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Hallucinations, Emergency Medicine

Basics

Description

- Psychiatric - Schizophrenia - Bipolar disorder, mania - Major depression

- Sympathomimetics - Amphetamine - Methamphetamine - Cocaine - Synthetic cathinones (i.e., MDPV, "bath salts")

- NMDA antagonists - Ketamine - PCP - Dextromethorphan

- Serotonergic - MDMA (Ecstasy) - LSD - Peyote cactus (mescaline) - Mushrooms (psilocybin) - 2C series (i.e., 2CB, 2CT-7) - 5-MeO series (i.e., 5-MeO-DMT)

- Medications - Anticholinergic agents - Steroids - Methylphenidate

- Withdrawal - Ethanol - Benzodiazepines - Barbiturates - GHB

- Substance-induced disorders - Methamphetamine-associated psychosis - Prolonged duration of psychosis, auditory hallucinations and recurrence without relapse of using drug

- Infectious - Meningitis - Encephalitis - In patients with dementia, any infection (i.e., UTI, pneumonia) can trigger hallucinations

- Ocular - Glaucoma - Macular degeneration - Charles Bonnet syndrome

- Others - Food, sensory, sleep deprivation - Fatigue, extreme stress - Heat-related illness - Religious and ritual activities - Falling asleep and awakening from sleep

- Acute psychosis - Disorganized thought - Responding to internal stimuli

- Delirium - Altered level of consciousness - Not oriented - Abnormal vital signs

- CNS lesion - Cranial nerve deficit - Aphasia - Any focal neurologic finding - Gait abnormality - External signs of trauma

- Signs of intoxication or withdrawal - Sympathomimetic intoxication, ethanol/benzodiazepine withdrawal - Agitation, excited delirium - Mydriasis - Tachycardia, hypertension - Hyperthermia - Diaphoresis

- Opiate - Miosis - Bradypnea - Needle marks

- Serotonergic - Tachycardia, hypertension - Hyperreflexia - Clonus - Tremor

- EKG - Thyroid function - Liver function tests - RPR, folate, B12, thiamine - Specific drug concentrations

- More likely to be from psychiatric illness: - Auditory and command hallucination - Hallucinations and illusions incorporated into delusional system - Age of onset 13-40 yr old - Flat affect - Normal orientation - Disorganized attention

- The following groups are considered to be at higher risk for nonpsychiatric illness: - Elderly - History of substance abuse - No pre-existing psychiatric history - Presence of pre-existing medical disorders - Lower socioeconomic level

- Visual hallucinations more common: - Delirium - Dementia - Migraines - Dopamine agonist therapy (i.e., carbidopa) - Posterior cerebral infarcts - Narcolepsy

- Address ABCs and any abnormal vital signs (i.e., supplemental oxygen for hypoxia) - Check FSBG - Consider thiamine 100 mg IV/PO - Treat acute agitation (see Agitation) - De-escalation techniques - Physical restraints - Chemical sedation

Hallucinations are a symptom or feature and not a diagnosis. They may be auditory, visual, tactile, gustatory, or olfactory. Hallucinations and similar phenomena are often defined as follows:

  • Hallucination:Sensory perception that has the compelling sense of reality of a true perception without external stimulation of the relevant sensory organ and is experienced as a sensation through that organPatients may or may not have insight that they are having the hallucination
  • Illusion:Misperception or misinterpretation of a real external stimulus
  • Flashback:Recurrence of a memory, feeling, or perceptual experience from the past that may have the compelling sense of reality
  • Pseudohallucination:Hallucination that is not experienced by a sensory organ (i.e., voices inside head or "inner voice" as opposed to hearing voices)

Epidemiology

Incidence and Prevalence Estimates

  • Lifetime incidence of auditory hallucinations is 4-8% in general population (although some estimates are higher due to vague definitions or inclusion of pseudohallucinations)
  • More than 50% of elderly patients with dementia have paranoia or hallucinations

Etiology

There are numerous causes of hallucinations. The following are common: (An exhaustive list is beyond the scope of this chapter)

