Hallucinations: Theoretical and Clinical Overview

Ghazi Asaad, M.D., and Bruce Shapiro, M.D.

stimulus. They may involve any of the perceptual

The authors review the literature on senses. Consequently, there are several types of hallu-
hallucinations; provide theoretical background on cinations: auditory, visual, tactile, olfactory, and gus-
these phenomena from physiological, biochemical, tatory. There are also mixed or complex perceptual
and psychological points of view; and discuss the hallucinations, which will be discussed later in this
presentations of hallucinations in different diagnostic review.
categories. The longstanding notion that
hallucinations are to be equated with schizophrenia,
they conclude, is clearly unfounded, and ETIOLOGY AND PSYCHOPATHOLOGY
hallucinations are never pathognomonic of any given
disorder but can be relatively specific for some Although the exact cause and pathogenesis of hal-
conditions. Current knowledge and methods of lucinations are not known, there is a substantial body
research have produced no single mechanism to of knowledge that points toward multiple etiological
account for the etiology or pathogenesis of factors for hallucinatory phenomena.
hallucinations. The authors present an integrated
approach toward viewing the etiology and clinical Psychophysiological Approach
presentation of hallucinations that involves concepts
of biological vulnerability and psychological Jackson (4) originally presented a formulation in
influences. which the CNS is seen as having three evolutionary
(Am J Psychiatry 143:1088-1097, 1986) levels: the higher cortical level, the middle structures
(such as the basal ganglia), and the lowest level, which
includes the spinal cord. It was his belief that halluci-
H allucinatory
with insanity
phenomena
throughout
have
history,
been associated
and they have
nations
the uppermost
occur when the usual
level are impeded,
inhibitory
thus leading
influences
to the
of

contributed a great deal to the mystery of “madness.” release of middle-level activity, which takes the form of
According to Webster’s Third International Dictio- hallucinations. Thus, Jackson’s model is one of disso-
nary, “hallucinate” was derived through the Latin ciation leading to disinhibition and, consequently, the
word hallucinatus or alucinatus from the Greek origin emergence of hallucinations.
halyein or alyein, which means “to wander in mind” More recently, West (5, 6) proposed the “perceptual
(1). It was first used in the English language in 1572 by release” theory. He suggested that the brain continu-
Lavater to refer to “ghostes and spirites walking by ally receives sensory stimuli of all sorts from the
nyght” (2). After that, the word was used to describe external environment as well as from within the body
behavior that is intended as serious by the person but (6). The brain selectively excludes from consciousness
is perceived as heedless and foolish by an observer (2). the majority of impulses that are irrelevant to atten-
The term “hallucination” in the technical sense was tiveness or otherwise not needed for environmental
first introduced in 1837, when Jean Etienne Esquirol adaptation. According to this theory, the censorship
(1772-1840) published his textbook Des Maladies mechanism can operate properly only if there is a
Mentales (3) and described with great clarity the constant flow of sensory impulses. Such a flow serves
meaning of the term. Esquirol’s description became the to inhibit earlier perceptions from emerging into con-
basis for the current definition of hallucinations. sciousness. If the sensory input is disturbed or absent,
Hallucinations may be defined as perceptions that as in the case of excessive affect during “functional”
occur in the absence of a corresponding external psychosis, faulty synaptic transmission during toxic
states, or prolonged periods of sensory deprivation,
Received March 7, 1985; revised Aug. 7, 1985; accepted Sept. 13, then the censorship mechanism is impaired. Such an
1985. From the Department of Psychiatry and Behavioral Sciences, impairment allows the emergence of earlier percep-
New York Medical College, Valhalla; and the Department of tions or “traces” into consciousness, which the mdi-
Psychiatry, Stamford Hospital, Stamford, Conn. Address reprint
vidual reexperiences as hallucinations. Increased cor-
requests to Dr. Asaad, New York Medical College, Psychiatric
Institute, Valhalla, NY 10595. tical arousal, induced by a diminution of sensory
Copyright © 1986 American Psychiatric Association. impact, is essential for this process to take place.

