Algorithmic approach to refractory auditory hallucinations in the geriatric population

ObjectiveAuditory hallucinations are generally considered to be a psychotic symptom. However, they do occur without other psychotic symptoms in a substantive number of cases in the general population and can cause a lot of individual distress because of the supposed association with schizophrenia. We describe a case of nonpsychotic auditory hallucinations occurring in the context of migraine.MethodCase report and literature review.ResultsA 40-year-old man presented with imperative auditory hallucinations that caused depressive and anxiety symptoms. He reported migraine with visual aura as well which started at the same time as the auditory hallucinations. The auditory hallucinations occurred in the context of nocturnal migraine attacks, preceding them as aura. No psychotic disorder was present. After treatment of the migraine with propranolol 40 mg twice daily, explanation of the etiology of the hallucinations, and mirtazapine 45 mg daily, the migraine subsided and no further hallucinations occurred. The patient recovered.DiscussionVisual auras have been described in migraine and occur quite often. Auditory hallucinations as aura in migraine have been described in children without psychosis, but this is the first case describing auditory hallucinations without psychosis as aura in migraine in an adult. For description of this kind of hallucination, DSM-IV lacks an appropriate category.ConclusionPsychiatrists should consider migraine with acoustic aura as a possible etiological factor in patients without further psychotic symptoms presenting with auditory hallucinations, and they should ask for headache symptoms when they take the history. Prognosis may be favorable if the migraine is properly treated. Research is needed to explore the pathophysiological mechanism of auditory hallucinations as aura in migraine.

Auditory Hallucinations Associated With Paget’s Disease

A pilot double-blind sham-controlled trial of repetitive transcranial magnetic stimulation for patients with refractory schizophrenia treated with clozapine

Persistent Auditory Hallucinations That Are Unresponsive to Antipsychotic Drugs

Patients with schizophrenia may sometimes have refractory symptoms that do not respond to medical treatments. One such symptom commonly seen in schizophrenia is refractory and distressing auditory hallucinations that do not respond to medication and psychotherapy. Transcranial direct current stimulation (tDCS) has been used successfully in adult patients in the management of refractory auditory hallucinations in schizophrenia. We report here a case of severe distressing refractory auditory hallucinations in a 66-year-old male with schizophrenia that responded to once daily tDCS which was then continued over a 3-month period. More than 80% improvement was reported in a month of treatment which was then continued over 3 months to yield 95% improvement. The patient had a better quality of life and relief from a distressing symptom. No side effects were noted due to the tDCS treatment. This case report supports the view that tDCS is an effective treatment for resistant and refractory auditory hallucinations in geriatric patients with schizophrenia.

