Efficacy of electroconvulsive therapy in treating auditory verbal hallucinations in a deaf patient with schizophrenia: A case report

Abstract

BACKGROUND

Auditory verbal hallucinations (AVHs) are believed to be characteristic symptoms of schizophrenia. The prevalence of AVHs in deaf patients with schizophrenia is comparable to that in patients with schizophrenia who have normal hearing ability. AVHs in deaf patients with schizophrenia require treatment.

CASE SUMMARY

A 22-year-old deaf woman with schizophrenia had experienced AVHs for 3 months. Her psychotic symptoms were not alleviated by antipsychotic medication alone. Modified electroconvulsive therapy in combination with antipsychotic drugs effectively alleviated her AVHs and disorganized behavior. During outpatient follow-up for 6 months, her condition have remained stable, and she has been able to take care of herself.

CONCLUSION

Treatment with modified electroconvulsive therapy was found to be safe and might be indicated for deaf patients whose symptoms are not well managed with antipsychotic medication alone. Deaf people might be unable to communicate through spoken language; therefore, to make proper diagnoses and provide appropriate treatment for these patients, psychiatrists must have patience and seek to understand patients’ mental state.

Key Words: Deafness; Auditory verbal hallucinations; Schizophrenia; Antipsychotic drugs; Modified electroconvulsive therapy; Case report

Core Tip: Antipsychotics alone have poor efficacy in treating patients with deafness experiencing auditory verbal hallucinations. Our patient’s psychotic symptoms were controlled with antipsychotic drugs combined with electroconvulsive therapy treatment. Antipsychotic drugs plus modified electroconvulsive therapy might therefore be safe for the treatment of deaf patients with auditory verbal hallucinations. During outpatient follow-up for 6 months, her condition have remained stable, and she has been able to take care of herself.

INTRODUCTION

Evidence indicates that schizophrenia, like neurodegenerative diseases[1,2] such as Parkinson’s disease, Huntington’s disease, and Alzheimer’s disease, also involves the central nervous system[3]. Disruptions in the central nervous system’s ability to accurately distinguish thoughts from actual speech and auditory inputs may lead to symptoms such as auditory hallucinations[3]. The prevalence of schizophrenia in deaf individuals is similar to that in the general population[4]. Auditory verbal hallucinations (AVHs) are believed to be characteristic symptoms of psychosis, particularly schizophrenia[5]. Although sound-based hallucinations in deaf people might be an unexpected phenomenon, the prevalence of AVHs in deaf patients with schizophrenia is comparable to that among normal-hearing patients with schizophrenia[4,6]. One study has reported a rate of AVHs of approximately 50% among prelingually deaf people with schizophrenia[7]. Prelingual deafness significantly influences the course of schizophrenia[8]. A longitudinal study has shown that prelingually deaf patients with schizophrenia are much more severely affected than normal hearing controls with schizophrenia, in terms of assessment of resident symptoms and social status[9]. Effective treatment is necessary to improve symptoms in this group of patients.

Antipsychotic drugs are the mainstay treatment for schizophrenia with AVHs but are not always effective in treating AVHs[10]. Electroconvulsive therapy (ECT), a treatment in which electrical stimulation is applied through electrodes usually placed on both sides of the scalp to induce seizures, was introduced in 1938 as a treatment for schizophrenia[11]. ECT is highly effective in patients with treatment-resistant schizophrenia or those requiring a rapid response[12]. Serious adverse effects associated with ECT are rare, and include cardiac arrhythmias, respiratory distress, prolonged apnea, aspiration, prolonged paralysis and prolonged seizures[13]. Advances in the safety, tolerability and efficacy of modified ECT (MECT) have been made through the use of an aesthetics and muscle relaxants.

Many reports have described diagnosis[14,15], AVHs[16-19] and medication treatment[20] in deaf patients with schizophrenia. However, no reports have described the use of ECT in deaf patients with schizophrenia. In this report, we describe the case of a deaf patient with AVHs. She was treated by an experienced, patient senior-level psychiatrist. However, she showed a poor response to antipsychotic medication alone. To better manage the patient’s symptoms, we first communicated with the patient’s guardian regarding MECT treatment and explained the potential risks. Subsequently, we, together with her guardian, communicated with the patient in written language, and obtained her consent for the treatment. The patient’s guardian then signed a written informed consent form for MECT treatment. The patient’s psychotic symptoms were controlled after MECT treatment in combination with antipsychotic medication. The mechanisms underlying the therapeutic effects remain unclear. ECT may induce brain plasticity, manifesting as changes in gray matter volume during the treatment of schizophrenia, through a mechanism distinct from that of antipsychotics. This treatment may ameliorate positive psychotic symptoms in patients with schizophrenia by preferentially targeting limbic brain regions such as the inferior hippocampal gyrus/hippocampus[21]. Our patient did not report any side effects such as dizziness or headaches after the treatment. Combing antipsychotic drugs and MECT therapy might therefore be safe for deaf patients with schizophrenia.

