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Visual Hallucinations in Schizophrenia vs MDD with Psychotic fx

Discussion in 'Psychiatry' started by Ceke2002, Aug 20, 2015.

  1. Ceke2002

    Ceke2002 Purveyor of Strange
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    Just out of interest I've noticed, anecdotally speaking of course, that in discussions I've had with other patients regarding the content and type of visual hallucinations, that it appears their is, in general at least, a fairly distinct difference between the most common types of visual hallucinations reported by those diagnosed with Schizophrenia, and those diagnosed with MDD with Psychotic fx. Is this because the VH in MDD with Psychotic fx tend to reflect (although my understanding is not always) a more mood congruent state, or is it actually that different parts of the brain are at work/being affected (or that the same part of the brain is just affected to a different degree), a combination of all of the above, or something else entirely.
     
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  3. shan564

    shan564 Below the fray
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    Combination of that plus the fact that many patients (and non-psychiatric doctors) use the word "hallucination" loosely to refer to something that might not really be a hallucination. For instance, an ER doctor might call me and say "the patient is having visual hallucinations of ghosts in the room" whereas he actually had a delusion that the fluorescent lights were ghosts (that guy was schizophrenic). Or a patient might say that she sees evil bunnies running around in the room, but she actually just sees shadows and has delusions that they're evil bunnies (that person had a diagnosis of MDD with psychosis, but I suspect that she might have actually been schizophrenic).

    There's also diagnostic inconsistency which only becomes clear with longer-term observation - for instance, I've seen at least two patients who were diagnosed with MDD with psychosis due to VH, but long-term observation showed that they actually had MDD plus Lewy Body dementia. And I've seen many patients whose VH were actually dissociative symptoms or pseudohallucinations which were actually caused by an underlying personality disorder.

    In general, whenever I hear about VH from a primary psychiatric illness, further careful evaluation often shows that it's not really VH. VH in schizophrenia tend to be vague (i.e. halos around lights, etc.) which are often misinterpreted as something sinister (i.e. evil spirits).

    I also tend to be skeptical of an MDD with psychosis diagnosis when the patient is frankly and severely psychotic. It happens, but a good chunk of the time, those patients turn out to have something else going on (i.e. delirium, Lewy body dementia, prodromal schizophrenia/schizoaffective disorder, bipolar disorder, etc.). And then it's hard to clarify the diagnosis later because you treat the symptoms, so you don't necessarily see what they'd look like in the absence of treatment.
     
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  4. Ceke2002

    Ceke2002 Purveyor of Strange
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    Yes, I can see the difficulty. My understanding has always been that VH in psychosis is relatively uncommon and therefore considered an atypical symptom most of the time, which warrants further investigation/observation before any sort of primary psychiatric diagnosis can be made. I can see how that could be complicated if you had a patient that was also experiencing pseudohallucinations or illusions caused by other underlying pathology on top of potential psychosis or psychotic type features.

    Interesting you mention VH in Schizophrenia tend to be vague. All of the Schizophrenic patients I've known over they years who do experience visual hallucinations have always described them as being fully formed, and that's always tended to be my experience of VH as well (as opposed to the non VH type seeing shadows out the corners of your eyes and thinking their ghosts because you're anxious and haven't slept properly type pseudohallucinations).
     
  5. shan564

    shan564 Below the fray
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    I shouldn't comment on your own personal experience without doing a full evaluation, and that borders on giving medical advice on the forums. But we do know that there's no blanket answer - symptoms can vary from person to person. Most of the patients I've seen who have frank well-formed VH in schizophrenia actually turn out to have something else.
     
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  6. Ceke2002

    Ceke2002 Purveyor of Strange
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    Oh no, sorry, absolutely didn't expect you to comment on my case, was just wondering out of curiosity in general. So leaving me out of the equation (I've already been thoroughly evaluated and diagnosed so I'm really a moot point) what are the differential diagnosis in frank VH if not Schizophrenia? I know lewy body dementia is one of them, I take it most of the differential diagnosis have something to do with an organic type psychosis? It's okay if you can't or don't feel comfortable answering this considering I mentioned my own experience in the previous post (apologies again I didn't even think about mentioning something like that in passing).
     
  7. MacDonaldTriad

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    Visual hallucinations = A. malingering, B. organicity, or C. a very atypical and rare symptom of schizophrenia or major depression with psychotic features. It is A or B 99% of the time. In the rare case that you rule out A and B and think it is C, 99% of the time, it ends up being A or B after all.
     
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  8. Ceke2002

    Ceke2002 Purveyor of Strange
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    Yes, that was my understanding as well, that malingers will endorse atypical or rare symptoms, such as visual hallucinations, far more often, or that it's possibly an organic process. I probably should have clarified that out of all of the diagnosed schizophrenics I've known over the years (around 10 people, some friends, most loose acquaintances) only 3 have endorsed visual hallucinations as a symptom, and I know one of them was malingering for sure (considering the severity of her symptoms was in direct proportion to the amount of attention she got, plus she was rediagnosed as borderline at a later date), one was a bonafide diagnosis of pretty severe schizophrenia (I seriously doubt a malingerer could keep up an act of both positive and negative symptoms and not miss a beat in over 5 years) and the other was diagnosed but stable on medication and as far as I know he only experienced visual hallucinations with his second episode after stopping medication, scaring the beejebus out of himself, and going straight back on it. My Dad had some pretty interesting visual hallucinations in the later stages of dementia as well, so obviously an organic process going on there. And in my case, which I mention only for (non) discussion sake, I pretty much lost track at one point of just how many times various Doctors wanted me to repeat the same brain scan, imaging, blood test, what else can we poke her with/put her through type tests in a single year whilst they were ruling out any sort of organic issue - and of course I've also had 5 years in which to be observed and assessed (or reassessed if that was the case) by an experienced Psychiatrist, so not malingering either (and yes I've been asked all the 'Do you think cars are part of an organised religion' type questions as well), which I guess officially makes me part of the special snowflake brigade. :laugh:

