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Abstract: Perceptions of patient's auditory verbal hallucinations (AVHs), commonly termed voices, have important impacts on their everyday lives. Despite research emphasizing the consequences of malevolent voices, preliminary results suggest that beliefs about voices may not be mutually exclusive. As such, we aimed to characterize the heterogeneity of beliefs about AVHs and describe their clinical correlates. We recruited 78 patients referred to a Voices group therapy for refractory and distressing voices. Based on the Revised Beliefs About Voices Questionnaire, clustering analysis yielded four subgroups of patients with distinct pattern of beliefs about AVHs. These subgroups differed significantly in terms of affective disturbances, engagement, and resistance to their voices. Furthermore, no significant changes in beliefs about voices were observed after 6 weeks. Results of the current study suggest that the heterogeneity regarding the beliefs about AVHs should be targeted in treatment to reduce their associated negative outcomes., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Hallucinations can occur in different sensory modalities, both simultaneously and serially in time. They have typically been studied in clinical populations as phenomena occurring in a single sensory modality. Hallucinatory experiences occurring in multiple sensory systems-multimodal hallucinations (MMHs)-are more prevalent than previously thought and may have greater adverse impact than unimodal ones, but they remain relatively underresearched. Here, we review and discuss: (1) the definition and categorization of both serial and simultaneous MMHs, (2) available assessment tools and how they can be improved, and (3) the explanatory power that current hallucination theories have for MMHs. Overall, we suggest that current models need to be updated or developed to account for MMHs and to inform research into the underlying processes of such hallucinatory phenomena. We make recommendations for future research and for clinical practice, including the need for service user involvement and for better assessment tools that can reliably measure MMHs and distinguish them from other related phenomena., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin's chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin's mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860-1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: We explored common and distinct pathological features of different subtypes of auditory hallucinations (AHs) to elucidate the underlying pathological mechanisms., Methods: We recruited 39 individuals with constant commanding and commenting auditory verbal hallucinations (CCCAVHs), 49 with own thought auditory verbal hallucinations (OTAVHs), 46 with nonverbal AHs (NVAHs), 32 with replay AVHs (RAVHs), and 50 healthy controls. Functional connectivity density mapping was used to investigate global functional connectivity density (gFCD) alterations in these AH groups relative to the control group., Results: We observed common brain functional alterations among four subtypes of AHs, such as increased gFCD in the bilateral superior temporal gyrus and mesial frontal lobe, and decreased gFCD in the bilateral medial prefrontal cortex. Increased gFCD was detected in the bilateral insula in CCCAVH individuals, bilateral thalamus in OTAVH individuals, bilateral precuneus in NVAH individuals, and bilateral hippocampus in RAVH individuals. The common and distinct gFCD alterations among four AH subtypes were located in main components of the frontoparietal, default mode, salience, central executive, and memory networks. Different AH subtypes exhibited specific aberrant patterns., Conclusions: Our findings suggest that aberrant functional activity and metabolism in the abovementioned networks play key roles in the occurrence of AHs. Our findings provide evidence for distinct gFCD alterations in specific AH subtypes., (© 2019 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

Objectives: The purpose of this study was to explore associations between specific types of hallucinations and delusions and suicidal ideation in a sample of children and adolescents with bipolar I disorder., Methods: Participants (N = 379) were children and adolescents aged 6-15 years (M = 10.2, SD = 2.7) with DSM-IV diagnoses of bipolar I disorder, mixed or manic phase. The study sample was 53.8% female and primarily White (73.6% White, 17.9% Black, and 8.5% Other). Presence and nature of psychotic symptoms, suicidal ideation, and functioning level were assessed through clinician-administered measures. A series of logistic regressions was performed to assess the contribution of each subtype of psychotic symptom to the presence of suicidal ideation above and beyond age, sex, socio-economic status, age at bipolar disorder onset, and global level of functioning., Results: Hallucinations overall, delusions of guilt, and number of different psychotic symptom types were uniquely associated with increased odds of suicidal ideation after accounting for covariates. Other forms of delusions (eg, grandiose) and specific types of hallucinations (eg, auditory) were not significantly uniquely associated with the presence of suicidal ideation., Conclusions: Findings of this study suggest the presence of hallucinations as a whole, delusions of guilt specifically, and having multiple concurrent types of psychotic symptoms are associated with the presence of suicidal ideation in children and adolescents with bipolar I disorder. Psychotic symptom subtypes, as opposed to psychosis as a whole, are an under-examined, potentially important, area for consideration regarding suicidal ideation in pediatric bipolar I disorder., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

That trauma can play a significant role in the onset and maintenance of voice-hearing is one of the most striking and important developments in the recent study of psychosis. Yet the finding that trauma increases the risk for hallucination and for psychosis is quite different from the claim that trauma is necessary for either to occur. Trauma is often but not always associated with voice-hearing in populations with psychosis; voice-hearing is sometimes associated with willful training and cultivation in nonclinical populations. This article uses ethnographic data among other data to explore the possibility of multiple pathways to voice-hearing for clinical and nonclinical individuals whose voices are not due to known etiological factors such as drugs, sensory deprivation, epilepsy, and so forth. We suggest that trauma sometimes plays a major role in hallucinations, sometimes a minor role, and sometimes no role at all. Our work also finds seemingly distinct phenomenological patterns for voice-hearing, which may reflect the different salience of trauma for those who hear voices.

