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Clinical significance of pseudohallucinations
Letters to the Editor
propriate antibiotic orders or a cardiologist order cardiac medications for my patient without first speaking with me. I would hope, however, that one of the surgical residents would be informed, as a method of teaching about these drugs. On the other hand, if a cardiologist canceled my surgery in order for a patient to have a stress test without first discussing this change with me, I would be justifiably upset despite the fact that the consultant’s advice was medically appropriate. The authors also ignore the importance of the issue of time acting as an impediment to physician discussion of orders. Physicians’ busy schedules, including time spent in operating rooms or otherwise occupied, frequently result in lack of availability of one of the two parties of a consultation. This problem may explain the apparent contradiction between actual physician practice and “ideal” practice. The majority of internists and surgeons surveyed in this paper believed that directly writing orders would increase the likelihood that the orders would be followed and that patient care would improve. Most of these physicians stated that they were likely to write consultation orders without first discussing them with the requesting physician. Yet these same consultants, except internists, agreed with a hypothetical hospital policy which would require prior discussion with or written authorization from the requesting physician before orders could be written. I suspect that the unavailability of one of the two parties to a consultation played a large role in this discrepancy between presumed best practice and actual practice. I think the question of liability which the authors raise is overstated. Using my prior examples, I would be less vulnerable legally as the primary physician with the consultants writing medication orders in their specialties, even without my direct permission or knowledge. It is true that the consultant becomes legally responsible for his portion of care but that responsibility is appropriate. And finally, I believe the authors draw conclusions that are not substantiated by their data. First, they document the lack of knowledge by staff physicians about whether or not a hospital policy on consultation exists. They conclude that this lack of knowledge “may argue for the importance of such policies in clarifying the role of consultants.” The only conclusion that can be drawn is that there is a lack of knowledge and not that such a policy would make a difference. Although discussion between the two parties of a consultation clearly makes good sense, that a hospital policy clarifying the role of the
124
consultant would improve patient care is yet to be demonstrated by the authors. Their contention that application of a standard of best practices would require such a discussion between parties is not substantiated by the data presented. john g. schuler, m.d. Director of Surgical Training Mount Auburn Hospital Cambridge, Massachusetts 02238 PII S0163-8343(99)00060-2
References 1. Van Hoof TJ, Schwartz HI: When consultants write orders: physicians’ attitudes, beliefs, and practices. Gen Hosp Psychiatry 21:333–339, 1999
Clinical Significance of Pseudohallucinations To the Editor Pseudohallucinations have been defined as a “perceptual experience” occurring in “inner subjective space” and “perceived with the inner eye” [1]. In order to elucidate pseudohallucinations, Sedman [2] used concepts such as “not being a veridical perception” and being “psychologically meaningful” to the point where the patient “gained comfort.” Hare [3] argued that pseudohallucinations “lie somewhere on a continuum” between hallucinations and real perception with preserved insight into the phenomenon. Kraupl Taylor [4] discussed the definitional differences regarding insight versus subjectivity of perception and concluded that two types of pseudohallucinations exist: perceived and imagined. This debate on the definition of pseudohallucinations in British psychiatry is still unresolved. The clinical significance of the phenomenon of pseudohallucinations has been hitherto neglected in American psychiatry. Yager and Gitlin [5] dismiss the concept of pseudohallucination and suggest using the term “partial hallucinations” for this phenomenon, analogous to partial delusions. The aim of this case report is to emphasize that pseudohallucinations are often misinterpreted as “true” hallucinations, leading to inappropriate diagnosis of schizophrenia and subsequent treatment with neuroleptics.
Letters to the Editor
Case Report A 40-year-old white male with a previous diagnosis of schizophrenia presented with alcohol abuse, depressive symptoms, and suicidal ideas relating to an ongoing “voice” which was recognized by the patient as a former friend “Joey,” who had died in a motorcycle accident about 20 years ago. The patient expressed tremendous guilt because he had followed Joey’s motorcycle, in a car, the night of the accident. The patient clearly identified the solitary voice, located inside his head, as being that of his dead friend. The voice spoke to him on a regular basis. During times of stress, it would tell the patient to kill himself so that “we can be together.” The patient did not hear the voice during periods of intense activity or sleep. Previous treatment with antidepressants and neuroleptics did not alter the intensity or the frequency of the voice. During a 2-week hospital course, the patient was found to have normal thought processes. There were no other auditory or visual hallucinations, no bizarre delusions, no catatonic symptoms, and no Schneiderian first rank symptoms. This “voice” started prior to the onset of his alcohol problems. It was unrelated to ongoing alcoholic binges and was unaltered by ongoing alcohol use or alcohol withdrawal. The patient also denied any illicit drug use. A negative urine toxicology screen substantiated this. Physical examination and a lab workup including a complete blood count, admission panel, thyroid panel, serological test for syphilis, and HIV test were within normal limits. His symptoms of depressed mood, decreased appetite, decreased energy, and decreased concentration remitted soon after inpatient admission and without antidepressants. Persistent attention-seeking and histrionic behaviors were noted by the nursing staff and others. He had unresolved bereavement issues about the death of his friend Joey and underwent bereavement counseling. At the time of discharge, he was without depressive symptoms, yet the “voice” remained. He did not satisfy the diagnostic criteria for major depression or schizophrenia. All symptoms except the “voices” improved without any pharmacological treatment and he was discharged without any psychotropic medication. There are differences in opinion regarding the definition of pseudohallucinations in terms of location in internal vs external subjective space and presence or absence of insight. Despite not having insight regarding the nature of this voice, this patient had no other psychotic features, had a
sense of wish fulfillment and the content of the “voices” reflected a strong personal significance. He demonstrated a personality style that has been described more frequently with pseudohallucinations. The patient’s voices were clearly described as “internal” and subjective in nature. Furthermore, the phenomenon was related to his friend’s untimely death, and increased with loneliness, inactivity, or stress. This voice was temporally unrelated to episodes of depressive symptoms or alcohol abuse. Phenomenologically, “hearing voices” can be categorized as true hallucinations, pseudohallucinations, imagery, or illusions. This case elucidates the common characteristics of pseudohallucinations which can occur under a variety of conditions including major depression, stress-related disorders, personality disorders, and bereavement [1]. The importance of clarifying the psychopathological significance of the “symptom of hearing voices” is imperative to appropriate clinical diagnosis. There is very little in the literature on bereavement and pseudohallucinations in younger individuals although there is some research on this issue in the elderly. Clinically understanding and acknowledging the concept of pseudohallucinations should help decrease the inappropriate prescribing of neuroleptics and consequently decrease the incidence of serious side effects such as tardive dyskinesia. However, most American psychiatrists are unaware of this phenomenon and patients with pseudohallucinations are likely to receive an inappropriate diagnosis of schizophrenia [6]. The DSM-IV appears to inadequately address the issue of pseudohallucinations [7] and states explicitly that sleep-related (hypnogogic or hypnopompic) hallucinations or experiences lacking “the quality of an external precept” are not psychotic hallucinations [7]. Although the DSM-IV has adopted a narrow Kraeplinian approach to the diagnosis of schizophrenia [8], the concept of pseudohallucinations does not fit neatly into DSM-IV diagnostic schemas. We suggest that the presence of pseudohallucinations analogus to hypnogogic and hypnopompic hallucinations does not warrant a diagnosis of psychotic disorder. We strongly believe that the concept of pseudohallucinations has heuristic and clinical significance and should not be abandoned in clinical psychiatry on grounds of its complexity. The general lack of familiarity with this clinical and phenomenological concept in American
125
Letters to the Editor
psychiatry needs to be addressed in various residency training programs. adityanjee, m.d., mrcpsych ashley b. benjamin, m.d., ma. Mental Health Service Line Dayton VA Medical Center 4100 West Third Street Dayton, OH 45428, USA
References 1. Sims A: Symptoms in the Mind. Philadelphia, PA, Saunders, 1995 2. Sedman G: A comparative study of pseudohallucinations, imagery and true hallucinations. Br J Psychiatry 112:9–17, 1966 3. Hare EH: A short note on pseudo-hallucinations. Br J Psychiatry 122:469–476, 1973 4. Kraupl Taylor F: On pseudo-hallucinations. Psychol Med 11:265–271, 1981 5. Yager J, Gitlin MJ: Clinical manifestations of psychiatric disorders. In Kaplan HI, Sadock BJ, (eds), Comprehensive Textbook of Psychiatry, 6th ed. Williams & Wilkins, Philadelphia, 1995, pp 637–669 6. Adityanjee: The concept of pseudo-schizophrenia. Neuropsychiatry Neuropsychol Behav Neurol 11:171– 174, 1998 7. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association. Washington, D.C. 1994, pp 273–315 8. Adityanjee, Aderibigbe YA, Theordoridis D, Viewweg WVR: Dementia praecox to schizophrenia: the first 100 years. Psychiatry Clin Neurosci 53:437–448, 1999
PII S0163-8343(99)00051-1
Neuropsychiatric Sequelae in a Case of St. Louis Encephalitis To the Editor Encephalitic illnesses have been associated with acute and residual neurologic and psychiatric symptoms. Brain infections and disorders studied in this century have led to the association of various symptom manifestations with specific pathologic findings. A variety of acute and residual neuropsychiatric symptoms have been described for St. Louis Encephalitis since its initial recognition in 1933. These symptoms have included, among others, memory deficits, weakness, ataxia, and nervousness, but not previously obsessive-compulsive disorder (OCD) [1]. This case describes development of OCD along with psychosis and mood disorder following a case of St. Louis Encephalitis.
126
Case Report A 30-year-old Asian female was initially admitted to the hospital by her family physician after failure to resolve a febrile illness. Her symptoms included fatigue, nausea, and anorexia of 3 weeks duration. She had been previously healthy with the exception of a history of rheumatoid arthritis, for which she was taking prednisolone 7.5 mg daily. During that hospitalization, her liver function tests were elevated, but screenings for hepatitis A, B, and C, cytomegalovirus, Ebstein Barr virus, and tuberculosis were negative. Sedimentation rate was elevated to 58. Her CBC revealed a marked leukopenia of 2800, which responded to iv steroids. Four days after admission, following resolution of her fever, she was discharged with the presumption that she had been suffering from a viremic illness. She left the hospital on prednisolone 40 mg daily. She attempted to return to work, but noticed problems with her memory and energy level. Three weeks later, she was readmitted with symptoms of headache, right arm weakness, paranoia, and disorientation. Other abnormal neurological findings included hypoactive reflexes and an unsteady gait. Magnetic resonance imaging (MRI) of her head showed bilaterally symmetrical abnormalities of the entire basal ganglia suggestive of an infectious process. Increased signal intensity was noted bilaterally in the mid portion of the medial temporal lobes, the amygdala, and the hippocampus. Her EEG showed excessive slowing in the temporal areas bilaterally, consistent with encephalopathy. Testing for connective tissue diseases was negative. Lumbar puncture (LP) results revealed a white blood cell count of 23 (95% mononucleocytes, 5 RBCs, protein: 104, glucose: 57). Repeat cerebrospinal fluid (CSF) analysis 2 weeks later showed findings returning to normal. A complete screening of blood, respiratory tract, and CSF for infectious process was negative except for testing for antibodies for a panel of encephalitides. All were negative except for indirect fluorescent antibody assay (IFA) positive for St. Louis Encephalitis at a titer of 1:512. At the time of psychiatry consultation, the patient had a fluctuating level of consciousness and was overtly paranoid, whispering to the examiner that her mother-in-law was perpetrating a “cyberplot” toward her and describing traffic inside the building. Despite initiation of haloperidol at 5 mg a day, mental status changes persisted. The patient’s family requested that no more antipsychotics be given.
