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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 150-152

Transcranial direct current stimulation for auditory hallucinations in a 66-year-old male patient with schizophrenia


Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Avinash Desousa
Carmel, 18, St. Francis Road, Off S.V. Road, Santacruz West, Mumbai - 400 054, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_50_16

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  Abstract 

Patients with schizophrenia may sometimes have refractory symptoms that do not respond to medical treatments. One such symptom commonly seen in schizophrenia is refractory and distressing auditory hallucinations that do not respond to medication and psychotherapy. Transcranial direct current stimulation (tDCS) has been used successfully in adult patients in the management of refractory auditory hallucinations in schizophrenia. We report here a case of severe distressing refractory auditory hallucinations in a 66-year-old male with schizophrenia that responded to once daily tDCS which was then continued over a 3-month period. More than 80% improvement was reported in a month of treatment which was then continued over 3 months to yield 95% improvement. The patient had a better quality of life and relief from a distressing symptom. No side effects were noted due to the tDCS treatment. This case report supports the view that tDCS is an effective treatment for resistant and refractory auditory hallucinations in geriatric patients with schizophrenia.

Keywords: Auditory hallucinations, refractory hallucinations, resistant hallucinations, schizophrenia, transcranial direct current stimulation


How to cite this article:
Desousa A. Transcranial direct current stimulation for auditory hallucinations in a 66-year-old male patient with schizophrenia. J Geriatr Ment Health 2017;4:150-2

How to cite this URL:
Desousa A. Transcranial direct current stimulation for auditory hallucinations in a 66-year-old male patient with schizophrenia. J Geriatr Ment Health [serial online] 2017 [cited 2019 Aug 22];4:150-2. Available from: http://www.jgmh.org/text.asp?2017/4/2/150/221908




  Introduction Top


Patients with schizophrenia may sometimes have symptoms that do not respond to medication and nonmedical interventions.[1] One such symptom commonly seen in clinical practice is resistant/refractory auditory hallucinations which can be very distressing for the patient.[2] Transcranial direct current stimulation (tDCS) is a noninvasive method of brain stimulation where there is a continuous passage of a very small current between electrodes placed on specific sites on the scalp.[3] It has been used with fair success in the management of depression,[4] resistant auditory hallucinations,[5] tinnitus,[6] stroke,[7] and tension headache [8] in adult patients. There is a scarcity of data of tDCS use in geriatric patients and its safety and efficacy in geriatric cases is not yet established.[9] tDCS is advantageous in the Indian setting as it is a treatment which is safe and can be administered by the patient themselves at home. This saves patients time and effort, and they may find tDCS a useful alternative when he may not be able to come for routine visits and treatment. We present, herewith, a case of a 66-year-old male with schizophrenia who had distressing auditory hallucinations that failed to respond to medical treatments and responded to once daily tDCS which was continued over a 3-month period.


  Case Report Top


A 66-year-old male with a history of paranoid schizophrenia since the past 22 years used to have continuous distressing auditory hallucinations while most of the symptoms had abated with medical treatment and was maintained on risperidone 4 mg/day, olanzapine 10 mg at night, and trihexyphenidyl 2 mg at night. The hallucinations did not show a response to medications and the patient had been given aripiprazole (20 mg/day), amisulpride (300 mg/day), haloperidol (20 mg/day), and quetiapine (100 mg/day) but did not show any response. The hallucinations were present off and on throughout the day and would disturb the patient. The patient would hear derogatory and abusive voices which were imperative in nature and commanded the patient to do things like hit his wife and son and run away from home. The voices were of people unknown to the patient and the patient used to hit his head to try and stop the voices but to no avail. The patient was a retired school teacher, and the voices did not allow him to socialize and lead a happy retired life. The patient had no major medical illnesses and was otherwise fine. The patient was offered clozapine as a treatment but refused the same as he did not want to undergo the trouble of repeated blood count monitoring when mentioned to him. The patient had recovered well with medicine (except for his hallucinations) and did not wish to undergo a course of electroconvulsive therapy which was also offered to him. The patient was following up in our outpatient department since the past 4 years. No previous case papers were available to indicate the onset and how the diagnosis was made initially.

