Hallucinations: Common features

and causes
Awareness of manifestations,
nonpsychiatric etiologies can
help pinpoint a diagnosis

N
ot all patients who experience hallucinations
have a psychotic disorder. Many physical and
psychiatric disorders can manifest with hal-
lucinations, and some patients have >1 disorder that
could cause different types of hallucinations. To avoid
providing unnecessary or ineffective treatments—and
to ensure that patients receive proper care for nonpsy-
chiatric conditions—it is important to accurately diag-
nose the disorder causing a patient’s hallucinations.
In this article we describe common features and psy-
chiatric and nonpsychiatric causes of auditory, visual,
© IMAGEZOO/CORBIS

olfactory, gustatory, tactile, and somatic hallucinations.

Awareness of typical presentations of hallucinations
associated with specific disorders can help narrow the
diagnosis and provide appropriate treatment.
Shahid Ali, MD
Assistant Professor, Clinical Psychiatry
Milapkumar Patel, MD Auditory hallucinations
Research Associate Also known as paracusia, auditory hallucinations are
Jaymie Avenido, MD perceptions of sounds without identifiable external
Research/Forensic Psychiatry Associate
stimuli. This type of hallucination has various causes
Rahn K. Bailey, MD, FAPA
Associate Professor (Table 1).1 A frequent symptom of schizophrenia, audi-
Shagufta Jabeen, MD tory hallucinations can cause substantial distress and
Assistant Professor, Clinical Psychiatry functional disability.2 Approximately 60% to 90% of pa-
Wayne J. Riley, MD, MPH, MBA, MACP tients with schizophrenia and up to 80% of those with
Professor of Family Medicine
affective psychoses experience auditory hallucinations.1
••••
Auditory hallucinations in psychosis usually are
Department of Psychiatry and Behavioral Sciences
formed and complex.3 A common manifestation is
Meharry Medical College
Nashville, TN hearing ≥1 voices. A patient might experience 2 voic-
es talking about him in the third person. The voices
Current Psychiatry
22 November 2011 may be perceived as coming from inside or outside
the patient’s head. Some might hear their Table 1
own thoughts spoken aloud. According to
DSM-IV-TR, “hearing voices” is sufficient Common causes of auditory
to diagnose schizophrenia if the hallucina- hallucinations
tions consist of a voice keeping up a run- Peripheral lesions
ning commentary on the person’s behavior Middle ear disease
or ≥2 voices conversing with each other.4
Inner ear disease
Auditory hallucinations also are seen in
Auditory nerve disease
mood disorders but tend to be milder than
CNS disorders
their psychosis-induced counterparts.
Temporal lobe epilepsy
Simple (unformed) auditory halluci-
nations—referred to as tinnitus—can be Pontine lesions

