DISORDERS OF PERCEPTION

Presenter : Dr. Imon Paul Chairperson : Dr. Shyam Sunder

PERCEPTION
Interpretation of what we take in through our senses Requires sensation information to be taken in from outside world Eliminating the irrelevant Associating what is seen with other relevant data to form a percept

ABNORMAL PERCEPTION
Sensory distortions Changes in intensity Changes in quality Changes in spatial form Constant real perceptual object percieved in distorted way False perceptions/ sensory deceptions Illusions Hallucinations Pseudo-hallucinations New perception which may/may not be in response to external stimulus

SENSORY DISTORTIONS - INTENSITY

Hyperasthesia Intense emotions Lowering of physiological threshold Neurotics and hypochondriacal personalities

Hypoasthesia anxious preoccupation delirium (rise in threshold)

QUALITY Mainly visual distortions Usually due to toxic substances, some antihelminthics Xanthopsia - caffeinism Chloropsia - digitalis toxicity Erythropsia - preretinal and vitreous haemorrhage

SPATIAL FORM/ DYSMEGALOPSIA

Micropsia

Macropsia

Metamorphopsia

Retinal diseases - Disorders of accomodation and convergence - Temporal lobe lesions - Delirium, degenerative brain diseases affecting visual association cortex - Atropine/hyoscine poisoning Porropsia- retreat of objects without change in size

SENSORY DECEPTIONS
Illusions Hallucinations

SENSORY
DECEPTIONS

ILLUSIONS
Misinterpretation of stimuli arising from an external object Stimuli from a perceived object are combined with a mental image to produce a false perception transformations of perceptions coming about by a mixing of the reproduced perceptions of the subjects fantasy with natural perceptions (Hagen)

TYPES

Completion depend on inattention for occurrence Incomplete perception meaningless of itself is filled in by a process of extrapolation from previous experience to produce significance

Affect combination of heightened emotion and misperception Can be understood in context of prevailing mood state A child waking up in the middle of the night scared in the dim light , mistakes the towel hanging on the wall for a person

Pareidolic - are created out of sensory percepts by an admixture with imagination. - Images seen from shapes - the percept takes on a full and detailed appearance - becomes more intricate with attention

Fantastic illusions Person sees extraordinary modifications of his environment eg. Looking into a mirror and seeing head of a pig instead of own head.

D/D Intellectual misinterpretation Functional hallucination

HALLUCINATIONS

A perception without an object

(Esquirol)

A false perception, that is not a sensory distortion or misinterpretation but which occurs in the same time as a real perception (Jaspers)

1.

2. 3.

Three criteria are essential for hallucination: Percept like experience in the absence of a stimulus Has the full force and impact of a real perception Which is unwilled, occurs spontaneously, cannot be readily controlled by the recipient (Slade)

CAUSES
Emotional states Suggestion Sensory deprivation CNS disorders

CLASSIFICATION

Sensory Modality: Visual, Auditory, Olfactory, Gustatory, and Kinesthetic. Form: Elementary and Formed. Precipitating circumstance: Functional, reflex, hypnagogic, and hypnopompic.

Degree of attenuation of reality: True hallucination, pseudo-hallucination and Imagery

AUDITORY HALLUCINATIONS
May be elementary noises partly organized music completely organized voices Imperative Seen in schizophrenia, affective psychoses, chronic alcoholic hallucinosis content could be commanding, critical, abusive

Schniderian first rank symptoms: - hearing ones thoughts being spoken aloud ( Gedankenlautverden) - voices speaking about patient in third person - voices in form of running commentary

VISUAL HALLUCINATIONS
Types: Simple - colored lights Partly organized - geometric shapes Completely organized - scenes, humans, animals

Seen in organic brain conditions like occipital or temporal lobe lesions, dementing illnesses, sensory deprivation, eye pathology, hallucinogens

Delirium tremens seeing rats, mice, squirrels, spiders, insects, lilliputian etc Scenic hallucinations epilepsy, oneiroid states visions of fire, religious scenes etc Combined auditory visual hallucinations in temporal lobe epilepsy Very uncommon in schizophrenia

OLFACTORY HALLUCINATIONS
occur in schizophrenia, temporal lobe epilepsy (commonly aura) and some other organic states. The smell may or may not be pleasant but usually has a special and personal significance For eg- people putting poisonous gas/ anaesthetic into the house sometimes relating to oneself I smell repulsive

A delusion in which a patient believes himself to smell malodorously without an accompanying olfactory hallucination is common in schizophrenia.

