hallucination or delusion or both?

[toby jones]

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If a patient says 'I hear my dead aunt Bee talking to me telling me to do x and y and z' then... Does the patient have a hallucination (in virtue of hearing a voice) or a delusion (in virtue of having the belief that her dead aunt is talking to her) or both?

I'm wondering... If hallucination is a proper subset of delusion such that whenever hallucination is present you get delusion for free.

(So two criterion A for the price of one)

What am I missing?????

 

[manwhoisthursdy]

If a patient says 'I hear my dead aunt Bee talking to me telling me to do x and y and z' then... Does the patient have a hallucination (in virtue of hearing a voice) or a delusion (in virtue of having the belief that her dead aunt is talking to her) or both?

I'm wondering... If hallucination is a proper subset of delusion such that whenever hallucination is present you get delusion for free.

(So two criterion A for the price of one)

What am I missing?????

Sounds like a clear-cut case of hallucination to me, based on the patient quote. If you really perceive something that isn't there, but based on the perception conclude it's real ... that sounds fairly reasonable to me, not delusional.

If you asked the patient if anyone else heard his aunt, and he responded, "No ... but I know she's talking to me from beyond the grave because I have been chosen to save the world and she's giving me special instructions on how to do it..." (e.g.) then I'd say there's also delusional content.

 

[manwhoisthursdy]

In other words, a delusion is a false belief in the face of evidence to the contrary, and believing a hallucination is a false belief *as a result of evidence* that just happens to be unreliable, as an outside observer could see.

 

[strangeglove]

If a patient says 'I hear my dead aunt Bee talking to me telling me to do x and y and z' then... Does the patient have a hallucination (in virtue of hearing a voice) or a delusion (in virtue of having the belief that her dead aunt is talking to her) or both?

I'm wondering... If hallucination is a proper subset of delusion such that whenever hallucination is present you get delusion for free.

(So two criterion A for the price of one)

What am I missing?????

My guess is that if the patient actually believes that Aunt Bee is actually saying the things that she is saying, it qualifies as a delusion, since it involves a false belief that Aunt Bee is somewhere nearby (or in the television, or whatever). If, on the other hand, the patient knows that the voices are not real, then it is just a hallucination. This distinction has clinical significance: I've had patients who were initially convinced about the realness of the voices they were hearing, who, on antipsychotics, would still hear the voices, but started to understand them as "in their heads." So, there is a reason hallucinations and delusions exist as two separate diagnostic criteria for psychosis, which has to do with reality testing and insight.

 

[toby jones]

Thanks for the interesting answers 🙂

> If, on the other hand, the patient knows that the voices are not real, then it is just a hallucination.

That was what I thought too. But then I was surprised to learn that an hallucination is defined as a non-veridical experience that the patient accepts as veridical. An hallucination that isn't accepted as veridical is known as a pseudo-hallucination.

So... I guess I'm thinking that IF you want to retain the hallucination / pseudo-hallucination distinction (as defined above) AND all delusions involve some kind of anomalous experience (e.g., a 'delusional awareness' or a 'feeling of significance' or an experience as of a voice etc) THEN the distinction between delusions and hallucinations breaks down because they are definitionally co-extensive.

As such, it is possible to figure out a-priori (from the armchair) that a person who has delusions has hallucinations (and vice versa) just on the basis of the definitions outlined above and the line of reasoning provided. It wouldn't be an empirical matter at all. And... Having delusions and hallucinations down as two SEPERATE symptoms would be a mistake. It would be counting the same symptom twice.

But surely... I must be missing something...

 

[manwhoisthursdy]

Thanks for the interesting answers 🙂

> If, on the other hand, the patient knows that the voices are not real, then it is just a hallucination.

That was what I thought too. But then I was surprised to learn that an hallucination is defined as a non-veridical experience that the patient accepts as veridical. An hallucination that isn't accepted as veridical is known as a pseudo-hallucination.

So... I guess I'm thinking that IF you want to retain the hallucination / pseudo-hallucination distinction (as defined above) AND all delusions involve some kind of anomalous experience (e.g., a 'delusional awareness' or a 'feeling of significance' or an experience as of a voice etc) THEN the distinction between delusions and hallucinations breaks down because they are definitionally co-extensive.