Background: Evidence for efficacy of cognitive-behavioural therapy (CBT) in treatment of schizophrenia is growing. CBT is effective and cost efficient in treating positive and negative symptoms. To effectively meet the needs of diverse cultural groups, CBT needs to be adapted to the linguistic, cultural and socioeconomic context. We aimed to assess the feasibility, efficacy and acceptability of a culturally adapted CBT for treatment of psychosis (CaCBTp) in a low-income country., Methods: Rater-blind, randomised, controlled trial of the use of standard duration CBT in patients with psychosis from a low-income country. Participants with a ICD-10 diagnosis of psychosis were assessed using Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Psychotic Symptom Rating Scales (PSYRATS), and the Schedule for Assessment of Insight (SAI) (baseline, 3 months and 6 months). They were randomized into the intervention group (n = 18) and Treatment As Usual (TAU) group (n = 18). The intervention group received 12 weekly sessions of CaCBTp., Results: The CaCBTp group had significantly lower scores on PANSS Positive (p = 0.02), PANSS Negative (p = 0.045), PANSS General Psychopathology (p = 0.008) and Total PANSS (p = 0.05) when compared to TAU at three months. They also had low scores on Delusion Severity Total (p = 0.02) and Hallucination Severity Total (p = 0.04) of PSYRATS, as well as higher scores on SAI (p = 0.01) at the same time point. At six months only the improvement in PANSS positive scores (p = 0.045) met statistical significance.., Conclusions: It is feasible to offer CaCBTp as an adjunct to TAU in patients with psychosis, presenting to services in a lower middle-income country., Trial Registration: Clinicaltrials.gov identifier NCT02202694 (Retrospectively registered).

Background: Auditory hallucinations are experienced by 60-80% of all patients diagnosed with a schizophrenia spectrum disorder. However, in this patient group, the prevalence of hallucinations in multiple sensory modalities, i.e. multimodal hallucinations (MMHs), is unknown., Aims: To assess the prevalence of MMHs in patients diagnosed with a schizophrenia spectrum disorder, data were analyzed from 750 patients who participated in the Dutch Genetic Risk and Outcome of Psychosis (GROUP) study., Method: We drew on the section of the CASH (Comprehensive Assessment of Symptoms and History) that probes into the lifetime presence of auditory, visual, somatic/tactile, and olfactory hallucinations., Results: A lifetime prevalence of 80% was found in this group for hallucinations in any of these modalities. Within the whole group, 27% of the participants reported unimodal hallucinations and 53% MMHs. There were no significant differences in prevalence rate for Dutch versus migrant participants from Morocco, Turkey, Surinam or the (former) Dutch Antilles., Conclusion: We conclude that MMHs, rather than auditory hallucinations, are the most frequent perceptual symptom of patients diagnosed with a schizophrenia spectrum disorder. Our data also suggest that hallucinations experienced in a single sensory modality (notably auditory ones) stochastically increase the risk for more sensory modalities to join in. We recommend that future studies take into account all 14 sensory modalities in which hallucinations can be experienced. For this we provide a classification of MMHs that allows characterization of their serial versus simultaneous occurrence and their congruent versus incongruent nature., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Many patients with psychiatric and organic disorders may present primary or secondary psychotic symptoms. Based on the ICD 10 classification, this article describes the possible underlying diseases and their subdivision. The main focus will be differential-diagnostic evaluations of psychotic syndromes., Results: In the clinical setting, the differential diagnosis of the paranoid schizophrenia and other psychotic disorders into three main disease groups is important: 1. other psychiatric diseases, 2. primary and secondary organic diseases and 3. autoimmune diseases. The first group contains, for example, drug-induced psychoses, affective disorders, personality disorders. The second group includes forms of dementia, forms of deliria or metabolic diseases. Recently, another focus is set on autoimmune diseases, especially encephalitides., Summary: A detailed medical history, a physical examination and organic diagnostic can lead to the correct diagnosis and therapy. The differential-diagnostic classification and the detection of organic causes is an important part of psychiatric care, but often a good cooperation with organic specialties is needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

This article reports on the Third Biennial Meeting of the International Consortium on Hallucinations Research, held in Melbourne, Australia, in October 2015. Following a public conference in which research findings were considered in relation to subjective experience and practice, 9 multidisciplinary working groups examined key current issues in progressing the conceptualization and research of hallucinations. Work group topics included: multicenter validation of the transdiagnostic and multimodal Questionnaire for Psychotic Experiences; development of an improved outcome measure for psychological therapies; the relationship between inhibition and hallucinations across multiple levels of explanation; hallucinations in relation to sleep phenomena; emotion and hallucinations; multiple interactions between the experience of self and hallucinations; interactions between language, auditory and memory networks; resting state networks including the default mode; and analyses arising from functional magnetic resonance imaging (fMRI) data-sharing. Major themes in hallucinations research identified during the meeting included (1) progression beyond the auditory verbal modality in schizophrenia to consider hallucinations across modalities and different populations; (2) development of new measures; (3) the central role of multisite collaboration through shared data collection and data pooling; (4) study of time-based and interactive models of hallucination; and (5) the need to increase the accessibility and availability of "real-life" interventions for people with persisting and distressing hallucinations., (© The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: This paper firstly explores the historical concept of pseudohallucinations and their phenomenology. It then examines the experience of hallucinosis in two subject groups, one with post-traumatic stress disorder with dissociative symptoms and the second with schizophrenia., Method: The two groups were assessed using the Psychotic Symptoms Rating Scale with a view to identifying differences in the hallucinatory and delusional experience., Results: There was no significant difference between the groups in loudness, control, position, duration, or frequency of the voices. Delusions and negative content differed significantly, however., Conclusions: Researchers have started to describe pseudohallucinations along a continuum. We build on this dimensional approach and suggest a collaborative nomenclature for subtyping., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Auditory hallucinations constitute a phenomenologically rich group of endogenously mediated percepts which are associated with psychiatric, neurologic, otologic, and other medical conditions, but which are also experienced by 10-15% of all healthy individuals in the general population. The group of phenomena is probably best known for its verbal auditory subtype, but it also includes musical hallucinations, echo of reading, exploding-head syndrome, and many other types. The subgroup of verbal auditory hallucinations has been studied extensively with the aid of neuroimaging techniques, and from those studies emerges an outline of a functional as well as a structural network of widely distributed brain areas involved in their mediation. The present chapter provides an overview of the various types of auditory hallucination described in the literature, summarizes our current knowledge of the auditory networks involved in their mediation, and draws on ideas from the philosophy of science and network science to reconceptualize the auditory hallucinatory experience, and point out directions for future research into its neurobiologic substrates. In addition, it provides an overview of known associations with various clinical conditions and of the existing evidence for pharmacologic and non-pharmacologic treatments., (© 2015 Elsevier B.V. All rights reserved.)

