A 17-y-old girl presented for evaluation of auditory hallucinations that started 3 months ago when she had to move away from her father's home. The parents divorced a year ago. The patient experienced considerable anxiety about her parents' divorce and moving in with her mother. The hallucinations occurred a few minutes after closing her eyes at bedtime, lasted for less than a minute, and initially occurred every night. She heard 2–3 different voices, belonging to either family members or friends, which would either speak to her or speak to each other. On nights when she was more anxious, the voices increased in intensity and had a more aggressive tone; on nights when she was less anxious, the voices had a casual tone. The patient maintained insight that the experience is an erroneous perception, and the voices did not take the form of commands.
The patient goes to bed at 22:00, falls asleep within 30 min, does not awaken during the night, and wakes in the morning at 07:30 feeling rested. She denied excessive daytime sleepiness, witnessed snoring, witnessed apnea, sleep paralysis, cataplexy, or lower extremity restlessness.
Besides anxiety, she denied a history of depression, mania, paranoia, or visual hallucinations. The patient was in high school, had no interpersonal problems with peers or teachers, received grades of A's and B's, and had not noted a recent decline in academic performance.
Review of systems was negative for weight changes or eating disorders. Past medical history was negative. She did not take any medications, and was not under the care of either a psychologist or psychiatrist. There was no family history of narcolepsy or psychiatric disorders. She denied use of tobacco, alcohol, or illicit drugs; urine drug screen was recently negative. Physical and neurological examinations were unremarkable.
QUESTION: What is the diagnosis?
ANSWER: Anxiety disorder with exclusively hypnagogic auditory verbal hallucinations
Hypnagogic hallucinations were first described by Jules-Gabriel-Francois Baillarger, a French psychiatrist in the 1840s. Sleep-related hallucinations have a reported prevalence of up to 37% in the general population, with up to 25% experiencing hypnagogic hallucinations and 18% experiencing hypnopompic hallucinations.1 The International Classification of Sleep Disorders, Third Edition describes them as predominantly visual hallucinations (but can also include auditory and tactile hallucinations) that occur predominantly during sleep and are often associated with insufficient sleep, insomnia, or narcolepsy.2
Auditory verbal hallucinations (AVH) are classically conceived as indistinguishable from real perceptions, except that there is no stimulus. Voices may be single, multiple, male, female, recognized, or unrecognized. Lack of insight into the abnormality of the experience often signals serious mental illness. AVH have been reported to occur in 70% of patients with schizophrenia, 23% with bipolar disorder, 46% with borderline personality disorder, and have been reported in up to 20% of the general population at one point in their lives.3 AVH may represent either brain dysfunction without specificity for a single disorder, or simply the extreme of normal experience. Hypnagogic auditory verbal hallucinations are often the voice of someone known to the patient and usually speak directly to the patient.4 AVH in children are usually transitory, resolving with time, unless they are associated with a severe underlying psychiatric illness.5
AVH have also been reported in anxiety and posttraumatic experiences.6 Depending on the traumatic experience, auditory hallucinations can change in character and quality. Negative traumatic experiences can develop into negative voices. Susceptible personality types may experience AVH, particularly during periods of intense stress.7 Some suggest that AVH are a coping mechanism and may take on assorted contexts ranging from pleasant and supportive, to aggressive and controlling. Volume/intensity can increase depending on the intensity of emotional distress.8
The differential diagnosis of AVH includes partial seizures, central nervous system neoplasm, and substance induced (drugs, alcohol, and medications). Other conditions that can present with predominantly visual hallucinations but can also include auditory hallucinations are migraines, dementia, narcolepsy, REM behavior disorder, and occipital seizures.5
Treatment options for exclusively hypnagogic AVH are aimed at the underlying condition. Sleep extension is commonly recommended when sleep insufficiency is suspected. Psychiatric or neurologic evaluation may be needed to diagnose and manage the underlying conditions. Antipsychotics have not been studied in AVH. Cognitive behavioral therapy has been reported to be helpful. Our patient underwent cognitive behavioral therapy and relaxation techniques, with resolution of her exclusively hypnagogic AVH.
SLEEP MEDICINE PEARLS
Hypnagogic hallucinations may take the form of auditory verbal hallucinations
Exclusively hypnagogic auditory verbal hallucinations may be associated with mood disorders
Treatment of exclusively hypnogogic auditory verbal hallucinations is aimed at addressing the underlying condition, and may respond to cognitive behavior therapy and/or relaxation techniques.
This was not an industry supported study. The authors have indicated no financial conflicts of interest.
DelRosso LM, Liegmann J, Hoque R. An anxious 17-year-old girl who hears voices only at sleep onset. J Clin Sleep Med. 2017;13(2):355–356.
Ohayon MM. Prevalence of hallucinations and their pathological associations in the general population. Psychiatry Res. 2000;97(2-3):153–164. [PubMed]
American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
Upthegrove R, Broome MR, Caldwell K, Ives J, Oyebodie F, Wood SJ. Understanding auditory verbal hallucinations: a systematic review of current evidence. Acta Psychiatric Scand. 2016;133(5):352–367.
Foulkes D, Vogel G. Mental activity at sleep onset. J Abnorm Psychol. 1965;70:231–243. [PubMed]
de Leede-Smith S, Barkus E. A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals. Front Hum Neurosci. 2013;7:367. [PubMed Central][PubMed]
Ratcliffe M, Wilkinson S. How anxiety induces verbal hallucinations. Conscious Cogn. 2016;39:48–58. [PubMed Central][PubMed]
Jessop M, Scott J, Nurcombe B. Hallucinations in adolescent inpatients with post-traumatic stress disorder and schizophrenia: similarities and differences. Australas Psychiatry. 2008;16(4):268–272. [PubMed]
Badcock JC. The cognitive neuropsychology of auditory hallucinations: a parallel auditory pathways framework. Schizophr Bull. 2010;36(3):576–584. [PubMed]