caused by disease of the middle ear (oto- Stroke

sclerosis) or inner ear. These unformed hal- Arteriovenous malformations
lucinations consist of buzzing or tones of Syncope
varying pitch and timbre.1 Toxic metabolic disturbances
Partial seizures may cause auditory Alcoholic hallucinosis Clinical Point
hallucinations. Perceptions of music have Delirium Auditory perceptions
been associated with partial seizures.5 Hallucinogens
of music have been
Curie and colleagues found that 17% of 514 Schizophrenia
patients with temporal lobe epilepsy had associated with
Mania
auditory hallucinations as a component
Psychotic depression
partial seizures
of their seizures.6 These hallucinations
Dissociative identity disorder
typically are brief, stereotyped sensory
Posttraumatic stress disorder
impressions and, if formed, may be trivial
Source: Reference 1
sentences, previously heard phrases, or
commands.
Alcoholic hallucinosis is a hallucinatory
syndrome caused by alcohol withdrawal. may consist of formed images (eg, people)
These hallucinations usually are vocal and or unformed images (eg, flashes of light).12
typically consist of accusatory, threaten- Visual hallucinations occur in numerous
ing, and/or critical voices directed at the ophthalmologic, neurologic, medical, and
patient.1 Patients with alcohol hallucino- psychiatric disorders (Table 2, page 24).13
sis also may experience musical auditory DSM-IV-TR lists visual hallucinations
hallucinations.7,8 as a primary diagnostic criterion for sev-
CNS neoplasms can produce auditory eral psychotic disorders, including schizo-
hallucinations in 3% to 10% of patients.9 phrenia and schizoaffective disorder,4 and
Hemorrhages and arteriovenous malfor- they occur in 16% to 72% of patients with
mations in the pontine tegmentum and these conditions.14,15 Patients with major
lower midbrain have been associated with depressive disorder or bipolar disorder
acute onset of auditory hallucinations. The also may experience visual hallucinations.
sounds typically are unformed mechanical Visual hallucinations in those with schizo-
or seashell-like noises or music.10 phrenia tend to involve vivid scenes with
Patients with migraines rarely report family members, religious figures, and/or
auditory hallucinations. When they occur, animals.16
they typically consist of perceived unilat- Delirium is a transient, reversible cause
eral tinnitus, phonophobia, or hearing loss. of cerebral dysfunction that often presents
with hallucinations. Several studies have
shown that visual hallucinations are the
Visual hallucinations most common type among patients with
Visual hallucinations manifest as visual delirium. Webster and Holroyd found vi-
sensory perceptions in the absence of ex- sual hallucinations in 27% of 227 delirium
Current Psychiatry
ternal stimuli.11 These false perceptions patients.17 Vol. 10, No. 11 23
continued
 Table 2 These simple visual hallucinations are
most common; more complex hallucina-
Common causes of visual tions are seen more frequently in migraine
hallucinations coma and familial hemiplegic migraine.
Neurologic disorders
Approximately 5% of patients with
epilepsy have occipital seizures, which al-
Migraine
most always have visual manifestations.
Epilepsy
Hallucinations Epileptic visual hallucinations often are
Hemispheric lesions simple, brief, stereotyped, and fragmen-
Optic nerve disorders tary. They usually consist of small, bright-
Brain stem lesions (peduncular hallucinosis) ly colored spots or shapes that flash.22
Narcolepsy Complex visual hallucinations in epilepsy
are similar to hypnagogic hallucinations
Ophthalmologic diseases
but are rare. Intracranial electroencepha-
Glaucoma
lography recordings have shown that
Retinal disease pathological excitation of visual cortical
Clinical Point Enucleation areas may be responsible for complex vi-
Up to one-half Cataract formation sual hallucinations in epilepsy.19
Choroidal disorder Dementia with Lewy bodies (DLB) is
of patients with
Macular abnormalities associated with visual hallucinations.23
Parkinson’s disease Visual hallucinations occur in >20% of pa-
Toxic and metabolic conditions
may experience tients with DLB.24 Patients with DLB may
Toxic-metabolic encephalopathy
visual hallucinations see complex scenarios of people and items
Drug and alcohol withdrawal syndromes that are not present. Visual hallucinations
Hallucinogens have an 83% positive predictive value for
Schizophrenia distinguishing DLB from dementia of the
Affective disorders Alzheimer’s type.25 There is a strong cor-
Conversion disorders
relation between Lewy bodies located in
the amygdala and parahippocampus and
Sensory deprivation
well-formed visual hallucinations.26
Sleep deprivation
Visual hallucinations are common in
Hypnosis Parkinson’s disease and may occur in
Intense emotional experiences up to one-half of patients.27 Patients with
Source: Reference 13 Parkinson’s disease may experience hallu-
cinations similar to those observed in DLB,
which can range from seeing a person or
animal to more complex, formed, and mo-
Delirium tremens typically is accom- bile people, animals, or objects.
panied by visual hallucinations. Visions
of small animals and crawling insects are
common.18 Hallucinations due to drug in- Olfactory hallucinations
toxication or withdrawal generally vary Also known as phantosmia, olfactory hal-
in duration from brief to continuous; such lucinations involve smelling odors that
ONLINE
ONLY experiences often contribute to agitation.19 are not derived from any physical stimu-
Migraines are a well-recognized cause lus. They can occur with several psychi-
Discuss this article at of visual hallucinations. Up to 31% of those atric conditions, including schizophrenia,
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with migraines experience an aura, and depression, bipolar disorder, eating dis-
CurrentPsychiatry
nearly 99% of those with aura have visual orders, and substance abuse.28 Olfactory
symptoms.20,21 The classic visual aura starts hallucinations caused by epileptic activity
as an irregular colored crescent of light are rare. They constitute approximately
with multi-colored edges in the center of 0.9% of all auras and typically are described
the visual field that gradually progresses as unpleasant. Tumors that affect the me-
Current Psychiatry
24 November 2011 toward the periphery, lasting <60 minutes. dial temporal lobe and mesial temporal
sclerosis are associated with olfactory hal-
lucinations.29 Olfactory hallucinations also Related Resource
have been reported in patients with multi- • Teeple RC, Caplan JP, Stern TA. Visual hallucinations: differ-
ential diagnosis and treatment. Prim Care Companion J Clin
infarct dementia, Alzheimer’s disease, and Psychiatry. 2009;11(1):26-32.
alcoholic psychosyndromes. In patients Disclosures
with schizophrenia, the smell may be per- Drs. Ali, Patel, Avenido, Bailey, and Jabeen report no financial
ceived as coming from an external source, relationship with any company whose products are men-
tioned in this article or with manufacturers of competing
whereas patients with depression may products.
perceive the source as internal.30 Patients Dr. Riley is on the board of directors for Vertex Pharmaceuticals.
who perceive that they are the source of
Acknowledgment
an offensive odor—a condition known as The authors would like to thank Marwah Shahid, Research
olfactory reference syndrome—may wash Associate, Vanderbilt University, Nashville, TN.
excessively, overuse deodorants and per-
fumes, or become socially withdrawn.30

