Hallucination

For other uses, see Hallucination (disambiguation).

Hallucination
Classification and external resources
My eyes at the moment of the apparitions by August Natterer.
ICD-10	R44
ICD-9	780.1
DiseasesDB	19769
MeSH	D006212

A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space. The latter definition distinguishes hallucinations from the related phenomena of dreaming, which does not involve wakefulness; illusion, which involves distorted or misinterpreted real perception; imagery, which does not mimic real perception and is under voluntary control; and pseudohallucination, which does not mimic real perception, but is not under voluntary control.^[1] Hallucinations also differ from "delusional perceptions", in which a correctly sensed and interpreted stimulus (i.e. a real perception) is given some additional (and typically bizarre) significance.

Hallucinations can occur in any sensory modality — visual, auditory, olfactory, gustatory, tactile, proprioceptive, equilibrioceptive, nociceptive, thermoceptive and chronoceptive.

A mild form of hallucination is known as a disturbance, and can occur in any of the senses above. These may be things like seeing movement in peripheral vision, or hearing faint noises and/or voices. Auditory hallucinations are very common in paranoid schizophrenia. They may be benevolent (telling the patient good things about themselves) or malicious, cursing the patient etc. Auditory hallucinations of the malicious type are frequently heard like people talking about the patient behind their back. Like auditory hallucinations, the source of their visual counterpart can also be behind the patient's back. Their visual counterpart is the feeling of being looked-stared at, usually with malicious intent. Frequently, auditory hallucinations and their visual counterpart are experienced by the patient together.

Hypnagogic hallucinations and hypnopompic hallucinations are considered normal phenomena. Hypnagogic hallucinations can occur as one is falling asleep and hypnopompic hallucinations occur when one is waking up.

Hallucinations can be associated with drug use (particularly deliriants), sleep deprivation, psychosis, neurological disorders, and delirium tremens.

Classification

Hallucinations may be manifested in a variety of forms.^[2] Various forms of hallucinations affect different senses, sometimes occurring simultaneously, creating multiple sensory hallucinations for those experiencing them.

Visual

The most common modality referred to when people speak of hallucinations. These include the phenomena of seeing things which are not present or visual perception which does not reconcile with the consensus reality. There are many different causes, which have been classed as psychophysiologic (a disturbance of brain structure), psychobiochemical (a disturbance of neurotransmitters), and psychological (e.g. meaningful experiences consciousness). Numerous disorders can involve visual hallucinations, ranging from psychotic disorders to dementia to migraine, but experiencing visual hallucinations does not in itself mean there is necessarily a disorder.^[3] Visual hallucinations are associated with organic disorders of the brain and with drug and alcohol related illness.^[4]

Sometimes internal imagery can overwhelm the sensory input from external stimuli when sharing neural pathways, or if indistinct stimuli is perceived and manipulated to match one's expectations or beliefs, especially about the environment. This can result in a hallucination.^[5]

Auditory

Main article: Auditory hallucination

Auditory hallucinations (also known as paracusia),^[6] are the perception of sound without outside stimulus. Auditory hallucinations can be divided into two categories: elementary and complex. Elementary hallucinations are the perception of sounds such as hissing, whistling, an extended tone, and more. In many cases, tinnitus is an elementary auditory hallucination. However, some people who experience certain types of tinnitus, especially pulsatile tinnitus, are actually hearing the blood rushing through vessels near the ear. Because the auditory stimulus is present in this situation, it does not qualify as a hallucination.

Complex hallucinations are those of voices, music, or other sounds which may or may not be clear, may be familiar or completely unfamiliar, and friendly or aggressive, among other possibilities. Hallucinations of one or more talking voices, are particularly associated with psychotic disorders such as schizophrenia, and hold special significance in diagnosing these conditions. However, many people not suffering from diagnosable mental illness may sometimes hear voices as well.^[7] One important example to consider when forming a differential diagnosis for a patient with paracusia is lateral temporal lobe epilepsy. Despite the tendency to associate hearing voices, or otherwise hallucinating, and psychosis with schizophrenia or other psychiatric illnesses, it is crucial to take into consideration that even if a person does exhibit psychotic features, they do not necessarily suffer from a psychiatric disorder on its own. Disorders such as Wilson's disease, various endocrinological disorders, numerous metabolic disturbances, multiple sclerosis, systemic lupus erythematosis, porphyria, sarcoidosis, and many others can present with psychosis.