The patient was then offered tDCS explaining to him that it is an experimental procedure and success cannot be guaranteed. The patient and relatives readily when they realized that the device is small and portable and that side effects are minimal. They were offered a device made by an Indian company (Zeebeetronics, Bengaluru, Karnataka, India). The cathode was placed midway between T3 and P3, and the anode over the F3 point as per the 10–20 system of EEG electrode placement. This is the standard placement suggested by authors who have used tDCS in resistant auditory hallucinations.[10] A current of 1 mA for 20 min was delivered using nickel plated electrodes, and the electrodes were held in place by a Velcro headband. Daily sessions were conducted for the first 4 days (patient was admitted as an inpatient) and then the patient's son and wife were explained the entire procedure and advised daily sessions at home (7 days a week). Within the first 4 days, the patient reported a 10% reduction in his hallucinations and was discharged and asked to follow-up after a week. When the patient followed up after a 15-day period, and after 20 daily sessions of tDCS, he reported a 60% reduction in hallucinations (both intensity and frequency). The patient was then advised to increase the current to 2 mA and to increase the duration of the session to first 25 min for a week followed by 30 min. This was done to further improve the results obtained.

When the patient followed up after another 15 days, he reported a 95% reduction in the hallucinations and the patient's wife mentioned that she had never seen her husband happy and active like this in the past 25 years. The patient was advised daily tDCS for a month and then asked to follow-up. The patient's family decided to purchase a device for use at home. The son used to administer the treatment (he was a qualified engineer). The patient reported no further improvement in a one a month period and mentioned that the hallucinations did not go away completely but would come 2–3 times a day for the very brief period and would not bother him. He rated his improvement as 95%–98%. He mentioned that he had never been this better with any treatment taken so far. We had advised the patient to stop tDCS for a week to see if the hallucinations reappeared, but the improvement seen with tDCS was so great that the patient said he did not mind taking tDCS lifelong if the hallucinations disappeared. He refused to stop the treatment and see the effects as he was very happy with the progress made and feared any deterioration. He is currently taking daily tDCS for approximately 95 days. No cognitive monitoring was done during therapy but no cognitive deterioration was reported either and no other side effects due to tDCS were reported. The patient is currently maintained on risperidone 4 mg/day, olanzapine 10 mg at night, and trihexyphenidyl 2 mg at night with daily tDCS. The dose of medications was not changed during tDCS as improvement was noted on the treatment.


  Discussion Top


Cathodal tDCS results in prolonged hyperpolarization of the underlying temporoparietal cortex resulting in an inhibitory mechanism that would reduce auditory hallucinations.[11] There have been case reports and case series of tDCS use in refractory and resistant auditory hallucinations in adult patients with schizophrenia of varying duration.[12],[13],[14],[15] This case report is probably the longest duration for which tDCS has been used in a geriatric patient with schizophrenia. The portability and ease of the device and relatively minimal side effects make tDCS an effective tool for use in older patients with psychiatric disorders. The fact that geriatric patients may be less mobile and would need domiciliary care should prompt clinicians to try using tDCS in these subjects. One limitation of the case report was that objective measurement of psychopathology, or cognitive functioning was not done.

Researchers have reported that maintenance tDCS can maintain acute tDCS-induced improvements and that the frequency can be varied from once to twice daily based on the requirement of the patient.[16] Maintenance tDCS is continuing the tDCS treatment on a regular basis even after significant improvement is obtained to consolidate and maintain the gains that have been achieved. Maintenance tDCS can be delivered by family members as a domiciliary treatment; however, periodic checks are necessary to confirm adherence to stimulation protocols.[16] It is important that tDCS be administered when needed in geriatric patients to enable determination of its safety and efficacy over a wider group of patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Suzuki T, Remington G, Mulsant BH, Uchida H, Rajji TK, Graff-Guerrero A, et al. Defining treatment-resistant schizophrenia and response to antipsychotics: A review and recommendation. Psychiatry Res 2012;197:1-6.  Back to cited text no. 1
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Wolf ND, Sambataro F, Vasic N, Frasch K, Schmid M, Schönfeldt-Lecuona C, et al. Dysconnectivity of multiple resting-state networks in patients with schizophrenia who have persistent auditory verbal hallucinations. J Psychiatry Neurosci 2011;36:366-74.  Back to cited text no. 2
    