Tactile hallucinations have been associ-

Gustatory hallucinations ated with obsessive-compulsive disorder Clinical Point
Patients with gustatory hallucinations may (OCD).37 Fontenelle and colleagues suggest- Sinus diseases
experience salivation, sensation of thirst, or ed that OCD and psychotic disorders may
have been linked
taste alterations. These hallucinations can share dysfunctional dopaminergic circuits.37
be observed when the sylvian fissure that to olfactory
extends to the insula is stimulated electri- and gustatory
cally.31 Similar to olfactory hallucinations, Somatic hallucinations hallucinations
gustatory hallucinations are associated Patients who have somatic hallucinations
with temporal lobe disease and parietal report perceptions of abnormal body sen-
operculum lesions.31,32 Sinus diseases have sations or physical experiences. For exam-
been associated with olfactory and gusta- ple, a patient may have sense of not having
tory hallucinations.33 Brief gustatory hallu- a stomach while eating.35
cinations can be elicited with stimulation This type of hallucination has been asso-
of the right rolandic operculum, parietal ciated with activation of postcentral gyrus,
operculum, amygdala, hippocampus, me- parietal operculum, insula, and inferior pa-
dial temporal gyrus, and anterior part of rietal lobule on stereoelectroencephalogra-
right temporal gyrus.34 phy.34 In a study of cerebral blood flow in 20
geriatric patients with delusional disorder,
somatic type who were experiencing so-
Tactile hallucinations matic hallucinations, positron emission test-
These hallucinations may include percep- ing scan demonstrated increased perfusion
tions of insects crawling over or under the in somatic sensory processing regions, par-
skin (formication) or simulation of pressure ticularly the left postcentral gyrus and the
on skin.35 They have been associated with right paracentral lobule.38 Other researchers
substance abuse, toxicity, or withdrawal.28 have linked somatic hallucinations with ac-
Tactile hallucinations are characteristic of tivation in the primary somatosensory and
cocaine or amphetamine intoxication.35 posterior parietal cortex, areas that normal-
Tactile hallucinations are a rare symp- ly mediate tactile perception.39
tom of schizophrenia. Heveling and col-
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Bottom Line
Auditory, visual, olfactory, gustatory, tactile, and somatic hallucinations can
be caused by a wide range of physical and psychiatric conditions. Awareness of
common presentations of hallucinations associated with specific disorders can
Current Psychiatry
help narrow the diagnosis and lead to more efficacious treatment. Vol. 10, No. 11 29