3.

Disturbances of perception

Before we start talking about the disturbances, we first have to understand what
perception actually means and what the difference between sensation and perception
is.

Sensation vs. Perception:

1) Sensation:
- Sensation can be defined as the passive process of bringing information from the
outside world (or the inside of the body) towards the brain.
- Sequence of events in sensation:
- 1st: sensory organs absorb energy from a physical stimulus in the
environment (or the body)
- 2nd: sensory receptors convert this energy into action potentials and send
them to the brain.
- The 5 senses of a human being are: Vision, Hearing , Smell, Taste, Touch

2) Perception:
- Perception can be defined as the active process of selecting, organizing, and
interpreting the information brought to the brain by our sensations.
- The brain organizes the information and translates it into something meaningful.
- E.g.: I see Linus on the street.
-sensation: I see a person with certain characteristics (dark hair, short penis,…)
-perception: The person I see is actually my friend Linus -> the brain has
connected the person I see to my memory -> this is how I realize that the
person I see is not just any random person but actually my friend Linus ->
PERCEPTION -> further work on the incoming stimuli-
>analysis,organization,etc
- Perception refers to the set of processes we use to make sense (not sensation ;) ) of
the different stimuli that reach us.
- Our perceptions are based on how we interpret different sensations. This means that
2 people could be exposed to the exact same visual sensation but they both perceive
this visual sensation differently and thus they end up seeing different things -> e.g.
Rubin’s Vase

Some people see a black vase. Other

people see 2 white faces that look at each
other.
- The perceptual process begins with receiving stimuli from the environment and ends
with our interpretation of those stimuli -> This process is typically unconscious and
happens hundreds of thousands of times a day.
- When we attend to or select one specific thing in our environment, it becomes the
attended stimulus

- Again: perception means we interpret stimuli, which simply means that we take the
information and turn it into something that we can categorize.
Perception is our sensory experience of the world around us and involves both the
recognition of environmental stimuli and actions in response to these stimuli.
Through the perceptual process, we gain information about properties and elements of
the environment that are critical to our survival. Perception not only creates our
experience of the world around us; it allows us to act within our environment.
Perception also includes what is known as proprioception, a set of senses involving
the ability to detect changes in body positions and movements. It also involves the
cognitive processes required to process information, such as recognizing the face of a
friend or detecting a familiar scent.

The perceptual process:

- The perceptual process begins with the environment and leads to our perception of a
stimulus and an action in response to the stimulus.
This process is continual, but you do not spend a great deal of time thinking about the
actual process that occurs when you perceive the many stimuli that surround you at
any given moment.
- The Steps in the Perceptual Process: The environmental stimulus -> The attended
stimulus -> The image on the retina -> Transduction -> Neural processing ->
Perception -> Recognition -> Action

a) The environmental stimulus:

- The world is full of stimuli that ca n attract our attention through various senses.
The environmental stimulus is everything in our environment that has the potential to
be perceived -> This might include anything that can be seen, touched, tasted, smelled
or heard.
- For example, imagine that you are out on a morning jog at your local park. As you
perform your workout, there are a wide variety of environmental stimuli that might
capture your attention. A man is out on the grass playing fetch with his Golden
Retriever; a duck splashes in a nearby pond, etc -> All of these things represent the
environmental stimuli, serving as a starting point for the perceptual
process.

b) The attended stimulus:

The attended stimulus is the specific object in the environment on which our attention
is focused. In many cases, we might focus on stimuli that are familiar to us, such as
the face of a friend in a crowd of strangers at the local coffee shop. In other
instances, we are likely to attend to stimuli that have some degree of novelty.
- From our earlier example, let's imagine that during your morning job you focus your
attention on the duck floating in the nearby pond -> The duck represents the attended
stimulus.

c) The image on the Retina:

Next, the attended stimulus is formed as an image on the retina. The first part of this
process involves the light actually passing through the cornea and pupil and onto the
lens of the eye. The cornea helps focus the light as it enters the eye, and the iris of the
eye controls the size of the pupils in order to determine how much light to let in. The
cornea and lens act together to project an inverted image on the retina.
As you might already be aware, the image on the retina is actually upside down from
the actual image in the environment. At this stage of the perceptual process,
this is not terribly important. The image has still not been perceived, and this visual
information will be changed even more dramatically in the next step of the process.

