Hallucinations
Hallucinations: Excerpt from In a Page: Signs and Symptoms
Hallucinations are psychotic symptoms in which patients perceive stimuli that do not exist. Any of the five senses (auditory, visual, tactile, gustatory, or olfactory) may be involved, with auditory hallucinations being the most common. Patients may believe the hallucinations to be true or they may identify them as false. Distinguish all hallucinations from illusions, the misinterpretation of real but ambiguous stimuli. The patient's medical and psychiatric condition, as well as the type and duration of hallucinations, are important in reaching the correct diagnosis.
Differential Diagnosis
- Delirium
–Develops over hours to days
–Fluctuates throughout the day
–Causes include dehydration, drug-induced, electrolyte imbalance, UTI, URI, hypoglycemia, and alcohol or drug withdrawal
–Occurs in 10–30% of hospital patients
–Drug-induced delirium (e.g., cocaine, β-blockers, alcohol, corticosteroids, pseudoephedrine, dopaminergic drugs)
- Alcohol withdrawal (delirium tremens)
–Often presents in hospitalized patients about 3 days after admission
–Commonly presents with tactile hallucinations (e.g., formication—the sense of insects crawling over body)
–May be accompanied by seizure activity
- Hallucinogenic syndromes (e.g., LSD, marijuana, mescaline, phencyclidine, mushrooms, amphetamines)
- Schizophrenia
–Auditory hallucinations are most frequent; visual hallucinations occur in about 50% of patients, tactile in 20%, olfactory in 6%
–Progresses to positive psychotic symptoms (e.g., hallucinations, delusions, thought disorder) and/or negative symptoms (e.g., anhedonia, poor concentration, flattened affect, poor social/personal function)
–1% incidence in the general population, males >females
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Schizophreniform disorder
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Schizoaffective disorder
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Post-traumatic stress disorder
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Dementia
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Systemic lupus erythematosus
–Auditory hallucinations caused by corticosteroids; visual and tactile by lupus psychosis
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Bipolar disorder
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Psychotic depression
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Postpartum major depression
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Mass lesions
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CNS infections/encephalitis
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Seizures
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Occipital lobe injury
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Heavy metal ingestion
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Lewy body dementia
Workup and Diagnosis
- History and physical examination
–In caring for patients with major psychiatric illness, follow three important principles: Know the patient's drug regimen, work with psychiatrist if changes are needed, and remember that chronic psychiatric patients have difficulty communicating medical history and needs
–Diagnosis of schizophrenia requires two positive or negative symptoms present for 1 month and signs continuing for at least 6 months (DSM-IV criteria)
–Assess for suicidal/homicidal ideations
–Note timing of hallucinations (e.g., following alcohol or drug use, at random, under stress)
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Initial labs may include electrolytes, glucose, calcium, BUN/creatinine, albumin, liver function tests, alkaline phosphatase, magnesium, phosphate, CBC, ECG, pulse oximetry, urinalysis, toxicology screen, and drug levels
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Chest X-ray may be indicated for infectious etiologies of delirium; lumbar puncture may be indicated
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Further tests, if delirium is suspected, include vitamin B12 and folate levels, ANA, ammonia, and heavy metal screen
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EEG may reveal slowing activity in delirium, low-voltage fast activity in alcohol withdrawal
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Psychiatric consult after medical causes of psychosis are ruled out
Treatment
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Treat hallucinations symptomatically with antipsychotic drugs (e.g., haloperidol, risperidone, olanzapine)
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Delirium: Treat underlying cause (e.g., hydration, proper nutrition, oxygen, thiamine, and glucose)
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Alcohol/sedative withdrawal: Monitor and treat for seizures with benzodiazepines
- Schizophrenia: Traditional antipsychotics (e.g., haloperidol, chlorpromazine)
–Extrapyramidal side effects (parkinsonism, akathisia, dystonia) are common
–Neuroleptic malignant syndrome (hyperthermia, rigidity, hypertension, tachycardia) may rarely occur in first week of treatment and can be fatal
–Clozapine carries a 1% risk of fatal agranulocytosis
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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