Alcoholic hallucinosis

Alcoholic hallucinosis is a verbal hallucinosis in people with alcohol dependence, combined with delusional ideas of persecution.

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What causes alcoholic hallucinosis?

• Long-term course of the disease - alcoholic hallucinosis develops, as a rule, not earlier than 10-14 years of the existence of advanced alcoholism, more often observed in women.
• Long-term systematic alcohol intoxication.

Symptoms of Alcohol Hallucinosis

Acute alcoholic hallucinosis manifests with affective disorders in the form of anxiety, worry, fear, and sleep disorders are often observed. Against this background, hallucinations occur in the form of individual sounds, noises, words, and phrases. Usually, patients can clearly localize the source of the sound (from the corridor, window, neighboring room, etc.). Hallucinations are accompanied by motor restlessness, an affect of bewilderment. Psychotic disorders often disappear after deep sleep, and affective disorders are reduced at the same time.

With further development of psychosis, multiple verbal hallucinations appear, to which secondary delusions (relationships, influences, accusations, persecution or physical destruction) join. Patients are extremely susceptible to attacks of fear and panic, and are extremely suspicious. Gradually, the patient begins to build delusions into a certain system - hallucinatory experiences are woven into real events (sometimes quite plausibly). After therapy is prescribed, psychotic disorders, as a rule, are quickly reduced, criticism of the experience appears, but depressive and asthenic disorders may persist. At the same time, patients, as a rule, remember well their experiences and behavior in a state of psychosis.

Reduced acute alcoholic hallucinosis

Acute hypnagogic verbal hallucinosis

When falling asleep, akoasmas or simple in form and neutral in content verbal hallucinations occur - individual words, singing, etc. After waking up, these disorders disappear. Affective disorders are represented by a depressed-anxious mood. The duration of psychosis does not exceed several days. It should not be forgotten: hypnagogic hallucinosis can be replaced by a more complex hallucinosis.

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Acute abortive hallucinosis

May be limited to simple verbal hallucinations of neutral content. With the complication of the psychopathological structure, hallucinations may become threatening, accusing, imperative, addressed directly to the patient. Accordingly, a delusional concept is not formed, affective disorders in the form of anxiety, fear arise, behavior changes, motor agitation increases, and a critical attitude to the experienced disorders disappears. The duration of such psychosis is from several hours to a day. The exit is critical. Sometimes abortive hallucinosis precedes full-blown hallucinatory psychoses.

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Acute alcoholic hallucinosis (classical)

Acute alcoholic hallucinosis most often begins against the background of hangover disorders, accompanied by anxiety symptoms, paranoid mood, vegetative disorders, and in women - against the background of depressive disorders. However, sometimes hallucinosis develops after prolonged, daily drinking, accompanied by insomnia.

The symptom complex of acute alcoholic hallucinosis includes true auditory hallucinations, their delusional interpretation, and the affect of fear.

The onset of the disease is usually acute. For several weeks, there may be precursors in the form of anxiety, worry, depressed mood, dizziness, etc. Psychosis usually develops in the evening or at night. The patient is overcome by severe anxiety, he cannot fall asleep or wakes up in fear, drenched in sweat, after a short sleep. At first, auditory hallucinations are elementary - noise, ringing, crackling, rustling, whispering, screaming, individual simple words. Later, they quickly take on the character of a monologue, dialogue and, in the final stage, polyvocal verbal hallucinosis in the form of successively replacing each other scenes linked by a single theme. As a rule, the voices speak about the patient in the third person, but sometimes they directly address him. There are many voices, they are sometimes quiet, sometimes loud, reaching a roar. They speak together, intertwining, arguing and cursing. The content of the hallucinations is unpleasant for the patient. These are various threats, accusations, condemnation of the patient for past actions, especially for excessive drinking and the consequences associated with it. The voices confer, argue, discuss what to do with the patient and how to punish him. They can be not only accusatory, but also defending the patient. The patient, naturally, is a witness to such disputes, but sometimes becomes their participant. The topics discussed are always related to real events in the patient's present or past life. With an influx of hallucinatory experiences, a short-term inhibition and detachment arise, but can be qualified as a phenomenon of hallucinatory substupor or stupor.

