DISORDERS OF

PERCEPTION
DR SHUBHIKA AGGARWAL
PG-JR1, SMS&R
 PERCEPTION
• It’s the process of becoming aware of what is presented through the sense
organs.
 Abnormal
perception

Sensory Sensory
distortions deceptions
 Sensory Distortions
• There is a constant real perceptual object, which is perceived in a distorted
way
 Sensory Distortions
• Changes in intensity of the stimulus

• Changes in quality of the stimulus

• Changes in spatial form of the perception

 Sensory Distortions
changes in intensity

• Hyperaesthesia( Increased intensity of sensations) may be the result of

intense emotions
lowering of physiological threshold
 Eg.Hyperacusis ( sensitivity to noise)
in
 Anxiety
 Depressive disorder
 Hangover from alcohol
 Migraine
• Hypomania
Hyperaesthesia
• Epileptic aura
• LSD

may see colors

as very intense and
bright

Intense normal Emotions-

being in love
 Hypoaesthesia
 Eg -Hypoacusis

Seen in

 Delirium
 Depression
 Attention deficit disorder
 CHANGES IN QUALITY
• Mainly affects visual perceptions

• Toxic substances- santonin, poisoning with mescaline or digitalis

XANTHOPSIA CHLOROPSIA
ERYTHROPSIA

• Qualitative change most assoc. with drugs now is metallic taste a/w use of LITHIUM
• Derealization- Everything looks unreal and strange
• Mania- looks perfect and beautiful
 Changes in spatial form
- dysmegalopsia

Micropsia
A Visual disorder in which the patient sees objects
smaller than they really are

Macropsia/megalopsia
Seeing objects larger than they really are
• Lilliputian hallucinations
Changes of size in hallucinations

In micropsia; accompanied by pleasure

and amusement
 Dysmegalopsia-
objects that are Metamorphopsia –
perceived to be larger objects that are
on one side than the irregular in shape
other (sims2003)
 • Object appearing far
Telopsia away

• Object appearing
Pelopsia nearer than it should
• Micropsia – edema of retina
partial paralysis of accommodation

 Macropsia –scarring of retina with retraction

complete paralysis of accommodation
 Dysmegalopsia

• Retinal ds
• Disorder of accommodation & convergence
• Temporal and Parietal lobe lesions
• Poisoning with atropine, hyoscine
• SCHIZOPHRENIA (rarely)
• Aura or in the course of the fit
 Distortions of Experience of Time
 Psychopathological point of view
 Physical- Determined by physical events
 Personal- Personal judgement of passage of time. This is
affected
Mania- Time passes quickly
Depression- Time passes slowly
Acute Schizophrenia-Time goes in fits and starts may have a delusional
elaboration that clocks are being interfered with.
Age disorientation – c/c schizophrenia
Temporal Lobe Lesions- Time passes slowly/quickly
 Sensory Deceptions

Perceptions
Misinterpretations
of stimuli from
illusion without
external object hallucination external
stimulus
 ILLUSION

 Stimuli from a perceived object are combined with

a mental image to produce a false perception
• Not indicative of psychopathology
• Can occur in -anxious patient
-delirium

 visual illusions- most common

 Completion Illusion – These depends on inattention-
misreading words in newspapers

 Affect Illusion- These arise in the context of particular

mood state- a bereaved person may momentarily believe
they see the deceased person

 Pareidolia – vivid illusions without the patient

making any effort; result of excessive fantasy
thinking and a vivid visual imagery
 hallucinations

hallucinations
 Hallucination

Jaspers –
* a false perception

*which is not a sensory distortion or misinterpretation

*but which occurs at the same time as real perceptions

HALLUCINATIONS VS TRUE PERCEPTIONS
Come from within although the subject reacts to them as if they were true perceptions coming
from without.