Back to table of contents Previous article Next article LettersFull AccessAuditory Hallucinations as the Only Presenting Symptom of Right-Parietal Spontaneous Hemorrhage: FDG-PET Evidence of Corpus Callosum HyperactivityMassimiliano Godani, M.D., Andrea Ciarmiello, M.D., Cesare Capellini, M.D., and Massimo Del Sette, M.D.Massimiliano GodaniSearch for more papers by this author, M.D., Andrea CiarmielloSearch for more papers by this author, M.D., Cesare CapelliniSearch for more papers by this author, M.D., and Massimo Del SetteSearch for more papers by this author, M.D.Published Online:1 Jan 2012https://doi.org/10.1176/appi.neuropsych.11020054AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Auditory hallucinations are very rare in stroke patients. We report FDG-PET findings in a case of hemorrhagic stroke presenting with auditory hallucinations.Case ReportA 67-year-old woman was admitted to the emergency room of our hospital for acute onset of complex auditory hallucinations; she reported hearing loud music and voices of known persons speaking “filthy.” She had never suffered any psychiatric disorders in the past, and she was taking atenolol for many years as the only treatment for chronic arterial hypertension.Neurological examination did not show any focal neurological signs, and blood tests were normal. Brain CT scan revealed a right-parietal hemorrhage involving both superficial and deep territory of the posterior branches of middle cerebral artery (Figure 1 [D]). EEG showed absence of focal paroxystic epyleptiform discharges. Brain MRI and MR-angio confirmed the intraparenchimal hemorrhage, excluding the presence of aneurysm or artero-venous malformations. FDG-PET scan showed a significant increase in glucose metabolism (versus normal control database) in the middle and posterior areas of corpus callosum as well as in the precuneus and cuneus cortex (Figure 1 [A, B, C]).The auditory hallucinations gradually resolved in a few days without any treatment. She was discharged after 18 days from onset, and neurological examination showed visuospatial deficit as the consequence of right-parietal damage.DiscussionAuditory hallucinations are uncommon phenomena in patients with acute stroke; in particular, they have been reported in acute ischemic lesions of the brainstem but very rarely reported after cortical ischemic strokes.1 To our knowledge, this is the first case of auditory hallucinations as the only presenting symptom of a spontaneous hypertensive parenchymal hemmorrhage.In our case FDG-PET scan showed high relative glucose metabolic rates in the middle and posterior areas of corpus callosum. Hyperactivity of corpus callosum has already been reported in schizophrenic patients with auditory hallucinations.2,3 In particular, abnormalities in the posterior part of corpus callosum has been associated to schizophrenic positive symptoms.4 We speculate that in our patient the acute cortico-subcortical hemorrhage caused, through rapid development of peri-lesional edema and release of excitatory mediators such as calcium ions and amino-acids, an electrode-like effect,5 which abnormally activated the posterior part of corpus callosum, with consequent development of auditory hallucinations. We believe that a better understanding of corpus callosum pathophysiology could help in clarifying the mechanism of perceptive disturbances of various origin.Neurology UnitS. Andrea HospitalLA Spezia, ItalyCorrespondence: Massimiliano Godani, M.D.; massimiliano.[email protected]liguria.it1. Yair L , Mordechai L , Ronit G, et al.: Auditory hallucinations in acute stroke. Behav Neurol 2005; 16:211–216Crossref, Medline, Google Scholar2. Buchsbaum MS , Buchsbaum BR , Hazlett EA, et al.: Relative glucose metabolic rate higher in white matter in patients with schizophrenia. Am J Psychiatry 2007; 164:1072–1081Crossref, Medline, Google Scholar3. Hubl D , Koenig T , Strik W, et al.: Pathways that make voices. Arch Gen Psychiatry 2004; 61:658–668Crossref, Medline, Google Scholar4. Kubicki M , Styner M , Bouix S, et al.: Reduced interhemispheric connectivity in schizophrenia: tractography base segmentation of the corpus callosum. Schizophr Res 2008; 106(2–3):125–131Crossref, Medline, Google Scholar5. Weber B , Fouad K , Burger C, et al.: White-matter glucose metabolism during intracortical electrostimulation: a quantitative fluorodeoxyglucose autoradiography study in the rat. Neuroimage 2002; 16:993–998Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byJournal of the Neurological Sciences, Vol. 398Frontiers in Psychiatry, Vol. 8PET and SPECT Findings in Patients with Hallucinations29 January 2014 Volume 24Issue 1 Winter 2012Pages E28-E29 Metrics PDF download History Published online 1 January 2012 Published in print 1 January 2012

