Psychiatry Case Challenge: A 9-Year-Old With Suicidal Behavior

James Robert Brasic, MD, MPH


January 25, 2022


Hallucinations, the perception of sensory stimuli in the absence of environmental stimuli, represent interesting medical phenomena with a vast array of differential diagnoses.[1] Adolescents and adults who experience unilateral auditory hallucinations are likely to exhibit contralateral lesions of the central nervous system and ipsilateral lesions of the peripheral nervous system.[2] This child, with a unilateral conductive hearing loss, developed ipsilateral auditory hallucinations when bombarded with severe environmental stress, just as older people with severe sensorineural hearing loss may develop auditory hallucinations.[3]

This patient developed unilateral auditory hallucinations affecting an auditory system with a mild ipsilateral conductive hearing loss affecting frequencies crucial for understanding human speech. This is an example of the common pattern that neuropsychiatric disorders are prone to develop in portions of the nervous system damaged by prior disease. Although auditory hallucinations may result from ontologic pathology,[4] auditory hallucinations may also result from neurologic and neuropsychiatric pathologies.[5]

The symptoms of this patient represent a manifestation of the continuum of causality with nervous and mental disorders likely to occur in persons already impaired by previous trauma, even trauma in the prenatal, perinatal, and postnatal periods.[6,7] The child was conceived though a rape. His mother apparently used a spectrum of nonprescribed drugs throughout the gestation. Although his Apgar score at 1 minute was 6, just under the lower limit of the reference range, it was 8 (within the reference range) at 5 minutes.[8]

He was born with a cleft palate, hyperbilirubinemia, and sepsis. He was born with the umbilical cord around his neck. He experienced frequent episodes of otitis media in early childhood, leading to the placement of bilateral myringotomy tubes present at the time of his admission. Apparently, he observed and experienced physical violence throughout his childhood. His nervous system experienced multiple physical assaults during the prenatal period, at birth, and throughout childhood. Thus, although mild unilateral conductive hearing loss would not normally lead to unilateral auditory hallucinations, unilateral auditory hallucinations and other symptoms and signs of psychosis resulted in this child whose nervous system was already damaged by chronic physical and emotional insults since before his birth.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.