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1 Symptoms of Psychosis. Hallucinations

Hallucinations in Psychosis
by

Geoff Brennan

on 8 September 2016

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Transcript of 1 Symptoms of Psychosis. Hallucinations

1. Hallucinations
Hallucinations
We begin the exploration of psychotic symptoms with possibly the most well known.

Hallucinations.






What is a Hallucination?
Auditory Hallucinations: What they can feel like.
Some definitions:

"A hallucination is a perception without an object. "
(French psychiatrist Jean-Étienne Esquirol in 1838!)

"Hallucinations are sensory perceptions in the absence of external stimuli."
Frangou and Murray (2000). Schizophrenia
2nd ed.

Note "sensory". Hallucinations can affect all five senses.

Can you remember all 5 types of hallucination before the next slide?
1. Hearing
2. Vision
3. Smell
4. Taste
5. Touch
1. Auditory
2. Visual
3. Olfactory
4. Gustatory
5. Tactile
Hallucinations are a well known symptom. But can you name all five types of hallucination? Can you say which one is most common in psychosis? Can you say which may be experienced in conditions other than psychosis? What is a pseudo-hallucination? Do you know what Charles-Bonnet syndrome is? Do you know which type of dementia is associated with hallucinations?
If you don't, you will soon. I Promise.
Nursing office
SENSES
TYPE OF HALLUCINATION
Auditory Hallucinations
The most

common type of hallucinations

encountered in psychosis are
auditory hallucinations.

Whilst auditory hallucinations can mean a person hearing music or unspecified noise, the most common type of auditory hallucination is
hearing voices.

Some studies have found that
three quarters
of those diagnosed with schizophrenia are said to hear voices that are a false sensory perception.


As the previous image showed, this can often be an
extremely distressing
experience.

The experience of hearing a voice that orders a person to behave in a certain way or to do certain things is called a ..............
Command Hallucinations (CHs)

When someone has a hallucination that takes the form of a voice commanding them to do something, these are known as command hallucinations (CHs).

The command may be to do something dangerous and can result in harm to self or others.

Differing studies have found them to be common in "voice hearers" - with between
33% to 74%
reporting such hallucinatory experience.

The link between the command and the hearer carrying out the action is unclear.
It is clear however, that CHs
are not sufficient in themselves
to make a person carry out dangerous acts and that many people find ways of coping.

CH's are an important part of a persons presentation. We should find out how the person manages them and support them in not carrying out the commands. They should also be documented and communicated to the care team.


Visual Hallucinations
Visual hallucinations affect
sight
and are visual images in the absence of any cause or stimulus.

They can range from
spots and strange lights or colours, through to human or other figures, to panoramic or horrific scenes
.

Although well recognized as a symptom of psychosis, they are not as common as auditory hallucinations.
Olfactory Hallucinations

Gustatory Hallucinations
You're probably getting the hang of this now and can guess from the image that Gustatory Hallucinations are when a person
tastes
something without cause of stimulus.

As with Olfactory Hallucinations, these are rarer in psychosis and tend to accompany other symptoms, e.g. " Someone has contaminated my drink and
I can taste it on my tongue
, even if I suck sweets or mints."

Also, if the symptom occurs without any other evidence of psychosis, temporal lobe epilepsy or other organic causes should be considered.
Tactile hallucinations
Tactile Hallucinations are when a person
feels sensations
on their skin or in their body which have no cause or stimulus. They are sometimes refereed to as
Haptic
Hallucinations.

These sensations can be
on
the skin and feel as though the person is being stroked, pricked or strangled. They can also be
on or just under
the skin and feel like insects crawling or worms burrowing.

They can be even further into
the body
in what are known as
Hallucinations of Deep Sensation
. These Hallucinations can feel like snakes or animals inside the body, like the gut or organs are being pulled or distended, like the person is being sexually violated or they are experiencing electric shocks inside the body. In other words, they can be really horrible.

Tactile Hallucinations can be a very real and very nasty feature of drug or alcohol withdrawal.
"True auditory hallucinations

are heard as external to the subject’s mind. They sound as if they come from in the room, or from outside in the street, or from some external object, or sometimes from a part of the subject’s body.


Pseudo auditory hallucinations

are heard as in the mind or inside the head.

True visual hallucinations

have all or most of the visual qualities of a real object. They appear solid, three dimensional, coloured, and may move about in space. They tend to persist rather than appear fleetingly.
Pseudo visual hallucinations

do not appear convincingly real because they lack most of the above qualities. They may appear translucent, flat, colourless, and they may be very fleeting. Formless flashes of light and dots before the eyes should be put in this category."

