• Academics highlight challenges in diagnosing patients with non-psychotic auditory hallucinations

BY Ruwan Laknath Jayakody Inadequacies of the main diagnostic classifications, a lack of familiarity with symptoms, and the cultural factors influencing clinical presentations may lead to difficulties in diagnosing children and adolescents presenting with non-psychotic auditory hallucinations, thus the chance of them being inappropriately managed and labelled as “psychotic”, local case studies on the matter noted. Therefore, understanding the psycho-social contexts in which non-psychotic auditory hallucinations occur among children and adolescents may help to reduce such, local researchers observed. These observations were made in an opinion piece on “Non-psychotic auditory hallucinations in children and adolescents”, which was authored by Prof. H. Perera (attached to Colombo University’s Medical Faculty’s Psychological Medicine Department), U. Attygalle (Registrar in Psychiatry), C. Jeewandara (Medical Officer in Psychiatry), and V. Jayawardena (Senior Registrar in Psychiatry at the Lady Ridgeway Hospital for Children) and published in the Sri Lanka Journal of Psychiatry 2 (1) in June 2011. In B.J. Sadock and V.A. Sadock’s Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry, the clinical phenomenon of auditory hallucinations is defined as auditory perceptions in the absence of identifiable external stimuli. The presence of auditory hallucinations is viewed, as per Perera et al., as being synonymous with psychotic disorders, which in turn indicate serious psychopathology and an unfavourable prognosis. However, auditory hallucinations in children and adolescents are relatively less significant diagnostically speaking and a range of other mental health problems may produce this symptom. Auditory hallucinations have been described in children and adolescents with conduct and emotional disorders (M. Garralda), difficulties in coping, bereavement, affective syndromes (illnesses that affect the way one thinks and feels), migraine, anxiety, and adjustment disorders (as per T. Yates and J. Bannard’s “The haunted child: Grief, hallucinations, and family dynamics”; H.A. Schreier’s “Auditory hallucinations in non-psychotic children with affective syndromes and migraine: Report of 13 cases”; and S. Kotsopoulos, J. Kanigsberg, A. Cote, and C. Fiedorowicz’s “Hallucinatory experiences in non-psychotic children”). In “Hallucinations in children and adolescents: Considerations in the emergency setting”, G.A. Edelsohn found that out of children presenting with non-psychotic hallucinations to a psychiatric emergency service, 34% were depressed, 22% had attention deficit hyperactivity disorder (ADHD), and 12% had a disruptive behavioural disorder. On the other hand, in “Visual, tactile, and phobic hallucinations: Recognition and management in the emergency department”, M. Pao, C. Lohman, D. Gracey, and L. Greenberg found a related condition as being benign phobic hallucinations present in preschool and early school age children, where visual and tactile phenomena are associated with anxiety, are transient, and present mostly at night. In clinical populations, the reported incidence of auditory hallucinations in non-psychotic children and adolescents range from 1.1% to 5.7% (as per Garralda; “Hallucinations in children” by P. Burke, M.D. Beccaro, E. McCauley, and C. Clark; “Hallucinations in non-psychotic children: More common than we think?” by H.A. Schreier; and “Hallucinations in non-psychotic children and adolescents” by J.F. Simonds). The incidence for the same was high (9%) in abused children (as per R. Famularo, R. Kinscherff, and T. Fenton’s “Psychiatric diagnoses of maltreated children: Preliminary findings”). In follow-up studies (“Independent course of childhood auditory hallucinations: A sequential three-year follow-up study” by S. Escher, M. Romme, A. Buiks, P. Delespaul, and J.V. Os) of non-psychotic children and adolescents, the discontinuation rate of auditory hallucination was 60%, thus suggesting that the hallucinations are non-psychotic in nature in the majority. However, Perera et al. noted that psychotic states are rare in children and that the discontinuation of hallucinations is less common when they do occur. Studies (A. Moskowitz and D. Corstens’ “Auditory hallucinations: Psychotic symptom or dissociative experience?”) have suggested that non-psychotic hallucinations are a dissociative phenomenon. Personal and family stresses, according to Perera et al., have also been identified as precipitants. The change of school, admission to hospital, actual or threatened separation from parents, and the loss of friends or relatives through death have all been described as causative factors (Yates and Bannard). A higher rate of having a positive family history of psychosis and depression has also been reported, when compared to non-hallucinating children (Burke et al.). Non-psychotic auditory hallucinations have also been recognised, as per Perera et al., as indicating