Introduction Auditory verbal hallucinations (AVH): the ‘subjective experience of hearing voices speaking in the absence of corresponding physical stimulation’ (Kompus et al 2013) are part of Schneider’s first rank symptoms. They are included in the American Psychiatric Association DSM-5 diagnostic criteria for Schizophrenia and can be difficult to treat in a proportion of patients with drug resistance in up to 25% of cases
Case Our case is a 52 year old gentleman with a background of treatment resistant schizophrenia, who presented to hospital with a right sided hemiplegia and aphasia. He was diagnosed with a left middle cerebral artery territory stroke. A post CVA MRI showed ‘an extensive mature infarct in the left middle cerebral artery territory and encompassed the left superior temporal gyrus (STG) where the primary auditory cortex (PAC) is located’. He was known to a mental health team from 1989 and had eight inpatient psychiatric admissions, under section, with thought disorder and paranoid thoughts with aggressive behaviour endangering himself and the public.
Prior to the stroke he was treated with monthly Pipothiozine Depot Injections, however, these were missed post stroke; he remained untreated for his paranoid schizophrenia and no signs of distress or paranoia were identified by any of the treating staff. Due to his speech impairments, his mental state remained difficult to assess, however, in conjunction with speech and language colleagues the Neuropsychiatrist ascertained that there was no evidence of psychosis, beliefs or behaviours similar to his pre-morbid mental state.
Discussion The human PAC is part of the temporal lobe and is the final target for afferent auditory signals. It is found bilaterally, specifically within the STG, occupying the dorsal and lateral surface of the STG and encompassing Heschl’s gyrus. There are several different hypotheses regarding the neural mechanisms behind auditory verbal hallucinations. Multiple studies have implicated the primary auditory cortex as being central to this process and functional imaging has shown the STG to be activated in patients with schizophrenia during hallucinations. The resolution of symptoms in this case supports the involvement of the PAC in AVH and could represent a target for future therapies.
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