Hallucination

Topic presentation as a part of disorders of perception.

1. Hallucination Presenter: Dr. Subodh Kumar Sharma MD Psychiatry Resident Moderator: Dr. Shuva Shrestha, MD Department Of Psychiatry National Medical College, Birgunj, Nepal

2. Content History Definitions Causes Hallucinations of individual senses Hallucinatory syndromes Special hallucinations Body image distortions Patient’s attitude towards hallucination

3. history Derived from Latin word / allucinari / Meaning “wander in the mind to mislead” Brought into English literature by Sir Thomas Browne, 1646 Used in Psychiatry by Esquirol (1817) Defined hallucination a “ A perception without object.” WHO SCAN 1998: “false perception”

4. definitions Jaspers, (1962): False perception which is not a sensory distortion or a misinterpretation, but which occurs at the same time as real perceptions. Slade , (1976): Three criteria are essential for an operational definition (A) Percept-like experience in the absence of an external stimulus ; (B) Percept-like experience that has the full force and impact of a real perception (C) Percept-like experience that is unwilled, occurs spontaneously and cannot be readily controlled by the percipient.

5. DEFINITIONS Horowitz (1975): Hallucinations are mental images that occur in the form of images, are derived from internal sources of information, are appraised incorrectly as if from external sources of information, usually occur intrusively.

6. Qualities of Hallucination Perceiving: Experienced as sensation and not as thought or fantasy. Behavioral relevance: Relevance for his own emotions, needs or actions Objectivity and existence: An object is considered to exist if the observer feels certain that it still exists even though nobody else is experiencing it at that time Involuntary: Doesn’t depend on subject’s will Quality of independence: That his experience is not simply the result of being in an unusual mental state

7. What the doctor calls a “hallucination” is a “normal sensory experience” to the patient.

8. The quality of Publicness : found mostly to be absent with hallucination in which the experiencer would be aware that anybody else with normal sensory faculties would be able to perceive this something. Often, the hallucinator does not believe that others could share his experience. (SIMS’ Symptoms in Mind, Fifth Edition, Femi Oyebode)

9. Causes of Hallucinations Intense emotions Suggestion Disorders of sense organs Sensory deprivation Disorders of CNS Psychiatric disorders

10. intense Emotions Depressed patients with delusion of guilt Hallucination: short phrases, words, usually abusive or unpleasant Schizophrenia or Severe depression with psychotic features: Persistent hallucinatory voices More organized and complete sentences

11. Suggestions Normal subject can be persuaded to hallucinate By hypnosis or brief task motivation instructions

12. Disorders of Sense Organs Hallucinatory voices : in ear diseases Hallucinatory images: in eye disease or CNS disorders Hallucinations in organic states: peripheral lesions in sense organs Charles Bonnet Syndrome: no obvious psychopathology

13. Sensory Deprivation In normal subject if i ncoming stimuli reduced to minimum they can hallucinate after few hours Changing visual hallucinations R epetitive phrases Black patch disease delirium following cataract extraction in the aged result of sensory deprivation and mild senile brain changes.

14. Disorders of CNS Lesions of diencephalons and cortex:   Lateral geniculate nucleus, Thalamus, temporal lobe, parietal lobe Hallucination: visual / auditory

15. Psychiatric Disorders Severe Depression with psychotic symptoms Schizophrenia Schizoaffective Disorder B ipolar Disorder with psychotic symptoms Delirium Dementia Sleep Disturbances

16. Hallucinations of Individual Senses Hearing Vision Smell Taste Touch Pain and deep sensation Vestibular sensations The sense of presence

17. Hearing (AUDITORY HALLUCINATIONS) Elementary (unformed) Simple noises, bells Undifferentiated whispers Monophonic voices Seen in : organic states Partially organized Musical Seen in: older women, deafness, Brain diseases without Psychiatric disorder

18. Completely organized voices Are of more diagnostic value Can be short sentences or few words Peremptory orders or abusive remarks Seen in : Severe depression , Organic states Can be complex Commanding Running commentary Own thoughts heard loud (thought echo) Second person ( addressing patient directly) Third person (talk to each other and address patients as he or she)

19. Nature Of Auditory Hallucinations Adverse Neutral Helpful Incomprehensible/ Nonsense Neologism Running commentary Thought echo Gedankenlautwerden : thoughts spoken at the same time or before they are occurring. Echo de la penses : thoughts are spoken just after they occurred.

20. Vision (VISUAL HALLUCINATION) Elementary - flashes of light Partly organized - patterns Completely organized - people, animals, objects. May appear against the normally perceived environment or Can occur as scenic hallucinations in which whole scenes are hallucinated rather like a cinema film as in epilepsy.