GUSTATORY HALLUCINATIONS
Can occur in schizophrenia (odd tastes in food, food is being poisoned, etc.) Difficult to establish whether these are clear hallucinations at times Can also occur in temporal lobe epilepsy

HALLUCINATIONS OF BODILY SENSATIONS

May be superficial, kinaesthetic or visceral superficial : Thermic Haptic a dead hand touched me Hygric a perception of fluid all my blood has dropped into my legs

Kinaesthetic: - of muscle or joint sense - perception of limbs being twisted or muscles being squeezed. - in schizophrenia, organic states, withdrawal states from BZDs or alcohol Visceral: sensations referred to internal organs, common in schizophrenia

Formication/ cocaine bugs Internal delusional zoopathy : - eg: sensation of a wasp wandering inside the body External delusional zoopathy: - sensation of an animal crawling about on the body

PSEUDO-HALLUCINATIONS

A type of mental image which although clear and vivid, - lack the substantiality of perceptions, - are seen in full consciousness, - located in subjective space. (Jaspers) Difference between real and pseudo-hallucinations depends on the absence or presence of insight. (Hare)

True Perception
-

Substantial
-

Mental Image / Fantasy

Incomplete

Objective Space
-

Subjective space
Not clearly delineated

Clearly delineated
-

Constant
-

Inconstant
Dependent on will Have to be recreated
(Jaspers)

Independent of will
-

Sensory elements: Full & Fresh

PSEUDO-HALLUCINATIONS
Similarities to True perception
-

Similarities to Mental Image / Fantasy

-

Clear & Vivid

Type of Mental Image

In full consciousness
Involuntary

Lack the substantiality

Not a real perception Subjective Space

Perception=Hallucinati on
Experience Location Definition Vividness Constancy Independence Insight Bhv. relevance Sensory modality Existence Concrete, tangible, objective, real Outer obj. space Definite, complete Full, fresh, bright retained Cannot dismiss/recall at will Quality of perception relevant Another modality independent

Pseudohall ucination
Inner eye

Imagery

Pictorial subjective Inner subjective Indefinite, incomplete Dim, neutral evanescent Voluntary creation Quality of idea Not relevant Not possible dependent

SPECIFIC/NAMED HALLUCINATIONS

Functional hallucinations: - occurs only in the presence of an external stimulus in the same modality, but is perceived separately (eg. hearing voices only when a fan is switched on, though the sound of the fan is perceived separately) - both perceptions are distinct and real

Synesthesia: - is the stimulation of one sensory modality eliciting a perception in a different sensory modality, as in seeing a sound. - associated with toxic states, - considered the classic perceptual disturbance of LSD intoxication

Reflex hallucinations: - a morbid variety of synaesthesia in which a stimulus in one modality (eg. Hearing someone laugh) produces a sensation in another modality (eg. a pain in the chest) Extracampine hallucinations: hallucinations experienced outside the limits of sensory field Imperative: voices giving commands

Autoscopy : experience of seeing oneself and knowing that it is oneself Negative autoscopy : looking in the mirror and seeing no image at all. Internal autoscopy: seeing ones internal organs

Experiential: hallucinations of past memories (visual and auditory) in temporal lobe epilepsy Hypnagogic / hypnopompic: occurring as subject is falling asleep or waking up; generally a normal phenomenon Cenesthetic: bizarre visceral hallucinations in schizophrenia semen travelling up my vertebral column to brain where its laid out in sheets"

Lilliputian hallucinations: visual hallucinations of small figures / animals (i.e. with micropsia), usually perceived as pleasant Charles Bonnet syndrome: visual hallucinations of human / animal figures in elderly patients with eye disease, in the absence of other psychopathology

Phantom limb: perception of sensation from a limb that has been amputated (or, more rarely)has been denervated Occurs in about 95 percent of amputees does not necessarily correspond to previous image of the limb

EVALUATING HALLUCINATIONS
Schizophrenia: usually distinct and continuous voices, often in the third person, male or female, delusional elaborations Depression: rarer (about 10-20% in psychotic depression), intermittent, disjointed voices Organic states: usually less well formed, elementary, simple voices (but depends on site of lesion

Alcoholic hallucinosis: auditory hallucinations, derogatory or threatening Delirium tremens: visual hallucinations (usually small animals, insects) Epilepsy: all modalities may occur in temporal lobe epilepsy Dementia: visual and auditory hallucinations, simple or partly organized

Hallucinatory syndromes Confusional Self reference Verbal Fantastic

DESCRIBING HALLUCINATIONS
Modality : Auditory Level of consciousness From Outside or Inside Known / Unknown peoples voices Content - Pleasant / Unpleasant Intermittent / continuous / running commentary type

Directly to the patient or talking among themselves Commanding / Non-commanding Controllable or not Insight Acting out behaviour

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