Risperidone Does Not Cause Auditory Hallucinations—It Treats Them
Risperidone is an antipsychotic medication specifically designed to reduce auditory hallucinations and other positive symptoms of psychosis, not cause them. 1, 2, 3
Mechanism and Therapeutic Effect
Risperidone works through dopamine D2 and serotonin 5-HT2A receptor antagonism, which directly targets the neurochemical pathways responsible for hallucinations and delusions. 2 Multiple randomized controlled trials demonstrate that risperidone effectively reduces positive symptoms including auditory hallucinations in patients with schizophrenia, with superior efficacy compared to older typical antipsychotics like haloperidol. 3
- In short-term studies, risperidone produced significant improvement in the Positive and Negative Syndrome Scale (PANSS) compared to haloperidol (n=2368,9 RCTs, RR 0.72, NNT 8). 3
- Long-term data show sustained benefit in reducing psychotic symptoms including hallucinations (n=859,2 RCTs, RR 0.51, NNT 4). 3
Important Clinical Caveat: Reemergence vs. Causation
One case report documented auditory hallucinations reemerging after 8 months of risperidone therapy, but this represented treatment failure or inadequate dosing—not drug-induced hallucinations. 4 The authors specifically noted three possible explanations:
- Inadequate risperidone dosage 4
- Natural progression of the patient's schizophrenia independent of medication 4
- Individual variation in treatment response 4
This single case report describes breakthrough symptoms despite treatment, which is fundamentally different from a medication causing hallucinations as an adverse effect.
Common Side Effects of Risperidone
The actual adverse effects of risperidone include:
- Somnolence/sedation (51% of patients) 5
- Extrapyramidal symptoms at doses above 2 mg/day, particularly in elderly patients 1, 6
- Weight gain (15-20% of patients, mean 2.84 kg) 5
- Hyperprolactinemia leading to amenorrhea and sexual dysfunction 2
- Headache (29%) and dyspepsia (15%) 5
Auditory hallucinations are not listed among risperidone's known adverse effects in any guideline, drug label, or systematic review. 1, 5, 2, 3
Clinical Bottom Line
If a patient on risperidone reports new or worsening auditory hallucinations, consider:
- Inadequate dosing requiring upward titration 4
- Disease progression or breakthrough symptoms 4
- Medication non-adherence 3
- Comorbid substance use 6
- Underlying medical causes (infections, metabolic disturbances) 5
Do not attribute hallucinations to risperidone itself—this medication suppresses rather than causes psychotic symptoms. 2, 3