This distinguishes it from vivid mental images which come from within but are recognized as
such.
 True Perceptions vs Mental Images

True perceptions Mental images

• Perceptions are substantial
• Appear in external objective space
• Clearly delineated
• Independent of will
• Their sensory elements are full and
fresh
• Incomplete
• Exist in internal subjective space
• Not clearly delineated
• Dependent on will
• Inconstant and have to be recreated
 Pseudo Hallucinations
• Type of mental image
• Although clear and vivid
• Lack the substantiality of perceptions
• Are seen in full consciousness
• Known to be not real perceptions
• Located in subjective space (eg. Inside the head)
 Hallucinations
causes
• Intense emotions or psychiatric disorders
Depressed patient with delusions of guilt uttering single or short phrases“rotter”
• Disorders of peripheral sense organ-
Auditory hallucinations- ear disease; Visual hallucinations - eye disease
• Sensory deprivation
If all incoming stimuli are reduced to a minimum in a normal subject they will begin to hallucinate after a few
hours. Changing visual hallucinations /repetitive words or phrases
BLACK PATCH DISEASE delirium following cataract surgery in the aged as a result of eye patch and
mild senile brain changes
• Disorders of CNS
Lesions of diencephalon and cortex; Usually visual but can be auditory
 Charles Bonnet Syndrome
• Phantom visual images
• Complex visual hallucinations
• Absence of any psychopathology and in clear consciousness
• a/w either central or peripheral reduction in vision , commonly seen in
elderly
• D/d from psychopathological causes of hallucinations
Hallucinations of individual senses

Hallucinations of individual senses

 Auditory Hallucinations
• Organic states- delirium, dementia

• Schizophrenia

• Severe depression
 Auditory Hallucinations
 May be elementary or unformed.
 Elementary – noises, bells or undifferentiated whispers ; in organic states
 Partly organized- music
 Completely organized- hallucinatory voices- schizophrenia- persecutory in
nature
 Severe depression voices heard, less well formed than schizophrenia
Imperative hallucination
 Voicessometimes give instructions to the patient
may or may not act upon them

Voices-
 Adverse
 Neutral
 Helpful
 Incomprehensible nonsense
 Neologism

• Effect on patients is variable

 Thought echo - hearing one’s own thoughts being spoken loud, voice may
come from inside or outside the head.
i. GEDANKENLAUTWERDEN- thoughts spoken at the same time or
before they are occurring.
ii. ECHO DE LA PENSES- thoughts are spoken just after they occurred.
SCAN classifies thought echo as a disorder of thought rather than as a
hallucinatory experience

 Running commentary hallucinations and voices speak about the

patient in third person- not diagnostic of schizophrenia. Can occur in
mania
 Visual Hallucinations
• Flashes of light
• Patterns
• Visions of people, objects or animals
• Scenic hallucinations- like a cinema film
 Visual Hallucinations
• Delirium- small insects and animals
• Psychiatric d/r a/w epilepsy –
scenic hallucinations
• Temporal lobe epilepsy –
combined auditory & visual hallucinations
• Schizophrenia - Extremely rare
• Occasionally without any psychopathology CHARLES BONNET SYNDROME
 Smell (olfactory)
• Schizophrenia

• Temporal lobe epilepsy

• Depression (uncommon)

• PADRE PIO PHENOMENON- religious

people can smell roses around certain
saints
 Taste (gustatory)
• Schizophrenia and acute organic states

• Depressed patient often describes loss of taste

 Touch (tactile)
• Small animals crawling over the body
• Formication
• Common in a/c organic states

• Cocaine psychosis – cocaine bug

tactile hallucinations
+
delusions of persecution
 Tactile Hallucinations
• Sims 2003
-superficial
-kinesthetic
-visceral
 Superficial

-thermic – cold wind blowing across face

-haptic – feeling a hand brushing against skin
-hygric – feeling fluid such as water running from the head
-paraesthetic (pins & needles)- common organic origin
 Kinesthetic Hallucinations

• Affects muscle and joints

• Limbs are being twisted, pulled or moved
• Occur in – alcohol intoxication
- delirium tremens
- BZD withdrawal
- Schizophrenia
 Visceral Hallucinations

c/c schizophrenia
- complain of twisting and tearing pains
-organs are being torn out
-flesh is being ripped away

