right? Like we know for other things, if I’m a normal person and I want to experience God, I might take some drugs, right? I might take some drugs. And you’re like, Rachel, what causes it? You know? Well, the drugs for one. Also, things that cause hallucinations. Sleep deprivation. We know what causes those. But what about schizophrenia hallucinations? What do you think, Gabe? What causes the hallucinations in schizophrenia?

Gabe Howard: I honestly have no idea and sincerely, I’m not sure that anybody does.

Rachel Star Withers: Correct. I don’t think anyone does, either. There’s so many different theories, so there is no clear cut answer. Science is evolving with mental disorders, and when it comes to the brain, there is still so little we know. Some of the more interesting theories on what causes schizophrenia hallucinations, brain deficits, meaning we’re either we’re missing something in our brain. Parts of our brain are smaller. We have reduced function. On the opposite side of that coin, other theories are heightened brain activity. We have too much going on in our brains. We have overdeveloped areas, some sort of alternate connectivity where we’re going in overdrive. That’s what creates the hallucinations. Our brain is bored, so it just starts making fun stuff. I like that because we have two opposites. I’m going to go with the second one of those two, Gabe. I’d much rather be I have a superpower brain than a deficit brain. I like the second, but like I said, they don’t even know. Brain hyperactivity does come up quite a bit with schizophrenia, where it’s been tied to other things like OCD, attention deficit disorder, even manic episodes. All have been kind of tied to maybe schizophrenia being that overactive brain.

Rachel Star Withers: As I mentioned earlier, I have been on many antipsychotics throughout my life. And they do tend to work for a few months and many times when that’s happened, my brain is went quiet and that is terrifying because I’m so used to hallucinating constantly and my brain racing that those times when I’ve been on an antipsychotic and it worked, the stillness, the quietness, it scared me. Not enough that I stopped taking the medication, but I did. I felt like something was missing. And I remember once crying because I was so scared of the quietness. Hallucinations are seen as something you don’t want. But when you’re so used to them, it can be, yeah, kind of like, where did they go? Like, I’m missing a part of me. It has a happy and sad thing.

Gabe Howard: Especially in our cases, Rachel, because we were diagnosed into our 20s. We felt this way our whole life. And then somebody came along and said, Look, your feelings are hurting you. That’s how it was pushed to me. It’s like your feelings, your thoughts, they’re hurting you. They’re not helping you. And that’s true. They were hurting me and I didn’t want to feel this way. But it was a bitter pill to swallow, to be told that my entire brain process was working wrong for literally my entire life. When mania went away, there was a part of my life that was gone forever. Overall, that is a good thing. It is a good thing. But there’s still a part of my life, something that was unique to me that I had experienced since birth that was just missing one day. And yeah, I don’t think it’s unreasonable to miss that. And people describe this all the time, in other things. To use an analogy, there are many relationships that just were not going to work out. We could not live with that person anymore. We could not marry that person. They were not the one. And so we break up with them and then we say to somebody, You know, I really miss hanging out with ex when we used to watch Survivor together and then somebody throws in your face, well, why’d you break up?

Gabe Howard: Well, because you can’t sustain an entire relationship on a few good points, right? Nobody is all or none. Even when a relationship breaks up, it’s OK to mourn the things that you liked. I think that’s very, very reasonable. And it always kind of makes me sad when I hear people being told, well, it was for your own good. We needed to get rid of it because it was hurting you. Look, I agree it is for your own good and it was hurting you. But, but really? You can’t have some compassion? Like a big chunk of somebody’s life just went away and you’re just dismissing it like it’s nothing. I mean, could you imagine if we had that in physical health? Hey, we’re going to go ahead and chop off your leg because it’s filled with cancer. Oh my God, I’m worried about that. Oh my God, it’s filled with cancer and you care that it’s being cut off? You, big baby. It’s for your own good. That would just be a horrible thing to say to somebody.

Rachel Star Withers: With these different theories, comes the actual brain. So, brain stimulation. We’ve talked in the past, I’ve had electroconvulsive therapy, that’s literally where they take electricity and shock your brain, which has been seen to help with depression and schizophrenia. Another way of stimulating the brain is transcranial magnetic stimulation, and this is kind of one of the new frontiers that they’ve been studying because it’s a much safer way of stimulating the brain than just shocking it with electricity all over the place. What’s really interesting is that they’ve been using this trying to find what areas of the brain do different things. We have an incredible guest, Dr. Paul Fitzgerald, a researcher into brain stimulation.