Musical hallucinations are also relatively common in terms of complex auditory hallucinations and may be the result of a wide range of causes ranging from hearing-loss (such as in Musical Ear Syndrome, the auditory version of Charles Bonnet syndrome), lateral temporal lobe epilepsy,^[8] arteriovenous malformation,^[9] stroke, lesion, abscess, or tumor.^[10]

The Hearing Voices Movement is a support and advocacy group for people who hallucinate voices, but do not otherwise show signs of mental illness or impairment.

Command hallucinations

Command hallucinations are hallucinations in the form of commands.^[11] The contents of the hallucinations can range from the innocuous to commands to cause harm to the self or others.^[11] Command hallucinations are often associated with schizophrenia. People experiencing command hallucinations may or may not comply with the hallucinated commands, depending on circumstances. Compliance is more common for non-violent commands.^[12]

Olfactory

Phantosmia is the phenomenon of smelling odors that aren't really present. The most common odors are unpleasant smells such as rotting flesh, vomit, urine, feces, smoke, or others. Phantosmia often results from damage to the nervous tissue in the olfactory system. The damage can be caused by viral infection, brain tumor, trauma, surgery, and possibly exposure to toxins or drugs.^[13] Phantosmia can also be induced by epilepsy affecting the olfactory cortex and is also thought to possibly have psychiatric origins.^{[citation needed]} Phantosmia is different from parosmia, in which a smell is actually present, but perceived differently from its usual smell.

Olfactory hallucinations can also appear in some cases of associative imagination, for example, while watching a romance movie, where the man gifts roses to the woman, the viewer senses the roses' odor (which in fact does not exist).

Olfactory hallucinations have also been reported in migraine, although the frequency of such hallucinations is unclear.^[14][15]

Tactile hallucinations

Tactile hallucinations are the illusion of tactile sensory input, simulating various types of pressure to the skin or other organs. One subtype of tactile hallucination, formication, is the sensation of insects crawling underneath the skin and is frequently associated with prolonged cocaine or amphetamine use^[16] or with withdrawal from alcohol or benzodiazepines. However, formication may also be the result of normal hormonal changes such as menopause, or disorders such as peripheral neuropathy, high fevers, Lyme disease, skin cancer, and more.^[16]

Gustatory

This type of hallucination is the perception of taste without a stimulus. These hallucinations, which are typically strange or unpleasant, are relatively common among individuals who have certain types of focal epilepsy, especially temporal lobe epilepsy. The regions of the brain responsible for gustatory hallucination in this case are the insula and the superior bank of the sylvian fissure.^[17][18]

General Somatic Sensations

General somatic sensations of a hallucinatory nature are experienced when an individual feels that his body is being mutilated i.e. twisted, torn, or disembowelled. Other reported cases are invasion by animals in the person's internal organs such as snakes in the stomach or frogs in the rectum. The general feeling that one's flesh is decomposing is also classified under this type of hallucination.^[19]

Stages of a hallucination

1. Emergence of surprising or warded-off memory or fantasy images^[20]
2. Frequent reality checks^[20]
3. Last vestige of insight as hallucinations become "real"^[20]
4. Fantasy and distortion elaborated upon and confused with actual perception^[20]
5. Internal-external boundaries destroyed and possible pantheistic experience^[20]

Cause

See also: Psychosis (causes)

Hallucinations can be caused by a number of factors.

Hypnagogic hallucination

Main article: Hypnagogia

These hallucinations occur just before falling asleep, and affect a surprisingly high proportion of the population. The hallucinations can last from seconds to minutes, all the while the subject usually remains aware of the true nature of the images. These may be associated with narcolepsy. Hypnagogic hallucinations are sometimes associated with brainstem abnormalities, but this is rare.^[21]

Peduncular hallucinosis

Main article: Peduncular hallucinosis

Peduncular means pertaining to the peduncle, which is a neural tract running to and from the pons on the brain stem. These hallucinations usually occur in the evenings, but not during drowsiness, as in the case of hypnagogic hallucination. The subject is usually fully conscious and then can interact with the hallucinatory characters for extended periods of time. As in the case of hypnagogic hallucinations, insight into the nature of the images remains intact. The false images can occur in any part of the visual field, and are rarely polymodal.^[21]

Delirium tremens

Main article: Delirium tremens

One of the more enigmatic forms of visual hallucination is the highly variable, possibly polymodal delirium tremens. Individuals suffering from delirium tremens may be agitated and confused, especially in the later stages of this disease. Insight is gradually reduced with the progression of this disorder. Sleep is disturbed and occurs for a shorter period of time, with rapid eye movement sleep.