Background: The phenomenological heterogeneity of auditory hallucinations (AHs) means individual models struggle to account for all aspects of the experience. One alternative is that distinct subtypes of AHs exist, with each requiring their own unique explanatory model and tailored cognitive behavioural intervention strategies., Aims: This exploratory study tested for the presence of one specific potential AH-subtype, hypervigilance hallucinations (HV-AHs)., Method: Four specific aspects of the phenomenology of AHs (chosen on the basis of the predicted phenomenology of HV-AHs) were assessed using a semi-structured interview in 32 individual AHs taken from reports from 15 patients with psychosis., Results: Cluster analysis (at the level of the individual AH-experience) offered support for the existence of a distinct HV-AH subtype, characterized by hearing threatening, externally-located voices when attention was externally-focused. Other clusters identified all shared the contrasting properties of occurring in quiet contexts when patients' attention was internally focused., Conclusions: The results offered tentative support for the existence of an HV-AH subcategorization and justifies future research in larger samples. Potential implications for models of AHs are also considered.

Problems in psychiatric classification have impeded research into psychopathology for more than a century. Here, I briefly review several new approaches to solving this problem, including the internalizing-externalizing-psychosis spectra, the 5-factor model of psychotic symptoms, and the more recent network approach. Researchers and clinicians should probably adopt an attitude of promiscuous realism and assume that a single classification system is unlikely to be effective for all purposes, and that different systems will need to be chosen for research into etiology, public mental health research, and clinical activities. Progress in understanding the risk factors and mechanisms that lead to psychopathology is most likely to be achieved by focusing on specific types of experience or symptoms such as hallucinations., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

The phenomenological diversity of auditory verbal hallucinations (AVH) is not currently accounted for by any model based around a single mechanism. This has led to the proposal that there may be distinct AVH subtypes, which each possess unique (as well as shared) underpinning mechanisms. This could have important implications both for research design and clinical interventions because different subtypes may be responsive to different types of treatment. This article explores how AVH subtypes may be identified at the levels of phenomenology, cognition, neurology, etiology, treatment response, diagnosis, and voice hearer's own interpretations. Five subtypes are proposed; hypervigilance, autobiographical memory (subdivided into dissociative and nondissociative), inner speech (subdivided into obsessional, own thought, and novel), epileptic and deafferentation. We suggest other facets of AVH, including negative content and form (eg, commands), may be best treated as dimensional constructs that vary across subtypes. After considering the limitations and challenges of AVH subtyping, we highlight future research directions, including the need for a subtype assessment tool., (© The Author 2014. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Acute and transient psychotic disorder remains an important element of the clinical field. It was first observed by Philippe Pinel in the 19th century. Other figures, such as Philippe Chaslin and Valentin Magnan, have contributed to the identification of the disorders and a psychopathological classification. While the central clinical element of acute and transient psychotic disorder is delusion and hallucinations, its resolution can be quick or it may be a sign of the gradual onset of a psychiatric pathology.

A comprehensive understanding of the phenomenology of auditory hallucinations (AHs) is essential for developing accurate models of their causes. Yet, only 1 detailed study of the phenomenology of AHs with a sample size of N ≥ 100 has been published. The potential for overreliance on these findings, coupled with a lack of phenomenological research into many aspects of AHs relevant to contemporary neurocognitive models and the proposed (but largely untested) existence of AH subtypes, necessitates further research in this area. We undertook the most comprehensive phenomenological study of AHs to date in a psychiatric population (N = 199; 81% people diagnosed with schizophrenia), using a structured interview schedule. Previous phenomenological findings were only partially replicated. New findings included that 39% of participants reported that their voices seemed in some way to be replays of memories of previous conversations they had experienced; 45% reported that the general theme or content of what the voices said was always the same; and 55% said new voices had the same content/theme as previous voices. Cluster analysis, by variable, suggested the existence of 4 AH subtypes. We propose that there are likely to be different neurocognitive processes underpinning these experiences, necessitating revised AH models.