Gabe Howard: Rachel, I’m excited for our listeners to experience this. Let’s go ahead and play that interview.

Rachel Star Withers: Joining us today is Dr. Paul Fitzgerald, who is a psychiatrist, a professor and a researcher. Thank you so much for being with us today, sir.

Prof. Paul Fitzgerald: You’re most welcome, Rachel.

Rachel Star Withers: And you’re coming from across the globe, where are you located at?

Prof. Paul Fitzgerald: In Melbourne, in Australia.

Rachel Star Withers: Thank you so much for joining us from so far away. The first thing I want to jump into is as far as when we were choosing a guest for this show, I wanted someone who actually studied kind of the mechanics of the brain. So right away, I want to ask you what part of the brain does schizophrenia usually affect?

Prof. Paul Fitzgerald: Unfortunately, the answer to that question is a little bit complex, Rachel.

Rachel Star Withers: Mm-hmm.

Prof. Paul Fitzgerald: Pretty much everything we think about when we think about brain functions and how they go wrong now has shifted over the last sort of 10 or 20 years from thinking about individual brain regions being responsible for a particular function and also individual brain regions being responsible for a, I suppose, a dysfunction or something going wrong. If we’re thinking now about memory or our ability to do a mathematical task or really whatever it might be, we tend to think about the brain working in sort of connected networks that there’s multiple areas working closely together underpinning any particular cognitive function. And we also think about those networks as going wrong when something happens in the brain, such as schizophrenia, that ultimately results in symptoms. And that sort of matches really what we’ve known for a long time about the areas of the brain that are implicated in schizophrenia, that there are seemingly multiple and there’s never been necessarily a perfect way to sort of tie those together. But understanding that these different areas around the brain have different roles in these networks, I think makes the most sense of what we know. So, for example, we know that the frontal areas of the brain. so the so-called prefrontal cortex seems to be involved in some of the symptoms of schizophrenia that involve people having troubles with their motivation, their capacity to be driven and to engage in things as much as they would like to, the ability to experience pleasure in day to day life. But those areas of the brain may not be so directly involved in some of the psychotic symptoms, the abnormal beliefs and so forth. Other than potentially those areas of the brain failing to regulate other areas of the brain that are involved in those symptoms. So, what we’re talking about ultimately is a complex sort of interaction between these different brain regions in a condition like schizophrenia.

Rachel Star Withers: Research wise, have they found an area of the brain that may be responsible for hallucinations or, let’s say, lights up when someone is experiencing, you know, hallucinations or a psychotic episode?

Prof. Paul Fitzgerald: We know more about hallucinations than we do about other psychotic symptoms. And they’ve really been two, or perhaps three with variations, competing theories about the neuroscience that underpins hallucinations. And the perhaps most simplest model to understand is that the area of the brain, particularly on the left side of the brain, that is involved in hearing speech and processing, receiving speech in the brain. So that’s in what we call a sort of left temporal parietal cortex. That’s where the temporal lobe and the parietal lobe sort of meet each other. That area would light up on a brain scan if I was just lying in the brain scan and listening to somebody talking to me. There’s evidence that that area of the brain is overactive in people who experience hallucinations when they’re not necessarily hearing normal speech and perhaps also when they’re actually experiencing hallucinations. One of these theoretical models is that that area of the brain has in some way become autonomously active, that there’s a failure of the circuitry that would normally dampen down activity to do that, so that the potentially auditory memories, snippets of conversations, a variety of different auditory experiences are being re-experienced because there’s this failure of suppression going on in that area. The other big competing hypothesis is slightly more complex, essentially that this relies on an understanding of a of a concept called inner speech, which is that in the more lateral frontal part of the brain, an area of the brain that known as Broca’s area tends to be involved in generating speech.

Prof. Paul Fitzgerald: And as this model goes, there’s a message from Broca’s area back to the area of the brain that I was talking about before that’s telling me that it’s my own speech so that I don’t become confused and think I’m hearing somebody else talking when I’m speaking myself. And this model goes that there’s a failure of this feedback mechanism so that you may end up in circumstances where you’re generating speech, not necessarily external. You’re not actually talking out loud, but you’re generating this speech internally. And when there’s this failure of the feedback mechanism, you’re then not recognizing that this so-called inner speech is coming from yourself. Therefore, it’s recognized as being external and experienced as hallucination. Both models are really supported by different lines of research, and it may well be that, when we think about something like hallucination, there isn’t one explanation. And I think just if we think about how people experience hallucinations, it might help that make more sense. This inner speech model makes sense to me when I think about the experience of patients who describe a running commentary or a single voice that’s pretty much constantly speaking to them. Because that would make sense if this is inner speech that’s constantly there, that they’re not recognized as their own. But it wouldn’t necessarily make sense of the experience of hallucinations where people hear multiple voices or short, discontinuous elements of speech. That would fit much more concretely with the former model that I described. So it may well be that we’ve got different areas of the brain involved for different people with underlying different types of hallucinations.

Rachel Star Withers: Whenever I have audio hallucinations and obviously I don’t speak for all people with schizophrenia, but, I hear it and I could tell you where it came from. Most of mine actually come from behind me and either to the left or right. Sometimes I’ll hear like ticking or scratching in the walls, and I could point to the exact place. Mine is very outside of my head. Does the brain react the same way to, let’s say, actual noises as it does my hallucinated noises?

Prof. Paul Fitzgerald: I don’t think we fully understand how this works, but I suspect what happens is this experience is being generated internally. The brain has to make some coherent sense of that. Neuronal pathways are firing fairly automatically that situate that in space, situate that in time or, you know, all the sort of contextual factors that come when you’re listening to anything with music, somebody’s talking to, et cetera, et cetera. So, the brain is really imposing that context on something that’s been generated internally because it just doesn’t make sense otherwise. In the limited number of studies where this has been done, where people are in a scanner and they’re basically asked to indicate by a button press when they’re experiencing their hallucinations, researchers are then trying to compare what’s lighting up in their brain while they’re experiencing hallucinations versus when they’re not. And you do typically see relatively similar areas to what you would see when somebody’s listening to external speech. It’s not exactly the same, but there’s certainly significant overlaps. Interestingly, the opposite is also slightly true, that some scanning studies suggest that when people who have a history of experiencing hallucinations, when they’re listening to external speech in the scanner, those areas of the brain light up slightly less. It’s almost as if the resources of the brain are being taken up by the experience of hallucinations, so they’re not necessarily automatically available to the same degree when they’re processing sort of normal aspects of speech. It’s the overactivity for the hallucinations, but then denying the resources for processing normal aspects of speech.

Rachel Star Withers: Interesting thought. Now a lot of your research has been in transcranial magnetic stimulation. What is that exactly when it comes to schizophrenia?

Prof. Paul Fitzgerald: Transcranial magnetic stimulation is a technique where we use a fairly strong magnetic field to try to indirectly activate nerve cells in the brain. Magnetic fields have this interesting property that they’ll pass through us without any resistance, which is why you can have an MRI scan, for example. What we do when we do TMS is we place this coil on the scalp. It generates a strong magnetic field but doesn’t electrify the scalp in any way. But that magnetic field passes into the brain, and when you apply a magnetic field to something that conducts electricity, you can induce electrical currents. So we can actually make nerve cells fire. So if you put one of these TMS coils just on the muscle area of the brain, say the area of the brain that controls the nerves in your hand, for example, it’ll stimulate those nerves to send a signal down to cause a muscle twitch, which is a little bit odd. It’s not painful at all. You just feel this twitch in your hand and this thing clicking on your head. When we repeatedly stimulate with these TMS pulses, we can make areas of the brain more or less active by repeatedly stimulating them over time. And that’s had direct relevance to thinking about whether we could use this with some sort of therapeutic value in people with schizophrenia. And that research has really gone in two quite different directions. Probably the most advanced of those directions has been trying to use TMS as a potential treatment for patients who experience hallucinations, where those hallucinations have not responded adequately, gotten better with various medication therapies.

Prof. Paul Fitzgerald: And that model matches what we were talking about before. It targets the auditory processing part of the brain under the assumption that when people are experiencing hallucinations, that area of the brain is overactive and it uses a type of TMS that aims to reduce brain activity over time. And from a practical perspective, that would involve somebody having a series of pulses for 15 or 20 minutes, usually on a daily basis over a number of weeks. And what that research shows is that you certainly can get therapeutic benefits, in our experience, both in the clinical trials we’ve done, but also when we’ve just tried this on a clinical basis and followed people over time. The other way in which TMS has been used in people with schizophrenia is to actually target the frontal part of the brain, much in the same way as we use TMS as a treatment for patients with depression, where we use it in the frontal part of the brain to try and increase brain activity. And that has been used in patients for a couple of reasons. It’s been used in people with schizophrenia who have depression because we know it’s an effective antidepressant treatment, but it’s also being tested as a way of trying to improve the so called the negative symptoms of schizophrenia. The lack of drive, the lack of energy, the lack of motivation, the lack of capacity to experience pleasure, those sorts of symptoms . Even more recently, also to see if it can improve some of the cognitive elements of schizophrenia as well to improve people’s ability to concentrate and to focus. That research isn’t perhaps quite as well developed as the research using TMS in treating hallucinations.

