Disorders of Perception

Dr Avinash Waghmare
Assistant Professor in Psychiatry
Smt. Kashibai Navale Medical College,
Narhe, Pune

STEP 2016 27 & 28 August - By TIPPS

 Definition
• Perceiving is not merely receiving a sensation.
• Sensation plus attributing a meaning to it is
perception.
• For eg: Hearing a tick tick is a sensation.
Hearing the tick tick sound and knowing that
it is coming from a clock which is hung on the
wall opposite me is perception.

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 Disorders of perception
• Sensory distortions
• Changes in quality
• Changes in intensity
• Changes in form
• Changes in associated affect
• Splitting

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 Disorders of perception
• False perceptions (sensory deceptions)
• Illusions
• Hallucinations
• Pseudohallucinations
• Imagery

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– Illusion: Misinterpretation of stimuli arising from
external object
– Hallucination: A false perception which is not a
sensory distortion or misinterpretation and occurs
in the same time as real perception (Jasper).

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 Clinical Assessment
• In the last week have there been times where
you have had any unusual or strange
experiences?
• For eg when you were awake and alone and
nobody was around you were you able to hear
voices of people talking to you or any unusual
sounds?
• Whether these sounds (elementary) or music
(partly organized) or voices (fully organized)

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• Can you describe to me about these voices or
sounds? (whose voices are they?,
familiar/unfamiliar people?, male or female?
Number of voices? What do they say –
friendly/threatening/voices
discussing/commentary/commanding? How
frequently do they occur?/ Do other people
also hear these voices?

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• Are these voices as clear as my voice when I
am talking to you?
• Where do these voices come from? Can you
pinpoint its location?
• Can you control these voices and make them
stop when you don’t want them?
• Are these voices real or could they be your
imagination?

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• How do these voices make you feel? Do they
upset you or cause distress?
• How do you react to these voices? Is there
anything you do to reduce them?

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• Have you had any other similar experiences
for eg: Do you see things which other people
around you are not able to see or do you get
any unusual smells which other people do not
or do you feel any strange sensations?

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AS WITH ALL ABNORMAL MENTAL
PHENOMENON, IT IS NOT POSSIBLE TO
MAKE AN ABSOLUTE DISTINCTION…
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• Hallucinations have all the qualities of True
perceptions except that these are false

• Differentiate between true perception and

mental imagery

• Pseudo-hallucinations come in between

hallucinations and imagery
• True perceptions-Hallucinations-
Pseudohallucinations- Imagery

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 Attribute True Pseudo- Imagery
hallucinati hallucinati
on on
Experience Concrete, Less so Not clear
real
Source of Out of mind Inner/outer Inner space
perception space (Mind)
Vividness Full Dim / Not vivid
neutral
Constancy Retained Evanescent Evanescent

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 Attribute True Pseudo- Imagery
hallucinati hallucinati
on on
Control/ Cannot be Partial Voluntary
dependent controlled control control to
large extent
Insight Absent Variable Present
Dependent No Yes Yes
on “state”
Conscious Awake Awake/goin Awake
ness g into or
coming out
of sleep
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 Hallucination
• A 30 year old female reports she is able to hear
voices of 3 people when she is alone almost
throughout the day. These voices are unknown
people, 2 male 1 female who speak in hushed
tones but are clear, voices come from behind the
cupboard in her room but when she looks there
she can’t find anyone. These voices talk among
themselves about her and are plotting how to kill
her. She believes these voices are true, not her
imagination and cannot control them and is very
distressed by them. She reacts to them by talking
back to them and scolding them
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 Pseudo hallucination
• The same female patient after 1 year of
antipsychotic treatment reports the intensity and
duration of voices has reduced. The female voice has
been silenced but 2 male voices are heard
intermittently, but they are not plotting that often.
She is able to talk back to them and silence them and
they sometimes listen to her. She still perceives the
voices to be coming from behind the cupboard but
says that she is not sure… since she has looked so
many times and cannot find them may be they could
be her imagination.
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 Imagery
• After 2 years of antipsychotic treatment she now
says that since last 3 months she is able to see
pictures of god coming one after the other in
front of her eyes like a movie reel. She is able to
distract herself and temporarily stop them by
closing her eyes or shaking her head but they
come back. These are nude images of gods and
doesn’t want them to come. She is particularly
distressed because she knows that they are
coming from her own mind and are not like the
voices she used to hear earlier which were real.