    And now I'm wondering how many bonafide cases of schizophrenia, mdd with psychotic fx, or any other psychotic type disorder, gets misdiagnosed as malingering because a patient does appear to endorse visual hallucinations more strongly than the more typical auditory et al type pathology, simply because the visual stuff is more noticeable and might just be the first thing that comes to mind when a Psychiatrist enquires about symptoms. I know there's obviously tests like m-fast, structured reporting of symptoms, and probably several others I don't know about it, but considering they would have to have some degree of false positives for malingering, how exactly do you tell if someone presenting with visual hallucinations is just FOS, or if they really are a legitimate case of atypical symptoms (presuming of course organic causes have been ruled out)? I suppose I'm assuming you use a combination of tests for malingering and clinical judgement?
     
    #7 Ceke2002, Aug 21, 2015
    Last edited: Aug 21, 2015
  9. st2205

    st2205 Attending
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    I would say exactly this except I'd modify it slightly:
    A. Malingering / fictitious / personality.
    B. Delirium.
    C. Psychosis*

    *75% of the time you're mistaking their delusions for hallucinations (i.e. describing Jesus appearing to them or seeing FBI agents hiding in their house).

    But yes, it's nearly always (99%) A or B and they're quite easy to tell apart.
     
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  10. Ceke2002

    Ceke2002 Purveyor of Strange
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    I'd probably add anxiety/panic disorder, stress response, sleep disorder, dissociative something or other and possibly OCD misinterpretation of intrusive thoughts causing potential illusions. But definitely soft psychosis personality disorder trait for the win!

    "Like OMG this one time at band camp/when I hadn't slept for days/was possibly lying in a darkened room trying to sleep whilst experiencing severe anxiety/having a panic attack/emotionally disregulating because I broke up with my boyfriend of 2 weeks, I totally saw shadow figures out the corner of my eyes/heard my name being called/felt dizzy and saw floating lights, glanced at something and momentarily thought it was something else/started experiencing over active imagination-itis, which mean I'm like totally psychotic right now you guys. No, really, I think I need to be in hospital, and medicated, on Seroquel, with Xanax, and Klonopin, and a Mood Stabiliser, possibly more than one, and several different Anti Depressants, and oh stuff it throw in another Atypical Antipsychotic for good measure, I mean clearly I'm totes out of touch with reality what with this psychotic epicus proportionus episode that I've just diagnosed myself with....blah blah blah, defensive accusations, blah blah blah, you'll be sorry you didn't listen to me, blah blah blah you're the fourth incompetent therapist I've had to fire this month. HERE COMES MY 19th NERVOUS BREAKDOWN!"
     
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  11. hamstergang

    hamstergang may or may not contain hamsters
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    I was actually talking about this the other day, though in the context of auditory hallucinations. I said that a patient seemed anxious and was likely misinterpreting their own intrusive thoughts as coming from someone else. But then I thought, isn't that what hallucinations are anyway? I became less clear about the line I was drawing. I can come up with some justification to keep these things distinct, but I'm not sure if this is reality based or not.
     
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  12. Ceke2002

    Ceke2002 Purveyor of Strange
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    Speaking purely from personal experience I can tell the difference between intrusive thoughts, ruminating type thoughts, negative self talk, inner thought processes, etc etc and auditory illusions vs auditory hallucinations. I can't explain how I can tell the difference exactly, and it's something I have kind of had to train myself to do over a number of years (some of that with the assistance of my Psychiatrist), but there is a distinct difference between how I suppose the word would be 'perceive' or 'hear' the different thoughts or auditory illusion/hallucinations process. Sorry, that's probably not much help.
     
  13. Shikima

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    Just would like to add that if there are behavioral disturbances with visual hallucinations, think biological such a synucleopathy - (DLB, MSA, PD).
     
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  14. Ceke2002

    Ceke2002 Purveyor of Strange
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    *nods* Agreed. My late father had vascular dementia, presumably with lewy bodies due to his behavioural disturbances and florid visual hallucinations as the disease progressed (apparently Jesus was hanging in a tree, and the neighbours that lived behind my parents were beaming porn movies into the backyard). At one point there was talk from a non neurological and/or neuropsychiatrist/geriatric psychiatric specialist point of view of changing my Dad's diagnosis from an already tested, and confirmed, organic process to one of MDD with Psychotic fx. Even to a lay person I think it would have been more than abundantly obvious there was something else going on other than a simple episode of mental illness, but it does go to show how easily misdiagnoses can be made when someone without the requisite amount of training and experience hears the words 'visual hallucinations' and 'disturbances in behaviour' and then rubber stamps a patient with a diagnosis on the psychotic spectrum.
     

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