Unlocking Behaviors: Auditory Hallucinations
By Ley Linder, MA, M. Ed, BCBA and Craig Escudé, MD, FAAFP, FAADM
This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion. Dr. Escudé and Ley are the proud recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series.
Shanda is a 39-year-old woman with a mild intellectual disability who is an effective communicator, expressively and receptively. She lives with three other women of similar functioning ability and has held various jobs working in restaurants and other businesses providing light janitorial services. She is a gregarious woman with robust social systems, including family, friends, romantic relationships, and the support staff at her group home. She has psychiatric diagnoses of depression and anxiety, for which she takes citalopram and lorazepam.
Shanda can struggle to manage stressors (e.g., too many consecutive workdays) and navigate social relationships. Although she is highly reinforced through social interaction and is a friendly person, Shanda can misinterpret social interactions (verbal and non-verbal), which can lead to difficulties in maintaining healthy, appropriate, and long-term relationships.
Two days ago, Shanda lost her job because she was using her cell phone excessively, and a “romantic interest” at the job had become a constant distraction, leading to ongoing poor work performance. Staff at her home have reported that since she was terminated, she has been pacing around the house, continually agitated, sleeping poorly, and “is in her bedroom talking and yelling at people who are not there.”
“Many considerations must be made to determine if a person is experiencing hallucinations of any kind. Behavior analysts can assist medical professionals by clearly and concisely describing the behavior’s characteristics.”
Medical Discussion
Changes in behavior should prompt a thorough investigation of underlying medical conditions, and one of the first to consider is the possibility of medication side effects or drug interactions. Citalopram, often used for depression, can sometimes cause tiredness, nausea, headaches, and sleep disturbances. Neither citalopram nor lorazepam is known to cause hallucinations typically, but Lorazepam can contribute to behavioral changes, cognitive changes, and sometimes, paradoxical hyperactivity and aggression. However, if Shanda has been stable on these medications for quite some time, and there have been no recent dosage changes, it is unlikely that these are the cause of her symptoms.
Hyperthyroidism can cause a wide variety of symptoms, including agitation, mood swings, difficulty sleeping, and others, and can be ruled out with a simple blood test. Certain recreational drugs can cause hallucinations, and the possibility of her using these should also be considered. Urinary tract infections (UTIs) can also cause cognitive changes, but this is usually seen in older people. While medical causes should always be ruled out, in Shanda’s situation, it seems that most of her symptoms can be attributed to her current life circumstances.
Behavioral Discussion
The most striking part of Shanda’s current behavioral presentations is the staff reports that she is “talking and yelling at people who are not there.” Discussions about this type of behavior immediately beckon healthcare providers and, potentially, the use of psychotropic medications. Many considerations must be made to determine if a person is experiencing hallucinations of any kind. Behavior analysts can assist medical professionals by clearly and concisely describing the behavior's characteristics. This can be done by describing what the behaviors look and sound like, the setting, temporal information, the history of the behavior, and any social context, to name a few.
From a behavioral standpoint, it is essential to consider other explanations for this behavior beyond psychiatric presentations. What if Shanda is talking to people who aren’t there, but it’s part of a coping skill? Many people have internal conversations with themselves, known as an “inner monologue,” which can help navigate challenging situations, allowing for problem-solving and conflict resolution via role play. Perhaps Shanda’s “talking and yelling at people” is her inner monologue that she verbalizes.
Stress management for people with intellectual and related disabilities (ID/RD) is not a topic that garners enough attention, particularly in the realm of explaining and addressing behavior presentations. The lives of people with ID/RD have similar stressors as any other person, but it is not uncommon that they have less robust coping skills. Behavior approaches can help identify everyday stressors for a person, such as misinterpretation of social cues, to help decrease known causes of stress and assist with stress management strategies.
Outcome
Shanda’s behaviors were concerning enough that an appointment was made with the interdisciplinary team, including the psychiatrist. The team discussed the global concerns of the reasons for losing her job, appropriate social relationships, and the idea that she was exhibiting psychiatric symptoms. During the meeting, including a conversation with Shanda, it was determined that the possible auditory hallucinations were her verbalizing her thoughts and “self-soothing talk.” She was expressing her emotions towards her supervisor, her romantic interest, and others who had made her mad (including historical issues). The team agreed to increase her support network to help manage the acute stressors, but that continuing to work on appropriate social and work skills would also be beneficial for Shanda – without the introduction of new psychotropic medication or a dosage increase in her current medications.
About the Authors:
Ley Linder is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He works closely with national organizations such as the National Down Syndrome Society and the National Task Group on Intellectual Disabilities and Dementia Practices and is the Founder/CEO of Crescent Behavioral Health Services based in Columbia, SC.
Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine and President of IntellectAbility. He has more than 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the “Curriculum in IDD Healthcare,” an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD.