A family member hears voices even when he is not drinking. Is it caused by the alcohol or does he have schizophrenia?

In medical school, one is taught that visual hallucinations are generally indicative of an underlying medical problem, whereas auditory hallucinations are more indicative of a psychiatric problem. This is only a general guideline, however. Most patients suffering from delirium see and hear things that are not there. A variety of medical problems, including but not limited to alcohol withdrawal, cause delirium. Some psychiatric patients report visual hallucinations that are clearly the result of their psychiatric illness. The idea that an alcoholic can hear voices, however, "seems" to cross the boundary between what is medical and what is psychiatric.

We have covered a number of devastating effects that alcohol has on the brain. Is it any wonder that short of dementia, delirium, seizures, metabolic derangements, and the high incidence of head injury someone might not hear voices as well? All of these conditions can be the reason for hearing voices and can certainly increase the risk for hearing them, but hearing voices can occur even without any of these conditions present. In fact, this rare but frightening symptom occurs in roughly 3% of alcoholics during intoxication and/or withdrawal and can linger long after physiological withdrawal symptoms (rapid heart rate, high blood pressure, tremors, and insomnia) abate. The more frequently one "see-saws" through intoxication and withdrawal, the easier it is to develop withdrawal symptoms such as seizures, DTs, and hallucinations with an ever-lessening amount of alcohol. Thus, for some patients, even a day's worth of drinking followed by abstinence can set it off. The brain has become sensitized. This process of heightened sensitivity to the neurotoxic effects of alcohol occurs through a process known as kindling. Kindling was first demonstrated in rats when it was shown that ever-lessening doses of either seizure-inducing electricity or chugs caused the rats to have ever more intense and prolonged seizures.

Kindling an effect on the brain whereby repeated electrical or chemical stimulation of the brain eventually induces seizures. This may explain why cocaine and alcohol previously did not lead to seizures but after repeated use now do.

Psychosis a state in which an individual experiences hallucinations, delusions, and disorganized thoughts, speech,and/or behaviors.

Although antipsychotic medication can treat the symptoms and decrease the agitation associated with them, sustained abstinence is the only cure. If the voices fail to clear after sustained abstinence, further investigation of the underlying causes should be pursued. Alcohol-related psychosis may be confused with other psychiatric disorders. Other street drugs, particularly the stimulants and the hallucinogens, can cause hallucinations. Psychiatric causes can include schizophrenia, but the diagnosis of schizophrenia is based predominantly on symptoms other than the presence of hallucinations. Mood disorders, particularly manic depression or bipolar disorder, can present with hallucinations. Patients with psychiatric disorders do tend to abuse drugs and alcohol to a greater degree than the general population. The cause of alcohol-related psychosis is generally determined by the patient's past history and family genealogy. In general, however, for patients with severe alcohol dependence, the most likely cause of his or her hallucinations is probably medical and directly related to the consequences of chronic heavy drinking.

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