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 GHAZI ASAAD AND BRUCE SHAPIRO

Other researchers have proposed further modifica- nism leads to the emergence of dreams or hallucina-
tion of the dissociation and disinhibition theories of tions. Observations that transcontinental air travel
hallucinations. Marrazzi et al. (7-9) proposed a may induce hallucinations (23) have led to the sugges-
“neurophysiological dissociation” theory wherein dis- tion that altered sleep-stage architecture, with shifts in
sociation of the primary receiving cortex from the REM onset and periodicity, may be etiologically re-
cortical association areas leads to hallucinatory phe- lated to hallucinations. Again, a possible physiological
nomena. Fischer et al. (10, 11), however, proposed a relationship between the sleep-wake mechanism and
“sensory-motor ratio” theory focusing on a dis- hallucinations is posited.
equilibrium between the internal and the external According to Green and Preston (24), although
sensory inputs to the CNS, leading to increased sen- auditory hallucinations in schizophrenic patients are
sory awareness and decreased motor responsiveness. usually thought to be private events, several early
Other neurophysiological investigations (12) have writers observed vocalizations concurrent with hallu-
indicated that abnormal excitation of brain tissue and cinations. The content of such vocalizations corre-
abnormal regulation of cognitive activity, probably sponds to what the voices are reported to have said.
involving left frontal lobe cognitive deficits, may con- The vocalizations are increased to an intelligible level
tribute to hallucinations. On the basis of several by the use of auditory feedback. This observation has
neuropharmacological studies in animals, Winters (13) implications for neurological theories of hallucinations
suggested that the disorganization of sensory systems and for possible self-control of hallucinatory symp-
and perceptual abnormalities in hallucinations may toms.
result from states of hyperexcitation of the CNS. Memory traces may constitute the building blocks of
Penfield et al. (14, 15) demonstrated that electrical hallucinations, as they do in dreams. Indeed, it has
stimulation of certain cortical or subcortical structures been theorized that hallucinations may be the result of
may induce different types of hallucinations. These abnormalities in the memory retrieval system (25).
studies support the theory of abnormal brain excitabil- Some studies (26) have suggested that hallucinations
ity as a mechanism for the production of hallucina- occur in certain people because of abnormalities in the
tions. Other investigators (16-18) have offered sup- imagination process related to either enhanced vivid-
porting work in this regard. ness or imagery deficit. Other studies (27) have argued
Regional cerebral blood flow studies have been that certain people are predisposed to hallucinations as
unable to pinpoint any specific correlates between a result of impaired ability to make clear perceptual-
blood flow and hallucinations. A review of the litera- conceptual distinctions (i.e., boundary confusion). Sie-
ture (19) found that some studies show reduced blood gel and Jarvik (28) proposed that the human mind
flow to several postcentral cerebral regions during could be considered an information-processing system,
hallucinations, while others show increased temporo- with sensory input and output. They suggested that
parietal blood flow in hallucinating patients. Cerebral hallucinations occur when imagery is projected outside
glucography with positron emission tomography the subject and viewed as separate from the projector,
(PET) (20) suggested that schizophrenic patients have and they postulated that increased cortical arousal is
a greater glucose uptake by the auditory areas and the necessary for this projection to take place. Horowitz
temporal lobe during auditory hallucinations. (29) also proposed an information-processing model,
Electroencephalographic findings indicate that certain based on evidence from experimental studies of per-
waves, called pontine-geniculate-occipital waves (nor- ception and imagining as well as clinical observations
mally present during REM sleep), may emerge into of illusions and hallucinations. He argued that hallu-
non-REM sleep and even into waking states. The cinations are a final common pathway of various
occurrence of these waves seems to coincide with determinants in the information-processing system
hallucinatory-like behavior in animals. On the basis of that cause a subject erroneously to regard an image of
these observations, Fishman (21) proposed that internal origin as an external perception. More re-
pontine-geniculate-occipital waves were the “minimal search is needed in these areas to support such hypoth-
neural substrate” of dream images and that the intru- eses.
sion of such wave forms into the waking state might be Other studies (30) have traced skin conductance in
responsible for the hallucinatory phenomena seen in schizophrenic patients during periods of auditory hal-
schizophrenia or drug-induced psychosis. A defective lucinations. The onset of hallucinatory periods is as-
serotonergic gating mechanism was suggested as a sociated with a substantial rise in the spontaneous
possible etiology underlying the abnormal emergence fluctuation rate of skin conductance. Additional re-
of these waves. On the basis of several sleep studies, ports (31, 32) have noted functional and anatomical
Hartmann (22) suggested that dreams and hallucina- cerebral asymmetry associated with hallucinations in
tions lie on a continuum. An inhibitory factor, psycho- schizophrenic patients.
logically related to the function of “reality testing” and It is clear that within the psychophysiological frame-
physiologically mediated by ascending cortical norad- work hallucinations have been investigated from var-
renergic systems, prevents the emergence of hallucina- ious viewpoints, none of which has yet been integrated
tions and dreams into the waking state. Physiological into a comprehensive pathophysiological concept of
or biochemical disruption of this inhibitory mecha- hallucinations.