Delusional ideas are closely related in content to hallucinations, therefore they are fragmented, fragmentary and not systematized. In expanded hallucinosis, the affects of fear, anxiety, despair prevail. The patient is always the mind of the events taking place, his behavior corresponds to the content of hallucinations and delusions. In the first days, the patient, under the influence of delusion, does not see a way out of the created situation or, with the prevalence of imperative voices, makes suicidal attempts. Later, with the prevalence of the affect of anxiety, the patient begins to flee, he develops motor excitation. Often, patients in this state resort to desperate self-defense, barricade doors, board up windows, turn off means of communication, create their own alarm system, etc. Such behavior of the patient is called a "situation of one situation." Often in such a state, patients begin to defend themselves, turning into aggressors, waiting for invisible enemies, armed with sharp objects, bladed weapons or firearms. At the next stage, the patient turns from the persecuted into the persecutor. This can lead to unforeseen consequences: he can attack random people for self-defense, since in such a state he interprets everything around him in a threatening sense. The addition of delirious disorders (usually at night) increases the frequency of various forms of inappropriate behavior. However, in the future, the behavior of patients can become sufficiently ordered there, masking their ability to socially dangerous actions.

Suggestibility in alcoholic hallucinosis, unlike delirium, is absent: it is impossible to convince the patient of his delusional interpretation of the situation or suggest other hallucinations to him.

Alcoholic hallucinosis occurs against the background of unclouded consciousness, this is evidenced by undisturbed orientation in one's own personality, in one's location, this significantly distinguishes it from delirium tremens. Only with a thorough clinical and psychopathological examination can one note some stupefaction.

Patients retell the content of painful experiences quite accurately and in detail, external events are also not erased from their memory, patients reproduce them almost error-free consistently. Memory does not suffer in alcoholic hallucinosis. Confabulations are practically not observed.

Psychosis usually ends critically after a long period of deep sleep. At the lytic end of hallucinosis, the intensity of verbal hallucinations first decreases, then the affective charge disappears, and later the delusional constructions fade. A critical attitude to the experience does not arise immediately, residual delirium is possible in men (depressive disorders often occur in women). The duration of acute hallucinosis is from several days to 4 weeks.

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Mixed acute alcoholic hallucinosis

Acute hallucinosis with pronounced delirium

The distinctive features of this psychosis are a combination of comparatively poor, scanty verbal hallucinations of a predominantly threatening nature with pronounced persecution delusions. In addition to typical delusional statements related to the content of hallucinations, there are indirect delusional constructions not associated with hallucinatory disorders. Delusion is sensory, figurative in structure, as evidenced by the symptom of confusion, affect of intense anxiety and fear, illusory perception of the environment, isolated false recognitions. Reduction of mental disorders occurs gradually and consistently: affective disorders - verbal hallucinations - delusional disorders. Residual delirium is not uncommon.

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Acute hallucinosis associated with delirium

Delirious disorders occur at any stage of hallucinosis development. They usually join at night. In the initial period and at the end of hallucinosis, these are isolated episodes, and at the height of hallucinatory psychosis, one can observe expanded symptoms of delirium. Rarely, delirium pictures become predominant; more often, verbal hallucinosis remains the core disorder. Patients experience influxes of visual hallucinations; tactile and thermal hallucinations may appear. The affect of fear alternates with euphoria. With such psychosis, fragmentary symptoms of professional delirium may occur. Reduction of psychopathological disorders begins with the disappearance of symptoms of clouding of consciousness, further development is similar to acute hallucinosis. The exit is usually critical.

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Atypical acute alcoholic hallucinosis

In the atypical course of acute alcoholic hallucinosis, the clinical picture shows a combination of symptoms of hallucinosis itself with oneiroid clouding of consciousness, mental automatisms, or depressive symptoms.

