tinnitus is the perception of sound in the absence of a corresponding external sound source . it affects up to 15% of the population1 across all age ranges2 
 3 , but is predominant in the elderly4 
 5 . in addition to its multiple organic causes  otologic , metabolic , neurologic , somatosensory , cardiovascular , or dental tinnitus involves major psychological components3 
 4 
 6 
 7 , which are associated with the interpretation and management of the condition . the types of tinnitus most commonly reported by patients involve the perception of pure tones ( e.g. , a whistling sound ) or frequency ranges ( akin to white noise ) . however , during regular otolaryngological evaluation in the tinnitus research group of the university of so paulo , some patients began reporting unusual and complex auditory perceptions such as hearing music and voices in addition to typical tinnitus . perception in the absence of a corresponding object is generally characterized as a hallucination . as this is a controversial topic in psychiatry and there is no consensus in the definitions employed8 
 9 , we chose to use a single , general term for such manifestations in our study : hallucinatory phenomena . little is known about the prevalence of hallucinatory phenomena in the general population , but evidence suggests they are frequent10 . auditory and visual phenomena are considered a risk factor for psychiatric disorders11 , but do not occur exclusively in psychosis12 . of all the hallucinatory phenomena , the auditory phenomena are of the greatest interest to otological practice , as they require differential diagnosis . among these , auditory verbal hallucinations ( avhs ,  hearing voices  ) are more common than musical ones . both types of hallucinatory phenomena have been associated with several neurologic changes ( such as stroke or brain tumors ) , psychiatric disorders ( such as depression and schizophrenia ) , and drug use ( ketamine , ranitidine , benzodiazepines , alcohol , cannabinoids , etc . ) , among other factors13 
 14 . musical phenomena may be associated with sensory deprivation15 
 16 
 17 ; the presumed mechanism involves the disinhibition of certain neuronal circuits , which would lead to the recall of memory traces . in addition to the cerebral changes involved in the etiology of hallucinatory phenomena , other theories correlate the onset of these phenomena and their content with psychic and emotional factors . according to these authors , such manifestations arise when patients ( psychotic or otherwise ) lack sufficient symbolization resources to cope with certain traumatic situations , such as intense physical distress , sensory deprivation , loss of time space orientation , or assaults on the patient 's ideals18 . due to the characteristics of their psyche , psychotic patients perceive hallucinatory phenomena as reality19 . in view of the need for further clarification of certain psychological aspects of patients presenting to otolaryngology services with tinnitus and concomitant auditory hallucinations , the present study sought to assess whether hallucinatory phenomena of an auditory nature : are related to psychosis ; are related in content or form to the patient 's psyche ; are related to aspects of depression , whether associated to tinnitus or otherwise . this study and its informed consent form were approved by the research project analysis committee of the university of so paulo school of medicine clinics hospital ( hc - fmusp ) : no . in light of the rarity of the study phenomenon , we included all patients seen at the tinnitus research group of hc - fmusp between february 2007 and february 2008 who had tinnitus with concurrent auditory hallucinations . we excluded any patient who would have been unable to begin or complete the stages of the study ( due to neurologic illness or hearing impairment not addressed by aural rehabilitation ) . the final sample population comprised 10 patients , 8 of whom were women ; aged 4385 years ( mean age , 65.7 years ) . from an organic standpoint , all patients were diagnosed with hearing loss ( conductive , sensorineural , or mixed type of a mild to profound degree ) during pre - study medical and audiologic evaluations . the 10 cases were analyzed in a 2-stage process : the first stage ( conducted by a trained assistant researcher ) comprised : 12 semi - structured interviews meant to characterize the hallucinatory phenomenon ; application of the hamilton depression rating scale ( ham - d ) to assess the intensity of depression symptoms . the second stage ( conducted by the chief researcher ) comprised : 24 unstructured psychoanalytic interviews , where the patient spoke freely to the analyst , meant to detect the presence or absence of based on assessment of the manner in which the fundamental aspects of the patient 's psyche were organized . analysis was conducted in accordance with the theoretical foundations of each instrument : content analysis of semi - structured interviews