As such, it is possible to figure out a-priori (from the armchair) that a person who has delusions has hallucinations (and vice versa) just on the basis of the definitions outlined above and the line of reasoning provided. It wouldn't be an empirical matter at all. And... Having delusions and hallucinations down as two SEPERATE symptoms would be a mistake. It would be counting the same symptom twice.

But surely... I must be missing something...

That's the first time I've heard of this hallucination/pseudohallucination distinction. It directly contradicts what I've been taught!

 

[strangeglove]

That's the first time I've heard of this hallucination/pseudohallucination distinction. It directly contradicts what I've been taught!

Me, too. I've never heard the term "pseudohallucination" used in clinical practice. Nor does this term exist in the DSM, which is, I believe, what the OP was referring to when he/she was talking about diagnostic criteria. Also, I refer you to the following article about the validity of pseudohallucinations:

Pseudohallucinations: A pseudoconcept? A review of the validity of the concept, related to associate symptomatology. Comprehensive Psychiatry, Volume 42, Issue 1, Pages 42-50. R. van der Zwaard, M. Polak

I think a neurobiologically based distinction between delusions and hallucinations may be that whilst delusions emerge from higher-order cognitive processes, such as episodic memory, working memory, self-awareness and cognitive control, hallucinations (or pseudohallucinations) can be elicited by stimulation of a primary sensory area, such as V1.

 

[whopper]

I specifically ask---"Do you hear a voice as if its a real voice?--do you actually hear it as noise?"

Whether or not its a delusion or a hallucination doesn't matter much in terms of meds if its evidence of psychosis.

However "delusions" can sometimes merely be cultural based notions, beliefs or religion & spirituality coming in and have no psychosis involved whatsoever.

E.g. William Wallace in Braveheart mentions his wife Muron watches over him. Was he psychotic? No.

A resident from my program, (who by the way I thought wasn't a good doctor) would ask "do you hear voices?". The patient would often answer "yes-I hear your voice", then he'd immediately start that patient on an antipsychotic. Often times the pt had no psychosis and was merely meaning to say they hear voices-that were real voices. This guy was so lazy and so wanting to make the interview as short as possible he let his fast food approach mess up his interview style.

So if a patient ever does answer "yes" to my question of voices--I ask the following--
"Is the voice a real voice--do you hear it like you hear my voice?"---> If yes, then its probably a hallucination.

If no--then its either a ruminating thought, or culture/religion/spirituality or a delusion.

 

[strangeglove]

I specifically ask---"Do you hear a voice as if its a real voice?--do you actually hear it as noise?"

Whether or not its a delusion or a hallucination doesn't matter much in terms of meds if its evidence of psychosis.

However "delusions" can sometimes merely be cultural based notions, beliefs or religion & spirituality coming in and have no psychosis involved whatsoever.

E.g. William Wallace in Braveheart mentions his wife Muron watches over him. Was he psychotic? No.

A resident from my program, (who by the way I thought wasn't a good doctor) would ask "do you hear voices?". The patient would often answer "yes-I hear your voice", then he'd immediately start that patient on an antipsychotic. Often times the pt had no psychosis and was merely meaning to say they hear voices-that were real voices. This guy was so lazy and so wanting to make the interview as short as possible he let his fast food approach mess up his interview style.

So if a patient ever does answer "yes" to my question of voices--I ask the following--
"Is the voice a real voice--do you hear it like you hear my voice?"---> If yes, then its probably a hallucination.

If no--then its either a ruminating thought, or culture/religion/spirituality or a delusion.

Another good question to ask is "What are the voices saying?" In general, I find it useful to engage with the patient as if their experience is real (it is to them), rather than just asking them questions for the sake of checking off a box on the DSM criteria. You will find that what the voices say is pretty interesting and may be useful clinically. For example, people with psychotic depression may hear persecutory voices telling them they are worthless. Even more important to know about would be voices telling the patient to commit suicide of homicide. This is pretty obvious stuff, though.

