Alcoholic hallucinosis.

Alcoholic hallucinosis is a rare complication of chronic alcohol abuse characterized by predominantly auditory hallucinations that occur either during or after a period of heavy alcohol consumption. Bleuler (1916) termed the condition as alcohol hallucinosis and differentiated it from Delirium Tremens. Usually it presents with acoustic verbal hallucinations, delusions and mood disturbances arising in clear consciousness and sometimes may progress to a chronic form mimicking schizophrenia. One such case with multimodal hallucinations in a Defence Service Corps soldier is presented here.

Alcoholic hallucinosis is a rare complication of chronic alcohol abuse characterized by predominantly auditory hallucinations that occur either during or after a period of heavy alcohol consumption.[1] Although this condition had been noted for centuries, its nosological status is not yet clear. Bleuler (1916) termed the condition as alcohol hallucinosis and differentiated it from Delirium Tremens. International Classification of Diseases-10 (ICD-10), it was relabeled as Alcohol induced Psychotic Disorder, Predominantly hallucinatory type.[2] Usually it presents with acoustic verbal hallucinations, delusions and mood disturbances arising in clear consciousness and sometimes may progress to a chronic form mimicking schizophrenia. In our setup it is rare to see such cases due to early detection and intervention of alcohol abuse. One such case with multimodal hallucinations in a Defence Service Corps (DSC) soldier is presented here.

CASE REPORT

A 43-year-old DSC soldier with few months of service was referred for psychiatric evaluation in January 2010 by unit authorities in view of his behavioral abnormalities noted since joining the unit. He was found to be gloomy, reclusive, not sleeping and talking to oneself. Evaluation revealed that he was apparently asymptomatic when he retired after 18 year of service in Army (Para Unit) in 2004. He had been consuming alcohol since 1984 and gradually the frequency and quantity increased to 360 ml of rum daily by 1996. He used to have sleep disturbances irritability and tremors on temporarily stopping alcohol consumption.

After leaving the service in 2004, he started consuming about 600 ml of country liquor daily. By 2005, family members noted him to be talking to himself, not taking adequate self care and becoming irritable easily. He complained of hearing voices of family members, even when he was alone, abusing him and threatening him. Initially he used to reply to these voices but gradually started neglecting them. Sometimes he used to see the faces of pervious acquaintances, which used to change in shape and size. He also used to feel as if someone touching and fondling with his genitals. All these things used to disturb him, he was not doing any job and to over come these problems used to drink country liquor regularly. Though his family members got him treated from local doctor, there was no significant improvement.

He joined DSC in August 2009. After the initial training of short duration, while on leave he was consuming country liquor daily, before joining the new unit. There also he started consuming about 120 ml of rum daily. His behavior was abnormal and hence he was hospitalized. There was no other significant family or past history. There were multiple unprotected exposures to commercial sex workers. Physical examination was within normal limits except for fine digital tremors. Mental status examination showed multimodal hallucinations in visual, auditory and tactile spheres, no delusions but biodrives were deranged. Investigations showed human immunodeficiency virus (HIV) positive status (ELISA and Western blot), raised Aspartate Amino Transferase (AST) and Alanine Amino Transferase (ALT), computed tomography (CT) and Magnetic resonance imaging (MRI) brain revealed bilateral lateral ventricle enlargement with narrowing of lower end of aqueduct of sylvius. The patient was advised regular follow-up by the neurosurgeon. His CD4 and CD8 counts were 235 and 674, respectively. He was put on three drugs ART regime by the immunologist.

He was treated with Risperidone. The dose was gradually increased to 4 mg per day and he responding quickly. On improvement he was sent on four weeks sick leave on the advice of immunologist. Subsequently he was noted to be abstinent from alcohol, compliant with treatment and free from all kinds of hallucinations. He expressed relief and strong motivation for future abstinence from alcohol.

DISCUSSION

Alcohol is the most frequently abused psychoactive substance and may lead to various clinical conditions like intoxication, withdrawal, Delirium tremens, Wermicke-Korskoff syndrome, alcohol-induced psychotic disorder and alcoholic dementia. Although a syndrome similar to what we now call alcoholic hallucinosis was described as a separate entity as early as 1847 by Marcel, who called it folie divrogne (drunken madness), there continued to be great uncertainty as to which group this condition belonged diagnostically. Patients were even given a diagnosis of paranoid schizophrenia and treated with neuroleptics, indefinitely. Alcoholic hallucinosis has also been considered to be a heterogeneous condition with a varied outcome, or even a distinct entity in its own right with a particular etiology, course and outcome. Perme et al.[1] did a follow-up study of 52 patients diagnosed with alcoholic hallucinosis and after three years noted that 13.5% patients continued to hallucinate even though remained abstinent, and 21% patients did not have relapse even though continued to consume alcohol. None of the patients required a revision of diagnosis to schizophrenia or affective disorder. No relationship of development of hallucination to severity of alcohol dependence at baseline was noted.

Based on Positron Emission Tomography (PET) findings, Soyka, et al.[3] suggested a hypo function of thalamus in alcoholic psychosis. Carl Sherman[4] had described a follow-up study undertaken by Dr. JM Anderson in East Glasgow, where alcohol dependence syndrome (ADS) is known to be particularly severe in the population. Initially 16 of 124 (13%) patients with a diagnosis of ADS had alcoholic hallucinosis of which five had continuous hallucinations. Hallucinations were auditory, distinct and usually in second person. At follow-up after eight years three had deceased, five were abstinent and without psychosis and two were abstinent but had features of schizophrenia. Five were consuming alcohol and had features of alcoholic hallucinosis.

Kitabayashi, et al.[5] by using Single Photon Emission Computed Tomography (SPECT) noted decreased regional blood flow in frontal lobes, left basal ganglia and left thalamus in alcoholic hallucinosis. On treatment with neuroleptics and benzodiazepines, hallucinations disappeared and SPECT showed normalization of blood flow in basal ganglia and thalamus but not in frontal lobes. Soyka, et al.[6] also had reported reduced thalamic activity using SPECT. Management has always been with abstinence from alcohol and use of neuroleptics.[7] Recently Valproate has also been found to be effective in the treatment of alcoholic hallucinosis and was well tolerated.[8]

Alcoholic hallucinosis is a rare complication of chronic alcohol abuse and a prevalence of 0.6-0.7% in alcoholics has been reported.[3] No study has conclusively demonstrated that it is an acute illness with pronounced similarities to Delirium tremens or as a chronic illness resembling paranoid schizophrenia. In short, there is no consensus as to the nature of the illness. In our case, the individual with chronic alcohol abuse had presented with multimodal hallucinations that persisted even when he remained abstinent. But he responded well to treatment with neuroleptics and became asymptomatic.