Psychotic symptoms are a central element in the diagnosis of schizophrenia, although their precise definition has varied through the multiple iterations of DSM and the ICD. Schneiderian first-rank symptoms (FRS) have received a particularly prominent position in the diagnostic criteria of schizophrenia since ICD-9 and DSM-III. In the current iteration of DSM (DSM-IV-TR), whereas two characteristic symptoms are ordinarily required to meet criterion A, only a single symptom is necessary if the psychotic symptom happens to be a FRS, notably a bizarre delusion or auditory hallucination of a running commentary or 'conversing voices'. Because of limited data in support of the special treatment of FRS, DSM-5 has made changes to criterion A, requiring that at least two psychotic symptoms be present in all cases with at least one of these symptoms being a delusion, hallucination, or disorganized speech. To assess the impact of these changes on the prevalence of schizophrenia, we examined a research dataset of 221 individuals with DSM-IV schizophrenia to study the prevalence and co-occurrence of various criterion A symptoms. Although bizarre delusions and/or Schneiderian hallucinations were present in 124 patients (56.1%), they were singly determinative of diagnosis in only one patient (0.46%). Additionally, only three of the 221 patients (1.4%) with DSM-IV schizophrenia did not have a delusion, hallucination, or disorganized speech. DSM-5 changes in criteria A should have a negligible effect on the prevalence of schizophrenia, with over 98% of individuals with DSM-IV schizophrenia continuing to receive a DSM-5 diagnosis of schizophrenia in this dataset., (Copyright © 2013 Elsevier B.V. All rights reserved.)

An extraordinary variety of experimental (e.g., flicker, magnetic fields) and clinical (epilepsy, migraine) conditions give rise to a surprisingly common set of elementary hallucinations, including spots, geometric patterns, and jagged lines, some of which also have color, depth, motion, and texture. Many of these simple hallucinations fall into a small number of perceptual geometries-the Klüver forms-that (via a nonlinear mapping from retina to cortex) correspond to even simpler sets of oriented stripes of cortical activity (and their superpositions). Other simple hallucinations (phosphenes and fortification auras) are linked to the Klüver forms and to pattern-forming cortical mechanisms by their spatial and temporal scales. The Klüver cortical activity patterns are examples of self-organized pattern formation that arise from nonlinear dynamic interactions between excitatory and inhibitory cortical neurons; with reasonable modifications, this model accounts for a wide range of hallucinated patterns. The Klüver cortical activity patterns are a subset of autonomous spatiotemporal cortical patterns, some of which have been studied with functional imaging techniques. Understanding the interaction of these intrinsic patterns with stimulus-driven cortical activity is an important problem in neuroscience. In line with this, hallucinatory pattern formation interacts with physical stimuli, and many conditions that induce hallucinations show interesting interactions with one another. Both types of interactions are predictable from neural and psychophysical principles such as localized processing, excitatory-inhibitory neural circuits, lateral inhibition, simultaneous and sequential contrast, saccadic suppression, and perceptual opponency. Elementary hallucinations arise from familiar mechanisms stimulated in unusual ways.

The aim of this study was to estimate the prevalence and risk factors for the development of hallucinations in patients with Parkinson's disease (PD). This cross-sectional study included 180 consecutive, non-demented patients with PD. Out of them, 24 patients (13%) experienced some kind of hallucinations. Visual hallucinations were present in 22/24 (90%) subjects. Univariate logistic regression analysis has shown relationship between presence of hallucinations and the following variables: age of patients (p = 0.025), PD duration (p = 0.001), duration of levodopa treatment (p = 0.001), total daily dose of levodopa (p = 0.033), presence of levodopa-induced dyskinesia (p = 0.002) and their duration (p = 0.021), and experience of nightmares (p = 0.042). Hallucinations were also associated with higher scores of the UPDRS (p = 0.001), HDRS (p = 0.001) and the NPI total score (p = 0.001), and higher H-Y stages of the disease (p = 0.001). Multivariate regression analysis has demonstrated that the duration of PD (p = 0.024) as well as NPI total score (p = 0.002) was significant independent risk factors for hallucinations in PD.

The objective of the study was to assess the development and evolution of visual and nonvisual hallucinations in patients with Parkinson's disease over 10 years. Hallucinations increase over time, but minimal attention has been placed on nonvisual domains. We studied 60 patients with Parkinson's disease who had never hallucinated at baseline and followed them over 10 years. The Rush Hallucination Inventory monitored frequency and type (visual, auditory, tactile, olfactory) of hallucinations at baseline and after 0.5, 1.5, 4, 6, and 10 years. Descriptive statistics were applied, and general estimating equation modeling assessed longitudinal risks. Over 10 years, visual hallucinations were endorsed by patients more frequently than other sensory modalities. Whereas isolated visual hallucinations dominated the early hallucination profile, visual plus nonvisual hallucinations accounted for progressively higher proportions of hallucinators over 10 years: 0.5 years, 0%; 4 years, 26%; 6 years, 47%; 10 years, 60% (odds ratio, 1.17; confidence interval, 1.01-1.37; P = .04). Once visual plus nonvisual hallucinations developed, the risk of continuing to have multidomain hallucinations was high (odds ratio, 3.67; confidence interval, 1.13-11.93; P = .03). Hallucination severity was highly associated with current visual plus nonvisual hallucinations (odds ratio, 4.06; confidence interval, 2.93-5.61; P < .0001) and the continuation of multidomain hallucinations (odds ratio, 1.58; confidence interval, 1.12-2.24; P = .01). Whereas visual hallucinations in isolation are classic in Parkinson's disease, nonvisual hallucinations emerge over time, and the combination of visual with nonvisual hallucinations predominates in late Parkinson's disease. To capture the breadth and severity of hallucinations in chronically hallucinating patients with Parkinson's disease, screening inventories and practice-based interviews must include questions on both visual and nonvisual components., (Copyright © 2011 Movement Disorder Society.)

The semiology of delusions and hallucinations corresponds to precise definitions. Systematised or not, their mechanisms and their themes are varied. Psychodynamic and biological approaches give an insight into the therapies to use with patients who are affected.

Background: We are rapidly increasing our knowledge about the correlates of auditory hallucinations. If we are to understand and integrate this new knowledge it is essential that the nomenclature for this special area is clear and unambiguous., Aim: To review and to re-evaluate the concept of auditory hallucinations belonging to classical psychiatry., Method: Relevant data were collected from books, PubMed, Embase and the Cochrane Library., Results: On the basis of our findings we present different classifications for auditory hallucinations., Conclusions: Our review emphasises the need for a re-appraisal of these concepts, clearer definitions and an improved nomenclature. These will make it easier to set up, conduct and interpret neurological studies of these frequently occurring phenomena.

Auditory verbal hallucinations are a cardinal symptom of schizophrenia. Bleuler and Kraepelin distinguished 2 main classes of hallucinations: hallucinations heard outside the head (outer space, or external, hallucinations) and hallucinations heard inside the head (inner space, or internal, hallucinations). This distinction has been confirmed by recent phenomenological studies that identified 3 independent dimensions in auditory hallucinations: language complexity, self-other misattribution, and spatial location. Brain imaging studies in schizophrenia patients with auditory hallucinations have already investigated language complexity and self-other misattribution, but the neural substrate of hallucination spatial location remains unknown. Magnetic resonance images of 45 right-handed patients with schizophrenia and persistent auditory hallucinations and 20 healthy right-handed subjects were acquired. Two homogeneous subgroups of patients were defined based on the hallucination spatial location: patients with only outer space hallucinations (N=12) and patients with only inner space hallucinations (N=15). Between-group differences were then assessed using 2 complementary brain morphometry approaches: voxel-based morphometry and sulcus-based morphometry. Convergent anatomical differences were detected between the patient subgroups in the right temporoparietal junction (rTPJ). In comparison to healthy subjects, opposite deviations in white matter volumes and sulcus displacements were found in patients with inner space hallucination and patients with outer space hallucination. The current results indicate that spatial location of auditory hallucinations is associated with the rTPJ anatomy, a key region of the "where" auditory pathway. The detected tilt in the sulcal junction suggests deviations during early brain maturation, when the superior temporal sulcus and its anterior terminal branch appear and merge.

Introduction: The early diagnosis of Alzheimer's disease is a new challenge. This study concerns 50 patients, 34 females (68 %) and 16 males (32 %) with Alzheimer (AD), according to NINCDS-ADRDA diagnostic criteria., Objectives: To systematically evaluate in all patients behavioral and psychological signs and symptoms of dementia (BPSSD), according to the stage of AD, with the patients of our population separated into two MMS groups., Methods: The first group was composed of patients with an MMS score from 10 to 20 (eight males and 19 females). Patients of the second group had an MMS score between 21 and 28 (eight males and 19 females). The Neuro-Psychiatric Inventory (NPI) was used to collect information on the presence of BPSSD in AD patients. NPI scores were correlated to the cognitive part of the Alzheimer's Disease Assessment Scale (ADAS-Cog) that permits evaluation of the severity of cognitive impairment in AD patients. Before starting the study, all patients gave their informed consent to participate in the study of BPSSD in AD. Statistical treatment of data was performed using STATVIEW., Results: Our study demonstrates that BPSSD are present not only in early but also in moderate stages of AD. As cognitive impairment, BPSSD are an integrate part of the clinical picture. With a frequency of 74 % for the whole population, "anxiety" represented the more predominant BPSSD for all our patients at all stages of AD. At the very early stages of AD, BPSSD appeared to precede cognitive disorders., Conclusion: The symptomatic association of "depression", "agitation", and "irritability of mood" may remain in a steady state for a few months before the appearance of verbal episodic memory impairment, which is characteristic of hippocampus involvement. "Irritability" seems to specifically characterise the initial phase of AD. On the other hand, two BPSSD are characteristic of the late stages of AD: "sleep disorder" and "hallucinations"., (Copyright © 2009 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Neuropsychiatric symptoms (NPS) affect almost all patients with dementia and are a major focus of study and treatment. Accurate assessment of NPS through valid, sensitive and reliable measures is crucial. Although current NPS measures have many strengths, they also have some limitations (e.g. acquisition of data is limited to informants or caregivers as respondents, limited depth of items specific to moderate dementia). Therefore, we developed a revised version of the NPI, known as the NPI-C. The NPI-C includes expanded domains and items, and a clinician-rating methodology. This study evaluated the reliability and convergent validity of the NPI-C at ten international sites (seven languages)., Methods: Face validity for 78 new items was obtained through a Delphi panel. A total of 128 dyads (caregivers/patients) from three severity categories of dementia (mild = 58, moderate = 49, severe = 21) were interviewed separately by two trained raters using two rating methods: the original NPI interview and a clinician-rated method. Rater 1 also administered four additional, established measures: the Apathy Evaluation Scale, the Brief Psychiatric Rating Scale, the Cohen-Mansfield Agitation Index, and the Cornell Scale for Depression in Dementia. Intraclass correlations were used to determine inter-rater reliability. Pearson correlations between the four relevant NPI-C domains and their corresponding outside measures were used for convergent validity., Results: Inter-rater reliability was strong for most items. Convergent validity was moderate (apathy and agitation) to strong (hallucinations and delusions; agitation and aberrant vocalization; and depression) for clinician ratings in NPI-C domains., Conclusion: Overall, the NPI-C shows promise as a versatile tool which can accurately measure NPS and which uses a uniform scale system to facilitate data comparisons across studies.

Introduction: The literature on the possible neurobiologic correlates of auditory hallucinations is expanding rapidly. For an adequate understanding and linking of this emerging knowledge, a clear and uniform nomenclature is a prerequisite. The primary purpose of the present article is to provide an overview of the nomenclature and classification of auditory hallucinations., Materials and Methods: Relevant data were obtained from books, PubMed, Embase, and the Cochrane Library., Results: The results are presented in the form of several classificatory arrangements of auditory hallucinations, governed by the principles of content, perceived source, perceived vivacity, relation to the sleep-wake cycle, and association with suspected neurobiologic correlates., Conclusions: This overview underscores the necessity to reappraise the concepts of auditory hallucinations developed during the era of classic psychiatry, to incorporate them into our current nomenclature and classification of auditory hallucinations, and to test them empirically with the aid of the structural and functional imaging techniques currently available.

