Recently, a colleague of mine requested a “curbside” consultation regarding a patient to whom she had not been able to give a definitive diagnosis, and about whom she was increasingly concerned. Psychologists often are called upon by colleagues to consult on difficult or challenging diagnostic or treatment issues, and this was one of those cases.
The patient in question is an 18-year-old young woman who had sought treatment due to constant worry and fear that something terrible was going to happen to her. She was still living at home with her parents, who were increasingly concerned about her condition. She had been accepted to a local college and had elected to live at home, even though the cost of staying on campus would not have been a burden to her family.
She had become increasingly anxious starting in her junior year of high school. It was at that time that she expressed concern to her friends that she might not be able to handle the stress of going to college and was feeling very pressured to get into the best school she could by her parents.
Her friends were supportive and nothing seemed too out of the ordinary. She started classes and found them to be considerably more challenging than the ones she had taken in high school. This only added to her tension and stress. As she worried more and more about not being able to do well in her school work, she found it increasingly difficult to settle down and do homework, and she nearly panicked when she had to take an examination.
As you might imagine, this soon began to negatively impact her sleep. The low sleep situation was made worse by the fact that she was often staying up late, trying to finish her homework, while also getting up early in order to drive to school and find parking before her first classes started.
Of great concern to her was that she had started “hearing and seeing things that were not there.” This seemed to usually happen in the later part of the night, often toward the morning. On less frequent occasions, it would start seemingly shortly after she fell asleep.
Sometimes, she would hear several voices talking. Not to her or about her, but just in the room. She could not tell if they were friends or relatives, but they seemed familiar most of the time. She could not easily remember what they had said, and she usually fell back into a troubled and uneasy sleep after a while.
The emotional quality of the voices did seem to change, and she came to believe that they more often sounded angry on the days that she felt the most stressed. She also began to experience visual effects in which she thought there was another person in the room with her, or that odd, random, geometric objects would seem to float in front of her. Sometimes she would force herself fully awake, shaken, while other times she fell back into a fitful sleep.
My colleague had met with the patient for an initial consultation and several additional psychotherapy sessions. She had focused on what appeared to be a growing generalized anxiety disorder that was being fueled by the intense stress of the patient’s competitive academic environment.
As the patient began to talk more about her hallucinatory experiences, especially with the report of auditory hallucinations and her growing tendency to isolate herself socially, my colleague was increasingly alarmed and concerned about the development of a possible psychosis. Hallucinations are experiences of sensations that do not have a basis in some external stimulus (including normal stimuli within the body, such as taste), but have the quality of true perception and cannot be distinguished by the perceiver as not originating from the environment.
Now, this was not an unreasonable concern. Psychotic disorders, such as schizophrenia, usually develop early in life and often at times of transition, such as taking a first job, moving out of the parental home, joining the military, or going to university.
Secondly, one of the primary positive symptoms of schizophrenia is hallucinations, especially auditory ones. Positive symptoms are relatively rare in people who do not carry a diagnosis of schizophrenia and include experiences such as hallucinations (which can occur in any sensory modality, but are most often auditory), delusions (strongly held false beliefs often used to explain the odd experiences the person is having), and strange alterations of speech that may be difficult for other people to follow or understand. Negative symptoms consist of deficient emotional or cognitive processes such as lack of motivation, anhedonia, and inability to form social connections.
Most medications used to treat schizophrenia are more effective in managing the positive rather than the negative symptoms. Schizophrenia is a very challenging disorder that is hard to treat, strikes early in life, can be debilitating, vastly reduces quality of life, and typically results in a shorter life expectancy of about 10 years. Clearly, if this patient were having the initial signs of schizophrenia, that would be very concerning. The best course of action would be to get a proper diagnosis and initiate treatment, including medication management.
On the other hand, there is reason to doubt that this is the beginning of a psychotic disorder. First, the experiences seem to be limited to the night and are associated with sleep. Second, the patient is aware that these are unusual experiences and do not seem to be genuinely outside of herself. Third, she is more socially isolated, but has maintained friendships and continues to attend classes and makes an effort to complete her work. Except for the reported hallucinatory experiences, the other symptoms are more consistent with an anxiety disorder.
As we discussed the case, I suggested consideration of a possible diagnosis of hypnagogic and hypnopompic hallucinations occurring in the context of an anxiety disorder with increased stress, which had worsened the patient’s sleep and exacerbated the hallucinations due to the fragmented quality and insufficient quantity of her sleep.
There are a number of situations in which these types of experiences occur, including sleep disruption similar to what the patient had experienced going to college, and in conditions such as narcolepsy. If it were narcolepsy, then these hallucinations could be an early symptom, and others, such as excessive daytime sleepiness, could occur as well.
I suggested not alarming the patient or her parents, but given the symptoms, further evaluation was clearly warranted. My colleague referred the patient for a diagnostic evaluation with a psychiatrist and for a sleep study to rule out other sleep disorders.
After further workup, it was determined that this was not a schizophrenic illness, and other sleep disorders, such as narcolepsy, were ruled out by polysomnography and multiple sleep latency testing. The patient has continued in therapy for anxiety and used cognitive behavioral techniques to improve the quality of her sleep. Last I heard, she was doing well, had finished her first year of college successfully, and was sleeping soundly with no further report of nocturnal hallucinations, either visual or auditory.
DelRosso, Liegmann, & Hoque (2017) reported on a similar case of an anxious adolescent who was having nocturnal hallucinations of an auditory nature. Their patient reported hearing voices upon closing her eyes to go to sleep. They only lasted a few minutes and seemed to be the voices of family members or friends. In this case, the patient was experiencing significant stress and anxiety related to her parents’ divorce and having to move away from her father. There was no history of, or other current symptoms of, another psychiatric disorder, such as depression, mania, or substance abuse.
They noted that hypnogogic hallucinations, which occur upon falling asleep, were first written about by the French psychiatrist Jules-Gabriel-Francois Baillarger in the 1840s. They are not uncommon and are reported by as much as 37 percent of the general population. Hypnogogic hallucinations are more common than hypnopompic ones, which occur upon awakening. Both are most often visual in nature, but can also be auditory or tactile. They are most often associated with insomnia, insufficient sleep, and narcolepsy. Typically, these sleep-related hallucinations resolve with time.
Medical and psychiatric evaluation may be needed with some patients, as the full differential diagnosis involves consideration of other psychiatric disorders (schizophrenia, bipolar disorder, borderline personality disorder, and post-traumatic stress disorder), substance use disorders, medical disorders (migraine headaches, dementia, seizures, and neoplasm), and other sleep disorders (narcolepsy and REM sleep behavior disorder).
The typical treatments for sleep-related hallucinations are increasing the amount of sleep; if sleep has been insufficient, cognitive behavioral therapy and relaxation techniques. If you or someone you know has been suffering with unexplained sleep-related hallucinations, there is hope, and the place to start is by discussing them with your primary care physician.
DelRosso, L.M., Liegmann, J., Hoque, R., (2017). An anxious 17-year-old girl who hears voices only at sleep onset. Journal of Clinical Sleep Medicine, 13(2), p. 355 -356.