Rachel Star Withers: My follow up question, I’m sure that everybody’s thinking, have you found an area of the brain to like stimulate that could either induce hallucinations or maybe suppress them?

Prof. Paul Fitzgerald: Umm,suppressing certainly, yes, with that, the first target that I was talking about, and we clearly see some people whose hallucinations are suppressed and some in whom they completely resolve and that may be sustained for a significant period of time, many, many months. We see patients who have hallucinations just go away for and stay away for a protracted period of time. I’ve certainly never seen a circumstance where we have induced hallucinations. There’s this a very unusual property with TMS, which is that it seems to be very hard to change the brain activity when brain activity is actually normal. If you target a normal brain function in healthy individuals or normal areas of the brain that seem to be functioning normally, even in somebody who’s got some other brain problem, it’s very hard to make it more or less excitable. The brain is strongly sort of homeostatic. It’ll push back against whatever you do. So we might be able to say, for example, make the brain slightly more excitable. But then if we double the dose of stimulation to try to get a more dramatic effect, often instead of doubling the effect we get, it kind of goes back in the other direction and we find we’re getting no effect at all. So there seems to be some sort of almost inherent safety mechanism to prevent us being able to do to do things that are too aberrant to the brain with these sorts of techniques, which is certainly reassuring.

Rachel Star Withers: That just blew my mind. I’ve never thought of it that way. I honestly think as far as, quote unquote normal people, I kind of assumed their brain would act just like mine. I didn’t realize that it could push back. So what you’re saying then would lead me to believe that since hallucinations, you know, are a positive symptom of schizophrenia so far, they can’t stimulate the brain to make them worse, but hopefully they could stimulate it at some point in time to suppress them.

Prof. Paul Fitzgerald: Look, with what we know now, I think that’s the case. Maybe we could do more damage if we knew, if we knew more, not saying that we would want to do so. But I think,

Rachel Star Withers: Right.

Prof. Paul Fitzgerald: You know, one of the neurochemicals involved in brain function that there’s a common neurochemicals known as GABA, which is the main inhibitory neurotransmitter, so it suppresses activity. And there are theoretical reasons to propose that there may be not enough GABA, not enough of this inhibitory activity underpinning some things like hallucinations. So hence you’re getting too much activation. But if I try to say overexcite a healthy part of the brain, what is likely to happen is the brain will respond by producing more GABA so that it then suppresses that activity that I’m artificially trying to produce. That may happen in a healthy brain, but that also might happen if I was trying to stimulate kind of an area of the brain that was normally functioning in somebody who had schizophrenia. When we looked at trying to improve cognitive function with a type of TMS in individuals with schizophrenia and at the same time, we looked at if that same type of stimulation produced improvements in cognition in people who didn’t have schizophrenia, there was what we call a dose response curve in the people with schizophrenia. In other words, the higher dose of stimulation produced greater effects. Whereas in people without schizophrenia, they get a slight improvement at the low dose. But then they didn’t get any greater improvement at the high dose. If anything, the benefits seem to be less. So, that is some evidence that we’re probably more able to change activity when it’s, when there’s a problem than when there’s no problem.

Rachel Star Withers: How far are we away from like you being able to prescribe someone some sort of device that they could take home and like, put on their head? Science wise, how far are we away from that, do you think?

Prof. Paul Fitzgerald: Not very far in the sense of having the device and having them being used for at least one or two different applications, treating hallucinations or schizophrenia probably won’t be the first cab off the rank and how those devices will be used. But we’re already doing. We’ve got three clinical trials going at the moment using at home stimulation devices. These are not using TMS pulses because TMS, the machines are big, they’re bulky, they’re expensive, require a lot of electricity. But we’re doing it with other forms of very weak electrical currents. We’re doing it with a particular type of stimulation called transcranial alternating current stimulation, which is just a very, very weak electrical current. And we’re testing that at the moment in young people with depression, as well as a couple of studies in older people with mild cognitive impairment and Alzheimer’s disease. But there are have already been some studies investigating this type of technology, either this so-called transcranial alternating current stimulation or a thing called transcranial direct stimulation in treating hallucinations. And some of those studies are quite promising.