  • PsychiatricSchizophreniaBipolar disorder, maniaMajor depression
  • Acute intoxicationsEthanolCannabisMarijuana alternatives (i.e., K2, Spice)SympathomimeticsAmphetamineMethamphetamineCocaineSynthetic cathinones (i.e., MDPV, "bath salts")NMDA antagonistsKetaminePCPDextromethorphanSerotonergicMDMA (Ecstasy)LSDPeyote cactus (mescaline)Mushrooms (psilocybin)2C series (i.e., 2CB, 2CT-7)5-MeO series (i.e., 5-MeO-DMT)Kappa opioid receptor agonistSalvia divinorum (cause synesthesias - i.e., hearing colors or smelling sounds)OpiatesInhalants
  • MedicationsAnticholinergic agentsSteroidsMethylphenidate
  • WithdrawalEthanolBenzodiazepinesBarbituratesGHB
  • Substance-induced disordersMethamphetamine-associated psychosisProlonged duration of psychosis, auditory hallucinations and recurrence without relapse of using drugCannabis-induced psychosis
  • InfectiousMeningitisEncephalitisIn patients with dementia, any infection (i.e., UTI, pneumonia) can trigger hallucinations
  • MetabolicHypoglycemiaElectrolyte imbalancesThyroid diseaseAdrenal diseaseWilsons diseaseThiamine deficiency
  • NeurologicSeizuresPartial simple or complex seizures can result in visual, auditory, olfactory, and gustatory hallucinationsMigrainesCNS hemorrhage or tumorCVATourette syndromeNeurodegenerative disordersParkinsonsDementia (Lewy body, Alzheimer)HIV
  • OcularGlaucomaMacular degenerationCharles Bonnet syndrome
  • OthersFood, sensory, sleep deprivationFatigue, extreme stressHeat-related illnessReligious and ritual activitiesFalling asleep and awakening from sleep

Hallucinations are relatively common in children and adolescents and are often developmentally normal. Most children with hallucinations do not have psychosis. Hallucinations can occur as part of a delirium, such as from fever. As with the adult patient, carefully conduct a search for a medical or neurologic etiology.

In the elderly patient, hallucinations are most often from an organic cause. They can commonly accompany dementia, depression, medication reactions and substance abuse, and are often associated with agitation. Atypical antipsychotic agents are effective treatment for hallucinations with agitation in the elderly.

Diagnosis

Signs and Symptoms

History

  • Obtaining accurate and thorough history often difficultCollateral history should be obtained from bystanders, EMS, police, family, physicians
  • Assess for changes in behavior from baseline
  • Explore for delusions or persecutory beliefs
  • Previous episodes of hallucinations
  • Change in medications
  • Substance abuse history
  • Alteration in cognition that rapidly develops and waxes and wanes throughout course of the day suggests delirium
  • Headache may suggest CNS lesion or migraine

Physical Exam

  • Acute psychosisDisorganized thoughtResponding to internal stimuli
  • ManiaExcessive talking or pressured speech
  • DeliriumAltered level of consciousnessNot orientedAbnormal vital signs
  • CNS lesionCranial nerve deficitAphasiaAny focal neurologic findingGait abnormalityExternal signs of trauma
  • Systemic or infectious illnessAsterixisFeverNuchal rigidityMyoclonusJaundiceAscites
  • Signs of intoxication or withdrawalSympathomimetic intoxication, ethanol/benzodiazepine withdrawalAgitation, excited deliriumMydriasisTachycardia, hypertensionHyperthermiaDiaphoresisOpiateMiosisBradypneaNeedle marksSerotonergicTachycardia, hypertensionHyperreflexiaClonusTremorNMDA antagonism

Diagnosis Tests & Interpretation

  • Common tests:CBC, serum chemistriesEthanol, acetaminophen, salicylate serum concentrationsUrinalysis
  • More focused studies depending on comorbid conditions or clinical concerns:Urine drug of abuse screenInterpretation can be difficult as this is a test of use and not intoxication. In addition, it is not designed to detect newer drugs of abuse, although some may cross-react with this assay.EKGThyroid functionLiver function testsRPR, folate, B12, thiamineSpecific drug concentrations

Imaging

  • Brain imaging (CT, MRI)
  • Chest x-ray

Diagnostic Procedures/Surgery

  • If suspicion exists for medical cause, should consider procedures such as:
  • If hallucinations are from acute psychiatric illness or decompensation of chronic psychiatric illnessObtain emergent psychiatric consultation

Essential Workup

Patients with a clear psychiatric history with characteristic symptoms need minimal testing (CBC, chemistries). However, patients with undifferentiated hallucinations, especially those in high-risk groups, require extensive testing.

