Metabolic disorders, such as hypercalcemia, hyponatremia, uremia, hepatic encephalopathy, thyroid disorders, hypoglycemia, vitamin deficiencies, and porphyria, can cause delirium associated with hallucinations and delusions. Intoxication or withdrawal from substances of abuse can cause psychosis at any age. New-onset paranoia and hallucinations in a 52-year-old man have a broad differential diagnosis. He was admitted to our psychiatric service. Laboratory work, including a basic serum chemistry panel, a CBC, tests of liver enzymes, a urine drug screen, and a urinalysis, were all unremarkable. At the time, he was unwilling to discuss the nature of the visual hallucinations. His perceptual disturbances included auditory and visual hallucinations. His thought content was notable for paranoid delusions and delusions of thought insertion. However, his thought processes were fluent, logical, and goal directed. A described his mood as “scared.” His affect was congruent. A’s mental status examination revealed a well-groomed, well-nourished 52-year-old white man who looked his stated age. The results of a physical examination were unremarkable. A’s vital signs in the emergency department were a temperature of 36.4° C, a blood pressure of 141/88 mg Hg, a pulse of 78 bpm, and a respiration of 16 breaths per minute his pulse oximetry showed an oxygen saturation of 97% on room air. He regularly attended Alcoholics Anonymous meetings. A admitted to a remote history of polysubstance abuse that had been in full remission for over 2 years. He reported no recent drug, alcohol, or supplement use. His past medical history was significant for a diet controlled for adult-onset diabetes mellitus. A stated that he had stopped taking risperidone because it made him feel uncomfortable. The attending psychiatrist at an outside hospital treated him with risperidone (0.5 mg b.i.d.) and bupropion for new-onset depression with psychotic features. He stated that he was discharged from a psychiatric hospital the previous day. A also complained of visual hallucinations that he was unable to describe. He stated that he had recently been put on the FBI’s list of child sexual predators. He also expressed the fear that he was being set up to look like he had committed suicide. The voices had been keeping him awake at night. A said they were inside his head and could complete his thoughts. The voices had been worsening at the time of his presentation, Mr. However, 3 weeks earlier, he had begun hearing voices outside of his head. A stated he had been treated for depression for about 9 months with immediate-release bupropion (100 mg b.i.d.), which he described as helpful. He said he could hear the FBI coming after him because he was a sexual predator. A,” a 52-year-old man, was brought to the emergency department by his family because of worsening paranoia and auditory hallucinations. To highlight the importance of taking a thorough history, we present the relevant data longitudinally, in the same manner in which it was obtained. This article recounts the treatment course of a patient with new-onset auditory hallucinations. Although the meaning, significance, and etiology of these voices depend on their context, auditory hallucinations are most often a symptom of severe, disabling psychiatric or neurological illness. Many historical figures, from Socrates and Caesar to Descartes and Joan of Arc, have been reported to “hear voices” (5). Auditory hallucinations have been linked to left-brain alterations in imaging studies, more specifically Broca’s area, the anterior cingulate, the superior temporal lobe, and the primary auditory cortex (4). Auditory hallucinations have been estimated to occur in 10%–15% of those without neuropsychiatric illness (3). However, auditory hallucinations have been described in conjunction with many life circumstances and diseases, including religious phenomena, bereavement, drug intoxication, sensory deprivation, and near-death experiences, as well as psychiatric or neurological disorders. Auditory hallucinations are found most often in patients with schizophrenia, with a prevalence of 75% in that population (2). These are the most common forms of hallucinations (1). According to DSM-IV-TR, a hallucination is “a sensory perception that has a compelling sense of reality of a true perception, but occurs without external stimulation of the relevant sensory organ.” Thus, an auditory hallucination is a false perception of sound.
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