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Psychobiochemical Approach sciously experienced as coming from the external

world. The contents of hallucinations are thought to
The regular occurrence of hallucinations as symp- reflect their psychodynamic significance. Thus, the
toms of nonpsychiatric medical conditions and as side patient experiences feelings of guilt, expressed in spo-
effects of many medications has stimulated researchers ken language as auditory hallucinations of criticizing
to investigate the biochemical aspects of hallucinatory and censuring voices. This represents verbalization and
phenomena. Several observations have indicated that projection of critical superego contents. Hallucinations
neurotransmitters are directly involved in the regula- may also be experienced in response to other
tion of hallucinations. Dopamine is believed to play a psychodynamic influences, such as wish fulfillment,
major role in these phenomena. It is well-known that enhancement of self-esteem, or gratification of re-
treatment of Parkinson’s disease with L-dopa prepara- pressed and rejected impulses. Fears of some aspects of
tions may induce psychosis, mainly a hallucinatory the personality, such as aggressive impulses or murder-
syndrome, probably as a result of the drug’s direct ous wishes, may be symbolized and projected into
dopaminergic effect (33, 34). It is also known that visual figures such as a terrifying animal or monster
drugs which block central dopamine activity (antipsy- (37).
chotic medications) alleviate the hallucinations of psy- Modern psychodynamic views, such as the concepts
chosis, which also points toward the involvement of presented by object relations theorists, offer another
dopamine in the process of hallucinating (33). Further understanding of hallucinatory phenomena. Bion (38)
evidence pointing toward dopamine as a factor in the formulated the concept that hallucinations are the
production of hallucinations is that d-amphetamine, result of projective identification, with the violent
an indirect dopamine agonist, induces psychosis and expulsion and projection of what he termed “bizarre
hallucinations (21, 33). objects.” These objects are seen as related to early
The involvement of serotonin has also been consid- primitive elements of internalized bad objects. When
ered in the biochemistry of hallucinations. It is believed they are projected, they are experienced by the mdi-
that low central levels of serotonin might be an impor- vidual as existing in the external world and thus form
tant factor. In fact, a number of hallucinogenic drugs, the basis of a hallucination.
such as lysergide (LSD), mescaline, and amphetamine, Hallucinations often occur with delusions during
appear to act, at least in part, by blocking central psychotic states and may represent the concrete sym-
serotoninergic receptors. Furthermore, LSD causes a bolic expression of delusional ideas that are seeking
decrease in the rate of brain serotonin turnover and is other routes of expression. Auditory hallucinations are
itself structurally similar to serotonin (21, 33). Other reported less commonly in patients with higher cogni-
reports (34) have suggested that cholinergic neurotrans- tive and developmental levels, who may present with
mission may also be involved in the pathophysiology more delusions than do patients with lesser cognitive
of hallucinations. abilities. These observations suggest that hallucina-
Here too, in the biochemical arena, we find a tions reflect the cognitive limitations of patients, who
number of theories that have not yet been integrated may choose different ways to describe a stressful
into a cohesive chemical explanation of hallucinatory internal experience (39, 40). The occurrence of audi-
phenomena. tory rather than visual hallucinations may be deter-
mined by several factors-physiological, psychologi-
Psychodynamic Approach cal, and cultural (41).

Freud (35) felt that hallucinations are very similar to

dreams and that both conditions represent psychotic CLINICAL ASPECTS
states in which there is a complete lack of time sense.
In this process, thoughts are transformed into images, Hallucinations in Nonmorbid Conditions
mainly of a visual sort; that is, word presentations are
taken back to corresponding “thing” presentations. Some forms of hallucinations have been reported in
According to Jones (36), however, Freud concluded people who are not mentally ill. The significance of
that hallucinations cannot be explained by a simple these unshared sensory experiences is not quite clear
regression of the kind that takes place in dreams; (1). In some societies, such experiences may be consid-
something has to happen to the “criteria of reality” as ered within the cultural norms. In such cultures, hal-
well. Jones interpreted Freud as meaning that halluci- lucinations are often experienced in the course of
nations can never be an early symptom of any psycho- religious or ritualistic activities and may be understood
sis but come about only if there already is a major as dissociative states, manifested as visions, trance
impairment of the ego. states, or hysterical possession (2, 42, 43). Some
Hallucinations are thought to represent a break- children describe clear images of people or objects as
through of preconscious or unconscious material into imaginary companions with whom they play and
consciousness in response to certain psychological whom they treat as real. The child recognizes that the
situations and needs. This material takes the form of object does not exist yet seems to experience these
sensory images that get projected and are then con- perceptions in the absence of external stimuli (44).