3.
Fregni F, Nitsche MA, Loo CK, Brunoni AR, Marangolo P, Leite J, et al. Regulatory considerations for the clinical and research use of transcranial direct current stimulation (tDCS): Review and recommendations from an expert panel. Clin Res Regul Aff 2015;32:22-35.  Back to cited text no. 3
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Kalu UG, Sexton CE, Loo CK, Ebmeier KP. Transcranial direct current stimulation in the treatment of major depression: A meta-analysis. Psychol Med 2012;42:1791-800.  Back to cited text no. 4
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5.
Brunoni AR, Shiozawa P, Truong D, Javitt DC, Elkis H, Fregni F, et al. Understanding tDCS effects in schizophrenia: A systematic review of clinical data and an integrated computation modeling analysis. Expert Rev Med Devices 2014;11:383-94.  Back to cited text no. 5
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6.
Song JJ, Vanneste S, Van de Heyning P, De Ridder D. Transcranial direct current stimulation in tinnitus patients: A systemic review and meta-analysis. ScientificWorldJournal 2012;2012:427941.  Back to cited text no. 6
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Marquez J, van Vliet P, McElduff P, Lagopoulos J, Parsons M. Transcranial direct current stimulation (tDCS): Does it have merit in stroke rehabilitation? A systematic review. Int J Stroke 2015;10:306-16.  Back to cited text no. 7
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Magis D, Jensen R, Schoenen J. Neurostimulation therapies for primary headache disorders: Present and future. Curr Opin Neurol 2012;25:269-76.  Back to cited text no. 8
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9.
Concerto C, Al Sawah M, Chusid E, Trepal M, Taylor G, Aguglia E, et al. Anodal transcranial direct current stimulation for chronic pain in the elderly: A pilot study. Aging Clin Exp Res 2016;28:231-7.  Back to cited text no. 9
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Nitsche MA, Cohen LG, Wassermann EM, Priori A, Lang N, Antal A, et al. Transcranial direct current stimulation: State of the art 2008. Brain Stimul 2008;1:206-23.  Back to cited text no. 10
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11.
Brunelin J, Mondino M, Gassab L, Haesebaert F, Gaha L, Suaud-Chagny MF, et al. Examining transcranial direct-current stimulation (tDCS) as a treatment for hallucinations in schizophrenia. Am J Psychiatry 2012;169:719-24.  Back to cited text no. 11
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Nawani H, Kalmady SV, Bose A, Shivakumar V, Rakesh G, Subramaniam A, et al. Neural basis of tDCS effects on auditory verbal hallucinations in schizophrenia: A case report evidence for cortical neuroplasticity modulation. J ECT 2014;30:e2-4.  Back to cited text no. 12
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Shivakumar V, Bose A, Rakesh G, Nawani H, Subramaniam A, Agarwal SM, et al. Rapid improvement of auditory verbal hallucinations in schizophrenia after add-on treatment with transcranial direct-current stimulation. J ECT 2013;29:e43-4.  Back to cited text no. 13
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Andrade C. Transcranial direct current stimulation for refractory auditory hallucinations in schizophrenia. J Clin Psychiatry 2013;74:e1054-8.  Back to cited text no. 14
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Mondino M, Jardri R, Suaud-Chagny MF, Saoud M, Poulet E, Brunelin J. Effects of fronto-temporal transcranial direct current stimulation on auditory verbal hallucinations and resting-state functional connectivity of the left temporo-parietal junction in patients with schizophrenia. Schizophr Bull 2016;42:318-26.  Back to cited text no. 15
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Andrade C. Once- to twice-daily, 3-year domiciliary maintenance transcranial direct current stimulation for severe, disabling, clozapine-refractory continuous auditory hallucinations in schizophrenia. J ECT 2013;29:239-42.  Back to cited text no. 16
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