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 Clinical interpretations
• Presence of specific types of hallucinations
such as running commentary, third person
auditory hallucinations, thought echo are First
rank symptoms with diagnostic significance
• Presence of visual hallucinations should
sensitize the clinician to the possible presence
of organicity

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 Clinical interpretations
• Olfactory hallucinations could be part of aura
or ictal phenomenon in complex partial
seizures
• Hallucinations can occur in individuals with
sensory deprivation. This phenomenon is
called Charles Bonnet syndrome. Elderly
people with paraphrenia and multimodal
hallucinations should be evaluated for sensory
impairment (cataract, hearing loss)

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 Clinical interpretations
• Presence of command hallucinations should
sensitize clinician to possible risk of harm to
self or others. The hallucination may
command individual to attempt suicide or
attack perceived persecutor.

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 Clinical interpretations
Sometimes …. difficult to differentiate between a
hallucination and delusion.
• Case of gustatory hallucination (person may say
family members are persecuting him because he
can taste or smell poison in his food).
• Case of delusion of reference (person may say
people are talking about him and he knows this
because he can hear people talking about him).
• Food tasting of arsenic
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 Explain these
• Pale hallucinations
• olfactory reference syndrome
• functional hallucination
• reflex hallucination
• Apperceptive hallucinations
• coenesthetic hallucination
• Extracampine/Intracampine

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 Coenesthetic hallucination

• A peculiar visceral or other bodily sensation

that cannot be explained by reference to any
known physiological mechanism
• E.g. Scratching feeling in inside one’s skull

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 Somatic hallucinations
• Superficial: can be of touch (haptic),
temperature (thermal) or liquid (hygric)
• Kinaesthetic: sensations of movement or from
muscles / joints. Seen in schizophrenia,
substance withdrawal and epilepsy
• Visceral: sensations referred to internal
organs, common in schizophrenia

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 Some specific (named)
hallucinations……
• Lilliputian hallucinations: visual hallucinations
of small figures / animals (i.e. with micropsia),
usually perceived as pleasant
• Charles Bonnet syndrome: visual
hallucinations of human / animal figures in
elderly patients with eye disease, in the
absence of other psychopathology

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 Some specific (named)
hallucinations……
• Extracampine hallucinations: hallucinations
outside the field of perception (“voices from
my native village” when patient is in
hospital)
• Intracampine hallucinations:
• Reflex hallucinations: a morbid variety of
synaesthesia in which a stimulus in one
modality (eg. seeing someone laugh)
produces a sensation in another modality
(eg. a pain in the chest)
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 Some specific (named)
hallucinations……
• Autoscopy: visual hallucination of one’s own
self
• Negative autoscopy: not seeing one’s reflection
in a mirror
• Functional hallucination: occurs only in the
presence of an external stimulus, but is
perceived separately (eg. hearing voices only
when a fan is switched on, though the sound of
the fan is perceived separately)
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 Some specific (named)
hallucinations……
• Hypnagogic / hypnopompic: occurring as subject is
falling asleep or waking up; generally a normal
phenomenon
• Imperative: voices giving commands
• Somatic passivity: somatic hallucination with a
delusional elaboration of being caused by an
external agency (also a first-rank schizophrenic
symptom)
• Experiential: hallucinations of past memories
(visual and auditory) in epilepsy
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 Some specific (named)
hallucinations……
• Formication: tactile hallucination of insects
crawling on the body, seen in cocaine
intoxication / alcohol withdrawal
• Phantom limb: perception of sensation from a
limb that has been amputated (or, more
rarely, has been denervated)
• Scenic: whole scenes are hallucinated like a
film

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• Fantastic hallucination: Mass hallucinations…
many modalities… large number of people are
being tortured and murdered

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