21. Common causes of visual hallucinations: Ophthalmic disorders : Cataract, Macular degeneration, Glaucoma. Blindness Neurological disorder : O ptic nerve disorder, Brain stem lesions Migraine : patient may see spots and zig zag line in his vision. E pilepsy Visual cortex lesions of brain

22. Toxic and metabolic causes : Hepatic Diseases, Endocrine Diseases, Vitamin Deficiencies, Infectious Diseases R ecreational drugs: Marijuana, LSD D rugs used in the treatment of depression, Parkinsonism, Convulsion Drug and alcohol withdrawal Psychiatric disorders: Schizophrenia, Schizoaffective Disorders Dissociative Disorders Sleep deprivation Hypnotic trance or when a person is under mental stress and fatigue

23. Charles bonnet syndrome Named after the 18th century Swiss scientist, C harles B onnet Is a condition that causes people with decreased vision and various eye diseases to have visual hallucinations. These hallucinations can include seeing patterns, or more complex images such as people, animals, flowers, and buildings . No obvious psychopathology are demonstrable .

24. Hallucinations in Charles Bonnet Syndrome Occur in a “state of quiet restfulness” • Start without warning, last for a few minutes or for several hours • Are very detailed, and much clearer than patient’s current vision • Interact and conform to actual surroundings • Always outside the body • Patient knows they are not real • Have no personal meaning to the patient

25. Lilliputian hallucination   Micropsia affects visual hallucination so that they see tiny object or people. Alcohol withdrawal Syndrome with Delirium Tremens Rarely in schizophrenia Charles Bonnet Syndrome   

26. Olfactory hallucination PHANTOSMIA Usually foul or disgusted odor are perceived: Schizophrenia Organic states like temporal lobe epilepsy Depression (uncommon) Rarely pleasant smell: PADRE PIO PHENOMENON - religious people can smell roses around certain saints.

27. GUSTATORY HALLUCINATION Seen in Schizophrenia Organic states Depression : loss of taste or loss in distinction of taste Temporal lobe lesions of brain ?

28. Tactile hallucination F alse perception of tactile sensory input that creates a  hallucinatory sensation of physical contact with an imaginary object. Classified into 3 types Superficial Kinesthetic Visceral

29. Tactile hallucination Superficial: Thermic: an abnormal perception of heat and cold Haptic: of touch Hygric, a perception of fluid Paraesthesia : sensation of tingling or ‘pins and needles’.

30. Kinaesthetic : Affects muscles and joints Patient feels limbs twisted pulled or moved Schizophrenia Organic states - alcohol intoxication benzodiazepine withdrawal Visceral: discussed as deep sensation and pain

31. Tactile hallucination Formication - animals crawling over the body In organic states Cocaine Bug / M agnan syndrome (cocaine intoxication psychosis) Ekbom Syndrome (tactile hallucination along with delusion of infestation) Sexual hallucinations - having intercourse or genital stimulation acute and chronic schizophrenia

32. Organic Tactile hallucination Almost exclusively the result of lesion which produces sensory defect Phantom Limb: Most common organic somatic hallucination 95% of amputation after 6 yrs. Of age P atient feels he sees the limb from which in fact he is not receiving any sensations either because limb has been amputated or sensory pathway destroyed. In rare cases with Thalamo -parietal lesion the patient describes a third limb.

33. Phantom limb Most phantom limbs are produced by peripheral and central disorders. Occasionally it develops from lesion of peripheral nerve or the medulla or spinal cord. Thalamoparietal lesions have phantom third arm or leg. Correspond to the previous image of the limb.

34. Pain and deep sensation hallucination Visceral hallucinations are false perceptions of the inner organs. Possible visceral sensation: pain, heaviness, stretching or distension, palpitation Various combinations of these, such as throbbing. Bizarre schizophrenic false perceptions and their explanations. “One man believed that he could feel semen travelling up his vertebral column into his brain, where it became laid out in sheets.”

35. The sense of presence The feeling that someone is present, whom they cannot see, and may or may not be able to name Normal people Organic states Sleep deprivation Schizophrenia Conversion disorder Fervently religious

36. Special hallucinations Functional hallucinations: A stimulus causes a hallucination but the stimulus is experienced as well as the hallucination. Reflex hallucinations : Morbid form of Synesthesia. Stimulus in one sensory field produces a hallucination in another Unlike in functional hallucination normal stimuli cannot be perceived. Extracampine hallucinations: the patient has a hallucination that is outside the limits of the sensory field.

37. Autoscopy: Phantom mirror image Experience of seeing oneself and knowing that it is oneself Doppelganger: seeing ones double Visual hallucination+ kinesthetic hallucination +somatic sensation. Negative Autoscopy: A few patients suffering from organic states look in the mirror and see no image, known as negative autoscopy Internal Autoscopy: subject sees their own internal organs. The description of the internal organs is that which would be expected from a layperson.

