A 32-year-old male with ASD, intellectual disability, generalized anxiety disorder, and schizoaffective disorder was brought to the emergency department by the family for concerns of acute-onset paranoia and delusions in the setting of an olanzapine taper initiated by his outpatient psychiatrist due to lack of efficacy for psychosis and experienced weight gain. The patient was admitted to our psychiatric unit after reporting paranoia over the smoke detectors in his home and was worried his neighbors were spying on him and having a staring episode that raised concern for seizures. At time of admission, his general anxiety disorder-7 (GAD-7) score was 20 and patient health questionnaire-9 (PHQ-9) score was 14. On admission, the patient was continued on olanzapine 20 mg at bedtime and started on risperidone 1 mg, which was increased to 1 mg twice a day the following day with a plan to cross-taper. His home divalproex delayed release 750 mg twice a day, pantoprazole delayed release 40 mg daily, lisinopril-hydrochlorothiazide 10-12.5 mg daily, pravastatin 20 mg daily, topiramate 50 mg twice a day, and venlafaxine extended release 150 mg daily were continued. Gabapentin 300 mg three times daily was added for chronic back pain on hospital day 1.
In addition to psychotic symptoms, the patient endorsed having misophonia. He described developing a headache and a negative emotional reaction to various sounds, including the sounds of people eating, talking, snoring, fireworks, and cell phones ringing. Before admission, the patient kept his phone on vibrate at all times for fear of the sound of the ringing. The patient also described multiple instances where he would leave the area, put a pillow over his head, or have a "big blowup" fight with the individuals making the noise where he would scream and become physically aggressive. He also actively avoided a relative who he knew was "a loud eater with breathing issues", which made him feel guilty, and he often asked his parents to leave the room due to the sounds they made while eating. During admission, the patient initially was noted to be very uncomfortable when in environments with many people talking or eating, such as during group or during meals. In quiet environments, he was observed to be calmer and not in distress. The patient's misophonia was evaluated using the 10-item Amsterdam misophonia scale-revised (AMISOS-R), consisting of 10 items, with a total score ranging from 0-40 (I.). The scale has not been fully validated, but preliminary analysis has demonstrated good reliability. Higher scores indicate higher misophonia severity; our patient scored 31, indicating severe to extreme misophonia.
On the psychiatric unit, the patient continued to report paranoia towards others, including staff members. He had a behavioral outburst and refused to speak until the door was closed because he feared others were listening. He also reported experiencing audio and visual hallucinations. After seven days on the psychiatric unit, the patient was transferred to the medical unit for a neurological workup of a suspected seizure on the unit. Neurological workup, including MRI and EEG, were negative, indicating no epileptic waveforms or other findings indicative of seizures. Psychogenic nonepileptic seizures could not be ruled out. The patient was fully tapered off his olanzapine on hospital day seven, after being transferred to the medical service; and the following day, his risperidone was increased to 2 mg twice a day. He tolerated this dosage increase and as detailed below and responded well to it. The patient was then retransferred to inpatient psychiatry on hospital day nine. No further seizure-like activity was noted. On hospital day 12, the patient was discharged and was noted to be future-oriented, denying paranoia, hallucinations, suicidal ideation, and homicidal ideation.
The effect of increasing risperidone to 2 mg twice a day on the patient's misophonia was sudden and dramatic. He was engaged and pleasant for the remainder of his hospital stay, with no further behavioral outbursts, and he attended all groups. His score on the AMISOS-R dropped to five, indicative that the patient's misophonia had become subclinical. On the day of discharge, the patient reported that he was feeling less irritable, more talkative overall, and was no longer bothered by the sounds of people eating or talking, and that those formerly distress-inducing sounds instead "rolled over him." The patient noted that he could now easily tolerate his roommate's snoring, which he was not able to do before his hospitalization. At the time of discharge, the patient wondered aloud if he would now be able to turn on the ringer on his cell phone and tolerate a family member who was a loud eater.
One month after discharge from this hospitalization, the patient's mother reported that the patient's misophonia remained improved. However, he continued to experience some irritability and sensitivity to noises when the family ate meals together. The patient remains on risperidone, with the dosage increased to 2 mg daily and 3 mg at bedtime following another hospitalization for agitation unrelated to misophonia approximately 2 months after his hospitalization at our facility.