Hallucinations
Background
- The perception of auditory, visual, tactile, or gustatory sensations without an actual stimulus
- Etiology may be from underlying psychiatric disorder or organic cause.
Clinical Features
Differential Diagnosis
Organic causes
- Delirium
- Intracranial mass to occipital or temporal lobes
- Encephalitis, limbic encephalitis, anti-NMDA receptor encephalitis
- Migraine
- Seizure
- Hypocalcemia/Hypercalcemia
- Rift valley fever
- Rabies
- Syphilis
- Vitamin B7 deficiency
- Pellagra
- Dementia
- Parkinson's Disease
Other Toxicologic Causes
- Alcohol Withdrawal
- Anticholinergic Toxicity
- Tricyclic (TCA) Toxicity
- Synthetic cannabinoids
- Inhalant abuse
- Nitrogen narcosis
- GHB withdrawal
- Hydrocarbon toxicity
- Heavy metal toxicity
- Multiple medications: montelukast, doxapram, hyoscyamine, tizanidine, peramivir, amantadine, rimantadine, bromocriptine, methylergonovine, benztropine, doxepin, voriconazole, acyclovir, valacyclovir, ganciclovir, cimetidine, penicillin G Procaine, clarithromycin, metoclopramide
- Inhalant abuse
Psychiatric Causes [1]
- Schizophrenia, schizoaffective disorder, schizophreniform disorder
- Depression with psychotic features
- Bipolar disorder
- Charles Bonnet Syndrome (in the visually impaired)
Evaluation
- Workup should be targeted toward specific diagnosis.
- In non-auditory hallucinations, assume organic pathology until proven otherwise.
- New diagnosis of psychiatric disease as cause of hallucinations should generally not be made in ED without first ruling out organic pathology
- If concern for suicidal or unknown toxic ingestion:
- Acetaminophen level
- Salicylate level
- ECG
Management
- Treat the underlying pathology.
- If hallucinations distressing, can trial dose of PO antipsychotic
- In the case of alcohol withdrawal hallucinosis, no standard therapy has been established,[2] although treatment with neuroleptics (e.g. Haldol) has shown some benefit. [3] Also continue to treat the alcohol withdrawal.
References
- Visual Hallucinations: Differential Diagnosis and Treatment. PMID PMC2660156
- Neuroleptic treatment of alcohol hallucinosis: case series. PMID 18030655
- Alcohol-induced hallucinosis. Clinical aspects, pathophysiology and therapy. PMID 9064548
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