d) Transduction:
- The image on the retina is then transformed into electrical signals in a process
known as transduction (Rods and cones in Retina contain Retinal, which helps to
convert light rays into action potentials).
- This allows the visual messages to be transmitted to the brain to be interpreted.

e) Perception:
- Now, we actually perceive the stimulus object in the environment. It is at this point
that we become consciously aware of the stimulus.
- Let's consider our previous example, in which we imagined that you were out for a
morning jog in the park.
- At the perception stage, you have become aware of that there is something out on the
pond to perceive.
- But: It is one thing to be aware of stimuli in the environment, and quite another to
actually become fully consciously aware of what we have perceived.
- In the next stage of the perceptual process, we will sort the perceived information
into meaningful categories.

f) Recognition:
- Perception doesn't just involve becoming consciously aware of the stimuli. It is also
necessary for our brain to categorize and interpret what it is that we are sensing.
- Our ability to interpret and give meaning to the object is known as recognition.
- Continuing our example, it is at the recognition stage of the perceptual process that
you realize that there is a duck floating on the water.
- The recognition stage is an essential part of perception since it allows us to make
sense of the world around us.
- By placing objects in meaningful categories, we are able to understand and react to
the world around us.

g) Action
- The final step of the perceptual process involves some sort of action in response to
the environmental stimulus. This could involve a variety of actions, such as turning
your head for a closer look or turning away to look at something else.
- The action phase of perceptual development involves some type of motor action that
occurs in response to the perceived and recognized stimulus. This might involve a
major action, like running toward a person in distress, or something as subtle as
blinking your eyes in response to a puff of dust blowing through the air.

Finally we reach the disturbances of perception:

Important: PSYCHOSIS:
A patient who suffers from illusions, Hallucinations, Dissociative phenomena or
delusions (all are explained later) is said to have a psychosis (!!!). It is crucial to take
into consideration that even if a person does exhibit psychotic features, they do not
necessarily suffer from a psychiatric disorder on its own. Disorders such as Wilson's
disease, various endocrine diseases, numerous metabolic disturbances, multiple
sclerosis, systemic lupus erythematosis, porphyria, sarcoidosis, and many others can
present with psychosis.

1) Illusions:
- are misinterpretations (misperceptions) of real external stimuli
-> it is really important to know that there is an existing stimulus! But this stimulus is
interpreted abnormally! If there is no stimulus at all, but the person still perceives
something, then we call it hallucination (later)! So the major difference between
illusions and hallucinations is the presence or absence of a real stimulus!
- Illusions appear mainly in conditions of qualitative disturbances of consciousness
(missing insight = kein Verständnis, keine Erkenntins -> ne raspiram)
- Illusion is also described as distorted perception of objects, which may occur when
the general level of sensory stimulation is reduced

- Types of illusions:
a) Physical: caused by light propagation laws -> mirages in the desert, a spoon looks
as if broken when half submerged into water and so on -> optical illusions
b) Physiological- caused by fatigue, affective states (fear), poor visibility
c) Pathological- no insight (as above, ne raspiram)
d) Visual: a patient sees his neighbor in other patients, or a key as a gun
e) Auditory: hears in the conversations of othersthreats
f) Gustatory: in food a taste of poison
h) Olfactory:

2) Hallucinations
- are perceptual experiences of images, phenomena in the absence of actual
stimulation of the sensory system
- the patient is unable to distinguish it from reality
- Types of hallucinations: auditory, visual, olfactory, gustatory, tactile, extracampine,
Hypnagogic and hypnopompic (explanation below)

a) Visual hallucinations:
- These include the phenomena of seeing things which are not present at the moment
-There are many different causes, which have been classed as psychophysiologic (a
disturbance of brain structure), psychobiochemical (a disturbance of
neurotransmitters), psychodynamic (an emergence of the unconscious into
consciousness), and psychological (e.g. meaningful experiences)
- Numerous disorders can involve visual hallucinations, ranging from psychotic
disorders to dementia to migraine, but experiencing visual hallucinations does not in
itself mean there is necessarily a disorder. E.g. we had a patient in our seminars who
saw and heard people who nicely talked to her -> The patient simply was very lonely
and these hallucinations helped her to cope with her loneliness! There was no mental
disease or anything.
- Visual hallucinations are not typically considered the result of a psychiatric disorder