according to the established topics ; freudian and lacanian theory ( for psychoanalytic interviews ) . in light of the rarity of the study phenomenon , we included all patients seen at the tinnitus research group of hc - fmusp between february 2007 and february 2008 who had tinnitus with concurrent auditory hallucinations . we excluded any patient who would have been unable to begin or complete the stages of the study ( due to neurologic illness or hearing impairment not addressed by aural rehabilitation ) . the final sample population comprised 10 patients , 8 of whom were women ; aged 4385 years ( mean age , 65.7 years ) . from an organic standpoint , all patients were diagnosed with hearing loss ( conductive , sensorineural , or mixed type of a mild to profound degree ) during pre - study medical and audiologic evaluations . the 10 cases were analyzed in a 2-stage process : the first stage ( conducted by a trained assistant researcher ) comprised : 12 semi - structured interviews meant to characterize the hallucinatory phenomenon ; application of the hamilton depression rating scale ( ham - d ) to assess the intensity of depression symptoms . the second stage ( conducted by the chief researcher ) comprised : 24 unstructured psychoanalytic interviews , where the patient spoke freely to the analyst , meant to detect the presence or absence of based on assessment of the manner in which the fundamental aspects of the patient 's psyche were organized . analysis was conducted in accordance with the theoretical foundations of each instrument : content analysis of semi - structured interviews according to the established topics ; freudian and lacanian theory ( for psychoanalytic interviews ) . quantitative analysis consisted of counting the number of events . musical phenomena were more frequent ( n  =  8) than auditory verbal hallucinations ( n  =  4 ) , with 2 patients in the sample experiencing both phenomena . among the 8 patients reporting musical hallucinations , 4 reported hearing songs from their childhood or youth and 3 reported hearing choirs singing familiar tunes or religious hymns . of the 4 patients experiencing auditory verbal phenomena , 2 reported having more than one type of avh . the most common hallucination was the perception  quite clear to some patients  that someone was calling the patient 's name ( n  =  3 ) , particularly during moments of intense solitude and/or fear . two patients reported hearing sounds that appeared to correspond to the speech of one or more people , but were unable to understand these perceived utterances . six patients reported being afraid of the phenomena , with a particular fear of losing their minds ; 5 patients reported difficulty concentrating while the hallucinations occurred . half of all patients ( n  =  5 ) reported improvement in tinnitus - related distress or auditory hallucinations during moments of calm or absentmindedness , but also reported not having explored this possibility in much depth . regarding the duration of hallucinatory phenomena , 5 patients all 10 patients were aware that the tunes or voices they heard were subjective in origin and came from their own minds rather than an external source ; however , 6 patients reported being confused at times about the source of the phenomena due to the remarkable clarity of what they heard . all patients exhibited depressive symptoms to some extent , as measured by the ham - d ( table 1 ) . by means of psychoanalytic interviews , we determined that none of the 10 patients showed signs of psychosis , not even those who reported auditory verbal hallucinations . the patients ' discourse during psychoanalytic interviews showed that their hallucinatory phenomena ( songs or voices ) performed some kind of function in the individual psyches of these non - psychotic patients . generally speaking , the phenomena functioned as a metaphor for aspects of the patient 's life that had been lost or intensely threatened , allowing patients to recover these aspects in a way and working as a sort of unconscious protection to help them deal with current difficult life situations . the content of songs or voices heard constituted a privileged means of obtaining this protection , as these 2 examples show : hannah ( name changed to maintain confidentiality ) , 84 , widowed , lives alone . everyone has their partners , and no one can be with me  , she said resignedly . mobility issues forced her to stop attending the church to which she had always belonged . soon afterward , musical phenomena occurred in the form of religious hymns . hannah made a point of noting that she had been named after a biblical prophetess , citing another prophetess , deborah ,  who , with her singing , gathered her people  . through her hallucinatory phenomena , hannah unconsciously achieved something similar : soon after being separated from the group to which she had always belonged , she was able to reunite with her people , in a manner of speaking , through the religious