Suggest treatment for auditory hallucinations
Patient: MEDICAL HISTORY Dear Doctor, I am writing this letter for our daughter (23 years now). We started our USA life in Florida on 2001. She started her study at 5th grade. We have two children (Son and daughter). She is our youngest one. 1)     When she was studying in 10th grade (2005 year), A big hurricane hit our house window glass and burst. At that time we were praying in another bedroom. That wind burst our bed room window where we were praying burst outward. She feared very lot at that time but she has no problem at that time. 2)     One day she was taking shower after her school some boys hit her bath room. She feared, ran to sitting room and could not speak some. My wife asked so many times, after some times she told her this incident. Our house was on ground floor.This was the second incident. 3)     After one year, when she was studying in 11th grade, some boys bothered her so much. She told me that no one never touched her but they teased her with words like prostitute etc. when she travel by school bus or she was studying in school because she is nice, beautiful. So they tried to attract but failed. She needs to live holy, doesn’t want American people life. She didn’t know who is working in background. At last she found told us that one of boys is living above our apartment house. Her tension increased, one day we noticed that she is smiling and talking herself. This was starting point. We admitted in hospital and discharged from hospital after 10 days. They gave Seroquel tablet. We found that our daughter will not get peace if she stays in our apartment house. So I sent daughter and my wife to India in February 2007. We admitted her in hospital, Kerala India and they doubted, it may be Schizophrenia. They gave medicines Night: Quetiapine (Ingredients: Substituted for Seroquel) Morning: RIZ LS - Risperidone and Trihexyphenidyl Hydrochloride Orodispersible tablet (Ingredients: Risperidone BP 2 mg, Trihexyphenidyl Hydrochloride IP 2 mg) When she was taking, she told us that she cannot look naked body when she bath or change her dress and she is hearing voice. My wife told this problem then doctor told her that ignores it. My wife didn’t know that it was medicine side effects. 7 years she suffered these problems and she studied 11th, 12th and graduated B.Sc. in year 2013 with very good marks. I got a new job in Texas, USA on June 2012. So I moved from Florida to Houston. So we decided to bring my wife and our daughter to here (Texas, USA) and our daughter can continue her education. They came here on July 2013. At that time she was taking medicines as follows. Night: Quetiapine 50 mg (Ingredients: Substituted for Seroquel 50 mg) Morning: RIZ LS - Risperidone and Trihexyphenidyl Hydrochloride Orodispersible tablet (Ingredients: Risperidone BP 2 mg, Trihexyphenidyl Hydrochloride IP 2 mg) As per our doctor s instruction india, we reduced medicine from Quetiapine 50 mg to Quetiapine 25 mg (bed time). On 2014 March 2nd night (after one month), She couldn t sleep, so I brought her to Hospital Emergency Room on March 3rd morning. They tested her blood but they didn t give any medicine and discharged from hospital. Then I called our doctor in India, he told me that increase medicine Quetiapine 25 mg to Quetiapine 50 mg. So we gave Quetiapine 50 mg on March 3rd night but she couldn t sleep again. So I brought her to Emergency Room (Mid night). At that time she was very nice to talk to us. They admitted her on March 4th evening on patient care. So doctors stopped all medicine then she has no problem and she can sleep without any issue. Also she can look her naked body when she was bathing and she has no hearing voices etc after stopping these medicines. Everything happened because of these medicines side effect. Next day they discharged from hospital and prescribed started Risperidone 2 mg and Benadryl tab 25 mg bed time only for safety. They didn t check prolactin level before giving Risperidone tab. I was watching her and found that something is going on her but she has no issue. Her period (menses) started March 3rd, 2014. After taking this medicine 18 days, her period was started again. Then I identified, it is an issue of this medicine. We got appointment after 5 days as per hospital referral doctor. March 26, 2014, we consulted the doctor and I told her the problem. Doctor didn t believe my words. Because of my request, doctor wrote prescription to test prolactin level. We gave her blood on March 28, 2014 Friday and Lab told, they will send result to doctor on Monday March 31, 2014. Friday after noon, she was completely changed and she was throwing all old dress to garbage, tore old photos, documents and etc. Next day again worst, she throws all disliked items to garbage. I contacted doctor but she didn t change medicine. Two times I brought her to hospital, they didn’t believe our words. I am not able to stop medicine without right help. At last again brought her to our hospital Emergency Depart, there duty doctor stopped this medicine and prescribed a tablet to sleep and discharged. The doctor told us to contact our follow up doctor on morning. We gave this sleeping tab at midnight and then she slept on that night. Morning, we went to doctor s office, at that time, doctor got prolactin result and result was abnormal (124.5) which is 6 times more than the maximum (18). She changed medicine quetiapine 50 mg in night (bed time) and Quetiapine 25 mg morning only. Doctor didn t give any medicine for Risperidone internal reaction. One week, we suffered very lot and found that our daughter’s tendency “to throw old dress” which was not completely cured. We found another good doctor (Neuro Psychiatrist) and changed appointment to him. During this period, we tested Neuro transmitter test and found that Dopamine is normal but DOPAC