Makindo Medical Notes

Auditory hallucinations are perceptions of sound (voices, noises, music) in the absence of an external stimulus. They are most often associated with psychiatric illness, but can also arise from organic, neurological, or substance-related causes. 🌟 Always rule out organic and drug-related causes before assuming a primary psychiatric disorder.

🔍 Clinical Assessment

• 📚 History: Onset, duration, content (commentary vs commanding voices), associated mood/psychotic symptoms, drug/alcohol use, medical history.
• 👪 Collateral: Essential for reliability and risk assessment.
• 👀 Examination: Full mental state exam (MSE), neurological exam, cognitive screening if indicated.
• ⚠️ Risk assessment: Command hallucinations → risk of harm to self/others.

🧪 Investigations

• 🩸 Bloods: FBC, U&E, LFTs, TFTs, glucose, B12/folate, CRP.
• 💉 Toxicology: Alcohol and drug screen.
• 🧲 Imaging: CT/MRI brain if neurological signs or late onset.
• 📊 EEG: If temporal lobe epilepsy suspected.
• 🦻 Audiology: If hearing impairment suspected.

🛠️ Management Principles

• 🏥 Treat underlying cause: e.g. antibiotics for infection, AEDs for epilepsy, treat hypothyroidism.
• 💊 Antipsychotics: For schizophrenia/psychotic depression (e.g. risperidone, olanzapine, haloperidol).
• 🧠 Psychological therapies: CBT for psychosis can help with coping strategies.
• 🚑 Substance withdrawal: Managed with benzodiazepines (alcohol), or cessation programmes (stimulants, cannabis).
• 🦻 Hearing aids: For hallucinations associated with hearing loss.
• 👨‍👩‍👧 Support: MDT involvement (psychiatry, neurology, social services) and family education.

🧠 Causes of Auditory Hallucinations

Category	Examples	Clinical Clues
Psychiatric	Schizophrenia spectrum disorders Bipolar affective disorder (mania, psychotic depression) Severe depression with psychotic features Post-traumatic stress disorder (PTSD)	Voices often critical, commanding, or conversational; associated with delusions, thought disorder, mood symptoms
Neurological	Temporal lobe epilepsy Brain tumours (temporal/frontal) Dementia (esp. Lewy body dementia) Parkinson’s disease	Seizures, automatisms, fluctuating cognition, visual hallucinations, focal neurology
Substance-related	Alcohol intoxication or withdrawal (DTs) Cocaine, amphetamines, cannabis, hallucinogens Prescribed drugs (levodopa, steroids, antidepressants)	Temporal link to drug use, intoxication, or withdrawal; agitation, autonomic signs
Sensory impairment	Hearing loss (Charles Bonnet-type auditory hallucinations) Tinnitus-associated percepts	Elderly patients, background of deafness; simple sounds or music rather than voices
Medical/Metabolic	Delirium (infection, metabolic disturbance) Endocrine (thyroid, Cushing’s) Electrolyte disturbance	Acute onset, fluctuating consciousness, systemic illness, visual > auditory hallucinations

🚩 Red Flags

• Command hallucinations instructing harm to self or others
• Acute onset in an older adult (consider delirium, stroke, tumour)
• Associated neurological signs (fits, cognitive decline, focal deficits)
• New onset after age 40 with no psychiatric history → rule out organic pathology

📈 Prognosis

✅ Prognosis depends on cause: substance-related or delirium-associated hallucinations are reversible, while schizophrenia and dementia carry a chronic course. 🌟 Clinical pearl: Hallucinations alone do not equal schizophrenia – always assess context, cause, and risk.

✅ Conclusion

Auditory hallucinations are a symptom, not a diagnosis. The approach must be broad: exclude organic causes, assess for psychiatric illness, and always evaluate risk. Early recognition and tailored treatment can reduce morbidity and improve quality of life.

👂 Case 1 — Schizophrenia

A 22-year-old man reports hearing multiple unfamiliar voices conversing about him when he is alone. He also describes social withdrawal and thought disorganisation. 💡 Auditory hallucinations are a hallmark of schizophrenia, typically experienced as external voices giving commentary or running dialogue. They arise from abnormal dopaminergic signalling in the mesolimbic pathway. Management includes antipsychotic medication, psychological therapies, and psychosocial support.

👂 Case 2 — Severe Depression with Psychotic Features

A 48-year-old woman with a history of major depressive disorder presents with pervasive low mood, guilt, and insomnia. She hears a voice repeatedly telling her she is worthless and should die. 💡 In psychotic depression, auditory hallucinations are often mood-congruent and derogatory. They reflect severe illness and high suicide risk. Management requires urgent psychiatric input, combining antidepressants with antipsychotics, and sometimes electroconvulsive therapy (ECT).

👂 Case 3 — Alcohol Withdrawal (Delirium Tremens)

A 55-year-old man with chronic alcohol dependence presents 48 hours after stopping drinking. He is agitated, sweating, and reports hearing threatening voices. 💡 In alcohol withdrawal delirium, hallucinations (auditory, visual, tactile) occur alongside autonomic overactivity and confusion. This is a medical emergency with high mortality if untreated. Management involves admission, benzodiazepines for withdrawal control, thiamine supplementation, and supportive care.