songs and hymns she began to hear subjectively . claire ( name changed to maintain confidentiality ) , 43 , experienced musical phenomena in the form of short children 's songs that she was sometimes unable to recall . always a very insecure person , claire was forced to marry a boorish man who never gave her any support . after her eldest son began exhibiting strong signs of drug addiction and her brother , who had forced her to marry , died , claire entered a period of major depression , and soon began to hear , very clearly , people 's voices calling her name . faced with the possibility of losing her main support , her eldest son , and finding herself alone and increasingly insecure , claire began to hear voices calling out to her . psychoanalytic interviews showed that in all cases , patients exhibited a strong tendency toward recalling and dwelling on past distressing situations , maintaining a victimized or suffering posture even when revisiting distant events or those they had already overcome . both tinnitus and hallucinatory phenomena were added to this rote repetition of scenarios associated with suffering , thus aiding the maintenance of a condition of suffering , with patients failing to perceive or accept possibilities for positive change , including , in some cases , the treatment strategies proposed by the attending otolaryngologist . their depressive symptoms reportedly arose or worsened particularly when they were unable to cope with loss or life changes in a satisfactory manner ; aging , changes in social mores and values with the passage of time , and the fear of upsetting or being disregarded by others were stressed as factors . in 2 patients , vocal phenomena were strongly associated with severe depression ; one of the patients improved considerably after treatment with antidepressant medication . musical phenomena were more frequent ( n  =  8) than auditory verbal hallucinations ( n  =  4 ) , with 2 patients in the sample experiencing both phenomena . among the 8 patients reporting musical hallucinations , 4 reported hearing songs from their childhood or youth and 3 reported hearing choirs singing familiar tunes or religious hymns . of the 4 patients experiencing auditory verbal phenomena , 2 reported having more than one type of avh . the most common hallucination was the perception  quite clear to some patients  that someone was calling the patient 's name ( n  =  3 ) , particularly during moments of intense solitude and/or fear . two patients reported hearing sounds that appeared to correspond to the speech of one or more people , but were unable to understand these perceived utterances . six patients reported being afraid of the phenomena , with a particular fear of losing their minds ; 5 patients reported difficulty concentrating while the hallucinations occurred . half of all patients ( n  =  5 ) reported improvement in tinnitus - related distress or auditory hallucinations during moments of calm or absentmindedness , but also reported not having explored this possibility in much depth . regarding the duration of hallucinatory phenomena , 5 patients all 10 patients were aware that the tunes or voices they heard were subjective in origin and came from their own minds rather than an external source ; however , 6 patients reported being confused at times about the source of the phenomena due to the remarkable clarity of what they heard . all patients exhibited depressive symptoms to some extent , as measured by the ham - d ( table 1 ) . by means of psychoanalytic interviews , we determined that none of the 10 patients showed signs of psychosis , not even those who reported auditory verbal hallucinations . the patients ' discourse during psychoanalytic interviews showed that their hallucinatory phenomena ( songs or voices ) performed some kind of function in the individual psyches of these non - psychotic patients . generally speaking , the phenomena functioned as a metaphor for aspects of the patient 's life that had been lost or intensely threatened , allowing patients to recover these aspects in a way and working as a sort of unconscious protection to help them deal with current difficult life situations . the content of songs or voices heard constituted a privileged means of obtaining this protection , as these 2 examples show : hannah ( name changed to maintain confidentiality ) , 84 , widowed , lives alone . everyone has their partners , and no one can be with me  , she said resignedly . mobility issues forced her to stop attending the church to which she had always belonged . soon afterward hannah made a point of noting that she had been named after a biblical prophetess , citing another prophetess , deborah ,  who , with her singing , gathered her people  . through her hallucinatory phenomena , hannah unconsciously achieved something similar : soon after being separated from the group to which she had always belonged , she was able to reunite with her people , in a manner of speaking , through the