As I think back over my training as a psychiatric nurse I am struck as much by the things we weren’t taught as by the things we were. Information that now seems absolutely vital for mental health nurses to know never even warranted a mention whilst hour upon hour was devoted to the almost religious doctrines of psychiatric classification. We’ve already discussed the limits of classification in the section on diagnosis and I won’t repeat the argument here.
One omission was the relationship between hallucinations, illusions and delusions. Had this been made clear even once during our three years of pre-registration training my fellow students and I might have had a fighting chance of dealing with psychosis. So might our patients.
Instead the three primary signs of psychosis (hallucinations, delusions and thought disorders) were always presented separately as though they had not and never could have any relationship to each other. I hope to show that they not only can be related but that they almost inevitably must be in any problematic psychosis.
I’m specifying ‘problematic’ because, let’s face it, hallucinations without accompanying delusions or cognitive difficulties aren’t going to cause any problems anyway. There are many people who experience hallucinations without having any problems but they’re not my patients and they’re probably not your service-users either.
To make the relationship clear I need to start by talking briefly about hallucinations and also ‘illusions’.
As we have already seen an hallucination is a sensory experience that is not actually caused by an external stimulus. To put it more simply the smell you smell isn’t real, the vision you see isn’t actually the result of light hitting your retina and no sound waves move through the air around you to produce the voice you hear. Hallucinations really are your senses playing tricks on you.
Illusions are different. They are misinterpretations of sensory evidence but they are based upon real external events. When we imagine a face in the shadows it’s not an hallucination because there really is a shadow. We’ve just misinterpreted what we see. However that doesn’t mean that illusions don’t matter – they very clearly do.
So how does this relate to delusions?
The standard medical definition of a delusion is
“A fixed, false belief, not amenable to reason”
A delusion is more than just a vague idea or a half-considered opinion. It’s entrenched and hard to shift. Modern therapeutic protocols have shown that it is possible to reason around (and through) delusions but that doesn’t mean that it isn’t difficult. That’s precisely why delusions are so problematic – because they are so strong.
Ask yourself a question ….
If a person lives in terror because of a delusional belief that the Mafia plans to murder them does it really make a difference to their quality of life if the belief is based upon an illusion (they mistook a stranger for a hit man) or an hallucination (they heard the voice of a Mafia boss ordering the ‘hit’)?
The terror is the same in either case and the delusion will be equally hard to shift.
Here’s another question….
When mental health professionals distinguish between hallucinations and illusions can they always be sure? If I wasn’t there and didn’t see the face at the window can I really distinguish between:
- Actual face of a real stalker?
The experience is the same whatever the cause. The person is still frightened and their belief is identical.
Why does this matter?
We can see that in both cases (illusion or hallucination) people’s beliefs spring from their perception. For example…
For example, antipsychotic medication sometimes (less often these days) creates problems with involuntary movement. People experiencing these side effects sometimes develop ‘delusions of automatism’ where they believe that their bodies are being controlled by others. It could be argued that this ‘delusion’ might be dealt with very easily by making sure that the person concerned knew the true, chemical cause of their problem. Then they wouldn’t need to find alternative explanations.
This point will become important later when we discuss ‘evidence’ and ‘explanation finding’ with people experiencing delusions.
A young man who sees images of demons in the embers of a camp fire will be no less terrified than if he heard Satan’s voice promising to steal his soul.
A woman I once worked with experienced ‘hallucinations’ of a spiritual monk walking around her flat. She interpreted this as a bad omen foretelling disaster for herself or for her family. She was terrified. As it turned out this ‘hallucination’ was actually an ‘illusion’ caused by shadows in her flat and a slight visual problem that needed ophthalmic treatment. Yet it was diagnosed as an hallucination simply because nobody had bothered to investigate other possibilities. These are all firm, distressing delusions based upon the evidence of the senses. The key is interpretation. This is also the key to dealing with them.
If we can help people to reinterpret their sensory experiences then we can help them to deal with many forms of delusions – but not with all of them. Not all delusions come from misinterpretation of sensory evidence but an awful lot of them do. Enough to warrant proper understanding of the link before workers are ‘let loose’ on delusional people.
In the future we’ll consider ways to help people overcome their delusions and distress. We’ll look at the power of attribution and the meaning of recovery. We’ll get into ‘delusional mood’ and ‘selective abstraction’ as well as the principles of real world experimentation. But they’re for later in the series.
Next we’ll cover delusions that seem not to be based upon sensory evidence but rather upon a form of ‘sequential reasoning’ or even ‘wishful thinking’. These delusions may not be pleasant but they do tend to serve a purpose and often that’s as much about self-preservation as it is about anything else.
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