Real hallucinations

[Orange2black]

Hi all

I read in another post on this forum (cant remember which one) something along the lines of "most hallucinations are not real".

What do you generally class as "real" auditory hallucinations?

I was always taught they had to originate from outside the head but then I know of some schizophrenics who hear them both inside and out.

Just wondering what people consider "real"?

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[st2205]

I think you’re paraphrasing a statement I made. People who hallucinate rarely subjectively report hallucinations. I’m also of the belief that visual hallucinations don’t really exist in primary psychiatric disorders except in incredibly rare circumstances. I think most “visual hallucinations” is a combinations of pseudo psychosis and a poor evaluator, a psychotic person describing a delusion and having it misperceived as a hallucination by a poor evaluator, or some kind of organic cause. If I had a nickel for every time I saw a “psychotic” person who “sees shadows,” I’d be making over 200k/yr.

Hearing voices =/= psychosis and many people with psychosis never experience hallucinations. I don’t ever waste time asking whether someone experiences it in their head or outside their head. Look at the larger context.

Us psychiatrists over-call psychosis. We also miss it when it’s staring us in the face.

Psychotic disorders are thought disorders.

 

[deleted736562]

I think you’re paraphrasing a statement I made. People who hallucinate rarely subjectively report hallucinations. I’m also of the belief that visual hallucinations don’t really exist in primary psychiatric disorders except in incredibly rare circumstances. I think most “visual hallucinations” is a combinations of pseudo psychosis and a poor evaluator, a psychotic person describing a delusion and having it misperceived as a hallucination by a poor evaluator, or some kind of organic cause. If I had a nickel for every time I saw a “psychotic” person who “sees shadows,” I’d be making over 200k/yr.

Hearing voices =/= psychosis and many people with psychosis never experience hallucinations. I don’t ever waste time asking whether someone experiences it in their head or outside their head. Look at the larger context.

Us psychiatrists over-call psychosis. We also miss it when it’s staring us in the face.

Psychotic disorders are thought disorders.

Psychosis by definition is a detachment from reality. So by definition hearing voices that are not there makes you psychotic. Thought disorder, while a cardinal component of schizophrenia, is not equivalent to psychosis.

Also, while auditory hallucinations are more frequent in schizophrenia patients, visual hallucination are not entirely absent either. The data suggests that around 20-30% of patients with schizophrenia will have visual hallucinations (Visual Hallucinations in the Psychosis Spectrum and Comparative Information From Neurodegenerative Disorders and Eye Disease | Schizophrenia Bulletin | Oxford Academic). And from my experience, the more chronically sick the patient is, the higher the likelihood.

 

[Attending1985]

I also believe psychosis is way over diagnosed. I see it as a global detachment from reality not just I have this weird experience of hearing “voices” but I’m otherwise totally grounded in reality. I see it as an abnormal perceptual experience which can be a symptom of many things but not by itself indicative of psychosis. Unfortunately most people have no nuance in their approach.

 

[st2205]

Psychosis by definition is a detachment from reality. So by definition hearing voices that are not there makes you psychotic. Thought disorder, while a cardinal component of schizophrenia, is not equivalent to psychosis.

Also, while auditory hallucinations are more frequent in schizophrenia patients, visual hallucination are not entirely absent either. The data suggests that around 20-30% of patients with schizophrenia will have visual hallucinations (Visual Hallucinations in the Psychosis Spectrum and Comparative Information From Neurodegenerative Disorders and Eye Disease | Schizophrenia Bulletin | Oxford Academic). And from my experience, the more chronically sick the patient is, the higher the likelihood.

Right, but “hearing voices” isn’t simply psychosis. And I really don’t believe the 20-30% number on visual hallucinations — at all. I feel it’s more likely a result of overcalling pseudopsychosis, attributing visual phenomena to psychosis, and mistaking delusions for visual hallucinations.

 

[st2205]

And not to mention delirium, as we’re the specialty that should always recognize this, or at the very least have it register on the differential, but how many people have come to me on antipsychotic for years (though they may have other psychiatric issues) and have been conceptualized as having schizophrenia or bipolar disorder when the initial “episode” was pretty clearly delirium.

 

[deleted736562]

Right, but “hearing voices” isn’t simply psychosis. And I really don’t believe the 20-30% number on visual hallucinations — at all. I feel it’s more likely a result of overcalling pseudopsychosis, attributing visual phenomena to psychosis, and mistaking delusions for visual hallucinations.

With all due respect, I'm going to go with the data. The data published since early 1900s seem fairly consistent and it's doubtful it's down to misdiagnosis or errors by raters. There are a lot of "urban legends" that keep getting perpetuated in our field and that are easily challenged with studies.

I agree the phenomenology of "hearing voices" is not so straightforward and it may mean different things in different contexts. Sometimes they really are intrusive thoughts misinterpreted as voices..etc, but ultimately I'm inclined to go with the experience of the patient.

 

[LadyHalcyon]

My pet peeve is the assumption that psychosis = schizophrenia/schizoaffective

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[clausewitz2]

My pet peeve is the assumption that psychosis = schizophrenia/schizoaffective

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I have to say that mine is "is kinda psychotic + has some feels = schizoaffective"

 

[clausewitz2]

With all due respect, I'm going to go with the data. The data published since early 1900s seem fairly consistent and it's doubtful it's down to misdiagnosis or errors by raters. There are a lot of "urban legends" that keep getting perpetuated in our field and that are easily challenged with studies.

I agree the phenomenology of "hearing voices" is not so straightforward and it may mean different things in different contexts. Sometimes they really are intrusive thoughts misinterpreted as voices..etc, but ultimately I'm inclined to go with the experience of the patient.

My read of the literature on this that I have read to date is that really complex audiovisual hallucinations, especially seeing people who are talking in a comprehensible way -is- quite rare outside of delirium, but it is not at all hard to find many, many accounts of chronically psychotic folks who talk about frequently seeing things like faces in clocks or on the wall where it is hard to say that this is a delusion rather than a hallucination. Might warrant a bit more effort at ruling out less traditionally psychiatric causes but it is not at all a reason to dismiss out of hand the possibility of a primary psychotic disorder.

 

[hamstergang]

I was always taught they had to originate from outside the head

I was taught to ask all sorts of questions about "hearing voices," such as inside or outside the head, one ear or another, multiple voices or just one, names of voices, male or female, recognizable voices or not, and I'm sure more. However, I don't know the purpose of these; I don't know how management or diagnosis changes based on the answers.

 

[Attending1985]

I think the most important question to ask is what do you makes of these voices? Answers will range from it’s my own thoughts to aliens inserting them in my head.

 

[psych md jd]

I was taught to ask all sorts of questions about "hearing voices," such as inside or outside the head, one ear or another, multiple voices or just one, names of voices, male or female, recognizable voices or not, and I'm sure more. However, I don't know the purpose of these; I don't know how management or diagnosis changes based on the answers.

The patient could be malingering:

How to distinguish between malingering, genuine psychosis

 

[LadyHalcyon]

I have to say that mine is "is kinda psychotic + has some feels = schizoaffective"

Doesn't that description "kinda" describe us all though?

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[LadyHalcyon]

The patient could be malingering:

How to distinguish between malingering, genuine psychosis

Or they could have HPD and/or BPD

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