Rachel Star Withers: Thank you so much for joining us today. I have learned so much. You’ve definitely given me a lot to think about as far as how our brain works.

Prof. Paul Fitzgerald: You’re most welcome.

Gabe Howard: Rachel, as I said, I was super impressed at how much you got out of that interview because you understand hallucinations, you live with hallucinations, but you learned a ton. Walk us through everything that we don’t know.

Rachel Star Withers: Dr. Fitzgerald blew my mind. The thing that stood out to me the most was that you can’t induce hallucinations via brain stimulation. I just assumed that if you plop down a human brain in front of me and we like poked different parts, we could eventually poke it and find like, Hey, that’s the hallucination and delusion area. When I poke it, the person really goes crazy. I just assumed that was a thing. And then to be told that you can treat the deficits of schizophrenia through stimulation, but you can’t add things. It really shows you how schizophrenia in general is not just black and white. It isn’t just, OK, take a pill and this will fix everything. There’s so much that no one has a clue what’s causing it.

Gabe Howard: It’s also a little bit scary that nobody has a clue what’s causing it, because, my friend, you, live with it. Anything that is that is impeding your best life, I want to know as much as possible. And I think that we do a disservice not telling people who are experiencing hallucinations that it’s scary. It’s scary how little we know about the brain and how little we know about hallucinations. It’s always, Oh, we’re helping. We’re doing the best we can. We’re trying. Seek help, do your part. I understand why this is terrifying. We know so little. And yet we’re asking you to have faith in a in a process that is still emerging. So everybody experiencing hallucinations? You’re very, very brave. Thank you. Thank you for being brave, and you should be proud of yourself for everything that you’re managing.

Rachel Star Withers: One of the research articles that I came across, it had a sentence talking about what causes hallucinations in the brain, and I want to read you this sentence. This is all one sentence. Hallucinations are influenced by multiple gene and gene × environment interactions from genetic level, by glutamate level imbalance from neurometabolic level, by dysfunctional forward model, sensory gating deficits, MMN deficits, dysfunctional γ frequency oscillations, and alterations of other frequency spectrums and spectral interactions from EEG level, by fasciculus alterations of white matter and morphological changes from sMRI level, and by altered cerebral blood flow, abnormal cerebral activations, and dysfunctional brain connectivity of interregion, intranetwork, and internetwork from fMRI level. Wow, that is complicated.

Gabe Howard: And it’s clear as mud, right, listen, Rachel and I do this for a living, she lives with schizophrenia. I live with bipolar disorder. We host the show. We work in the mental health field. We’ve done so, and I can’t understand it. I knew like four words in that entire sentence. And that troubles me. It does trouble me. I just consider that sentence to be utterly terrifying.

Rachel Star Withers: I have to add, though, it’s also amazing, Gabe, to think that all those things which we don’t even fully understand. Ok. I don’t even know what most of those words meant, but all those things take place for someone with schizophrenia to have a hallucination that that blows my mind right there, that all that stuff is going on inside my brain when I see a shadow monster. Inside my brain, all those little things have to happen, have to fall in order for me to hear voices that aren’t really there. That’s amazing. So many people messaged me and tell me that they feel their brain is broken because they have schizophrenia. They’re broken. And I felt that exact same way and still do at times. But when you hear that that is the opposite of broken, that just is incredible. All the inner workings going on to create that hallucination. So if you are out there, I definitely say you’re not broken. That’s incredible that our brains can create that. We might not always enjoy hallucinations, but I don’t know. I do think there is some wonder to it of how the brain works. And yes, do our brains that have schizophrenia work differently than the norm? Absolutely. But that’s OK. Thank you so much for listening to this episode of Inside Schizophrenia. Please, like, share, subscribe and rate our podcasts, and we’ll see you next time here on Inside Schizophrenia, a Healthline Media podcast.

Announcer: You’ve been listening to Inside Schizophrenia, a podcast from Psych Central and Healthline Media. Previous episodes can be found at PsychCentral.com/IS or on your favorite podcast player. Your host, Rachel Star Withers, can be found online at RachelStarLive.com. Co-host Gabe Howard can be found online at gabehoward.com. Thank you and we’ll see you next time.