Krawiecka, Goldberg, Vaughn (1977) Acta Psychiatrica ScandinavicaVolume 55, Issue 4, Pgs 299-308
from "KGV Symptom Scale (modified version)"
(S. Lancashire, Manchester University (1994))
Assessment
Key aspects of assessing Hallucinations
1) FREQUENCY
-
How often.

2) DURATION

-

How long.

3) LOCATION -

Inside or outside the persons head.

4) LOUDNESS -

How loud.


5 ) BELIEFS RE-ORIGIN OF VOICES
-
Internally (self) or externally generated.

6 ) AMOUNT OF NEGATIVE CONTENT OF VOICES -

From no negative content to all negative content

7) DEGREE OF NEGATIVE CONTENT OF VOICES
-
From nothing to threats of harm.

8) AMOUNT OF DISTRESS -

From not distressing to voices always distressing

9) INTENSITY OF DISTRESS -

From feeling the voices not distressing to feeling the worst they could be.

10) DISRUPTION TO LIFE CAUSED BY VOICES -

From no disruption to the person not able to function.

11) CONTROLABILITY OF VOICES
- Person total control to person feels they have no control over voice.

AHRS
The key to assessing hallucinations, as with all symptoms, is to get as
detailed
an account of the experience
from the person
as possible.

With hallucinations,
observation
plays an important part as the hallucinatory experience can be very distracting.

In the next slide we shall look at the 11 aspects of auditory hallucination assessed within the "auditory hallucination rating scale" (AHRS). Before we look at it, what factors do you think are important when assessing hallucinations?
Principles of assessment for all hallucinations

As can be seen, the aspects to assess are:

1. Mechanics -
How often, how powerful, how long?

2. Belief -

How does the person understand them?

3. Emotional Effect -

Is it a positive or negative experience?

4. Disruption to functioning -

Does it interfere with daily living?


Olfactory Hallucinations are when a patient experiences a
smell
in the absence of any cause or stimulus for the smell.

In psychotic illness, these hallucinations usually occur as an adjunct to other symptoms - e.g. " My body is dead and
I can smell it rotting
." (see Nihilistic Delusions in next section)

Olfactory hallucinations are rarer than auditory and visual hallucinations and tend to be experienced alongside the next hallucinatory type, Gustatory Hallucinations.

Gustatory and Olfactory Hallucinations occurring
without
any other psychotic symptoms would indicate a possible organic cause, such as Temporal Lobe Epilepsy or brain trauma.
Charles Bonnet Syndrome.
There some types of true visual hallucination that should not be considered as psychotic.

In
Charles Bonnet Syndrome
a person who has visual impairment experiences a clear and true visual hallucination in the absence of any other symptoms.

Often the person has insight into the fact that they are hallucinating and the hallucination itself will stop if eyesight is improved.

This syndrome can occur in people afflicted with poor eyesight from birth, but can also be prevalent in the elderly population as eyesight deteriorates.

Just to make life difficult, however, there is also a form of Dementia called
Dementia with Lewy Bodies
that is known to induce auditory and visual hallucinations. Good assessment should help us differentiate as as a person with dementia has a range of additional memory and functional symptoms.
"The patients experience can be explored by observing the impact voice hearing has on them, noticing their distraction, their talking back to the voices and their body language. However their experience can also be explored by asking such questions such as:

‘how loud’, ‘how long does it last’, ‘how many voices’, ‘what do they say’, ‘how frequently does it happen’, ‘is it saying anything about me’, etc.,

in order to ‘try to get to the heart of their experience’. Some nurses used structured questionnaires in order to systematically understand what patients were experiencing.

Conversations might have to be timed to periods when the patient is not actively hallucinating, or the patient might not wish to talk about them, in which case this needs to be respected."
Page 44
"Hearing the experience
The expert nurses advised that assessment could be carried out through the use of scales such as the AHRS, but that nurses should also be able to assess hallucinations through observation and asking gentle questions at the right time.
Quiz Time:
Got your pen and paper ready?
Pseudo-hallucinations
Before we go on to consider how to asses hallucinations, we need to consider what are known as
"pseudo-hallucinations"
and other forms of hallucination which may not indicate an underlying psychosis.