propriate antibiotic orders or a cardiologist order cardiac medications for my patient without first speaking with me. I would hope, however, that one of the surgical residents would be informed, as a method of teaching about these drugs. On the other hand, if a cardiologist canceled my surgery in order for a patient to have a stress test without first discussing this change with me, I would be justifiably upset despite the fact that the consultant’s advice was medically appropriate. The authors also ignore the importance of the issue of time acting as an impediment to physician discussion of orders. Physicians’ busy schedules, including time spent in operating rooms or otherwise occupied, frequently result in lack of availability of one of the two parties of a consultation. This problem may explain the apparent contradiction between actual physician practice and “ideal” practice. The majority of internists and surgeons surveyed in this paper believed that directly writing orders would increase the likelihood that the orders would be followed and that patient care would improve. Most of these physicians stated that they were likely to write consultation orders without first discussing them with the requesting physician. Yet these same consultants, except internists, agreed with a hypothetical hospital policy which would require prior discussion with or written authorization from the requesting physician before orders could be written. I suspect that the unavailability of one of the two parties to a consultation played a large role in this discrepancy between presumed best practice and actual practice. I think the question of liability which the authors raise is overstated. Using my prior examples, I would be less vulnerable legally as the primary physician with the consultants writing medication orders in their specialties, even without my direct permission or knowledge. It is true that the consultant becomes legally responsible for his portion of care but that responsibility is appropriate. And finally, I believe the authors draw conclusions that are not substantiated by their data. First, they document the lack of knowledge by staff physicians about whether or not a hospital policy on consultation exists. They conclude that this lack of knowledge “may argue for the importance of such policies in clarifying the role of consultants.” The only conclusion that can be drawn is that there is a lack of knowledge and not that such a policy would make a difference. Although discussion between the two parties of a consultation clearly makes good sense, that a hospital policy clarifying the role of the
124
consultant would improve patient care is yet to be demonstrated by the authors. Their contention that application of a standard of best practices would require such a discussion between parties is not substantiated by the data presented. john g. schuler, m.d. Director of Surgical Training Mount Auburn Hospital Cambridge, Massachusetts 02238 PII S0163-8343(99)00060-2
References 1. Van Hoof TJ, Schwartz HI: When consultants write orders: physicians’ attitudes, beliefs, and practices. Gen Hosp Psychiatry 21:333–339, 1999
Clinical Significance of Pseudohallucinations To the Editor Pseudohallucinations have been defined as a “perceptual experience” occurring in “inner subjective space” and “perceived with the inner eye” [1]. In order to elucidate pseudohallucinations, Sedman [2] used concepts such as “not being a veridical perception” and being “psychologically meaningful” to the point where the patient “gained comfort.” Hare [3] argued that pseudohallucinations “lie somewhere on a continuum” between hallucinations and real perception with preserved insight into the phenomenon. Kraupl Taylor [4] discussed the definitional differences regarding insight versus subjectivity of perception and concluded that two types of pseudohallucinations exist: perceived and imagined. This debate on the definition of pseudohallucinations in British psychiatry is still unresolved. The clinical significance of the phenomenon of pseudohallucinations has been hitherto neglected in American psychiatry. Yager and Gitlin [5] dismiss the concept of pseudohallucination and suggest using the term “partial hallucinations” for this phenomenon, analogous to partial delusions. The aim of this case report is to emphasize that pseudohallucinations are often misinterpreted as “true” hallucinations, leading to inappropriate diagnosis of schizophrenia and subsequent treatment with neuroleptics.
