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HALLUCINATION PRIMER

22 August, 2015

CATEGORIZING HALLUCINATIONS

Hallucinations can be categorized by (1) the sensory modality involved, (2) how elaborate/detailed the hallucinations are, (3) the conditions of their occurrence, and (4) whether or not the organs of special sense are experience as being involved.

MODALITIES

Hallucinations can occur in any sensory modality: the special senses (vision, hearing, taste, smell); bodily sensations including proprioception (the sense of body part location), bodily motion, bodily orientation, tactile sensations (touch), somatic sensations (tissues below the skin’s surface); and what I call sixth sense hallucinations. The older the sense involved was in evolution, the more serious a hallucination is considered.  Vision is a relatively new sense, evolutionarily, and, among special sense hallucinations, visual hallucinations are quite common.  The sense of smell came early in evolution, and the olfactory lobes are actually a part of the earliest structures of the brain.  Olfactory hallucinations are usually a sign that something more serious is wrong, such as the olfactory hallucinations (auras) experienced by persons with epilepsy.

ELABORATENESS

Visual hallucinations can range from simple ones to being very elaborate.  The nearly amorphous, furtive, shadowy shapes seen by survivors in the corners of their eyes is a perfect example.  For most survivors, the silhouette-like figure that appears at the foot of their beds rarely has any details beyond its shape. More serious hallucinations may be in full color and detailed.

SENSE ORGAN INVOLVEMENT

Sometimes, though there is a sensory modality associated with the hallucination, there is no experience of the related organs of sense being actually involved.  The most simple to explain are auditory hallucinations that don’t involve the ears.  These hallucinated sounds are experienced as being between the ears — in the head itself.  Anyone who has worn headphones while listening to a monaural sound has had a similar experience.  The sound doesn’t seem like it’s coming through the ears.  Rather, the sound seems to be in the middle of the listener’s head.  Such experiences are called hallucinations of concept or psychic hallucinations.

Theoretically, the more the sense organs are involved, the more serious the hallucination.  These experiences are called hallucinations of percept or psychosensorial hallucinations.  Psychologically, the stimulation appears to be coming from outside of the body.  Hearing a voice with a distinct direction, distance and location away from the ears is a far different story than one seeming to exist solely inside one’s own head.

It is more difficult to characterize, for instance, visual hallucinations of concept which don’t involve the eyes.  These visual hallucinations, not uncommon in survivors, are ‘seen’ with what some have called “the mind’s eye.”  For instance, a survivor described one such hallucination which would occur when she closed her eyes.  In her “mind’s eye” she would see quite vividly an attacker approaching her from the rear.

PSYCHOSES vs. SURVIVORS’ PTSD

Though especially serious abuse, and/or secondary substance abuse, can lead to very elaborate, multi-modality hallucinations (hallucinations I call “the perfect storm” in another post), for the most part the hallucinations of survivors are very simple, psychosensorial, unelaborated experiences.  However, rather elaborate Psychic hallucinations of voices are fairly common.  Survivors may hear a single voice condemning them and suggesting they should die.  They may also hear multiple, detailed voices which appear to be discussing them, or the experience may be unelaborated — a sort of indistinguishable mumbling rather like being in a room full of people where conversations are clearly going on but in which individual conversations cannot be discriminated. The hallucinations suggesting the committing of suicide may rise to the level of commands to do so and are thus called command hallucinations.  Persons with actual psychoses may be distressed by the content of their hallucinations but not by the fact that they exist.  For them, that the hallucinations exist says nothing to them about their mental state.  Survivors, on the other hand, usually fear for their sanity simply because the hallucinations do exist.

NON-DISCLOSURE

The fact is that, during evaluation, survivors rarely reveal spontaneously the fact that they have hallucinations.  There is a fear that they are crazy, or going crazy, and a concern that revealing the hallucinations to a mental health professional will result in confirmation of that fear.  Still, revelations do happen at times and usually result in nasty psychiatric name-calling (misdiagnoses) in which survivors are dismissed as being psychotic, perhaps even schizophrenic, and put on anti-psychotic medications.  Because there is usually so much emotional turmoil and affects are so unstable, a diagnosis of borderline personality disorder is frequently given to them.

There is a combination of sexism, denial and ignorance involved here.

SEXISM

While male combat veterans with similar experiences are readily diagnosed as having PTSD, female sexual abuse survivors are cut no such slack.

DENIAL

There is something somewhere in the male psyche that causes difficulty in conceiving such childhood experiences as being lastingly harmful in any way, much less devastatingly so.  For example, I recall sitting with a psychiatrist who was interviewing a survivor for any medication needs, and who asked “That doesn’t still bother you, does it?” Just recently (April, 2015) there was outrage over an Orange County, California judge reducing the sentence of a man who sodomized a 6-year old, saying there was no evidence the perpetrator had intended to harm the child!  Quite frankly, that level of denial makes me suspicious of the denier’s own sexual proclivities.

IGNORANCE

The possible history of sexual abuse often goes without exploration in the initial evaluation of women presenting themselves to psychiatrists for treatment.  Even if psychiatrists might be disposed to connect the survivor’s symptoms with such trauma, the history being unquestioned leaves the cause of the symptoms subject to the standard sources of disorders, such as the largely genetic, biophysiological disorder called schizophrenia.  Usually, the “presenting complaints” are of such things as anxiety, depression or relationship problems, and all too often only those symptoms become targets of intervention with no attention to their etiology.

DIFFERENTIAL DIAGNOSIS

A careful and thorough mental status examination is needed to make a good differential diagnosis, whether dealing with survivors or persons with actual schizophrenia (vs. bipolar disorder, vs. brain tumors, vs. paranoid disorders, etc.).  Sadly, very few in the mental health professions (even psychiatrists) have had decent, in-depth, structured training in the conducting of mental status examinations.  So it is that — even if sexism, denial and ignorance were not the picture — there may still be the danger of misdiagnosis.  Diagnosis matters.  Diagnosis at the least suggests, if not dictates, efficacious treatment.  Years of misdiagnosis and related, poorly conceived treatment plans leads only to frustration on the part of both the professional and the survivor.  Worse yet, the lack of response to treatment often only further convinces psychiatrists in particular that they are dealing with a biophysiological disorder.  This all makes it difficult for me to decide to be depressed or outraged.  Most of the time, I am the latter.

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2 Comments
  1. Grey permalink

    I found this posting particularly interesting. Over the last few years, I’ve wondered a great deal about the connection between what I believe to be Misophonia and childhood trauma, particularly abuse of the physical and sexual varieties. More and more I am realizing how sensate of a person I am. It crosses across nearly all the senses. I am particularly sound sensitive– to the degree of Misophonia. Any thoughts you have on this would be appreciated.

    Thank you for the work you’ve done and are actively continuing.

    • Misophonia is not among the syndrome symptoms I encountered. Pure Misophonia, a dislike of all sounds, has been thought to be neurological, though a few have proposed that it can be classically conditioned. However, I would not doubt that survivors of sexual abuse might have adverse reactions to some specific sounds associated with their trauma. They do have such reactions to certain smells, tastes and textures. The telling thing would be whether the person with Misophonia has other pathognomonic symptoms that make up the syndrome. I do have some doubt that all misophonia is due to trauma. It seems to me likely that the bulk of cases are neurophysiological in origin.

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