Parkinson's disease and Lewy body dementia

Parkinson's disease is linked with Lewy body dementia for their similar hallucinatory symptoms. The symptoms strike during the evening in any part of the visual field, and are rarely polymodal. The segue into hallucination may begin with illusions^[22] where sensory perception is greatly distorted, but no novel sensory information is present. These typically last for several minutes, during which time the subject may be either conscious and normal or drowsy/inaccessible. Insight into these hallucinations is usually preserved and REM sleep is usually reduced. Parkinson's disease is usually associated with a degraded substantia nigra pars compacta, but recent evidence suggests that PD affects a number of sites in the brain. Some places of noted degradation include the median raphe nuclei, the noradrenergic parts of the locus coeruleus, and the cholinergic neurons in the parabrachial and pedunculopontine nuclei of the tegmentum.^[21]

Migraine coma

This type of hallucination is usually experienced during the recovery from a comatose state. The migraine coma can last for up to two days, and a state of depression is sometimes comorbid. The hallucinations occur during states of full consciousness, and insight into the hallucinatory nature of the images is preserved. It has been noted that ataxic lesions accompany the migraine coma.^[21]

Charles Bonnet syndrome

Charles Bonnet syndrome is the name given to visual hallucinations experienced by blind patients. The hallucinations can usually be dispersed by opening or closing the eyelids until the visual images disappear. The hallucinations usually occur during the morning or evening, but are not dependent on low light conditions. These prolonged hallucinations usually do not disturb the patients very much, as they are aware that they are hallucinating.^[21] A differential diagnosis are opthalmopathic hallucinations.^[23]

Focal epilepsy

Visual hallucinations due to focal seizures differ depending on the region of the brain where the seizure occurs. For example, visual hallucinations during occipital lobe seizures are typically visions of brightly colored, geometric shapes that may move across the visual field, multiply, or form concentric rings and generally persist from a few seconds to a few minutes. They are usually unilateral and localized to one part of the visual field on the ipsilateral side of the seizure focus, typically the temporal field. However, unilateral visions moving horizontally across the visual field begin on the contralateral side and move towards the ipsilateral side.^[17]

Temporal lobe seizures, on the other hand, can produce complex visual hallucinations of people, scenes, animals, and more as well as distortions of visual perception. Complex hallucinations may appear real or unreal, may or may not be distorted with respect to size, and may seem disturbing or affable, among other variables. One rare but notable type of hallucination is heautoscopy, a hallucination of a mirror image of one's self. These "other selves" may be perfectly still or performing complex tasks, may be an image of a younger self or the present self, and tend to be only briefly present. Complex hallucinations are a relatively uncommon finding in temporal lobe epilepsy patients. Rarely, they may occur during occipital focal seizures or in parietal lobe seizures.^[17]

Distortions in visual perception during a temporal lobe seizure may include size distortion (micropsia or macropsia), distorted perception of movement (where moving objects may appear to be moving very slowly or to be perfectly still), a sense that surfaces such as ceilings and even entire horizons are moving farther away in a fashion similar to the dolly zoom effect, and other illusions.^[24] Even when consciousness is impaired, insight into the hallucination or illusion is typically preserved.

Schizophrenic hallucination

Hallucinations caused by schizophrenia.

Drug-induced hallucination

Main article: Hallucinogen

Hallucinations caused by the consumption of psychoactive substances such as LSD or DMT.

Sensory deprivation hallucination

Hallucinations can be caused by sense deprivation when it occurs for prolonged periods of time, and almost always occur in the modality being deprived (visual for blindfolded/darkness, auditory for muffled conditions, etc.)