Letters to the Editor
Case Report A 40-year-old white male with a previous diagnosis of schizophrenia presented with alcohol abuse, depressive symptoms, and suicidal ideas relating to an ongoing “voice” which was recognized by the patient as a former friend “Joey,” who had died in a motorcycle accident about 20 years ago. The patient expressed tremendous guilt because he had followed Joey’s motorcycle, in a car, the night of the accident. The patient clearly identified the solitary voice, located inside his head, as being that of his dead friend. The voice spoke to him on a regular basis. During times of stress, it would tell the patient to kill himself so that “we can be together.” The patient did not hear the voice during periods of intense activity or sleep. Previous treatment with antidepressants and neuroleptics did not alter the intensity or the frequency of the voice. During a 2-week hospital course, the patient was found to have normal thought processes. There were no other auditory or visual hallucinations, no bizarre delusions, no catatonic symptoms, and no Schneiderian first rank symptoms. This “voice” started prior to the onset of his alcohol problems. It was unrelated to ongoing alcoholic binges and was unaltered by ongoing alcohol use or alcohol withdrawal. The patient also denied any illicit drug use. A negative urine toxicology screen substantiated this. Physical examination and a lab workup including a complete blood count, admission panel, thyroid panel, serological test for syphilis, and HIV test were within normal limits. His symptoms of depressed mood, decreased appetite, decreased energy, and decreased concentration remitted soon after inpatient admission and without antidepressants. Persistent attention-seeking and histrionic behaviors were noted by the nursing staff and others. He had unresolved bereavement issues about the death of his friend Joey and underwent bereavement counseling. At the time of discharge, he was without depressive symptoms, yet the “voice” remained. He did not satisfy the diagnostic criteria for major depression or schizophrenia. All symptoms except the “voices” improved without any pharmacological treatment and he was discharged without any psychotropic medication. There are differences in opinion regarding the definition of pseudohallucinations in terms of location in internal vs external subjective space and presence or absence of insight. Despite not having insight regarding the nature of this voice, this patient had no other psychotic features, had a
sense of wish fulfillment and the content of the “voices” reflected a strong personal significance. He demonstrated a personality style that has been described more frequently with pseudohallucinations. The patient’s voices were clearly described as “internal” and subjective in nature. Furthermore, the phenomenon was related to his friend’s untimely death, and increased with loneliness, inactivity, or stress. This voice was temporally unrelated to episodes of depressive symptoms or alcohol abuse. Phenomenologically, “hearing voices” can be categorized as true hallucinations, pseudohallucinations, imagery, or illusions. This case elucidates the common characteristics of pseudohallucinations which can occur under a variety of conditions including major depression, stress-related disorders, personality disorders, and bereavement [1]. The importance of clarifying the psychopathological significance of the “symptom of hearing voices” is imperative to appropriate clinical diagnosis. There is very little in the literature on bereavement and pseudohallucinations in younger individuals although there is some research on this issue in the elderly. Clinically understanding and acknowledging the concept of pseudohallucinations should help decrease the inappropriate prescribing of neuroleptics and consequently decrease the incidence of serious side effects such as tardive dyskinesia. However, most American psychiatrists are unaware of this phenomenon and patients with pseudohallucinations are likely to receive an inappropriate diagnosis of schizophrenia [6]. The DSM-IV appears to inadequately address the issue of pseudohallucinations [7] and states explicitly that sleep-related (hypnogogic or hypnopompic) hallucinations or experiences lacking “the quality of an external precept” are not psychotic hallucinations [7]. Although the DSM-IV has adopted a narrow Kraeplinian approach to the diagnosis of schizophrenia [8], the concept of pseudohallucinations does not fit neatly into DSM-IV diagnostic schemas. We suggest that the presence of pseudohallucinations analogus to hypnogogic and hypnopompic hallucinations does not warrant a diagnosis of psychotic disorder. We strongly believe that the concept of pseudohallucinations has heuristic and clinical significance and should not be abandoned in clinical psychiatry on grounds of its complexity. The general lack of familiarity with this clinical and phenomenological concept in American