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Acute hallucinosis with oneiroid clouding of consciousness

Oneiroid disorders are more common in hallucinosis than in delirium, and develop at the height of hallucinosis. The development of this form of psychosis is limited to the stage of oriented oneiroid. Compared to oneiroid disorders that occur in delirium, patients predominantly experience scenes of fantastic content, representing various world cataclysms, star wars, interplanetary flights, etc., but these themes remain unfinished in terms of plot, fragmentary, as in a restless dream; often "fantasy" experiences are combined with scenes of drunkenness.

The beginning of hallucinosis is classical, then polyvocal verbal scene-like hallucinosis joins in: the patient has a sharply expressed affect of fear, he is in a substupor. Then figurative delirium with illusory perception of the environment arises, at night visual pseudohallucinosis may develop, reflecting the content of verbal hallucinations. Reduction of psychosis begins with oneiroid disorders, verbal hallucinosis disappears at the end.

Acute hallucinosis with stuporous disorders (alcoholic stupor)

The development of alcoholic stupor or substupor is indicated by disorders of the motor sphere that accompany alcoholic hallucinosis. As a rule, at the height of hallucinosis, the patient is immobilized, detached from the surrounding world, and busy. Negativism is absent. Inhibition can be replaced by excitement or alternate with it. The duration of the above-described disorders is from several minutes to several hours.

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Acute hallucinosis with mental automatisms

Similar to other, atypically occurring forms of psychosis, mental automatisms appear at the height of its development, during the formation of polyvocal hallucinosis. They always intensify and become more complex simultaneously with the intensification of verbal hallucinosis, mainly in the evening and at night. Most often, ideational automatisms are observed - a feeling of openness and advancement of thought, violently arising thoughts, mentism. phenomenon of external influence ("unwinding" of memories). It is noteworthy that the symptom of echo thoughts, as a rule, is not registered. The development of mental automatisms in the structure of hallucinosis is always accompanied by an expansion of the content of delusional statements and the emergence of a tendency to systematize them. Delirious and oneiroid disorders may occur with automatisms. When exiting psychosis, mental automatisms are the first to be reduced.

Subacute (protracted) alcoholic hallucinosis (F10.75)

Subacute hallucinations include those that last from 1 to 6 months. The most common duration of such psychosis is 2-3 months.

The onset of psychosis is almost completely the same as that of acute alcoholic hallucinosis; differences arise later and are usually associated with the addition of pronounced delusional or depressive disorders to hallucinations. There are frequent cases of verbal hallucinations that cannot be reduced and determine the subsequent clinical picture. According to the prevalence of certain disorders in the clinical picture (verbal hallucinations, depressive disorders or delirium), protracted alcoholic hallucinosis is conventionally divided into three variants.

Subacute alcoholic hallucinosis with predominance of verbal hallucinations

They are encountered relatively rarely. In the clinical picture, after the reduction of affective disorders and delirium, verbal hallucinations come to the fore. The behavior of patients is orderly, often the performance of everyday and even professional duties is preserved. As a rule, the patient is aware of the presence of the disease.

Subacute alcoholic hallucinosis with predominance of depressive affect

At the height of hallucinosis development, motor and affective disorders are transformed. The clinical picture begins to be dominated by a depressed mood, depression, and pronounced melancholy. The intensity of depressive disorders, including depressive delusional formation, increases. Ideas of self-accusation arise, gradually beginning to prevail over other delusional statements. The reduction of psychosis is gradual, beginning with affective disorders.

Subacute alcoholic hallucinosis with predominant delusions

As a rule, at the height of verbal hallucinosis development, sensory disorders gradually reduce. Ideas of reference and persecution begin to predominate in the clinical picture. The affect of anxiety and fear is constant and intense. Patients have a symptom of adaptation disorder - an increase in psychotic symptoms when the environment changes. Reduction of psychosis begins with the leveling of affective disorders, delirium disappears last of all.

Chronic alcoholic hallucinosis

Chronic alcoholic hallucinosis is a relatively rare disease. Psychosis can begin as acute alcoholic hallucinosis, less often as alcoholic delirium. However, according to some authors, chronic alcoholic hallucinosis immediately begins with the development of complex conditions, with the simultaneous presence of symptoms of delirium and hallucinosis, or hallucinosis is combined with depressive-paranoid disorders.