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 GHAZI ASAAD AND BRUCE SHAPIRO

During grief reactions, some people may experience Tactile, olfactory, and gustatory hallucinations have
hallucinations, such as seeing or hearing the deceased also been reported in schizophrenia (58). Hallucina-
(45, 46). Hallucinations can occur in normal people tions that occur during manic states, major depres-
when subjected to prolonged isolation and sensory sions, and other psychotic conditions may not be any
deprivation (47, 48), sleep deprivation, fatigue (49), different from those described in schizophrenia and
food and water deprivation (SO), or life-threatening may have very little diagnostic value in differentiating
stress (51). Hypnagogic hallucinations occur in some between various psychotic states. However, they may
healthy people during the period preceding falling have useful application in the differential diagnosis of
asleep, while hypnopompic hallucinations occur dur- psychotic disorders and organic disorders associated
ing the transition from sleep to wakefulness. The with hallucinations.
clinical significance of these hallucinations is contro-
versial (52, 53), but they commonly occur in the Hallucinations Associated With Alcoholism
absence of major mental disorders. Hallucinations
may also be produced during hypnosis or trance states Withdrawal from alcohol can cause visual halluci-
(54). Hallucinations in all these nonmorbid conditions nations as part of the syndrome of delirium tremens.
are usually recognized by the subject as being unreal This syndrome usually begins on the second or third
perceptions. It may be more accurate to call these day after the cessation of or reduction in drinking but
perceptions “pseudo-hallucinations” (55-57). may have its onset as early as 1 day or as late as 1 week
after abstinence. Other types of hallucinations (audi-
Hallucinations in Psychiatric Disorders tory, tactile) have been reported as part of the clinical
picture in alcohol withdrawal (58). Alcoholic hal-
It is fairly common in clinical practice to evaluate lucinosis is different from delirium tremens and
hallucinations as a major part of the clinical presenta- presents with mainly auditory hallucinations that per-
tion of several psychiatric conditions, such as schizo- sist after a person has recovered from symptoms of
phrenia, bipolar disorder, major depression, and dis- alcohol withdrawal and is no longer drinking. Audi-
sociative states. Although it is widely known that tory hallucinations in this syndrome can resemble to a
auditory hallucinations are more characteristic of great extent the auditory hallucinations of schizophre-
schizophrenia, they have been reported in other psy- nia. The voices are usually unpleasant and may cause
chiatric conditions. Furthermore, other types of hallu- patients to harm themselves or others in an effort to
cinations are common in schizophrenia, mostly in avoid the consequences of their threatening content.
combination with the auditory hallucinations. Most frequently the disorder lasts a few hours or days,
Auditory hallucinations in schizophrenia and other but in some cases it may last several months or even
“functional psychotic conditions” are usually formed become chronic. Alcoholic hallucinosis is a rare con-
and complex. For example, the patient might experi- dition and may be impossible to differentiate from a
ence two voices talking about him in the third person; schizophrenic disorder when it occurs in someone with
they may debate in an approving or antagonistic a concurrent alcohol abuse disorder (DSM-III; 59).
manner or they may command the patient to act in a
certain way. It is important to note that command Hallucinations Induced by Drugs
hallucinations may precede bizarre, destructive, or
suicidal behavior. The voices may be heard as coming Hallucinations induced by drugs are predominantly
from inside the head or from outside, and schizo- visual, with vivid colors and images. They are usually
phrenic patients of both sexes can hear both male and preceded by unformed visual sensations-alterations
female voices. In some cases the patient may not hear of color, size, shape, and movement. The images are
the voices clearly (58). usually abstract, such as lines, circles, stars, and flashes
Visual hallucinations are also common in schizo- of light. Later on, the person may experience more
phrenia, usually in addition to the auditory type. Some formed hallucinations, with images of people or ob-
studies suggest that hallucinations in schizophrenia jects or events. These images are more readily seen
can be mainly visual; this may especially be true in with the eyes closed or in darkened surroundings (6,
other cultures of the world (21). Visual hallucinations 28). This may speak toward a possible modulation of
in schizophrenia are usually formed and can be de- hallucinations by external stimuli. Auditory hallucina-
scribed by patients as images of people or animals or tions have been reported in drug-induced psychoses,
events taking place in front of them. In some instances, but when they occur they are usually unformed and
they may be less formed and may be experienced as experienced as indistinct noises. Occasionally, how-
flashes of light. The visions may appear in color but are ever, they can become more formed and be heard as
sometimes in black and white. Visual hallucinations in music or even voices (60). Tactile hallucinations
psychotic disorders appear suddenly and without (sometimes called haptic hallucinations) in the form of
prodromata in a psychological setting of intense affec- insects crawling up the skin are experienced during
tive need or delusional preoccupation. Unlike visual cocaine (61) and amphetamine (62) intoxication. Pa-
hallucinations induced by drugs, these hallucinations tients under the influence of psychedelic drugs may
do not change if the eyes are closed or open. experience synesthetic hallucinations (28), wherein the