Background: There are several clinical phenomena that resemble hallucinations which are inadequately studied because the terminology defining them is inadequate., Methods: A review of the relevant literature, identified by searches of Ovid and PubMed databases., Results: A historical review reveals that the term pseudohallucination has been used to describe several separate and unrelated phenomena. Herein this term is redefined, and an additional term, parahallucinations, is introduced. Hallucinations are defined as sensory perceptions that have the compelling sense of reality of true perceptions but that occur without external stimulation of the relevant sensory organ and are experienced as following the sensory path, that is, can be localized in three-dimensional space outside the body. Pseudohallucinations are defined as hallucinatory phenomena that do not follow the sensory path and are experienced predominantly by psychiatrically ill subjects. Parahallucinations are defined as hallucinatory phenomena that occur due to an injury or abnormality to the peripheral nervous system. Insight into the reality of these experiences-the realization that they are not real-is not felt to be important in their phenomenology., Conclusion: Utilization of this classification system during clinical investigations will yield greater insight into the pathophysiology, course, treatment, and prognosis of psychiatric and neurologic disorders.

Background: Our knowledge about the neurobiological correlates of positive visual perceptual disorders is increasing rapidly. If we are to understand and integrate this emerging knowledge, the nomenclature needs to be clear and unambiguous., Aim: To provide an overview of the different classifications of visual hallucinations to reach a better understanding of new neurobiological views in these phenomena., Method: Relevant data were obtained from books, PubMed, Embase, and the Cochrane Library., Results: The results are presented in the form of various classifications of visual hallucinations, grouped according to the following guiding principles: shape, size, content, relation to the sleepwake cycle, co-occurrence with percepts in any of the other sensory modalities, and association with neurobiological correlates. In addition, a classification system for visual illusions and distortions is presented., Conclusion: The overview emphasizes how important it is to reappraise the concepts of positive visual perceptual disorders that were developed during the era of classical psychiatry. By becoming familiar with these concepts we will find it easier to design, execute and interpret neurobiological studies of these frequently occurring phenomena.

While auditory hallucinations (AH) are prototypic psychotic symptoms whose clinical presence is often equated with a psychotic disorder, they are commonly found among those without mental illness as well as those with nonpsychotic disorders not typically associated with hallucinations in DSM-IV. This incongruity presents a significant challenge for clinical work and efforts to revise the next iteration of the DSM. Auditory hallucinations found among "normal" people suggest that either AH are not as pathologic as they are typically taken to be, or that less-than-hallucinatory experiences are routinely mischaracterized as AH. Such hallucinations in the context of conversion disorder, trauma, sensory deprivation, and certain cultural settings strengthen an association between AH and psychopathology but suggest limited diagnostic specificity and relevance. It may be useful to think of AH like coughs-common experiences that are often, but not always, symptoms of pathology associated with a larger illness. Although these issues have been known for many years, they are rarely discussed in American psychiatry and need to be addressed in future research and clinical work.

Epileptic populations are generally considered inappropriate to investigate hemispheric specialization. However, (1) because hallucination occurs in the early stage of the ictus during which activation is observed in and around the focus, the former could be a direct result of the latter (hypothesis 1), and (2) the type of psychological content of ictal hallucination could depend on which hemisphere is ictally activated (hypothesis 2). It was predicted that, on the basis of quantitative analysis of previously published singles case reports, unilateral ictal hallucinations should occur in the visual field, ear or hemibody contralateral to the side of the ictal focus (test of hypothesis 1). It was also predicted that verbal ictal auditory hallucinations should result more often from left hemisphere foci, and non-verbal auditory ictal hallucinations from right hemisphere foci (test of hypothesis 2). Previously published cases (N=217) of ictal hallucination from a unilateral epileptic focus were reviewed and analyzed with multivariate statistics. Both predictions were strongly supported.

This paper reviews the presence of psychotic features in the nonclinical population. The results of a literature review suggest that delusional and hallucinatory experiences are more common in the general population than we may think, and that there could well be a symptomatic continuum between people who have and people who have not been diagnosed with indisputable psychotic disorders. In the nonclinical population, voices are mainly positive and nonthreatening. Conversely, in the psychiatric population, they tend to be frequent, intrusive, and distressing. We address the question of voices considered as various human experiences and describe the emergence of the nonclinical group of people who hear voices. We also review the pathophysiology of auditory hallucinations as an illustration of a neurophysiological anomaly, which is useful to understand psychosis or schizophrenia. The main obstacle in the category-specific thought is that it remains impossible to unmistakably demarcate the border around schizophrenia. It is evident that the creation of a boundary is always possible by using arbitrary criteria that improve interrater reliability but exclude a considerable number of people who share multiple common features with diagnosed people.

Objective: To review the evidence from empirical studies regarding the validity of 'post-traumatic stress disorder with secondary psychotic features' (PTSD-SP) as a separate diagnostic entity., Method: The authors performed a review tracing publications between 1980 and January 2008., Results: Twenty-four comparative studies were included. These studies indicate that PTSD-SP is a syndrome that comprises PTSD-symptoms followed in time by the additional appearance of psychotic features. The psychotic features are not confined to episodes of re-experiencing, but remain present continuously. PTSD-SP seems to have some biological features differentiating it from schizophrenia and PTSD, e.g. there are differences in smooth pursuit eye movement patterns, concentrations of corticotropin-releasing factor and dopamine beta-hydroxylase activity., Conclusion: There is currently not yet full support for PTSD-SP as a nosological entity. However, the delineation of PTSD-SP from other psychiatric syndromes is notable and biological studies seem to support the validity as a separate diagnostic entity.