high levels of arousal, arising from chronic stress, the evidence for which comes from significant rates of family disruption, dysfunction, and domestic violence (Kotsopoulos et al., Edelsohn, and M. Manosevitz, N.M. Prentice and F. Wilson’s “Individual and family correlates of imaginary companions in preschool children”). Schreier has hypothesised neurological disturbances such as migraine and anxiety disorders associated with it as a cause, especially in the presence of a strong family history of both disorders. Also, children may, according to Manosevitz et al., P. Bouldin, and C. Pratt’s “A systematic assessment of the specific fears, anxiety level, and temperament of children with imaginary companions” and N.T. Best and P. Mertin’s “Correlates of auditory hallucinations in non-psychotic children”, describe their thoughts as voices due to their cognitive immaturity and their natural tendency for illogical thinking, where sometimes, children talk to themselves and to imaginary friends in order to alleviate loneliness and to assist in allaying various fears. Perera et al., therefore, presented a case series of 12 children and adolescents where auditory hallucinations were a prominent feature in the clinical presentation. Case one A 12-year-old male heard a male voice that commanded him to read the book Lord of the Rings and asked questions on the story. He had acted out the contents of the book. He had attended school but refused to work at school, and had read books during lessons and late into the night and had disturbed sleep. He had no other interests. He had always been a loner. He was worried about contamination with germs, leading to frequent hand washing. He was bullied at school. He was initially diagnosed with schizophrenia (symptoms can include delusions, hallucinations, disorganised speech, trouble with thinking, and the lack of motivation). He was initially managed with an atypical antipsychotic used to treat schizophrenia, but due to the poor response, another atypical antipsychotic was later prescribed. He was not compliant with it. The revised diagnosis was Asperger’s syndrome (neuro-developmental disorder characterised by significant difficulties in social interaction and non-verbal communication, along with restricted and repetitive patterns of behaviour and interests). The outcome was that he improved with social skills training and behavioural interventions. No medication was given. He was eventually able to function at school and the hallucinations completely disappeared. Case two A 15-year-old female heard the voice of a neighbour planning to send toxic fumes through the windows to kill her. She refused food believing that it was poisoned. She refused to leave her bed for fear of contamination with germs and engaged in repeated hand washing. She was suspicious and quarrelsome and accused her family of conspiring against her. The change of residence was a possible precipitant. The initial diagnosis was schizophrenia. She was initially managed with an atypical antipsychotic. The revised diagnosis was obsessive compulsive disorder (OCD – chronic and disabling conditions characterised by recurrent intrusive thoughts and compulsive acts). The outcome was partial improvement with an antidepressant and atypical antipsychotic. There was poor compliance with medication and behaviour therapy. At the follow-up, however, hallucinations were not a consistent complaint. Case three A 16-year-old female heard voices that predicted that some harm will befall her parents and therefore, she avoided passing the cemetery believing that her parents would die if she did so. She feared contamination with germs and engaged in repeated hand washing. She was suspicious of others and had poor anger control. She failed the General Certificate of Education (GCE) Ordinary Level examination. The initial diagnosis was schizophrenia. The initial management was with an atypical antipsychotic. The revised diagnosis was OCD. The outcome was that she responded to treatment with an antidepressant and behavioural management, and the hallucinations completely disappeared. Case four A 10-year-old male heard the voice of his dead grandmother. He refused to go to school and had poor academic skills with difficulties in reading and spelling. The parents also believed in the grandmother’s presence as an invisible force in the house. The school teacher had admonished him for getting low marks at an examination. He suffered a viral fever just before the onset of the symptoms. The initial diagnosis was low academic performance. No specific interventions were made in terms of the initial management. The revised diagnosis was ADHD with specific developmental disorder. The outcome was that he improved following treatment with a central nervous system stimulant and remedial teaching, and the hallucinations completely disappeared. Case five A 17-year-old male heard an unknown being comment on all his actions and believed that neighbours and teachers were making negative comments about