Differential Diagnosis

The primary goal of ED evaluation is to differentiate psychiatric from nonpsychiatric cause of hallucination. (See Psychosis, Medical vs. Psychiatric)

  • More likely to be from psychiatric illness:Auditory and command hallucinationHallucinations and illusions incorporated into delusional systemAge of onset 13-40 yr oldFlat affectNormal orientationDisorganized attention
  • The following groups are considered to be at higher risk for nonpsychiatric illness:ElderlyHistory of substance abuseNo pre-existing psychiatric historyPresence of pre-existing medical disordersLower socioeconomic level
  • Visual hallucinations more common:DeliriumDementiaMigrainesDopamine agonist therapy (i.e., carbidopa)Posterior cerebral infarctsNarcolepsy

Treatment

Pre-Hospital

Observe details of patients environment not available to hospital care team

  • Disorganized living environment
  • Drug paraphernalia

Initial Stabilization/Therapy

  • Address ABCs and any abnormal vital signs (i.e., supplemental oxygen for hypoxia)
  • Check FSBG
  • Consider thiamine 100 mg IV/PO
  • Treat acute agitation (see Agitation)De-escalation techniquesPhysical restraintsChemical sedation

Ed Treatment/Procedures

  • If underlying medical cause identifiedTreat medical etiologyThese patients typically do not require antipsychotic medications
  • In patients with acute psychosis or decompensation of chronic psychotic illnessUse antipsychotics and benzodiazepines (see Psychosis, Acute)
  • In patients with hallucinations due to intoxication with excited deliriumGeneral supportive careBenzodiazepines
  • If dementia with hallucinationsTreat underlying medical etiology, if anyAtypical antipsychotics have benefits and harm (CVA, extrapyramidal symptoms)

When treating hallucinations with an excited delirium due to acute intoxication (except for ethanol), use benzodiazepines.

Follow-Up

Disposition

Admission Criteria

Disposition determined by medical condition or psychiatric evaluation. Hallucinations from some intoxications such as methamphetamine or cannabis may persist even after drug is metabolized.

Admission Criteria

  • Medical condition requiring admission
  • Acute psychiatric illness or decompensation of chronic psychiatric illness requiring psychiatric hospitalization

Discharge Criteria

  • Symptoms have resolved and reversible medical cause (i.e., intoxication, UTI)
  • Decompensation of chronic psychiatric condition has been addressed, home environment appropriate and mental health follow-up available.

Issues for Referral

Alcohol/drug treatment as appropriate

Followup Recommendations

As appropriate for medical or chronic psychiatric condition(s)

Pearls and Pitfalls

  • Do not assume that auditory hallucinations are always from psychiatric illness whereas visual, tactile, olfactory, and gustatory hallucinations are nonpsychiatric - always perform thorough evaluation.
  • Even though 10% of cases of schizophrenia occur in patients older than 45, do not assume hallucinations are from psychiatric cause in older age group without extensive workup.
  • Do not treat hallucinations with excited delirium from an acute intoxication (except due to ethanol) with antipsychotic agents.

Additional Reading

  • El-Mallakh RS, Walker KL. Hallucinations, psuedohallucinations, and parahallucinations. Psychiatry. 2010;73(1):34-42.
  • Piechniczek-Buczek J. Psychiatric emergencies in the elderly population. Emerg Med Clin North Am. 2009;24(2):467-490.
  • Sood TR, Mcstay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009;27(4):669-683.
  • Sosland MD, Edelsohn GA. Hallucinations in children and adolescents. Curr Psychiatry Rep. 2005;7(3):180-188.

Codes

ICD9

  • 291.3 Alcohol-induced psychotic disorder with hallucinations
  • 368.16 Psychophysical visual disturbances
  • 780.1 Hallucinations

ICD10

  • F10.951 Alcohol use, unsp w alcoh-induce psych disorder w hallucin
  • R44.1 Visual hallucinations
  • R44.3 Hallucinations, unspecified
  • R44.0 Auditory hallucinations
  • F12.951 Cannabis use, unsp w psychotic disorder with hallucinations
  • F16.151 Hallucinogen abuse w psychotic disorder w hallucinations
  • F19.951 Oth psychoactv sub use, unsp w psych disorder w hallucin
  • R44.2 Other hallucinations

SNOMED

  • 7011001 Hallucinations (finding)
  • 64269007 Visual hallucinations (finding)
  • 417633001 Alcohol induced hallucinations (finding)
  • 45150006 Auditory hallucinations (finding)
  • 191486006 Drug-induced hallucinosis (disorder)
  • 29139005 Gustatory hallucinations (finding)
  • 39672001 Olfactory hallucinations (finding)