Friday, December 12, 2008

Noises in the Attic

Alas, how is't with you,
That you do bend your eye on vacancy,
And with th'incorporeal air do hold discourse?


(Illustration by Adolf Wolfli, hospitalized for psychosis in Berne, Switzerland from 1895 until his death in 1930).

Auditory hallucinations are the darndest thing. We all have our moments in life obviously, and I think that my own experiences plus a willing imagination can provide at least a vague idea of what it might be like to undergo a good number of the clinical syndromes I see. Can I know exactly? Of course not, as some patients like to point out, but that is always the case between two people (can they know exactly what it is like to be me?). Like any decent doctor or therapist, I make the effort and continually check in with the person in question to see how my imagined approximation is holding up.

Voices are tough though, as I have never experienced anything like them. The ominous creak upstairs, the pillow in the dark mistaken for something else, yes, but voices are something else entirely. I doubt that dreams provide any semblance of waking hallucinations. I can only imagine that they are disturbing at the least and potentially terrifying. My lack of experience makes me all the more curious about what it might be like to have them, so I hope that imagination gives empathy a needed boost.

Voices are most commonly associated with schizophrenia, but they constitute psychotic symptoms that may occur in various other conditions: severe depression or mania, substance abuse or withdrawal, and various neurological disorders such as dementia and delirium. Visual hallucinations can occur along with voices, but the former are more commonly seen in "organic" conditions such as substance withdrawal and delirium. Atypical voices can occur with borderline personality disorder or post-traumatic stress disorder. Not long ago I saw someone with voices that, she volunteered, had names. This is unusual, and given her history of severe abuse, it may suggest dissociative identity disorder (the same as "multiple personality disorder").

If someone hears the voice of a loved one who has died, this is considered normal. Similarly, hearing the voice of God is normal if such is culturally appropriate for the person and not accompanied by psychopathology. It is also possible, although perhaps rare and certainly not well understood, for some people to have random and isolated auditory hallucinations without having a psychiatric or neurologic condition.

Like much in psychiatry, the heterogeneity of auditory hallucinations is impressive. Most commonly they are strange (i.e. not sounding like anyone known to the patient) and derogatory. That is, they utter insults, often using profanity. Somewhat less commonly, they issue commands, sometimes bizarre and sometimes threatening.

But auditory hallucinations can be quite subtle, and in those cases it is hard to know how aggressively to go after them (particularly when they aren't obviously distressing to the patient). Someone may hear faint voices but be unable to make out what they are saying (this is often described as hearing a barely audible conversation in an adjoining room). They may hear noises that don't seem "real" (i.e. generated by the physical environment) but that aren't voices. Some people hear music; this seems to occur with the elderly more often. Some of this may be more likely with the relative sensory deprivation of hearing loss.

When it comes to true schizophrenia, there is nothing quite like seeing someone in the grip of a first psychotic break, or in the months thereafter. There is a distinct air of dismay, bewilderment, and consternation. The patient appears at once puzzled, confused, and afraid. I am often surprised that patients and their families are not particularly focused on the diagnosis--it is as if they know already at some level. I give it to them anyway as gently as I can (or remind them as the case may be) and emphasize manageability of symptoms with treatment.

The psychotherapy of psychosis involves education and intentional self-distraction among other things. People in the grip of voices sometimes wander long distances away from home, as if they are being hounded. It takes them a while to learn and to believe that they don't have to listen to the voices, that the voices, despite their threats, are actually powerless to hurt them or anyone else. People who have lived with schizophrenia for years become relatively accustomed to voices, although they can obviously still be upset and agitated by an exacerbation.

While recent studies have suggested that older antipsychotic drugs (like haloperidol (Haldol)) are every bit as good as newer ones, in my experience the newer ones are better tolerated in a subjective sense. Patients are more willing to take them. The metabolic side effects (weight gain and diabetes) can be a major problem.

In the ten years since residency I have never accepted drug company gifts or support of any kind. So my drug preferences are based on what I read in the literature and my experience with patients. Risperidone (Risperdal) is my favorite antipsychotic to start with; it seems to balance solid effectiveness with good tolerability. I found out the other day that 30 doses of generic risperidone 3 mg was only $46; I was surprised, that almost approaches affordability.

