Case Study: New-Onset Complex Auditory Hallucinations in a 28-Year-Old Woman with Complex Psychiatric History and Polypharmacy

Case at a Glance

A 28-year-old female with a history of anxiety, depression, PTSD, and endometriosis presented with new-onset, complex auditory hallucinations. The patient, who is on a complex regimen of multiple psychiatric medications, supplements, and daily cannabis, reported hearing non-existent television sounds, nature sounds, and whispers. These symptoms emerged in the context of significant psychosocial stress, recent major surgery, and poor sleep quality, raising a broad differential diagnosis including medication side effects, a primary psychotic disorder, and stress-induced perceptual disturbances.

Patient's Story

The patient is a 28-year-old woman living in an urban, high-rise apartment. Her symptoms began several months prior, initially manifesting as hearing a television sports broadcast playing clearly in her home when the device was off. These episodes occurred intermittently, typically while she was resting. More recently, the hallucinations evolved. She began hearing the distinct sounds of crickets and cicadas, sounds she had previously used as a sleep aid but had not listened to for over two months. These nature sounds occurred at any time of day, regardless of her activity. The most distressing symptoms were indecipherable whispers that felt very close, and isolated sounds like a dog sighing in her room, despite not owning any pets. The patient expressed significant fear and anxiety about these experiences, noting a family history of paranoia in her father and worrying about her own mental stability. She recalled a single, similar 'whisper' event from childhood and an episode of a loud, explosive sound upon waking during college, which she self-identified as possible exploding head syndrome.

Initial Assessment

The patient presented as a well-spoken 28-year-old female, visibly anxious about her symptoms. She had a significant past medical history including Stage IV deep infiltrating endometriosis (status post-excision surgery five months prior), generalized anxiety disorder, major depressive disorder, PTSD stemming from childhood abuse, and suspected OCD. Her medication regimen was extensive and included Wellbutrin 300mg, Effexor 225mg, Klonopin 0.5mg, Trazodone 50mg (as needed), Adderall ER 30mg, and Adderall IR 15mg. She also consumed a daily THC/CBD gummy and took numerous supplements. The patient reported significant recent stressors, including a major surgery and a difficult attempt to sever contact with family members. She also noted her sleep quality had been poor for the preceding two months, though she denied feeling overtly sleep-deprived. She acknowledged having some degree of baseline tinnitus.

The Diagnostic Journey

The patient's presentation prompted a wide differential diagnosis. A primary psychotic disorder such as schizophrenia was considered, given the nature of the hallucinations and her father's history of paranoia. However, the patient maintained full insight, which argued against this. The most prominent consideration was a substance/medication-induced disorder. Her complex polypharmacy, particularly the combination of a stimulant (Adderall), multiple serotonergic agents (Wellbutrin, Effexor, Trazodone), a benzodiazepine, and daily cannabis use, presented a high risk for adverse neuropsychiatric effects, including hallucinations. The temporal link between her poor sleep, high stress, and the worsening of symptoms was also significant. Perceptual disturbances related to sleep, such as hypnagogic (while falling asleep) or hypnopompic (while waking) hallucinations, were considered. While her symptoms initially fit this pattern, their progression to occurring during full wakefulness suggested that severe stress and sleep dysregulation might be blurring the lines between sleep and wake states. A neurological cause, such as temporal lobe epilepsy, was a less likely but important consideration to keep in mind if symptoms persisted after addressing other factors.

Final Diagnosis

Complex Auditory Hallucinations Secondary to Polypharmacy, Exacerbated by Psychosocial Stress and Sleep Dysregulation. The patient's historical report of a loud 'boom' upon waking is consistent with a past episode of Exploding Head Syndrome, a non-pathological parasomnia.

Treatment Plan

The immediate recommendation was an urgent consultation with her psychiatrist for a comprehensive medication review. The primary goal was to simplify her medication regimen, with particular attention to the high-dose stimulant and the combination of multiple psychoactive agents, to reduce the risk of drug-drug interactions and adverse effects. The patient was also strongly advised to discontinue her use of THC/CBD products until her symptoms resolved. A focus on improving sleep hygiene was critical to address the underlying sleep dysregulation. Continued engagement in psychotherapy was recommended to manage the high levels of stress and address her underlying PTSD, which were acting as significant triggers. A neurological evaluation with an EEG would be considered if the hallucinations did not resolve with medication adjustment and improved sleep.

Outcome and Follow-up

Prognosis was considered favorable with appropriate intervention. It was anticipated that by simplifying her medication regimen, improving sleep quality, and managing acute stressors through therapy, the patient's auditory hallucinations would resolve. Close and frequent follow-up with her psychiatrist was deemed essential to carefully taper medications, monitor for symptom recurrence, and establish a safer, more stable long-term treatment plan for her underlying psychiatric conditions.