Objective: The aim of this study was to verify the existence of areas of clinical and neurofunctional homogeneity in a group of patients with auditory verbal hallucinations (AVHs) as an isolated symptom, attributable to what we have called "Hallucinatory Disorder" (HD) in an attempt to propose a clinical picture that is distinct from Schizophrenia., Method: Nine patients clinically characterised by chronic AVHs were compared with nine schizophrenic patients using the Structured Clinical Interview for DSM-III-R, BPRS, PANSS, SAPS, SANS, HRS-A, HRS-D, CDSS, MMSE, CGI and PSYRATS. Both groups of patients and nine healthy subjects underwent EEG and SPECT examinations., Results: Considering the psychopathological dimensions of Schizophrenia, in the HD patients clinical evaluations revealed a mono-dimensional clinical profile, whereas all these dimensions contributed to the clinical picture of the schizophrenic patients. The SPECT data showed that the schizophrenic patients had a reduced rCBF in some areas of the right frontal lobe, while the HD patients did not show any area of hypoperfusion. The SPECT hyperperfusion data showed an activation pattern in the HD patients that was characterised by the involvement of various cortical and subcortical cerebral areas, similar to those found in studies of inner speech and auditory verbal imagery., Conclusions: The two groups of patients present significant differences that seem capable of supporting the proposed hypothesis that HD may be an independent nosographical entity.

The authors review current literature on hallucinations in Parkinson's disease (PD). Recent neuropathological studies showed that hallucinations occur in synucleinopathies and are a significant predictor of Lewy Body depositions. Therefore, hallucinations are a hallmark of PD and of dementia with Lewy Bodies. Visual hallucinations are mostly complex and kinematic; preserved or disturbed insight on the nature of hallucinations is a major prognostic factor, although eventually all hallucinators will present with reduced insight. Current theories on the origin of hallucinations point to visual dysfunction, dream overflow and cognitive impairment, yet objection can be raised on each one of the putative models of hallucinations. Understanding of the origin of hallucinations is required in order to develop treatments: all treatment evaluations were focused in general on psychosis, and only clozapine obtained positive evidence-based ratings on efficacy. However, it is likely that cholinesterase inhibitors, antipsychotics and anti-5-hydroxytryptamine(3) agents and drugs acting on sleep regulation will have different and perhaps opposite effects on different types of hallucinations, whether they are accompanied by disturbed insight, sleep disorders or other psychotic features. Further studies will try to separate phenomenology and responses to treatment and will investigate the relevance of concomitant sleep disorders and abnormality of frontoparietal networks involved in the attention process.

Objective: The aim of this study is to determine empirically a possible classification of psychotic symptoms, and identify the frequency of such symptoms in dementia with Lewy bodies (DLB)., Methods: This was a clinical study of prospectively observed patients from the memory clinic at Shiga Medical Center. The authors conducted a factor analysis of psychotic symptoms in 96 probable DLB and 4 possible DLB patients, clinically diagnosed according to the consensus criteria, were included., Results: Four factors were obtained. Factor 1 was closely akin to misidentifications, including Capgras syndrome, phantom boarder, and reduplication of people and places. Factor 2 consisted of reduplication of people, the belief that deceased relatives are still alive, and the belief that absent relatives are in the house, which was classified as a type of misidentification or paramnesia. Factor 3 was akin to visual hallucinations of nonhuman objects, and factor 4 mirrored the hallucination of people and feeling of presence. Delusions were independent of these factors. Following the results of factor analysis, the rates of each symptom group were identified. Hallucinations were the most frequent psychotic symptom in DLB (78%), followed by misidentifications (56%) and delusions (25%)., Conclusion: This study suggested that hallucinations, misidentifications, and delusions should be separately considered in understanding of underlying pathophysiology or psychopathology of DLB.

Cenesthesia is portrayed as a rare differential diagnosis to persistent idiopathic facial pain, including the resulting therapy with antipsychotics. In this case report a female patient developed persistent facial pain 2 years after manifestation of a depressive disorder. The symptoms appeared as a bizarre pain phenomenon closely resembling the psychotic phenomenon of cenesthesia (body hallucinations). Treatment with imipramine and doxepin or a combination of venlafaxin, carbamazepine, and tilidine N had not been successful. Based on diagnostic classification of the complaint as cenesthesia in the context of a depressive disorder, add-on therapy of the atypical antipsychotic ziprasidone was administered. This led to clear improvements in mood and pain symptoms after 4 weeks of treatment.

Objective: We compared brain perfusion image using 3D-SSP analysis of (123)I-IMP SPECT between Parkinson's disease patients with auditory verbal hallucination and those without auditory hallucination., Methods: Eighty-three cases with Parkinson's disease were studied. In 6 of these patients, auditory hallucination was noted. Among them, four cases had verbal hallucination and two other cases had elementary hallucination. Auditory hallucination was not found in the other 77 cases., Results: Right thalamic perfusion was significantly increased in the verbal hallucination group compared to the group that lacked auditory hallucination., Conclusion: In Parkinson's disease, the right thalamic hyperactive state may be related to verbal hallucination.

