Online Exclusive

Hallucinations: The Ultimate Betrayal of the Mind

Hallucinations are false sensory perceptions that are unrelated to outside events.  Essentially, a hallucination is seeing, hearing, tasting, feeling, or smelling something that does not exist while a person is awake and conscious.

Have you ever experienced a physical feeling (floating, falling, paralyzed), a smell or taste (chocolate, bacon, maple syrup), a sound (your name being called, a doorbell ringing), or seen images (random speckles, lines, tunnels of light, geometrical patterns), as you are falling asleep or before awakening?  These vivid sensations are known hypnopompic or hypnogogic states.  They are not uncommon or dangerous, and they are not considered true hallucinations if you are not awake.  However, they do set up a framework to understand what it feels is like to hallucinate.

Hallucinations can be amusing and/or pleasant, annoying and/or frightening.   Hallucinations can also lead to violence, suicide and homicide.  Take the case of an English serial killer, Peter Sutcliffe (The Yorkshire Killer), who in 1981was convicted of murdering thirteen women because loud hallucinations had instructed him to kill them.  Sutcliffe believed he was the instrument of God’s wrath on earth and waged a holy war against immorality.   His delusional system centered on the belief that God had given him a mission to rid the world of prostitutes.

The primary sensory hallucinations that individuals experience are auditory (hearing voices when no one has spoken), visual (seeing something that isn’t there), or tactile (feeling a crawling sensation on the skin). Hallucinations related to smell or taste are rarer. Some people experiencing hallucinations may be aware that the perceptions are false; whereas others may truly believe that what they are seeing, hearing, tasting, feeling, or smelling is real.

Hallucinations should not be confused with illusions or delusions.  Hallucinations are false sensory perceptions of things that are not there.  Illusions are misperceptions of sensory things that are in fact there.  Delusions are deeply fixed beliefs maintained by an individual despite contradictory information or evidence.  Individuals who experience auditory hallucinations frequently also have a paranoid delusional disorder.

Common Causes of Hallucinations

There are numerous medical and psychiatric causes of hallucinations.  Hallucinations have been a hallmark of mental illness throughout time. They may be present in any of the following mental disorders: psychotic disorders, bipolar disorder, psychotic depression, PTSD, delirium, or dementia. Up to 75% of schizophrenic patients admitted for treatment report hallucinations.

Hallucinations can be symptoms of medical or neurological disorders; liver failure, kidney failure, AIDS, brain cancer, Parkinson’s disease, strokes, tumors, fever and seizures.  Or they can be symptoms of sensory disorders such as blindness and deafness. 

Additionally, the use of certain recreational drugs may induce hallucinations: amphetamines, cocaine, hallucinogenics (ecstasy, LSD, psilocybin), PCP, steroids, and certain potent types of marijuana. Withdrawal from alcohol, sedatives, narcotics, hypnotics, or anxiolytics can also cause hallucinations.  Occasionally, after repeated ingestion of drugs, some people experience "flashbacks"; spontaneous visual hallucinations during a drug free state, often months or years later.

Hallucinations can occur in people who are not mentally or physically ill. Sensory, sleep, food, and water deprivation can produce hallucinations. Transitioning from sleep to wakefulness and vice versa can also result in hallucinations.  In some cases, hallucinations may be normal. For example, hearing the voice of, or briefly seeing, a loved one who has recently died can be a part of the grieving process.

Types of Hallucinations: 

Auditory:  Auditory hallucinations are by far the most common type and are most often caused by schizophrenia or other psychoses.   An auditory hallucination (AH) is the false perception of sound, music, noises, or voices. Hearing voices when there is no auditory stimulus is the most common type of auditory hallucination in mental disorders. AH can be vague (humming or indistinguishable murmuring), fragmentary (words or phrases that are repeated such as "fag", "fat whore", "go to hell", or "get him"), or complex (hearing a voice or voices talking to an individual or talking about him/her or providing a running commentary about them. Typically voices are mocking, critical, condescending and disparaging. Often these voices warn the subject of perceived danger, including conspiracy theories that place him/her in imminent danger. Auditory hallucinations can also take the form of voices or other sounds which may or may not be distressing to the subject at all. In fact, 13% of individuals who experience AH find the voices to be soothing and calming.  Auditory hallucinations may be experienced as coming from within one's body or from without.  Voices heard outside one's own head are generally considered more severe. These voices can range from being amusing, to offensive, to controlling, or even commanding. The intensity, frequency and volume of auditory hallucinations are quite variable; soft or loud, continuous or infrequent. The subject may recognize the voice(s) as someone familiar or not at all.

Command Auditory Hallucinations:  A command hallucination is when a voice tells an individual to carry out a specific act(s). A person experiencing this kind of hallucination frequently feels under a powerful obligation to carry out such actions. The results are often devastating. Approximately 30% of schizophrenics have command hallucinations in which they feel they must do what the voice tells them to do. Studies indicate between 22-58% (the best estimate is 40%) of these individuals report that they have complied with such commands. Statistically, over 50% of command hallucinations are to commit suicide, 10% for homicide, and 10% for some other non-lethal injury. Command hallucinations are a compelling predictor of violence. Suspects who experience command hallucinations to harm others are more than twice as likely to be violent. This risk is increased if the command voice is familiar, especially that of a close family member such as a parent.