The acute stage of chronic hallucinosis is characterized by unusually vivid visual and auditory hallucinations. The stage lasts 1-2 weeks.

Depending on the prevailing clinical picture, the following types of chronic alcoholic hallucinosis are distinguished.

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Chronic verbal hallucinosis without delusion

The most common form of chronic alcoholic hallucinosis. In the prodromal stage, anxiety, severe restlessness, and sleep disorders are significantly expressed. Falling asleep, patients hear that someone is sneaking up on them, wants to grab them, etc., in fear they jump up and scream. Soon, abundant auditory hallucinations appear. Their content is unpleasant, threatening, commenting or antagonistic hallucinations may join. In the acute period, auditory hallucinations are distinguished by a bright emotional coloring, as a result of which patients perceive them as reality. In the background are visual hallucinations (insects, small animals, unreal creatures, various shadows, etc.). In the acute period, kinesthetic, tactile, and physical hallucinations may occur. Against the background of hallucinatory disorders, delusions of persecution or relationship are formed. Consciousness, similar to other types of hallucinations, is not impaired, but at the height of psychosis development it becomes not entirely clear. After 7-10 days, the fear of patients decreases, from the entire spectrum of disorders only auditory hallucinations remain, less threatening than before. Subsequently, patients begin to get used to them. At the same time, external forms of behavior are normalized, patients can perform everyday activities, are able to engage in professional activities. No noticeable changes in memory for the past are noted, memory for current events suffers slightly. Over time, alcoholic hallucinosis loses intensity. Hallucinations can acquire a simple character, sometimes disappear completely, appearing only with external stimuli (the so-called reflex hallucinations). Awareness of the disease appears even in the acute period and persists throughout the painful disorders. With the resumption of alcohol consumption, the previous symptoms of hallucinosis reappear and worsen. This form of chronic hallucinosis is stationary and does not progress. Sometimes it lasts for many years without leading to dementia or personality decline.

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Chronic verbal alcoholic hallucinosis with delusions

In this case, the characteristic hallucinatory syndrome is accompanied by delirium of a peculiar nature. Unlike the usual one, it is amenable to certain correction and is not absurd. More often, such patients exhibit persecutory delirium of a stereotypical nature (the patient expresses delusional ideas in the same formulations); the complications of delusional ideas do not occur over time. Under the influence of alcoholic excesses, naturally, exacerbation of painful phenomena occurs periodically. In terms of intellectual preservation, this form of chronic alcoholic hallucinosis does not differ from the first variant.

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Chronic verbal hallucinosis with mental automatisms and paraphrenic change of delusions

It is considered the rarest form of chronic hallucinosis. The core disorder is true verbal hallucinosis. Over time, first episodic, and then quite persistent phenomena of mental automatisms appear. As a rule, these are ideational automatisms in the form of auditory pseudohallucinations, openness of thoughts, anticipatory thoughts, mentism; individual ideas of influence are noted. With the further course of psychosis, a change in the content of auditory hallucinations and pseudohallucinations is observed, megalomaniacal delirium is formed. Patients talk about their unusual, special position, but not in the present, but in the future (he will be fabulously rich, will get a high position, will be awarded for services, etc.); very often the content of delirium has a shade of puerilism, childishness. Labile affect prevails, euphoria is easily replaced by irritability. This variant of psychosis is characterized by sufficient intellectual preservation, but organic decline slowly increases.

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Differential diagnostics

Hallucinosis of all types of progression requires differential diagnosis with schizophrenia complicated by alcoholism.

Hallucinosis, similar to delirium, is classified by the main clinical signs of the course and features of psychopathological manifestations. According to the clinical picture, a distinction is made between: typical, or classical, reduced, mixed and atypical forms of hallucinosis.