BackgroundSchizophrenia is a chronic and disabling disease that presents with delusions and hallucinations. Auditory hallucinations are usually expressed as voices speaking to or about the patient. Previous studies have examined the effect of repetitive transcranial magnetic stimulation (TMS) over the temporoparietal cortex on auditory hallucinations in schizophrenic patients. Our aim was to explore the potential effect of deep TMS, using the H coil over the same brain region on auditory hallucinations.Patients and methodsEight schizophrenic patients with refractory auditory hallucinations were recruited, mainly from Beer Ya'akov Mental Health Institution (Tel Aviv university, Israel) ambulatory clinics, as well as from other hospitals outpatient populations. Low-frequency deep TMS was applied for 10 min (600 pulses per session) to the left temporoparietal cortex for either 10 or 20 sessions. Deep TMS was applied using Brainsway's H1 coil apparatus. Patients were evaluated using the Auditory Hallucinations Rating Scale (AHRS) as well as the Scale for the Assessment of Positive Symptoms scores (SAPS), Clinical Global Impressions (CGI) scale, and the Scale for Assessment of Negative Symptoms (SANS).ResultsThis preliminary study demonstrated a significant improvement in AHRS score (an average reduction of 31.7% ± 32.2%) and to a lesser extent improvement in SAPS results (an average reduction of 16.5% ± 20.3%).ConclusionsIn this study, we have demonstrated the potential of deep TMS treatment over the temporoparietal cortex as an add-on treatment for chronic auditory hallucinations in schizophrenic patients. Larger samples in a double-blind sham-controlled design are now being preformed to evaluate the effectiveness of deep TMS treatment for auditory hallucinations.Trial registrationThis trial is registered with clinicaltrials.gov (identifier: NCT00564096).

IntroductionAuditory hallucinations are defined as experiences of auditory perceptions in the absence of a provoking external stimulus. They are the most prevalent symptoms of schizophrenia with high capacity for chronicity and refractoriness during the course of disease. The transcranial direct current stimulation (tDCS) – a safe, portable, and inexpensive neuromodulation technique – has emerged as a promising treatment for the management of auditory hallucinations.ObjectiveThe aim of this study is to analyze the level of evidence in the literature available for the use of tDCS as a treatment for auditory hallucinations in schizophrenia.MethodsA systematic review was performed, searching in the main electronic databases including the Cochrane Library and MEDLINE/PubMed. The searches were performed by combining descriptors, applying terms of the Medical Subject Headings (MeSH) of Descriptors of Health Sciences and descriptors contractions. PRISMA protocol was used as a guide and the terms used were the clinical outcomes (“Schizophrenia” OR “Auditory Hallucinations” OR “Auditory Verbal Hallucinations” OR “Psychosis”) searched together (“AND”) with interventions (“transcranial Direct Current Stimulation” OR “tDCS” OR “Brain Polarization”).ResultsSix randomized controlled trials that evaluated the effects of tDCS on the severity of auditory hallucinations in schizophrenic patients were selected. Analysis of the clinical results of these studies pointed toward incongruence in the information with regard to the therapeutic use of tDCS with a view to reducing the severity of auditory hallucinations in schizophrenia. Only three studies revealed a therapeutic benefit, manifested by reductions in severity and frequency of auditory verbal hallucinations in schizophrenic patients.ConclusionAlthough tDCS has shown promising results in reducing the severity of auditory hallucinations in schizophrenic patients, this technique cannot yet be used as a therapeutic alternative due to lack of studies with large sample sizes that portray the positive effects that have been described.