b) Auditory hallucinations:
- Auditory hallucinations are the perception of sound without outside obvious
stimulus.
- During investigations was found out that the area responsible for speech perception
(some part of left temporal lobe) becomes activated during auditory hallucinations.
- Auditory hallucinations can be divided into two categories: elementary and complex.
- Elementary hallucinations: are the perception of sounds such as cry, whistling, an
extended tone, and more
- Complex hallucinations: are those of voices, which may or may not be clear, may be
familiar or completely unfamiliar, and friendly or aggressive, among other
possibilities.
Hallucinations of one or more talking voices are particularly associated with psychotic
disorders such as schizophrenia, and hold special significance in diagnosing these
conditions.
However, many people not suffering from diagnosable mental illness may sometimes
hear voices as well.
One important example to consider when forming a differential diagnosis is lateral
temporal lobe epilepsy (Remember that epilepsy does not always lead to tonic clonic
seizures. Depending on which brain area fires excessively, it can also lead to
hallucinations! Only when the motor cortex fires excessively we will get a tonic clonic
seizures!!!
Musical hallucinations are also relatively common in terms of complex auditory
hallucinations and may be the result of a wide range of causes ranging from
hearing-loss (such as in musical ear syndrome, lateral temporal lobe epilepsy,
arteriovenous malformation, stroke, lesion, abscess, or tumor.
Command hallucinations are verbal hallucinations in the form of commands.
The contents of the hallucinations could have the content to cause harm to the self or
others. Command hallucinations are often associated with schizophrenia. People
experiencing command hallucinations may or may not comply with the
hallucinated commands, depending on circumstances. Compliance is more common
for non-violent commands. Command hallucinations are sometimes used in defense of
a crime, often homicides. It is essentially a voice one hears and it tells them what to
do.

Recent theory is that the auditory hallucinations in schizophrenia are due to

disruption of connections between the frontal and termporo-pariental language
areas. This work suggests that failure to deactivate the temporal cortex allows
increased spontaneous activity, and auditory hallucinations.

c) tactile hallucinations:
- Tactile hallucinations are feelings of tactile sensory input, simulating various types
of pressure to the skin or other organs.
- One subtype of tactile hallucination, formication, is the sensation of insects crawling
underneath the skin and is frequently associated with prolonged cocaine or
amphetamine use or with withdrawal from alcohol
or benzodiazepines. However, formication may also be the result of normal
hormonal changes such as menopause, or disorders such as peripheral neuropathy,
high fevers, Lyme disease, skin cancer, and more!

d) Hypnagogic hallucinations: Als Hypnagogie bezeichnet man einen

Bewusstseinszustand, der beim Einschlafen auftreten kann, also beim Übergang vom
Wachzustand in den Schlaf. Eine Person im hypnagogischen Zustand kann visuelle,
auditive und taktile Halluzinationen erleben (unter Umständen, ohne sich bewegen zu
können -> Schlafparalyse). Obwohl der Person bewusst ist, dass sie halluziniert, kann
sie in den meisten Fällen nicht darauf reagieren.
e) Hypnopomping: same as above, but during the transition period between being
asleep and waking up.

Hallucination is a fundamental symptom in psychiatry. Two hundred years of research

into this phenomenon has not yet answered the following questions:
1) Are hallucinations pathognomic (characteristic for a particular disease) of
psychosis?
2) Can the presence of hallucinations as such or in different modalities and forms
include or exclude certain diagnoses?
3) What is the neural substrate of hallucination?
Conventionally, hallucinations are treated as psychotic features. However, there is
ample evidence to support the fact that hallucination could be present in nonpsychotic
conditions as well -> Illusions of inappriopriate familiarity with the current experience
or hallucinatory recall of memories have been reported in temporal lobe epilepsies.

