Hearing voices, time traveling, and being hit with a high-heeled shoe
Mr. P, age 47, is arrested after breaking into a stranger’s apartment. He cannot explain his behavior, but reports that his grandmother died recently and he is homeless. How would you help this man?
“Time travelling” with incomprehensible behavior could be interpreted as dissociation, but dissociative fugue or dissociative disorder not otherwise specified (NOS) cannot be diagnosed if symptoms might be the direct effect of a substance, such as Cannabis. Mr. P admitted to substance abuse. We can rule out borderline personality disorder because he did not display or admit to tempestuous interpersonal relationships.
A schizophrenia diagnosis requires the presence of auditory hallucinations that commented on his behavior or conversed among themselves, a second psychotic symptom for ≥1 month, or negative symptoms, which Mr. P lacked (unless belief in time travel is considered delusional).
Last, a physician might have considered malingering or a factitious disorder when Mr. P was found not able to participate in his own defense, but this seemed less likely after he revealed that he experienced auditory hallucinations since age 10.
HISTORY Bad beatings
With a few days of beginning risperidone, 4 mg/d, Mr. P reports that his hallucinations have stopped and he feels less sad. He reveals that, at age 10, when the hallucinations began, his mother hit him over the head with a high-heeled shoe, causing a scalp laceration that required a visit to the emergency room for suturing. His mother beat Mr. P for as long as he could remember. She beat him “bad” at least twice weekly, and he was taken to the hospital 7 or 8 times for injury, but she also beat him “constantly” with a belt buckle, sometimes striking his head. She instructed him to tell nobody.
The author’s observations
Auditory hallucinations in adults have been associated with childhood abuse, particularly childhood sexual abuse,12 in clinical and non-clinical samples.13 Some argue13 that child abuse itself causes hallucinations and other psychotic symptoms.
OUTCOME Depressed and sleepless
Mr. P admits that he had been smoking marijuana 2 to 3 times daily for a year. He also reports insomnia, sleeping approximately 4 hours a night and spending hours awake in bed thinking of his grandmother, with depressed mood and tearfulness. He denies suicidal ideas and hallucinations. He is treated for depressive disorder NOS first with amitriptyline, 50 mg at bedtime, for sleep, then paroxetine, 20 mg/d, for depressive symptoms, in addition to risperidone, 4 mg/d. Although Mr. P does not describe re-experiencing his childhood trauma, avoidance of stimuli associated with the trauma, or symptoms of increased arousal (except for insomnia), the treatment team did not ask, so it remains uncertain if he has PTSD (Table 2).
When Mr. P is discharged to a clinic, he smiles easily and is positive and supportive with other patients. He spruces up his appearance by wearing jewelry and works in the hospital kitchen.
Bottom Line
Chronic auditory hallucinations are associated with psychiatric illnesses other than chronic schizophrenia, particularly those resulting from trauma such as posttraumatic stress disorder. They can also occur in the absence of diagnosable psychiatric illness and rarely cause distress or functional impairment. Auditory hallucinations in adults have been associated with childhood abuse.
Related Resources
- Moskowitz A, Schafer I, Dorahy MJ. Psychosis, trauma and dissociation: emerging perspectives on severe psychopathology. West Sussex, UK: John Wiley and Sons, Ltd.; 2008.
- The International Hearing Voices Network. www.intervoiceonline.org.
Drug Brand Names
Amitriptyline • Elavil Paroxetine • Paxil
Benztropine • Cogentin Risperidone • Risperdal
Haloperidol • Haldol
Disclosure
Dr. Crowner reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