Gamma oscillations are essential for brain communication. The 40 Hz neural oscillation deficits in schizophrenia impair left frontotemporal connectivity and information communication, causing auditory hallucinations. Transcranial alternating current stimulation is thought to enhance connectivity between different brain regions by modulating brain oscillations. In this work, we applied a frontal-temporal-parietal 40 Hz-tACS stimulation strategy for treating auditory hallucinations and further explored the effect of tACS on functional connectivity of brain networks. 32 schizophrenia patients with refractory auditory hallucinations received 20daily 20-min, 40 Hz, 1 mA sessions of active or sham tACS on weekdays for 4 consecutive weeks, followed by a 2-week follow-up period without stimulation. Auditory hallucination symptom scores and 64-channel electroencephalograms were measured at baseline, week2, week4 and follow-up. For clinical symptom score, we observed a significant interaction between group and time for auditory hallucinations symptoms (F(3,90) = 26.964, p < 0.001), and subsequent analysis showed that the 40Hz-tACS group had a higher symptom reduction rate than the sham group at week4 (p = 0.036) and follow-up (p = 0.047). Multiple comparisons of corrected EEG results showed that the 40Hz-tACS group had higher functional connectivity in the right frontal to parietal (F (1,30) = 7.24, p = 0.012) and right frontal to occipital (F (1,30) = 7.98, p = 0.008) than the sham group at week4. Further, functional brain network controllability outcomes showed that the 40Hz-tACS group had increased average controllability (F (1,30) = 6.26, p = 0.018) and decreased modality controllability (F (1,30) = 6.50, p = 0.016) in the right frontal lobe compared to the sham group. Our polit study indicates that 40Hz-tACS combined with medicine may be an effective treatment for targeting symptoms specific to auditory hallucinations and altering functional connectivity and controllability at the network level.

BackgroundAbout 25% of schizophrenia patients with auditory hallucinations are refractory to pharmacotherapy and electroconvulsive therapy. We conducted a deep transcranial magnetic stimulation (TMS) pilot study in order to evaluate the potential clinical benefit of repeated left temporoparietal cortex stimulation in these patients. The results were encouraging, but a sham-controlled study was needed to rule out a placebo effect.MethodsA total of 18 schizophrenic patients with refractory auditory hallucinations were recruited, from Beer Yaakov MHC and other hospitals outpatient populations. Patients received 10 daily treatment sessions with low-frequency (1 Hz for 10 min) deep TMS applied over the left temporoparietal cortex, using the H1 coil at the intensity of 110% of the motor threshold. Procedure was either real or sham according to patient randomization. Patients were evaluated via the Auditory Hallucinations Rating Scale, Scale for the Assessment of Positive Symptoms-Negative Symptoms, Clinical Global Impressions, and Quality of Life Questionnaire.ResultsIn all, 10 patients completed the treatment (10 TMS sessions). Auditory hallucination scores of both groups improved; however, there was no statistical difference in any of the scales between the active and the sham treated groups.ConclusionsLow-frequency deep TMS to the left temporoparietal cortex using the protocol mentioned above has no statistically significant effect on auditory hallucinations or the other clinical scales measured in schizophrenic patients.Trial RegistrationClinicaltrials.gov identifier: NCT00564096.

Efficacy and safety of continuous theta burst stimulation for auditory hallucinations: A GRADE-assessed meta-analysis of randomized sham-controlled trials.

163 Emergency Department Procedural Sedation in Geriatric Patients: A High Risk Patient Population

ObjectivesZZAuditory hallucinations are a common complaint in patients with schizophrenia. They are also refractory to treatment in a substantial number of patients. The aim of this study was to investigate the effects of listening to music on auditory hallucinations, positive and negative symptoms, depression, and quality of life in subjects with schizophrenia. MethodsZZOur study employed a single-blind (assessor blinded) randomized design with a crossover trial. Ten patients with schizophrenia were randomly assigned to two groups. The first group (AB group) experienced an initial ‘music listening period’, followed by a resting period. This sequence was reversed in the second group (BA group). Each period was two weeks in duration. Measurements of outcome were performed by a blind assessor at baseline and at two and four weeks after randomization. ResultsZZThe effect of listening to music on auditory hallucinations, positive and negative symptoms, depression, and quality of life was not statistically significant. On self-report questionnaires, 40% of the subjects reported that ‘listening to music was helpful’ and 90% responded that they would positively consider listening to music when experiencing an auditory hallucination in the future. ConclusionZZListening to music did not result in a statistically significant treatment effect ac cording to objective symptom scales. However, several subjects replied that it was ‘helpful’, implying that it may be useful as an adjunctive treatment for patients suffering from refractory auditory hallucinations. J Korean Neuropsychiatr Assoc 2012;51:202-209

