Hallucinations and hearing voices

Hallucinations and Hearing Voices (Auditory Hallucinations)

Hallucinations are false sensory experiences that occur without an external stimulus. They may involve any of the senses—auditory, visual, tactile, olfactory, or gustatory—but auditory hallucinations (hearing voices) are the most common type, particularly in psychiatric conditions. They can range from simple sounds (buzzing, whispering) to complex voices conversing or giving commands. Hallucinations and hearing voices are symptoms rather than a disease themselves, and they require thorough assessment to determine the underlying cause.

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Causes

1. Psychiatric disorders

   • Schizophrenia spectrum disorders (schizophrenia, schizoaffective disorder, schizophreniform disorder)

   • Severe depression with psychotic features

   • Bipolar disorder with mania or psychosis

   • Post-traumatic stress disorder (PTSD)

   • Borderline personality disorder (sometimes in stress-induced states)

2. Neurological and organic causes

   • Epilepsy (particularly temporal lobe epilepsy)

   • Parkinson’s disease

   • Dementias (Alzheimer’s disease, Lewy body dementia)

   • Brain tumors or lesions affecting auditory pathways

   • Stroke or traumatic brain injury

3. Substance-related causes

   • Intoxication (alcohol, cocaine, amphetamines, hallucinogens, cannabis, LSD)

   • Withdrawal states (alcohol withdrawal delirium, benzodiazepine withdrawal)

   • Side effects of medications (dopaminergic drugs, steroids, anticholinergics)

4. Medical/metabolic causes

   • Delirium (infection, electrolyte imbalance, hypoxia, metabolic encephalopathy)

   • High fever

   • Sleep deprivation or extreme stress

   • Endocrine disorders (thyroid disease, adrenal dysfunction)

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Symptoms

• Hearing voices or sounds without external source

• Voices may comment, converse, or command

• Visual or other sensory hallucinations may coexist

• Associated symptoms: disorganized thinking, paranoia, mood disturbances, agitation, withdrawal

• Distress, fear, or functional impairment

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Diagnosis

Evaluation involves:

• History & examination: psychiatric history, substance use, medical conditions, medications

• Mental state examination: thought content, mood, insight, and perception

• Physical & neurological examination

• Investigations (when organic causes suspected):

  • Blood tests (CBC, electrolytes, thyroid, liver, renal function)

  • Urine toxicology screen

  • Brain imaging (CT or MRI)

  • EEG for seizure activity

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Treatment

Treatment depends on the underlying cause.

1. Psychiatric disorders

   • Antipsychotics (first-line for schizophrenia and psychosis):

     • Risperidone 2–6 mg/day

     • Olanzapine 10–20 mg/day

     • Quetiapine 300–600 mg/day

     • Aripiprazole 10–30 mg/day

     • Clozapine 300–600 mg/day (for treatment-resistant schizophrenia)

   • Mood stabilizers (for bipolar disorder with psychosis):

     • Lithium carbonate: 600–1200 mg/day (maintain therapeutic serum levels 0.6–1.2 mmol/L)

     • Valproate: 750–1500 mg/day

     • Lamotrigine or carbamazepine when indicated

   • Antidepressants (for psychotic depression, with antipsychotics):

     • SSRIs: sertraline 50–200 mg/day, fluoxetine 20–60 mg/day

     • Tricyclics in severe cases under supervision

   • Psychological therapies:

     • Cognitive-behavioral therapy for psychosis (CBTp)

     • Supportive therapy, family therapy

     • Coping strategies for distressing hallucinations

2. Neurological/organic causes

   • Antiepileptic drugs (e.g., carbamazepine, valproate, levetiracetam for epilepsy)

   • Dopaminergic dose adjustment in Parkinson’s disease

   • Cholinesterase inhibitors (donepezil, rivastigmine) for dementia-related hallucinations

3. Substance-induced hallucinations

   • Discontinuation of offending drug or substance

   • Supportive care in withdrawal, benzodiazepines for alcohol withdrawal

   • Long-term treatment for substance use disorder

4. Delirium or metabolic causes

   • Treat underlying cause (infection, hypoxia, electrolyte imbalance)

   • Supportive care: hydration, oxygen, correction of metabolic derangements

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Precautions and Support

• Ensure patient safety (voices commanding harm require urgent attention)

• Hospitalization if high risk of harm to self or others

• Avoid alcohol and recreational drugs

• Maintain healthy sleep patterns and stress management

• Family education and support groups

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Drug Interactions

• Antipsychotics interact with:

  • CNS depressants (alcohol, benzodiazepines) → additive sedation

  • QT-prolonging drugs (antiarrhythmics, macrolides, fluoroquinolones) → arrhythmia risk

  • Carbamazepine (reduces plasma levels of antipsychotics via enzyme induction)

• Lithium interacts with:

  • NSAIDs, ACE inhibitors, diuretics (increase lithium levels → toxicity)

• SSRIs interact with:

• MAOIs (risk of serotonin syndrome)

• Warfarin (increased bleeding risk)