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patient perceives a colorful visual hallucination after preceded and accompanied by various types of hallu-
hearing a loud noise or may have auditory hallucina- cinations.
tions in response to a bright light. It is believed that In convulsive disorders, relatively unformed per-
this phenomenon occurs because of drug-induced cor- cepts may occur during the aura (63). Olfactory and
tical hypersensitivity, which allows a strong stimulus visual hallucinations occur in migraine (81, 82).
in one area to trigger other areas of the cortex. It is Hypnagogic hallucinations occur in narcolepsy (83).
important to keep in mind that a certain drug may not Olfactory hallucinations have been reported in
produce the same hallucinatory effect every time. Parkinson’s disease (84). In addition, as noted earlier,
These effects may vary according to the person, dose, several types of hallucinations may occur as a result of
mood, social setting, and physical condition. Con- treating Parkinson’s disease with L-dopa preparations
versely, the same hallucinatory experience may be (34). Visual and tactile hallucinations not associated
produced by a wide variety of different drugs. In any with delirium have been reported in cases of dementia.
case, the nature of the material hallucinated is greatly A global degenerative process with possible involve-
influenced by the individual’s psychological back- ment of the temporal association area has been sug-
ground (63). gested as a contributory mechanism (85). Hunting-
After repeated ingestion of drugs, some people may ton’s chorea (86) and Sydenham’s chorea (87) may
experience a phenomenon called “flashbacks,” which also present with hallucinations. Cerebrovascular dis-
are spontaneous recurrences of illusions and visual eases, hemorrhages, and infarctions of the temporopa-
hallucinations during a drug-free state similar to those rieto-occipital regions of the brain may cause several
experienced during the active stage of drug adminis- types of hallucinations (88). Head trauma and brain
tration. These flashbacks may occur months after the concussion may also induce hallucinations (89). Com-
last use of the drugs. There is no clear explanation of pression of the brain by space-occupying lesions, such
the mechanism of these phenomena (28, 64). as tumors, abscesses, or vascular aneurysms, may
produce hallucinations (90, 91). CNS infections, such
Hallucinations as a Side Effect of Medications as meningitis and encephalitis, have also been reported
to present with hallucinations (87, 92).
Hallucinations have been reported as side effects of
a variety of medications commonly used in clinical Hallucinations in Other Organic Mental Disorders
practice. Among these medications are the anti-
depressant medications, such as amitriptyline, ma- In addition to the various conditions mentioned
protiline, doxepin, amoxapine, trazodone, imipra- here, hallucinations may be found in several other
mine, and others (65-70). Formed and unformed organic conditions that present with different psy-
visual hallucinations have been reported during treat- chotic symptoms. Delirium, which can be induced by
ment with digoxin even without the appearance of many factors, often presents with hallucinations. 5ev-
other toxicity symptoms (71). Propranolol and other eral metabolic disorders, such as endocrine abnormali-
3-adrenergic blocking agents have been reported to ties, uremia, electrolyte imbalances, mineral distur-
induce visual hallucinations (72). Benztropine mesyl- bances, and vitamin deficiencies, may produce hallucina-
ate and trihexyphenidyl hydrochloride were also re- tory states. Toxic levels of many chemical substances,
ported to cause visual hallucinations (73). Atropine such as carbon dioxide, mercury, and bromide, can
and other anticholinergic agents may produce visual produce hallucinations. Systemic lupus erythematosus,
hallucinations, including Lilliputian hallucinations, in which may involve the CNS, and temporal arteritis may
which people appear greatly reduced in size. This type present with hallucinations as well (79, 93-95).
of hallucination may also occur in other organic brain
syndromes and in psychosis (74). Hallucinations have Hallucinations Associated With Ear and Eye
been reported in patients treated with cimetidine (75, Diseases
76), clonidine (77), and bromocriptine (78). Several
other drugs have been reported to induce hallucina- Auditory hallucinations have been reported in pa-
tions in some cases; examples include antihyperten- tients with a long history of progressive bilateral
sives, anti-inflammatory agents, corticosteroids, anti- hearing loss. These hallucinations have included both
biotics, and other antimicrobial agents as well as unformed types, such as tinnitus and irregular sounds
antineoplastic medications (79, 80). of varying pitch and timbre, and formed hallucina-
tions, such as instrumental music, singing, and voices.
Hallucinations in Neurological Disorders The patients with acquired deafness described by
Hammeke et al. (96) did not have any psychiatric
Formed and unformed visual hallucinations occur as disturbances or any other organic conditions that
a result of cortical lesions involving the occipital and might account for these hallucinations. It has been
the temporoparietal areas. Olfactory hallucinations hypothesized that such phenomena are secondary to
and, less commonly, gustatory hallucinations are usu- chronic sensory deprivation (6). A study of prelingual-
ally associated with temporal lobe lesions and uncinate ly and profoundly deaf schizophrenic patients (97)
gyrus fits (37). Complex partial seizures are often revealed that most of them had experienced visual