CASE PRESENTATION

Chief complaints

Our patient was a 22-year-old woman who became deaf at approximately the age of 1, because of the use of gentamicin. She had abnormal speech and disorganized behavior, and poor sleep for 3 months.

History of present illness

She was involuntarily admitted to our hospital for treatment. She had been working in another city 3 months before admission. Her mother observed that she was behaving abnormally when during a video chat on WeChat. The patient exhibited winking, made faces, and showed a lack of concentration and difficulty in communicating normally. Her parents went to the city where she worked, and took her home. At home, she subsequently showed erratic behavior, including yelling, kneeling and kowtowing, talking to herself and gesticulating with her hands. Her mother was with her all the time. The patient used sign language to express that she could hear someone talking to her, that she was dying and that the voice ordered her to die. She believed that she was an alien and that her real parents were aliens. She thought that someone was trying to hurt her. She was too afraid to sleep, and she frequently shouted. Before she attended our hospital, her parents had taken her to the local hospital, and she had taken 5 mg olanzapine per day for 1 month with unsatisfactory results.

History of past illness

She had deafness caused by gentamicin use at the age of approximately 1 year.

Personal and family history

She had been educated in a special school and had graduated from junior high school. She was able to write and communicate in sign language, and also pronounce simple words. She had no history of substance use and no family history of mental illness within three generations.

Physical examination

A physical examination of various systems revealed no abnormalities except deafness. Through written communication, we found that her thinking was disorganized, that she had AVHs, that she heard voices telling her to die and that she sometimes wrote “dying”. She believed that she was an alien; indicated that she wanted to go back to the outer planets; and believed that there was too much electricity on the Earth and that it was unsafe.

Laboratory examinations

Laboratory examinations, including complete blood count, liver function, renal function, diabetes mellitus lipid profile, cardiac enzyme profile and thyroid function tests, were performed to rule out a secondary organic etiology.

Imaging examinations

A computed tomography scan of her head yielded normal findings.

FINAL DIAGNOSIS

According to the International Classification of Diseases, Tenth Revision-10 diagnostic system, she was diagnosed with schizophrenia.

TREATMENT

She was given 6 mg paliperidone extended-release tablets and 200 mg quetiapine extended-release tablets daily for approximately 4 weeks. She still heard voices, felt insecure, sometimes lost her temper and gestured with her hands. Her mother was very worried and anxious that her daughter would not be cured, and asked for better treatment. The patient’s condition was reassessed, and her treatment programme was readjusted. Quetiapine was stopped and changed to clozapine in combination with MECT. MECT was applied to the patient by using the Thymatron (Somatics, United States). She was fasted for at least 8 hours, and her vital signs were measured and bladder was emptied before MECT. Prior to MECT, succinylcholine chloride (20 mg) was used as a muscle relaxant, atropine (0.5 mg) was administered to reduce airway secretions, and etomidate (12 mg) was given to maintain anesthesia. Antipsychotic medications were discontinued during each treatment session. The electrodes were placed on her both temporal lobes. An initial electrical dose was based on 2/3 of the patients’ age and subsequent dosing was adjusted according to her physique, and seizure responsiveness. The patient underwent six sessions of MECT in 2 weeks, and clozapine was increased to 150 mg per day. The treatment course is shown in Tables 1 and 2. We used the positive and negative syndrome scale[22] to assess her psychiatric symptoms. Her symptoms markedly improved (Figure 1), and she was successfully discharged after 56 days of hospitalization.

Figure 1 Changes in total positive and negative syndrome scale scores over time. PANSS: Positive and negative syndrome scale.

Table 1 The patient’s drug treatment history.

Time	Quetiapine extended-release tablets	Paliperidone extended-release tablets	Clozapine
March 4, 2024-March 5, 2024	50 mg/day	-	-
March 6, 2024-March 7, 2024	100 mg/day	-	-
March 8, 2024-March 10, 2024	150 mg/day	-	-
March 11, 2024-April 3, 2024	200 mg/day	-	-
March 9, 2024-March 14, 2024	-	3 mg/day	-
March 15, 2024-April 29, 2024	-	6 mg/day	-
April 4, 2024-April 5, 2024	-	-	25 mg/day
April 6, 2024-April 7, 2024	-	-	50 mg/day
April 8, 2024-April 11, 2024	-	-	100 mg/day
April 12, 2024-April 29, 2024	-	-	150 mg/day

Table 2 The patient’s modified electroconvulsive therapy treatment history.