Pathophysiology

Various theories have been put forward to explain the occurrence of hallucinations. When psychodynamic (Freudian) theories were popular in psychology, hallucinations were seen as a projection of unconscious wishes, thoughts and wants. As biological theories have become orthodox, hallucinations are more often thought of (by psychologists at least) as being caused by functional deficits in the brain. With reference to mental illness, the function (or dysfunction) of the neurotransmitters glutamate and dopamine are thought to be particularly important.^[25] The Freudian interpretation may have an aspect of truth, as the biological hypothesis explains the physical interactions in the brain, while the Freudian deals with the origin of the theme of the hallucination. Psychological research has argued that hallucinations may result from biases in what are known as metacognitive abilities.^[26]

These are abilities that allow us to monitor or draw inferences from our own internal psychological states (such as intentions, memories, beliefs and thoughts). The ability to discriminate between internal (self-generated) and external (stimuli) sources of information is considered to be an important metacognitive skill, but one which may break down to cause hallucinatory experiences. Projection of an internal state (or a person's own reaction to another's) may arise in the form of hallucinations, especially auditory hallucinations. A recent hypothesis that is gaining acceptance concerns the role of overactive top-down processing, or strong perceptual expectations, that can generate spontaneous perceptual output (that is, hallucination).^[27]

Treatments

There are few treatments for many types of hallucinations. However, for those hallucinations caused by mental disease, a psychologist or psychiatrist should be alerted, and treatment will be based on the observations of those doctors. Antipsychotic and atypical antipsychotic medication may also be utilized to treat the illness if the symptoms are severe and cause significant distress.^{[citation needed]} For other causes of hallucinations there is no factual evidence to support any one treatment is scientifically tested and proven. However, abstaining from hallucinogenic drugs, managing stress levels, living healthily, and getting plenty of sleep can help reduce the prevalence of hallucinations. In all cases of hallucinations, medical attention should be sought out and informed of one's specific symptoms.

Epidemiology

One study from as early as 1895^[28] reported that approximately 10% of the population experienced hallucinations. A 1996-1999 survey of over 13,000 people^[29] reported a much higher figure, with almost 39% of people reporting hallucinatory experiences, 27% of which were daytime hallucinations, mostly outside the context of illness or drug use. From this survey, olfactory (smell) and gustatory (taste) hallucinations seem the most common in the general population.

See also

• Apparitional experience
• Closed-eye hallucination           
• Dimethyltryptamine
• Focal seizures
• Folie à deux
• Hallucinations in the sane           
• Imaginary friend
• Microwave auditory effect
• Phantom eye syndrome
• Psychosis
• Simulated reality
• Vision (spirituality)

Further reading

• Johnson FH (1978). The anatomy of hallucinations. Chicago: Nelson-Hall Co. ISBN 0-88229-155-6.
• Bentall RP, Slade PD (1988). Sensory deception: a scientific analysis of hallucination. London: Croom Helm. ISBN 0-7099-3961-2.
• Aleman A, Larøi F (2008). Hallucinations: The Science of Idiosyncratic Perception. American Psychological Association (APA). ISBN 1-4338-0311-9.

