Hearing voices

Hearing Voices (Auditory Hallucinations)

Overview
Hearing voices, medically referred to as auditory hallucinations, is a perception of sound without an external stimulus. These experiences can range from hearing simple sounds like buzzing or whispering to complex voices giving commands or engaging in conversation. While sometimes associated with serious psychiatric disorders, hearing voices may also occur in non-psychiatric contexts such as extreme stress, sleep deprivation, bereavement, or substance use.

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Causes

1. Psychiatric Conditions

   • Schizophrenia spectrum disorders – the most common cause; voices may be accusatory, commanding, or conversational.

   • Bipolar disorder with psychotic features – hallucinations may occur during manic or depressive episodes.

   • Severe depression (psychotic depression) – voices often have a negative or self-critical tone.

   • Post-traumatic stress disorder (PTSD) – re-experiencing trauma through intrusive voices.

   • Borderline personality disorder (BPD) – transient hallucinations often linked to stress.

2. Neurological and Medical Causes

   • Temporal lobe epilepsy – seizures can cause auditory hallucinations.

   • Brain tumors or lesions in auditory pathways.

   • Dementia (e.g., Alzheimer’s, Lewy body dementia) – hallucinations can occur in advanced stages.

   • Delirium – acute confusional state often linked to infection, metabolic imbalance, or drug withdrawal.

3. Substance-Related Causes

   • Alcohol withdrawal (delirium tremens) – can cause frightening voices.

   • Illicit drugs (e.g., cocaine, amphetamines, LSD, cannabis) – hallucinogenic effects.

   • Prescription medications – e.g., corticosteroids, levodopa, certain antidepressants, or anticholinergics.

4. Non-Pathological / Transient Causes

   • Sleep-related – hypnagogic (falling asleep) or hypnopompic (waking up) hallucinations.

   • Grief / bereavement – hearing the voice of a deceased loved one is relatively common and not always pathological.

   • Severe stress and social isolation – may predispose to hearing voices.

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Associated Symptoms

• Delusions (fixed false beliefs).

• Disorganized speech or thought patterns.

• Changes in mood (mania, depression, anxiety).

• Cognitive impairment (memory, concentration).

• Physical symptoms if due to medical or neurological illness.

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Evaluation

A structured assessment is essential:

• History taking – onset, duration, content, triggers, and emotional impact of voices.

• Mental state examination – insight, risk of harm, co-existing symptoms (delusions, mood).

• Medical evaluation – neurological exam, blood tests (thyroid, B12, electrolytes, liver/kidney function), urine toxicology screen.

• Brain imaging (MRI/CT) – to rule out structural lesions.

• EEG – if epilepsy is suspected.

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Treatment

1. Psychiatric Management

   • Antipsychotics (first-line for schizophrenia and psychotic disorders):

     • Risperidone (2–6 mg/day)

     • Olanzapine (10–20 mg/day)

     • Quetiapine (300–600 mg/day)

     • Aripiprazole (10–30 mg/day)

   • Antidepressants if hallucinations are associated with severe depression:

     • SSRIs (e.g., fluoxetine 20–60 mg/day, sertraline 50–200 mg/day).

   • Mood stabilizers in bipolar disorder:

     • Lithium, valproate, carbamazepine.

2. Psychological Therapies

   • Cognitive Behavioral Therapy for Psychosis (CBTp) – helps patients reinterpret and cope with voices.

   • Trauma-focused therapy in PTSD-related hallucinations.

   • Support groups / peer support – may reduce stigma and distress.

3. Medical / Neurological Management

   • Antiepileptics (e.g., carbamazepine, valproate) for temporal lobe epilepsy.

   • Treatment of underlying metabolic, infectious, or structural causes (e.g., antibiotics for infection, surgery for brain tumor).

4. Lifestyle and Supportive Care

   • Adequate sleep, stress reduction, and avoiding alcohol or recreational drugs.

   • Structured daily activities to reduce isolation.

   • Crisis planning if voices are commanding harm to self or others.

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Precautions

• Immediate medical attention is needed if voices give harmful commands (suicidal or homicidal).

• Avoid abrupt discontinuation of antipsychotic or antidepressant medication.

• Monitor for side effects of psychiatric drugs (weight gain, metabolic syndrome, tardive dyskinesia).

• Regular psychiatric follow-up is essential to adjust treatment.

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Drug Interactions

• Antipsychotics + CNS depressants (benzodiazepines, alcohol) – excessive sedation and respiratory depression risk.

• Antipsychotics + QT-prolonging agents (e.g., macrolide antibiotics, amiodarone) – risk of arrhythmia.

• SSRIs + MAO inhibitors – serotonin syndrome.

• Lithium + NSAIDs / ACE inhibitors / diuretics – increased lithium toxicity.

• Carbamazepine + oral contraceptives – reduces contraceptive effectiveness.