Alcoholic hallucinosis

Alcoholic hallucinosis is an alcohol-induced psychotic disorder in which prominent auditory hallucinations, usually accusatory or threatening voices, arise during or shortly after heavy drinking in a person with long-standing alcohol dependence.酒精性幻觉症是一种酒精所致精神病性障碍，长期酒精依赖者在大量饮酒期间或其后不久出现突出的幻听，多为指责性或威胁性言语。

Consciousness and orientation are characteristically preserved, which separates the disorder from delirium tremens, and the hallucinations usually resolve within days to weeks with abstinence.意识与定向力典型地保持完好，这将其与震颤谵妄区分开，幻听多在戒酒后数日至数周内消失。

Terminology and classification

• The term was fixed in the psychiatric literature by Emil Kraepelin in the 1907 edition of his textbook, where alcoholic hallucinosis was described as a distinct psychotic reaction to chronic alcohol use.该术语由 Emil Kraepelin 在 1907 年版教科书中确立于精神医学文献，把酒精性幻觉症描述为慢性饮酒所致的独立精神病性反应。
• ICD-10 places it within F10.5, the psychotic disorder of the alcohol-dependence block, and ICD-11 release 2025-01 gives the specific code 6C40.60 for alcohol-induced psychotic disorder with hallucinations.ICD-10 将其置于酒精依赖区块的精神病性障碍 F10.5 内，ICD-11 2025-01 版则给出特异编码 6C40.60，即酒精所致精神病性障碍伴幻觉。
• The United States clinical modification splits the category into F10.51 with hallucinations, F10.52 with delusions and F10.59 other, and the first of these is the usual billing code for hallucinosis.美国临床修订版将该类别分为伴幻觉的 F10.51、伴妄想的 F10.52 与其他的 F10.59，其中第一项是幻觉症的常用计费编码。
• DSM-5, published in 2013, does not list alcoholic hallucinosis separately and folds it into alcohol-induced psychotic disorder, a decision that remains contested.2013 年出版的 DSM-5 不再单列酒精性幻觉症，而将其并入酒精所致精神病性障碍，这一决定仍有争议。
• Interoperability anchors are MeSH D011604 for alcoholic psychoses, HPO HP:0008765 for auditory hallucination and Wikidata Q1040275 for alcoholic hallucinosis itself.互操作锚点为酒精性精神病的 MeSH D011604、幻听的 HPO HP:0008765 与酒精性幻觉症本身的 Wikidata Q1040275。
• The disorder has no entry in MONDO or Orphanet and no standing as a rare disease, because it is a substance-induced syndrome defined by temporal relationship rather than by a distinct pathology.该病在 MONDO 与 Orphanet 中无条目，也不属罕见病，因为它是按时间关系定义的物质所致综合征，而非具有独立病理的疾病。
• Older terms include alcoholic delirium of the hallucinatory type and alcoholic psychosis with hallucinations, and both should be mapped to the modern category rather than treated as separate diagnoses.较早的术语包括幻觉型酒精性谵妄与伴幻觉的酒精性精神病，二者应映射至现代类别而非视为独立诊断。

History

• Descriptions of hallucinatory states after heavy drinking date to at least 1907, when Kraepelin separated them from delirium tremens on the basis of clear consciousness.对大量饮酒后幻觉状态的描述至少可追溯到 1907 年，Kraepelin 以意识清晰为依据将其与震颤谵妄分开。
• Nineteenth-century alienists had already noted that some drinkers heard voices without confusion, but they grouped these cases with alcoholic insanity in general.十九世纪的精神病学家已注意到部分饮酒者听到人声而无意识混乱，但通常将其笼统归入酒精性精神病。
• The mid-twentieth-century debate asked whether hallucinosis was simply schizophrenia unmasked by alcohol, and follow-up studies found that most patients recovered without a chronic psychotic course.二十世纪中叶的争论在于幻觉症是否只是被酒精揭开的思觉失调，随访研究却发现多数患者恢复且不进入慢性精神病性病程。
• Glass's 1989 review called alcoholic hallucinosis a psychiatric enigma because its nosological status had resisted a century of classification attempts.Glass 在 1989 年的综述称酒精性幻觉症为精神医学之谜，因为其分类地位历经一个世纪仍未确定。
• The withdrawal hypothesis replaced earlier psychodynamic explanations after studies showed that symptoms begin 12 to 24 hours after the last drink, a timing consistent with the falling alcohol level.戒断假说取代了更早的心因性解释，因为研究显示症状在末次饮酒后 12 至 24 小时开始，与血酒精浓度下降的时间一致。
• Neuroimaging and dopamine studies in the 2000s supported a withdrawal-kindling model rather than a primary degenerative lesion, and this shifted treatment towards withdrawal management.2000 年代的神经影像与多巴胺研究支持戒断点燃模型而非原发性退行性病变，使治疗重心转向戒断管理。
• The 2013 DSM-5 reclassification, which removed the standalone diagnosis, was a reversal of the earlier ICD-10 decision to retain it as a distinct code.2013 年 DSM-5 取消单列诊断，与 ICD-10 此前保留独立编码的决定相反，构成一次分类上的回退。