Pseudo-hallucinations are hard to define, but in essence they are sensory experiences that are perceived as
not as quite real
or
true
as normal or which the person recognises are located in their "inner subjective space" rather than the real world. Therefore if a voice is heard "inside my head" this is very different to one I can hear coming from the next room.

This does not mean that pseudo-hallucinations are not important. As with command hallucinations, they should be accepted, documented and communicated to the care team

To help understand them, the next slide is from the
KGV symptom scale
and gives advice on recognising pseudo hallucinations
.

As well as pseudo hallucinations, there are 3 things to consider when someone seems to be describing a Hallucination.

Sleep, sensory deprivation and special conditions.

If a person describes a rare hallucinatory experience while waking up, it is called a
Hypnopompic
Hallucination. If is just before falling asleep, it is called a
Hypnogogic
Hallucination.

These are quite common experiences and not necessarily psychotic. They have been typically described by the recently bereaved, e.g. "On the day of my mum's funeral I swore I heard her call my name as I was falling asleep."
Similarly, a person who is
sensory deprived
, eg. through lack of sleep, or who has a near fatal experience, can experience what are known as
Autoscopic Hallucinations
, which are more commonly
known as
out of body experiences
. Here, the person has a sense of floating and seeing themselves from without. While not in itself psychotic, in rare occasions it can come with a conviction that the person has a double (or doppleganger) and has ceased to exist. This may be clinically significant as we shall see in the next section on delusions.
Finally, there are hallucinatory experiences that are very specific to certain situations, for example a person only has them when water is running or a person has visual hallucinations only when music is playing. These are called
Reflex Hallucinations
.

Basically, though, we should carefully assess and accurately record
all the experiences
that our patients tell us.
• The 5 types of hallucination.

• Hallucinations not associated with psychosis.

• Assessment of hallucinations.

• Advice within core text on how to help someone with hallucinations.

Contents
In this section we shall examine:

KILL YOURSELF
)
0
Can you name the
5 types of hallucination?
SLEEP
Sensory Deprivation

Summary: How to assess and work with your patients hallucinatory experience.
Observe.
One way to explore your patients' experience is to observe how they are reacting

Are they distracted?
Do they appear to be talking back to hallucinations?
What can you tell from their body language?
Ask questions
You can also ask questions to try to get to the heart of their experience.

How loud are the voices? What can you see?
How long does it last?
How many voices?
What do they say?
Do you recognise the voice?
How often do you hear them?
Is it saying anything about me?
Are they upsetting?
But to start us off, can you give a definition of what a hallucination is?
DID YOU GET THEM ALL?
Expert Nurses Advice
1. Tolerate and make allowances for auditory hallucinations.
Do not expect patients to be able to easily communicate and explain what is going on for them. Be patient, build a rapport, be prepared to make allowances. Work out good times to talk and times when the hallucination are less severe.

2. Not too much too fast.
Go at their pace. Allow the patient to dictate when is a good time.

3. Say their name.

Hallucinations are disorientating. Saying their name, and reminding them who you are can help to keep them focused.

4. Be creative.
You don't always have to talk. Try and build rapport through other means, like making the environment comfortable, playing music, offering alternatives activities.

"It’s about trying different things, if something doesn’t work then it’s not just saying, well that, that person is really disturbed and you can’t get through to them. It’s about trying different things and that’s what we do."
Working with patients who are experiencing hallucinations.
Hearing the patients experience through assessment is only the beginning of the process. The expert nurses describe a range of options for the issues that patients experience: keeping them safe; offer a means of distraction; offer opportunities to explore and confront, and even times when they would openly challenge the hallucinations.

However, all these options need to be thought through with reference to the specific patient and what would be best for them. As with the principles of the
recovery
model, it is not our aim to take away the experience, but rather to guide a patient in gaining control of their life in spite of the experience.
See pages
24-26
and 44-47
Congratulations!
You have just completed
1. Hallucinations.


DONT TRY AND REMEMBER ALL THIS.

IT IS NOT EXPECTED THAT YOU WOULD CARRY OUT SUCH AN ASSESSMENT WITH EVERY PATIENT.

THE POINT IS - LOOK AT THE FACTORS THAT INFLUENCE HOW A PERSON EXPERIENCE HALLUCINATIONS.

IT'S MUCH MORE THAN A SIMPLE "DO YOU HEAR VOICES?"

IN THE NEXT SLIDE WE HAVE GROUPED THESE FACTORS INTO GLOBAL THEMES.

WHAT DO YOU THINK THEY WILL BE?.


Full transcript