Disorders of Perception

Introduction-

Sensation-
It is the detection of the elementary properties of a stimulus.

Perception-
It (Latin perceptio, percipio- per (“through”) + capiō (“capture, seize;
understand”) is the organization, identification, and interpretation
of sensory information in order to represent and understand the
environment.
- Wikipedia
Imagery-
It is the internal mental representation of the world and is
actively drawn from memory.
Characteristics of images(Jaspers)-
Normal perception Imagery

Perceptions are of concrete reality Images are figurative and have a

character of subjectivity.
Occur in external objective space Appear in inner subjective space

Clearly delineated Incomplete and poorly delineated

Constant and remain unaltered. Dissipate and have to be recreated.

Independent of our will Dependent on our will

 Classification of disorders of perception-

1)Sensory distortions-
In distortions there is a constant real perceptual object, which
is perceived in a distorted way.

2)Sensory deceptions-
In sensory deceptions a new perception occurs that may or may
not be in response to an external stimulus.
Sensory distortions(Fish/SIMS)-
These are changes in perception that are the result of a change
in the intensity and quality of the stimulus or the spatial form
of the perception.

Anomalous experiences(Jaspers)-
These are deviations from the customary appearance of
something without prejudicing the knowledge of the sort of
thing it is.
Classification of sensory distortions(Fish)-

Changes in intensity-
Changes in quality-
Changes in spatial form-
Distortions of the experience of time-
Changes in intensity(hyper/hypo-aesthesia)-

Hyper-
Hyperacusis-
Increased sensitivity to sound, normal sounds cause discomfort.
Seen in- Anxiety, depression, hangover, migraine.

Visual Hyperaesthesia-
Colours appear very bright and intense.
Seen in- Hypomania, epileptic aura, LSD.
Hypo-
Hypoacusis-
Need for normal speech to be louder to hear.
Seen in- Delirium, depression and ADHD.
Changes in quality-
Xanthopsia- Yellow
Chloropsia- Green
Erythropsia- Red
Cause- drugs-Santonin, Mescaline, Digitalis.

Derealisation-
‘’ Everything looks clear but it all looks miles away’’.
“People look like toys-almost dead, lifeless, carry out automatic
movements without special meaning.”
Feeling of unreality in perceptual field.

Intense quality-
Mania-Objects look perfect and beautiful.

Achromatopsia- complete absence of colour to visual field.

Cause- Uni/bilateral occipital lesions, usually lingual/fusiform gyri.
Changes in spatial form-

Micropsia- Objects are smaller than they are.

Cause- Partial paralysis of accommodation, aura, retinal oedema.

Macropsia/Megalopsia- Objects appear larger than they usually are.

Cause- Complete paralysis/over activity of accommodation, weakened
convergence, retinal scarring, aura.

Porropsia/teleopsia- Retreat of objects in to the distance without any

change in size.

Pelopsia- Object appearing nearer than it should.

Dysmegalopsia/Metamorphosia- Distortion of shape.

Cause- Temporal/parietal lobe lesions, Schizophrenia, retinal
oedema/scarring, disorders of accommodation, atropine/ hyoscine
poisoning,aura.

Paraprosopia- When metamorphosia affects only face.

Distortions of the experience of time-
Personal time is affected in psychiatric disorders.
Depression- Time slows down.
Mania- Time speeds up.

Schizophrenia- Age disorientation, time misjudgments(intervals),

moves in fits/stops.
 Classification of anamalous experiences(Critchley/Cutting)-
Visual

Colour Achromatopsia, dyschromatopsia

Uniqueness in time Palinopsia

Uniqueness in space Polyopia, monocular diplopia

Spatial position Visual perseveration,alloaesthesia,teleopsia,pelopsia

Shape Metamorphopsia

Size Micropsia,macropsia

Reality value Derealization

Familiarity value De’ja’ vu, jamais vu

Emotional value Kakopsia, kalopsia

Movement Akinetopsia

Backdrop of experience, Weltbild Delusional mood, strange Weltbild

Auditory-

Uniqueness in time Palinacousis

Intensity Hyperacusis

Spatial position Auditory alloaesthesia

Olfactory/gustatory-

General quality Non-specific alteration

Miscellaneous-
Palinopsia- This is the recurrence/prolongation of a visual
phenomenon beyond the customary time limits of the
appearance of the real event in the world.
Seen in-Occipital/temporal/parietal lesions(R>L)-basilar artery
occlusion.
Palinacousis- Persistence of sound.
Akinetopsia- Impairment of visual perception of motion in
which the individual is unable to perceive the motion of
objects.
Alloaesthesia- Perceived object is in a different position from
what is expected so that the patient experiences the
transportation of objects from left to right.
Sensory deceptions-
Two types-
1) Illusions
2) Hallucinations

Illusions-
Misinterpretations of stimuli arising from an external object.

