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

🚩 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.