Why rTMS? One hypothesis suggests that auditory hallucinations are unrecognized and unsuppressed manifestations of inner speech generated in the speech areas of the brain. The best evidence of efficacy, however, has emerged with the use of low-frequency (eg, 1 Hz) and other types of repetitive transcranial magnetic stimulation (rTMS) applied over the left temporoparietal cortex 10-12 treatment gains herein may be sustained with maintenance rTMS 13 much as treatment gains with ECT are sustained with maintenance ECT. Some patients with antipsychotic-refractory auditory hallucinations may respond to a benzodiazepine drug 7 behavioral interventions, many of which have been described, 8, 9 may also result in benefits. Furthermore, none of the preceding interventions has been studied in patients in whom the target symptom is persistent auditory hallucinations. 3 Experimental strategies include augmentation with valproate, 4 topiramate, 5 or allopurinol, 6 although the efficacy data on these 3 drugs are equivocal, and none has been specifically studied in clozapine-refractory patients. In positive-symptom schizophrenia that is refractory to clozapine, possible treatment strategies include augmentation with a second antipsychotic, 1 augmentation with lamotrigine, 2 or a trial of electroconvulsive therapy (ECT). Treatment Options for Refractory Auditory Hallucinations Are there other conventional or unconventional approaches that might attenuate the hallucinations? Adequate trials of several different typical and atypical antipsychotic medications failed to attenuate the hallucinatory experiences clozapine, which he has been receiving for the past 6 months, has also proved unhelpful. During the past 2 years, he has repeatedly complained about hearing abusive and threatening voices that are present for most of his waking hours these experiences are markedly distressing and diminish his quality of life. Mr D is a 32-year-old patient with a 5-year history of schizophrenia. © Copyright 2013 Physicians Postgraduate Press, Inc. Transcranial direct current stimulation therefore appears to be a promising noninvasive brain stimulation technique for patients with antipsychotic-refractory auditory hallucinations. In patients with refractory auditory hallucinations, tDCS has been delivered at 1- to 3-mA current intensity during 20-30 minutes in once- to twice-daily sessions for up to 3 years with no apparent adverse effects. Benefits with up to 3 years of maintenance tDCS have also been described. At present, the case for tDCS treatment of refractory auditory hallucinations rests on 1 well-conducted randomized, sham tDCS-controlled trial and several carefully documented and instructive case reports. Such patients may benefit from a short trial of once- to twice-daily transcranial direct current stimulation (tDCS) with the cathode placed over the left temporoparietal cortex and the anode over the left dorsolateral prefrontal cortex negative, cognitive, and other symptoms, if present, may also improve. Some patients with schizophrenia may suffer from continuous or severe auditory hallucinations that are refractory to antipsychotic drugs, including clozapine.
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