Epidemiology

• WHO estimated in 2018 that 283 million people aged 15 and over, about 5.1 per cent of adults, had an alcohol use disorder, and 3 million deaths a year are attributable to alcohol.WHO 在 2018 年估计 15 岁及以上人群中有 2.83 亿即约 5.1% 的成人患酒精使用障碍，每年 300 万例死亡可归因于酒精。
• Alcoholic hallucinosis is an uncommon complication even within that population, and most series describe patients with more than a decade of heavy daily drinking.即便如此，酒精性幻觉症在該人群中仍属少见并发症，多数病例系列中的患者有十余年每日大量饮酒史。
• Men outnumber women in published cohorts, and the typical patient is in the fourth or fifth decade, consistent with the long latency of severe dependence.已发表队列中男性多于女性，典型患者处于四五十岁，与重度依赖的长潜伏期相符。
• Symptoms begin about 12 to 24 hours after abrupt cessation of heavy drinking and last for days, although some patients report voices for several weeks.症状在突然停止大量饮酒后约 12 至 24 小时出现并持续数日，部分患者可诉人声持续数周。
• The risk of recurrence with relapse is high, and repeated episodes are thought to reflect kindling of withdrawal-related psychopathology rather than cumulative brain damage.复饮后复发风险高，反复发作被认为反映戒断相关精神病理的点燃效应而非累积性脑损伤。
• Under-recognition is substantial because patients often conceal voices, and routine detoxification services rarely apply structured psychotic symptom scales.识别不足相当普遍，因为患者常隐瞒幻听，常规戒酒服务也极少使用结构化的精神病性症状量表。
• Population data come from WHO global alcohol reports, national hospital discharge registries and cohort studies of alcohol-dependent inpatients rather than from dedicated surveillance.人群数据来自 WHO 全球酒精报告、各国住院出院登记以及酒精依赖住院患者的队列研究，而非专门监测系统。

Pathophysiology

• Chronic alcohol exposure down-regulates GABA-A receptors and up-regulates NMDA receptors, so abrupt withdrawal leaves the brain in a state of neuronal hyperexcitability.长期酒精暴露下调 GABA-A 受体并上调 NMDA 受体，突然戒断使大脑处于神经元高兴奋性状态。
• Mesolimbic dopamine sensitisation is the leading explanation for the psychotic content, and hallucinosis is conceptualised as a release phenomenon of the auditory system during withdrawal.中脑边缘多巴胺敏化是精神病性内容的主要解释，幻觉症被概念化为戒断期间听觉系统的释放现象。
• Repeated withdrawal episodes produce progressive sensitisation, the kindling model, which explains why later episodes begin after shorter and lighter drinking bouts.反复戒断产生渐进性敏化即点燃模型，这解释了为何后续发作在更短更轻的饮酒后即可出现。
• Thiamine deficiency and Wernicke encephalopathy can coexist and must be excluded, because they produce confusion, ataxia and oculomotor signs that hallucinosis alone does not.硫胺素缺乏与韦尼克脑病可并存而须排除，因为它们造成意识混乱、共济失调与眼动体征，而单纯幻觉症没有这些表现。
• No structural lesion is required for the diagnosis, and imaging studies in uncomplicated cases are typically normal apart from atrophy attributable to chronic alcohol use.该诊断不需要结构性病变，无并发症病例的影像通常正常，仅见慢性饮酒所致萎缩。
• Genetic variation in dopamine and GABA receptor genes, together with concurrent stimulant use, is associated with a higher risk of psychotic complications of alcohol withdrawal.多巴胺与 GABA 受体基因的遗传变异，连同合并使用兴奋剂，与酒精戒断出现精神病性并发症的更高风险相关。