125
Letters to the Editor
psychiatry needs to be addressed in various residency training programs. adityanjee, m.d., mrcpsych ashley b. benjamin, m.d., ma. Mental Health Service Line Dayton VA Medical Center 4100 West Third Street Dayton, OH 45428, USA
References 1. Sims A: Symptoms in the Mind. Philadelphia, PA, Saunders, 1995 2. Sedman G: A comparative study of pseudohallucinations, imagery and true hallucinations. Br J Psychiatry 112:9–17, 1966 3. Hare EH: A short note on pseudo-hallucinations. Br J Psychiatry 122:469–476, 1973 4. Kraupl Taylor F: On pseudo-hallucinations. Psychol Med 11:265–271, 1981 5. Yager J, Gitlin MJ: Clinical manifestations of psychiatric disorders. In Kaplan HI, Sadock BJ, (eds), Comprehensive Textbook of Psychiatry, 6th ed. Williams & Wilkins, Philadelphia, 1995, pp 637–669 6. Adityanjee: The concept of pseudo-schizophrenia. Neuropsychiatry Neuropsychol Behav Neurol 11:171– 174, 1998 7. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association. Washington, D.C. 1994, pp 273–315 8. Adityanjee, Aderibigbe YA, Theordoridis D, Viewweg WVR: Dementia praecox to schizophrenia: the first 100 years. Psychiatry Clin Neurosci 53:437–448, 1999
PII S0163-8343(99)00051-1
Neuropsychiatric Sequelae in a Case of St. Louis Encephalitis To the Editor Encephalitic illnesses have been associated with acute and residual neurologic and psychiatric symptoms. Brain infections and disorders studied in this century have led to the association of various symptom manifestations with specific pathologic findings. A variety of acute and residual neuropsychiatric symptoms have been described for St. Louis Encephalitis since its initial recognition in 1933. These symptoms have included, among others, memory deficits, weakness, ataxia, and nervousness, but not previously obsessive-compulsive disorder (OCD) [1]. This case describes development of OCD along with psychosis and mood disorder following a case of St. Louis Encephalitis.
126
Case Report A 30-year-old Asian female was initially admitted to the hospital by her family physician after failure to resolve a febrile illness. Her symptoms included fatigue, nausea, and anorexia of 3 weeks duration. She had been previously healthy with the exception of a history of rheumatoid arthritis, for which she was taking prednisolone 7.5 mg daily. During that hospitalization, her liver function tests were elevated, but screenings for hepatitis A, B, and C, cytomegalovirus, Ebstein Barr virus, and tuberculosis were negative. Sedimentation rate was elevated to 58. Her CBC revealed a marked leukopenia of 2800, which responded to iv steroids. Four days after admission, following resolution of her fever, she was discharged with the presumption that she had been suffering from a viremic illness. She left the hospital on prednisolone 40 mg daily. She attempted to return to work, but noticed problems with her memory and energy level. Three weeks later, she was readmitted with symptoms of headache, right arm weakness, paranoia, and disorientation. Other abnormal neurological findings included hypoactive reflexes and an unsteady gait. Magnetic resonance imaging (MRI) of her head showed bilaterally symmetrical abnormalities of the entire basal ganglia suggestive of an infectious process. Increased signal intensity was noted bilaterally in the mid portion of the medial temporal lobes, the amygdala, and the hippocampus. Her EEG showed excessive slowing in the temporal areas bilaterally, consistent with encephalopathy. Testing for connective tissue diseases was negative. Lumbar puncture (LP) results revealed a white blood cell count of 23 (95% mononucleocytes, 5 RBCs, protein: 104, glucose: 57). Repeat cerebrospinal fluid (CSF) analysis 2 weeks later showed findings returning to normal. A complete screening of blood, respiratory tract, and CSF for infectious process was negative except for testing for antibodies for a panel of encephalitides. All were negative except for indirect fluorescent antibody assay (IFA) positive for St. Louis Encephalitis at a titer of 1:512. At the time of psychiatry consultation, the patient had a fluctuating level of consciousness and was overtly paranoid, whispering to the examiner that her mother-in-law was perpetrating a “cyberplot” toward her and describing traffic inside the building. Despite initiation of haloperidol at 5 mg a day, mental status changes persisted. The patient’s family requested that no more antipsychotics be given.