Sir, A 47-year-old male, case of treatment-resistant schizophrenia, had presented with refractory auditory hallucinations, delusion of persecution, and reference at our center. The patient had a continuous progressive illness of 20 years with good compliance to treatment. Initially, he had positive symptoms such as thought broadcast, delusion of persecution, and derogatory auditory hallucinations. In the course of treatment, the symptoms responded with medications and ECT. However, the auditory hallucinations remained refractory to treatment. In 2010, the patient was started on clozapine, which was gradually escalated up to 450 mg. In 2016, haloperidol was added for augmentation, still the hallucinations persisted. Hypersalivation was noted ever since the patient was started on clozapine. Glycopyrrolate (4 mg) was added for the same; however, minimal improvement was noted. In 2020, when the patient was taken for tDCS therapy in view of refractory auditory hallucinations, he was already on clozapine (450 mg) and glycopyrrolate (4 mg). The patient received tDCS sessions on an outpatient basis after taking informed consent. The target areas of stimulation were left temporoparietal junction as the cathode and right dorsolateral prefrontal cortex as the anode. The intensity was kept at 2 mA and stimulation was given for 30 minutes once daily on weekdays. At the end of 15 sessions, there was a significant decline in PANSS scores (composite score reduced from 11 to 3) along with a near-complete cessation of auditory hallucinations. It was observed that not only hallucinations but hypersalivation also improved significantly. Even in the follow-up visits, hypersalivation did not remain a major concern as previously. However, the patient continued to take 4 mg of glycopyrrolate. DISCUSSION The causes of hypersalivation, a distressing side effect that occurs in 31%–54% of patients receiving clozapine therapy, are nonspecific.[1] It may be mediated by the imbalance between M3 receptor blockade (decrease in salivation) and M4 receptor stimulation (increase in salivary output). Another explanation is that clozapine interferes with the swallowing reflex, leading to the pooling of saliva and, therefore, patient complaints of hypersalivation.[2] tDCS administered to the hyperactive left temporoparietal junction (“inhibitory” cathodal) and to the hypoactive left dorsolateral prefrontal cortex (“excitatory” anodal) improves refractory hallucinations as studied earlier.[3] However, the action of tDCS on clozapine-induced hypersalivation has not been noted earlier. It has also been reported that anodal tDCS projecting to the swallowing sensorimotor cortical acts on cricopharyngeal muscles and improves swallowing.[4] Bihemispheric anodal tDCS has been applied to better modulate the excitability of esophageal cortex (proximal to pharyngeal cortex) and improve dysphagia.[5] Nitsche etal.[6] have also stated that tDCS mediates increase in catecholamine through neuroplastic changes. The above-mentioned theories could possibly explain the improvement in hypersalivation in this case. CONCLUSION Although no direct association of tDCS on clozapine-induced hypersalivation has been observed or reported earlier, the above case suggests a temporal correlation between the two. Effect of tDCS through its action on pharyngeal musculature or by catecholaminergic changes could be a topic of further research. tDCS could also be used as an adjunct to pharmacotherapy in treating clozapine-induced hypersalivation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

To investigate the durability of positive effects of cognitive behaviour therapy (CBT) with coping training on psychotic symptoms and social functioning. Forty patients with schizophrenia or related psychotic disorders and refractory auditory hallucinations were given CBT and coping training in an integrated single family treatment programme. In a naturalistic study patients were followed after 2 and 4 years since the start of treatment. The treatment improved overall burden of 'hearing voices', with a generalization into daily functioning. Improvement with regard to fear, loss of control, disturbance of thought and interference with thinking was sustained by 60% of the patients while one-third improved further. Complete disappearance of hallucinations occurred in 18% of the patients. CBT with coping training can improve both overall symptomatology and quality of life, even over longer periods of time, but a status of persistent disablement indicates a continuing need for mental health care.