him. He had a low mood. He avoided school. He lost interest in previously pleasurable activities. He slept and ate poorly. He was socially withdrawn. He drew pictures of demons, believed in supernatural forces, and preferred to wear black clothes. He had a breakup of a relationship with his girlfriend before the onset of the symptoms. He had no previous contact with psychiatric services. The diagnosis was depression and Asperger’s syndrome. The outcome was that he improved on an antidepressant and when helped with problem solving strategies for coping with adversities, and subsequently, the hallucinations completely disappeared. Case six A 17-year-old male heard a voice commanding him to leave the home and live elsewhere and he felt compelled to act on this command. He talked to himself. He served tea and biscuits to an imaginary person. He had a homosexual relationship with a friend he had contacted over the internet. He refused to attend school. He defied his parents. Delusional thinking was not elicited. He was initially diagnosed with schizophrenia. He was initially managed with a typical antipsychotic. The revised diagnosis was bipolar affective disorder (causes extreme mood swings that include emotional highs or mania or hypomania and lows, or depression), a manic episode without psychotic symptoms. The outcome was that he improved with sodium valproate and was able to cope with the voices he heard, which were inconsistent upon follow-up. Case seven A 16-year-old female heard the voice of the priest at the local temple and the voice of her class teacher, both directly addressing her. The voices were not present when she was engaged in an activity she liked. She was suspicious of and aggressive towards her family members. She claimed that her body was changing its shape. She demanded that a job be found for her, but rejected opportunities when they arose. She was restless, irritable, and slept and ate poorly. She blamed her family for her problems. The onset was attributed to a failure at an examination. She was a loner with few friends. The initial diagnosis was schizophrenia. She was initially managed with an atypical antipsychotic. The revised diagnosis was Asperger’s syndrome. The outcome was that she was treated with an antidepressant and sodium valproate for mood dysregulation. She, however, continued to have behavioural difficulties, but the hallucinations were inconsistent and not considered a major problem by the patient at the time of follow-up. Case eight A 16-year-old female heard the voice of an unidentified person commenting about the Buddha and the voice also asked her to hit her mother. She refused to go to school due to the fear of contamination with germs and frequent hand washing was present. She was initially diagnosed with schizophrenia and initially managed with an atypical antipsychotic. The revised diagnosis was OCD. The outcome was that she improved on an antidepressant and behavioural interventions, and the hallucinations completely disappeared. Case nine A 12-year-old female heard voices threatening to kill her parents. She was irritable, had poor sleep and episodes of excessive crying, and constant restlessness and pacing. She ran away from home on one occasion. There were many somatic (relating to, or affecting the body, especially as distinguished from a body part, the mind, or the environment; corporeal or physical) complaints. The failure at an examination occurred before the onset of the symptoms. No definite diagnosis was made. The initial management was with atypical antipsychotic, an antidepressant, and sodium valproate. The revised diagnosis was that she had an anxious temperament and that she reacted to the depression in her mother, and had features of side effects of psychotropic medication. The outcome was that she improved after the medication was discontinued. The mother was treated for a depressive disorder. The girl was provided help with problem solving, and the hallucinations completely disappeared. Case 10 A seven-year-old male heard the voice of his grandmother who died of a brain tumour, calling his name, and he was preoccupied with thoughts about his grandmother’s death. He complained of recurrent headaches and attributed a superficial lump on his scalp to a malignancy in his brain. His mother had the same worry and recurrently sought medical help and reassurance. He had a period when he complained that he could not recognise his mother. The initial diagnosis was temporal lobe epilepsy. He was initially managed for anxiety disorder. The revised diagnosis was OCD. The outcome was that he improved following psycho-education of the mother about the child’s condition, and the hallucinations completely disappeared. Case 11 A 12-year-old male heard the voice of the demon Badrakali commanding him. He believed that there were ghosts around him and was persistently fearful of them. He was restless and impulsive. He was aggressive towards his parents. His cognitive skills were below normal for his age. His family shared