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 GHAZI ASAAD AND BRUCE SHAPIRO

hallucinations as well as what was described as anal- provement or deterioration. In that respect, they are
ogous to auditory hallucinations, although actual extremely useful because they can be easily identified
voices may not have been heard. This would seem to and monitored. The diagnostic significance of halluci-
indicate that auditory hallucinations may not require nations seems to be limited, however, since they are
an intact hearing sense at birth. Similarly, visual hal- relatively nonspecific; any type of hallucination may
lucinations have also been reported in patients with occur in many different disorders. Furthermore, pa-
eye disease leading to impaired vision and blindness. tients who have hallucinations involving one sensory
White (98) reported formed visual hallucinations con- modality may experience hallucinations involving
sisting of brightly colored stereotyped figures, animals, other sensory modalities at other times (58). On the
or objects in patients suffering from partial blindness; other hand, although hallucinations may vary from
these hallucinations faded away as blindness pro- one condition to another, some characteristics may be
gressed. Similar forms of hallucinations have been useful in terms of differential diagnosis. This has been
reported in patients who have been blind for several recognized, for example, in the diagnostic criteria for
years; such phenomena may also be explained by the hallucinations of schizophrenic disorder noted in
prolonged sensory deprivation (99). DSM-III. In addition, if hallucinations are to be used
as a factor in making a differential diagnosis, it is
Other Forms of Hallucinations extremely important to obtain a detailed history to
evaluate all aspects of the hallucination. The clinician
In addition to the different types and forms of must be alert to various dimensions and phenomeno-
hallucinations already mentioned, more complex hal- logic aspects. Is the patient denying hallucinations? Is
lucinatory phenomena may be encountered in clinical the patient pretending to hallucinate? What sensory
practice. modalities are involved? What is the content of the
Cenesthetic hallucinations (100) are peculiar vis- hallucinated experience? How real and vivid does it
ceral sensations, usually reported by schizophrenic seem? What are the associated thoughts or feelings?
patients. These sensations are not perceived under When do the experiences occur? Is the experience
appropriate physiological conditions. For example, a constant or intermittent? How much is the patient
patient might report feeling the blood flowing inside aware of the unreality of the hallucinations? How
his blood vessels or a burning sensation in his brain. much do they affect the patient’s judgment? And,
Kinesthetic hallucinations (37) are perceptions of importantly, to what extent is the patient likely to act
the movement of body parts that are not actually out on the content and in what way? (6).
moving. These hallucinations may include parts of the
body that have been amputated; the phantom limb
syndrome is a good example of such hallucinations. TREATMENT
Negative hallucinations (6) refer to the failure to
perceive things that are present. These conditions may Treatment of hallucinations is usually part of the
best be understood as forms of dissociative states. treatment of the entire psychotic syndrome. Antipsy-
Autoscopic phenomena (101, 102) consist of hallu- chotic medications are effective in eliminating or re-
cinatory experiences in which all or part of the per- ducing various types of hallucinations. In fact, their
son’s own body is perceived as appearing in a mirror. effectiveness seems to be greater for the “positive”
This specter is usually colorless and transparent but is symptoms of psychosis than for the more “negative”
seen clearly, appears suddenly, and imitates the per- defects in affect and social relatedness seen in schizo-
son’s movements. In addition to the visual perceptions, phrenic disorders. In organic mental disorders, the
there may be hallucinations in the auditory and other treatment of choice is the correction of the underlying
spheres. The person usually is aware of the unreality of causative disturbance. However, antipsychotic drugs
the experience and reacts with bewilderment and, are also effective in all organic conditions in control-
often, with sadness. This condition is rare. It may be ling hallucinations and other psychotic symptoms. For
related to migraine or epilepsy, but it is not sympto- example, the clinical practice of prescribing low-dose
matic of any particular mental disorder. The cause of neuroleptic medication for relief of symptoms in the
the condition is unknown. One theory holds that the hallucinating geriatric patient with organic mental
phenomenon reflects an irritation of areas in the disorder is well-known. Hallucinations induced by
temporoparietal lobe; another holds that it represents hallucinogenic drugs can also be effectively treated
the projection of specially elaborated memory traces. with antipsychotic medications, even though some
This experience may occur once in a lifetime in some physicians prefer the use of minor tranquilizers, de-
persons, but it may be found repeatedly in others. pending on the type of hallucinogen. Lingiaerde (103)
reported on the effect of the benzodiazepine derivative
Diagnostic and Clinical Significance of estazolam in a group of chronic schizophrenic patients
Hallucinations who, in response to neuroleptics alone, continued to
experience auditory hallucinations and other psychotic
Hallucinations are often used in clinical practice as symptoms. After a few weeks of treatment with
guidelines by clinicians to evaluate the patient’s im- estazolam in addition to the neuroleptics, patients

