Disorders of

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: 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.

STEP 2016 27 & 28 August - By TIPPS Disorders of perception

• Sensory distortions • Changes in quality • Changes in intensity • Changes in form • Changes in associated affect • Splitting

STEP 2016 27 & 28 August - By TIPPS Disorders of perception

• False (sensory deceptions) • • • Pseudohallucinations • Imagery

STEP 2016 27 & 28 August - By TIPPS – : Misinterpretation of stimuli arising from external object – : A false perception which is not a sensory distortion or misinterpretation and occurs in the same time as real perception (Jasper).

STEP 2016 27 & 28 August - By TIPPS 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)

STEP 2016 27 & 28 August - By TIPPS • 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?

STEP 2016 27 & 28 August - By TIPPS • 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?

STEP 2016 27 & 28 August - By TIPPS • 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?

STEP 2016 27 & 28 August - By TIPPS • 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?

STEP 2016 27 & 28 August - By TIPPS AS WITH ALL ABNORMAL MENTAL PHENOMENON, IT IS NOT POSSIBLE TO MAKE AN ABSOLUTE DISTINCTION…

STEP 2016 27 & 28 August - By TIPPS • 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

STEP 2016 27 & 28 August - By TIPPS 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

STEP 2016 27 & 28 August - By TIPPS 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

STEP 2016 27 & 28 August - By TIPPS 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

STEP 2016 27 & 28 August - By TIPPS 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. STEP 2016 27 & 28 August - By TIPPS 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.

STEP 2016 27 & 28 August - By TIPPS 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

STEP 2016 27 & 28 August - By TIPPS 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)

STEP 2016 27 & 28 August - By TIPPS 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.

STEP 2016 27 & 28 August - By TIPPS 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 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

STEP 2016 27 & 28 August - By TIPPS Explain these

• Pale hallucinations • olfactory reference syndrome • functional hallucination • reflex hallucination • Apperceptive hallucinations • coenesthetic hallucination • Extracampine/Intracampine

STEP 2016 27 & 28 August - By TIPPS 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

STEP 2016 27 & 28 August - By TIPPS Somatic hallucinations

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

STEP 2016 27 & 28 August - By TIPPS 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 , in the absence of other psychopathology

STEP 2016 27 & 28 August - By TIPPS 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 in one modality (eg. seeing someone laugh) produces a sensation in another modality (eg. a in the chest)

STEP 2016 27 & 28 August - By TIPPS 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) STEP 2016 27 & 28 August - By TIPPS 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)STEP 2016 in 27 &epilepsy 28 August - By TIPPS Some specific (named) hallucinations…… • : tactile hallucination of crawling on the body, seen in intoxication / withdrawal • : perception of sensation from a limb that has been amputated (or, more rarely, has been denervated) • Scenic: whole scenes are hallucinated like a film

STEP 2016 27 & 28 August - By TIPPS • Fantastic hallucination: Mass hallucinations… many modalities… large number of people are being tortured and murdered

STEP 2016 27 & 28 August - By TIPPS