Time	MECT
April 2, 2024	First time
April 3, 2024	Second time
April 6, 2024	Third time
April 9, 2024	Fourth time
April 13, 2024	Fifth time
April 16, 2024	Sixth time

MECT: Modified electroconvulsive therapy.

OUTCOME AND FOLLOW-UP

During half a year of outpatient follow-up, her condition have been stable, and she has been able to take care of herself.

DISCUSSION

This case report describes the diagnosis and treatment of schizophrenia in a patient who had been deaf since childhood. Diagnosis and treatment of such patients is challenging for psychiatrists because of communication barriers.

Diagnostic challenges in patients with deafness

Making a definitive psychiatric diagnosis is highly difficult for people with deafness. To make a clear diagnosis of our patient, we took a detailed history from her parents and closely observed her behavior. Through sign language and written language, we conducted a detailed psychiatric examination of the patient. She experienced AVHs, a core symptom of schizophrenia[11]. She heard a male voice commanding her to die. She also experienced delusional symptoms and believed that her parents were aliens. She thought that there was too much electricity on Earth and that it was unsafe. She sometimes made noises, laughed to herself and made odd gestures. Because she was unable to communicate orally, we encountered difficulties in examining her thought disorder. In written communication, her written sentences contained logical errors and confusing concepts, such as “I’m an alien, a man, and I’m going to die”. Her social functioning and ability to work were impaired, and she had no self-awareness. The duration of the disease was 3 months. Apart from deafness, we found no other significant abnormalities in laboratory and imaging examinations. According to the International Classification of Diseases, Tenth Revision-10 system, her presentation was consistent with a diagnosis of schizophrenia.

Language disorders have long been recognized as a major identifying feature of schizophrenia. People with schizophrenia have language-processing deficits in many aspects. Deaf people often use sign languages as their principal means of communication. To communicate well with deaf patients, psychiatrists must learn some sign language. Psychiatrists should have patience to cultivate a good doctor-patient relationship and carefully observe patients’ various manifestations. Psychiatrists should repeatedly confirm their symptoms and make a clear diagnosis to provide proper treatment.

Treatment challenges in patients with deafness

Our patient had significant psychiatric symptoms and emotional instability. After administration of quetiapine extended-release tablets at 200 mg/day, her symptoms did not substantially improve, and she still showed abnormal behavior, sometimes including shouting. After addition of paliperidone extended-release tablets at 6 mg/day, she still experienced AVHs and poor concentration. She had been hospitalized for more than 1 month, and her mother was very worried that her daughter would not be cured and requested adjustment of the treatment programme.

Through discussions with our supervising physician, we developed a new treatment strategy including MECT to relieve her psychiatric symptom. We discussed the advantages and possible adverse effects of this treatment with the patient’s mother and asked her to communicate with her daughter about the treatment. The patient and her mother agreed to the treatment and signed an informed consent form. Quetiapine extended-release tablets were discontinued, and clozapine tablets were gradually increased to 150 mg/day to treat the patient’s psychiatric symptoms. After 6 sessions of MECT over 2 weeks, the patient’s psychiatric symptoms of hallucinations and bizarre behavior were markedly alleviated.

She was emotionally stable and able to express herself through sign language and written language. After 56 days of hospitalization, she was discharged. At discharge, she was taking paliperidone extended-release tablets at 6 mg/d and clozapine orally disintegrating tablets at 150 mg/day. She has been visiting our hospital for regular follow-ups for 6 months and remains in stable condition. Treatment of psychiatric patients is more challenging in patients with deafness than those with normal hearing, because of the inability to communicate through spoken language[23]. Psychiatrists communicated with our patient in writing during daily rounds to better understand her thoughts and the efficacy of the medication. The nurses and her mother recorded her daily performance, emotional responses and behavioral changes. If poor outcomes were observed, the treatment plan was adjusted in a timely manner. MECT was found to be safe for our deaf patient and, in combination with antipsychotic medication, relieved her psychiatric symptoms.

CONCLUSION

Our deaf patient, who exhibited the same verbal hallucinations, delusions and behavioral abnormalities observed in people with schizophrenia with normal hearing, was diagnosed with schizophrenia. During the course of treatment, after drug treatment had been administered for a sufficient period and was found to be ineffective, MECT was promptly administered, and her psychiatric symptoms were controlled. Her condition remained stable during 6 months of follow-up after discharge. To make proper diagnoses and provide appropriate treatment for similar patients, psychiatrists must have patience and make efforts to better understand the patient’s mental state.

ACKNOWLEDGEMENTS

We express our gratitude to the patient and her parents, whose co-operation and consent were essential for the documentation of this case.