Clinical features

• Auditory hallucinations dominate, most often second-person or third-person voices that accuse, threaten or comment on the patient, and they are experienced as external and real.幻听占主导，多为第二或第三人称的指责、威胁或评论性言语，患者体验为外部且真实。
• Visual hallucinations may accompany the auditory ones, but isolated visual hallucinations should prompt a search for delirium, occipital disease or another substance.可伴视幻觉，但孤立的视幻觉应促使查找谵妄、枕叶病变或其他物质原因。
• Consciousness, orientation and attention are preserved, which is the single most useful bedside discriminator from delirium tremens.意识、定向力与注意力保持完好，这是与震颤谵妄鉴别时最有用的单一床旁指标。
• Patients are frequently frightened and agitated, and many retain partial insight, recognising the voices as unreal even while responding to them.患者常恐惧激越，许多人保留部分自知力，虽会回应人声却知道其不真实。
• Mild autonomic hyperactivity, tremor, sweating and insomnia often precede the hallucinations, reflecting the underlying withdrawal state.轻度自主神经亢进、震颤、出汗与失眠常先于幻觉出现，反映潜在的戒断状态。
• Complications include self-harm, aggression, suicidal ideation, accidental injury and progression to delirium tremens, and each requires active screening.并发症包括自伤、攻击、自杀意念、意外伤害与进展为震颤谵妄，均需主动筛查。
• Pregnancy, hepatic impairment and old age change drug handling and increase the risk of oversedation, so the same symptoms require different management.妊娠、肝功能损害与高龄改变药物代谢并增加过度镇静风险，相同症状需不同处理。

Diagnosis

• The diagnosis rests on three elements: recent heavy drinking or abrupt cessation, predominantly auditory hallucinations, and a clear sensorium without disorientation.诊断依赖三要素：近期大量饮酒或突然停酒、以幻听为主，以及无定向障碍的意识清晰状态。
• The Clinical Institute Withdrawal Assessment for Alcohol, the CIWA-Ar, quantifies withdrawal severity and guides symptom-triggered benzodiazepine dosing.酒精戒断临床评定量表 CIWA-Ar 可量化戒断严重程度，并指导按症状触发的苯二氮䓬类给药。
• Laboratory assessment includes blood alcohol, electrolytes, magnesium, liver enzymes, mean corpuscular volume, gamma-glutamyl transferase, thiamine and vitamin B12.实验室评估包括血酒精、电解质、镁、肝酶、平均红细胞体积、γ-谷氨酰转移酶、硫胺素与维生素 B12。
• The differential diagnosis includes delirium tremens, schizophrenia, stimulant-induced psychosis, Wernicke encephalopathy, hepatic encephalopathy and acute delirium from infection.鉴别诊断包括震颤谵妄、思觉失调、兴奋剂所致精神病、韦尼克脑病、肝性脑病与感染所致急性谵妄。
• Delirium tremens is distinguished by clouded consciousness, marked autonomic instability and onset about 48 to 72 hours after the last drink.震颤谵妄以意识混浊、显著自主神经不稳定与末次饮酒后约 48 至 72 小时起病相区分。
• Schizophrenia is distinguished by a longer pre-existing course, negative symptoms and persistent delusions after alcohol has cleared, and it requires longitudinal rather than cross-sectional assessment.思觉失调以更长的既往病程、阴性症状及酒精清除后妄想仍持续相区分，需要纵向而非横断面评估。
• Neuroimaging, electroencephalography and lumbar puncture are reserved for first episodes, focal signs, fever or failure to improve, because they are not routinely indicated.神经影像、脑电图与腰椎穿刺仅用于首次发作、局灶体征、发热或未见好转者，不作常规检查。
• Screening with the AUDIT or AUDIT-C in emergency and detoxification settings improves case finding, since spontaneous disclosure of hallucinosis is uncommon.在急诊与戒酒机构使用 AUDIT 或 AUDIT-C 筛查可提高检出率，因为患者很少主动吐露幻觉体验。

