Question
I have a patient who has paracusis (auditory hallucination). She has normal hearing but she claims that she can hear an old lady's voice without the presence of external stimulus. How do you differentiate tinnitus from auditory hallucination? What is the best management for this kind of patient - referral to psychologist or psychiatrist? Or can you manage the same as you would manage tinnitus?
Answer
As you know, tinnitus is typically a simple sound or a monotone: e.g., ringing, clicking, banging, buzzing, or pulsating sound. It occurs in the normal population, particularly with those who have hearing loss, or who have experienced head injury or other assaults to one's nervous system. In contrast, people with auditory hallucinations typically imagine hearing more complex auditory phenomena, such as clear and articulate voices saying certain things, well-defined singing or music. These auditory hallucinations are a sign of mental illness, such as psychotic disorder or schizophrenia.
However, there is another nosological category called "pseudo-auditory hallucinations." These are not clearly articulated voices or music, as in true auditory hallucinations, but are typically more vague and not understandable. These may overlap to some degree with tinnitus or paracusis as they may be indistinct sounds, like the wind blowing or vague humming.
The context and timing of the auditory experience is crucial for differential diagnosis. For example, even in normal persons, hallucinations and illusions are not uncommon between waking and sleeping states: so-called hypnagogic hallucinations.
The first step for differential diagnosis is referral to a mental health professional. However, in my experience, unless the referral is made in a careful and compassionate manner, it will likely result in non-adherence by patients and may damage your relationship. It would be important to normalize (de-stigmatize) the referral. When first referencing the patient's emotional pain, do not use loaded words such as "mental health," or "psychotherapy", as these words may be experienced by patients as assaults to their self-esteem and integrity.
Instead, you can emphasize that optimal treatment of hearing loss necessitates a team approach. You can make reference to the mind-body connection or terms such as "holistic" or "multi-disciplinary approach" which are recognized and accepted in today's culture. In addition, it would be important to humanize the mental health professional. The more patients know about who they are being asked to see, the less anxiety and fear of the unknown they will experience. Finally, you can ask permission to telephone the mental health professional in front of the patient.
Dr. Harvey is a Clinical Psychologist, private practice in Framingham, Mass. and Consultant Faculty at Salus University. His most recent books are The Odyssey of Hearing Loss: Tales of Triumph and Listen with the Heart: Relationships and Hearing Loss. He can be contacted at mharvey2000@comcast.net.