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Case Report
Introduction
Auditory hallucinations are a common symptom of psychotic disorders and are often refractory to treatment with 25% of patients being nonresponsive to standard therapy (Shergill et al. 1998). Command hallucinations with homicidal and suicidal content create particularly difficult and dangerous cases (McNiel et al. 2000). Here, we describe our experience with the use of bilateral tinnitus sound generators for augmentation in treatment-resistant auditory hallucinations. Tinnitus sound generators are similar to hearing aids in appearance and direct noise into the wearer's ears in attempt to attenuate the bothersome nature of tinnitus.
Case
The patient is a 31 year-old African-American female with five year history of schizoaffective disorder, bipolar type. She suffered from intense egodystonic command suicidal and homicidal auditory hallucinations with ideations resulting in frequent and prolonged psychiatric hospitalisations causing significant psychological distress. Her hallucinations were two loud male voices with continued negative commentary, pausing only for minutes and commanding the patient to kill herself and others with a mean score of 40/50 on Auditory Hallucinations Rating Scale (AHRS). The patient had been trialed on risperidone, quetiapine, aripiprazole and olanzapine at appropriate doses and durations without significant improvement in her auditory hallucinations, thus prompting initiation of clozapine. The clozapine was discontinued due to non-adherence and inability to achieve therapeutic blood levels. She was then transitioned to paliperidone palmitate monthly injections titrated to 234 mg once a month but without any significant change in her auditory hallucinations. Mood stabilisers including divalproex and lamotrigine had been previously attempted but discontinued due to intolerance. Transcranial magnetic stimulation (rTMS) had been unsuccessfully attempted previously, with the goal of reducing the presence of auditory hallucinations.
The patient was observed listening to loud music which she purported helped in the alleviation of auditory hallucination awareness. The first and senior authors have made similar observations among other psychotic patients with auditory hallucinations and this has been examined in a single study with beneficial outcomes (Na & Yang, 2009) among patients with schizophrenia. A single case series (Kaneko...