References

1. ^ Leo P. W. Chiu (1989). "Differential diagnosis and management of hallucinations" (PDF). Journal of the Hong Kong Medical Association 41 (3): 292–7. http://sunzi1.lib.hku.hk/hkjo/view/21/2100448.pdf. 
2. ^ Chen E. and Berrios G.E. (1996) Recognition of hallucinations: a multidimensional model and methodology. Psychopathology 29: 54-63.
3. ^ Visual Hallucinations: Differential Diagnosis and Treatment (2009)
4. ^ semple,David."oxford hand book of psychiatry" oxford press.2005.
5. ^ Horwitz, M. (1975). Hallucinations: An information-processing approach. New York: Wiley. pp. 163–194. 
6. ^ "Medical dictionary". http://medical-dictionary.thefreedictionary.com/paracusia. 
7. ^ Thompson, Andrea (September 15, 2006). "Hearing Voices: Some People Like It". LiveScience.com. http://www.livescience.com/humanbiology/060915_hearing_voices.html. Retrieved 2006-11-25. 
8. ^ Engmann, Birk; Reuter, Mike: Spontaneous perception of melodies – hallucination or epilepsy? Nervenheilkunde 2009 Apr 28: 217-221. ISSN 0722-1541
9. ^ Murat Ozsarac, Ersin Aksay, Selahattin Kiyan, Orkun Unek, F. Feray Gulec, De Novo Cerebral Arteriovenous Malformation: Pink Floyd's Song 'Brick in the Wall' as a Warning Sign, The Journal of Emergency Medicine, In Press, Corrected Proof, Available online 13 August 2009, ISSN 0736-4679, DOI: 10.1016/j.jemermed.2009.05.035.
10. ^ "Rare Hallucinations Make Music In The Mind". ScienceDaily.com. August 9, 2000. http://www.sciencedaily.com/releases/2000/08/000809065249.htm. Retrieved 2006-12-31. 
11. ^ ^{a b} Beck-Sander, A.; Birchwood, M.; Chadwick, P. (1997). "Acting on command hallucinations: A cognitive approach". The British journal of clinical psychology / the British Psychological Society 36 ( Pt 1): 139–148. PMID 9051285.  edit
12. ^ Lee, T. M.; Chong, S. A.; Chan, Y. H.; Sathyadevan, G. (2004). "Command hallucinations among Asian patients with schizophrenia". Canadian journal of psychiatry. Revue canadienne de psychiatrie 49 (12): 838–842. PMID 15679207.  edit
13. ^ Phantom smells
14. ^ Wolberg FL, Zeigler DK (1982). "Olfactory Hallucination in Migraine". Archives of Neurology 39 (6): 382. PMID 7092619. 
15. ^ Sacks, Oliver (1986). Migraine. Berkeley: University of California Press. pp. 75–76. ISBN 9780520058897. 
16. ^ ^{a b} Berrios G E (1982) Tactile Hallucinations. Journal of Neurology, Neurosurgery and Psychiatry 45: 285-293
17. ^ ^{a b c} Panayiotopoulos, Chrysostomos P. A clinical guide to epileptic syndromes and their treatment: based on the ILAE classification and practice parameter guidelines. 2. ed. London: Springer, 2007.
18. ^ Barker, P. 1997. Assessment in Psychiatric and Mental Health Nursing In Search of the Whole Person. UK: Nelson Thornes Ltd. p245.
19. ^ Barker, P. 1997. Assessment in Psychiatric and Mental Health Nursing in Search of the Whole Person. UK: Nelson Thornes Ltd. P245.
20. ^ ^{a b c d e} Horowitz MJ (1975). "Hallucinations: An Information Processing Approach". In West LJ, Siegel RK. Hallucinations; behavior, experience, and theory. New York: Wiley. ISBN 0-471-79096-6. 
21. ^ ^{a b c d e} Manford M, Andermann F (Oct 1998). "Complex visual hallucinations. Clinical and neurobiological insights". Brain 121 ((Pt 10)): 1819–40. doi:10.1093/brain/121.10.1819. PMID 9798740. http://brain.oxfordjournals.org/cgi/content/abstract/121/10/1819. 
22. ^ Mark Derr (2006) Marilyn and Me, "The New York Times" February 14, 2006
    
23. ^ Engmann, Birk (2008). "Phosphenes and photopsias - ischaemic origin or sensorial deprivation? - Case history" (in German). Z Neuropsychol. 19 (1): 7–13. doi:10.1024/1016-264X.19.1.7. http://www.psycontent.com/content/m507n73711u73652/?p=400b10f998844a6abe524fcf44626323&pi=1. 
24. ^ Bien CG, Benninger FO, Urbach H, Schramm J, Kurthen M, Elger CE (2000) Localizing value of epileptic visual auras. Brain 123:244–253 PubMed
25. ^ Kapur S (Jan 2003). "Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia". Am J Psychiatry 160 (1): 13–23. doi:10.1176/appi.ajp.160.1.13. PMID 12505794. http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=12505794. 
    
26. ^ Bentall RP (Jan 1990). "The illusion of reality: a review and integration of psychological research on hallucinations". Psychol Bull 107 (1): 82–95. doi:10.1037/0033-2909.107.1.82. PMID 2404293. http://content.apa.org/journals/bul/107/1/82. 
27. ^ Grossberg S (Jul 2000). "How hallucinations may arise from brain mechanisms of learning, attention, and volition". J Int Neuropsychol Soc 6 (5): 583–92. doi:10.1017/S135561770065508X. PMID 10932478. 
28. ^ Francis Nagaraya, Myers FWH et al. (1894). "Report on the census of hallucinations". Proceedings of the Society for Psychical Research 34: 25–394. 
29. ^ Ohayon MM (Dec 2000). "Prevalence of hallucinations and their pathological associations in the general population". Psychiatry Res 97 (2–3): 153–64. doi:10.1016/S0165-1781(00)00227-4. PMID 11166087. http://linkinghub.elsevier.com/retrieve/pii/S0165178100002274. 
    

External links

• Hearing Voices Network
• "Anthropology and Hallucinations", chapter from The Making of Religion
• "The voice inside: A practical guide to coping with hearing voices"
• Psychology Terms