Management

• Benzodiazepines such as diazepam or lorazepam are the first-line treatment for the underlying withdrawal, given in symptom-triggered doses guided by CIWA-Ar scores.地西泮或劳拉西泮等苯二氮䓬类是一线治疗，针对潜在戒断状态按 CIWA-Ar 评分以症状触发方式给药。
• Short-term antipsychotics, usually haloperidol, are added when hallucinations cause severe distress or agitation, with electrocardiographic monitoring for QT prolongation.当幻觉引起严重痛苦或激越时加用短期抗精神病药，通常为氟哌啶醇，并监测心电图 QT 间期延长。
• Thiamine should be given before or with glucose, together with folate and multivitamins, to prevent Wernicke encephalopathy during refeeding.应在葡萄糖之前或同时给予硫胺素，并补充叶酸与多种维生素，以在再喂养过程中预防韦尼克脑病。
• Fluid and electrolyte replacement, correction of magnesium and phosphate, and a quiet well-lit environment reduce perceptual disturbance and agitation.补液与电解质纠正、镁和磷的校正，以及安静明亮的环境可减少知觉紊乱与激越。
• Abstinence is the definitive treatment, and relapse prevention uses naltrexone, approved by the Food and Drug Administration in 1994, or acamprosate, approved in 2004.戒酒是根本治疗，预防复饮可用 1994 年获美国食品药品监督管理局批准的纳曲酮，或 2004 年获批的阿坎酸。
• Disulfiram remains an option for supervised patients, and psychosocial treatments including cognitive behavioural therapy and motivational interviewing improve abstinence rates.双硫仑仍是受监督患者的选择，认知行为治疗与动机式访谈等心理社会干预可提高戒酒率。
• Suicide risk should be assessed daily while hallucinations persist, and patients with command hallucinations or severe depression need psychiatric admission rather than home detoxification.幻觉持续期间应每日评估自杀风险，存在命令性幻听或严重抑郁者需精神科住院而非居家戒酒。
• Prognosis is good for the episode itself, with most patients becoming symptom-free within days to two weeks, but the long-term outcome depends entirely on sustained abstinence.发作本身的预后良好，多数患者在数日至两周内症状消失，但长期结局完全取决于能否持续戒酒。

Research and controversies

• Whether alcoholic hallucinosis is a distinct disorder or a forme fruste of schizophrenia remains unresolved, and family studies report both increased schizophrenia risk and complete recovery in most probands.酒精性幻觉症是独立疾病还是思觉失调的顿挫型仍未解决，家系研究既报告思觉失调风险升高，也报告多数先证者完全恢复。
• The withdrawal-kindling model predicts that earlier and lighter relapses will trigger psychosis, a prediction supported by clinical cohorts but not yet by controlled prospective studies.戒断点燃模型预测更早更轻的复饮即可触发精神病性症状，该预测得到临床队列支持但尚无对照前瞻研究证实。
• No drug is approved specifically for alcohol-induced psychosis, and antipsychotic use is extrapolated from schizophrenia trials despite a different presumed mechanism.没有药物专门获批治疗酒精所致精神病，抗精神病药的使用是从思觉失调试验外推而来，尽管推定机制不同。
• Dopamine imaging studies report both presynaptic synthesis capacity changes and D2 receptor alterations, and small samples prevent firm conclusions about causality.多巴胺影像研究报告突触前合成能力变化与 D2 受体改变，但样本量小，无法就因果关系得出确定结论。
• The main unmet need is diagnostic standardisation, because the DSM-5 merger has made hallucinosis invisible in research cohorts and hampers comparison across countries.主要未满足需求是诊断标准化，因为 DSM-5 的合并使幻觉症在研究队列中不可见，妨碍跨国比较。