Delusional zoopathy- Delusional belief that there is an animal crawling about in

body. Hallucinatory component since the patient feels it (Hallucination) and can
describe in detail.
 Hallucinatory Syndromes
• Hallucinosis
• Persistent hallucinations in any sensory modality in the absence of other
psychotic features
• Alcoholic hallucinosis- auditory; may be threatening or reproachful; Sensorium is
clear and hallucinations rarely persist longer than 1week
• Organic hallucinosis- dementia esp Alzheimers; auditory or visual; disorientation
and memory is impaired
Special kinds of hallucinations
Special knds of hallucinations
 Functional Hallucinations
• An external stimulus is necessary to provoke hallucination
• but the normal perception of the stimulus and
• the hallucination in the same modality
• are experienced simultaneously

• A schizophrenic patient heard hallucinatory voices only when water

was running through pipes of his ward
 Reflex Hallucinations
• Synaesthesia –experience of stimulus in one sense modality producing a sensory
experience in another

• Eg. Feeling of cold in one’s spine on hearing a fingernail scratch on the blackboard

• Under the influence of hallucinogenic drugs- LSD or mescaline

• Reflex hallucination-morbid form of synaesthesia

 Reflex Hallucinations
• eg. A patient felt pain in her head(somatic hallucination) when she
heard other people sneeze( the stimulus) and was convinced that
sneezing caused the pain
• A stimulus in one sensory modality producing a hallucination in another
 Extracampine Hallucinations
• Hallucination that is outside the limits of sensory field

• Patient sees somebody standing behind them when they are looking
forward
• Hearing voices talking in Noida when they are in Delhi
 Extracampine
Hallucinations

• Schizophrenia
• Organic
conditions – I can see U
including
epilepsy
 Autoscopy/Phantom mirror image
• Experience of seeing oneself and knowing that it is oneself
• Visual hallucination + kinesthetic & somatic sensations
• Healthy subjects- emotionally upset/ exhausted-
some change in consciousness
• Organic states- epilepsy ; Parieto-occipital lesions
• Delirous State
• Depression
• Schizophrenia
 Autoscopy

Negative Autoscopy- Subject

will look in the mirror and see
no image

Internal Autoscopy- Subject

sees their own internal organs
 Hypnagogic & Hypnopompic
• Aristotle
These are perceptions which occur
• Hypnagogic - going to sleep
• Hypnopompic – waking up
• Auditory – most common
• Visual, Kinesthetic, Tactile
• Hearing the phone ring
• Seeing a man coming across the bedroom
 Hypnagogic & Hypnopompic
• Narcolepsy
• Glue sniffing
• Acute fever(esp in children)
• Post infectious depressive state
• Phobic anxiety neurosis

The importance of these phenomena in psychopathology is to recognize that they are

not necessarily abnormal, even though they are truly hallucinatory
 Body Image Distortions
Hyperschemazia Hyposchemazia Paraschemazia Hemisomatognosia

• Perceived • Perception of • Parts of the body • Unilateral lack of

magnification of body parts as are distorted or body image in
body parts absent or twisted or which the person
• Painful body part diminished separated from behaves as if one
appears larger • Parietal Lobe rest of body side of body is
• Paralysis of limb, Lesions, Healthy • Hallucinogenic missing
PVD, MS volunteers when drug, Epileptic • Migraine,
• Hypochondriasis, underwater aura, Migraine Epileptic aura
depersonalization,
conversion
disorder, anorexia
nervosa
 Patient’s Attitude
• Organic conditions, delirium - terrified
• Lilliputian hallucinations - amused
• Depression – believe that they deserve to hear, not frightening
• a/c schizophrenia – frightening
• c/c schizophrenia – treat them as old friends
• Few patients with insight may deny hallucinations
 REFERENCES
• FISH’S CLINICAL PSYCHOPATHOLOGY- 3rd edition
• SIM’S SYMPTOMS IN THE MIND- 6th edition
• Shorter Oxford Textbook of Psychiatry- 6th edition
• Synopsis of Psychiatry- 11th edition
• https://psyc.ucalgary.ca/PACE/VA-Lab/AVDE-Website\xanthopsia.html
• Internal Autoscopy: a case report by K.N Rao Indian J. Psychiat., 1992,
34(3), 280-282
Thank you