 

[toby jones]

Hmm... I checked out the DSM and it doesn't say that hallucinations must be accepted as veridical in order to count as hallucinations. It also makes no mention of pseudo-hallucinations, as you note. So now I'm wondering 'where on earth did I pick that up from?' and I'm thinking it was a philospohy seminar where the guy had an odd view of the contents of visual perception... So... Probably not so relevant to psychiatry after all.

That being said, I do remember hearing the hallucination / pseudo-hallucination distinction in the context of differentiating psychosis from dissociation. One idea was that psychotic voices tend to be heard as originating from 'outside' the head whereas dissociated voices tend to be heard as originating from 'inside' the head. Another notion was that psychotic voices tended to be experienced as 'other' or 'not me' whereas dissociated voices might be experienced as 'part of me but not me'. I have heard that distinction is problematic, however.

So... If we don't want to retain the hallucination / pseudo-hallucination distinction then we don't find ourselves in the particular variety of trouble that I outlined above...

That being said...

> I think a neurobiologically based distinction between delusions and hallucinations may be that whilst delusions emerge from higher-order cognitive processes, such as episodic memory, working memory, self-awareness and cognitive control, hallucinations (or pseudohallucinations) can be elicited by stimulation of a primary sensory area, such as V1.

Though the experience of hearing voices has more to do with language production areas than with primary sensory areas, I think, so I'm not sure whether the distinction breaks down over a fairly central case. Though it might be the case that the experience of hearing voices is a borderline case between delusion (I believe I'm hearing the voice of dead aunt mavis) and hallucination (I'm experiencing hearing the voice of dead aunt mavis). The relationship between the content of the experience and the content of the belief is unclear... I suppose it doesn't matter if the distinction breaks down over fairly preripheral cases, but hearing voices is the most paradigmatic case of hallucination (and delusion) that there is, I would have thought. As such... One symptom or two? I'm still wondering...

 

[manwhoisthursdy]

I happened to run across a explanation of hallucination vs. psuedohallucination in Sims' "Symptoms in the Mind."

Hallucinations, whether really accepted as true or not, "seem" true. They come from without, and the individual experiencing them sees them as clearly true perceptions of external reality ... and I guess, if the individual doesn't believe them, it's because he or she came to realize, over time, that they are hallucinations.

Psuedohallucinations, like hallucinations, are defined. So a visual pseudohallucination, for example, will often have definite colors, a clear, outlined shape, and will not change at the whim of the person experiencing it (unlike other visual phenomenon). They key difference is that a psuedohallucination does not seem real at all, but seems like something "from within."

Sims' emphasizes that hallucinations are in "objective space" whereas pseudohallucinations are in "subjective space." For a more thorough and better written explanation -- go to Sims' directly, obviously.

 

[toby jones]

Thats interesting... It sounds a little bit like the distinction I heard in the context of differentiating psychosis from dissociation.

I also found this:

http://www.medilexicon.com/medicaldictionary.php?t=73382

I guess that I was hearing a similar idea with the notion that the difference between hallucinations and pseudo-hallucinations was whether the experience was accepted as veridical or not.

Under that understanding, I guess visual illusion would count as pseudo-illusory if the person had insight into the illusory nature of their experience.

I guess there is a lot of controversy over whether the distinction is clinically useful, though.

What was strange about the talk I heard is that the guy is a disjunctivist about the contents of visual perception. Basically... What that means is that when you aren't verdically perceiving then the contents of your experience are delivered to you by way of a judgement rather than a phenomenology. So... It isn't that we experience a pink elephant when we hallucinate, it is rather that we judge a pink elephant to be present when we hallucinate. Why? Because for disjunctivists the notion is that 'perceive' is a success term in the sense that to see an elephant logically entails that there is an elephant there that is being seen. Part of the motivation for being a disjunctivist is that it explains the 'transparency of experience' quite well (the notion that when all goes well we literally see things the way they are in the world - we directly apprehend them). Part of the problem with being a disjunctivist is that they are left having to conclude that hallucination and illusion aren't states of visual perception after all - and his line was to say that really they are faulty judgements. So for him the distinction between misperception and delusion is going to break down.

I guess I'm just having trouble seeing how to retain the distinction in the case of hearing voices...