Can occur in normal people. Eg- people hear words in

conversation that resemble their name and believe they are
being talked about.

Types-
Completion illusion-
Affect illusion-
Pareidolia-
Completion illusions-
Depend on inattention for their occurance.

An incomplete perception that is meaningless of itself is filled in by a

process of extrapolation from previous experience to produce
significance.
Eg- He was reading a ook and the b..k had many mistakes.

Affect illusions-
These arise in the context of a particular mood state and can be
understood only in the context of prevailing mood state.

Eg- Child who after watching a wildlife movie in the night, returns
scared to his dark room and perceives any movement to be a lion,
only to realize otherwise after carefully scrutinizing the room.

Illusion lasts till the intense fear lasts and is banished by attention.
Pareidolia-
Illusions which result from vivid visual imagery and
excessive fantasy thinking, without any conscious
effort and sometimes even against his will.

Eg- A child who always sees a rabbit in clouds and that

evolves to many bunnies playing in the sky.

First two illusions disappear by attention, where as

Pareidolia becomes prominent with attention.
Common in children.
Hallucinations-
Jaspers-A false perception which is not a sensory distortion or a
misinterpretation, but which occurs at the same time as real
perceptions.
SCAN-‘false perceptions’.
Esquirol- A perception without an object.

To the patient it is a “normal sensory experience’’.

What makes the patient doubt the percept-There is no corroborative

evidence for the percept in other modalities.
Eg- Women hears voices(neighbour) commenting on her in the
house, however she can’t see the person in front of her. She
thinks some one has fixed a speaker/altered her sense of hearing.
At no point does the hallucinator doubt the percept but rationalizes
it.
Slade’s criteria-

a) Percept like experience in the absence of external stimulus.

b) Percept like experience that has the full force of and impact
of a real perception.

c) Percept like experience that is unwilled, occurs

spontaneously and cannot readily be controlled by the
percipient.
Rasmussen concepts-
Six qualities that are seen in normal perception and
hallucination.
1) Experienced as sensation and not as thought or fantasy.
2) Have quality of behavioral relevance.
3) Quality of objectivity.
4) Object is considered to exist if he feels that it exists.
5) They are involuntary
6) Independence from mental state

Hallucinations come from within but patients fail to recognize it,

where as in imagery they recognize it as from within.
Causes-
1)Emotion- Intense emotions can cause hallucinations.
People with severe depression with delusion of guilt may hear
voices reproaching them, they are disjointed, fragmentary,
uttered in single words/short phrases.
Eg- thief….killer..

2)Suggestion-
People can be persuaded to hallucinate either by hypnosis or by
brief task-motivating instructions.
Eg- Ask a subject to hallucinate a tune and by telling him that
normal people can hallucinate by trying hard.
Turn right when u see light,while passing through the tunnel.
3)Disorders of peripheral sense organs-

Hallucinatory voices occur in ear diseases or eye diseases, but

there is usually a central nervous system disease.

Charles Bonnet syndrome(phantom visual images) is a

condition in which complex visual hallucinations occur in the
absence of any psychopathology and in clear consciousness.

Seen in- either central or peripheral reduction in vision,

common in elderly.
4) Sensory deprivation-
Reducing the stimuli to minimum in a normal individual will lead
to hallucinations- visual & auditory.

Eg- Deafness can lead to paranoid disorders in deaf.

Eye patches after cataract can produce delirium in elderly.

5)Central nervous system disorders-

Cortex and diencephalon lesions can produce visual/auditory
hallucinations.
 Phenomenological classification of halluciantions(Cutting)-
Sensory modality Content

Visual Visual-

Auditory Elementary

Olfactory Formed

Gustatory Panoramic

Bodily(kinaesthetic,tactile,visceral) Auditory-

Multimodal Non-verbal
Precipitating circumstance- Voices

Functional Degree of attenuation of reality-

Reflex True hallucination

Hypnagogic Pseudo-hallucination
Hypnapompic Extracampine halluciantion

Heightened imagery
Hallucinations of individual senses-
Auditory hallucinations-
Elementary-
Consists of unstructured sounds.
Eg- whistle, rattle, music
Seen in- brain disease-delirium/dementia, deafness, early
schizophrenia.
Formed-
Well formed sentences.
First person hallucination(Thought echo)-
Gedankenlautwerden- Hearing one’s own thoughts spoken aloud
just before / at the same time they are occurring.
Echo de la pensée (French) is the phenomenon of hearing them
spoken after the thoughts have occurred.
Second person hallucination-
Voices speaking to the patients, sometimes giving
instructions(imperative hallucinations) to them.

Third person hallucination-

Voices speaking about the subject amongst themselves, or giving
running commentary on his/her actions.

Seen in Schizophrenia, mania.

Visual hallucinations-
Elementary- Flashes of light.
Partly organised- Patterns.
Completely organised- Visions of people, objects or animals.