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HALLUCINATIONS

showed significant improvement in their hallucinations address the role of psychotherapy in the treatment of
and in their general clinical condition. Lithium has hallucinating patients. Psychotherapy can provide
been used in the treatment of schizophrenia and schiz- knowledgeable reassurance, education, and even in-
oaffective disorder. Zemlan et al. (104) suggested that sight for these patients, helping them to cope with
lithium may be effective in controlling the core symp- these disturbing experiences. However, patients with
toms of psychosis, including hallucinations. ego-syntonic hallucinations may learn to adapt quietly
Other approaches to the treatment of hallucinations to their hallucinatory experiences.
have been used with some success. It has been sug-
gested that increasing external visual and auditory
stimuli might decrease the intensity and frequency of DISCUSSION
hallucinations. This principle has been used clinically
in the treatment of auditory hallucinations by radio Any attempt to integrate current knowledge of hal-
headphones (105). In addition, Magen (106) reported lucinations into a comprehensive model must begin
the case of a schizophrenic patient whose auditory with an understanding of some universal aspects of
hallucinations increased when she stopped watching hallucinatory states.
television and decreased when she began to watch it All people either do hallucinate (in waking states, in
again. Margo et al. (107) investigated the effect of dreams, as part of psychiatric disorders) or can be
variations of auditory input on hallucinatory experi- made to hallucinate with a variety of drugs (hallucino-
ences in schizophrenic patients. Their results suggest gens) or states of deprivation. Hallucinations regularly
that stimulation per se is not enough to decrease occur in certain morbid psychiatric states and have
hallucinations significantly; rather, the structure pres- been hallmarks of these disorders for thousands of
ent in the material used for stimulation and its atten- years. Hallucinations in the waking state do not occur
tion-commanding properties are what may determine in the large majority of individuals under normal
the occurrence of hallucinatory phenomena. circumstances, but hallucinations during sleep do oc-
Behavioral and conditioning techniques have also cur regularly in otherwise healthy individuals as part
been used to control hallucinations. Baskett (108) of the normal psychological/physiological experience
reported the case of a patient whose psychotic symp- of dreaming.
toms, including hallucinations, were successfully How do we account for a phenomenon that on the
treated by behavior modification. This patient was one hand (during the two-thirds of our lives we spend
suffering from chronic, severe psychotic depression awake) is distinctly abnormal, yet on the other hand
after neuroleptics had to be withdrawn due to the (during the one-third of life in which we sleep) is
appearance of tardive dyskinesia. Fonagy and Slade clearly part of normal functioning?
(109) reported that aversive conditioning-noise It seems to us that any integrative theory of halluci-
whenever auditory hallucinations were reported-pro- nations must postulate the failure of a screening mech-
duced reductions in the hallucinations of schizophrenic anism which functions during waking and most non-
patients. Social interference, self-control, and cognitive REM sleep stages and is “turned off” during REM-
reinterpretation (1 10) have also been shown temporarily stage sleep. Furthermore, it would seem that the nature
to reduce hallucinatory-delusional verbalizations. of this “on-off switch,” or screening mechanism, lies at
Lamontagne et al. (1 1 1) reported that the technique of the heart of the biological component of hallucina-
“thought stopping” combined with the administration of tions. The evidence from normal dream physiology,
neuroleptics was superior to neuroleptics alone in the sleep EEG studies, and nonpsychiatric disease states
treatment of persecutory delusions and auditory halluci- such as narcolepsy (REM-type) points toward the
nations in patients with chronic schizophrenia. Thought brainstem as the anatomical site of this “on-off/
stopping combined with anger induction techniques has screening” mechanism. A pontine site generating
also been reported to be effective in reducing visual pontine-geniculate-occipital-like wave forms is the
hallucinations and obsessional thoughts (112). Wage- most likely brainstem area in which this mechanism
maker and Cade (1 13) suggested that schizophrenic functions.
symptoms decreased after hemodialysis therapy. Malek- In the “functionally psychotic” patient it is likely
Ahmadi et al. (1 14) reported the case of a chronic that there is a neurotransmitter-mediated or CNS-
schizophrenic patient whose auditory hallucinations dis- receptor-mediated dysfunction that permits failure of
appeared after both hemodialysis and sham dialysis; this normal inhibitory mechanism and thus the emer-
hemodialysis, however, induced a much longer partial gence of the symptom of hallucination during the
remission. waking state. It is most likely that whatever is the basis
Despite all the treatment modalities mentioned here, for the “vulnerability factor” for schizophrenia (e.g.,
some forms of hallucinations may persist in some genetic, viral, or endotoxin) is also the basis for the
patients, who do not respond to any form of treat- vulnerability to hallucinations in the waking state. In
ment. These patients have used various coping strate- short, one has a greater or lesser somatic vulnerability
gies, including changes in activity, interpersonal con- to hallucinations due to an as yet unknown mecha-
tact, manipulation of physiological arousal, and at- nism.
tentional control (115). Finally, it is important to According to current research methods, the biolog-