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39. Causes of Autoscopy: Normal subjects- emotionally disturbed/ exhausted Hysteria Schizophrenia Acute and S ub acute delirious states E pilepsy Focal lesions in parieto - occipital region C hronic alcoholism

40. Hypnagogic Hallucination Occur when the subject is falling asleep during drowsiness Are discontinuous Appears to force themselves on the subject Commonest is auditory but visual and tactile forms are not uncommon. Geometrical designs , abstract shapes , faces , figures or scenes from nature

41. Hypnopompic Hallucination Occurs when the subject is waking up Hallucinations persisting from sleep when the eyes are open S een in : N arcolepsy Cataplexy Toxi c states (glue sniffing, acute fever) Post infective depressive state Phobic anxiety neuroses

42. Body image distortions Hyperschemazia – perceived magnifications of body parts Organic causes Non organic causes Brown Sequard Syndrome Peripheral Vascular Disease Multiple Sclerosis Thrombosis of Posterior Inferior Cerebral Artery Hypochondriasis C onversion disorder Depersonalization Anorexia nervosa

43. H yposchemazia – body parts as diminished P araschemazia – distorted of body image as a feeling that body parts are distorted or twisted from rest of the body. Hemisomatognosia - unilateral lack of body image in which the person behaves as if one side of body is missing

44. Aschemazia - perception of body parts as absent Anosgnosia: “denial of illness” Right hemisphere strokes denied their knowledge early after stroke and refused to admit to any weakness in their left arm S omatoparaphrenia: delusional beliefs about the body, distorted, inanimate , severed, or in any other ways abnormal.

45. Hallucinatory Syndromes Hallucinosis, refer to those disorders in which there are persistent hallucinations in any sensory modality in the absence of other psychotic features. Alcoholic Hallucinosis: These hallucinations are usually auditory Occur during periods of relative abstinence. They may be threatening, although some patients report benign voices. Sensorium is clear and hallucinations rarely persist longer than 1 week Associated with long-standing alcohol misuse

46. Organic Hallucinosis These are present in 20−30% of patients with dementia Especially of the Alzheimer’s Dementia Most commonly auditory or visual. There is also disorientation and memory is impaired.

47. Hallucinations Organic causes Psychiatric causes Auditory Hearing Loss Brain Lesions Drug Use Schizophrenia Bipolar Disorder Psychosis Borderline Personality D/o Posttraumatic Stress Disorder Sleep Disorders Visual Ophthalmic Disorders Irritation/ Lesions (Visual Cortex) Delirium Dementia Parkinson’s Disease Seizure Disorders Migraine Brain Lesions/Tumors Hallucinogens Creutzfeldt-Jakob Disease Schizophrenia Schizoaffective Disorder Depression Bipolar Disorder Sleep  Problems

48. Hallucinations Organic causes Psychiatric Causes Olfactory Lesions of Olfactory Pathway or olfactory bulb Temporal lobe seizure Sinusitis Brain tumors Parkinson’s disease Schizophrenia Severe Depression Gustatory Temporal lobe Lesions Brain lesions Sinus  diseases Epilepsy (TL) Schizophrenia Severe Depression Tactile or Somatic Drugs: Cocaine Delirium tremens Alcohol Alzheimer's disease Lewy body dementia Parkinson's disease Schizophrenia Schizoaffective disorder

49. Patients attitude towards hallucination In organic hallucinations the patient is usually terrified by the visual hallucinations and may try desperately to get away from them. Most delirious patients feel threatened and are generally suspicious. Impulsive attempts to escape from the threatening situation may jeopardize their lives. The exception is lilliputian hallucinations, which are usually regarded with amusement by the patient and may be watched with delight.

50. Patients with depression often hear disjointed voices abusing them or telling them to kill themselves. They are not terrified by the voices. Voices in acute schizophrenia is often very frightening The patient at times may attack the person he believes to be their source. Those patients who are knowledgeable about their illness or who have insight into it may deny hallucinations, since they know this is an abnormal feature.

51. ASSESMENT OF HALLUCINATING SUBJECT Form/ Nature of hallucination (experience) ? Auditory/ ?Visual Is it distressing , pleasant or fluctuating? Is it in same form through out? Flashes, patterns vs objects OR sounds, phrases vs sentences Clarity of the experience. Clear, blurred, loud, low Hostility or friendliness of the experience Location of perception? How far? Do subject think anybody else can see or hear the same experience? Duration. How long they last?

52. Referral? Second person/ third person? Familiarity of object or voices? Condition of occurrence? While in crowd or only alone? What do they say or do? Are voices or objects suggesting or commanding? Do you try to control the experience? How? Diurnal variation of experience.

53. Variation in number of objects or sounds? Does medicine/drugs/alcohol has any effect in the experience? What? Age of onset when first experienced? What as he doing during the first experience? Has the experience been better, gone away or become worse? Why do you think? Anything you want to add on the experience?

54. References Fish’s Clinical Psychopathology, 3 rd Edition, Patricia Casey, Brendan Kelly Sims’ Symptoms In The Mind, Text Book Of Descriptive Psychopathology, 5 th Edition, Femi Oyebode Shorter Oxford Text Book of Psychiatry, 6 th Edition, P. Cowen, P. Harrison, T. Burns Kaplan and Sadock’s Synopsis of Psychiatry, 11 th Edition, BJ Sadock, VA Sadock, Pedro Ruiz Auditory Hallucinations Interview Guide, Louise Nigh Trygstad, Robin K. Buccheri, Martha D.

55. Thank you!