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Treatment of alcoholic paranoid (F10.51*) and acute alcoholic hallucinosis (F10.52*)

In the treatment of acute alcoholic hallucinosis and delusional psychosis, psychopharmacotherapy occupies a key place. The drugs of choice are neuroleptics with predominantly antipsychotic action [for example, haloperidol 5-10 mg 2-3 times a day or risperidone (rispolept) 4-6 mg/day], in case of severe affective disorders, benzodiazepine drugs are additionally prescribed (0.1% phenazepam solution 2-4 ml intramuscularly or intravenously, lorazepam 2.5 mg, maximum dose - 15 mg/day). Nootropic agents, vitamins are also used, symptomatic treatment is carried out.

Treatment of acute hallucinations and delusional psychoses

State	Recommended cookies
Acute alcoholic hallucinosis and delusional psychosis	Neuroleptics with predominantly antipsychotic action [for example, haloperidol 5-10 mg 2-3 times a day or risperidone (rispolept) 4-6 mg/day]
	Therapy aimed at relieving affective disorders: 0.5% solution of diazepam (Relanium) 2-4 ml intramuscularly or intravenously by drip up to 0.06 g/day; or 0.1% solution of phenazepam 1-4 ml intramuscularly or intravenously by drip, up to 0.01 g/day
	Vitamin therapy: 5% thiamine solution (vitamin B1), 4 ml intramuscularly; 5% pyridoxine solution (vitamin B6), 4 ml intramuscularly; 1% nicotinic acid solution (vitamin PP), 2 ml intramuscularly; 5% ascorbic acid solution (vitamin C), 5 ml intravenously; 0.01% cyanocobalamin solution (vitamin B12), 2 ml intramuscularly.
	Neurometabolic therapy: picamilon 0.05 g 3 times a day; aminophenylbutyric acid (phenibut) 0.25 g 3 times a day
	Hepatoprotectors: ademetionine 400 mg 1-2 times a day, thioctic acid 600 mg 1 time per day Symptomatic therapy of somatic complications

Treatment of chronic alcoholic psychoses (F10.6*, F10.7**)

In cases of prolonged and chronic hallucinosis and paranoids (F10.75*), antipsychotics are mainly used: haloperidol and other drugs of the butyrophenone, phenothiazine series, or atypical neuroleptics (sometimes in combination). Prescribed are haloperidol 10-20 mg/day, perphenazine 8-20 mg/day, risperidone 4-6 mg/day, quetiapine 300-600 mg/day, olanzapine 5-10 mg/day. If the patient has alcoholic delusional jealousy, griftasine 5-15 mg/day or haloperidol 10-30 mg/day are indicated. Various neurometabolic agents (in long courses), amino acid preparations, and multivitamins are also used. For anxiety disorders, hydroxyzine is used at 25-75 mg/day.

In chronic encephalopathies (F10.73*) and Corsacon psychosis (F10.6*), long-term treatment with nootropic agents, amino acids (methionine 2 g/day, glutamic acid 1.5 g/day, glycine 0.05 g/day), drugs that improve metabolism and cerebral circulation (instenon, pentoxifylline, inosine, etc.), and multivitamins is necessary.

Treatment of chronic alcoholic psychosis

State	Recommended treatment
Protracted and chronic alcoholic psychoses	In case of psychosis symptoms, antipsychotic drugs are prescribed, the drugs of choice for long-term therapy are atypical neuroleptics: quetiapine 150-600 mg/day; olanzapine 5-10 mg/day. If it is impossible to use these drugs or they are ineffective, haloperidol 10-20 mg/day is indicated; perphenazine 8-20 mg/day; risperidone 4-6 mg/day; triftazin 5-15 mg/day.
	For affective disorders of the anxiety circle, hydroxyzine is used at 25-75 mg/day.
	Neurometabolic therapy: picamilon 0.05 g 3 times a day; aminophenylbutyric acid 0.25 g 3 times a day.
	Vascular agents: instenon 1 tablet 3 times a day; cinnarizine 25 mg 2-3 times a day
	Multivitamin preparations: Aerovit, Complivit, Glutamevit, Centrum, 1 tablet/day
	Hyperbaric oxygenation course
	Symptomatic treatment of somatic and neurological diseases