Olanzapine (Zyprexa) has the worst metabolic side effects on average, but its efficacy is impressive; it is often a reasonable option for those having major insomnia and who are thin (to start with). Unfortunately it is exorbitantly pricy. Quetiapine (Seroquel) is well-tolerated, but as it too can cause weight gain (and is very expensive too), so is often prescribed too loosely for insomnia and anxiety (in the absence of psychosis). Aripiprazole (Abilify) is a decent alternative because it produces less drowsiness and weight gain, but not uncommonly it generates unpleasant akathisia (a restless feeling).

The other day at our small clinic 37 patients received their monthly or bimonthly antipsychotic injections (they are for people who cannot or will not keep up with taking pills daily, but these kinds of shots are voluntary). I heard that Risperdal Consta now comes with a smaller needle for deltoid rather than gluteal use; I suppose that is an improvement. I imagine it must hurt though.


Anonymous said...

I recently read a book by Daniel B. Smith 'Muses, Madmen, and Prophets' which explores the phenomenon of auditory hallucinations. It includes: history; cultural interpretations; notable voice hearers; biographical interludes of the author's father's experience; psychiatry; physiology etc.

An interesting case mentioned was that of a man with schizoaffective disorder who suffered auditory hallucinations for 20 years. It started with a singular tinny voice at 14, and progressed to a multitude of voices that he organised into a complex political structure with names and unique roles to help manage his experience. The final 'comforting' voice he began hearing was that of what he designated as 'the voice of God'. He said highschool really stuffed him up -- that's when most of the voices came. Not surprising; highschool is a challenging time even for those who have their sanity intact!

Novalis, have you ever thought of taking mescaline (or have you already) to simulate the experience of auditory hallucinations suffered by schizophrenics? It'll strengthen your understanding, rapport and empathy with your patients...if you return, that is. Let us know!

Some of the great scientists of our times have self-experimented that the world may know that their ideas are not sheer lunacy!

Anonymous said...

Actually, I've suffered auditory hallucinations; although not from any mental disorder (despite a recent wishful diagnosis to the contrary...).

I've experienced sleep paralysis which was terrifyingly accompanied by ominous sounds and shadows. It seemed to affect me mostly in my late teens; I very rarely experience it now. I only see dead people...and not even every day.

...that last part IS a, really it is! Except for that other time...briefly I, I've forgotten about it..sorry, must be my ultra (certifiably)-sane self getting the better of me, again...

Novalis said...

Mescaline is an intriguing option, although it's probably best that I refrain for now. But Aldous Huxley's experiences with it as documented in "The Doors of Perception" were fascinating.

I didn't mention that people do occasionally malinger hallucinations as they may anything else, and it can be interesting trying to distinguish feigned voices from real ones. The best way is to try to lead someone into a "positive review of systems." If someone claims to be having "hallucinations" in all five sensory modalities at once, particularly if they are peculiar (do you ever see blue squirrels? do you ever smell pipe smoke?), then I tend to be suspicious.

Dr X said...

This is just fascinating to me. Taking a history recently, I was told about a one-time only auditory hallucination. The person denied any hallucinations before or since. It was a short P.A. announcement in a room with no P.A. system. The content of the announcement suggested that the speaker might be God, and it was a reassuring rather than persecutorial announcement. It was loud, clear and no one else he asked heard it. He didn't know what to make of it and still doesn't know what to make of it.

Anonymous said...

I had a one-time-only auditory hallucination, too.

I was extremely depressed and stressed at the time, but had agreed to take a friend to a clinic for a prenatal check-up. While sitting in the waiting room, I started hearing someone urgently whispering my name, as if trying to get my attention. The voice sounded almost frantic, and the feeling I got was that I should leave the room (quickly).

I looked up every time I heard the voice but could never determine where the sound was coming from. After examining the other people around me, and scrutinizing the room thoroughly, I decided no one was paying any attention to me, and the voice must have been hallucinated. I ignored it after that and it eventually stopped.

That was 25 years ago, and it hasn't happened since.