Auditory hallucinations

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Psychiatric Causes

Schizophrenia: Characterized by chronic or recurrent episodes of psychosis, including auditory hallucinations, often with delusional beliefs or thought disorder.
Bipolar Disorder: Auditory hallucinations may occur during manic or depressive episodes, often associated with mood-congruent themes.
Major Depressive Disorder with Psychotic Features: Severe depression accompanied by hallucinations, typically with negative or self-critical content.
Post-Traumatic Stress Disorder (PTSD): Hallucinations often related to the traumatic event.
Borderline Personality Disorder: Transient hallucinations, often stress-induced.

Neurological Causes

Temporal Lobe Epilepsy: May include auditory hallucinations, often described as unusual sounds or voices.
Brain Tumor: Lesions, particularly in the temporal lobe, can cause auditory hallucinations.
Dementia: Advanced stages, especially in Lewy Body dementia, may present with hallucinations.
Parkinson’s Disease: Hallucinations may occur as part of the disease or secondary to medications.
Delirium: Acute onset of hallucinations, often fluctuating and associated with medical illness or drug intoxication.

Substance-Induced

Alcohol Withdrawal: Typically occurs within 12-24 hours after cessation, often as part of delirium tremens.
Illicit Drug Use: Hallucinogens (e.g., LSD), stimulants (e.g., cocaine), and cannabis can induce hallucinations.
Medication Side Effects: Particularly anticholinergics, dopaminergics, and some antidepressants.
Toxins: Exposure to certain chemicals (e.g., carbon monoxide) can cause hallucinations.

Other Medical Causes

Hearing Impairment: Charles Bonnet syndrome in auditory form can cause hallucinations in people with hearing loss.
Infections: Encephalitis, meningitis, and severe systemic infections can cause hallucinations.
Thyroid Dysfunction: Both hypo- and hyperthyroidism can contribute to hallucinations.
Electrolyte Imbalances: Severe derangements, such as hyponatremia, can lead to hallucinations.
Vitamin Deficiency: Particularly B12 deficiency, which can lead to neuropsychiatric symptoms.

Key Points in History 🥼

Onset and Duration

Acute onset: Suggestive of delirium, substance intoxication, or withdrawal.
Chronic and insidious onset: More indicative of a primary psychiatric disorder such as schizophrenia.
Episodic: Consider epilepsy, especially temporal lobe epilepsy.

Content of Hallucinations

Voices discussing the patient: Common in schizophrenia.
Critical or derogatory voices: Seen in major depressive disorder with psychotic features.
Command hallucinations: Can occur in schizophrenia and require urgent risk assessment.
Non-verbal sounds: Consider neurological causes such as temporal lobe epilepsy.
Related to traumatic events: Suggestive of PTSD.

Background

Past Psychiatric History: Previous diagnoses of schizophrenia, bipolar disorder, or depression.
Medical History: Known neurological disorders, thyroid dysfunction, or hearing impairment.
Drug History: Current or recent use of medications with potential psychiatric side effects.
Substance Use History: Alcohol, recreational drug use, or recent cessation.
Family History: Psychiatric illnesses, especially schizophrenia or bipolar disorder.
Social History: Recent stressors, trauma, or significant life changes.

Possible Investigations 🌡️

Laboratory Tests

Full Blood Count (FBC): To rule out infection or anemia.
Electrolytes and Renal Function: To identify imbalances or renal failure.
Liver Function Tests (LFTs): To assess for hepatic encephalopathy or chronic alcohol use.
Thyroid Function Tests: To rule out hypo- or hyperthyroidism.
Vitamin B12 and Folate Levels: To assess for deficiency.
Toxicology Screen: To detect drugs or toxins.

Imaging

MRI or CT Brain: To identify structural abnormalities such as tumors, strokes, or temporal lobe epilepsy.
EEG: To assess for epileptiform activity, particularly in suspected temporal lobe epilepsy.

Specialist Assessments

Psychiatric Evaluation: Comprehensive assessment of mental state and risk.
Neuropsychological Testing: To assess cognitive function if dementia or brain injury is suspected.

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