1. Mr. Smith, a 58-year-old hat factory worker, was hospitalized after losing consciousness at work and developing agitated behavior and auditory hallucinations overnight; 2. Further examination revealed signs of alcohol withdrawal including elevated blood pressure and heart rate as well as liver abnormalities; 3. Information from his wife indicated a long history of heavy drinking, suggesting the most likely diagnosis is alcohol hallucinosis.

1. Clinical Detective
The Case of the
Hallucinating Haberdasher

2. The Case of the Hallucinating
Haberdasher
A 58-year-old hat-factory worker, Mr. Smith, had fallen on
the job and was hospitalized for observation due to a 30
minute loss of consciousness. He was in the hospital over
night when he grew increasingly nervous and agitated. He
began hearing voices that were unstructured, and ill-
developed.
The attending physician has not ordered any medications
for this patient, other than standing Motrin 800 prn up to
TID, and Temazepam 15 mg po prn insomnia.
Imaging studies did not detect any encephalopathy
including cerebrovascular problems, space occupying
lesions.
The doctor calls the C&L service saying that the patient
has been examined for head injury and believes that this is
just a “psych case.”

3. The Case of the Hallucinating
Haberdasher
1. What type of history would you want to obtain on this
patient?
2. What other modes of data collection are available to you?

4. The Case of the Hallucinating
Haberdasher
Consider Historical Information
Chronology of symptom formation
Onset, Duration, Character, Aggravating factors, Reliving
factors, Timing and Severity
Past Mental Health History
Past Medical History
Current Medications
Family illnesses
Substance Use
Developmental
Personality Disorder under stress likely to experience
psychotic symptoms
Sexual History

5. The Case of the Hallucinating
Haberdasher
Other data available:
Observe the physical findings
Review the medical record for:
Vitals
Admission notes
Nursing notes
Physical exam
Medications
Past medical history
Labs and procedures ordered/results
Collateral Information from available friends/relatives

6. The Case of the Hallucinating
Haberdasher
You learn that he has worked in the same factory for over
20 years without difficulty.
He has been married for 30 years.
His physician has noted on admission that he has treated
Mr. Smith as an outpatient for several years, and this is the
first onset of auditory hallucinations.
Nursing notes indicate that Mr. Smith keeps scratching at
his arms and neck and they have had to place a dressing
on his left forearm secondary to bleeding from his
scratching.
During your interview he appears to be sweating profusely.
He also appears tremulous and is becoming increasingly
agitated. He denies suffering from hallucinations. He says

7. The Case of the Hallucinating
Haberdasher
The patient is showing impaired concentration and
poor reality testing. He denies any history of
significant medical or psych problems. You
consider him an unreliable historian.

8. The Case of the Hallucinating Haberdasher
Is this presentation typical for schizophrenia
so far?
Why?

9. The Case of the Hallucinating Haberdasher
Answer
Not typical
Age range (peak onset 18-24)
Hallucinations are acute (occurring in hospital setting)
Hallucinations are ill-defined
Physical symptoms acute
Note
Good premorbid adjustment is seen more often in patients
with psychosis due to neurologic/systemic disorders,
whereas poorer adjustment is more common in patients
with mental illness.
Baseline behavior useful discriminant.
Persons with schizophrenia, for example, often demonstrate
evidence of disturbed thinking between psychotic episodes.
Interpersonal relationship and work histories tend to be more
disrupted in patients with primary psychiatric disease

10. The Case of the Hallucinating
Haberdasher
Your review of available data show:
Vitals
SBP >200 mmHg, DBP >110 mmHg;
HR >140
T >101F
Labs:
Decreased Albumin
Elevated Sodium
Abnormal LFTs
Elevated Gamma-glutamyl transpeptidase, GGT
Elevation of Aspartate Transaminase (AST) and Alanine Transaminase
(ALT)
AST:ALT ratio of 2:1
Elevated Mean Corpuscular Volume (macrocytosis)
Elevated Carbohydrate-deficient transferrin (CDT)
CAGE Score = 3
C1A1G1E0

11. The Case of the Hallucinating
Haberdasher
Your collateral interview with wife provides the following:
Her husband comes home every night and just sits in
front of the television drinking beer.
He has a 30 year drinking history, but intake has
increased over the past few years.
Most of the time he just falls asleep in front of the
television and she has gotten to the point she just leaves
him there.
He eventually stumbles into bed some time in the night,
but usually he has trouble sleeping and will leave the
house before she awakens.
He doesn’t eat much anymore even though he used to
have a voracious appetite.
With more questioning you learn that the patient’s

12. The Case of the Hallucinating
Haberdasher
What is your most likely diagnosis?

13. The Case of the Hallucinating
Haberdasher
Alcohol Hallucinosis
Typical Presentation
30-60 years old
Acute
If due to withdrawal, begins 8-12 hours
after cessation of drinking
Hallucinations are usually auditory
Anxious, Depressed
Impairment of cognitive functioning
Spontaneous improvement (last <week)