‘Hearing voices’, ‘pseudohallucinations’ and ‘lucid dreams’

Expanding on the post: Clinical perspectives on the relationship between psychosis and dissociation: utility of structural dissociation and implications for practice (2015)

‘Pseudohallucinations versus hallucinations: wherein lies the difference?’ [1]:

“Pseudohallucination has been variously defined in the literature as an experience similar to hallucinations but falling short in some formal characteristics. The concept has achieved greater relevance in psychiatry with the introduction of the Hearing Voices Network in Australia by Richmond Fellowship in 2005. In this program, voices are understood as part of the individual’s life experience with an emphasis on acceptance and respect. However, there does appear to be a blurring of phenomenological differentiation in hallucinosis that has significant relevance to the psychiatric profession.

The term pseudohallucinations was first used by the German psychiatrist Hagen to refer to a perceptual phenomenon that could be mistaken for a hallucination. Kadinsky built on this definition as he had experienced both hallucinations and pseudohallucinations himself. He defined pseudohallucinations as subjective stimulation of sensory areas giving rise to concrete perceptions that lacked the objectivity or the realness of the hallucinatory experience.

Jaspers, who built on Kadinsky’s work, emphasized the concept of the inner subjective space, where vivid, subjective sensory images occurred spontaneously but lacked the realness of hallucinations. Blueler viewed pseudohallucinations as perceptions with full sensory clarity, internal localization and intact reality testing.

The theme in these early writings is that pseudohallucinations could be differentiated from hallucinations in that the experience occurred in the subjective inner space and lacked the sensory realness of hallucinations.

Van der Zwaard and Polak did a comprehensive review on pseudohallucinations and found that internal localization of voices and subjective insight did not discriminate pseudohallucinations from hallucinations. They broke down the concept of pseudohallucinations into categories. Nonpsychotic hallucinations represented isolated experiences of external voices such as hearing a loved one’s voice after death. Partial hallucinations were those having reduced sensory vividness with the presence of insight. Lastly, transient hallucinations represented lack of insight as in brief reactive psychoses.”

Comparing schizophrenia with PTSD, the authors found several differences:

  • Delusions differed significantly between the groups, with schizophrenia subjects scoring significantly higher than PTSD subjects. By any measure of effect size this difference was large.
  • PTSD subjects reported more negative content than schizophrenia subjects, including verbal abuse or personal threats to self. The effect size for this difference was moderate to high.
  • The groups differed significantly in terms of their experience of abuse.

“PTSD clients appeared to experience the voices in isolation rather than as part of a complex delusional system. The voices were also more likely to be critical and negative towards the individual, consistent with the experience of abuse.”

On the contrary:

“PTSD subjects were just as likely as schizophrenic subjects to perceive voices as loud, occurring outside the head and having no control over them. There was no difference between groups in the duration and frequency of hallucinations with both groups reporting the phenomena occurring daily or hourly and lasting over time.”

To conclude:

“It is important to note that neither this study nor the literature support the traditional view of pseudohallucinations necessarily occurring in the internal subjective space or retaining insight. The experience of hearing voices could not be easily differentiated in terms of loudness, position, control, frequency or duration of voices.”

Some guidelines are provided:

“Experienced clinicians are highly sensitive to the extreme suggestibility of the dissociated individual and may appropriately minimize discussion of the experience of hallucination to avoid exacerbating the situation. Informal feedback however from individuals taking part in this study, were that their clinicians tended to avoid discussion of their experiences, and they perceived themselves as not being believed with regards to these distressing experiences. The term pseudohallucination was seen as negative and critical of their experience.

Some of the experiences of pseudohallucinations are far more persistent than transitory, as shown in the above individuals with PTSD with dissociation. The diagnosis of brief psychotic disorder does not appropriately describe the phenomenology. The term trauma-intrusive hallucinations has been recognized as occurring along a continuum with hallucinations and could be added to a dimensional system, as a symptom of PTSD associated with dissociation. It would be significantly less pejorative than pseudohallucination, which associates with being “unreal” or “not severe”

subtyping of pseudohallucinations

“…the standard of care when the disorder is more complicated, such as with complex PTSD, trauma-related borderline personality disorder, and complex dissociative disorders, is phase-oriented treatment. The treatment phases are (a) safety, stabilization, symptom reduction, and skills training; (b) treatment of traumatic memories; and (c) personality (re)integration and (re)habilitation. Their application often takes the form of a spiral, in which different phases can be alternated according to the client’s needs. Phase-oriented treatment models have developed based on consistent clinical observations that the majority of patients with complex trauma-related disorders need to develop specific skills prior to meeting the challenges of integrating traumatic memories and their personality. Empirical support is developing for this clinical standard of care.” [2]

Lucid dreams responding to a novel intervention have also reported [3].

“Lucid Dreams are a form of dream life, during which the dreamer may be aware that he/she is dreaming, can stop/re-start the dreams, depending on the pleasantness or unpleasant nature of the dream, and experiences the dream as if he/she were fully awake. Depending on their content, they may be pleasant, un-pleasant or terrifying, at least in the context of patients, who also exhibit characteristics of Reward Deficiency Syndrome (RDS) and Posttraumatic Stress Disorder (PTSD). We present eight clinical cases, with known substance abuse, childhood abuse and diagnosed PTSD/RDS. The administration of a putative dopamine agonist, KB200Z™, was associated with the elimination of unpleasant and/or terrifying, lucid dreams in 87.5% of the cases presented, whereas one very heavy cocaine abuser showed a minimal response. These results required the continuous use of this nutraceutical. The lucid dreams themselves were distinguishable from typical, PTSD nightmares insofar as their content did not appear to reflect a symbolic rendition of an originally-experienced, historical trauma. Each of the cases was diagnosed with a form of RDS, i.e., ADHD, ADD, and/or Tourette’s syndrome. They all also suffered from some form of Post-Traumatic-Stress-Disorder (PTSD) and other psychiatric diagnoses as well. The reduction or elimination of terrifying Lucid Dreams seemed to be dependent on KB220Z, whereby voluntary stopping of the agent results in reinstatement of the terrifying non-pleasant nature of the dreams. Following more required research on a much larger population we anticipate confirmation of these seemingly interesting observations. If these results in a small number of patients are indeed confirmed we may have found a frontline solution to a very perplexing and complicated symptom known as lucid dreams.”

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