Monday, October 5, 2009


Hallucinations are perceptions which take place in the absence of a stimulus from the peripheral or sensory nervous system.

They may be classified in a variety of different ways (this is an incomplete list):
1)by sensory modality
a) auditory: these are most common, and may be perceived as voices speaking or mumbling; musical sounds; or other more cacophonous sounds
b) visual: these can occur more commonly in delirious states or medical illnesses affecting the brain. Many people experience normal, but unsettling, visual hallucinations, just when falling asleep or waking up.
c) tactile: these are most common in chemical intoxication syndromes, such as with cocaine.
d) olfactory: more common in medical illness

2) by positionality
-when describing hallucinated voices, if the voices are perceived to originate inside the head, or to not have any perceived origin, then they could be called "pseudohallucinations." If the voices are perceived to originate from a particular place, such as from the ceiling or from across the room, then they could be called "hallucinations" or "true hallucinations." This terminology has been used to distinguish between the hallucinations in schizophrenia and psychotic mood disorders (which are typically "true hallucinations") and those experienced in non-psychotic disorders (pseudohallucinations are more typically--though not invariably--associated with dissociative disorders, borderline personality, or PTSD).

3) by insight
An individual experiencing a "psychotic hallucination" will attribute the phenomenon to stimuli outside of the brain. An individual experiencing a "non-psychotic hallucination" will attribute the phenomenon to his or her own brain activity, and recognize the absence of an external stimulus to account for the experience. In most cases, "insight" fluctuates on a continuum, and many individuals experiencing hallucinations will have some intellectual understanding of their perceptions being hallucinatory, but still feel on a visceral level that the perceptions are "real."

4) by character
Voices in particular can be described in a variety of ways. So-called "first rank symptoms of schizophrenia" include hallucinated voices which comment on a person's behavior, or include several voices which converse with each other.
The quality of the voice can vary, with harsh, angry, critical tones more common in psychotic depression, and neutral emotionality more common in schizophrenic states.

--all of these above descriptions are incomplete, and associations between one type of hallucination and a specific "diagnosis" are imperfect. A great deal of variation exists--

It is probably true that some hallucinations are factitious (i.e. the person is not actually hallucinating, despite claiming to), but of course this would be virtually impossible to prove. Something like functional brain imaging might be an interesting, though impractical, tool, to examine this phenomenon. People with psychotic disorders or borderline personality might at times describe factitious hallucinatory phenomena in order to communicate emotional distress or need to caregivers. Or sometimes the phenomena may convey some type of figurative meaning. The motivation to do this might not always be conscious.

There are a variety of ways to treat hallucinations.

In my opinion, the single most effective treatment is an antipsychotic medication. Hallucinations due to almost any cause are likely to diminish with antipsychotic medication treatment.

There is evolving evidence that CBT and other psychotherapy can help with hallucinations. Here are some references:

Some individuals may not be bothered by their hallucinations. In this case, it may sometimes be more the physician's agenda than the patient's to "treat" the symptom. Yet, it is probably true that active hallucinations in psychotic disorders are harbingers of other worsening symptoms, so it may be important to treat the symptom early, even if it is not troublesome.

Other types of behavioral tactics can help, including listening to music, wearing ear plugs, other distractions, etc. In dealing with pseudohallucinations or non-psychotic hallucinations, "mindfulness" exercises may be quite important. A well-boundaried psychodynamically-oriented therapy structure could be very helpful for non-psychotic hallucinations or pseudohallucinations associated with borderline personality dynamics or PTSD. Care would need to be taken, in these cases, not to focus excessively or "deeply" on the hallucinations, particularly without the patient's clear consent, since such a dialog could intensify the symptoms.


Anonymous said...

In this post you say "People with psychotic disorders or borderline personality might at times describe factitious hallucinatory phenomena in order to communicate emotional distress or need to caregivers."

1) Do you think this is intentional? How can you tell if it is a factitious motive (with out a brain scan)?

2) If it was proven to be factitious (somehow.. maybe the patient admitted it), what is your opinion on this as a type of communication for emotional distress? (ie: would you think negatively about the patient or label them as dependent/ needy?)

3) If this type of behavior continued would you eventually resent the patient due to this tactic being therapeutically exhausting for yourself?

I only ask this because I know patients may sometimes choose not reveal all symptom information, due to their fear of exhausting their therapist/psychiatrist which may consequently lead to their therapist being unable to help other patients.


GK said...

1)In a formal view of factitious disorders, the behaviour is intentional, with the motivation having to do with communicating emotional need or eliciting care. This differs from "malingering" in which a person deliberately lies about symptoms in order to get external "secondary gain", such as financial compensation, analgesic medication, etc.

Another diagnostic category is so-called "somatoform disorders", in which a person may describe symptoms which do not correspond with objective findings, yet this symptom description is not consciously motivated or deliberate.

I believe there is a continuum between somatoform disorders (including those involving psychiatric symptoms), factitious disorders, and malingering -- in terms of how conscious the person is of generating the symptom, and in terms of whether there is overt secondary gain. Also the existence of symptoms in these categories often co-exists with symptoms of the same type outside of these categories (e.g. those with factitious seizures or pseudoseizures often also have epileptiform seizures at other times). Likewise, individuals with schizophrenia may have hallucinations at times, but may also describe hallucinations factitiously at other times.

I don't think there is a way to tell for sure--regarding hallucinations in particular-- unless there is a frank discussion about it. Yet I guess there are characteristics of the descriptions of the hallucinations, and behavioural correlates, which increase the likelihood of the symptoms being factitious.

Another angle on this, is that many individuals or cultures may express distress in a figurative or symbolic manner. While they may describe their experiences as being literal truths, the experiences I think need to be understood as expressions of underlying themes. In this sense it is similar to my view of religious belief. So, hallucinations could be discussed as figurative truths, and could be worked with therapeutically as such. Many practitioners would do this therapeutic work with a mutual belief that the symptoms are "literal truths", in the same sense that many religious practitioners or counselors would believe in the literal dogmas of their religious system. I believe it is most honest and ethical never to treat figurative or metaphorical truths or themes as "literal."

2) I believe symptoms of this type deserve to be approached with respect, gentle empathic understanding, practical frank discussion, and supportive care, with problem-solving around both the symptoms as subjectively reported, and the underlying motives which drive the symptom complaints. I don't think negatively about this at all. Often times the phenomenon arises from a place of great suffering and distress. Mind you, part of a therapeutic process, if the person wishes to engage in it, can be to work on ways to convey or express needs in a direct verbal fashion, without factitious symptoms or physical acting out. Also, sometimes a factitious or figurative description of a problem could be a step forward therapeutically, compared to other manifestations of distress, such as those causing overt physical injury.

3)Behavioural phenomena or symptoms need not be exhausting to a therapist. It is the way of most human phenomena to recur. It is also the way of most unhelpful human reactions, to convey frustration or exhaustion.

Attempting to understand, and attempting to be empathic, are not exhausting processes. I do think a healthy therapeutic relationship is one in which both people have a sense of security and comfort about sharing information without fear of judgment, with the knowledge that the therapist can accept and handle the information; but also with the acceptance that the therapy environment is a place which gently encourages or invites change, with the knowledge that the same phenomena need not keep recurring forever, that there is hope, and a clear pathway towards positive change.

Anonymous said...


Found an interesting article which categorizes hallucinogenic activity.