Visual:  A visual hallucination (VH) is a false perception of sight. VH are the second most common type of hallucination in psychotic disorders such as schizophrenia (24-72%).  The content of the hallucination may be anything (such as shapes, colors, shadows, flashes of light) but are typically people or human-like figures.  Disturbing examples include faces morphing in a mirror, corpses, the headline “Death” on every newspaper, vicious/wild animals, etc.  Visual hallucinations are also commonly experienced in alcohol and drug related psychoses; seeing rats, snakes, insects, tiny people.  Organic brain disorders (dementia), Parkinson’s disease, Charles Bonnet syndrome, sensory deprivation, cataracts, macular degeneration or glaucoma can also cause visual hallucinations.    Sensory deprivation, hearing loss or deafness may also trigger auditory hallucinations.

Tactile:  A tactile hallucination (TH) is a false perception or sensation of touch or of something happening in or on the body. The most common tactile hallucination is feeling like something is crawling under or on the skin, known as formication. Formication hallucinations are characteristic of cocaine/amphetamine intoxication, and alcohol/ benzodiazepines withdrawal.  Other examples include tingling, burning, itching, feeling electricity through the body, and feeling a phantom limb after an amputation. Schizophrenics experiencing TH, frequently have comorbid paranoid delusions (machines or microchips planted by the government under the skin or the brain, skin itching from radioactivity beamed at them from a hostile source.).  Tactile hallucinations are also seen in certain medical disorders; peripheral neuropathy, fever, Lyme disease, and skin cancer.

Gustatory:  A gustatory hallucination is the false perception of taste. These hallucinations re experienced as strange tastes in something they are eating or drinking; pizza tasting like blueberries or meat tasting like bleach.  Usually, the experience is unpleasant. For instance, an individual may complain of a persistent taste of metal, onions, etc. This type of hallucination is rare and is more commonly seen in some medical disorders (frontal lobe epilepsy, brain tumors, and migraines) than in mental disorders. 

Olfactory:  An olfactory hallucination is a false perception of odor or smell. Typically, the experience is very unpleasant. For example, the person may smell decaying fish, dead bodies, burning rubber, feces, rotting manure, or sulfur. The scent is frequently indescribable.  Sometimes, those experiencing olfactory hallucinations believe the odor emanates from them. Olfactory hallucinations often accompany gustatory hallucinations and are more typical of medical disorders than mental disorders. 

Treatment for Hallucinations

Hallucinations that are symptomatic of a mental illness should be treated by a psychiatrist. Anti-psychotic medications are effective in reducing and often eliminating hallucinations; Haldol, Thorazine, Clozaril, Risperdal, etc.  When the hallucinations are part of a medical disorder, it is necessary to treat the underlying condition, remove the causative agent, and add antipsychotic medications.

Implications for Law Enforcement

If someone begins to hallucinate and is detached from reality, a prompt medical evaluation should be sought.   Many medical and psychiatric conditions that can cause hallucinations may quickly become emergencies.  People who are hallucinating may become agitated, paranoid, and frightened.  They should never be left alone.  Assess for signs and symptoms of excited delirium, if ED is suspected, advanced life support paramedics should be called to stand by.

If an individual is mentally ill, acutely psychotic and experiencing hallucinations, it is crucial to remember that you, your partners, and others may be in harm's way. The presence of command hallucinations is a heads-up to exercise superior cautionary skills. Usually violence against officers by a psychotic individual is related to the subject's misinterpretation of the officers' intent, equipment, and a feeling of being cornered.  The subject’s perception of law enforcement presence may also be based on the command hallucinations he/she is experiencing, a voice telling the individual “Kill him before he kills you”.  If the subject is actively violent or threatening there is no question that you should respond with the appropriate level of force. Command hallucinations of violence are a definitive indicator that the subject requires psychiatric inpatient hospitalization. Inform emergency department staff of the violence potential so that they can institute appropriate restraints.

If the situation is secure, and if no one can be accidentally harmed, you should adopt a non-threatening and non-confrontational stance with the subject.  Remove distractions and disruptive people from the scene.  One officer should try to establish rapport and speak with the subject. Back up, slow down, don’t crowd or force eye-contact, do not posture, and maintain a calm and confident composure.  Speak simply and briefly, giving clear and firm directions. Do not give the subject multiple choices; this will only further confuse him/her. Understand that a rational conversation may not take place. Ask about his/her hallucinations, but do not challenge them. Get updates on what the voice is currently telling the subject.

Don't forget to run a criminal check. Does the subject have a criminal record?  Does he/she have a history of substance abuse?  Is the subject under the influence, or in possession of illegal drugs? Any wants/warrants? This will help you determine if it is best for this individual to get his/her psych services from a hospital or from jail.


About The Author:

Pamela Kulbarsh, RN, BSW has been a psychiatric nurse for over 25 years. She has worked with law enforcement in crisis intervention for the past ten years. She has worked in patrol with officers and deputies as a member of San Diego's Psychiatric Emergency Response Team (PERT) and at the Pima County Detention Center in Tucson. Pam has been a frequent guest speaker related to psychiatric emergencies and has published articles in both law enforcement and nursing magazines.