level is low. We tested neurotransmitters (after her periods) from urine (They told give 2nd urine to avoid any medicine trace). Neurotransmitters: Serotonin (5 HT), Catecholamine (Dopamine, Norepinephrine, Epinephrine), GABA (Gamma- Amino butyric acid level), Glutamate, R/E Ratio, Glycine, PEA (Beta-phnylethylamine level), Acetylcholine, Endorphin, Melatonin. A test result, DOPAC is low and others are fine. The new doctor told Quetiapine is also allergic to her. He told us that Risperidone damaged her brain which affected her thyroid gland function and hormone. He gave Latuda 20 mg in night only. After some blood test we found that her Vitamin D is low. Doctor told that it will affect her mood. So doctor prescribed vitamin D. After giving 3 days vitamin D medicine, our daughter told that she feels snake crawling on her body. Next day we watched and gave vitamin D to her, after one hour our daughter was alerted and she told snake strangling her neck also. So we contacted doctor and he looked her problem. Doctor told it is hormone sensitivity which was caused by Risperidone. He stopped vitamin D and prescribed a tablet to decrease prolactin level and prescribed a medicine to increase thyroid function. After 2-3 days giving this medicine, our daughter’s mood were changed, the doctor stopped these medicines and referred to hospital. One week, our daughter was admitted this hospital. This hospital told us that her disease may be some kind of Psychosis. So the doctor prescribed the medicine Abilify 5mg(aripiprazole) and Activan (Lorazepam 0.5 mg) twice a day. We told doctor that she is going back to home country India to take master degree or other professional degree. Her mood is changing in her period’s time. Also if she eats any item with ingredients Corn her mood will change (eg: Oats). As per our watching, something is connected to her hormone. They left to India again. One doctor in India, increased Ablify and gave another tablet ‘pacitane tablet’ to remove side effects but she fell down unconsciously two times. Also we give quetiapine tab before, same thing happened in USA. Suddenly my wife take her to another doctor in cochin, she explained all allergies etc. Doctor told , Abilify is not the right medicine, he changed medicine to Sizodon LS tab half morning and half evening, Activan 10mg night. My wife told doctor that Risperidone is severe allergic to her. Two days before we found that her behavior is changing, we tested prolactin which is elevated from 5.5 to 45 within 10 days. My wife told but doctor is not considering these changes. If prolactin increase Here is the list of behavior change happened in USA 1) The habit of doing/telling lies (Same thing happened in kerala today when my wife observed Our daughter, she pretend sleep on bed tonight and also she covered her body with blanket {which used in cold weather} when the atmosphere was very hot now in kerala.) 2) She sits alone on a room and anyone comes to room, she will get out from there. (This happened in kerala one day before).       3) She took important items and throws them in trash. 4) She tore photos and valuable documents. 5) She loses touch with reality and starts talking non-sense After all these behavior changes, we suffered 3 months to bring back our daughter at least 50% with her right behavior. Doctor in USA told, Risperidone tab affected her pituitary gland and prolactin level based on blood test results. So we cannot continue this medicine. We need right treatment. Now she is allergic to Corn, Soy, Pistachio, Walnut, Corn Oil and Quetiapine tab, Risperidone tab, Vitamin D tab, RIS-LZ tab. We need proper help to bring back our daughter with her nice behavior with minimum medicine. All these issues happened after giving Risperidone. What is will be alternate medicine for Sizodone. If we give aripiprazole tab, only issue is, some mood changes (not always). So what is the right medicine for her Regards Doctor: Hello thanks for asking a question from HCM for your health related queriesYou have mentioned detailed history and it can help in making a provisional diagnosis. From the history you have mentioned and age of the onset of her symptoms it appears that her diagnosis of Psychosis is correct and probably she is suffering from Schizophrenia. A lot of factors affected her psychological development like migrating from India to USA and then due to fear from boys and change in culture she was migrated again to India. Over protective parenting also resulted in increased pressure on her like her decision to remain "holy" even you were aware of this and this is not a expected behaviour. Her symptoms started with muttering and later progressed to violent episodes. Initially she was well with quetiapine but later due to shifting to USA her symptoms relapsed. She developed hyper prolactenimia due to risperidone and this has resulted in galactorrhoea. She failed to respond to Quetiapine again. Aripiprazole has cause intolerance and mood changes and Extra pyramidal side effects. Neurotransmitter studies revealed abnormal receptor functionsAs per my opinion she should underwent one MRI scan of brain with special target to pituitary ares. Porlactin increase to such levels with such doses of Risperidone is no so common. MRI will rule out any prolactinoma or other tumour. Once it is ruled out then we can think about other medicines. Olanzapine is relatively better tolerated and is safer. Clozapine can also be considered as a good option. The drug is useful for resistant symptoms and have excellent efficacy. You can discuss with your psychiatrist regarding prescription of these drugs. Both drugs will help in sleep also.Thanks hope this helps you. If you have some more doubts then you can contact me directly via that link-http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=65151Dr. Seikhoo BishnoiConsultant Psychiatrist