the beliefs about ghosts. He was punished by a teacher for poor school performances. A computerised tomography scan of the brain and the electro-encephalography test were normal. Delusions were not elicited. He was initially diagnosed with schizophrenia. He was initially managed with an atypical antipsychotic. The revised diagnosis was intellectual impairment with challenging behaviour. The outcome was that the medication was discontinued which initially led to a reduced food intake and loss of weight, thus causing anxiety to the parents. However, he improved with behavioural interventions targeting both the child and the family, and the hallucinations completely disappeared. Case 12 A 11-year-old female heard a voice commanding her to come to a nearby cemetery and the voice also threatened to kill her. She had visions of a dark unidentifiable face that was very frightening. She had panic attacks in school with abdominal pain, difficulty in breathing, and palpitations. She was irritable, had crying spells, marked agitation, social withdrawal, and muttered to herself. She attempted to dismiss fears by reading religious texts but failed. She attained menarche four months ago and the family believed that she was influenced by a bad spirit. There was no evidence of child abuse. She had no previous contact with psychiatric services. The revised diagnosis was anxiety disorder. The outcome was that she improved with an antidepressant and atypical antipsychotic at night and behavioural interventions for anxiety, and the hallucinations completely disappeared. Discussing the findings, Perera et al. explained that in children and adolescents, the content of auditory hallucinations themselves may not provide a useful guide to diagnosis, as the content of the hallucinations, both of a psychotic and non-psychotic nature, is remarkably similar. According to Kotsopoulos, and Moskowitz and Corstens, in the presence of low mood, stress, and anxiety, the voices may urge aggressive action against others and warn of danger and possible harm. Inaccurate diagnosis, Perera et al. noted, may occur, unless auditory hallucinations in children and adolescents are evaluated from a broader clinical perspective than in adults, and the application of the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual (DSM) diagnostic criteria is done with due consideration to the associated phenomena.

1. Bhugra and K. Bhui pointed out in the “Clinical management of patients across cultures” that unfamiliarity regarding the phenomenon of non-psychotic hallucinations is likely to promote the tendency to look for a more familiar diagnosis that would fit in with the patient’s presentation, even if all clinical criteria are not fulfilled. I. al-Issa observes in “The illusion of reality or the reality of illusion: Hallucinations and culture” that auditory hallucinations in a child or an adolescent are likely to cause much anxiety to the parents and the child or adolescent, and that their emotional reaction to the symptoms in turn may also influence the psychiatric evaluation, unless all aspects of the presentation are carefully evaluated. Therefore, Perera et al. emphasised that the associated behaviour involved in the presentation may help to a certain extent in making the distinction between psychotic and non-psychotic hallucinations.

Moreover, M. Garralda’s “Characteristics of the psychoses of late onset in children and adolescents: A comparative study of hallucinating children” elaborated that children and adolescents with a psychotic disorder have associated disturbances in language production, diminished motor activity, incongruous mood, bizarre behaviour, delusional beliefs, and social withdrawal. Evaluating auditory hallucinations in children and adolescents with neuro-developmental disorders, especially those with mental retardation, pose, Perera et al. added, a particular challenge to the clinician, as due to the nature of the predisposing cerebral vulnerability in such a child or adolescent, auditory hallucinations could be associated with a psychotic disorder or the prodromal (relating to or denoting the period between the appearance of initial symptoms and the full development of such) stage of a psychotic disorder, or it could also be associated with emotional and behavioural disorders as well as seizure disorder (A.D. Hurley’s “The misdiagnosis of hallucinations and delusions in persons with mental retardation: A neurodevelopment perspective”). Additionally, K. Bhui and D. Bhugra’s “Communication with patients from other cultures: The place of explanatory models” noted that cultural influences related to ethnicity, religious beliefs, rural or urban living, and family values on the presentation of symptoms of mental disorder may also challenge the clinician’s familiar tried and tested strategies in diagnosis and management. Hence, clinicians familiarising themselves with the manifestations of cultural beliefs under psychologically demanding experiences could improve their diagnostic skills.