religious songs and hymns she began to hear subjectively . claire ( name changed to maintain confidentiality ) , 43 , experienced musical phenomena in the form of short children 's songs that she was sometimes unable to recall . always a very insecure person , claire was forced to marry a boorish man who never gave her any support . after her eldest son began exhibiting strong signs of drug addiction and her brother , who had forced her to marry , died , claire entered a period of major depression , and soon began to hear , very clearly , people 's voices calling her name . faced with the possibility of losing her main support , her eldest son , and finding herself alone and increasingly insecure , claire began to hear voices calling out to her . psychoanalytic interviews showed that in all cases , patients exhibited a strong tendency toward recalling and dwelling on past distressing situations , maintaining a victimized or suffering posture even when revisiting distant events or those they had already overcome . both tinnitus and hallucinatory phenomena were added to this rote repetition of scenarios associated with suffering , thus aiding the maintenance of a condition of suffering , with patients failing to perceive or accept possibilities for positive change , including , in some cases , the treatment strategies proposed by the attending otolaryngologist . their depressive symptoms reportedly arose or worsened particularly when they were unable to cope with loss or life changes in a satisfactory manner ; aging , changes in social mores and values with the passage of time , and the fear of upsetting or being disregarded by others were stressed as factors . in 2 patients , vocal phenomena were strongly associated with severe depression ; one of the patients improved considerably after treatment with antidepressant medication . in this sample of tinnitus patients , hallucinatory phenomena ( as assessed by semi - structured interviews ) were not associated with psychosis . despite the clarity of auditory phenomena in some cases , all patients remained connected to reality and were aware of the subjective ( non - external ) nature of their hallucinations ; this is consistent with our assessment that psychosis was not involved . according to the literature , auditory verbal hallucinations ( hearing voices ) are the most common , particularly in schizophrenia or severe depression13 
 23 ; musical phenomena are far less common , occurring mostly in socially isolated elderly females14 
 16 
 17 , and may be associated with hearing loss , neurologic impairment , or psychiatric disorders , especially those in the depression spectrum14 
 16 
 17 . musical phenomena predominated in our sample , but this actually corroborated the existing literature , as the sample mostly comprised hearing - impaired women in situations of social isolation . in the study of musical hallucinations , the repetitive and intrusive nature of the perception , coupled with the awareness that this perception is subjective in origin , has led authors to question whether these are truly hallucinatory phenomena or something more akin to obsessive symptoms24 
 25 
 26 ; in this line of research , such phenomena are considered repetitive mental rituals . these repetitive mental rituals are present in the strong tendency toward recall , particularly of unpleasant facts and situations , exhibited by all patients in our sample . this influences and intensifies the perceived distress caused by tinnitus and the occurrence of auditory hallucinatory phenomena , and is indicative of a strongly depressive outlook on life . one particularly interesting finding that suggests this was that half of all patients in the sample ( n  =  5 ) reported an improvement in tinnitus or auditory hallucinations whenever they were calm or distracted . nevertheless , they reported making very little use of this possibility as a means of obtaining relief from their symptoms ; one may say they strangely preferred to remain in discomfort . therefore , we can not state with certainty that patients became depressed due to the presence of tinnitus and hallucinatory phenomena , but instead may state that patients ' depressive outlook on life , with a tendency toward stressing and dwelling on moments of suffering , jeopardizes treatment and decreases the possibility of symptomatic improvement . although hearing loss has been reported as a condition that favors the onset of hallucinatory phenomena15 
 16 