Mostly organic cause- epilepsy, occipital lobe lesions,post

concussion states, dementia, Huntington’s chorea.

Temporal lobe epilepsy- Vivid visual scenic hallucinations, often

accompanied by auditory hallucination.

Delirium tremens- Lilliputian hallucinations.

Charles Bonnet’s syndrome- No visual cortex pathology.

Hallucination of bodily sensation-
1)Supeficial hallucinations- Affects skin sensation.
a)Thermic-
Abnormal perception of heat and cold. Eg- “My feet on fire.”

b)Haptic-
Abnormal perception of touch. Eg- “A dead hand touched me.”
Formication- Sensation of little animals /insects crawling on skin.
Seen in- Cocaine addiction, alcohol withdrawal, delusional
infestation.

c)Hygric-
Abnormal perception of fluid.
Eg- “I feel a water level in my chest”.
2) Kinaesthetic hallucinations-
Hallucinations of muscle or joint sense.
Eg- My bones were vibrated.
Seen in- Withdrawal states

3) Visceral hallucinations-
False perceptions of inner organs.
Eg- Stretching of stomach, worms in intestine.
Seen in – Schizophrenia/Delusional disorder.

Coenaesthesia/Cenesthesia(OTP)- Perception of normal

movements/functioning of internal organs. Or Feeling of
inhabiting one’s body.
Olfactory hallucinations-
1)Unpleasant-
Seen in Schizophrenia, depression, temporal lobe epilepsy.
Eg- Poisonous gas leaking in to house.

2) Pleasant-
Eg- when some religious people can smell roses around certain
saints-Padre Pio phenomenon.
Gustatory hallucinations-
Seen in depression, temporal lobe epilepsy, schizophrenia.
The sense of presense-
Sense that some one is present around them.
Seen in- Schizophrenia, organic states, borderline personality.
Special Hallucinations-
Autoscopy/Phantom mirror-image(Doppelganger)-

It is the experience of seeing oneself and knowing that it is

oneself; involves visual halluciantion, somatic & kinaestethic
sensation.

Seen in – Healthy individuals(when upset/exhausted),

Schizophrenia, epilepsy, pareito-occipital lobe focal lesions,
infections of basal regions of brain,

They may some times occur as pseudohalluciantion(“in the

mind’s eye”)-Schizophrenia.

Negative autoscopy- Absense of one’s own image in mirror.

Functional hallucination-
Hallucination requires the presence of another real sensation,
that is normal sensation and halluciantion are experienced in
the same modality and simultaneously.
Eg- Running water produces bird song-Schizophrenia.

Reflex hallucination-
Synaesthesia-Sensory stimuli in one modality produces sensory
experience in another modality.
Reflex hallucination is a morbid form of synaesthesia.
A sensation in a modality produces hallucination in another
sensory modality.
Eg- Hearing a voice produces head ache.
Seen in- LSD, Mescaine use.
Extracampine hallucinations-
Patient has hallucinations that are outside the limits of the
sensory field.
Eg- Hearing voices from America.
Seen in –Epilepsy, Schizophrenia, healthy people-hypnogogic.

Intracorporial hallucinations-
Hallucinations emanating from any part of body except the
head(inner subjective space) and perceived inside the head.
Eg- I can hear voices from my navel.
Seen in -Schizophrenia.
Hypnagogic /pompic hallucinations-
Hypnagogic hallucinations occur during drowsiness, are
discontinuous, appear to force themselves on the subject and
do not form part of an experience in which the subject
participates as they do in a dream.
Hypnopompic halluciantions is the term reserved for those
hallucinatory experiences that persist from sleep when the
eyes are open.
Can occur in- Narcolepsy

Multimodal hallucinations-auditory/tactile/visual/kinaesthetic.

Importance- They are not indicative of any psychopathology and

are seen in normal subjects.
Organic hallucinations-

Phantom limb is the most common organic somatic hallucination

of psychiatric origin.
Patient feels that they have a limb from which in fact they are
not receiving any sensations either because it has been
amputated or because the sensory pathways from it have
been destroyed.

Charles Bonnet syndrome-

Temporal lobe lesions- Complex scenic halluciantions.

Pseudohalluciantion-
They are a type of mental image that, although clear and vivid,
lack the substantiality of perceptions; they are seen in full
consciousness, known to be not real perceptions and are
located not in objective space but in subjective space (for
example, inside the mind) and are involuntary.

Insight? Vs Subjective space

Continuum to hallucination?

Importance- Normal?
First Rank Symptoms-Perception abnormalities-

Audible thoughts.

Voices arguing/discussing or both.

Voices commenting.

Somatic passivity.
MSE questionnaire-
• Perception(differentiate from thought)
• Timing(Awake/hynogogic/hypnopompic)
• Modality
• Description(Intensity/Distance/Content/No.of persons)
• Clarity
• Control
• Insight
• Precipitating factor
• Pts attitude to the hallucinations