1094 Am] Psychiatry 143:9, September 1986

 GHAZI ASAAD AND BRUCE SHAPIRO

ical basis of hallucinatory vulnerability will most likely being completely understood or explained by any
involve pathology in postsynaptic catecholamine, in- single mechanism. It is likely that hallucinations will be
doleamine, and/or cholinergic receptor sites and/or a best explained through an integration of physiological,
neuroregulatory imbalance among a number of nor- biochemical, and psychodynamic variables, and they
mally interacting neurotransmitter chemical systems. may well represent a final common pathway involving
As in affective psychoses, these systems are “fluid” and biological vulnerability and psychological influences.
can be affected by environmental variables, such as Hallucinations occur in a wide variety of clinical
exposure to light, phase shifts of the sleep-wake cycle, syndromes, ranging from purely “organic” states to
or, perhaps, other, psychologically induced “stres- vaguely understood “functional” psychoses. They
sors.” The appearance of hallucinations as symptoms have been prominent hallmarks of mental illness
of temporal lobe disease states, head trauma, or other throughout recorded history and remain a prominent
“higher than brainstem foci” may either reflect a psychiatric symptom to the present day. It is clear that
different (e.g., unformed) hallucinatory experience or study and better understanding of these leading symp-
relate to descending aminergic or other neurotrans- toms of psychosis may help to uncover the etiology
mitter tracts, which influence brainstem biochemistry and pathogenesis underlying schizophrenia and other
as do environmental changes that induce hallucina- psychotic conditions. Freud stated that dreams are the
tions. (Jackson [4] was thinking along similar lines at royal road to the unconscious. It may very well be that
the turn of this century.) It is likely that pathological an understanding of the etiology of hallucinations will
neurochemistry or receptor neurophysiology repre- mark the modern path to uncovering the mysteries of
sents the neural substrate for the psychoanalytic con- madness.
cept of “weak ego.” There may be degrees of vulner-
ability that reflect themselves clinically in variations in
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