3) Dissociative phenomena
a) Depersonalization
- disturbance in one’s experience and awareness of one-self
- is characterized by a feeling of detachment from one’s mental processes or body.
- The whole body or different parts of it are perceived as enlarged, reduced, doubled
or misshaped.
- “I’m not the same”. “I lost my memories”

b) Derealization
- disturbance of perception of environmental realities. The external world has
changed.
- Can occur in temporal lobe epilepsy, organic syndromes, schizophrenia, depression.
- Examples of derealisation:
- Déjà vu- already seen. Finds some situations very familiar though actually
he/she is seeing it for the first time.
- Jamais vu -never seen. Frequently seen and familiar objects and environment
seem to be unfamiliar to the individual, as though seen for the first time
-> The connection between the current experience and the past experience at a given
time is broken. Can Occur in normal and pathological states

FOR NERDS:
Some fucked up knowledge about the theories for pathogenesis of illusions and
hallucinations:
Pathophysiological hypotheses have been put forward, involving either the limbic
regions of the temporal lobe (Jackson), the temporal neocortex ("interpretive cortex",
Penfield), or both (Bancaud).
New data, acquired in the course of presurgical investigations through intracerebral
electrodes recording, demonstrate a critical role of the sub- and para-hippocampal
cortices. A new hypothesis of cortico-limbic network is developed as well.

PSYCHODYANMIC APPROACH
Freud (1953) felt that hallucinations are very similar to dreams and that both
conditions represent a psychotic state in which there is a complete lack of time sense

PSYCHOPHYSIOLOGIC APPROACH
Neurophysiologic hypothesis: Jackson (1932) suggested that hallucinations occur
when the usual inhibitory influences of the uppermost level are impeded, thus leading
to release of middle-level activity, which takes the form of hallucinations. This
model is known as disinhibition model.

Neurotransmitter hypothesis
a) Dopamine
In schizophrenia (SCZ), there is evidence that very high levels of dopamine in the
limbic system play a major role in emergence of hallucinations and delusions.
Antipsychotic medications, which block central dopamine activity, alleviate the
hallucinations of psychosis
b) Acetylcholine:
A deranged cholinergic neurotransmission has also been involved in the
pathophysiology of hallucinations. For example, alteration of consciousness and
hallucinations have been described widely since ancient times for members of the
Solanaceae family of plants (belladonna), which contain scopolamine, atropine and
other antimuscarinic agents. Hallucinations occur in about 30% of patients with
Alzheimer’s disease and 60% of patients with Lewy body dementia, which are
characterized by reduction in acetylcholine and abnormalities in nicotinic and
muscarinic receptor expression.

c) Serotonin
Serotonin has also been implicated in the causation of hallucinations, based on the fact
that a number of hallucinogenic drugs, like lysergic acid diethylamide (LSD),
mescaline, psilocybin and ecstasy, appear to act, at least in part, as serotonin 5 HT2A
receptor agonist or partial agonists. In addition, hallucinations have been reported as
side effects of Selective serotonin reuptake inhibitors (SSRIs), which increase the
availability of serotonin in the synaptic cleft.

d) Glutamate
A possible role of glutamate in hallucinations is suggested by the finding that
glutamate antagonists like phencyclidine and ketamine can induce hallucinations. This
has led to the hypothesis that psychotic symptoms may in part be attributed to
hypofunction of NMDA receptors.

e) GABA-A
PET and SPECT studies using GABA-A receptor ligands showed that the intensity of
hallucinations was strongly associated with diminished GABA-A binding, specifically
in the left medial temporal region.

Recent theory is that the auditory hallucinations in schizophrenia are due to

disruption of connections between the frontal and termporo-pariental language
areas. This work suggests that failure to deactivate the temporal cortex allows
increased spontaneous activity, and auditory hallucinations.Also, It is possible that
decreased activity in hippocampus-parahippocampal gyrus and
possibly the cerebellum allows the increased spontaneous activity of the
temporal cortex. Horga et al. (2011) drew attention to a possible central role for the
caudate, in auditory hallucinations. Recent work (Amad et al., 2013) suggests
abnormal connectivity patterns, involving the hippocampus, in people with
schizophrenia and visual hallucinations.