Hallucinations

Hallucinations can affect any sensory modality, but most commonly hearing (auditory). Indeed, hallucinations affecting vision or smell would give rise to a suspicion that the patient might have an organic (physical) condition affecting the brain, and appropriate examinations and investigations (e.g. MRI of the brain) would then be considered. Nevertheless, visual hallucinations and tactile hallucinations are seen in patients with very extreme schizophrenic states.

Detailed enquiry into the possible hallucinatory experiences is vital at a first presentation. It is all too easy for phenomena to be labelled as 'auditory hallucinations' when, in fact, they do not satisfy criteria for this. The problem is that recording of auditory hallucinations in medical notes may immediately give rise to a diagnosis of psychosis/schizophrenia, so that the patient is placed on antipsychotic medication, and the symptoms and diagnosis repeated from year to year.

Patients with personality disorder may hear voices. 'They're inside me 'ead, Doc, they keep telling me to cut meself.' These are not true hallucinations, and they are sometimes referred to as 'pseudohallucinations'. In contrast, true auditory hallucinations in schizophrenia are experienced as coming from the outside world. They are real to the patient. It is a real voice to him, but there is no one there speaking.

It is necessary to find out the patient's explanation for this experience. Many patients, at least in the early stages, will find the hallucination completely terrifying. Other patients may regard it as 'part of the plan', as it will be part of a system of delusions. Still others will, as time goes by, get used to the idea that the voices are not real, even though they were undoubtedly psychotic phenomena in the early years, and remain so.

Voices discussing the patient in the third person are characteristic, but second-person voices which talk to the patient are common too.

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