A case series of 10 patients with a diagnosis of borderline personality disorder (BPD) presenting with auditory hallucinosis is examined. In this series, the hallucinations were persistent, longstanding, and a significant source of distress and disability. Extrapolating from this series to our sample of 171 patients with BPD suggests that a form of auditory hallucinosis may occur in almost 30% of this population. The failure to emphasize this phenomenon in current systems of classification risks misdiagnosis or inappropriate treatment. Use of terms such as pseudohallucination or quasi hallucination dismisses the phenomenon as unimportant or as "not real." There is an emerging literature on the frequency of hallucinosis among nonpatients. A basis for understanding different forms of hallucination is discussed with reference to the concept of "normativity." We propose a nomenclature for hallucinosis that is expressed in positive terms, reflecting the clinical significance of the phenomenon in different contexts: (1) normative hallucinosis, (2) traumatic-intrusive hallucinosis (as in our series), (3) psychotic hallucinosis, and (4) organic hallucinosis.

To study prevalence of hallucinations in patients with Parkinson's disease (PD) during a 1-year period, and identify factors predictive of the onset of hallucinations in patients who were hallucination-free at baseline, 141 unselected outpatients with PD were evaluated prospectively for a set of demographic, clinical, and therapeutic variables and the presence of hallucinations during the previous 3 months. Patient groups were compared with nonparametric tests, and logistic regression was applied to significant data. Follow-up data were available for 127 patients. The hallucination prevalence rates (%) at the first and second evaluation were, respectively, 41.7 and 49.6 for hallucinations of all types (NS), 29.1 and 40.2 for minor hallucinations (i.e., presence or passage hallucinations, and illusions) (P = 0.02), 22.8 and 21.2 for formed visual hallucinations (NS), and 8.7 and 8.7 for auditory hallucinations (NS). Hallucinations rarely started or ceased during the study. The most labile forms were minor hallucinations, which developed in 20% of patients and ceased in 9%. During follow-up, 15% of patients started to hallucinate. Three factors, all present at the first evaluation, independently predicted the onset of hallucinations in patients previously free of hallucinations at baseline (odds ratio; 95% confidence interval): severe sleep disturbances (14.3; 2.5-80.9), ocular disorders (9.1; 1.6-52.0), and a high axial motor score (5.7; 1.2-27.4). Hallucinations have a chronic course in most parkinsonian patients. Factors predicting the onset of hallucinations point to a role of extranigral brainstem involvement and a nonspecific, facilitating role of ocular disorders., (Copyright 2004 Movement Disorder Society.)

Several reports emphasize the importance of differentiating between psychosis in schizophrenia and the psychotic form of narcolepsy. The failure to identify narcolepsy leads to the labeling of patients as refractory to standard treatments for schizophrenia and retards consideration of intervention for narcolepsy in which psychosis can improve with psychostimulant treatment. Psychosis in patients with narcolepsy can occur in three ways: (i) as the psychotic form of narcolepsy with hypnagogic and hypnopompic hallucinations; (ii) as a result of psychostimulant use in a patient with narcolepsy; and (iii) as the concurrent psychosis of schizophrenia in a patient with narcolepsy. The present case report describes a difficult-to-treat patient who likely had concurrent schizophrenia and narcolepsy. It then summarizes the literature related to the treatment of the three types of patients with psychosis associated with narcolepsy.

Based on a series of self-reports of a previously undescribed and undocumented experiential event, we are postulating the existence of a newly identified state of consciousness, daytime parahypnagogia (DPH). DPH is more likely to occur when one is tired, bored, suffering from attention fatigue, and/or engaged in a passive activity. Individuals describe DPH as a transient and fleeting episode that is dissociative, trance-like, dreamlike, uncanny, and often pleasurable; but, unlike a daydream, it is not self-directed. A DPH episode is spontaneous and may consist of a flash image, thought, and/or creative insight that is quickly forgotten. However, the individual remains aware of having had a DPH experience. This paper details the experiential characteristics associated with DPH. Through a brief review of the literature, the authors differentiate DPH from related phenomena and establish DPH as a unique and distinct altered state of consciousness.

We systematically reviewed the localization of focal brain lesions that cause isolated hallucination in a single sensory modality. Case reports of post-lesion nonparoxysmal hallucination in 1 (and only 1) of 3 sensory modalities (i.e., visual, auditory, somatic) were reviewed, and the content of the qualitative descriptions was analyzed for each modality. The lesion is practically always located in the brain pathway of the sensory modality of the hallucination. There seem to exist localized sensory brain circuits that in healthy people diminish the intensity of internal sensory representation. After a lesion, hallucinosis seems to be caused also by compensatory overactivation of tissue in the nearby brain sensory pathway. This type of hallucination may indeed be termed a "release" form, whereby patients are aware of the hallucinatory nature of their experience, but not usually of "dream centres" as proposed by Lhermitte. Instead, we propose that it is dreaming that should be considered a special case of neural "release."

Objective: The aim of this study was to determine whether reported childhood sexual abuse is related to the severity of symptoms in patients who experience auditory hallucinations., Method: A sample of 26 adult male and females with psychotic disorders involving auditory hallucinations were interviewed and were asked to complete three self-report measures: the Dissociative Experiences Scale (DES-II and DES-taxon versions); the Beck Depression Inventory (BDI); and the Beliefs About Voices Questionnaire (BAVQ). They were also asked about any history of sexual abuse in childhood., Results: A history of childhood sexual abuse was reported by 10 of the 26 patients (38.5%), and was associated with higher levels of depression and dissociation, as well as being linked to a tendency to regard the voices as more malevolent. The same three features were all associated with the age at first reported abuse, with a younger age of first experience being related to higher levels of psychopathology in all instances., Conclusions: These results require replication and refinement in future research, but indicate a need for greater attention to be paid to the possible role of childhood sexual abuse when understanding and treating auditory hallucinations.