 17 , the onset of hallucinations in our patients occurred many years after hearing loss and was always tied to traumatic occurrences with which they were unable to cope due to a lack of symbolic resources . hallucinatory phenomena thus arose as a sort of unconscious means of psychic protection in the face of helplessness created by a new and distressing situation18 , as shown in the example cases of hannah and claire . in addition to being a source of distress and fear , hallucinatory phenomena served as something of a surrogate for something lost and then found again in a curious manner . this would lead to the activation of memory traces , not by a random release of neuronal circuits15 , but by emotional aspects relevant to each patient . in non - psychotic patients , hallucinatory phenomena are a creation of the mind that arises when symbolization capacity is insufficient to cope with feelings of helplessness ; they constitute the remnants of a past reality that act as a protective shield against symbolic emptiness18 . viewed from this standpoint , hallucinatory phenomena are somewhat akin to dreams as understood by freud : they create the possibility of satisfying an unconscious desire , as well as the possibility of some confusion between representation and perception . our sample was almost entirely composed of elderly individuals who indirectly mentioned the challenges of aging and the fear of displeasing others or being taken for granted . this reflects the human need for being and feeling heard and regarded by others , which is a key point in the organization of the psyche ; it is a lifelong search , and has been since the beginning of time27 
 28 . conversely , the isolation caused by hearing loss and the feeling of being disregarded by others , sometimes due to the experiences of aging , lead to immense psychic distress and diminished motivation , sometimes to the point of losing interest in life , jeopardizing language relations and the patient 's perception of the world29 . being able to rely on the support of others is a key mediator in overcoming physical or emotional limitations30 . when isolated from everyday social and emotional ties , the elderly tend to find pleasure only in remembering the past29 . therefore , we posit that living in an affectively stunted setting , whether due to aging or hearing loss , may lead to intense , subconscious recall of remnants of the past , when living conditions were better , in the form of hallucinatory phenomena . this may support the repetition of these phenomena , as well as patients ' difficulty or reticence in pursuing treatment that could reduce their occurrence . clinical practice in the cochlear implant group of our service some patients with sudden hearing loss and with no evidence of psychosis also report musical and auditory verbal hallucinations , some with reproaching content . in these patients , however , hallucinatory phenomena are more transient and appear to fade as they adapt to deafness . although it was not an objective of this study , we found that factors causing emotional distress play a very important role in the treatment of tinnitus patients9 
 5 
 8 . this also holds true for patients with tinnitus and hallucinatory phenomena ; depressive aspects are of particular importance . based on our findings , we may state that hallucinatory phenomena in tinnitus patients are not directly related to psychosis , but may be strongly associated with patients ' emotional experiences , their perception of their current situation , and the manner in which they cope with the challenges of life ; particularly important are behaviors brought on by a depressive worldview . nevertheless , they do provide interesting research directions , including those for further study of patients experiencing distressing situations in association with deafness .
summary 
 introduction :  over the last few years , our tinnitus research group has identified an increasing number of patients with tinnitus who also complained of repeated perception of complex sounds , such as music and voices . 
 such hallucinatory phenomena motivated us to study their possible relation to the patients ' psyches . 
 aims :  to assess whether hallucinatory phenomena were related to the patients ' psychosis and/or depression , and clarify their content and function in the patients ' psyches . 
 method :  ten subjects ( 8 women ; mean age  =  65.7 years ) were selected by otolaryngologists and evaluated by the same psychologists through semi - structured interviews , the hamilton depression rating scale , and psychoanalysis interviews . 
 results :  we found no association between auditory hallucinations and psychosis ; instead , this phenomenon was associated with depressive aspects . 
 the patients ' discourse revealed that hallucinatory phenomena played unconscious roles in their emotional life . in all cases 
 , there was a remarkable and strong tendency to recall / repeat unpleasant facts / situations , which tended to exacerbate the distress caused by the tinnitus and hallucinatory phenomena and worsen depressive aspects . 
 conclusions :  there is an important relationship between tinnitus , hallucinatory phenomena , and depression based on persistent recall of facts / situations leading to psychic distress . 
 the knowledge of such findings represents a further step towards the need to adapt the treatment of this particular subgroup of tinnitus patients through interdisciplinary teamwork . 
 prospective .